Your Questions

Q: Dr. Eppley, I am interested in the following proceduers: Face Lift, Neck Lift, Brow Lift, Temple/Brow and Cheek Fat Grafting or Implants, Lip Lift, Tracheal Shave, Laser Skin Resurfacing.

Can all these procedures be reasonably combined in a single surgery?

My specific questions about these procedures are: 

Face Lift- do you perform Deep Plane and or Vertical facelifts? 

Brow Lift- I’m interested in having the “tails” or outer corners lifted 

Eye area loose and sagging in general 

Temple Filler- I’m interested in either Temple/Brow and Cheek Fat Grafting or Implants. 

Lip Lift- Can I get a Lip Lift without increasing the size of my upper red lip? When I lift the center of my upper lip (with my finger) it leaves the outer corners of my lower lip sagging downward (frowning) and open. Will the facelift raise my lower lip and mouth area or is there another procedure to address this area? My mouth area is sagging in general.

I’d like to make my cupids bow slightly more narrow and raise/accentuate my vertical philtral ridges and white roll. I’d like to improve the delineation between the red border of my lips and the white of the skin surrounding my lips. 

Neck Lift and Tracheal Shave- Does having a Tracheal Shave done simultaneously with a neck lift limit how tight the neck lift can be? 

How are the vocal cords located and protected for the tracheal shave? Can you use a burr instead of knife if necessary on older patients with harder thyroid cartilage? What method of scar treatment is recommended if needed for tracheal scar revision? 

Can I get wound healing treatments at the time of my surgery. 

Laser Skin Resurfacing- I’m interested in the most effective method of skin resurfacing and skin lightening to have done at the same time as my facelift to take advantage of my facelift recovery down time. 

A: In answer to your aesthetic facial surgery questions:

1) All of the procedures you have mentioned can be done in a single surgery with one caveat….when laser resurfacing is done with any form of facial lifting it must be done more conservatively than if done alone because of blood supply and potential healing concerns.

2) The facelift technique I use depends on what the patient’s aging tissue optimally needs…not every facelift technique is for every patient.

3) Males are generally better served by tail of the brow lifts and not the whole brow which feminizes the face.

3) For the temples subfascial implants are superior to fat grafting.

4) By definition you can not do a lip lift and not increase the prominence of the cupid’s bow or red part of the central lip.

5) A facelift is not going to raise the sagging corners of the mouth. That requires a direct corner of the mouth lift to change.

6) Without a vertical prolabial scar you can not narrow the distance between the philtral columns.

7) White roll accentuation requires the placement of either filler or some form of a graft underneath it to cause it to become more pronounced.

8) A tracheal shave does not limit the effectiveness of a neck lift.

9) In performing tracheal shaves the key in protecting the vocal cords is to not over do the resection which can destabilize the two halfs of the thyroid cartilage. This has never yet been a problem I have seen.

10) In most older patients it is necessary to use a burring technique due to the partially calcified cartilage.

11) Laser resurfacing is the likely needed technique for tracheal scar revision.

12) When you refer to wound healing treatments you are likely referring to PRP or other wound healing agents. (e.g., BioBlast)

13) I refer you back to answer #1. The most effective laser resurfacing treatment is one done in isolation not where extensive skin undermining has been simultaneously preformed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, In doing a mid facelift is there any way this can lift the smile to make the upper teeth more prominent?

Also can implants be done after a facelift or does timing matter?

A: In answer to your facial surgery questions:

1) A midface lift can not lift the smile, corners of the mouth or make the upper teeth more visible. This is asking such an operation to do more than it is capabable of doing.

