Your Questions

Q: Dr. Eppley, I am very interested in skull reshaping surgery. Since I was young I always thought my head shape was oddly shaped making it unpleasant to cut my hair short, wear hats, or even have different hairstyles. I would like to know how long you have been doing this surgery because a surgery like this can go very right or very wrong unless someone is very experienced in doing it. I know that the same surgery is also done in Korea but I would rather not go so far. I always hoped that a surgery would be able to fix my head shape, I just never knew that there were surgeons out there who could do it. My head is flat in the back and is not even symmetrically flat as one side (the left) is more flat than the other. Please tell me what you think can be done.

A: There are many options in skull reshaping surgery. I would need to see some pictures of your head shape to determine what needs to be done exactly. But by your description it sounds like a case of a flat back of the head (occipital brachcephaly) with some asymmetry to it. Thus the surgical treatment would be augmentative as an onlay cranioplasty approach, probably using PMMA as the material as the volume addition would be at least 60 grams maybe more.

I have done many such skull reshaping surgeries, and many other variations of it, for over 10 years based on a lot of craniofacial plastic surgery and biomaterials experience previously.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am considering facial implants to rejuvenate my youthful face. I am 27 years old and underwent gastric bypass surgery 4 years ago and it seems all the volume in my face went away. I hate the excess skin under and above the eye and the deep grove under the eye..I use to have chubby cheeks that went away after the surgery. I tried Radiesse a year ago that didn’t give me the cheek volume I desired and didn’t address the hollow grove under the eye and my face went back flat in about eight months. I have always hated my nose. I hate that the bridge is flat but have a big round tip and my nostrils are huge. I always wanted a small nose that lined up with my eyebrows..I shaved my eyebrows and draw them on until I find the perfect surgeon for a forehead/brow lift to address the hanging/excess skin. I am aware that some people want a subtle change..not me I want a drastic change. I lost over 160 pounds so I feel like a new person but I look like a old person. I have searched high and low for the perfect facial surgeon please let me know if you can help.

A: Facial implants can be beneficial for all three areas that you have mentioned, tear trough, cheeks and the nose. But in applying facial implants to these areas, it is important to realize what they can and can not do. Tear trough implants, which have to be placed through a lower eyelid incision, will help fill in the depressions along the infraorbital rim but they will not get rid of loose skin on the lower eyelids. In many cases skin removal may be simultaneously done but you seem to have little room for loose skin removal even though you are demonstrating the laxity of the skin by pulling on it. Cheek implants, which are placed through the mouth, can be used to build up overall cheek area although your cheeks already seem full. (but then I have no idea what you looked like before your weight loss) Nasal implants are commonly used in rhinoplasty to build up the bridge of the nose. When combined with tip narrowing and elevation and nostril narrowing, significant changes can be achieved in the shape of the nose. Although the thickness of one’s skin will control how much narrowing of the tip can be obtained so one has to be realistic with these type of rhinoplasty outcomes.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I was wondering if you can preform an ear reduction surgery. My ears are very big (tall) and I would like them reduced in size. They have always been too big for my head and it has bothered me all of my life. I have done some imaging of ears to show my “desired” results, I understand that they might not be exactly attainable. Any information is greatly appreciated.

A: What you are demonstrating is vertical ear reduction. This is possible but not by the way you have imaged it. You have shown imaging where the upper third of the ear has been reduced which is an area of the ear that can not be reduced without disruption of the shape of the superior crus and helix which would give the ear an unusual shape…not to mention prominent scars. Vertical ear reduction must be done through the middle portion of the ear where the scars can be better hidden and the alignment of the outer helix and the antihelical fold can be preserved. Also that amount of vertical ear reduction is probably a little more than can be achieved.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a subnasal lip lift problem. Wish I’d seen your website some months ago. Four weeks ago today, I underwent a sub-nasal upper lip advance (bull horn) by another surgeon. Pre-op I had a lot of distance between my upper lip and my nose and it meant that when I smiled, only my lower teeth showed .(making it appear that I was grimacing). I was advised that I had 21 mm of distance from the top of my lip to the base of my nose, and that I would  benefit from having 6 – 7 mm of tissue removed, in order to show more upper teeth, even when my face was relaxed. Sadly, although visual imaging was available, the visualization was not shown to me. (My mistake for not asking to be shown what I would look like with a lip lift). Although I was told that only 6 mm of tissue was removed, it appears that more than this amount was, in fact, removed. From the base of my nose (columella?) to the top of my cupids bow I have 12 mm of ‘space’ and (for a male) a ‘cupid’s bow’ that is a bit too pronounced. I feel extremely self-conscious, and have been limiting contact with friends and family ever since the surgery. At four weeks post-op, I would imagine that it is doubtful that my upper lip will ‘settle’ any further? Even a ‘gain’ of one or two mm would help things, although 3 mm would be perfect! Although I suspect that this cannot be repaired by replacing tissue, I wonder if surgery to my ‘dangling colummella’  of my nose would allow me to pick up an extra two or three millimeters of space between my nose and upper lip? Of course, not sure if that would ‘relax’ my upper lip so that I did not have such a pronounced ‘cupid’s bow’. Is this something that you have encountered in the patients of other surgeons, and if so, what (if anything) can be done to try to revise this undesired outcome? Incredibly, as you mention in your website, it really is a case of only a few millimeters.

