Your Questions

Q: Dr. Eppley, . I have seen you have had experience with temporal artery ligation and success dealing with this  procedure in the past which is why I am contacting you. Attached is a picture of my problem. The artery gets larger if my heart rate is up or its hot outside. I have another one that is not as bad on my left side as well  that I would like to deal with at some point if the initial procedure works.  Is the success rate of this procedure pretty high, in terms of greatly minimizing the size of the entire artery? I am very interested in having this procedure done.

A: The success rate of temporal artery ligation in my experience is always 100% or very close. That would be expected when you shut down both ends of the pipe so to speak. That is actually not the question that is the most relevant. The more relevant question is…does collateralization or shunting of flow occur?  This means if you shut down one section of the pipe way will other previously invisible sections of the pipeline appear later. It is important to remember that all the arteries in the scalp and forehead are very extensive and interconnected. So in theory the blood flow that went to the vessel that was shut down could be shunted and cause vessel dilation elsewhere. I only mention this point in cases of men that shave their head where the entire scalp can be seen. I have had a few patients contact me over the years who had their temporal arteries ligated elsewhere and they developed  visible dilated vessels elsewhere in the scalp weeks to months later which they felt was a worse aesthetic problem than the one they had treated. This shunting is not a problem that I have seen with temporal arerty ligation but it is one of which to be aware and a potential risk of the surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Dr. Eppley, I have just learned of fat injections to help narrow small shoulders. Could you help me learn more about it? I have a lot of fat around my abdomen and obliques. Could that fat be used to make my shoulders bigger (broader and thicker)? If I were to diet, does that mean I would lose fat in the shoulders and they would shrink and I would have to repeat the fat transfer procedure? A lot of stomach fat has been something I always had. Even at 125 lbs. even when I do lose weight, I still have a big stomach. Would that fat be as difficult to lose in my shoulders as it is my stomach? How much broader could I make my shoulders with the fat transfer procedure (half inch, full inch)? Sorry to bombard you with questions. 

A: Deltoid augmentation by fat injections can be a successful method for shoulder enhancement. The key is whether one really has enough fat to do the procedure or, more relevantly, to make it worthwhile. While you may think that you have enough fat, and you may very well do, that is somewhat hard to imagine at a 125lb weight. Whatever stomach fat you think you may have by appearance, that protrusion may be from an intraperitoneal basis (behind the abdominal muscles) rather than in front of it. (intraperitoneal fat is inaccessible from liposuction) This is obviously an issue that requires further assessment/examination even if only by pictures.

But for the sake of discussion let us assume you could have the procedure. Abdominal fat transfer to the shoulders (or anywhere else) is going to behave like the donor site and not the recipient site. Meaning if you lose weight the fat cells will get smaller as well as the reverse. These transferred abdominal fat cells have depot behavior with higher metabolic activity. Thus they are more sensitive to weight changes that normal shoulder subcutaneous fat would be. How much increased shoulder definition you could get would completely depend on how much fat is capable of being transferred…and how much survives the transfer process. Thus it could be anywhere from a very modest change to a more robust 1/2 inch or so.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 29 year old female who four years ago had silicone injections done into my buttocks. Now I’m having some issues with pain and uncomfortability. I am trying to find a doctor who can help me but I have not found one yet. Do you remove these silicone buttock injections?

A:No one can completely remove silicone oil injections from the buttocks unless major excisions (cut outs) are done. While curative the aesthetic trade-off is a resultant disfiguring buttock deformity. So the concept of complete removal by excision is very rarely ever done.

Silicone injections can be treated, however, through liposuction and fat injections. The liposuction removes some of the oil and, more importantly, breaks up the scar tissue/granulomas. The fat injections add fresh cellular elements and encourages new tissue ingrowth as well as maintaining one’s existing buttock size. This will usually relieve most of the symptoms caused by silicone granulomas in my experience. But complete removal of silicone buttock injections is not possible. Think treatment and symptopmatic improvement instead.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I had a skull implant placed six days ago. I have a question about the result of my surgery so far. I have noticed the areas on the top front of either side of my forehead are really soft (squishy). When I press on these areas it feels like I am pressing against a small water balloon. The squishy points are along side the implant edges on the front sides of my head where I do not have any hair. This might also be the case in other parts along the edge of the implant, but I can not tell as much because I have growing hair on rest of my skull. I believe the implant is noticeable from underneath the skin at this point in the healing process. Can you please explain to me what this may indicate? Is this an expected thing at this point? or is this an indication that my implant my not be concealed and will remain noticeable going forward? Thank you.

