Your Questions

Q:  Dr. Eppley, I have a question regarding browlift surgery. I have a low hairline which is only about 2 inches from my eyebrows to my hairline. Would a browlift/forehead lift increase my forehead length and can this be done without moving my eyebrows higher. I am young but I have a lot of laxity in my forehead. Thanks!!

A: The simple answer is…no. You can’t lift/stretch the forehead skin upward without moving the eyebrows to any significant amount. Since the whole forehead skin must be loosened to get any movement, the eyebrows will naturally be raised although not to the degree that the skin is lifted since they are the furthest away from the location of the pull. You might get a half inch up to an inch if your forehead is really lax but no more. Browlifts, by definition, raise the eyebrows.

It is possible to really lengthen your forehead through tissue expansion but this is a two-step surgical process. This is where a tissue expander is initially placed under the forehead skin during the first procedure. This is gradually inflated by saline injections over four to six weeks to make the forehead skin ‘grow’. Once adequately expanded, the tissue expander is removed and the forehead lengthened with the extra skin created. This can increase the forehead skin length by several inches if desired.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I am interested in getting cheek and jaw angle implants. My jaw angles are very steep which got worse after jaw surgery for a bad bite several years ago. My cheeks have always been flat and I get Radiesse in them which makes them look better. Can you tell me what types of implants I should get and what are some of the complications that could happen that I should be aware of. I have attached some pictures for you to see what my face looks like.

A: Thank you for sending your pictures. I have reviewed all of them. The key to your successful facial implant surgery is to have appropriately-sized implant selections. For the cheek area, you would benefit by implants but they must be small to not overwhelm your feminine face. Small malar shell style would work well for your face. For your jaw angles, you need implants that provide some vertical lengthening but minimal width increase, otherwise you will create a wider fatter face and not a nice jawline enhancement that fits your face. Small Medpor RZ angle implants (3mms width and 10mms length) should work nicely, but no bigger.

Implants should be placed that fit the face. As it turns out cheek and jaw angle implants are the most highly revised of all facial implants. The problem with many cheek implants is that they are too big. The problem with many jaw angle implants is that they are improperly positioned and/or secured.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am looking for an opinion regarding correction of my steep jaw line. I had orthognathic jaw surgery in 1998 to correct an underbite, but over the years I feel that the angle of my jaw has gotten steeper, giving my profile a “harsh” look. A doctor has suggested jaw angle and cheek implants to balance out my chin and soften my face. I am hesitant to go under general anesthesia and am concerned with the risks of the procedure and, most importantly, whether it will improve my look. I was told that another option is filler in the jaw line, but that an implant would provide more correction.What would you recommend for me? Do you think that jaw angle implants would improve my look? Do you think I could achieve good results with just filler? After going through orthognathic surgery, I was hoping to have achieved a better result and I feel self conscious about my jaw line. I have attached some pictures for you to review.

A: Based on the viewing of your side profile, your jawline is characteristic for someone who has had a mandibular setback osteotomy for a Class III malocclusion due to an original mandibular prognathism. This can adversely shorten the jaw angle and increase its plane angle. I can understand the proposal of jaw angle and cheek implants to give your face more skeletal balance. The real questions are, however, will it make a positive change and is it worth undergoing surgery for it.

There are two ways to provide insight to those questions. First, computer imaging should be done with jaw angle implants alone and then combined with cheek implants. While computer imaging is an estimate and not a guarantee, I have always found it very helpful for prospective patients. I have done that for you and it is attached. These are based only on a side view. The front view you have provided is not good for imaging because you are smiling and it doesn’t show the jawline/angle all that well. The three-quarter or oblique view is the next most helpful view to evaluate. Secondly, injectable fillers can be an alternative to see if the concept of implants would be appropriate. When placed next to the bone they can provide some bone augmentation. But they will never produce the same effect as adding implants because of the sheer volume differences. Injectable fillers are never a comparative substitute for facial implants but they may provide some insight into whether bony augmentation is the right concept. If one is not absolutely certain that implants are the right answer, try fillers first.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Hello Dr. Eppley: I had a kidney transplant in 2006 in which my donor was my identical twin sister. Therefore, would I still be a high risk for the surgery? Fortunately, I do not take any anti-suppresent medications. Thank you.

A: I do have experience performing elective plastic surgery on kidney transplant patients. Ironically, about 10 years ago, I performed face and breast surgery on two sisters who were cadaveric kidney recipients. I performed multiple procedures on them and never had a problem. Just a few months ago, I performed a facelift and rhinoplasty on a man who had a family-given kidney three years previously. In his case as well, he healed without any problems.