2) Implants can be done before, during or after a facelift.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hello, a friend of mine has recommended Dr. Eppley. I was either born with a flat head (on the backside of my head) or could’ve been from my parents laying me on my back when I was an infant? Either way, I do have a COMPLETELY FLAT HEAD on the back, I wish I had a picture I could send you but I always keep my hair longer on the back of my head than the top of my head to give the image of a round head. But now that I’m starting to lose my hair, I cannot even can consider Shaving my head because of the flat head syndrome that I have. The back of my head it’s like drawing a 90 degree angle a complete flat line that goes all the way down to my neck. I Remember I was in a fire training camp which we had to have our heads shaved and from the staff to crew members they all teased me about my flat head. Someone even said it looks like I’ve been hit on the back of my head with a pan which painted a very clear picture on how it actually looks to others even though I have a perfect idea on what my head looks like. I just want to have a round head, from the front to the top of my head it looks normal however when I look on the mirror the corners On top, towards the back of my head Are somewhat pointed out a bit which I think has also been cause because my skull on the backside is flat causing the sides of my head to somewhat pop out. I am certain Dr. Eppley with his many years of experience has seen it all and might have a good idea what my head looks like. I will draw a picture of the posterior of my skull and also the sinister and dexter of my skull as well to give an idea to what my head is shaped like. I have also filled out a patient form with my information. Thank you for your time and I’ll be looking forward to hear back from your office. 

A: Good drawing, makes it very clear. When the back of the head is really flat the parietal eminences become very prominent. (pointed corners) The key question is not whether the back of head can be successfully augmented but what degree of change is desired and what effort does one want to put forth to do so. The genesis of this question comes from the natural tightness of the scalp which limits how much augmentation can be done in a single surgery. The immediate placement of a skull implant will provide a moderate improvement in the shape of the back of the head. While a two stage skull augmentation approach (first stage scalp expander) provides the optimal back of the head augmentation result.

Dr. Barry Eppley

Indianapolis, Indiana

Dr. Eppley, I have uneven temples and I can’t work out the reason and I’m not sure if they need reducing or the one just needs an implant to make them look even. I just wanted to know the risks of surgery and the chances of serious health issues.

A: It comes down to which temporal side you prefer, the smaller or the fuller. That is a decision you have to make. It is fair easier to augment the smaller anterior temporal side that it is to try and reduce a fuller anterior temporal side. There are no health risks in doing so.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Is a combination of counter clockwise jaw surgery and upper lift lip better procedure for midface shortening better than a lip lift alone? Wouldn’t doing a lift lip alone create gummy smile because you are just moving mouth upwards. 

A: When it comes to shortening the midface, you need to clarify what you want to accomplish. No form of orthognathic surgery will shorten the external soft tissue midface short of correction of excess gingival show. Only a lip lift or vermilion advancement can create a visible soft tissue shortening. Such soft tissue maneuvers do not create gummy smiles.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I highly admire your work and love how you are also available to answer questions of patients in the community. I wanted to ask you specifically about the lip lift procedure. I got one done 8 weeks ago but the philtrum is protruding and the lip, especially the middle part looks too hicked up compared to the sides. I’m trying to hide from the world and have high hopes that the weird look is due to residual swelling ? I saw a reply you made to another patient with a similar issue and you mentioned the lip would most likely drop around two mm within the next few months? Also stretching the lip would help ? Thank you so much for your time and attention to this.

A: A lip lift works by the removal of skin…which makes it an irreversible procedure. But like all things lifted there is some partial relapse or settling that will occurs up to six months after the surgery. Stretching can only help that process.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hi There – I am reaching out in hopes of learning how I can best correct my receding chin and lack of defined jawline. I had a chin implant put in about 6 years ago that certainly improved the area but didn’t achieve the results I was looking for. I would love the opportunity to discuss what the best option may be. Looking forward to hearing from your team soon. I’ve included a photo for reference: one is with my natural bite (receding) and another with my chin pushed forward (this is similar to what I wish it looked like naturally). Thank you!

A: Thank you for your inquiry and sending your pictures. What you are actually demonstrating with your jaw thrust is the attached dimensional changes which are largely vertical. If you add that to your current chin implant your dimensional chin augmentation changes are 5mms forward and 5mms down. Such dimensional changes can only be created by either a custom chin implant design or a sliding genioplasty.

I am assuming when you refer to a ‘lack of a defined jawline’ you mean the chin. If you truly mean the whole jawline (back to the angles) then only a custom jawline implant can achieve that aesthetic effect.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I recently read the article you wrote on soft tissue augmentation of the jaw angle. Several years ago, I had a custom wraparound jaw implant placed. As your article identified, due to the extent of vertical lengthening achieved by my implant, the fullness of my masseter muscle actually sits above the bottom of the jaw angle. Whenever my jaw is clenched, this issue is exacerbated – but even at rest the fullness of the muscle being higher than ideal seems undesirable aesthetically.  

