Your Questions

Q: Dr. Eppley, I have lip incompetence/mentalis strain. I have tried relaxing with Botox and it had worked but it is not permanent. I have been to the orthodontist and I have a slight skeletal open bite for which they said only jaw surgery would be able to fix my incompetent lips. However jaw surgery is a very risky and expensive procedure and I do not want to go through with it. Can a sliding genioplasty be able to bring the chin in a more forward manner and reduce the strain/incompetent lips? Thank you!

A: Improvement in lip competence and reduction of mentalis strain in some sliding genioplasty patients is one of the potential benefits of the surgery.  But that would depend on what type of chin movements are done and what is the anatomy of the patient’s chin initially.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a sliding genioplasty five years ago and hydroxyapatite paste added to the jaw angles. However, the HA paste is VERY uneven and one side is rounded and the other more angular. I tried to have it removed but the surgeon was unable to remove it since it had integrated too much into my tissues. Could a small amount of HA paste be added to even it out? Ive tried fillers like Juvederm and Volux (designed for chin and jaw augmentation) and Radiesse in the past but they are still too soft to emulate bone and end up looking puffy after a few weeks.

A: You have encountered exactly what one would expect with using HA paste in the jaw angle areas…asymmetry and irregularities. It is hard enough to place preformed implants into the correct position over the jaw angle area let alone an amorphous paste.

I am not sure why the combined material/bone can not be removed despite having some bony integration which is exactly what one would expect to happen in a subperiosteal pocket with a thick overlying muscle layer. (it is a highly osteogenic site)  It is not easy but that should not be confused with can’t be done. But that issue aside secondary HA augmentation can be done. The relevant question is how much volume and where should it go….an imprecise secondary procedure for sure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have Poland’s Syndrome. Do you offer custom pec implants or are they pre-made?

A: All Poland’s syndome pectoral implants are custom made. It would be impossible to achieve a good result in most cases with a standard pectoral implant.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was affected by positional plagiocephaly after birth and now have a strange head shape. Can total correction of the skull be done in heads like mine which would include the forehead, temporal and back of head areas?

A: Optimal treatment of cranioscoliosis from positional plagiocephaly would involve the forehead/frontal (reduction vs augmentation), temporal reduction and back of head augmentation. The question is not whether that can be done but whether all mentioned skull regions need to be treated and whether the various incisions needed to do it (particularly the forehead/frontal region) are worthy tradeoffs for the benefits. That would have to be determined on an individual basis.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a slightly recessed chin. I want it to be more protruded and shorter. My profile angle is also weak (is there an alternative to getting implants? can bone be broken instead to wake it wider?)

 My cheekbone is also flat on the front view. I’ve had a previous consultation, the doctor said that my cheek is quite low for my age. I just want it to be more lifted and to have more angle. But the side view of my cheeks is alright for me and don’t want it to be more apparent. Only on the front view. 

i sent a pic of me smiling. i don’t like it when my cheeks elongate, they look like chipmunk cheeks….I recently had a buccal fat removal to see if it could improve my face. i would not like an implant to make them bigger…so just want a more structured and defined cheeks.

A: In answer to your questions:

1) The pnly chin option to make it longer and shorter is a vertically shortening sliding genioplasty.

2) Jaw angle augmentation can only be done with implants. No bony method can ever make the jaw angles wider or more pronounced.

3) With a flatter cheekbone on one side the options are either a small implant or fat injections.

4) There is no surgery that can change the way the cheeks look when you smile. You have probably learned this from the buccal fat removal. Smiling is a dynamic maneuver while surgery only affects structures in their static position.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I read your comparison on medpor and silicone jaw and chin implants, you say that there is some bone erosion that happens after placing implant. 

My question is will chewing gum (flexing jaw muscles) and moving chin muscles result in more bone erosion than it would be if one never chew any gum, in both silicone and medpor implants (does chewing gum has impact on bone erosion after placing implant)?

 Also you say there is soft tissue ingrowth in medpor implants, did you meant jaw muscles? 

Thank you! 

A: In answer to your questions:

1) Bone imprinting occurs with all facial implants, regardless of its material composition. It is a natural biologic reaction.

2) Such bone imprinting is not affected by motion or overlying muscle pull.

