Your Questions

Q: Dr. Eppley, I’m unhappy with my asymmetric face and would like to have a nose job and chin implant to correct it. Would it be possible to correct it with standard Medpor chin implants? Which chin implant it would suit to me better to correct it and can I get a view how would I look after these changes to my face.

A: Thank you for your inquiry and sending your pictures. I have done some imaging on your nose and chin. Your rhinoplasty is straightforward, meaning that tip shortening with narrowing and a little lift and dorsal line straightening with narrowing of the upper nose with osteotomies would be done. Your chin is severely short and I could argue that an implant is not the best choice given the limits of how much horizontal advancement can be obtained with off-the-shelf implants. (only up to 10mms) But I have imaged what I think the most that a chin implant can achieve. When it comes to chin implant type, there are advantages and disadvantages to either silicone or Medpor materials. While some surgeons and patients get focused on their theoretical biological differences, I have never found them to be distinctly different in that way. I am more interested in what styles and sizes of chin implants the various manufacturers offer. In your case, I would likely choose a two-piece square chin Medpor implant of 11mms horizontal projection.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I want a fuller butt to compliment the rest of my body. I don’t have any pictures at this time but I’m a black female with what they call a flat butt that doesn’t go with the rest of my body. What are my options for getting a bigger butt?

A: Buttock augmentation can be done by two techniques; implants and fat injections. Each as their own advantages and disadvantages. By far the most common buttock enlargement method today is fat injections also known as the Brazilian Butt Lift. Fat injections offer the advantages of simultaneous body contouring from the liposuction fat harvest and a natural method of enlargement that has a fairly quick recovery. It’s one disadvantage is that there is no predicting how much of the fat will survive. As a general rule, fat injections can produce only a modest enlargement in buttock size. Synthetic implants have the advantage of a permanent method of buttock enlargement that can produce a larger result that is maintained. Its disadvantage is that it requires a small intergluteal scar and has a longer and more difficult recovery.

While many patients can choose between implant or fat injections, some will have no choice but to have implants. If one has little or inadequate donor fat to harvest, then fat injections can not be performed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have some questions about the lateral commissuroplasty procedure. Could a corner lip lift be done in a manner which would not shorten the upper lip or “plumpen” the lips (these things are mentioned as coming along with a corner lip lift but I would rather not have them as I think they would be top feminine). I also realized you do brow shaping. My eyebrows arch out on the ends and I would rather them lay straight across (or at least close to that). Could this be done? Finally, could all these procedures be done in one session?

A: You appear to have some misconceptions about the corner of the mouth lift. It does not affect lip size or shorten lip length. Whether a corner of the  mouth procedure is done to lift up the corner or to widen horizontal lip length, there is no change in the rest of the lip shape or size.

From a brow bone shape standpoint, it sounds by your description that you have too much lateral brow bone protrusion. That can easily be reduced through an upper eyelid incision by burring down the side of the brow area that does not have the frontal sinus lying underneath it.

Both the corner of the mouth and brow bone procedures could be done at the same time. Combined it would be a two hour procedure done on an outpatient basis.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in implants to correct my jaw asymmetry. My jaw angles are very asymmetric and I feel I would be more attractive if my facial asymmetry was corrected. I have always been curious about art with respect to beauty.  What is beauty?  I’ve concluded that beauty is not only in the eye of the beholder but also in the symmetry of the viewed.  When you see a symmetric butterfly, it looks beautiful.  When you see the symmetry of a supermodel, it is beauty.  So this is something that I have become aware of over the years… and others have as well.  In fact, there is now an iPhone app that can rate your attractiveness by measuring your symmetry…  and guess what actor ranks the highest…  It’s Brad Pitt.  His left side of his face is exactly like his right side.

I have read your comment about not being able to reach a perfect match on anyone’s facial asymmetry, but instead improving on it.  I like that realistic goal.  I personally would be highly satisfied if I used a string that was measured and cut to reach from the corner of my left outer eye to the corner of my left corner back jaw (mandibular ramus) and have that string reach the same distance on the right side of my face as well.  It currently does not match.  But if it did, I would be a happy man.  And I also understand that even if I had this result, the symmetry would not be perfect since the position of the corner jaws may be different in the 3-D x-y-z coordinate system.

