How Many Body Contouring After Weight Loss Procedures Can I Have At One Time?

Q: Dr. Eppley, I am interested in numerous body contouring procedures since I have lost 130 lbs. But I did not achieve this weight by bariatric surgery so would it be possible for me to have multiple procedures in one day? I have a lot of loose skin from my arms to my thighs so I need a lot of work done and the quicker I can get it off the better.

A: The origin of one’s weight loss has little impact on how any number of body contouring procedures are done in a single operative event. Actually extreme amounts of weight loss achieved by non-bariatric means, diet and exercise, are ‘safer’ since there are no metabolic issues to consider. (unlike a gastric bypass) There really are few differences between body contouring after weight loss and bariatric plastic surgery considerations when it comes to the type of body reshaping procedures considered and how they are put together. The key issues in doing multiple  body contouring procedures is the length of time to do the surgery and what period of recovery time does the patient have. As all body contouring involves considerable trauma to the body if you just consider the size of the body surface areas being treated.

Dr. Barry Eppley

Indianapolis, Indiana

What Is The Best Technique For Chin Narrowing?

Q: Dr. Eppley, I have a wide chin and am interested in a chin narrowing procedure. What is the best way to make the chin bone more narrow? 

A: The benefits of chin narrowing is very clear as you do have a boxy square chin. To obtain substantial chin narrowing there are two basic techniques, bony genioplasty wedge (sliding genioplasty with central wedge reduction) and lateral tubercle ostectomies. (cut off the corners without down fracturing the chin) There are advantages and disadvantages of each method of chin narrowing. Having done them both numerous times, they both can work but there are subtle differences between them that can carry aesthetic consequences. The advantage of the bony genioplasty wedge reduction method is that it does not strip off all the attached soft tissues so the risk of the soft tissues not adequately reattaching afterwards is minimized but it is a ‘bigger’ operation due to the need to down fracture the bone  and the bone cuts come closer to the exit of the mental nerve from the bone. (risk of numbness) The lateral tubercle ostectomy method merely cuts off the corner of the boxy chin and does not need to down fracture the chin bone and thus there is no need for plates and screws to put it back together.  Its bone cuts stay further from the mental nerve so the risk of lip numbness is less. Its disadvantage is that it may not produce as significant a chin narrowing effect and detaches more of the soft tissue.

Dr. Barry Eppley

Indianapolis, Indiana

What Type Of Jaw Angle Implants Do I Need?

Q: Dr. Eppley, I have been opening your website and reading your articles for a while. I think your website is very informative. I would like to thank you for creating this website. Without any doubt i can say your are one of the world’s best and most skilled plastic surgeons. I wish I was very wealthy, I would have flown to USA and set an appointment with you, but unfortunately I don’t have a strong budget at the moment. I intend to travel locally for a chin osteotomy or implant and jaw angle implant. I want to make my face look very masculine and angular. I am attaching my photo to have your viewpoint about the type of jaw angle implant. I want to do something permanent and long lasting. I think my jaw needs a thick implant but I don’t know which shape and type is better. Thanks in advance.

A: While most commercially available silicone jaw angle implants provide only width, the vast majority of men who seek a stronger and more defined jawline need vertical lengthening of the jaw angles as well. Thus a more masculine jawline usually needs a combined vertical and width dimensional change to have a more pronounced flare to their jaw angles. Your pictures certainly show that to be true. The only question is how much vertical and horizontal thickness in millimeters would look best.

Dr. Barry Eppley

Indianapolis, Indiana

Will A Sliding Genioplasty Make My Face Less Short And Round?

Q: Dr. Eppley, I have been self conscious about my deficient chin my whole life. If I so much as look down, I develop a double chin despite being 5’7″ and weighing only 114 pounds. I used to diet often thinking that this would decrease the roundness/fullness of my face but it wasn’t until recently that I realized it is really the lower 1/3 of my face and its overall deficiency that is causing my face to look round and short.

As you can see, I have a very horizontally as well as vertically short chin. The reason I would like the sliding genioplasty vs. a chin implant is to add vertical length to my face as I feel its shortness makes me look younger than I am and also meek/shy which decreases my confidence in my daily interactions with others.

I’ve done the research on sliding genioplasty vs. chin implant, and one of the questions I have is: If I would like a little extra width added to my actual chin (You can tell in the pictures, especially the one head-on picture, that it is not only short vertically and horizontally, but it is narrow), I have read that only an implant can widen at this area, and that a genioplasty by nature of cutting the bone and advancing it will actually serve to further decrease the width of the chin. Is this true? I would like to decrease the odds of this happening if at all, although perhaps adding width to the chin would not even be as beneficial as I think given my facial size in general and would throw everything out of line aesthetically?

In addition, I have read that only a sliding genioplasty can add vertical height to the chin in addition to horizontal projection, but in other more recent publications I have read that there are new implants manufactured now that can be tailored to the patient and add vertical height as well. Would this be an option for me as it is more cost effective or is sliding genioplasty exclusively the way to go given my individual anatomy?