3) Fibrous soft tissue ingrowth occurs on the surface of any textured or porous implant material.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in hip pelvic implants but not the kind that are simply stuffed into a pocket, I’ve been to numerous doctors and the only type of procedure they do are standard hip implants stuffed in a pocket. I have contacted a hospital in Seoul that is known for pelvic plasty but noticed one of your replies on Real Self in response to a similar inquiry. I am very lean and narrow hips and are looking to round out my figure. I am also a trans woman which only adds to my hip deficiencies. I have attached photos for your review. Look forward to hearing back from you! Thanks so much!

A: Thank you for your inquiry and sending your picture. The type of hip augmentation to which you refer is that of iliac crest implants which provides a bony augmentation to the upper hip region rather than a lower soft tissue augmentation over the greater trochanteric region of the hips. (see attached) As you know only the country of Korea offers such implants made of metal…which may (or may not) be the ideal material for augmenting the iliac crest. No one really knows since so few such surgeries have ever been done. Here is the U.S. metal iliac crests are not an FDA approved device. (and may likely never be approved as a cosmetic implant given the low demand for it) No U.S. orthopedic manufacturer will even make it as a custom implant because it falls outside of their FDA reconstructive implant approvals. As a result I have designed ultrafirm solid silicone iliac crest implants as an option here in the States but have yet to actually implant them in a patient to date.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, As you can see from the photos I suspect a webbed neck deformity (pterygium colli). I have already done the Noonan syndrome’s genetic test and it’s result was negative. I would like to know if i could be operated to correct this deformity and what should i do. I wait for your news. 

A: Thank you for your inquiry and sending your pictures. Webbed neck surgery is based on excision of tissue on the back of the neck. Its success depends on how much laxity of the tissues exist as well as the acceptance of a midline scar on the neck.

That being said, you have two issues of concern for his surgery. First you are a male with shorter hair where the resultant scar will be exposed. Having never yet having a male request or undergo the procedure I would have concerns about the appearance of the scar in a more exposed area. (in women with longer hair this is not a concern) Secondly, intermediate neck webbing like yours is associated with tighter tissues that often resist or have greater amounts of postoperative recoil to the midline pull of the procedure.

This is not to say you can not undergo the procedure successfully, these are just preoperative issues to consider.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, With vertical orbital dystopia, is it possible to lower the eye that is situated higher if one prefers the appearance of the lower eye/mid face or is such an approach impossible? The infraorbital bone would have to be shaved down I assume but placing an implant superiorly above the globe would probably involve greater health risks. Are nerve damage and vision problems likely complications with these kinds of procedures? I suspect my dystopia would be in the 5mm range. It really ruins facial harmony and I noticed people that are widely considered attractive almost always have either none or very little eye asymmetry. Is it possible to receive a quote for a possible surgery assuming it would involve cheek and eyelid work as well? (the sides of my face are asymmetrical across the entire face)

A: To lower a higher eye that is done by dropping down the bony orbital floor like is done in orbital decompression surgery. This is not a precision procedure, like raising the eye with a premade implant, so exact amounts of lowering are hard to predict. Besides that issue the more pertinent concern is that the position of the upper eyelid will remain the same when the eyeball lowers…affecting the lid-globe relationship. Unlike raising the eye where the upper eyelid can be surgically raised by ptosis type procedures to restore the lid-globe relationship, there is no surgical procedure to lower an upper eyelid. Thus another aesthetic problem may result with too much scleral show between the upper eyelid margin and the superior margin of the iris.

I would need to see a picture of your eye asymmetry to determine how these potential issues may apply to you.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was interested in receiving more information on the Occipital knob reduction. In addition how safe is having this procedure completed? I am apprehensive due to concerns of safety and anxiety considering I have never had any other surgery. 

A: Occipital knob skull reduction is a perfectly safe and effective surgery. The occipital bone is thickest of the skull bone particularly along the nuchal ridge area so the brain is safely removed from the reduction area.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I just recently found out through your blog that as a child I had positional plagiocephaly. I have a flat spot on the right side of the back of my head. I have always thought there was something wrong with my eyes and was in the process of finding a surgeon for my facial asymmetry. I now know where the asymmetry came from and I really want some of the asymmetry to be improved as much as it came be. I personally like my right eye better because it appears bigger and more of the eyelid can be seen. I also believe I have a small deviated septum which causes my nose to curve over to the right which I would prefer be fixed If I do a consultation will it need to be done in person due to the cause? I’m not sure what needs to be done to make my face feel more symmetrical so I am hoping your practice can help me. Thank you so much! 

