Your Questions
Your Questions
Q: Dr. Eppley, can we practice an onlay cranioplasty with tkryptonite in the front of the skull and end up having a smooth forehead shape? Are the most common complications of kryptonite cranioplasty surface irregular and a palpable demarcation between the bone of the skull and the kryptonite in certain areas? What is the likelihood that a second would be needed to smooth the surface of the kryptonite? If the demarcation between the bone of the skull and the kryptonite is especially annoying on the forehead after surgery, what is the solution?
A: In answer to our specific questions:
1) It will not likely create a smooth contour.
2) What you have mentioned are the two aesthetic complications with an injectable or minimal incision kryptonite cranioplasty.
3) It can be done endoscopically (small scalp incisions) with a long handled rasp.
4) It will be and it is corrected secondarily as mentioned in #3.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I desire a more womanly face. My face is very big and square and is way too masculine looking. I am not sure if my jaw angle needs reducing or if Botox injections will suffice. Can you please advise? I have attached some pictures for you to see my big square face.
A: A square face, by definition, is when the lower jaw width is just as wide as that of the cheekbones. The width of the jaw angle area plays a major role in creating the horizontal dimension of the lower face in the frontal view. The width of the back part of the jaw (jaw angles) is created by three anatomic components; the thickness or flare of the jaw angle bone, the thickness and volume of the masseter muscle and the flare of the jaw from the front (chin) to the back. (posterior border of the ramus) Only the thickness of the masseter muscle by Botox injections and the flare of the jaw angle (ostectomy or jaw angle reduction) can be reduced. The key question is which one of these two is making the greatest contribution to the width of your lower face. While I suspect it is more bony than muscle by your pictures, it is important to make the right diagnosis. I would recommend getting some simple x-rays (frontal, side and submental plain x-rays) where the bony anatomy will be very apparent. A frontal and lateral cephalometric film (orthodontic type x-rays) with a panorex will also suffice for making this diagnosis.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, The problem with my face is it’s very skinny when I don’t smile. When I smile I have the biggest fattest face ever! I have these fat pockets around my nose. And instead of a smile I look like I’m sneering. I was in an auto accident and it caused nerve damage to my left lip. I want to fix my smile so its even again and you can see more of my teeth. I also have a brow that I hate and would like to get rid of. I also would like some work done on my chin because I hate the way that looks. And also when I smile I have “jowls” and I’d like to get rid of those and my double chin. My double chin is hereditary and being tall and skinny this looks very strange. I would also like to get a nose job because I have my fathers nose and I think it looks very masculine. Overall what I am trying to achieve is a slimmer face, with more feminine features and a better more applying smile. I don’t feel like my face goes with my personality, and how I feel. Also anything else you see that needs to be done please let me know.
A: Thank you for sending your pictures. In looking at your face and reading your objectives I would consider the following procedures. A rhinoplasty is needed to make your nose thinner and less wide, particularly in the tip. I would also recommend buccal (cheek) fat pad removal (subtotal) and small cannula liposuction of the fullness above the nasolabial (lip-cheek) grooves. A lip lift (vermilion advancement) done with differential skin removal (left greater than the right) will help with better lip symmetry and overall fullness. A submental chin reduction is needed to decrease the amount of chin prominence and protrusion. Liposuction can be done in the neck and jowls to remove fat in these areas.
Unfortunately, I can only do limited computer imaging because your pictures are inadequate. Smiling photos make a lot of facial feature distortion.
You mentioned a dislike for your brows but I am uncertain what specifically you do not like about them. Until I know more, I can not make any recommendations on whether they can or cannot be favorably changed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I recently had Botox injected into my lips to help treat my lip lines. I was not pleased with the results at all. Besides not getting rid of any of the wrinkles it also gave me the unhappy effect of making my upper lip look funny (not in a good way) when I smile. I happened to have heard on my way out when paying my bill that this was the first time the doctor had ever injected Botox into a lip. I am upset that I paid for not only no result but that it may me look worse. On my own investigation I read on the internet that Botox is only approved for use in the forehead. I think I should get my money back and maybe even sue the doctor. What do you think?
