Your Questions

Q: Dr. Eppley, I have a skull implant question. In your experience how do these two materials perform in terms of edge transitions (edge of implant to the skull)? Is there a noticeable step off from the implants onto the skull on a shaved head?

A: In the shaved or bald male head, there is always a concern about a visible transition of a skull implant to the bone. Eventually any less than smooth transition will be seen no matter how thick the scalp is. PEEK implants can not be made with a feather edge to them because of the way they are manufactured. (machined) Furthermore they were never designed to be used an an onlay and the company will probably not make them knowing that it is to be used as an onlay since they are only FDA-approved as inlay skull implants for defects. Conversely silicone skull imlpants can be made with a fine feather edge by virtue of the way they are manufactured. (poured and oulled off of a mold)

In short, a silicone skull implant offers the best material capability for the smoothest implant to bone transition. In the exposed scalp patient a skull implant needs to have a virtual feather edge at its perimeter.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in cheekbone reduction. I am a 24years old female. I would like to have Zygoma reduction. (by intraoral route if its possible) I want to do this surgery to have more slim face. Do you do on the CT face scan analysis and do you use melting screw? Do you do Anterior segmental osteotomy surgery? Looking forward to hear from you. Thank you.

A: Cheekbone reduction osteotomies for facial narrowing is usually done with an intraoral anterior osteotomy of the posterior zygomatic body combined with a posterior osteotomy of the zygomatic arch where it connects to the temporal bone with a very small incision in the hairline. Small 1.5mm titanium plates and screws are used for bone fixation. While resorbable plate and screws can be used they are much more expensive than titanium and do not work as well. While an anterior osteotomy of the posterior zygomatic body can be done alone, it does not create as much facial slimming as when a posterior zygomatic arch osteotomy is done as well. I usually like to see a 3D CT scan before surgery to determine how much inward movement can be obtained with cheekbone reduction osteotomies.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in having blepharoplasty surgery to remove the extra skin of the upper eyelids and the skin and fat from my lower eyelids. The poor condition of my eyelids appears to have gotten worse in the past year when I was diagnosed with an IgA automimmune skin condition and have been on dapsone and tetracycline antibiotics which have helped tremendously get it under control. My question is whether this medical condition and my medications will adversely affect blepharoplasty surgery?

A: Dapsone, also known as diaminodiphenyl sulfone (DDS), is an antibiotic that is best known for its treatment for leprosy. It has had this use in leprosy since the early 1940s. Ss an antibiotic dapsone inhibits bacterial synthesis of dihydrofolic acid which is very similar to how sulfa antibiotics work. The most common side effect of dapsone is blood-related with the development of some degree of hemolysis in about 20% of patients on the drug. From a skin standpoint dapsone can cause mild skin irritation, redness and dryness and burning and itching. There is no evidence that it impairs the ability of skin to heal.

Linear IgA bullous disease (LABD) is an autoimmune skin disorder in which blisters form in the skin and mucous membranes. Blistering occurs because of the development of a split between the epidermis and the dermis, where IgA autoantibodies react to components of the hemidesmosome and basement membrane. Linear IgA bullous dermatosis improves or clears with the use of dapsone. Dapsone is often combined with a tetracycline antibiotic for maximal effect. I find no evidence that wound healing is impaired in linear IgA bullous disease. While there are rare cases of eye involvement in LABD, wound healing impairment of the eyelid skin has not been described.

In conclusion, having LABD and being on dapsone medication does not appear in any way to be a contraindication to having eyelid or blepharoplasty surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I suffer from an upper labial artery aneurysm. I also have the visible pulsating happening in the center right of my lower lip too but its in the inside of my lip so it isn’t visible to people that see me. I’ve been suffering with this humiliation for the past ten years. 

You can literally see the artery in my upper lip pulsating in the center right part of my upper lip(extremely noticeable to other people). The entire artery through out the right side of my upper lip is so swollen that I can bite it and feel it against my teeth. 

But on the same day this happened ten years ago, even though the pulsating on my bottom lip is harder to see, the right side of my bottom lip became severely discolored. The discoloration on the bottom lip is on the right side as well and stops right were the pulsating blood vessel is on my bottom lip. and where there pulsating is on my bottom lip there is a small lump. Do you think that is the source of the pulsating/swollen upper and lower labial artery? At the time all the doctors after all the scans and blood test weren’t able to help me. Just recently did I find out myself that this is a medial condition that other people suffer from. I thought I was alone suffered with this problem. 

Will laser therapy work in hiding the pulsating artery? 

A: The surgical treatment for an upper labial artery aneurysm or prominent labial artery is ligation. This almost always has to be done through at least two ligation points. In your case it may actually require three given the upper and lower labial artery involvement. In a true aneurysm the protruding sac may also need to be removed as well.

