Your Questions

Q: Dr. Eppley, I am strongly considering a temporal reduction in the near future due to my wide head, but i have a few questions.

1. Is this procedure dangerous in any way?

2. Will the temporalis muscle grow back once it is reduced?

3. With my age being only 19, am i too young for this operation?

4. How often do you perform these procedures?

5. Roughly, what is the cost for this procedure?

I hope I am not asking for too much, but a response would be greatly appreciated. Thank you.

A: In answer to your temporal reduction questions:

1) This is a very safe procedure

2) The muscle will not grow back

3) Age 19 is not too young for the surgery

4) I perform Temporal Reduction surgery on a regular basis

5) My assistant will pass along the cost of the surgery to you later today.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, it looks like I’ll be moving forward with the custom infraorbital-malar and jawline implants next year.

I am seeking temporary improvement before I see you. I find that when I pull my skin in an upwards/diagonal vector, I see large improvements in the nasolabial area and my overall appearance. Would a PDO threadlift (I know its effectiveness is debated, but the nurse I’d be seeing uses a newer thread and had compelling before and afters) be contraindicated given implants with you in May?) My understanding is that most of the effects of the threadlift would likely dissipate by May, but there is a chance some of the sutures won’t have completely dissolved.

A: Pulling your skin upward by fingers is not representative of what a thread lift can really do. It will have a much less significant effect than that simulation and will never make the nasolabial folds appear less deep. Such digital manipulations way over estimate what is possible with any thread lifting procedure. 

Otherwise any threadlift done now will not impact any custom facial implants planned for next year. The effects of the thread lift will long be gone by then.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I really dislike the lower-mid portion of my face, which seems to be getting worse (sagging) as I age…the area closest to the nose around the nasolabial fold.

I’ve asked many doctors about this bulge and they all suggest cheek implants or filler. I’ve had filler in the cheekbone area and while that helps to hide it, I still want to address the bulge because with the filler in the cheekbone I just end up looking too bloated for my liking. 

No one seems to have an answer for how to address the fullness in those areas. I’ve gotten a couple of mid face lift suggestions but from what I understand,  the lift will move some tissue up over the malar area but not really attack the bulge because the incision too far away to reach that area of correction. An I correct here?  Could a modified lift be done with your ingenuity with an incision closer to the area? 

I consider myself a highly motivated patient and would be willing to undergo a two or three or multiple stage surgery where after the fat or muscle or whatever it is removed, then the area and skin is tightened and then scar revision done if the scar is more visible to my liking in a young patient like myself. I wear make up and am fine with revising scars with lasers, injections and even scar revising surgeries if I can get a good aesthetic pay off. 

Also do you think it’s more muscle, skin, or fat that is there? 

Thank you. 

Attached are photos of the issue I’m speaking of and following photos circled are areas where it is flat and in my opinion, ideal

A: Thank you for sending your pictures and detailing your concerns. Unfortunately the facial area (lower midface fullness reduction) to which you refer is a very difficult if not impossible area to significantly improve. While some slight reduction of it is possible, if your goal is the male picture in which you have circled, such a result is not remotely possible with any surgical method. While small cannula liposuction can be done in the nasolabial fold/perioral mound area I would expect the result to be very modest. This is a facial area in which the buccal branches of the facial nerve exist eliminating the possibility of any excisional approach regardless of a lack of concern about scars..

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, i’m looking to do skull augmentation and I noticed you often use PMMA material for implant but other doctors refuse it saying it causes inflammation in 40% of cases and only use PEEK. In your experience how safe is PMMA and do you overcome its sterilization issues when prepared? My target is large skull augmentation since my problem is small head/face.

A: Thank you for your inquiry. Let me provide you with some clarifications on some of your skull augmentation biomaterial statements in your inquiry.

1) For elective aesthetic skill augmentation today, I primarily use custom made silicone skull implants from the patient’s 3D CT scan. That is a far superior method to the use of any form of bone cements or PEEK material for a variety of reasons.

2) When I did use PMMA bone cements I never see any problems with inflammation or infection…and I have used it in hundreds of cases.

