Your Questions

Q: Dr. Eppley, I need scar revision surgery. I have already had one procedure on my forehead to improve the look of the scar, but  following the revision surgery (which was over two years ago) scar tissue slowly developed creating a deep crevice in the middle of my forehead. The crease is perfectly straight, which is very noticeable. My kids refer to it as the “butt crack” on my face. Attached are some photos.

My biggest concern is the “butt crack.” I am not sure if you can revise the scar to minimize the crease. I would actually prefer to have someone create a new incision where the crease is, remove some of the underlying bulging scar tissue, and then sew it up in a zig-zag pattern so that it is not so straight and noticeable and to prevent it from getting deeper in the future. IT would not bother me at all if some scar tissue developed under the “butt crack” to keep it from becoming a deep crease on my face again.

A: Thank you for sending your pictures. That is the type of glabellar forehead scar I have treated numerous times before. The reality is it is deceptively more difficult to make improvement than it seems because of its depth and the muscle contraction that runs perpendicular to it. Simple scar revision will not work as your own experience indicates. While a geometric excision and closure is needed for the skin, it is what is done underneath that will make the real difference in improvement. Volume needs to be added as well as muscle rearrangement. I usually do this by augmenting the bone with an ePTFE implant and excising and rearranging the muscle before the skin part of the scar revision procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 32 year old female. I have had bariatric surgery and have successfully lost 120lbs. 320 to 200 at 5’8 tall. And while I am very happy with my weight loss, I am left with a large amount of sagging skin in multiple areas, arms, back, breast, abdomen, and thighs. I believe that I would like to eventually seek an arm lift, breast lift with aug, TT with muscle repair, and thigh lift, possible liposuction to these areas, if needed to achieve best results. My question is, which of these procedures can be combined? What would you suggest as an approach. What is the consultation fee? Do you suggest I lose more weight? 

Thank you for your input,

A: In answer to your post bariatric body contouring questions:

1) You want to maximize your weight loss before having any body contouring done…this always goes without saying. A weight loss of 120lbs is very impressive and you are to be congratulated. If significant more weight loss is your goal then you should do so. But if you are only going to lose another 10 or 20lbs at best then you can go ahead anytime with the surgery. In other words if you are at 85% to 90% of your weight loss goal, then it is Ok to process with surgery as that process will carry you the rest of the way with the final weight loss.

2) Many body contouring procedures can be combined. But for the purposes of recovery and to limit surgical risks, no one is going to have all their desired procedures in a single setting. Thus I tell patients to pick their top two procedures of most importance and do those first. In the last majority of cases patients often choose an extended tummy tuck and armlets as their top priorities. Your most important procedures may or may be the same.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a mini tummy tuck, I think. I am thin but after two pregnancies I have a lot of loose skin round my belly button. I also need a diastase’s muscle repair and possibly fixing an umbilical hernia as well. I have attached pictures for your review and recommendations.

A: Thank you for sending your pictures. While you may be small and thin, your abdominal problem is not ‘small’ and a mini-tummy tuck is not going to provide the type of improvement you probably seek.

You abdominal problem is a classic ‘tweaner’, meaning a mini-tummy tuck is inadequate and a full tummy tuck to really correct the problem has its own aesthetic distraction. What defines a mini vs a full tummy tuck is the decisional pattern of the skin/fat segment removed.This is illustrated in the attached images based own your abdomen. A mini tummy tuck removes a horizontal ellipse of tissue BELOW the belly button. This keeps the belly button attached to the skin, so no scar occurs around it but leaves all the loose skin and stretch marks around it or above the cut out area. While the pull down to close the tummy tuck does stretch out the tissue around there all still be stretch marks and some loose skin around the belly button in the end. The one advantage of the mini tummy tuck is that the scar is shorter and can sit lower, well within your pant or underwear line…but it does NOT correct the full extent o the abdominal problems.

The full tummy tuck provides the definite treatment by removing all of the loose skin and stretch marks by having the cut out pattern extend above the belly button. While providing the optimal removal of loose tissue, it does result in a scar around the belly button and a higher positioned and longer transverse tummy tuck.

As you can see there is no perfect tummy tuck for your abdominal concerns. You have to which of their liabilities is most acceptable to you….incomplete tissue removal of the mini tummy tuck or more scar from a full tummy tuck.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in secondary genioplasty surgery. I really hope you can help me out. I had jaw reduction in South Korea two months ago, where only the outer layer of my bone was cut off. I am grateful to myself that no bone angles were cut off but a problem I didn’t think I would encounter has arisen.

The back outer cortex part of the jaw was cut pretty evenly but I’m afraid I cant say the same for the sides of my chin. The right side is perfect and exactly the way I wanted it. However, the left side has been slightly more overshaven, and dents inwards, especially when I smile and the tissues are stretched back.

It’s especially visible in photos and makes my lower face look asymmetrical. I think if it was just slightly more built out, it would have been perfect. What options do I have to do this?

Is there some sort of permanent injectible filler or bone filler that could be used to just to build out this area very very slightly. It’s not a major augmentation but I would feel so much more at peace if it could be slightly more build out. 

I know they use some sort of paste in sliding genioplastyto hide the notch or dent in the jawline. Can the same material be used to slightly build out the overshaven jaw cortex in this area?

A: To answer your question about secondary genioplasty surgery, a variety of materials can be used to fill in the dent behind the left side of your chin. An injectable approach will not work for a permanent effect since there are no truly effective and completely safe permanent injectable fillers. Hydroxyapatie cements or ePTFE sheets can be placed intraorally to build out the overshaved chin area.