A: Thank you for your inquiry and sending your pictures. Your facial asymmetry is undoubtably due to congenital plagiocephaly. The left eye is more posteriorly positioned as is the brow bone, cheekbone, and infraorbital rim. The challenge in preferring the right eye is how to make the left eye appear more similar. One thing you can not do with an eye is to bring it further forward since it is attached/tethered by the optic nerve. Thus the left eye can not be brought further forward which is the ideal manuever to improve the eye symmetry. But besides being more posteriorly positioned it also sits a bit higher. The orbital floor can be lowered which will being the eye down a bit. That combined with cheekbone reduction should help the eye/facial asymmetry.

A 3D CT scan of the face is the first place to start in making an accurate assessment of the bony asymmetries and in making a more informed treatment plan for them.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My lower face is much wider than my forehead. Getting older has accentuated this effect. I have just retired this month and would like to go into my later years looking a bit less cartoonlike. Would prefer to under-correct than overcorrect, however.

A: Thank you for your inquiry and sending your picture. Aging has increased the wider lower facial appearance with the typical soft tissue descent that occurs. The soft tissue can be relocated/resuspended by a neck-jowl tuckup procedure which is the basic approach that is needed.

The more pertinent question is since this is a natural/congenital issue there is a bony component to the lower facial width as well as a naturally more narrow forehead. In treating this issue more comprehensively at the bone level the options are for a jaw width reduction or a forehead augmentation/widening procedure. There are advantages and disadvantages with either approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hello! My frontal bumps are very pronounced and I want to get rid of them, but my hair is not thick and I’m balding, so I can’t do surgery with a coronal or hairline incisions, a big scar is not acceptable for me.Can I reduce the frontal eminences endoscopically? One doctor said that endoscopic removal is dangerous, why? If an endoscopic osteoma can be removed, then why can’t the eminences be removed as well?

A: An endoscopic technique is not going to work for frontal eminence reductions because such reductions require power equipment which can not pass through a small incision or work around a curved surface. Frontal eminences are broad based bone elevations of the outer cranial surface.

Conversely endoscopic removal of osteoma uses an osteotome which is effective for them because they are bone growths just above the outer cranial surface that is attached to it by a narrow base. (like a mushroom) Thus they are rather easily separated from the surface by the osteotome.

The one intermediate technique that I have found useful in cases like yours is the rasp technique. With incisions as small as that used for endoscopic surgery a large toothed rasp is inserted which can aggressively remove bone manually. It is a blind technique where the reduction is ultimately guided by eternal appearance and feel.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Is 3cms of lengthening on each clavicle possible? Im 6’3″ tall and very narrow and hope for the best possible result. 

A: Thank you for sending your picture. It is also a balance between how much clavicle lengthening can be achieved vs ensuring that the bone will heal properly. The longer the lengthening the better the aesthetic result but the higher the risk of non-union. I would agree that 3cm of lengthening per side would be best but until I get to surgery and make the bone cuts I can not say whether that length is achievable.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, What do you think about using long term resorbable meshes for augmentation of flat back head? I have such a condition and I saw a plastic surgeon conducting augmentation using non-absorbable meshes. I would not like to have foreign material in my body for ever but I am really curious about resorbable meshes and their effects in cranioplasty.

A: I could not imagine that a non-resorbable or resorbable meshes would be a very good skull augmentation material for a variety of reasons. Perhaps for very small amounts of ‘spot’ augmentations it may be fine but for the much more common larger surface area skull augmentations that most people desire it would be a far inferior material choice. The key criteria for an aesthetic onlay skull augmentation material is: 1) having a smooth outer surface contour and fine feather edges, 2) easily modified or removed later if the patient is unhappy with the result or desires a change, and 3) able to be placed and properly positioned through small scalp incisions. 

There is a corollary to your question and that is the use of mersilene mesh for the chin …which has never become a mainstream technique in chin augmentation surgery.

