Your Questions

Q: Dr. Eppley, I’m interested in knowing more about the liposuction for calves and ankles. I’m 24 years old and am 5’ tall and weigh 140 lbs.. Many surgeons where I live have refused to perform liposuction in that area because of the risk of prolonged edema. I was wondering how much you would charge for liposuction of the entire leg( thighs, calves and ankles). Also, can I expect the whole leg to be done in one session? Thank you very much. I look forward to hearing from you.

A: What you referring is, as you have mentioned, total leg liposuction or near circumferential extremity liposuction. Your surgeons are correct in my opinion that performing liposuction on the whole leg will result in prolonged edema. And it is even possible that some of the edema may even be permanent. (rare risk) It is much more prudent to think of trying to thin the whole legs in two stages, upper (thighs) and lower liposuction. (knees to ankles) The lower legs should be done first, followed six months later by the upper leg section. This is the safest approach to prevent prolonged lower leg edema and also provides an opportunity to touch up any uneven or under corrected areas on the lower leg.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a mini tummy tuck. My main concern is the recovery. I exercise daily, Pilates and tabata a few times a week. I just think of the time away from that and I cringe. Recovery time is a concern also because I travel a lot and if I’m going to do this I want to do it soon before our next scheduled trip in June. I have attached a picture. I know with the stretch marks I’m going to be scarred anyway but losing the excess skin would be fantastic.

A: Thank you for sending your picture and expressing your concerns about the procedure.  Between the picture and your concerns, the reality is that the mini tummy tuck is probably the not best procedure for you. In addition your recovery concerns are not going to be surmounted by having a ‘smaller’ tummy tuck operation. You have so much loose lower abdominal skin that a mini tummy tuck is going to produce a very subpar result. Even with a mini tummy tuck when you bend over there is still going to be loose skin that hangs between your belly button and the lower scar line. To really get rid of the maximum amount of loose lower abdominal skin a full tummy tuck pattern is needed in your case. While there is nothing wrong with choosing a mini tummy tuck for a smaller and lower scar, it is important to understand and accept that its improvement will be far less than you may expect.

The amount of abdominal skin to be excised aside, it is a significant misconception that the recovery time for a mini tummy tuck is really smaller than a full one. The stark reality is that regardless of the tummy tuck operation chosen you will need a minimum of three weeks away from such strenuous activities that you love.  The biggest risk and complication that every tummy tuck patient faces is that of developing a fluid collection (seroma) due to early and excessive physical activity. Once a seroma develops it will set back recovery a month and will result in the need for weekly aspiration of fluid and the risk of lower abdominal skin contracture/deformty. It really doesn’t matter whether it is a mini- or full tummy tuck this risk is the same. In fact it is a higher risk in mini- tummy tucks because the patient often thinks it is ‘less’ of an operation and they can go back to full activity as soon as they feel like it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Would temporal implants cause any facial muscles movments difficulty? For example, it wouldn’t look natural when doing facial expression?

A: Temporal implants are placed in a subfascial position over the temporalis muscle. The temporalis is a muscle of mastication (chewing) not of facial expression.  It can not affect any aspect of how the face moves in making any form of facial expression. The temporalis muscle is attached to the lower jaw and it major responsibility is in elevating or closing the lower jaw. But since the immplant sits on top of the muscle (but under its fascia) it causes no interference with jaw movement or jaw closing either.

Temporal implants are designed to be add visible volume to the temporalis muscle in the area above the zygomatic arch and to the side of the eye. It is maintained in its subfascial location by being bigger than the circumference of the space inside the zygomatic arch and the bony coronoid process beneath it. Because the implant is smooth the temporalis muscle glides smoothly under it without interference or scar contracture. Its add permanent volume which makes it superior to temporary fillers and fat injections.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Thank You so much for your time and your quick response to my questions about maxillary setback surgery. Would there be any possible alternative to the use of orthodontics which I’m hesitant of because of my age? (65 years old0 Perhaps wiring the mouth shut post surgery for a longer than normal period of time?

One reason I chose to contact you is because I could see from your website your practice  seems unique in that you do a wide variety of plastic surgeries and are involved with developing research and studying the latest techniques while at the same time you have a of experience in maxillofacial surgery as well. When searching for a doctor I had originally thought of those with practices limited to oral and maxillofacial surgery but I felt led to contact you when I saw your website. I have contacted no other physician as I am praying you can help me.

I know you have to be incredibly busy but I would greatly appreciate it if you could give me a few minutes of examination time and take a chance on me. Thanking you again so much for getting back to me.

A: In traditional jaw surgery the key element is how the teeth will fit together when one or both bony jaws are moved. That is the actual purpose of orthodontics…to get the teeth aligned for their new jaw position and to correct any malocclusion or dental aligment issues that result afterwards. So keeping the jaws more immobilized (wired together) is not a solution for overcoming malocculsion issues that may be created by any jaw movement issues.

At 65 years old it is perfectly understandable, however, that orthodontics in not in your ‘future’ and is not the best from either a periodontal/root resorption issue or the time involved to do so. Thus an alternative approach must be looked at and there are viable options based on the exact nature of your overbite/upper jaw problem. A premaxillary setback (with premolar tooth extraction) is an option that would allow the upper teeth in the front (incisors and canine) to be moved back into the premolar extraction defect. This would also allow your existing molar occlusion to remain as it is which is critically important for eating. This is also a less extensive procedure than a complete maxillary setback and allows more setback movement anyway.

