Your Questions

Q: Dr. Eppley, I am actually a previous patient of yours, I received a full custom jaw implant almost two years ago. Honestly, I could not be happier with my results. The fullness that the custom implant provides has given my profile a much more masculine and esthetic look. My jaw angles are also much more ideal and overall I am very happy with how my facial tissues adapted to the implant. The only concern that I still have — and we did briefly discuss this issue before my surgery, is how deep the labiomental fold may become post-surgery. I have always had a relatively deep labiomental fold, even though my chin was exceptionally underdeveloped for my profile. With the addition of the custom chin implant, my labiomental fold has only become more pronounced. I know this issue is not a large concern for most individuals; however, it is less than ideal for me, especially when viewing my side profile. Now that I am considering surgical options, I would love to hear your professional opinion on what can be done to fix this issue surgically, pricing, as well as what sort of expectations I should have post-surgery. I am uploading 4 pictures of my current profile, 1 picture of my profile before the full custom implant (in case you would like to add a before and after to your website), and 1 picture of my ideal labiomental fold (to note if a result like that is even possible). Thank you so much for your time and I look forward to hearing back from you.

A: Thank you for sending your picture and the longer term followup. In my experience there is no more effective treatment for a deep labiomental sulcus than a release and placement of a dermal-fat graft. The deep labiomental sulcus really represents a soft tissue deficient particularly when the chin has been augmented from its congenital shape.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, -hope you’re doing excellent! Huge fan of your work, as there is a reason you have the credentials/track record you do. (college student-live in Carmel area) Despite never having any cosmetic surgeries, my eyebrows have always been higher-throwing off my facial/width/height harmony. As seen in the first picture, my eyebrows are at there current position. Then, the right and left eyebrow are brought down just by me gently pressing my finger above each eyebrow. I know this seems like an odd request, but my brow bone projection from the side profile seems as if my eyes would be ‘deep set’. Perhaps they already are deep-set, but my eyebrows are just located slightly higher on my brow ridge? I know botox could be mentioned to lower the eyebrows, but would there be any surgical option that is safe/effective long-term? I have analyzed results from different ‘almond eye surgery’ variations, but I believe my overall shape and under-eye support is adequate enough, in your opinion? The lack of lowered brows allows my upper eyelid exposure to be much more visible, throwing off my entire mid-facial measurement. Would there be any way to retract underneath the eyebrows and pull them down towards my eyelid, making them more so “hooded”? 

Appreciate your time, you’re the man!! 

A: Thank you for your inquiry and sending our pictures. I believe you have answered your own questions accurately down to the last one. There is no operation that can pull the eyebrows down. While they can be pulled up (browlift) they can not be pulled down. To do so they have to be pushed down by an underlying brow bone implant which would not cause a good aesthetic tradeoff.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have some specific questions regarding the projection of my upper and lower jaws because I’m unsure if I would be a candidate for maxillomandibular advancement or not.

Is my maxilla projected forward enough in your opinion? Are my tear troughs caused by a deficient maxilla or something else? I saw an orthodontist two years ago and she said I have class I bite. I have moderate crowding in my lower dental arch and light crowding in my upper arch; I am mentioning this because I’ve read that the teeth can indicate whether the jaws are recessed or projected forward.

I’m also aware that my chin is recessed; do you think I could potentially benefit from a double jaw surgery? I have attached some photos for your reference. 

Thank you,

A: In answer to your questions:

1) I see no indication whatsoever for maxillomandibular advancement surgery. You have adequate forward midface projection and a Class I occlusion.

2) Your moderate infraorbital deficiency and very modest chin recession are independent skeletal underdevelopments of the normal projecting maxilla and mandible.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hey, I am somewhat contemplating getting a chin implant and was wondering what are realistic options.

A: Thank you for your inquiry. I am not absolutely sure what you mean by ‘realistic options’. But in any form of facial augmentation, including that of the chin, the first step is to determine your aesthetic goals and the dimensional requirements to achieve them. (projection, length and width) Knowing the dimensional requirements then allows one to determine if a standard or custom chin implant is best suited to achieve them.

To determine your aesthetic chin augmentation goals I would need pictures as well as a description of your goals to do computer imaging from which we can then determine what would be the appropriate chin augmentation approach for you.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want to reshape my forehead for a more feminine appearance. Here are a couple of images. As you can see, my forehead is rather sloped, instead of rounded. Likewise, from the front, there is a horizontal crevice that can be seen in certain lighting. Also, I am looking at how to make my side profile more feminine and attractive. Thanks!

