What Type Of Chin Reduction So I Need?

Q: Dr. Eppley, I am a 32 year old female interested in having chin reduction surgery. I underwent orthognathic surgery in 2011 to correct a class III malocclusion and to straighten my midline with a bilateral sagittal split mandibular setback osteotomy. I am pleased with the way my bite looks as a result of this surgery, but I am still unhappy with the extent to which my chin protrudes. I am very interested in learning what can be done to reduce the size of my chin and to improve my facial profile. I have attached some frnt and side view pictures for you to review.

A: Chin reduction surgery must take into account the extent of bone and soft tissue to determine what technique to use. What I see is a central button of bone on the chin which appears to be the primary culprit. It looks like it could be horizontally reduced by at least 5mms and the bone tapered backward along the jawline a few cms. The real question is whether this should be done by a submental or an intraoral approach. It is tempting to do it from inside the mouth but there is always the issue of what will happen with the overlying skin. As tempting as that seems with a smaller chin excess problem like yours, that is  probably a mistake. The submental approach has the added benefit of removing and tucking in any soft tissue excess which complements the bone reduction.

Dr. Barry Eppley

Indianapolis, Indiana

Will My Mons Get Lifted With My Tummy Tuck?

Q: Dr. Eppley, I am interested in some form of a tummy tuck. I am 42 years old, totally done with babies,  5’6” and my highest weight was 235 (pregnant) and I’m down to 150lbs and has been that weight for over a year. I’m trying to come down 10 more lbs. Should I get down 10lbs more before I have surgery?  If I do the surgery, will I be okay to lose 10 more and possibly work off that top fullness, or will it look lose again?  I go to the gym three to four days a week and I’ve been working really hard for a really long time.  It’s getting the point where I’m starting to get really discouraged, because the more I lose, the worst my stomach looks. :(   I have attached pictures of my stomach from all sides. I did try to get the  best photos possible (I am attaching a back view—just in case) since I’m not sure if I need an extended tummy tuck or the body lift.  Do you think I need it or will the extended TT will be sufficient?  I mean, obviously the hanging belly is the biggest issue, but I really want a good contour.  I am also very self-conscious about my mons area, and hope it will get pulled up (maybe a tiny bit of lipo on it?) in the process.  (It’s totally embarrassing!)  Will that happen?  I really like how your previous patient (2nd attachment–tummy tuck after) turned out—the scar symmetry, the low profile, and how the mons area looks.  I also have attached another photo from the web that I thought looked similar to me in the before photos.  Do you think I could achieve a result like that?

Tummy Tuck with Mons Lift (Dr Barry Eppley IndianapolisA: Your pictures were great and show exactly what you need. You definitely do not need a body lift and just a bit of an extend tummy tuck. Your mons will be liposuctioned and lift at the same time as the tummy tuck. Whether any patient can achieve the result that another patient obtained can not be precisely predicted. But if you look similar before surgery, then a similar result may be possible.

If you are within 10 to 15lbs of your weight goal, there is no reason to lose any more. The surgery process will take care of that weight. (what is removed during surgery and the weight loss after surgery during the recovery)

 

Dr. Barry Eppley

Indianapolis, Indiana

Does A Mini Tummy Tuck Move The Belly Button Lower?

Q: Dr. Eppley, I have loose skin around my belly button after having several children. I went to a plastic surgery consult and was given the option of a mini tummy tuck and moving the belly button lower from the ‘inside’.  I have some concern about the tummy tuck option for my belly. My only hesitation is the aesthetics of having my belly button one inch lower.  Most of my pants/jeans/swimsuits sit just below my bellybutton which, other than the puffy ring around my bellybutton, looks good (generally speaking). I attached a few pics with jeans and swimsuit bottom. I am thinking that it will look “odd” after a mini tummy tuck, such that the bellybutton will no longer be visible with these clothes on and my overall appearance will look “strange”.  Where my belly button sits is between my waist and hip; it seems that the belly button would be moved down around my hip which might appear “not quite right”. Are there any other alternatives for a better appearance of this area?

A: Unfortunately there are no other effective solutions for the excess skin around your belly button other than the mini tummy tuck approach. Unless one puts a horizontal scar across the belly button area (which would obviously be unacceptable) the only way to work out the extra skin is to translocate the belly button lower through a mini-tummy tuck approach

Like just about everything in aesthetic surgery, it is all about the tradeoffs…you usually tradeoff one problem for another. You just have to decide which problem you can live with the best…the skin the way it is around the belly button or less skin around a belly button which is positioned lower. There are no ideal solutions for your problem that don’t have their own drawbacks.

Dr. Barry Eppley

Indianapolis, Indiana

How Big Of A Lip Reduction Can I Get?

Q: Dr. Eppley, I had a lip reduction six months ago which, quite frankly, did very little. It may have resulted in a 10% reduction of my lip size. I am now considering further lip reduction surgery for better results but have a few questions.

1) I’m looking for very specific results so I need to be sure you are confident in your ability to perform a reduction of at least 1/2 of the size on each lip? I want results that are very significant and not subtle.

2) I would also like to reduce the bulkiness of each lip, in other words, less meaty.