A: In performing subnasal lip lifts, my general rule is to never remove more than 1/3 of the philtral length in females and only 1/4 of that length in men. In judging the amount of upper lip skin removal, it is always better to be conservative as one can always do more. If too much is removed, some skin relaxation will eventually occur (even up to six months after surgery) but there is no method to add more skin. This skin can not be recruited from the columella…hanging or not. You should keep working on stretching the upper lip with your fingers and tongue as you should be able to gain a millimeter or two over time.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had Medpor infraorbital rim and paranasal implants placed last year. The recovery was uneventful, but I’m hoping for further augmentation that’s more suitable for my face. This is why I’m contemplating getting a custom made implant for the entire mid-face region. However, my biggest concern is with removing these implants. I understand that Medpor removal comes with its risks. Assuming that I’m willing to undertake these risks, can I just check if it will at all be possible to remove the infraorbital rim and paranasal implants? If so, what kind of soft tissue damage can I expect? Would any tissue resuspension be necessary, especially if I were to replace them with the custom made implants in the same surgery? Thanks!

A: Having done a lot of Medpor facial implant removals, I have yet to see an implant that could not be successfully removed. There really is no risk with their removal other than the swelling which naturally occurs afterwards which usually isn’t worse than the original implantation surgery. I don’t think there is any risk of soft tissue sagging with their removal particularly if replacement implants are being simultaneously inserted.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I just finish reading an interesting piece on your website regarding paranasal implants and premaxillary implants.  I am seriously considering having this procedure done you since you seem to be the resident expert in this field. While I am aware the difference between a premaxillary implant versus a paranasal implant, I couldn’t decide which one of the two would I need, or  if I need both. I personally felt that my midface is a little flat. I have had rhinoplasty done before with the hope to fix this issue and while it did improve my feature, but not to a point that I satisfied with.  I’ve attached a few photo of my profile for your reference. Hopefully after looking at them, you would be able to determine which of the two I need.

A: Paranasal implants and premaxillary implants are very close cousins as they are implants that augment the pyriform aperture area. The front of the pyriform aperture is the premaxilla where the implant is placed across the anterior nasal spine. Its principal effect is to open up the nasolabial angle as it pushes out the upper lip/base of the columella. The sides of the pyriform aperture is below the sidewalls of the nostrils where it joins the cheek skin and is where a paranasal or side of the nose implant has its effect. It builds up the base of the nose by pushing out this area to reduce its concavity. These implants can be used independently or in combination.

With your natural facial profile and shape, a combined parasnasal-premaxillary implant would help complete the effect that you thought you would achieve with your initial rhinoplasty.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I read an article about temporal muscle reduction and it said that 70% of their clients died after two years, due to the surgery. Now I don’t know if it was specifically talking about shrinking the muscle. My question is, has this procedure been tested safe for people, because us people should not be put under the knife for a surgery which has been invented just recently and doesn’t have enough evidence to know if it’s safe or not. And is cutting and shrinking the temporal muscle dangerous? will it cause infections, brain damage, dead blood vessels, cancer and so on…

A: When it comes to aesthetic temporal reduction, primarily by muscle reduction/shortening, your perception or readings on it (of which I am not aware anything has ever been written in the medical literature in regards to  aesthetic temporal reduction) are grossly inaccurate. You are obviously confusing intracranial vs. extracranial temporal surgery. Temporalis muscle reduction is very safe and effective. as it is done on the outside of the skull. The only issues are aesthetic, the need for a fine line vertical incision in the temporal scalp and how much tenporal reduction can be achieved.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have been looking into getting facial implants, specifically chin, cheek and jaw angle implants, now for quite some time. During my time researching these procedures I have come across many reputable sources of information, like yourself, and millions of internet experts professing to know the ‘truth’ of some sort of another regarding facial implants. Nowhere amongst all this are clear and unambiguous answers to some of the most basic questions. Hopefully you can provide these for me. My questions are as follows: 

1. If a chin, cheek or jaw angle implant is placed, the surgical wound heals, all is well and the patient loves the result several months after the operation, what is the likelihood that the implant will become infected years or decades later.