A:This is all normal at this point in your skull implant recovery. Remember I said it will take 6 weeks for all swelling and internal fluids to be absorbed. You are not seeing the edges of the implant. Rather you are seeing the limits of the tissue dissection where the scalp has been lifted up from the bone. This goes well beyond where the implant sits on the bone. (implant pocket creation) The edges are where the scalp tissue is tightly adherent to the bone. With swelling and fluid it creates a ‘perimeter’. For this visible perimeter to go away this requires swelling and the fluid to be absorbed so the tissues stick back down. This is an issue for 6 weeks to resolve, not 6 days.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I have had multiple chin bone surgeries (sliding genioplasty) and my mentalis muscle now droops and dimples badly upon lip closure. (which I never had initially. The first surgery lengthened my chin inadvertently which made my face more gaunt looking. A second surgery was done to reverse the sliding genioplasty but that was not really done. The chin bone was not pushed back anywhere near as much as needed and it was asymmetrical. It appears the surgeon actually burred down the chin rather than a true sliding genioplasty reversal. Now I have step-offs that are astronomically different in size. What would you suggest to fix this all?

A: As best as I can determine from your description, you initially had a sliding genioplasty and then had it reversed. Rather than a complete osteotomy reversal, the bone was burred down to create part or all of the ‘reversal’. This has left you with bony irregularities and a soft tissue chin sag with dimpling. Comparing your preop x-rays to now I would assume that your goal would be to vertically shorten the chin and get it back as close as possible to your original chin position. This still will require an osteotomy (true sliding genioplasty reversal) as your chin is vertically longer than before. The mentalis muscle/chin pad could be resuspended at the same time. The chin dimpling is a more vexing issue as this is a result of multiple surgeries and aberrant muscle movements due to scar contracture. I would probably inject a little fat into the mentalis muscle to try and soften some of the scar contracture which may or may not be effective.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a very flat back of my head. I’ve never had any problems but as a female I can only wear my hair down and I puff it up everyday so you can’t see it. But by me doing that it is causing hair loss around that area. It is honestly very embarrassing and I am very insecure about it. Also my forehead is flat and the way my nose is shaped does not help at all. So I’m talking maybe three surgeries but I’m not sure how that all works. I have attached a series of pictures so you can see the scope of my concerns. Please reply I would amazingly appreciate it.

A: Thank you for sending your pictures. It is a very classic and common type of occipital-vertex deficiency that I see in women. While it can be very effectively augmented by a custom made implant (custom occipital implant) the question is how much augmentation do you seek…which defines whether it can be done as a single stage or requires a first stage scalp expansion by a tissue expander. Essentially a first stage can augmented the entire area by about 12 to 15mms maximum. A two-stage approach can augment the skull by 25 to 30mms. This is an important consideration up front. Ultimately the question is whether one wants a modest augmentation (one-stage) or a more significant one (two-stage) when it comes to designing a custom occipital implant.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am scheduled to have an old cheekbone fracture reapir procedure by you in a few weeks. The two procedures you will perform on me are: (21407) treatment of fracture of orbit except blowout with implant Left side and (21270) augmentation of cheekbone left side. My questions are what exactly will you be doing as far the actual repairs? Will it require breaking the bone? If screws are used anytime in the procedure, will that negate my ability to have an MRI of the head region in the future because of the metal? Will I feel the implants and screws in my face when I rub it? Lastly, how durable will the implants be if I get hit in the face playing basketball? Thank you for being able to help me restore my features after so long of an injury. I trust you and your reputation and I feel I am in the best competent hands possible.Thank you for your time.

