Your Questions

Q: Dr. Eppley, I am a 37 year old man who is extremely self conscious about the shape of my head. I’ve longed for a nicely rounded back head. Through my research I recently learned of your practice who performs surgical back of the head reshaping. 

I typically where my hair rather short…prefer it to be shorter than the pictures attached. I think the custom implant is the way to go for me, but am concerned about a really noticeable scar. Would these sutures be similar to those use on the face when cosmetic work is done? 

How do you determine if a two step skull implant process is required? 

Another concern for me is if l the implant will create a “pulled look” in my face and pull my hair line back? 

Where do you suggest making the incision?

I look forward to hearing from you. 

A: In answer to your questions about back of head reshaping:

1) Generally scalp scars heal really well and can be very hard to see even in short hair. In my experience, for a variety of reasons, they do best in thicker scalps. For occipital skull implants the incision is placed low on the back of the head with a horizontal incision at about the level of the top of the ear and is usually about 7 to 8 cms.

2) Computer imaging is done to determine what you consider a ‘nicely rounded back of the head’. That will tell me how much augmentation is needed and whether a one stage or two stage approach is needed.

3) The implant will not pull up on your face or pull our frontal hairline back.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a young adult male who is three weeks post-op from jaw shaving and cheekbone reduction (front and back end osteotomies) surgeries in Korea. I understand that these surgeries take quite a while for the swelling to subside but I have a question I must ask.

When I look in the mirror now, I have developed quite distinct nasolabial lines which were definitely not there prior to my surgeries. I am still quite young and I am starting to feel paranoid. 

Are these nasolabial folds the result of sagging or is it the swelling even though I am already 3 weeks post op? Will they go away over time?

A: The short answer to your question is that after jaw shaving and cheekbone reduction it would be important to let all the swelling go down, which takes up to 3 months or more after surgery to see the final facial shape result.  Only then will you know if the soft tissue effects you are seeing now is the result of the loss of cheekbone support. For now you can assume the appearance of the nsaolabial folds is an effect of the swelling. But time and healing will provide the definitive answer.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to ask about facial implants for under the eyes, I believe they are known as custom infraorbital rim implants. I have inherited hollowed eyes and I would like to ask how well are the implants attached, if it moves while smiling and if you can feel it. Thank you in advance.

A: The ideal treatment for undereye hollows is a custom infraorbital rim implant that sit on top and in front of the infraorbital rim ad can extend out onto the cheek a bit if so desired. They are secured to the bony rim with miniature screws so they will never move. They do not affect smiling or lower eyelid movement. A good fit to the bone and implant design allows them to usually not be felt.

While it is more of a surgical procedure than the traditional use of fat injections, the effectiveness, smoothness and permanent volume of the implants can offer in the properly selected patient a good correction of underage hollows.

A custom infraorbital rim implant is made from a 3D CT scan where the coverage and dimensions of the implant are preoperatively determined and controlled.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Last year I went to a famous Chinese plastic surgery hospital for cheekbone reduction surgery. My cheeks were not extremely big but only had mild protrusion, but I still decided to go through with the surgery to get a thinner face. At 4 months after operation and after all the swelling went down, I was very pleased with the result. Now it has been almost 8 months since my cheekbone reduction surgery but I am starting to have a problem. I have attached a recent photo of me. The top photo is unphotoshopped and the bottom photo is what I would like to achieve.As you can see from the unphotoshopped photo, my face is saggy from excess skin and this extra skin is pulling my face down so I have deeper nasolabial folds. I would like to get more surgery done to get the bottom photo look (permanent solution), but I will not be returning to the Chinese plastic surgery hospital. My previous surgeon said the saggy skin is because I am naturally getting old (I am very young and my skincare routine is very good!!!)

1~ Please can you explain why my skin starting to sag at 8 months after the surgery? If I leave this skin alone will it get worse or shrink?
2~ What surgery should I do to achieve the bottom photo look. I would like a permanent solution as I cannot keep flying overseas for touch up. 
I would not like cheek implant because I underwent surgery to get rid of my cheeks in the first time. I would like to just cut the excess skin off but I do not know if there is a surgery for that.

A: Thank you for your cheekbone reduction surgery inquiry.

