Your Questions

Q: Dr. Eppley, I have been trying to figure out about the chin surgery. I have asked a couple of plastic surgeons about what is the difference between chin filling and chin implants. Will either one give you the same type results?

A: What you are asking about is the difference between use injectable fullers to augment the chin  as an office procedure with an instantaneous results versus the use of a chin implant which involves surgery and a recovery. The simple answer is no. The effects they will create are radically different. Injectable fillers to the chin are going to create small temporary augmentation changes while an implant is going to create a larger permanent volume change. Each approach has a role to play in the right patient. But injectable fillers to the chin plays a very small role in the overall number of chin augmentation procedures that are done because the changes are both small and temporary. But if one is looking for just a little augmentation, does not want surgery and is willing to accept that the result is not permanent, then this could be a good treatment. In my experience, I find that this is always a female patient who wants just a little central point augmentation to make the chin more feminine. I use Radiesse injectable filler as it lasts fairly long (one year) and its more thick consistency gives a good push to the overlying soft tissues of the chin as it is placed deep down at the bone level.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I really like what you have done for my temporal augmentation. But I had read some bad reviews on silicone implants. Would you be able to do Gore-tex implants instead? I am weary of silicone…

A: I have no concerns about silicone facial implants and I don’t know where those ‘bad reviews’ come from. Your body doesn’t care if it is silicone, gore-tex or any other material, it treats them all the same…as a foreign body which is enveloped by a layer of scar tissue. (capsule) Any beliefs that the body treats one synthetic material different than another is not based on any known science of biomaterials.

That being said, it doesn’t make any difference to me what material a patient wants to use as long as it can do the job adequately. I almost always use silicone temporal implants because they are preformed, very soft and flexible and are the most economically efficient for the patient. I can certainly use Gore-tex but it will cost more because you have to buy a block of it and then hard carve out the implants during surgery. It is easy for me to do, it just costs more.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want lip enhancement, exactly like the Robert Pattinson picture which I have sent to you. I have sent three additional pictures also. Is it possible to make my lips look exactly like that?

A: The simple answer is no. It is not possible to make you or anyone else’s facial features look exactly like someone else. This is not a realistic goal in plastic surgery. And undergoing a lip enhancement procedure with the belief that such a result will be the outcome is a setup for disappointment afterwards.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would be interested in learning more about the jaw augmentation procedure  through the insertion of  mandibular implants (both angle and ramus). I know that it is usually not possible to estimate costs and length of recovery in patients that the surgeon has not had a chance to examine and talk to in person, but still, I was wondering if you could give me a (general) idea of how much the total cost of the surgery would amount to (all inclusive: implants, surgeon, anesthesiologist, facility etc.) as well as how long the downtime would be.

A: In answer to your cost question, part of the cost would relate to what type jaw angle implants are used. (silicone vs Medpor)  There are different styles and shapes based on the jaw angle result desired. But taking that into consideration, the total cost would be in the range of $6500 to $8500.

The concept of recovery after any surgery depends on how one chooses to define recovery. From a significant facial swelling standpoint, think three weeks. From judging the final result, it is a minimum of 6 weeks and ideally 3 months. From a physical recovery standpoint, one can return to work as soon as they feel able., which for most people would be 10 to 14 days.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want to get my ears fixed. They stick out and I get ridiculed by how they look. While they don’t stick out as bad as some people I have seen on your plastic surgery website before and afters, they definitely are not normal looking. I want to get them fixed so I can be a whole person and not have to worry about hiding them with my hair. What seems to make them stick out is not so much the outer rim of the ear but the part closer to the hole. It is big and very stiff. What type of otoplasty do I need and how long and painful is the recovery?

A: On the surface, otoplasty surgery can seem all the same being done from an incision on the back of the ear. But how the ear cartilage is reshaped is done differently based on the cartilaginous anatomy of the ear. The two basic cartilage reshaping methods are creating a more prominent antihelical fold by suture placement and conchal size reduction by excision and suturing it to the mastoid fascia. Often a combination of manuevers are done to create the desired effect. Your protruding ears sound like a large and prominent concha is the major issue so conchal reduction and setback is needed.

