Your Questions

Q: Dr. Eppley, I am interested in custom cheek implants.  I has severe sleep obstructive apnea and it took maxillomandibular advancement surgery where both jaws were advanced about 8 MM) to finally cure me.  As you can from the attached photos the maxillomandibular advancement surgery changed my face for the worse. Some people do not recognize me, others say I really aged and others say I look totally different. Other people on the internet that had maxillomandibular advancement surgery for sleep apnea say that they got there face back by having cheek implants put in. I would like to augment my cheeks in the best way and have other procedures and/or fillers to get me looking at least as good as I was before the sleep apnea and maxillomandibular advancement surgery.

A: The current state of your facial skeleton/appearance is rather classic when the upper and lower jaws are significantly moved forward when there is no natural malocclusion. These osteotomies are done below the level of zygomas (cheeks) and thus they create a relative state of upper midface/cheek deficiency as there is now a big forward step off between the zygoma and the maxilla as opposed to the reverse step off that normally exists. Cheek and/or cheek-infraorbital rim implants are the logical solution for this induced facial skeletal deformity. There are arguments to be made for either using preformed or custom cheek implants for your midface restoration. But the very altered bing anatomy does make an argument for the custom approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have had rhinoplasty, Medpor jaw angle implants (11mm projection) and silicone chin implant (medium 7mm). But I want a stronger look that is more masculine. I  also want cheek augmentation and I want a stronger chin. But the biggest chin implant I can find only gives 8mm horizontal projection so I’m considering a sliding genioplasy to have both horizontal and vertical augmentation. For the cheek implants iIm considering Design M Malar Implants from Medpor, I think they’re more anatomic than silicone ones, and also Medpor ones augment from zygomatic arch to the cheek bone which I think will give a stronger and masculine look. I would like to know which size would you recommend me to use. (4.5mm or 7mm) so they would look proportional to my jaw angle implants (11mm) I read in the internet that when you use facial implants, you have to consider the soft tissue augmentation that is different from the size of the implant… for example if you have a chin implant with 10mm projection…you’ll end up only with 7mm in soft tissue projection. So if I have cheek implants size of 4.5mm I’ll end up with 3mm augmentation, but if I have the 7mm ones,, I’ll end up with 4.9mm, So i don’t know which ones to use. I read in your blog that when it comes to cheek augmentation you should not over do this specific part because you will look unnatural. I definitely don’t want that. But also I have read that the cheek or zygomatic bone should be bigger than jaw angle.

A: I would take exception with your supposition that there is not a 1:1 correlation with the translation of implant thickness to how much change is seen on the outside. When it comes to any form of jawline augmentation, it is pretty much a 1:1 correlation. In the cheeks it is most commonly a 0.8:1 ratio. However the thickness of the soft tissues in any patient is so variable that no absolute implant size to external change seen can be generalized. Thus I would always assume it is a 1:1 relationship through the skeletal structure of the face. This would be true in my opinion given your relatively thin face.

I would also point out that a little bit in the cheeks goes a long way so I would be careful about going too big here. It is very easy to end up with cheek implants that are too big. Thus, I would lean towards the 4.5mm implants as opposed to the 7mm thick cheek implants.

Lastly, you can certainly do a sliding genioplasty using/keeping the existing chin implant in place  getting the dual benefits of both techniques. However be aware as the slidinjg genioplasty moves forward and down there will be a slimming.narrowing effect on the chin. Thus if you want to end with a more square chin look than you have now, the chin implant should be switched to a square design or even a more square one and not a rounder anatomic style.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve been looking for a more permanent solution for a lip augmentation. I was looking into fat grafting, but I understand that that procedure may not turn out as well as I would like if not done by a surgeon who is very experienced in that procedure. I’ve also been looking into permalip, but I don’t know if that would be for me because my top lip is uneven (as you can see in the picture I’ve attached). In your opinion, which procedure would be better for me? Roughly, how many times have you done each procedure? And what are your prices for both procedures?

