Your Questions

Q: Dr. Eppley, I am interested in facial asymmetry surgery. I developed facial asymmetry over past five years and it gets worth each year. I have very low self esteem and would want the least invasive procedure to correct this. I am interested in knowing the causes for this and learning more on options to correct. As you can see in this photo the right side of my face seems to droop. It is not as toned as the left side. To me it seems to be pronounced when I talk and less pronounced when I smile. The concern I have is why–about 5 years ago I didn’t notice this extreme droop at all and over the past few years it seems to get worse. I have always had a lazy eye and that never really bothered me but now that it has advanced to my lip it does concern me. What are causes for this? I get my eyebrows done and the technicians have told me it’s hard to get them to match because they are just different that is when I really began noticing. It just seems like the two sides of my face are totally different. I appreciate your time. 

A: Your facial asymmetry is congenital where the entire right side of your face sits lower than the left. Yo have known this inadvertently for a long time because of the eye asymmetry (‘lazy eye’) but it has become more apparent now as the entire right face is dropping as you age. That is why it is much more apparent now and gets better when you smile since smiling picks up the sagging tissues.

There are no ‘minimally invasive methods of facial asymmetry correction. This is a problem that will respond only to surgery. The simplest and most effective approach to your facial asymmetry surgery would be a combined right endoscopic brow lift and right lower facelift/jowl tuck up procedure. This will resuspend the tissues up higher so the right facial droop is corrected and better matches the left side of your face.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in occipital augmentation surgery. My 5 year old son has a flat spot on the back of his head. We consulted out pediatrician about it from an early age and were told it would “round out”. It didn’t so at 18 months we paid out of pocket for a helmet and got minimal results because of he was passed the age of best results. 

This has caused a lot of pain and regret for us even though my son doesn’t have a clue that anything is wrong. At what age is it safe to consider doing something about the issue? We don’t want him to face any social issues because of bad advice from our pediatrician and late action on our part. What are our options?

A: The aesthetic correction of unilateral occipital plagiocephaly by occipital augmentation can really be done at just about any age in my opinion. Correction involves building out the bone with hydroxyapatite bone cement (at at early age) or a custom made implant at older ages. Whatever is placed on the bone will grow with the slowly expanding skull growth. I think hydroxyapatite cement is most appropriate for young children since its the inorganic mineral content is most similar to bone. The decision and timing for occipital augmentation surgery at this point in your son is a personal one and is most appropriately done when you and your wide deem it most psychologically protective.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My eyes are too wide- apart which is the biggest regret in my life. I have normal to level 1 of hypertelorism (advised by one doctor before) and I think I am close to no deformity. I would like to know if orbital box osteotomy can be performed in non-deformed patients through milder approaches, like via infra-orbital or oral incisions since my inter-pupillary distance is not as wide as the deformed cases. In my home county and East Asia, there is very rare information about this procedure. I would like to know if any osteotomy procedures can be done to my eyes. Much appreciated and awaiting eagerly for your response. Many thanks doctor!

A: Orbital translocations, aka orbital box osteotomies, can only be performed through a coronal/scalp incision with a frontal bone flap craniotomy removal. There are no effective more limited ways to do an orbital hypertelorism procedure. The only less invasive way that the eyes can be made to appear closer together is with some camouflage procedures such as nasal bridge augmentation and/or medial canthoplasties/medial epicanthoplasties. These small changes to the nose and inner eyes, particularly if done together, can often have major influence on how close the eyes may appear.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am  looking for a surgeon who has proper training to do “mandible angle reduction”surgery. (This is a form of plastic surgery, aesthetic not reconstructive, to reduce the square jaw angles for patients who do not have jaw angle deformities but just wish to reduce square jaw angles.) However, I am not sure what training a doctor should have to perform this type of surgery.

a) Is it enough for a plastic surgeon to attend a 3 day forum for “ Surgical-Orthodontic Approach to Dentofacial Deformity”, to  perform “mandible angle reduction”and cut people’s square jaw angle bones?

b) Would attending a 3 day forum on “Surgical 0rthodontic Approach to Dentofacial Deformity” be RELEVANT to equip a plastic surgeon to perform “mandible jaw angle reduction?

c) I cannot find information on line about “Orthodontic Approach to Dentofacial Deformity” so I have no knowledge/understanding. What is this about? Orthodontic is a branch of dentistry so I cannot quite see how this 3 day forum relates to doing mandible jaw angle reduction.

d) What training should a plastic surgeon have, which would be relevant or adequate to perform “ mandible jaw angle reduction” ?