Otoplasty surgery is not particularly painful but it does make the ears sore for a while. Recovery after otoplasty can be viewed as  matter of days or weeks depending upon how you define recovery. Returning to work and resuming all normal activities will occur in matter of days. To have most of the swelling gone and the ears feel completely normal again, think four to six weeks after surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I desire a smoother, lower forehead. Currently I have indentations on each side of my forehead that run all the way down to my cheekbone arches. I would really like to have those indentations filled in using bone cement or some other reliable material. I also have a high forehead and would like to have it lowered. My forehead looks big and masculine right now and does not fit well with the rest of my face. I have attached pictures of me for your review.

A:  The indentations to which you refer are the temporal fossa, which is largely a soft tissue space filled with the temporalis muscle to the side of the forehead. It extends from the anterior temporal line at the edge of the forehead down to the zygomatic arches inferiorly. While these could be filled in with bone cement deep under the muscle, that would not be my approach and could be improved much more simply. Silicone temporal implants can be placed under the deep temporal fascia and on top of the muscle. This is a more effective, reliable and cost effective technique.

When you speak to a large forehead, I am assuming you mean a high one in which the distance is vertically long from the eyebrows to the frontal hairline. That is different that a large forehead in which the frontal bone is bossing or prominent. While the forehead can be vertically shortened by a centimeter or so through a frontal hairline advancement and skin excision, I would be very cautious about performing that procedure in you. A forehead reduction results in a scar along the frontal hairline. In pigmented skin types like yours, I would be concerned about how such a scar may turn out. Hair density and hairstyle is also an important consideration is deciding about the aesthetic merits of a forehead reduction procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have jaw asymmetry as a result of a prior fracture. My idea for the jaw was to break just the mandible in and reposition it as it originally had been before the trauma with a little added refinement. I already had wires/braces and even though it sucked, I don’t mind going through it again for better results. I was also wondering if you could give me a breakdown of the total that a mandibular osteotomy to restore the jaw to its original form would cost with braces, surgeon fee, anesthesia, and facility. Thank you.

A:  When trying to improve jaw asymmetry, the choice of a mandibular osteotomy must be considered very carefully. The reason to go through a mandibular bony repositioning through ramus osteotomies is because of either an existing malocclusion or an occlusal cant with an open bite or a cant with an otherwise good occlusion. The first step is to consider whether a mandibular osteotomy is worth the effort by getting an evaluation by an orthodontist. This is a decision ultimately based on its effect on the occlusion and only secondary on the shape and position of the mandible

But for the sake of discussion, let’s say it is a worthy procedure. This will require 6 to 12 months of orthodontic preparation and 5 months or so of  after surgery orthodontics. A cost estimate would need to come from an orthodontist but we’ll use the general figure of $5,000. The cost of a  mandibular sagittal split osteotomy include surgeon’s fee, operating room and anesthesia with an overnite stay would be in the range of $ 17,000 to $19,000. For an over $20,000 investment, one needs to be absolutely certain that the end result justifies this effort.

If this degree of effort is deemed excessive, then there are other camouflages procedures for jawline enhancement such as implant, bony shaving and reductions and chin osteotomies.   

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 24 years old and 7 years ago had an otoplasty done. The results are very unnatural and unleasing. The antihelix is very large and the ear is similar to “telephone ear deformity”. Is a revision possible to correct these problems?  I would like to know the procedure for them to be fixed and what are the risks?

A: In general, an overcorrected otoplasty creates a prominent antihelix and a retruded helix. This can be caused by either too much postauricular skin excision, antihelical creation sutures that were overtightened or a combination of both. Most commonly the cartilage deformity is the real culprit. This requires it to be released by scoring/releasing the fold and then holding it outward so it heals in this new shape. This is ideally done with cartilage grafts which can be harvested from the concha. The biggest risk of this revisional otoplasty procedure is how well or effective it can be. Improvement is almost always obtained in otoplasty revision.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want symmetry in my face after a few events that changed it. I want to breathe better. I want my nose to be as it was before trauma, might need cartilage graft on left side. I want my jaw to be more angular and symmetrical with osteotomy after having broken jaw. I want my left eye to look like my right eye, cause could be previous rhinoplasty or trauma involving prolonged eye poke. Here are some pictures of me.

A: Thank you for your inquiry and sending your pictures. I can clearly see your concerns in all three areas. In looking at your pictures, I can give you the following suggestions for these areas as follows:

1) Nose –  a septorhinoplasty is needed to straighten the septum, harvest a septal cartilage graft, decrease the size of the inferior turbinates, and reconstruct the external nose with a right middle vault spreader graft. Your external nose may benefit by other changes but that is as much as I can say based on these two pictures.