A: Botox is used for a wide variety of aesthetic facial applications. It was initiallystudied and subsequently cleared by the FDA for glabellar (between the eyebrows) wrinkles and is known as an ‘on-label’ use. Despite this one approved cosmetic use in the face, it is a perfectly acceptable medical practice to use Botox for numerous other expression-reducing/wrinkle reduction indications. This is known as ‘off-label’ use and is commonly done with many drugs. It is neither wrong nor malpractice to do so. The use of Botox in the upper lip can be effective at wrinkle reduction but is technique and dose sensitive. Unfortunately for you, this effort did not turn out to produce the desired effect. The good news is that your Botox will wear off in a few months and you will return completely to normal. I would discuss your dissatisfaction with the treating doctor and see what accommodations they may be willing to do.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have heard alot about you and even read alot about the scar revisions you do on the internet. I found your website very helpful. I had a car accident in January, 2010. I had an injury under my chin. I was taken to the hospital and the doctor just cleaned the wound and put a band-aid on it. After a month when i shaved i had two scars under my chin. one in oval shape and one in small line red-pinkish in color. I showed it to a plastic surgeon and he told me to use Kelo-cote gel for two months. i used it for 2 months and the scar was a little bit soft but not much result was seen. Then n November, 2010 i had a revision surgery on both the scars. One remained the same and the other was reduced to 60% of the original since doctor had told me she will reduce the whole scar in two surgeries. I am not satisfied with the results from the first surgery. The scar is very visible and is pinkish in color and is even more visible now. I am attaching a picture of my scar before surgery and after revision. I would welcome your recommendations.
A: In looking at your submental or neck scars, I can see that both scars are fairly wide and in need of further scar revision. The biggest scar from the beginning was a tough assigment given its very large width. I have no idea as to the type of scar revision that was performed but I suspect it was a simple linear excision. Both scars would fare better with geometric approach to scar revision to distribute the tension on the closure better to decrease the amount of postoperatve widening. This is particularly needed when the excisions are wide and in an area prone to scar stretching influences.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, what is the difference between the silicone used in breast implants as opposed to that used as as ‘black market’ soft tissue filler? if it is so dangerous to inject silicone into other parts of one’s body like the buttocks and the breasts, why then are silicone breast implants considered safe? Since silcione breast implants could rupture and leak out, how is that silicone in your body any different than injecting it elsewhere? This doesn’t make any sense to me.
A: This is a good question and it doesn’t make sense to you because, although the name silicone implies that all is the same, they are somewhat different chemically and how they are packaged. This turns out to make a big difference when introduced into the body.
Injectable silicone used for illegal soft tissue augmentation is an oil that is less polymerized and less stable. It is also dispersed in the soft tissues in small droplet form. This leaves a lot of surface area of the oil onto which inflammation and scar tissue can form. Silicone in breast implants is in a more highly-polymerized (stable) form that is encased in its own protective bag or barrier. This results in no actual silicone being exposed to the body so no reaction to it occurs. The only reaction the body as is to the bag that contains it. If ruptured, the released silicone is further protected by the body by the natural scar (capsule) that always forms around the implant. (a second bag or barrier if you will) The more polymerized silicone gel causes less inflammation or reaction from the body than oil even if it does become exposed to it. Silicone gel in breast implants has also been highly studied and evaluated by the FDA with rigorous scientific scrutiny as to its bodily effects. Injectable silicone oil has never been exposed to such scientific scrutiny as a soft tissue filler and thus has never been approved for an injectable augmentation approach.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I banged my forehead when I was 11, I’m now 19 years old. I have been left with a noticeable dent in the middle of my forehead and would like it to be less noticeable. A cut type of scar would be much more acceptable than the dent that I have now. I would much prefer a cut scar from surgery that I can cover with make up, rather than a dent that A LOT of people notice and feel they need to point it out to me. Thank you!
A: If this forehead indentation is bone based or from soft tissue atrophy, it may be best treated by building up the bone underneath it. (frontal cranioplasty) This would be a ‘scarless’ way to do it and it could be done from a small incision back in the scalp where it would not be noticeable. While the indented forehead area could be excised if it was small enough, I woudl question whether a scar would be a good trade-off for the indentation. The size of the indentatio could also preclude the excisional option. I would have to see pictures of the indentation to see what would be the best surgical treatment.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Ive come to highly respect your opinion, especially regarding the lower face as you’ve done some beautiful work. I have an asymmetric face. In seeing an orthodontist, he said I am not a candidate for jaw surgery. I think he is wrong. I think jaw surgery is probably the only real solution that will properly address my lower face. My jaw is clearly longer on one side than the other in both the ramus and the condyle, its visible in X-rays. The cheekbone is also visibly lower on one side both externally an by Xray.
My questions aside from obvious rhinoplasty and chin augmentation, can anything at all be done to address this “tilted” look to my face and eye area? It bothers the heck out of me . Your feedback would be highly appreciated. I think surgery is my real need and only true solution.
A: I do not have the advantage of seeing any x-rays so my comments can only relate to your photographs. The most significant component of your facial asymmetry is in the orbits with the one being lower than the other. That is potentially improveable through a brow shaving procedure through the upper eyelid and a lateral canthopexy corner of eye tightening procedure done on the lower orbit. That is relatively low risk and is an operation commensurate with the magnitude of the problem.