The way for me to know the feasibility of a premaillary setback is to see you and analyze your dental models and x-rays. All I need is for your dentist to make simple stone dental models and a panorex x-rays. (which most dentists can easily do) Looking at you in person with that information will answer the question if this will work for you

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Here you have some pictures 3 months post op from my custom malar-infraorbital and custom jawline implants. As you can see all (or almost all) of the swelling in the jaw and chin area has subsided. There is still some swelling (or puffiness) under my eyes but that is slowly improving. To this date is a bit better than in the pictures. The scar under the chin is almost imperceptible and I can shave without feeling anything.The blepharoplasty scar at the corner of my eyes are less noticeable. I am happy with the result and I think it definitely is an improvement. I’d like to ask you about your opinion on a second implant advancing my chin still a bit and pushing the jaw angle a bit backwards (I am happy with the width of the jaw but I wonder how feasible it would be to take it a bit lower and backwards)

A: Thank you for the followup. In looking at your before and after pictures, I would agree that there has been overall improvement in both the eye/cheek area as well as the jawline. It looks natural and not overdone. I would also agree that we certainly did not overdo the jawline (which was an initial concern) and there is room for further chin and jaw angle improvement through a redesigned implant. The good news is that a new custom jawline implant is so much easier the second time because there is already a pocket in place so the trauma of extensive soft tissue dissection is over. Also we have the advantage now of knowing what the existing custom jawline implant does and that makes it much more predictable in terms of how to redesign a new one for added augmentation benefits.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve given it a lot of thought and done some research over the internet. I’ve been having problems resulting from a previous jaw/chin reduction. And I really want my face bone structure to go back to where it was, or close to my original chin/jaw line. I need help and really want a chin/jaw implant(s).

See my chin in 2013 CT scan. A surgeon reduced my chin in 2013, I had a CT scan in 2014 and realised the surgeon took off about 4.27 mm. Until this day, the soft tissue (chin area) just has never felt right. It feels out of place, uncomfortable. I’m always pulling my chin skin down. The chin skin dips down when I smile. (side profile) I have 2 new dimples. My chin area, just right below my lower lip(right side), protrudes when I smile. (very noticeable) I hope this is not to do with mantalis suspension. The stitching line which the surgeon has done does look lower than my original mantalis line along the gum line right below my lower teeth. Saliva also drips, when I sleep, drips down the corner edge of my right side lower lip (I’m not so bothered. But I don’t know if it’s implication of any issue? 

I really want my old chin back with a chin implant; hopefully it will solve some problems. I’d rather have chin implant incision under my chin, it sounds like the incision inside the mouth can affect the muscle or tissue affecting the lips?

1. Is it possible, that I have my chin augmented so that it will be the same as my original chin in 2013 CT scan? (Unfortunately, the CT scan in 2013 is all pictures, no raw data, so I don’t know if that  CT scan can help in making a chin implant to achieve the original chin size or length?)(However, my new 2014 CT does have the raw data needed to make custom jaw/chin implants. But my chin has been reduced on 2014 CT)

2. What kind of chin implant will I need, vertical or horizontal? (I dare not do chin sliding osteotomy.)

3. Logic tells me I will also need to do a jaw line augmentation to line up with my desired chin. I’m thinking it’s best to do a custom chin/jaw implant. So will this be  3 pieces implant or 1 implant that wraps around? For best results.

4. What material will the implant(s) be made of? If silicone, what kind of silicone exactly? Heard of silastic but usually associated w/ chin implants. 

A: Thank you for sending the pictures and a detailed description of your chin concerns. Based on the pictures I assume your chin reduction was done through an intraoral approach. An intraoral approach to a vertical chin reduction should be done by a vertical wedge ostectomy through the middle of the chin bone (vertical reduction bony genioplasty) to preserve the attachments to the bottom of the chin bottom to prevent soft tissue ptosis. (or an empty soft tissue pocket as the chin tissue will fail to adhere to the bone) In looking at the CT scan, and it may be a function of your drawing, it looks like just the bottom of the chin was cut off. (a lower chin ostectomy) That would be a very unusual approach to a vertical chin reduction but would account for many of your current symptoms. This you have two current problems, an aesthetically shorter chin (which perhaps may not be a concern for you) and soft tissue chi ptosis/mentalis sag.

The optimal way to correct these chin concerns is a custom chin implant with a jawline extension as a one piece implant. (one could argue that a vertical lengthening bony genioplasty would also be appropriate but you have excluded that option. While there is no true way to know exactly match your previous chin (since the DICOM data is not available), the design could be reasonably guessed. It is only a question of how far back along the jawline one wants to go. This looks like it would be a pure vertical lengthening chin implant. Such custom chin implants are made of solid silicone material. The term silicone and Silastic are synonymous. The name Silastic was trademarked in 1948 by the Dow Corning company for their silicone polymer product and it is name that is still occasionally used today been though the Dow Corning company no longer makes any aesthetic silicone products.

This custom chin implants should fill in the loose tissue at the bottom of the chin and eliminate that feeling of looseness of the soft tissue at the end of the chin. The only residual concern is that of your salivary drooling and that raises the question of whether mentalis muscle resuspension should be done at the same time. If you have lower lip incompetence/sag I would say yes. But if not I would leave it alone and see effect the chin bone restoration achieves.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am an otherwise very thin healthy 42 year old female searching for a forehead augmentation solution to my upper forehead contour defect. I had what would be considered minor trauma in 2010 (struck forehead on breakfast bar) with a resultant depressed skull fracture. To fix the resultant indentation I have had 2 fat grafts and several Radiesse injections with no resolution. Is there any hope of a repair with a closed procedure; something akin to Artefill w/o Bovine Collagen (allergic)?  Bone graft?  Stem cells?  Can frontal bone be shaved down to create a smoother contour endoscopically?