A: There are multiple options for lip augmentation from fat injections, implants and mucosal advancement procedures. (V-Y lip lengthening) There are advantages and disadvantages to all of these procedures and none of them are perfect. They all have flaws such an unpredictability of volume retention (fat injections), asymmetry and palpability (implants) and longer recovery. (mucosal advancements) While they all can be effective, it simply depends on which of their flaws you find most acceptable. I have performed many of all of these and I think the ‘safest’ (less risk of complications) is fat injections. Permalip implants are the easiest and can always be replaced by fat grafts should one not like their feel.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a problem with the mentalis “balling up” when I try to elevate my lip after having a genioplasty. Prior to the genioplasty I had an indentation (not really a cleft but a small ridge) in the lower middle of my chin, this since is gone and simply looks like a ball of tissue when I elevate my lip (at rest it looks okay). I did consult with a local surgeon over a year ago who then performed a mentalis resuspension. This showed some improvement but afterwords, due to still having the “balling” found out that he never fully released the mentalis and he’s recommending releasing the entire mentalis and resuspending again. I’ve been doing some research about mentalis resuspension. One technique goes intraorally to do a wide release of the mentalis but also makes a small incision under the chin until the mentalis is completely released. Once the mentalis is fully released it is suspended intraorally and then the chin pad is anchored rom below. Do you think this will work? My main objective is to reduce (or eliminate if possible) the balling effect, hopefully returning that nice indentation (which I feel is the main reason the area balls up) and hopefully reducing my lower teeth show (full competence would be nice however I’d be happy with a mere improvement). Please let me know if this is something that you perform and if it’s something you’d feel comfortable with.

A: As you know there are different variations and extent of mentalis muscle releases. Depending upon how much the mentalis muscle is released will determine how much it can be resuspended. The mentalis muscle has its origin on the bone in the incisive fossa of the incisor teeth superiorly and inserts inferiorly into the skin of the chin. (not really the bone on the bottom of the chin) It is the insertion point of the muscle that actually contracts and pulls the skin upward. Thus when you are talking about a balling up of the muscle when you elevate your lower lip, that suggests that the problem may be exactly the opposite of what you think. I would question with your history if releasing the whole insertion of the mentalis muscle from below is really going to correct this balling up issue. Rather that anatomically suggests that the balled up area of muscle may represent the fact that the insertion point of the muscle in that area has been lost. However given that it is very difficult to re-establish a long-standing disinsertion point of the mentalis muscle (chronic scarred muscle contracture) the only real effective option may in fact be complete mentalis muscle insertion release. This does require a submental incision to really fully release it properly. Once fully released then it would have to be resuspended intraorally.

That is a long answer to say that this full mentalis muscle release and resuspension would be the only hope of eliminating this balling up issue even though it is ‘anatomically incorrect’ when you look at how the muscle moves and its origin and insertion points. That most certainly could be done under a sedation and local anesthesia approach like before.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, After doing some more research, I’ve also wondered about the possibility of facial liposuction or a buccal lipectomy with my vertical chin lengthening procedure.. I know that buccal lipectomy has to be done selectively, because it can cause a gaunt look. Do you think that buccal lipectomy or some cheek liposuction would help me? The fullness of my cheeks bothers me a lot and so I thought the genioplasty would help elongate my face to reduce the roundness or fullness. Basically my question is if some sort of facial liposuction may be a better option, or if it should be done in addition to the genioplasty? (I’ve had one other doctor mention that my chin height isn’t really lacking and that not much vertical height would need to be added). I’m interested in getting your opinion on this.

A: It would not be rare to do further facial derounding by a subtotal buccal lipectomy as a complement to other procedures. A buccal lipectomy produces a subtle effect so it alone would rarely create significant facial slimming. As long as it is not done overaggressively, it will not ultimately produce the gaunt look and will reduce some fullness right under the cheekbones.

By aesthetic measurements, you vertical chin height may be fine. But in the spirit of what you are trying to achieve, vertical chin lengthening is needed. Rather than rely on numbers or what looks right to someone else, use computer imaging to see what facial look is created with and without vertical chin lengthening.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I feel my chin is strong and I like my cheekbones, but they are wider than my jaw rami. I would simply like to add width to the lower third of my face by jaw angle implants. How can that be done? I have attached some pictures of my face so you can see what I mean.

A: I can see by your pictures as to exactly what you mean by narrow jaw angles compared to the rest of your face. Since I do not know what your jawline looks like from the side, I can not tell if it is just a width issue or a combination of width and some vertical lengthening. That distinction is critical in choosing the right style/design of jaw angle implants. Your have stated that you only need width so I will assume for now that is the only jaw angle dimension increase that you need.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, can I get a wrap around jawline implant made of Medpor material?

