Your Questions

Q: Dr. Eppley, I am interested in eyelid surgery (I'm Asian), nose surgery, jaw surgery and I have a small skull. I want some plate inserted to make my head fuller as I cannot tie back my hair without looking awful with small skull and square jaw. I need help as my self-esteem is very low and just can't accept my aging.When I was younger, I had a long face. Now that  I am 43 years old my jaw got wider. I am short and this just makes me look uglier. My skull is small and flat on top for my face. I am okay with the back of my head. I want  a fuller top without teasing up my hair to make my face proportional. I would like to be able to tie my hair back and tight without my face looking big and wide. I would like a deeper set of eyes and nicer nose too. I have expression lines across my nose. I wake up early for work and the fleshy eyelids means a lot of space for water retention. I have attached pictures for your review and thoughts.

A: Thank you for sending all of your pictures. Let me start by reviewing your requests based on the pictures that I see.

1) Eyelids – I see that you do have a high eyelid crease that is now overhanging with skin. I suspect given your ethnicity that you have always had a slight overhang with a crease but the skin is now overhanging more. Removal of the overhanging skin would be indicated which could be done to leave a little residual overhang or have no overhang at all, whichever is your preferred aesthetic result.

2) Nose – With your nose shape and ethnicity, the typical aesthetic goals would be a higher bridge and a narrower and more projecting nasal tip with possible nostril narrowing. Computer imaging will be needed to be certain of your exact aesthetic goals.

3) Skull – Based on your description, you desire a higher cranial height at the top located more to the back of the head. (vertex) This could be built up using a PMMA material with an increased height of approximately 10 to 15 mms using my standard skull reshaping techniques.

4) Jaw – Your wider lower jaw is as common ethnic feature that could be improved by either muscle reduction by Botox injections or jaw angle width reduction by lateral ostectomies. Given that these are rather different treatment approaches (noon-surgical vs surgical), it would be very important to have a precise understanding of your exact goals and their importance in this facial area.

What I would like you to do is to review these points, give me your thoughts on each and establish a list of  the most important to least important changes on this list.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  I have an unusual question. I’m half Chinese but my eyes are more Caucasian-looking. So I was wondering if there is a surgery to create an epicanthal fold at the medical canthus? ( the one that half covers/hides the tear duct). Some doctor once told it’s possible with a w-plasty or a jumping man flap to create a fold in the inner most part of the upper lid. And is it possible to lower the height of the eyelid? Like taking apart the previous fold and resetting it at a lower position? Many thanks and sorry for all the questions

A: The epicanthal fold area is composed of very thin and delicate skin that is prone to poor scarring, particularly in the Asian patient. Because of this scarring potential, unless the epicanthal fold is really prominent and bothersome, I generally steer away from surgical manipulation of this delicate skin.  Many of the operations described for epicanthoplasty, like the w-plasty and the jumping man flap, create a lot of tiny skin flaps and often scar poorly. They look great on paper and in diagrams, and do get rid of the epicanthal fold, but their scar result may not be a good trade-off. For this reason, I prefer a smaller z-plasty technique for epicanthoplasty which helps open up the narrowing effect that the fold has on the horizontal dimension of the eye.

Your question is one of the reverse of an epicanthoplasty or the creation of an epicanthal fold. I have never heard of that being done and certainly nothing is written about it. In my opinion that is possible through a different orientation of a z-plasty but my concern would be the scarring. As the fold of skin that would normally make up the epicanthal fold would likely have a line of scar on it, that may or may not have a natural appearance.

When you speak of lowering the height of the eyelid, are you referring to the location of the lid margin or the height of the supratarsal skin crease of the upper eyelid?

Please send me some photos of your eyes for my further assessment.

Dr. Barry Eppley

Indianapolis Indiana