A: I am not surprised that your frontal defect in the upper forehead could not be adequately contoured/restored with any of the injectable methods that you have had. They simply will not work for a bone contour defect nor is there are injectable material like fat or any other synthetic filler that will work.

There are a variety of minimally invasive procedures, however, that will work for your type of forehead augmentation. Through a small incision in the scalp (3 to 4 cms) done endoscopically, a variety of implant materials can be introduced to smooth out the upper frontal bone depression. These can include PMMS or HA bone cement or even a small semi-custom or custom implant. These are all procedures that can be done under local anesthesia/IV sedation. The most economical approach would be PMMA bone cement. I will have my assistant Camille pass along the cost of the procedure to you tomorrow.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, about four years ago I emailed you with questions surrounding an injury I sustained to my eye and cheek area some 20 years ago. Again briefly, I was assaulted and never had my cheek and eye fixed. Now I would like to because of the appearance I see in the mirror of a flattened left cheek and slight drop under my left eye. I could not have the procedure done when I first contacted you because of the finances and then the collapse of the economy. But now I am in a position to have the work done and I think and feel you are the best doctor qualified for the job. Can you please provide me again with what would need to be do be done as far as if a CT scan is needed, measurements need to be made and things of that nature. In the light, up close and when I smile, I look fine. But when the lights are dimmed and looking at my face from a distance, the obvious damage and asymmetry is noticed. It is as if I can see the imprint of a fist on my face. I want the left side of my face to be even, full and balanced like my right side. I have included some new pictures. Thank you for your time and please respond and help me if you can.

A: I remember your inquiry and your face problem quite well. You obviously had a cheekbone fracture that resulted in flattening of your cheek bone area as well as along the infraorbital rim. Fortunately your eyeball position looks fairly even with the right side  (at least based on the pictures) so no orbital floor or lateral canthal work needs to be done. I think cheek augmentation alone should suffice and the cheek implant needs to be put up high on the flattened cheek bone. Fat injections also need to be done to build up the cheek area where the implant will not reach. We could get a 3D CT scan but that will probably not change your surgical needs unless we decided that a custom made cheek implant would be used for the reconstruction.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, it’s been almost one year since my rhinoplasty. Today I wore snow goggles for about an hour and now I have a red small bump on the bridge of my nose. I’m pretty concerned. I iced it for a bit and it hasn’t gone down. Is there anything else I can do? I don’t want to ruin your beautiful nose work. Thanks! 

A: Being a year after a rhinoplasty with hump reduction and osteotomies, your nose should be sufficiently healed to handle any type of eyewear. It is not possible that snow googles would cause any change in the underlying nose structures. It is important to realize that snow googles press on a broader area of the nose than regular glasses and thus cause more pressure. I would suspect that by tomorrow or even later today the red area on the nose will be gone. It may be a year after your rhinoplasty but your nose skin is probably a bit sensitive still. So the pressure from large snow goggles may cause the temporary skin deformity that you are seeing.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 35 year old woman. I have attached some pictures for your reference. I would like you to give me your opinion on what you could do to make my shape more curvy. (widen hips, increase buttock projection and decrease waist, back and arms size) I think liposuction to the abdomen, flanks and back plus re-distribution to the buttock and hip area is certainly something I would like to consider. 

As you can see in my pictures I also have had a breast augmentation and have been told that these are polyurethane, so they may be hard to remove. I would like your thoughts on what you may do to make my breasts slightly smaller and less projected, but more natural and rounded.

Could you tell me how long I would need to stay in hospital, then in the area before I fly home ( and details of how soon I can fly) Thanks!

A: Thank you for sending your pictures and providing your body contouring objectives. I believe you are correct in the approach to improving your body shape through a combination of aggressive liposuction of the abdomen, waist, back and arms with redistribution of the fat aspirate to your buttocks. That combined procedure has a name and is the well known Brazilian Butt Lift with assured body contouring benefits from the fat harvest and buttock augmentation from the liposuction ‘discard’.

In regards to your breast implants, these are harder to remove than smooth silicone shell implants but let’s not confuse harder with impossible. Most likely they have some degree of encapsulation which makes them look very ‘stuck on’ and firm due to the encapsulation. Removing the implants and their capsule with a slightly smaller volume implant should make them softer and a little less projected. It would ultimately be helpful to know what the implant volume is when planning their replacements and I would probably drop the volume down by about 50cc.

This type of body contouring surgery is done in my private surgery center, not a hospital, where the costs are much lower. Given that you are from afar, I would keep you overnight but you could go back to the hotel the next day. I would anticipate you flying home within 5 to 7 days after the procedure at most.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in temporal and jaw angle implants. But when I get really old would it look like this if I have implants in my face?  See the attached picture of breast implants where one is able to see all the edges of the implants. This is a scary picture.

A: It is important to separate what can happen with facial implants vs that of breast implants with aging. The show of breast implants can become more obvious when one loses weight or has very little subcutaneous fat cover from aging. Breast implants are ultimately only covered by the thickness of the breast tissue and if they are partially under the muscle. (which the lady’s implants in the pictures are not) Facial implants are placed next to the bone with a soft tissue cover that is not as influenced by fat loss. (more muscle cover) Thus, facial implants will never get as skeletonized or develop implant edge show as breast implants can. Facial implants are bone implants while breast implants are soft tissue implants. That is a fundamental anatomic difference. Because facial implants add support to the overlying soft tissues they often are a positive additive feature rather than a detraction from aging.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Do you do temporal implants for people after craniectomy/craniotomy? Or only for those with wasting from other nonsurgical issues. I had a craniectomy after brain surgery after fractured my skull in a car wreck. Despite the severity of the injury I have made a full neurologic recovery.