A: There are two basic types of wrap around Medpor implants depending upon how you choose to have them preoperatively prepared. There are preformed implants (a variety of chin and RZ angle styles (also known as the Matrix system) and then there are custom implants. Due to the extremely high cost of custom implant fabrication from Stryker ($15,000) I do not consider that a practical option for most patients. Thus with Medpor it is a matter of selecting amongst the various preformed ‘parts’ to create a wrap around jawline effect. A true custom wrap around jawline implant prepared off of a patient’s 3D scan can only really done today economically if it is made of a silicone material.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I came across your website in search of a surgical procedure that would add more volume to the back of my head. (occipital augmentation) I have essentially a flat head, and would like to change that. My question is; what is the average price (I know they are not all the same) for this procedure.

A: The typical occipital augmentation procedure uses about 60 grams of bone cement (which is just about the extent that the scalp can stretch to accommodate the underlying bone expansion) placed over the flat area on the back of the head through a scalp incision. In most cases of occipital augmentation this produces a satisfactory result. However there are a minority of cases where this volume addition may not meet the aesthetic expectations of the patient based on the degree of flattening that they have. Thus it would be helpful to see a picture (side view) of your head to determine if this one stage approach would be enough. In more severe cases, a two-stage approach can be used but obviously we would like achieve a good enough improvement that only a single surgery is necessary.

As a general number, the average total cost of a cone-stage occipital augmentation procedure (all expenses included, surgeon’ fee, operating room and anesthesia and bone cement material costs) is around $8500.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would be pleased if you could tell me if in my case whether an endoscopic midface lift would help to get rid of the sagging face after cheekbone reduction?

A: I have read through many explanations of facial sagging and its causes and treatments after cheekbone reduction surgery and find very little of substance there that is helpful. It only tells what is already known…that if the osteotomized bone segments are not stabilized by plate and screw fixation (particularly at the zygomatic body) the natural contraction force of the masseter muscle will pull the entire cheek segment downward including the attached soft tissues. In addition, over release of the masseter tendon from the zygomatic body will have the same effect even if the bone is properly stabilized in an inward and superior position. Fixing this type of msuculofascial sag is not going to be helped by any overlying skin repositioning maneuvers such as any type of facelift procedure that merely pulls on the skin. Thus, while any sort of midface lift may be of some help, it does not fully address the root cause of the facial sagging…musculofascial contraction.

For all intents and purposes, it is not really possible to reattach or lift scarred masseter muscle. This is why some form of skeletal cheek augmentation is usually needed with the lift to volumize the submalar cheek zone. This could be done with either implant or fat augmentation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have thought about liposuction a long time on my abdominal area which has always had a roll, even as a child. I would like to consult on liposuction and perhaps breast augmentation. I am going on vacation by the middle of June and did not know if it is even possible to schedule with you prior to that time.

A: It is very common to perform breast augmentation with any number of other body contouring efforts. Coming breast implants with a little bit of liposuction would not extend that recovery to any significant degree. Given that you are going on vacation in the middle of June, I would recommend that you have this surgery at least six weeks in advance of that event so you can be fully recovered, have few if any twinges of discomfort/soreness and be able to be completely in the the benefits phase of the surgery with little body ‘memory’ of the actual surgery. Thus it would be ideal for you to have this surgery no later than the end of the month. We strive to service our patients in an expeditious manner so I can see that happening on our end. I will have my nurse contact you tomorrow to find a convenient consultation time as soon as possible.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, from my research and various consultations, I believe Medpor facial implants is the way to go. I have heard that with silicone it will eat away the bone’s density as it has shown on my latest CT scan. (which was sent to you also)  Over years will the bone keep deteriorating from the silicone? What is your opinion on both types? pros/cons?

A: Whatever you have heard about silicone facial implants is both inaccurate and untrue. It does not cause any deterioration of the bone. That is an occasional passive phenomenon in the chin where the implant may settle into the bone from the pressure of the overlying muscles if the implants are placed too high on the chin bone. It is a simple passive phenomenon and not an active inflammatory process, It is never seen beyond the chin area in my experience.