A: While I have found that perfect symmetry can be difficult to achieve in facial surgery, that does not mean it is not the goal. There are different methods in trying to achieve that symmetry regardless of the location of the implants. Traditional, and still the most commonly done, method of facial implant surgery is to pick out the implants based on a more or less artistic assessment of the patient’s needs. There is no precise method of matching the implants to the underlying bone shape or knowing exactly what the outward changes will be. As unscientific as that is, it works most of the time when the patient’s facial bones are symmetric and the patient isn’t overly detailed or looking for perfection. When it comes to improving facial asymmetry, however, it is easy to see how an unexact science applied to a variable problem is prone to some degree of a persistent level of asymmetry.

To counter these issues, an ideal approach is to make custom implants off of a 3-D model. When this is economically feasible, it is easy to see why this is better than ‘eyeballing’ it.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, The right side of my skull is caved in and bulging therefore causing an asymmetrical appearance on my facial profile. From my right temple area, the skull leans towards the right, almost appearing to sag to the right side of my head. I wish to straighten that side so that both sides of my skull are structured straight up and are symmetrical. The pictures limit how much you can actually see, I believe an x-ray would do justice to my explanation. The problem is it bulges outwards. Whether it is muscle atrophy or bone, the cause was due to the way I would lay down on my side at 12 years old. The palm of my right hand would be pressed into my skull pushing the temple muscles upwards or inwards causing the deformed bulge. I basically used to use my right hand as a pillow, so my whole right face was subjected to being pressed into causing the disfigurement. It wasn’t the best way for me to lay but it was the most comfortable at the time. I put a lot of strain on my neck area, as my head and palm pressed into each other. Months afterwards, I noticed pain in my neck. Whenever I moved my right arm in a punching motion, I would feel a shock of pain surge through my neck causing me to yell out in pain. Migraines followed for sometime then stopped. My jaw was affected as well since my palm would push into it while my head rested on it. I can see a noticeable difference when I look at the right side of my maxilla and the left, the right is pushed in, so the top right row of teeth slant inwards. In response, it changed the alignment of my whole top row teeth in that it slants to the right. This is something I can see when I open my mouth, and using my tongue can feel the change including when I bite down on things. Then there’s the problem with my right nostril. It feels like it’s always stocked up in that whenever I sleep it tightens up so that I barely breath out of that side of my nostril. Also, whenever I’m in a warm environment, it closes and I’m forced to breath out of one nostril. I believe I damaged that area as well by applying pressure and somehow pressing inwards into the right side of my maxilla/nostril. It’s not congestion. So, here I hope is a general outlay of my problem and the problems along side it. I honestly believe an x-ray is much needed because a visual will better explain what words fail to. I can feel it and I’ve lived with the changes and a thorough scan of my head and neck will show you what I’m talking about.

A: You are correct in that the pictures don’t do justice to the skull/facial problems as you have described it. It would be highly unusual to reshape bone by any form of external pressure beyond the first few years of life but it is possible. That issue aside, I would agree that the best way to determine of your skull and facial issues are from bone or soft tissue deformity is to get an x-ray study. I can make those orders to any facility in your geographic location. The question is what type of x-rays would be best. The best type of x-ray to get is a 3-D CT scan of your craniofacial skeleton. That would provide an absolutely clear view of your skull and facial shape. In an ideal world, we would even get a model made from these x-rays which could even be used in treatment planning/designing the surgery. But from a cost standpoint, the bare minimum x-ray study you should get is a plain skull and facial series.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  You have a great website and blog! I especially enjoyed reading about the mandibular angle implant procedures that you’ve done and your sensitivity to avoid asymmetrical results. My biggest concern is to correct my asymmetrical jaw.  The left vertical side extends to cause the horizontal jaw line to extend about a 1/2 an inch lower than the right.  This may not seem like much but it is enough to slightly make the left side of my nose droop down in an asymmetrical way.  What I wish I could have done is the right side of jaw lowered to match left perfectly and to do this with mandibular angle implants that would be about a 1/2 inch longer (vertical) on the right than the left. This would give me a symmetrical yet stronger jaw.