Lastly non-resorbable meshes are synthetic polymers…an implant material in the skull that may never really absorb. It has never been tested for that implantation site. One should not confuse what happens when such a material is implanted on muscle vs on top of skull bone.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hi about a year ago I had jaw angle implant surgery and around 3 months ago removed them due to not liking the look of them. It seems like the corner of my jaw is missing on 1 side now and when i bite my jaw angle appears higher now, i was wondering if its possible to correct this, its on my left side, I’m 21 year old male, and healthy.

A: What you undoubtably have is masseteric muscle dehiscence for which there are two treatment approaches, muscle repositioning and onlay contouring, each with their own advantages and disadvantages.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, How can I correct my asymmetrical mouth and nose? I am not sure what is causing it. Do you think it’s my jaw? 

A: The mouth corner, nose and lower jaw asymmetry are reflective of the overall congenital facial asymmetry. It could be called a left facial hypoplasia or a right facial hypertrophy depending upon which side  facial length wise) you prefer.

The mouth corner needs a corner of the mouth/lateral vermilion lift to make it more even to the other side.The nose requires a rhinoplasty with right nostril narrowing.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have had a genioplasty 4 weeks ago but something does not feel right. My chin feels more to my left. 

I feel there is more tension to my left, slight pain, there’s still numbing and awkward popping sounds come from my left. Not the popping noise I sometimes get from tmj but tiny popping sounds as if bubbles are bursting. They occur when my mouth is closed and if I clench my teeth. 

The left side has all these discomforts yet it also looks like the least advanced. I still look soft and round on that side. I have two different jaws (one side is always slightly longer than the other). 

My lips dont feel supported anymore as they did when I came out of surgery. Its naturally sits open. It nows feels back to its recessed self. I feel a strain, would I need botox there? 

I have attached pictures and would like to know your opinions. Do you think there could have been a better way of cutting my chin? 

I would be very grateful for your opinion. Currently my surgeon is not being 100% honest with me and believes he did a great job although I have suspicion he is turning a blind eye. 

A: Since this is early in your recovery process and you are still under active care by another surgeon, I do not provide commentary on a procedure in which all I have is ‘one side of the story’. But what I would tell any patient or surgeon that has concerns about a chin implant position or a chin osteotomy, no matter when it is in the recovery process, is get a 3D CT scan or cone beam scan of the chin. That will provide exact visual insight into what was done. Looking from the outside is just guessing and open to various interpretations of what may lie underneath.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in lip implants with a subnasal lip lift.

A: Thank you for sending your pictures and lip augmentation goals. You are not a good candidate for an isolated subnasal lip lift due to having very thin sides of the lips down into the mouth corners. A subnasal lip lift is mainly a central lip  enhancement procedure that leaves the thin sides as they are. This will create an upper lip vermilion disproportion which is seen too frequently in isolated lip lifts. Such a subnasal lip lift would have to be either combined with lateral vermilion advancements or a total vermilion advancement should be done. (which moves the entire vermilion to wherever one wants to put it and is always the most effective procedure in thin lips)

While lip implants add volume that does not equate to more vermilion show. In thin lips because of the lack of vertical vermilion height what results is a horizontal protrusion rather than a vertical elongation…which is one of the causes of ‘duck lips’) Lip voluminization works well when adequate vermilion height already exists. This would be the case in your lower lip where more natural vermilion show exists.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Do you have any CT scans of before and after a genioplasty. Or is it possible for me to get one? Also is it possible to eventually take the titanium plate and screws out?

A: In answer to your questions:

1) I do not routinuely get before and after CT scans of  genioplasties. While they would always be interesting to review that is an expense the patient would have to bear.

2) One can always remove their hardware as early 3 to 4 months after the surgery if the patient so desires…but no patient has ever yet done so.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Interested in custom facial implants to balance out facial assymetry caused following orthognathic surgery. This means I have titanium plates (screws?) In my face. Can you still perform facial implants for me? Thank you so much! I have some xrays from a few years back when they took them right after surgery if you needed to see those. I would love to have a balanced profile if you think this could help? Thank you very much!