Your article suggests that dermal grafts or subdermal soft tissue implants are an option for treatment. But can these grafts be shaped in such a way to provide both angularity and fullness lower than the current masseter position, even at rest? I enjoy the angularity of the implant from the side view, but it seems my current masseter position prevents this from being visible from the front view.

A: Only an ultrasoft silicone soft tissue jaw angle implants can add both assured fullness and angularity back to the jaw angle region. I find them to be superior to that of any form of dermal grafts.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 25 years old and I train a lot at different martial arts (kickboxing, wrestling, BJJ, MMA,…) and I even compete in BJJ. I am considering the procedure of a skull reshaping surgery and I would like to know if training and competing in martial arts after the surgery is a problem or not. Furthermore could you give me any recommendations for doctors in europe? Because I only found you here in the states. 

Would appreciate an answer very much. Thanks in advance. 

A: For my patients I recommend they wait three months after any skull reshaping procedure before returning to contact type sports or physical activities.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was in contact with you a while back regarding issues after my sliding genioplasty. It has been 2 years now since the surgery and it’s still tight. The area under the lower lip is very tight, the scar feels very tight and when I move my mouth everything feels even tighter. My lower gums and lower teeth also feel tight and sticky. It’s a weird sensation. 

You did advise that the bone position was high and the chin tissues may be compressed and this could cause the tightness. I also saw on your website that you can use a fat graft in the labiomental fold. I did see this and then try HA filler in the area which does seem to have improved things a little a bit, not significantly but it does help and it seems to help with my speech,

I don’t get as much of the pulling and tugging feelings when speaking like I did before. The filler is voluma so does feel quite hard. It might have been better with a softer filler. I’m not sure the nurse who injected understood my complaint fully too. 

You are the only person in the world it seems who suggests this. I’m astonished that no other surgeons seem to know about this problem!! 

With this in mind, how do you see my revision? If I came to you what would you do with my chin? 

Would you move it down and back and place a fat graft? Is that the way you think it should go or leave the bone and just do the fat graft? 

Here is my X Rays again to remind you and also a 3D scan. 

I’ve been to a facial pain clinic at my local hospital today  and they are telling me this is neuropathic pain as a result of the surgery. They said that this can sometimes, very rarely happen where the brain starts sending the wrong signals causing strange and uncomfortable feelings in the area. They said this is permanent and surgery can make worse and won’t make any better. My surgeon doesn’t agree. 

Your help is so much appreciated.

A: If you are satisfied with the aesthetic result I would do an intraoral release and place a dermal fat graft. That seems to work really well in cases like yours. The observation that injection of HA produced some mild improvement in your symptoms supports this therapeutic approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, After a septorhinoplasty and jaw surgery (upper jaw expansion, impaction and advancement, and lower jaw advancement), I have found that my nose and smile looks much like Bryce Dallas Howard’s after picture on the right. I don’t like how the sides of the nose seem to cave in and the cheeks seem to bulge out and appear artificially bunched up. I much prefer the natural look of the before, and I am not sure what the reason is for looking like that after. Is it due to overexpansion of the upper jaw or is it due to the septorhinoplasty (or other)? Can it be reversed? 

A: These are many of the unspoken soft tissues changes of the midface that can occur after LeFort osteotomies due to soft tissue stripping from the bone and the change of the bone’s shape. Most of these changes are irreversible. The only one that isn’t is nostril widening, the most common adverse aesthetic effect seen after a LeFort osteotomy. This can be treated by secondary nostril narrowing techniques through an external approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, This girl isn’t me (I found her pics on reddit) but the area I circled is almost the same exact area where I have protrusion 

I. Is that subcostal rib margin? 

2. If so are they low enough where they could be removed or shaved? 

3. I don’t mind scars but would the surgery make much of a difference? 

4. Even if they aren’t the subcostal rib margin, are they still ribs that can be removed? 

Thank you. 

