Your Questions

Q: Dr. Eppley, Apologies if this is a strange question but I will be travelling quite frequently via airport and I just want to consider any issues that may arise. I have a solid silicone elastomer testicle implant. Given this is a solid material is there any chance of this implant could create an anomaly during a body/xray scan? Or even metal detectors? As I know some forms of silicone are metal detectable. I wouldn’t want to be pulled aside for a body search because my implant would be picked up by the body scans.

Kind regards.

A: There are no concerns with having a testicle implant being detected by body scans at the airport. Silicone is an invisible material by radiographic examination. It is non-metallic and is a pure element (#14 on the Periodic Table) of which it is not ‘seen’ by standard x-ray images. It would be detectable by CT and MRI scans but these are not what the airports use for body scanning. Also I know of no forms of silicone that are metal detectable unless they actually contain metal.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, my son of 10 years of age has occipital plagiocephaly and a big flat spot in the back of his head. I recently sent in his old CT scan and updated photos to a doctor in our area. The surgeon recommended waiting for the completion of puberty and then to evaluate for an implant in the back.  

This doctor did not not recommend a silicone implant.  If I recall correctly, he said they were found to deteriorate with time.  Do you know anything about this?  Do you still think a silicone implant is okay for the skull?  Things seems to change with time and between surgeons.  

The thing I like about silicone implants is the reduced incision length.  The doctor thought imaging could be used to determine the optimal location and length for an implant made of some material other than silicone.  What are your thoughts on this? 

A: I do agree that waiting until after puberty to have the occipital implant surgery is reasonable. However, it is absolutely not true that silicone skull implants degrade with time. They can never breakdown or degrade. Silicone is a fundamental element (#14 on the Periodic Table) and there are no human enzymes that can degrade the material. A thousand years from now the implant will look the same as the day it was put in.

There are a variety of materials that can be used for a custom occipital implant including silicone, HTR and PEEK materials. While these materials are chemically and structurally different, how the body reacts to them and treats them is not fundamentally different. The biggest difference to a patient is going to be the length of the incision to place them. Stiff rigid materials like HTR and PEEK are going to require a full coronal incision to place. Conversely, silicone can be placed through a much smaller incision because the material is flexible.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I am in desperate need of finding the right person to help me with mentalis resuspension. I had two previous chin/genioplasty surgeries at least a year ago and my biggest fear is not being able to close my lips together without strain or headaches.  The first surgery was a chin implant under the skin, the second surgery was done by an different surgeon who did a removal of the implant and performed a genioplasty of about 8 millimeters of my bony chin moved forward intraorally. The last surgery was done to correct the ptosis or wrinkling of the chin by the same surgeon a year later by putting in a button chin implant. The result was horrible and was removed a couple of months later and me not being able to close my mouth without strain was the after effect. I’m so depressed…I have thousands of photos where you can tell I’m trying to close my mouth or trying to make it not noticeable that I can’t function like a normal person anymore. I regret the surgeries trying to reach perfection and now I lost the ability to just do a simple thing of closing the mouth without strain. I have been turned down by surgeon’s either because they don’t see a problem or don’t think it’s anything that can be done. Please give me options. So far your the only one I hear about that has enough knowledge in this area.  

The photo’s here are examples of myself trying to take nice picture’s but as you can see every photo my lips are open. That is the best I can do as far as closing my mouth without really forcing myself but when I do the last picture describes it…it’s tight as if I’m sucking on a sucker and it’s very uncomfortable.

A: Thank you for providing the pictures and a detailed explanation of your chin surgery history. What you have is some lower lip retraction, tightness and chin dimpling. These problems can not be corrected by a mentalis resuspension as you really don’t have a muscle displacement issue. Your chin tissues are scarred and do not have the flexibility that they once had after several surgeries. I do not see that invasive surgery will provide any significant relief and may likely even make it worse or at least no better for the effort. My suggestion is that of fat injections using PRP. The tissues need to be softened/scar reduction and to try and get some suppleness back into them. This can be combined with V-Y mucosal advancement of the lower lip. This approach is my opinion has a better chance of improvement than trying to release and reposition the scarred mentalis muscle.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to have wider face as my lower jaw is too small. What is your opinion based on the attached picture? Should I have jaw angle augmentation? I have already cheek implants. Thank you.

