Paranasal Augmentation

Q: Dr. Eppley, I had a rhinoplasty done and ever since something about it has been bothering me since I have done it. I’m not sure what the doctor called it since it’s been 4 years ago. I was concerned that the side of my nose was big. It was the bone beside the bridge of the nose. I originally thought I wanted it to  be smaller. I just realized after that what I was after wasn’t to get rid of that but I wanted my bridge to be smaller. I feel like now there is a hollow line of a downward from under eye to about 3-4 cm. And the width is about from the bridge to the side around 1-2 cm. I only remember him saying that he has made the bone in that area less thick. I think as a result, it leaves some kind of hollow, especially when taking picture that area seems to be looking deep and I don’t think it was like that before I did it. I think it’s not supposed to look like this. I think the doctor wasn’t skillful enough and removed too much bone and now I look kind of old. When I smile it’s the most obvious. 

Is it possible at all to fill it up with something permanent fixed to my bone beside the bridge(basically to make the bone on that area thicker) that wouldn’t move when I smile? I don’t want a fat graft which doesn’t last and would move or get pushed up when I smile. Or any other material ? I’m aware that there would be a curve at the bridge down to the sides. But I’m really not sure where exactly the doctor got rid of my bones. But it wasn’t by squeezing the bone, he literally kind of use some tools to get rid of the bone.

A: I can not tell from your description whether this high paranasal deficiency is the result of nasal bone infracturing done at the time of a rhinoplasty or whether this area was directly burred from an incision inside the mouth. Regardless of its origin, the paranasal/medial maxillary process region can be built up using a variety of different material from an inside the mouth approach. (paranasal augmentation) Having built up this area before, it is a highly sensitive areas to augmentation and it only takes a few millimeters to make a very visible difference. Whatever material is used the upper edges need to have fine tapered edges ti avoid any visible external transition areas.

Dr. Barry Eppley

Indianapolis, Indiana

Tummy Tuck and Hernia Repair

Q: Dr. Eppley, I have an umbilical hernia and have been told that a general surgeon would be needed for this procedure. In addition to needing a mesh piece placed in the hernia, I would like the resulting belly button to be aesthetically pleasing. I also have a c-section scar with some loose abdominal skin. Can you address all my concerns during a single procedure without an additional general surgeon in the OR at the same time?

A: What you are specifically asking is to have a tummy tuck done with an umbilical hernia repair at the same time. This is not a rare situation for a plastic surgeon to encounter and manage. During an open tummy tuck procedure most umbilical hernias are repaired by using your own natural tissue through midline muscle plication. It would be very uncommon for a plastic surgeon to have to resort to the placement of a synthetic mesh for hernia repair during a tummy tuck. The only concern is the fate of the belly button during an open tummy tuck operation. Many umbilical hernias have disrupted the attachment of the belly button to the abdominal wall. During a full tummy tuck the outer connection of the belly button is removed from the surrounding skin. If the umbilical hernia has also separated the base of the belly button, it may not have adequate blood supply to survive afterwards and be lost. So the objective of obtaining a better looking belly button may be a difficult challenge when a full tummy tuck is done with a concomitant umbilical hernia repair. This does not mean that the two should not be done together, as they should, but one has to appreciate the potential implications for the belly button and its postoperative fate.

Dr. Barry Eppley

Indianapolis, Indiana

Liposuction for Weight Loss

Q: Dr. Eppley, I contacted you last year about liposuction. I’m finally ready to get the right procedure cause I’m not sure what would be best. I’m 5ft 7inchs tall and weight 283 pounds. I would like to lose as much as possible. Can you tell how much I might be able to lose just so I have an idea. I would like to get down to 195 pounds but I don’t know if that is possible or if that is dangerous. Can you please help me pick the safe and best procedure. thank you for your time.

A: I am afraid that you have the wrong idea about liposuction surgery and what it can accomplish. It is not a weight loss method nor would it be appropriate at your current weight of 283 lbs. Liposuction is a body contouring surgery to remove select areas of fat that are diet and exercise resistant.The only way you are going to lose 75 to 100 lbs through surgery is by a bariatric surgery approach with either a lap band or a gastric bypass. Liposuction at 283 lbs is not only dangerous but would be ineffective at making any substantive body shape or weight loss changes.

Dr. Barry Eppley

Indianapolis, Indiana

Lower Leg Fat Grafting

Q: Dr. Eppley, I have mild muscular dystrophy that has left my right leg and ankle much smaller than my left. I have two calf implants in now but my ankle and the inside of my leg are still much smaller. Is there any way you think you could help?

A: Calf implants do a good job of increasing the size of the upper half of the lower leg between the knee and ankle. But its augmentation effect stops where the gastrocnemius and soleus muscle meets which is about halfway between the knee and ankle. One way to augment the lower half of the leg and continue the effects created by the calf implants are fat injections. As long as one has enough fat to harvest, fat injection augmentation can be done in the lower half of the leg. (leg fat grafting) Its biggest problem is in how well the fat will survive which can be difficult in the tight tissues of the lower half of the lower leg. Multiple fat injection sessions may be required.