A: I don’t see any circle area on the picture so I circled what I think you are likely referring to which would be the lateral subcostal margins. (see attached) Those rib margin areas can be reduced by shaving. It is the most common anterior rib area treated for reduction. It does require a small incision over the area to perform the procedure and the acceptance of the resultant scar is the only limiting consideration.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, hello, I am inquiring about clavicle surgery for masculization. My question is whether the clavicle can simply be surgically elongated similar to the limb lengthening surgeries done on femurs. 

I am a body builder with a sub-par shoulder to waist ratio and my waist cannot get any smaller. No amount of muscle development in my shoulders will ever create the taper effect needed. I know that a longer clavicle is what my bone structure needs. Is this possible? And if so, does this surgery have any negative effects on the ability to continue building muscle in the chest and shoulders? 

Thank you.

A: At this time there is no method yet available for distraction lengthening of the clavicles for shoulder width increase. The concept is a valid one but the devices to do so have yet been developed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have had a blepharoplasty and rhinoplasty performed on me in the past.  I would like to kindly know:

• Can you make me look like the actor, Pierce Brosnan – with an emphasis on the eyebrows – as though I’m in my early 30’s with dimples and surgically remove my frown lines? (please see our pictures below)  If you can do it, please kindly let me know. If you can’t do it, please kindly recommend a surgeon who can make me look like the actor, Pierce Brosnan.  

• If you can do it, may I kindly ask: what is the ballpark cost?

Thank you kindly, Dr. Eppley.  I look forward to your answers!

A: No surgeon or surgery can make you look like another person. These are not realistic expectations for plastic surgery of the face.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Can you do a complete capsulectomy after cheek implant removal either by micro surgery, dissolving the scar tissue with enzymes, or cauterizing? Do you believe that the residual capsule may be absorbed by the body? Are you Is familiar with Implant Illness?

Thank you so much! 

A: In answer to your questions about cheek implant removal:

1) The cheek implants and the capsule on the bone can be removed. The outer capsule attached to the soft tissues can not.

2) The remaining capsule will be absorbed over time.

3) Implant illness is associated with silicone gel implants, almost exclusively of the breasts. There are no known illness cases associated with solid silicone facial implants.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am looking at your website about the ‘head widening surgery’. I am bothered by the fact that I have a ‘narrow head’, and that my face looks a bit like a ‘tree leave’. I attached a pic from your website which is a young man having a ‘head narrowing surgery’. Am I right to assume that a ‘head widening surgery’ will have a result of the man’s head before the ‘head narrowing surgery’? Since I cannot find any before-and-after picture for the ‘head widening surgery’. Also am i right in saying that the ‘head widening surgery’ has nothing to do with the temple part of one’s face? If it doesn’t, will a ‘head widening surgery’ create an illusion that one has ‘wider temple’ (more volume), despite the surgery is enhancing a different area (head skull) of one’s face? Moreover, since two implants will be put on one’s sides of the head skull, and since the implants are big in size, will they impose pressure on surrounding nerves? Lastly, I am trying to do research but i’m not seeing doctors that do this surgery. May I ask if you discover such surgery yourself? Is there any surgical case or any before-and-after photos you’d be able to share? Thank you very much!

A: Head widening surgery is done by temporal augmentation with custom designed implants. Whether that is done partially (anterior or posterior areas) or completely (anterior and posterior depends on the type of head widening effect one wants to achieve. Such implants are placed from an incision in the crease of the back of the ear either in the submuscular, subfascial or suprafascial location depending on the temporal coverage needed.

Out of patient’s request for confidentiality, before and after pictures are not available.

Dr. Barry Eppley

Indianaplis, Indiana

Q: Dr. Eppley, I consulted with you in the past about possible chin augmentation, and after that having visited many plastic surgeons for various reasons you are the only one I trust when it comes to facial sculpting/implants. I have moved on from the chin for now because I realized a much more pressing issue is my cheeks. Another plastic surgeon told me I was a good candidate for buccal fat removal, but after reading some of your Q+A on realself I am unsure if that is the exact area where my cheek fullness even comes from so am worried it would not even make a noticeable difference! It seems like no other doctor understands (or at least is transparent) that there are other reasons for chubby cheeks that are NOT the buccal fat and therefore removing it would not fix the problem in those cases! 

