Your Questions

Q: Dr. Eppley, My brows and eyes give me a cold look and I’d like to have a softer image. I am consider getting brow reshaping, but what else can be done to improve my appearance. I have attached a front and profile picture to see what you think can be done.

A: Thank you for sending your photos. I would not disagree that your brow bone shape and promience do give your eyes a bit of a harder look. While the brow bones can be surgically reduced, there is always the tradeoff of a scalp scar to do it. That can be a precarious trade-off in men based on their hair pattern, density and potential hairline instability. I am niot ruling it out for you but I think there are other facial issues that I think would be equally, if not more effective, that can be done with no such trade-off. Your prominent nose and short chin create a significant amount of facial imbalance. Their alteration by reduction rhinoplasty and chin augmentation puts your face in better balance and would help to give your face less of a cold look. I have attached some imaging to see what you think of the nose and chin changes.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a question about mentalis resuspension. Can you explain what is the procedure you perform and what is the percentage rate of success. I have heard that this procedure will never restore the lip position back to normal (prior to when the injury occurred). I also heard that most of the time the lower lip descends back to its malposition (as though the mentalis resuspension never occurred) within the first couple of months after the mentalis resuspension procedure.

A: I am not sure where you have been getting your information about mentalis resuspension and under what circumstances or techniques that it is performed. There is a difference between uplifting the chin tissues from an injury vs attempting to alter a naturally low/genetic chin ptosis. Soft tissue sag of the chin has a higher success rate when its origin is that of an injury. The best mentalis resuspension technique uses suture anchors that can adequately lift and maintain the position of the muscle until they heal to the bone. The success of mentalis suspension is also enhanced by a concomitant V-Y mucosal lengthening procedure done at the same time which is helpful for improving the horizontal position of the lower lip. These are some general concepts and I would have know more about your particular chin problem to know how they may apply.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m unhappy with my face. I think the horizontal projection is very poor and the jawline is weak. Just starting to look into options and I would be happy to hear any ideas you have. My first thought was that chin implants might be helpful. I’m hoping to create a face that Asian and white women will find very attractive and projects warmth while also commanding respect in a business setting. I have attached a profile picture for your thoughts.

A: I am not sure what Asian or Caucasian women would necessarily find attractive or what facial appearance projects warmth while commanding respect in a business setting. But in looking at your side view pictures, I would agree that your chin is weak and out of proportion to the rest of your face. Having a more proportionate chin would give your face better balance and is what I think you would give you an improved facial appearance that may be considered more attractive as well as casting an image of greater masculinity. I have done some imaging on your side picture to see if you agree. The chin augmentation, which could be done by either implant or a sliding genioplasty, would benefit by concomitant neck liposuction as well.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a question about 3D-generated chin implants. I have read that a perfect implant can be created without the trial and error process through the Implantech company. When reading further I don’t know if it means it reproduces exactly what you have crafted or it reproduces a perfect chin implant based on the dimensions of the face. Could you please clarify?

A: a 3D or custom facial implant must be made off of a skeletal model, whether that is off of a 3D CT scan or an actual hand-held model that is made from a CT scan. Either way, the implant is made based on the surgeon’s specifications/dimensions and it is ‘perfect’ because it matches exactly what the surgeon envisions. It is not perfect because the computer or its software have some method of knowing how to make an implant that would look the best based on how the patient’s face looks or its dimensions.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am going through a divorce due to domestic violence. I have lost a little over 100 pounds since I left my abusive marriage with our son. I for so many years buried my head into food. Even though I have lost all of this weight I often look in the mirror and cry due to the way I look. I feel empty inside, I want to feel beautiful and content with myself. I want back all of that confidence that he took from me. I have a lot of extra skin from all of the weight I lost. I am only 30 years old but I dress like a 40 or 50 year-old due to my body’s look. I don’t want to feel like I am dying inside anymore, I want to feel alive again, confident, young, and beautiful. These are the goals I want to achieve. Most of all I want to be able to bring my son to a beach in a bikini he is so young I do not want him to miss out on things due to my insecurities, He has suffered so much due to this divorce and domestic Violence. I try to keep a positive outlook on everything. I have attached some pictures so you can see what you have to work with.

A: Thank you for sharing your very personal story and in losing in the weight. This is obviously a transitional period in your life and changing how your body looks would be a complementary component to it. The excess skin and fat represent both physical and emotional baggage. In looking at your pictures, I can see that you would get some good benefit out of the following procedures… a full tummy tuck, liposuction of the lower abdomen (prior to its removal) and flanks with transfer to the buttocks, and a breast lift. Together these would all make a significant improvement in the shape of your body and reverse some of the effects of your prior weight gain.. All those procedures could be done together with the tummy tuck as the foundation procedure which is the one that really involves any significant recovery. Breast lifts are relatively painless and fat injections to the buttocks only as minimal discomfort.