I have used plenty of both silicone and Medpor facial implants in both primary and revision work. I could detail all of the advantages and disadvantages of each but, in short, if I never could place another Medpor implant I wouldn’t. (I still do when patients want but I have yet to see any advantages with its use and there are plenty of disadvantages) It costs more, has a higher rate of infection (as any textured surface implant does anywhere), is difficult to place, requires longer incisions to insert, is harder to modify, and poses a real problem when it comes to revisional surgery. (and remember even with custom implants the revision rate is not insignificant in the young male face patient) Whatever benefits they may be to some tissue ingrowth are overwhelmed by all of these disadvantages and screw fixation easily eliminates its only one advantage. (tissue ingrowth = implant stability) Over the years I have come to one conclusion about Medpor… it is an implant material that is really a poor choice for facial implants but it has been around so long and is an alternative to silicone that doctors keep trying to make it work.

But some patients are very emotional in their decision for Medpor although the logic of its use does not meet the scientific test for being any better than silicone. (and is a much worse handling material) But if that is what the patient wants, I will use it most of the time unless I feel it really compromises the ability to get the desired result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I really need an opinion on what I should do to correct facial sagging or ‘bulging’ around my perioral area. I had upper jaw surgery six months ago which was a maxillary impaction. Since then, the left side of my face looks normal but the right side looks ‘pouchy’ and droopy to me. I’m glad I did the jaw surgery for my bite, but the way the right side of my mouth looks makes me feel old and ugly. I had a tiny bit of Juvederm injected in my cheeks and near the corner if my right lip a few weeks ago, but it hasn’t made any difference whatsoever to the problem. What do you recommend?

A: When you think about the mechanics of this type of facial skeletal surgery, it is perhaps no surprise that some facial sagging can occur in a few patients. When the maxilla is vertically shortened and the lower jaw rotates more upward in a new bite relationship, the overlying soft tissues have not changed. Thus there may be a relative ‘excess’ of soft tissue to bone. (bone is removed but the soft tissue is the same amount) While this is theoretically true, it rarely poses an aesthetic problem. But this can be a source of the tissue sagging…a relative soft tissue excess compared to the vertical length of the facial bones.

The options for improvement could be simple perioral mound liposuction on the fuller/sagging side or attempt to lift the sagging tissues by a variety of cheek augmentation methods. Which one may be best for you I can not say based on just this one picture and how you feel about the rest of your midface.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a cranioplasty. I have a depression in my forehead for the past twelve years. I am twenty-two years of age and this depression started showing around age ten and has just been there ever since. It makes me feel alien, I don’t like taking pictures, I only comb my hair in one style to cover it kind of and I really think that I would be a more confident person had I have a normal forehead. I desire a “normal” forehead, without a sink in it :(. I have attached pictures of what it looks like.

A: In looking at your pictures, what you have is a classic case of what is known as linear scleroderma which creates a deformity known as the ‘coup de saber’ (cut of the saber) effect when it appears on the forehead. It is a condition that usually develops as a child and causes a loss of fat and an indentation in the bone. It is progressive and the tissue atrophy effect eventually burns itself out by the time one is a young adult in most cases. Its causes is not really understood and is currently felt to be related somehow to the nerves. When it appears on the forehead, it usually follows along the line of the first division of the trigeminal nerve. (supraorbital nerve which comes out of the brow bone and extends vertically upward into the forehead) This is why you have a very groove going upward from your brow bone, hence the description ‘cut of the saber’.

I can not tell completely from the pictures about the quality of the overlying skin, which usually is thinned and mottled in color although your skin along the groove does not appear so. (but the pictures are fuzzy) Treatment could consist of fat injections, a minimal incision endoscopic cranioplasty for bone augmentation or a combination of both. I would know exactly what to do by feeling it but I suspect it ail requires a combined fat and bone augmentation technique for optimal forehead augmentation contour improvement.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am inquiring about temporal muscle reduction surgery. My husband’s temporalis is very prominent when he chews and I was wondering if this is something to be worried about. He’s a healthy 25 year old and has no symptoms. Can this be fixed?

A: Having prominent, large or hyperactive temporalis muscles is not something to be worried about for any medical reason… unless one is having chronic muscle pain or spasm from their large size. Many men in particular have prominent temporalis muscles which can become very prominent in its convexity on the side of the head. The larger the lower jaw, the bigger the muscle has to be to open and close it. Thus, the bigger the muscle the more prominent it will be seen when in use from chewing when it maximally contracts.