However the neurosurgery itself caused a massive amount of temporal hollowing. My neurosurgeon for the last year has said I’d be eligible for 3D custom implants. However after waiting a year and consulting with another doctor who is supposed to specialize in 3D custom implants he told me he had only donetwo temporal implants which both had to be removed and would not do them on me. I’m not sure if there was a further scientific based reason for this as my appointment with him only lasted five minutes. He also said he would not recommend me to get the implants done by anyone else. 

I understand these 3D custom implants have been around only shortly since 2013 but I know regular temporal implants have been around for decades. I feel trapped in being disfigured like this and don’t know where to really look for a solution. I’m not sure why my neurosurgeon would recommend me for 3D custom implants for a year and then I’d not be eligible for them or for any cosmetic solution to my temporal hollowing. 

Do you take patients from Canada? I would really be relieved to find a solution to this as Canada does not have many plastic surgeons in total and then even fewer that have dealt with cranioplasty let alone anything with soft tissue replacement implants.

A: I have done temporal implants for years for both aesthetic purposes as well as for reconstruction after neurosurgery due to temporal muscle wasting/detachment. The key factor in success in neurosurgery patients is whether they have had radiation to the temporal region or not. With your trauma history, you clearly have not received temporal irradiation. I can not give you a good reason why two separate surgeons would not do a 3D temporal reconstruction on you. Unless there is something that is not clear to me, I can not envision the circumstances where it is not possible. Can you send me some pictures of your temporal deformity and any CT scans that have been done since your surgery. I know the CT scans may or may be available and are not important right now. If based on your pictures I feel you are a good candidate then we would need a new 3D CT scan anyway.

The success of any craniofacial implant reconstruction is the quality of the overlying soft tissue cover. Adequate thickness and good vascularity of the tissues are important for long term success.

I have patients that come from all over the world and Canadian patients, because of proximity to the U.S.,  are some of the most common international patients I treat.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to remove fat from both sides of chin and redefine my jawline and make my face symmetric again. I had a procedure 3 months ago to remove fat from my cheeks (bichat fat) in order to make it look thinner. I did not attain the expected results as my face doesn’t look thinner but is now asymmetric and it looks like I have a lot of fat on both sides of my chin (makes me look older!). Can you please help?

A: Often surgeons think that taking out the buccal fat pads will make a face thinner when the fullness problem is actually much lower. There are two separate fat compartments between the cheek and the jawline, the well encapsulated globular buccal fat pads located just under the cheek bone and the more superficial and less volume perioral mounds located just under the skin besides the corner of the mouth and extending down to the jawline. Since I have no idea what you looked like before their removal, I can not say whether removing the buccal fat pads was truly the main cause of your facial fullness concerns. But the subcutaneous fat around the mouth and chin (perioral mounds) now looks fuller because it remains unchanged as the area above it where the buccal fat pads are is now thinner. It may be that microliposuction of this fat area would complete the ‘project’ and should help. Whether any fat should be replaced due to the asymmetry above caused by the buccal fat pad removal may be a solution to also consider. It is either that or do further removal on the fuller side. That choice is a matter of your aesthetic judgment.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was reading the information over skull reshaping in the site and I noticed that the procedures for narrow skulls are usually done with infants or toddlers but my question is if it were anything that could possibly be done to a 20 year male skull? My skull isn’t exactly large but very narrow and long.the reason I’m asking this question although I am aware that this procedure is most common for toddlers is because I research a few before and after pictures on give and I noticed that some of the males appear to be in their mid 30’s or so. I’m praying that anything could be removed or reduced from the front or back of my skull to make it appear at least close to normal if I am fortunate enough to have this procedure done. Please feel free to contact me anytime of the day. Thank you

A: While the most common treatment for a congenital long and narrow skull is complete calvarial remodeling or suturectomy of the sagittal suture, that is for the infant condition known as sagittal craniosynostosis. That type of surgical approach has nothing to do with treating a long and narrow skull in an adult. Such treatments can only focus on camouflage efforts on the outside as the brain is no longer growing and occupies a fixed space on the inside of the cranial ‘box’. Whether these adult efforts at skull reshaping can be done with frontal and occipital bone reduction (which is limited) and/or widening in between the front and the back awaits analysis of your skull shape. PLease send me some pictures of your head at your convenience.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in breast implant replacements. I currently have 400cc saline breast implants in and the plastic surgeon I went to suggested replacing them with 650cc smooth round silicone implants. Based on where I am now and where I want to be (I attached a bunch of ideal breast augmentation results) I do not think he and I are on the same page. I don’t think he understands what I mean when I say extreme breast augmentation. Can you look at all my pictures and tell me what you think. Your reputation as a plastic surgeon precedes you so your opinion would mean a lot to me. Thanks!

