Your Questions

Q: Dr. Eppley, I would like to ask about rib removal surgery. How many ribs will be extracted if I want a thinner waist as well as a longer torso. Also, I’d like to know about post surgical pain and recovery period. Thanks.

A: Thank you for your inquiry. Rib removal surgery is a collection of procedures designed to treat various torso issues. There are ribs removed to narrow the waistline (ribs 10,11,12) or to vertically lengthen the waistline. (rib #s 7,8,9) The lower ribs are removed through incisions on the back while the upper ribs are removed through incisions on the front. If both are done at once as many as portions 12 ribs can be removed.  (ribs are not totally removed only portions of them are) I would need to see pictures of your waistline/torso to determine if either of these ribcage modification procedures are appropriate for you.

Postoperative discomfort is managed by the use of intraoperatively placed Exparel injections as nerve and muscle blocks that last as long as three days after surgery. This goes a long way in helping control what would otherwise be an uncomfortable experience.Recovery depends on what type of physical activity one is trying to recover for.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a sliding genioplasty two years ago and I’m not fully satisfied because I would like more projection. The surgeon is brilliant and he did everything very well but I just want a little more. Is it possible to repeat a sliding genioplasty and will the bone heal the same? 

Also 10 months after the operation when I visited the surgeon who performed the genioplasty he pressed quite hard on my chin with his thumbs to feel the bone. Could that have pushed it back or am I just paranoid? Is the bone, plate and screws strong enough for that kind of treatment after ten months? 

I visited him again 16 months after the operation and he did the same thing again. 

I also hit my chin a little when I pulled my cover up while sleeping yesterday. I’m constantly worried that it’s shifting or lose. Do I need to be? 🙁 

Sorry for such a long message. Thank you!

A: There is no reason that you can not have a secondary bony sliding genioplasty years later that would heal just as well as the first one. While there is no good reason to be pushing on the bone, there is no risk of causing it to move backward. The plate and screw fixation is more than adequate to resist any displacing forces early after surgery and the healing of bone s more than adequate to do so months to years later.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a small lipoma on my stomach that I’m interested in having removed without a scar. I found some of your posts relating to this issue and LipoDissolve (Kybella) seems like a viable alternative. Your post mentioned that it might take multiple injections, do these injections have to be within a certain amount of time? I work outside the US most of the year and only travel home to Indy a few times per year so I might have to spread the injections over a long period of time. 

A: The only non-surgical alternative to surgical excision of a lipoma is injection therapy. While one known as Lipodissolve, it is now known as Kybella injections. These are pure deocycholic acid injections which help break down the lipoma by disrupting the cell walls of the adipocyutes within the lipoma capsule. Over the years I have treated a fair number of lipomas with injections and it almost always takes ore than one injection treatment to get the maximal reduction. While I usually space these as close as 6 weeks apart, there is no harm in having much longer periods between the injection sessions. It does not adversely affect the injection’s effectiveness.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, The side profile shot is taken of what I consider my weaker side, though the left side has only slightly better bone and muscle definition, it is a noticeable difference. Its something I have been conscious of all my life – lowering and pushing my jaw forwards in photos etc and now as I get older, it appears to be more noticeable. 

I’m not looking for a wide angular jaw bone as I have an oval face and a fairly small head size so that would look weird. I’m relying on your aesthetic appreciation of my request based on the following considerations to hopefully provide a stronger, but normal looking, less saggy and symmetrical jaw line.

1. To gain a slight vertical lengthening of my jaw line
2. Consider the amount/effect (if any) of slight vertical lengthening of my chin with this procedure. Or will this make my face unbalanced?
3. To further enhance the weaker right hand side to correct the slight bone and muscle asymmetry to match the left side. 
4. Determine if I would benefit aesthetically by a slight chin projection to help the overall balance and proportion of my face?

Hopefully, if this can be met it will take up some of the slacker soft tissue and negate any surgical lifting and provide balance and proportion? That’s my aim anyway.

I look forward to hearing from you soon.

A: Given your multiple aesthetic needs of your lower jawline, only a custom jawline implant can come close to achieving all of your goals. The addition of vertical lengthening of the jawline as well as some horizontal chin increase can only be done by such an implant. Because the custom jawline implant adds overall bony volume it will by definition pick up some loose tissue along the jawline.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I have some questions having to do with facial reshaping.