Whether one should reduce the size of the muscle ‘(fix it’) by temporal muscle reduction surgery is an aesthetic concern not one of medical necessity. Some of the most prominent portions of the temporalis muscle can be reduced/thinned to reduce its bulging appearance (make the area above the ears flatter and not convex) without any effects on jaw opening and closing in my experience with this type of surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to find out if I am a good candidate for chin ptosis repair. I have been doing some research online and found your name. I am interested in a possible facelift later but wanted to address my chin at this time as it is a problem I have had my whole life. My chin pad just seems to fall off of the end of the chin bone and looks worse when I smile. Thank you.

A: You certainly do have a ptotic chin pad and it is just part of your natural development as you have stated it has been there your whole life. That can be markedly improved or eliminated by a submental technique for chin ptosis repair where the extra and loose hanging chin pad is removed and tucked in from underneath. Yours is not an issue where the chin pad is pulled up but rather pulled under and removed. This leaves a fine line scar in the submental skin crease area. This is a short procedure that can be done under IV sedation that has a very minimal recovery as it appears your chin ptosis repair needs only soft tissue reduction and does not require any bone work.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a question about perioral mound liposuction. Do these mounds include the triangle from the corner of the mouth down to the jaw line? I was wandering if the jaw can be reached through the same procedure (I read on realself that you liposuction through the inside of the corners of the mouth.) I live on the east coast and cannot find any professional willing to do this. I am thinking of flying in for the procedure and would like to know the cost and recovery time.

A: You are describing exactly the location of the perioral mound, the subcutaneous fat that runs from the corner of the mouth radiating outward towards the cheek and down to the jawline including the jowls if so desired. Perioral mound liposuction is a very simple ‘micro’ liposuction procedure which, although only removing a few ccs of fat from each side, can make very visible difference in my experience. Although than some mild swelling there really is no recovery per se.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am seeking a chin implant revision. I had a Medpor round chin implant six months ago. I’m not satisfied with the thick sides with visible edges at the end and round shape. I want a square front but with shorter thinner more blended wings. About 1 months ago, I went back to the same doctor for a minor revision. Since he doesn’t do square implant he decided to shave down the sides to fix the problem. Result is very bad as he shaved down the front part of the sides but didn’t go back to the end edges. Now I have a very narrow pointy front ( worse than before revision the round front) and still with thick wings and visible ends. But the good news is that he told me the implant did not grow into the tissue yet and is very easy to remove at this time. So I’m now seeking a revision to remove my current implant with a wide square looking one but with short thin blended wings. I really don’t want to go under general if it’s possible since my Medpor chin implant is not that attached.

A: When it comes to a chin implant revision, it rarely works well when chin implants are trimmed in place. To really properly trim them, they need to be removed and modified outside of the patient and then put back in. However with the trimming now done to your existing chin implant, a new one is really needed now to achieve your goals. Having removed many Medpor facial implants, I do not believe that ‘the implant is not attached’ or that it does not have good tissue adherence. If that were really true then your surgeon should just have removed the implant to modify it if it was that simple. There is no doubt it can be removed but it will have considerable tissue adherence and is not a procedure that I would do under local anesthesi.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am seeking a chin implant revision. I had a Medpor extended large chin implant and I’m seeking for a revision. One reason I’m not satisfied is the sides are very wide and do not blend in my own jawline and I can feel the edges where it ends. Another reason I’m not satisfied is I want a square looking chin shape. I did tons of research and I found out that Terino style 2 has a square wide front looking but sides are not as long and thick as my medpor implant. That means I will get a square looking front but more blended and with thin side wings. But the only problem is the Terino style 2 doesn’t have big projections at all, the maximum is about 6 mm while my current one is 9mm projection and I at least need that much since my chin is very receded. What can I do? I want Terino style 2 square chin implant but with more projection.