A: To lengthen the vertical height of the mandibular ramus, a vertical lengthening jaw angle implant needs to be used. This is one of the two types of off-the-shelf preformed jaw angle implants that are commercially available. It is the more difficult of the two types of jaw angle implants to place because a portion of it must go below the existing lower bone border of the jaw.
When it comes to correcting jaw angle asymmetry, I would avoid the use of the term ‘perfect match’ as I can tell you that is unlikely to occur. A realistic goal is improvement in the symmetry of the jaw angles. Perfect symmetry may happen but less asymmetry is a more likely outcome. Jaw angle implants are the most difficult of all facial implants to place.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley,  I came across your site, and was looking through the breast augmentation surgery, the results look really great. I’m a transsexual, I do have some breasts after being on hormones for about 4 years, and I was wondering would it to be too hard to do breast implants to someone who doesn’t have a whole lot of breasts?

A: If you look at a lot of breast augmentation results, it will become apparent when seeing before photos that many patients have little to no breast tissue. In fact, many of the best breast augmentation results come from those that have little breast tissue and nice taut skin. In such patients the resultant breast mound from implant placement attains a nice round shape.  As long as the implant size chosen is not too big, the breast shape will not look unnatural.

In short, it is not difficult to place breast implants when there is little breast tissue present. This is what is commonly seen in many patients. The partial elevation of the pectoralis muscle with the overlying skin provides adequate space for almost any breast implant size. The limits of breast implant size is the base diameter of the chest/breast. As a general rule, it is good practice to match that diameter with the base diameter of the implant in each patient.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have been interested in maybe some breast implants with a lift, but also a tummy tuck. I am 46, with three c-sections and have had laparoscopies and I have a tendency to keloid.  For many years, my belly button has developed keloids, and my Ob/Gyn would attempt to remove them permanently, this last time (2-3 years ago), gave me a “mini” tummy tuck during the revision surgery and all was paid for by insurance.  The keloids came back, it frequently smells and oozes, and of course, is painful to the touch underneath all the bumpy skin.  Do you think I could have this corrected and have some of it covered by insurance due to the ongoing medical issue of infection?

A: Without seeing some pictures of yoru abdominal concerns, I can not give a definite answer as to what may be the best treatment. But as a general concept about scars, tummy tucks and insurance, I can say that this is not a likely scenario to get it covered by insurance. It is understandable why you would think they should, and they may provide coverage for excision of the hypertrophic/keloid scars on their own, but it is not reasonable or ethical practice to expect to get some form of a tummy tuck as part of it. The tummy tuck is a cosmetic procedure and is not instrumental in solving the scar issues.The insurance industry views such physician behavior with one word…fraud. So this is not a practice that board-certified and reputable plastic surgeons would endorse or participate in.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am currently going through menopause and I am considering a tummy tuck and I am on hormone replacements. I am having a lot of difficulty loosing the belly weight. Should I wait till menopause is over? Will the weight come back somewhere else as I have read this is what happens?

A: Going through menopause is not a contraindication to tummy tuck surgery. It in no way affects how the surgery is done, the success of the procedure, or your recovery. Its only relevance is how you feel and whether you feel good enough to go through a tummy tuck surgery with the physical and mental challenges that menopause unfairly inflicts on women. As for what happens after a lipo-abdominoplasty procedure (combined tummy tuck and waistline liposuction), there is a common misconception that fat reaccumulates elsewhere known as the fat homeostasis theory. Recent studies have shown that this is not the case and the result can be very stable if your weight does not significantly increase.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like a more toned looking armpit, upper back, and upper arm. I feel that, although I am relatively lean and well proportioned throughout the rest of my body, where my arms attaches to my shoulder and chest is just too thick. I have attached some pictures so you can see what I mean. There is also a glob of fat in my upper breast next to the arm that sticks out in clothes. 