I also know I have extremely weak cheekbones in the mid-face beneath my eyes and am just trying to decide if I need an infraorbital rim implant with malar extension or just the malar cheek implant (or if I am better off just with filler.)  I am thinking any cheek implant or filler would be a bad idea without getting rid of the soft tissue fullness beneath the cheek bone FIRST, as it would just add to the fullness. I am just unsure what the best procedure would be for me to address that. While losing 25-30 lbs would effectively get rid of all that fullness in my face, I am already a bit underweight so I know that’s not the answer.

A: Based on your pictures I would say the following:

1) I would view buccal lipectomies and perioral liposuction as a complementary or adjunctive procedure to cheek implants for your midfacial enhancement. Facial defatting alone is not going to create more defined cheeks. One can certainly do the defatting first and see what it looks like.

2) I don’t think you are a good candidate for a cheek implant that has a substantial infraorbital extension as that would require a lower eyelid approach to place. (true custom infraorbital-malar implant) Your infraorbital rim deficiency is mild.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Can the plates and screws be removed in the future after cheek reduction surgery? Or, is there a way to do this without using plates/screws (For example – I saw a mention of a non-fixation method)

A:In answer to your questions:

1) The plates and screws can be removed after 6 months if the patient so desires.

2) The Quick Cheekbone reduction surgery does not need the plates and screws because it is done differently. Rather than an anterior cheek bone osteotomy, the cheek bone is merely shaved down. The posterior zygomatic arch osteotomy is angled and the bone is just pushed inward. While the Quick reduction method is faster and avoids plate and screw fixation it also produces less cheek width reduction.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have lost around 100 pounds, since 2013. Last year had a Full Torso Lift and that area looks great. However, the Surgeon I used will not do the following for me. 

– Outside thigh lipo / tuck 

– Inside around knees – lipo / tuck 

– Arm lift – only because my right arm had 9 lymph nodes taken out when I had breast cancer – which were all negative and I have had zero issues with it. 

Can you do these 3 items. I realize this cannot be done all at same time.

A:Thank you for our inquiry and sending your pictures to which I can say the following:

1) When referring to the thighs I think you mean an extended inner thigh lift (see diagram) which is the appropriate approach to your thigh tissue redundancy.

2) As for the armlift I can certainly understand the concern as the risk of chronic lymphedema could result on the side with the prior lymph node excision. But I think it is reasonable to do if the following criteria are met:

    a) No history of radiation to the armpit

    b) No current chronic arm swelling

    c) A not overly aggressive armlift that does not extended into or past the axillary region.

3) You are correct in that both the arms and thighs should not be done during the same surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, for years I have been following your work and I have esteem for you and envy for your patients, who thanks to you revolutionize their lives. I am a 31-year-old boy suffering from plagiocephaly, my skull has a greater volume in the frontal, parietal and right temporal part and vice versa on the nape. I also dream of undergoing remodeling surgery using prostheses and I hope to find a competent doctor in Italy too. I have some questions to ask you. Having to use two prostheses, would it be possible to avoid cutting from ear to ear and opt for two accesses? Working (given my height) I often bang my head is the risk of the prosthesis moving so high? you work as a farmer in a greenhouse, often with temperatures close to 50 ° C and the sun beating down, can the prosthesis interfere in any way with the tissues or inhibit their ability to dissipate heat? Thank you

A: In answer to your skull implant questions:

1) Even for two skull implants I would never use a coronal incision.

2) Heat nor trauma will not harm skull implants in any way.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Thank you for reviewing my inquiry. I’m wondering if you would recommend a chin implant for me and if yes, what size/type? I am looking for a very conservative, natural, feminine and pretty result, especially since I am petite. 

I have an asymmetric chin, with the left side being shorter than the right and the thickness might even vary, even though it’s subtle. I also have hollowing on the sides that is concerning as I age (I just turned 40). And my chin is a bit square-shaped, so I don’t want anything that is going to make me look masculine. I am thin and have a long-ish face, so I wouldn’t want length either, though I understand with most chin implants some length is a given? 