A: Your old cheekbone/infraorbital rim fracture is going to be treated by a camouflage technique to build out the depressed bone and lower eyelid and cheek facial areas. This would be a combined cheek implant and infraorbital rim implant. Any implants used would be screwed into place with very small titanium screws. (about the size of eyeglass screws) They do not interfere with any type of x-rays. With such an old and healed facial fracture there is no benefit to breaking the bone and repositioning it. That would be very traumatic and less effective at this point that building out and filling in the obvious facial indentations/asymmetry. These implants are very durable and would pose no problems playing contact sports. In some ways you can think of them like placing protective bumpers on the bone.

Dr. Barry Eppley

Indianapolis, Indiana

Q; Dr. Eppley, I was born with club foot and now my right leg is slightly smaller than the left.  I’ve attached two pictures. Let me know if you need another.  My basic concern is having to do multiple implants and have also been thinking about fat transfer. I believe to make my right leg look symmetrical I will need one of the longer implants, because it would need to follow down to very bottom of my leg if possible. I have no Achilles tendon and your able to see my fibula bone if I flex my leg.

A: Your best obtainable result is going to come from a combination of calf implants and fat transfer. Calf implants do not go all the way to the ankle nor can any implant go past midway between the knee and the ankle. (can not go past the gastrocnemius muscle/fascia) Below this level any augmentation has to be done with fat transfer although it is important to be aware that fat grafting below the calf survives very poorly due to the tight tissues. Given the small size of your calf you will need both medial and lateral calf implants.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dear Dr Eppley, After a rhinoplasty I was left with a big space between my nose and lips. My surgery was 6 days ago. Do you think this might still change and I should wait longer until considering a subnasal  lip lift? Thank you so much!

A: It would be entirely premature to judge what effect your rhinoplasty will have on your upper lip length at just six days after surgery. While it is unknown to me as to what type of rhinoplasty you have had, any rhinoplasty surgery that results in tip rotation and/or tip shortening is going to initially create the perception that the upper lip is longer. In reality it be now more exposed with the change (opening) of the nasolabial angle…or it is possible that it may have indeed become lengthened. But until all the swelling from the rhinoplasty surgery has resolved and the tissues have fully settled, any aesthetic judgment on upper lip length can not truly be appreciated. I would not perform an upper lip lift on a rhinoplasty until they are six months out from the procedure, not only because of the uncertainty of the aesthetics, but because of the intervening skin between an open rhinoplasty incision and that of the subnasal lip lift.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a full wrap around custom jaw implant as it seems to be exactly what I need for the look I am interested in. When making the wrap around it it possible to make the side ends thick to get an end result like I have illustrated in this example but also build in the chin implant on the wrap around to make my chin longer and more aesthetic? With my current chin implant I feel like the chin implant was placed too high and has altered my smile, so fixing it all in one go would be great. I am from around Loa Angeles so could I fly out prior to surgery and get a 3D CT scan and show you exactly the type of implant I wanted? Also would I need to get my wisdom teeth removed before the surgery? I talked to another doctor who required it.

A: The wrap around custom jaw implant is the only way you can get that continuous jawline look that goes from side to side. That jawline implant look (large wide jaw angles) can be designed although many patients would consider the look to which you reference as being excessively wide in the jaw angle area. Vertically lengthening of the chin as part of the design is commonly done for many custom jawline implant proedures.

The 3D CT scan which is needed can be done where you live so there is no need to come here to get that done. The design part is done from afar with you and it takes about three weeks from design to having the implant ready for surgery.

Whether your wisdom teeth should be removed depends on whether they fully erupted or partially or full bony impacted and whether they have ever been symptomatic. (e.g., developed pericoronitis) If they are full erupted  and are asymptomatic then it does not matter if they are in place or not. But if they are less than fully erupted they should be removed 3 months prior to the custom jawline implant procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a saline testicle implant placed last year and I hate it. It feels hard as a rock and very unnatural. I would like to replace it with a softer but larger silicone testicle implant. In addition I would like to make the opposite testicle larger. I have read that there is a way to do this by wrapping it with an implant. Is that true? I read it on the internet so you never know how accurate that information is.

