Your Questions

Q: Dr. Eppley, I am looking to undergo complete brow and forehead augmentation all the way to the furthest part of the brow beyond the lateral ends of the eyebrows. I would also like complete skull augmentation which I have seen advertise through the use of a custom implant on your skull reshaping website. My question is whether a combined implant can be made which covers the entire skull in addition to the forehead and the entirety of the brow bone.

A: As to whether the entire skull can be augmented from brows to occiput depends on the amount of scalp elasticity that one has. While any size and shape skull implant can be designed, the overlying scalp must stretch to accomodate it. There are limits to that stretch and for most people a total skull augmentation, as you may be describing, would require a first stage scalp tissue expander to undergo a secondary total skull augmentation.

This is a general statement and I would need to see pictures of you and have you provide some visual guide as to what degree of brow and forehead you are seeking along with the rest of the skull to provide a more qualified answer to your question.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to ask a question regarding a case that you dealt with. The case I am referring to is this occipital skull reduction case:

http://exploreplasticsurgery.com/case-study-occipital-skull-reduction/

My situation is identical to his preoperative photo and my desired outcome is identical to the postoperative photo. How many mm of bone was burred down in his case? I would also like to ask what numerical difference this reduction would make to my skull circumference as a whole. I currently have a skull circumference of 22.5 inches, how much size here can I expect to lose with this sort of reduction?

A: As is typical for most occipital skull reductions the amount of bone thickness that can be safely reduced is in the range of 5 to 7mms. I can not tell you what, if any, circumferential skull reduction is achieved by such occipital reduction as I have never made any such measurements in the patients. Occipital skull reduction is a ‘spot’ area of skull reduction and probably has little circumferential skull reduction effect in most cases. Think of it as a contouring procedure that in profile makes the back of the head stick out less.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a nose scar due to a dog bite. I would like to remove it as much as I can since I am a model. This scar is causing me a lot of distress. I will be waiting patiently for answer so we can talk thru and discuss options.

A: You did not say how old your nasal scar is. But that issue aside, these is no such thing as ‘scar removal’. All that exists is scar reduction. Once you have a scar you will always have it, it is just a question of how less noticeable it can be made.

Your nasal scar revision options do not include excision or any form of cutting it out, that will only make it look worse. The same applies to dermabrasion. While potentially effective there are risks of going too deep and causing worse scarring. Microdermabrasion poses the opposite risk of assuredly making no difference. It is too superficial of a skin treatment. Your nasal scar revision options to consider, therefore are fractional and ablative laser resurfacing techniques. Given its small surface area on the tip of your nose I would first try an ablative laser surfacing treatment and see how much improvement can be obtained.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a breast lift done and new implants put in about three years ago. Unfortunately, the stitches weren’t closed correctly and I have a very bumpy unsightly looking scar under each breast. I want smaller implants put in along with a scar revision on the areola and the vertical scars underneath. I am also interested in rib removal as my ribs have always been much larger in comparison to my body. Can the ribs be removed through the breast lift scar?! Thanks!!

A: Scar revision of breast lift scars usually produce much better scars particularly when the implants are being downsized. There is less tension on the incisional/scar revision closure. I would need to see pictures of your breasts to assess your scars. What is the current size of your breast implants in volume (ccs) and what size were you looking to downsize to in volume. (ccs)

No form of rib removal, anterior or posterior, can be done through breast lift scars. They are simply too far away. I have tried several times to perform subcostal rib reduction through inframammary breast scars but the amount of rib that can be removed is much more limited compared to a more direct incisional approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in cheek augmentation for my right flatter asymmetric side. I understand that the silicone facial implants has silica in it. As a result, silica gel extrusion will become more and more serious over time, the tissue compatibility is not very good, and serious complications may occur. Expanded PTFE, is an implant material that can replace human tissue. It is very close to being real, the compatibility is also good, and it is very easy to carve and shape. But I do not know whether it can have a long-term, permanent presence in the body. If possible, this may be the best choice for my cheek augmentation as the zygomatic osteotomy is very traumatic. Between the two, I would choose expanded PTFE facial implant.

A: You have several facial implant material misconceptions. Facial implants are made out of a solid silicone material, not a gel so there is no extrusion or tissue compatibility issues. They are not like breast implants which can fail and need to be replaced.