Straightening your nose through rhinoplasty is of obvious benefit as well as chin augmentation, via an implant or osteotomy, as you are already aware.
As for jaw surgery in terms of orthognathic repositioning…no. Your orthodontist is correct based on what I see in the photographs. I have no clue as to what your occlusion is but this would involve a major effort and years of orthodontic work. There would have to be a major malocclusion to justify that effort. You are far better off camouflaging the jaw asymmetry with chin augmentation and possibly a lower border shave/ostectomy on the elongated side.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interesting in what you refer to as an extreme chin augmentation (osteotomy and an implant). I have a short lower jaw, but unfortunately have been told I’m not a candidate for orthognathic surgery due to the position and condition of my teeth. To help correct this problem, I have had a chin implant placed but the results do not satisfy me as it is not big enough. I am attaching a copy of my ceph x-ray. I do not have a profile picture at this time, but it is pretty clear where my chin is from this x-ray. Can you please comment on having this surgery? I have seen a lot of your before/after pictures on other sites for chin augmentation and am very impressed with your work and the knowledge you seem to have from the questions you answer on your site.
A: Thank you for your inquiry and sending your ceph x-ray. You do an underlying significant lower jaw deficiency as seen on your film. Your current indwelling chin implant provides only 7mms horizontal projection and is positioned just slightly high on the bone. Your true chin deficiency is more in the range of 16 to 18mms deficient. You therefore already have half of an extreme chin augmentation with the existing implant in place. You now need a chin osteotomy done just above your existing implant to advance the bone (carrying the implant) forward about 10 to 12mms with a vertical opening of 2 to 3mms. This will create the most ideal chin projection for you. So doing the previous chin implant was not a wasted procedure. You would have needed it anyway as the bone can only be brought forward so far. i have done some computer imaging and predictive tracings on the ceph x-ray that you have sent me.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in having a more round forehead appearance. It is too flat and doesn’t seem to fit the rest of my face. I would like to know the best method for forehead augmentation; fillers, implant, or bone grafts. Thank you!
A: Thank you for your inquiry and sending your pictures. I can clearly see that there is a disproportion between the projection and shape of your forehead (and the upper portion of your nose, the frontonasal junction) compared to the rest of your face. Your entire lower forehead and brow needs to be built out, including an upper nasal (bridge-frontonasal junction) augmentation. I have done some imaging to show what that would look like based on the one photo that you have sent. Forehead augmentation can not be done with fillers, bone grafts or preformed synthetic implants. It requires a moldable cranioplasty material that is specifically moldeded in surgery to the desired forehead shape and allowed to harden. The two basic types of cranioplasty materials are hydroxyapatite and acrylic. (PMMA) Each has their own advantages and disadvantages. Because of your recessed forehead/brow area, the nasal junction of the forehead is severely recessed. That would need to be built up with a small bridge implant placed through the inside of the nose. If not done, building up the forehead/brow will make that area look even more recessed inward.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m not sure what is the best procedure for me but I want permanent filling of my concave or hollowed temple areas. I have tried injectabvle fillers but none even lasted a year. I loved the look to my face that made it look more symmetrical and younger but they just didn’t last. I also had fat injections done last year but that didn’t take either and I am still concave there. It was only one fat transfer procedure so maybe it takes more than pne? I’m starting to lose hope that there’s any way to fill in the temples permanently. I feel that this issue makes me look older and definitely doesn’t help my outer droopy eyelid area. I’m unsure what my options are for a permanent fix and appreciate any direction you can provide.
A:The only real permanent fix to most cases of temporal hollowing is to place a non-resorbable temporal implant, either that of a synthetic composition (silicone) or that of a collagen matrix. (dermal graft) These are placed under the temporalis muscle fascia and are tremendously effective…and are permanent.These implants are placed through a small incision in the temporal area, have minimal swelling or discomfort, and have virtually no discomfort. This would be the best solution given that you have tried all of the injectable approaches. I do not believe that repeat fat injections will work if they did not last the first time. While temporal implants can get rid of temporal hollowing, it does not lift up or provide any improvement to a droopy eyellid area. That is outside the influence of temporal augmentation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in buccal fat removal to make my cheek area less full but I have a few questions. If complete removal of the buccal fat pads is what is decided to be the best result after seeing my photos, is there a high risk for nerve damage? I’ve read that partial, more superficial removal is fairly safe but complete removal poses a risk of possible facial paralysis and/or nerve damage. From what I’ve heard and read it seems as if plastic surgeons are either for or against buccal fat pad extraction, in regards to the risks and how the patient will look when aging. I don’t seem to find any middle ground.