A: The question you are asking about what qualifies a surgeon to perform jaw angle reduction surgery is not a simple one as that training/experience could be gathered from a  variety of different experiences. Any surgeon that would perform this procedure would be trained and very experienced in facial bone surgery. This could come from a plastic surgeon with craniofacial surgery training or an oral and maxillofacial surgeon with good orthognathic surgery experience. Jaw angle reduction surgery, while simple in concept, is technically challenging as is all surgery of the mandibular ramus due to the limitations of surgical access.

I can speak about the forum you have mentioned in the context of your question since I have not seen or attended the program. Although that is clearly a course in orthognathic surgery of which aesthetic jaw angle reduction would not typically be a part of that course curriculum.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to get some information about the PRP hair injections for hair loss. I have been diagnosed with Telogen Effluvium. I believe it may be CTE now as its going on a year. Will this treatment help stop the shedding as well as help with growth?

A: PRP (platelet rich plasma) has had good success with a variety of medically induced hair loss problems, not just for androgenic male hair loss only. (PRP Hair) Since telogen effluvium is a reactive process and not genetically induced it should theoretically respond to a variety of stimulatory agents. PRP contains platelets which are concentrated sources of high levels of growth factors. Such growth factors are known to stimulate a variety of cells including the follicle cells in the hair bulb. For hair loss PRP is mixed with other hair growth agents such as niacin to maximize its effects. It is administered through a number of small droplet injections throughout the scalp using a very small 30 gauge needle. While there is no guarantee for response in any patient, the autologous nature of PRP has no downside to its use. PRP hair treatments can also be combined with other hair regrowth methods such as minoxidil for a synergistic effect.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in chin reduction surgery. Here are my questions:

1. What is your recommended approach for me…burring down vs. cutting the bone, intraoral vs. submental, etc? Just the chin or the jaw also? Changes to the fat/muscle/skin?

2. What can it achieve (can you simulate it with a digital image)?

3. What are its limitations and possible side effects?

4. What are the risks and how do you minimize them?

5. What can I do to ensure the best results possible? Are there limitations on travel?

6. Can you share before/after photos of women who have undergone this surgery?

7. Your site states $6500 for chin reduction – does this include anesthesia, operating room, surgeon’s costs? Does the cost differ by surgical method?

8. How much time to I need to plan to take off work and/or work from home?

9. How many trips would be required? (pre-op, surgery day, post-op/follow up?)

10. Would you recommend doing rhinoplasty and chin reduction at the same time or separately?

11. What are your Care Credit terms (6,12,18 months no interest?)

12. Do you require dental x-rays or some other type of imaging?

13. Would liposuction be effective in achieving a more defined chin/jawline? Is this considered a separate procedure from the chin reduction? Is there enough fat in your estimation that re-injecting it to my cheeks would produce a good result? Would  a future pregnancy alter the results?

A: Thank you for sending the detailed questions about chin reduction. My answers to your questions are as follows:

1) If vertical chin reduction is all that is needed than an intraoral wedge bony genioplasty approach would be used (this would include narrowing the chin  if desired) But all other chin dimension reductions are best done by a submental approach.

2) Computer imaging is always done before any facial reshaping procedure. Chin reduction is no exception.

3) Scar (if submental approach is used), asymmetries, uneven jawline, soft tissue redundancies are all potential risks and complications from chin reduction surgery.

4) As you can see in #3 the risks are essentially aesthetic in nature. Knowing how to manage the soft tissues in a chin reduction is actually more important than the bony reduction part of the operation.

5) Preoperative choice of the correct chin reduction procedure is the most important step to ensure the best result.

6) Because of patient confidentiality, there are very few before and after pictures that can be shared. And this is coming from someone who has done a lot of them.

7) This is a logistical question for my assistant Camille. Until we know the exact chin reduction procedure she can not give you an absolute number.

8) Recovery is all about the swelling and when you feel comfortable being seen in public. Everyone is different in that regard. It could be one week for some and three weeks for others.

9) One trip for the surgery is all that is needed. All followups can be done electronically.

10) Rhinoplasty and chin procedures are commonly done together. That is a personal choice.

11) Another economic question for Camille.

12) No preoperative x-rays are needed unless one is getting an intraoral bony genioplasty.

13) Liposuction rarely, if ever, can make a more defined jawline. Such changes are a reflection of what happens to the bone not the soft tissues. Any fat injections done would need a harvest site not from the neck. The amount of fat needed exceeds what can be obtained from the neck. Chin reduction surgery will not be affected by pregnancy.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, what is the difference between the effects of cheek implants and a cheek lift? In looking at pictures cheek implants looked more subtle than the lifting of the  cheek tissues. The cheek implants themselves looked more obvious than the cheek lift, however. The cheek lift appears to pull on the face and make the nose a bit wider and even lift the lip. So the overall change to other facial features with implants seemssubtle while there were more changes to other facial features with the cheek lift,despite the cheeks themselves looking more natural. Am I correct in this assessment?