3) You should not confuse aesthetic onlay skull augmentations with reconstructive cranioplasties which are done to fill in a removed or lost full-thickness skull defect. These are completely different patient populations which have different risk profiles and tissue makeups. It is that population to which other surgeon’s comments are most likely directed. 

4) If large skull augmentation is your aesthetic goal, you will require a first stage scalp expansion followed by a second stage skull augmentation with a computer-designed skull implant. That is the only effective way to achieve that kind of skull enlargement in a safe and predictable way.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was under the impression that there would be some discussion regarding the testicular enlargement implants, especially regarding sizing and fit, before surgery.  Maybe that is not necessary?  I assume they are ordered since they require three weeks to manufacture. 

A: The timing to determine the design of any custom testicle implant is about six weeks before the surgery so your email is timely.

The two dimensions that are needed to determine the design of custom testicular enlargement implants is the outer and inner diameter. The outer diameter is the desired final size of the testicular enlargement. This is typically between 5 and 6 cms as measured in the north-south or longitudinal direction. The inner diameter is the relief need to accommodate the existing testicular size. Most men are in the 3.5 to 4 cm range. You simply need to measure your own and let me know what it’s measurement is. Most testicles are slightly different in size but that doesn’t matter since the inside of the custom testicular implant is modifiable during surgery. The outer diameter, however, is not. (or should not be as its smooth surface will be lost)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I have a unique ear condition that I can’t seem to find anyone with a similar case. I always had prominent, asymmetrical ears that made me slightly self-conscious, but grew to live with them and be comfortable. The prominence was due to me not having an antihelical fold on either ear. In January of this year, I was diagnosed with a cholesteatoma in my left ear which required a mastoidectomy and reconstruction. The surgeon used cartilage from my concha bowl to reconstruct my ear canal which worked fine. What I wasn’t prepared for was the cosmetic toll this would take on my left ear. The surgeon removed a large part of my concha bowl, and I also suffered from post-surgical bleeding due to the amount of trauma from the surgery that left me with some additional scarring/shrinkage of my concha bowl. 

This left my left ear almost flush with my head and created massive asymmetry between my prominent right ear and stuck to my head left ear. In May, a plastic surgeon performed an otoplasty on my right ear to bring it more in line with my left ear. He also performed a scar release on my left ear to bring it out. Both of these procedures were successful. My right ear looks great and my left ear did come out some from my head with the scar release, but I’d still like a little improvement. I’m curious if there is a type of implant that can be placed behind my ear where my concha is located to bring out my ear a few more mm. I’m not looking for perfect symmetry as my ears have always been asymmetrical, I’m just looking for more improvement. I don’t want a big jump, as I like my ears closer to my head, since my ears protruded a lot. Since there is no antihelical fold on my left ear that needs to be released and the concha just needs to be boosted, is this easier than a typical reverse otoplasty? Can this be done under local anesthesia? Thanks in advance.

A: Based on your description I suspect that a ‘wedge’ placed behind the ear to help push it out is what is needed. This is probably done best by a cadaveric cartilage graft rather than an implant. This would required that there is adequate soft tissue cover to do so. I would need to see pictures of the left ear to provide a more qualified answer. Regardless of how  it would be done, it could be done under local anesthesia.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hello, I have read several of your comments on Realself.com. It seems the popular opinion is that fat transfers are better than silicone implants for hip augmentation. But my research suggests otherwise – fat transfers on hips don’t last no matter what technique the surgeon uses. Can you please advise if you have compared the two? Thanks.

A: It is not really a question of whether fat injection or implants are better for hip augmentation as they are very different treatments for the same problem with different risk profiles. As a general rule, if you have enough fat to use for the hips then that should always be attempted first as it has little risk other than partial loss of some hip volume. If one doesn’t have enough fat or has failed fat grafting, then implants are the only options with the typical risks of infection and a scar bit also offering an assured volume retention.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a number of facials reshaping procedures I want to undergo I am interested suborbital/chin/malar/paranasal/midface/jaw/cheekbone implants, rhinoplasty, some aspects of FFS (hairline advancement, blepharoplasty, slight jaw and chin reduction to reduce broadness/squareness) Apologies for the laundry list of procedures but I didn’t want to miss anything I might benefit from changing.