A: Saline testicle implants feel very firm because they are an overfilled water sac which is under tension. Conversely silicone testicle implants are very soft and squishy because they are made of a low durometer solid silicone material. There is no question that silicone testicle implants feel a whole lot softer than saline ones. I will have to compare the largest silicone implant with that of saline to make sure it is bigger. But I would have confidence that it would be since the largest silicone testicle implant is up to 4.5cms in length with an oblong shape.

Capping the existing testicle is how it is made bigger. You take a large silicone implant, cut in in half and then remove the inside of the implant leaving only a thinner outer shell. Then you put the two halfs together over the existing testicle and put it back together like a clamshell. A space needs to be left between the two calfs so that the vascular pedicle and cord that goes to the testicle is not pinched off.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley,  I am interested in orthognathic surgery even though my bite (Class 1) normal. Thus any orthognactic surgery would be cosmetic and not functionally beneficial. It just appears to me that my face and the bones in it did not grow in an optimal aesthetic direction. It seems that my face is too long and has dropped to a gaunt look with a flat midface. Could this be due to a downwards grown maxilla or other bones? Can it be fixed with a maxillary impaction?

A: Your malocclusion is modest and within the confines of a general Class I occlusion. The point being is that it is not the source of your aesthetic facial concerns. The difference between your child face and your adult one is the relatively standard change between the 2/3s dominance of the upper face in childhood to the completion of facial growth in early adulthood with a reversal in that proportionate relationship. Whether your face is too long is a personal assessment and not a function of actual facial structure disproportions.

Changing your facial proportions is done by decreasing the vertical length and improving the midface projection width. This is usually best done by a vertical wedge reduction genioplasty (chin) and malar-submalar implant augmentation. Doing a maxillary impaction would bury your upper teeth under your upper lip and would also require a concurrent mandibular osteotomy to keep your bite relationship from changing unfavorably.

Dr. Barry Eppley

Indianapolis, Indiana

Dr. Eppley, I found your name on the American Society of Plastic Surgeons and also on the website, RealSelf. 

I am experiencing pain and restrictions from an old c-section scar from 1985. The left end of the incision is indented and has adhered to the underneath muscle. I have tried many rounds of physical therapy to help it, but it now seems to be pulling so much that my hip flexor and groin area are becoming restricted and painful. 

I have hated the look of it ever since the day I got it, but I can’t deal with the restrictions and pain. Had it looked at by a general surgeon where I live about 10 years ago and he said he didn’t ‘believe’ in scar adhesions. 

Is a scar revision normally covered by insurance? Thank you for your time.

A: It is not rare that a c-section scar can create an adhesion down the abdominal wall, resulting in scar contracture pain. Whether the general surgeon you saw believed in scar adhesions or not, they do exist and they are real. Such c-section scar adhesions are easily solved by total excision of the scar down to the abdominal wall and bringing in fresh tissue to reconstruct the tissue layers from the bottom up to the skin. (C-section scar revision)  Scar revisions are not usually covered by insurance but that is a determination they have to make not one that I can since they write the policy and make the decisions about coverage.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to have v-line jaw surgery, a lower facelift and a subnasal lip lift. As far as the lower facelift and neck there is not too much laxticity today but the jaw reduction will likely increase it so a lower neck and facelift will be needed. Can these procedures be performed in a single surgery?

A: V-line jaw surgery usually does not create excessive jowl or neck skin as it is really a redistribution of the bone shape not always a real total jaw reduction. If you do not have any skin laxity now I doubt any will be created after. There is simply not that much jaw bone removed to create substantial less skin support. But that is somewhat dependent on your age and natural skin elasticity. But for the sake of discussion let us assume that some neck-jowl tightening would be needed then a lower facelift can be performed at the same time as the V-line jaw surgery…or await and see if it is really necessary which would be the most practical approach. Certainly there is no problem doing a subnasal lip lift at the same time as the v-line jaw surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, do you do mole removals on the face? I have several raised moles on my face that I would like to see about removing. Is the cost for it per mole?  I have one about the size of a pencil eraser and the others are smaller. Do you have before and after pictures of facial mole removal procedures? I’m worried about the scarring and not sure if it is worth it. 