A: Thank you for sending your pictures. The reason your forehead appears masculine to you is that you have brow bone hypertrophy and a result suprabrow bone break (horizontal crevice that you see) which then becomes a more recessed flatter forehead. Admittedly this is a classic male forehead shape, not that of a female. The combination of brow bone reduction by burring and a small amount of bone cement to the forehead above it will help feminize your forehead.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hi, i want to question if only trans woman can do shoulder reduction, a cis man can do too? I would like to know if only trans women can do shoulder reduction surgery or cis men can do it too? I feel very dysphoric about my shoulders.

A: Shoulder reduction surgery is not limited to any specific gender. While it is often called shoulder feminization surgery, there is no reason a cis male can not do the surgery if they have excessive shoulder width concerns. An uncommon request should never be confused with a surgical contraindication.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was wondering if I could possibly get a quote in regards to the removal of my keloid on the front and back of my ear. This is the result of a piercing and i’ve had it for about 5+ years. Around 3 years ago, I did a couple rounds of steroid injections that did not change the size at all. Please let me know if you’re able to provide me a quote based on the photos attached. Thank you!

A: Once you have an established hypertrophic scar, steroid injections are not going to be effective. Steroids only work in the active phase of scar formation for the most part. These require excision as you have surmised with concomitant injections of Kenalog (steroid) to hedge the chance against recurrence.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I understand there aren’t ‘after’ photos for hip implant augmentation procedure- totally relate to wanting to be discreet on that front. But would you say the patients who get this procedure are usually satisfied / happy with their results? Are there any common complaints / problems after surgery for most patients who have this done?

Thank you!!

A:In answer to your hip implant questions:

1) Patient satisfaction with hip implants, barring any complications (infection,seroma) is generally good. It is important to mention, like most implants in the body, perfection is rarely obtained and there are always some aesthetic deficiencies. (enough projection?? is there any visible edging??) But if one can live with less than ‘perfect’ results then it can be a good body contouring operation. However for the perfectionist this is not a good operation as secondary attempts to make such changes are never a good idea. This is best way I know to stir up trouble, of which infection and seromas can appear, in a secondary operation when manipulating an unnatural substance in the body. Getting the body to accept an implant the first time is a blessing. But I don’t advise patients to ‘spin the roulette wheel’ the second time. As my motto goes with implants anywhere in the body…’an uncomplicated 70 to 80% result is much better than a 100% result with a complication’.

2) I would also add that implants at different anatomic locations in the body have higher risks than others. (thus lower satisfaction rates)  Breast implants, for example, while far from being complication free, have the lowest risk of implant-related complications of any body implant. (extracting implant related deflation/ruptures which are mechanical device complications and not systemic reactions to the implant) The point being is one should not judge the fate of hip implants by the more familiar breast implant. They are much more compatible to buttock implants.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a chin implant which, while offering some improvement, leaves me wanting for more. How much more different would a custom jawline implant make?

A: Thank you for your inquiry and sending your pictures. You do have a small lower jaw both in projection and width that is disproportionate to the rest of your face. I have done some imaging looking at just one potential type of jaw augmentative change. In answer to your questions:

1) The chin implant would only be removed during the jawline implant placement. For the implant design the chin implant is digitally removed. The size and shape of your current chin implant will be seen in the 3D CT scan.

2) The only relevance of having a chin implant in place and still having the chin deficiency you have is that it is possible you may be better served by removing the chin implant and getting a combined sliding genioplasty and custom jawline implant. This would depend on how dimensionally deficient your actual real chin is and what projection/length you want from this new total jawline augmentation effort.

3) Once I receive a 3D CT scan of your face I will be in a better position comment on whether #2 is the needed approach or not.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Can I have an idea of the material you use in custom facial implants and how effective it can last when you move and sleep for example. Do you still feel normally with your face like before that. Thank you so much.

A: A variety of different materials can be used for custom facial implants but solid silicone is the most common and versatile. Such materials are permanent and can never degrade or breakdown. Like your normal bone they are unaffected by facial movement or sleeping positions. One’s face will feel normal once one has recovered from the surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My pubic bone protrudes by about an inch instead of lying flat against my body (I am certain this issue is due to the bone rather than an overly fatty mons pubis as I am slim and cannot feel much fat there). I find this very unflattering and feel reluctant to wear swimsuits and leggings. Is there any way to safely reduce the size of this bone? Perhaps through bone shaving? Or through reducing the length of the bones that lead to the pubic symphysis? Could this have any adverse effects on sex or pregnancy? I know of many other women through online forums who share this issue and know that a monsplasty would not make a difference. I have attached a picture of someone else’s. Mine is larger. 

