Your Questions

Q: Dr. Eppley, I’m hoping that the full facial laser ablation will help greatly with my acne scarring. My only concern is that I have a few scars on my cheeks that are noticeably larger than the rest (they look more like “boxcars” whereas the others just look like large pores) Would you recommend doing the full facial laser ablation first then tackling any punch excisions if needed? Or would it be better to do punch excisions on the few larger ones immediately prior to full ablation in order to maximize success? Of all of the aesthetic goals I’m trying to achieve, having a beautiful “poreless” face is of the most importance.

A: The most important concept about laser resurfacing of facial acne scars is that perfectly smooth and poreless skin is not possible. Improvements in skin texture and irregularities can be obtained, it is just about how much improvement can be obtained and whether one treatment alone is adequate. This can not be specifically gauged beforehand in any patient and more in that regard will be known after the results of the laser treatment is seen. Acne scars that are amenable to excision (ice pick scars, not boxcar scars) should be done beforehand. That way those scar revisions get the benefit of the laser resurfacing as well.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I know a tummy tuck focuses on the abdomen below the belly button. However, I have two fat “dumplings” immediately above and to the left and right of my belly button. If this skin gets pulled down because the lower skin is excised, I was worried that these two fat “dumplings” would look like a new pannus. (if that makes sense).Is liposuction ever being performed on the area immediately above the belly button during a tummy tuck also?

A: In a tummy tuck, the excision of full-thickness skin and fat in the lower half of the abdomen results in an advancement or stretching of the undermined upper abdominal skin flap. This will ‘unravel’ much of the upper abdominal fullness and irregularities because this tissue unit must now stretch out and cover twice the surface area that it used to. Liposuction is never done on the upper abdominal skin flap during a tummy tuck because of blood supply and healing concerns. By doing so there is a very significant risk of causing skin necrosis and wound healing problems of the tummy tuck incisional closure. Once the upper abdominal skin flap is undermined to allow it to stretch out, the perforating vessels feeding the tissues are cut off from the underlying muscles. The skin is now surviving on the more superficial vessels near the skin that comes in from the sides. Liposuction will injure those vessels and make the central upper abdominal tissue have jeopardized vascular perfusion. The small increase in aesthetic improvement is not worth the risk of major tummy tuck wound healing problems. But those areas you are referring to above the belly button are not going to be carried lower as they now exist. They should be completely flattened out for the most part.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I’m having surgery in a few weeks consisting of a full tummy tuck and liposuction of the, flanks and outer thighs. How much fat did you estimate in inches that can be removed from each of these areas? Particularly with my outer thighs, I was hoping that whatever amount of fat was removed would be visibly noticeable to the eye.

A: While I don’t have the advantage of knowing what your body/thighs look like, there would be little purpose in having the procedure if the change was not noticeable. I never like to use inches as a circumferential measurement outcome for any liposuction-treated area or a tummy tuck because the visible change can be substantial but the circumferential measurement change can be less impressive. This, of course, highly depends on the body type and the size of the original problem. But you have to remember that only one section of the thigh (outer) is being treated not the circumferential thigh so that measurement will never be impressive as the outer profile or silhouette view. For a tummy tuck, only the front half of the body is being treated so the amount of ‘inches’ reduction will depend on the existing size of the frontal abdominal fullness and/or overhang.

While in many patients, inches do come off from a tummy tuck, that can be avery disappointing assessment criteria when looking at outer thigh liposuction…that is rarely an inchess off procedure.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I recently had a breast augmentation with 175 cc implants placed under the muscle.. I went round and round with the surgeon, who had never placed implants that small. I showed him an “A” bra that I was interested in filling (I was a double A) and he assured me that that was where I would end up. No such luck. I am a very full B, and very much doubt that waiting for swelling to go down, drop and fluff, etc, will attain the very, very, very moderate look I wanted: again, an A cup. I had explained to him that I was looking to acheive an “A”, no more, to restore my former breast before the 20-lb weight loss. I am very upset to be so thin (5′ 10 and 120) and have much bigger breasts than I have ever had in my life! Would you deem me a good candidate for revision?

A: It is true that breast augmentation with implants under 200cc in volume is very rare. But yet they do make them as small as 125cc in volume. But most of such implants are used as an adjunctive component of breast lifting surgery.

Had I seen you before your desired breast augmentation procedure what I would have said is that no size of existing breast implant will make you an A cup, no matter how small you started. Even putting in a very small breast implant is going to make most women some form of a B cup even if it is a small one. Granted you are very tall and thin, but even a small breast implant will make some degree of a visible mound which is by definition a B cup.