A: You are quite accurate in your assessment of the influence of the cheek lift vs cheek implants and their effects on the face. Cheek implants push the tissues more out and forward while a cheek lift pulls the tissues more up and back. Thus their effects on the cheeks are different. A cheek lift can widen the nose and pull upward on the lips. Conversely cheek implants have no effect on the nose and the lips.

This is why a cheek lift often creates a bigger change on one’s face while cheek implants have a isolated effect on just the cheeks.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a forehead implant. What would the duration of the stay after surgery need to be? How long is it going to take to make the forehead implant? Also what is the maximum you can fill the forehead outward just for reference? How large are the implants able to go? Mine won’t be a very large one I don’t believe, but I’ll send you a picture as requested.  Its more the upper part of the forehead I’d like to add volume to and maybe the brow area also if you can do that. But it is mainly the upper forehead so I have more even side profile and not a slanted forehead.

A: With a 3D computer designed forehead implant the dimensions of it can be just about whatever one wants. Given your descriptive requirements there does not appear to be a limit to the thickness of the implant particularly at the upper part of the forehead which usually never needs more than 7 to 8mms of thickness. The implant fabrication process takes about three weeks from design to having the sterile implant arrive for surgery.

You would likely not need to be here after surgery for more than a few days so ou feel comfortable traveling home after your forehead implant surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I contacted you six months ago about cheek implants. I had gotten cheek implants placed, removed, and then a cheek lift. I promised a six month update. Wow, what a difference six months post op can make. My desire for to have implants reinserted (in this present moment) has vanished along with all of the swelling that previously existed. Swelling can play serious tricks on the mind, and it’s unfortunate that many people don’t realize this. I had mentioned that I wished I had waited the full 6 months to see the cheek implant result, and that still rings true, but not much can be done about that now. I’m sure as a plastic surgeon you must go batty trying to help people understand what is just swelling and to wait out the full six months before judging the final result.

Anyway, things are great for now, but moving forward, if several years from now I am interested in getting implants reinserted, I will definitely keep you in mind. Thank you very much for your help regarding my cheek implant issue.

A: One of the hardest things for facial reshaping patients to understand is the time it takes for all swelling to subside, soft tissue contraction to occur and one to psychologically adjust to the new facial look. The patience it takes to go through these phases is highly variable and some patients are more tolerant if it than others. There definitely is a tendency for some patients to want to reverse their result in the early phases of healing  for the comfort of what they used to look like.

Cheek implants are no different in this regard and the tendency is to think they are too big early after surgery. When months later had they waited it out it may be just fine…or in some cases not enough of a cheek augmentation effect.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, two years ago I have had chin and jaw implants done. I like the results, but I want something much better and I have researched your practice and can see that you perform custom implants in that same area that go all around the lower face and I am interested in that. Just before I take the big step to make appointments I would just like to know that is it necessary to remove the implants and wait some time for face to heal and get the CT scan or is the removal of the implants I have already and to put new ones are all done at the same time? Thanks a lot for the help.

A: It is not necessary to remove your current implants to either design or place a custom jaw implant. As a matter of fact that would actually be contradictory to what should be done. Besides creating the need for extra surgery and scar tissue, your current implants will help guide the design of the new custom jaw implant. Since you already know the effect that the current implants create, this is invaluable information in helping make the new implant design which will be done on the computer right over them. It is more predictable to get to where you want to go if you know where you have already been. The computer design can see the implants and then digitally remove them to make the final design.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, What I don’t like about my nasal implant is that it looks stiff and sits on top of the bone rather than conforming to the natural contours of the bone.  The frontal view looks nice but the side view not as good.  From the side view I prefer more of a “ski slope” look.  Is rib cartilage as stiff and firm as the implant?  Can rib cartilage still warp? Is rib placed in the bridge area the same way the implant is?  Does the nose have to be cut open to place rib?  I was also wondering if tip surgery is generally less expensive without an implant in my nose?  Thanks for the info.