Laser treatments are not going to be remotely effective for this type of vascular problem.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 43 year old female and suffering from a flat back of my head. I was born with normal head BUT at a very young age (talking 10-15) I have been applying metal rollers to my head and in order to make the curls tight I would tighten up the rollers on maximum and then slept on them – EVERY NIGHT and I remember my head used to hurt in the morning. This was going on for a long period of time because I used to hate my straight hair and wanted them curly….. Then, at later stage as a teenager it became clear that I have destroyed my head shape. The back of my head is very flat. 

I understand this would have to be a surgery. I have heard of an implants that could be placed under the scalp to help to improve the shape of the head and I would appreciate if you could let me know whether you have experience in this procedure. 

Many thanks in advance.

A: There is no question that the definitive treatment for a flat back of the head is a custom occipital skull implant. I am an international authority on this procedure and have performed it many times. It is done ideally using a 3D CT scan from which the implant is designed and fabricated. Most custom occipital skull implants are placed through a low horizontal incision on the bottom of the hairline on the back of the head. The only question is whether there is enough scalp to stretch over the size of the occipital skull implant that one desires. I would need to see pictures of the back of your head to determine your degree of flatness and how much skull augmentation you need.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I found a picture below on your site, and i wanted to ask you what exactly has been done here.It looks like lip lift but it has been lifted not only in the middle, but on the sides too!I wanted to do a lip lift, but i always was aware that it lifts only the middle part, which makes lips look unnatural, but doctors who I’ve asked said that it is not true. You are the first one who confirmed my suspicions, so I kind of trust your opinion now.

A: You are correct about a lip lift, it can never do more than lift the central part of the lip. (cupid’s bow) It can look natural if it is not overdone. Some surgeons do overdo them because they believe that the more one pulls up in the center that it will somehow lift up the sides. But this, as you have surmised, is incorrect. The lady in the pictures had a lip or vermilion advancement which moves (‘lifts’) the entire vermilion or lip edge upward from mouth corner to mouth corner. This is done by removing a strip of skin at the lip edge.

The lip advancement is a close cousin to the lip lift but is much ore effective and is the only good lip enhancement option in very thin lips. The trade-off for its effectiveness is that it creates a very fine scar at the lip-skin junction. But in properly selected patients this does not turn out to be a concern.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Would the custom forehead implant also augment the temporal regions that require augmentation or would I need separate temporal implants?  

I have seen surgeries performed where the implant is rolled up and inserted via a small (4 cm) incision that runs from front to back of the scalp versus side to side.  Is this possible regarding the implants you use? Thank you.

A: A custom forehead implant can be made to any dimensions and size including incorporating the temporal region. Whether it should extend past the anterior temporal line at the sides of the forehead into the temporal region depends on where you are looking to achieve temporal augmentation.

The concept of using only a 4 cm long scalp incision to place a forehead implant only applies to small round central forehead implants usually used in women. Men that get a larger custom forehead implant that includes the brow and temporal regions need a longer scalp incision despite the fact that they may be rolled for insertion. A custom forehead implant covers a large surface area and, as as result, need a longer scalp incision for insertion that does a smaller more central forehead implant.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve been googling all night and saw a picture of my butt! When I followed the link it led me to your site. I have suffered with them embarrassment of my saggy butt for most of my life. Even in my late teens when I got down to 95lbs due to working out three times day I still had a saggy butt! I’ve researched butt implants and fat transfer to my butt (I don’t have enough fat) but I really don’t need a bigger butt. I just don’t want the sag. How many of these procedures have you done? How long would I have to stay in Indianapolis after surgery before I could fly home?

A: You are referring to a lower buttock lift or tuck. I have done many lower buttock lifts and it does work well to correct a lower buttock skin sag. Please send me some pictures of your buttocks for my assessment for this procedure. I will have my assistant Camille pass along the cost of the procedure to you later today. You could return home the following day as this is a procedure which is not associated with much pain and all sutures are placed under the skin so there is no need for suture removal later.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in revision rhinoplasty. With rhinoplasty surgery my surgeon shortened my nostrils, cut my hump on my bridge, and my nose tip didn’t cut at all, just is rotated upward. I need to know how to reduce with revision rhinoplasty that distance between upper lip and nose and the fat philtrum and how to narrow nose like it was before. Can nose be longer like it was before and narrow with all size. I’ve heard that by lengthening nose with cartilage graft, nose can get wider. I must say again, that I don’t won’t to go with a lip lift, just thinking about revision rhinoplasty.