A: With your cheek implants your lower jaw now looks too narrow for your face. You now have a very inverted or triangular shaped face which looks disproportionate. Jaw angle implants are the only way you can widen your lower face. The only question is whether they should be a width only style or a combined vertical lengthening as well as widening style. That determination can not be made based on a frontal picture only.

While female jaw angle implants are much less common than in males, they are being done more frequently than ever before. Women are increasingly desirous of a more prominent and well defined jawline. Like men, women usually need vertical lengthening jaw angle implants more than they need width. It is still important to keep the flare of the jaw angles inside of the upper facial width.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am seeking silicone breast augmentation. I am currently a 32A cup and looking to be a D cup. I am interested in a silicone implant with the transaxillary approach placed in the submuscular location. Are you very experienced in this approach? How many of these have you performed compared to other techniques?

A: When it comes to breast augmentation over the past twenty years,I have placed over 500 transaxillary breast implants. The use of silicone implants being placed through the armpit incision has been more recent with newer silicone implant styles and insertion techniques.

When using silicone breast implants, however, there is a limit as to the size of the implant that can be inserted through the transaxillary approach. Generally it becomes difficult to place implants greater than 400cc to 450cc due to the greater stiffness of today’s gummy bear breast implants. Their insertion is helped greatly by using the Funnel insertion device technique and also lowers the risk of injury to the implant shell as well. Whether that will take you to a D cup remains to be determined by an actual physical examination and assessment of your desired results using a Volume sizing system. Larger implants can be placed but this often leads to a longer transaxillary incision and resultant scar.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I had a craniotomy from a car accident several years and it has left me a skull deformity. My skull deformity is around my left temple, a slight deviation/protrusion of the temple and temple area muscles especially when I move my mouth, such as when I am  chewing. Along with a slightly more serious deviation (a dent) by my left ear skull area. They are both very minor, most people say they don’t notice it but it makes me very self conscious. All this being said…My next question is approximately how much will a plastic procedure to repair my damage cost? and will the repair be “undetectable” ? Just a “ballPark” figure/number?…I mean, does it sound like a $5,000 or $10,000 plastic repair? Or are we talking $50,000 or more to repair?

A: Based on your description of your concerns, I would lean towards fat injection as the corrective approach. You can’t shrink down the temple muscle protrusion and it is there simply because the temporal muscle has atrophied above it due to detachment from the craniotomy procedure. Your skull deformity is in the temporal area above the ear and again is likely due to a muscle issue. Since they both are ‘minor’ and are muscle based on their origin, fat injection grafting would be the simplest and most economical approach to their treatment.

I will have my assistant pass along the cost of the procedure to you. You will find it very affordable based on the numbers you have put forth.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, for my upcoming breast implant replacements surgery for implant replacements I have been researching and reading on the multivitamins to take, which do you recommend? Also, is a surgical bra provided after surgery or will I need to bring one? If I need to bring one how do I know what size to buy? I am going from the 300cc saline to 655 high profile silicone. Also, what do you recommend on scar prevention? My option of what I read is the silicone scar sheets? Also I was reading something about arnica Montana for bruising?  So many brands and so many options, I would like to know what my surgeon recommends from experience. 

A: Whether it is an initial breast augmentation surgery or for that of breast implant replacements, I see not need for the use of vitamins or other supplements. They provide no documented improvement in healing and I have never used them for breast augmentation surgery.

You will be provided with a surgical bra which is applied at the conclusion of the procedure.

In terms of adverse scar prevention, topical silicone gel or sheets are fine. Sheets are usually the easiest to use as a bra helps hold them in place and also applies pressure to the sheeting which is known to be beneficial for optimal scar appearance when applied early after surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like a shorter, fuller face with softer, more feminine features. I am wondering if I need corrective jaw surgery or could a chin reduction and facial fillers alone achieve the look I want. If there isn’t a great difference in the results of corrective jaw surgery and chin reduction surgery, then I would be more inclined to just get chin surgery because it is less invasive and costly. I do not like the large space between my nostrils and my upper lip. Could rhinoplasty help to shorten that distance? You might not be able to tell from these pictures but as far as my nose. I do not like the hump and I do not like my nasal tip. It is very bulbous and when I smile I feel the span of my nostrils becomes very wide. Finally I feel that I have a very prominent brow bone and feel it makes me look even more masculine. I am wondering if I am a good candidate for brow bone reduction surgery and also hairline lowering in order to decrease the length of my face. Thank you in advance for your help. I look forward to communicating with you soon and seeing the computer facial images.