1) Your facial skin has sagged for one very specific reason…cheek bone support has been reduced and it has required the detachment of cheek soft tissues to do so. This is not a surprise and is one of the very well known aesthetic complications (technically it should be called a tradeoff) of doing this surgery. While it does not occur in every one who has the procedure, it is not rare. What you have now learned is that every cosmetic surgery has aesthetic tradeoffs, some procedures more than others.

2) There is no surgery to help you achieve your desired look now…not a cheek lift or even liposuction.

3) The soft tissue say you have now will be stable for awhile because of your young age. But when aging does eventually set in it will become worse as it does in everyone.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, Sorry that I was groggy right after my skull implant surgery and I didn’t had a chance to ask you some questions and I hope I can still ask you through email.

1) I know you usually use dissolvable suture for skull implant and planed the same to my case, but at the end you used staple sutures. Is it because it was too tight?
2) I remember you mentioned that my surgery “was fine. and it’s really tight”. Is there anything that I need to be aware due to it’s tightness? Did the implant need to be trimmed or altered in order to put in during the surgery?
3) I am trying to palpate the implant but have a hard time to locate due to the pain and numbness of my scalp.  I am wondering later on am I able to palpate the implant when it’s fully healed?
4) Please tell me how you want me to remove the staples.

A:Thank you for your early followup. In answer to your skull implant surgery questions:

1) Metal staples were used for your skin closure because it was very tight and I did not trust dissolvable sutures. The good part of that is that means you have gotten the absolute maximum amount of skull augmentation that your scalp will permit.

2) The implant was not modified in shape in any way. It was placed with the outer contours as depicted in the 3D planning pictures.

3) You probably will not be able to tell where the implant is when all the swelling goes down and the scalp feeling returns.

4) The ear sutures are dissolvable so they will eventually fall out on their own. But they can be trimmed off now if they are irritating.

5) The scalp staples can be removed anytime 10 days or so after surgery. Since you have the staple remover it is a matter of finding someone to do it, it is easy to do. Whether that is a friend or any medical personnel who feels comfortable doing it is the only question.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I’ve read a lot of your responses on RealSelf, as well as sifted heavily through your blog and website. I appreciate you taking the time to read about my situation.

I am Chinese and as I grew into a teen I started noticing that my facial structure is very asymmetrical. My chin is in the centre however, the angle of my jawbone is different on both sides. Though not severe, it is still quite noticeable. My cheekbone on one side protrudes more than the other..

I understand that you are well aware of the aesthetic desires of most east asian cultures – by that, I mean the v-shaped chin and jaw line, as well as a slim malar area. My question to you are:

1). is it feasible to have facial bone contouring surgery on just one side of my face so that my features can become symmetrical?

2. As I am still quite young and my skin elasticity is quite good, would my “excess” soft tissues and skin around the cheekbone area and the jawbone area also “shrink” in size to stick to the reduced bone structure?

Many patients on RealSelf or those who have undergone malarplasty seem to come to you for advice regarding their ‘sagging’ of tissue on your website. I am definitely not keen on having one side of my face extra saggy.

3. Do you employ the same techniques as those in China and Korea? How can I avoid sagging like a bulldog and getting a double chin with these procedures?

A: In answer to your facial bone contouring questions:

1) It is possible to do facial bone contouring on one side on the face if that is indicated, I do it all the time. A 3D CT scan would provide a good diagnostic evaluation of your facial structure to best answer that question.

2) Generally younger patients do better with soft tissue contraction around reduced facial bones. But there are limits at any age of how much bone can be reduced and successful tissue contraction around it to occur.

3) The bone techniques used (osteotomies) for facial bone reductions are not unique to any country as there are only so many ways to do any surgery. What is likely unique is the individual approach taken for each patient and the balance struck between the amount of facial bone reduction done vs the soft tissue risks of sagging vs the patient’s aesthetic goals. Having expanded my experience with some training in China they tend to be very aggressive because many of their patients do have really big cheekbones and jaws. But not every Asian patients does so the exact same operation for everyone will have some slightly different aesthetic outcomes. (e.g., soft tissue sagging)

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I had a question I was hoping you could shed knowledge regarding delayed jaw implant infections. I had jaw implants placed two years ago and just yesterday I noticed some tenderness on the right jaw implant, specifically more on the bottom/underneath, in the middle of the jaw line (as opposed to any tenderness at the back of the mandible). No noticeable swelling as of yet, and no trauma to speak of…..but I did get over a bad bacteria-based throat infection about three weeks ago, so hoping the bacteria didn’t travel and infect the implant. In your experience, are late-stage (over at least a year) bacteria  (so non trauma initiated) jaw implant infections a pretty regular occurrence? Anything I should really watch out for before seeing a doctor? 