A: The height of the pubic bone is the pubic symphysis, an actual joint between the two pelvis bones. The height of its protrusion is consistent in women with being at the level of the clitoris. While this union of the two pelvic bones may indeed be a primary source of your protruding mons it can not be surgically reduced. Besides having numerous suspensory ligaments attached to it, maintenance of the joint surface are essential for weight transfer while walking for example. Thus the only mons reduction procedure you can do is small cannula liposuction which, while not creating a perfectly flat mons profile, does always make a difference of at least 50% of its projection in my experience.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a bulging temporal artery and my vascular surgeon has performed a ligation on it. (two incisions) However the artery began to bulge a few days after the operation. Do you have any advice for a second ligation that would be more effective? I have provided a picture as well. Please, any info is greatly appreciated. This thing is killing my self-esteem. 

Thank you for your time.

A: What you learn in temporal artery ligations is that two ligation points is insufficient.  While that seems like it would be effective (cut off the front and back flow) it never is. You have to go out further along its course and get several other ligation points as there are more vessels that feed into it that it appears with its superficial location. It would also be interesting to know the exact two locations where it has been ligated which is not obvious in your picture.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I read your description of iliac crest reduction surgery with great interest. I am a 40 year old male with distinct protrusion of this part of the pelvic bone. If I understand the description correctly, it can be possible to reduce this part of the bone by surgery. I would like to know more about this possibility, and if this is a procedure you have done.

A: I have harvested many iliac crest bone grafts so the anatomy I know quite well. Thus it is possible to reduce the widest flare (width) of the iliac crest for aesthetic purposes although I have yet to do so.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I think I have a short face syndrome. How can I treat it, I’ve turned 19 recently and I am thinking about getting a surgery in 2-3 years, cause I feel pretty bad having this short chin, also my face doesn’t look harmonious at all because of this, What surgery would you reccomend Dr Eppley? I attach 2 pics, side and front, I would be very happy with your reply, cause I know I want a surgery, but I’m not sure what surgery would that be.

A:With your very short lower third of the face and flat mandibular plane angle you would need either a chin wing osteotomy or custom jawline implant. Either one will differentially vertically lengthen the entire jawline, greatest at the chin and less so as it proceeds back to the jaw angles. Such a treatment approach presumes that orthognathic surgery is not an option. (which I can not say just based on your external facial pictures)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Here are two more chin surgery questions:

1. My chin is deviated 2mm to the left (as indicated on CT scan). I take it that can only be corrected via an SG reversal and not by burring with a submental approach?

2. Could you explain a little more why reversing the SG (in whole or in part) will be more effective here for correcting the ptosis than a submental tuck w/jaw implants? Your writings seem to suggest that the submental approach is more effective – or that sometimes both are needed simultaneously.

Thanks again for answering my numerous questions.

A:In answer to your sliding genioplasty questions:

1) An inferior border burring approach can be used to correct a chin asymmetry.

2) The submental approach is always more effective than any intraoral approach because it better manages the soft tissue redundancy/ptosis. But that also depends on the degree of chin ptosis that exists.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hello, I have a question about scalp advancement/forehead reduction procedures in men. I know most of the time these procedures are down with a trichophytic hairline incision and generally they heal very well. If a man (in this case me, I’m a 30 year old guy) and as I got older my hairline were to recede a bit, would this scar be very noticeable or does it generally blend well?

A: The long-term fate of a frontal hairline incision in a young male is a good question to which the answer is not one of which I know. I have done plenty of hairline incisions in young men and have yet to see a hairline recession later. This does not mean that it can not happen, just that I have not yet seen it. I would speculate that the scar line should this occur will not just ‘blend in’ and be invisible however.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a tall, narrow skull, which as a man is an aesthetic death-sentence. Women want a short, compact so-called “warrior skull” with the facial bones developed and forward-projected while maintaining overall facial harmony, along with a flat occiput and skullcap. 

Question: Is there a way to significantly reduce the size of my neurocranium? 

Because the two factors causing my tall and narrow skull are my long midface (vertical maxillary excess) and large neurocranium.

A: The skull can certainly be reduced in height. Whether one would view how much safe height reduction is allowable by the bone thickness (7mms) is the relevant aesthetic question.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hello, I saw a case on your site the Ligation for Prominent Pulsations. The Dr stated that you wouldn’t see the full results until months later. I was wondering if the surgery helped this patient? 