A: All of the facial fershaping procedures you have mentioned would be helpful in shortening the appearance of your face from hairline lowering, rhinoplasty, subnasal lip lift and vertical chin reduction. It is impossible to comment on whether corrective jaw surgery or chin reduction would be better since that decision requires knowing the state of your bite. (occlusion) If your bite is good, then chin reduction would absolutely be the better procedure.

Brow bone reduction would be helpful to feminize your forehead and would be needed with your rhinoplasty to help bring back the glabellar (central) area of the brow. Otherwise the hump reduction with your rhinoplasty will make a deep nasofrontal angle which is more of a masculine facial feature.

While a subnasal lip lift would be helpful, it can not be performed at the same time as a rhinoplasty due to blood supply concerns to the intervening columellar skin between it and the open rhinoplasty incision.

To properly do computer imaging, I need more than just a lateral or side view. Additional views from the front and even a three-quarter (oblique) view make for a complete imaging assessment of the aforementioned facial changes.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Do you preform liposuction using local anesthesia? If so how many areas can be treated at once?I am interested in getting my inner and outer thighs treated. Are there any disadvantages to having liposuction done under local anesthesia.

A: While I do occasionally perform liposuction under local for small body and facial areas and is some cases of revisional liposuction, I am not a fan of larger areas done similarly. My experience is that it limits the amount of fat that can be removed in a single session and patients do not seem to be perfectly comfortable in many cases. There is also the issue that it ultimately costs more because it takes a lot more of my time to perform it.

I am well aware that liposuction under local is a procedure that numerous surgeons of various backgrounds tout and promote. They have their own reasons for so doing that may depend on their training, board certification, operating room privileges and experience. While successful outcomes can be achieved with local anesthesia, It is just not the way I perform liposuction most of the time and certainly not how I would have it done if I was undergoing the procedure myself.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I got silicone injections in my hips. I like the results but the left side is just a little bigger then the right. Do you know if you can get Kenalog injections to bring this bigger hip down? A plastic surgeon told me that he can try to make a incision and try to suck some of it out.. please get back to me. Thanks.

A: You can not remove or reduce silicone injections by steroid injections. Silicone oil is not like your natural fat tissue. It is a natural element (number 14 on the periodic table) that can not be broken down nor can your body absorb it. The tissue reactions to it can be treated by steroid injections such as scar or over reactive granuloma formations. But steroids will not make the silicone oil change it any fashion.

What the steroid injections can do is that they may make things worse as it resorbs fat and leaves the lumpy silicone behind. This steroid injections is an uncontrolled method of tissue management and I would be very cautious with it. The only way that hip area can be safely and effectively reduced is by liposuction as a plastic surgeon has previously recommended to you.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, my question is if one wants to raise the lower eyelids, instead of doing a canthopexy/canthplasty (as I am only 24 years old) can one do a orbital rim implant and still raise the lower eyelid to decrease scleral show?

I’m guessing this would push the lower eyelids up, remove the hollows and possibly increase cheek projection?

One doctor I spoke to said that placing orbital rim implants through the lower eyelids is the worst surgery as you have to cut everything up and then put the implants in and then reattach everything. He would stick a cheek implant through mouth all the way near the rim of eye and get the same result.

A: Orbital rim implants can potentially have a minor influence in some patients on pushing up the lower eyelids with the potential for decreased scleral show.  But it is important to remember that the implants are on the inferior orbital rim bone which is below the actual lower eyelid. So I think this potential effect is more theoretical than actual in most cases.

When it comes to the incisional method for the placement of orbital rim implants, any doctor’s opinion will be colored by their experience. When a doctor has no experience doing this surgery through the lower eyelid approach, then for that doctor it is the ‘worst’ surgery. But in experienced hands the lower eyelid approach for orbital rim implants is both safe and effective.

Depending upon the design of the cheek/orbital rim implants, it is possible in some cases to go through the mouth for implant placement. But in many cases the orbital result may not be the same as with the lower eyelid approach. It is all about getting the implants in the right anatomic position.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am inquiring about a possible reduction in the “chin pad” on my chin. I actually previously had an actual chin reduction where the bone was burred down, and I was quite happy with the results of this compared to what it was before. 

