Your Questions

Q: Dr. Eppley, What is the side by side custom testicle implant? It is hidden when cold and hangs down when it is warm. So I am not sure if you are thinking one or two silicone prosthetics .. wouldn’t it be weird to have 4 balls to touch .. 🤔 I probably did not understand.

A: The side by side technique is where the much larger testicle implant displaces the smaller natural testicles up and out of the way. In most patients because of their naturally small testicles they are not usually felt. This approach avoids the 10% to 20% risk of testicle displacement out of the wraparound or clamshell style testicle implant.

All testicle implants are ultimately just going to hang regardless of the temperature. Natural testicles contract because of the muscles in the attached cord. Testicle implants have no attached muscular cord.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m in the beginning stages of planning a facelift. I’m a 32 year old male who lost 100 lbs when I was 17. I went from 285 to 175 – and with that weight loss, came some loose skin around my body. My face is my biggest concern as it’s hard to cover up and has not shown any signs of tightening up. 

I know 32 is young for a facelift but I’m open to other suggestions/options. My biggest concerns are my skin sagging around my cheek and mouth area, jaw line and neck area are not defined very well, some brow area is sagging a bit, and my whole face drops when face down (there’s an awful photo I included). My face is also not symmetric – not sure if that is solvable. I’ve attached some photos for reference. 

Looking forward to hearing more

A:Thanks you for your inquiry, sending your pictures and congratulations on the weight loss. With that amount of weight loss there is going to be some expected loose skin in the face. At your young age the skin has a great ability to shrink but at a 100lb weight loss even young skin can not shrink down completely. Given that the vast majority of your concerns are around the neck, jawline and lower facial area, a lower facelift would be the appropriate treatment for it. The question is not whether you can have a lower facelift but whether the scar locations can be adequately hidden (which is always challenging in a male patient) and still get enough of a result to justify the effort. While most of the time I can just look at a picture of a patient and know the answer to these questions, yours is a unique challenge in that regard. This is the one time that I think seeing you in person will help me evaluate whether this is a good procedure for you and will help you best understand the incisional/scar locations for a lower facelift surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I notice a lot of wraparound jaw implant cases from your practice. I myself am looking into jaw and chin augmentation and was wondering what justifies recommending jaw implants over orthognathic surgery besides the respective recovery periods? Are the transformations in appearance generally not as drastic with orthognathic surgery alone? Are implants primarily to place patients within normal cephalometric discrepancies or are they more to do with patient esthetics? Does an objective improvement in the jaw always positively correlate with being in normal ranges based on ceph tracings? 

A: There are major differences in aesthetic outcomes and indications for surgery between orthognathic surgery and facial implant augmentations which primarily include the following:

1) Orthognathic surgery is first and foremost a functional operation whose primary goal in most patients is occlusal correction. Any aesthetic benefits are byproducts of that effort.

2) Equally important is that orthognathic surgery mainly affects the sagittal plane, it can not create width or specific definition to the face/jawline beyond that of chin projection.

3) Custom facial implants of the facial thirds produces far more dramatic aesthetic changes than orthognathic surgery that are highly controllable.

4) In custom facial implants cephalometric evaluation/norms are irrelevant. While it is a bone-based procedure the whole intent is what effect it has on the external soft tissues. Thus patient aesthetics rule.

In short, orthognathic surgery and custom facial implants are not comparative operations nor are they interchangeable. Both are done for different reasons with non-comparable aesthetic outcomes.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, is hairline lowering + forehead augmentation possible during one procedure and for a male patient? I have a slight asymmetry in my frontal bone where one side bulges out and is more prominent while the other side is flat and has a slight dip. This can be seen in pictures. The result I would like to achieve is seen in pictures 5, 6, and 7. I’d like top of the frontal bone more rounded with the side profiles raised, so that the hairline drops down and wraps around the curve and sits straight relative to my face as seen in picture 5. 

From what I’ve read online, a scalp advancement/hairline lowering is not typically recommended for men due to problems resulting from male pattern baldness/receding hairline and the eventual visibility of the incision scar. If this procedure is done, could minoxidil/Rogaine be an effective measure to prevent the hairline receding and hide the scar? 

If the scalp advancement/hairline lowering is not done, what other ways could we achieve the result in pictures 5, 6, and 7?