2) Jaw – To correct your asymmetric jaw, I would not do a traditional jaw osteotomy. This requires preparatory orthodontics and a whole change in your bite. The asymmetry could be better camouflaged with a sliding chin osteotomy to correct the midline of the chin and jaw angle implants to create a more angular and defined look. 

3) Eye – Your lower positioned eye needs to have the orbital floor built up with an implant and possibly both the orbital floor and the orbital rim needs to be augmented. This would raise the eye up and help bring it more forward as well.

Your pictures are not really adequate to do good computer imaging but I have attached the best I could do with the one picture.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting a chin implant and think I want the Medpor type. I have read about them and what there advantages and disadvantages are.  They say their advantages are that tissue ingrowth decreases movement which prevents erosion of the underlying bone and permits access of the implant to the immune system, reducing the long-term risk of implant infection and rejection. They can also be carved better to solve asymmetries. Their disadvantages are that they are harder to remove, higher risk of infection in the first few weeks and are more difficult to place. Are these accurate?

A:While there are material differences between Medpor and silicone rubber (silastic) for facial implants, choosing an implant based on its material composition is findamentally flawed. What is most important are the following issues in facial implants: 1) What is the correct implant style and size for the facial skeletal problem and 2) How easy is it to place, secure and subsequently remove if need be. If you fail to achieve these first two goals in using facial implants, then it really doesn’t matter what the material composition is.

Neither implant material type and their style and size selections is right for every patient and every facial aesthetic need.  The advantages and disadvantages of each material must be considered on an individual patient basis. Some of your listed advantages and disadvantages of  Medpor facial implants are inaccurate such as being easy to carve and adapt to the bone site, they are actually much harder to shape and place. Medpor has no proven advantage over silicone when it comes to infection/rejection. Medpor also has many less styles and sizes of available facial implants compared to silastic facial implants.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting implants for my flat cheeks but am not sure what type of implant I really need. I have attached 4 images of three different individuals cheeks I really appreciate and believe to be prominent and masculine. They are Lars Burmeister, Fernando Torres, and Ben Affleck. All seem to have the prominence up on the side of the eyes and they wrap around to the front of the eye a bit. They all look more chiseled, narrow, and angular though, relative to the other examples of cheekbones I have attached. The other examples are of cheekbone structures that I would prefer to avoid. They are Zac Efron, Cilian Murphy, and Peter Facinelli. Their cheeks just cover too much surface area and look like an enlarged cheek mass, rather than finely chiseled cheekbones. They are prominent but look too feminine and bulky. Perhaps you can enlighten me more on what it is I both desire and do not desire in the above referenced cheeks.

Also, will I be getting the inferior orbital rim augmented as well? Reason being that my eye does indeed pass over this bone. Besides creating a better angular appearance to my face, I’m hoping the midface implants rejuvenate my face a bit and help me look less sickly when I get down to 10% body fat percentage or so. Would I need some kind of midface lift along with the implants to give myself this appearance? I am apprehensive to undergo a procedure that is often only discussed with people in their 40s or above.

Lastly I have attached a crude approximation of the area on my cheek I want to be augmented. The black marks denote areas I would prefer to see little to no enhancement on. They include the zygomatic arch, the base of the zygomatic bone, and underneath the front of the zygomatic bone beside my nose. Let me know if this is realistic.

A: Thank you for the detailed information about the desired cheek augmentation result. That is very helpful.

The first comment that I would make is that their is no standard or off-the-shelf ‘cheek’ implant that has exactly those dimensions that you have well outlined in your own photo. I would agree completely that the best aesthetic midface result for you is exactly what you have described, as you have a true combined anterior zygoma-lateral orbital wall-inferior orbital rim deficiency which is a reflection of the overall underdevelopment/flattening of the zygomatico-orbital complexes. Your issue is a bone problem not a soft tissue one so the concept of any form of a midface lift is not a consideration.