A: Thank you for your inquiry and detailing your objectives to which I can say the following:

1) The use of custom facial implants to correct disproportions and asymmetries after orthognathic surgery is very common in my experience.

2) All such patients have indwelling metal hardware which is not an impediment to placing implants and in some cases is even removed in the process. (if not overgrown with bone)

3) Custom facial implants require a 3D CT scan for designing which will fully reveal in detail not precisely seen your facial bony anatomy and metal hardware. Thus there is no need for any prior x-rays that you may have.

4) I would a description of your specific facial areas of concern and any pictures that so illustrate for my assessment. My assistant Camille will contact you to schedule a virtual consultation time to discuss further.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m a relatively young male and over the last 2 years my scalp has been gradually depleted of soft tissue due to a connective tissue disease that I have. I now have several indentations all over my head that were never visible until recently. You answered my RealSelf question about this, stating the surgical options were either fat grafting , or implants. My question is you said that fat grafting doesn’t always work well on the head, why is that? And two, if it were to be implants, would they be super visible on the edges and what would happen if my scalp continued getting deeper dents underneath the implant?

A: Since these indentations are soft tissue based the logical approach would be soft tissue grafting with fat injections. While injection fat grafting placed anywhere always has unpredictable survival/volume retention rates, certain body areas are more favorable while others are known to be less favorable. The scalp is an unfavorable site because it is composed of tight tissue layers that do not naturally have much fat in them. (fat survives best in areas which naturally have more fat) But that being said fat graftng is still the way to initially go and does not mean it would not be effective. Implants would only be considered when fat grafting has proven to be ineffective.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had two questions regarding clavicle lengthening. 1. How much is achievable for bideltoid width for each shoulder? I’m looking for 1.5-2cm on each shoulder. 2. How many times have you performed this surgery and what was the average amount of actual shoulder width gained per shoulder? Thanks.

A: Thank you for your inquiry. In answer to your clavicle lengthening questions:

1) The aim of each clavicle osteotomy is 2.0 to 2.5cms of lengthening per side.

2) Unlike clavicle reduction osteotomies, which I perform regularly, clavicle lengthening is a new shoulder procedure that has been performed just a few times.

3) Like clavicle reduction and shoulder width reduction, the effects of clavicle bone lengthening are essentially a 1:1 relationship of bone length:bideltoid width increase.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, When i was younger my head wasn’t that wide but with time and some jaw problems my temporal muscles got bigger and bigger because of the jaws. Now i feel like my head is a little bit ”too wide” in the temporalis place. When i press the muscles in with my hands i look way better and my skull looks more natural. I don’t know what to do because there aren’t any surgeons who do these kinds of surgeries where I live. Can you reduce the muscles with botox? and how long do that last?.

A: Botox is always a first place to start for temporal muscle reduction when surgery is not an option. It will not have the same effect as temporal reduction surgery but it will produce some modest temporal reduction effects…albeit of a temporary nature.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m looking to make my eyes a bit more symmetrical but I don’t know what sort of surgery that requires or how it might be possible. Looking for more information and potentially surgery! I’ve attached a photo of my face, front camera, and a photo of my face in selfies ! Would love to look more like the selfie (inverse) photo 🙁 

A: As best as I can tell from your picture, you appear to have a left upper eyelid ptosis as the primary reason for your eye asymmetry. Eyelid ptosis surgery therefore would be the appropriate correction. Before any surgery, however, an ophthalmologic evaluation is necessary to determine if there is a medical reason for the ptosis.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,To give you a bit of historyI had hairline reshaping surgery several years ago. (I am a cis gendered female, I just wanted to make a few tweaks to my hairline) The outcome unfortunately was not what I wanted.

 My hairline was significantly lower than what was discussed, and the shape given was a prominent widows peak instead of the rounded feminine hairline I wanted. I came to accept it since I thought there was no way I could ever be able to achieve the beautiful high rounded forehead that I wanted. Since then I have been embarrassed of my hairline and just wish I would pull it back into a high ponytail without showing the obvious unnatural widows peak shape. What can be done for it now? 