A: No revision rhinoplasty can reduce the distance between the base of your nose and your lip. Only a lip lift can make that change. There is no procedure of the lip that can reduce or thin out a ‘fat’ philtrum. The only way to narrow the nostrils is by lengthening the nasal tip and this will require a cartilage graft to do so. But this will make the tip longer which may be an undesired aesthetic change. You may instead consider shortening the tip and use alar rim grafts to help wide the nostrils.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am writing concerning liposuction and fat grafting into my breasts. (fat injection breast augmentation) I am curious as to if this surgery could be performed by mid April if I were to schedule immediately. I am 18 and my high school prom is April 30, so I was wanting this as soon as possible. Also, can liposuction incisions be made through previously existing laparoscopic scars? Thank you.

A: The first question about your potential procedure is whether you are a good candidate for breast augmentation by fat injections. The key question is whether you have enough fat to harvest to create enough of a breast size increase to justify the procedure. While the operation is understandably appealing, few women are actually good candidates for it…they either don’t have enough fat to harvest (it takes a lot more than most people think) or their breast size increase goals are not realistic with what fat grafting can achieve. (usually about a half cup size is the typical outcome) Thus it it important to understand that breast implants and fat grafting are not really interchangeable procedures in terms of their outcome.

There are a variety of secondary issues that are also relevant. If you have the procedure by mid-April you would be barely recovered to go to a prom by April 30th. Also more small incisions would be needed to harvest fat than just that from laparoscopic scars. That is because abdominal liposuction alone is unlikely to have enough fat in most people to do a worthwhile fat injection breast augmentation procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a recessed premaxilla even after jaw surgery, and I’m looking to ‘rotate” the base of my nose forward as per the image without increasing the volume at the side of my nose. Just wondering, does such an implant exist, and if not, how much will it cost to have it custom made?

A: What you are looking to do is increase the projection of the anterior-inferior portion of the pyriform aperture area, known as the premaxilla. There is, as you may know, a facial implant known as a peri-pyriform implant. This is really a combined premaxillary-paranasal implant. One could either remove the paranasal portion of the existing off-the shelf implant, hand carve the exact design from a carving block or have a custom premaxillary implant made. It is really all about how much projection (thickness) that the implant needs to have.

The premaxillary implant is placed through an intraoral incision across the lower edge of the pyriform aperture and across the anterior nasal spine of the maxilla in the midline. I would place two micros crews on each small wing of the premaxillary implant to ensure its positional stabilization after surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have 2 questions about injectable brow augmentation and chin asymmetry.

1. Is it possible to create a more deep set (masculine) brow via fillers? 

2. the bottom of my chin is a bit asymmetric. Can filler be used to even this out? Thank you for your time.

A: Inejctable brow augmentation and correction of chin asymmetry can certainly be done by using injectable fillers. It takes a fair amount of injectable filler to augment the brows, usually about 2 syringes. But it can create a significant brow augmentation effect. The improvement of chin asymmetry will take far less volume. While effective, like all injectable fillers, its effects will be temporary in the range of 6 to 9 months at best.

Injectable brow augmentation can be a very good initial ‘test’ to determine if overall brow augmentation produces a good result. If not it can always be easily reversed by hyaluronidase injections or simple the passage of time to let the filler resorb naturally. If one likes the result, one may progress to the use of fat injections or to a permanent brow bone implant. Permanent brow bone implants are made from the patient’s 3D CT scan and are usually placed through an endoscopic approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in chin ptosis correction. I had a rhinoplastymin my early 20’s to correct a deviated septum and reduce a nasal hump. My surgeon suggested a chin implant to improve my profile since my nose was over projected. He added a button type chin implant intra-orally. However it did not seem to make much of a difference aesthetically and actually hardly showed at all. To be honest, in hindsight, I’m glad it didn’t because I have come to realize that I didn’t really need a chin implant anyway.

As the years progressed, I started noticing that my chin began to droop, especially when smiling. With research I learned that this is supposedly quite common with intra-oral chin procedures? More recently I had my nose and chin corrected by another surgeon. This time a young plastic surgeon seemed confident that he could correct the chin ptosis…he did not. Through some sort of “miscommunication”, after removing the button type implant which was supposedly placed in a strange upper region of my chin and on a slant, he added a larger implant with wings!! Needless to say it was not a good look but I tried to give him the benefit of the doubt and lived with it for 6 months. I finally decided to have it removed. The same surgeon performed the explant and tried once again to correct the ptosis. He failed once again- hence me reaching out to you. He also agreed that the chin implant was a mistake and that I looked much better without one. Thanks.

Also, he left me with superficial numbing on the left side of my chin- from my bottom lip down to chin. He does’t understand why this is, because he said that he clearly saw the nerves and that they weren’t cut. He thinks that perhaps scar tissue might be putting pressure on the nerve(s). He offered to correct it but I don’t have faith or trust in him anymore. I’ve been living with the numbness ever since.