So it is not a question as to what you need but how to get there. In an ideal world from a bone standpoint, I would use Kryptionite bone cement/putty to intraoperatively fashion the implant exactly the way I want it and place it from above through a lower eyelid incision. This is most ideal not only because of the ability to create a truly custom implant but the area of augmentation needs to extend across the orbital rim (at least laterally). This infraorbital rim area is the ‘rate-limiting’ step in getting the ideal implant shape as it can not be accessed from below. (inside the mouth…the big infraorbital nerve is in the way) But due to cost considerations and that I nor you would be thrilled with making a lower eyelid incision, this ideal approach may not a good option for you. The other option is to pre-make a custom implant off of a 3-D scan and model, but again cost becomes a consideration with that approach as well.

With the ideal approach off the table, then we must look for using/modifying existing stock implants to achieve most of the cheek augmentation goals. One style of cheek implant, sometimes called the Malar II, augments the lateral orbital wall as well as cheek bone. It does not extend out onto the infraorbital rim to any degree which is its one limitation.

The other issue I would mention is that the use of these celebrity faces and pictures serve only as a direction that you want to go and that no cheek implant, even one custom made, will make you look exactly like them.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I got treated with Botox for migraines three months ago and it was not effective. It was done by a neurologist and when I asked why it did not work he said he did it in the “standard FDA” way by a band formation around the head, neck and forehead.  This is so disappointing and I paid around $3,000 to have it done.

A: That is certainly disappointing to hear not only because it did not work but because of the way it was done. There is no such thing as a ‘standard FDA’ way to do it. If that statement meant that it was done by using the clinical information and methods that was the basis for what made Botox approved for migraine treatment by the FDA, the ‘wrap around the head ‘ method was not it. Botox works for a select group of migraine patients who have identifiable peripheral trigger points in the frontal, temporal and occipital regions by both examination and history. It is these very specific points which are injected not in a random method. You may benefit by Botox injections if you have these trigger points so your lack of improvement is more likely due to that you are either not a good candidate or the injection approach was flawed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Is there a such thing as tarsal strip revision? I am also concerned with how this surgery  has left me with small and round eyes. Is tarsal surgery permanent? Is there a surgery that can reverse this? Have you performed revision tarsal strip surgeries in the past, or is this an unusual circumstance?

A:Yes there is. Tarsal strip procedures are generally done in an effort to tighten/raise the corner of the eyes, for a variety of medical and cosmetic reasons. Revisions of this procedure may be needed when it is not entirely successful, such as inadequate tightening/lid positioning or widened scars in the corners of the eyes.When the corners of the eyes are tightened, the lateral aperture of the eye (where the upper and lower eyelids meet) can become less sharp and more blunted. This can very well create the appearance of a smaller and more rounded eye. Once a tarsal strip lateral canthoplasty has healed, it will be permanent. A revision can be performed to open up or change the amount of aperture closure although they are not always successful. But a milllimeter or two of aperture change may be aesthetically beneficial.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am giving serious consideration to getting cosmetic surgery to reshape my skull. I have an compressed area on the top right/middle section of my head near or along the coronal suture. The distorted area is roughly about 2 in by 3 in. It hasn’t been much concern for me until now that I am losing my hair. I found your page and now have hope that I won’t have to feel embarrassed every time I take off my hat for the rest of my life. My ideal plan is to have a one time low maintenance fix. I saw some of the work on your websiteand it seems very good and I think that you might be able to help me. I have attached a few photos from a couple different angles so you can see the indented area. Ideally, I am looking to simply smooth it out and make my head symmetrical without a dent or a bump.. However I’m not all to sure on the technicalities of the procedure or if it’s as simple as I’m hoping. I would appreciate your honest opinion as to whether the risk of the surgery might cause more off looking results, like a bulging area or something? I’m more than sure you a very busy person but all the information you can offer me would be appreciated. Having this surgery is a huge, potentially life changing decision. Even more so considering it is on my head and I will have to display, see, and live with the outcome. Let me know what you think.