A: While the forehead can be augmented/reshaped, that will not change the shape of the frontal hairline. The hairline can be shaped but then a forehead augmentation can not be done. Forehead augmentation and hairline repositioning are diametric procedures…forehead augmentation needs more skin as well as does trying to bring the hairline back and/or fill in the sides. The only way to concurrently accomplish both is a first stage tissue expander…which takes an ultra motivated patient to consider that staged approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m a transwoman who’s looking into hip/buttock/breast augmentation surgery and your practice is one of the ones I’m considering. Your custom hip implants are what convinced me to contact you since I think the way they extend into the thighs may offer a more natural look (they remind me of my padded underwear I use to simulate hips). My goal is to achieve the curves cis-women have, that I was not born with. Can all three hip, buttock, and breast augmentation be done at the same time? If not, can two of them be done at the same time? I see you also do fat grafting and liposuction. Is that something that can be done in conjunction with implants to achieve a better look? I know the specifics of these questions (for example, whether lipo/fat grafting is recommended or not) would only be answered through a virtual consultation with pictures, dimensions, and weight. But I would appreciate if you could answer these questions to the best of your abilities. I sincerely look forward to your response as this is a procedure I’ve been very keen on getting done. Have a wonderful day!

A:Thank you for your inquiry and detailing your concerns and objectives: In answer to your questions:

1) All three implants (breast, buttock and hip) can not be done at the same time due to the recovery challenges that it poses.

2) Two of them can be done at the same time but I would not combined buttock and hips as the two because of the increased rate of complications.

3) It would medically prudent to do breast and buttock implants first for reason #4 below.

4) Despite have developed hip implants over the years they have the highest rate of complications and no alterations in surgical technique have made a substantial lowering of those risks. A s a result I remain very guarded with this surgery both in patient selection and in implant design/size. Because of these risks you want to keep this procedure isolated from others….and may even consider it not a viable option to do given the associated risks.

5) Fat grafting can be done to complement buttock or the hip regions, with or without implants. How this applied to you is not yet known to me.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hello! I was hoping for a little insight on my overhang. I am a mom of four with the most recent two being twins. I am struggling so bad with body image after these two and battling yeast infections off and on (mainly during my monthly cycle when I seem to be way more hot). Clearly I am not in a super healthy weight range and have always struggled with weight but I have never had the overhang to go with it. Just wanted to see what my options were at this point. 

Thanks!

A:There are two options for you at this point: 1) do an immediate panniculectomy/tummy tuck to get symptomatic relief and an immediate body shape improvement even though this will not produce the best result at your current weight or 2) lose some weight and then do the surgery which will allow for the best result but also prolongs the your current symptoms. You are really in the gray zone for this choice as if you were at a lower weight you would just go ahead and do the surgery vs if you weighed more you would have to lose some weight first.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I got a saggy butt because of weight loss. I’m a thin male in the upper body and have a saggy skin in my lower body especially my butt. This made me feel so uncomfortable I would like to do a surgery to remove this excess skin and make it look normal. You will find attached photos (naked) in this email. Thank you for the understanding. Best regards.

A:Thank you for your inquiry and sending your pictures. Typically excisional buttock lifts are done for overhangs of the infragluteal fold where the scar ends up along a natural crease or demarcation line. That is not the classic situation that your buttock excess presents. By looking at your own ‘pinch test’ that would place a scar line above the infragluteal fold in which I would question the scar tradeoff in such a more visible location. I can not see how I would get out the tissue excess if the excision was done in the more favorable infragluteal fold location.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, What is your opinion on Lefort 2 surgery? For cosmetic purpose most of surgeons perform Lefort 1. However from what I saw Lefort 2 provides better results aesthetically. Do you preform Lefort 2 and would Lefort 1, with paranasal implants give same results as Lefort 2. Also what is down side to Lefort 2? Pic I send you is from a woman that got Lefort 2 and results are impressive to say the least.

A: If you have a malocclusion that justifies a maxillary alveolar movement than it is an option…but it still leaves behind an infraorbital rim deficiency since it can’t provide a vertical elevation to the rim only a horizontal one. That deficiency would be more apparent if she wasn’t smiling in the postop frontal view which artificially elevates the rim/cheek/lid tissues.

It would be more effective to either d a LeFort I osteotomy with implants above it or a total custom midface mask implant and avoid any form of LeFort surgery at all.

Dr. Barry Eppley

Indianapolis, Indiana