A: Thank you for your inquiry and sending all of your pictures to which I can say the following:

1) A frontal hairline advancement and upper forehead augmentation can done during the same surgery.

2) Like any hairline advancement the first question is always whether the patient’s new hairline position is achievable. Based on your own simulation, by pushing your hairline forward, and the natural scalp flexibility that comes with darker skin pigments, I would say the 10 to 15mm advancement you are simulating appears to be possible. (see attached)

3) There are two significant considerations to make in a male hairline advancement, particularly with darker skin pigments….1) how well will the hairline scar do in such a visible area and 2) as you have mentioned what is the permanency in a male of their frontal hairline position? These are two very relevant aesthetic questions of which the answers can never really be completely known…until you do it. I certainly have done darker skin pigmented males for combination hairline advancements and forehead work and have yet to see these potential adverse issues. But not having yet seen them does not mean they can not occur in the next patient.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I believe I have hyperdynamic chin ptosis as my chin appears normal at rest, however it is very prominent when I smile. I have never had any surgery done, so I believe this might be genetic. I would like to have this issue adressed so that I look the same when at rest and when smiling (my chin no longer looks so prominent/witch-like). What procedure would be best suited for this? Ideally I would like to have the surgery this summer.

A: Like many hyperdynamic chin ptosis patients you have a borderline larger chin at result due to a larger soft tissue chin pad. This larger soft tissue chin pad then pulls down over the edge of the chin bone when you smile. This can only be improved by a submental chin reduction technique in which the soft tissue chin pad is reduced and tightened around the lower edge of the chin bone.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I recently had upper forehead contouring surgery. (attempted forehead horn reduction). The discussed outcome however wasn’t met, as my forehead had been made flat on one side with the other side still having a horn/bump on it, to the point where my forehead is sloped and uneven. The side where my forehead bone has been shaved down too much has also caused my skull to flatten on this side, and I fear that this is dangerous as my brain has essentially had to become squashed into a smaller and flatter skull area. This has definitely affected my concentration. I wasn’t informed that my skull/head would be made flatter prior to the forehead contouring surgery.

As an expert craniofacial surgeon and someone’s work I’ve seen and admire with regards to forehead shaping, I wanted to ask what corrective work can be done as a result of this? I’m looking to potentially fly out in the future and also wanted to ask for your advice on whether the surgeon’s prior work is considered to be medical negligence?

A: In answer to your after surgery forehead contouring questions:

1) I do not comment on other surgeon’s work or abilities, I can only comment on the anatomical problem that I see and what may done about its improvement.

2) There is no medical or harmful issues with your current forehead/skull shape. External bony reduction does not affect the intracranial space or the brain as they are on the other side of the skull. The inner cortical layer of the skull remains intact.

3) Based on your current forehead shape and concerns the indicated correction would be a small right upper forehead augmentation and further left upper forehead reduction.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in aesthetic forehead/skull reshaping, in addition to anterior temporalis muscle reduction for head width reduction, however I previously had a coronal brow lift done. 

I understand that certain procedures, such as hairline lowering in particular, are contraindicated if one has previously undergone a coronal brow lift due to potential of compromising blood supply to the scalp. Are there any other procedures that are contraindicated if one has previously undergone a coronal brow lift? Are skull reshaping and/or anterior muscle reduction for head width reduction feasible? I suppose I’m concerned because they all involve the scalp. 

Thank you for reading.

A:While a prior coronal browlift means one can not a frontal hairline advancement in the future, it does not preclude any other bony forehead or temporal muscle procedures.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have had manly broad shoulders my whole life it’s made me quite self conscious wondering if there’s anyway we couldn’t shorten them I’m not sure if this is a thing please let me know I look forward to a response! 

A: Shoulder reduction surgery is a real and effective surgery for narrowing one’s shoulders whether it is in a transgender male to female or cis-female patient. I would refer you one of my websites, www.exploreplasticsurgery.com, where you can place in the search box the terms, Shoulder Reduction, Shoulder Narrowing or Clavicle Reduction, where you can read in detail how the surgery is performed as well as the recovery from it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m looking for a solution to my hollowed out eyes. Or perhaps you would consider them deep-set. In any case, it seems that ocular surgeons are afraid or unwilling to fill the hollows under my eyes, and I can’t understand why. Perhaps you have a different opinion or solution.