A: Thank you for sending your pictures. I can see clearly the indentation across the top of your skull. The best and only way to treat this would be with an injectable cranioplasty approach. An open approach would leave a scar that I would not consider an acceptable trade-off. The injectable or minimal incision approach would use two very small incisions (about 1/2 to 3/4 of an inch) on both ends of the indentation. Through these, the material (Kryptonite) can be injected and molded. These incisions would heal up and be virtually undetectable later. This is a fairly simple procedure to go through with minimal pain and swelling afterwards. The only caveat to the simplicity of this approach is how even and smooth the augmentation would be. Since it is a blind procedure, all material molding is done from the outside by hand by pushing on the scalp as it sets up. As you have mentioned, it would also be important to not place too much material so the area does not become a ridge instead of an indentation. That is the artistry of the procedure. A good question is what is the likelihood of having a contour deformity that may need a secondary touch-up or rasping? In my experience so far, it has been about 50%.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had liposuction six months ago that has left me with some unevenness over the thigh areas. The skin has some dimpling and a few more obvious humps in the upper portion of outer thighs. My doctor told me to give it six months after surgery to see if they would smooth out and they definitely haven’t. Would Exilis be able to fix or improve how this looks? I have read about it and it seems like it would be one option. I don’t think there is a surgery that can fix this. My doctor said I would just have to live with it but she hadn’t heard about Exilis though. Thank you for your time.

A: Skin irregularities are the result of an uneven fat layer under the skin. They can become apparent after liposuction due to pre-existing cellulite, poor skin elasticity and an irregular layering of residual fat left behind. One has to look carefully at the lumps and bumps to determine if filling the indentations, decreasing the height of the lumps or some combination approach is best.

Exilis is a radiofrequency device that does spot fat reduction and has some degree of a skin tightening effect. I find it to be one of the best non-surgical approaches to treat liposuction deformities that are available today. It will likely have some beneficial effects on the contour of the thigh skin by helping to reduce the thicker or raised fat areas. It usually requires three or four treatments done in the office every two weeks to see the best effect.

But if the indentations are the main contour problems, those are best treated by fat injections.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would to get the big bump on the back of my head reduced. It sticks out and makes my head look odd from the side. I know that bone can be shaved down but I don’t know how far or much that can be done. I did have my doctor order a skull film and the report says that the ‘occipital bone thickness is 1.7cms at its fullest’. Does this mean I can get the back of my head taken down enough  to see a difference and still not injure the brain or be dangerous?

A: An occipital bone thickness of 1.7 cms is a measurement that involves the three layers of the skull. These include the inner and outer cranial table (solid bone) and an inner marrow space layer. (soft bone) Think of the skull like an oreo cookie. With a thickness of 1.7 cms, that indicates that safe cranial reduction can be done.  But the real question, as you have asked, is how much could be done and would the results justify the effort. I would need to get a digital copy of the x-ray so I can take a measurement of the outer cranial table thickness and do a tracing to be sure that enough reduction can be done to make a visible difference. The outer cranial table and the marrow space can be reduced but the inner bone table can not. Assuming that each section of skull thickness accounts for 1/3 (which it may or may not), then a 2/3s or close to a centimeter may be capable of being removed in a skull reduction procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Wwhat kind of temporal implants do you use? I have read that Medpor temporal implants has to be screwed under the temporal muscle onto the temporal bone. Is that the way you do it? Will the scalp incisions be bad in that case? Thank you very much.

A: There are different indications for temporal augmentation and that determines the type of implant used and its location. For cosmetic augmentation and in mild muscle atrophy after a craniotomy, the implant is placed under the fascia (on top of the muscle) in most cases. I prefer the use of soft flexible silicone rubber temporal implants when it is placed in this more superficial location. This is done through a very small vertical incision in the temporal hairline that heals inconspicuously. In more severe atrophy cases after craniotomy or at the time of a craniotomy, the implant is placed next to the bone and often needs to be larger. This is where a Medpor temporal implant is used as it is meant to be placed next to the bone and is usually screwed into place. It is placed through an existing larger scalp coronal incision.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Can you tell looking at a person if the fat is herniated prior to surgery and is the entire fat pads removed in bilateral upper lid surgery? Also, you mention a strip of muscle excised…is it removed from inner to outer corner of the eyes or is this just done for blepharospasm?

A: Photos are generally very helpful to determine if one has herniated eyelid fat. Most herniated fat generally occurs in the lower eyelids and less so in the upper eyelids. The lower eyelids have three distinct fat pockets that often herniate and are removed. The upper eyelid, however, has only two fat pockets that may be treated as the lateral compartment of the upper eyelid contains the lacrimal gland which should not be removed. It may be tucked back up with sutures if needed. The concept of removing the entire fad pads is not done either in the upper or lower eyelids as creating a ‘skeletonized’ and more aged looking eye area is possible with too much fat removal.

