Will A Mentalis Resuspension Fix My Lip Incompetence?

Q: Dr. Eppley, two years ago I had jaw advancement and sliding genioplasty surgery. Although my face symmetry has improved dramatically, this surgery has left me with lower lip incompetence. There is a 5mm to7mm gap between my top and lower lip when my lips are in resting phase, and although I have no evident mentalis strain when I force my lips to close, I would like to know if anything can be done to correct this lip incompetence. I have read that mentalis resuspension can work but I am not sure if this applies to me as I do not know the source of my lip incompetence (though I suspect it has to do with the mentalis muscle). Please see a before and after picture demonstrating the change in my lower face shape/size as well as my lower lip incompetence. 

A: Any lower lip repositioning  downward after any intraoral procedure that involves an incision inside the mouth at the chin area disrupts the mentalis muscle. Whether the muscle was adequately resuspended or not I would have no idea. But when the lower jaw is advanced combined with a sliding genioplasty, the amount of soft tissue to cover over the chin may simply have become ‘inadequate’ or stretched. This is reflected in the lower lip position which is affected by being pulled downward. Whether you can overcome the lower lip position by mentalis resuspension alone is suspect. That alone is unlikely to hold the lower lip upward and reduce the incompetence. This is a problem of tissue deficiency not just one of tissue malposition. The mentalis resuspension would have to be combined with other maneuvers to have chance of success. The addition of dermal-fat graft on top of the muscle suspension and a V-Y mucosal closure would be needed to end up seeing any improvement in your lip incompetence.

Dr. Barry Eppley

Indianapolis, Indiana

Does A Two-Stage Occipital Augmentation Require Extended Time Off Work?

Q: Dr. Eppley, I am concerned about my lack of volume and height in the back of my head. In order to achieve a more normal look, I am considering the two step  occipital augmentation process with the tissue expander. Would this require me to take a month off of work? Have people been happy with the results? Is it possible instead to perform a series of smaller buildups to avoid having an expander in my head for a month?

A: When large amounts of occipital (back of the head) augmentation is desired, the limiting factor is how much the scalp will stretch to accomodate the bone buildup. This is overcome by the use of a tissue expander. By initially placing an expanding balloon, the scalp is slowly stretched to the desired amount. The same effect can not be achieved by serially building up the bone due to the scalp scar tissue that is created with the bone augmentation material. Most women have little problem with continuing to work through much of the tissue expander period because their hair masks much of the scalp expansion that is occurring. In the handful of patients with flat back of the heads that wanted a large amount of occipital augmentation, all have achieved greater volume and most were happy with the new shape of their heads.

Dr. Barry Eppley

Indianapolis, Indiana

Does A Negative Botox Result Mean That Migraine Surgery Will Not Work?

Q: Dr. Eppley, I received Botox injections for migraine headaches once and they did not give me relief, If the injections did not give me relief…then would migraine surgery not give me relief as well?

A: Botox is usually used as an indicator of success for the actual migraine surgery. When the Botox test is positive, there usually is a near 100% success with surgery. But when the Botox test is not positive, I have seen a few patients still have success with surgery. The other questions is how and where were the Botox injections done. I have seen quite a few patients who have had Botox for migraines where the injections were not done properly. As a result they had a negative test when, in fact, it might have been a positive test result if the injections were properly placed near the nerves.

Dr. Barry Eppley

Indianapolis, Indiana

 

Do I Need A Chin Reduction?

Q: Dr. Eppley, I’ve read two things regarding facial attractiveness.

1) The middle third and lower third of the face should be roughly equal in size (my middle third is 224 and my lower 216)

2) The lower third can be divided into three sections and the top section, the upper lip, should equal 1/3 of the total area and the bottom two sections, the lower lip and chin, should equal 2/3 of the total lower third height.  (my upper lip is 71 and my lower lip and chin combined are 139 so it almost perfectly matches the ideal 1:2 ratio). 