3) In the technique you do will the scars be visible? What can I expect after everything is healed? Will there be any noticeable scars on the visible/dry part of my lips?

4) Will there be 2 scars, one from the prior surgery and one from this one, or can you remove the tissue from where the old scar is?

A:  In answer to your lip reduction questions:

1) Significant reduction can be obtained but there is a balance between reduction and the location of the scar. The only way to get significant lip reduction is to remove the DRY exposed vermilion not the wet invisible mucosa like you had the last time.

2) You really can reduce the thickness or meatiness of the lip per se. Right underneath the vermilion lies the labial artery which gives the blood supply to the lip as well as the orbicularis muscle which is responsible for some of its movement. Thus you can see that trying to debunk the lip by a deeper wedge excision is fraught with potential problems. All you can do is remove the surface vermilion to have less visible show but really thinning out the thickness of the lips is not surgically advised.

3) as per #1. The key point is…the bigger the reduction the more likely the scar may be visible.

4) The old scar would be removed with the new excision.

Dr. Barry Eppley

Indianapolis, Indiana

 

Are Preformed Skull Implants For Augmentation Safe And Effective?

Q: Dr. Eppley, I’m considering getting the custom skull implant for skull augmentation to build up the back of my head. Can you please share your experience of this type of skull implant surgery you have performed?

A: When considering preformed silicone implants for occipital or any skull augmentation, there are two basic methods to do it. Here in the U.S., a custom fabricated implant is always used since there are no preformed skull implants that are commercially available. It is always hard to argue with a custom implant since that is the ideal way to get a perfect fit and have it made to correct any existing asymmetries. That is the approach I have used over eight forehead/temporal augmentations and one occipital augmentations in the past two years. That being said, I have placed a few preformed skull implants (top and back) on international patients who brought the implant with them from overseas manufacturers. (they are illegal to directly import into the U.S. since they are not FDA-approved)

I do think such silicone implants do have role to play in forehead and occipital augmentations for the reasons discussed even if there is a modest increase in the infection rate. (out of 9 such skull implants in the past two years, I have had two infections that necessitated their removal (22%). This is contrasted to over 100 PMMA skull augmentations with no infections seen even in three cases where the implants became exposed due to wound dehiscences. (0%)

That begin said, I am enthusiastic enough about using preformed implants that I am now working with a major manufacturer to create a set of three sizes for occipital skull implants. For many patients this simplifies the procedure, allows for a slightly small incision and creates a moth contour even if it does not have perfect adaptation to the underlying bone.

Dr. Barry Eppley

Indianapolis, Indiana

What Type Of Skull Reshaping Do I Need?

Q: Dr. Eppley, I’m very interested in pursuing skull reshaping surgery to fix a congenital defect involving the right side of my skull. For as long as I can remember, it has been both a cosmetic concern and one of comfort. (causing pain/discomfort with prolonged lying on the right side or with wearing helmets of any sort). From reading your web-based article, I believe I may be a good candidate for your procedure. I’ve attached a few photos of the affected area for your review; of course it’s difficult to capture the magnitude and dimensions of the defect (a bulging, sharply angulated defect) with mere photos. I thank you in advance for your time and consideration.

A: As best I can tell from your pictures, the location you are referring to is the right parietal/posterior temporal region. You describe it as a congenital defect but also call it bulging. I suspect you mean a lifelong bulge in this area which is painful. This is very consistent in my experience with more of a temporalis muscle problem in that area. Most patients and even physicians have little appreciation of how thick the temporalis muscle is in that area and how far back it goes. It always feels like bone but there is a 5 to 7mm layer of muscle under exactly where you point. Having done a far number of temporalis muscle reductions/resections (temporal reduction) in this area for symptoms described just like yours, I can attest that your concerns are more likely muscular based than being a bone problem. A CT or MRI will show how thick the muscle is in this area. However, I often make the decision to do muscle resection/reduction based on the description and physical examination only.

Dr. Barry Eppley

Indianapolis, Indiana

Do I Need A Lip Lift Or A Lip Advancement?

Q: Dr. Eppley, I am interested in a lip lift. I have very thin lips and a long upper lip. I want them to have more shape and size although I don’t want them to be too big. I have read about lip lifts but am not sure what I really need. I would like your opinion. I have attached a front and side view of my lips for your recommendations.

Vermilion Lip AdvancementA: Thank you for sending the pictures. What they show to me is that unequivocally need a vermilion advancement and not a sub nasal lip lift. Your lips are very thing from corner to corner, has little cupid’s bow shape and there is a long distance between the base of the nose and the upper lip. This is a contraindication to a subnasal or bullhorn lip lift as it will only move up the central third of the upper lip but leave the rest of the lip behind, potentially creating an unusual and unpleasing shape. Only moving the physical location of the vermilion-cutaneous border, from corner to corner, of both lips can you make a significant improvement in the size and shape of your lips. I have attached an example of upper and lower lip vermilion advancements although this patient is older and she wanted a more dramatic change. The change from a lip advancement procedure is adjusted by the vertical size and shape of the skin excision and can be in any degree desired. The ‘test’ of the change a patient wants with a vermilion advancement is done by having them draw on the new border and shape of the lip with an eyeliner pencil. Then that becomes how much lip advancement is done.

