Your Questions

Q: Dr. Eppley, I am attaching some facial photos for assessment for perioral mound liposuction The area I am concerned with is particularly visible in a 3/4 facial profile, but it also shows up in straight-on shots as weird shadowing around and below the corners of my mouth. Ideally, I would like this area to flatten, so that I can have a straighter profile. However, I am worried that fat removal in this area could cause laxness or drooping of the skin. I would like to avoid jowling! 

I also have dimples in my cheeks when I smile — not sure if this makes any kind of difference, but I thought I would let you know. Thank you!

A: Thank you for sending your pictures. Your area of concern would be considered the perioral mound region and yours is a classic case of it. It is really only treatable by very small cannula liposuction through a small incision inside the corner of the mouth. I have not seen loose and lax skin develop afterwards as almost every perioral mound liposuction procedure I have done is in younger patients.

Having cheek dimples does not affect the results of perioral mound liposuction either positively or negatively.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am seeking extra large breast implants. I was a natural 34H and then got 800cc silicone implants under the muscle. the dr had said it would double my size. However it didn’t change my size at all, it only gave me a tiny bit more upper pole fullness was all. So I was very disappointed with spending all this money to not be bigger which was what I wanted. I have been told by a couple of Dr’s I could go up to 2000cc with overfilled saline. Is that something you would do? Or will you not go that large on patients? I want a good plastic surgeon with good ratings like you have. I am not a tiny framed lady, I do have a curvy build. Please let me know, thanks.

A: If 800ccs breast implants did not come close to your breast size goal, then at least twice that would be needed to make a more visible difference. Overfilled saline implants would be the only way to achieve that type of volume. Where the final volume might be on the spectrum of 1600 to 2000cc depends on how it looks and feels during surgery.

Please send me some pictures of your breasts for my assessment for these extra large breast implants.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I heard about you when I was researching Knee Lifts. After reading more about you ,watching your YouTube and reading your Bio as well as looking at your website I think you are indeed incredibly and uniquely qualified. Unfortunately I saw nothing on your website about my problem so I will ask you directly.

I believe I have stage 1 Lipedema,. After a few years of research I believe its Lipedema, based on my symptoms, age onset and process of elimination. The only treatment for Lipedema is liposuction from what I have read and spoken to surgeons about. I am planning to get my calves and ankles treated by liposuction but the surgeon I’ve spoken to doesn’t want to touch my awful, fat, disfigured knees as he says “knees are tricky”. He also isn’t too keen on my thighs as most of the disproportionate fat is right above my knees, which he says will make my knees much worse than they already are. I am not overweight, I am healthy, athletic and in shape. I would like to know what you know about Lipedema,and what your thoughts are about this type of surgery.

Thank you for taking your time to read this and reply.

A: As you know there are differences between lipedema and lymphedema by which you have come to the conclusion that you have the latter. Some improvements in true lipedema can be obtained by liposuction as you have stated.  When it comes to using liposuction for its treatment I would be more concerned about prolonged edema from the calfs and ankles but not the knees. There is nothing ‘tricky’ about the knees and there is not any anatomic feature that makes them different for liposuction surgery. What the skin will do when the fat is reduced can not be precisely predicted anywhere on the lower extremities but most likely it is not going to shrink in a perfectly smooth manner. That would be an expected tradeoff for the size reduction.

Those are the general comments I can make without having any specific visual knowledge of your lower extremity problem.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, what are the differences between lip ‘advancement’ and lip ‘enhancement’ and lip ‘lift’? I’m specifically looking to augment my upper lift for more fuller appearance.

A: In answer to your questions, lip enhancement is a global term that refers to any type of lip augmentation procedure, albeit injection or surgical.

A lip advancement, also known as a vermilion advancement or ‘gull wing’ procedure removes skin just above the upper lip and the vermilion or red part of the lip is moved up to cover the removed skin area. This increases vermilion show from one mouth corner to the other. In essence it pushes the vermilion towards from below.

A lip lift, also known as a subnasal lip lift or ‘bullhorn’ lip lift removes skin from below the nose and lifts the lip upward. It shortens the distance between the nose and the upper lip and improves the central vermilion fullness of the upper lip. It does not have any effect on the sides of the upper lip.

