Rib Removal

Q: Dr. Eppley, I have for a few years been researching rib removal for cosmetic reasons, but was unable to find surgeons doing this procedure. The only surgeon I found with information about this procedure said the rib removal alone would not make the waist look smaller. I found you when reading about the model having rib removal with you last year. Is removal of the floating ribs likely to make a considerable difference on a slim woman? Is it possible to receive more information about the procedure? Particularly about aftercare and risks, it is hard to come by legitimate information about this procedure. I understand that it is an extreme procedure, and you have probably received many messages about this procedure after the story came out. Is this a procedure you will do? How does a patient go forward with this? Is an in-office consultation necessary? I’m located in Europe. Other than being a motivated and healthy patient, what makes for a fitting patient for rib removal?

A: The best way to get the most accurate information about rib removal for waistline narrowing is by have a virtual consultation. My assistant will contact you tomorrow to schedule a Skype consultation. Rib removal with waistline training can successfully narrow a waistline in my experience of close to twenty rib removal patients. Those women who get the best results are usually the ones that are already fairly thin where the effects are seen the best. Please send me some pictures of your waistline and any examples of what you want to achieve.

Dr. Barry Eppley

Indianapolis, Indiana

Jaw Implants

Q: Dr. Eppley, About eight years ago I had a jaw implant that I was very happy with the result. However, as I’ve aged and my face has lost volume, I’m interested in slightly increasing the implants to (slightly) widen my face. I understand that one option may be to insert a “chip” underneath the existing implant. Is this correct? If so, what is the recovery period? Many thanks.

A: What you are referring to is the concept of adding a wafer of material under an existing implant or even placing an overlay on top of the implant. The latter is usually more effective as its effects are more directly translated to the overlying soft tissues. For widening  jaw angle implants which appears to be what you have, adding a wafer (shaved down implant) under the existing one would certainly be relatively atraumatic to do and would add just a slight bit of more width. However the complication rate is higher when two implants are stacked on top of each other. Thus while the wafer concept seems simple, it is probably better to just replace the jaw angle implants with new ones. This is really not much more traumatic than placing a wafer underneath them.i

Dr. Barry Eppley

Indianapolis, Indiana

Cheekbone Reduction

Q: Dr. Eppley, Please see CT scans for my current face bones of the right and left side. Also, photos before surgery and after surgery.

I went for jaw reduction but the doctor talked me into also having cheekbone reduction. The results were a strange shape face from the outside and deep burns from surgical instruments down my chin. 

1. Please look at my CT scans and tell me what you can see has happened to my jaw bones. 

2. Please look at my CT and tell me what you can see has happened to my cheek bones.

3. Please let me know if the cheek bones can be repairable and tell me the procedures  to fix the cheek bones.

4. Please let me know if the jaw bones are repairable, also the procedures to fix the jaw bones.

Something has gone wrong from this surgery and I am looking for help.

Please kindly help or advise in any way, I really need help.

A: Thank you for sending your CT scans of the jaw and cheekbone reduction procedures you had done. What the 3D CT scan shows is:

1) Complete amputation of the jaw angles

2) Cheekbone osteotomies with wide displacement of the anterior osteotomies with no obvious fixation of the bones and a downward rotation/internal collapse of the cheekbones

Just based on the CT scan you would need the following for reconstruction:

1) Vertical lengthening jaw angle implants to remake the amputated jaw angles

2) Repositioning and plate and screw fixation of the anterior cheekbone osteotomies.

Dr. Barry Eppley

Indianapolis, Indiana

Buttock Implants

Q: Dr. Eppley, I am a plastic surgeon practicing in Slovakia. I recall that you place your buttock implants intramuscular…..I am seeing a patient soon interested in gluteal implants. If you have a moment I have a few questions for you since my experience was limited in buttock augmentation.

intramuscular-buttock-implants-technique-dr-barry-eppley-indianapolis1.  Must I have the tool that is used  to split the muscle (pic attached attached)…..I don’t recall you using this tool…will a couple malleables, dever, and cautery work?

2.  How long until you let your patients sit?  Seems like a wide discrepancy in the literature.

3.  I recall you using the incision technique according to Raul Gonzalez where the midline is depithelialized preserving the sacrocutaneous ligament….I will do the same.