A:What you have is a very common problem, known as axillary breast fat. When combined with some circumferential fat around the upper arm and back, it makes the whole area look undesireably thick and full. Liposuction (technically liposculpture given the small volumes and discrete areas) of the axillary breast (upper lateral breast quadrant) and front and back of arms (extending into the upper back) would be a good approach to help contour this area and create a more sculpted look of the upper arm/chest area. That could be performed as an outpatient procedure done under anesthesia to get the best result in the most efficient time period. While there would be some swelling and maybe mild bruising, it would not be much of a prolonged recovery. It could be done late in the week, for example, and you could be back to work by Monday or Tuesday. (albeit with sore upper arms) Be aware that the final result from such a procedure would take a minimum of six weeks to become fully evident.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, there is an overall lack of definition to my face (flat cheeks and very prominent and long chin) which you will notice here.  It’s my belief that with some cheek contouring and possibly jaw as well, I may look as beautiful as I feel.  When I smile and when the lighting is even I have a much more appealing appearance as it seems to round out my face if you know what I mean. When I’m not smiling and when the light is harsh (as it usually is unless one is in a photography studi0 and manipulating light!) I feel like my face is a sliver- very long with nothing to break it up or draw the eye up.  I look forward to hearing what you think!

A: In looking carefully at your facial features, there are three areas that could be altered to help make the transition from a long flatter face to one with better proportion and angularity. As you have mentioned, your cheeks/infraorbital areas are flat, your chin is long and slightly retruded and your nose is slightly prominent and a little deviated. Changing all three would make the greatest change but I just want to focus on your cheeks and chin for now. Cheek implants with anterolateral augmentation and a chin osteotomy that vertically shortens the chin and brings it forward is the best way to help vertically shorten your face and ‘pull’ it outward. I have demonstrated that on the attached imaging pictures in the side and front views. I think a reductive rhinoplasty would also be very helpful to shorten and deproject the nose, which would make the midface look more full, but the pictures you have sent are not of good enough quality to do the rhinoplasty imaging justice. But these initial images will give you some good material to think about.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was just wondering do you do liposuction on teenagers? If so, will you guys take payments or do I have to pay it all at once??

A: Liposuction can be performed on many body areas regardless of patient age. Any cosmetic surgery, including liposuction, can be done under the age if 18 if one has parental consent. Teenage plastic surgery requires the blessings from one’s parents or guardians. Like all cosmetic surgery, the fees are all paid up front in advance of the surgery. While many patient do finance through outside companies, such as Care Credit, that is not going to be possible for anyone under age 18 or maybe even under age 21. This is why all teenage cosmetic plastic surgery is authorized and paid for by the parents in every case that I have ever done.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a double chin that I hate. I am only 32 years old but my neck makes me look much older and heavier than I really am. I am interested in a double chin reduction surgery that I have read about. My question is does the double chin reduction grow back after certain time due to weight, age, etc… Thanks!

A: Most double chins are due to a combination of a full neck in the submental area and a weak chin. The upper bump chin is one’s real chin (short) and the lower bump of the bubble is neck fat and skin. Therefore, double chin reduction surgery usually consists of  a combination approach of submental/neck liposuction (reduction) and a chin implant and/or osteotomy (augmentation) to eliminate the double roll. In my experience once this is done it is a long-term sustained result because the anatomy is permanently changed. The short chin bump will never return because it is been permanently brought forward. The neck roll usually stays away unless one gains a lot of weight in the future. This combined approach has a great influence on making the face and neck appear more slim and well-defined. Often when combined with buccal lipectomies (cheek fat removal) the slimming effect can influence the face above the jawline as well.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I am interested in having one ear of my previous otoplasty partially reversed. It is pulled back too far and needs to come out 4 or 5mms so the helical rim is seen again. I have a few questions about the specifics of the operation.

1) Could it be performed under local anesthetic?

2) Roughly what size would the cartilage graft be?

3) Does the graft become knitted in place by new scarring or remain somewhat movable under the skin?

4 Should I expect lumps from the cartilage/scars to be visible following healing?

5) Have you performed the operation before and if so, what success rate have you had?

Thank you for your time.

A:  In answer to your questions:

1) The procedure can be performed under local anesthesia given that it is one ear and fairly limited in scope.

2) The cartilage graft needs to fit in between the released folds and generally is no bigger than 10mm x 5mms.

3) The graft is sewn in and heals to the other cartilages so it is not moveable.