Expanded PTFE facial implants are another good biomaterial but they are not replaced by human tissue. There advantage is that they acquire some tissue adhesion to their surfaces due to the micro fibrillar structure.

While either implant material would have successful outcome for your right cheek augmentation, I would opt for the expanded PTFE since this appears to what you feel most emotionally comfortable using.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, do I need a chin augmentation with my lower facelift? I know my chin is deficient but I am worried that it might look too big for my small face.

A: Thank you for sending your pictures and talking to you yesterday. I have done imaging with the sole purpose of looking at your chin, which is really the cornerstone of your lower facial rejuvenation. I have done some imaging looking at chin augmentation in both the horizontal and mainly vertical dimensions. Your chin is small but it more than just a horizontal shortness. It is a 3D deficiency with the vertical being more important than even the horizontal. You need a 45 degree directional 3D chin augmentation. That will help make your entire jawline look better and will really help the improvement of a jowl-neck touchup procedure. The diametric movements of the chin coming down and forward and the loose skin/deeper tissues moving up and back will make the best rejuvenative change possible.

Most chin implants produce a 2D effect on the chin. (horizontal and width increases) But specially design implants can be made that add the vertical element creating a true 3D chin augmentation effect.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, ill the orbital rim implants push my lower eyelid upwards creating a more narrow eye shape? And do you think it is necessary to get a canthopexy along with the orbital rim implant to create a more aesthetic/narrow eye shape? Thanks.

A: As a general rule you should not expect orbital rim implants to push the lower eyelid lash line margin upward. I wish it was that simple or that effect could be created. That is a very hard anatomic maneuver to achieve and it requires more than just a ‘push from below’. That is not to say that orbital rim implants or even fat grafting to the lower eyelids does not create a little bit of an upward push but never to the extent that most patients want it to be.

It would have it be combined with a lateral canthopexy or a lateral canthoplasty to have any chance of achieving a lid lifting/more narrow eye shape effect. Even with these two maneuvers combined, however, it can not be assured that the desired more narrow eye shape will be achieved. Such an eye shape change is just not that simple to create and be sustained.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, my ribcage has been deformed and “caved in” on all sides from sleeping on floors and on cheap memory foam mattresses. It hurts and my chest is visibly changed to where my chest does not stick out like it used to and my ribcage is noticeably more narrow making my belly protrude more than normal. The ribs in my back are flat also. From the side I now look like the “thinman” whereas I used to have a “manly” pronounced chest. Is there any way a procedure could be done where there are items attached to the ribcage/sternum that would allow for an external “pulling” force/apparatus to be hooked to it (like cables etc in a 360 degree arc all pulling outward)? Or is there any other procedure that can help?

A: I am not aware of how a ribcage could become deformed, given that most of it is bone, once formed by the teenage years. But that issue aside there are no devices or surgery that can create a ribcage expansion effect that would allow the entire arc of the bony and cartilaginous ribs to be changed to a greater arc for a ribcage expansion effect.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am 35 years old and in need of facial reshaping surgery from Acromegaly. The tumor was removed successfully from her pituitary gland three months ago. My hormone levels are good right now and I’ll be monitored for the rest of my life. I have seen significant changes in my appearance and I am actually the one that researched why this change was happening and discovered it was Acromegaly ! I am asking for your HELP.! It breaks my heart to see my facial features change my beautiful looks!! My friends and family see it too. I was hoping that you can help or recommend a doctor in Montana that could do my facial surgery to soften my facial features. It has really affected my cheek bones, nose and chin! I am also hoping that insurance would cover this because it was caused by this disease. Please help me feel good again about myself and make me look beautiful again! Looking forward to hearing from you!

A: It is unfortunate to hear of your medical condition but encouraging to know that the cause has been identified and safely treated. The facial changes from Acromegaly are well known and effect both bone and soft tissue. I am not aware that once the growth hormone levels are restored to normal that the facial changes, particularly the skeletal ones, are completely reversible. The medical literature suggests that they may be although it takes ‘considerable time’.