2. In your experience, if an implant is placed uneventfully can the patient then go on to live for decades having ‘forgotten’ about the implant, so to speak? I don’t want to have to come back to any implants later in life, I want to have my first cosmetic surgery and then forget about it forever.

3. Is the removal of an integrated Medpor jaw angle implant as difficult as it is said to be? Also, is there a silicone jaw angle implant that can provide the so called drop down effect?

4. There is a lot of confusion regarding cheek implants for men who want their cheekbones to flare out laterally. Do you think it is a deficiency in zones 1 and 2 of the malar-zygomatico complex that needs to be corrected in order to achieve the male model look? If so, are custom cheek implants capable of achieving this in the right individuals 

5. Individual implants will not make a person look radically different. Is this something that can happen, for good or ill, when several implants are placed at once?

A: In regards to your questions about facial implants ( cheek, chin and jaw angle implants), my answers are as follows:

1) The risk of implant infection is greatest in the perioperative period (first month or two after surgery) usually as a result of implant contamination during placement. Delayed facial implant infections are very rare. not impossible, but it would require contamination into the implant capsule like from a dental local anesthetic injection. Delayed infection risks are so rare that they are almost case reports for the literature.

2) If one has uncomplicated healing and is pleased with the size and symmetry of the facial implant result, having them will quickly become a ‘natural’ part of one’s anatomy and they will be forgotten as being a synthetic extension of one’s face.

3) Medpor implants,including those of the jaw angle, can be removed and I have removed many of them. They are much more difficult to remove than silicone implants but that is an issue of relativity. Silicone facial implants are so easy to remove that anything that is more adherent seems difficult.

New styles of vertical lengthening silicone jaw angle implants are now available. I designed them to provide a better implant material to that of Medpor. They are much easier to insert and replace/modify if necessary.

4) The concept of getting cheek implants to achieve any type of facial look is more ambiguous and harder to achieve that most would think. The cheek area is a complex four-dimensional structure and the interpretation of what is a pleasing shape is as variable as the anatomy of each person’s cheek bones. It frequently is not as simple as just pulling an implant off the shelf, regardless of its style and size, and the desired look is achieved. Even using custom designed implants is not a guarantee that the desired look can be achieved as the ability to translate a design to what it makes the outside of the face look like is not a mathematical one. Many men seek the so called ‘male model’ look which often but not always means a high angular skeletonized cheek look. You would have to define what cheek look you are after by using model pictures as examples. While all of them are models, many of their cheek shapes are quite different.

5) The more facial implants that are placed, if they are not properly sized, the more different one can look.

The one caveat I would add to all of this is a basic fact based on my very extensive experience with male (almost always young) facial skeletal augmentation surgery…such patients have a remarkably high revisional surgery rate which approximates 50% or greater in the first six months after surgery. These revisions are almost never because the implants have any medical problems but because many young men are impatient of the healing process and often are uncertain if they like the aesthetic outcomes of their procedures even if it is exactly what they thought they wanted. Thus, when you think about getting facial implants this revisional surgery issue is what you need to consider, not all the other concerns that you have mentioned which are fairly irrelevant compared to this consideration.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in orbital dystopia corrective surgery. I have vertical orbital dystopia as a result of craniofacial trauma when I was a child. There were no orbital bone fractures that I know of.The severity of my condition seems to be very similar to the case study posted on your web page. In your case study, you’ve seem to have done a orbital approach alone. However, research on the web has led me to believe that surgical correction for this deformity can be very complex as stated by these 2 doctors where one describes a very invasive intracranial approach. So my question is would you be able to perform the correction using an orbital approach alone. Attached is a picture of my eyes. I would guess that the right eye is at least 5mm lower than the left. I would like to know what procedure you would recommend.