In conclusion, after many google filled evenings researching chin specialists, I came across your website. I’m hoping that you could help me.

I’m worried that excising tissue might change my appearance or my smile and i’m afraid of more numbing. The ptosis is only visible by profile view. I don’t want to change my frontal appearance. Your advice and expertise would be greatly appreciated.

A: Thank you for providing your detailed history and pictures. With your degree of chin ptosis, I would have zero confidence that any intraoral approach would correct it. You have extra chin pad tissue now from two implants and their subsequent removal. (like have breast implants removed) That extra tissue is not going to be able to be lifted back up onto the chin….unless there is the support added to it by an implant. Since you do not need an implant, and never did, your only option now is a submental chin tuck. This is where the redundant chin tissue is removed from below.  This is a very effective procedure that will not cause any pulling of the lip downward, affect one’s smile nor cause additional nerve numbness. It is a different and simpler experience because the whole intraoral approach to its execution is avoided.

The sensory nerve numbness that you have occurred from the placement of the winged chin implant. Whether the numbness is the result of nerve stretch or some other injury during the surgery will never be known. But I know of no procedure that could reliably and safely return the feeling to the mental nerve distribution which is now affected.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I had a PMMA forehead implant placed a few years back, but I’m looking for more augmentation still. I would like to go with the custom silicone implant route, but I have a couple of questions. Is it possible to remove the PMMA implant and design the silicone implant from scratch? I’ve heard some surgeons say that bone cement is impossible to remove, much like Medpor. Can the incisions used for the previous implant be used again for the new silicone implant? I would like to avoid additional scarring if possible.

A: Thank you for your inquiry. In answer tho your questions, a PMMA forehead implant can be removed quote easily. So the surgeons who have said it is difficult or impossible to remove must have no experience with it. A silicone custom forehead implant is designed off of a 3D CT scan. During the deign process the PMMA implant is digitally removed so only the bone is seen. Thus it is no problem to design a forehead implant with an existing PMMA implant in place. I will use the ghost image of the PMMA implant to design the new implant since it serves as a useful reference for how much more augmentation can be achieved. The identical scalp incision used to place the PMMA implant would be used for the new custom forehead implant so no new scarring would be created.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I’m 370 lbs with 52N size breasts, with severe ptosis and painful sagging breast tissue, I have severe back pain from supporting such pendulous heavy breasts for years, will you reject me as a candidate for the surgery?

A: As you have surmised, at your current weight you are not a good candidate for breast reduction surgery. While there is no doubt you would benefit by such surgery, your current weight increases your surgical risks and poses several logistical issues which I will enumerate for you.

1) Any patient over 300 lbs has to be done in a hospital setting. This is not only because of the more comprehensive medical setting and your increased risk of medical problems, but you also need to be conserved overnight after a 3 to 4 hours surgery done under general anesthesia.

2) The other reason a hospital setting is essential is that they have the operative beds that can handle any weight over 300 lbs, most outpatient surgery centers do not.

3) Due to the cost of surgery in a hospital, it is only economically feasible if the cost of surgery is done through insurance.

4) No health insurance will approve a breast reduction with one’s weight being over 300lbs. One of their criteria for coverage is that one’s weight should not be more than 30% of their ideal body weight. At the least they expect to see that the patient has a documented history of substantial weight loss efforts. While we know that weight loss is not going to be the cure for the symptoms of your large breasts, it is an insurance criteria they use.

For all of these reasons, you are not a good candidate for breast reduction surgery at this time. What you need to do kids get your weight under 300lbs which would help lower your medical and surgical risks and give you a better chance to have your surgery approved by insurance.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I’m interested about rib removal surgery for a smaller waistline. What are the qualifications for this type of body contouring  surgery. mIf I qualify, how long will I stay in the hospital? When can I get back to work? My work requires a lot of standing and some walking. Thanks a lot 🙂

A: Rib removal surgery is best done in patients that have a reasonably thin body frame (not  lot of fat around the waistline) in which the anatomic waistline is not well-defined. It is also important that liposuction of the abdomen and waistline will not help to create the more defined wasitline and that the ‘obstruction’ is caused by the flare of the lower ribcage.

For most patients, rib removal surgery can be performed  as an outpatient if you have someone to take you from the surgery center and be with you. (the procedure is done in a surgery center not a hospital) If not, then it will be an overnight stay. One can return to work when one feels capable. That will vary amongst different people and could be anywhere from 10 days to three weeks for a semi-strenuous type of work. One can not hurt the surgery sites by anything that they physically do.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am dissatisfied with my facial profile and wonder if a sliding genioplasty would help. I feel my jaw is vertically too long, yet I can’t exactly put my finger on it. My maxilla/jaw just doesn’t match up. PIctures irritate me the most, because its so evident. Id like to achieve a better look, maybe with a sliding genioplasty and fat injections to the cheeksTake a look…. and thank you very much sir. You are by far the best Ive researched in this area. You surely are the right plastic surgeon for me.