I had a consultation with a doctor who recommended a size small Implantech extended anatomical implant. However, I see that you are the authority on facial implants and surgery and your opinion would be greatly appreciated, as I would like to plan a procedure and feel that your care and expertise would be of comfort. 

Also, what is the cost of this service under your care? 

Thank you kindly for your time and consideration.

A:Thank you for your inquiry and sending your picture. You have fairly short chin that is angulated backwards and is vertically long. With such anatomy you are not really a good candidate for a chin implant as implants are technically designed to sit on the front of the bone which will make your chin longer. The implant can be moved up higher but this is not how they are ideally designed to work. You are a far better candidate for a sliding genioplasty which can bring your chin forward AND make it shorter. This may not be the operation you want but it is the better chin augmentation option from a dimensional standpoint than an implant with your chin anatomy.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Lateral Chin Ostectomies – Narrowing the Broad or Wide Chin…. Saw article about this from you and it felt like something I am interested in. I feel my chin is too wide (the actual fatty part of the chin should not be as long horizontally). I always felt like making it more V shaped would look good. How does this differ from V shape surgery? I want my chin more pointed and narrow. Curious how imaging would look to. I have had a chin implant/buccal fat removal before but this is something that really interests me.

A: Thank you for your inquiry and sending your picture. How to narrow your chin is based on an understanding of why it looks wide…and that is because it is vertically short. So while the chin can be narrowed at its current vertical height (see attached prediction), it is more effective to vertically lengthen it as well. (see attached second prediction) This is known as ‘mini V line’ surgery, technically known as a combined vertical lengthening and narrowing chin osteotomy. (also known as the T-shaped bony genioplasty)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am undergoing double jaw surgery for my recessed maxilla and mandible. I have a lack of undereye support that has caused sclera show and ptosis in both of my eyelids, resulting in a very tired look at rest. I wanted to go for lower eyelid retraction surgery (possibly with a canthoplasty), but I was under the impression that without adequate support, these surgeries have a high chance of failure. 

I mentioned infra-orbital implants to my surgeon (he does indeed do them), but he said that he wouldn’t indicate them in my case because he didn’t feel I needed them, and that he hopes the sclera show will be less after the surgery anyway. I’m hesitant about this, as the sclera improvements I see from only a normal LeFort 1 aren’t really what I was looking for (neutral/positive canthal tilt, no droopiness of the lower eyelid) . He did mention that he was going to use a High LeFort 1 cut instead to help fill out my cheek and midface more. My question is whether a High Lefort 1 would be enough to help provide support to my lower eyelid such that canthoplasty/lower eyelid retraction would be acceptable. I’ve struggled to find answers to this question online, and while my surgeon is very experienced, he prefers to go for the results that the average person won’t mind (lower eyelid surgery is probably not a thing the average person thinks about). 

Thanks for reading!

A:A Lefort I osteotomy, regardless of the level, can not provide any improved infraorbital rim skeletal augmentation/support. To even think this is remotely possible fails to have an understanding of the basic anatomy of the periorbital region.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve been meaning to get clavicle lengthening, in order to increase my biacromial width, at some point in the next few years. I just had a question regarding this. Is there a one-to-one correspondence between the gain in biacromial width and the gain in armspan/wingspan? So, for example, if someone gets their clavicles lengthened by 1 inch per side for a total 2 inch increase in biacromial width, does their armspan/wingspan also increase by exactly 2 inches?

Thank you. 

A: That is a very good question, I would assume it would since the clavicle is a horizontal bone and the wingspan is a horizontal measurement affected by shoulder width. But, quite frankly, I have never measured arm span width in clavicle surgery patients.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in skull width reduction. I have attached a CT scan of my skull. I have a few questions: 

1. Based off my CT scan alone, is my skull clearly wider at the top than average? A google search tell me yes, but I’m sure with your extensive experience viewing CT skull images you can easily say whether mine jumps out as wider than average. 