While all four procedures would provide the most benefit in terms of body changes, the most important one is the tummy tuck with flank liposuction. That is the foundational procedure that produces the best benefit out of all the potential body procedures.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had jaw surgery over 20 years ago and am experiencing headaches and upper jaw movement. I saw a surgeon who took a c-scan and said there is no bone holding jaw in place just scar tissue. I am looking for consultation. I would like to find some one who has experience in this procedure.

A: Based on your description of upper jaw surgery, I am going to assume that this means you originally had a LeFort 1 osteotomy. This would be a standard horizontal maxillary osteotomy done right above the tooth roots. If done over two decades ago, it may likely have been secured at the time of surgery with stainless steel wires rather than the more common plates and screws used from about 1990 on.

To have upper jaw movement at this point, you would have to have a partial or complete non-union of the osteotomy site which is hard to imagine at this point in time after your surgery. But a CT scan would show the bony anatomy across the osteotomy site and should have been completely healed in with bone even at 6 to 12 months after surgery. So if the surgeon sees that now, I would conclude that it is a real phenomenon as unusual as it is. This should be evident clinically by seeing if the maxilla (upper jaw) has much movement in it.

The question now is what to do about it, particularly given your symptoms. If your occlusion (bite) is good, I would recommend a debridement of the osteotomy line, placements of plates and screws and bone grafting to provide stability and get at elast a partial union across the osteotomy site.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, my face is very unbalanced as my chin is very short. This also makes my neck look fat even though I am at a good body weight. I have attached some pictures for you to tell me what you can do for my really short chin. It looks like the lower part of my face is just missing.

A: Here is a side view prediction based on the combination of a chin bony advancement (sliding genioplasty) combined with an implant. Your horizontal chin deficiency exceeds 15mms which puts you well beyond what any conventional chin implant can do. A chin osteotomy will advance you up to 12mms, which is better, but also not ideal. Therefore, in cases like yours I will put an implant in front of the advanced chin bone as well that will add another 5mms to the projection. The addition of the implant also has the advantage of its extended lateral wings which will fill out the sides, making the chin a little more square. That is an advantage for a male who benefits by a more square chin anyway. In addition, your thicker neck tissues would simultaneously benefit by liposuction under the advanced chin area to try and thin that out a little but.

The combination of a chin osteotomy and implant combined with neck liposuction can make some significant changes as the imaging suggests. This type of ‘extreme chin augmentation’ is necessary to get the best result in larger male chin deficiences like yours.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I want to get a forehead burr hole filled from a previous craniotomy that I had done. If you used hydroxyapatite (HA) material, would the HA be applied directly on the burr hole coming to direct contact with the dura? Would a mesh and screws be also used?

In addition, I want to get my brow ridges built up as they are a little flat for a guy. Do you favor having the the eyebrow implants custom-made or would you make them during the surgery? Can’t HA cause a necrosis of the surrounding tissue during curing? What would be the advantage of using HA for the eyebrow ridge implant over medpor, PEET, or any other existing material?

A: In answer to your questions:

1) When reconstructing/filling in burr holes, it is first necessary to dissect the soft tissue/scar from both around the hole and the bone edges to identify clearly the bony margins. This scar tissue directly lies over the dura so the material does not lie in direct contact to the dura. Even if it did, however, this would be of no consequence or concern. Because they can be some ballooning of the scar/dura into the burrhole, it can occasionally be necessary to push this tissue down so the bone edges of the hole are exposed. This is done with a small piece of titanium mesh (no screws) whose edges grip the bone to keep it in place.

2) I am not sure where you get the impression that any cranioplasty material, HA or even PMMA, can cause any tissue necrosis during curing. HA is a completely cold curing material that has no exothermic reaction during setting. Even PMMA, which does have an exothermic reaction during curing, is very mild and never exceeds 110 degrees F. The actual temperature at which tissue damage could occur is at 142 degrees F and above. Decades ago the original PMMAs had high cure temperatures but those versions no longer exist. This has never been an issues with HAs and, when they were introduced in the mid 1990s, that was one of their big advantages over PMMA, a neutral set temperature.