The management of surgery on a kidney transplant patient is to first check with their nephrologist and let them know of any surgical plans and get their clearance. As long as there is no risk of excessive  bleeding that would drop one’s intravascular volume and/or require high volumes of fluid or blood products (which no cosmetic procedure involves), then there are no major risks to the kidney or healing. One should not use any anti-inflammatory medications or oher drugs that would have any nephrotoxic effects during or after surgery. Other than these considerations, there should be no problems with undergoing plastic surgery or healing from it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had in orthognatic surgery several years ago for a bad bite that gave me a lot of problems with my teeth and pain in my jaws every morning. While the surgery went fine from a technical standpoint (my bite is better) it left me with a very bad look. I think it is because he made some mistakes with repositioning the masseter muscle as my face shrunk on the sides and left me with a lot of loose skin. This makes me look 10 years older then my age. I’m now 50 and I look older. I am used to always looking much more younger than I am. I’m very unhappy and I don’t think normal lifts of skin will help because what is missing is underneath, it needs to be filled in. I need deep tissue filling not just stretching the skin. Here are some photos for you to see what I mean.

A: What I see on the photos is lack of jaw angles and loose jowl and neck skin. The jaw angles actually appear both high and indented or concave. I think the jaw angle issue is a result from your orthognathic surgery but it was not a mistake by the surgeon. Mandibular osteotomies involves elevating the masseter muscles off of the bone to perform them. There is no such thing as having to reposition them during the surgery as they simply fall back into place. But what can happen is muscle atrophy/shrinking from the trauma of the surgery and I believe this is what you have experienced. Because of the lack of a jaw angle, you would benefit by small lateral augmentation style of jaw angle implants. This could be combined with a limited neck-jowl lift (facelift) to create a more youthful jawline and nek appearance.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I have concerns about cheek implants that I had placed about six weeks ago. My cheek implants were Medpor implants that were screwed into place. What I am worried about is that I have numbness of my left lip and cheek ever since the surgery. I thought it would be gone by now but it hasn’t. Is this normal? Also, it feels extremely tight around my nose. I think all of the swelling has gone away so I thought they would feel more normal by now. What do you think? Thanks.

A: Depending upon the style, size and location of the cheek implants, they likely extend around the infraorbital nerve which comes out of the bone just below the rim of the eye socket.  This is a big nerve that is responsible for the feeling of the skin around the nose, upper lip and teeth. (but not movement) When cheek or midface implants are placed around this nerve, it would be common to have a period of numbness to the areas that the nerve supplies. The key about this numbness is whether it is improving or not. If there has been some gradual improvement in the amount of numbness six weeks after surgery, then it is likely going to go away in a few more months. If it is just as numb today as it was the first week after surgery, the implant may be putting pressure on the nerve and may need to be repositioned. Screw fixation of cheek implants can sometimes be a double-edged sword. The implant is rigidly fixed into place and if it is leaning up against the nerve, there is no relief from the pressure of the implant.

As for the tightness of the face, this is a feeling that should go away as the swelling subsides and the overlying tissues adapt to the ‘push’ of the implant.  Since the implant and the bone on which it sits is rigid, the overlying tissues must adapt to them. As a general rule, you should not judge the look and feel of a cheek implant for at least 3 months after surgery to these tissues time to relax. It is also possible that the tightness is because the implant is too big, so you need to see how it looks as the swelling goes away.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  Will massage make my Botox go away more quickly? I got Botox to my forehead several weeks ago and love the results! I regularly get facials and massages and am worried that putting pressure on my forehead or rubbing bit too much will make the Botox wear off. I have read that this can happen. Is is true?

A: I have heard that question many times from numerous patients and I can tell you emphatically that it is not true. When you understand how Botox actually works, and more importantly, how it wears off you will see that rubbing or massage has no bearing on the length of its effectiveness.

Current understanding of how Botox works is that it goes into the nerve endings and blocks the release of the neurotransmitter, acetycholine, from the mitohondria where it is produced.  This is why it takes days for Botox to work. The nerve ending must use up the acetycholine that still exists (has been released) into the nerve ending. Once depleted (and it is not making anymore) the nerve ending can no longer send its chemical signal to the motor end plate of the muscle and make it move. Conversely, Botox wears off by growing new sprouts or axons from the nerve around its non-working ending to attach to the muscle to start working again. To the best of our knowledge, massage or any other manipulation does not increase the growth rate of these axons. Thus, you can’t really make the muscle start working by pushing around on it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  you have mentioned your experiences with porex facial implant removals. I am looking to get my pair of porex cheek implants removed that were placed about a year ago. I am 26 years old and hoping my face will be able to return to its pre-surgical state, but given the scar tissue must be removed am I setting my expectations too high? I am worried that if they are removed my cheeks could be even more depressed than before my original surgery.

A: I have heard and read about the ‘scar tissue’ that must be taken with Medpor facial implant removals numerous times. From my perspective, it is largely a myth and not reality. It is very similar to them being hard to remove as well. Both those issues stem from a comparative experience with that of silicone facial implants. Compared to the very easy removal of any silicone-based implant (it is very smooth so it slides in and out easily), the porous outer surface of Medpor does make it more ‘difficult’ but then anything would be hard compared to silicone. Medpor implants can be removed with just a little more effort and there is no reason to be taking out any scar tissue (known as the surrounding capsule) with them.