A strip of orbicularis muscle is often removed in upper and lower blepharoplasty surgery. It is done in the upper eyelid to help create more of an upper eyelid fold and is done on the lower eyelids to get rid of fullness below the lashline, often called an orbicularis roll. The condition of blepharoplasm is treated with Botox injections, not muscle removal.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am writing you in regards to my daughter is now two and one-half years old. The back of her head is flat (plagiocephalus) and asymmetrical (1cm difference). According to the doctors there was no need to treat with a helmet. Still the deformation is quite obvious. Is there anything that can be done about it at your clinic? I suppose she has to wait until she is 18 years old?

A: At this age, there is no form of helmet or external molding therapy that will change the shape of the skull. It is too thick at this point to be externally molded. It can be treated for its cosmetic deformity by an augmentation cranioplasty on the flattened side. That can be a very effective procedure and in some cases this is done by an injectable cranioplasty approach. This is probably the ideal procedure for plagiocephaly deformities that are mild to moderate. In laregr degrees of flattening, an open approach is better. The question is at what age should that be done. There are no hard and fast rules about the age to do this procedure. That is a personal choice of the parents. I have had requests to do them as early as age  but the timing of cosmetic correction of a plasgiocephalic skull is psychological not physical.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to have my temporal muscle on both sides reduced. They are overdeveloped and makes my face look awkward. I would like to have face proportioned right on both sides. Please tell me some options that I might have. Thanks.

A: Thank you for your inquiry and sending your pics. Yes you do indeed have very big temporalls muscles, probably one of the biggest that I have ever seen by proportion to the rest of the face. The largest portion is just above the zygomatic arch where the bulk of the muscle lies. It is the bulge between the side of the forehead and the position of the zygomatic arch that is aesthetically disproportionate. A line drawn between the two should be either straight or have a slight concave curve to it. Significant convexity of the temporal area makes it stand out and be very noticeable.

Reducing the size of a temporalis muscle is a very rare procedure. I have done a lot of cosmetic temporal surgery, all of which has been to create the opposite effect of temporal augmentation. The only option to reduce the temporalis muscle size is surgical through reduction and thinning of the muscle. You need an approximate 50% reduction in the size of the muscle. This would need to be done through a scalp incision approach to access the attachments of the muscle to the skull to lift and thin it. This would create actual muscle debulking and reduce the visible bulge.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in correcting the asymmetry of my face. The right side of it, particularly in the jaw angle area, is tilted upwards and shorter. I have read that a jaw angle implant may be able to correct this tilt.Would this implant make the right side look closer to the left and would I feel the difference? Would a cheek implant help along with the mandibular angle implant to even out the balance? I don’t want the right looking more full and balanced then the left.  Would braces help fix or improve the jaw tilt/angle?

A: In the ideal correction of facial asymmetry, it rarely is just one facial area that is shorter or asymmetric. In most cases of facial asymmetry, the entire side of that face is shorter. For this reason, jaw angle and cheek implants together are often done and produce the greatest amount of facial lengthening and correction of the shorter side.

Braces change how the teeth fit together but will not change the tilt of the jawline.

The goal of facial asymmetry correction with facial implants, the most common treatment method, is to try and get the best match between the two sides as possible. While perfect symmetry is never possible, the closer the two match the better. In the spirit of that goal, it is always better to be slightly less full than too full when deciding about implant sizes.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve heard that you perform temporal implants. Where does these implants go, is it under the superficial temporal fascia or the deep  temporal fascia? I have heard the deep temporal fascia cannot stretch to cover an implant. Is that true? Also, does this implant reach down to the zygomatic arch and can these implants become infected? Thank you so much.

A: They are almmost always placed under the deep temporal fascia. There is no problem with the fascia stretching to cover it and the fascia is often released along the lateral orbital rim and superior zygomatic arch to accomodate bigger implants. I have rarely put temporal implants on top of the deep temporalis fascia as there is the possibility that the dissection or the pressure of the implant may injure the frontal branch of the facial nerve. The lower edge of temporal implants almost always extends down to the zygomatic arch. Like all facial implants, there is a risk of infection but this is usually very low around a 1% chance.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am confused about the whole facelifting thing. I am 53 years old and am beginning to show it. My neck and jowls are getting droopy and they make me look like a bulldog. I saw one plastic surgeon who said I needed a complete facelift (which I didn’t agree with) and I would need two or three weeks for recovery. Then a second plastic surgeon told me I just needed a ‘tuckup’ (I forget the name that he actually called it but it was something that used the word fast or quick in it) and I would be fine in a week. Why is there such a difference between the two recommendations and what do you think I really need? 