I would need to see pictures of your lip to determine which lip enhancement procedure may be best for you. Most patients graduate to surgical lip enhancement after trying injectable lip enhancement methods.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in correcting my jawline asymmetry.  I’ve always hated taking pictures head on or from the right side of my face because of the asymmetry of my chin and the angle of my jaw on the right side. It’s almost as if my jaw has shifted down and has caused my chin to shift and protrude forward on one side.  This has been the case for as long as I can remember and I almost feel as if it’s getting worse. Probably because my skin is thinning and I can see the outline of the chin a little more. I’ve never had any dental issues or braces and no dentist has ever told me my bite needed to be corrected. I just wanted to find out my options-and see if this was actually possible to fix. Thank you so much in advance!

A: Thank you for sending your pictures and describing your lower jawline asymmetry concerns. What you have is an overgrowth of the right lower jaw that makes the jaw angle slightly bigger,  the right jawline lower and the chin shift to the left. Usually with such jaw overgrowth there would be associated bite and occlusal plane asymmetry…but you seem to have largely avoided that typical accompanying issue. The treatment would be one of a chin and jawline bone shave from the left side of the chin all the way back to the jaw angle. This would be done through a submental incision approach. The amount of bone to remove would be determined from a simple panorex x-ray based on millimeter comparative measurements of he height of the mandible from midline chin to the ramus.

Dr. Barry Eppley

Inianaopolis, Indiana

Q: Dr. Eppley, I have consulted with you many times about my facial structure and have plans to do the jaw implant. I’m just wondering if I already have surgeries on my chin (1st surgery sliding genioplasty. 2nd surgery reverse sliding genioplasty 3rd surgery shaved the corner of the chin from expansion as it made my chin becomes square) will it be safe to do the jawline implant? Not doing anything with the chin but maybe will be the same area that got cut several times. Will it increase the risk of infection? I don’t plan to do jaw inplant with any doctor in Korea or anywhere as I think a doctor with experience is the best. And I had to save up again and again after my previous failure for other parts.

I really plan to do it but will be about a year or two from now since I have to finish my braces first in another country. 

A: Regardless of your prior chin surgeries, that does not preclude you from getting a jaw implant in the future. The custom jawline implant is made from a current 3D CT scan so this will show your current bony anatomy. That happened to the chin bone in the past does not affect placing an implant across it in the future. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a custom jawline implant. I am attaching a few photos of my face and you will see that my lower third is narrow. My general interest is in a wraparound jaw implant in order to widen the face, tighten up the submental, improve aesthetics of the face and protrude the chin to balance the protrusion of the nose. What does your aesthetic eye think of this possibility judging by my photos?

Do the custom made implants have a high success rate as in the forum for plastic surgery knowledge I frequent there is a patient from Western Europe of yours that has had 2 revisions to his jaw implants in the span of 7 months? He says its “finetuning to look natural”. I am not extremely interested in having it revised because I dont want to endure the whole ordeal again.

A: If you are looking for increased lower facial width and dimensions of the chin and jaw angles that has a smooth linear connection than a custom jawline would be the preferred choice.

It is not uncommon for many patients to have revisions of custom facial implants including custom jawline implants. This is primarily because they often don’t know what they really want until they wear it to so speak. In the case you so described the patient himself chose the dimensions and that was what was exactly provided to him…only later to decide he wanted a different look. (Less strong)

The key in any custom jawline implant is that less is more. It is always to better to go smaller in dimensions as its effect is more substantial than a patient can anticipate. In looking at your face that its exactly what you…a smaller custom jawline implant. I cll this type a ‘jawline defining implant’ as it just adds angularity and a little width.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have put some thought into those measurements you told me about regarding zygomatic arch implants. I have made some research of my own and I have a found a cheek implant from Stryker that is not far from being a zygomatic arch implant. It’s measurements are close to the ones you suggested  for me and my aesthetic goals (yours: 5cm length / 6-8mm width / 5mm projection height) which I assume can be carved/cut to meet your measurements even more.

Despite doing all of that sizing modification, the implant isn’t originally designed to sit on top of the zygomatic arch only. (This implant is also slightly bent in its shape). In the sample photo above, you can see that it is positioned in a way that starts just halfway on the zygomatic arch, going further over the malar prominence, whereas it ends at the maxillary buttress.

My question is; after the surgeon have carved/cut this implant to meet the sizing recommendations you sort of suggested, is it even acceptable to position this implant on the entire zygomatic arch?

