Your Questions

Q: Dr. Eppley, l’d like to know of any promotions offered for breast augmentation surgery. My friend and I both would like to have breast implants. I have had four children and at 31 years of age I would like to feel like pretty woman again. We both have A cup breasts and would like a normal, beautiful cup size. Please contact me when possible and thank you for your time.

A: Breast augmentation is one of the few cosmetic surgeries that is often viewed like a  traditional retail product. Because it is commonly done by every plastic surgeon and is a highly sought after procedure, it is one cosmetic procedure for which there are often specials and promotions for it. Most of these promotions are based a certain amount of money off the standard cost if done in a timely manner or whatever the deadline that is provided. You are also asking about what is know as the ‘two-fer’ procedure, discounting based on two people signing up and having the procedure in a timely manner. This is another well known breast augmentation discount approach.

There is no question as to the benefit of breast implants in a woman who has lost all of her breast tissue after having had four children. It can make a world of difference in her self-image and feeling like a total woman again.

Dr. Barry Eppley

Indianapolis, Indian

Q: Dr. Eppley, I am an Asian female with prominent jaw angle. I would like them reduced to be more angular. They are also causing pain to my neck and shoulders. I want to make them more narrow so my neck isn’t as tight.

A: Thank you for your inquiry and sending your pictures. I can clearly see your flared jaw angles which seem not to fit the rest of your face. I have not heard of prominent jaw  angles causing neck discomfort and tightness but you would know best how it feels on you.  The jaw angles are enveloped by the pteryomassteric muscles and not any neck muscles per se so I can not speak for how successful they would be in reducing your neck and shoulder pain. Your jaw angles could be reduced by a sagittal saw reduction technique to narrow them as opposed to a complete transection technique of the entire angle. This is my preferred method which I think gives a better aesthetic result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 37 year old female with microtia of the left ear. I have thought long and hard about pursuing the reconstructive surgery but I have decided not to proceed with it. I think I have become a little more comfortable with the situation just understanding more about the condition and I am also deterred by the uncertainty and expense. I am however interested in any minimally invasive option to improve my facial asymmetry. Are facial implants an option to do so?

A: Thank you for sending your pictures. As I suspected in left hemifacial microsomia, the jaw on your affected side is smaller with no jaw angle present. Surprisingly the rest of your face above the jawline has minimal to no effect in terms of underdevelopment. You are correct in assuming that a jaw angle implant would be helpful. An implant could be placed that builds out the left jaw angle and jawline as it comes forward. This implant would be placed through the mouth and then screwed into the existing jaw bone. There are two ways to go about choosing the jaw angle implant style and shape. The ideal way is to custom make an implant off of your jaw model that would be made from a CT scan. While this is ideal, it adds considerable expense to the cost of the surgery. The other way is to use an off-the-shelf jaw angle implant and modify it during surgery to fit. It would not create as good a result as a custom implant but it would still make good improvement for you.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  two months ago I received surgery which was to rebuild my jaw bone deficiency due to prior jaw reduction surgery. This was done with jaw angle implants placed through the mouth. But I am not satisfied with the result. I have heard of custom made implants? Can I get to my previous appearance by using this method? If it is possible, how much does it cost? And can the Medpor jaw implants with screws be removed?

A: There is no question that custom implants made off of a patient’s mandibular model is the best way to get whatever desired jaw angle shape one wants. Nothing can be more accurate than premaking an implant for the exact defect. Off-the-shelf implants, while successfully providing a new look in many cases, do not work well when one is trying to restore their original anatomy. That is not what they are made for. I have removed/modified many Medpor jaw angle implants, and although they are certainly not easy to remove, it can be successfully done. The sooner they are removed after placement the better but even if in place for years they can still be successfully extracted.

The cost of manufacturing custom implants adds about $3500 in addition to the overall cost of jaw angle implant surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had extensive surgery involving a large number of facial implants and forehead augmentation and back of the head skull reshaping two weeks ago. While I knew there would be a lot of facial swelling, I think much of the swelling is gone now and I am concerned about some of the areas that have been augmented, particularly the forehead and cheeks. Both areas seem too big or prominent although each day they seem a little different. At what time would you consider revisional surgery?