2. How many millimeters of bone can be burred? 

3. I do not want to remove the temporalis muscles considering my head is widest at the top bony area and removing muscle beneath is will only make it appear even wider–especially considering muscle removal has a far more dramatic effect than bone burring, so even if both were done I imagine I would still get that effect. If only the bone above the temporals muscle were burred, would I be able to avoid a lateral scar? Additionally, would the swelling be less significant considering the muscle won’t be manipulated? 

4. Are there any side effects from such a procedure it would be helpful for me to know about? It’s not a common procedure, so I would can’t find such an answer online. 

5. How long would it take for swelling to reside? 

6. Considering volume is removed from the skull, will the soft tissue shrink back down over the bone? 

Thanks in advance.

A:In answer to your skull reshaping questions:

1) Yes it is.

2) In the 5mm range

3) An incision is needed to do the bone burring. The postoperative swelling would be less than with temporal muscle removal.

4) The scar is the only ‘side effect’. (aesthetic tradeoff)

5)  7 to 10 days for most of it to subside.

6) There will be no problems with loose scalp skin.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hi I’m a young female looking into mandibular angle implants I came across your social media. Most I’ve seen done is on males do you do this for females add some width and length to the ramus without it looking too masculine ? Also with facial implants which are meant to be lifelong is this true or do they have to be changed down the line because I’ve ready somewhere that Brest implants have had to be removed because of degradation. What is the success rate for mandibular angle implants I’ve seen many say negative things some positive but id really like some more information before I have any consultations with anyone right now I’m just researching. I have pictures of my profile too if that helps thanks.

A: In answer to your jaw angle implant questions:

1) The vertical lengthening style of jaw angle implants is the only really suited for most female jaw augmentations.

2) Solid silicone facial implants should not be confused with gel breast implants. Such facial implants never degrade or need to be replaced due to implant material fauilure.

3) Like all facial implants jaw angle implants have all of the same risks of infection, asymmetry as well as sizing/shape issues.

4) I would need to see some pictures for imaging of potential results of which the most valuable are the front and three-quarter views, the profile view is the least useful in imaging jaw angle implants.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, First of all, thank you for the more than complete information you provide in your websites. It is very useful for those of us who need information about surgical procedures that are not usually offered by most plastic surgeons. My problem is that I suffer from plagiocephaly, with the right back side of my skull flattened (comprising the occipital, parietal and temporal bones) and the right side of my face being more prominent (forehead, orbital rim and cheekbone) than the left one. Although I have found extremely useful all the information collected in your websites, I have some questions: 

1. In occipital augmentation, and when a single custom implant (due to the extent of the malformation) must simultaneously cover the occipital, parietal and temporal regions, taking into account that the temporal bone is covered by muscle and that the occipital and parietal zones do not, between which layers is the implant inserted, I mean, over which layers does the implant sit? 

2. I have read in your posts that the “bony suboccipital” area (the lower area of the occipital bone that is below the neck muscles and below the superior nuchal line) can’t be augmented due to possible neck muscles problems, but is there any reliable and permanent “muscular suboccipital/subnuchal” augmentation method? Could a custom silicone implant (or semi-custom hand-carved) be placed over the upper neck muscles? Would this implant sit directly over the muscle or in another plane? Over what muscle/s? What durometer silicone implant would be required? Would fat grafting be another permanent option? Would this fat be injected in a submuscular or in a subdermal plane? Would a first previous stage of scalp expansion be necessary or recommended? 

3. In the case of the face, is it possible, by burring technique, to reduce the horizontal projection of the anterolateral region of the forehead and the horizontal projection of the orbital rim (superior, lateral and inferior areas, from the supraorbital notch to the zygomaticomaxillary suture) (black painted areas in the attached picture)? And how many mm approximately? 

Thank you very much for your time and patience.

A: In answer to your questions:

1) Any skull implant that covers a combined non-muscle and muscle areas must go on top of the temporalis fascia.

2) As a general rule there is little aesthetic value to having a skull implant go much beyond the nuchal ridge line of the occiput onto the neck muscles and there are potential complications from doing so. Any soft tissue neck deficiency below the nuchal ridge must be treated by conventional soft tissue augmentation methods (fat injections) although they work poorly in the tight posterior neck area.