A: I would be very cautious about using a Medpor material as a zygomatic arch implant. Besides the issue of its natural underlying shape (curved), the tissue ingrowth from this material will make it virtually impossible to ever remove or revise it later. There is a branch of the facial nerve that crosses over the posterior zygomatic arch that supplies movement to the forehead. While there is a very low risk of injuring this nerve during the insertion of the implant, trying to remove a Medpor zygomatic arc implant later due to the tissue ingrowth will almost certainly increase that risk considerably. If injured there will be some paralysis of the forehead. Thus this is not a material I can endorse as a zygomatic arch implant. Easy reversibility of a facial implant can be an important feature whose importance varies based on the anatomic facial location of placement.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I hate to say it but I’m second guessing my decision about rhinoplasty surgery the more I read online.  Perhaps I shouldn’t be reading online but I’m reading things like “nose job is the worst possible procedure to have done for a male.”. And that the problem is a lack of facial bone growth, not a big nose, which in my case is certainly true as I have a narrow face and underdeveloped lower third.  So I’m wondering will a rhinoplasty simply be a regression for me, further feminizing my face?  I know ultimately it’s my decision but obviously you understand aesthetics better than I do and could offer some sort of assurance as to why a rhinoplasty would be beneficial for me.

A: The psychological preparedness of a patient before any aesthetic surgery is of great relevance. A patient’s behavior will follow after surgery the exact pattern that they had before surgery. This is a plastic surgery experience that we see on a near daily basis.

 It is one thing to be anxious about the surgical process, which most people normally are, but to be questioning whether one should have surgery at all based upon an uncertainty about the facial changes speaks to a different level of anxiety. It is important to realize that almost every patient after elective aesthetic facial surgery goes through a point in their recovery where they question the wisdom of their choice. For those who have few doubts before surgery they get past it at some point in their recovery. For those that were internally questioning whether such facial changes would be beneficial at all,  they may never get past it and may recover to regret having had surgery. This is relevant since rhinoplasty is an irreversible change. It is not like a cheek or chin implant which can be pulled out later. This its why computer imaging should always be done before rhinoplasty which can help the patient visually determine if the surgery is worth it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a lateral commissuroplasty (mouth widening surgery) as I have a small mouth. How risky is this procedure in terms of end results? Does it always leave visible scars? And how visible are these scars? Will the scars heal evenly on both corners of the mouth? I’m curious to see some before and after photos of this procedure as I could not find any online.

I am also wondering about functionality after the procedure. How will smiling, eating, talking potentially be affected? Will there be a problem with drooling?

Thank you for your time!

A: Thank you for your inquiry. An opening lateral commissuroplasty or mouth widening procedure works because it removes a triangular segment of skin at the sides of the mouth and moves the vermilion of the mouth corner outward. By definition this leaves a v-shaped incision line at the mouth corner and a resultant fine line scar at the vermilion-cutaneous border. How discrete that mouth corner scar looks can vary but does well most of the time. Regardless of how they heal they cause no functional issues and do not interfere with eating, talking or smiling.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in eye widening surgery. My eyes are too close set together. I am looking for a way to widen them apart.Is there any chance getting the so called “box orbital osteotomy” surgery? Do you perform it? I understand this is a major cranofacial surgery but nowadays these types of procedures can be done safely. Could it increase the interpupillary distance for a few millimeters without looking deformed? Appreciate your help and time.

A:As an adult orbital box osteotomies are not appropriate for aesthetic eye spacing issues or is a form of eye widening surgery. I only perform orbital hypertelorism repair in young children. This is major cranofacial surgery of which its safety is not the issue. It is that it requires a craniotomy and the creation of numerous other aesthetic trade-offs (scalp scars, bony step-offs etc) that do not justify this type of orbital surgery for a few millimeters of inter pupillary distance increase.