That being said the question is what could be done from a facial reshaping standpoint now that would be aesthetically beneficial. Facial reduction procedures are far more challenging to perform, and thus less commonly done, than facial augmentation procedures in the subspecialty of facial reshaping surgery. I can not speak for whom may perform these procedures in Montata if anyone, I can only speak for what I can do and perform on a regular basis. If you would like me to be of assistance the first place to start is to send me some pictures for my assessment and recommendations. Ultimately surgical planning will require a 3D CT facial scan as well as being necessary to submit to insurance to determine possible coverage.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I had Botox injections for square jaw in the masseter muscles three months ago, 32 units each side. Now I dont like the way my face looks. It is heavy, not v-shaped with saggy skin and prominent cheeks. You are an expert. Is it reversible.? My jawline that was perfect is now like a jawline of an old person.

A: Botox in a reversible neuromuscular drug which achieves a temporary muscle thinning effect as the nerve input to it is decreased. However in the vast majority of patients the master muscles should return to its previous state of fullness once it has worn off in 3 to 4 months. I have yet to see Botox injections cause a permanent muscle thinning effect in just one injection treatment. This almost never happens or at least I have never seen it. Most patients who have this treatment for a square lower face or thick masseter muscles wish it would work with just one injection treatment,. I would need to see some pictures of your face to see what you looked like before Botox and now after for further commentary/recommendations.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am in desperate need of revisional facial slimming surgery. Two years ago I had cheek and jawline reduction in Thailand and it has turned out to be a disaster. It has left my cheeks sagging, my jawline has disappeared and I got a deep burn across my chin from a hot instrument during surgery. I have attached before and after pictures as well as x-rays. I do not look anything like I did before the surgery. This has been a nightmare and I need an expert like you to help me!

A: Thank you for your inquiry, sending all of your pictures and x-rays and describing a very unfortunate surgical outcome from a typical facial slimming procedures of cheek bone and jaw angle reduction surgery. My comments are as follows:

1) From a bony standpoint, you have the classic cheekbone reduction sag that occurs when the anterior osteotomies are not fixed by a plate and screws or has an osteotomy design that is self-retaining. While this effectively narrows the cheek bone, it causes a soft tissue sag as the attached soft tissues sink in and down with the bone.

2) Your jaw angles shows a complete amputation of the bony angles at a 60 degree angle. While this will also narrow the lower part of the face, the complete lack of any bony support causes the face to sink in and look prematurely aged. There is also asymmetry between the jaw angle cuts which is common.

3) Your lower lip/chin burn was a 3 degree burn injury undoubtably causing by the heat from the power equipment used to cut the bone inadvertently laying against the skin while in use. Based on its location and angle I would assume this was from the cheekbone cut. Such an extensive burn injury I have not see before from this type of facial procedure. It has gone on to heal with the expectant hypertrophic scar.
My recommendations for revisional facial slimming surgery that may be of benefit at this point:

1) Excision of hypertrophic burn scar and geometric skin closure.

2) Anterior zygomatic bone elevation/repositioning with plate fixation

3) Bilateral vertical jaw angle implants to put back some of the lost bony support.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, Can a chin augmentation be done that doesn’t simply just push the bottom tip of the chin forward ?(but fills in below the lower lip as well)

A:In regards to your chin augmentation question, the depth of the labiomental fold (under the lower lip) can never be changed by any form of chin augmentation and it will always end up a little deeper with any form of increased chin projection. That is because the labiomental fold represents the attachment of the mentalis muscle above the chin bone. The attachment of the muscle can not be changed or removed for the obvious functional reason. That being said it can be treated at the same time as a chin augmentation by either fat injections  (externally) or a dermal-fat graft. (internally) The latter is more effective at reducing the labiomental fold than the former.

The only facial bone procedure that can change the position of the lower lip as well as the depth of the labiodental fold is to advance the whole lower jaw. A mandibular advancement, unlike a more limited chin advancement (by implant or bone movement) carries with it the teeth and its attached bone. (dentoalveolar unit) This is what pushes the lower lip and labiodental fold forward.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am looking forward to have custom jaw and chin implants, but I’m located outside the us, and since I’m unmarried it would be nearly impossible for me to get a us visa in my country. So I was wondering if it would be possible to have the custom implants made for me without me having to visit your clinic personally. Like, I send you my 3D CT scan, we have a consultation over Skype, you get the implants made to custom fit my face and have them shipped to my location, and finally I have them implanted by a local surgeon in my country. Does that make sense? I wasn’t able to find any doctor doing custom facial implants here, they all have those made-to-fit all OTC implants which I don’t find appealing. So if what I suggested could be done, please let me know. I know it could be risky or maybe won’t give perfect results, but I’m willing to have it done regardless. Thanks. Looking forward to your reply.