Dr. Barry Eppley

Indianapolisk Indiana

Q: Dr. Eppley, I am roughly 8 weeks post op from zygoma reduction, buccal fat reduction, and genioplasty to reduce the width of my chin. I really hope you can help me out with some questions because my original surgeon is not being very helpful and is now unresponsive.

Prior to the surgeries, one of my cheekbones protruded more than the other, causing some facial asymmetry. But my doctor removed a wedge of bone of the same length from both sides of my face. Is it normal to reduce the left and right zygoma by the same length when the original cheekbones are obviously asymmetrical? Would this not just keep the asymmetry and push them in, so that it’s pushed in and asymmetric. Why wouldn’t different widths have been taken out.

What I’ve also noticed is that the side with the originally less protruded zygoma, is some asymmetric cheek fullness as well. When I smile it becomes very obvious. There is this deeply sunken in part right underneath the arch area of the zygoma and right in front of ear tragus and on the mandible area. Would this be from the zygoma reduction or the buccal fat pad removal?

I understand that there is definitely some residual swelling left but this has been extremely distressing. If this sunken in area persists, what should I do?

I’m not sure about whether I should fat graft the area, but I’m also worried about spending money on a procedure that can’t guarantee fat retention. Or is there some sort of permanent injectable that can be used to build out the area. I don’t need a specific shape like a cheek implant, but just like a slight pushing out of the area.

A: In answer to your after surgery zygoma reduction questions:

1) The specifics of your surgery are only known to your surgeon. That is his responsibility to explain what was done and why.

2) It will take a full is months to see the final result of your reshaped face and that should be taken into consideration when considering any revision.

3) Buccal fat removal will not cause any indentations back by the ear or underneath the zygomatic arch, that is caused by the bone reduction.

3) Fat injections, while not always predictable, are the safest soft tissue volumizing filler to use.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My rhinoplasty questions are the following :

-Would my case be done with open or closed rhinoplasty?

-I think the tip is a very prominent part of the face and Im scared about the tip looking stitched or asymmetric. Is it possible to deproject the nose  without touching the tip with the surgical knife? With tip I mean the part that is colored in pink in the photo “tip photo”.

-Which are the chances that a second surgery would be needed?

-Is it possible to achieve a reduction like the modified photo compared to the original photo?

-Would it be necessary in my case a graft in the tip or in another part?In which part? 

A: Thank you for your inquiry. Unfortunately all of your pictures dd not come through so I can not make an assessment of how realistic an imaging or ideal goals are. But to answer your specific rhinoplasty questions:

1) Am open rhinoplasty approach is needed. Deprojecting any nose is not a rhinoplasty technique that lends itself to favorable closed rhinoplasty results.

2) I do not know what you mean by ‘deprojecting the tip without touching it with a knife’. That statement is an oxymoron as only surgery can change the projection of the tip of the nose.

3) With most forms of tip modification it is almost always best to at least place a columellar strut graft to maintain the shape and projection of the reshaped tip.

4) The general revision rate in rhinoplasty averages around 15% but that number is influenced by what type of rhinoplasty or nasal shape changes are being done.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am very interested in a custom skull implant done. It has been bothering for as long as I can remember. I do have a few general questions for you (I hope that you don’t mind): 

1) What is the recovery time? 

2) Can the entire procedure be done in one session? I live in California, as you know, and it would be difficult for me to travel back to Indianapolis for follow-up treatment(s) or visit(s). 

3) How big will the prospective scar be on the back of my head? 

4) any potential hair loss? 

5) will my head be shaved for the procedure? 

6) any side effects or potential issues that I should be aware of? 

7) will the implant be secure — if for example, I fall, etc., is it prone to move if significant pressure is placed on it? 

8) is 15 mm a decent sized implant? I.e., will my head be round. 

9) How much does the procedure cost — total? 

10) will the implant last long / forever? 

A: In answer to your custom skull implant questions:

1) Most patients are well recovered in two weeks or less.

2) Patients get their 3D CT scan where they live. They only come in one time for the actual surgery.

3) It is a fine line incision usually about 9 cms long placed low in the occipital hairline.

4) These scalp scars usually heal remarkably well with no hair loss.

5) No hair shaving is necessary.

6) No adverse side effects have yet be seen.

7) The implant is never going to move from its healed position on the skull.

8) a 15mm is the maximum projection that can be achieved given the limits of the scalp to stretch in a single procedure. It certainly be a lot more round than it is now.

9) My assistant has been instructed to pass the cost of the surgery on to you.

10) The implant will last forever, it can never degrade or break down or need to be replaced.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I received a large chin implant about 5 months ago, but I am still not quite happy with the projection. I’m looking to achieve a more angular, masculine face and feel I could use some length at the bottom of my face in addition to projection. Attached are my before and after pictures.

I’d like to explore a sliding genioplasty in addition to buccal fat removal and would love your opinion.

A: While a sliding genioplasty will bring your chin further forward and even provide some vertical lengthening, be aware that will make your chin look more narrow in the front view. This would be contradictory to your goals of a more angular/masculine lower facial appearance, you need to see the side profile changes as well as a chin/jawline widening effect in the front view. This is not what a sliding genioplasty can do. While a sliding genioplasty is a very versatile chin reshaping procedure, it can not address all dimensional changes of the chin.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m 23 and always had a weak chin and jaw. I had an extra large chin implant last year. Although it was an improvement I still don’t have much of a jaw definition. My concerns are the following: 

1) Jaw Asymmetry. My left jaw is longer then my right jaw which gives my face an asymmetric look. I like profile pictures taking from my left side much more. I was wondering if a genioplasty could be done to correct this even though I already have a chin implant. 