A: In my experience such potential delayed jaw implant infections have not occurred…unless there is some small opening in the original incision lines inside the mouth. (that is known or unobserved) The occurrence of blood borne infections seeding an implant would be extremely rare. I am sure in the annals of surgical history it has happened but not something that would ever be considered either common or expected. To make an  analogy, think of all the women in the world that has breast implants and the common illnesses that occur but yet we don’t hear about such delayed implant infections occur.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I had an otoplasty done several years ago to correct my protruding ears. When I saw the results, I was disappointed and thought my ears were undercorrected. I decided that I wanted another operation. We did the operation again 3 months after the previous operation, which I think caused my antihelix to thicken. nI don’t mind that my antihelix is thick, I do mind how close my ears are to my head. I also developed a telephone ear deformity. All I would like to do is return back to how my ears looked before, but I know that might be difficult. How difficult would it be to return it the original shape and protrusion or something close to the original shape and protrusion?

A: I would need to see pictures of you ears, both now and before, to better answer your question. But I think the question is not whether your ears can return to their initial preoperative state, because they can’t, but how close or what type of result, could such an otoplasty reversal come to it. There is no going back home, so to speak, there is only how much closer to home can you get. Very few surgeries are ever 100% reversible.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, i am writing to you for some possible assistance. I was reading a thread just now that was posted a few years back about bulging temple veins. One of the gents on the forum talked about how he went to you for treatment for his” wiggly worms” on his temples. I have the same issue much more mild though on my right side, i thought i would ask you if you know anyone personally that resides in my area that does this procedure and is very good at it? It is a old post so i was curious, has treatments become more advanced since then? Like it can be done with lasers now or is done with just a trip to the surgeon office? I don’t know the first thing about all this and that is why i have come to you, i don’t mean to bother you. This gent spoke very highly of you and thought i would enquire.

A: What you are actually referring to are known as prominent temporal arteries, not veins. This is the type of prominent vasculature that occurs most commonly in men in the temples and forehead region. The only technique for their reduction/removal is my multipoint ligation technique. I could not tell you whom in your geographic area may perform this temporal artery ligation procedure.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, Thank you for the informative consultation a few days ago, I am currently in the process of narrowing my choices. I just had a few questions.

1.) What are the odds of long term side effects with genioplasty vs jaw implants? Is one significantly safer than the other?

2.) Would a custom jaw implant benefit my chin as well? If yes, would it benefit my chin to the extent a genioplasty would?

3.) Would a custom jaw implants be much better than standard implants in terms of symmetry?

A: In answer to your questions:

1) A genioplasty (chin) and jaw angle implants carry with them different risks. I am not sure I would ever say one is safer than the other but because the jaw angles involve an implant and the chin is done by moving one’s own bone, jaw angle implants carry a risk of infection than a bony genioplasty does not.

2) By definition a custom jawline implant wraps around the entire jawline from angle to angle and crosses the chin. An implant can create the same amount of horizontal augmentation that a sliding genioiplasty but also can widen the chin which a genioplasty can not do. (it actually makes the chin more narrow from the front view)

3) One of the benefits of a custom jawline implant approach is that it is one piece, using standard implants is a three implant approach. This reduces the potential risk of asymmetry both by its design and placement.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am a young female and am interested in lip advancements. I just have a few questions about the lip advancement procedure. I have pretty full lips. I have lip implants in currently and I like them. However, I would like my lip size to be a lot bigger. I don’t like fillers at all and, after reviewing what is offered, I am most interested in the vermillion advancement. My questions are:

1) Would this option of lip enhancement be good for a young person who dislikes lip fillers?

2) Can I have a vermillion advancement with Permalip implants in?

3) How big would I be able to make my lips with the vermillion advancement? I would want a big difference.

4) Would I lose any current lip projection (volume forward/pout), after the advancement?

A: In answer to your lip advancement questions:

1) Short of injectable fillers and implants, a surgical lip advancement procedure is the only option for making one’s lips bigger.

2) A vermilion advancement can be done with lip implants in place.

3) As a general rule, lip advancements can increase the vermilion show of the lips by 4 to 5mms on the upper lip and 3 – 4mm on the lower lip. Lip advancement are very powerful procedures for increasing lip vermilion show and their perceived size.