A: With any single facial implant and certainly with multiple implants, you are far from having all swelling gone or are looking at the final result. I set the minimum time of three months before I would pass judgment on the result. This is not only to let all facial swelling resolve but it also takes time to adjust to one’s new look. This is a hard psychological time for patients to go through but it is very important to not rush to judgment on a ‘moving target’. It is good to remember over the next few months, these skull and facial shapes will change, go up and down, one day look good and the next day uncertain, until the final evolution appears months later. This is a lot to endure and watch evolve. How you feel today might be different next week. It also doesn’t help, and is not unfortunately therapeutic, when all you have to see and talk to about these issues is yourself. That is a good way to lose perspective not only on facial surgery in particular but on life in general. One of my tasks as a plastic surgeon for my patients is to not let them lose perspective and make premature decisions and judgments. I can never tell anyone what they should like, but I can guide them as when their surgical results are finalized.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in skull reshaping for a prominent ridge down the center of my head. But I am concerned about the scar that is needed for the surgery. What are your thoughts on the scar and what can be done to make it heal the best?

A: The scalp scar in men for any type of skull or forehead surgery is always an issue to ponder very carefully. Whether it is worth it or not depends on a variety of factors including the magnitude of the deformity and one’s concern/focus on it, hair follicle density and hair style and the location of the scar on one’s scalp. I have done numerous skull reshaping procedures on men who are bald or shave their heads and the scar for them has been worth the trade-off. But I am certain that it was an acceptable aetsthetic trade-off because this very issue was discussed at great length beforehand and they have had plenty of time to make the proper determination for themselves about the scar trade-off. Scalp scars generally heal very well and how well they heal is largely determined by how the incision was made and how carefully it is closed with respect to preserving hair follicles.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 29 years old woman, married, and haven’t any children with a positive family history for  breast cancer in my mother and sister. I had two lesions removed from my left breast (intraductal carcinoma) with clear margins recently. The surgeon suggested for removal both breasts and replacement prosthesis. But there is a limited size of prosthesis in Iran and the plastic surgeon said that my breast size is too small for the smallest  size of  prosthesis that there is in Iran. In your opinion, is there a solution for this problem? How much would this type of surgery cost in your country? Is there any charitable surgery in your country for this type of surgery?

A: It appears that with your family history and recent breast lesion pathology that you would benefit from bilateral prophylactic mastectomies with immediate breast implant reconstruction. I am unclear as to the statement that ‘your current breast size is too small for even the smallest breast implant’. That makes no sense to me nor would I believe that is true. Breast implants come as small as less than 200cc so there is a size of an implant that would fit you. Your solution is a straightforward subcutaneous mastectomy with immediate implant placement. I know of no charitable organization that would provide free care for this standard prophylactic breast cancer surgery for foreign visitors. I would be happy to provide you a fee for what this costs in my center. In the interim, it would also be helpful to see what your current breast status/size is with a few pictures if that is possible.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m contacting you regarding my chin. I have looked at many pictures of mine and my conclusion is that its too long, has too much soft tissue at the bottom, my right bottom tip is lower than the left and I think that maybe the bottom half of my lower jaw is a little too narrow and not symmetrical to the rest of my face. Also I think its too round. I have a big head and strong features and want my chin and jaw to look balanced. I noticed that my chin was too long  and pointy when I was 16 so I want to do something about it because I think it detracts from my looks and that I could look a lot better with it corrected. I would like to know what you think and what you would recommend.

A: Thank you for your inquiry and sending your pictures. Your long chin appears to be largely comprised of excessive soft tissue. There may be a slight bony excess but that clearly is not the major component. The ‘proof’ that the soft tissues are a major element of your chin problem is in how your chin looks between the non-smiling and smiling images. When excessive soft tissues are the problem with chin hypertrophy this requires a submental chin reduction approach. Only from below can the tissues be excised, tucked and closed. A small amount of bone can be burred down as well if needed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My 15 year-old son needs his forehead reconstructed after an injury last year. He lost a portion of his forehead from the fracture and now has a large indentation from his brow up to just under his hairline. Which is better for his reconstruction, a cranial bone graft or a bone cement?