3) You are going to get roughly 5 to 6mms of bony reduction on the highlighted forehead and orbital regions.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve been a clandestine fan of your practice; you’ve been quite innovative. Congrats. 

I have a question about rib resection, something I have no experience with or have thought about much. I just don’t get it, one can make the case that the floating ribs don’t have much effect on the waist (except maybe some for girdlers), and even might confine it by keeping soft tissues from expanding . In any event why do they need resecting, why not just remove a chunk of proximal rib and let the distal end truly float. I read on your Instagram feed that you remove some muscle, how much effect do you think that has? 

A: Thank you for your thoughtful questions about rib resection and in answer to them:

1) Ribs do make a contribution in waist girth, just not in the way that it is commonly perceived. It comes down to their soft tissue support that they provide. It is really about weakening the framework that supports the enveloping soft tissues.

2) When it comes to the floating ribs (11 and 12), 11 is by far more important…and I would argue that 12 is completely irrelevant as it is slmply too short and ‘hidden’ except in exceptionally thin females.

3) The false rib #10 makes an equal contribution as #11 which is why 10 and11 subtotal resection are the keys to the procedure. (12 is usually just taken as a ‘convenience’ and in the spirit of making a maximum surgical effort)

4) How the arc of the rib is weakened doesn’t really matter. Whether that is a distal resection, a segmental mid-resection or a proximal resection. (the latter two being collapse techniques) What does matter, of course, is the surgical risk in doing so. The proximal resection would have the higher risk being closer to the spine and is the hardest to get to being covered by the erecti spinae muscle. Distal resection is the easiest to perform through one very small incision and has a negligble morbidity in doing so.

5) The LD muscle is the largest soft tissue contributor as is incredibly thick even in small females. (1 to 3 cms) Because it has to be transgressed to perform the rib resection I have learned and observed that removing a longitudinal portion of the muscle is helpful in the overall objective with no loss of function.

6) In my experience it is the combination of structural support reduction (rib removal) and soft tissue resection (muscle excision) that creates the result. Thus the term ‘rib removal’ doesn’t really accurately describe what is actually done.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I hope this email finds you well and healthy

I am a dermatologist in Brazil and am writing about a male patient with cutis verticis gyrata (CVG) who came to my office at an early stage and I would like to know if you have positive therapeutic experience with fat grafting or PRP for this clinical condition.

Thank you for your time and I wish you an excellent week.

A: In mild cases of CVG injection fat injection grafting can be successful with a combination of  release and injection. PRP alone will not work.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My rhinoplasty questions are:

1. Is it possible to do a nose reshaping with results similar to the pictures I’ve attached? My main concern is how far my nostrils project into my nose tip. I would like to have more of a tip to my nose. I also would like my nose to be just slightly shorter. It is important to me that my nose would look very natural and not extremely narrow or perfect. 

2. I am also concerned about the look of my neck and jaw. I’d like to remove fat from around my lower cheeks, jaw, and neck. Could this procedure be done at the same time as my nose? Are there extra risks to doing both at the same time? 

3. What would be the cost to have both of these done? And the cost for them separately? 

4. Does your team provide financing options? What are the terms of the financing options? 

5. How far out would I have to schedule? 

6. I also have POTS and fibromyalgia, though not to a severe level. Would this affect my candidacy for these procedures? I have been under anesthesia before. 

7. How long would I have to stay locally for these procedures? 

8. How much pain could I expect for both of these procedures? Could I manage the pain with ibuprofen or advil alone?

A: Thank you for sending your pictures to which I can say the following:

1) While the general type of profile nose shape can be achieved the reduction in nostril length/exposure is probably overly optimistic.

2) Submental/jawline liposuction can be done at the same time as a rhinoplasty. Doing them together does not increase the risks of either procedure over being done alone.

3, 4 and 5) Will be answered by my assistant.

6) I am not aware that POTs or fibromylagia have any adverse effects in these facial procedures.

7) Most patients return home the following day.

8) These are not particularly painful procedures that require any narcotics.

Dr. Barry Eppley

Indianapolis, Indiana