According to these measurements, my chin is actually not too long. This surprises me because I was always under the impression I had a long chin and would benefit from a slight reduction in chin height. (vertical chin reduction)

Do you have an opinion on my chin height? I’m trying to approach this scientifically, but I’m not sure I’m succeeding.

A: What you are learning is that facial measurements and ratios are general guidelines and do not always translate directly into perceived attractiveness. Case in point…you felt your chin was too vertically long but the numbers say otherwise. While the numbers may be ‘right’, in the end all that matters is what you think. What you need to do is approach your chin concerns in reverse…so some computer imaging with shortening the chin (vertical chin reduction) and see if it looks better to you.

Dr. Barry Eppley

Indianapolis, Indiana

Can Cheek Implants Be Removed Under Local Anesthesia?

Q: Dr. Eppley,I had cheek implants done 6 months ago, but they have unfortunately have become infected with a low-grade infection. My surgeon has advised that I get them removed, and has given me the option of either local or general anesthesia. I’m trying to save on this if possible, but I have a few concerns about going the local anesthesia route. Anyway, here are my questions:

1) Is it safe to get them removed via local? Is this something that you’ve done for your patients?

2) More importantly, how comfortable is it? Will it be a very painful experience, or just some mild discomfort at worst?

A: In answer to your questions:

1) The use of local anesthesia to remove your cheek implants is certainly safe. Fortunately I have never had a cheek implant infection so I have never had to do it. But if I did and that is the way the patient wanted to remove them, I would. Are your cheek implants silicone or Medpor. Are they screwed in? That would affect the question of whether local anesthesia is a good option or not.

2) With good local infiltration and infraorbital nerve blocks, it should be able to be done comfortably. But that would depend on the skill and experience of the surgeon in doing the local anesthetic injections.

Dr. Barry Eppley

Indianapolis, Indiana

Can I Have Breast Implants Put In Through My Bellybutton?

Q: Dr. Eppley, I was interested in having breast implants done via TUBA. Do you perform those? Is What is the cost of this surgery? My daughter is getting married in June and I really want to have this done before that. I have attached 2 photos. One is with my normal bra and the other is what I would like my breasts to look like (I used several bras to accomplish this). I look forward to hearing from you.

Breast Augmentation  oblique view Dr Barry Eppley IndianapolisA:Trying to place breast implants via the umbilical approach (TUBA) is a very poor way to do the operation. It is fraught with problems such as the inability to use silicone implants, difficulty in getting into the proper submuscular plane and persistent problems of after surgery upper abdominal pain. If you are looking for a scarless method of breast augmentation, the transaxillary approach is far more successful with less potential complications. Using saline implants through the armpit would also be the most economical approach to breast augmentation. It is hard to know exactly the size (volume) of implants you would need just based on how the change in the upper pole of your breasts. (as shown in your pictures) A volumetric sizing method is the best way to pick the proper size for you.

Dr. Barry Eppley

Indianapolis, Indiana

 

What Is The Best Age For Flat Back Of The Head Correction?

Q: Dr. Eppley, Our four year old daughter has a flat back of the head due to positional brachycephaly. She has the additional bone growth over her ears that we would consider also having reduced. We want to know our options for building up the flat spot when she gets older. What is the right age? Have you built up flat spots for younger kids? We’d prefer to wait until she’s at least a teen but want to fully understand our options. Does the single step procedure provide enough material to build up the flat spot to the satisfaction of most clients or would you anticipate the two step method where the scalp is stretched to accommodate more material might make more sense? 

A: The timing of elective skull augmentation for a flat back of head is matter of personal preference. In my opinion, it can be done very young or anytime later in life. Building up the bone requires the overlying scalp to stretch and age does make any difference in that regard. Since this is an onlay technique, the hydroxyapatite cement will grow with the surrounding bone so age is not a concern in that regard. I have done a child with unilateral occipital augmentation as young as age 4. The timing is merely a matter of parental and, if old enough, patient choice.

Because your child has bilateral occipital issues with biparietal width increase, the need to reduce the wider bone indicates a need to do it when she is older and the bone is thicker. So the teenage years would be a good consideration in your child’s case. While most cases are done in a single stage procedure, that would depend on how flat it is and how much occipital expansion is needed. If more than 15 to 20mms of occipital expansion is needed, then a first stage tissue expansion would be needed.