1. Is there a limitation in how many millimeters can one widen the cheekbones with a zygomatic osteotomy?

2. Since custom made cheek implants can be created as large as a patient desires, will the dimensions of the implants follow the dimensions of the widening result of the face or more specifically the soft tissue of it? For example, if a patient was to have inserted cheek implants that were about 5 mm wide each, would that lead to a total centimeter increase in bizygomatic width, or more and even less than that?

3. Aside from lip lifts, rhinoplasty and cheek implants are there any other effective ways to give an illusion of a shorter pupil to lips distance that appears long on a face? I was thinking that some work around the eyebrows could be a potentially good idea but I’m not sure how this could be done.

Thank you in advance.
A: Thank you for your inquiry. In answer to your facial reshaping questions:

1) Generally 5 to 7mms of out fracture of the anterior arch can be done before there becomes an obvious step-off externally.

2) In onlay custom cheek implants the overlying soft tissues generally follow on a near 1:1 basis.

3) Without seeing pictures of your face I can say what may or may not be effective in decreasing the pupil to lip distance.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in lower buttock lifts. mI have been trying to correct my saggy buttocks for over a year now. I have been very athleltic all my life and no matter how toned the rest of my body is there is always a saggy pouch below my buttocks. I had fat injections which didn’t take then I asked my surgeon to excise the sagging skin and fat. But he didn’t emove much at all and it’s basically still the same. I have found your website and it appears you know what you are doing with this. So I am wondering if you can correct this (no implants or anything required, simply removal of that pouch) and what sort of recovery I will be facing?

A: Lower buttock lifts are really the only technique that can improve redundant tissue that hangs over the infragluteal fold or loose tissue just under the fold. Please send me some pictures of the your lower buttocks so I appreciate the issue that you have and where your current lower buttock scar is. Most likely your last surgery simply did not remove enough tissue to see much change. The recovery from lower buttock lifts is really only limited by how much you can bend over after the surgery to avoid excessive pulling on the suture line. One should avoid returning to most forms of strenuous exercise for four to six weeks after surgery.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, Can you please tell me whether a custom high cheek implants for males can also be adapted to provide augmentation to the under eye area? And also can custom cheek implants be designed to give more volume than other implants as I desire noticeably higher cheekbones whilst still looking natural.

A: It is actually very common to have an infraorbital extension under the eye as part of many custom cheek implants as part of their design. (compared to a standard cheek implant which is the darker blue one) This can be seen in the attached custom cheek implant image example. Not only can there be an anterior infraorbital extension but often there is a posterior infraorbital extension back along the zygomatic arch as well. By definition custom cheek implants are usually bigger and thus have greater volumes than standard sized cheek implants. It is important to know that the design of the implant and the bone that to covers is more important than thickness or size. It doesn’t matter how big the cheek implant is of it is not the right implant style and design. This is why i do so much custom cheek implants as many patients don’t get the right design of the implant for the look they are trying to achieve.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I asked for your consult about getting a more chiseled and angular face with much more symmetrical proportions through facial reshaping surgery. I had a surgery three month ago including putting in a chin implant, buccal fat removal and very small cheek implants. Unfortunately I didn’t get the desired results with those procedures. In the coming week I’ll go to visit my Doctor again. But it seems that I have to find out my problem and reforming options by consulting with you and then asking my own doctor to do that. Maybe you have gotten my before operation photo so I will send you my present look photos. In my opinion and after watching your videos on Youtube, my chin implant shall be removed and I should get a vertically shortening and horizontally augmenting sliding genioplasty plus jaw angle implants and submalar big cheek implants. Please let me know what do you recommend, even if its possible in details, such as size and shape of implants.

A: The creation of a more defined and angular face is not going to come just from chin and cheek implants and a buccal lipectomy in most patients. These procedures may be part of the solution but they alone are usually going to be inadequate. This could have been predicted before your prior surgery. The creation of a more defined jawline is a big part of creating an overall more shapely face through facial reshaping surgery. What jawline procedures, or other procedures, would be best in that regard must be determined by the doctor who is going to do the surgery. It is not medically appropriate that I provide a list of procedures and specific implants so you can pass that information along to another surgeon. That decision must be made between you and the treating surgeon.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I have purchased a book in which you were a co-author of called “Aesthetic Surgery of the Craniofacial Skeleton”. I have an inquiry on a certain procedure that is in it. I am looking to increase the width of my actual eyes (horizontally). (Lateral Orbital Rim Osteotomies) The book entry says you can reduce the width of the eyes by cutting the outer orbit bone and putting it closer in. But is is possible to do the reverse and position it further outward and this would lengthen the eyes?