I am anxious to hear back from you, and thank you so much for taking the time to review my pictures!

A: Many of your perceptions about chin augmentation surgery are correct as it relates to the differences between a sliding genioplasty and a chin implant. Historically, it was true that only a sliding genioplasty could add vertical length to the chin but that is no longer true. There are new performed vertically lengthening chin implants (actually they move the chin position out at a 45 degree angle thus adding both length, projection and width) and custom implants can be made from the patient’s 3D CT for any amount of differing chin dimensional changes.

While a one-piece sliding genioplasty particularly if it adds vertical length can make the chin more narrow, that can be solved by modifying the bone  That can be managed by doing a midline split/expansion genioplasty technique and widening the bone as it comes forward and down.

As you can see there are a number of ways to accomplish what you are after for our chin. But the first place to start is to precisely determine what exact chin dimensional changes you need. I will have to do some computer imaging but my initial guess is that about 5mms forward and 5mms vertically longer would be about right. I doubt if your chin should be made any wider as you want to get away from a round and short look and even a slightly more narrow chin in and of itself makes the face look longer.

Dr. Barry Eppley

Indianapolis, Indiana

Can SERI Silk Mesh Be Used To Smooth Out My Face?

Q: Dr. Eppley, I have a lot of deep saucer-shaped scars and indentations on my face. I recently read about the use of GalaFLEX and would like to know if this product could be used to smooth out the appearance my face. I once had a doctor in California who suggested using sheets of a “derma” product to place between the skin and the underlying tissue to smooth it out.  When I read about GalaFLEX it appears to be the same type of product. Perhaps you can give me your thoughts on it.

SERI Silk Scaffold in Plastic Surgery Dr Barry Eppley IndianapolisA: The concept of an interpositional material between the skin and the underlying fat/SMAS is an interesting one. As of today there are over a dozen allogeneic and synthetic matrixes/scaffolds that are currently available for use. So this concept is not new and Galaflex just represents one of the synthetic options to consider. All of these have been developed primarily to support the lower pole of the breast in breast reconstruction and in treating bottoming out of the breast in aesthetic breast augmentations. Of the synthetic options, the one I would consider is SERI Silk mesh as opposed to Galaflex since it is currently FDA-approved while Galaflex remains under FDA clinical trials.

Moving beyond the materials, the real question is whether placing an interpositional material under the skin would help smooth out the face. That part is unknown since this is not what it has been studied for and I have know of no patients who has been so treated for that facial skin problem with this method. But I guess there is always a first time in the right patient.

Dr. Barry Eppley

Indianapolis, Indiana

Is There Any Cure For Black Market Butt Injections?

Q: Dr. Eppley, If ever you need a guinea pig for studies in regards to the use of liposuction and fat transfer for treating deformities from black market butt injections, please contact me. Sadly, I was one of the many young, naive, stupid girls (1000′s from what I now know from doing so much research) whom underwent this black market procedure of silicone (now don’t know what it really was, but the devil was calling and I fell to his vanity trap and oh boy am I paying for it now) butt injections which has completely ruined my life. I am consumed with anxiety, depression and regrets for my ignorant, immature and impulsive decision for trying to look better to be able to compete with other women for attention that I wasn’t getting at home after losing 80 lbs. I have become not only unhappy but overwhelmed at what my life has become over some very stupid decisions. I am only reaching out because I want to know what the average cost is for this procedure, but also to tell you that there are so many women on forums that are seeking help from professionals, willing to pay thousands because they have the money, but doctors say there are no procedures to help us.

Black Market Butt Injection TreatmentsA: The problem of deformity and hardness from the scar and granulomatous reactions from black market butt injections of silicone and other unknown substances is a difficult problem for which there are no certain cures. But the use of liposuction and fat injections is one potential treatment option that has some biologic merit. While the injected material can not be substantially removed, breaking up the scar tissues using liposuction cannulas and then introducing fat may create a softening effect while maintaining volume. One has to have enough fat to harvest to do the procedure but not to the volume that would be needed in a traditional buttock augmentation procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Can I Get Rid Of My Labiomental Fold?

Q: Dr. Eppley, I would like to accomplish a chin with less harsh of a labiomental fold, preferably no fold at all. But have the area more smooth. Maybe somehow add vertical volume to the chin area or adjust the mentalis muscle to achieve the desired result. I would like to here your thoughts on what procedure you would recommend to achieve the most attractive chin possible.

A: Altering the labiomental sulcus or crease is the hardest portion of the chin to change. This is because it is a fixed anatomic structure that correlates to the depth of the anterior mandibular vestibule intraorally and the upper attachment of the mentalis muscle beneath it. It is simply not possible to completely get rid of the labiomental sulcus. It may be softened a bit by various injection and implant materials but the operative word here is ‘a little bit’. If the chin is lengthened vertically by a bony genioplasty method, it may appear  slightly less deep because the chin is longer and the labiomental fold is stretched out. That lessening effect may be enhanced by the simultaneous placement of a small fat graft.