A: Every plastic surgeon does facial mole removal which is done in the office under local anesthesia in most cases. Your facial picture which makes it very clear as to your facial mole issues and their large number. I could easily identify three facial moles (right face, right nose and right upper lip) and probably six that would benefit by removal. While every faoial mole removal does leave a very fine scar in its wake, this would seem to be of less significance than what they are replacing based on your picture and the sized and location of the moles. In general a small flat scar is usually better than a raised darkly pigmented mole which often can have hair growth associated with it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had an otoplasty on my right ear, but unfortunately it was overdone and is causing a lot of problems. The surgeon removed a lot of cartilage and skin from my ear causing my ear to be set back a lot and completely attached to my head in some areas. This has affected my life greatly and now I am looking for a very experienced surgeon who can reverse this. I don’t have any stitches holding my ear to my head, so the only fix I believe is doing cartilage and skin grafts to separate my ear from my head and spring it back to match with the other one. Is this something you can do? And what is your experience with such reconstruction surgeries? I really appreciate you help.

A: Most otoplasty reversals require a method to spring the cartilage back out which can be done with a rib cartilage graft or a special metal spring that I use. If there is a true skin deficiency a skin graft will be initially needed prior to any effort at cartilage reshaping. However is some cases I have done a simultaneous fascial rotation flap after the ear is released and then skin graft on top of that at the same time as a cartilage graft. I would need to see pictures of your ear to see exactly what needs to be done. It may also be that a skin graft alone may suffice.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a very wide face and protruding cheek bones and it’s always been an insecurity of mine. I’ve also always has chubby lower cheeks.when I smile my cheeks tend to protrude a lot which makes my profile look very awkward. I really want to have a slimmer more masculine face/jawline. I’ve also been considering a lip lift to shorten the gap between my upper lip and nose, and a nose job for a slimmer less bulbous nose. What surgeries are right for me? And what combination of surgeries are safe to perform simultaneously?

A: When it comes to fullness of the lower cheeks, which are below the cheekbones and down closer to the side of the mouth, a defatting approach is needed. Given your pictures and the fullness that runs from just below the cheekbone almost down to the jawline, I would recommend the combination of a buccal lipectomy and perioral mound liposuction. These two together are the most you can do for helping change a round face to a more V-shape based on soft tissue changes only. It is also important to remember that the thickness and quantity of skin also plays a role so there are limits as to what facial defatting can do.

When it comes to a rhinoplasty and a subnasal lip lift, I do not recommend that these two procedures be done together. This has to do with ensuring good blood flow into the intervening columellar segment. They will need to be staged or done separately.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was just curious on the cost of the filler for forehead horns. My brow bone sticks out too far and I would like to have it filled like I see in the photos on the website. Do you know the cost roughly? Also, would you ever have to get this procedure done again in the future or will it be permanent once it’s done? Thanks in advance!!

A: For filling in the central depression of the forehead, I really don’t use an injectable filler technique for it in most cases. Synthetic injectable fillers are only very temporary (a few months) while the fate of fat injections is uncertain as well as its permanency. I have used injectable bone cement as a form of injectable filler but it is difficult to get it perfectly smooth and, if it does not become smooth, a secondary revision of it is going to a larger incision to access it to even it out. The most successful strategy in my experience has been the use of a wall custom implant made from a 3D CT scan. This fills in the depression nicely and is permanent. I would need to see some pictures of your forehead to provide a more specific answer as to what work best for you. But central forehead augmentation to fill in a depression between the brow bones and the upper forehead prominences is usually best done with a custom forehead implant approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 39 year old male who was born with a noticeable asymmetry in my face. This is most pronounced on my right lower which is not as full/pronounced as my left side. It has always bothered me for as long as I can remember so I finally decided to do something about it. In January of this year I consulted with a local facial plastic surgeon who seemed confident that he would be able to eliminate the asymmetry with an off-the-shelf implant and so I ended up scheduling surgery a week later. I had some initial concerns because the consultation only took about 15 minutes and no details of the surgery or what my options were was presented. The doctor sent me out for a 3D CT scan prior we did not look at the scan and measure out where the asymmetry was and what areas needed to be augmented and by how much. I reluctantly decided to proceed regardless of my intuition telling me not to and this ended up being a costly mistake. About a month after surgery when the swelling began to subside, I noticed that the implant he choose actually ended up causing more asymmetry than I originally had. The implant he chose was a Medpor  type implant that under augmented my horizontal deficiency by 50% and over augmented my vertical deficiency by 100% as well as changing the mandibular angle (something that I didn’t want to do as the angles matched before surgery).