That being said, where you do go from here…how do you revise what you have to reach your size goal? It would be extremely helpful to know whether you have saline or silicone gel implants and what projection/profile they are. For the sake of assumption, let us assume that you have silicone gel implants. There is no where to go in terms of size as the smallest silicone gel breast implant is 170cc, regardless of the manufacturer. If you have saline, then there is the possibility of downsizing particularly if the 175cc are overfilled. The smallest saline breast implant made is 125cc in the lowest or moderate projection style. By switching to this smaller saline implant, you would realize a 30% reduction in size (maybe more if they are overfilled) and perhaps some less projection if they are anything higher in projection than a low profile implant.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I am writing in reference to what I have read in a posting on your site: Case Study: Lower Buttock Lift for the Saggy Derriere from Friday, July 20th, 2012. It seems as if the procedure you perform is one that sutures de-epthelialized dermal flaps to the gluteal fascia, thus redefining the infragluteal  fold. My situation is that I lost about 15 pounds a few years ago, resulting in a saggy buttock. This is also likely age related as I am 45 years old. I am happy enough with my buttock per se, which although small might be redefined by the removal of the offending skin, I’m thinking. If I send you pictures would you be able to tell if this procedure would work for me? Thank you in advance for your time and responses to my question.

A: Pictures of your buttocks will do quite nicely in determining your eligibility for a lower buttock lift. Please send a picture from a full back and side view of your buttocks. You are correct in how a lower buttock lift is performed, de-epithelization of the excess buttock fold skin in a horizontal orientation and then suturing the skin edges down, if possible, to the buttock fascia. All skin sutures are placed in a subcuticular location and are of the barbed dissolveable variety so no suture removal is necessary. The only dressing used is glued on tape. There usually is very little discomfort after this procedure. One just needs to avoid bending over at the waist beyond 90 degrees and strenuous exercise for 3 to 4 weeks after the procedure.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I had scar revision on my knee area. The surgery helped my scar to look thinner but there is still this image of a straight line cut. I had my operation last September 5, 2012. I am planning to undergo laser treatment for my scar. Can I have it done by December of same year?

A: While you certainly can treat your scar revision by laser resurfacing in the early months after a scar revision, I would not expect it to change how it looks. (like a residual straight line cut) Laser resurfacing is almost always perceived as if it is a ‘magic eraser’ but that is not how it works at all. Lasers do not have the capability to wipe away scars and often are overused and overhyped.

A scar, no matter how thin, is a full-thickness layer (most of the time) of abnormal tissue that is largely white and unpigmented tissue. Laser resurfacing removes a layer of the top of the scar but doing so will only reveal more of the scar. Only in the most superficial of scars can laser resurfacing reveal more normal underlying dermis which then can re-epithelize. Thus in full-thickness scars no improvement will be seen. And after surgical scar excision, your scar is most certainly full-thickness.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I’m going to ask you a question you probably heard 10000 times. What procedures do I need to perform in order to get “the male model look” and look handsome?  I think(I may be wrong) I need: Skull Reshaping, Cheek Augmentation, Chin Advancement, cheek and chin;jaw/mandibular Implants,  nose rhinoplasty; lip reduction; Neck Contouring; I’ve attached a few photos of me. My face looks fat. That’s because i have about 20 pounds of excess fat. 

A: You are correct in assuming that I have been asked that question a lot….and have subsequently done a lot of male facial sculpting surgery. In getting a better balanced and more defined facial shape in a male, there is a list of procedures to consider most of whom you have mentioned. But each face is different and therefore has different needs to improve its proportions and get closer to a more sculpted look. There is also the issue of priority and the associated cost to do them so making the proper diagnosis as to the anatomic problems is extremely important in surgical procedure selection.

Your most glaring anatomic problem is your severe lower jaw/chin deficiency. A short lower jaw makes the entire lower face both horizontally and vertically short. This is what contributes to your impression that your fat is fat…it is not. It is just that the lower 1/3 of your face is overpowered by the upper 2/3s. This is further accentuated in profile by a moderate nasal hump which makes the facial convexity worse.

Your most important procedure is to get the lower 1/3 of your face in proportion. This is beyond what a chin implant alone can do. You really need a chin osteotomy (sliding genioplasty) combined with a small square chin implant placed in front of it. Removing your nasal dorsal hump would then complement your facial profile. (see attached side profile prediction) These are the two most important procedures. Secondary consideration could also be given to cheek implants. (see attached front view prediction)

While some other procedures may be complementary, this is the foundation for helping you get closer to more of a ‘male model look’.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 24 year-old guy looking out for skull reduction surgery. I have very wide skull especially above ears, also muscle over the portion is so hard and overdeveloped it is creating very absurd symmetry. I don’t want to have Botox reduction as it is temporary solution hence looking for permanent solution through reduction surgery. Can you please tell me is it possible to reduced muscle to large extent? Also I want skull side to be reduced to some extent. I am looking for narrow skull with vertical indentation. I feel very upset and depressed because of this. Please advise me as soon as possible. Really looking forward for your help.