A: I fill undereye hollows all the time. If the surgeon is not familiar with the use of custom infraorbital and infraorbital-malar implants then they do not have adequate tools to ideally treat the problem for certain patients…which would explain their hesitancy/inability to do so.

It is not that it can’t be done but you have to have all of the tools/techniques to do so.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had an online  consultation with you three years ago and you provided me with predictive imaging of the procedures I would be getting. (custom Infraorbital, midface and jawline implants). I had originally planned on getting these procedures done this year but after getting a sleep study and CBCT scan of my airway done, I have come to learn that I will have to undergo double jaw surgery to address these issues. I have also attached updated pictures and a CBCT scan of my skull if it is of any help. Please let me know if I can provide any further information.

1. While double jaw surgery will address my maxilla , lower jaw and chin, I have read that it often will exacerbate an “upper midface” deficiency around my eye area (which I already have). I would like to address this area with custom implants. Is it possible to come up with a surgical plan for this after my orthognathic surgery?

2. What is the approximate cost for custom midface and custom infraorbital implants ? I realize this is a very broad question but was wondering if it would be possible to get a rough range.

3. What is the maximum vertical augmentation possible to get in custom orbital rim/zygomatic implants.

A: In answer to your questions:

1) Bimaxillary advancement surgery will definitely exacerbate an infraorbital-malar skeletal deficiency as it is left behind from what moves forward below it. It is not uncommon to design custom midface implants to treat that issue secondarily.

2) My assistant Camille will provide that cost information.

3) There is no absolute vertical maximum for raising the height of the infraorbital rim, short of staying below the level of the orbicularis muscle below the lashline. I have never seen anyone that needs more than 7 to 8mms. Most patients are in the 3 to 5mm range

 Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hi, I want to look tall with a head implant. Is that possible? And how many cm will I grow? Minimum how many cm?

A: With a 1st stage scalp tissue expansion one can have a skull implant that adds 3cms…but you have to careful in just adding height as the head may look too ‘skinny’…so it needs to come down over the sides into the temporal region as well.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, my situation is I had a zygomatic sandwich surgery done and now look like a woman. It gave me way to much projection in the lower part of the cheekbones, I have a revision surgery booked for later this month and I will either reverse 100% the zygomatic sandwich surgery and get a implant at a later date, or I will reverse just 50% of my zygomatic surgery… but I still don’t think it will achieve what I want as I am looking for a very high look with projection on the zygomatic arch back to the ear, 

This is why I need to talk to you as soon as possible so you can help me decide if I should reverse 100% and get a implant or reverse the surgery just 50%

I have attached three photos, two photos is where the zygomatic arch was done with filler and had the high cheekbone look and the second is with the zygomatic sandwhich surgery. It gave me a chipmunk look. I want permanent projection like I had with the filler. 

A: The question you may be seeking to answer I can answer right now based on your goals and how the zygomatic sandwich osteotomy (ZSO) procedure works…you need to reverse it 100% and get an implant later. The ZSO procedure does not create a high cheekbone look which is what you are seeking and what your previous filler has created. The ZSO pushes out the main zygomatic body laterally but not the zygomatic arch, creating a wider anterior cheek look. While it is an autologous procedure (avoids an implant) it simply can not create the high cheekbone look and trying to do so with it is a structurally flawed concept.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting a mandibular angle implant surgery (on one side only) to correct asymmetry on the lower part of my face. In other words, I am looking to match the side that is flatter to the side that is fuller. I had asymmetry in the mandibular area since birth. It bothered me a bit less since the overall facial volume/baby fat camouflaged the asymmetry somewhat when I was younger. But as I aged and lost facial volume, I started noticing the issue become more apparent to the point where I feel the need to address it. Moreover, the lack of fullness in the mandibular area not only causing visible asymmetry but also does not provide adequate support for the upper face, which exacerbates the sunken/gaunt appearance. I have looked into fillers but I prefer a permanent solution in the form of an implant. 

1. Based on the picture, would you recommend “off the shelf” or a custom implant to address the issue? Or any other type of implant? 