That being said, they may be other more minor eye procedures that may be of benefit but I would need to see a frontal view picture of your eyes to determine if they may be successful.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I had lip surgery last year with an asymmetric outcome. My mouth even got smaller (horizontal) which is a problem. Another thing is, that I’d like to reduce the red part of the lip with white skin. Now I wanted to know upfront if a correction is possible and if it is possible to reduce about 2mm of the red lip. (but not from the lip inside)

A: What you have done were lip advancements, also known as vermilion advancements. (An upper lip advancement is also known as a gull wing procedure) Your mouth got smaller and probably a but tighter because the advancements were carried out to the very corners of your mouth at both the upper and lower ends, thus creating a scar line around the corners. Lip advancements should never be connected at the corners to prevent creating a circumferential scar contracture which acts like a drawstring around the mouth as it heals. This can be corrected by doing a scar release at the corners and advancing the mucosa back out. This will also increase the horizontal distance between the mouth corners as well.

I am certain what you mean by ‘reduce the red part of the lip with white skin’. I assume you mean sort of reverse lip advancement? If that is what you mean, that is not possible to do. While the vermilion of the lip can be brought out by removing skin, the reverse can not be done.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m a 23 year old male who suffers from severe flatness of the back of my head. It has bothered me immensely for my entire life and has seriously affected my self esteem and my overall satisfaction out of life and the way I look. It’s very difficult for me to open up about this to anyone, but I am absolutely desperate to change my appearance. I was wondering what your suggestion would be in terms of what kind of skull augmentation procedure could be done. Thank you very much for your time and consideration. I cannot express the relief I felt when I discovered you and your practice online. 

A: Back of head augmentation is one of the most common skull reshaping procedures that I perform. A custom occipital skull implant is made to fit the back of the head from the patient’s 3D CT scan. Whether this is a one-stage procedure or requires a first-stage scalp tissue expander depends on how much skull augmentation is needed/desired. For most men a one-stage skull augmentation procedure is usually done, although in rare cases I have seen a few men choose a two-stage approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in cheekbone reduction reversal. I had cheekbone reduction surgery done five years ago in south Korea. One year after the operation, I developed right cheekbone pain which often persists all day  and I realized I can’t chew anything on the right side of jaw. In addition, I could hear sounds from both of my cheekbones every time when I’m swallowing. Recently, my right cheekbone pain is getting worse, the pain prevents me from opening my month, and I can’t even speak normally because of the pain from my right cheekbone. 

I have been doing some research on cheekbone reduction, and try to find the cause of my pain. It seems like the cause of my pain could be the improper fixation on cheekbone so that the screws get loosed. Since I have heard a lot of recommendations about you, I want to ask you is there anyway can fix my cheekbone and relieve my pain? I can send you my CT scan if you need it. I would greatly appreciate it if you kindly give me a short reply on my problem.

A: Thank you for your inquiry. By your description of symptoms, it sounds like that you either have a non-union of the cheekbone osteotomy, malposition of the cheekbone position or a combination of both. X-rays would establish that diagnosis. A 3D CT scan would be ideal but the CT scan you have may also be adequate.

Secondary surgery can certainly be done with repositioning of the bone segments and rigid plate fixation. Given that it has been a year, the bone edges will also need to be freshened up and an allogeneic bone graft placed probably. The difficulty with opening your mouth indicates that the coronoid process may be impinged and this may also need to be released.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a double jaw surgery one month ago to advance my lower jaw about 8mms. I also had a chin implant placed more than ten years ago. After the surgery, as the swelling goes away, I can tell the advancement was not sufficient and my chin is still a bit recessed. I’m considering getting a sliding genioplasty to get more advancement. Also the sliding genioplasty would replace the chin implant as it does not look very natural when I smile. When would be a good time to do the chin bone movement after lower jaw advancement? 

A: You can certainly do a sliding genioplasty with a chin implant in place. Or you can remove the chin implant and do the sliding genioplasty at the same time. The amount of additional horizontal chin bone movement equals the width of the chin implant to be removed plus the advancement needed for improved chin projection as determined by external chin measurements. I would wait a full three months after the double jaw surgery to let all the swelling go away and have a full recovery from that surgery before proceeding with the bony chin advancement.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a buttock implant revision. About ten years ago I got tear drop shaped buttock implants.  I had very little fat on my butt, so it was a bit disappointing after surgery.  I did have some augmentation, but my rear looked kind of pointed in the center.  I went back for some fat grafting towards the bottom to blend them in a bit, and it did help, but it was a so so result.  I figured it was better than having a completely flat butt, so lived with them for the next five years.  I had occasional soreness after exercise and sitting for long periods of time, but nothing unbearable. 