Dr. Barry Eppley

Indianapolis, Indiana

Can An Umbilical Hernia Be Fixed At The Same Time As A Tummy Tuck?

Q: Dr. Eppley, I have had three babies in just under four years. Each time, I was all belly, which was ok while I was pregnant, but it’s left my stomach impossible to flatten again! I’m interested in a tummy tuck and possible liposuction on my sides. I also have an umbilical hernia. Could that also be repaired at the same time?

Tummy Tuck Surgery Dr Barry Eppley IndianapolisA: Pregnancy, if repeated often enough and at close enough frequencies, makes numerous permanent changes to the abdomen. Stretched out skin, stretch marks and umbiilical hernias are common sequelae of pregnancy. While losing baby fat and weight can help make some difference, there is no amount of exercise and dieting that can help remove extra skin, reapproximate a rectus diastasis or fix an umbilical hernia. Because of the wide open exposure of a tummy tuck, both the umbilical hernia and the rectus diastasis can be repaired. The removal of extra abdominal skin completes the tummy tuck and can, in many cases, make a woman’s abdomen completely flat again. The amount of loose skin and fat, condition of the rectus muscles and whether a hernia exists or not makes for numerous types of tummy tucks.

Dr. Barry Eppley

Indianapolis, Indiana

What Is The Cost of Gummy Bear Breast Augmentation?

Q: Dr. Eppley, I am a mother of  three and have breastfed each baby for about 13 months. I amcurrently breastfeeding my 9 month old. Once I’m done, I’d like to have breast augmentation with gummy bear implants. After breastfeeding, I’m left with very small breasts (embarrassing!). I’ll be probably a small B cup and will want a natural looking D cup. What is the cost of gummy bear breast augmentation?

Gummy Bear Breast Augmentation with Nipple Lifts Dr Barry Eppley IndianapolisA: Breast feeding eventually leads many women to consider or undergo breast augmentation surgery. Each child and each round of breastfeeding causes more breast tissue loss known as involution. I have seen many women who after two or more children have virtually lost all of their breast size and with that some of their feeling of being an attractive woman. Breast augmentation is a quick way to restore what was once lost. An important issues is whether you have any sagging after three children and that may necessitate some form of a breast lift with your implants. The other issue is that it is a good idea to have your milk dried up before having the surgery. (although the surgery can still be done with some light milk production) The total cost of gummy bear silicone breast augmentation is around $5500.

Dr. Barry Eppley

Indianapolis, Indiana

Are Cheek Implants A Good Idea?

Q: Dr. Eppley, I had two facial problems my entire life, dark circles and retracted lower eyelids. I have always hated my look when I am not squinting and because of that I think that my ower eyelid muscles have become overdeveloped. I have attached pictures of when I squint and when I don’t. This will give you an idea of my orbital/cheek area.

The area circled in the picture was filled with Juvederm already as suggested by a local plastic surgeon to improve lower eyelid projection but it didn’t help at all. Though I do like my cheeks now and I am also thinking about making this permanent with cheek implants to give even better support to lower eyelid. What do you think about this idea? The local plastic surgeon seemed to think that cheek implants were a bad idea.

What procedures would you recommend? Also would canthopexy/canthoplasty address problem with overdeveloped muscle, or would it need to be trimmed with another procedure ? Could all procedures be done together?

A: Your pictures show a large orbicularis muscle roll of the lower eyelid (when squinting), cheek bone hypoplasia and lower eyelid hollows. (with some slight scleral show) I would recommend medium submalar shell cheek implants, a pinch lower blepharoplasty with excision of redundant muscle and fat injections for undereye hollows, all of which could be done as a single procedure. When done locally this is an outpatient procedure but, if from afar, most patients would return home in 48 hours. It would take about 10 to 14 days to look very acceptable without obvious signs of surgery.

Dr. Barry Eppley

Indianapolis, Indiana