A: You are correct in assuming that the full area above your ears is as much temporalis muscle as it is bone. Temporal bones are often quite thin so even though they may protrude they can not be reduced very much, usually no more than a few millimeters Muscle reduction is the primary tissue to reduce for narrowing/thinning. Reducing the temporalis muscle is a combination of muscle release and muscle resection. The temporalis muscle is a very large fan-shaped muscle that  extends from above the zygomatic arch up to thue anterior temporal line at the top of the skull as well as back to the occipital region. To do temporalis muscle reduction, the enture muscle is released from its origins for the lateral orbit up and across the skull. A central wedge of kmuscle is then taken. Much of the reduction ultimately comes from the contraction and atrophy of the muscle which can take up to six months after surgery to be fully realized. Because it is a muscle of mastication and inserts into the lower jaw, expect some temporart restriction and soreness with mouth opening after surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had chin and cheek computer imaging done to show me what the effects of this surgery would be on my face. I notice in looking at the images that there is some asymmetry with one side being different than the other. Is this what I can expect from the outcome of the surgery?

A: There are some basic concepts of computer imaging in plastic surgery that are important for every patient who undergoes it for any procedure to understand. First, the quality of computer imaging is only as good as that of the original pictures. In your case, you provided the pictures which were not of great quality.  (slightly blurry and out of focus) When these pictures are magnified for imaging, the quality is not good enough to create very good detail. Second, computer imaging is designed to serve as a method of  communication so the patient and the surgeon can see if they are on the same page, it is not intended to be an exact replica or a guarantee of the result. Contrary to popular perception, there is no computer that does the imaging. It may be done on the computer but ultimately it is the hand of the operator (often using Photoshop) that is creating what he/she thinks the effects will be from the surgery. That is the reason it is called ‘computer prediction imaging’…it is a prediction not an assured result. Third and most important, Plastic Surgery is not Photoshop. The body does not respond to trauma and healing like pixels do on a computer screen.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, does the mandibular angle implant bond to the bone through time?  Or is it just the screws that hold it in place for the rest of my life?

A: There is no synthetic facial implant materials that truly bond to the bone in the truest sense of the word. Bonding denotes an actual bone ingrowth and attachment to the underlying bone without the interface of scar, much like a dental implant where bone bonds directly to the metal. That does not happen with either silicone or Medpor materials.

What does ultimately stabilize and maintain a facial implant into a secure position is the development of a surrounding layer of scar known as a capsule. This takes several months to form a solid capsule around the implant. So the primary purpose of implant screw fixation is to maintain the desired position until a good capsule forms. Medpor material does develop a more robust capsule formation than silicone but early implant stability can only be completely assured by screw fixation as that still takes time to develop. Medpor material also has a much higher frictional resistance (which is also why it is much harder to insert and usually needs bigger incisions) so this may help a little with early implant stability. But that is not enough for me to rely exclusively on this material property. Silicone has little frictional resistance and pocket development alone does not provide assurance that implant migration/mobility will not happen after surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a large bump on my forehead that has bothered me all my life. I am a 25 year-old man and this kind of gives me a ‘horned’ appearance. What are my options for getting rid of it? I have attached some pictures from different angles and it becomes really prominent when I raise my eyebrows and put wrinkles on my forehead.

A: Thank you for sending all your photos. The involved forehead area is quote distinct and, interestingly, does not allow any wrinkles to form across it. I suspect that is from the effect of pressure where the overlying forehead tissues are being pushed out more. The cause of this forehead ‘bump’ most likely is just a thicker area of forehead bone but I would always confirm that with a simple lateral skull x-ray before operating on it for burring reduction. This bump is moderately large so the issue is one of surgical access. I would definitely not make a hairline (pretrichial incision) because your hairline, like most males, does not appear stable for the long-term. The endoscopic approach could work but that also placed a sagittal (vertical) incision behind the hairline, that once again, may not prove stable. I think the best and most direct approach would be to use a horizontal forehead wrinkle line. This would also provide access to get the greatest amount of assured bony reduction which is obviously the intent of the operation. This form of frontal skull reshaping is actually very simple with minimal recovery, it is just all about how to get in to do it and where to ideally place an incision.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a gummy smile. I would like to see what options are out there to correct this issue. I have attached pictures of me smiling and not smiling for you to see how much gummy smile I have.

A: Thank you for sending your pictures. The first thing I can say is that you are not a candidate for any bone surgery (maxillary impaction) for your gummy smile (thank heavens) as one has to have lip incompetence at rest…which you do not. Therefore, any effort for improvement in your gummy smile has to be directed towards soft tissue management. While there are internal soft tissue lengthening procedures which will have long-term benefits, your long upper lip (skin between your nose and upper lip) poses some concerns. One has to be careful that you don’t fix the gummy smile but then also lengthen the upper lip. (may not be a good trade-off) The good news is that there is a test before doing the procedure to see how the result of the surgery might work. That is Botox. A few units of Botox (generally 2 – 4 units per side) on each side of the nose will simulate the effects of a muscle release and mucosal lengthening. if you like the result of the Botox injections, you can just continue with the Botox (much less units and cost than the typical injection sessions done in the forehead which are usually 20 to 30 units) or then proceed for the surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had buccal fat removal upon the misleading instruction of a doctor . Now my cheeks look sunken and dented. After reading your article “Contemporary Cheek Enhancement – Malar and Submalar Zone Considerations”, I have the following questions which are consistently suffering me.:

1. Will the removal of buccal fat pad lead to great fat loss (lipoatrophy)? e.g. due to loss of the supporting fat. I just found myself look like dying.