About three years ago I noticed the upper right side of my left buttock seemed sore pretty frequently.  I also wanted to investigate a different type of implant, so I found a doctor that preferred round implants.  He inserted a fairly large round implant that aesthetically was more pleasing and natural looking.  I’ve found that I have much more soreness with this pair. After exercise, after sitting for long periods of time, even laying flat in bed for a long time (if I’m sick) can cause discomfort for days afterwards even weeks.  It seems to be more around the “edges” of the implants or the implant pockets, but they are generally sore all over.  Especially that upper right corner again. Occasionally, it seems to radiate down the back of my legs, but this is rare. It seems to be getting progressively worse. 

They actually look pretty good.  There is nothing that unusual or unnatural looking about them. I don’t think the average person would ever know..so that part is not the issue..it’s the discomfort about 50% of the time. 

I’m really tempted to just remove them, but I’m afraid of being disfigured without them. It would be some period of time (6 mo’s- year) before I could do some fat grafting or anything else to remedy the issue.

Any thoughts on what’s going on and what I should do?

A: In answer to your buttock implant quandary, there are some critical pieces of information missing in your description. Are the implants in the subfascial or intramuscular position? What is the volume size of the implants? Who is the manufacturer and what is their durometer? (durometer = degree of firmness of a silicone material)

That information aside I can make the following general comments:

1) I think you would feel deformed if they were removed. It is no different than having breast implants and then taking them out…the resultant appearance will not be like what it was before they were put in.

2) It is hard to justify doing a buttock implant revision with an implant result that looks good even with some discomfort symptoms. The only reason to do so is if the buttock implant you have could be improved by new buttock implants that have much lower durometer. (much softer)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Ive had jaw angle lengthening implant surgery 5 weeks ago. But the masseter muscle didn’t come down with the lower edge ofthe implant. So I had Botox yesterday in order to downsize the relatively large upper muscle. But I am now really regreting that this was a bad idea because I heard this type of surgery needs at least 3 months of recovery time.

Can these Botox injections make my final look worse than it should be? And if so what can I do from now?I would have had Botox anyway but it was too premature.

A: You are correct in that one should wait a full three months after any facial implant surgery to have a full and accurate appraisal of the final result. Doing Botox at 5 weeks after surgery was not only premature but you ran the risk of inadvertently inoculating the implants and causing an infection. That alone should have given everyone pause for reflection on the merits of these early injections.

While Botox is a valid treatment for masseteric muscle disinsertion, waiting for the full recovery and then evaluating the merits of Botox injections, masseteric muscle resuspension or a change in the jaw angle implant style could be more prudently done.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a custom jawline implant placed last year. I’m currently dealing with a bout of bacterial acute tonsillitis for which I’m taking antibiotics for. Yesterday I noticed my right side of my face, notably the upper part of the mandible, below the ramus, is feeling tender and a bit swollen. This could just be swollen glands, as other glands around my neck are swollen too due to infection, but I wonder if there’s a chance the bacteria from my tonsilitis could lead to an infection of my implant as well? Have you ever seen this before? Anything in particular I should watch out for or do?

A: While it is theoretically possible that a facial implant could become inoculated by any distant or contiguous infection in the body, this is not something I have seen. If infection of the jawline implant was present it would have swelling with at the angle and further forward along the body of the jaw to the chin.

Most what you have are swollen lymph nodes in the neck which are the filters of infection from upstream. As long as you are on antibiotics until the tonsillar infection is resolved, I would think you will be fine.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a follow-up question pertaining to something you had mentioned at my rhinoplasty consultation the other day.  So you said I have very thick nasal skin.  I’m reading that thick skin often does not shrink as well as thinner skin so it might not conform properly to the reduced nasal size.   Also that it leads to scar tissue buildup in those open areas where the skin did not shrink sufficiently, resulting in a squishy, shapeless nose.  Should I be at all concerned about my thick skin or would you consider it a non issue?  Thanks much.