A: Thank you for your inquiry and sending your pictures. Regardless of your current state  of your occlusion (which are not going to be furthered modified by orthodontics), your maxillomandibular relationship shows a very mild mandibular retrusion and vertical elogation of the chin. There is also submental fullness below the jawline. A sliding genioplasty to bring the chin slightly forward  (3 to 4mms) as well as vertically shorten it (5mms) combined with submental/neck liposuction would make the desired improvement in your profile. Fat Injections to the cheeks would help add some cheek highlights for otherwise flatter cheeks. Another consideration would be to transpose your buccal fat pads as ‘cheek implants’. That would create a better cheek contour result by increasing malar projection while decreasing submalar fullness.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Thank you for your amazing job you do as a surgeon and to inform all the patients online. I know (as read on your site) custom implants would be my best choice. However, i really do not want implants, there’s a 0% chance of me getting implants. A friend of mine had a “zygomatic osteotomy” and a “chin wing osteotomy” and I think his results were very good.  Do you perform these surgeries? Do you use some bone grafts? Why would you, or why wouldn’t you recommend the following procedures’?

A: When one tries to compare different facial reshaping operations it is important to carefully investigate up front what dimensional changes they can actually make. I have perform many zygomatic osteotomies (for cheekbone narrowing and cheekbone widening) as well as the chin wing osteotomy. The zygomatic osteotomy provides width and width only to the zygomatic arch and the very posterior aspect of the zygomatic body. It can not provide any anterior projection to the cheek as that is not the direction that the bone moves. The interpositional gap created by the zygomatic expansion osteotomy can be grafted by bone or an hydroxyapatite block. The chin wing osteotomy is useful for two types of jawline changes. It is primarily useful in creating a sliding genioplasty effect where the entire jawline is moved as the chin comes forward and downward. It can also be used to vertically lengthen the entire jawline.

The only reason I ever do these types of facial osteotomies is when the patient wants to do a ‘natural’ operation as opposed to the use of custom facial implants for a very specific type of facial dimensional change as outlined above.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in brow bone reduction surgery. I have very deep set eyes, protruding forehead with brow bossing.  I look like I’m mad and my eyes are hooded by bone. My forehead slopes downward from orbital rim a little and brow is very low set.  Also I have calcium deposits on the front and sides of my head.  I wouldn’t mind something dramatic but just doing some shaving on forehead and brow in front, possible slight brow lift would do wonders. I want to open up my face. I want to project what I feel on the inside and when I go out side I don’t want to see my brow especially when I squint which I’m usually forced to do.

A: Than you for sending your pictures. You do have prominent brow bones and you are correct in what their effect is on your eyes/face. I would agree that a brow bone reduction and forehead shaving and a brow lift would be very beneficial. Like in any man, however, the key issue is the surgical access to do so. This is always problematic in men where the use of a coronal scalp incision creates its own aesthetic trade-off. Usually in men because of their hairline location and hair density, the better option may be a mid-forehead incision in a horizontal wrinkle line. This eliminates the ability to do an overall forehead bony reduction. But an endoscopic browlift can still be done through very limited scalp incisions at the same time.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a LeFort 1 osteotomy done two years ago and I’m looking for a revision as it was done poorly. For the first surgery, I only had rubber bands and was allowed to remove them after the first week for meals. (soft food) However, I’ve read of many cases whereby the patient is completely wired shut for weeks. Why do some patients have such strict fixation while others don’t? Would not getting wired shut lead to a greater chance of relapse or a poorer outcome?

A: Historically, LeFort 1 osteotomies were done using wire bone fixation and the need to use maxillomandibular fixation (jaws wired together) to hold the bone in place as it heals. Since the late 1980s and early 1990s, LeFort osteotomies have been held into place using plates and screws thus obviating the need for wiring the jaws shut after surgery for six weeks to allow the bones to heal.

While I have no idea what type of bony movements were done with your LeFort 1 osteotomy, your after care with temporary rubber bands suggest that you had plate and screw fixation. If properly done the use of plate and screw fixation would create a comparative result to wiring the jaws shut for six weeks. In theory long-term stability would be improved with the plate and screw fixation technique. The risk of a malaligned bite after a LeFort 1 osteotomy with the jaws wired shut for six weeks, as uncomfortable and historic as that is, has a lower risk than that if rigid plate and screws fixation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want to get cheek implants, a sliding genioplasty and jaw angle reduction.My question is that I have just had maxilla advancement jaw surgery (LeFort 1 osteotomy) one months ago. Only the maxilla was moved forward. The mandible was not moved. How long is necessary to wait before I can come see you to get these surgery procedures done? I worry the maxilla may be banged in the surgery or after 4 weeks is this not a problem?