A: From a growth standpoint, his skull/forehead is essentially fully formed so the method of reconstruction is not really important from that standpoint. What counts is how smooth it can be after it heals and will have the least chance of irregularities down the road when all swelling truly subsides. Either a bone cement or bone graft has their own advantages and disadvantages in this regard. A bone cement will give the smoothest contour result by far because it can be molded completely into the defect and smoothly contoured to the surrounding bone edges. While it is a synthetic material, it is made of hydroxyapatite which is the inorganic composition of natural bone so ti is very biocompatible.  While bone grafts are an autogenous material, they are prone to some resorption and hence irregularities down the road. Even though the forehead has thick soft tissue, plate and srew profiles inevitably become evident unless very low profile (< 1mm) devices are used. It is likely that I would do a combination frontal cranioplasty, using bone grafts to obliterate any frontal sinus exposure and bone cement to fill the defect and contour into the surrounding forehead.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m just trying to achieve a more manly look….more of a chiseled face. I feel like I look like a 12 year old when im actually 21. I want a stronger brow…more defined cheeks and finer and stronger nose and chin. I would like to know if this is all possible to do in one sitting? I would also like to know the price. Thanks very much

A: When men want stronger facial features, particularly a more chiseled face, there are two general facial features they are trying to change. Conceptually, it is about accentuating or increasing the convex facial bony prominences and decreasing the intervening soft tissue concavities between these prominences. The facial bony prominences to consider augmenting are the chin, jaw angles, cheeks , nose and brow ridges. The soft tissue concavity to deepen, or at least appear to deepen, is the soft tissue triangle that lies between lines from the cheeks, chin and jaw angles as well as the temporal fosa. It is also important that the neck/submental area be as flat as possible. Not every man can achieve this look and, in general, thinner men with less facial fat are more likely to achieve a more chiseled facial look, sometimes known as the ‘male model look’.

You do have a very desireable face to achieve this more chiseled look because you are young, have a thin face and already have some evident facial prominences albeit weak. I have done some imaging based on an ideal surgical approach to your desired result including brow bone augmentation, rhinoplasty with dorsal line augmentation, tip refinement and nostrail narrowing, and cheek, chin and jaw angle implants. All of this can be done at the same surgery and is common to do so.

While all of these procedures are helpful, I always find that for each male patient some are absolutely essential and others are of secondary importance. I categorize these into primary and secondary procedures based on their benefit because one has to always be vigilant about cost. Your primary benefit procedures are chin augmentation and rhinoplasty. These will provide the most benefit at a lower cost. Cheek and jaw angle implants and brow ridge augmentation provide secondary benefits. Together, all five are ideal but at a minimum the chin and nose need to be changed to help get a more defined facial look.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was thinking if I would be a good candidate for a custom implant? I had a chin implant done two years ago but had it removed six months later because it did not look and appeared unnatural and asymmetric. This time, I want the implant to address the asymmetry of my chin and also add length and width to my jawline while also lengthening my chin. I have attached pictures to try and show you what I’m looking at getting resolved. Also, are custom implants significantly more costly? My left side of the chin is about 3-4 mm shorter than my right side. Also when I feel where my chin transitions to my jawline, there is more of a “dip” in the bone on my left side. I would like a more smoother jawline transitioning to my chin and a more prominent jawline on both sides as well. I have outlined the area of jawline I am referring to and that I would like it both extended horizontally and vertically. I have attached the picture of my previous implant to show the increase in asymmetry that the implant caused. I think the asymmetry caused the implant to not fit snug and was also the reason why I was able to move the implant from side to side even months after.  And finally I have re-attached the ideal chin and jawline. I think what i’m looking to fix would give me the desired look.

A: Based on your pictures and your good illustrations, the only way you would get that chin result is with a custom chin implant. There is no off-the-shelf chin implant that would have those exact dimensions and shape. Why your first chin implant resulted in that undesired look is not known to me because I don’t know what style and size of chin implant it was. It may have been inappropriate for your chin based on a variety of factor6s including style, size and technical placement of the implant.

That being said, there are three ways to go about getting a ‘custom chin implant’. They are different because of how they are done and their cost.

#1.The least expensive way, because it costs no more than a standard implant, is to select a certain chin implant style and size and custom carve it either before and during surgery based on the illustrations you have shown. The limitation is that it is an approximation of the underlying chin anatomy.

#2 The second way is to get a 3-D CT scan and have an exact mandibular model made. From that model, I can then take an off the-shelf implant and then carve it to shape by placing it on the model. This is better than #1 because we would know the exact chin anatomy. The limiting factor is how close existing chin implants are to your needs. Besides the cost of a 3-D CT scan of your mandible (which your insurance will likely cover) is the cost of having the model made. ($ 1100)

#3 The most ideal way to get a custom chin implant is to take the mandibular model and I will then hand-care out a completely custom implant which will then be sent out for formal implant manufacture. The total additional cost of this approach is $3500

As you can see there are multiple ways to get a custom chin implant. But when it comes to having a chin implant that blends smoothly back along the jawline, a true custom chin implant is the only way to get that result in most cases.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a revision of my primary rhinoplasty last summer and don’t like the shape of the nostrils and the tip. I also don’t breathe well from right nostril. Do you think I need grafts from ears or rib??