A: The well known issue with thicker nasal skin is how much it will shrink down to reflect any changes to the underlying bone or cartilage that has been modified. This is really only a concern in the nasal tip where the skin is the thickest. As long as the nasal tip cartilages are not aggressively reduced (which is not needed in your case) then the concern of the amorphous (shapeless) nose is not an issue. I mention it in every rhinoplasty patient who has thick nasal skin of the tip, whether it is male or female, to temper any expectation that they are going to get a small or thin-shaped nasal tip as thicker nasal skin will prevent that from being a realistic result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a question on chin implant recovery and I’ll be so glad ıf i can get an expert opinion from you. I removed my silicone extended anatomical small size 5mm chin implant after only keeping it for 2 days due to not liking it. Both incisions made under the chin. Its been 4 weeks since the removal and i still feel tightness numbness and lack of movement in my lower lip. Is it normal? Or should i be worried since its already been 4 weeks. I see a little improvement. And my main question is…after chin implant removal empty pockets left and i think they fill with edema ot collected blood. Does this edema etc resolve itself and dissepear so the pockets will shrink back or do they turn into scar tissue and stay there? My chin is still so huge comparing to my original chin İ wonder i its permanent? It ll mean so much for me if you can answer.  Thank you!

A: Like putting in the initial chin implant, in which you had it removed long before you ever had an idea of the final result, the same issue applies to the recovery from its removal. Taking out the chin implant will not expedite the recovery and it will take up to three months after the procedure to see the final result. Whether you put a chin implant in, or take it out immediately, the recovery is going to be the same. You can not judge the result until three months after surgery.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in custom jaw angle implants.  I’m finding out that standard implants (i believe 10mm) are not as strong as I would’ve hoped and not providing me the stronger look i seeked. 

I would like to find out if I can make my jaw stronger with bigger or custom jaw angle implants and whatever else needed or if that result is not possible I’d get my current ones removed since the current result is an improvement on the right track but still does not provide enough strength in my jaw I desired to balance out my face. At some points early in the recovery though swollen my jaw seemed a lot fuller and stronger than now. I believe increased height as much as feasible and a bit wider. 

This after result below seems strong I would like to see if I can reach this point by whatever means and I believe at some point in recovery with swelling my jaw was in fact that wide in proportion to my face.

A:Thank you for sending your before and after pictures. As you have now discovered, the final result of any facial implant augmentation is going to largely reflect the size and surface area that the implant covers. In the end you have more defined jaw angles which is exactly what the size of the implant does. What you have also learned by going through the process is that the overall jawline fullness that came from the swelling is more of your desired jawline look. That is going to take an implant design that covers more of the jawline from the angles the chin…which can only be done by a custom jawline angle implants design.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in chin asymmetry augmentation. I have an uneven chin, where the right hand side has less horizontal projection, and more vertical projection than the left hand side. I would like to improve that symmetry as much as possible and perhaps add a minor amount of projection to my chin. Is this possible? Would you recommend a genioplasty or implant?

A: Thank you for your inquiry. For an uneven chin in which you want to improve its symmetry and add a little more projection, a custom chin implant would be the ideal way to do it. Only through the use of computer designing could you be assured that all chin dimensions are adequately made symmetric. Using standard chin implants and ‘eyeballing’ them during surgery for placement or hand carving them in trying to compensate for the bony chin asymmetry is fraught with not only not solving the asymmetry but even making it worse. Because the chin is a projecting structure even subtle amounts of asymmetry are hard to hide. Thus the use of a custom chin implant made from a 3D CT scan is the best way to avoid this aesthetic problem.

I would need to see pictures of your chin to give a more qualified answer.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I have some cheekbone reduction questions. I’m already quite dissatisfied with the droopiness of the lower third of my face and along my jaw. Hence, I’m extremely worried that the cheekbone reduction would further worsen this droopy look. I’m sure you’ve heard about the “falling tent without its support” metaphor, to describe what happens to the surrounding skin when the cheekbone is reduced. I’m hoping to gain a more balanced midface without this happening.

While you mentioned that I may be too young for any lifting, I would be very interested in any lifting/liposuction procedures to effectively ameliorate the droopiness that I’m seeing, both in my midface and my neck area.

A: Any time you disrupt the attachments of the cheek, there is always the risk of some soft tissue sag. As I stated in my prior email this has not been an issue that I have seen from cheekbone reductions due to fixation of the osteotomized bone segments in their correct anatomic position. But that being said, the only way to have zero risk of that not happening is to not have the procedure.