A: Vertical orbital dystopia refers to one eye being lower than the other as a result of the shape or size of the orbital box (bones) in which the eyeball resides. A 3D CT scan can precisely determine the bony component of the orbital dystopia by looking at the periorbital bones. Generally in cases of 5mm or less orbital dystopia, this is completely correctable by an intra-orbital approach. This is done by building up the orbital floor and inferior orbital tim. In reading the comments from the other doctors, although well intended, they are not accurate in how smaller amounts of orbital dystopia can be treated. By your picture, you are correct in that the eye is about 5mms lower than the left and could be lifted by the described infraorbital approach. Be aware that as the eye comes up,  however, it will be further buried under the upper eyelid by a similar amount. This means that the upper eyelid will need to be elevated by a ptosis repair, either done at the same time or as a separate surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had breast implants done about one year ago.  I had textured silicone gel shaped breast implants placed under the muscle. They were 335cc in size. My breasts were A cup size before surgery. I would like to know if corrective surgery with bigger implants will create more cleavage.  have quite a small frame and chest. I would not mind getting bigger implants but only if they looked natural and the breasts did not move any further out to the sides than they are now.

A: One of the basic principles of breast augmentation surgery is that the breast implants merely take the breast features that one currently has and makes them bigger. Therefore, if one’s breasts are fairly widely spaced, getting implants will not create cleavage. It is clear based on your pictures that your breast mounds, small as they were, were more to the sides of your chest wall. That can clearly be seen by how far your nipples are to the side before and after breast implant surgery. With the placement of implants under the muscle, it is hard to create any semblence of cleavage unless one has breast mounds that are naturally close together. That being said, the question is whether bigger implants will give you cleavage. If you place large enough breast implants, you will likely end  up with more cleavage but they will not likely look very natural and will be oversizes for your frame. You are better off just accepting the good breast augmentation result you now have even if it doesn’t create the cleavage you want. That is where bras can compensate for what implants can’t do.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I believe I have a mentalis strain, my chin starts to dimple and looks somewhat “bubbly.” My chin looks pretty short and recedes to me , but I am happy with the size my lower jaw except for the receding and the strain. Will my lower jaw have to be wider to fix the problem or can i just simply have my jaw  moved forward enough to fix the problem without having to change the size of my jaw?

A: Most mentalis strains are the result of a short lower jaw, a horizontal bone deficiency. This makes the mentalis muscle ‘overwork’ to try and achieve lip competence. Whether this is best treated by a lower jaw advancement or just a chin augmentation depends on many factors including one’s existing occlusion (bite), how horizontally deficient the chin position is and what effort one wants to put in to treating the problem. The width of the lower jaw/chin has no impact on the cause of the mentalis strain or in the treatment of it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, would a lip lift benefit my facial features and add more symmetry to my face?  Is there any other procedure that would make my features more attractive? How many of lip lifts do you do yearly? Do you have more before and after pictures of this procedure. How much increase in lip size would I achieve with this procedure given I have very thin lips? Thank you.

A: A lip lift can be aesthetically beneficial for those patients, women and men, that have a long upper lip with little accentuation of the cupid’s bow. As a general rule, about 1/4 up to 1/4 of the vertical skin distance can be removed. Women generally want p to 1/3 the distance while men are close to 1/4 to avoid to an over elevation of the cupid’s bow area. Lip lifts are very common in my plastic surgrey practice and I usually perform 1 to 2 lip lifts per month

In regards to other potential facial improvements, I have looked at a tip rhinoplasty with nostril narrowing and buccal lipectomies with perioral mound liposuction. There are are destined to help create a facial slimming effect as your face is naturally more round. I have included these in the attached lip lift imaging projections as well.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in an unusual form of skull reshaping.  I am currently investigating possible procedures that could change my skull contour. I have congenital skull asymmetry/tilt, and have attached a simple drawing approximating the current shape of my skull. The area I would like to treat is on the left side of my posterior skull/occipital bone. If possible I would like some reduction of the skull near the occipital bone/protuberance and nuchal ridge on that side. In addition to this I would like to increase the volume beneath the ridge with a fat transfer. The goal of this would be to make it appear as if the nuchal ridge was lower on that side than what it actually is. My understanding thus far is that a solid implant would not be suited to this area as it could not be secured and it would have to lie on top of tendons/nerves and I’d prefer a more long lasting treatment over temporary fillers. Assuming there is enough bone that some can be safely removed, what amount (i.e. how many mm) can this part of the skull usually be reduced? I’ve seen photos of fat transfers treating various defects on different parts of the body and am curious how much projection could potentially be possible. The area I would like to increase volume in is roughly 2cm wide and 7cm long with varying depth. The depth would vary up to a max of 1cm. I know that fat transfers are unpredictable and can take multiple sessions, but I’m curious is this would be potentially feasible. My weight is stable and does not fluctuate much. In your estimation would these procedures be technically possible or something that you could potentially perform? I would very much appreciate your input.