During my follow-up visit the doctor agreed that this was not a good outcome and said he would redo the surgery with a custom jaw implant. However he has now abandoned me and has left me now with this Medpor implant that needs to be removed immediately. Thus I am looking for a doctor to help me out in this situation. I would like my current implant removed and a new custom implant put in in its place. 

A: I am sorry to hear of your unfortunate outcome. In treating facial asymmetry, ‘winging it’ throws multiple variables into an already difficult problem and that usually never works out well. There is no doubt that a 3D CT scan needs to be done at the minimum for diagnostic assessment. But in 2015 designing a custom implant for facial bone asymmetry gives one the best chance for substantially improving facial symmetry. Since you already have a 3D CT scan you can proceed expeditiously to beginning the custom jaw implant design.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in breast implant replacements with or without a breast lift. I have saline implants that are 18 years old. I was a small B and the implants brought me to a small D. I’ve had two children and breast fed without complications. I feel like the implants stayed in place and my breasts didn’t. I don’t really want them this large anymore anyways but I’m unsure if I should take them out and get a lift or get them smaller with a lift. It would partly depend  on cost but also on which one will look better. I just want a normal size and breasts that are perky.

A: It is not rare that pregnancy causes the existing breast tissue over implants to sag off of them after becoming enlarged and then deflated. This indicates that some form of a breast lift is absolutely needed, the only question is whether smaller implants are still needed to maintain persistent upper pole fullness of the breasts. A breast lift, while moving the nipple back up and tightening the breast mound around it will not maintain long-term upper pole breast mound fullness. This it is very likely that a small implant may still be needed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I may be interested in skull reshaping surgery. I am contacting you because I have been searching for a professional opinion relating to some worries I have concerning the shape of my head, and I thought that you might be able to help. I have noticed that there is a clear ridge sloping outwards, and above that, the shape seems to be flatter than when compared to many other people I have seen. 

I never used to be so preoccupied, but this changed when I recently saw my head in profile. I have begun thinking that it is not ‘standard’, and I’ve been wondering whether there may be a reason for this.  

I believe that some attitudes of people towards me, in the past, have been influenced by its shape. Do you think that undertaking cosmetic surgery to correct this would be possible/advisable, based on the images provided?

I realize it’s probably nothing, but I think it’s best to be certain about something like this. 

A: I can tell you whether your skull shape should be a concern to you or not, that is a personal judgment. Beauty is in the eye of the beholder so speak…in this case an abnormality is also.

What I do see is a skull shape that has a flat occiput which has resulted in the posterior sagittal ridge area being raised up and sloping downwards toward the forehead. These skull shape issues are all interconnected and they are a well known type of skull abnormality.

Whether this skull shape should be of concern to you and whether it should be corrected is a personal and aesthetic judgement on your behalf. But it can be done through aesthetic skull reshaping surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m considering getting facial feminization surgery but I want to know the cost, recovery time and the amount of pain to be expected. I want to get the most change of my face that I can but am not sure how much I can really achieve. You are the facial feminization surgery expert so I would need your guidance as to what would be best for me.

A: Facial feminization surgery is a broad collection of hard and soft tissue procedures that are individually selected for each patient based on what has the best value to help change the shape of their face. There is no standard FFS surgery where everyone gets exactly the same procedures. I would need to see pictures of your face to make an assessment with computer imaging to see what works best for you before any cost quote can be given. Regardless of the exact procedures, FFS is always a compilation of numerous procedures that will cause a lot of swelling and takes about three weeks until one looks fairly normal and non-surgical…but really complete recovery from this type of facial reshaping surgery takes up to three months for everything to completely normalize.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley,I’ve recently e-mailed you inquiring about deltoid implants/fat grafting and I was wondering what other areas of the body that fat grafting can be applied to?