4) The graft fits between the folds of the cartilage on the back of the ear so it can not be seen or felt from the front. You may or may not be able to feel it from behind the ear.

5) I have performed this ‘reverse otoplasty’ several times successfully. There is nothing new or magical about this procedure. It is a technique borrowed from my days when I regularly performed microtia reconstructions, the most complex form of external ear surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in having the upper and lower lip advancement like the woman featured on your site who found that fillers did not make her lips large enough. I have this same problem. I am also interested in the price.

A: In thin lips, injectable fillers often produce unsatisfactory results as there is not enough vermilion (pink part of the lips) to fill. Without enough vermilion, the injectable filler material can only push outward rather than upward as well. This creates an abnormal looking often call ‘ducklips’. If one’s lips are very thin and injectable fillers have failed to produce a good look, the lip advancement procedure is an alternative. By physically moving the vermilion border up (upper lip ) or down (lower lip), the size of the lips is increased. Usually lip advgancements are done as an office procedure under local/oral sedation. The cost is $2,00 0 per lip or $3,500 for both lips. Because they permanently change the amount of exposed lip vermilion, they can have a powerful effect on the appearance of lip size. While lip advancements are the most effective procedure for making bigger lips out of thin ones, there are some minor trade-offs. There will be a resultant fine line scar at the junction of the skin and the vermilion which for most patients is barely perceptible. But it is important to know that there will be a residual scar, fine as it may be.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had saline implants placed under the muscle 12 years ago. There were fine until about three years ago when I noticed rippling on the undersides. I am a thin woman being 5’7” tall and weighing 126 lbs. Why has this rippling appeared now years after surgery? Will it get better or is it permanent? Will it get worse? What is the best way to get rid of it?I am very unhappy with the shape, size and asymmetry, along with the rippling, so am leaning towards having them redone anyway.

A: Rippling is common feature of saline breast implants and every women will develop some degree of it unless they had a fair amount of breast tissue initially. It will be felt along the bottom and sides of the implants where there is not a muscular interface underneath between the implant and the skin. While perhaps not noticeable early after surgery, it may appear months to years later as the swelling goes away and the breast tissue thins over time. This rippling issue is particularly relevant in thin women with little breast tissue. This is an important consideration to know before breast augmentation surgery so this is not a surprise when it appears later. The best correction of the rippling problem is an exchange to silicone implants where the amount of rippling is considerably reduced due to the thicker and more congealed silicone gel material. This is one of the advantages of the newer gummy bear breast implants.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have indentations/notching at the sites of my previous mandibular osteotomies. (sagittal split advancements three years ago) I want to get implants to build the bone back out as well as make my jaw angles more prominent. Given the differences between the two sides, I think I will need custom-made implants. How are custom implants made? Do you secure them to the bone somehow so they do not move afterwards? How painful is the procedure?

A: In answer to your questions:

1) Custom are hand-made off of a 3-D model obtained from a CT scan of the patient’s mandible.

2) All facial implants are secured to the bone by screws.

3) Since you have had a prior mandibular osteotomy that is a good reference point point to discuss pain and recovery. Suffice it to say it is less than that process although there are numerous similarities such as the area of facial swelling and the temporary issue of some mouth opening restriction. But if sagittal split osteotomies are a 10 on the scale of pain/swelling etc, jaw angle implants by comparison are a 2 or a 3.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, do you ever do a forehead burring/scalp advance/brow lifts without the sinus setback? I am a woman and my brow bones are not that big so I don’t think I need the frontal sinus setback.

A: Most forehead reductions in women are actually done by burring and not osteotomies/sinus setbacks. That is more of a male procedure in most cases. In women it is common to do a brow bone reduction by burring and/or forehead reshaping with a hairline advancement (scalp advancement) or a browlift. Seeing some photos of you would be helpful in determining which are the desired procedures.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, my daughter is turning 13 next month. She had cleft lip (not palate) and had it repaired when she was 4 months old. She is very self conscious about her appearance. There is a visible scar between the upper lip and nose and a lopsided nose. I want to know about the possibilites to remove the scar and correct her nose asymmetry. Please let me know about the procedure. Thank you very much.