Therefore, when it comes to removing your Medpor cheek implants, a potential loss of volume in the cheeks will not come from having had scar tissue removed. But it is likely that it will occur due to a common implant sequelae known as tissue expansion. Depending upon the size of the implants you have in, there will likely be some cheek volume loss and/or sagging due to the stretching of the overlying tissues and the separation of the attachments of the tissues to the bone. Once the implants are removed, these tissues may not stick back down just the way they were before surgery. This potential problem can be countered by either inserting a smaller replacement implant, performing soft tissue resuspension, or inserting a dermal graft into the implant space to act as a ‘natural’ implant volume replacement. Whether any of these are appropriate for you is impossible me to tell based on the information that you have provided.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had extractions and braces before as a child and it left me with a very flat face. I am now having the teeth brought back forward and the spaces re-opened. However even with the lips looking normal I’m thinking my midface my still be a bit concave and am wondering if bone grafts for the missing upper bicuspids would fill in the midface paranasal area or would I be better off just getting something like paranasal implants?

A: Any adjustment at the tooth or alveolar bone level, orthodontic or otherwise, is only going to affect the lip that sits in front of it not the facial profile. The base of the nose and the rest of the face sits above the level of the upper tooth roots. Therefore, bone grafting into the bicuspid space would not be helpful even if it could be done. Bone grafts on the paranasal area, while in the right place, are associated with almost complete resorption due to a lack of stimulation through masticatory forces. The predictable solution would be paranasal implants which are structurally stable and can be carved or shaped into any thickness that matches the needs of the patient’s paranasal augmentation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting cheekbone reductions and fat injections at the same time. I think with the cheek reductions I don’t want my face to be too narrow, long and look too old. Does this make sense to you? Also where are the incisions for the cheek reductions? I know that these are uncommon surgeries for Americans so what is your experience with them?

A: My recommendation is that you wouldn’t do fat injections at the same time. That would be counterproductive. The reason is cheek bone reduction, at its best, can never make your face too long or sunken in. The procedure never overshoots the goal, at best it will underachieve. There is a limit as to how far the cheek and zygomatic arch can be moved inward…it is known as the masseter and temporalis muscles. That is what lies underneath the width of the arch so they are a rate-limiting step as to how much facial narrowing in this area can be achieved. Therefore, I think the idea of simultaneous cheek fat injections is both presumptuous and unnecessary This is a good example of the plastic surgery principle…let the results prove that you need more surgery.

Cheekbone reductions, as I have described, are done from two approaches. The front part from inside the mouth and the back part from a small incision in the temple hairline.

You are correct in assuming that almost all cases of cheek bone reductions are in Asians. (although I have done one Caucasian patient to date) No one’s experience in the U.S. is extensive with this procedure since the demand is so low. But this is a cosmetic procedure that has its origins in cheek bone fracture repair and reconstruction of which a plastic surgeon with extensive craniomaxillofacial experience is very familiar.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in changing the look of my nose. I am Asian and my nose looks too much like a button on the end. I would it to be slimmer. I have attached some pictures of my face. What type of rhinoplasty do you think I need or would be helpful to achieve this goal?

A: Your nose has many typical Asian features marked by a short columella and broad tip with thick skin. There is no definition to the tip which I assume is what you mean by a button tip. But the shortness of your columella has also created a nasolabial angle that is less than 90 degrees. This magnifies the ‘button’ appearance of the tip of the nose and certainly make it look flatter. This could be improved by a rhinoplasty that reshapes the tip through a columellar strut graft onto which the lower alar cartilages can be reshaped. This would help open up the nasolabial angle and provide a little bit more length to it. This would produce tip narrowing and elevation, effectively changing the flat and wider tip to a more shapely one. The thickness of your nasal skin will limit how much narrowing can be done but improvement can certainly be obtained. I have attached some rhinoplasty predictive imaging of the front and side views to illustrate these potential changes. These are provided with the understanding that they are predictions and not guarantees of the rhinoplasty outcome.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am Asian and interested in making my face more narrow. It is too wide in the cheek area. I also think my chin is too long and would look better if it was shorter. I woud like my face to be more oval and not so wide and square. Do you think cheek and chin reduction will achieve what I want? I have attached a picture for you to see my face from the front and show me what the changes would look like. Thanks!

A:I have done some imaging based on the single photo that you have sent me. It is a partial smiling photo so it is not ideal to use but it is acceptable to give you a general idea of the proposed changes. This predictive image is based on the following two procedures:

1) Cheek Reduction with osteotomies at the zygomatic body (front) and the temporal end of the zygomatic arch. (back) Your frontal facial photo shows a wide or bowed zygomatic arch from the cheek on backwards. This is best treated by total zygomatic arch narrowing as opposed to zygomatic body reduction. One would need a submental (vertex) x-ray before surgery to look at the extent of the bowing and determine how change (inward movement) of it could be done.