More aggressive labiomental fold reduction can be done but this requires a skin incision and the subcutaneous placement of a dermal-fat graft under the released skin edges.

Dr. Barry Eppley

Indianapolis, Indiana

Do I Need A 3D CT Scan For Forehead Augmentation or Temporal Implants?

Q: Dr. Eppley, I am considering having a cranioplasty and/or temporal shell implant. I recently had a cranial CT done, and was wondering if you would be able to recreate that into a 3D CT scan in order to make the temporal shell implant, or at least to get a better idea of which areas are deficient in the cranium in order to better place the PMMA cement. Could you please let me know the costs associated with translating the CT scan into a 3D format, and if this would help you even with a PMMA cranioplasty without temporal shell implant?

A: Unless the original CT was taken in high resolution cuts (1mm or less), you can not get it converted into 3D CT images.

When it comes to what you are calling a temporal shell implant, I need to know exactly the temporal area to which you refer in terms of augmenting. There is skin only area between the temporal hairline and the eye which is where preformed temporal shell implants are used to augment. I am going to assume this is the temporal area to which you refer. A regular or 3D CT scan is not helpful in addressing the volume needs of this area since this is a muscular augmentation area and not bone. A CT scan, particularly a 3D one, only shows bone.

The only reason to get a 3D CT scan for the forehead is if one is getting a custom temporal implant made. If one is using PMMA bone cement, the scan is not really helpful as this is artistically applied and shaped during surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Should I Have Hairline Lowering By Surgery Or Hair Transplants?

Q: Dr. Eppley, I am a 26 year old female, I am very self conscious about my forehead and have been for years. I am so tired of feeling embarrassed and having to hide it and limiting what I can and cannot do for fear of it showing. I’ve been researching transplants to lower my hairline. I’ve ran into your website and was wondering if you do hair transplants to lower hair lines? If so a round about cost to have it done? I’m really hoping you can help me and I can get this done and feel 110% more confident with myself.

A: Lowering the hairline, as you may know, can be done by either scalp flap advancement or hair transplants. There are advantages and disadvantages with either approach and neither one is perfect. So let me review these with you. The advantages of hair transplants for lowering the hairline is that it does not create a fine line scar along the frontal hairline (although it will create a scar in the back of the head from the harvest site) and does not involve a true surgical procedure under general anesthesia. Its disadvantages is that it will take at least two hair transplant sessions and close to eight hours of procedure time to get the new hairline properly filled in and up to six to nine months to se the final result. A scalp advancement for hairline lowering creates an immediate hairline lowering in a fairly simple procedure under anesthesia. (like a reverse browlift) It disadvantages is the fine line scar along the frontal hairline and the possibility that some hair transplants may be needed along the scar line for better camouflage. (may or may not be needed)

When comparing these two, it is also important to look at the costs differences between the two. Two hair transplant sessions will definitely cost more than a surgical hairline lowering procedure.

Dr. Barry Eppley

Indianapolis, Indiana

What Type of Facial Reshaping Surgery Do I Need After Orthognathic Surgery?

Q: Dr. Eppley, I am interested in facial reshaping surgery. I am a female with a recessive lower chin and a minimal jawline. I have had orthognathic surgery twice now, which has improved my teeth but not the balance of my face. I still have a very convex facial profile with an extremely long vertical jaw angle. Here are some images of my face. I hope these will help you to assess my situation. My last surgery was 11 months ago in which my upper and lower jaw were brought forward to correct an overbite and an open bite. I do feel that my upper jaw (between nose and upper lip) is more elongated than before. As you will see from the photos it is difficult for me to close my lips. I realize that this cannot probably be fixed, however I would like my face to look less long and narrow and my jaw line  more defined. My jaw is rather vertical in angle. Any advice very much appreciated.

A: The forward positioning of the maxillomandibular complex has placed a strain on your lip closure as this was not the bony relationship that your lips were ‘designed’ to function over. Along with the upper lip lengthening, these are not rare changes that occur with such maxillomandbular forward movements. In addition, loss of the jaw angle can occur with sagittal split ramus osteotomies (SSRO) of the mandible particularly when the lower jaw moves forward. This can be accentuated in females who may already have a thin and slightly high vertical has angle position initially.

The way to make your face look less vertically long and not so narrow is through a combined sliding genioplasty and jaw angle implants. Small vertically lengthening jaw angle implants (7mm vertical length and 3 to 5mms width) will create more defined jaw angles but not over power the upper face. A sliding genioplasty of the movements of 3mms forward and 6mms vertical reduction would shorten the chin length and also help push up the soft tissue chin pad. This may provide some potential benefit also to reducing the lip strain through a better lower lip position at rest.

Dr. Barry Eppley

Indianapolis, Indiana