A: Isolated cleft lip always affects more than just the lip. The cleft defect extends to involve the nose in a very classic pattern of lower alar cartilage slumping resulting in an asymmetric tip of the nose with a widened nostril. Even in a well done cleft lip repair, the nose deformity becomes evident as the child grows manifesting itself fully by the teenage years. This always leaves two areas of potential improvement as a young adolescent, the repaired lip scar and the unrepaired nose.

 
Your daughter would undoubtably benefit by a cleft rhinoplasty and lip repair. Without seeing pictures of her I can not say whether she needs a complete septorhinoplasty or an isolated tip rhinoplasty procedure. Most commonly the fuller version of the rhinoplasty is needed with cartilage grafts. As for the lip, it is better to think of further scar reduction and not scar removal. Completely eliminating the cleft lip scar is virtually impossible. Please send me some pictures of her for a more analysis to determine her exact surgical needs.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, How much does a breast augmentation procedure cost? On one site, I read about cohesive gel. What is that? Is it better than silicone or saline implants?

A: The typical cost of breast augmentation varies based on whether one uses saline or breast implants. The cost of a pair of breast implants, which is included in the total fee for the procedure, adds anywhere from $1,000 to $ 2,200 to the composite total fee. Saline breast implants cost less than silicone breast implants because the implants cost less. In general, silicone implants are better than saline because they will last longer, do not develop rippling and the breast will not deflate immediately should the implant develop a hole or a rupture in its shell. These benefits explain why the cost of silicone implants is higher. The term ‘cohesive gel’ is a generic term that really applies to all silicone breast implants today. It means that rather than being a silicone liquid, the silicone is more congealed or is an actual gel. It does not flow like a liquid but acts more like a ‘gummy bear’ candy. This material feature explains why the silicone implant does not deflate should it rupture and why it feels more natural than a bag of water. (saline)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I feel like I have always had a weak chin amd jawline. It makes too feminine and disproportionate to the rest of my face. As a result, I have been considering getting a chin implant. My concern is that I am HIV positive but otherwise healthy. I have been on antiviral meds for the past ten years. Becuase of this medical condition I feel a little bit vain as I don’t want to risk my health and cause a problem with the surgery. What has been your experience with this surgery in HIV patients.

A: The medical evidence is fairly clear on the risks of elective surgery in HIV patients. There are no apparent increased risks or complications from surgery as long as one’s counts/levels are good. As long as you are not immunosuppressed, the outcomes from elective facial surgery are the same as non-HIV patients. I have treated numerous HIV patients with chin augmentation procedures, including implants and osteotomies, and have not seen any problems. Therefore, if this is a procedure that will make you feel better there are no increased medical risks for doing so.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I feel my face is a little weak down around my jawline area. Iwas hoping to have a more masculine jaw with out elongating my face any more… just maybe make it more full. Also as you can see on my photographs, my face is very asymmetrical. My right temple seems sunken in so was researching your page and saw you have a temporal implant, was wondering if I good candidate for the procedure. And last but not least, my nose is also very asymmetrical. If I feel above the nostril I can feel more cartilage on the left side of the nose and my right doesn’t have any. I am open to suggestions please if you can let me know the procedure you believe I will benefit from.

A: From a jawline standpoint, there is a clear chin deficiency but with a slightly long (rotated backwards) chin as well. While an implant can be used and probably not lengthen the chin, the most ideal treatment is an osteoplastic genioplasty where the chin can be brought forward and shortened as well. I have imaged that potential change in the attached profile pictures. In addition, I have also added some small jaw angle implant in the front view to see if widening the posterior jawline is also aesthetically beneficial. 

As for your nose, I can see a slight retraction of the alar rim upward creating nostril asymmetry. That would also account for the differences you feel in the lower alar cartilages in the tip of your nose. This could be improved by the addition of an alar rim/onlay graft to the right side of the tip of the nose.