2. It is also important to me that an implant is made out of silicon and NOT porous polyethylene, as I would not want to have anything in my face that can’t be easily removed if there is an issue down the road. Also, from doing my research about this procedure, I think it is important for a surgeon to secure an implant with screws to avoid any type of implant migration. Do you agree? 

3. Also, I would like to know the recovery (how quickly can you return to work, etc.) associated with this type of surgery. 

Thank you very much and I look forward to your response.

A:In answer to your jaw angle asymmetry questions:

1 I would never try and use a standard implant to correct jaw angle asymmetry. All that will do is just create a different type of jaw angle asymmetry. These asymmetries may seem ‘simple’ to correct but they are not. It requires implant design precision to do so and only a custom approach gets the best chance to optimize jaw angle asymmetry.

2) Solid silicone is my custom implant material of choice for the very reason you have mentioned. There is no type of jaw angle implant that should be placed without screw fixation.

3) Swelling is the primary recovery issue which will take 2 to 3 weeks to look non-surgical and up to 3 months after surgery to really judge the final aesthetic result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hi there! I had a question about facial implants.  I had vertical lengthening jaw angle implants about four years ago and I am starting orthodontics for TMJ soon and it will be moving my lower jaw forward just shy of 2mm and moving other teeth etc.  I was hoping that my jaw implant won’t be affected by the orthodontics and jaw bite plate that will move my jaw joints?

Thanks so much

A:If you are not having an open surgical procedure on the jaw angles, which it appears you are not, then your jaw angle implants should be unaffected by these orthodontic treatments.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,I am slightly concerned about the eye incision for the infraorbital-malar implants:

• • 1) What are the reasons for not inserting them through the mouth?
  • 2) What types of patients are more at risk of developing lower lid retraction?
  • 3) Are patients with darker skin tones more likely to develop lower lid retraction?
  • 4) If lower lid retraction does happen, are there any procedures that can be done in the future to help improve their appearance?

A: In answer to incision questions about the the infraorbital-malar implants:

1) When placing the implants through the mouth the risks of infection, implant malposition and permanent numbnerss of the infraorbital nerve are dramatically increased. Have done that many times and seen all of these issues it is not an approach I will ever use again when the eyelid incision has virtually none of these issues.

2) The risk of lid retraction is very low in this procedure because it is a non-excisional tissue access approach usually done n young people with good lower lid tissues and canthal support…and infraorbital rim support is being added.. This should not be confused (which it often is) with a traditional lower blepharoplasty done in older patients with weaker lid support and where lid tissues are actually removed. The few times I have ever seen any lid retraction is if a postoperative hematoma has occurred or the infraorbital rim is raised excessively high in close proximity to the incision location.

3) Skin pigmentation does not increase the risk of lid retraction or adverse scarring in my experience.

4) The treatment of lid retraction is well established with release, spacer grafts and canthopexy/canthoplasty as effective techniques.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 20 years old and my skull and temples are narrow which makes my face looks bigger is there any other way other than surgery and implants. Can’t you put something on top of the scalp or skin and not inside it. I just want to look normal but I am very scared of surgery especially on my head and temples.

A: Unfortunately the very thing you fear is the only way to make any difference for a narrow head shape.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am just over 3 weeks out from having double jaw surgery (3 piece lefort 1 w/BSSO).  I also had cheek implants added because of deficient mid face growth. Lastly I had a mandibular jaw angle implant on one side only… reason was that  the other side has a little bump that jetted out and the implant was to make both sides symmetrical. However, swelling/ that side of my face where the angle implant was placed is way bigger than the other side. I got steroid shots but no improvement. My doctor said the swelling is preventing the jaw to set properly in the joint on that one side which makes it look worse. Two other things he noted: location for that implant requires much more than just reposition the jaw like the other side…he said it requires positioning it under the back muscle which requires work that induces note swelling. 

I noticed the structure itself compared to the other side was not symmetrical when putting my finger to both and using my ears to gauge. He said not to use that because the tissue on one said was thicker than the other so he accounted for that so you can go off bone because it will even out when settled in which could be 7-9 months.

Would like to get someone else to look at it to be sure it’s not the implant size that’s incorrect and too big. Pretty sure it was a Medpor implant…. 12 months from now could make it hard to replace.

However, if this is all normal and you’ve seen similar instances turn out well given time to heal, I wouldn’t mind that and happy to wait… just want a good outcome.