Brow ride augmentation can be done nearly 10 different ways, largely depending on what material is being used. In the right hands, they all can be effectively done from an aesthetic standpoint. What one has to look at then is the material’s biology, what is the process to place them and the cost to do it. The most biologically compatible material is HA because it is composed of the inorganic content of bone, calcium phosphate. This bone will bond directly to it and may even get a small amount of bone ingrowth. It is also the easiest to place and mold into a desired shape. All other typical synthetic facial implant materials, such as silicone, Medpor and Gore-tex, must be hand carved at the time of surgery from a block of material. While this is very doable, it adds to surgical time and the they must be screwed into place for stability. Materials such as HTR and PEET must be made beforehand off of a 3-D skeletal model. Between the costs of the model and the fabrication of the implants, this could easily add up to $10,000 in cost to the surgery. That would be acceptable if there was some overwhelming biologic advantage to the these materials, but there is not.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I had orthognathic surgery of my upper jaw 2 years ago. My upper maxilla was impacted (5mm), advanced (5mm) and moved to the right (2mm) with a Lefort and lateral segmentation of my upper jaw. I got cheek implants, a mentoplasty without implants and jaw angle implants (porex) in standard size. I want my jaw angle implants removed and replaced as I am not happy with the results. My surgeon did a second surgery to try to file the existing implants and create more symmetry (one side is longer than the other with the implants) but even then the result is not good and the only thing to do is to remove the porex implants and replace with custom made. In addition to asymmetry I find that there is not a nice jaw line between the implant and my chin (not continuous line) which create a strange visual effect (it feels that the jaw implant should have continue to meet with my chin). To me is very important that the surgeon that is going to perform the surgery is both knowledgble and has a ‘cosmetic’ eye. I wish to have advice of how difficult this type of corrective procedures are.

A: I am not surprised that revision of porex jaw angle implants did not improve the problem. They are virtually impossible to merely ‘file’ in place due to their harder plastic structure. In addition, it is very common to have some disruption of the jawline between the chin implant and the jaw angle implants, particularly if the jaw angle implants created any vertical lengthening.

While I don’t have the advantage of knowing what your face looks like and an appreciation of skeletal anatomy, I can make some general comments. Removal of porex jaw angle implants is difficult but far from impossible. I have removed such implants numerous times. The question is how best to replace them. There is obviously a reason you had them placed initially whether it was for angle definition, widening or vertical lengthening. Such desired changes would be important to know. It does not appear that standard jaw angle implants may suffice. Custom jaw angle or jawline implants are made off of a 3-D skeletal model. They can be made in any shape and size based on needs and are fabricated out of silicone not porex. Placing the new jaw angle implants is no more difficult than the insertion of the initial jaw angle implants.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I would like to know if it is possible to have two procedures done at the same time. I want my ears tucked and a mini face lift or a limited lift done. Thank you.

A: Both an ear pinning (otoplasty) and a facelift can be done at the same time under certain cirucmstances. The key to whether these can be performed together is what type of otoplasty and what type of facelift is being planned. In a traditional full facelift there is an incision along the back crease of the ear. This would be lower than the incision traditionally used for an otoplasty which is higher up on the back of the ear. Many plastic surgeons may justifiably feel uncomfortable having two paralleling incisions along the back of the ear due to intervening skin survival concerns. So an otoplasty may not be recommended at the same as a full facelift. In a limited or mini-facelift, the incision on the back of the ear is more limited or not used at all. So an otoplasty can always be performed at the same time as a mini-facelift.

When an otoplasty is done with a facelift there will be some greater and more persistent swelling of the ear but this is an eventual self-solving issue.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, for the longest time I have had my heart set on rhinoplasty but didn’t want to go through a big operation. However I have recently learned that a much less complicated procedure can be preformed that involves reshaping of the nasal tip. (tip-plasty) I was wondering whether or not you feel as though tip plasty would be to my benefit or if you feel as though I should undergo full rhinoplasty. The only aspect of my nose that I have ever had an issue with is that the tip appears too bulbous from the front and 3/4 side view. I also feel as though it protrudes slightly too far from my face. I tried taking some high definition photos, but they would not upload so I had to use webcam photos. the frontal photo is extremely bright however it was the only way to show the definition of my nose from the front.

A: Rhinoplasty is very much like many other aesthetic facial operations, they are numerous versions in magnitude that are used based on the problem being treated. Simplistically, rhinoplasty can be thought of as either a full rhinoplasty or a tip rhinoplasty. The difference between the two is that a full rhinoplasty includes significant changes in the bridge of the nose and will always involve osteotomies or breaking of the nasal bones. Tip rhinoplasty usually does not include much internal work such as septal straightening and turbinate reduction. While there are many cross-overs between these two basic rhinoplasties, depending on patient need and desires, this is a very basic way to view them. More tip rhinoplasties are done in revisional surgery than in primary rhinoplasty.