2) The chin reduction is a vertical shortening which is what I think you mean by chin reduction. I have no side view of your chin so I can not comment on any horizontal issues.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I would like to get Medpor cheek implants for higher and more defined cheekbones. My question is, since I am relatively young (25), will Medpor implants hold throughout my entire life if they don´t get infected or damaged by an accident? Could I be, let’s say 100 years old, with a Medpor implant in my midface since I was 25 years old? Do Medpor implants show any tendency to dissolve over time? Is it true that Medpor becomes more like a part of your body due to its porous nature that allows blood vessels grow into the implant?

A: Medpor facial implants are composed of a porous polyethylene (PPE) material. This is a well known medical implantable synthetic material that is most commonly used on orthopedic implants as the lining of joint surfaces. (high molecular weight PPE) As a facial implant, it is a lower molecular weight which gives it some flexibility. Pertinent to your question, it is a stable material that does not degrade. There is no enzyme in the body that can break it down…ever. Your facial implants will be found on your skeleton thousands of years from now. Medpor does have surface porosity so there is some tissue growth into the outside of the implant.  This property is often touted as being a superior implant feature but its main benefit is that it helps fix and secure the implant into place. Screw fixation obviates the need for that material feature. This material property does make the implants more difficult to remove should that be necessary so it is a double-edged feature.

Rather than getting hung up on the material composition of a facial implant, one should focus more on does it have the right shape and size for the desired result. Medpor cheek implants do have less options for styles and sizes than silicone-based cheek implants.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I have read a recent blog post of yours about an implant for the treatment of temporal hollowing with great interest. I have a depression on my left temple as a result of a craniotomy performed to clip an unruptured brain aneurysm. I would like to know more about this implant including the manufacturer, case studies of its use, and any before and after photos if available. Many thanks for your help.

A: The new temporal implant to which you refer is manufactured by Osteosymbionics in Cleveland Ohio. While it is not the first temporal implant ever designed, it is unique due to its shape and flexible design. You would have to contact the company for their clinical experience to date. I have not yet used this implant although I have used about every conceivable material  for temporal augmentation and reconstruction. The material of this implant is a soft and flexible elastomer, which is what composes the vast majority of facial implants used.

For temporal defects from craniotomies, the size and extent of the depression must be carefully assessed and the implant matched to it. Some defects are due to mild to  moderate atrophy of the temporalis muscle. This will appear as a more central indentation most prominent above the zygomatic arch and to the side of the forehead. An implant like this new temporal one may work well for this type of depression. Other temporal defects are bigger and are due to atrophy and a retraction of the attachments of the posterior and superior skull attachments. This creates a larger temporal depression and a bigger implant or other form of temporal reconstruction must be used.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I found your website researching the vermilion advancement or gullwing lip lift and  wonder if you could help me. I had a subnasal or bullhorn lip lift procedure done a month ago in order to show upper teeth when keeping my mouth open. I have always had a long philrum. Before surgery it was 20mm in length and now it is 13mm. Just like before, however, I do not show any upper teeth when my mouth is open or when I talk or when i smile. I do not have any more swelling at this point so I know this result is final and am considering a revision. Do you think a gull wing lip lift help me show my upper teeth?

A: With a central reduction of upper lip length from 20 to 13mms, that is a 1/3 reduction which is about the limits of this centrally-based upper lip shortening procedure. It is surprising that you have not made even a little upper tooth exposure with that reduction. But your anatomy and direction and vectors of lip movement may be working against you to achieve any better dental show. I would not be optimistic that a lip advancement would produce the desired dental uncovering. Lip advancements are great at making the lips bigger but I have never seen them result in any increased dental show of either the upper and lower lip. Lip lifts (bullhorn) are more effective at that than lip advancements. (gull wing) It may be possible but is not the primary intention of that procedure.

I would have to see pictures of your lips, both at rest and smiling,to give you a more qualified answer. It is also possible that you may benefit by an internal mucosal reduction which provides the ‘missing link’ in complete upper lip shortening.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I am considering some facial surgery to improve my overall aesthetics. I have previously been through a rhinoplasty, chin implant and cheek implants. While these have been helpful, I still want to get better results. I am hesitant in doing any more surgeries, however, unless the results will be a significant improvement in facial aesthetics and symmetry.  To help me visualize what  I want I have used a facial aesthetic program which morphed the “ideal male ” with mine.  The pictures seem to make the chin width smaller and less square and with an even jawline to the posterior angle of jaw. The images seem to downsize the cheek implants and to make the tip of nose more symmetrical and smaller with a raised nasion. I have attached a few of these  pictures.  The first two pictures are that of an ideal female face with mine.  The last three are the ideal male face combined with mine.  Thirty points on my face were used for my facial proportions to generate these pictures.   Is it possible to achieve this morphed look since it seems the resulting face is more aesthetic.Your thoughts and concerns are greatly valued regarding what is achievable.  If you have a software program regarding what the  postop look will be regarding the different procedures I would be interested in seeing those results.