A: Thank you for your inquiry. Essentially what you are asking is whether I could design your custom facial implants for you, have them made and then shipped directly from me to you so your surgeon of choice could implant them. That can not be done based on two fundamental issues: 1) I can take no responsibility nor should you assume that your surgeon has the knowledge and experience to successfully place them. Custom facial implants often require surgical technique modifications to be successfully placed, and 2) the regulation and legal issues with importing medical devices vary greatly amongst countries and I am certain shipping a medical device directly to a patient from an outside country violates many of those laws.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I just wanna start off by saying, I love your work! I wish I lived in the same state as you to visit your office for a consultation for facial reshaping but unfortunately I’m not. Anyway, I really would like to know if I am a good candidate for a chin implant and jaw implant. I have a round (moon) face and I desire a square face. is it possible for me to obtain that facial structure ? I know you can’t tell me if it’s possible or not because you haven’t seen my face yet but I’d like to email you some photos of my face for a virtual consultation , so please get back to me as soon as you can – thank you!

A: In looking at your pictures the correct facial  reshaping procedures for your moon face are a sliding genioplasty (not a chin implant) and jaw angle implants for skeletal augmentation and facial defatting through submental/neck and perioral liposuction as well as buccal lipectomies.

A chin implant would be the absolutely wrong procedure to do for your chin because you need both horizontal and vertical lower facial lengthening. This is a critical element of changing your facial shape. It will also help your neck contour by pulling out the underlying neck muscles.

Q: Dr. Eppley, We had previously discussed a facial reshaping surgery consisting of verical jaw angle implants, infraorbital-malar implants and a glabellar implant. Last week I had a second consult with another plastic surgeon that also specializes in facial implants as well. He offered very similar plan to you with only minor differences. I do have a few questions/confirmations i wanted to bring up after looking over the surgery plan:

1. The jaw implants for me would have both vertical and horizontal dimension?

2. Are the vertical and horizontal dimensions given in mm’s?  if so, what are the ranges of each dimension?  what size would you use for me?

3. The semi custom infraorbital-malar implants will be 5mm?

4. The other surgeon recommended a subperiosteal midface lift with the infraorbital-malar implants. Would you also do the subperiosteal midface lift?  

5. How many screws to secure jaw implants?  infraorbital-malar implants?  the glabellar implant?

Thanks for your time and answers.

A: In answer to your questions:

1) Every standard jaw angle implant style offers both vertical and width augmentation changes. What makes the two basic styles different (vertical vs widening ) is the ratio of the vertical and width dimensions. Widening jaw angle implants provide more width than vertical length. Vertical jaw angle implants offer more vertical length than width.

2) Every facial implant, regardless of style and size, has very specific millimeter measurements which are provided by the manufacturer on their website complete with drawings and measurements. The best jaw angle implant style for you would be vertical jaw angle implants of the ‘large’ size. (11mm vertical, 5mms width)

3) The semi-custom infraorbital-malar implant will be 5mms at its thickest portion.

4) Every infraorbital-malar implant that is placed through a lower eyelid incisional approach is closed with a ‘subperiosteal midface lift’. Some surgeons chose to specifically call it as part of the procedure and even charge a separate fee for it. But, by definition, making the pocket for the implants requires raising a subperiosteal midface pocket to insert the implant. When the tissues are closed over the implant by sutures to the bone this is what constitutes the subperiosteal midface lift. It is an integral part of the procedure, some surgeons just chose to call it a separate procedure.

5) Jaw angle and glabellar implants generally only require one screw. The infraorbital-cheek implant may also only need one or possibly two. The judgment about the total number of screws is made at the time of surgery based on the stability and fit of the implants to the bone. Probably the correct  number of screws will be 8 not 6.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in your orbital dystopia surgery. You can see my right eye is much lower positioned than the left one on the side view photo you can also see I don’t have prominent cheek bones. They’re really “hollow” and on the photo where I lift up my lower lids is how I kind of would like them to be (just bigger as on the photo) a lifted almond shape but you still can see that the right eye is positioned too low… so If I would just do lower lid tightening or something like that I can already tell you I won’t be happy because I’m just a perfectionist..I think my right eye needs to move up and then I need lower and upper eyelid correction and maybe some cheek implants or filler. what would you recommend me to get even, beautiful well shaped eyes?