4) Lip advancements will not decrease the forward projection of the lips.

Dr. Barry Eppley
Indianapolis, Indiana

Dr. Eppley Q: Dr. Eppley, Can you please give me some information on custom facial implants? If I decide to go ahead with the procedure how much time do I need in the USA?

From the date that I arrive – 

to have the CT scan, 
to manufacture the jaw or skull model ? 
To sit together and design the implant 
To manufacture the implant 
To operate 
To leave hospital 
To be able to leave USA ? 

I am extremely concerned about infection – because I have just had cervical disc put into my neck. An infection my spread to them and create a big problem causing them to be removed. 

Also extremely worried about pain – that is the one thing keeping me from going ahead – how can we totally control this ? Can I stay in hospital of the first couple of days so that I can get stronger IV pain medication \? 

A: In answer to your custom facial implant questions:

1) The design and manufacture of custom facial implants is a 4 to 6 week process. Therefore patients get their 3D CT scan in their local geographic region and send it to me. I then take the scan and do the design process. Patients only come here for the surgery for the obvious practical reason.

2) The design process is done in sessions with engineers from 3D Systems. Patient do not directly participate in these actual sessions. I then take the design files and share it with the patients for their input. We have three design sessions to come up with the final approved implant designs.

3) The surgery time for a custom jawline implant is 2 hours.

4) If you are coming by yourself, and given your immediate pain concerns, you would stay overnight in the surgery center. This surgery is not performed in a hospital as that changes the cost of surgery significantly.

5) You would fly home when you are comfortable doing so. Each patient is different but I would give yourself at least 5 days after surgery before leaving.

6) While infection is always a concern in jawline implant surgery, I would have no concern about it spreading to your cervical disc implants should it occur. When occurring it remains localized to the implant pocket.

7) While the most common postoperative custom facial implant issues are aesthetic in nature, infection is the one medical issue that we pay a lot of attention to try and avoid through a host of strategies. But infection is not something that ever occurs immediately, its occurrence is always in the range of 3 to 6 weeks after surgery…a time that surprises patients as they think they are well past it at that point.

8) While every patient is different about pain, that has never been a postoperative issue that has been a problem with any custom facial implant patient. You may every well be different in this regard although I would think your cervical disc surgery would have been far more painful than jawline important. While one would receive IV pain medication in the overnight stay int the surgery center, there is no capability to go to a hospital for IV pain medication after the first night after surgery.

9) Pain is not something I worry about in any patient as that seems to be well controlled by standard pain medication. What I do worry about is that few patients are psychologically prepared for the large amount of facial swelling that will occur (from the patient’s perspective) and the duration of time that it takes to go away. This can be very psychologically destabilizing for some patients…and they are always the male patients that have the most difficulty with it.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I have a couple questions about some problems I have with the lower third of my face and lip area. To begin with, I’ve noticed that my lips have begun to age. My upper lip looks quite long, and I’ve always had a downturned mouth and aging has exacerbated it. I look extremely sad/angry, even when I’m not. I have vertical maxillary excess, causing bite problems and lip incompetence too.

Is there anything I can do to fix all this? I was thinking a combination of a corner lip lift, upper lip lift and facelift would address the lip problems, but I would still need something done for my maxilla, to shorten it and help with the lip incompetence.

Thank you very much for your attention.

A: If you have maxillary excess that needs to be treated and would be beneficial to do so, that is what you need to treat first. All the external changes of the lips and face need to await that fundamental skeletal change. You would only do the lip and facelift procedures first if you knew that you were never going to have a maxillary impaction procedure. I would need to see pictures of your face to provide a more qualified answer.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I would like to ask are cheekbone reductions always bound to have some sort of sagging of the midface area or incur premature aging?I thought I had done enough research on zygoma reduction before deciding to undergo the procedure. I knew there would be risks or trade offs, but I didn’t know it would be this bad.The L-osteotomy surgery I had included a 4mm removal of bone on each side. My front and 45 degree cheekbone was not prominent. Only the lateral of my cheekbones was quite prominent, giving me a strange wide and manly face shape. Why is it that my front cheeks sagged so much after the surgery? 