A: In looking at your frontal picture, I see widely spaced domes on the tip and significant tip asymmetry due to the right alar rim being very low compared to the left side. The profile view from the left side show a big step-off at the mid-columellar incision.

Your nose certainly has room for improvement, particularly given that you have had two rhinoplasty procedures. Why you have ended up with this result is a bit puzzling given that you have had open rhinoplasty approaches. I certainly would be tempted to say that further improvement is certainly possible but whether cartilage grafts are required to do it is a bit premature. It would be helpful to have more information if possible such as the operative notes from the two operations. That issue aside, what is needed always becomes evident in a revision when the tip is degloved and anatomy of the tip cartilages become evident. While swelling and scar tissue can obscure underlying tip cartilage anatomy, most external tip deformities are a direct result of how the underlying cartilages are shaped. You have such a significant tip deformity that I would wager the right lower alar cartilage is twisted and rotated downward, perhaps due to lack of support. In that case, cartilage grafts are needed such as a strong columellar strut from the septum and an alar onlay graft from ear cartilage. I would doubt that rib cartilage is needed. But I would leave that as an option to be determined during your revisional rhinoplasty procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a question about the skull contouring procedures that you do. My question is that can a small strip of bone be burred down from the top of my head which is pointed and thick, back down do the forehead? I’ve seen a video on Youtube where they do this for metopic synostosis.

A: What you are referring to is the reduction of a midline or sagittal ridge of bone, which represents the original fusion of the sagittal suture between the front (forehead) and back (occipital) fontanelles. In some people this line of sutural fusion can get quite thick and becomes a raised ridge of bone that can be quote prominent. This midline ridge of bone can be burred down (reduction cranioplasty) so that it is more level with the surrounding bone. How much it can be reduced depends on how thick the skull is along the ridge.Usually the ridge is thicker than the surrounding bone so that is not a problem. But it is a good idea to check its thickness first with an x-ray before actually having the procedure.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 30 year old male with a odd shape head that hunts me still now. I keep a lot of hair on my head to give my head a fuller look. I also constantly cover my head with a bandanna, sleep with it on my head, never remove it. My head sweats, get dried and builds up a bad case of dander because I hate my head shape and smallness…. I need help with this problem and people is driving me crazy, I haven’t been outside normally for 13 years, only go out when I have no choice. It is all my mother fault, she shaped my head by pressing on it when I was a child because she believed wide flat foreheads are a great look for men but she done it all wrong, I am flat front and back, my skull is small as well…. please help me! 

A: Your description of your unhappy head shape sounds like fronto-occipital flatness. This could be improved by augmentation of your forehead and the back of your head by an onlay cranioplasty. Whether both areas should be done or just the front or the back would depend on the area of the greatest aesthetic concern. How much augmentation can be done depends on what your scalp will permit by stretching. By using a coronal scalp incision between the two areas, good scalp expansion can be obtained and the closure of the incision is well away from the material location which is always a bonus.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I’m emailing to consult on your ability to improve some concerns that has not been ameliorated through exercise and diet.  I am 5’10 and weight 172 pounds.  Specifically, my upper cheeks and face carry a significant amount of fat which appears to be genetic and gives my face a chubby look.  I have attached pictures and circled the areas of my concern. In addition, I’m curious what you can do for the fat in my chest and underarm area.  A number of military guys I have spoken with have mentioned a procedure known as “pectoral etching”.  What it sounds like is liposuction in this area with some contouring to create a more defined/chiseled pectoral look.

A: What you are demonstrating in your pictures is a zone of cheek and perioral subcutaneous fat, a layer that lies just under the skin. It should not be confused with deeper fat layers, such as the buccal fat pad, which it is not. These are very difficult areas to successfully reduce although its treatment is straightforward. Small cannula liposuction is used from a small incision inside the mouth and the bottom end of the nasolabial fold. In my experience I have seen good and mediocre results with this procedure. The hardest area to improve is that closest to the eye. The other  issue with facial liposuction in this area is some prolonged swelling. While this is very typical of liposuction anywhere, it is very visibly noticeable when it is in the middle of your face.