A: Thank you for sending your pictures and I can clearly see the lower right eye. Orbital dystopia is a difficult problem to successfully treat and the concept of changing from your orbital dytopia problem to one of ‘beautiful well shaped eyes’ is not going to happen. You can not make that type of dramatic change in one surgery and have it perfect. You focus first and improving the orbital dystopia by raising the right eye and making some lid adjustments on that eye. Thereafter you focus on any additional adjustments that are needed and other cosmetic periorbital/cheek changes. As you can see this will require a series of operations but even in the end, perfectly symmetric and well shaoed eye  results are not going to be possible.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m not sure what I need to help my face. I’m 54 years old and  have been noticing sagging in my neck and the beginning of jowls. I had a “liquid facelift” in last year but it didn’t seem to help much. Just wanting to talk to you about what other options I have.

A: One of the many signs of facial aging is the development of lower facial changes including the appearance of jowls and a droopy neck. While many purported no-surgical therapies exist to treat these signs of facial aging, including the so called Liquid Facelift (pumping  bunch of injectable fillers into the face), none of them can really lift up a truly sagging face. There are really for younger people who have only the earliest signs of aging. The only approach that will work is surgical and has the name, facelift.

Facelift surgery is one of the most misunderstood of all facial plastic surgery procedures. It is a spectrum of lower facial rejuvenation procedures that range from a limited jowl lift to a full lower facelift. The type of facelift surgery performed is adapted to the patient’s aesthetic needs. This is undoubtably the type of treatment you need. It is just questions of what type of facelift.

Please send me some pictures of your face for my assessment and recommendations.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have attached two photos for your assessment for scar revision surgery. The scar is slanted towards the left at the top and slopes downwards towards the right. The scar healed flat at the top 2 inches and bottom 3 – 4 inches. It’s the section in the middle that healed wider and is slightly raised. Aside from silicone scar sheets and micro needling, I haven’t tried anything else to alter the scar. What I would like to achieve would be a flatter, less bumpy scar.
 
**I understand that area is prone to scarring badly, so I’m unsure if it is best to leave well enough alone. 

A: Thank you for sending your scar pictures for possible start revision surgery. As midline chest and upper abdominal scars go, this is just typical scar widening that commonly occurs in this area. It is not a hypertrophic or keloid scar which is good. The only effective treatment would be to cut out the scars and reclose it in a finer line…and hope that it heals better this time. At this point treatments such as scar sheets and gels and microneedling are completely ineffective in an established scar like yours. The reason the  middle part of the scar is the most irregular is due to the constant tension from the pull of the breasts. This is a very common adverse scar effect seen in women with larger breasts.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I’m concerned with my severe chin recession. Although in the attached photo I think I might have slightly tucked my jaw in my neck, it appears like I have a very full neck and almost a double chin. It really doesn’t have to do with body fat since I’m almost underweight at 130 lbs considering I’m 5’10” tall. After some research, I found that my particular neck appearance is due to the anatomy of the surrounding neck muscles and the hyoid bone. I’m also attaching a lateral X-Ray cephalogram in case it’s helpful to determine anything related to anatomy.

Is the image morphing that I have attached any realistic? I’ve thought of four possible routes to come close to it :

1) Sliding genioplasty combined with submentoplasty for a better cervicomental angle
2) A custom jawline implant designed to posteriorly extend the jaw as much as possible
3) Sliding genioplasty + custom jawline implant + submentoplasty
4) Lower jaw advancement surgery (BSSRO) , though I’m not sure if I am a candidate for it since my bite seems normal -except an overjet I have-
What do you think would be the best route for my goals? Feel free to do your own imaging if you think mine is not realistic.

A: The answer to your chin recession surgery and neck issues is #2, a custom jawline implant. Besides the fact that it would most likely resemble the computer imaging you have done, it provides a recruitment of tissue from the neck to create the definition along the jawline. Options #3 and 4 are not viable approaches for you for a variety of reasons. Your choice really comes down #1 and #2. The problem with #1 is that a sliding genioplasty will have no impact behind the chin and will make the chin more narrow from the front view.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley,  I’m interested in a tummy tuck, liposuction and fat injection breast augmentation. (breast fat transfer) A breast implant augmentation wouldn’t be an option for me so I’m hoping to have the breast fat transfer but it doesn’t seem to be performed much in this area. I appreciate your thoughts!