As for the temple areas, I am having a hard time to seeing the amount of asymmetry between the two sides. This may be a function of the photograph. For temple asymmetry, a small subfascial temporal implant can provide a moderate amount of augmentation to the more depressed side.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I underwent otoplasty done over ten years ago with a pretty good result. But I have felt ever since that the corrections on the ears were too pronounced, particularly on the left which now has a largely hidden helix.  The technique used consisted of some skin removal on the back of the ear, weakening of the cartilage on its anterior surface and absorbable sutures used to create the fold. (from operative note from the procedure) The only scarring discernible to my touch is at the bottom of the antihelix and it is this scarring which seems to act as anchor for the over corrected folds. I have read that once scars have set several months post-op the ears become difficult/impossible to un-correct.  Nonetheless, I am emailing you my details to see whether you think my ears might have some potential for improvement and whether you think you might be able to help me with that improvement. My ears, apart from the scars, feel supple and flexible (perhaps because I’ve got in the habit of massaging them whilst pondering their post surgical shape and potential for improvement). I hope for only a subtle improvement, perhaps only noticeable to me, and would be keen to explore options or ideas which feature the least amount of invasiveness and slicing possible.

A:  You are correct in your assumption that ears that have undergone otoplasty surgery are difficult to undo, meaning to bring the ear back out. This is due to the long-established fold in the cartilage and the scar surrounding it. While it is difficult that does not mean that it is impossible. Since your goal is a ‘subtle one, perhaps a few millimeters, to bring the helix out from behind the antihelical margin, there is one approach that can be effective. Releasing the scar between the folds, scoring the cartilage and the placement of a small cross-beam cartilage graft (harvested from the concha right below the release) between the folds can bring the helix back out a little bit. This sounds complicated but it is not and can be done through just a portion of your old post-auricular incision.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley,  I have suffered a jaw angle deformity since I had jaw surgery two years ago. There is a big notch along the border of my lower jaw in front of the jaw angles. I think jaw angle implants would make a massive difference. It is something that’s high on my list to do providing I can find someone who will do a good job and providing there isn’t any major risks with my prior surgery. I was thinking fillers as a temporary fix until I can find someone who can perform the surgery as I would much rather have a permanent fix. 

How would you build up the bone? What’s involved in that? 

How does notching come about?  Was that a complication from surgery? Was it something I was born with?

A: Without question, jaw angle implants are the solution to your problem. The only question is what size and shape should they be. Most likely, off-the-shelf inferolateral border jaw angle implants will be satisfactory. Ideally, custom jaw angle implants are the best but that adds some expense to the procedure.

Injectable fillers are fine if you are not planniing to have the surgery anytime in the next six months or so. But if you are then I would not do them so they do not interfere/obscure the surgery.

Notching of the inferior border after sagittal split mandibular osteotomies can occur from a variety of reasons including a non-union, bad osteotomy split, too much rotation of the posterior mandibular segment, inadequate bone fixation, and the shape of one’s natural mandibular ramus anatomy.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a lip lift procedure and I have attached some pictures. I have several questions and concerns about the procedure. Is my columella retracted? Do I have an acute nasalabial angle? I am concerned about visible scarring. I read you use dissolvable sutures for out of town patients. I want to look great for my daughter’s wedding, which is Oct 7 this fall. Can you schedule me soon enough?
I’m in excellent health.

A: In Answers to your questions:

1) Your columella is veryretracted with an acute nasolabial angle.

2) Although most subnasal lip lift scars do very well, scarring is always a risk particularly in patients with pigmented skin. Your retracted nasal base does help with the potential scarring visibility.

3) With less than six weeks before the wedding, I would not advise it to be done that close to an important date. That is about the time a scar, anywhere on the body, will likely be looking its worse long before it has adequately matured. I wouldn’t do this procedure any sooner than three months before an important social event.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I am 21 years old and want to have a better-shaped upper lip. Which  is better for reshaping the cupids bow, a v-y advancement or a lip lift? I have a short distance between nose and my upper lip.

A: There is no question that the best way to reshape or accentuate the cupid’s bow of the upper lip is an external skin excisional procedure. Whether it is a lip lift done from under the nose or a lip advancement done directly at the cupid’s bow area, the closer the tissue excision/movement is done to the cupid’s bow the more likely a significant change can be seen in it. However, both of these procecures will SHORTEN the upper lip which is a problem when one already has a short upper lip. The v-y mucosal advancement procedure is about improving the volume of the vermilion of the upper lip but it will not change the shape of the cupid’s bow area in any appreciable way. I am afraid that in someone with a short upper lip, there are no truly effective procedures for improving the shape of the cupid’s bow area.