2) No jaw angles. Would like to look into possibility of jaw angle implant. 

A: Thank you for the clarification on your facial concerns and sending your pictures. In answer to your questions:

1) A chin implant never creates jawline definition so that was never a realistic goal with the type of facial implant surgery.

2) A genioplasty will not correct a jawline asymmetry. In fact it has an equal chance to make it look worse as it does to make it look better.

3) With your jawline asymmetry and lack of jaw angles in conjunction with an indwelling chin implant, your best chance of a more complete and successful jawline augmentation is going to be with a custom total jawline implant.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a reverse sliding genioplasty. I had double jaw surgery last year which moved my lower jaw forward for 8mm. Then I had a sliding genioplasty to move my chin forward for 4mm downward for 2mm six months later. Now I feel my chin is too pointy and not natural. I want my chin to go back when it was after the jaw surgery. I really regret the genioplasty. I have high cheek bones. So the genioplasty creates hollows on my cheeks. This makes me look old. My face looks so thin and long. Also, the lower lip looks rolled in like an old person. Do you think it’s possible to move the chin back to where it was? If so, how would the muscle and lip respond to the change? Will the reversal cause sagging and jowling issue? The most important, will the hollow on my face get recovered? I’m 33 years old now but my skin is good and I’m very healthy.

A: While you can certainly have a reverse sliding genioplasty, it is important to know that not everything is going to go back exactly the way it was before the chin surgery. While moving the bone back is a very predictable maneuver, what the soft tissues will do is not as predictable. With such a small genioplasty movement, it is likely that most of the soft tissues will recover. But the one way to really know is to do it and see what happens.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had jaw reduction surgery in Asia a year ago and I wasn’t completely happy with the results. I wished the surgeon I had chosen had been a bit more conservative with the jaw amputation of the angles.

I’m content with the width of my face but I’m wishing for some slight improvements. My face was quite round/square-ish prior to the surgery, and post-surgery my face became a lot more heart-shaped or tapered from the front view.

1. Would transforming a slight heart shaped face to a more oval shaped face require augmentation of the jaw angles from the back (the posterior amputated bone area) or involve augmentation of the angles/sides of the chin? I don’t want a dramatic change or a large augmentation, but would just like to change the curve of my faceline from the front perspective as I’m not a fan of the tapered heart face and chin. I would not like to widen my face.

Is it possible to achieve this minor/moderate vertical augmentation with hydroxyapatite or some other form of bone cement?

I had rhinoplasty back in 2012 that involved putting in a silicone implant, and I realised then how much I hated plastic materials inside of my body. I would largely prefer something known to be a lot more biocompatible. 

If you have any other suggestions or input, it would be greatly appreciated. 

A: Thank you for your inquiry. The critical question is whether jaw angle reconstruction and restoring some degree of jaw angle length would create a more oval-shaped face. Or even adding some chin width. I would have to see pictures of your face and do computer imaging to best answer that question.

But for the sake of discussion, let’s assume that it does. There is no other way to reliably augment it without using an implant. Hydroxyapatite cement can not be used to build out missing jaw angle bone.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in two procedures, revision rhinoplasty and chin reduction surgery. I nave a over reduced bridge and nasal bone which resulted a polly-beak look and inverted-V. My tip was over rotated and appears shorter. What I am hoping to have done is to bring back the shape of my nasal bone prior to surgery so it has the “Y” shape between my eyes I once had. I did research and found that you use implants and I wanted to see if it was a possibility to use an implant in that area. I took a 3D CT scan right before surgery, so I have access to what my nasal bone was prior to surgery. The second surgery I would like is a chin reduction surgery. I had a sliding genioplasty and immediately had lip issues. I feel my chin appears too long and may have contributed to my lip issues. My lower lip seemed to have rolled into my mouth after surgery and also shows a lot of my lower teeth now. When I take my finger and push up on the skin of my lower chin, it literally resolves all my issues. When I push up several millimeters on my chin, my lower lip rolls back out of my mouth and also takes its shape prior to surgery and covers my lower teeth like before. I have pictures of multiple angles of my face showing my nose and chin. Also a picture of me pushing up on my chin showing the result. 

A: Thank you for your inquiry and detailing your surgical history and secondary desires.  From a revision rhinoplasty standpoint, restoration of the dorsum can be done with either cartilages grafts or an implant. While an implant would do well for the mid- and upper dorsum, particularly in recreating the Y shape, it can not be used to derotate the tip. Tip work always needs to be done by cartilage grafting to avoid a high rate of complications from the pressure of an implant on the nasal tip skin.

By your description of lip symptoms, reducing the projection of the chin (partial reverse sliding genioplasty) with soft tissue resuspension would offer a combined benefit. Pushing up on the soft tissue chin pad in these situations always improves the lip retraction issue but such a simulated result does not always translate completely into what surgery can achieve. 

Please send me any pictures you have of your nose and chin issues.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I initially had a very broad, and blunted rectangular face. I desired a more oval face and thus pursued surgery in South Korea. My chin tip was narrowed by 7mm, my jaw angles were amputated and the outer layer of my mandible was also shaven off. 