Thank you for your time!! 

A:I do not comment on any surgical result while under the active care of their primary surgeon. That is both inappropriate and a disservice to both the patient and the surgeon. What I can say as a general statement is that when the positioning of any facial implant is in question, whether it is 3 weeks, 3 months or 3 years, you don’t guess by external look or feel. You get a 3D CT scan which can show the exact position of where the implant is.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,I have a few additional questions about the secondary t-shaped genioplasty procedure.

I would be interested in a small amount (2-3mm) of additional narrowing at the same time as my projection is restored. Would this be possible given that I had a t-cut osteotomy as part of my original genioplasty in November, or would the risks of shattering/unwanted fracturing be too high? How much time passage between my original surgery and the revision would allow this cut to be done safely (or would it never be possible)?

Additionally, part of the reason I’m interested in restoring my projection is to address soft tissue laxity in the submental region and ptosis of the chin pad that has come from the horizontal reduction. If I were to have a few millimeters of narrowing, would that fully or partially negate the benefits of restoring the projection horizontally? What are the risks of ptosis from narrowing genioplasty vs from horizontal reduction?

A: In answer to your secondary bony genioplasty questions:

1) I would not advise doing a secondary narrowing of a t-shaped sliding genioplasty for a few extra millimeters of narrowing. That bony union is often incomplete and it never heals in a completely normal shape. Doing it a second time may risk further incomplete healing. Point being is that it is not worth it for that small amount of difference.

2) Any loss of bone support, regardless of the dimension, is another factor that either creates more or risks optimal improvement in the chin ptosis.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, In 2017 I had double jaw surgery, bottom was moved backwards and top moved forward. After time has passed my cheeks have gotten really saggy and my midface is unbalanced. I am wondering if maybe cheek inplants can sort of give me more fullness in the mid face and also add structure, to kind of lift my saggy cheeks.

A: One of the well known adverse effects of a LeFort osteotomy can be loss of cheek fullness and/or the development of excessive persistent fullness in the lower cheek area. (due to the wide subperiosteal tissue release needed to perform the procedure) Such effects can become more apparent also based on the type of upper jaw movement, particularly in larger forward advancements. Increasing the bony support of the cheekbones can help but the key to doing so is to get the right style and size of cheek implants in place. What you really lack is a combination of undereye and high cheekbone structural defieciency. This is where a custom infraorbital-malar cheek implant style works best. Standard cheek implants do not have the ability to provide this type of bony footprint coverage.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I underwent a buccal lipectomy about a year and a half ago and I was very dissatisfied with the result. Searching for a solution to my problem, I recently read your article on buccal lipectomy reversal with dermal-fat grafts and was interested. I would like to know if you did more cases similar to the one reported in the article and if you had good results. In addition, I would like to know the chances of graft necrosis in the procedure. 

A: As you may know the most common treatment for any form of facial fat loss/atrophy would be fat injections. But in the handful of cases where patients have specifically requested non-injectable dermal-fat graft for buccal fat restoration have done well and have not suffered fat loss/necrosis. That is not a surprise to me as the typical size of the buccal fat pad is in the 3ccs range, which translates into a small dermal-fat graft, which usually does well anywhere on the face when implanted.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would be interested in finding out about fixing the shape of my skull (a bit pointy towards the top and flat on the back). See the pictures attached. I just found out about Dr. Eppley’s work here online and am impressed by the results from the photos I saw. Please contact me and let me know.

A: Thank you for your inquiry and sending your picture. From the front view reduction of the pointy head is usually done by reducing the height of the sagittal crest. (point) The flat back of the head (which I know by your description but have not seen a picture of it, is usually treated by a custom skull implant.

Both the posterior sagittal crest reduction and the augmentation of the flat upper back of the head can be done through the same small incision.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, The back left side of my head is a little smaller than the right side and I never really realized there was a difference until now. I’m now 25 years old and I’m extremely self conscious about it. It’s extremely noticeable when I turn my head to the side, my whole left side of my face looks smaller because of this. I believe it’s called plagiocephaly but I have never talked to a Dr about it. At my age is it too late to have a surgery because I know you’re supposed to catch this early on?

