Your Questions
Your Questions
Q: I have scleroderma and there are quite a few things that bother me about my face. Because of the scleroderma, it has caused a lot of damage to my appearance and the whole left side of my body is smaller than the right. If I could change how I look, I would want to look as close to normal as possible. I know I won’t look perfect but just looking like I’m not sick is good enough for me. My main issues are my cheeks which are sunken in, my chin which is uneven, my lips in which the top and bottom left sides are smaller and my nose which I think is too pointy. There is also an indentation on my forehead and the area under my eyes seems very hollow, all these affected more on the left side. I would really like to hear your opinions are on what I mentioned and your recommendations. I have attached a series of pictures for you to review.
A: I have taken a look at your pictures and your overall problem which is two fold; a short lower face and a lot of soft tissue thinning and atrophy. (more on the left than the right) In making an effort to get you looking better, you need a two-level approach. First, it is necessary to change the bony foundation by making the chin longer, more even and further forward by a chin osteotomy as well as a rhinoplasty to bring the nose/middle part of the face back into better balance. (this is what is imaged in the side views) Cheek implants are also needed to add some fullness to the cheek area. (this is what is imaged in the front views) The soft tissue deficiencies, which are difficult to image, are addressed by the placement of multiple dermal grafts and/or fat injections (if you have any fat elsewhere on your body to harvest) in the forehead, lower eyes, side of the face below the cheeks and in the left upper and lower lips. All of these could be done in one single surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have a question about jumping genioplasty. I am curious, if you have had previous chin surgery with indwelling plates and screws as well as possible internal scarring of the muscle that causes creases in your chin when you smile, can you still undertake a jumping genioplasty? Or would the scar tissue and plates and screws from the previous ostetomy prevent this? I understand this makes surgery more difficult to carry out. I was just wondering if it is still possible.
A: While you are correct in that it is more difficult, it is not impossible and sometimes is fairly uncomplicated. The only limiting factor is the plates and screws used from the first osteotomy and how easy they are to remove. The typical osteoplastic genioplasty, if the chin has been advanced, is a step titanium plate with 4 or 6 screws. As long as bone had not completely grown over these metal devices, they are often fairly easy to unscrew and pry out the step plate. But if bone has completely covered these devices, their removal can be very difficult and destructive. Fortunately, complete bony healing over the plate and screws is not common. Once the devices are removed, the osteotomy is straight forward and the prior chin surgery actually makes it easier to complete a secondary bone cut.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hi there, I was interested in your lip lift procedure and wondering if you did fat transfer to the face for reshaping/volumizing, and a butt lift using fat transfer. I’ve been researching for several months and I’m ready to have it done, but I’m wanting to find the right surgeon for me.
A:I do a lot of fat injection surgery, most commonly to the face for volumetric enhancement and to the buttock for augmentation, otherwise known as the Brazilian Butt Lift. Fat transplantation by injection is a really exciting approach for numerous face and body contour problems even if its ultimate survival is not always assured. The exact technique for fat preparation varies by surgeon and there is no absolute agreement as to how it should be done. I use a fat concentration technique and then mix it with PRP and Acell Particles to enhance survival and volume retention. These are by far the most common recipient locations. The key is whether one has enough fat to harvest which is an issue for the buttocks and not the face.
Lip ‘lifts’ can be done as either a subnasal lip lift or a vermilion advancement depending upon the shape of the upper lip and the patient’s scar tolerance. Please send me some photos of your lip for my assessment. Both approaches can be very successful when properly done. Vermilion advancements produce the most dramatic change in lip size and shape. True subnasal lip lifts are more limited in how they change the shape of the upper lip.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am a 35 year old mother of two. I’m 5’4″ and 144 lbs. I have been planning my mommy makeover for a while now and have put a alot of thought and research into it. I need a breast makeover with a lift and implants and a tummy tuck. The other area that bothers me a lot is my inner thighs. I have very little fat just loose skin with a lot of stretch marks. I know an inner thigh lifts creates scars and I am not wild about that idea. I know that thse groin scars can move downward as they heal which could be a problem in a swimsuit. Would a body lift be a better option? I know the scar goes the whole way around but how well would it lift the inner thigh area? What are your thoughts?
A: Your thought process is a good one but you have an understandable misconception about what the the lower body lift or circumferential lipectomy procedure can do. By removing skin and fat all the way around (360 degrees), it will make significant changes to your abdomen, lower back, buttocks and outer thighs. But it will have little if any effect on the inner thigh area. You wouldn’t do a lower body lift if you thought one of its main advantages was improvement in the inner thighs. The only way to improve the inner thighs is to treat them directly with an inner thigh lift. This would be far easier and more effective than a lower body lift. With well-placed incisions, the scars should remain fairly hidden in the groin creases.
Dr. Barry Eppley
Indianapolis Indiana
Q: My forehead sticks out from the side is there anyway you could make it flat and look at least normal? I have attached s side view of my forehead so you can see how far it really sticks out.
A: Thank you for sending your picture. It does show a fair amount of convexity to your forehead. The amount of convexity could be reduced but it can not be made to be flat. The bone thickness will not support that much reduction.
Here is a computer image of what I think is the best that could be achieved with a burring reduction of the forehead bone. There is one way to know absolutely for sure how much reduction can be done and that is to get a simple lateral skull film x-ray. On that x-ray the thickness and, most importantly the thickness of the outer cranial table can be seen. The skull (forehead) is composed of three layers; an inner and outer hard cortical bone layer in between which exists a softer marrow diploic space. The amount of horizontal reduction of the forehead is limited by the thickness of the outer cranial table. It can only be reduced until one gets close to the diploic space. Measuring that on the x-ray could show how much the forehead could be reduced in thickness. A tracing of the before and after cranial contour could then show you the exact profile change that could be achieved.
Dr. Barry Eppley
Indianapolis Indiana
Q: Is a cheek implant that is placed high (near the orbital rim) and lateral, that extends to the orbital rim and that provides a significant augmentation (5 mm or more), able to lift the portion between the iris and the lateral canthus (not the lateral canthus itself) of the lower eyelid a little bit? I noticed this feature of the lower eyelids in people who have naturally very high and prominent cheek bones.
A: The simple answer is that it is unlikely. While it seems logical that the lower eyelid can be pushed upwards, and it is easy to do with one’s finger, try it by pushing up on the cheek tissue. You will notice the lower eyelid does not really move upward but just creates bunching of tissue right beneath the lid line. This is because the lateral lid line is fixed by the lateral canthal tendon. The only way to change the lateral lid line is by repositioning or tightening the lateral canthus. I suspect that putting in a cheek implant as you have described may seem to work during surgery, only to be disappointed later when no change is seen.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have a very high jaw angle. My goal is to have a jaw implant that will lower my jaw angle as much as possible. The problem is that the biggest implant I have seen only has 35mms of vertical length and the inferior ridge is just under 10mms. Does a bigger jaw angle implant exist and I have just not seen it? If not, how can a bigger one be made if possible?
A: Your are correct in your assessment that no off-the-shelf jaw angle implant can drop one’s angle down anymore than 10mms at most. Anymore more than that requires a custom implant to be made which can bring it down closer to 20mms. Such exceptional jaw angle extensions are uncommonly requested or needed which is why no stock implant exists with that degree of accentuation. I have made custom jaw angle implants that do achieve what you are after. They require a jaw model to first be made which is done from a 3-D CT scan of the patient. The jaw model made is then the exact anatomy of the patient from which the design and model are created.
Dr. Barry Eppley
Indianapolis, Indiana