A: Thank you for your inquiry and sending your picture. Like all major facial reshaping procedures where many changes are desired, it becomes important to establish a priority list or levels of importance for the various facial procedures. This become relevant because in most cases patients are unable to under all of them at one time. Therefore I recommend to patients to establish three levels of priority from most important, to important but it can wait, to nice if done but could live without it. I would then place just three procedures in each category. This will be a very useful exercise for you to do and will enable me to help you in a more useful manner.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Could you help me with a problem I have ?  Somebody told me that you are a top doctor. I can´t reach my surgeon. I got a facial fat transfer to the temples ( 2ml each side ).

The day after the operation, I was in the city and I walked around slowly for 3 hours . 

Now I am afraid that it was too long and the fat could have migrated downwards, due to the vibrations from walking slowly.

Could that fat migrate / move one day after the OP due to walking for 3 hours  ? 

I hope you can calm me down.

A: Such fat migration is not a phenomenon I have seen. There is the inevitable occurrence swelling from the surgery which takes 2 to 3 days to reach its fullest extent which would always occur lower on the face due to gravity.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Most transwomen need a quite a bit of width at the hips to be able to balance their shoulders – we are looking at 2.5 -3 cm added projection on each of the sides. This means a very substantial amount of fat needs to be transferred. I do have ample, (un)fortunately!

I understand the vast majority of people are happy with what stays in their butt after fat transfer but I honestly dont know a single person who had enough left at the hip one year after surgery! 

What percentage of patients do you think can retain an inch of extra fat on each of the hips permanently? Won’t quote you on this! If the odds are not great, I would much rather consider implants. I understand they need “maintenance” – how often do you see displacement? I would assume they are at high risk because of the range of motions our hips go through! 

A: I would not disagree with you on the hips and the lack of fat retention, It is a very different recipient fat site than that of the buttocks. My general statement is that if you have enough fat you always give that a go first as, even if much of the fat is lost, you are making the hips a better recipient site for implant placement later.

But in the long run a 2.5cm to 3 cms increase is only going to be obtained by hip implants.

With custom made hip implants I haven’t see any worse issues that what occurs in buttock implants.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Papers on buttock augmentation strongly recommend placing the implants between the muscle to avoid implant palpability and displacement.  I understand this is not possible with hips and the implant has to be placed below fascia. I found the following piece of information regarding hip implants. What do you think?

“Hip implants are problematic in several ways.  There is not much tissue to hide the implant so they can look fake.  Also, there’s significant risk that the implant may migrate because there is no natural pocket to constrain it in place.  It also has to be placed over the femur (leg bone) so that it is not subject to flexure when sitting.”

A: I find that commentary on hip implants erroneous on every level:

1) The way to avoid a hip implant from looking fake is to actually have a custom hip implant made that is designed specifically for that area. Since there is no such thing as a standard hip implants surgeons use body implants made for something else, like a buttock implant on the hips. No wonder it ends up not looking natural.

2) With a custom implant design that favors tissue ingrowth and a well made pocket for it, migration is not an issue.

3) Custom hip implants are commonly placed over the femur and its superior trochanteric extension. This does not interfere with flexion when sitting, standing or any other bodily movement.

Such comments are made based on an historic or a complete lack of a contemporary approach to hip implant augmentation.

Dr. Barry Eppley

Indianapolis Indiana

Q: Dr. Eppley, I  am planning rib removal surgery but i want to combine this with a breast augmentation with another doctor on the same trip. My question was I plan to have rib removal surgery first and then a week or 10 days later have the breast augmentation. Would that be workable? Regarding the infraorbital rim implants I am gonna have double jaw surgery. Would you recommend doing the implants before or after the jaw surgery? And how long would you recommend between these surgeries?

A: In answer to your rib removal, breast augmentation and infraorbital implant surgery questions:

1) Breast augmentation can be performed during or anytime after rib removal surgery. It is a common combination body reshaping surgery so it can be done as a staged approach also.