The surgeon did the reduction via submental incision, and I actually already did have a scar in that area prior to the surgery. (stitches from an old sports injury)

However, even before I had my chin reduction, there was a prominent “fat pad” on my chin, and it is slightly more obvious now (although the overall appearance of my chin compared to before the reduction is significantly better now). I would not consider it to be a classic “witch’s chin” .

I was wondering if it would be possible to discuss what could be done to reduce the fat pad? I am a medical student and did read in a textbook chapter Dr. Eppley mentioned liposuction should not be performed on the face, but also read on a post on realself he mentioned a possible intraoral chin pad thinning. I have attached a few pictures, showing me at the present showing the prominent “fat pad”.

A: Your assessment that treating a full chin pad by liposuction is not a good idea. Liposuction of the chin fad pad is not advised as it will result in irregularities and mentalist muscle distortions. The only way to treat an excessive chin pad is with a submental excision and tuck of the remaining tissue.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a fat graft 4 years ago that I am unhappy with. I have too much fat particularly along the jowl line and near my masseter/jaw area. It feels as if some of the fat near the sides of my jaw/masseter has calcified. Do you think that either 5FU or diluted Kenalog could help in either of these locations? I realize that Kenalog could cause a dent, but perhaps a dent near the jowl would look good versus an area where there is soft tissue only?

A: While injected fat grafts have the potential to undergo located areas of calcification, that is more common in the breasts and buttocks where large volumes of fat are placed. Calcified areas in facial fat grafting are much more unlikely due too smaller graft sizes and better blood supply of the facial tissues. If a fat graft is calcified, I doubt at this point that this fat can be ‘dissolved’. However if the fat is soft even though it is an ‘old graft’, it still may be susceptible to the effects of triamcinolone. (Kenalog) I would start off with a very low concentration (like 5mg/ml) and give it 4 to 6 weeks before repeating or increasing the concentration. If steroids are injected in low concentrations over time you should have success of thinning it out without creating the reverse problem of indentations.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Should I take out a 10 year old chin implant (silicone button type) first several months before a sliding genioplasty? Or can it be done at the same session as the genioplasty? If the latter (keep chin implant in until genioplasty operation), will it affect the accuracy of the cephalometric analysis? What about scar tissue – should it be removed first several months and healed up before the genioplasty? Which way is recommended to produce the result?

A: A sliding genioplasty is a good chin implant replacement method. It can fill the void left by the removal of the chin implant and replaces it with one’s own chin bone. There is no reason to stage the replacement of a chin implant with a sliding genioplasty. That creates an additional operation that provides no benefit to treatment planning or making the tissue bed any better prepared. The chin implant and its scar tissue layer against the bone can easily be removed and the sliding genioplasty performed unimpeded. It is not necessary to remove the capsule (scar tissue) up against the soft tissue side of the chin. The sliding genioplasty also provides the opportunity to creat different dimensional changes than an implant. (such as vertical lengthening, vertical chin shortening, chin narrowing/widening)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in cheek implant removal surgery.What techniques are used in Medpor removal to avoid any tissue sag? Does Medpor hinder the face returning to normal after removal.

A: Any cheek implant removal has the potential for a soft tissue sag thereafter, regardless of the material composition of the cheek implant. It is a simple function of tissue expansion of the overlying tissues and release of the soft tissue attachments. The likelihood of this happening in any cheek implant removal patient can not be precisely predicted and is a function of implant size, implant location and the patient’s inherent anatomy. This raises the question then of whether any type of cheek resuspension/tissue reattachment method should be done at the same time as their removal. This is not an easy decision and there is no method to accurately know if it is really needed. But I think one has to recognize that the face is not going to return completely to its preoperative state. (any more than removing breast implants will return the breasts exactly back to what they were before surgery to make a comparative tissue expansion analogy) If in doubt the best method is to do a soft tissue cheek resuspension through a remote temporal incision. The other more limited option is to use a bone anchoring method through the intraoral incision alone.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a prominent sagittal ridge on my skull that has bothered me greatly since I began losing my hair several years ago. I’ve viewed your before-and-after sagittal ridge reduction photos, and have a couple questions for you:

As you can see from my attached profile photo, the midline ridge on my skull is prominent not just on top but also extends about half way down the backside of my skull. Is it possible to obliterate the full length of the ridge through just one incision? If so, approximately how long would such an incision need to be?