Thank you

A: In the treatment of prominent pulsations of facial arteries (most commonlhy the temporal artery) by facial artery ligation the elimination of the pulsations must occur immediately at the conclusion of the procedure. The definitive test of a permanent result is months later to be certain some of the pulsations has not recurred from an unseen feeding vessel into the artery. You likely misintepreted judging the long term outcome for the immediate one.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, so about 2-3 years ago I was dating this guy and very long story short he punched me in the face and fractured my left cheekbone. I never got a surgeon to look at it because honestly I’m super broke. I mean I have money for small payments but I definitely don’t have thousands to spend. I guess I’m really wondering how much exactly is costs? It’s just been bothering me a lot recently and if I can save up the money to come to you to get it fixed I would love that. So how much would I be looking at do you think? Also idk if you can tell in the picture but I tried to point out where it was fractured. Sometimes my jaw gets stuck or pops weird and honestly I’m just really self conscious about it and I wanna put that part of my life behind me.

A: Thank you for your inquiry and sending your picture. What you have is the classic zygomatic arch fracture, a unique but well known type of cheekbone fracture. This is where the arch of the bone is broken and the two ends stick inward (like a bridge pushed inward at the middle of its span), creating an external contour depression over the arch as well as the ends of the broken bone sticking into the masseter muscle. (which is why your jaw gets stuck when trying to open) Int the treatment of acute zygomatic arch fractures the displaced bone is pushed back outward through a minimal invasive surgery. (Gilles approach) For a long term displaced zygomatic arch fracture this would probably not be successful in keeping the bone pushed back into place but it may get the bone stuck into the muscle out of the way improving the jaw sticking. For the contour deformity I would then just injection fat graft it at the same time.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Would like lip implants and corners of mouth to have less frown. Can both procedures be done at the same time?If I’m a good candidate please quote me a price and how long it usually takes to get scheduled. Thank you.

A: Thank you for your inquiry and sending your picture. Lip augmentation and corner of the mouth lifts can be done concurrently under light IV sedation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m interested in breast augmentation and a few other procedures. I’ve done some research and it seems as if the Revolve system provides the longest lasting results. Is that something you do??

A: There are numerous specific systems and many ‘by hand’ fat preparation methods for concentrating fat for injection. Resolve is one of the commercial preparation systems and I have used it many times. There is no real prospective data on any of these preparation methods as determining fat graft survival is a multifactorial issue of which preparation is just one variable. So to say Resolve produces the longest lasting results in fat grafting is not clinical data that would be supported by most plastic surgeons.

Any time there are dozens of different ways to do the same thing, with many vocal proponents that their way is the best, that is a sure sign that there is no one best proven way to do it. Nowhere is this more evident in plastic that with injectable fat grafting.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I find your articles very informative and interesting to read .I am wondering what is your opinion on the use of PEEK for infraorbital rim augmentation? Best wishes.

A: PEEK material is just fine for infraorbital rim augmentation. It is matter of the patient’s choice as well as the cost of the material and the ability to get it positioned properly based on the size of the implant.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My surgeon has ordered x-rays, and the radiology clinic will call me next week to schedule those. I wasn’t going to bother you again, but I won’t get a second consultation with him (or really a way to communicate directly with him) until after he has the x-rays, and there’s a question that is causing me to worry and lose sleep. This implant is held by a single screw in the very center of the chin, and it is oriented upward about 30 degrees which should make it very accessible for an intra-oral incision.. However, it is much larger than the screws that normally appear to be used with chin implants. From an older x-ray which I have this screw is estimated to be 17 mm long – about 6 mm through the plastic and 11 mm into the jawbone (no kidding). Will this size make it easier or more difficult to remove the screw? Will the bone recover and refill with this size screw? Changes in the bone have caused the implant to become uncomfortable, and I particularly feel pressure around that screw, so I definitely want it out. So I really want to know if that screw will be an impediment to removal.

Thank you again so much.

A: While such a screw length into the bone was completely unnecessary for implant fixation, its removal should be successful as long as the screw head has not been stripped. But even if it has it can usually be removed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I read some news about the use of the “fat grafting” technique to increase the height.  Basically, there would be fat injections under the heels. I wonder if you find it a good idea and a valid and lasting method to increase height by inches. I am doubtful about the lifetime stay in that area, that is from what I read ( but you will be able to give me the exact answer ),your own fat worked with stem cells, is not a permanent method for injections. Lipofilling would last less than fillers but above all, there is another doubt. Injecting fat under the heels will it bring problems to the foot and posture or even just to walk normally ? Let’s say that motor functions and heavy exertions are limited by these lipofilling to the heels. 