From a chest standpoint, you are correct about pectoral etching. There is nothing magical about this technique. It is the artistic use of liposuction to create a better pectoral definition, largely using reduction of the lateral pectoral triangle for its effect. I have used it frequently with overall chest liposuction in male gynecomastia liposuction surgery. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I know it will cost more money if you are a plus size women to receive Buttock Augmentation by Fat Transfer but is it still safe or do you recomended the person lose weight first. I would love to get the procedure but want to do what works the best. I want my butt area to be considerably larger and I thought being bigger would be better for what I’m trying to achieve because I have more fat to transfer but its only been a bigger headache considering most of my weight comes from my breast area. 

A: Your understanding of how much fat that can be transferred to the buttocks is correct. The more you have to give, the more that can be transferred. It is never a good idea to lose weight before having a BBL (Brazilian Butt Lift) because you are going to lose it from the donor sites,, (abdomen and flanks) The fat that is liposuctioned out for transfer has to be filtered, washed and concentrated before being injected into the buttocks. This means that only about 1/3 of what is suctioned out will be usable. This makes it clear why few patients ever have too much fat to use. I would have to see a picture of your stomach area/body to see how much you have to give you a specific answer as it applies to you, but these are some basic guidelines about fat transfer to the buttocks.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 55 year old women who is a little overweight. At 5’4” and 190 lbs, I wouldn’t call myself fat just above my ideal body weight. The reality is that this weight is very stable and have been relatively the same weight for almost 20 years. I exercise and eat reasonably and this is just the way it is. I am fine with that as I am otherwise healthy.  My face has always been al little plump but otherwise firm until the past few years. I have noticed that there is some jowling that has appeared along the jawline but the real problem is my neck. It has gone to hell in the proverbial hand basket. It has gotten so droopy and saggy that I know it is time for some type of necklift. My question is am I too fat to get any benefit from such a procedure?

A: Your question is a good one and would be a lot more relevant when you were younger. But as you have gotten older, enough though it sounds like you have a rounder fuller face, the skin in the neck has begun sag. This sagging is the result of the skin stretching and loosening, no longer being able to support the weight of the fat it contains. While I would have to see pictures of your neck to be certain, many females with similar situations and face shapes actually get great benefit from neck reduction/tightening. Until proven otherwise, it may be that you may get a greater benefit from a necklift than someone who is thinner with less loose skin. It would make sense to delay your facelift if you were planning on losing weight but that clearly is not the case.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am having an otoplasty (ear pinning) soon and want to do everything to help it heal well. I take a cartilage supplement glucosamine-chondroitin liquid, Joint Juice) daily because of a previous knee injury. The supplement also contains green tea extract as well as multiple vitamins and a few carbs. Is it ok to keep taking it for my surgery? It is supposed to help strengthen cartilage so do you think it would be helpful for recovery? Should I double up on my amount per day to make my ears heal better?

A: In the nutritional supplement craze in which we live, it is very logical to ask if a cartilage repair supplement might help an otoplasty to heal better. After all, an otoplasty works by cartilage bending and healing in a new position. To make the linear assumption then that a supplement to repair cartilage should be helpful for healing ear cartilage as well would seem to make sense. The only thing I can say for sure is that your continued use  of it will have no adverse effects on your otoplasty healing. Whether it has any benefit at all is unknown and doubtful. There is a big difference in the cartilage of a synovial-lined joint and that in the ear or nose. That is an assumption that probably wouldn’t hold up under any scientific scrutiny. Therefore, I would not increase your intake of this supplement for your otoplasty surgery. The only real beneficiary of that approach would likely be the manufacturer of the product.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I believe I need jaw implants from the gonial to the chin area. I have had a sliding genioplasty at the chin several years ago.  I have a short jaw bone that angles upward from the chin area to the bottom of the ear. I need to bring this to a more horizontal angle.

A: Thank you for your inquiry. It sounds like you have a pretty good handle on what you need. Ideally you need custom jaw angle implants that extend from the jaw angle right up to the chin area. Such an implant is not available as a stock or off-the-shelf implants. Off-the-shelf jaw angle implants will not reach the chin area, at best they will reach to the mid-body of the mandible behind the cut or notch from the prior osteotomy. That is an acceptable approach if one can accept an indentation between the chin and the jaw angles. But a completely smooth transition from the chin back to the jaw angles requires a custom implant approach based on a 3-D model mandibular model made from a CT scan. This is the best and only way to get a jawline that is completely harmonious fro one side to the other.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 38 year-old woman and am bothered by the amount of skin under my chin. I would like a more youthful and tightened neck look. I have read about lot of different neck rejuvenating procedures such as a necklift and a ‘trampoline’ neck lift. the necklift/facelift seems like it is too much for my problem while the reviews I have read on the trampoline lift do not give me much confidence. What would be the best procedure for my sagging neck skin?