A: Thank you for sending all the photos of your breasts and that of your ideal result. Based on how your breasts look now with 400cc implants and their degree of sag and nipple position, none of those ideal results are achievable for your breasts. Your breasts have too much skin and sag to look that high up on the chest or to be that round…regardless of the size implant used. All that can be done is to make them bigger and somewhat more round but getting enough implant volume in place is the key. It is clear to me with these goals that 650cc is not going to adequate. more likely it is somewhere between 800ccs and 1000ccs to be able to fill out your breasts for a rounder fuller look. No silicone implant is made over 800ccs and its weight will make the breasts bigger but not as round as you would like. Only overfilled saline implants will create a more rounder effect as they naturally sit higher and rounder when overfilled. Most likely an 800cc saline implant filled to 960cc to 1000cc will be needed. It would also be important to use an areolar incision when placing such large breast implants to keep the incision at the top of the mound and away from the skin stretching effects as the base of the breast mound. Anytime one gets over 800ccs in implant volume that would fall into the classification of extreme breast augmentation or the use of very large breast implants.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I just Skyped with you on Friday about the procedures that I need to have done on my forehead (forehead reduction) and the occipital bone. (occipital implant) I am going to call on Monday and pay for the implant so we can start the process for it to be made.  I just wanted to know what your idea was for the shape you were thinking would make a difference.  I know my head is way too small for my face, so I would like it to be as big as possible and go all the way down the sides of my head and the back at the crown and come up all the way to my forehead if that is possible.  Like you said without looking at my CT scan it is kind of hard to really see what the problem is at the back. But looking at the 3D CT scan you would be able to see how much forehead reduction is needed and how the rest of the skull could be augmented to match. Also just out of curiosity what is the implant made out of? Thank you again for talking to me. I look forward to having this done. I think it could change my life.

A: All custom skull implants are made of a solid but soft/flexible silicone material. Having done cases similar to yours before, I envision a horseshoe-shaped implant that augments the back and then wraps around the side of the head coming forward almost to the forehead. Just as you might imagine it is how it would be designed. The 3D CT scan will allow the fine details of extent and thickness to be worked out. Once you see the PDF file of the initial skull implant design it will become very clear to you as to how it would look.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a flat area on the back of my head exactly like the picture you have on your website and have attached it so that you can see what I’m describing. If you can, even though you haven’t been able to see the back of my head in person, could you give me an approximate cost for the type of procedure to correct this? Please let me know if you need any additional info. I’m 50 years old and in good health. Thank you.

A: Such an occipital augmentation can be done using a skull implant made of silicone that is created one of two ways. The picture you are describing is that of an actual custom made occipital implant from the patient’s 3D CT scan. One could argue that is the ideal way to do the procedure. The other approach is to use preformed occipital implants that I have developed in different sizes as an off-the-shelf option that avoids the need for a 3D CT scan and is done at a lower cost due to being performed and not custom made.

I will have my assistant Camille pass along the costs of both occipital implant augmentation approaches (preformed and custom skull implants) to you on Monday.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I saw you say this on your website: “When attempting to  reduce the width of the head (bitemporal/biparietal distance), it is usually necessary to do a combined muscle and bone reduction. Burring down the temporal bone is not as productive in regards to width reduction but still has a valuable role to play. The bone can usually be reduced up to 3 mm to 4mms per side.” When doing temporal reduction, do you usually do bone burring along with muscle removal?

If I want the best result of head narrowing, is surgical reduction of posterior temporal and  Botox injections on anterior temporal muscle the correct approach to do so? Usually how many treatments are needed to effectively narrow a forehead? I heard that Botox’s effect is only temporary, if one stops getting injections the muscles will become alive again. Is this true?

A: What I have to be most effective for posterior temporal reduction to change the convexity of the head above the ears is complete removal of the posterior temporal muscle belly. It is an incredibly thick muscle that often is 7mm to 9mm thick per side. There are no functional issues with doing so and I have done it a large number of times so i have unique insight into that issue. That does more for changing the head width convexity that any temporal bone reduction. This contrary to what people and surgeons think but that has been my experience.

Whether I do any posterior temporal bone reduction at all with the muscle excision largely depends on the incisional approach. If the patient wants a ‘scarless’ method by using an incision that stays in the post auricular sulcus bend the ear then no bone reduction is done due to access. If the patient wants bone reduction also and does not mind a small vertical temporal hairline incision then I will do so.

For anterior temporal width reduction (besides the eye and in the anterior the temporal hairline), particularly in the muscle area above the zygomatic arch, only Botox injections can be used. However if one is getting any type of forehead procedure where surgical access can be had to the upper anterior temporal zone, muscle release and resection can be done to drop the upper anterior temporal muscle fullness and reduce the temporal line/lateral forehead bone to make the forehead more narrow.

The effect of Botox on masticatory muscles, like the temporalis and masseter muscles, can have a profound effect on shrinking muscle mass. The only question is how many times does it need to be done and how permanent can the result be. That is highly variable in my observation with some sustained permanency in some patients and only a temporary effect in others.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am sure as people read stories and see photos about breast augmentation results they start to freak out. Everyone on RealSelf is saying there is no projection with the Sientra high profile implant and how many are disappointed. I know a lot of things go into play for each individual. However, since I have the mentor round smooth saline now at 300cc, I’m wanting a FULLER, ROUNDER, BIGGER implant. We had decided on 655cc Sientra high profile silicone. Again I read because of being under the muscle you lose a lot off cc’s there. I don’t wanna be the same size I am now and I’m not looking to just increase one size. Are these actually the “right” implant for the “look” I’m after? I don’t want to be disappointed. I’m just under 3 weeks from surgery. This is the kinda look I’m after now. I’m 5ft, 111lbs and you have my measurement. I just want to be proud and satisfied.

A: Thank you for sharing this pictorial result from another patient’s outcome as it is very helpful to figure out what may be best for you. It is important to point out that you are never going to get that same result no matter breast implants you use because you simply do not have her body or breasts. That is not a realistic result for you on your breast implant exchange. It does, however, provide further insight into what you should do to help get as close that type of result as possible for your breast implant replacements.