A: The issue with fat transfer for breast augmentation is not whether you an do it…but whether it will remotely come close to the result you seek. Fat injection breast augmentation is not commonly done because most breast augmentation patients don’t have enough fat to do it and, even if they do, the usual outcome is about a 1/2 cup size increase. Such a breast size change will be inadequate for most patients seeking breast enhancement. If one takes the approach of ‘anything I get will be better that what I have’ then the result would be worthwhile for that patient. But if one seeks a defined breast size increase that is more than a half cup or so then the result will be disappointing.

I would need to see some pictures of your body to determine how this answer applies to you and your desire for fat injection breast augmentation.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am a plastic surgeon who has a patient that wants to do hip implants. I just want to confirm that you put them under vastus lateralis fascia, over muscle, like calf implants. Any tips as this is new to me? A Canadian plastic surgeon describes placing them under TFL muscle. This seems risky to me.

A: The options for placement of hip implants are limited and are really subcutaneous in location for most patients in my experience. If you look carefully where most people want them it is higher that the upper extent of the vastus lateralis muscle. It is either over the trochanteric depression or even slightly behind and above it.  In theory the TFL is more anatomic to the hip augmentation region but placing them under it runs a real risk of chronic pain not to mention the limited augmentative effect that will result from the tight fascia over it. Using an incisional approach high and behind the augmentative site also avoids any risk of running into the lateral femoral cutaneous nerve.

While it is always nice to have an implant deeper in the tissues, the hip region doesn’t provide any good and safe options to employ that concept. The other important implant feature of the hip region is that it needs to be of composed of an ultrasoft silicone polymer. (solid but feels like an ultra cohesive breast implant) For this reason I have them all custom made to get the dimensions needed and the right implant feel. It also makes them easier to insert with a smaller incision.

I hope this is helpful,

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a facelift revision.I really feel in order to look more natural this surgery is essential.  You would be basically restoring the thin skin to an area that “thick” skin has been pulled over.  I understand that this could look patch work like, but I also feel like there would be a more natural looking appearance.  Pulling the facial skin over the tragus gives the appearance of a wider face and on a man look really funny.  Men have lines that are essential to a man’s look.  If I was a doctor I would NEVER do this to men especially this being “hair bearing” skin.

1.  It’s been 3 months since this facelift  was performed.  Is this enough time to do this?  

2.  Would this also loosen up the skin from your incision line to my nose in the mid face?

3.  Your incision will basically be my new beard hair line which will go from under my sideburn to the bottom of my ear lobe, correct?

4.  Your incision will basically be a “section” of skin.  What if this section of skin sits over some scar tissue?  Will this scar tissue be completely removed so that the new graft has the ability to project the tragus?  

5.  Will the facial skin be thinned to connect the new thinner skin graft?  To give a better transition.

6.  You’ve said something about taking skin behind my ear which is NOT an option in my case.  That is an area that has been completely exhausted.  Could you take the skin from under my bicep between my arm pit to my elbow?  If so, I think this scar could be hidden under my arm near my arm pit.  Is this an option?

7.  On one side part of my tragus was cut off.  Can you rebuild this?  If so where would you get the cartilage?

Thanks in advance.

A: In answer to your facelift revision questions:

1) Three months after the original procedure is an appropriate amount of time for any revisional surgery.

2) I don’t think a tragal release/skin graft would create any additional skin looseness between the nose and the ear. Time will eventually make that happen. Although some effort can be made to do some skin undermining and any plication suture releases which may be of benefit.

3) I am not sure I understand how you are envisioning the release. What I envision is to remove the beard/facial skin just off of the tragus and skin graft that area.

4) All skin including scar will be removed down to the cartilagious tragus.

5) You can’t thin the facial skin. The skin on the tragus is naturally a lot thinner anyway than the adjacent facial skin.

6) A skin graft can be taken from just about anywhere. I was suggesting behind the ear because that would probably be the closest color match. (technically the neck skin would be most ideal) You would be surprised how different skin color is from different parts of the body. While you certainly can take it from the armpit area that is will look remarkably whiter than your facial skin.