My face is definitely thinner and longer now, but it’s not the shape I had been hoping for. My face shape went from broad and rectangular, to a heart shaped face. My chin tapers in slightly when I rest my face with no expression, instead of the oval U shaped curve I was wanting. 

What bothers me most now is when I smile. My surgeon failed to alert me that the shape of my smile would be so drastically affected with these surgeries.

Prior to surgery, my face was very round and full when I smiled. Now, when I smile with teeth showing, from the ears down, it is an upside down triangle. The chin is extremely tapered in and I just feel it doesn’t look natural at all. The chin tip is also extremely small and its width is probably less than 3cm wide. 

I really hope you will answer my enquiries because I really don’t know where to start to rebuild my face to what I wanted it to be.

(1) I am looking into chin widening surgery. How much can the chin tip be widened with an interpositional bone graft before a step off is visibly noticeable when smiling/tissues stretched back on the bone? Would this surgery keep the curve to the chin or make it more square (ideally not square.) If I were to reinsert a 6mm bone graft, that would logically create an excess of 3mm on the sides of the chin that do not blend into the jaw line. Would 3mm create a visible dent or step off in the face line when I smile?

(2) Is the extreme tapered-ness of my chin when I smile with teeth from the outer layer shaving of the mandible or from the amputation of the jaw angles?

(3) To be quite honest, I like that my jaw angle now starts from below the ear and do not wish to add any vertical length here. Therefore, what area would I need to augment in order to get a more rounded face when I smile? Would I need to augment the back jaw angle in order to get the oval face shape I desire when I smile?

(4) I said in my previous email that I would ideally like to steer clear of silicone, ideally medphor as well. If nothing else can be used then I would need more time to wrap my head around it and get over these feelings. Can whatever augmentation materials I need be pre-formed implants using acrylic PMMA or hydroxyapatite or any more biocompatible materials?

Attached is a photo of my smile.

A: In answer to your chin widening surgery questions:

1) A 6mm interpositonal graft should not make the chin look too square. If any step-offs occurred to the side of the chin they could be shaved down at the same time.

2) The extreme tapering of your chin when you smile is from the loss of bone from the sides of the chin primarily. There is not enough support for the soft tissues as they retracted upward from smiling.

3) Getting a more rounded face now has nothing to do with the jaw angles. It is what is done to the chin and the bone right behind it.

4) Trying to make bone cements to work for the chin/anterior jaw widening effect is not going to work as well as preformed implants. But the use of hydroxyapatite cements is a possibility. It is not ideally made for this type of onlay facial bone application but an experienced user can do it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  My doctor confirmed that i was experiencing chin ptosis as a result of poor attachment of the mentalist muscle. He said that there was no tightness in the scar from the intra-oral incision. The problem stems entirely from the suspension of the mentalis muscle.This doctor does not perform the corrective surgery i require and i am still interested in moving forward with yourself. 

However it would be great to know a little more about mentalis muscle resuspension and your experience with this particular surgery. 

1) Can mentalis muscle resuspension be performed with permanent results or does the muscle return to its original position eventually?

2) How many resuspension have you performed thus far?

3) Of the patients you have treated, how many patients have experienced sustained results?

I look forward to your answers.

A: The questions you are asking about chin ptosis repair are not about the sustained ability of the muscle resuspension…as that always stays where it is put. What you are really asking is how well does resuspendinjg the muscle work at fixing the chin ptosis and improving the lower lip position. While the two are related. it is not a 1:1 correlation. All successful mentalis muscle resuspensions do not always effective solve those two issues completely. Having done lots of them I can say that it is about a 50% improvements in the associated lip and chin issues with the procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 55 years old and in excellent health. Over the years my testicles have shrunken and I would like to enlarge them back to where they use to be. Specifically I mean that I wan t enlarge the size of the testicles I have. How can this be done? Thanks.

A: Testicular enlargement surgery is done by creating custom testicle implants that are larger in diameter than your existing testicles. (based on how much size increase you want) What is unique about them for this purpose is that they have a hollow center which is an approximate size of your existing testicles. In surgery such implants are bivalved (cut in half) and then used to encase your testicles and put back together. A hole remains on one end for the vascular pedicle/vas deferens to exit.

The other implant option is to use standard testicle implants and hollow them out during the surgery. This is obviously far more tedious but avoids the custom implant route.

The surgical approach is a through a midline incision on the raphe of the scrotum. This allows the testicies to be dissected out  and delivered through the incision with its pedicle oriented inward.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had an extra large Implantech conform chin implant put in last year and then got a revision to up the size to an extra large Implantech Terino 1 square chin implant. 

However, with the increased size in implant, a few additional issues have arisen. 

1) I am still unsatisfied with my profile view – my chin still looks slightly recessed. I am interested in a sliding genioplasty to further augment my chin. 

2) The larger implant size has made the pre-existing asymmetry in my chin more evident. If I were to undergo any sort of sliding genioplasty procedure, I would want to have the asymmetry corrected in terms of removing the excess bone growth on the right side of my chin. 

3) The dip/groove between my lower lip and chin has deepened. It is a horizontal line (not sure if it’s the labiomental groove or not) and has become more prominent with the implants. Not sure what would be done to fix this. 

In summary, there’s an array of things I’d like to do to my chin area – would this all be possible while still maintaining the chin implant? As in, either leaving it in during the procedure or temporarily removing it and placing it back in in order to maintain the increased projection. 