A: There are a variety of neck tightening procedures as you have mentioned. In the array of neck improvement options, they have differing effects on neck rejuvenation depending upon what they are designed to treat. Given your relatively young age, it is hard to imagine that you have enough loose skin to warrant the maximal tightening procedure of a full necklift. It may be that simple liposuction, particularly Smartlipo or laser liposuction, may create enough of a skin tightening effect. This  would depend on whether you also have enough fat in the neck to warrant it. A so-called trampoline necklift achieves its skin tightening effect from liposuction. The sutures placed are designed to create a sharper cervicomental neck angle not to tighten the skin. A more simplified version of this procedure is the standard submentoplasty where sutures are placed to tighten the platysma muscle above the thyroid cartilage and liposuction is used to reduce fat and tighten skin. I would really have to see pictures of your neck to determine what may be of best benefit to you.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am coming for a facelift and chin augmentation from out of the country and have a visa to travel to the U.S. But my wife does not so she can not accompany me there. How do you handle the arrangements for after surgery care in patients in my situation?

A: Almost every male patient that comes from afar to my practice comes alone. This is actually common and we are very familiar with handling such a situation. Postoperative care would be provided by either staying overnite in the facility or we arrange to have one of our nurses take you back and stay with you the first night after surgery in our hotel. Being from out of town and having a facelift (and being a male), staying overnite in the facility would be the more ideal postoperative scenario. Once the drains and hear dressing are removed the next morning, you will be in a better situation to be by yourself the next day after surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am going to get a facelift and chin implant at the same time. In remaking a new jawline (or a rejuvenated one), I thought that maybe jaw angle implants would be beneficial as well. Do you think it would give my jawline more definition?

A: My concern about jaw angle augmentation in your face is that the only effect it may have would be to make it look bigger/rounder/more fat. Your tissues are so thick over the parotid gland/jaw angle area that it would provide no definition and just bulk. And the last thing you need is more bulk/width in the posterior part of your face. Jaw angle implants work best in a thinner or already more defined face where the outline of the implants can be better seen. Jaw angle implants are not just about adding bulk. That result is often not helpful, and even detrimental, to the aesthetics of a fuller face.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want to get a new chin augmentation procedure. I had one done over 20 years ago but I always thought it wasn’t enough. It was done from an incision inside my mouth. In getting a new and larger implant, would the old chin implant have to be removed?

A: Whether your existing chin implant would be removed or not during the placement of a new one is an intraoperative decision. In theory, one would assume that the old one would have to go to make way for the new one. But this is not always true. Given that your original chin implant was placed over 20 years ago and was placed from an intraoral approach, it is likely that it is very small and positioned high on the bone. If it is not in the way, I will often leave the old one and placed a new one right on top or below it taking advantage of whatever augmentative effect it already provides. If it is positioned low I may either remove it, or if it has settled into the bone, I may just shave off the prominent part of the old chin implant to make a smooth platform for the new one to rest on.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would be very grateful if you could answer some questions about the removal of the buccal fat pad. What is the level of risks of sustaining damage to the buccal nerve branch of the facial nerve? Approximately how long does it take to recovery and when to expect the end result?

A: The buccal fat pad is an encapsulated fat mass in the cheek which is located between the buccinator muscle and the masseter and zygomatic muscles and largely lies underneath the zygomatic arch.  It is deep to the malar fat pad which lies directly under the skin and the jowl fat pad which is situated much lower near the jawline and should not be confused with these two regionally close fat collections. The buccal fat has one large body and usually four processes like fingers which extend outward from it. The part that is removed in a cosmetic buccal lipectomy is part of the main body. The biggest risk in buccal lipectomy is transection of its blood supply,  the buccal artery or vein during its removal. This can result in bleeding and a hematoma afterwards. The key to avoiding this complication is gentle dissection of the main body outward and cauterizing attached blood vessels under direct vision. The buccal branches of the facial nerve are in close proximity to the main body but usually cross over top of it. Staying inside the buccal fat pad capsule and not being too aggressive with removal are the keys to avoiding a traction nerve injury. It is not a complication that I have ever seen. Trying to pull too much fat out runs the risks of pulling the nerve branches into the field of removal/cautery.