A: Rib cartilage is stiffer and more firm than a nasal implant. Unlike a nasal implant, rib grafts do have the risk of warping although that is largely related to the shape of the rib graft harvested and how it has been carved. Like nasal implants rib grafts are put in the same way which is best done through an open rhinoplasty approach. The cost of a tip rhinoplasty would be the same regardless of whether a nasal implant already was present in the nose.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m a healthy 32 yr old man who previously had a successful rhinoplasty one yr ago. One week ago I had Radiesse (1,5 ml x 2) injected in my cheeks and I loved the results immediately after. But since the inflammation has gone away, I lost that chiseled male model look I am going for. It still looks good but not as good and not that chiseled look anymore. I can’t afford to inject my cheeks with Radiesse every week so I need a permanent result. The problem with off the shelf cheek implants is that they only provide a 4 mm thickness and the post op pictures look too subtle for me. (because I want to be a model). I have low body fat and a narrow face with thin cheeks so I feel that I have the anatomical prerequisites to achieve that attractive look with the help of a skilled surgeon like yourself. What is your opinion on this? I have attached 2 photos from before and immediately after my Radiesse injections. I also attached photos of three male celebrities with the chiseled look that I am looking for.

A: Injectable filler treatments can be a good test to see the effects of cheek augmentation but are clearly not suitable for a sustained and repeated cheek augmentation approach over time. If an injectable filler treatment gave you very pleasing results then I am certain that a bone-based cheek implant can do the same if not better. Cheek implants do come in thicknesses greater than 4mms so I am not certain that a preformed standard cheek implant of the right style and size would not work for you. There is, of course, always the option to make custom cheek implants.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My question is about the limits of a lip lift and the use of one in a postoperative Lefort patient. In most of the pictures I’ve seen it looks like a surgery that merely helps make the vermilion more visible but it doesn’t really “lift” the lip if it’s really hanging. I received orthognathic surgery years ago to make my face shorter and since then my upper lip has been hanging lower than usual. It also looks flat and dead instead of curled up and reactive to facial tension. I was wondering if a lip lift could help in this case and if one with muscle hemming (a technique that I rarely see talked about) would be a better option. Thanks.

A: Your correct in that a subnasal lip lift primarily exposes more vermilion (and reduces the skin distance between the nose and the lip) bit does not lift the bottom edge of the lip vermilion any higher. A subnasal lip lift is largely a static procedure not a dynamic one. Many upper lips after an intraoral vestibular incision used for a LeFort 1 procedure become somewhat less animated due to the stripping of the collateral muscle attachments. I can’t see, however, how a muscle hemming procedure of a subnasal lip lift would improve that problem. It would likely cause other adverse effects on upper lip movement and smiling which is why it is not written about much and is largely shunned today.

If you want to raise the upper lip with a subnasal lip lift it should be combined with a horizontal horizontal mucosal resection on the inside of the lip.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had eyebrow transplants done 3 weeks ago with 50 FUEs to each brow area,  I’m looking to get a rhinoplasty with a silicone implant done a month from now. Can I just check and see if it will be fine to do so or will my grafts be damaged if I get a rhinoplasty done so soon after? My surgeon says it is fine but I wanted to get some additional expertise from someone of your professional caliber.

A: The follicle of a hair transplant has taken by two to three weeks after being placed. The hair shaft will have exfoliated by then but the transplanted follicle lies deep to the skin surface where it will be unaffected by any external forces. It will cause no harm to recently transplanted follicles to have a rhinoplasty done one month after the hair transplantation procedure. In fact hair transplantation could be done at the same time as a rhinoplasty if it were not for several logistical issues. (e.g. time of the procedure and the typical environment (office ) where most hair transplantation procedures are done) Rhinoplasty even using a silicone implant will have no negative impact even on hair transplants that are so new.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Three years ago I had a functional rhinoplasty with adenoids were removed and turbines shrunk which has dramatically changed my voice. My nose and face have changed. The flesh all around my nose, the triangle from under my eyes down my cheeks and under my nostrils / tip of my nose has completely sunk. It is fixed and depressed against the bone of my skull. My top lip has flattened and hangs lower over my teeth. The nose tip is also thinner and lower. I am interested in a pyriform implant a surgeon here recommended that might support the base of the nose off of my skull again and lift the flesh up with it. It is a concave depression right now I keep poking out with my tongue over my teeth. Also my cheeks have sunk either side of the nose so I have folds and have lost my natural volume over my naturally high check bones. I had a young face but have aged over night. My eyes look sunken and everything pulled down as if the implants fixed my cheeks inwards and down. I have seen different surgeons and there is no consensus between implants or fat grafting but I also feel as if my cheek and lip muscle around my nose need lifting back into place. I keep being told I am attractive and too young for a face lift. I feel as if no one is listening. I seem to be researching similar treatments as cleft palate patients. Between the nose and lip and around the nostrils up to the eye are indented. 

Please find attached some pictures for your review. You can see how my lips jutting out under the lip and the front of the cheeks is flat, particularly indented on either side of the nostrils and where the mouth cheek folds are. I look forward to hearing from you.