4.  How long until you let your patients sit on an airplane?

5.  Do you place drains with the intramuscular approach?

6.  How do you determine implant volume choice….do you use templates?

Thanks for your help!

A: Be aware that buttock implants are the hardest of all body implants to placed and when you do your first case you are likely to ask yourself why made you think it was a good idea to do this surgery. The other very important preoperative consideration is that the size of buttock implants that can be placed different dramatically from subfascial vs. intramuscular. You and the patient have to have a clear idea as to expectations. Intramuscular buttock implants will almost always be smaller than the patient wants, have a very long recovery and are very hard technically to do since there is no natural plane of of dissection. Subfascial buttock implants allow for much larger implant sizes, have a somewhat quicker recovery and are technically much easier to do. But to answer your intramuscular buttock implants questions:

  1. The duckbill dissector to which you refer is not absolutely essential as a wide malleable restractor can similarly be used. At at $850 for the instrument it really becomes non-essential.
  2. I let patients discomfort determine when they can sit…as they eventually have to do some sitting for certain functions
  3. Re-establishment of the sacrocutaneous ligament is essential in closure of the intergluteal incision.
  4. Same as answer #2
  5. There is no reason to use drains in the intramuscular buttock implant technique.
  6. With intramuscular buttock implants you are never going to get an implant in and satisfactorily covered with muscle over it that is bigger than 330cc. It just can’t be done. Your implant options are going to be either 270, 300 or 330cc. When in doubt choose the smaller implant size.

Dr. Barry Eppley

Indianapolis, Indiana

Custom Facial Implants

Q: Dr. Eppley, The more I sit here the more I am feeling like I would just like to come and see you for a 3D CT scan of my face. The sliding genioplasty and lip issues is one thing but I am seeing marked asymmetry in my whole face (the one side literally looks like it is 1/2 inch out farther than the other side causing my cheek and jaw on the one side to be much much larger and lop sided. 

To clarify what I had done: 

Sliding genioplasty 

Mid jaw implants 

Back jaw implants 

Cheek implants 

Buccal fat removal 

I know I would feel better if I saw you for a look over and a scan. My surgeon didn’t do a CT scan on me and claimed he did custom facial implants but from the very first day my one side has looked larger and it is now day 8 and doesn’t feel puffy – just hard like the implant yet it sticks out way way wider than the other side. I specifically asked for no width to be added to the face and for it to stay slim but I feel masculine and disfigured. Even if it just means taking things out for now I’m okay with it. 

A: Having had all of these implants and bone work it would be very common at your early postoperative period to have facial swelling that was asymmetric. So I would not try to judge the symmetry of the results at this early juncture as that is really impossible to know. But if you really want to know how all the implants looks by position and size, then a 3D CT scan would answer those questions. As long as the implants are silicone they can clearly be seen on the scan. Medpor implants are much harder and often impossible to see. The sliding genioplasty of course can be seen very clearly. That is a scan you can get where you live. You just find a place to have it done and I can fax in the order to have it done. You do not need to come here to get the scan but can if you would like.

True custom facial implants require a 3D CT scan to fabricate but your surgeon may have been referring to just shaping standard implants at the time of surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Masseter Muscle Reduction

Q: Dr. Eppley, I am interested in getting the masseter muscle reduction and the upper trapezius muscle reduction and I am looking for a more permanent solution.  Here are a few of my questions…

– What to expect on results
– Recovery Time
– Healing and when can I leave to go back home to NJ
– Vitamins and meds to take to help with swelling and healing

Please also see my attached photos of a view of my side, front, and back and let me know if you need any more information from me…thank you.

A: Thank you for sending your facial pictures. In answer to your questions:

1) Surgical masseter muscle reduction is done through an intraoral approach by muscle release and electrocautery reduction. After surgery it would take a full three months to see how much muscle has been reduced. The trapezius muscle is done through an incision at the back of the occipital hairline. From this location a wedge of trapezium muscle is removed to reduce the raised contour of the line from the neck out to the shoulders.

2) Recovery time is based on swelling and level of discomfort. There is really no postoperative restrictions. The swelling of the jaw angles would be more noticeable than the trapezius and would take about 10 days before returning to its preoperative size and months before the final result is seen.

3) You could go home in 1 to 2 days after surgery, whenever you feel like traveling.