Thanks for your time! 

A: Thank you for your inquiry and detailing your chin surgery issues as well as objectives. In answer to your questions:

1) If the chin implant is in the proper position, (low on the chin bone), then a sliding genioplasty can be done with the chin implant in place.

2) It is not clear to me just yet whether/how the chin asymmetry can be improved. It may be best done by making a change in the movement of the sliding geniopalsty from side to side as it comes forward. It may be difficult to remove bone from the chin with the chin implant in place. But just based on a description I can not yet say how it might be done.

3) Deepening of the labiomental groove is always to be expected as the chin comes forward albeit with an implant or a sliding genioplasty. Further forward movement can be expected to even worsen its depth. With a sliding genioplasty the management strategy can be to fill in the bony step-off with cadaveric bone chips/graft.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Recently, I’ve been reading your patient questions on chin widening – a procedure I am very much interested in. 

One year ago I had a sliding genioplasty to push my chin forward. Without discussion, my surgeon also burred it down on the sides. I had asked for harmonious facial features but burring my chin down to make it narrower was out of line. While the sliding genioplasty itself did improve the side profile of my face, it and the burring has narrowed my chin from the front view and has feminized my face. My surgeon appreciates the look – I do not.

Like some people, I am hesitant on implants and I understand it may be the easiest option to achieve my desired outcome. But i am just not comfortable with the idea of an implant.

1. Is a chin widening osteotomy possible in my case or does the pushed forward chin bone from the sliding genioplasty make it more difficult?

2. I’ve read in one of your responses that this type of osteotomy can create a step off in the chin to jawline area. Is there a limit to which the chin can be widened with a t-shaped osteotomy before it is visibly noticeable in the smile? I’m only interested in adding 4mm or 5mm of width. I’m alright with being able to feel the bone but visibility may be a problem.

3. If a step off deformity is a problem, is there a reason why the step offs can’t be shaved down to meet the edge of the jawline?

4. Is a bone graft necessary for a gap of 4mm or 5mm. If a bone graft is not placed, will the gap stay hollow and eventually fill out or create a bum chin look?

Thank you for your time.

A: In answer to your chin widening osteotomy questions:

1) A widening chin technique can be done in a chin that has already had a horizontal sliding genioplasty.

2) At 4 to 5mms expansion this should not create a lateral step off. Such a step off can be avoided by placed a ‘keystone-shaped interpositional graft and make the separation in the middle osteotomy (without a graft) like a keystone shape.

3) Shaving the pushed out lateral wing if it is present is also a technique to eliminate any lateral protrusion.

4) With a small 4 or 5mm defect an autologous bone graft is not necessary. It is nice to use a small cadaveric bone graft or hydroxyapatite wedge for both stabiity and to ensure complete bony healing.

Dr. Barry Eppley

Indianapols, Indiana

Q: Dr.  Eppley, I am interested in a rhinoplasty and otoplasty revision. I had a rhinoplasty and otoplasty two years ago when I was 18 years old.I believe the surgery did not go as expected because of healing and post-care reasons (wrapping and such). Maybe even due to my young age.

I am now 20 years old and am not thrilled with the outcome of these procedures. I can say that I am much happier with how I looked after then I did before, but I definitely believe he could have done better.I am not looking for perfection but I believe as humans we all enjoy the idea of becoming photogenic and being rather more symmetrical.

I will attach pictures before and after the surgery.

In regards to the otoplasty and rhinoplasty. The problem is the left ear, but I only want to fix it if you think it is possible to be perfect and make appear a but more natural. As for the right ear, I am extremely unhappy with. It looks like a cauliflower ear and mildly deformed.

I am mildly content with the shape when looking at my entire front facial profile, but the side profile bothers me, I am sure you will agree.

As for the rhinoplasty, I am mildly content with the side profile. However I would have liked a stronger profile, and not so much of a dip. As for front forward, it is crooked towards the tip. It is almost as if it looks like the right of my nose lacks cartilage due to the crookedness.

Ultimately looking to straighten, strengthen the bridge, and fill my nose with this revision (I want a more masculine/strong nose)

If you believe that you are not capable of making this my first and last revision, please let me know, with either surgery. If that is whether you believe there is another surgeon who may be able to better assist me or you believe I should seek a revision from my original surgeon, please be honest.

I initially came to you in hopes of jaw implants. I know that underlying, I have a nice base jaw structure, but I only want to improve it and strengthen its appearance in seek of a more masculine, well defined face, with sharp jaw edges.

I stumbled upon your YouTube videos and those results are priceless. There is no other doctor I would trust after seeing your work.

Looking at my pictures, what do you think? What do you recommend? 

A: Thank you for sending all of your pictures and detailing your concerns. In answer to your rhinoplasty and otoplasty revision questions:

EARS. There is definite cartilaginous deformity of the upper antihelix/scaphal areas. This is undoubtedly caused by the way the sutures were placed to fold the ear back. There is also a bit of overcorrection of the middle third of the ear compared to the upper third and the earlobe. On the left ear it is also as you have aptly described a cauliflower ear deformity which is a result of the how the cartilage was folded and healed. While this is the ‘easiest’ problem that you have to treat, it also the most unpredictable of whether it can be improved. I would have to unfold the cartilage from the back side and see if the fold can be recreated in a more natural way. The middle third need to be brought out a bit and the upper third and earlobe to be move in a bit. None of this is technically hard to do but how the scarred ear cartilage will respond now can not be precisely predicted.