While your tip is large, I would agree that the top portion of your nose looks in better proportion. I think that an isolated tip rhinoplasty would be of great benefit to you.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m honored that a surgeon of your stature and extensive experience in reconstructive/cosmetic surgery has replied to my posting. My understanding was that “Kryptonite” was the best material to be used for a cranial implant. I also have a burr hole just above one of my eyebrows and I believed “Kryptonite” would be suitable for both the supraorbital implants an the burr hole plug. As you know HA is brittle. Both HA and PMMA lack the osteo-conductivity of Kryptonite so what is the problem with Kryptonite will it be back on the market at some point or is it off the market for good? I hate the idea of having too loose foreign bodies floating on my forehead. Could enough bone be taken from my hip to carve two implants for my eyebrows and the burr hole?  Theres also a crack that extends downwards from the burr hole. What would you put on this crack.? Bone shavings? If access to the burr hole form the endoscopic brow lift of the upper blepharoplasty isn’t good enough, would it b possible to mke an incision in the eyebrow that will be covered by hair? As you can imagine I would like to avoid a coronal incision at all costs although I had one before and didn’t have any problems afterwards. Would this surgery need to performed by a plastic surgeon like yourself an oculoplastic surgeon, or a maxilofacial surgeon? You are not a maxilofacial surgeon, correct?
I thank you in advance for your help. 

A: I believe you have some basic misunderstandings about the various bone cements. Kryptonite is no more osteoconductive or has higher biomechanical properties than its ‘cousins’, the hydroxyapatite cements. Kryptonite is composed of calcium carbonate while hydroxyapatites are composed of calcium phosphates, thus they are very similar. They are not brittle when applied to the bone and do not become loose. I have used them in many patients for cranial defects and for forehead/skull brow augmentation and have never seen any issues with fracture or fragmentation. That is a theoretical concern that has little clinical relevance.

While Kryptonite had the one feature of some degree of injectability, it otherwise has no other biologic or mechanical advantages. It is no longer available, to the best of my knowledge, because the company voluntarily withdrew it from the market for reasons they did not disclose. I would have no idea if it would ever be back on the market. But your case is not a good case for injection anyway due to your prior surgeries and scar.

The best solution to your brow/forehead issues is to re-open your coronal scar, fill the burr hole and cracks with hydroxyapatite cement and build up the brows also with hydroxypatite cement. This would provide the good access to do the procedure properly. This can not be done through an endoscopic approach nor would the scars through the eyebrows turn out very well. I understand your desire to avoid the coronal incision but that can not be avoided and get a good smooth bony result in the desired shape and fill.

Lastly, I am board-certified in both plastic and reconstructive surgery as well as oral and maxillofacial surgeon with a lot of craniofacial experience since you asked.

Dr. Barry Eppley

Indiana;polis, Indiana

Q: Dr. Eppley, I was wondering if you could help fix my forehead; it’s been through a lot. When I was a toddler, I ran face-first into a wall, and since then, I’ve had a bump on the right side of my forehead. A year ago, it started to seem more prominent, and it wasn’t my imagination, because family pointed it out too, and sometimes the bump felt sore. I went to see a dermatologist who referred me to a facial plastic surgeon who injected the bump with steroids. This only left a dent around the bump, which he filled with Juvaderm, which has since worn off. Now I have a dent and a bump, and they each make the other look more prominent. It’s mostly noticeable when I move my forehead, which is a lot, because I’m pretty facially expressive. What should I do? I’d be happy to send pictures. Thanks!

A: Please send me some pictures of your forehead issue for my assessment. With your history, that bump is bone and not scar. That is the typical reaction to forehead trauma, a subperiosteal bleed that is a stimulus for bone formation. I would not have expected steroids to do anything. Most likely this would require bone reduction for elimination. The dent issue is soft tissue atrophy from the steroids which may need to be filled out with a dermal graft ‘ring’ around the area of bone reduction to get the most even forehead contour.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a birthmark that I tried to get removed. It was treated with a laser with no results. It is brown-colored and is a patch over the left side of my stomach. I have had it since I was born and it has grown in size as I have grown. I have attached a picture of it for you to see. What type of treatment should I get to remove it. Also, if it can’t be removed can it be tattooed over?

A: What you have is a classic cafe-au-lait birthmark that is virtually impossible to remove. The reason is that the brown pigment goes all the way through the skin, so no ‘pigment reduction’ laser/treatment will work. The brown color also will no respond to being lightened like age spots do with pulsed light therapies.  One option may be fractional laser… test patch an area to see the response.What type of laser treatment was done before? I doubt if it was fractional. Its an option but there are no good treatments for cafe-au-lait spot removal…short of excising it and trading that off for a scar…which I am not sure is a good trade-off. Also, you can not tattoo over it and match the surrounding skin. Besides an impossibility to match the surrounding normal skin pigmentation, it is not practical to make a darker skin color lighter by tattooing.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to know the sizes of butt implants? how big is the largest one and how many inches thick? and if it has liquid inside or if it has hard gel? Also can I dive to MO after couple days after surgery? Thank you.