4) Vitamins are not helpful for the swelling. I will give you steroids during surgery as well as  Medrol Dospak after surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Mentalis Muscle Resuspension

Q: Dr. Eppley, Following a chin implant being removed via an intra-oral incision six years ago, I have lower lip incompetence and chin ptosis.Is it possible to have a successful outcome with mentalis muscle resuspension without inserting another chin implant? Also is it possible to achieve a good result with absorbable Mitek sutures as opposed to titanium screws?

Another doctor has advised he would insert another small chin implant and use titanium screws. I’m not comfortable putting another chin implant in or with titanium screws in my chin.

A: One can certainly have a mentalis muscle resuspension surgery without placing a new chin implant. But the success of the procedure drops when the lower chin support provided by a new chin implant is not added. This does nor mean that it can not work just that the long-term success rate will be lower.

Mitek absorbable bone anchors are my performed method of mentalis muscle resuspension. They come with an indwelling bone device (anchor) that is composed of either a small piece of metal (nitinol) or a reservable polymer composition that takes 6  months to go away. The sutures attached to the bone anchors however are permanent.

Dr. Barry Eppley
Indianapolis, Indiana

Undereye Wrinkles

Q: Dr. Eppley, I would like to schedule an appointment to have something done to my undereye wrinkles. I have attached pictures of me smiling and not smiling and you can see the big difference as to how many undereye wrinkles occur when I am smiling.

A:Thank you for sending your pictures. Under eye wrinkles either are only present when one smiles or becomes much worse when one does smile. (have them at rest) Lower eyelid surgery really treats excess skin and wrinkles when one is not smiling. It is really an operation that treats a static problem since that is how the surgery is done. (patient not moving/smiling) More dynamic undereye wrinkles are treated by Botox injections as this injected agent treats a dynamic problem through muscle weakening. In other words, if your undereye wrinkles are mainly present when you are smiling that is a non-surgical Botox injection treatment issue. However, if a lot of undereye wrinkles are present when one is not smiling, and gets much worse when one does smile, then lower blepharoplasty surgery would be the most effective treatment. It is also important to point out that no treatment will completely get rid of undereye wrinkles, they can only reduce the number seen.

Dr. Barry Eppley
Indianapolis, Indiana

Skull Widening

Q: Dr. Eppley, I am interested in a skull widening procedure.I have a narrow skull/ head and was wondering if its possible to widen the sides of skull and forehead with Alloderm instead of implants? Im not comfortable with implants and was hoping instead that Alloderm could be used for such large areas. And if alloderm can be used for skull/head widening, does screws need to be used? Thank you.

A: While Alloderm can be placed on the sides of the skull for augmentation, there are several problems with its use for that application. Beyond the sheer cost of Alloderm (the material alone would probably costs $15,000 to $18,000 for a skull widening procedure that is at least 5 to 7mms thick) the material has a low propensity for persistence and a relatively high incidence of infection when stacked in layers which it would have to be for any skull augmentation procedure. I don’t think the use of Alloderm is a viable option for a skull augmentation material. If you are looking for a more ‘natural’ skull augmentation material, injected fat would be the most viable option as long as one is not looking for any major volumetric change.

Dr. Barry Eppley
Indianapolis, Indiana

Submalar Cheek Implant

Q: Dr. Eppley, What is the maximum amount of projection in mm that off the shelf submalar cheek implants can give and how much projection can custom implants realistically give? I am looking for a pretty decent amount of projection in order to give me a more rounded apple cheek look.

A: The submalar cheek implant  is designed to elect and reposition soft tissue in an anterior and superior position. It adds some lower mid facial fullness and may have a mild effect on softening the depth of the nasolabial fold in some patients. It can create the so called ‘apple cheek’ look which is usually more of a desired feminine facial trait.

In theory there is very little limit as the midface soft tissues can stretch fairly significantly. The only real limit is the thickness of the soft tissues ands can a competent and tension-free intraoral would closure be done. Standard submalar cheek implant sizes range from 4.5 to 6 mms. I have made custom cheek implants with up to 8mms in thickness in this area. Whether you would need more than 8mms would require an analysis of your pictures and computer imaging of your projected results. I would not think that you would as a general statement as a few millimeters in this facial area has much more powerful efefctr than one would think.

Dr. Barry Eppley
Indianapolis, Indiana