Do you perform this procedure or have a college that performs is? I really want to make my eyes longer.

A: While Lateral Orbital Rim Osteotomies can be done to narrow eye width, it does not work in reverse to make the eyes horizontally longer. This is because of the lateral canthal attachments and the position of the lower eyelids. By moving the bone or corner of the eye outward, you end up pulling the lid margin away from the eyeball. That will cause multiple eye symptoms of irritation, dryness and even excessive tearing. The eye requires that it maintains good apposition of the lid margin right up against the eyeball.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I’m a 48 year old HIV positive male who is healthy, have undetectable viral loads, and have been on Atripla for many years. I have always had a full round face and cheeks and was thinking of getting buccal fat pad removal.  (buccal lipectomies) I workout with weights and cardio. I will be getting cheek implants. Do all people on HIV meds get facial waiting? Is buccal fat pad removal totally contraindicated for me?

A: Historically HIV medications did cause a lipodystrophic spectrum of facial lipoatrophy and body lipohypertrophy. Newer medications, like Atripla, have a much lower incidence of causing these fat altering side effects. If your face is round and always has been then I would say that buccal lipectomies are not contraindicated and can be performed without concerns about adverse aesthetic long-term effects..

The key question now is not whether buccal lipectomies should be sone but whether they would produce a noticeable external facial thinning effect. That would depend on how round your facial shape is and where most of the fullness is. I have performed buccal lipectomies in a select few HIV positive patients whose face merited a facial defatting procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a revision rhinoplasty. I have had rhinoplasty one year ago. I got the results for what I asked for, my nose was straightened and the hump was reduced. My tip was never corrected as I was told by my doctor there was not need for it. It really seems to bother me and I would like it corrected. Would this be classified as a revision rhinoplasty surgery and would it be more harder to perform then the first surgery?

A: I am going to assume that your original rhinoplasty was done by an open approach. Secondary tip work would be no harder to perform now than during the first surgery. The scar tissue that is present would pose no issues for doing secondary degloving and tip work. Preoperative computer imaging may have been able to show whether tip work as needed.

If your original surgeon performed the tip rhinoplasty it may be considered a revision. But this would certainly not apply to a new surgeon performing the procedure. For the new surgeon this is a new procedure for which he/she has no obligation stemming from the prior rhinoplasty. An isolated tip rhinoplasty is, however, less costly than a full or complete rhinoplasty.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had breast reduction surgery on November,2015. I have had no problems and healed nicely. The tissue that was removed came back as clean with no cancer. At this time I have felt a hard small lump under the vertical incision at the left breast. It is hard and round just under the scar line. I am concerned about this. Thank you.

A: It is very common after breast reduction surgery to have firm lumps in the breasts due to scar tissue and fat necrosis. This is particularly evident in the first year after surgery. Many go on to soften over time but some never do and are permanent. That fact that it is situated right under the scar line speaks to how this is probably what you are feeling. But if you have any cancer concerns about this lump, these should be addressed by a breast cancer surgeon or the plastic surgeon who performed your breast reduction surgery..

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in fat injection breast augmentation. I’m 27 years old and have three children. I’m a 34/36 A cup, barely. I have an abdominal ‘pooch’ that I don’t think will ever go away. Breast augmentation is something I’ve been researching for over a year now. It’s something I want to do because it’ll make me feel better about myself and gain my confidence back. I would like more information about the fat injections as I’ve been concerned about implants and can’t decide between silicon or saline and I really don’t want to have to get “redone” years from now. Any information is appreciated.