A: Thank you for sending all of your pictures. You have a classic central midface deficiency. It is really a combined per maxillary-paranasal-maxillary deficiency which is commonly seen is certain ethnic groups. (e.g., Asians) The whole central part of your face is flat. While a peri-pyriform midface implant will be somewhat helpful it is inadequate in both design and size for your needs and its benefits alone will be woefully inadequate. By itself it will not provide fullness (more like bumps) to the side of the nose. What you ideally need is a custom midface implant made that will build up the entire deficient mid facial area from around the base of the nose up along the sides of the nose and out onto the maxilla. In addition the tip of the noses not going to be lifted up by any augmentation done at the bone level including the premaxillary region. Deprojection and lifting of your nasal tip will require a tip rhinoplasty to do so.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a skull implant for my child. What is the youngest age you would fit a pediatric skull implant to a child? Can it be done under local anesthesia?My son is three years old.. He has plagiocephaly of 6mm and 92% brachycephaly. Would he be suitable for a skull implant? Would he need more surgery as he got older? How many children have you fitted with head implants? Many thanks for your time.

A: I have done onlay cranioplasty surgeries in children as young as 4 years of age using hydroxyapatite bone cements. I have yet to use a silicone skull implant in someone that young although there is no specific medical reason not to do so. It is just a request I have never had. An onlay skull implant would grow with the child as the bone underneath it expands outward. There may or may not  be some settling of the implant into the bone a e] millimeters as the skull grows but this is a passive process not an active inflammatory or ‘erosive’ biologic event.  If his occipital deficiency is 6mms I would preferentially consider preferentially consider bone cement but I am not opposed to an implant. Either way these are not procedures done under local anesthesia in children. Please send me a picture which shows his occipital plagiocephaly deformity.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I’m a 35 year old man interested in a cranioplasty procedure. I haven’t been able to find a plastic qualified surgeon who is capable of performing cranioplasty in my or neighboring countries. There is a clinic in Korea. However their method is not predictable since reshaping given by surgeon at the time of operation by using bone cement requires a bigger incision. I have to undergo skull reshaping surgery due to a flat back of my head as well as the top head which is also flat head on top. In addition forehead recontouring and hair line lowering needs to be done. These procedures must be done in same session because of scalp efficiency concerns. In my case I guess scalp tissue expansion is gonna be first stage prior to skull augmentation in order to achieve maximum silicone implant thickness and to allow the hairline to come forward. I have copies of 3D CT scan in my hand so would please let me know which steps will be taken from now on? Kind regards.

A: You are correct in that those cranioplasty or skull augmentation areas and hairline lowering procedures would require a first stage scalp expansion procedure. I would need to see some pictures of your head as well as eventually a CD of your 3D CT scan. Given that you desire a combined hairline lowering and skull augmentation, the custom designed skull implant would need to be placed through the frontal hairline incision.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I practice plastic surgery in Chicago. I attended a cadaver course on facial implants last year in Las Vegas where you gave a superb number of  lectures on a variety of facial implant procedures. I have a question regarding temporal implants and which tissue plane to place it in, I can not remember exactly what you said. From what I remember, it was placed under the superficial layer of the deep temporal fascia (on the temporalis muscle). Is that correct?  Also, what would be the reason to not place it on the fascia?  Thank you for your time.

A: Temporal implants should always be placed in the subfascial tissue location. (under the deep temporal fascia and on top of the temporalis muscle. Temporal implants should NEVER be placed above the fascia. Placing temporal implants in this area is what has caused them to be described as a bad procedure due to complications. When temporal implants are placed above the fascia the outline of the implant will be seen when the swelling goes down…not to mention the potential risk of injury to the frontal branch of the facial nerve in placing it in this more superficial tissue plane.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have been interested in upper lip advancement (vermilion advancement) for a few years. My lips are full but very narrow toward the outer third. is there a maximum measurement of lip advancement that can be done in this area?

A: A vermilion lip advancement can be done to any part of the lip or its entirety. The only limits to vermilion advancement are aesthetic…you do not want the sides of the lips obviously fuller than the central part. Vermilion advancements of the outer third of the lips are not rare in my experience as many people have adequate central upper lip fullness but it tapers quickly down the sides into the mouth corners. This vermilion arrangement creates a mismatch between the vermilion fullness across the upper lip. Advancing only the sides of the vermilion upward is a simple and permanent solution to this aesthetic lip shape imbalance problem. It is done in the office under local anesthesia. There is usually minimal swelling and no bruising with a very quick recovery. The change in the vermilion shape is instantaneous and permanent. The only trade-off is the small fine line scar at the vermilion-cutaneous junction which certainly needs to be carefully considered.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I have a tracheostomy hole that is refusing to close. It have been over a year, and no ENT doctor or surgeon wants totry becaus they are afraid it will fail an dlave a larger hol.e. There is significant very har scar tissue or cartilidge on each sideto fhte helo, and nobody around here can figure a way to graft it back together and then suture the soft tisssue (which is very tight. the hole is less than the diameter than a dime, its just the tissue is tight and the soft tissue is so tight. Do you think you can help? And how?