First no silicone implant, regardless of manufacturer, can achieve that degree of roundness and upper pole fullness…unless one is 20 years old with tight skin and little to no natural breast tissue. This kind of approximate result can only come from overfilled saline implants. Saline implants create much rounder and fuller breasts because the fill material is under pressure. That is why they can look so round. Size also plays a factor and I would suspect that you would need a base size of a minimum of 650ccs filled to 800ccs (or more) to come close to that look. At the least if you use silicone implants they would have be ultra high profile (like from Allergan) and be close to 750cc to 800ccs in size.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want to get my buttock implants removed. They are misshaped and you can see their outline in my pictures. I want them removed and I am wanting to get the Brazilian butt lift to create a larger butt. I’ve had them around 5 years.  The shape has always been this way. My previous doctor told me that the implants would soften up and have a more natural shape. I have been waiting and in all the 5 years this has never happened. 

A: Thank you for sending your pictures. It appears that you have buttock implants that are in the subglandular (above the muscle) position. As a result you have capsular contracture and the implants just look ‘stuck on’ due to their encapsulation. The buttock implants can easily be removed (buttock implant removal) and it is not unreasonable to do fat grafting at the same time. The key to successful buttock fat grafting (aka Brazilian Butt Lift) in your case, besides an adequate amount of fat to harvest, is where the at is placed. Fat should not be injected directly into the pockets (empty spaces) where the implants were. Rather it needs to be placed around the buttocks and in the subcutaneous tissue layer between the skin and the implant capsule where the implants once were.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I write to you in hopes that someone of your expertise can help as my case of jaw reduction is an uncommon one. I had a sagittal split osteotomy two years ago. I had excessively wide and disproportional jaws so I wished to have them reduced. An obvious solution would be to have both the osteotomy and masseter muscle resection as mine was quite prominent. My surgeon refused to do the muscle resection claiming that the muscle can grow back and undergo hypertrophy or something along those lines. Trusting his expertise, I agreed to undergo just the osteotomy and not any muscle resection. Due to this, I had him assure me he would shave off as much as he possibly and safely could, and he did so.

The results were mediocre as my hunch about most of the volume in my jaws were from my muscles was correct. But this is not the issue. About six months later, I woke up one morning and I felt a loss of sensation on my lower jaws, that made me think that it was swelling because it felt like my cheeks were drooping. It happened literally overnight. I saw my dentist and he couldn’t find any swelling or infection. I mentioned that there was a tingling sensation when he touched the affected area to which he advised that it was probably nerve damage. The affected area starts from the outer corners of my mouth going to the middle of my jawline. It feels like a loss of sensation which makes it feel like my lower cheeks are dropping and very intense tingling when touched. This makes activities such as talking more difficult due to the feeling of droopiness. I have attached an image to illustrate the affected area. 

I have read that nerve damage heals by itself, but after over year and a half,  there has been no signs of improvement. Some days are tolerable, but some days the feeling of droopiness is so severe that I can barely talk. I had a CT scan and the doctor advised me that my mandibles have been reduced significantly and possibly excessively. 

Please advise me on your thoughts on my predicament, and possible steps I can take to deal with it. I honestly don’t know what to do, as all issues in regards to nerve damage are advised to wait it out. 

A: Thank you for sharing your jaw reduction story and there are several aspects to it that defy a clear biologic explanation. The procedure you had done was most likely a lateral corticotomy where the outer layer of the bone over the jaw angles was removed. It is a form of a sagittal split osteotomy but not in the classic sense that the entire jaw was not moved. This is the most aggressive form of bony jaw angle reduction over shaving/burring and is aesthetically better than traditional jaw angle amputation. However it does run the risk of exposing and injuring the inferior alveolar nerve which runs in the medullary space of the mandibular ramus right below the outer cortex. Since you had the outer cortex removed this is the sensory nerve at risk for injury.

However, such nerve injury would have been apparent right after surgery and would not spontaneously appear nearly half a year later. In addition, your description and illustration of sensory nerve loss does not follow the well known anatomic distribution that this nerve covers. (lips and chin…not cheeks and side of the jawline) The only other nerve that could remotely explain your symptoms is that of the long buccal nerve which supplies sensation to the inside of the cheeks along the mucous lining. It is often inadvertently cut from any procedure of the mandibular ramus from the incision location but usually is of no consequence. But again, such a nerve injury would not just spontaneously appear many months later.

But any of these potential nerve issues are usually not repairable. In rare cases nerve decompression and/or nerve grafting are done. But these are only attempted when the location of the nerve injury is very clear.

I am afraid that I have neither an explanation or a solution to your postoperative concerns.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I found your website, and I was wondering if you could offer a suggestion in my case. I had jaw surgery twice several years ago. First, a 2-piece Lefort I, IVRO, and a jumping genioplasty was done. (I was a skeletal Class II with anterior open bite.) The surgery, in every aspect, was poorly done and I had a re-do Lefort I six months later. Again, the outcome was not good, and I underwent re-do 2-piece Lefort I, BSSO, and re-do chin osteotomy about 10 weeks ago (with a different surgeon). In this final surgery, bite correction was achieved, and in most respects, it was a success. But I am still unhappy with the appearance of my chin. I have significant step-offs from the first genioplasty. In the re-do, my surgeon shaved down the bone (no cuts) in the front, but did not address the step-offs. From the ceph x-ray, it seems the bony part of the chin is in the right place, but I have significant soft-tissue protrusion that I am very unhappy with. I believe the success of the re-do was compromised by the technique used by the first surgeon (not sure why he didn’t do a sliding genioplasty, as my chin was not terribly receded in relation to my jaw). I am concerned that a third procedure to “correct” the chin may cause more harm than good, but I am not sure. I am also not sure how much swelling I still have in that area. I did not have this amount of soft tissue in the front of the chin area before the first surgery. It appeared after the first surgery, and only increased with the most recent surgery. The step-offs are clearly visible from the front and side, in addition to my being able to feel them. Thank you for your time.