A: Thank you for sending your images and your thoughtful morphing overlays. While I think they are helpful to see what direction you ideally want to go, I do not find them realistic or that those type of results are achievable. Images like this set the standard of how the patient will judge their outcomes afterwards and it always leads to results that fail to hit the mark and are disappointing. Their greatest value lies in helping the patient determine whether surgery is worthwhile, particularly the patient who has been through previous surgeries and is in the ‘revision mode’. Quite frankly, I and probably most plastic surgeons shutter when a patient goes through this exercise because the results will always fall short. Since I do not feel your results would meet these imaging goals, at least in my hands, I would recommend that revisional plastic surgery may not be worth the expense and recovery.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I am wanting to get the size of mons pubis reduced. I am so ashamed of its size and it restricts me from doing many things in my life. I am not obese or grossly fat, just about 30 lbs overweight. I have been losing weight but the mons will just not go down in size to any significant degree. I will continue to diet and exercise but I have no confidence that it will get any smaller. The skin tone over the mound is good and not loose. It feels firm but can be pushed in so I feel certain that it is fat and not bone. If liposuction is done and the fat from the mons reduced will that in any way affect sensation in this area?

A: Liposuction of the mons pubis or suprapubic liposuction is a very successful spot area of fat removal. It can be surprising how much fat is in the mons and how much of a difference it can make when it is done. Like all body areas treated by liposuction, there will be some temporary numbness of the overlying skin for up to six to eight weeks after surgery. This loss of skin sensation will completely return. The procedure will not, however, affect any feeling of the clitoris or sexual sensation. I have even had a few patients who have told me that their sexual sensation was actually improved after mons reduction, presumably due to an uncovering of the clitoris. Suprapubic mound reduction in men can have a similar effect due to exposure of greater penile length.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I would like to ask if it is possible to reduce the width of head? The width of the upper part of my head above the ears is big on both sides. Is there any possibility to reduce it? I am 30 years old and it has bothered me my whole life. Thank you for taking the time to answer.

A: The thickness of the side of the heads is influenced by both bone and soft tissues. The area directly above the ears is part of the temporal area and the thickness of the underlying temporalis muscle can have a major role in its thickness. The influence of this muscle decreases as one gets closer to the transition of the skull from a vertical to a rounder more horizontal orientation as it thins out. Depending upon where the bulge or too wide portion of the side of the head is located, some reduction is possible. I have performed successful reduction in this area by releasing and resecting the posterior portion of the temporalis muscle and some outer table skull burring. This can make for a 5 to 7mm reduction per side, which could be mean up to a 1.5cm reduction in head width. If the extreme width of the head extends more superiorly, then not as much reduction can be done and the procedure may not be worthwhile to undergo.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I want to achieve a better face shape with a wider and higher jawline, higher cheek bones, a wider upper face and a less ‘pear shaped’ face. I have attached two pictures. In the second picture I tried to draw the changes I want to make, if possible. Thank you.

A: Thank you for sending your pictures. Your highlighting the changes you desire makes it very helpful to know exactly what you are looking for. Based on your face and those highlighted changes, I can make the following comments. These are said with the acknowledgement you have some significant facial asymmetry as seen most prominently in your jawline and eyebrow areas.

1)      Your eyebrow asymmetry poses challenges as a high eyebrow can not be brought down. Only the lower eyebrow can be elevated to a more symmetric level to the higher one. Whether that is done by a unilateral endoscopic browlift or a hairline procedure that elevates the right brow and overall shortens the vertical length of the forehead depends on your other foreheads objectives.

2)      Temporal implants can easily augment and widen the temporal area.

3)      Your drawn concept of a lower eyelid lift is to raise the horizontal level of the lower eyelid. That is quite different than a typical lower blepharoplasty that removes excess skin but maintains the existing horizontal eyelid level. Raising the low horizontal lower eyelid with too much sclera show is not easy nor always predictable. To do so requires adding a spacer dermal graft in the internal lining (lamella) of the lower eyelid and tightening the lateral canthal tendon. It may be possible to raise the eyelid but not more than a few millimeters at best.

4)      Your cheek implants are positioned on the underside of the cheek, indicating that submalar implants would be most beneficial.

5)      Your nose changes shows expansion of the middle vault with spreader grafts, tip narrowing and shortening, and nostril narrowing. This can be done through an open rhinoplasty.

6)       Your lip drawings show upper and lower lip vermilion advancements but I am not sure whether those fine line scars would be acceptable. But only vermilion advancements can produce the results you are showing.

7)      Your jawline poses a bit of a challenge. It is not possible to make it as smooth from the chin back to the jaw angle as you have drawn. You can place lateral jaw angle implants, the right being bigger the left, to widen the lower face.

When it comes to changing the overall shape of one’s face, multiple procedures need to be done at the same time. Your composite drawings illustrate that well.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I want a consultation about my profile. I am confused as to what I may need. My bite is not bad and I have never had braces. My dentist told me my upper teeth forms a c-shape. I think my jaw line is asymmetric, my chin points to the left and my right side profile looks concave or flat. This had been bothering me for a while but I don’t know what will be the best to make my face look more symmetric and balanced. I have attached some pictures so you can see what I mean.