2. I guess the doctor just removed the whole fat pad, which was not told to me. May I know if there are any suggestions for repair with the least potential risks? I consider fat grafting, but it seems so unpredictable. Do fillers like Juvederm or Artefill work in my case?

I will move US next year and I think surgeons of US are better. Wish you can save me out of this. Thanks a million for your great help!

A: Buccal fat removal can be beneficial for facial reshaping in the properly selected patient, such as someone with a very thick and round face with full tissues. But in the wrong type of patient or if too aggressively done it can result in a gaunt overresected look. I suspect by your description you fit into the latter category. In answer to your questions:

1) I do not know how far out from surgery you are. But if you are six months or more after surgery, the result you see is likely stable. The degree of surgically-induced ‘lipoatrophy’ that you see could be worsened with additional weight loss or further facial fat loss with progressive aging. Whether this occurs or not depends on your facial type.

2)  Synthetic injectable fillers is certainly a simple albeit a short-term fix. I would not rule out injectable fat grafting. Its volume retention results may be unpredictable but the cheek  is one of the best areas on the face for fat transplant survival. Other options include submalar implants placed intraorally and even dermal-fat grafts placed through a limited facelift incision.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am very excited about my upcoming breast augmentation procedure. I am sending you some photos of the breasts in which I DO like and some in which I DONT~ let me know your thoughts when you get the chance. I want a round high full look but I don’t want the implants to go too far to the sides and I don’t ant a big gap between my breasts.

A: As I mentioned during our consult and as a general breast augmentation comment, breast implants mainly accentuate or magnify the exiting anatomy (positive or negative) of one’s natural breasts. The most perfect breast augmentation results typically occur in those women who have good breast anatomy  to work with, albeit smaller than they want. (good breast skin with the existing mounds high up on the chest, spaced close together and with the nipples centered on the mounds pointed straight forward) You have three ‘negatives’ that must be understood/managed in trying to reach the best result possible, moderate breast sagging, low and outwardly pointing nipples and widely spaced breast mounds.

The spacing between the breast mounds and a high very round upper pole look is purely related to volume and projection of the implant. While we had discussed 375cc high projection silicone  gel implants, your desired pictures suggest that more volume than that would be needed to expand the mound properly. If all we do is use implant volume to mainly expand the upper and inner poles, the nipple position will be driven further down which will not be completely negated by the nipple lifts. Therefore I think a slightly higeher volume like 435cc will be needed. Also although the nipple lifts will help, they will not end up perfectly centered on the mounds without a vertical breast lift…which I would not do in you for scar concerns. Any persistent or undesired low nipple position can be managed by a secondary additional nipplel ift down the road if desired when the tissues have relaxed and more upward movement may again be possible.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am looking for an experienced surgeon to preform gynecomastia surgery. I have hard tissue build up under the nipples caused from weight lifting supplements. I have a muscular body but I am self conscious about taking my shirt off and people staring at my nipples.

A: Supplement-induced gynecomastia is an increasingly common type of gynecomastia that I see. The patient type is very typical having a fairly lean and more athletic type body with the localized development of hard nodules underneath and around the nipples. It is a very glandular-type restricted mainly to under and around the areolas. While it may feel small, it can be quite surprising as to the actual size of the masses when they are removed. (often being 2 to 3X bigger than what they feel like) Because of the firm tissue quality, these areolar gynecomastias are best removed through a lower areolar incision. Peripheral liposuction is rarely needed and direct excision of all hard tissue back to normal soft fatty tissue is done. Drains may or may not be used depending on the size of the excision. A chest compression wrap is important should be worn for up to two weeks after surgery. It would be important to avoid strenuous chest exercises/lifting for 3 to 4 weeks after surgery to prevent a fluid build-up which can convert to scar tissue creating a partial return of a mass effect.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had silicone 4.5mm Malar implants place 9 years ago. I have never been happy with the implant look after placement due to their large size but have been scared of the unpredictable result if they were removed. (i.e. facial sagging) Unfortunately I developed an infection due to a facial injury and need them removed. I am wondering if you could tell me if preforming a soft tissue suspension typically works in these circumstances and how long (days/weeks) does a soft tissue suspension takes to “set” per say. Also is there anything that can be worn on the outside of the face to help hold the tissie up while its healing ie tape or a surgical mask? Thank you for your time answering my questions.

A: Because a cheek implant (actually any implant in the body) creates a circumferential capsular lining which is very smooth and avascular, implant removal leaves two sides of the smooth capsule to collapse together. Because of the soft tissue expansion caused by the implant and the fact the cheek bone is like a rock ledge on the side of a cliff, removal of the implants has the definite potential for the outer cheek tissue to slide down off the cheekbone as the smooth surfaces of the capsule will not stick together, resulting in post-implant removal cheek sagging. Whether this is a significant risk for any cheek implant removal patient depends on numerous factors such as the size of the original implant, the prominence/angle of the cheekbone and the existing quality and looseness of the overlying cheek soft tissues.