A: This is a simple chin implant revision problem to solve. I call it the wafer technique or the stacking of a certain thickness of a wafer of material under the front part of the implant so it adds more horizontal projection. This could be done by using a section of the existing medpor implant cut down to fit behind the new one just in the front, a 3mm wafer will make the square chin implant equal your existing horizontal projection.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m looking for some lip scar revision. Years ago I had Goretex strips implanted. Doctors finally took the implants out but tubular scar tissue remains that has not gone away even after shots of Kenalog for at least a year. I’ve also used mouth stretchers and massaged which has helped somewhat. However the major problem is that my top lip curls under when I smile which makes me very self conscious. After online research I think the issue is the scar tissue has gotten connected to the vermillion muscle as my scar tissue raises above my actual lip into the white area when I smile, otherwise it looks normal. I hear the only thing you can do is detach the scar tissue from vermillion with a needle subcision and hope it doesn’t grow back together. I wanted to get your thoughts on this procedure, and the likelihood that the scar and muscle will grow back together and whether post op fillers in between would help keep it separated?

A: You are correct in the diagnosis of a linear scar contracture from the path of the previous implants. Since it is impractical to completely excise the scar, scar release (subcision) would be the next logical approach. However, I do not believe that a type of lip scar revision that just includes a scar release alone will suffice as any gaps created in the scar line would just fill back in with more scar tissue. Rather than using injectable fillers after the procedure, I would recommend injecting fat at the subcision sites at the time they are released. You need a tissue graft that has the capability to form live tissue if the scar releases are too work.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in temporal artery ligation. I have an artery (or arteries) with small broken capillaries around it on the right side of my forehead. It weekly bulges and swells, then goes down a little over five to seven days. This has been going on since January. It never completely disappears. I’ve seen a dermatologist (who will not laser arteries), my general practitioner (who ruled out temporal arteritis) and a vascular surgeon (who says it’s not disease). I then consulted with a plastic surgeon in my area. He said he could ligate at the hairline but when I questioned him about back flow or multiple vessels feeding the bulging area he admitted to being uncomfortable doing the procedure. The vascular surgeon had noted that unless he pressed right where the artery branched off the main one the problem area did not collapse. I feel at a loss. I don’t want to do more harm then good but I’m uncomfortable with it’s appearance. I would love your opinion. Hopefully you can help me. I have attached a picture of the bulging artery.

A: It appears that you have a prominent branch of the anterior temporal artery. You are correct in assuming that it is best t have at least a two point an sometimes a three point ligation approach. That can be determined by an actual physical examination right before or during the procedure. Your plastic surgeon’s concern is the fear of potentially injuring the frontal branch of the facial nerve as it crosses the temporal area between the hairline and the eyebrow on its way to the forehead. Fortunately that small nerve branch runs anterior (in front of) where your bulging artery is located.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in temple augmentation I have a narrow forehead and narrow temporal region but the length of my forehead is fine. I was wondering if theres a procedure to widen the forehead and temporal muscle permanently as its really bothering me? I have provided an example in the photos of two celebrities, one of which has a narrow head width and the other one which is the look I desire.

A: The type of temporal augmentation you are describing can be done but it depends on how you define the side of the forehead and temporal regions. I believe by your description and the pictures that you are showing that you mean the anterior temporal regions and not really the the forehead per se. Many people confuse the anterior temporal region (non-hair bearing area between the eye and the hairline as the side of the forehead. If you look carefully at the picture of Leonardo DiCaprio you have provided you can see a very distinct line between the more convex temporal muscle and the actual bony forehead on each side.  Through an incision behind the ear, a custom made implant can be placed under the anterior temporalis muscle that will build it out permanently to create that temporal/forehead wider look.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am seeking a revisional rhinoplasty. I have had three nose surgeries, the last two years ago. Five years ago I had a rhinoplasty and revision by one surgeon but I was left with a bone spur on the bridge and a long nose with a heavy tip. I then had a revisional rhinoplasty by another surgeon who removed the bone spur and shortened my tip. But my nose tip is still much fuller than I like and my nose overall still does not have quite the shape I would want. Do you think a third revsional rhinoplasty (fourth surgery) would be helpful at this point? I just want to get it finally fixed.

A: When it comes to any nose that has been operated more than two times, it is no longer an issue of ‘fixing it’ as scar tissues and other issues make the quest for an ideal result no longer possible. The multiply operated nose can only be potentially improved in some areas and other areas not at all. Thus it it important to clearly identify the exact nasal concerns one has, make a priority list of what is most important and then have me (or other plastic surgeon) decide which on that list has the potential for improvement and which concerns can not be improved. Whether further rhinoplasty efforts are worth it, no matter how unhappy one may be with their nose and what they have spent in the past, depends on whether the most important concern at the top of the list is one in which has the greatest chance of improvement with further revisional rhinoplasty. At your point in time with your nose, this is how you determine whether any further surgery justify the efforts. There are no simple or quaranteed fixes (as defined by one more surgery or tweak here and all will be better) in the tertiary or quaternary rhinoplasty patient.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Can you tell me the difference between custom skull implants vs bone cement skull augmentation? Which method is safer, how do they compare in costs, and the long term outcomes of both methods.  How long can custom implants stay in without complication? Does bone cement break down?  Does one method seem to be safer than the other?  Infection rates?  Future “touch-up” surgeries?  Differences in recovery time?