A: Buttock implants come in a wide variety of sizes based on volume and base diameter. While buttock implants can range up in size to 550cc with 5 cms projection, there is little reason to put more than 300cc to 350cc in any patient. This produces a surprising amount of buttock enlargement  for most patients. This is about the maximal size that can be placed through a 7cm intergluteal crease incision and fit into the intramusular pocket. Trying to place anything bigger is an invitation to complications. While larger buttock implants can be placed above the muscle, this is not a technique that I use as it has a high complication rate such as implant displacement and fluid collections.

Buttocks implants are composed of a very soft silicone gel (not liquid) which feels like a compressible sponge.

Realistically, you would not be comfortable to sit on your buttocks and drive two days after surgery, even if you were just driving around the block. All patients will need someone to drive them home no matter where they live.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had gynecomastia reduction surgery one month ago. While I have fairly large boobs to begin with I am disappointed with what I see so far. I see very little difference. I thought all my chest fat was going to be removed and the saggy skin tightened. I expected a flat chest but that is not what I have. What do I do now?

A: While I have no idea what you looked like before and now after surgery, your description leads me to give some general comments. As was likely discussed during your initial consultation, gynecomastias that have more significant mounds and hanging skin are difficult problems. In such cases the problem is the amount of extra skin that you have and not so much the fat which has likely been significantly reduced from your surgery. (you can not remove all fat from any body site anywhere so this is not a realistic concept) In these larger gynecomastias the choices are to place large scars across your chest to adequately remove the extra skin in a single operation or to limit the scars to around the nipples and see how much improvement can be obtained being restricted by this approach. Large scars that extend out from the nipples are not acceptable in men in my opinion and a choice you would regret later no matter how flat your chest became from that approach. Because of keeping the scars acceptable and to just around the nipples, the chances were likely that a second surgery would be needed for further skin reduction and the best result. Your gynecomastia problem is undoubtably a challenging one and one of the most difficult to treat without undue scarring. 

At this point, it is too early to yet judge the final result from your initial gynecomastia surgery. It takes up to three months for all swelling to go away and the tissues to maximally contract to see the final result. Whether it will signficantly improve or not is unknown but you must give it that amount of time. I would suggest that you go back to your surgeon three months after the procedure for further follow-up and discussion.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have an abdominal scar directly down the middle of my stomach which measures about 15 inches along with train tracks. I had exploratory surgery done decades ago. I would like to have it removed. It’s not that its ugly but I am tired of looking at it and I want it removed. It makes me insecure and I don’t think that Icould ever be in a relationship with this scar. Please help.

A: There are two concepts about your abdominal scar that important to understand. First, the idea of scar removal is not possible. No scar can be completely eradicated from visibility. Scars can be reduced and made less noticeable but completely normal skin contour and color can never be achieved. There are limitations as to what scar revision can do. Second, the width of the train track portion of the scar is important as this will determine how much of the scar can be excised in a single scar revision procedure. If the train tracks are too wide, a staged scar revision procedure may be needed. A picture of your scar will suffice to answer this question.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had cheek implants and fat grafting 3 weeks ago. The left implant is sitting too close to the lower eyelid and the end of the implant can be seen and felt at the end of the eye.  I have numbness in the upper lip and teeth. Is this normal? Implant was silicone and attached with screws.

A: Cheek implant asymmetry is not a rare problem. As the swelling subsides, usually about the three week time period after surgery, the position and symmetry of the implants becomes apparent. The most common form of cheek implant asymmetry is that one of the implants is sitting too high as evidenced by the lateral wing of the implant being palpable close to the corner of the eye. While it is something that you can tell now, the question is whether it is an aesthetic issue that ultimately you will want improved. If it is not seen or causes a visible lump, then it is an issue that most patients can live with. If the end of the implant is visible, you likely will wanted it adjusted for better symmetry. Intraoral placement of cheek implants almost always cause some temporary numbness of the infraorbital nerve with decreased feeling of the upper lip and teeth. This is a temporary issue, which is expected, and should resolve over the next month or so.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, do you have any recommendations for topical ointments for my forehead laceration which was fixed about a month ago to help with the scar. Which are the best on the market? Do you have any knowledge or recommendations of using supplements like enzymes and vitamins to help reduce the scarring? I have read serraptase like in Vitalzym helps break up and remove scar tissue and was thinking of trying it. I’m trying to do anything I can to reduce it. Thanks very much for your time and advice!