7) While you can rebuild the tragal cartilage you would have to use an ear graft to do it known as a composite cartilage-skin graft. It would probably better to put a little piece of cartilage in it later when the graft has healed. Then the cartilage can be taken inconspicuously from the ear as it doesn’t need any skin with it.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I was interested in information about body shaping and fat grafting. I am transitioning and noticed you do facial feminization so wondered if you did body for transgender as well. One procedure I was most interested is is fat grafting breast augmentation. It seems this is not a extremely uncommon procedure at this point so wanted to check if this is something you could do. Thank you.

A: One of the most common transgender body reshaping surgeries for make to female is breast augmentation. I do breast augmentation by fat grafting (fat injection breast augmentation – FIBA)  as well as the complete face and other body procedures for transgender body reshaping plastic surgery. The main reason that FIBA is not commonly done is not because it is technically difficult but that patient selection for it is very limited. One has to have enough fat to harvest to do the procedure and also be willing to accept the unpredictability of the outcome (how much fat will survive) as well as a more modest  breast augmentation result. (1/2 cups size in most cases) Breast implants offer an immediate, sustained and more predictable result which is why FIBA is not commonly performed.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley,I’m interested in doing a mouth widening surgery combined with a chin implant.

I was just wondering what can I expect from getting a mouth widening surgery, in terms of post surgery scars. Will the visibility of the scars be like this?

http://exploreplasticsurgery.com/wp-content/uploads/2015/12/Subnasal-Lip-Lift-and-Mouth-Widening-Procedure-immediate-result-front-view-Dr-Barry-Eppley-Indianapolis.jpg

Will they be isolated to the corners of the both or below the nose as well ala above. Also, will the scars always remain as prominent as in the picture above? or will they gradually dissipate (not to become invisible but barely visible)? If the prominence of the scars do reduce over time, why are there so many doctors (on real self) against doing this surgery for cosmetic purposes?

Thanks for taking your time to answer my questions.

A: In regards to mouth widening surgery scars, the picture you have linked is an immediate right after surgery result. (and it also includes a concurrent subnasal lip lift which has nothing to do with the mouth widening)  While it is very important to be aware of the risk of hypertrophic scars that may require a revision with any corner of the mouth procedure (lifts, narrowing or widening), my experience has been that there is a low rate of adverse scarring for the mouth widening procedure. As to your question about other surgeon’s comments about the mouth widening procedure, I can not speak for their experience in performing it. Such comments matter if they are qualified opinions…meaning have they really performed the procedure and personally seen actual outcomes.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, as an expert in this facial surgery area I would like to take your opinion regarding bone resorption after placement of silicone jaw angle implants , I have noticed 2 to 3mm resorption after removal on an implant from two patients that didn’t like how they looked after placement. There was no infection or any other complaint.

Moreover, I would like to know if this resorption process is continuous or will stop at some point after placement and if you recommend a protocol for follow up or X-rays for a period of time.

Thanks for all your efforts.

A: What you are referring to is not bone resorption but passive bone remodeling. This is a very typical response to any facial implants placed under strong muscles and is largely only seen in the chin and jaw angles due to the influences (pressure) of the overlying mentalis and masseter muscles. It is a passive and self-limited tissue response and is to be expected. Also in the jaw angle area it is very common to see some bone overgrowth around the implant edges on the mandibular ramus due to the complete subperiosteal location of the implants. Passive bony remodeling and some bone overgrowth are common and benign bodily responses to an object who biologically was not intended to be there. There is no reason to followup the patient in this regard after the implants have been removed.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I was wondering which procedures you think could help my face become more photogenic? Some info about me/things that I’ve noticed: half asian, 5’7, 150 pounds, I’ve noticed that I have somewhat of a “flat nose” or middle section of my face but it’s only noticeable in certain lightings, something about my jaw maybe it’s too wide or could be my chin, and slightly puffy eye lids. Also, could losing a little weight help reduce my droopy/chubby lower jaw area? Or is this more of a bone structure issue that jaw surgery could correct? I also dislike the way my face looks when I smile, not sure what type of procedure could help to balance my face when I smile. Thanks for your time.