A: Treating adult plagiocephaly head shape concerns with a custom skull implant can be done at anytime in an adult’s life. You are referring to non-surgical helmet therapy for head reshaping which must be done in the 24 months after birth.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m curious about your testicular implant surgeries. I have used metal testicle stretchers (1-10 lbs at a time), and have done saline infusions into my scrotum (up to 2.5L of 5% dextrose saline) and have learned about your surgeries recently. I know of people that inject silicone into their scrotum, but the danger and permanence of silicone injection in that area has turned me away. Hearing about your work with silicone implants, that can ‘wrap’ around the existing testicles has piqued my curiosity, so I figured I’d reach out with some questions. On the page you describe the implant process, you mention the largest implants you’ve done have been 7cm in length. Doing some rudimentary measurements, one of my testicles is about 2 inches, and the other is about 1.5. Pulling my scrotal skin outwards, and measuring from the base of my scrotum the measurement is a bit over 8inches, and pulling apart the skin to the sides reads a bit over 7 inches. I was curious whether you considered doing larger testicular implants, and whether with large amount of ‘space’ I have what size I might be able to accommodate. I’m also curious about how many of these types of procedures (or similar) you’ve done. I know there’s not really such thing as a ‘safe’ surgery, but I was also curious what the risks of something like this may be. 

Thanks for taking the time to read this, and for any information you may have for me, 

A: In answer to your testicle implant questions:

1) Whether you can safely handle an implant size greater than 7 cms I can not say. It may be so. But external measurements by stretching scrotal skin do not really tell what the displacement effects may be with an internally spaced volume, particularly when there are two implants. But with your history of stretching and saline infusions it may be possible. In this situations/requests I have to be prepared for what happens if the size chosen (let’s say 8 cms) does not fit in surgery. Thus a backup smaller implant size must be available.

2) When it comes to specifically wrap around testicle implants the only complications I have ever seen in when the testicle slips out of the implant after surgery. (which has occurred twice and occurs early before encapsulation occurs) What I have learned from that experience is to place a suture between the closed end of the implant up through the bottom end of the testicular capsule and used that pull it into the implant and then tie it down. That will prevent that potential displacement issue.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I just had a quick question regarding surgeries you preform. Is it possible to get both clavicle reduction surgery, and rib removal surgery for a smaller waist, at the same time? Additionally, does liposuction of the waist work to get a smaller waist measurement for patients who are skinny or normal weight, and how much does it tend to reduce the waist by? 

A: Typically shoulder reduction and rib removal surgery is not performed at the same time. That is a difficult recovery that few people would be advised to undergo. In exceptional circumstances if the patient has accompanying support it may be possible in selected patients.

Liposuction of the waistline alone in skinny patients would not be expected have any real reduction effect of the waistline.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My face is severely lopsided and my lower jaw does not sit exactly in place. It is very noticeable when looking in the mirror or inverted photos of myself. One of my eyes is also larger than the other and one of my cheeks has much more skin/fat than the other as well.

A: Thank you for your inquiry and sending your pictures. What you have is a right facial asymmetry, which affects the entire right side of your face, but in which the greatest asymmetry is inferior or lower. Your chin/jaw deviation is the most severe component of your facial asymmetry which becomes less so as it proceeds superiorly. (mouth corner is lower, nostril is lower and wider, cheek is fuller, upper and lower eye corners are lower with upper lid ptosis)

All of the issues above the jawline can be improved by soft tissue procedures  which can be determined by what is seen externally. The chin/jawline, however, has undoubtably a major bony component to it. This will need to be assessed and treatment planed by first getting a 3D CT scan of your face.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have several questions about sagittal ridge reduction surgery: 

– Is a CT scan required if only burring will be performed (e.g., no implant)? 

– Do all sagittal ridge reductions require placement of a drain? If possible, I would like to avoid a second scar from the drain tube, even if it means a slightly longer recovery. 

– What determines the length of the incision? Is it the amount of distance you need to sweep the burr left-to-right (laterally)? The length of the ridge (posterior-anterior)? The curvature of the skull? The tightness of the scalp? 

– What determines the shape of the incision? For posterior ridge reduction, I noticed that some of your incisions have more of an arc (u-shape), while others are closer to a straight line. Why the difference, and does the patient have a choice of incision shape? 

– Are dissolving sutures used, or does the patient need to return to your clinic to have the sutures removed? 