I don’t know, what do you think Dr. Eppley ? Do you find it valid?

A: The only established method for height increase is distraction lower limb lengthening. Fat is a soft material whose retention would be very poor in high weight-bearing areas. It would be hard to imagine that fat injections into the heels would be a successful heightening procedure. I do not find this concept a valid method for any heightening effect at all.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I suppose this is an artery on my temple extending up into the forehead.. It pulsates the entire length of the bulge. Can it be removed? Thank you

A: Thank you for your inquiry and sending your picture of your prominent anterior branch of the superficial temporal artery. Admittedly, even in my extensive experience with his problem, I have never seen one that big and prominent. This is treated by multiple point ligations to shut off the flow into it. It is not treated by excision as the frontal branch of the facial nerve runs in proximity to it with a high risk of permanent paralysis of eyebrow movement if total excision of the artery was undertaken.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in knowing more about dermal fat graft for coccydynia.

A: Thank you for your inquiry. The use of a dermal fat graft for coccygeal coverage is done to provide additional padding to reduce its prominence and discomfort due ti lack of adequate soft tissue coverage. It may or or may be combined with a modest bit of coccygeal bone reduction. The graft is usually harvested from the lower abdomen although it could be taken from many other body areas as well.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I wonder if I could call upon your unique expertise one more time. I have found a plastic surgeon locally who is willing to remove my chin implant. He believes it may be a Medpor after all but won’t know for sure until he gets in there. I would prefer that another implant not be placed right away, and the chin be left “empty.” I tried to search online for photos of people who had had implants removed and not replaced, but there’s really nothing out there. My questions are: 1) what is this likely to look like – will the chin be droopy or have excess skin?; and 2) will the tissues fill in and the pocket tighten up so that a future implant (smaller, silicone, and a different shape) will fit relatively securely?

I value your opinion as I just don’t know how much experience other doctors have with this type of situation.

A: It would be safe to assume that the soft tissue chin pad will be somewhat droopy after chin implant removal. It is not a question of whether a soft tissue sag will occur, only in its aesthetic magnitude. Thus a submental tuck type technique would be beneficial. There is no future problems with chin implant replacement provided it is secured by screw fixation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a tall neurocranium (the upper third of my face is too big/tall compared to my lower and middle third), this results in a tall and narrow skull which, for males, isn’t sexually dimorphic thus not attractive. I want a more compact, “shorter” skull, so to speak. 

Is it possible to somehow reduce the size of the neurocranium AND/OR make the skullcap completely flat (which is a desired trait in men)? The most important part of this question is the FIRST PART (“Is it possible to somehow reduce the size of the neurocranium?”). 

Even if I fix my lower third and middle third with osteotomies followed by implants, my tall neurocranium will ruin my facial aesthetics.

A:I would say that a flatter top pf the head is more possible than a substantial size reduction as the skull which  will usually only allow a 7 to 8mm  reduction of the outer cortical bone layer.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have had a bony ridge in my forehead every since my youth. It’s visibility fluctuates with how much weight is on my face. I don’t mind the ridge that much though sometimes in photos you can see it. There are 2 protruding elements and a depression in the middle. However, when I lost alot of weight the bony ridges are painful. Sometimes it feels like the bone is pushing into my skin (especially when dehydrated during physical activity). Is there anyway to shave that ridge down a bit? It also protrudes more when I lose weight. 

A: Such an upper bony ridge of the forehead is not rare and can be effectively reduced by a bone burring technique through a hairline incision. (forehead reduction) I suspect it protrudes a bit more when you lose weight because the overlying soft tissues becomes a bit thinner.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, my right occipital bone is a little bigger than left, maybe 4mm I think. It doesn’t bother me that much but when I think about this I feel “sad”. My head otherwise is round and overall good. My right back is but a little bit back. I don’t want to use a 3D Implant, its possible with a drill to make it round? Because I have afraid of using a 3D Implant and not getting a “normal life”, and if happens something in the future with the 3D Implant? Thank you!

A: Leaving the misconception of the long term effects of skull implants aside, whether a reduction on the bigger right occipital side (occipital reduction) may suffice to make it rounder I can not say without seeing pictures. But as a general statement usually reducing the bigger occipital skull side is not enough to make it more round in most cases. If the true difference between the two sides was 4mms it may. But often if the head shape difference between the two sides is noticeable on the outside it is bigger than it looks on the inside. Only a 3D skull CT scan can provide a definitive answer to the actual bony thickness differences between the two sides.

Dr. Barry Eppley

Indianapolis, Indiana