2) Infraorbital rim implants should be done six months after orhognathic surgery. You want to get the lower facial bones moved forward first as this may affect the shape and size of the infraorbital rim implants.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have uploaded photos of me and a model for reference in the following link:

To put in words, These are my concerns regarding my forehead/brow ridge:

-I would want my brows to be further apart, straight, slightly lower, and flat. Instead of high, arched, close set, and somewhat rounded.

-I would like the entire sides of my forehead/brows to be built up on. At the moment, I have a rounded (specially to the sides) and somewhat narrow forehead.

– I would like an overall thicker supraorbital rim. 

-Rearding my skull, I have an extremely small skull for a 20 year old male. I would want considerable change here. Basically I would want more on the upper portion of my frontal bone (also towards the sides of it, to reduce the pear shape). and considerable support towards the back of the skull. (to also treat the flat back of head)

A: Thank you for your clarification fo your forehead/brow goals. Forehead/brow augmentation can certainly augment the brow bones (supraorbital ridges) and change the shape of your forehead as you have indicated. You can also increase the shape of your anterior skull as it goes back from the forehead and you would have to do so to have it blend in and look right.

But this augmentation will have no control over the overlying eyebrows and will most certainly to make them go lower…as that is an impossibility….nor make them further apart. Those are not realistic effects from the augmentation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have primary rhinoplasty about 8 months ago. I dislike the result and would like to restore most of my old nose back. My main concern is I want my tip/columella derotated/lengthened so my nose isn’t pointed up. My other major concern is after my surgeon took down my nasal bump my bridge is flatter appearing and my prominent contour dorsal lines are vanished. My bridge is too soft and blends into my face and I don’t like that. No nostril work was done but they changed from tip work.. they are thicker wider and more exposed. I also really dislike how my philtrum look longer because of nose upward rotation. 

What techniques could be used to restore some of my old nose back? Do u do this type of procedure , Pls help?

A: Derotating a nasal tip is a challenge and requires significant cartilage grafting to do so. The first important question is whether your septum has been previously harvested or not. If so this may require rib cartilage grafting to do so. It is also important to realize that while some changes are possible by secondary rhinoplasty surgery you can never return exactly to what your nose was before.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have had bicep and tricep implants. I am happy with the results apart from the prominent bottom part of the bicep implant I have circled in the attached photos. Just to clarify I’m fine with the rest of the margin been visible just not the bottom part I have circled. 

I have spoken to a couple of surgeons and the following solutions have been suggested:

1) Fat grafting was the initial suggestion but it was deemed I do not have enough fat. 

So use of Hyaluronic acid filler to hide the prominent bottom part of the bicep even if it is only temporary and will need a yearly top up was suggested. 

An amount of 10cc to 20cc using a generic non branded hyaluronic acid filler. 

However when I spoke about this solution to another surgeon he said there would be a risk of “infection” to the implant and so this is not a viable solution. Please could you let me know what your opinion is on this?

2) If I get a tattoo on the inside of the bicep would this be sufficient to create an optical illusion to make it less noticeable? 

Many thanks,

A: The combination of a non-feathered implant edge, an implant that is too long and slightly off axis from the muscle head is why that appears so. It may also appears this way as most of the distal edge of the bicep implant has come through the fascia poking right up against the skin. Filler and fat are a poor treatment options due to the risk of infection and that it will be very difficult to get them between the skin and the implant without entering the implant capsule. Viable options are to either change the implant to one with a better edge or tattoo over the exposed distal edge the implant.

Dr. Barry Eppley

Indianapolis, Indiana

  Q: Dr. Eppley, I write you because I want to ask you some questions about the surgery which I’m really interested: Temporal reduction. I will be so glad if you answer me this questions which are very important to me:

1. Is it safe that after the surgery I will not have problems to chew or another type?

2. All the people who had this surgery didn’t have any problem?

3. How many people approximately have had this surgery? 

4. There is in your plastic surgery center some personal who speaks spanish? I’m from Spain and it would be a lot easier if when I go there I can speak with someome who understands my language. 

Thank you so much!

A:In answer to your temporal reduction questions:

1) There are no after surgery chewing problems with temporal reduction surgery.

2) As stated in #1, no patients have ever had a chewing problem.

3) Over 50 patients have been treated with temporal reduction surgery.