NOSE What you have is a lower middle third of the bridge with an overprojected and crooked tip. This creates the dip in your nose which is not the look most men want… a straighter dorsum/bridge is more desired. The tip needs to be shortened and straightened and the bridge built up. This requires cartilage grafts  and I will assume that your septum was not touched during your initial rhinoplasty procedure. This would be critical to know as that would the first donor site chosen given the proximity and its straightness.

It goes without saying that it is always best, if you have confidence in him, to return to the surgeon who performed the original surgeries for your rhinoplasty and otoplasty revision as that would be your most economical approach. But revision ear and nose surgeries like yours requires an advanced level of expertise and experience for improvement…scarred tissues are never as responsive as before they ever had any surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had submental liposuction done last year for my double chin but I am unhappy because the results are so small. I still have a double chin. I went to two doctors and they both advised chin augmentation and liposuction but I didn’t want the former. My double chin is hereditary and I thought I would see a change. Would a submentoplasty have been better? I also got no jawline contour at all. I’ve seen that with Precision TX and incisions by the ear and under chin, there are nice results with contouring. I’m confused and don’t trust anymore. Can you please help me? What do you suggest?

A: Thank you for sending your pictures. The fundamental problem with your double chin is the your chin is short and your hyoid bone is high. Unless the submental area is stretched out (move the chin bone forward by a  sliding genioplasty) and the neck muscle tightened with direct defatting (submentoplasty), there is no further improvement possible.  Isolated procedures like a submentoplasty with a jowl lift can also be helpful. But short of these, everything else will be a waste of effort and esources.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, have two questions about what is possible with surgery. I had a lip lift a long time ago and it was brought up a lot so now it always looks like my lips are pouting like I’m sad. Is it possible to make the lips go out laterally to make the corners look like they are higher and outward a good amount like you’re smiling instead pouting. I know it can be done externally but that will leave a noticeable scar. Can it be done internally somehow? The other question I have is I have done work with you on my eyes which made them more open and I’m happy with it but I wanted to know is it possible to make eyes go out laterally as well? To make them wider? My eyes are round but very little in length.

A:  In answer to your corner mouth lift and eye widening questions:

1) The corners of the mouth and the side of the upper lip can only be moved through an external approach, not an internal one.

2) Stretching out the outer corner of the eyes through a lateral canthopexy (eye widening) can be done but it is notoriously unstable with a high rate of relapse. The eye is very sensitive to have good contact with the eyelid and if they are separated the body works really hard to bring it back in.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am not sure how common this eye reshaping question is. I was wondering about how far a plastic surgeon can go to alter the shape of someone’s eyes. My eyes are pretty standard Caucasian, round, double lids, no epicanthal folds, non-hooded, etc. But I wanted to change a number of things about my eyes. First off, when relaxed my eyes are round, really open-looking, and sort of just dull. That’s why I have a habit of squinting them to make them appear narrower, and I know that’s probably not good for them, but that’s besides the point. I was wondering if there is a surgery, (or probably a number of surgeries in my case) that can be done for the following: In the inner corners of my eyes, there are just normal looking open tear ducts. But I was wondering if there is anything that can be done to “hood them” or give them the slightest epicanthal folds, not enough that they look Asian, but just enough so that they look exotic and sharp and not as much “open.” Jennifer Lawrence’s eyes are sort of like that. The second thing I was looking into was having the lower eyelids lifted so that my eyes have more of a narrower shape so that I don’t have to squint them. The third thing is something that I have no idea is possible or not, but I was wondering if you can get the middle of your upper eyelids hooded? Not the outer parts of the top eyelids, just the middle so that they’d gradually fan out from sharp, exotic tear ducts, then to a hooded upper eyelid right at the arch of the lid, and then into nice, open outer lids. The fourth thing I was considering was I believe called a canthoplasty, and I’m looking to have the outer corners of my eyes raised slightly so that they have an upwards slant and look more exotic. Sorry this was so long! I just know that the eyes are the most noticeable/memorable feature of someone and I would kill for nice eyes.

A: Thank you for your inquiry. In answer to your eye reshaping questions, which are not uncommon:

1) For the inner corners of the eye, it is possible to close them down a bit for more coverage of the lacrimal lake. But that does not usually create a true epicanthal fold appearance.

2) The lower eyelid can be raised by the placement of an interpositional mucosal graft combined with a lateral canthopexy. Raising the horizontal level of the eyelid requires more tissue,  not just being ‘pulled  up’.

3) A hood can not be created in the upper eyelids as that would require more skin…and a skin graft would create a patchy unnatural appearance.

4) The outer corners of the eyes can be raised, but as discussed in #2, this requires an interpositional graft to maintain it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am attaching pics of my face (front and sides) for facial reshaping surgery. I have had these genetic fat deposits all around my mouth (corners and nasolabial folds) jowls, low cheeks and under my chin since I was very young. The results I would like to achieve is an overall more slimmed down and chiseled look in my lower face, in particular definition along my jawline, eliminate the perioral mounds, and the fat in my chin  

What would you suggest would be the best surgery procedures to achieve what I desire?  

How effective it would be in my case?

A: Thank you for your inquiry and sending your pictures. In short I think what you are trying to ideally achieve is not going to happen the way you want it to be. You already have a fairly thin face (albeit thick skin) and using the criteria of bending your head down and creating skin folds is not going to respond to any type of fat removal treatments. While liposuction can be done in the perioral mounds/lower cheeks and under the chin and along the jawline, its results will be very modest and will not create a very slimmed down or chiseled lower face/jawline appearance.