A: Skull reshaping can be done for a wide variety of bone issues. The area to which you want to reduce is known as the nuchal ridge of the occipital bone. It is actually where the posterior neck muscles attach to the skull. As a result it is very thick to accommodate the pull of these strong neck muscles, illustrating the biologic principle of form following function. This is why it is a raised edge of bone and can be substantially reduced in its prominence by a burring technique. As for augmenting the area below it, fat injections can be done but I would have little confidence that they would create, even if they survive, a raised ridge presence. You would be better served to have an actual implant placed down that low and secured to the bone. Since some of the neck muscle tissues has to be released anyway to do the burring, it would be more reliable to attached a small silicone implant with those dimensions to create an assured permanent ridge effect.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 22 year old man who is interested in custom facial implants. I have taken an interest in your practice because of your really detailed and informative website and photos and because of the experience you have with the particular facial implants I want done. I am interested in getting cheek and wraparound jawline/chin implants. I want the cheeks implants because my cheeks are quite small and I would like to have implants put in to make them larger and have a more sculpted face. As for my jawline and chin, it is quite small and narrow and I would like a wraparound jawline implant to give me a stronger wider jawline, a sharper jaw angle in the back, and a larger chin that are seamlessly connected together. I know this will require a custom implant approach to get the best implant symmetry and shape, provide a faster operating time, and provide me with a better chance of obtaining the results I am looking for. I want to know if these two surgeries could be done at the same time? I am really looking for a more masculine sculpted jawline and chin and cheekbones that provide a youthful face as well. I am really interested in you performing the surgery since so far you seem to be the only surgeon I have searched online who has a blog devoted to helping answer clients questions and you have an extremely thorough website.

A: You are correct in assuming that a custom facial implants is the best way to go when one seeks a wrap around jawline implant that is seamless from front to back. While off-the-shelf cheek implants could probably be used, one might as well make the cheek implants custom as well since that would add little cost as the 3D CT scan and software design process is already in place. It would be very common to do cheek, chin and jawline implants together to achieve a comprehensive overall facial enhancement result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I am interested in a geometric broken line closure scar revision but I have a few questions.

1) Would you do multiple layer closure underneath the skin to ensure that there is proper wound undermining. If so many layers?

2) Since I’d be an out of town patient could you use dissolvable sutures on the outside?

3) Would dissolvable sutures affect the outcome negatively or it shouldn’t?

4) Is there anything you can do to help prevent the scar incision becoming indented and the outside edges looking raised?

5) Do you normally have to perform dermabrasion after the GBLR and if so when would this be performed? Would it cost more if I had to do dermabrasion later.

6) Given the size and location of my scar right in the middle of my cheek in your professional opinion do you think that GBLR is my best option? I just worry having different zig zaggy shapes might be more noticeable than a straight line but the problem I have with the straight line is how the edges are raised.

7) I had scar revision done 7 months ago do you think that it is ok to do another revision now since I know the raised edges won’t get better or do you think it’s too early?

A: In answer to your questions about an irregular or geometric broken line scar revision:

1) Every plastic surgery wound closure uses multiple layers.

2) Yes

3) No

4) That happens when there is scar widening. Interdigitating the scar limbs, like in a GBLC, helps prevent that.

5) Whether dermabrasion is needed later depends on how it heals. I would say the risk of that is way less than 50%. It is something that I find uncommon to need to do. Maybe a light laser resurfacing but not dermabrasion in your type of facial scar.

6) Your results with straight line closure have proven that approach is not adequate. It is either GBLC or leave it alone and accept its current appearance.

7) You do a revision when one is certain that no further improvements are going to happen with further healing.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a bullhorn lip lift. No one can ever see my teeth when I talk or smile and it really bothers me. I have already had orthodontics and lowered the front teeth as mush as possible and still no one can see them. Are there any bad side effects of this procedure? Would this procedure correct this? Email me please.

A: While lip lifts are most commonly done in women, there are some men who benefit as well. Your smiling and non-smiling pictures show that you are one of those men. Your upper lip is very long and your upper lip vermilion is thin and pencil-like. Such an upper lip anatomy can mask most of the upper teeth which will largely be unaltered despite dental manipulations such as orthodontics and tooth lengthening by veneers or crown lengthening. A bull horn or subnasal lip lift would help in in that regard by lifting up the center part of the lip via shortening the nose to lip skin distance. This can be very effective as long as it is not overdone (too much skin removed)  and the lower edge of the upper lip line remains level. As an isolated procedure, it is usually done on the office under local anesthesia with minimal upper lip swelling afterwards and no real recovery. When the incisions are well placed along the alar base-lip junction, they can heal in an undetectable fashion.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a non-straight line scar revision. Attached are some pictures of my facial scar.. I marked up some pictures with a horizontal line showing how it is raised on the side of the scar nearer my nose. Do you think that it would be possible to remove the raised skin on the inside of the scar near my nose or do you not think that would be necessary. My goal would be to smooth it out as much as possible where we could get rid of raised part as well as indented part on the incision line if possible. Note I am happy with how narrow the incision line is, I’m just not happy with how raised it is around the incision and I’m wondering if you think that a GBLR might break up the line to make it less obvious or if you think I should just try dermabrasion first to smooth it out.  Also do you think a GBLR would be best or a straight line closure in the area of the cheek? I think the scar size is around 2 and a half cm in length.