A: When the whole cheek bone has been moved in, depending on the facial type, the risk of soft tissue sagging is a real one. That is whole skeletal support for the midfacial soft tissues, particularly the front part of the cheeks. By your own admission the front part of your cheekbones was fine but it was the back part (posterior zygomatic arch) that created the issue. Thus it would been better to just have the posterior arch osteotomies done with inward positioning as that would have caused no soft tissue sagging at all.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I had a lip lift in early December 2017. The surgeon took out 7mm of skin in the center of the upper lip. And now it seems that the nasolabial area looks bigger and mouth corners look down turned.  I would like to know if the Double Duck would be a good option for me, when can I get the surgery and if you could perform this surgery, how much would it be ? 

A: Thank you for sending your pictures, particularly that of the preoperative markings. When this amount of skin resection is done with a flat inferior border in a subnasal lip lift, it can cause an apparent over corrected appearance to the central upper lip and the sides of the lip are left ‘behind’. This creates an upper lip central to side vermilion disproportion and can also cause a downturning of the corners of the mouth. (too much central lip pull)

A strategy to improve to improve your upper lip shape could include the following:

1) Extended corner of mouth lifts with lateral vermilion advancements

2) Subnasal scar revision to try and move the scar line inside the nostril on each side of the columella (this is really a modification of the Double Duck Lip lift procedure)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I hope I can ask you this: I just had a Facial fat transfer 2 weeks ago. My surgeon is on holiday now. Please help me. I was walking today and I came into a storm with around 38 km/h of wind. Often the wind blew directly in my face for around 20 minutes. Do you think that killed some of the 2 weeks old fat? Thank you so much and warm regards.

A: The simple answer to your question is that I doubt external cold wind could adversely affect the volume retention of a facial fat transfer procedure…at least on a limited time exposue. You are undoubtably drawing this potential analogy from technologies such as CoolSculpting where cold temperatures are used to aid in some fat reduction. While seemingly a relevant analogy it is not. These are devices that are applied directly to the skin and held there for a duration of time to really lower the temperatures of the tissues under the skin. That is quite different than an external wind chill, which while dropping the skin surface temperature, would have a much harder time dropping the temperature of the deeper subcutaneous tissues if only ‘applied’ for a relatively short period of time. Much longer exposures, however, would be likely to do it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, In Korea, there are few clinic that offers posterior cheekbone reduction with 5mm sideburn and cut inside the hair (the posterior cheekbone reduction.) Many clinic in Korea also do not offer this method of surgery.

What are the risks of this method of surgery as I am interested in making my face smaller? The clinics I have consultations with told me that there are many revision case because people can feel and see the broken arch bone at the hairline or there is non connection of bone. Is this true? What other risks??

A: Thank you for our inquiry. I have done many isolated posterior zygomatic arch osteotomies (posterior cheekbone reduction) to narrow the width of the face on the sides. (but leaving the anterior cheek bone alone) I have not yet seen the complications which has been told to you such as bone edge visibility or palpability. By definition with plate fixation there is a non-connection to the bone but that is irrelevant as the bone is stabilized and there is always a non-connection of the bones no matter whether it is done in isolation or with anterior cheekbone reduction osteotomies.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in V-line facial contouring. There is a popular procedure in South Korea that offers a procedure called V line which slims the jaw and chin to make it doll like and I am very interested in getting it done in June 2018. I contacted several clinics in Korea and the procedure is much cheaper there when compared to USA. However, I am nervous going to a country I have never been before by myself. Before making a decision, I want to know my options for the in state surgeons. How much would facial contouring cost at Eppley Plastic Surgery Clinic?

A:Thank you for your inquiry. What you are referring is known as V-line facial contouring or V line jaw surgery of which I am very familiar. Whether you are a good candidate for that procedure depends on your pictures, x-rays and aesthetic goals. Be aware that when you go to South Korea they are going to do the procedure whether you are a good candidate or not. They treat everyone the same whether they are Asian for not or whether their bone structure can benefit from the procedure or not  I have treated many Caucasian US women who went there only to have a result they did not want and then had to be secondarily reconstructed. Cost aside I would first determine if what you want to achieve is even possible with your facial structure. It will be a difficult problem to secondarily correct if the operation has never had a chance to achieve what you want.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in tear trough injections using injectable fillers. I have deep tear troughs that I think would benefit by them. I have attached some pictures for your review and recommendations.