On a related note, in one of your “after” photos, I noticed that the gentleman has a raised area below the horizontal incision (on the back of his head). Is this raised area simply post operative swelling or is it excess bone that you couldn’t reach with your rotary burr?
Are there any curved burrs or blades that would allow you to more easily work around the curvature of the skull?

Thank you for taking the time to answer my questions.

A: The extent that any sagittal ridge can be reduced is a function of the thickness of the bone (before the inner cortex is encountered) and the length of the incision ‘permitted’ to do the procedure. It is not a function of the rotary burrs or large rasps that are used to do the surgery. They all can more than adequately take down bone at any location. To work around the curvature of the skull, incision location is the key element in sagittal ridge skull reduction. The more it it is located to the back of the head, the further around the skull curvature one can go. Generally incisional lengths will range from 5 to 7 cms.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had my only child two years ago and since then have lost 50 pounds. Although I am working to lose weight, I am only seeing my tummy continue to sag. As a type 1 diabetic, the saggy skin on my tummy has now gotten to the point I can’t attach my insulin pump. Would a tummy tuck be good for me and will it interfere with my need for insulin through a pump?

A: With a 50 lb weight loss, and the resultant skin overhang that would develop from this amount of abdominal deflation, it is easy to see how a tummy tuck would be beneficial. A tummy tuck will completely get rid of all the tissue looseness/overhang in the abdominal area. While you are at some increased risk due to your type 1 diabetes for some potential postoperative complications (e.g., infection, wound healing issues), a tummy tuck would be immensely helpful and could potentially reduce your insulin requirements. I have performed numerous tummy tucks and other body contouring procedures on diabetics and have not seen these types of complications develop in any significant manner. While you will have to change the location of your insulin pump during the healing phase of the tummy tuck (six weeks), you will be able to use your abdomen again after that recovery period.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in the following procedures:
1) Lateral commisuroplasty
2) Bullhorn lip lift

My questions are:
1) Is it possible to have the procedures in the same setting?
2) Are the procedures done under local anasthesia or twilight sedation?
3) What are the costs involved with the procedures?

My main concerns with my mouth are as follows:
1) my mouth is too small (horizontally)
2) the gap between the my nose and upper lip is quite long which i also dont like.

The result I am wanting to achieve is a more aesthetically pleasing, youthful looking mouth. I want to create a fuller appearance to this area of my face to create a balance in my face. Thank you for your time.

A: A subnasal lip lift (aka bullhorn lip lift) and lateral commisuroplasties (mouth widening procedure) can be done at the same time under local anesthesia. These are common office-based procedures done without the need for general anesthesia or IV sedation. They have minimal recovery in regards to pain, swelling and bruising. The scars do take some time to fade sufficiently but can be covered with make-up in the interim. (four to six months)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have had cheek implants for four months now and dislike them and want cheek implant removal. I’m sure this is a common story. The implants are Design M Malar by Medpor and I would like them removed by yourself. I had a bad experience with my surgeon and don’t want to return. Would removal be straightforward and would recovery be minimal? Thanks so much for your help.

A: It is certainly not the first time I have seen ‘buyer’s remorse’ after cheek implant surgery. That does not make cheek implants a bad procedure, just one that may not have oived up to one’s expectations for a variety of reasons. Removal of Medpor cheek implants, like any type of cheek implants, can be done. But unlike silicone cheek implants, whose removal would be very easy, quick and with minimal recovery, the removal of Medpor cheek implants is more difficult due to the tissue ingrowth. The ‘difficulty’ of their removal is a relative one given that silicone facial implant removal is so easy. While Medpor cheek implant removal procedure is straightforward, I would not necessarily call the recovery ‘minimal’. It is best to think of it as about 75% of the original cheek implantation procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a stomach stapling done in June  and have lost 56 pounds. I have had a tummy tuck, breast reduction and a brachioplasty ten years ago but have obviously ruined that. But now I’m on a healthy eating plan for life. I’m 64 years old and wondering what you would recommend for my body contouring. I have attached some pictures of how my disgusting body looks now.