Another option would be a custom made implant for the lower leg. But this has a much higher risk of complications than calf implants do because of its subcutaneous location as opposed to that of a subfascial one.

Dr. Barry Eppley

Indianapolis, Indiana

Custom Jawline Implant

Q: Dr. Eppley, I am interested in your assessment of my jawline issues. and what you would recommend for surgical improvement. I have a weak jaw but a fairly good bite. Had orthodontics as a teenager and they never recommended any surgery. The other issue which may be helpful is that I have obstructive sleep apnea (OSA) and wear a mouth piece at night to push my chin forward. I am tall and thin so I do not fit the ‘typical’ body type for many OSA patients. I have attached pictures for your review. I have been to several plastic surgery consults but each one suggests a chin implant. While that might be somewhat helpful it just seems that it is an inadequate solution for my problem.

A: Thank you for sending your pictures. My assessment is that you have an overall short lower third of our face as evidenced by a horizontal and vertical deficiency of your entire jawline. (mandible) Besides the visually apparent facial third discrepancy, the fact that you have OSA and require the use of nighttime CPAP speaks to the potential contribution of a short jaw as a contributing factor.

The optional treatment for this type of jaw deficiency is a custom jawline implant that can augment smoothly the entire jawline in a wraparound fashion from jaw angle to jaw angle including the chin with tridimensional changes including increased vertical, horizontal and some width changes. (see attached predictive imaging) Having significant OSA, however, throws a variable into such a plan however as it would provide no functional improvement in your airway….and that seems like a shame given its potential lifelong occurrence.

A variation on the custom jawline implant would be to combine a sliding genioplasty to bring the chin down and forward (carrying the anterior attachment of the tongue muscles with it and potentially offering some OSA symptom improvement) combined with a pre made custom implant that would augment the rest of the jaw. This would be the only way to have a completely smooth transition from the posterior edges of the sliding genioplasty osteotomy line to the body and angle of the jaw behind it from an augmentative standpoint. Like the total custom wraparound jawline implant it would need to be made from a 3D CT scan from which the osteotomy and implant design would be done.

The ‘simplest’ option would be to just have a sliding genioplasty with standard off-the-shelf vertical lengthening jaw angle implants.  While offering aesthetic and functional jawline improvement, it would not create a perfectly smooth jawline from front to back.

Dr. Barry Eppley

Indianapolis, Indiana

Laterally Extended Breast Lift

Q: Dr. Eppley, I am interested in a breast lift and tummy tuck. I’ve been thinking about the specifics of the breast lift and I’m hoping you can help with some questions. Attached are some images that will help guide our discussion. At the consultation we discussed the Wise pattern breast lifts with lateral extensions – Image1 is a quick sketch I did that represents my body type and my interpretation of what we discussed. What I’m unsure about is how much “pull” of excess lateral skin there will be with the breast lift and how much remaining fat will be left afterward. Also, would the lateral extension be an extension of deepithelialization from the breast lift or would there be skin and fat removal as is done in the tummy tuck?

If you take a look at attached images A and B you can see evidence of a pouch of fat lateral to the breasts post-surgery– this is what I’m hoping to avoid! Is this due to deepithelialization without fat removal? Images C, D, and E represent the flat appearance I’m hoping to achieve, all with different techniques. Image C is of a spiral flap procedure and this is the outcome I’m most fond of– though I’m not really interested in relocating the fat, just removing it from that lateral position! I’m wondering if this is the technique/outcome you had in mind or if this is something completely different.

A: Thank you for your questions about breast lift surgery. The issue at hand is how best to manage the excess tissue at the side of breast over the chest wall into the back. The Wise pattern breast lift procedure does provide some pull and tissue reduction to this area but will not produce a complete elimination of it. When the chest sidewall tissue excess is considerable, some direct management will be needed. Liposuction offers a ‘scarless’ method when fat is the main issue and one has good skin elasticity to allow for skin retraction. When there is a prominent skin roll extending the cut out from the breast lift into the sidewall and into the back is the most effective method for its reduction. But as your examples show it occurs with a price to be paid in terms of extended scars and scars that may not do as well as those of the breast lift or tummy tuck. But skin and fat needs to be removed from the side chest wall to be most effective.

Dr. Barry Eppley

Indianapolis, Indiana

Subnuchal Skull Implant

Q: Dr. Eppley, I am interested in a custom implant in the subnuchal region of my occipital skull. I know that fat grafting is another options to augment this area due to the neck muscles attaching to the skull there. My questions are what are the possible complications could be, and if you have seen these types of complications in any of the other skull shaping patients you’ve operated on.   Hypothetically, in my case, I believe that such an operation could involve clearing/removing a 2cm width band under and parallel to the nuchal ridge on one side before in order to have the implant attached.  Would this have a severe effect on head and neck movement and/or cause long term pain?