I’m 24 years old and have a very thin and bony structure, thin wrists, narrow shoulders, and thin neck which has led to years of insecurity, yet at the same time I have a decent amount of fat on my stomach and chest.Due to severe tendonitis and several joint problems – accompanied with a muscular dystrophic disease in earlier life, I’m entirely unable to engage in hypertrophy training so the option to increase muscle mass through weight lifting isn’t possible, though I have tried for many years to work around it.

I was wondering if somewhat of a comprehensive fat grafting/contouring upper body transformation (increasing forearm, upper arm, deltoid, and neck thickness) is possible. Could it be done and look natural? or is there an alternative surgery that could be more suitable? I just want to feel/look like a normal person.

Thank you.

A: I think the key issue in you, who is very thin most everywhere, is that fat grafting is very unlikely to be successful. This is because most likely you do not have enough fat to harvest to be used and in very thin people the injected fat rarely stays or stays so little that it does not make much difference. The only option for arms, shoulders, chest and calfs are body implants which can look natural as long as they are not overdone. (too big) There is no procedure that can make your neck thicker.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I’m a 32 yo man going for a sliding genioplasty. .I have lip incomptence therefore the surgeon is planning to remove a 5mm wedge of bone and I asked him to move the chin 10mm forward. However I’m a bit afraid of removing that amount of bone. I’ve read that with an angled genioplasty is also possible for height reduction but he seems reluctant because of the notch left on the jaw. I don’t know if these two procedures give the same result. The second picture is approximately what I expect and since I’ve had time I ‘simulated’ it on the x ray. Even though I rely on him, I’m looking for the best result that’s why I’m asking for another thought on it. Thanks for reading.

A:Please send me pictures of your face from the side view. That will be helpful to see how much vertical chin height reduction is needed if any in your sliding genioplasty procedure. If you really need vertical height reduction it is better to do it by a vertical wedge resection than a severely angled bone cut. That is the more assured method of achieving adequate vertical chin height reduction. Ideally seeing pictures of your lateral cephalometric x-ray would also be most helpful.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, a year ago I made a big mistake, I had a buccal fat removal operation (buccal lipectomy) and now I’m really sad about the results. My cheeks are too sunken and this makes me look older. I was reading an article you had written where you said that there two solutions for the buccal lipectomy defect. To add volume where my buccal fat was is it better a dermal-fat graft or fat injections? Will this leave scars on my face? 

A: To restore lost volume from an over aggressive buccal lipectomy you can either do fat injections into the buccal space or place an actual dermal-fat graft into the original buccal space. One harvests the fat by liposuction (injection) while the other by an excision. (dermal-fat graft) A dermal-fat graft creates more assured volume but does leave a scar somewhere in your body to harvest it. For this reason many patients may initially opt for the fat injections.  Either approach will leave no scars on the face as they are done from inside the mouth….just like your buccal lipectomy was done. In short, restoration of a buccal space defect must replace like with like…or fat lost with fat grafting.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in skull augmentation. I haven’t managed to find any possibility here for my skull flat shape and also smaller size, which is always a problem due to hiding its flatness in a puffy hair and that takes a lot of time and doesn’t allow me to wear the desired hair style. I’m 34 years old and I am struggling with such issue for a lifetime, and now I’m seriously looking for a permanent fix. My forehead is also flat and what I’ve lately done was to get injected fillers in my forehead, its corners and all over it, for creating a nicer curvature which is not a permanent but only temporary one, then within 1 year or a year and a half, I need to re-do this process which is not the most desirable fix, also only temporary.  I’ve been reading about a latest discovery, Kryptonite, and also learning about you Dr Eppley from online and also searching your website, and I’ve noticed you’re extremely experienced and a specialist in such matters.  I’d like to kindly ask about your opinion, if some injections with suitable bone adhesive (Kryptonite or otherwise) would solve my problem permanently, without any side effects or other later surprises?  I’m aware the injections would be the quickest fix, especially when 1.5 cm to 2 cm height in my skull’s curvature would be perfect and also a bit at the top back, plus a bit on the laterals for creating more volume around, therefore in a nutshell needing some attached patches in the right spots of my skull. I’m also reading online that such injections would have some side effects and in the longer term may bring some problems, not sure if that’s correct or not?  If possible, I’d appreciate it receiving your kind reply regarding such procedures, or if it’s better going for a whole skull patch addition through a more complex operation?  Obviously, I’d prefer the simplest but most efficient procedure, but if such quick injectable permanent safe fixes don’t exist, please kindly elaborate about the best fit in my case, in order for my forehead to be considered as well and curved accordingly with no weird marks after a possible operation or implants. 