A: Fat injection breast augmentation is only successful in a very few selective women. First and foremost one has to have an adequate amount of fat to harvest…and it takes a lot more than most women think. Your abdominal ‘pooch’ alone is not going to be remotely enough to do the procedure. With fat graft survival at way less than 50% of whatever is injected, even in women that have better fat harvest volumes, the best breast augmentation result can hope for may be a 1/2 cup size increase.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in chin advancement surgery for my obstructive sleep apnea. (OSA) Let me explain that I had an extremely underdeveloped chin and I had a chin implant out in over twenty years ago. The OSA has always been present and I snore really loud. I have made a few attempts to have this corrected but I’m a mouth breather. I have a CPAP machine but it really puts a lot of pressure on the chin implant and it hurts me to wear that awful mask. I have had the machine for over five years. I’m ready for a surgical solution. Ive spoken to my sleep doctor but she is not qualified to answer the surgical question.

A: Thank you for your clarification on your OSA history. With an extremely short chin it is very likely that mandibular advancement would be the most beneficial approach or even bimaxillary advancement surgery.. But doing so would require pre surgical orthodontics and that is often not feasible or very desirable when one is older. The other option, albeit less effective, is a sliding genioplasty chin advancement. This can  help to bring the tongue somewhat forward…although not as much as a total lower jaw advancement.

I aska about whom recommended surgery for your OSA because that may have meant that the sleep doctors had exhausted all they could do and detected a jaw bone deficiency in you.

I would need to see pictures of your face and your current bite to see whether these surgical options may be beneficial for you.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a custom jawline implant done by you last week. In looking at my result this week I feel that the chin is too big and the jaw angle look a bit asymmetric. I have talked to several close friends and they are in agreement.  I am thinking that I need a revisional surgery and would like to do that as soon as possible.

A: I am gong to repeat now what I stated from the very beginning…as you are going down exactly the path to which I pointed out to you that many young men take in this type of facial surgery. You are just one week from surgery and have a long way to go before seeing the final results. Much will change in both appearance and your perception of it. You are already prematurely critiquing your results and trying to pass judgment on issues to which you are not yet close to seeing the final results. As we have previously discussed, your premature reactions are not uncommon, but it’s important that you understand they are indeed premature.

The advice that I am going to repeat to you now is that you must allow the healing and adjustment process to complete. I will not discuss any facial situation that is in an evolutionary state, as it is a ‘moving target’ and it is not in your best interest to do so until the final results are clear, in 8 to 12 weeks after surgery.  It’s best not to entertain discussion at this point about pre-surgical implant design decisions and premature outcomes, as that would serve no purpose at this juncture.

This position may seem unduly harsh but it seems to be the only way in some patients to get them to understand the reality of the situation. I make it a priority before surgery to ensure patients understand how the process will unfold in these cases after surgery and, more importantly, how I will handle it after surgery. While your friends may offer their own opinions regarding your procedure and certainly know you on a personal level, it’s important to note that I have a great many years of experience in surgery, and am a specialist in this procedure.  I have spent thousands of hours in surgery and am your best resource regarding the postoperative process, and as such, will offer you expert medical advice as opposed to uneducated opinions.

You came to me for a reason…if you are not willing to accept my advice and recommendations then I can not offer much further help. If the early results are too distressing to tolerate or do not permit one to allow for the allotted recovery time to see the true final outcome, then the only alternative option is removal of the implant.  My advice again, is to allow the body time to heal and the postoperative process to resolve before any further considerations.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have some deep acne scarring and red pigmentation. I had Matrix laser done with 4 treatments. They promise at least 80% improvement. There was no change. Even they admitted to no improvement. But no offer to help any further. It was a complete waste of time and money. I read your testimonial and hope you can help. As I get older scars getting worse. I have watched about all types of acne scarring procedures on Youtube, excision and then follow up with deep laser seems to be my guess. But I’m not a doctor. I’ll send pictures.

A: Trying to improve acne scarring is a challenge to say the least. There are no magical treatments and modest improvement at best is really what is obtainable. You are correct in that excision without or without fat grafting of the deepest ones is the most effective. Fractional lasers and the newer HALO system offers some improvement of the more shallow ones. Older patients also have another treatment option as their loose facial skin contributes to the worsening acne appearance. Tightening the skin on the side of the face (mini-facelift) can also be effective as the scars get stretched out and more flattened by some doing.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Thank you very much for getting back to me. Please see attached, a few pictures. Two show the lower lip at rest. As you can see, there is virtually no display of the upper incisors and significant display of the lower incisors. Also the one showing me smiling shows some drooping of the lower lip on my right hand side (photos taken in selfie mode so it’s flipped). I have had a genioplasty done previously – the drooping may or may not have been related to that. I cannot remember if it was present prior to the genioplasty. 