While a facial defatting procedure will provide some benefits, it will just not be at the level of facial reshaping that you appear to desire.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve been following your website for some while now and was wondering if I could get some answers on cheek resuspension.I had zygoma reduction surgery last year and was interested in this procedure. Specifically I am interested in your preferred method of cranial cheek resuspension.

(1) I am 21 years old and of asian descent. Zygoma reduction has given me slightly lowered cheeks when I smile and puffy nasolabial lines. Would this cheek resuspension technique fix my problems?

(2) Is my age and race a problem with this type of surgery?

(3) Is there hair loss associated with the incision?

(4) How long would it take for swelling to go down and for people around me to not notice that I have swelling?

(5) Is this procedure the same thing as a cheek lift?

(6) Can this resuspension be done to look natural? I do not want to have chipmunk cheeks afterwards and think I only need a slight lift of the cheek tissues.

A: In answer to your post zygomatic reduction cheek suspension questions:

1) Cheek soft tissue resuspension would be the only treatment option for sagging cheeks after zygoma reduction surgery.

2) Your age range and race is the most common patient for cheek suspension after cheek reduction osteotomies.

3) No hair loss is associated with any scalp or temporal incisions.

4) Two weeks would be the maximal recovery for swelling.

5) Cheek suspension and cheek lifts are interchangeable terms.

6) A goal of a slight lift is good as that is what would usually be achieved and/or needed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in genioplasty however I would prefer biodegradable fixations. Is that possible for a lateral genioplasty. My chin is asymmetric therefore my chin would need to be moved to the right. It does not need advancement.

A: The use of metal plates and screws in common in all forms of bony genioplasty. Lactosorb biodegradable fixation devices have a long history of use in craniomaxillofacial surgery. Its use is not the most common in orthognathic surgery including bony genioplastigs. But it can be used for a genioplasty of the bony movements are not excessive. Sliding the chin to one side without an advancement is a fairly stable movement that maintains good bone contact. So the use of biodegradable devices is possible in this situation. It will cost more than the use of small metal plates and screws but it can be done if one is so motivated. It will require the use of 2.0 mm devices which will need to be prepped for the screws. The screws will engage the bone well in the downfractured segment. The only question is how well they will engage the thinner bone in the superior bone segment.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I am 23 years old. I’ve had undereye hollows or dark circles since I was a senior in high school. To hide them, I have to pack on a lot of concealer and foundation, layer after layer, and I’m tired of doing it!

I’ve tried fillers, but they never last long (maybe 3-6 months.) I think they tend to last a lot shorter of a time because I am young and quite active. It’s taken quite a toll on my wallet and to be honest, I can’t really afford multiple top-ups every year anymore.

I’ve actually consulted some surgeons on doing fat grafting for under the eyes, but most of them have told me the same thing. My undereye skin is thin compared to the skin everywhere else, and that they couldn’t guarantee that there wouldn’t be any lumps and bumps from the fat. 

So, I’ve been looking into undereye surgeries for Asians to correct my type of issue. Where better than Korea, where they specialize in Asian surgeries?

I’ve been looking at lower eye surgeries for young individuals in Korea and came across something called under eye fat repositioning. A fair amount of clinics seem to offer this type of surgery where they somehow relocate unnecessary fat swollen in the lower eye to the more hollowed parts. 

I was wondering what is your insight onto this procedure and would it be beneficial to me in reducing my undereyes?

They say no wrinkles are incised, making it different from a lower bleph, and I’m not really sure what to make of this.

What would be your suggestions to a long-term solution to my problem? I understand that no surgery can stop the ageing process but for me, surely there would be some long-term solution that at least slows down the aging process under my eyes?

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

1) Transpostiion of infraorbital fat out to the undereye area is a commonly performed lower blepharoplasty procedure today. However you have to have herniated or protruding infraorbital fat to do so….which you do not. Thus this form of ‘fat grafting’ will not work for you. You will have to bring fat from somewhere else into the lower eyelid to do so.

2) You have touched on the potential issue with injection fat grafting, that of irregularities. It can be an effective treatment if the fat is micronized, where the risk of irregularities is very low, but this also lowers its survival percent.

3) The other fat grafting option for undereye hollows is a dermal-fat graft which is harvested from some other body location and then placed through a lower blepharoplasty incision. This tends to survive better than injection techniques with a lower risk of irregularities but does have a donor harvest site. (scar)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I have perioral fat mounds. I would like to know about options to remove them. It seems like a fairly uncommon problem and most plastic surgeons in my area are unsure how to treat it. I live out of state but I would possibly be willing to travel. I would like to see before and after photos, but I could not find them on your website. Could you tell me where to find pictures for this procedure. I may be interested in scheduling a virtual consultation sometime soon. 

A: Thank you for your inquiry in regards to perioral mound liposuction. I will have my assistant Camille contact tomorrow to schedule a virtual consultation time. In the interim I would encourage you to check out my other website, www.exploreplasticsurgery.com and search under Perioral Mounds. There you can see many blogs on this topic as well as some before and after picture results. While the treatment of perioral mounds is uncommonly done, that does not mean it is not very effective. The use of microcannulas allows for controlled removal of this small area of subcutaneous facial fat from a very small incision incision inside the corner of the mouth.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m 26 years old and of Asian descent. I recently flew back to my home country of Korea two months ago to get jaw angle reduction surgery for cosmetic purposes. I unfortunately didn’t communicate to the surgeon well enough (as I had thought) that I didn’t want my jaw angles amputated up to the ear, but that’s what happened and it’s something that doesn’t cause me a lot of distress and I can just deal with it. 