To prevent or manage the risk of cheek sagging after implant removal, there are various strategies. One intraoral approach is to either suture the two sides of the implant capsule together with some permanent sutures (sliding the outer cheek tissue up as high on the bone as possible) or to replace the implant with the Endotine cheek lift device to provide uplifting support. Extraoral or external strategies can be done with either a transcutaneous lower eyelid approach to cheek soft tissue suspension or en endoscopic temporal or scalp approach to elevating the cheek tissues. Which approach is based would be based on the degree of cheek soft tissue sagging a patient has. If it is a pure preventative approach then use either of the intraoral technques. If cheek sagging is evident even with cheek implants in place, then an external approach would produce a better result with cheek implant removal.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I am 26 years old and have a really flat area at the back of my head. I am very self-conscious about this since I was 18.I want to kill myself to get rid of this pain. You would be my last hope. Please let me know if there is any way that I can fix this for a cosmetic purpose. Can something be implanted at the back of my head? I have attached a picture with my hair wet so you can see what is bothering me.

A: Having a flat back of the head is an aesthetic issue, not a problem that causes pain. While skull expansion can be done, I would nto expect it to emotional pain about the deformity but not actual physical pain. The key about building up the back of the head (occipital cranioplasty) is knowing the exact location where you want the skull expanded and a realistic assessment of how much expansion can be achieved. The limiting factor in skull expansion is always how much stretching of the scalp skin can be done. To some degree that is partially controlled by how much of a scalp incision a patient is willing to allow to be done. I have done some initial estimation of a result (attached imaging) although I am not clear where you see the need for the exact location of the correction of the flat back of the head. This imaging is just an initiation for further discussion about what you want to achieve.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 29 year old female that received liposuction in 2009 to the outer and inner thigh area because of stubborn fat that was left after a weight loss.. Immediately afterwards I had “banana rolls” or a double butt line that has gotten worse throughout the years. Plastic surgeons in my area said I would most likely need an incision to fix the problem but did not feel comfortable performing that sort of procedure. This deformity has prevented me from feeling confident. No matter how much I exercise the line stays the same. I cannot wear shorts, or a bikini bottom for that matter, and even jeans don’t fit properly anymore. I hide my backside from my boyfriend constantly. Your website gave me hope that the problem could one day be fixed. This would give me back the confidence I once did. Thank you for your time.

A: There is a difference between a double butt line and a true banana roll deformity. It is a matter of how much loose skin exists along the infragluteal crease. A banana roll has a skin overhang of varying degrees with an indistinct lower gluteal crease. It can only be treated by a skin excision and tuck, known as a lower buttock lift. A double butt line is a skin indentation, not necessarily a skin excess issue. It could be treated by either skin excision or fat injection, although the skin excision would be more effective. I would like to see a side profile view of your buttock to have a better idea of the buttock profile and the depth of the indentation.

A decision to do a corrective buttock lift is about accepting the aesthetic trade-off of a fine line scar instead of a double butt line. Either one is not perfect and it is just a choice of which one thinks looks better.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in seeing what the jaw angle implants could do, as I feel that I have very little definition of my jawbone (it’s almost just a continuation of my neck). I would especially be interested in seeing what some width (towards the back of my jaw) could do. I would like to have my overall look be feminine and not too harsh. I am really happy with the imaging results for my nose and chin. Would the jaw implants be a continuation of the chin implant or separate? Does it sit directly on the jawbone, or can you feel from touching the face that it’s an “implant”? I’m assuming the results would be permanent as well, and wouldn’t need to be replaced. Thanks so much for your time.

A: Jaw angle implants had width to the back part of the jaw over the masseter muscle area.  The implants sit under the muscle on the bone. Because the tissues are quite thick in this area, it is not possible to really feel jaw angle implants from the outside. Like other facial implants, they are permanent. They are separate implants from that of the chin, unless custom implants are made to create one smooth continuous jawline from one side to the other. (I do not feel you need this approach) The key to jaw angle implants in most females is to not overdo the width. Most women don’t need more than 3 to 5mms width expansion to have improvement but still keep a feminine facial appearance.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m a 21 year-old female with a frontal bone that is raised higher than the parietal bone in my skull which appears to be flat. I’ve developed really bad anxiety over the issue and refuse to wear my hair in any other hairstyle than a bun on top of my head to conceal my odd head shape. I have also developed really intense habits over the years which include examining my head side on in mirrors up to twenty times a day, taking photos of my head regularly, and constantly touching my head and I really wish to be rid of this paranoia and live my life without worrying about what my head looks like. I’ve considered looking in to getting some form of implant inserted over the parietal bone on my skull to raise it higher than the front region and I was wondering how much this procedure would cost, what risks are involved with this procedure, and what materials are used as a form of implant and do they pose a risk of rupturing? Thank you in advance for your help, I really appreciate it.