When I mentioned that you are too young for any lifting procedure, it is important that you understand what I mean by that statement. All facial lifting procedures have as their origin the treatment of tissues that have dropped or sagged due to aging. Thus there is tissue laxity by which they can be moved. Young people, however, do not have any tissue laxity and thus any true lifting procedure can not really be done. You can not move someone’s tissues into a ‘super normal’ anatomic position. While it is possible to re-establish normal tissue positions AFTER they have dropped, you can’t really lift tissues that have not dropped. In addition, and equally importantly, any effective lifting procedures require scars. In the midface that is going to be eyelid, temporal or both scar locations. This is always a potential aesthetic concern in young people, particularly in thicker Asian skin. My point being is that you have to have a really good reason to do these lifting procedures as you don’t want to trade off one aesthetic problem for another.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I would like to ask about forehead osteoma removal. I have it from about 8 years. It is very good visible in direct light. As an attachment I have some photos of my forehead. I also have attached  x-rays taken a few years ago.I see it on your website that I will need a CT scan anyway.

I have few questions:

1) What is the procedure, step by step, with a forehead osteoma of this size? 

2) Will it be done under local or general anesthesia? 

3) During the operation I will breathe by myself or with the respirator? Or you will find it after CT scan and with the knowledge if the oeteoma is only on the surface of skull or it is also inside the skull?

4) Can you remove the osteoma with endoscopic method with the drill? The endoscopic method would be the best for me because it leaves no visible scar and it is less invasive.

5) Can we consult by Skype?

6) Before the surgery I will need some relaxing medicines.

A: Thank you for your inquiry and sending your pictures. Your forehead osteoma is very evident. The very pertinent question is whether this is an osteoma that is an outgrowth of the outer cranial table or whether this is an osteoid osteoma that invades the full thickness of the cranial bone. This distinction is critical as their treatment differs radically. I will assume for now that you have the more benign and common outer table osteoma. In answer to your questions:

1) Endoscopic or hairline incisional approach for removal.

2) Full anesthesia

3) A CT scan must be done to make the proper preoperative diagnosis.

4) An endoscopic approach can not use a drill or any other power equipment, it uses an osteotome or chisel.

5) A virtual consultation is done before surgery.

6) Sedative medication can be provided.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in lip asymmetry correction. My lips are thin and uneven and I would like to get it corrected. It’s so awful that I don’t want to have a picture of me taken with family. Five years ago I was diagnosed with a brain tumor. The surgeon operated through my eyebrow as the tumor was behind my eye.  This surgery left me with a mouth droop. I have attached pictures for your review and recommendations.

A: Thank you for sending all of your pictures. It is clear that the neurosurgery procedure created some facial nerve weaknesses which has resulted in your upper and lower lip asymmetries. The right upper lip is weak and does not lift up as much as the other side. Thus it rolls in and is smaller. The right lower lip depressor is weak and this makes the the right lower lip elevate (rather than being pulled down) when you smile.

While the facial nerves can not be made to work more normally, the lips have to be adjusted at the vermilion-skin junction to create more symmetric vermilion show. (lip asymmetry correction) These are known as vermilion advancements. The right upper lip needs a vermilion advancement to  create greater vermilion show to match the opposite side better. The same is needed for the lower lip to bring out the the vermilion edge to match better to the left side.

These vermilion advancements can be combined with a subnasal lip lift to shorten the distance between the nose and the upper lip at the same time.

All three lip procedures can be performed at the same time under local anesthesia as an office procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had lower jaw surgery (Sagittal Split Osteotomy) done a few years ago to correct my bite, and believe I would benefit from a jaw angle implant to improve my jaw angle. From what I read, it seems like this a a procedure that has a relatively high rate of failure. I would like to discuss and determine if this procedure would be recommended for me.

A: Thank you for your inquiry. I have an extensive experience with jaw angle implants and they do not have a higher rate of problems than any other facial implant. But because they are bilateral, implant/angle asymmetry is not rare. This is not only technique-related but also because many patients have natural jaw angle asymmetry which becomes magnified with implant augmentation. Such jaw angle asymmetry most certainly applies to you since you have had ramus osteotomies whose healing always creates some bony asymmetry.