A: The concept of facelifts and their variations that have evolved in the past decade can be confusing. Combined with how they are marketed and advertised also lends an almost mystical quality to them. In reality, it is far simpler than what it appears. Facelift surgery traditionally speaks to correction of aging of the lower face only, the neck and jowls. As we age, jowling develops first which then leads to neck sagging and eventually wattles. Thus facelifts can be done either as a partial (aka mini-facelift) or a full version. The partial facelift is done when jowling is the main problem and any neck issues are either non-existant or minor. A full facelift is needed when the neck problem is the main issue or just as prominent a concern as that of the jowls. Thus, partial or limited facelifts are usually done on younger patients (less than age 55 or so) who have yet to develop significant neck sagging. The recovery from mini-facelifts is quicker because the operation is shorter and less invasive. These are also the type of facelifts that have become very popular, largely driven by people in the workface trying to look younger and refreshed to remain competitive. They have been given a lot of different marketing names that imply less surgery and faster surgery and recovery, all of which is true. But don’t let the names fool you, they are all very much the same surgery. A full facelift is usually needed in patients 55 to 60 years and older when the neck is a noticeable aging feature and either flaps around and/or gets in the way of shirts and neck wear. In these more complete facelift patients, other procedures may be beneficial and are combined with it such as eyelid tucks and browlift surgeries.

Between the mini- and full facelift patients lies an almost third category and may well be where you lie. In this facial aging patient, a partial facelift is not enough and a full facelift maybe more than they need. (this may be why you had two ‘different’ opinions.) In this type patient, I use what I call the 3/4 facelift whose level of invasiveness and recovery is somewhere between a partial and full facelift.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am confused about whether a just need liposuction or a tummy tuck. I am 5’ 3” and weigh 128 lbs. I have had two children but do not have stretch marks, I can only stretch my skin about an inch or two but it definitely is not loose. I have some excess belly fat  which looks strange on me given how thin I am everywhere else. My stomach muscles are tight and I don’t think there is any separation in them.

A:  I could not think of a better description of the indications for liposuction than in your question. A tummy tuck is needed when  one can grab more than an inch or two of skin, have one or more fat rolls, and can feel that there is separation of their vertical rectus muscle in the midline. Improving any or all three of these undesired abdominal features can justify the low horizontal scar that is the necessary sequelae of any form of a tummy tuck. The lack of stretch marks is significant because that signifies that your abdominal skin still has some elasticity…a key element in the successful obtainment of smooth abdominal skin after liposuction.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I am looking for help in fixing facial deformities and asymmetries. I have been to an Oral surgeon and a Maxillofacial surgeon before but they didn’t seem to care. I have a right sided facial deformity that bothers me alot. I would like to find some help for this problem. The right side of my face is under developed and I can see it and even feel it. My left and best side is more fuller and straighter.  My right side is smaller and recessed and less defined. Can an angled tilt in the jaws on one side be fixed? I have attached some pics for you to see.

A: Thank you for sending your pictures. I can see quite clearly the tilt to your jawline and the less full right mandibular angle area. It is not possible to cut the jaw bone and angle it downward without changing your bite on the right side. But it can be more simply and effectively treated by a mandibular angle implant, using specifically a type of jaw angle implant that extends the length of the jaw angle downward as well as making it more full. This would be done through an intraoral approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I plan on getting a rhinoplasty, chin, cheek and jaw angle implants this summer. It makes sense to me to have them all done at once. I have limited time off from work and only have a few weeks to recover at this time of the year. The one plastic surgeon I saw said he wouldn’t do them all at once as it would be too hard on me. I am not sure what he is talking about as I am young and healthy. I am aware that doing more surgery increases the overall risk of potential problems such as infection, but are there other risks to be taken into consideration, such as blood loss, that I am not aware of? Do you think it is safe and reasonable to have all of these facial procedures done at the same time?

A: In my experience and practice, I routinuely perform three, four, five or more facial procedures at the same time. For the reasons you have mentioned, such as recovery and other considerations such as cost, it is desirous to do a ‘facial makeover’ as a single stage procedure. There are no increased health risks for doing combination facial surgery in an otherwise healthy person. Blood loss is not a concern. With that being said, there is one risk that occurs in multiple facial restructuring procedures particularly those that involve facial implants…an increased aesthetic risk of implant asymmetries and the need for revisional surgery. The more procedures you do, the more risk there is for less than perfect results. Each individual procedure comes with its own aesthetic risks which are increased as more procedures are combined. Patients need to appreciate that the likelihood of the need/desire for revisional surgery is multipled as procedures are combined.   