If this is not a viable option I’m curious as to whether an implant could be placed in a pocket over the muscles/tendons and not directly against the skull.  I have read that implants used in other areas (ie. breast implants) are at times placed within or over muscles and are not secured to any hard body structure. Could an implant be placed in the subnuchal area over the tendons, thus avoiding their separation from the skull? Subsequently if there was an implant placed this way, and if a portion of the implant extended to an area of the skull without/ not covered in tendons, could it then be attached there? Alternatively is there a method of fixation to the skull that could occur through the tendons (i.e., with screws) to secure an implant in place. I ask this after reading of non-secured implants causing erosion of tissue with micro-movement over time.

At this time I am willing and able to pursue a surgery if there could be an intervention that was safe effective visually and that is stable over time. I would be grateful for any input you may have.

Nuchal Ridge Implant Dr Barry Eppley IndianapolisA: Placement of a subnuchal skull implant for low occipital/upper neck augmentation would have to be placed on top of the muscular fascia as opposed to under it against the bone. Stripping the muscular attachments off the bone is associated significant discomfort and  recovery of neck motion. Once in the subcutaneous tissue plane between the skin and the fascia the implant will generate a layer of scar around it which will keep it in placed. (much like a breast implant)

Greater occipital nerveThe only anatomic risk of placing an implant in this area is the greater occipital nerve. Fortunately this nerve lies under the muscular fascia and does not common through until higher up over the bone.

Dr. Barry Eppley

Indianapolis, Indiana

Gynecomastia Revision Surgery

Q: Dr. Eppley, First of all,  I want to thank you for the time that you took and will take to analyze my case,  I’ll be eternally grateful for any help that you can provide to me in order to improve my condition.I have been really traumatized over the years for this mistake on a surgery that  was made to me when I was 17 years old (I’m 39 years old now) Please see photos attached,  I’ll be waiting anxiously your answer.

A: Thank you for sending your pictures. You have a very classic gynecomastia ‘crater’ deformity from over resection of the breast tissue. This has left no intervening tissue between the nipples and the pectoralis muscle fascia, thus allowing the nipple to contract inward and scar down. Its appearance may have gotten a little worse as you have aged because the chest tissue around it (fat) may have gotten bigger allowing the inward nipple retraction look worse.

The correction of nipple retraction after gynecomastia reduction depends on the degree of severity and requires tissue grafting for release and improvement. Your case is fairly severe and you would ideally need an open release and dermal-fat grafts to level out the nipple contours. Dermal-fat grafts do require a harvest site somewhere which is usually done in the lower abdomen. Injectable fat grafting could also be done but that would definitely require multiple treatments to get the best result. There may also be a role for liposuction of the chest around the nipples to help optimize the chest contour also.

Dr. Barry Eppley
Indianapolis, Indiana

Cheekbone Reduction

Cheekbone Reduction Dr Barry Eppley IndianapolisQ: Dr. Eppley, I have always felt that the areas right inferior to my zygomatic archs are way too thick and hard and widened.I am not sure about the specific name of that muscle, but pretty sure it is not due to bone.I know that Botox is commonly used to reduce jaw angle, but I don’t even have an angle so I don’t know whether it will help, as it is like the area above masseter muscles (or it really is upper masseter muscle?).

A: Botox will not be an effective or prudent treatment for the area you have highlighted for the following reasons:

1) There is a significant risk that Botox injections placed in this area will inadvertently paralyze the frontal and buccal branches of the facial nerve, thus rendering your forehead, eye and upper lip areas paralyzed for the duration of the effects of Botox. (around 4 months)

2) The upper masseter muscle in this area is largely more fascia than muscle thus making it far less responsive to reduction than that of the jaw angles

The effective method of reduction would be check bone reduction (zygomatic arch reduction) to carry the attachment of the soft tissue inward with the bone.

Dr. Barry Eppley
Indianapolis, Indiana

Sliding Genioplasty Recovery

Q: Dr. Eppley, It’s been one month since my sliding genioplasty surgery and I am starting to feel that my results are just getting worse every day.  I’ve attached some pictures for you to see. My whole right side of my face looks rotated upwards & even more crooked than before.  Is there any chance this is going to get better?  I have a dent and now I also have lines on my right side.

A: I think it is important to understand that four weeks, which seems like an eternity when one is the patient, is a very brief time after surgery and many issues have yet to resolve or become clear. In intraoral genioplasties I do not judge the aesthetic outcome and any functional issues for at least six months. When the mentalis muscle is disassembled, the bone cut and moved and the muscle then reassembled, many expected short-term issues will appear. Stiffness and aberrant movements (soft tissue distortions) of the chin pad will initially develop as it heals as one might expect from such disruption of the anatomy. These almost always resolve but it will take time and patience to get there. Until all swelling, numbs and stiffness of the tissues resolve, you are not close to what the final functional outcome may be. The resolution and complete adaptation of the soft tissues down to the bone always takes much longer than any patient thinks. It would be impossible that your face is more crooked than before surgery given exactly what was done. Again the six month time period is when the true final outcome can be determined.

Dr. Barry Eppley

Indianapolis, Indiana