A: I am very sorry to hear of your very complex orthognathic surgery history. From a chin standpoint you had a jumping genioplasty (I have never liked this chin osteotomy technique) which has it own lateral step-off issues. Then the last genioplasty procedure burred down the front edge of the bone which is guaranteed to create a soft tissue excess issue. All of these genioplasty techniques understandably have left you with step-offs and some degree of soft tissue ptosis/sag. While you aren’t quite three months from the last surgery, I see no reason that your chin issues will improve with time. The best way in my experience to address these chin problems are from a submental approach for your genioplasty revision for chin reshaping. The step-off chin defects can be filled in and the chin sag removed with a submental tuck technique.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hello when I was little I had an accident that involved me hitting my forehead on a wall which lead to me being stitched up and left a scar in the middle of my forehead. It left a big bump on my forehead and just doesn’t look normal compared to a normal male forehead. It just sticks out and I guess you could say it’s deformed due to the trauma I had with the accident. So my question is what are the possibilities of shaving down the top/frontal part of my forehead to make it a more sloped appearance and the recovery time for this procedure?

A: It is certainly very possible to burr down any forehead prominence to reduce its visibility as well as provide more slope to the forehead. This type of forehead reduction is possible because the frontal bone is very thick so such a reduction is very possible. The only question is how to access the forehead as an incision has to be placed somewhere. That is the only important question. Whether it is at the frontal hairline (pretrichial) or somewhere back in the hair line is the more challenging question particularly in a male.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, if one has cheek implants (malar implants) placed high up and towards the lower orbital rim can this raise the lower eyelids a bit? Or result in decreased scleral show? I am hoping this is true.

A: I would never count on any any type of malar/cheek implants or orbital rim augmentation being able to raise the lower eyelids or decrease scleral show. Logically that would seem like it would work but that has not been my experience. What drives up the position of the lower eyelid from a scleral show standpoint is the support that lies within the eyelid itself  (adequate vertical tissue support) combined with medial and lateral canthal positioning.

While cheek implants push up the overlying cheek tissue that does not translate to the lower eyelid. The lower eyelids can usually only be vertically elevated by the use of spacer grafts placed within the lower eyelid or reattaching the outer corner of the eye up higher in the lateral orbital rim. That is not to say there might not be some supportive effect from elevation of the cheek tissues but it is just not a major one or one that can work completely on its own.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am two weeks after mini facelift. My tragus is all of a sudden swollen and slightly pulled forward and I can feel it is under some tension. It literally happened almost overnight. My surgeon told me today that the swelling will go down and that the pulled forward tragus will most likely correct itself. When I touch that forward tipped cartilage, I can’t imagine how it will correct itself. Is it really possible that it will?? I’m desperate for an honest answer. And yes, there is a incision inside the ear, and under the lobe and behind. Everything else is healing well except my tragus which is pulled forward and is swollen. Will I need revision surgery? 🙁

A: It is important to realize that healing is often not a linear event. Just because something pops up in the healing process that seems unusual, particularly in the first month, does not mean that something is wrong or will not turn out right. Facelifts of any type takes months to fully heal and six months or longer for all scars to mature and the tissue to feel completely normal.

Having said that a distorted or deformed tragus may settle down and return to normal with adequate healing time. At the least you will need six months to see how it heals. A deformed tragus, however, often is a reflection of too much skin removed in front of the ear or tension not adequately distributed around other areas of the ear. I have seen this to be most common today as many surgeons try to make a mini facelift work when a fuller facelift is really needed with long skin flaps and better tension distribution at the top and behind the ear. Neither the earlobe or the tragus will tolerate much tension at all without subsequent deformation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, my forehead bone has grown from from normal to abnormal. Because when I was young almost 10 years old I had fibrous dysplasia. I had an operation in 1999 and it started growing up at the age of 19 but then stopped at the age of 22. It is not growing anymore. I want to know now that it is not growing anymore if it is possible to make it normal? MANY THANKS

A: Thank you for your inquiry and sending your pictures. I can see that your brow bone has grown disproportionately compared to the rest of your forehead. Because the origin is fibrous dysplasia, your brow bone may well be completely ossified as opposed to be a large air-filled bone cavity. That could be determined by a CT scan. But regardless of what constitutes the brow bone protrusion, the surgical technique to reduce it is basically the same. I assume because you have had a prior operation that you already have an existing scalp incision/scar. This makes brow bone reduction ‘easy’ because there is not a concern about the method of access to do the surgery. Dramatic reduction can be done on your brow bones to get their appearance much more normal looking.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, The onset of my Bell’s Palsy right side paralysis was four years ago. My case was severe, and it took many months to see small changes/progress. I have developed Synkenesis, which has caused pain and dimpling of my chin, pain and stiffness in my neck, especially the tendons on the affected side, and have been experiencing a general ache and or soreness, especially during these winter months, on many places on my face. I have not sought out treatment of these symptoms, until just now. I was chewing my food recently and the muscles in my neck involved in swallowing contracted repeatedly, thus, delaying my ability to swallow momentarily. It was quite frightening that this may actually cause me to choke if I don’t seek treatment. I am interested in Botox and,if possible, facial re-training as a treatment for my Synkenesis. Any advice or referral recommendations would be greatly appreciated. Thank you so much for taking the time to hear my case.