A: Since you have all the scars from the prior procedures, you may as well take advantage of their existence and use them for skin and fat removal and overall tightening of the areas for your body contouring surgery. For your abdomen you need a fleur-de-lis extended tummy tuck to get rid of the loose skin in all dimensions. (horizontal and vertical) Thuis would need to extend around the flanks to chase the loose skin/dog ears. You would also benefit by a major breast lift, keeping all your existing breast tissue and lifting and tightening the breast mounds back up onto the chest wall. You can just use the breast scars that you already have. For the arms (which seem to have the least amount of excess and sagging skin) a repeat arm lift would be needed.

Most of these body contouring issues are fairly straightforward. The real question at age 64 is to not overdo any single operation and stress your body too much. While in younger patients I would do all three body contouring procedures together, that would be a lot for you to go through at your age. Thus I would recommend only the extended tummy tuck combined with at the breast lifts. These two procedures target the biggest problems that I see (and what most weight loss patients focus on the most) and would yield the single greatest body change.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a rhinoplasty done a week ago and my nose splint is still stuck tight despite my repeated showers and letting water run over my face. Do you have any suggestions that will help me remove it?

A: Sometimes the nasal splint gets very loose and other times it can be very adherent. But eventually there comes a time to try and remove it. That time would be tomorrow. If you want to try and do it, you start from the top to peel it down as that is here it is ‘open’ from a taping standpoint. The first thing you do is grab the wings of the metal splint and bend them up so they are flat. That will reveal all the tapes underneath it. Then you start to peel the tapes off from above by lifting them off the skin. this will create a loose dressing that is just peeled off down to the tip of the nose. This is where it will be the most adherent as the tapes wrap around the tip of the nose and are often partially stuck there by any dried blood in the nostril. You will not hurt anything as you keep peeling the dressing forward (I did not say that it was comfortable in doing so), you just have to be slow to get all the tapes off from around the tip of the nose.

If you are uncomfortable doing so and just can’t seem to do it, let me know and you can always come in and have me remove it for you.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am at a stage where I am set on receiving a frontal jaw width reduction procedure, but the question really comes down to which procedure. I thought jaw reduction surgery will be the answer to my problems, but I know that I also have quite large masseter muscles. Will jaw reduction surgery alone slim down my jawline? I know that Botox is an option, but I am looking for a more permanent solution. I have heard of masseter muscle excision. What do you think about this procedure?

A: In looking at your pictures, I can see that your very wide jaw angles are most likely a result of a combination of bony angle protrusion and masseter muscle thickness. How much the bony angle contributes to your jaw width can really only be determined by an x-ray (frontal cephalometric x-ray or 3D CT scan). This would be of particular relevance if an angle thinning procedure is to be done as opposed to an angle amputation procedure. Particularly with an angle thinning procedure, the masseter muscle must be managed (reduced) in some fashion of a real posterior jaw width reduction is to be achieved. Subtotal excision of the masseter muscle is never a good idea and that is prone to intraoeperative bleeding and postoperative facial irregularities. This is why most masseter muscle reductions are done by Botox injection since it is far safer…albeit temporary in many cases. I have evolved to a different approach to master muscle reduction with bony angle reductions and that is electrocautery. By cauterizing the inside of the muscle where the bony is lifted off of the bone, this causes a natural shrinking of the muscle due to fiber injury. This takes months to see the final outcome as the muscle shrinks down as it heals. But it can produce up to 25% to 33% reduction of the muscle width.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I lost my frontal, temporal, parital skull due to an accident. My surgeon used peek polymer for a skull reconstruction. I am not pleased with the sides and it feels like screws are sticking out all over and hurts. I’m not sure what to expect from such a large cranial reconstruction and if anything can be done from your point of view?

A: Regardless of the material used, large cranial reconstructions almost always will result in some amount of plate and screw palpability. This is not usually seen for many months afterwards until all the swelling has subsided and the scalp tissues have contracted down and around the implant and the plates and screws used to secure it. This because particularly so on the sides of the head where the temporal muscle thickness is lost due to atrophy and loss of attachments to create classic temporal hollowing after any type of craniotomy/replacement.