Buccal lipectomies will cause some swelling but most of that is gone after about three weeks from the procedure. The final result can be judged six weeks from surgery although some continuing fat atrophy may be ongoing based on how the fat pad was removed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 55 year-old woman who would like a facelift to remove jowls and improve droopy neck. I also would like my nose done as the tip seems to keep getting lower as I age. (is it really growing at my age?) The question I have is the timing of the nose surgery and the facelift. Should they be done separately or together? If separate, should the nose be done before or after the facelift? My thought would be after because it give my surgeon a better idea to do the nose based on the new way my face looks.

A: You are correct in your impression that the nose is getting longer and ‘growing’. It does not actually grow per se but the tip of the nose does fall as the ligaments weaken. As the tip falls downward the nasal length increases and the nasolabial angle decreases. This means that a very simple tip rhinoplasty to elevate the tip and open up the nasolabial angle can be quite rejuvenating to how the face looks.

There are arguments to be made on both sides of that discussion either combining or separating a facelift and rhinoplasty. In reality, it is not necessary to look at the ‘new’ face afterward to figure out how to change the nose via rhinoplasty surgery. Therefore, I have found it best to combine the procedures for the benefits of one single surgery and recovery and lower costs. In addition, a rhinoplasty is a central facial surgery while a facelift is a lateral or side facial surgery. One does not really impact the other when it comes to facial appearance changes or swelling and bruising. Put together, however, the combined facelift and rhinoplasty procedure can have quite a rejuvenating impact on the aging face.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to improve my profile. I am 53 years old and have always had a round face. But as I have gotten older and gained weight, it has gotten more so. About 20 years ago I had a chin implant placed. It helped a little but the result was not what I was looking for but I have lived with it. Now I would like to rejuvenate myself a little bit and get my jawline looking better. I have attached front and side pictures for your recommendations.

A: Thank you for your inquiry and sending your photos. In looking at them, you have chosen the correct procedures, neck recontouring and chin augmentation. The chin augmentation is straight forward. A forward projecting chin implant of 8mm to 9mms would give much improved augmentation.  This is in addition to the chin implant you already have. I suspect it is a very small inplant that is likely placed too high on the bone. So I would remove it and replace it with one that is bigger, more square-shaped and positioned lower on the bone. Your very full neck (bullfrog neck deformity) is the challenging procedure. This can be approached from three different approaches; liposuction only, liposuction with submentoplasty or a full necklift. I think with your size neck and excess skin that only a full necklift will give you the maximal improvement. Males with thick necks never get as much tightening and cervicomental angle creation as females so the most aggressive approach needs to be done. I have attached a side imaging profile to show what I consider to be a conservative result, meaning the least amount of improvement that I would expect.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  Could you explain briefly your procedure for eyebrow hair transplantation. Most are done through follicular units containing single hairs at a shaved donation site located in the back of the scalp. I know you can use the fine hairs behind the ear as the donor site. The question is do you shave that area site also?  Or do you transplant the recipient areas with the original length of that donor hair? My eyebrows are very light in density due to chemotherapy (in 2005) and possibly the present medication Fluconazole I am on which I will be taking for a few more months. My eyebrows  will never be the same. If I could just get an idea of about how much it might cost,for about anywhere from 60 to  100 hairs per eyebrow, I’ve been approved by care credit. But I don’t want to waste your time if I don’t have nearly enough to cover the cost. Thanks so much.

A: Eyebrow hair transplantation is unique only because of how the hairs need to be oriented in the brow area. The harvest and placement of the hairs is a standard single follicular unit technique. Where on the scalp the hairs are harvested is a function of how thick they need to be. Whether they are harvested from the back of the scalp or behind the ears is merely a function of the color and thickness of the hair shafts needed. The lighter and thinner the hairs needed, the more likely they would come from behind the ears over the mastoid area. No hairs are shaved for harvest because the shaft must be present to act as a handle for manipulation and insertion. The shaft may be cit very short but not shaved.
The antifungal drug Fluconazole has a well known side effect of hair loss, thus it would be best to not have the procedure before you have discontinued this medication.
The cost of hair transplantation can be done on a per follicle basis or by hair region. Eye brow transplantation is usually charged for by region. 

 
Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am a transitioning female-to-male transgender individual and my goal is to create a more masculine appearance. In particular, I have a very round, feminine face. I believe chin implants and possible jaw implants/contouring would help a lot, but I am open to hear suggestions as well.  I’m very concerned about price given my student status.