I don’t know if I am a suitable candidate for a lip lift but I was thinking of getting assessed for an upper and lower lip lift. In terms of a lower lip lift ,I am not sure if you do this particular procedure?

A: Thank you for sending your pictures. As for the upper lip, a subnasal lip lift would help with the show of the central and lateral incisors a bit. The other alternative would be an upper lip horizontal mucosal resection, a more direct approach, if one also thought their vermilion show of the upper lip was excessive. Your central lower lip droop reminds me of what can occur after a genioplasty procedure. Raising up the lower lip is very challenging and often not that successful as there are not anatomic structures to fix it to like that of the upper lip. I have used the V-Y advancement many times on the lower lip for that purpose and have found the improvement obtained is usually moderate and not a complete correction.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, After having read your in depth knowledge on jaw implants I wanted to get your opinion on what has happened to me. I have recently had jaw implants removed and I feel as though the masseter muscles have not been reattached correctly – they do not wrap around the angle of the mandible, instead they just go straight down. This has led to a strange look when I clench my teeth – a distinct difference of the masseter muscle and and bone angle itself. Can this be remedied? Will it resolve by itself over time? The implants I had were Medpor RZ. Thank you for your time.

A: What you have is disinsertion of the masseter muscle from the jaw angle. This is why when you clench your teeth the muscle bulges above the lower border of the mandible higher up on the ramus. While there is a procedure to try and reattach the muscle back down lower onto the edge of the bone, it has a low rate of success and leaves an external neck scar to do it. It is probably best to accept that this new position of the masseter muscle as permanent.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a sliding geniplasty reversal. It was supposed to be a 2mm sliding genioplasty, but ended up being moved forward 4mm. I had the hardware removed thinking it would soften my chin, but really didn’t do anything. I feel like my chin looks entirely too strong for my face, and it also has some places that the bone grew back weird leaving an indention. I also have to regularly get Botox in my chin because it gets dimpled whenever I contract the muscle, and makes it look even more pronounced. Overall, since the surgery I have just been very unhappy with the aesthetic of my face and it constantly draws my attention there. 

A: A 2 or 4mm genioplasty is certainly a small chin bone movement that is rarely done because it is hard to justify the magnitude of the procedure with that small amount of chin change. But that it irrelevant now. The critical question is whether moving the bone back (sliding genioplasty reversal) will improve the adverse symptoms you now have. I think it would soften the aesthetic strength of your chin and may even help the classic notch/indentation deformities along the inferior border. But I doubt very highly that it will improve your chin dimpling and mentalis muscle irregularities that you now have. Whether a sliding genioplasty reversal is worth doing depends on whether one can accept a partial improvement of their symptoms but not a complete resolution. In essence you can not return your chin back exactly to what it was before the sliding genioplasty.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Is it possible to have MAC anesthesia instead of a general anesthetic while performing breast augmentation surgery as I have a fear of being fully asleep?

A: The answer of whether breast augmentation could be performed under anything less than a general anesthetic depends on three factors. The first and most important consideration is whether the implants are to be placed above (subglandular) or below the pectoralis muscles. (submuscular) Subglandular breast augmentation can be performed under IV sedation fairly comfortably as there is no muscle dissection. Submuscular breast augmentation is a completely different story, as you might imagine, as lifting the pectoralis major muscle off of the rib cage would not be considered an innocuous procedure. While there may be some plastic surgeons that would do such a procedure under local/Iv sedation, I would not. There is no great comfort level that can be achieved with this muscular maneuver and lack of a supple muscle can limit how well the breast implants can be placed. Secondly there is the unknown variable of patient tolerance. I have see many a patient who says they are ‘tough’ and do not require much anesthesia. In most of these cases this does turn out to be accurate and the execution of the procedure ends up as both challening and very time consuming. Lastly the size of the breast implants play a role. Larger implants can be more uncomfortable to place without a general anesthetic due to the tissue stretch involved.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in chin implant revision. I contacted you many years ago regarding a few questions about jaw implants. I never proceeded as I live in another continent and the expenses plus travel were too much for me at the time. It seems I may have to pay you a visit after all. I recently underwent a Rhinoplasty and Chin implant combo with a domestic surgeon here no less than a week ago and it went poorly.