A: While beauty is truly in the eye of the beholder, I can make the following  asian facial reshaping suggestions. An augmentation rhinoplasty, buccal lipectomies with perioral liposuction and bony jaw angle/masseter muscle reductions would have the greatest slimming effect in your face. (I would also defat your upper eyelid and make the upper eyelid crease more apparent…but I can’t computer image that type of change) This is not an issue with your jaw relationship or any orthognathic surgery needs. These procedures combined with 10 to 15 lb weight loss would maximize this type of facial change.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley,I went to plastic surgeon to get rid of those temporal artery frontal branches. The surgeon cut a 1 cm section off from both sides from the lowest part at the hairline. Even with the 1 cm section of the artery gone it is still bulging and pulsating. How can this be, is there some backflow from the scalp to this artery? The surgeon said that I should wait for a couple of days to see if it was success even though the artery is still bulging. This is just a nightmare, how can I get rid of these ugly bulging arteries.

A: I would need to see pictures of where your temporal artery ligations were done. A single point ligation (or even artery removal in that location) rarely works in my experience. It takes at least 2 and sometimes up to 4 ligations points to be effective in some patients due to the sinuous pattern of the superficial temporal artery. The takeoff of the anterior branch of the superficial temporal artery is variable not to mention the issue of back flow from an arterial system that extends into the scalp. It is a complex blood flow system that is not an easily reducible as one would think by just cutting off one point of inflow.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a reconstructive cranioplasty. I was involved in a car accident three years ago which resulted in me undergoing a craniotomy. They fitted titanium mesh to cover the area since the bone was crushed and couldn’t be sued.. As I have become older, I now see that the skull is indented over that area and therefore I wanna have a reconstructive cranioplasty. I have consulted with several neurosurgeons without much luck lately, because of concerns about further surgery.

Therefore I have a question related to cranioplasty. As I already have titanium mesh fitted, would it be a problem to remove that – does titanium mesh attach to the dura or tissue for that matter? That seems to be the question I can’t find a answer to, so hoping you can help me! Or would it be possible to just leave the mesh and cover the area with either PMMA filler or hydroxyapatite bone cement?

A: While it is possible to remove your titanium mesh in your reconstructive cranioplasty procedure and replace it with a custom implant, the risks of dural tears and a CSF leak is not worth that effort. It is far better to leave the mesh in place and cover it with any of the available bone cements of your choice.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley,I am very familiar with injectables and have been using Botox for over ten years and Juvederm for at least the past five years5\. My eyes are looking extremely tired and I wear glasses every day to cover up the line. I am aware that the tear trough can be treated but have heard it is only for the experienced. Can you please let me know if this is something common in your practice? Thank you

A: Placing injectable fillers into the tear trough is the hardest area on the face for getting good results in my experience which is considerable. It is a facial area fraught with aesthetic problems such as irregularities and over correction issues. It is also a very aesthetically scrutinized area since it is in the eye region. Anything less than a perfect result will be viewed by the patient as unacceptable.

In my experience 50% of the patients treated have some issue that requires further injection treatment whether it be additional filler or hyaluronidase to reduce/remove the filler material. I would need to see some pictures of your face to determine what risk profile you have for tear trough injections in this difficult facial filler area.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a bone cement cranioplasty. You have previously told me that it would not be good idea to try and remove the titanium mesh. Maybe you can walk me a little through this. I thought the titanium mesh was placed above the hole in my head and mounted with screws in the skull. I don’t see how my dura could be teared when unscrewing the screws and lifting of the titanium mesh? Has the dura grown into the mesh?

According to bone cement, is there any specific one you would recommend or would any product do the trick? Its just that it is a somewhat bigger cranial defect, but maybe that doesn’t have anything to say? And will the bone cement attach to the mesh, and surrounding bone, holding it in place?

Thanks for your time!

A: Since I assume you have never performed skull surgery, it would be understandable why you would not know that scar tissue and dura adhesions have occurred into the mesh which is certainly not a smooth surface. While it can be removed there is a significant risk of dural tears and a postop CSF leak in doing so. It simply is not a risk that most patients and surgeons would take when the original problem has been solved.

For a bone cement cranioplasty, hydroxyapatite cement would be the preferred coverage material and the size of the cranial contour problem is not an issue. The cement will adhere to both the bone and the metal material. Adherence of the cement is not an issue.

Dr. Barry Eppley
Indianapolis, Indiana