I will make the assumption that the PEEK implant has a perfect fit to the surrounding bone because it was made from a 3D CT scan. (although often there is some edge demarcation between the bone and the implant) Almost all of these type of cranial reconstructions can be aesthetically improved through plate and screw removal, bone cement to smooth over any transition areas and fat grafting to create a thicker interface between the skin and the bone for temporal augmentation.

How any of these secondary reconstructive techniques may be applied to you would require an assessment of your exact condition through an analysis of any pictures that you can send.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Do you have experience with facial feminization surgery? Particularly with forehead recontouring, rhinoplasty, adam’s apple shaving, and hair line lowering?

A: I have considerable experience with facial feminization surgery (FFS) procedures, particularly the four that you have mentioned which are some of the most common FFS operations. All can make very successful feminizing effects. The key to the hairline lowering is the density of the frontal hairline where the incision has to be made. If this is adequate then the hairline can usually be lowered in a single stage of up to 2 cms based on one’s natural scalp laxity. Combining forehead/brow bone contouring with hairline lowering is particularly convenient since the pretrichial incision provides direct access to the entire forehead. Adam’s apple reduction (aka tracheal shave) is the simplest of the procedure and how much is can be reduced is dependent on what incisional access is used. (directly over it or the more remote submental incision) Reshaping the nose through a rhinoplasty to create a smoother and less prominent nose result depends on the thickness of the overlying skin. The thicker the skin the less it will contract and the size of the nose will reduce less.

Please send me some pictures of your face for my assessment and computer imaging to see what changes may be possible for you.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a less complicated process to nose reshaping. I have researched non surgical rhinoplasty. Can I achieve the same results using Restalyne as with a surgical rhinoplasty? I’d like to raise my drooping tip, then straight/sharpen my bridge to give appearance of thinning? 

A: Injectable fillers in the nose work exclusively by adding volume. Thus when evaluating whether an injectable or non surgical rhinoplasty will work, one needs to look at the nasal problem one is going to treat. Injecting the tip of the nose may be capable of lifting it but it will also make it wider or fatter in doing so. Fillers can raise a depressed bridge area and may be able to make it look a little thinner but I would not count on it making the nose straighter.

So to answer your question about whether a non surgical rhinoplasty can create the same result as a surgical one on your nose…probably not. Which raises the next question of whether it is good to do at all? I think as long as too much filler is not placed (a little goes a long way in the nose) then some improvements in the shape of the nose may be obtainable without any significant compromise. It is certainly the definitive way to answer the question of how effective a non surgical rhinoplasty may be and does not prevent one from eventually going on to a surgical rhinoplasty in the future.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to enquire about skull reshaping. I’m a 38 year old male and I remember from when I was a teenager that my skull changed shape on top. I developed a ridge at the top near the crown. It looks similar to the person on your website who you treated to reduce the height of the sagittal ridge/crest. I started losing my hair from around 18 so it became difficult to conceal this area. In desperation I had hair transplants, but they were placed in the front part of my scalp and the area with the ridge was untreated (it was the strategy in those days of using plug-grafts to place grafts in the front, in a horse-shoe shape and use scalp reduction to deal with hair loss in the crown – thankfully I didn’t have scalp reduction). So I am left with this prominent sagittal ridge. I am done with the hair transplants and just want to shave my head or have very short hair. The grafts are very irregular in their placement. I would like to know about how long  recovery in days is needed before returning home. Thank you.

A: Sagittal ridge skull reduction is a very straightforward skull reshaping procedure that uses a burring technique to reduce the height of the ridge. How far down the ridge can be reduced is dependent on the thickness of the ridge bone. It is done through a small incision at the back end if the sagittal ridge. Recovery for this procedure is very quick and many patients return home the day following the procedure…at most by the second day after the surgery. Even though there is a little swelling, it is not significant enough that anyone would know that you just had surgery. One can return to any and all physical activities as soon as one feels able.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I wanted to know if during brow bone reduction will the top of my eye socket orbit be addressed as well to better define and make my eyes pop a little more? Could the protrusion of my forehead upper and mid section be burred down also as the bulging extends beyond the sinus region. Lastly could the chin bone be chiseled down horizontally using the inner incision approach and a slight bit of vertically?