A:I don’t think there are any magical scar creams, lotions or potions…despite how they are marketed and promoted. I also don’t think there are any vitamins and enzymes that help scarring either. While you can use any or all of them, they are as much psychotherapy as anything else for the typical non-problematic scar or surgical incision. This is not what most patients want to hear as understandably everyone wants to do the most they can for their scar. Time will create as much improvement as anything else. I think if it makes you feel better to use them then you should. There are other early scar treatments to consider, such as fractional laser resurfacing and broad band light therapies, that may have more profound effects than topically applied creams and ointments. This should not be construed to imply that the treatment of known problematic scars, or those that might potentially become so, will not respond well to the use of silicone gel sheeting and topical silicone gels and oils. But whether these are of benefit in many lacerations and wounds that might otherwise do well on their own is a matter of debate.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am in the process of correcting my jaw. I have had SARPE for my first phase. My main concern for the second phase of the surgery is to correct my flat under eye region. I would like implants to corrects this region of my face. I have a negative vector, flat upper cheeks, however I have moderate submalar projection. I have been told that my cheeks will fill out and the cheek fat of the submalar region will be pushed upward creating a fuller cheek effect, which I am seeking. I was also told, if I am still unsatisfied with my cheeks, it’s best to wait a year after orthognathic surgery to augment my cheeks. I have been reading that these procedures can be done at the same time and that orthognathic Lefort I osteotomy will not provide the same results as cheek implants/augmentation. I keep reading mixed reviews, Please help.

A: Let me answer your two questions directly and unequivocally.

1) A LeFort osteotomy, no matter how it is done, will not create a cheek augmentation effect. Based on where the bone cuts are and the how the bone is moved, this is simply not possible. Anyone that would suggest otherwise does not understand cheek augmentation.

2) Cheek implants can be done at the same time as a LeFort osteotomy. I have done it many times without any problems. It is as good combined procedure for the right patient. Just because someone had not done it before or is unwilling to do it does not mean it can not be done.

I hope this is helpful,

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a scar from an accident that runs vertically on the middle of my forehead. The accident happened approximately one month ago. I am interested in hearing your thoughts about whether scar revision will significantly help as I am very self concious about it now.

A: As a general rule, one month after an injury would be way too early for scar revision for the vast majority of facial scars. The wound has barely healed and the scar is undoubtably very red due to the influx of blood vessels needed to help it heal. While being impatient is very understandable as it sits on a prominent facial area, patient is going to be urged in most circumstances.

That being said, there are two indications for early scar intervention. If the wound edges are horribly mismatched and it is apparent that no amount of healing time will improve its contour, then excising the scar and aligning the skin edges may be advantageous. The more common indications for early scar intervention is either fractional laser resurfacing and/or BBL. (broad band light therapy) These non-surgical approaches are done to help the redness of the scar fade sooner or to smooth out some fine edges early. Good wound approximation has to be present so there is no reason to suspect that scar excision would be needed later.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 25 year old man with a normal mandible angles but a slightly weak chin that has a little steeper angle then the rest of my jaw. Anyway I have been considering a square wrap-around or extend chin implant to slightly increase the width and moderately increase the forward projection of my chin But I am concerned that a chin implant will make my jaw angles appear greater so I was thinking a combination of a  chin implant with jaw angles might be right for me. So my question is generally speaking do you think that those people who undergo chin augmentation would benefit from jaw angle implants that increase the vertical height of the ramus decreasing the angle.(for me I think part of the reason my angles seem so square is because my chin is undersized and the angle is about 90 degrees but then after the groove increases to about normal dimensions) And then my second question do you have an photos that demonstrate the depression that is formed when off the shelf chin and jaw angle implants are used together?

A: There are no general statement that can be made about the influence of the chin on the appearance of the jaw angles. Each patient’s jawline and facial anatomy is unique and must be considered individually. The best way to answer your question is through computer imaging…change the chin without the jaw angles and see what it looks like. That is the best way to answer that question. You are correct in assuming that most standard chin and jaw angle implants do not meet in the ‘middle’ (body of the mandible) and, even if they do, these are thinnest and most tapered aspects of the two implants. Thus it is possible the jawline might not be perfectly straight from the chin back to the jaw angles and usually isn’t. But whether that occurs or not and is aesthetically significant depends on each patient’s jawline anatomy and the implants used.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a depressed scar across almost the whole of my forehead, cheeks and chin. I have tried chemical peel and microdermabrasion, but all seem to burn that arena alone precisely. I think the tissue or skin in that area is pretty damaged and I would like to have it excised.

A: Based on our description of a long depressed facial scar, I am not surprised that microdermabrasion or chemical peels were ineffective for its improvement. Neither of these are appropriate treatment strategies for scar reduction. I am glad that you went through those though so you could prove to yourself that scar excision, radical as it may seemed initially, is usually the only effective treatment for a depressed scar. A depressed scar by definition has a thinner and more atrophic skin composition and a surface contour discrepancy to that of the adjacent normal skin. No treatments are really going to lower the shoulders of the edges of the normal skin to match the depressed scar and that would not be appropriate even it could. Removing the abnormal scar tissue and leveling the skin edges by bringing normal tissue together (surgical scar revision) is almost always a better approach…even if it is surgery and does take time to heal and for scar maturation to occur.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in neck liposuction, revision rhinoplasty, and cheek augmentation. I want to get rid of neck fat, define my jaw and neck line, straighten nose-one side of nose is bigger, and add volume in mid- and lower cheeks and under eyes. I have attached pictures for your review and assessment.