A: When it comes to making a face more masculine, you are correct to first look at the jawline. That is one of the top areas in facial contouring in FTM transgender patients. your photos show a really soft jawline and that it makes priority number one from a surgical altering aspect. The rest of your face, as you have pointed out is round and feminine. From a both a cost and an effectiveness standpoint, I would focus on chin augmentation and buccal and submental fat reduction. In other words, a combined chin implant, submental liposuction and partial buccal lipectomies. This will help your jawline considerably and create improved definition sa shown in the computer imaging that I have done. The only debate about the chin procedure is whether it should be an implant or an osteotomy. Ideally, it should be an osteotomy because of your age  and the need for some vertical chin lengthening as well. But there is a cost difference between a chin implant and an osteotomy and that has to be factored into your treatment decision as well as you mentioned. Jaw angle implants are also an option but are far less important than chin augmentation in your case.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a few questions about building out a flat spot on my skull. I have attached some pictures for your evaluation. My questions are:

1)  Since the Kryptonite material is no more available there is only the PMMA,Hydroxyalite(HA) and custom silicone implant available. If I understand well all these materials are requiring an open approach under general anesthesia for two hours

and they all leave a scar between 8-10cm when they are introduced under the scalp. Will the scar be visible if i keep my hair a little longer then short?

2) Other than a scar ,minor contour issues remain as the only risk. If these contour issues ever occur later after surgery, what have to be done and how?

3) Hydroxyapatite material bonds to the bone with no risk of osteolysis. Does it make then (HA) safer than PMMA in that matter?

4)What is the biggest disadvantage in using hydroxyapatite material?

5) The safety is my biggest concern long after the surgery, which of these materials are best proven over the years? 

6) I would be traveling from abroad. How long do I have to stay in the U.S. and do I need some special medical insurance in case something goes wrong during the surgery.

A: Based on your photos, what I see you are demonstrating is a severe flatness to the back of the head, lack of occipital projection. In answer to your questions:

1) The  posterior scalp scar is about 8 to 10 cms that with hair will remain hidden. There are numerous bald.shaved patients who have the procedure as well but I think it is a good idea to be well aware of the scar potential.

2) If any contour issue arises, such as an edge than one can feel or some asymmetry, it can be easily adjusted/fixed through the same scar approach. I go to great lengths to avoid that happening for the obvious reason…no patient wants to go back to surgery. But despite my best efforts, surgery is not always perfect.

3) HA does have a direct bone to bone so, in theory, it is a more biocompatible material. I wouldn’t use the word safer as both materials have been used successfully for decades. But if I was a young person and had a choice between the two materials (cost is the big issue) then I would go with HA>

4) Cost is the only disadvantage to the HA material. By volume alone, it takes twice as much HSA to get the same volume effect as PMMA>

5) PMMA has been used as a cranioplasty material for over 40 years. HA has been used for over 25 years.

6) Almost all cranioplasty patients return home within 48 hours after surgery. No special medical insurance is needed as nothing is going to go wrong that would warrant any catastrophic medical care. This is the simple addition of a material on the outside of the skull bones, it is very safe. The risks of this surgery are aesthetic concerns not significant medical complications.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  Hi. I read article you wrote online.  I had a “lifestyle lift” six weeks ago.  I had a mild turkey neck. After surgery I had a significant swelling in my mid neck bilaterally.  Now much of the swelling is reduced but my previously unseen thyroid cartilage is now revealed. (I am a woman.) In your experience does this ever go away or will I need revision?  Thanks so much for any help you can offer.

A:  Unmasking of the thyroid cartilage would suggest that you had a very good midline pull and recontouring from the Lifestyle Lift procedure. I don’t know whether you had platysmal muscle plication or not (you would know if there is an incision under the chin), but the lateral pull of the skin and the defatting of a platysmal separation and its reapproximation can create a very improved cervicomental angle. These standard facelift maneuvers can occasionally make the outlines of the thyroid cartilage evident, particularly in the thin patient with little subcutaneous fat.

There is no way to undo the lift to camouflage the thyroid cartilage again. Continued aging will eventually cover up the thyroid cartilage again bit that is obviously going to take time and there is no guarantee that it will do so. An alternative suggestion is to do a simple thyroid cartilage reduction (tracheal shave). This is a common procedure to reduce the jutting and prominent thyroid cartilage.

Dr. Barry Eppley

Indianapolis, Indiana