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 42 years old and I had Smartlipo last month. My main reason for having it was to get rid of my neck and chin waddle. I see a difference in my lower face and chin, but I still see the waddle just like before surgery. I have worn my neck garment faithfully but I see next to no improvement in the neck waddle.  When should I be seeing results? The doctor told me it would take up to three months to see the final result as it takes time for the skin to tighten.

A: At your young age, it would seem logical that whatever neck and chin fat you have should respond well to liposuction. But the final results of liposuction performed anywhere depends on how well the skin tightens. Again at your age the skin should still have good elasticity. It is true that you should wait a full three months to see the final neck contour results. While the Smartlipo liposuction method does have some skin tightening capabilities, I emphasize to patients that this should be perceived in millimeters and not centimeters. Thus depending upon how much skin your waddle has, you may or may not see significant reduction over the next several months. If not you may need to consider a secondary tightening procedure such as some form of a necklift.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I am 49 years old and am interested in the LeFort 1 procedure. Please see attached photos and give me your advise, I had brace work done twenty years ago because my top teeth were behind my lower front teeth. I think a LeFort 1 procedure would have been more appropriate. Can it be done now? Please advise me as to what surgery would give me a more attractive face.

A: Thank you for sending your photos. What they demonstrate is that you have a midfacial hypoplasia and you are correct in that a LeFort I advancement done years ago would have been better for facial balance and midfacial fullness. But doing it now is not possible because it will change the way your teeth meet. This is why LeFort surgery and orthognathic surgery in general is done in conjunction with orthodontics. I have done them in patients your age and older but only if they were edentulous and wore dentures as new dentures are relatively easy to make.

What you can do now is camouflage your midfacial hypoplasia with paranasal/premaxillary facial implants to bring the base of the nose and the central maxilla more forward. This can be demonstrated with computer imaging. 

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I have been trying to figure out certain things about chin surgery. I have asked a couple of Plastic Surgeons about what is the difference between chin filling with injectable fillers and chin implants? Will either give you the same type results? Also, I would like to have a more pointed chin like that of the feminine version. Which procedure would give me this look, a chin shaving or chin implants?

A:  The use of injectable fillers vs an actual implant in the chin creates very different effects. One should not be confused with the other in terms of outcomes obtainable. Injectable fillers create small changes in chin projection and shape that are temporary. Implants create large amounts of chin projection and shapes that are permanent. The only role for injectable fillers in the chin in my practice is a test for some patients who are uncertain about proceeding with the placement of a permanent implant.

As to the best method of creating a more feminine pointed chin, that would depend on whether you are happy with your current chin projection both vertically and horizontally. If the present chin position is satisfactory, then it can be reshaped by lateral ostectomies through an intraoral approach . If the chin position is deficient in any dimension then a chin implant can be used to improve projection as well as shape. To obtain a pointy chin with an implant, a central button style should be used.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I read about your method of skull surgery. I am a young man with male pattern hair loss. Since no real cure is available I think I should just cut it very short or even shave it. The problem is that I have a skull indentation. I have never heard of this treatment. Should I go to a plastic surgeon or to a neurosurgeon to get some advice on this matter? Since I deliberately do not cut my hair that short for it to be noticeable I could not take a picture of it where you would be able to see it. I have attached a picture of a human skull and circled the area. It is an oval shaped indentation about 2″ long or thereabout and slightly less wide. It is at the part of the skull that is bending towards the top of the head. For this reason it is noticeable even though it does not appear to be a very deep indentation. I hope you are able to get a general idea of what I am talking about.

A: The relatively small skull indentation that you have is ideal for the minimal incision/injectable cranioplasty technique. Using Kryptonite bone cement, it is injected into the indented skull area after the scalp has been elevated. This is done through a very small incision of less than 10mms. Once the cement is injected in a putty state, it is molded from the outside until it sets firm, a process that takes about ten minutes from injection to set time. The trick to this technique is to get a smooth result that is not overcorrected.

Dr. Barry Eppley

Indianapolis, Indiana