– Will hair grow through the scar tissue? 

– For those who do opt for an implant, how often does the implant’s edge become visible once the swelling resolves? For horseshoe-shaped implants, I assume that it’s difficult to get the prefabricated implant to transition seamlessly into the burred crown region. 

– Have you done any off-label testing of verteporfin to minimize scar formation? This could be a game changer if it’s effective! 

A: In answer to your sagittal ridge skull reduction questions:

1) A preoperative CT scan is not usually needed if no implant is required.

2) All sagittal ridge skull reductions require a drain which is removed in 24 hours and leaves no visible scar when healed.

3) The length of the scalp incision is based on how much access is needed to properly do the reduction. I always start out very small and then enlarge as needed.

4) The shape of the incision largely follows the hair pattern. I have no preference if it is straight or curved. It heals very well either way.

5) Small dissolvable sutures are used which don’t need to be removed.

6) Hair rarely if ever grows through a scar. The real question is whether the hair will grow right up against the edge of the pencil thin scar…which it usually does.

7) Generally implant edging is either non-existant or very minimal…as has been revealed many times in the patient that provides the most severe test of that effect…the male who shaves his head. It is usually not a problem because I lok for it and adjust the implant edges as needed.

8) I would not use Verterporfin in humans based purely on studies performed in mice. How that translates to humans is not yet known…not so much in regards to its benefits but rather what the adverse side effects with its use may be. Why take an operation which typically has superb scars and risk it for a very minimal benefit. I shall await what incisions in humans reveal with its use.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,

•Is the Rhinoplasty with an open or closed scar? My previous surgery was closed and would really prefer not having another scar if possible.

•How far into the sides of my head is the incision for the forehead advancement? Also does the “zig-zag incision effect the shape of the hairline result or does it just mask the scar slightly.

A: 1) Any efforts at a secondary rhinoplasty require an open approach due to altered anatomy and scar. But that answer depends on what exact further nose changes you are seeking.

2) The hairline advancement goes into the upper temporal region. The zigzag portion is along the frontal hairline part, once into the temporal region it becomes straightline The role of the zigzag incision is for the frontal hairline where a straightline scar looks more unnatural.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a Zygomantic Sandwich Osteotomy 1 year ago. I want to reverse it and not do anything else. My face became somehow “bloated” and I don’t like it. I also had SARPE. I know, that a genioplasty would also improve my face, but that is not a concern at this moment. 

A: Bone rarely grows over the ZSO osteotomy fixation site. And whatever bone growth around the plates and screws that is going to occur has already occurred by now. Reversal of ZSO involves cutting out the healed bone graftand putting the cheekbone back from whence it came.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, For the pectoral implants, I have a question. I still have fatty tissue and glandular tissue on my male breast. It must first be removed before the pectoral inplants is inserted? 

A:  Gynecomastia reduction surgery can be performed concurrently with pectoral implant placement if the patient so desires.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, So I would like to place custom medpor cheek implants because I have read that over time it will adhere to the bone but I have also read that the risk of infection is higher than with silicone implants but I also read that silicone implants can cause bone erosion over time and that they were more likely to move, so I would like to know according to you which material is best for long term cheek augmentation without surgery revision and without the implant moving (for example for 60 years).

A: In answer to your custom cheek implant questions:

1) Every implant material has their own advantages and disadvantages, there is no one best material.

2) While Medpor does allow tissue ingrowth, it is considerably more expensive than silicone, does have a higher infection rate and is more difficult to revise/modify/remove.

3) Solid silicone remains the primary material I use for any custom facial implant as it is more economical, has  a lower infection risk and is much easer to revise/modify/remove should that be necessary.

4) It is a myth that silicone facial implants can move or migrate after they are healed in place. It is true that if you don’t screw them into place during surgery the size of the pocket needed to place any implant can allow them move then due to one slippery surface on another. (but not once healed) Thus the value of immediate screw fixation.

5) It is not realistic to believe that any implant placed in the face or body will never have a risk of revision. The most common reason for revision are aesthetic in nature not due to infection or ‘migration’. There is no guarantee that someone will like the aesthetic result or may feel the need to make some change in their size or shape, whether that is 60 days or 60 years after their placement.

Dr. Barry Eppley

Indianapolis, Indiana