4) Unfortunately no one in my practice speaks fluent Spanish.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’d like to know more about clavicular osteotomy. I’m not happy with the width of my shoulders, i want them to be more masculine/broader. With clavicular osteotomy used for cosmetic purposes, what are the potential effects on functionality? Would it possible to gain back full functionality after the operation? I’m most curious about how safe it is. Also, how much would it cost and who would perform it?

A: Clavicular osteotomies with an interpositional cadaveric bone graft can be used for shoulder widening and they can widen the shoulders by about an inch per side. When fully healed there should be no dysfunction, it is like recovering from a fractured clavicle. However doing both at the same time is a challenge from a recovery standpoint. The alternative to clavicular osteotomies are deltoid or shoulder implants which can also widen the shoulders with a farcquicker recovery and with much less scarring.

Clavicular osteotomies make more sense for wide shoulders for which there is no other treatment options. But when it comes to making wider or broader shoulders, the use of deltoid implants offer an equally effective and far simpler approach than cutting the clavicle and expanding it.

Dr. Barry Eppley

Indianapolis, Indiana 

Q: Dr. Eppley, what do you know about the Vampire Facial? Does your spa offer that service? I’ll jump on the website and check it out. I heard about it from a friend of mine but I’m wondering how much down time is involved and whether I would be a candidate for such. Thanks so much. Hope you’re well.

A: A Vampire facelift is just a branded name for the concept of a liquid facelift. This fundamentally means an injectable facial voluminization procedure using hyaluron-based injectable fillers (e.g., Juvederm or Restylane) mixed with PRP, a platelet extract of your own blood. In the case of a true ‘Vampire Facelift’ the skin is also microneedled and the PRP is applied topically as well for enhanced skin rejuvenation. These are injectable procedures that our master injector Amanda does here in my practice. Whether this would be of aesthetic benefit for you depends on what you are trying to achieve. While I spent most of my time with you at the buttock and knee levels, my recollection of your face is that it is more of a lipodystrophic issue (loss of facial fat with thinning of the face) than it is of a facial skin sag problem. This is the type of facial aging issue for which this treatment approach has merit.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve been researching aesthetic plastic surgery for quite some time now since I, like many others, would like to improve my appearance. 

But I haven’t been able to find an answer to one question, no matter where I looked. 

And the question is: If someone with volume loss in their face due to aging, or someone with a lack of facial volume simply due to genetics, even in their early 20s, were to have the volume restored/introduced through fillers or implants, would that raise the position of the lips, that is, would it lift the entire mouth vertically towards the nose?

Because this is exactly what happens when I pinch my skin and stretch it outwards, mimicking the volume that I lack. 

Currently, when I rest my mouth slightly open, I can see no upper teeth.

But if I do the same and repeat the little stretching action I described earlier, I can now see my upper teeth. 

My bite is balanced and I don’t have gum show, but nevertheless my upper lip, or entire midface including cheeks for that matter, droops.

I would very much appreciate your opinion on this, as an experienced surgeon with admirable work. 

Thank you in advance.

A: All I can say is that I am not sure that your facial pinch/stretch test really replicates what adding facial volume will do. I have never seen any facial voluminization procedure that lifts the lips up towards the nose and subsequently exposes more teeth..

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  Is there anything extra that can be done to make the abdominal etching more visible?

I’ve done extensive research into the pec implant procedure – and am still not sure whether the square or oval shape implants would be more appropriate for me. I’m looking for a nice lower pec and medial line of definition, and strong chest fullness throughout.

There are a couple of concerns about the pec implants and gynecomastia excision that I do have as well:

•In many thin patients with mild puffy nipples like me there have been issues of contour dips of the nipples – I’m just wondering if this can be prevented because we are looking at doing pec implants at the same time

•I’m concerned over how natural pec implants feel to the touch, as I don’t want people to see me shirtless, touching my chest that my pecs are fake

•Also – do the pec implants move fluidly with the pectoral muscle – i.e. contracting or moving up when tensing the muscle or, say, moving the arms upwards? I’m basically wondering how naturally pec implants move, as I’m confused if the implant fuses to the chest wall and remains fixed.