A: In looking at your pictures and your areas of interest, I can make the following comments/recommendations:

1) You jawline is ill-defined because your chin is both horizontally and vertically short. This makes your lower face look very deficient and creates a lack of any jawline definition. What you would ideally benefit from is a vertical-lengthening chin osteotomy which adds lower facial height and creates a more obvious jawline. This will also improve the appearance of a fuller/fatter neck although some submental liposuction done with the chin procedure would complement that improvement.

2) Your nose shows numerous secondary rhinoplasty issues. I do not have the benefit of knowing what you looked like before but I see issues relating to lack of upper dorsal height, tip asymmetry/thickness, nostril asymmetry and a deviated columella.

3) The need for volume in your cheeks and lower eyes is a bit perplexing to me. I see no benefit to lower eyelid volume augmentation. Perhaps with the chin lengthening, more volume in the lower cheeks (submalar implants) may be aesthetically beneficial to you. I have left those areas unimaged so you can see the other more important areas of facial change first.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, how big can custom facial implants be made? Can I get any size and shape that I want? I know you design a lot of facial implants for people having read your blogs. You talk about how it is better to be more conservative than extreme for many patients. Why can’t I just get any size facial implant I want?

A:  I have make these comments in my writings based on a lot of experience with men trying to design their own implants or providing me with very specific dimensions of what they want. I have seen too many cases where such outcomes have resulted in the need for revisional surgery because the outcome turned out to be different than they thought it would be based on its size and/or shape. I am always happy to accomodate patient requests and provide implant dimensions that one may desire, but I do so with the understanding that they then take responsibility for the outcome should the implant be too big or oversized. I make implant suggestions/recommendations based on my experience of seeing how a lot of facial implants turn out afterward as well as knowing the technical and tissue limitation difficulties that can come when trying to place large facial implants. While one can design anything on a 3-D model, that doesn’t always mean that the overlying soft tissues can equally accomodate its size. Custom implants must be designed with an appreciation of more than just how they sit or look on the facial bones.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a tummy tuck six  months ago and although I am happy with my lower abdomen I am not with my upper. It is still fairly thick and not as slim as the lower half. From the side view, the upper abdomen shows no difference unlike the lower. The only explanation that I can come up with is that my plastic surgeon refused to do liposuction of this area even though he did it to the sides of the tummy tuck. I can’t help but wonder if that had been done also it would look much better now. Can I get the upper abdominal area liposuctioned now and will it result in more loose skin afterwards?

A: Your question/concern of a tummy tuck result is a common one and one in which I review with every patient before surgery. Tummy tucks do their best work in the lower abdomen, where tissue is actually cut out, and offer more modest improvement in the upper abdomen. Your plastic surgeon was very prudent to not liposuction the upper abdomen during your tummy tuck as the risk of major healing problems can ensue at the central closure line . Thus many tummy tuck patients will have an upper abdominal fullness after their tummy tuck due to a persistently thick fat layer. This can be addressed after tummy tuck suction out extra fat and thin out its thickness. It will not cause any extra loose skin as that has been adequately tightened by the previous tummy tuck.

While we wish we could address the upper abdominal fat at the same time as the tummy tuck, it is wise to remember this basic motto in aesthetic surgery. It is far better to have two surgeries done safely than going for the perfect result and suffer a major wound healing complication which ca takes months to heal and leave a more devastating aesthetic problem than what one was initially trying to treat.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a large square chin implant that was placed 6 months ago that I am not happy with. As the swelling went away it became apparent quite quickly that it was not whaI wanted. The improvement is too small and it has little if any square definition from the front view. I have a 3-D jaw model done after the implant which I have sent to you. I am requesting a chin implant that is 19 mm thick and 3 inches wide from the front. I know that the implant  is going  to be fitted directly on the bone which means that it is going to curve around the chin to the side.That being said the squareness and the size of the implant is going to deviate from the criteria that I am trying to achieve because as the implant proceeds backward from the mid point of the chin it is going to take a different shape and size. Knowing that to maintain the squareness of the implant along the 3 inch width we need to increase the size of the implant as it proceeds backward from the midpoint of the chin. Please tell what you think.