A: The simple answer to your question is that no method injectable skull enlargement works well and has lots of complications. Kryptonite is no longer available and has been removed from clinical availability. The only effective method of significant skull augmentation (and a 1.5 to 2 cm enlargement would be considered significant) is a two-stage surgical procedure. The first stage is the placement of scalp tissue expander (to gain the room for the bone expansion) and the second stage is the placement of a custom skull implant made from a 3D CT scan. Like all surgical procedures, they are not risk free but this approach has had few complications in my experience.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was interested in removing the dimple or cleft in my chin. I have attached pictures of it so you can see if chin cleft removal will work for me. It is not a big chin cleft but it bothers me nonetheless.

A: Thank you for sending your pictures. What you have is a lower vertical chin cleft which is a direct manifestation of a notch in the chin bone. If you feel the chin bone under the cleft you will probably feel a notch or a groove in the middle of the chin bone. In this type of cleft it is important to fill in the bone ‘defect’ as well as add a little fat right into the soft tissue portion of the chin cleft since it also is making a contribution. This is done from inside the mouth with the placement of a very small mesh implant into the bony groove. The fat can be harvested from inside the bely button and injected into the soft tissue cleft or a small graft can be harvested from inside the mouth from the buccal fat pad and placed directly into the defect.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m 18 years old at height 5’4 and weigh 125lbs. I have breasts the size of 32DDD. I know I want to have a breast reduction sometime in life, and my question is if it’s worth having one before I have children?

A: When one undergoes breast reduction depends on how symptomatic one is from their large breasts. If they are heavy and painful and are interfering with your lifestyle then you do the procedure before children since you can get the benefits sooner rather than later. If they are large and not that uncomfortable then you wait and see what effect having children as on their sizes and the symptoms that are causing.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to inquire about depressor septi release surgery for correcting a transverse crease above my upper lip just below my nose. I do not know of this is the right approach but ti seems like it might work.

A: The release/removal of the depressor septi nasii muscle is usually done to stop the top of the nose from pulling down while smiling. It may or may not have an effect on a transverse crease in the upper lip. The best way to find out if it does is to initially do Botox injections first and prove that the elimination of its action will make an improvement. If Botox is successful then you should consider depressor septi muscle release surgery

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I have a question about the genioplasty and v-line surgery. ( jaw reshaping) What’s a good prediction of what the recovery will be like two  weeks forward in terms of speech, looks and smile? 

For the genioplasty, I definitely want to reduce the width. I think rather than projecting it forward to slightly bring in some height, I’d rather just lengthen it vertically right where it is. I prefer this because I don’t want dramatic length added so I wouldn’t think I want to do both, and I assume extending my chin bone downward will help change my chin profile from “slumping up” at the chine edge, to a more aesthetic look. 

In other words, I assume bringing the chin forward wouldn’t help change my chin’s profile and hence, moving the bone downward would benefit me best. I think if anything perhaps my chin could be brought forward a millimeter, but again the real thing I’m looking for is to reduce the width and add a little height for the sake of creating a more v-line jaw line.

A: I think your insights into creating more of a V-line jaw shape are correct. (v-linje surgery) Chin width reduction and vertical lengthening will go a long way towards changing the shape of the front half of the jawline.

It will take a good three weeks to have about 75% recovery and a full 6 weeks to show 90% of the result from V-line surgery. This surgery does not affect speech or the ability to eat but is mainly an appearance issue due to swelling and temporal chin distortion. There is no doubt your chin will be very swollen the first 7 to 10 days after surgery.

Dr. Barry Eppley

Indianapolis, Indiana