A: Since you just had a LeFort 1 osteotomy just four weeks ago, I would wait a full 8 weeks before doing any surgery that would involve re-entering the surgical site (cheek implants) This is not because the maxilla has any change to be displaced. (it is undoubtably rigidly secured into place with plates and screws) but because you want all the swelling to get out of the cheeks so you have a good idea when placing cheek implants so that the style and size of the implants could be best judged. As it relates to the mandibular procedures (sliding genioplasty and jaw angle reduction) the previous LeFort 1 osteotomy has no impact on their execution and vice versa. But waiting until all facial swelling has resolved is still worthy of the wait.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a large chin button and excess soft tissue padding as well. My oral surgeon plans to slid the chin button (sliding genioplasty) during a jaw surgery but can you reduce the soft tissue afterward? Does this sound reasonable?

A: In interpreting your question, I assume you are having a sliding genioplasty done with a sagittal split mandibular advancement osteotomies. Having a large chin button implies that there is a bony knob on the end of the chin. Onto which you are saying there is a large soft tissue chin pad on top of this chin button. Your question then implies there may be an excessive soft tissue prominence of the chin after the sliding genioplasty is done and whether this can be reduced secondarily. While I would think it can that is a statement made without any knowledge of what your chin looks like or what the lateral cephalometric x-ray shows before the surgery. (how thick does the soft tissue chin pad appear) While this would be an unusual sequence of chin procedures (sliding genioplasty followed by secondary soft tissue chin reduction), for now let us assume it is appropriate to be done.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a custom jawline implant placed six weeks ago. I can open my mouth fully and the swelling was pretty much gone around the 3 week mark. (As in, it was difficult to notice any further reduction in swelling.) There’s no numbness in the lip or the skin around the jaw.The implant looks pretty great, too. I would have benefited from a larger implant, but I am happy with the results in that it is still a significant cosmetic improvement.

Only one question: The tissue right at the angle of the mandible on the right side is sensitive to pressure. That is, if I press on it or the outer side I feel a dull ache. Sort of like a pressure point. I notice this when sleeping on my right side since the pressure on the jaw from the pillow can make it uncomfortable. It can vary in sensitivity depending on how often I try to sleep on that side (i.e. longer periods of pressure = more discomfort when reapplying pressure). I am wondering if this is might be, like abnormal sensory nerve regrowth or a ligament with a small tear. This issue has been present since I was able to start sleeping on my side after the surgery.

A: Every implant that involves the jaw angle has to elevate the masseter muscle off of the bone. This is particularly relevant in a custom jawline implant. Thus everyone sustains a large muscle ‘tear’ so to speak. There are no nerves or ligaments in the jaw angle area. Like many muscle injuries it can take up to three months to have full healing. Why one side would feel good and the other one is still sore is not rare and actually occurs most of the time. Bilateral surgeries never heal exactly at the same rate. I have no cause for concern at this still early point after surgery although it probably doesn’t feel that early to you.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 46 year old male. I was born with a high and wide forehead.  I noticed some hair loss/thinning beginning about 15 years ago. I had a strip hair transplant surgery at that time with approximately 1,000 grafts. I used Propecia/Rogaine for years after the procedure with no change. I have been off those hair regrowth medications for years now with no change.  I underwent an FUE hair transplant procedure last year of around another 1,000 grafts to improve and lower my hairline. As you can see from the attached pictures, there has been little hair growth with pitting and my forehead remains high and wide. Attached are pictures with a drawn in hairline.  The approximate distance from my natural hairs behind the FUE grafts to the central point of my envisioned hairline is approximately 3.5 to 4 cms. Do you think I am a better candidate for another hair transplant or a hairline lowering procedure?

A: A hairline lowering procedure without a first stage tissue expansion will only bring the hairline forward maybe 2.0 to 2.5 cms centrally. With the prior occipital strip harvest (where scalp tissue is lost) that may limit even that amount of hairline advancement. In addition a hairline only brings the central part of the hairline forward and moves the temporal regions less so. While you understandably find your hair transplant results underachieving, the placement of a frontal hairline scar to move the hairline forward does not seem to be a worthy tradeoff with your existing hair density. I would suggest that further efforts should be directed towards additional hair transplants for your hairline lowering efforts.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in multiple facial reshaping procedures. I went to a lot of surgeons who usually said that everything was perfect and no surgery needed. But I may see things a little bit more detailed or have a different idea of beauty. Some said my chin has an asymmetry, is too pointy, has too much soft tissue on it. Some wanted to do pre jowl implants. Some said my chin is too long and wanted to shorten it. I see that my chin is too long but I don’t think it is the length that is bothering me. It is the whole jawline what makes my chin look like this. My jawline is too long and narrow and not round enough. I will send you my picture first and the second one will be one picture that I changed with a Photoshop tool and I will explain on the picture exactly what Iwanted  changed. Please take your time to understand what I try to tell you. 