A: You have a well-epithelized tracheostomy scar/hole that is not going to heal or close over at this point. That is evident by the time that has passed after the tracheostomy tube removal but by the epithelium that now lines it. It may have gotten a smidge smaller due to surrounding wound contracture but this is now a healed permanent opening. Your surgeons are correct in that any attempts at trying to free up the surrounding tissues will not only not work but injuring the tissues runs the real risk of making it even bigger. (although the real risk is just one of wasting time and creating the need for more tissue healing since it has no chance of being successful)

Understanding how to successfully fix your tracheostomy hole (way beyond just a depressed scar) starts with understanding the true nature of the problem….there is a lack of tissue. The hole needs more tissue and the surrounding tissues are both scarred and are tissues of poor quality. They can not be relied upon to be the sole donor tissue for the closure. New tissues must be brought in to create one of the needed three layers. This is likely going to require a pedicled muscle flap from sternocleidomastoid muscle of the neck. (partial pedicled muscle flap) to serve as the vascularized interpositional tissue layer. This would be placed between the internal lining (created by turning in the current skin lining of the hole and either a small skin graft or local skin flap rotated over it.

Anything short of a solid three layer closure for your established tracheostomy closure is doomed to fail.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to consult with you concerning forehead contouring. I am mostly interested in using an injectable filler to achieve a more vertical and convex shaped forehead.

A: Forehead contouring can be done by a variety of surgical and non-surgical methods. But their effects in achieving the desired forehead shape is not the same and those distinctions are very important to understand. The use of any form of injectable filler for forehead augmentation is not a good treatment method for forehead augmentation. Whether it is a temporary filler or fat material, the result will often be irregular and only temporary. While there is nothing wrong with injecting fat into the forehead any irregularities may or may not eventually resolve as the fat resorbs and heals. Using bone cements or an implant is far more reliable and produces a much better result. Getting the desired shape with a smooth contour requires a material that can consistently allow that to happen. And placing the material through a scalp incision is the best method from which to accomplish that goal. I would need to see pictures of your forehead to better answer what would type of forehead contouring procedure would work best for you.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 15 years old male teenager. I have a plagiocephaly flat head which wasn’t treated when I was a baby. I hate it so much especially in pictures as it makes my face looks lopsided. I can not go on with this face anymore as it is embarrassing. I don’t like going out because of it as I don’t like showing my flat side of my face. It is very horrible. There is not one single person that I know and that I have seen that has this type of plagiocephaly head. I need you guys to help please (:

A: While the effects of plagiocephaly are often most pronounced on the back of the head it often will have facial effects as well. Since plagiocephaly is really a twisting of the skull during development this can create numerous facial asymmetries as well. What is seen on the front of the face is often the mirror image of what is seen on the back of the head. This craniofacial condition is often more common that one would think. Because of your age under 18 years old) I can not communicate with you any further for treatment recommendations without parental consent.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, how much would neck liposuction cost? Could you give me an idea of what my realistic expectations would be? If you performed neck liposuction on me on a Monday or Tuesday, would I be able to be back t work the following Monday?

A: The best way to think about results from ‘neck contouring’ is to look at the three surgical methods of doing it….1) liposuction alone, 2) submentoplasty (neck liposuction with muscle tightening) and 3) formal neck lift. These are increasingly progressive neck contouring methods that produce increasingly better results. On a scale of 1 to 10, a formal neck lift would be a 10 as it addresses all three issues that are causing the sagging neck. (extra fat and loose muscle and skin) Everything else need to be compared to that ‘gold standard’ which will create the best neck contour with a sharp neck angle and defined jaw line. Thus liposuction will produce a 4 to 5 on that scale as it depends on the skin tightening up a bit. (halfway between where you are now and what the ideal neck change is) A submentoplasty would produce a 6 or 7 on that scale, better than liposuction but not as good as a real neck lift.