A: During brow bone reduction surgery, it is possible to also reduce the horizontal projection of the brow bones. This is not a standard part of the operation but can be done at the same time. This does involve freeing up the supraorbital and supratrochlear nerves from the lower edge of the brow bone so that it may be reduced. That does create the increased risk of some permanent numbness of the forehead with the stretching or manipulation of these nerves. Simultaneous forehead bone reduction through a burring techniques can also be done with no increased risk.

While the chin bone can be reduced both vertically and horizontally through an intraoral approach, this is usually not a good idea as it will likely create chin ptosis due to the soft tissue excess. (the tissues do not shrink down so where does the excess go?) These types of chin reduction are best done from a submental approach as the excess soft tissues can then be managed (reduced) as well. (submental tuck)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am going to undergo a variety of plastic surgery procedures on my face in the next few months but I have one big concern. I fear that everyone will know that I had surgery and I will have an obvious look that I have had plastic surgery. While I see the benefits of these procedures I certainly don’t want to broadcast to everyone that I actually had them. I know that seems a bit contradictory (wanting surgery but not to look like I have) but it is just how I feel.

A: The emotion you are describing is incredibly common amongst many patients undergoing a wide variety of surgical facial changes. Very few patients come in and say they want to look ‘done’ or do not care what their social circle of family and friends think. While how significant these facial changes will be is dependent on the exact type and number of procedures done, here is what I tell my patients about this very concern beyond the recovery period.

People know other people’s face in a gestalt or overall appearance, they usually do not recognize the specific details of what makes up a face unless it is a very outstanding feature like a large nose or very short or large jaw. Witness the classic example of a man who removes a long standing mustache and people know something is different but are not sure exactly what. Thus people do perceive a difference in a face, a more pleasing proportion to it, but would be hard pressed in most cases of surgical alteration to ever know what was done exactly…and may not even recognize that it was surgery. ‘You look more refreshed…have you been on vacation…have you lost weight’ are common reactions and thoughts to many after surgery facial changes.

In addition, the general public does not even know that many facial plastic surgery procedures even exist. (e.g., jaw angle implants or chin reduction). People can only recognize plastic surgery procedures that they know. Therefore in many cases of well done (not overdone) plastic surgery, the facial changes are not often appreciated although the overall facial enhancement effect is.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, the sides of my head stick out and are very round. But if I pull my jaw down the sides go flatter as shown in the attached picture. Hopefully this could be corrected with some type of temporal manipulation? Also I have a pointy sagittal ridge which hopefully could be rounded off. As you can see in the attached picture if I pull my jaw down and put my hand on the sagittal ridge I feel my head has a more aesthetically pleasing shape. This in my mind is achieved by flatter sides and a rounded top of the head instead of a point. Lastly I had put a side profile as I’ve got a mild lump that sticks out which hopefully could be smoothed out . Could you tell me if these correction are possible?

A: Unfortunately your pictures are so cut off (cropped) that I can tell very little from them. But by description, temporal muscle reduction would be helpful as you can see that this is a muscular problem as evidenced by when the muscle is lengthened by jaw opening. Since it appears some of the pictures did not come through, I can not comment on the skull issues other than to say that their description sounds very typical for being capable to be corrected by bone reduction. (sagittal ridge reduction)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to create a more deep-set look to my eyes. That is, the nose between the eyes is not visible in the profile view. I was thinking of having a custom forehead and brow ridge implant to bring them in front of the eyes, and a Le Fort II osteotomy to bring the nasal bone forward to create a result like so in the after:

Would this be possible? I mentioned the Le Fort II osteotomy since I would like to significantly bring forward the flat mid face, including the base of the nose, which is not done in a Le Fort I osteotomy or paranasal implants.

A: A custom forehead/brow bone implant can be done and would be the most successful approach to augmenting the upper third of the face. However, unless you have a malocclusion which requires a maxillary advancement, and even if you do, a LeFort II osteotomy is not really a great approach for midface augmentation. It is the most difficult of all Lefort osteotomies to perform (getting clean osteotomy lines) and the resultant augmentation above the LeFort I level does not usually justify the effort. (in other words, it is a long slide for a short gain) It would be far better and effective to create a custom midface implant for the entire nasmasomaxillary region even if one is having a LeFort I osteotomy. It is simpler and more effective than trying to move the bone at or below the infraorbital rim/nasal side wall areas.

Dr. Barry Eppley

Indianapolis, Indiana