A: Your prior straight line scar revision demonstrates the drawback of this approach in a facial area that does not parallel the relaxed skin tension lines. The scar line may be narrow but the edges around it are raised and visually obvious. With geometric broken line closure, the scar is also narrow but the edges do not usually get raised as the scar line is interdigitated and the contractile forces on it are better dissipated.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting  tummy tuck.  At about this time three years ago, I had a miscarriage at five months. Unfortunately, my body never really recovered from all the changes it went through. In the last three years I managed to lose about half of the weight I put on. It seems that no matter how much I try I can’t get back to normal. I’m about to graduate college and start this wonderful new chapter of my life, but I’m afraid that being stuck with my pregnancy figure will keep me from fully enjoying it. I’ve attached a couple pictures of myself for you.

A: Based on your pictures, you have an ideal stomach issue for a tummy tuck and flank liposuction. With your body now, your stomach could end up completely flat and your waistline would have an hourglass shape from the liposuction. The trade-off for this abdominal and waistline change is the low horizontal scar that accompanies every full tummy tuck. This is an issue for every woman to consider that has not yet had children and may likely do so in the future. But besides the aesthetics of the scar, it does not prevent future pregnancies nor does it affect the ability to carry a child to full term.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am seeking steroid injections after gynecomastia reduction surgery. I had gynecomastia surgery almost two years ago. The surgery was fine, but of course I dealt with scar tissue problems afterwards. I got Kenalog shots and it really reduced it alot! I have a bout a pea size piece sticking literally right behind the nipple itself. When my nipple is hard or semi hard the scar tissue is jagged and literally sticks out just like my nipple (protruding my nipple out too much for me to live with for the rest of my life and extremely bothers me) But this is so small for surgery so I don’t want to risk it. I was wondering if you would hit me with a 5FU or 5FU/Kenalog controlled shot to flatten this jagged connective tissue that makes my middle nipple area still stick out.

A: It is very common after gynecomastia reduction surgery to have scar tissue form behind/beneath the nipple. When the initial gynecomastia problem is relatively small, any nipple scar tissue formation can leave one with a still persistently nipple protrusion problem. In the first year after surgery (really the first six months) steroid injections can be very helpful in breaking down any scar tissue formations. After one year the success of steroid injections to reduce prominent scar tissue diminishes considerably as the bonding of the collagen in the scar tissue becomes very mature. There is no harm in doing further steroid injections but be aware that the success of them at this far out from surgery may not be like what had occurred earlier after surgery. Should this fail you should consider a small revision through an open incision under local anesthesia as an office procedure. This can remove the problematic small area of scar with little risk of recurrence. I have done this numerous times in secondary areolar gynecomastia reduction surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a question about paranasal implants. May I ask what do you think about fat graft to the sunken paranasal area ( and a malar implant on top)? Will fat grafts ( say inclusive of a few touch ups ) have the same effect as a paranasal implant?

A: Fat grafts by themselves will not have the same effect as paranasal implants. A solid implant on the bone can very effectively push outward on the overlying mid face tissues. (it has a more rigid structure that the tissue that it is designed to displace) Conversely, a fat graft is soft and does not have the same degree of push (augmentation) as a solid implant. The overlying soft tissue has the same structural rigidity as the fat graft so there is some rebound effect and less defined augmentation than one would think. In addition, the retention of a fat graft is unpredictable.

Thus fat injections are not a comparative ‘implant’ to that to a true paranasal implant. For those opposed to the placement of an actual facial implant, fat injections are the only other option and are not unreasonable…it just does not create the same effect as a paranasal implant.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in brow bone reduction surgery. As you can probably tell from the pictures I have attached,  I suffer from Alopecia areata. I realize there will be a scar from the coronal incision, but I have no reference for how bad the scar will be. Would the trade off be worth it? I look forward to your assessment.