Long story short I was told after surgery the implant I wanted wouldn’t fit my mandible and would slide up with time. Instead another implant with wings was added which not only lengthened but widened my petite face considerably. I requested only a tiny bit of anterior only projection and the results horrified me.

If you don’t mind, my questions for you are:

– Will there be any ptosis or sagging if this implant is removed within a week? I don’t know whether to trust my surgeon now.

– Have you ever had this same complication with a patient who just wanted a little anterior projection? Were you able to solve it?

Perhaps custom implants would be the solution? You seem to be the only surgeon offering this.

Overall I would love to hear your opinion.

A: I am sorry to hear of your current situation and your desire for chin implant revision. While all chin augmentation procedures cause a lot of swelling initially (which can seem horrifying) given what you wanted and the implant you got there appears to be a mismatch. With someone wanting only central chin augmentation there are chin implants that just do that exact effect. I almost always screw them into place to avoid any shifting/rotation of them since they are so small. Usually central projecting chin implants are used in women but occasionally men may only want a small chin projection change that does not increase the width of the chin. I don’t see that you have to go the route of a custom chin implant to achieve the chin change that you want. Attached is the type of chin implant you probably would do well with using the 6.5mm horizontal projection size.

It would be ideal of you could just swap out your chin implant immediately. But if not get what you have out immediately and let the tissues settle down and heal for a few months. Then place the new chin implant style and size.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 48 years old and have lost about 60 lbs over the past year with diet and exercise. I am now three months from a facelift and neck lift. While my face did improve, I haven’t seen the results that I was expecting. I still have a round face. I was expecting a sharp cheek shape and sharp definition of jaw line. There’s still loose skin in mid face which I was hoping that a face ift would address. I understand that there is still swelling in lateral mid face and and around jaw line. My very specific goal prior to face lift was to get rid of double chin, which I still have. I also wanted to have the buccal fad pads removed which the surgeon determined intraoperatively that it   was not necessary. My surgeon said that he can do redo the liposuction of neck and face. I also had lower transconjunctival blepharoplasty, which improved the bags. However, I still have residual bags. He said he took out minimal fat to avoid sunken eyes which I agree. However, I still don’t like the residual eye bags. He said he can now remove the buccal fat pads and also perform subcutaneous midface liposuction along with fat grafting around the cheeks to create a prominence and blend into the eye bags. He mentioned that cheek implants are out of favor now as it is difficult to achieve bilateral symmetry and they have a high incidence of nerve impingement at inferior orbital canal. He also has offered to tighten the facial skin. He said the SMAS and platysma muscles have been maximally tightened and there is no room to further tighten it. 

I am just very confused as to what should be best approach to address my facial reshaping goals. I was very happy  to come across your reviews as you specifically address men’s faces. 

A: Thank you for providing all of the pictures and your more recent surgical history. From this information I can make the following comments:

1) No form of a facelift/necklift is going to create a more defined facial skeletal structure. Without adding volume to the cheeks or jawline their appearance is not going to be enhanced.

2) In looking at the pattern of the incisions for your face (which are often appropriate for some men) the effect of the lower facelift/necklift is going to be limited. Limited incision means limited results in many cases. The good outcome from that approach is that the incisions will be well hidden and will not create any secondary aesthetic issues. The bad news from that approach is that the neck will be left with some excessive tissue and the midface tissues will not change. The double chin can only be improved by a platysmaplasty and incisions on the back of the ear that allow for more tissue rotation.

3) A transconjunctival lower blepharoplasty can not create optimal correction of your lower eye bags. This requires a subciliary external incisional technique.

4) Fat grafting will not create any lasting cheek augmentation effect in your type of tissues. And even if it could it would create a rounded effect not an angular effect. Only a cheek implant can create that more defined cheek look.

5) Cheek implants have not fallen out of favor. They are used more today than ever before and they do not cause infraorbital nerve problems or a high risk of asymmetry when well placed. It is true that many plastic surgeons rush to use fat grafting because it is simpler and requires less surgical skill and experience over any form of facial implants. And for many patients this is more appealing and is easier to accept. But for cheek augmentation in men in particular fat grafting does not create the same effect as cheek implants.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in waistline reduction by rib removal surgery. I have the following questions about this surgery.