One potential option is to do a peak triangular excision at the current peak of your cupid’s bow to give it more of a sharper outline. This will not change the vertical distance from the nose to the upper lip in any appreciable manner.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have had prior jaw surgery which hasn’t gone so well. I was just wondering if you can have jaw angle implants put over a metal plate that was left in my face? I have bone scans which I can send to you to have a look at.

A: I suspect what you are referring to is a jaw angle/inferior border deformity after an orthognathic surgery procedure. I have placed jaw angle implants over metal plates in the mandibular ramus area numerous times. It is not rare to have mandibular ramus notching and bone resorption around healed sagittal split osteotomy sites. This problem may be severe if one developed a non-union or infection after the procedure. These deformities may be able to be improved by implant augmentation. Even though fixation hardware (plates and screws) exist on the outside of the bone and considerable scar tissue will be present, and pocket dissection is not easy, jaw angle  implants can be successfully placed. I shall look forward to reviewing your bone scans and photographs.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am writing you because I had an scar revision and the post surgical treatment was wrong. Now I am desperate and want to know if there is any solution to my problem. I have attached pictures of my before and after surgery condition.

A: In looking at your before and after pictures, I fail to see what you have described as wrong treatment. Your initial scar pictures shows an extremely wide scar, up to 2 cms, that extends from the corner of your mouth down to your jaw angle/neck area. Your postoperative photo shows a much more narrow scar that is in the healing process. In my practice, I would have told you from the beginning that a good result from your type of scar revision would take at least 2 stages (surgeries) and 12 to 18 months to get the final result. You have a horrendously wide scar that runs completely perpendicular to the relaxed skin tension lines of your face. These combined eatures makes your scar revision extremely difficult. The first stage (surgery) would be to just get the scar much more narrow and I would expect some rebound widening afterwards. That appears to be where you are now. You need to let this first stage scar revision heal and then proceed to the second stage (surgery) where further narrowing will be possible and the introduction of some broken line/geometric scar revision techniques used for improved scar camouflage.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am writing to get more information on The Patriot Plastic Surgery Program. I am in the Air Force. I am interested in a possible abdominoplasty as I have had 3 children and my stomach isn’t as tight as I would like. I am in shape and have tried every exercise imaginable with no luck tightening the skin.

A: Your story is a common one that I hear from many women after multiple childbirths. While there is value in doing your best to get to a good weight and be in shape, there is no way to non-surgically remove excess or loose abdominal skin. Skin, unlike fat or muscle, is not a tissue that is responsive to exercise, sweat and weight loss. This is where the value of tummy tuck surgery comes in, doing something that one can’t do by their own efforts. Loose skin must be removed to end up tighter.

The Patriot Plastic Surgery Program is intended to provide cosmetic surgery to military personnel and their families as a courtesy for their service and sacrifices. All types of cosmetic surgery are eligible for the program. The exact fee reduction depends on the procedure(s) involved and is determined after the consultation. Consultations can be done initially by phone or Skype video.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had Gortex implants removed from my upper lip in hopes to be able to smile fully again. It did not relieve the tension on my upper lip so no success. The only thing I can think of that may work is the mouth widening procedure. If we could widen my mouth just a little I think it would release some of the tension from my upper lip. The area above my lip has spread out and widened from the gortex and now scar tissue . It has caused some damage so i’m hoping this procedure will help so there’s no further damage to the area. I have small features so we don’t have to take off too much from the corners. How much does this cost and do you think it will work? I have realistic expectations so if we can only relieve the tension a little it’s ok, anything is better than nothing. Thanks!

A: The mouth widening or lateral commissuroplasty procedure may be effective for your problem IF you feel that the tightness is at the corners of your mouth. This would be most evident when you open your mouth and you feel tension or band where the upper and lower lips meet. This procedure is done in the office under local anesthesia.

Dr. Barry Eppley

Indianapolis, Indiana