A: Skull augmentation of the parietal/occipital bone can be easily done. Please send me a few of the pictures you have taken so I can see exactly the area and how much augmentation needs to be done.  This is skull augmentation surgery done with materials like PMMA and hydroxypatite bone cement that are placed and molded on top of the deficient bone area. These materials are solid and will never rupture or become displaced. It is actually a very straightforward procedure and it is just a matter of getting the right volume in the right area to create the desired effect. It does require a incision somewhere on the scalp to achieve it but for women with good hair density this is never a scar problem. It is done as an outpatient procedure under general anesthesia. The recovery is very quick and you would be fully functional in just a few days.

Once i receive the photos so I can assess the problem, then we can provide a cost for the skull augmentation procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want more angularity to my face. I want high cheekbones, a stronger jaw, an enhanced chin, and possibly removing fat from around my mouth. Do you this will give me what I want? I have attached pictures so you can show me what this may look like after.

A:I have done some imaging on the photos you have sent. Your photos are not the best quality for imaging (poor resolution, fuzzy) but I think they will illustrate the point.

To improve your facial shape, I believe you have correctly identified the structures to consider changing. Your face is somewhat vertically short and lacks keys points of angular definition. From a chin standpoint, you need vertical lengthening as well as increased horizontal projection. Unless one uses a custom implant, the chin can only be lengthened by a sliding genioplasty, it can be brought forward at the same time. I am estimating that you need 7mms of vertical lengthening and up to 9mms of horizontal projection increase. You may also benefit from jaw angle augmentation but your pictures are not good enough to do useful imaging for that evaluation. You would also benefit my higher cheekbones using implants and some perioral liposuction to remove some fat around your mouth area. I Have attached some imaging of these potential results, keeping in mind the limited nature of the quality of the original photographs.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, the question is that I have a flat head. I mean the back of my head is very flat and it really bothers me so that I can’t have short hair. I look very funny or deformed if my hair is too short, what can I do about it? I went through your webside and saw a lot of people had the same problem and you answered their questions. But one thing if i do the surgery I dont care about the scar, but will the surgery effect my hair growth?

A: Skull reshaping surgery and the use of scalp or coronal incisions will not affect your hair growth. The scalp is incredibly thick, around 1.5 to 2 cms for many people. The hair follicles reside in the upper 5 – 7mms of the dermis of the skin and protrude just below it into the subcutaneous fat. They are easy to see and it is important in surgical technique to avoid injuring them. (no use of cautery in making the incision, meticulous skin closure)The point being is that there is a low of tissue between the bone work and where the hair follicles live. The only issue of any potential hair loss is right around the incision not anywhere elese.The issue, therefore, for any patient is acceptance of a scar from the incision not one of hair growth.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  my first pregnancy was one very big baby for my little body. My stomach was completely stretched out like a big balloon. It got so big at the top of my stomach that it fractured the end of my sternum. It now sticks out and I am told it is called the xiphoid bone. Whatever it is called it now sticks out a little but but what is really bothersome is tht it moves around. and hurts when I stretch too much or bend over. I want to get a tummy tuck and was wondering if this could be fixed at the same time. However while researching the topic I couldn’t find anywhere that the two can be done together. You seem to be very creative and innovative so I was wondering if you could repair/remove it while performing a tummy tuck?

A: Fracturing of the xiphoid process from a large pregnancy is not a common problem but it certainly can happen. The xiphoid process is a small stick of bone that is attached to the end of the sternum which can become outwardly fractured with a consistent mass effect from below. Just because you did not find a simultaneous xiphoid process excision and tummy tuck on the internet does not mean that it is not done and I am certain many plastic surgeons have done them. It is easily done during a tummy tuck because at the upper end of the rectus fascial plication (muscle repair) sits the end of the sternum. So removal of the loose xiphoid process is easily done as it is right there. This does not lengthen the recovery or cause any prolonged pain after a tummy tuck.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  my jaw is small, not much of a jaw line, and have a slight receding chin. Wondering if an implant could achieve a balanced/symmetrical look or if I should pursue Orthognathic Surgery. Interested in Rhinoplasty as well. How long would recovery time be? Would the implant be permanent?

A:In looking at your pictures, I see no evidence/reason to pursue orthognathic surgery. Such jaw surgery is only done when there is a major occlusal (bite) problem which I suspect you do not have. Your facial balance could be improved by chin implant augmentation only. Chin implants are permanent and will never need to be replaced. I have done some imaging of that result which is best seen in side profile. You may also benefit from jaw angle implants for increased lower facial width. But I will await your response to what a chin implant alone does for your jawline. From a nose standpoint, your tip and nostril area is larger the rest of your nose. (out of balance) A rhinoplasty that focuses on narrows the tip cartilages and nostrils with a slight dorsal reduction would make a better balanced nose. I have done some imaging of that potential result which is best seen in a front view.