A: In answer to your questions about the two methods of skull augmentation,

1) Custom skull implants can generally be put in through smaller incisions, will have a perfect fit, are assured of having both a smooth contour and a seamless edge transition into the bone due to their computer design.

2) Bone cements with your type of skull augmentation would require a near coronal scalp incision to be adequately placed and allow visual access to get the smoothest contour possible.

3) Neither bone cements nor custom implants will ever break down or need replacing.

4) I have never had an infection with either material so I would not say there is any infectivity difference.

5) Both methods are safe, one is not safer than another. They are just different implant material methods to do the same thing.

6) Custom skull implants are going to have an increased expense over bone cements but the difference is not that significant as the higher cost of fabricating the implants is partially offset by the shorter operative time to place them.

7) There is a slightly less recovery time for custom skull implants because they are placed with a less extensive incision.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am inquiring about a cheek lift procedure. I had cheek implants placed four years ago. The right cheek had to be redone less than a month after placement because the implant had gotten loose and falling. Now that same cheek is loose and detached and sags and I also have a deep jowl. What are my options? Are you familiar with this? What kind of surgery would be involved?

A: The cheek sag you have now is probably not caused by your cheek implant being loose or fallen. I will have to assume that it is a true soft tissue sag. Why that would be just on one side and with an indwelling cheek implant in place is not clear. Usually a cheek implant actually helps protect against soft tissue sag as it has it own lifting effect by creating more support.

But that issue aside, a cheek lift is needed to reposition the sagging tissues over the cheek bone/implant prominence. There are multiple ways to do cheek lifts which have to consider the following variables; incision location, vector of the lift and type of suture suspension. If you don’t have any lower eyelid skin excess concerns, a combined temporal intraoral approach can be used. If there are lower eyelid skin concerns, then a lower eyelid incisional approach can be with a more superior cranial suture suspension done.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I recently had lower buttock lifts performed and I am concerned. I had a  banana roll deformity and I had the skin removed and a scar line created. At two months after surgery there are ripples by the incision line. While the incision line is thin I can’t help but notice, feel and see the rippling effect. I am using topical oil and silicone strips but nothing seems to change. I’ve contacted my surgeon and he says everything will be fine but after reading and seeing the pictures of your case studies I can’t help but think that I’ve ruined my body. Would you kindly tell me if this will go away. I’ve been nursing my scars for the past two months and it’s caused me considerable stress. I realize your assistance is a lot to ask so if you can find the time to be honest and realistic I would appreciate a second opinion on the scarring and healing process of these longer than expected incisions. Thank you for your time in advance and thank you for being so diligent in posting the case studies.

A: A Lower buttock lift places scars that should be placed in the infragluteal location. If well done they should not extend beyond the natural buttock crease so it is not visible from the sides. I am not sure why the incision is longer than you expected provided your surgeon was very clear before surgery as to its location and extent. The rippling to which you refer I can not tell based on your description as to whether this is along the incisional closure edges or are from skin ripples that parallel the scar. This distinction is important as one may improve with more time (incisional rippling) while the other (skin ripples) will not. I would need to see pictures of the lower buttocks to better answer your question as to the fate of these ripples.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have pretty substantial acne scarring and I would really like to have a procedure to remedy this. My scars cover a large area of my face, most of them are small indented scars but there are a few larger ones. I’ve looked into laser scar removal and chemical peels, but I’m not sure which one I would be the best candidate for. I’m also unsure of the average cost of these procedures and how long they will last. I want whatever I have done to have permanent results, at this point cost isn’t my primary issue, I just want results that will not fade within a couple of months. Any information you could give me on this would be great, I am definitely planning on having something done within the next couple months.