1) What is the  recovery? 

2) How many inches can I stand to lose? 

3) Will this effect my ability to do any movements in the gym permanently as a competitive athlete? 

4) What are the possible complications? 

5) Can I schedule an online consult since I am an out of town patient. 

A: In answer to your questions about rib removal for waistline narrowing:

1) Recovery from rib removal usually takes about 2 to 3 weeks until you are back to normal activities.

2) I don’t like to predict what exact waistline circumference measurement this procedure will create. That is highly variable. The reason one should consider it is because they have exhausted every other means to reduce their waistline and whatever change they get will be seen as s desirable improvement.

3) This procedure will have no negative effect or restrictions on any athletic activity.

4) Your consult can be online as I do with almost all out of town patients.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in chin reshaping surgery. I have attached a picture of asemi-famous internet woman with a great chin (and probably slightly over-filled lips). I did edits to the photos to show what I think would look good on me to the best of my limited abilitie).  Something more feminine, generally, and that would reduce the overall narrowness and length of my face.  In fact, the most fitting surgery descriptions I’ve found are often “feminization” surgeries for trans women. 

Looking forward to discussing it with you.

A: Thank you for sending your picture and providing clarification as to chin reshaping goals. Your imaging results are quite good and helpful. There are two methods of such chin reduction reshaping. One option is the intraoral t-shaped genioplasty. This is the workhorse of the well known V-line jaw reshaping. It can probably achieve about 50% to 75% of the result you are showing. The result you are showing goes fairly far back behind the osteotomy lines of this type of bony genioplasty. The other option is a submental approach which allows for the creation of a straighter line along the bottom of the jawline which can go further back. This would probably come closer to that look but does so with the addition of a scar under the chin.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in temporal injectable fillers. My temples are looking rather sunken these days and I’m hoping to get some fillers to the region. Could you kindly advise me on these queries?

– Would Radiesse be a good filler for the temples?

– How much filler is usually needed for the temples?

– I’ve used my fingers to simulate what adding volume to the temples would look like. One of the things I’ve noticed is that it seems to lift my face slightly. Based off your experience, do you notice such an effect from fillers to the temples?

– How much does each syringe of Radiesse cost?

Thank you!

A: When it comes to temporal injectable fillers, Radiesse is a fine choice. Good options would include either Radiesse or the hyaluronic-acid based filler, Voluma. It would take 1 to 2 syringes per side to get a good effect. Using your finger to simulate the effects if filler on your temples gives you an artificial sense on a facial lifting effect. Augmenting the temples by fillers or implants will not lift your face even to the slightest amount.

My nurse will pass along the cost of the syringes to you tomorrow.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a revision rhinoplasty. I am currently 10 months post op and my nose is soft, I’ve been told that my swelling is gone and this is the final result.
Ive attached the post op report as well as collages of “pre op, post op, and desired revision” noses. Ive also attached photos of my pre op nose and post op nose from different angles. You’ll see that my surgeon blunted my tip and made it bulbous and higher than before. I’d like my nose returned to its length and sharpness. I look forward to your assessment.

A: Thank you for sending your pictures and the operative note. In regards to your revision rhinoplasty, your current nasal tip shape is the result of reductive cartilage techniques. (blunted higher nasal tip as you have described) Thus any effort to re-establish a more defined nasal tip that is longer will require infralobular tip cartilage grafting as an onlay technique. (there are other methods but this would be most effective) This will require cartilage grafts to do so. Since your septum has already been harvested I would not have confidence that re-entry would produce the amount of cartilage needed to get an effective result. This leaves either the ears or the rib. One or both ears would have the required cartilage needed to effectively do the procedure.

In summary the key to your revision rhinoplasty is to restore what has been removed which is cartilage. The grafts are needed to push out the nasal length and give it volume so the overlying nasal tip skin looks longer and somewhat sharper. Whether you can get back completely to where you started can not be predicted beforehand but this approach will come as close as you can be to your preoperative nasal tip shape.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in having my under eye hollows treated with injectible fillers. I was wondering if you have ever done this procedure? If so, what product does you use, and what type of needle (blunt) or other? I live 3 hrs away so wanted to ask a couple questions before I booked a treatment. Thanks in advance for your reply!