A: When looking at a face there are two views to consider. The patient themselves sees the frontal view and, understandably, often considers it to be the most important. The profile and oblique views are what other people see and how the patient will usually see themselves in photographs. In your description of concerns, you mention both the profile and frontal view concerns.

As you have described in your frontal view, the chin and jaw angles are asymmetric (right chin deviation and left angle deficiency), and the right cheek is flatter or less pronounced than the left. If you look at other features of your face, you will see that there is an overall right facial deviation compared to the cranial base. This rotation is also why the right facial profile seems flatter in the cheek area.

I can not speak for your bite (occlusion) as it is not contained in any of the pictures you have sent. However, I doubt if your bite is severely off or misaligned and I don’t think it has any contribution to your facial asymmetry.

To improve your facial asymmetry, you have to think of ‘camouflage’ procedures for improvement. I would recommend left jaw angle and right cheek implants and either an asymmetrically-placed chin implant (with minimal horizontal increase) or a chin osteotomy with rotation and shifting to bring the chin point in the midline.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley,  I had a chin implant removed and my chin muscle sags now. Because the initial surgery was fraught with infections and complications, my chin muscle was cut into four more times after the first surgery. Doctors tell me now, 4 years later, that the chances that I could have my chin muscle reattached higher, where it used to be, is slim. Since there is very little of anything left to sew into, I’ve been told that they could try and drill screws near the nerves of my bottom teeth and try to attach something that way, but this is unlikely. Is there a surgeon out there who has dealt with this same issue successfully? I am desperate to get my face back. There must be some way to reattach my chin muscle!! Help, please!

A: Reattachment of the mentalis muscle is very possible. The key is to have a stable method and non-injurious place to attach the muscle/scar. This is best done with micro-suture anchors that are designed to be very small (1.5mms) and can be placed over (in between) the roots of the lower anterior incisor teeth. I have found this technique to be successful, regardless of how many times the mentalis muscle has been re-entered.

Despite re-attaching the mentalis muscle, complete improvement of the sagging chin pad may not still be obtained. The implant may have created some extra chin tissues through expansion that a combined submental tuck-up may be needed as well to get a tight redraping of all of the soft tissues over the convex chin bone. Whether this approach to you revisional chin surgery is needed would require photogtraphs and an examination to determine.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in having a rhinoplasty done but am uncertain as to whether the result would be worth it. I have a very big nose with very thick skin. It is way out of proportion to the rest of my face. No one else in my family looks like this so I don’t know where I got it. In looking online at a lot of rhinoplasty results, a lot of times I don’t see that much of a difference in many of them. I am worried that I might end up as one of those type of results. And when you have a nose like mine, you need a big change. I have attached some pictures for you to see. Tell me what you think, is a rhinoplasty worth it for me?

A: Rhinoplasty in noses that have a very large and thick skin sleeve are very challenging. Not so much because of the technical execution of the surgery but in how the skin will respond and how much shrinkage of it will occur. One can make a significant change in the shape of the underlying cartilaginous strutcures but if this skin does not adapt to it well, then much of those changes will not be seen. In looking at your nose, you are correct in pointing out that the size of the tip in particular is way out of proportion to the upper nose and the rest of your face. At least half of the size of your nasal tip is skin which can not be removed but can only shrink to some degree.

The key to rhinoplasty in the thick-skinned male nose is the recognition and realistic expectation that you can never have a small or well-defined nose. That is not anatomically possible. Most likely, you can never have the type of nose change that you would ideally want. But some improvements can be made anmd could be very worthwhile. In your rhinoplasty, I would tnarrow and lift the tip cartilages, defat the nasal tip carefully, augment the dorsum with cartilage grafts, and do a significant nostril narrowing. I have done some computer imging for you to see what may be possible. I would also consider a chin augmentation which would help balance your facial profile and is a classic manuever to help make the nose appear a little ‘smaller’ by changing other facial proportions.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was 16 years old when I got my rhinoplasty done. I am Asian and I had what appears to be a very typical Asian rhinoplasty using an implant. I think it is a silicone L-shaped implant. I originally had a very flat nose with a low bridge. It is now 20 years later and I want to take it out. I have never liked the way it feels and the idea of having plastic in my face bothers me. I think the skin has also gotten thin over it as I think I can see the implant when out in bright sunshine. Can it be removed at this point? How will my nose look when it comes out?

A: Your indwelling nasal implant can be removed at any time. The question is not whether it can be removed but whether to do anything else to replace it at the time of its removal. Taking the implant out will deflate the nose so it will get flatter and shorter, perhaps close to what you were before. Certainly that is the easiest option but perhaps not the most esthetic. Replacing it with a rib cartilage graft is the most aesthetic but not the easiest. Intermediate options include placing layers of allogeneic dermis (e.g., alloderm) on the dorsum and a septal columellar strut graft. That would be a good revisional rhinoplasty compromise as it would produce an intermediate aesthetic result without the need for rib graft harvesting. I suspect you really won’t like the appearance of the nose when the implant is removed but may not really want to have a rib graft harvested either.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I don’t know if you are familiar with Groupon (if you are on this planet you must by now) but it has been a wonderful idea for me. I have participated in numerous Groupon deals for a variety of merchandise and restaurants and have saved a lot of money by doing so. i am interested in getting breast augmentation later this year and was wondering if you will ever have a Groupon for breast implants?