A:Thank you for sending your pictures. Fillers or fat is not a proper procedure for your under eye concerns. What you have is overall fat protrusion of the lower eyelids with tear troughs. (medial orbital rim indentations)  These are really pseudo tear troughs that are magnified by surrounding infraorbital fat protrusion. Any attempt at filling the tear troughs will likely just make your overall lower eyelids look even more puffy than they are now. The correct approach is lower blepharoplasties to remove the herniated fat and transpose it into the tear troughs with some lower eyelid skin removal/tightening.

In my opinion the only role for an injectable approach to your lower eyelids is to ‘prove’ that lower blepharoplasties are the better treatment. Given that injectable fillers in the eyelid can take a long time to resorb I would be hesitant to even try such a treatment as you would have to have puffy eyes for some time. It would be better to just proceed with lower blepharoplasty surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting a Peri-Pyriform Implant. As shown in my X-rays, I had Lefort1 osteotomy last year. I also had cheekbone reduction, mandibular reduction, and chin augmentation back before that. I am planning to remove the titanium screws before I get the Peri-Pyriform Implant. I do not know if that is necessary and I would love to hear your professional opinion regarding removing the titanium screws. I am also interested in getting cheekbone implant. I found a surgeon in Asia who places a Medpor implant below the lower eyelid area (the dark circle area, rather than the actual cheekbone area which is located below the outer eye corners) to give the patient a more convex midface and a more youthful look. I am wondering if we could discuss the possibility of getting the same implant along with the Peri-Pyriform Implant during our virtual consultation. Thank you very much for your time and consideration. I look forward to speaking with you soon.

A: In answer to your questions about the Peri-Pyriform implant::

1) It is not necessary to do a separate maxillary plate and screw removal if you do not want to. I can do that at the time of the implant placement.

2) The subcheek and peri-pyriform aperture implants can be done all in one procedure with the same surgical access.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in cheekbone reduction reversal. I am a 21 year old Asian girl who thoughtlessly underwent cheekbone reduction surgery and jawbone reduction surgery in Korea. After six months of healing, I’m finding that my cheeks are sagging and it is making me look a lot older than I am. 

I’m not sure what to do. I’m depressed and regretful of my decisions. The cheekbone reduction was conducted via L osteotomy, with an oral and sideburn incisions. I’m hesitant about cheek implants as I’m not very keen on putting foreign objects in my body. Even though I am young, I am desperate. Would a cheeklift/soft tissue cheeklift be beneficial in my case.

A: Thank you for your inquiry. Your cheekbone reduction reversal options are limited. You have to re-establish bone support to lift the soft tissues back up, a cheeklift is not going to work. You either reverse the osteotomies or place some form of a cheek implant. But either way you have to build the bone back out somehow, you can not lift the tissues around it successfully in a young person. Implants are easier but revise osteotomies are more ‘natural’.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have three questions regarding the titanium screws for may custom jawline implant.

1.  Are they custom-made to different lengths, since they will be penetrating at three different spots of varying thickness along the mandible?  (Ie. 14mm/12mm at the gonial angle, ?mm at middle of mandible, and 4mm at chin, so they don’t over-penetrate or under-penetrate)

2.  Is there a torque limiter on your drill to prevent fracturing the bone?

3.  Can we place the six screws as follows?(on pages 6 and 7 of the pdf file below, which I have marked up)

A: In answer to your screw fixation questions for your custom jawline implant:

1) These are 1.6mm diameter self-drilling screws whose maximal length is 8mms. They are placed through portions of the implant were it is thinnest to accommodate the screw lengths.

2) These screws are smaller in size than Abraham Lincoln’s jaw on a penny. Thus the risk of bone fracture is not a concern.

3) All of the potential screws locations you have indicated are not viable options as either the implant is too thick or there is no point of access to do it. (center one) I have attached an imaging picture of what are the locations that can be used based on implant thickness and available screw lengths.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I recently had a rhinoplasty and lip lift procedure that I am unhappy with. I wanted my nose to be narrowed and instead the surgeon rotated it up and shortened it. It now looks wider at the tip. I want it to be much more narrow. I think a slight alar base reduction would look nice in conjunction with narrowing the tip and de-rotating the tip. Also, the lip lift did not lift my upper lip enough. I am hesitant to pursue another lip lift procedure as it may complicate the revision rhinoplasty and make the tip appear more upturned by pulling the columella and nostrils down. I’ve consulted with several surgeons who have advised me that this will be a very complicated procedure. I would love to know your thoughts on what, if anything, should be done. Do you think you could narrow my nose (possibly alar base) and bring the tip down to look this way? This was the “projected outcome” photo. Thank you very much for your time!