•I do have lots of armpit hair, so I’m wondering how percievable the scars from the puffy nipple removal and the pec implant insertation through the armpit would be – as I’ve seen some deep scars that are even visible when viewed straight on. Is it possible for the scars to become visible so no-one would know I’ve had surgery?

As for the ab ethching, I have seen some people where their etching looks very fake, usually in larger men. So I’m wondering how natural we can make my ab etching, otherwise there might be little point in the procedure.

I’ve not, in general, seen many plastic surgeons attempt pec implants, gynecomastia reduction and liposuction in one case  so I was wondering how many cases you’ve dealt with in each of these areas, and how I can optimise my surgery for maximum difference from my form today.

A: In answer to your abdominal etching, pectoral implants and gynecomastia reduction questions:

1) There are no magic methods to make abdominal  etching more visible.

2) There is no question, you and about every male, wants the square/rectangular style….never the oval shape.

3) Contour depressions occur in open areolar excisions because of over resection of tissues…the key is to not take too much tissue.

4) Quite frankly an implant in the body is fake….it is not natural and will never feel exactly as soft as the pectoral muscle.

5) Pectoral implants do not interfere with muscle movement as they are in a subpectoral (under the muscle) placement.

6) Axillary incisions generally heal very well, particularly with hair present with regrowth afterward. But no surgeon can make an incision and have no scar, that is not realistic.

7) Abdominal etching in thin people looks more realistic than in thicker abdomens which would not normally have it.

8) It is very common in my experience to do all three procedures at once. There is nothing rare about that combination as that is often what the patients needs. (you being an example)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My overbite is mild and my maxilla and lips are already well positioned, so I’m not really interested in orthognathic surgery since it would only be serving the purpose of chin advancement.

What is the maximum anterior chin advancement one could achieve without a BSSO? Could a double-step genioplasty be combined with either a chin implant or custom wraparound jawline implant to exceed 20 mm of advancement? What factors would determine the patient’s limit?

A: Chin augmentations using a variety of techniques (bone movements with implants can get upon into the range of 15 to 18mm. But even if they could exceed 20mms the depth of the labiomental fold that would ensue as well as other chin shape issues would be the limiting aesthetic factor. Trying to achieve a chin advancement of 20mms or more is not realistic as as single stage operation due to soft tissue restrictions. I woudl focus on getting a chin advancement in the range of 12 to 15mms first using a sliding genioplasty with or without an implant and then see what you think then. Your soft tissues will be more accommodating at that amount of chin advancement. 

Dr. Barry Eppley

Indianapolis, Indiana 

Q: Dr. Eppley, I was looking through some of your before and after pictures for sliding genioplasties, but could not find something I was looking for in particular. I am just wondering if you do sliding genioplasties on patients with a convex chin (moderately deep labiomental fold)? I have a slightly convex chin, which is especially true when I bite down due to a slight overbite. My chin is fairly recessed (15-18 mm), but I don’t intend to make it perfect, an 8mm horizontal projection would be adequate based on some of the morphs I have done. I am just wondering is it even possible to get an 8 mm projection with a slightly convex chin, without acquiring a “witches chin”?

A: An 8mm horizontal projection increase is fairly standard in sliding genioplasties in my experience. Whether that avoid your concerns of a ‘witches chin’ is hard for me to answer because I don’t know your definition of that term. In the medical sense that is a soft term used to describe a sagging soft tissue pad which is not a phenomenon ever seen in a sliding genioplasty due to the enhanced bone support that naturally occurs to the soft tissue chin pad from the procedure. It will, of course, deepen your labiomental fold.

Dr. Barry Eppley

Indianapolis, Indianapolis 

Q: Dr. Eppley, my surgeon had indeed mentioned the possibility of performing my midface lift with a more vertical vector through a combined intraoral and transconjunctival eyelid approach. He did not suggest the transcuteaneous approach due to my young age and the aesthetic scar trade-offs.

What are your thoughts on the transconjunctival eyelid and intraoral approach to midface lifting? 

I rejected this method as I was worried about the risk of ectropion.

I am very happy with my zygoma reduction from a bony standpoint but I really cannot live with the results of the soft tissue.