A:  While Groupon may be very appropriate and a good consumer concept for meals, spa treatments and other conventional retail items, it is a poor idea when it comes to plastic surgery. This makes the very serious endeavor of human surgery a trivial matter and places it as a mere commodity. It brings it done to the level of money-off coupons, day long specials and competition prizes. Besides the very serious breach of ethics of the American Society of Plastic Surgeons, such business tactics belittles plastic surgery and the medical profession as a whole. But the real tragedy is in how it may affect patients who will undoubtably suffer complications and even lifelong injuries from such promotional activity. What corners are being cut to provide plastic surgery at such low prices? Equally importantly, what are the qualifications and experience of surgeons who must use this patient draw tactic to get surgery? Aesthetic plastic surgery should be a thoughtful decision that is driven by consideration of the benefits vs the risks of the procedure not by low pricing. You can return a dress you don’t like or never go back to that restaurant where the meal was not very good, but plastic surgery is not ‘returnable’ and often is not even reversible. While the economics of elective plastic surgery (e.g., breast augmentation) is always an important issue, it should never be the most significant one.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, assuming that all goes well when putting in a chin implant, what about the feeling of having it. (mandibular nerves and the touch receptors of the hands?) How physically light is the implant? Will it feel weighted? I’m sure that your own senses will eventually incorporate it into being a part of it, but what about others. Will it be discernible if say someone else touches your face (jaw)? I know this is a tricky question, coming from a post operational/personal standpoint, but thanks for taking the time to answer.

A: The question you are asking it one related to every type of face and body implant…that of incorporating it as part of yourself and no longer have it feeling foreign. And I think the answer is the same for a chin implant as it would be for a breast implant for example. Intially the implant feels different as the tissues are tight and swollen and the overlying skin is numb. It probably takes about 6 weeks after surgery until it begins to feel more natural and really 3 months until it becomes part of you. At this point, the overlying tissues are relaxed and normal feeling has largely returned to the skin. The chin implant can largely not be detected by yourself or anyone else at that point. While for a patient three months seems like a long time, it is actually relatively short and it is amazing how soon one incorporates the new contours of their face into their body image.

The weight of a chin implant is but a few ounces. It is lighter than bone of the same size.

Dr. Barry Eppley

Indianapolis Indiana

Q: Dear Dr. Eppley, I recently read, that a revision on a chin implant that has been inserted through an intraoral incision, can lead to distortion of the chin muscle because this muscle would be cut through twice. I don´t have a chin implant, but porex cheek implants (inserted through an intraoral incision) that need to be shaved down on the left side. Now I would like to know if an intraoral performed cheek implant surgery also involves cutting through a muscle what eventually could lead to distortion of the soft tissue if this muscle is cut through twice.Thank you in advance for your reply!

A: When it comes to surgical access in the face for the placement of implants, they must be placed down at the bone level below the periosteum. This always requires cutting through attached muscle to get to the proper placement level. But there are significant differences between the lower jaw (mandible) and the rest of the face. The lower jaw is the only bone of the face that actually moves, the rest of the facial bones are fixed. This makes for significantly different types of muscular attachments.

The mentalis muscle of the lower jaw, while having no function in its opening and closing, covers the chin bone and affects the lower lip and soft tissue movements. When it becomes detached or scarred, one can develop lower lip and chin soft tissue sagging. While good soft tissue closure will avoid this problem it is always a risk. While there is  nothing wrong with secondary intraoral chin surgery, the upper attachments of the mentalis muscle are being severed and reattached twice. This does increase the potential for secondary mentalis muscle problems.

The intraoral placement of cheek implants does not cut through any muscles of jaw motion or those responsible for any soft tissue support. There are no risks, therefore, for muscle scarring that would affect any facial function or appearance. The muscle issues of intraoral chin implant surgery do not apply to intraoral cheek implant surgery.

Dr. Barry Eppley

Indianapolis Indiana

Q:  Dr. Eppley, I read your comment on floating belly button.  I saw a plastic surgeon recently who said it would be best for me to repair my abdominal muscles all the way to top, float the belly button and then reattach it right where it was as I have almost no loose abdominal skin. (mini-tummy tuck)  It sounds good in terms of a lower and smaller scar but the “cutting the cord” idea really bothers me and worse since I saw it on Youtube!  Since the belly button is sort of the center of connection for mothers, I just want to know if it is ok and safe and if it can really be reattached?  Thank you.