While there may be some swelling from liposuction 5 to 6 days after the procedure I do not see a limiting reason as to why you could not be back to work  again in less than a week. The swelling would probably not be worse than the way the neck looks now for the most part. (in terms of size)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m looking for a surgeon with experience in macrotia reduction and came across your website online. Both of my ears are large in height. I believe I need a helix creation and scapha reduction.. Attached are some pics. If you could give me an idea of how these procedures can be done and if you have any helix pictures you’ve done that would be great. Or any pics of people similar to my case that you have shortened. Do you think I need a helix created or is a scapha reduction enough to achieve results?

A: Macrotia reduction surgery is generally done by removing a portion of the scapha and then back cutting across the helix lower on the ear. Most of the scar is hidden inside the helical rim and the only portion ever seen is where it crosses the helix usually about in the middle of the ear. Your ears are a bit of a challenge for this procedure because you do not have a distinct helical rim (the inside of the rim is exposed) where such a scar line could be easily hidden. This is somewhat concerning for macrotia reduction surgery.

Creating a more prominent helical rim requires rib cartilage grafts to do so and I do not think that effort would be worth it unless you are very highly motivated to do so.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had cheek and orbital reconstruction on the left side of my face three weeks ago for an old cheekbone fracture. The left area of my face that you worked on is still about 40-50% swollen. I also am still numb in my left lip area and on occasion I feel tingling in my face.

My questions are is the numbness and tingling a normal part of the healing process and if so, how long can I expect that to continue? How long until the swelling goes down completely? Can I take anti inflammatory medicine and use ice packs on my face to help the swelling go down? Will the ice affect the fat injections? Lastly, will the asymmetry of the left side of my face eventually match the right side of my face because as of now, the left side of my face is making it appear that the right side of my face is the side that is flattened? 

A: You are recovering exactly as how I would have expected after cheekbone reconstruction (with cheek implant and fat injections). At three weeks after surgery only about 50% of the swelling will be gone. It will take a full three months to see the final result for all swelling to go away. Also I would expect some lip numbness to be present at this point but that will eventually go away with more time. Anti-inflammatory medication and ice packs will not make it go away any faster. This is a process of time for complete healing. I do not judge the result until three to four months after surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have few questions about rhinoplasty grafting. A few surgeons that prefer implants have told me that they do not prefer diced cartilage wrapped in fascia because the cartilage tends to flatten and the borders are irregular.  Other surgeons have said that it lasts a lifetime if placed correctly.  What has been your experience and what do you prefer as a natural substance?  Also, does skin thickness have anything to do with implant extrusion?  My skin is thin but my implant was placed properly and very well because there is no deformity and the skin is smooth.  Also, what is alum from a cadaver?  I have heard that this is something relatively new.

A: It is impossible to beat your own cartilage as the best natural and permanent nasal augmentation material in rhinoplasty grafting.. How to best shape the cartilage for the desired result depends on the source of the cartilage, the amount that can be obtained/needed and the surgeon’s ability to work with the material. It is not as simple as just using cartilage any way one wants. If one can harvest a nice straight piece of rib cartilage then that would make the perfect dorsal augmentation method to carve and shape. But many pieces if harvested cartilage are not straight and be diced and wrapped to ensure a straight result. It has not been my experience that diced cartilage grafts flatten out and create irregular borders. I will not use any type of cadaveric material for nasal grafting so I can not comment on its use.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am considering Jaw angle implants and have a few questions for you. I previously had upper jaw surgery, orbital rim and chin implants done. I feel that my jaw needs augmentation to fit in with the rest of my face, I am struggling to find a surgeon with great knowledge in jaw angle implants and am considering traveling abroad for surgery. If I were to fly to you for surgery how long would I have to stay in the USA before returning home? Also with Jaw implants I hear talking can be a struggle after surgery, how long realistically can I expect this to last? In so far as jaw angle implants type I cannot decide whether I would benefit best from lateral only or both lateral and vertical lengthening? Also the degree of augmentation (small/medium/large). I have attached photos, please can you advise. I am also interested in having the plates from my jaw surgery removed, would this be possible alongside jaw implant surgery?

A: Most patients who come from afar for jaw angle implants surgery return home within a few days after surgery. While patients will experience some difficulty with chewing in the first few weeks after surgery I am not aware that patients have any signficant talking problems. You did not really provide enough pictures to make a full analysis of your face as the all important front view is missing. But as best as I can tell from the pictures provided, medium size lateral width only jaw implants would be my initial impression for your facial needs. While plates and screws from prior surgery can be removed during jaw angle implant surgery I would need to see x-rays of their locations to properly find them. As long as not too much bone has overgrown then they can be removed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have had custom jawline implant (chin and jaw angle implants) made and placed and I have included my before surgery and after surgery pictures. I am very happy with the chin portion. I also like the jaw portion, but feel like it left me with a sort of puffy look versus the more v shaped jaw i was looking for. I know it isn’t possible to look like Brad Pitt or a male celebrity, but I at least wanted to try and emulate the general characteristics. Just going off of what the implants did, I figured going a few mm more in width and couple mm in posterior drop would be beneficial, but of course I defer to you.  I have attached some pictures of the general look I am going for, and would appreciate any comments on what you think would look good for me. Also, in seeing my pictures, do you think I would benefit from the temporal augmentation with implants? Or is it something you don’t think would add much? I have always appreciated your expert and honest advice.