What does cause me distress is the newly founded pudginess or fullness of my submental area. It may or may not be residual swelling as I am only 2/3 into the minimum “full recovery” of three months, but I would like some insight if you will.

I did read a past response on courses of action, in the case the pudginess or double chin effect remains after recovery. From memory it was a soft tissue tuck from under the chin or chin liposuction. I am open to both these ideas to get rid of the double chin if it does not retract. But I do have some questions which I hope you will answer.

(1) How would liposuction help if the double chin is caused by excess soft tissue sag and skin? I do not think I had a lot of fat underneath the chin area prior to the surgery and a double chin only appeared when I smiled. Do you think that something like CoolMini fat freezing would still be beneficial in my case?

(2) If liposuction of the chin area is not the solution in my case, I would be interested in a soft-tissue tuck instead. What happens with a soft tissue tuck? Is excess skin and tissue excised from beneath the chin area? How long is the scar?

(3) As I am Asian and I personally tend to scar quite badly, I am worried that if I were to proceed with a soft tissue tuck, it may leave a nasty scar from underneath the chin. Are there any other potential methods to reduce submental fullness from jaw angle amputation or reduce the scarring from underneath?

A: in answer to your after jaw angle reduction submental tissue sag/fullness questions:

1) Whether submental liposuction would of benefit for your double chin I can not say as the would depend on the thickness of your subcutaneous tissues. At the last it would be a lot more effective than any non-surgical fat reduction therapy.

2) While a submental tuck would undoubtably be the most effective procedure, I would he very hesitant to do so in an Asian patient, particularly a young female for the obvious scar concerns.

3) Other than liposuction or a submental tuck there are no other procedures to treat your postoperative jaw angle reduction submental fullness.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in chin reshaping. I was wondering if it is possible to turn a slightly tapered chin into a more curved, U-shaped rounded chin without the use of implants? Are there bone cements of some sort which are able to achieve this?

A: Chin reshaping that involves augmentation can be done using a variety of materials and implants. The problem with the use of bone cements for this aesthetic purpose is their cost, workability and smoothness. It is very hard to get bone cements placed through a semi-wet intraoral approach in a tight subperiosteal tunnel that will allow them to set up and be shaped properly. It is not impossible but their use is much more potentially problematic than that of preformed implants. Hydroxyapatite cements are mixed into a putty intraoperatively and then applied and shaped. Until they are fully set they are easily deformable. While partial set is achieved in 10 to 15 minutes, a full set may take a day. Based on these working properties it is easy to see how they can be potentially problematic for stable and assured facial bone augmentation. The use of hydroxyapatite granules is not any better as granules do not acquire a stable set shape during surgery. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Around half a year ago, I underwent cosmetic malar bone reduction to correct some facial asymmetry. I’ve always been conscious of the asymmetry of my cheekbones and always had my hair down to cover their protrusion.

The surgery did reduce the cheekbones. When my face is in a still, non-smiling position, there is still some very very minor asymmetry but only in my eyes.I understand that perfect symmetry can’t be achieved.

However, though the surgery solved one problem, it gave rise to another.Though my surgeon corrected the asymmetry to the best of his abilities, I’m now worried about my right side. My right side initially has less of a protrusion prior to the left but my surgeon reduced the zygomatic bone by the same amount as the left.

I’m finding that on the right side of my face (right in front of the ear, right underneath the zygomatic arch bone, not the anterior bone) there is a very slight depressed area of tissue or bone (?) when I smile. I am annoyed because I spent money to fix my asymmetry problem and now I have another from trying to fix it.

I’m finding that when I smile, my bottom side on the right side juts out right underneath the depressed area. The left side doesn’t seem to have this problem and fully curves out when I smile. It makes me look lop sided when I smile and I STILL have to use hair to cover my insecurities.

What can be done to fix this? I know that it’s stupid to fix something on your face when it’s in a smiling position but I just hate that my face has become lop sided after I tried to fix lopsidedness from another area. I would like a more permanent solution if there is one.

Can hydroxyapatite cement be used to build out this area?

A: Certainly the depressed area could be augmented as it probably represents the infractured portion of the posterior zygomatic arch. There are a variety of materials that would be used to achieve this augmentation of which hydroxyapatite cement would be one of them.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have been experiencing headaches in the occipital region for over 10 years. I’ve had injections and tried 3 different medications to no avail. It is to the point that I take 3 Alleve every other day. The pain even radiates down to my neck and shoulders and sometimes to the top of my ear. I wonder if this procedure would be helpful. My insurance is Anthem Blue Cross/Blue Shield. I’m really starting to worry about what the Aleve is doing to my body. I have not tried Botox injections yet (even though my Neurologist wanted me to try them) due to the cost. Interested to know your thoughts. The pain comes on the right side straight over from the bottom of my ear in that little indention.

A: The critical questions in candidacy for migraine surgery are: 1) does the origin and location of the migraines coincide with a cranial nerve exit point from the skull/location and 2) does it respond to Botox injections.

Based on your description it is it clear where the exact location of the migraines is A picture pointing to it would be helpful. Having the migraine location receive Botox injections would also provide useful information.

Dr. Barry Eppley

Indianapolis, Indiana