A: I think the first concept you have to grasp in that after a primary rhinoplasty the obtaining of a dream or ideal nasal outcome is probably not realistic. Whether it was ever a realistic goal initially I can not say as I wasn’t involved in that process. Now you are looking to recover from an over correction in a nose that is now scarred and is short of cartilage structure. Getting the tip of the nose back down is a lofty goal in itself and will require significant cartilage grafts to do so. That will be an accomplishment by itself. Making the more narrow is probably not going to happen as much as you would like. For a revision rhinoplasty, now a reconstruction project, one’s goals should be more modest.

I would certainly agree that any further lip lift efforts should be delayed until well after the revision rhinoplasty.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, thank you for your presurgical consultation today regarding my rhinoplasty tomorrow. I know we have been over my nose surgery numerous times and you have done a lot of computer imaging for me. I know that no surgery can create perfection but I still need to know if my nasal tip projection will really be shortened by the 2mms that i need. I also need to make sure my nostrils shape will not change in any way. I don’t want to seem pedantic at this point but I am concerned.

A: I would not use the word ‘pedantic’ or even over analytical. Those are patient behavior’s that are common and largely understandable. The concern that I always have with such behaviors is what may lie behind them…unrealistic expectations.

It is important to really understand that surgery is not Photoshop or any other completely predictable method of facial manipulation. Such efforts are important preoperatively but what they really represent is a method of communication as to what the patient’s goals are. Surgeons need goals to try and accomplish what the patient wants. They are, however, not completely accurate representations of what the results may be even though that is the goal. The manipulation of tissues, how they respond in surgery and how they heal afterwards, is not like manipulating images on a computer screen. It is far less predictable and no result will end up perfect or completely symmetric no matter how hard the surgeon tries. Patients who are most satisfied with their plastic surgery have an inherent understanding of realistic and not always predictable outcomes.

As an additional note I must make reference to the type of patient who is at greatest risk of having unrealistic expectations in plastic surgery and one of which I have an enormous experience…the young male patient who is having elective facial surgery. Often times an overanalytical preoperative behavior is a set up for postoperative disappointment…as any result can not withstand the scrutiny and degree of perfection such patients often seeks.

I pass along these thoughts as a note of caution as you are about to proceed into rhinoplasty surgery and hope that your expectations fall in line with what surgery can actually achieve…improvement but never perfection.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m seeking your opinion on my chin, neck and jaw. I’m open to all options. My chin is further back than it should be. I would like to know the pros and cons of the sliding genioplasty operation. I would also like to know if the simpler silicone chin implant would give me good results in your professional opinion.

A: Thank you for sending your facial pictures. With a chin deficiency of close to 9 or 10mms, both a chin implant and a sliding genioplasty will offer improvement as assessed in the side view. They probably can’t be differentiated from that viewpoint. But from the fontal and oblique views is where they will be aesthetically different. A sliding genioplasty will usually narrow the chin as it comes forward particularly in the prejowl area. Conversely a chin implant will widen the chin with the increased horizontal projection. In addition a sliding genioplasty can make the chin vertically longer if desired while most chin implants can not. These aesthetic differences in their chin augmentation effects need to be considered for a true 3D chin augmentation surgery.

There is also the consideration of how one feels about an indwelling implant vs using one’s own bone for the surgery. Unlike the logical aspects of their different aesthetic effects this consideration is emotional and personal but may be of no less importance in this decision between the two chin augmentation options.

Lastly, chin augmentation no matter how it is done does not affect the back part of the jaw, only its front part.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am seeking information about the management of a fat grafted breast infection. I came across a question that someone sent to you and your answer to it in regards to infection during fat grafting to breast. Here is the link to it: http://eppleyplasticsurgery.com//why-did-one-of-my-breasts-after-fat-injections-become-infected/. I was wondering if by chance you know what happened to that person and how their issue was solved because I seem to be in an exactly the same situation and wondering what the best and fastest way to fix it. Please let me know if you know how that patient’s case got resolved or if you had a similar one or know of a similar one and what it took to fix it: number of injections to correct, amount of cc-s injected each time and the timing – how long it took between procedures. I really appreciate your help. Thank you.