A: While I can appreciate your concern, you have nothing to fear. The umbilicus, or belly button, is really nothing more than a band of scar that runs from the midline of the union of the rectus abdominal muscles to the overlying skin. While it is a remnant or scar from the original umbilical cord, it serves no useful purpose other than its aesthetics….and that it would look weird if someone didn’t have one. In a mini-tummy tuck it is very common to release it from its attachment to the fascia of the muscles so it is out of the way for a complete vertical repair of the loose rectus muscles. It is easily sutured back down either to its original location or lower depending upon how much abdominal skin is removed. This is a perfectly safe procedure and I have never seen it to be a problem afterwards.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am interested in cheek implants and until now I have thought that this compared to other plastic surgery procedures would be a relatively simple procedure with a minimum of complication rate. Recently I have seen a scary video on Youtube that shows a patient who developed a bunch of complications a few weeks after this procedure. He isn´t able to smile on one side of his face. One implant moved the whole way down the cheekbone and the other implant developed some kind of air pocket between the cheekbone and implant.One of the implants got infected. This patient also mentioned in his video that the surgeon removed some bone of his cheekbones before he inserted the implants. I can imagine that you don´t like to comment on another surgeon´s work. Could you please tell me if these are complications that could have been easily avoided by a well trained surgeon?

A: You would be correct in assuming that I wouldn’t comment on any specifics about another surgeon’s work or results. That is not a protective maneuver for other surgeons but because many details of other patient’s surgeries and cases are not known to me and often how the information is presented may not be complete. There is also the old motto of ‘there are two sides to every story’.

But I can make some general comments about cheek implants and their potential outcomes and complications. I have never seen the type of complications from cheek augmentation that you have described. In my experience, the most common complications are aesthetic in nature. Asymmetry of cheek implant position or too large a size or incorrect implant style for the desired effect are more likely complications to be seen. These can be resolved by implant adjustment and/or replacement. Infection of the implant is also a potential complication but this is uncommon in my experience with cheek augmentation. I have done many cheek implants in combination with maxillary or LeFort osteotomies, where the implant sits directly over an open sinus cavity, and have yet to see an infectious outcome with its use in that ‘higher risk’ use. The best way to avoid many of these cheek implant problems is to secure them to the underlying bone with a screw and get a good two-layer soft tissue closure over them.

I have a hard time figuring out how any type of permanent facial nerve injury can occur from cheek augmentation as the terminal buccal branches of the facial nerve are well above the subperiosteal dissection used for the placement of the implants across the zygomatic bone surface.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am considering getting nipple reduction surgery if this is possible. I am a 19 year-old male college student who has a very athletic body type. I suspect I have always had nipples which stuck out and they didn’t used to bother me. But now they do and it has been giving me self-esteem issues. What type of surgery do I need to correct this problem, how is it done, and how long is the recovery?

A: When I get requests for ‘nipple reduction’ surgery, it is important for me to discern exactly what the problem is. Nipples can stick out from two causes and the difference is in understanding the anatomy of the nipple-areolar complex.. The first is true nipple protrusion or hypertrophy. This is where the small central raised nipple sticks out too far, either all the time or when it becomes temporarily erect. This creates a small almost sharp point that can be seen through shirts or makes for a non-smooth chest profile. Nipple reduction is essentially a wedge amputation, is done in the office under local anesthesia, and will produce a permanently flat nipple. There is no recovery at all. The other cause of the entire nipple-areolar complex sticking, also mistakenly called a protruding nipple, is gynecomastia. When the size of the gynecomastia is small, it can push out the entire nipple-areolar complex. This makes a ‘nipple mound’. This areolar gynecomastia reduction is removed through a lower areolar incision and is done in the operating room under general anesthesia as an outpatient procedure. The enlarged and firm mass of breast tissue is removed to bring the profile of the nipple-areolar complex back to a smooth chest contour. There is about 7 to 10 days of recovery in which the patient wears a circumferential chest wrap to reduce the chance of any fluid collection in the space where the breast tissue was removed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I have had three hair transplants performed over the past 18 months. While I definitely have more hair, the results of these surgeries do match what I paid to get them. I have a couple of donor scars which when I cut my hair very short, show quite obviously and leave an unsightly scars at the back of my scalp. I would like to reduce the appearance of these as it is otherwise very difficult to be able to buzz my hair short without feeling self conscious about the scars.

A: Scalp donor scars for hair transplants can become wide, particularly when the same donor site is used more than once. This is a function of tension on the scar line which widens and leaves a gap between the sides of the hair-bearing scalp. Any scar widening, or ‘hair gap’, in the scalp is easily seen. Scar revision of hair transplant donor scars can be successful at narrowing their width based on total excision of non-hearing scar/scalp and deep suture support at the galeal level. Any tension on the skin will result in new scar widening. In some cases, I have done a geometric (running w-plasty) scalp scar excision to distribute the tension at the skin level and break up an otherwise straight line scar. Every manuever of tension reduction is important in scalp scar revision, particularly in those from hair transplants in the low occipital horizontal orientation.

Dr. Barry Eppley

Indianapolis Indiana