I would anticipate that recovery, from a return to work and not obviously looking like you have had surgery, would be 7 to 10 days. It would take the final shape and form of the nose and chin up to 3 months after surgery to have subtle changes in swelling to resolve and to see the true final result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, when using diced cartilage graft for nose augmentation do you overgraft to compensate for potential resorption?  Did you use a columellar strut on your nasal augmentations and do you do anything for wide and flared nostrils? In some rib graft rhinoplasty results, the nose looks pinched. I have read that some doctors place two extra grafts on each side of  the nose giving the frontal view a very nice look to it. What are these grafts and how are they done? While I love the idea of diced cartilage mainly because there is less chance of warping, I am concerned that there would not be enough build up to achieve the height that I desire with this. In addition, my rib graft rhinoplasties that I see have a tip that is bulbous and not sharp. I would like a much pointier and defined tip. I feel like this is one of the biggest flaws I keep seeing over and over in the before and after results that I have seen on asian ethnicity patients. It seems as if the surgeons augmented the bridge and completely forgot the tip.

A: In answer to your questions:

1) In looking/suspecting the degree of augmentation that you want from your rhinoplasty, I would ‘overgraft’ as much as possible. The limiting factor in any augmentation rhinoplasty is what the skin will accomodate (how much can it be stretched) and how much recoil (deformational elastic limit) the skin will do. The thicker the skin, the greater the elastic recoil will be. (push back) This is what leads to resorption of cartilage more than any other factor.

2) Columellar struts are used in every augmentation rhinoplasty. The length of the columellar strut and its stiffness (thickness) depends on how much nasal tip lengthening is needed. Most non-Caucasian rhinoplasties need and get nostril narrowing as part of their rhinoplasty.

3) There is no question that whole rib grafts are going to give more of a push on the skin and resist recoil than any diced cartilage graft. Given the result you are showing, a whole rib graft would need to be used as that is pushing it to the limits of what the skin can tolerate. What you are referring to as ‘side grafts’ are known as lower alar rim grafts, sometimes called batten grafts. (although this is not technically correct) They are placed obliquely to the rib graft at the nasal tip. This adds expansion/fullness to the lower alar cartilages so that when the tip gets significcantly elevated, it is not like a tent pole sticking out of the top of the tent. (pinched look)

4) What you are seeing in the tip is more often a conservative approach to tip projection/stress, rather than ignoring the refinement of the tip area. You have to remember that when you significantly push the tip up in an open rhinoplasty, the tip skin over the graft has very little blood supply. There is a real risk of tip skin necrosis after surgery, a disastrous event in rhinoplasty. There are well documented cases of it happening and I have seen it with a bone graft many years ago. In your type of nose, the columella is very short. Once you push up the tip area with rib grafting, the open rhinoplasty incision must be closed. If the rib graft is too high, one can not close the columellar incision. Pulling the tip skin down pushes the partially devascularized nasal tip skin tight over the graft. This is where the risk of tip skin death is and the blood supply may get cut off. This is an important issue to recognize during surgery as a sharp point on the end of the rib graft, if the skin is too tight, will cause this problem to occur. It is far better to have a more rounded end of the rib graft and not too tight of columellar skin closure over it to avoid this nightmare of a problem. This is the likely biologic explanation for some of the nasal tip results you are seeing.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have found your website to be very helpful.  I was wondering if I could please make an inquiry on an important personal matter. My son is now 5 years old. He had a laceration in his scalp when he was 3, and the stitches were made by an emergency room doctor (not plastic surgeon). Attached please find several pictures of my son’s scar. Would a scar revision or hair transplant be viable options for us to consider for him? Any thoughts which you may have would be truly valued and appreciated!

A:  Your question about scars is the scalp is a common one. What makes scalp scars noticeable is the lack of any hair. Even slight scar widening in the scalp is noticeable because of the lack of hair. The question then becomes how best to get the scar area covered with hair. While hair transplants would seem like a logical approach, they are a secondary choice for most scalp scars. Hair transplants take very poorly into scar tissue so their success rate is very low. In extremely small scars, a strip hair transplant rather than single follicular units would be more successful because the poorly vascularized scar tissue is being removed. But the far simpler approach is to recruit normal scalp and hair tissue from around the scar. In other words, scar excision and scalp advancement and closure. The scalp can be mobilized significantly and most linear scalp scars should be approached in this way. Your son’s scar is a good example of where scar revision by excision would work well.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 37 years old and although I still have a fairly young looking face, I am beginning to develop a few bothersome issues. I am beginning to get some marionette lines and the very beginnings of jowling. I have tried some injectable fillers to improve these issues and all they did was make my face look bottom heavy. I have read about mini-facelifts and jowl lifts which sound like more of what I need given the problem. What are the advantages/disadvantages of having this type of facelift at my age? I prefer to take a preventative approach and address issues before they become too big. But will starting early make me look unnatural?