I would need to see pictures of your face for an assessment and computer imaging as well as current x-rays (at least one year after your surgery) to see what your jaw angles look like. It is a question to determine what style of jaw angle implants you aesthetically need as well as whether standard or custom implants would be needed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I has a temporal artery ligation procedure done by a doctor in Beverly Hills who performed 2 point ligations on each side and double tied) a little over 6 weeks ago.  The left side did not work – the pulsation is still there – and the doctor is going to go back in a few months to retreat it.  On the right side, the pulsation is gone, however, I worked out very hard today, and the artery swelled up and the zig zag that was previously there (and previously had the pulsation) is back – but this time with NO pulsation. Has this happened to any of your patients (where the pulsation went away but the outline of the artery is still there)?  My doctor here has not seen this before.  And if so, what can be done to further correct it? 

A: In temporal artery ligation If you don’t strip the artery of blood before you tie off the ends, blood will stagnate in the vessel and its appearance may remain… albeit with no pulsation. But the most likely reason is that not all contributing feeders have been ligated. I have found that rarely does just two point ligation work well. Without knowing what the specific ligations locations are or what your arterial pattern was before surgery, I can not provide any further meaningful insight.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in making my face look better, some sort of facial rejuvenation surgery if you will. While I am only 50 years old, I feel like I look much older. Here are some starting pictures of me for your assessment.

While I’d like to fix the “bag” effect under eyes, the depressions in my cheeks, and the acne scaring…I’m looking at all possibilities as well. My nose has a slight hump in it (might be called a dorsal hump from looking online) and my nose seems a little wide at the top (I have no idea what the proportions of a nose should be relative to my face).

You can see the skin wrinkling in front of my ears, I’m guessing some sort of facelilt procedure to fix that as well. Another doctor told me that the bags under my eyes might go away with a full or advanced facefilt as well.

I don’t care for my smile and would love to have a bigger smile that shows more of my teeth.

A: Thank you for sending your pictures. You really don’t have herniated fat under your eyes, what you have are alar festoons. These are bags of tissue that appear over the highest part of the cheekbones. They are not easy to eradicate but are treated through a lower blepharoplasty procedure not any form of a facelift.

The skin wrinkling in front of your ears would be treated by a limited form of a lower facelift.

The mouth area would be treated by a corner of the mouth lift that turns up the corners as well as makes the corner to to corner mouth distance bigger.

Your nose could be improved any a hump reduction and shortening and lifting of the nasal tip.

All four of these facial rejuvenation procedures could be done at the same time.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, . I have a multitude of facial asymmetry issues stemming from a mild Kaban/Pruzansky birth defect. I have a confirmed hemifacial microsomia that has primarily affected the eye, orbit, and cheek regions and ramus of my jaw. They really bother me and I want to fix some of them. I am not sure whether to go for orthognathic surgery and a custom cheek implant. Or to do all implants on the affected side. If you place an implant in the cheek (malar-ygomatic arch), will this also make the affected eye and brow look more bizarre as it will look even further back with the projection of the cheek? How do I improve my facial asymmetry without looking even more bizarre in other words. I also have a skinny face with the cheekbones projected like you see in fashion models (though I am no model!). Will custom implants look bizarre as I do not have a tremendous amount of overlying fat? I have dealt with this for almost 30 years as I am almost 29 and I want to move on with my life.

A: Thank you for your inquiry about facial asymmetry correctiobn. There is little I can tell you by your description alone. To be most helpful and to properly treatment plan, I would need pictures of your face and bite and a 3D CT scan.

With this information meaningful recommendations can be made. In short, if your bite is fine and your occlusal plane is reasonably level, custom implant augmentation of the smaller side would be appropriate.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in cheek scar revision.  I have got scar tissue in my mouth and cheeks from multiple cheek procedures. cheek (implants, cheek implant shave down, cheek implant removal, revision implant placement). I also had jaw and chin work done two times. It caused lots of scar tissue. My lips move weirdly now and is thick in my cheeks. Can scar revision be done to cut out the scar tissue? Can anything can be done to reduce it or remove it? Thank you for your time.

A: I would not think about scar tissue removal as that would just make things worse. You fundamentally have a tissue deficiency (which is really what scar tissue really is) which is why your lip vestibule is tight and tethers your lips from a normal outward movement and stretch. What you really need for a cheek scar revision is scar tissue release and the placement of small interpositional dermal-fat graft to help restore lip flexibility and prevent recurrence. The placement of an autologous tissue graft between the lips and the underlying maxillary bone fills in the tissue gap that is created by the scar release and returns needed healthy tissue to the area.

Dr. Barry Eppley

Indianapolis, Indiana