A:I have placed injectable fillers and fat in the under eye area many times. I consider it the most tricky and precarious place on the face into which any type of filler material can be placed. It is very hard to get a smooth even layer of filler or fat over the lower eyelids and infraorbital rim area. The thin tissue of the lower eyelids are very unforgiving of any material irregularities and every injectable filler procure has some degree of material imperfections. Thus there is a relatively high incidence of contour issues (creating puffiness and irregularities) in my experience of the injected undereye area. Blunt-tipped injection cannulas and hyaluronic-based fillers are always used as these techniques have the best chance of lowering these risks and avoiding bruising. Not everyone is a good candidate for injectable fillers in the undereye area. Thin eyelids and tissue covering over the infraorbital rims have the highest incidence of post injection issues. I would need to see some pictures of your undereyes to determine if you are a good candidate for injection treatments.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I was curious how your temporal reduction procedure is done. Do you remove the whole portion of the muscle directly in front of and behind the ear or do you reduce the depth/thickness of the muscle? I have attached a picture that shows what I am talking about specifically. If you do remove the whole portion of the muscle, then what happens if the muscle was too thick and then there is now a visible transitions into the anterior portion of the muscle. I’m worried that it might look odd. What are your thoughts?

A: Thank you for your inquiry about posterior temporal reduction. You are correct in that this is a muscular reduction procedure to decrease head width above the ears. Your attached diagram shows very precisely the location of the muscle removal. I could not have drawn it any better myself. It is not really possible to remove just a portion of the muscle and, even if you could, you would not want to. To make a visible head width narrowing it requires the entire thickness of the muscle to be reduced which is usually 5 to 7mms. (or more in some patients) Your concern about having an uneven edge to the back part of the anterior temporalis muscle (a step-off) is a valid one and a finding I have observed every time I do the procedure. But it is a self-solving problem as the muscle edge shrinks down and becomes more feather edged as it heals. (muscles shrink and contract when injured) This is also helped by using electrocautery at the muscle edge to induce it to shrink as well as the entire temporal reduction procedure is done in the subfascial plane. The tight overlying fascial layer acts to push the muscle down and obscures this temporary step-off as it heals.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, Thirty four years ago (when I was 12) I had 4 teeth extracted and braces. This pushed back my maxilla and mandible. I saw that you do jaw advancement, sometimes without orthodontics, and I really feel that I need that to open my airways. I’m so tired, yet can’t sleep properly. I was recently diagnosed with sleep apnea. How much is this type of surgery and do you accept Aetna?

A: Thank you for your inquiry. What you are referring to is Bimaxillary Advancements (upper and lower jaw advancement) for sleep apnea. You can’t just move the upper jaw forward alone as that would throw off your bite considerably. One needs to move both the upper and lower jaws forward together so the bite remains the same. This is sometimes covered by insurance but requires a very specific set of qualifications. I would go to Aetna’s policy online and look under what is required in the surgical treatment for sleep apnea. They have very strict criteria for coverage. This is the first place to start. While such surgery can be done like any other aesthetic surgery from a cost basis, it is important to initially see whether you would qualify under your health insurance.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, Was told by another ps that I’d need a reverse tummy tuck due to existing scar on my stomach. Is this so and what type of results would I get? Have you done this procedure before?

A: Thank you for your inquiry. While your large abdominal scar is certainly an issue for any form of a tummy tuck, I do not see a reverse tummy tuck of being beneficial for you. Reverse tummy tucks are usually down on patients whose lower abdomen is flat and the loose skin they have is above the belly button. Thus by pulling up on the upper abdominal skin the tissue overhang around the belly button is improved. And most of these women are usually thinner with a simple skin pull can be more effective. This is clearly not the situation you have. While you could do a reverse tummy tuck it will have virtually no effect on your lower abdomen and does not really solve the vascular risk issue that you have with your current abdominal scar. In conclusion I have done a fair number of reverse tummy tucks and you would not be a candidate for one in my opinion. The only tummy tuck that would be effective is a more traditional lower tummy tuck. Your large scar does give one pause when considering that procedure but that is a separate issue from your initial question.

Dr. Barry Eppley
Indianapolis, Indiana