A: When it comes to treatment of an infection that has occurred in an injected fat graft site, the treatments are oral antibiotics (possibly IV as the breast is a big site with a probably big fat load) and possible needle or small incisional drainage. Having no knowledge of your fat grafted breast infection specifics (what does it look like, how long after the surgery did it occur, how much fat as injected) I could not provide specific recommendations as to your case. But as a general statement such infections should be treated aggressively combining antibiotics and some form of drainage. It is important to realize there is a large amount of dead tissue in there (injected fat with little to no blood supply) so all that can be done should be done right up front. If it is not too ‘severe’ oral antibiotics and needle aspiration may be fine. If it is more ‘severe’, IV antibiotics and incisional drainage may be needed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have linked you to an article you wrote in 2015 dealing with injecting fat into the scalp. I was under the impression that by injecting anything (fat) to a tight scalp it would make it more tight. However you state that introducing adipose tissue is actually beneficial for the scalp. Can you elaborate on this? I am interested in a solution to a thin/tight scalp. Thank you. 

A: Injected fat is a soft tissue expander/relaxer even if none or only some of the fat survives. It is a simple volumetric principle of stretching the connective tissue between the dermis of the scalp and the underlying galea against the bone. Any fat that survives has to displace/stretch the existing scalp tissues. Any fat that survives pushes the scalp outward and, because it is fat, the scalp will eventually become softer with its survival since it is adding a tissue the that is softer than what most of the scalp is naturally composed. 

The key in injecting fat into the scalp is to place it above the galea and right under the skin. This is the easiest tissue plane to enter with a blunt cannula.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am male but my facial appearance lacks masculinity. My eyebrows shape is not straight but arched, the overall vertical extension of the eye area is high, and the forward protrusion of the brow bone is minimal. Could my brow bone be augmented in such a way that the base for the eyebrow moves down, and the eyebrow repositioned downwards and forming a straight line appearance. How close to that could my eyebrows get fixed? Thanks a lot.

A: This is a common question from young men who seek brow bone augmentation. The simple answer to your question is….no. Brow bone augmentation will push the eyebrows forward but not down. No surgical procedure can make your eyebrows go lower…short of a tissue expander placed first in the forehead to create more skin and then a brow bone implant placed. This is because the forehead/brow soft tissues are too tight and the amount of tissue that is available has been ‘made’ based on how the bone has developed. You would have to free up the tissues and create some excess to have the brows be driven further downward. But this would not likely create a straight eyebrow shape from a natural arched one.

Dr. Barry Eppley

Indianapolis, Indiana

Dr. Eppley, I’ve had buccal fat pad removal two year ago and  it derounded my fat considerably. I am happy with the results. However, it did no good to my perioral mounds. I came across the your name online while looking for perioral mound liposuction. I wonder how much the procedure costs, its duration and recovery time. I saw three doctors and none of them were familiar with the procedure and they all discourage me to have it done. Note this is a genetic thing, my father and my brother also have it.

A: As you observed by your own experience, buccal lipectomies do not address the perioral mound area. That is a separate subcutaneous fat layer that sits below the encapsulated fat of the buccal space. Perioral mound liposuction is done through small incisions inside the mouth. Other than some swelling there is no real other recovery issues. I would correlate its recovery to that of your prior buccal lipectomy experience. Because it is a small amount of fat removal it will take longer to see the final result than that of a buccal lipectomy, roughly 6 to 8 weeks to see the very final effect on the shape of the face in that area.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Do you preform breast injections with a Sculptra, or a similar lactic acid polymerized substance. And would you be willing to try a breast injection procedure?

A: Breast augmentation by resorbable synthetic fillers, like Sculptra, is quite frankly a problem waiting to happen. (Sculptra breast injections) Such fillers in significant volumes create soft tissue reactions such as lumps and even granulomas. This creates breast lumps and scar tissue which is the antithesis of what a soft breast should feel like. In addition, creates such soft tissue reactions in a bodily structure  in which lifelong cancer surveillance is important is not the best medical decision.. Detecting breast cancer would be made more difficult in such an injected breast and these soft tissue reaction would make breast cancer detection challenging.

In addition, the volume of material needed and the need for repeat injection would make it a very costly endeavor. This cost factor is magnified when one realizes that such injections are not a long-term solution to a sustained increase in breast size.

A safer and more medically sound approach to non-implant breast augmentation than Sculptra breast injections is to use fat injections…provided one has enough fat to do so.

Dr. Barry Eppley

Indianapolis, Indiana