A: When it comes to brow bone reduction surgery, the degree of brow bone protrusion is important as that determines whether surgery is worth it and how it might be done. You do have a Grade IV brow bone protrusion which aesthetically is very severe so I can understand your pursuit of brow bone reduction surgery. A dramatic change in your forehead can be obtained through a combination of a brow bone reduction via an osteoplastic bone setback and a little forehead augmentation just above it. The very legitimate question is whether the scalp scar trade-off is worth it. I certainly have done a significant number of forehead and skull reshaping surgeries on men who shave their head or are otherwise bald but always do so with great trepidation. Since much of aesthetic surgery is always about trade-offs, one has to be sure that what one is trading off into is better than the initial problem. I can not make that decision for any patient as only they can place those type of values, all I can do is provide information that may help in making that decision. I will send you a picture of the scalp scar from a brow bone reduction patient who largely was bald across the top by tomorrow. This may help you in making that trade-off decision.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in an injectable rhinoplasty. You probaby can’t tell by the pictures so much, but I have a droopy tip to my nose. The bridge is fine but from the frontal view it droops and I am wondering if it could be lifted up by injection fillers.

A: An injectable rhinoplasty can be very effective if used for the right nose problem. While injectable fillers can be placed into the tip of your nose, they will make it somewhat bigger in an effort to lift it which may be viewed as aesthetically counterproductive. It would be more predictable to do a simple tip rhinoplasty where the tip could be reliably lifted and avoid making the size and width of the tip any bigger. A droopy tip in a thick skinned male nose is not a good indication for the use of injectable fillers in nose reshaping.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am in need of a chin implant revision. My surgeon used a 10mm Medpor chin implant. My face was round and small before, now its very long and wide so I look masculine. I’m female by the way. Is 1 month too early to tell? The shape of it has not changed since the first day after surgery and I hate it. I have attached some pictures of me before surgery and the way I am now.

A: The timing of a chin implant revision depends on when one is certain that its size and shape are not satisfactory. Even though it is just one month after surgery, if the chin augmentation looks too big and wide to you, it is because it is. I usually use the benchmark period of six weeks after surgery for one to have 90% of the facial implant result. Medpor chin implants have a very poor taper to them due to the material thickness and their extensions backward along the jawline are destined to make many women have wide looking chins. A large 10mm implant is most assuredly going to cause this widening effect. While you clearly appear to have been a good candidate for a chin augmentation, I am afraid that you appear to have the wrong implant style for your female facial features. Both your pictures and how you feel at this point indicate that clearly this is the case. I would suggest that you have a chin implant revision that either has the existing chin implant reshaped or exchange it for a chin implant that better matches your feminine facial shape.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m interested in CO2 laser resurfacing and skin under my eyes and also to remove dark spots on my cheeks. Or maybe I need a pinch blepharoplasty instead. I had a lower blepharoplasty three years ago which left my eyes more wrinkled. I was told this procedure would remove the fat and then cut and tighten underneath. Only the fat was removed. I’ve load an up close picture which also shows the spots and a smiling picture you can see how much extra skin is under my left side, which makes me not want to smile as it shows worse when I do. 

A: By your description your original lower blepharoplasty sounds like a transconjunctival one in which no skin was removed but only fat from the inside of the lower eyelid. By deflating lower eyelid ‘bags’ (fat), skin wrinkles are often worsened as the skin retracts. This is why many transconjunctival lower blepharoplasties often include a simultaneous skin resurfacing procedure (laser or chemical peel) to avoid this aesthetic problem with fat ‘deflation’.  At this point, you need a pinch lower blepharoplasty, as you have surmised, to get rid of the roll of skin and muscle that is just under your lashline. With smiling not all of the extra skin can be completely removed but a significant improvement can be obtained.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am looking into buccal fat pad removal (buccal lipectomy) and possibly perioral mound liposuction. My face holds a lot of weight compared to my low body fat percentage. I workout consistently and follow a very precise diet but no matter how hard I try I can never seem to lose the fat on my face. I am self conscious and try not to smile in public as smiling makes the fat on my face more apparent. My father and my grandfather both have the same issue. I would like to know your opinion on what could be done to improve my appearance. I would really like to have a thinner face, similar to that of a male model.

A: I think your face would benefit by a buccal lipectomy and perioral mound liposuction to provide some improved contouring. Whether that would be enough of a change to give your face the ‘male model’ look is a more indeterminate question. It would definitely be beneficial in that regard, and you have the right face for these procedures that will best show their effects, but the male model look per se may be asking more than is possible. That, of course, depends on how one expects that type of face to look.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a chin implant, jaw angle implants or both. I believe chin implants/jawline  implants come in different dimensions or sizes? Would it be better to do one procedure at a time? What face shapes are good candidates for this type of procedure?