I want to look softer instead of elegant and have a rounder fuller face. I don’t like my high cheekbones and the spot where my cheekbones end there is nothing but flat. I don’t like my eyebrows they are sticking out to the front too much instead of the eyebrow bone being more flat or far in.I don’t like that my chin sticks out too much too. Can we take it back or should we widen it? I have no Idea. Every surgeon said my nose is perfect but they maybe didnt see that when I laugh it points downwards and I personally think that for my narrow face my nose should be flatter. The tip of my nose has to go slightly up. So  you see I like to have a more flat more wide face. Everything in my face sticks out too much. I hope you can understand what I mean.

A: Thank you for your inquiry. I have studied your descriptions and concerns as well as your pictures. My facial reshaping surgery responses would be as follows:

CHIN – It has too much horizontal projection. It should be set back about about 5mms by intraoral reverse sliding genioplasty

JAWLINE – It can be rounded/made wider by a custom jawline implants that extenjd from the jaw angles to just behind the chin.

NOSE – As you have well described it, the tip needs to be shortened and rotated upwards and some reduction of the radix height between the eyes.

INFRAORBITAL RIMS/CHEEKS – These should be augmented with an implant that combines the infraorbital rim and cheek area as a single implant. These would be placed through an intraoral or lower eyelid incisions.

BROW BONE – The tail of the brow bones would be flattened by bone burring through upper eyelid incisions.

All of these procedures could be performed as a single operation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Thank you for getting back to me so quickly in regards to my cheek implant removals.This has been such a nightmare and I just want to let you know how appreciative I am of your time. I had small malar/submalar implants put in one year ago. In hindsight I did not need the implants. I felt the implants were sharp and didn’t go with my soft delicate features. I waited for six months and then had them removed.

Now I have a whole new set of problems. I now have stretched out skin and sagging nasiolabial folds ( I think it’s my cheek collapsed) that are making me look much older and less beautiful than I am. I have attached a photo of me before and after removal so you can see what’s going on. I am considering having implants put back into my face as one option. Please let me know if you have any thoughts and or suggestions. I read your article about cheek suspension in situations similar to mine and I am hoping you may be able to help me.

A: Thank you for sharing your story of cheek implants and subsequent cheek implant removals. The sequelae from their removal is common and makes biologic sense since the implants disinsert the bony attachments of the overlying cheek soft tissues. Once the implants are removed, the overlying cheek tissues slide downward creating the effects you now see. Given that it has been six months since your cheek implant removals, you now have a good feel of how you look and whether you can live with the tissue changes.

Improving the fallen cheeks comes down to three options; 1) put back in new cheek implants, 2 ) do fat injections instead of cheek implants or 3) perform cheek resuspension.  All three cheek restoration approaches have their advantages and disadvantages. The easiest is volume restoration through either new cheek implants or fat injections. Cheek implants would be more effective than fat injections for a variety of reasons. Cheek resuspension is always more appealing as it directly treats the actual problem but it is more unpredictable and is best done through a lower eyelid incision. Given your young age and what you do professionally, I would be hesitant about any external incisions on you no matter how well they may heal. Intraoral cheek suspension avoids this external scar concern but is far more challenging to do. The Endotine cheek/midface lift is one device that helps successfully execute the cheeklift procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am going to have a custom facial implant procedure and am participating in its design. I would like to have an implant that creates a dramatic amount of a facial augmentation effect. My surgeons seems skiddish about such a large custom facial implant design. What do you think?

A: While I have no details about your custom facial implant design, your desires probably are coming close to making a classic custom facial implant implant design mistake. Just because it can be designed and it fits on the implant model, that doesn’t mean it will actually fit in you during surgery. Implant designing must take into consideration the soft tissue cover and how thick or thin it is. That is knowledge that the surgeon has that patients don’t. I have also learned, and more painfully so for those patients involved, that lack of consideration of the soft tissue layer can result in major complications that have led to the need to remove the implant. It is important in any custom facial implant design to not get too greedy. Reaching for the maximum implant design often leads to complications. It is far better to have an uncomplicated outcome that is 70% to 80% of the desired result than obtaining 100% of the desired result with a complication.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, We have already had a very informative Skype discussion about a possible nuchal ridge skull reduction at the back of my head with occipital implant above it. I think you suggested that the scar may be in the region of 7 to 9cms in length. I spend a lot of time on your excellent website and am certainly impressed by some of the outcomes relating to skull cosmetic work. The one thing thing which is causing me trouble and keeping me awake at night is the prominence of the residual scar. I intend to have my hair very short, but not fully shaved and keep imagining a visible white line across the back of my head where hair won’t grow.