A: Facial acne scarring is a difficult problem and there is no complete cure for it. It can be improved but rarely can the skin ever be made completely smooth. The most effective treatment is going to be laser resurfacing not chemical peels for acne scars that are not too deep and are large in number. It is often best to have an initial fully ablative laser resurfacing treatment followed by a fractional laser resurfacing three months later. This will give you the best improvement with a sustained result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested suprapubic mound reduction surgery. I have grown up with  a prominent suprapubic mound for a long time and did not know there was anything I could do.I have in the process of losing weight buteven growing up in high school when I was thin I always had it.

A: There are two approaches to reducing the size of a suprapubic mound for improving better show of penile length. Liposuction is part of any technique and may be adequate by itself if there is not a skin excess. However many suprapubic mounds do have excess skin, particularly in those patients who have lost weight, and may require a concomitant pubic lift (like a reverse mini-tummy tuck) with liposuction. I obviously do not know which one would be better for you based on your description alone. Ultimately I would need to see pictures or perform an actual examination to know whether suprapubic mound liposuction would be adequate.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am looking to have an orbital floor augmentation procedure. My left eye is placed about 3mm lower than the right and I am searching for different methods to correct this, trying to find the least invasive method possible. Is it technically possible to correct the orbital dystopia with injections? I mean, using some kind of injectable cement or even fat that would be injected for orbital floor augmentation. I have searched the internet but I haven’t found much information about a possible injectable orbital dystopia correction procedure. What would be the risks of such hypothetical procedure?

A: Injecting any material, even fat, into the orbit would be neither safe nor effective for correcting orbital dystopia. The most severe risk of this procedure would be blindness or visual field loss. The safe and effective procedure would be orbital floor augmentation done through a standard lower eyelid/blepharoplasty incision. Bone cement can be placed to build up the orbital floor to the desired level. This is not really much more invasive than a lower blepharoplasty procedure. It would be good to see before surgery an orbital 3D CT scan to see the exact location and extent of the orbital floor differences. A custom orbital floor implant can also be made from this same 3D CT scan.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m interested in improving my profile with a chin implant (custom or pre-shaped implant – whichever you feel would achieve the best desired results), along with possible injection to my nose. I have always wanted a stronger jawline and chin. I have always felt that I look this way, but in reality I just don’t have that masculine look. By adding a chin implant, will that also improve the jawline since the skin is being stretched further forward? I’ve attached a side-by-side of the results I’m looking for versus my actual face. For my nose, I’m interested in very minimal nose work. I’m fine with my turned up nose as I believe it’s unique, but would like to know if injection was possible to smooth the “slope” to make it appear less concave where the bridge and tip merge?

A: You have demonstrated well the benefits of a chin implant with your prediction imaging. That amount of horizontal advancement is around 9 to 10mm and, when the chin is lengthened, will improve your jawline. The key chin/jawline feature which you have not evaluated yet is how the chin will change in the frontal view and whether it should become more narrow or wider. Such an assessment will help make the determination of whether a preformed stock or custom chin implant will be needed.

From a rhinoplasty standpoint what you are seeking is simple dorsal augmentation. But using an injectable material, even fat, is not going to produce a successful or sustained result. This is going to require the use of either a septal cartilage graft or an implant, both of which can be done through a closed rhinoplasty result. A dorsal augmentation closed rhinoplasty is a fairly minimal nose surgery with a very quick recovery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in the Quicklift procedure for my aging face. Can you tell me if this procedure works and whether it would be good for me?

A: When someone inquires about highly marketed and franchise type facial rejuvenation procedures like the Quicklift or Lifestyle Lift, the first question I always like to ask is what has drawn one to these type of facial surgeries. The answers are almost always going to be because promote a quick to minimal recovery, lower cost or avoid the use of a general anesthetic. While there may be some truth to all of these claims, that is only so because they are ‘minimal’ type facelifts that are limited in the extent of surgery and thus limited in the kind of result that can be achieved with them. This is fine as long as one has the type of facial aging problem that is likewise not extensive and would respond well to this approach. There is considerable unhappiness with these types of facelifts and that is because often the patient’s problem exceeds what the operation can do under the circumstances in which it is being provided.

As a result, it is important to know the degree of one’s facial aging concerns to see if there is a match or whether a different type of facelift would be more appropriate. This can easily be done by sending me a few pictures for my assessment.

Dr. Barry Eppley

Indianapolis, Indiana