With the scarred tissues from my zygoma reduction and my intraoral/temporal lift, would my tissues be too scarred and atrophied to attempt a more vertical vectored lift?

Thank you again for your insight.

A:The transconjunctival approach does offer a more vertical midface lift but I would have concerns that the limited access through the inner eyelid and the ability to fix the tissues well to the bone would limit the result as well. Another option that provides a stronger vertical cheeklift is the cranial-based approach coming down from way above, avoiding eyelid incisions at all, and suspending the tissues through a small scalp incision to the bone. (combined with an intraoral approach to place the sutures to the cheek tissues.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had orthographic surgery and a sliding genioplasty 5 months ago. I am very happy with the outcome of my jaw but HATE my chin and want to have it undone. Since the surgery I have extreme tightness in my chin, which prevents me from moving it, smiling correctly, and even makes it hard to speak sometimes. I am assuming it is scar tissue. I am wondering how much worse this will be after having another surgery to put my chin back to its original position. I am terrified of being worse off. The tightness has not improved at all since about 1 month post op. Will having the genioplasty reversed make the scar tissue worse? If so, is there anyway to have that fixed after a second surgery? 

A:The answer to your question cannot be predicted beforehand although making it worse seems unlikely. But if you don’t like the look of your chin and the tightness has not improved, it would seem you have little choice but to partially or totally reverse it. (sliding genioplasty reversal) I would seem little risk of making anything worse by doing so and it would be logical to assume that both the appearance and the tightness would be improved by doing so.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to reduce the length of my philtrum, however, I have normal size lips! I am concerned about changing their shape and size. As a male I like the shape and size of my lips as they are and do not want them to look any fuller. But I don’t like the length of my philtrum, so I am getting a lip lift. My question is whether a small lip lift of about 1.5mm in an average person would create any change in the shape of the red upper lip ? If I place my finger where the base of my nose is, and pull the soft tissue upward, it makes my upper lip look ridiculous and triangular shaped, even if I only pull upward a little. Will a lip lift create the same difference to the upper lip as pulling the philtrum upward with my finger does? Please help me stop worrying! 

A: The two comments I can make about your upper lip lift concerns are the following:

1) There is not a 1:1mm correction between the how much skin is removed from under the nose and how much the central upper lip enlarges. It is probably closer to 50% or less from that of the skin removed.

2) Using your finger way over exaggerates the effect of a lip lift and is not representative of it. The wooden end off a Q-tip is more representative to do some lifting under the nose to see the lip lift effect.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a flat head from the back and it has restricted me from being able to be confident with my hair. I have to tease my hair to reduce the flat look and was wondering what exactly it was that could he done to fix this. 

If implants are required, how dangerous is it to have them next to my skull and will my hair grow less because of it? 

Thank you! 

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

1) Skull implants are as safe as any other cosmetic implant used in the face or body.

2) Skull Implants do not inhibit hair growth. Skull implants aren placed deep on top of the bone while the hair follicles are right under the skin several tissue layers away.

3) The only relevance to hair growth is the incision used to place the skull implant, not the skull implant itself. Great care is taken in both making the incision as well as in closing it to lessen the risk of injury to any hair follicles in the incision’s path. The avoidance of electrocautery and placing dermal sutures are the most important maneuvers in limiting hair follicle damage from the incision.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in having calf and ankle liposuction done. I know treating these areas can be a difficult procedure and I am on the hunt to find a surgeon that specializes in lower leg liposuction. I have attached some pictures of my lower legs so you can see what the ‘assignment’ is.