A:  While the concept of a facelift historically seems inconceivable at your age, today’s facelifts are not your mother’s facelifts so to speak. Contemporary facial rejuvenation procedures, and facelifts in particular, are tailored to the magnitude of the problem rather than a standard cookie cutter approach. In essence, small early aging problems merit a more limited facelift, more advanced aging issues need a more complete and extensive facelift approach. Although you are young, appearance and need are more important criteria than a chronological number. There are numerous advantages to early intervention…everything is smaller from the scope of the surgery to recovery to cost. Early facelifts actually create a more natural look because the changes are less dramatic than when a facelift is done at an older age.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, what is the best way to correct skin discoloration above upper lip and to fix lines?

A: Both hyperpigmentation and vertical wrinkles line of the upper lip are challenging problems. There is no ‘one best way’ or one single method that will work for every women afflicted with these lip concerns.

Upper lip hyperpigmentation is common and it is important to be aware any known causes of it such as birth control pills and pregnancy. Topical bleaching creams, chemical peels and pulsed light therapies (BBL) are the most common methods we use. In many cases we have to try or use several of them to get a lightening effect.

Upper lip wrinkles can be by injectable fillers and fractional laser resurfacing. Injectable fillers is best for those that are present right at the vermilion-cutaneous (pink of lip with skin) border. Laser resurfacing is better for lip lines that go well above the vermilion-cutaneous border into the lip skin. In some cases, both methods can be used for lip augmentation and wrinkle reduction. It is best not to think of ‘fixing’ the lip lines since there is no permanent cure for them. They can be treated and reduced but never gotten rid of forever with any treatment. They are caused by the sphincteric action of the lips and, unless one is not planning to move their mouth again, they will eventually reform.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I researched and read many articles and visited many websites before I had my Bullhorn procedure performed. Unfortunately, I don’t believe my plastic surgeon had much experience with the procedure. At first he removed an eliptical piece of skin inside the nostril (“italian lip lift”) which did nothing to decrease the distance nor pout the lip. (my mouth is tiny, lips were thin and philtrum long)  Next about 5 months later, he did the bullhorn… he did not ever carefully review my anatomy, measure any important distances, nor did he take enough tissue… again, no improvement. Then, 4 months later (late August 2012) he performed the Bullhorn again and I had to inform him that the normal distance between the base and vermillion should be 5-7mm.. my result: right side of my lip droops… on the left the sutures were placed within the nostril, on the left they were not. also, i do not know what he did with the muscle.. I’ll have to get my op report. I know stiffness is expected, but what I don’t know is if I can smile at all. When I do, my smile seems to be distorted a bit.. but I know it’s early. I feel stitches deep and I don’t want to pull them. I would appreciate your feedback, I think I need a second post op opinion, but most doctors don’t want to become involved especially so soon after surgery. However, I am concerned because I also had a facelift with this doctor and I believe it was overcorrected.. can’t move my upper cheeks and have constant swelling and pain around my eyes. Very weird, almost like I can not squint!

A: It is hard to make much of a usual comment when I don’t have pictures to review. Nor do I know exactly what was done during your last procedure in which the more conventional lip lift or bullhorn procedure was performed. The aesthetic result would not be my main concern right now, I would be more focused on the lip tightness and the difficulty with smiling. These are not usual postoperative findings even in the early stage. I have seen too many upper lip lifts where deep sutures were placed into the muscle or even down at the bone level…which is a mistake and should be corrected early before too much scar tissue forms.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I’ve had two procedures done 20 yrs ago. I don’t know the name of the procedure but I had a large amount of gums showing when I used to smile. They cut my upper jaw and raised it up, so I didn’t have the “gummy” smile. I then had my chin moved forward 11mm. I believe I have some underlying scar tissue from my upper jaw surgery underneath my cheeks. When I smile, my cheeks stand out and my face looks disproportionate. Can this be improved? Also my chin is still somewhat horizontally short. Can it be moved further forward again?

A: Your original surgery was a LeFort I or maxillary impaction to shorten the upper jaw and a sliding genioplasty to move the chin forward. The fullness that you have/feel in your cheeks is not really scar tissue per se. It is due to the release of the facial tissues made during the vestibular incision for your maxillary osteotomy. This causes some of the tissues and their muscular attachments to retract out to the sides into the cheeks, creating increased cheek fullness and what I call a ‘LeFort Look’ which is classic. This has long been recognized and is why at the completion of the maxillary bone surgery the vestibular incision is closed in a V-Y fashion to restore the midfacial tissues position. At this point in time after surgery, these tissues can not be respositioned. It may be possible to remove some of the buccal fat pad to reduce this fullness.

From a chin standpoint, osseous genioplasties or chin osteotomes can be repeated. The only complicating factor could be the fixation hardware used to secure the bone from the original surgery. Whether it was wires or plates and screws, these devices often get covered by bone healing and can be difficult to remove, hence blocking a good bone cut. Depending upon the indwelling hardware, it may be preferable to consider an implant rather than a repeat osteotomy. Whether chin implant or osteotomy should now be done can be determined by a simple x-ray, like a panorex, so the type of hardware in place can be seen.

Dr. Barry Eppley
Indianapolis, Indiana