A: I have received your 3-D model of your mandible with the existing chin implant you now have. The current implant you have appears to be a Style I square chin implant of 9mms horizontal projection. It is significantly asymmetric due to placement with the right wing of the implant being very high and right up against the mental nerve location. 

As to your dimension request for a new custom chin implant, this needs to be carefully thought over as 19mms of horizontal projection is significant and would be roughly twice of that you have now. The 3 inch squareness width, or 7.5 cms frontal width, is considerable and is about a 3.5 cm width increase over the implant you now have. It would be unusual to need more than 5 or 5.5 cms in most men to develop a square chin look from the front. With such a wide frontal square width, this necessitates the need for a wide width around the corner of the implant as it transitions back into the side of the jaw.

I would be careful to oversize the implant and it is easy to do. It may seem that these dimensions are needed/desired, but it can be surprising as to how these translate to one’s appearance once in place due to the overlying soft tissue thickness. You do not want to end up with a ‘Jay Leno’ chin afterwards which is way too big and result in the need for revisional surgery. 

I would suggest some smaller dimensions to the custom implant, more like 15mm in horizontal projection and 5.5 cms square chin width.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had my buccal fat pads removed over 10 years ago which looked great. Then I lost a considerable amount of weight, over 50 lbs, and now look too sunken in. What is the best filler used to replace where buccal fat pads have been removed?

A: The answer to your question partially depends on how much volume is missing (how sunken in you are) and what method (surgical vs non-surgical) you want to pursue. But using the injectable filler criteria as your question posed, I will answer based on that one variable only. Because of the volume of the buccal fat pads (usually 5 to 10cc per side), the best replacement filler is fat injections. While the injection of fat is unpredictable, it offers an unlimited amount of volume for facial injections and it has the potential for some permanent volume retention. While there are many proponents for the various synthetic injectable fillers that are currently available, one has to recognize the cost of the volume needed per side based on the volume lost and that none are permanent. But if one had to go for a synthetic injectable filler, I would first use one of the longer-lasting hyaluronic acid fillers, like Perlane or Juvederm, to see if you like the effect. While there are longer-lasting fillers, such as Sculptra, Radiesse and Artecoll, they can be associated with higher risks of lumpiness and irregularities than the non-particulate hyaluronic acid-based injectable fillers when it comes to larger volume augmentations.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I just need info on getting my belly button repaired. I don’t need a tummy tuck, literally just need my belly button put back after it “popped” during my pregnancy.

A: What has undoubtably happened is that you have developed an umbilical hernia as a result of your pregnancy. This has changed your belly button from an inne to an outie. The attachment of the belly button to the abdominal wall is an inherently weak point along the midline attachment of the vertically-oriented rectus muscles and their enveloping fascia. The enlarging fetus during pregnancy puts a lot of pressure directly behind the umbilicus. For some women this results in the area around the base of the umbilicus to separate. This results in the base of the belly button coming away from the abdominal wall and some intraperitoneal fat protruding outward. This push of tissue from underneath creates the change from an innie to an outie. You can probably push your outer in and feel a small hole underneath it. This can be repaired through an umbilicoplasty procedure, closing off the hole and re-attaching the umbilical stalk back down to the abdominal wall.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I need some help with an issue. I had an orbital floor fracture repair done a year ago with mesh implant. Since then I now have enophthalmos and nerve damage in my face. I want to know at this point is there anything you can do for me or suggest? PLEASE help me if you can I would greatly appreciate you! 

A: I will assume that you had an isolated orbital floor blow-out fracture. When that occurs, the supporting thin bony floor of the eye drops down. If significant enough (greater than a 1 cm floor defect) the eye will drop down. (enophthalmos) In addition, the large infraorbital nerve runs just under the orbital floor so it frequently gets trapped or pinched as the floor drops down. This is a sensory nerve (maxillary division of the trigeminal nerve) that supplies feeling to the cheek, lip and side of the nose. If injured or entrapped, patients may suffer long-term numbness or pain.

During an orbital floor repair, I always check for this nerve and make sure it is not entrapped in the blow-put fracture. Sometimes the nerve may be irreversibly injured, other times it may be entrapped and needs to be released. Reconstruction of the orbital floor can be done by a wide variety of synthetic implants or bone. There are proponents for all approaches and any of them can work with good surgical technique. The goal of orbital floor reconstruction is to prevent long-term dropping of the eye, known as enophthalmos, due to loss of support.

Since you have enophthalmos and infraorbital nerve dysesthesia, I suspect that further surgery may be beneficial by removal of the mesh implant, exploration and decompression of the nerve and a new floor reconstruction done. The first place to start, however, is with a good CT evaluation. I would get a 3-D CT scan of the involved orbit to first look at the anatomy. Based on that information, surgery can be planned appropriately.

Dr. Barry Eppley

Indianapolis, Indiana