A: A chin implant and jaw angle implants come in a wide variety of styles and sizes so there is a range of changes that can be done. The purpose of computer imaging is to first see whether these type of facial changes and their magnitude is what someone is looking for. Different implants will create different degrees of change.

When it comes to elective facial surgery, you do the procedure in which you are absolutely convinced is needed. Any procedures in which you are uncertain you wait and see how the first procedure affects the facial area of uncertainty.

The best candidates for chin augmentation is just about any face because it is a ‘edge’ or profile procedure that would improve any face in which the chin is short. Conversely, jaw angle implants work best in thinner faces where their effects enhance or skeletonize the face as opposed to a fuller or rounder face in which it may just make it more bottom heavy.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I may be interested in a revision rhinoplasty. I had excessive swelling after nose tip rhinoplasty; nose tip looks great, but my formerly thin nose is much wider and uglier above the tip; and very damaging to me psychologically. I have had two Kenalog (diluted) injections within 15 to 18 months post-op, with limited results. I am completely aware of the risks of revision rhinoplasty. Please advise on whether further kenalog might help, or would recommend a revision.

A: At over one year after a rhinoplasty, there is not going to be much of a change from any form of steriod injections. Steroids or even 5FU work by either preventing or helping to break down early scar tissue formation. This can occur when the collagen bonds are relatively newly formed. But when the scar is mature, as it would be at one year after the initial rhinoplasty, the collagen bonds are too stable to be pharmacologically broken down. Whether a revision rhinoplasty will help thin out a nose above the tip in the middle vault area or higher, however, is suspect. It is not like in the tip where scar tissue can be easily removed and additional reshaping of the cartilages can be done. There is also the distinct possibility that with a more narrow tip, the rest of the nose above it may merely look bigger by comparison. That may not be a major component to the existing nasal issue, but it may be part of it.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I am wondering if chin reduction may be helpful for me. I had a chin implant which I was not keen on so I had it removed. It’s been two months now and the chin is not what it was, it looks more masculine and wider than it was originally. Do you think that this will improve?

A: A chin implant adds volume to the bone as an onlay but do so but stretching out the soft tissues of the chin that is on top of it. Thus, when a chin implant is removed, it requires the overlying soft tissues to shrink back down and readapt to the bone. Whether that can happen successfully is influenced by how large the original implant was, how long it was in and what the surgical approach was to place it. (submental vs. intraoral) I don’t think you can have an absolute certain answer for three to four months after its removal, but in many cases the chin will not return to its original shape. Even though it has only been two months, I would not be optimistic based on how your pictures look. Chin reduction surgery may be beneficial in chin removal cases like yours as it removes and tightens the loose soft tissues and may contour the chin bone as needed for additional chin shape contouring.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have an indented scar on my cheek that needs some type of scar revision. It started out getting an injectable filler treatment (Restylane) that got infected. After antibiotics cleared the infection a few months later the area appeared indented and became a samll atrophic scar.  It then had V-beam treatment for the indentation several months later but only became more indented. It lost whatever fat it had. It is an area under the eye where the cheek fat pad starts where there is a circle that is indented. One surgeon said there is no fat there and that is why it is sunken. I want to know if there a full thickness fat graft or some type of soft tissue implant that can be used to fill it?

A: The scar revision to which you refer is really the need for fat volume restoration. It sounds like you have a distinct area of fat atrophy with scar contracture on your cheek. While this is water over the dam so to speak, the use of a V-beam treatments was ill-advised for that type of depressed scar and did exactly what could have been predicted. That issue aside, options include fat injection or the placement of a small dermal-fat graft that treats exactly what the problem is…lost fat volume. Fat injections involve no incision or harvest site but are somewhat unpredictable in terms of volume retention and do not do a good job of releasing and scar contracture. A small dermal-fat graft would be more effective but it has to be placed somehow through a small incision and requires a harvest site which could be behind your ear.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Can Jaw and/or chin implants give me more of a chiseled/angular/square longer lower face? I don’t want to have the procedure if it can not create this kind of look.

A: In the right type of face, chin and jawline implants can indeed create a more angular or chiseled look. The right type of face is a thinner or lean one that can show skeletal highlights better. Fuller or ‘fatter’ face can not get a more chiseled look from facial implants as the soft tissue cover is too thick to show their outlines. This is particularly true of jaw angle and cheek implants which are facial locations that do not jut out like the chin can.

Dr. Barry Eppley

Indianapolis, Indiana