A: As you know, synkinesis is a common sequelae when the facial nerve fibers regenerate and start working again after any cause of paralysis. Synkinesis is the inability to coordinate various muscles  on that affected side of the face. Unusual combinations of facial movements occur that were never present before the paralysis and have no functional reason for their occurrence.of half of the face.  It results in a wide range of both functional and aesthetic changes.  Common changes include narrowing of the eye during smiling, smile asymmetry, dimpling of the chin, asymmetry of the forehead an pulling sensations in the neck

Botox for facial synkinesis is an established treatment with proven effectiveness. But its role is most commonly done in the superficial face and platysmal neck muscles that are innervated by the seventh cranial nerve. I have treated such patients from facial nerve issues such as hemifacial spasm and at various period of recovery from facial nerve paralysis. The swallowing muscles are not, however, innervated by the seventh cranial nerves but by other motor nerves and I have no experience in treating those pharyngeal muscles by injection therapy. I am also uncertain that the swallowing sensations you have experienced are caused by muscles not innervated by the facial nerve.

Botox injections are used for two distinct effects…to either dampen down an overactive or spastic muscle or to weaken a normal acting one to help balance out certain facial expressions. It can be used to open a narrowed eye, soften the smile, and relieve the pulling sensation in the neck. It requires a careful assessment of the facial movements to determine the proper injection points so as to not cause additional facial asymmetry problems. This is of paramount importance around the eye area and injecting the orbicularis muscle.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am roughly 75 pounds over my ideal weight looking and to have a Buttock Augmentation with Fat Injection.  (Brazilian Butt Lift) My question is do you do what’s considered “Large Volume Liposuction” or do you have an issue with larger patients?

A: . One’s weight per se does really influence the ability to have a successful Brazilian Butt fit surgery…unless one has very little fat to harvest to be able to do the procedure successfully. (have enough fat to inject) Therefore patients that have excessive weight do not represent a limiting factor in being to do the BBL procedure. The only issue with patients with more weight is that they realize the liposuction harvest for the BBL is not going to make them thin nor serve as a weight loss method. Also there is a safe limit of fat harvest which is generally around five liters and that is where it is prudent to stop no matter how much more fat may be able to be harvested. Going about that ceiling and venturing into true large volume liposuction increases the risk of complications such as deep vein thrombosis and pulmonary emboli. Also it really can make the recovery period prolonged and can take weeks until one is fully functional again.

Lastly, using the ratio of about 1/3 fat concentrate results from the unfiltered liposuction fat harvest, the amount of fat that can usually be maximally injected is around 1,500 to 1,800cc or 750cc to 900cc per buttock.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m wanting to know if you do Smartlipo the non surgical procedure for belly fat?

A: I do use Smartlipo for body fat reduction but it is NOT a non-surgical procedure and it is best done under general anesthesia…if one wants the best result with the most fat removed. Smartlipo works just like any other liposuction technique. It is an invasive procedure that involves the need for tumescent infiltration, the use of probes inserted to heat the fat and the use of traditional cannulas inserted under the skin to extract the fat as the final step. There is a common misconception that Smartlipo is not surgery when nothing could be further from the truth.

Smartlipo is, unfortunately, often promoted and marketed as if it isn’t surgery. It is made to seem that it can be done without much anesthesia, without recovery and that the results are instant. Such marketing claims do make it seem like it isn’t surgery and I can understand how many prospective patients do get that impression. But like many marketing claims…if it seems too good to be true, it almost always is. Your perception of Smartlipo certainly falls into that category.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Last week I was in the office for some Botox and asked your nurse to share with you an unusual medical issue I have had on and off for a about six weeks.

A “salivary stone” was initially diagnosed by my internist and he suggested I treat it with sour lemon drops and massaging my jaw. Yes it finally disappeared but then it reappeared. Upon the stone recurrence, I was referred to an ENT, by the time of the appointment it had disappeared and the Dr. gave me the same advice as before.

Long story short, the stone or whatever it is, comes and goes. Currently, it has nearly disappeared, yet, the right side of my jaw is still slightly sensitive, very peculiar.  I was thinking it may be a cyst?!

Knowing your maxillofacial/dentistry background I’m hoping you will be able to ascertain where I should go with this? Perhaps I should visit my dentist? 

I am simply uncomfortable with unfamiliar signs or symptoms when it comes to my body. 

I have respected your opinion, throughout the years, your knowledge and guidance has been so very helpful and a comfort. Thank you for your time.

A: What you are describing certainly sounds like a parotid duct stone. The lemon drops (to increase salivary flow output) and the massage (to milk the stone along) are all designed to help the stone pass…not dissimilarly to that of a kidney stone. (drinking fluids although no massage is used) It is very possible these actions causes the parotid duct to partially relieve the backup of saliva behind the stone, but the stone did not actually move, and the salivary backup resumed causing persistent discomfort.

Having said all of that, have you ever had a CT scan that has actually made that diagnosis or even a plain x-ray to see of there really is a stone obstructing the parotid duct. That would be the first diagnostic test. To date it all has been theory (and it may well be accurate) but you really don’t have a definitive diagnosis yet. If it is a true salivary stone it may pass on its own if it is small enough. But large ones can merely sit there and serve as a partial obstruction without ever passing and may need to be surgically extracted by balloon dilatation.

Dr. Barry Eppley

Indianapolis, Indiana