A: From a lower leg standpoint, calf and ankle liposuction is the appropriate and only treatment for them. That being said there are some very distinct caveats that come with doing liposuction on lower legs like yours. First, it is very likely you will not get the ideal desired reduction that you may seek. You can’t take thick legs and make them skinny or ‘normal’ size. They can be reduced but there are anatomic limitations as to how much reduction can occur. Secondly, there is going to be a lot of swelling and it will take months for it to go away. It is just the nature of what happens when extensive trauma is done circumferentially to the calfs and ankles particularly when there is a large tissue reservoir initially. Lastly, almost all such lower legs like yours inevitably will need a second liposuction session to get the best result. It is very hard to get the maximum fat out or have ideal symmetry between two legs particularly given the intraoperative positioning required to perform the procedure. (in the horizontal sleeping position your legs have to be manually held in the air)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Six months ago I had  a PEEK chin and jaw Implant (custom but not wrap-around. Pics of scan attached), while the jaw implants have added a good deal of width and strength, the area around my chin still fails to project enough and does not give the desired strength, thus I am considering a full wrap around implant. Incisions were made via external approach. 2x under jaw angles and one under chin. I prefered this approach due to reduced infection risk. My recovery period was also very easy…almost no swelling and pain.

Have you ever removed PEEK implants before? I believe that unlike Medpor they don’t allow tissue ingrowth so similarly to Silicone should be straightforward.

Are you able to insert a wrap around implant by external incisions only? 

If not, is a custom ‘extended’ chin implant a possibility. One which could almost meet my current jaw implants and could be inserted under the chin?

A: You are correct in that PEEK material does not get the degree of tissue adhesion that Medpor does. I have placed and removed PEEK implants before so I am familiar with their in situ handling properties.

You certainly could place a more complete jawline implant through your current incisions although be aware that it would not to be able to done keeping it as a one piece implant. Depending on its thicknesses it would need to be placed in either a two- or three-piece implant and assembled in situ.

It would also be possible to make an extended chin implant design to meet your current jaw angle implants. Although the arc and the rigidity of the material on that type of chin implant would still make it necessary to have it inserted in a two piece fashion.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a zygoma reduction in January of this year. I’m 22 years old but I had some soft tissue trade offs and it didn’t really achieve the look I was after. I actually saw some tissue sagging 3 weeks post-op, but I had hoped it was swelling. Unfortunately, even now, I can still see the slight sagging. The area above the nasolabial area has become fuller and bulkier, and ages me. I feel older and don’t feel beautiful. 

The body of the zygoma was reduced by 4mm and the back of the arch was cut via a pre-auricular incision. I feel as if my surgeon over-corrected the reduction. When I smile, my side cheekbone area looks flat and my masseter muscle area is bulky and protrudes. I would like to add more volume to the outer portion of the zygoma body so that it isn’t as flat and over-corrected.

As for the sagging, I don’t know what to do? Please can you help?

I’m only 22 and I feel a midface lift is too invasive at this age. But I also hate seeing my sagging cheeks in the mirror and don’t think I can live with this. Will implants be enough to resolve my sagging? How big do I have to make the implants to resolve the sagging? 

I read on your blog that with jaw implants, the soft tissue from the face is stretched out, rather than from the neck. Would the malar implants be able to flatten my surgery-induced nasolabial folds as it stretches the cheekbone prominence back outwards?

A: Thank you for your inquiry. Yours postoperative situation is a common one that I see and your question as to whether zygomatic augmentation will reverse your cheek sagging/nasolabial folds is a valid one and the only recourse to this problem other than a midface lift.

The simple answer is that if the zygomatic augmentation replicates the shape of the zygoma and zygomatic arch before the surgery, this will give it the best chance to have a cheek lifting effect.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a question regarding the “installation” of a custom jawline  implant. Is the implant installed as one complete piece? Or the implant is divided in three pieces? For example. Left Jaw angle piece, center piece and Right Jaw angle piece… In case I only like the angles or in case if the center area only needs revision because infection in the tissue or maybe we need to decrease the size. This way we don’t need to remove it all.

A: Custom jawline implants can be placed either as a single piece, split in the middle and placed as two pieces or sectioned into thirds and placed as three pieces. I have always done it in one or two pieces but have not done it in three pieces although that is a viable method. Whether it is placed as one or two pieces depend on the size of the jaw angles and whether they will safely slide under the mental nerve if placed in a front to back single piece method. If possible this is the preferred method. But if the jaw angles are greater than 9mms and can not be folded to safely fit under the mental nerve, the implant is split in the middle and inserted in back to front method and then reunited in the middle over the chin.

But I have no opposition to the three piece method if it is necessary and that is what you prefer.

Dr. Barry Eppley

Indianapolis, Indiana