Dr. Barry Eppley

Indianapolis, Indiana

Will Custom Cheek Implants Restore My Face?

Q: Dr. Eppley, I am interested in custom cheek implants.  I has severe sleep obstructive apnea and it took maxillomandibular advancement surgery where both jaws were advanced about 8 MM) to finally cure me.  As you can from the attached photos the maxillomandibular advancement surgery changed my face for the worse. Some people do not recognize me, others say I really aged and others say I look totally different. Other people on the internet that had maxillomandibular advancement surgery for sleep apnea say that they got there face back by having cheek implants put in. I would like to augment my cheeks in the best way and have other procedures and/or fillers to get me looking at least as good as I was before the sleep apnea and maxillomandibular advancement surgery.

A: The current state of your facial skeleton/appearance is rather classic when the upper and lower jaws are significantly moved forward when there is no natural malocclusion. These osteotomies are done below the level of zygomas (cheeks) and thus they create a relative state of upper midface/cheek deficiency as there is now a big forward step off between the zygoma and the maxilla as opposed to the reverse step off that normally exists. Cheek and/or cheek-infraorbital rim implants are the logical solution for this induced facial skeletal deformity. There are arguments to be made for either using preformed or custom cheek implants for your midface restoration. But the very altered bing anatomy does make an argument for the custom approach.

Dr. Barry Eppley

Indianapolis, Indiana

What Type Of Cheek Implants Do I Need?

Q: Dr. Eppley, I have had rhinoplasty, Medpor jaw angle implants (11mm projection) and silicone chin implant (medium 7mm). But I want a stronger look that is more masculine. I  also want cheek augmentation and I want a stronger chin. But the biggest chin implant I can find only gives 8mm horizontal projection so I’m considering a sliding genioplasy to have both horizontal and vertical augmentation. For the cheek implants iIm considering Design M Malar Implants from Medpor, I think they’re more anatomic than silicone ones, and also Medpor ones augment from zygomatic arch to the cheek bone which I think will give a stronger and masculine look. I would like to know which size would you recommend me to use. (4.5mm or 7mm) so they would look proportional to my jaw angle implants (11mm) I read in the internet that when you use facial implants, you have to consider the soft tissue augmentation that is different from the size of the implant… for example if you have a chin implant with 10mm projection…you’ll end up only with 7mm in soft tissue projection. So if I have cheek implants size of 4.5mm I’ll end up with 3mm augmentation, but if I have the 7mm ones,, I’ll end up with 4.9mm, So i don’t know which ones to use. I read in your blog that when it comes to cheek augmentation you should not over do this specific part because you will look unnatural. I definitely don’t want that. But also I have read that the cheek or zygomatic bone should be bigger than jaw angle.

A: I would take exception with your supposition that there is not a 1:1 correlation with the translation of implant thickness to how much change is seen on the outside. When it comes to any form of jawline augmentation, it is pretty much a 1:1 correlation. In the cheeks it is most commonly a 0.8:1 ratio. However the thickness of the soft tissues in any patient is so variable that no absolute implant size to external change seen can be generalized. Thus I would always assume it is a 1:1 relationship through the skeletal structure of the face. This would be true in my opinion given your relatively thin face.

I would also point out that a little bit in the cheeks goes a long way so I would be careful about going too big here. It is very easy to end up with cheek implants that are too big. Thus, I would lean towards the 4.5mm implants as opposed to the 7mm thick cheek implants.

Lastly, you can certainly do a sliding genioplasty using/keeping the existing chin implant in place  getting the dual benefits of both techniques. However be aware as the slidinjg genioplasty moves forward and down there will be a slimming.narrowing effect on the chin. Thus if you want to end with a more square chin look than you have now, the chin implant should be switched to a square design or even a more square one and not a rounder anatomic style.

Dr. Barry Eppley

Indianapolis, Indiana

What Is The Best Method Of Lip Augmentation For Me?

Q: Dr. Eppley, I’ve been looking for a more permanent solution for a lip augmentation. I was looking into fat grafting, but I understand that that procedure may not turn out as well as I would like if not done by a surgeon who is very experienced in that procedure. I’ve also been looking into permalip, but I don’t know if that would be for me because my top lip is uneven (as you can see in the picture I’ve attached). In your opinion, which procedure would be better for me? Roughly, how many times have you done each procedure? And what are your prices for both procedures?

Upper Lip V-Y Lengthening Dr Barry Eppley IndianapolisA: There are multiple options for lip augmentation from fat injections, implants and mucosal advancement procedures. (V-Y lip lengthening) There are advantages and disadvantages to all of these procedures and none of them are perfect. They all have flaws such an unpredictability of volume retention (fat injections), asymmetry and palpability (implants) and longer recovery. (mucosal advancements) While they all can be effective, it simply depends on which of their flaws you find most acceptable. I have performed many of all of these and I think the ‘safest’ (less risk of complications) is fat injections. Permalip implants are the easiest and can always be replaced by fat grafts should one not like their feel.

Dr. Barry Eppley

Indianapolis, Indiana