A: Your jaw angle implants did not get close to your desired result because they did not go back far enough and had no vertical drop. Thus they may you look ‘puffy’ but did not add any angularity to the jaw angles and don’t really match the chin that well. Also the inplant design appears to be connected on the left side but not on the right for some reason. Without dropping the entire jawline from chin on back to the angles you will not improve your posterior jaw shape. In essence you need a connected wraparound cusyom jawline implant that is better designed for your objectives.

If you increase your jawline than I would agree that the width of your temporal and lateral forehead region is comparatively too narrow. Extended anterior temporal implants would provide a good balance with a new posterior jawline.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I am 49 year old male and in good shape but yet I have a really bad sagging neck. Attached are photos of my neck from the front and both sides.  I’ve always had a sagging neck and had liposuction done 24 years ago so the fat under the neck is not great but the muscle and skin sag.  I’d like a sharper jaw line.  I consulted with a surgeon here who stated that to achieve a sharp jaw line, I’d need a full facelift and that a neck lift alone would only achieve a partial result.  This doctor stated that I should get a facelift and I don’t want a full facelift – I just want the neck tightened up.  Thanks for your time.

A:  Thank you for sending your pictures. The dilemma that you have is a common one for many men. They want to improve their neck and jawline but don’t want the facelift operation to do so. They believe that a ‘necklift’ will solve their concerns. What the plastic surgeon told you was correct…partially. You can only redrape the neck and jowl skin up over the existing jawline through a lower facelift procedure. The concept of a full necklift is really the same as a lower facelift….they are one and the same. There are other neck tightening procedures but they achieve their effects by making changes below the jawline.Thus they tighten but never really truly lift the neck…achieving only the partial result that your plastic surgeon correctly informed you of.

This dilemma leaves you with two options. First an isolated submentoplasty can be done from under the chin which will tighten up the neck angle but will have no effect on making the jawline sharper or more prominent.  (neck angle change) The other approach to augment the jawline with the submentoplasty. This would be particularly beneficial in your case as your jawline/chin is somewhat vertically deficienct. Improving the prominence of the lower jaw through a wraparound jawline implant with a submentoplasty will make the entire jawline stronger, will pick up loose skin in the neck and create a sharper neck angle.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I hope this email finds you well. I have always been self conscious of my small head and weak Jaw. I recently had custom jaw and chin implants placed 7 months ago. I am happy with the results, especially with the chin, but would like to go with something bigger at the jaw with more support at the side between the jaw and chin. I assume I would need an inferior drop to the jaw, where my prior implants had none.  I wanted to know how feasible this is to do from a safety standpoint and how the recovery would be compared to the original?

Regarding my forehead, it narrows inward and is concave compared to my zygomatic arch. I saw that you perform temporal implants with amazing results. I just wanted to know if these implants will feel natural once they are placed?

Finally, what kind of costs am I looking at for these procedures? I would want custom implants again for the chin/jaw but I don’t know what you would recommend for the temporal area. I would of course defer to you for both decisions. Finally, how much would these procedures cost in total if done together versus done staged? 

A: Thank you for your inquiry. I would need to see pictures of you to give specific answers but I can provide the following general comments.

Since you have indwelling jaw angle implants in place that do not appear to provide any vertical elongation, new jaw angles can be placed. It helps that you have existing pocket so, in theory, the swelling and recovery would be less. (I assume your custom implants are made of silicone. Releasing the implant pocket and dropping the jaw angles down further is not a safety concern.

Based on your description of your temporal deficiency, it sounds like it goes all the way up to the forehead. Thus what you need would be what I call extended and Zone 1 and 2 temporal implants. All such temporal implants are placed on top of the muscle but under the fascia. Patients do not report any problems with such temporal implants feeling unnatural.

As for cost I am a but unclear as to how your current chin and jaw implants were made when you say custom. I assume this was done off of a 3D CT scan. If so that same scan can be used again. I will have my assistant Camille pass along the cost of the procedures if done together during the same surgery.

Dr. Barry Eppley

Indianapolis, Indiana