I know most of your pictures on the website can only really be taken before and immediately afterwards, but it is the medium (several weeks) and long term view (months/yrs) that I would really like to get a handle on. Would you have any images you would be able to share with me?, or alternatively, I see many men on your website who have had similar procedures in a similar context (v. short hair) – would it be possible to ask to forward my details to some of them in the hope they could provide insights into how their scars have settled down?

I accept that their will be  a trade off when undertaking a procedure like this, but at the moment my view is not as informed as I would like.

A: Like all patients, particularly men, the issues of scars on the scalp is a major aesthetic concern and consideration in doing any skull reshaping procedure such as nuchal ridge skull reduction. This is particulalry paramount in men that shave their head or have very closely cropped hairstyles. Since I almost never see any patients long-term and men are particularly private about their aesthetic surgery, the information you request is not obtainable. On the positive side, the fact that I have never had a scar complaint or performed a secondary surgery just for the revision of a scalp scar speaks to the general issue that it has not been a poor aesthetic trade-off.

However, the reality of scar concerns in any surgery is that what happens in one patient or lots of other patients is no guarantee that your scalp scar may turn out just as favorable or not of a postoperative concern. Therefore, I have a simple strategy for how to approach the uncertain nature of how scars will turn out in aesthetic surgery and whether one should proceed with surgery. When there is any doubt or apprehension….don’t do it. One should only press forward when they have the attitude that however the scar turns out, its trade-off is more acceptable than the problem they currently have. When a patient tells me they are so concerned about the appearance of the residual scar that it ‘keeps them up at night’, they are not a good candidate for the surgery.

You may think that with more education about the scar, you could make a better decision. But that is actually incorrect and even misleading. One happens on on patient does not always translate to another. Scars are both trade-offs and gambles, one has to have the attitude of ‘rolling the dice’ is worth it for the other benefits of the surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in rib removal surgery. I am a 44 year old transgender male to female that is struggling to obtain an hour glass figure.I have breast and buttock implants and was hoping to reduce my waist line. I run everyday and do abdominal trainings but I have the body I was born with and am trying to improve on it. It does not appear I am making much progress and I can’t get any thinner by diet and exercise.

A: What you struggling to achieve is to overcome the natural anatomic differences between the male an female ribcage. The actual number of ribs between males and females is actually the same despite the well known biblical citation …’The Lord God fashioned into a woman the rib which he had taken from the man…’ (Genesis 2:22) Both genders have 12 pairs of ribs although a few individuals have an extra rib or pair of them.

There are, however, some shape difference between them. The last pair of floating ribs in a female tend to be smaller in order to permit child bearing and is one reason women have a more narrow anatomic waistline. The other if not more important reason is that the arc or curve of the ribs in men is wider particularly in the lower half of the ribcage. This gives men a more ‘barrel effect’ of their torso and not that or a t=more tapering look as the level of the anatomic waistline.

Thus you are correct in that you are battling an anatomic difference that can not be changed by diet and exercise. You have really done all you can physically do. This is very common in transgender female and is one of my three types of patients who benefit by rib removal surgery. Removing ribs 11 and 12 combined with abdominal side wall liposuction all done from the prone position is the surgical step that will overcome this natural anatomic limitation.

Dr. Barry Eppley

Indianapolis, Indianapolis

Q: Dr. Eppley, I am interested in lip reduction surgery. My goal is to reduce to size of my lips by about 30% or a bit more. As you can see from the photos, my lower lip hangs and my upper lip goes out far. I would very much like a more even reduced lip look.

A: Thank you for sending your lip pictures. The typical reduction amount achieved in most lip reductions is in the 20% to 25% range. Sometimes it may be as much as 30% to 35%. But it is always best to think of lip reduction surgery as possibly consisting of two stages to get the ideal lip size reduction result or the best scar outcome. This is more true in very large lip reductions that I have done in many African Americans. The goal is to achieve the maximal lip reduction in one surgery but there are limits as to how much lip tissue can be removed and get the wounds closed in a single surgical event. Thus it may be necessary to ‘walk’ the lip edge backwards through two operations. One should separate the two lip reduction surgeries, if needed, by at least 3 months.

Dr. Barry Eppley

Indianapolis, Indiana