A: Having done many buccal fat manipulations over the years, I have no concern with facial nerve damage with buccal fat removal. It is not something that I have ever seen. Whether it is subtotal or closer to a more complete buccal fat removal, that problem is completely avoidable if you know how to do the procedure properly. How aggressive one should be with buccal fat removal is based on what type of face they have and how much the buccal fat pads are contributing to the submalar fullness. The amount removed varies depending upon the patient, their immediate thinning needs, and in consideration of what the future may be as they age with their kind of face shape.
Dr. Barry Eppley
Indianapolis, Indiana
Have you ever looked in the mirror and seen that tired look and wondered why? If you are over forty, this might be a near daily occurrence. Fullness or extra skin of the upper eyelid is one of the most common causes of tired looking eyes. You may be wondering what’s the best way for me to remove this fullness and restore the youthful, attractive look to my eyes. Is it an eyelid lift (blepharoplasty), a browlift or some combination that is right for me?
Fullness and heaviness of the upper eyelids occurs for two reasons. The most common reason is too much skin and fat. Due to the constant stretching of opening and closing your eyes (the upper eyelid accounts for most of eyelid closing) extra skin is created over time. Eventually this can become so significant that it hangs down onto your eyelashes, known as hooding. The other contributing reason can be the position of the eyebrows. If the eyebrows have dropped down and are too low (gravity does usually win) this can also add fullness to the upper eyelids as it pushes the eyelid skin down.
To really know whether it is the eyelid skin, the eyebrows or a combination of both that is causing those full and tired looking upper eyelids, you must do an eyebrow placement test. By putting your eyebrows in the proper aesthetic position (by pulling up on the forehead skin until you have the desired eyebrow position) and then opening and closing your eyes, one can see the true amount of upper eyelid fullness remaining. By so doing, there are three possibilities for correction which will be revealed.
When the eyebrows are lifted to a better position, all the upper eyelid fullness is gone. This means the fullness is due to low eyebrows and the solution is some form of a Brow Lift. In this situation if only an eyelid lift was done, it would actually cause your eyebrows to become lower.
When the eyebrows are lifted, some but not all of the upper eyelid fullness gone. This means a combined browlift and eyelid lifts are ideally needed. It would also be perfectly appropriate to just do an eyelid lift and accept the lower eyebrow position. For men this is usually more common than in women as most men have naturally lower eyebrows.
If the eyebrow is already in a good position on the lower end of the forehead and all of the eyelid fullness remains, than only eyelid lifts are needed. This is , by far, the most common tired eye scenario particularly if one is under the age of 55 or so.
Plastic surgery correction of aging of the upper eyelids must consider its upstairs eyebrow neighbor to determine the best solution to a less tired and rejuvenated look.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would to make my face less fat. It is very round and the fattest area is on the side of my face. It gets a lot better when I suck my cheeks in as this seems to draw in the area where it is the fattest. What is the best procedure to get rid of this facial fat?
A: It is always a little unclear to me when a patient says the ‘ side of their face’, that can mean different things to different people and is of particular significance when one wants a defatting or thinning procedure. Having said that I have a strong suspicion when you mean the equivalent of when you suck your ‘cheeks’ in means the entire side of your face….of which there is no surgical procedure that can accomplish that look completely. There are some areas that make up a portion of the side of the face that can be improved by liposuction. The perioral mound area extends from the corner of the mouth back about halfway between the corner of the mouth and the ear, which is the anterior half of that area. For fullness that goes all the way to the back to the ear, there is no solution.
You would be best off to consider subtotal buccal lipectomies and perioral and lateral facial liposuction. But it will never equate to the contouring or thinning effect of sucking in one’s cheeks.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting deltoid and biceps implants. I am not a body builder nor am I trying to bulk myself up. I have a congenital deformity involving my left shoulder and arm. No one knows why but it never developed right and my shoulder has a big indentation in it and is very embarrassing for me. I also can not lift my left arm even up to 90 degrees on that side. I just want to look more normal in appearance. I have attached some pictures for you to see and tell me what you think.
A: I can see that you have an ipsilateral deltoid hypoplasia. It almost seems that there is a general delto-pectoral hypoplasia present on your left side. Deltoid augmentation would definitely help for symmetry. The question is whether this should be done with an implant or fat injections. Each has their own distinct advantages and disdvantages. The advantage of an implant is that the volume would be stable. Its disadvantages are that there is no preformed implant that matches your deformity, it requires an incision for placement, the outline of the implant may be visible, there is a risk of infection and the location of the implant may interfere with raising your arm. The advantages of fat is that it would have none of the aforementioned complications of an implant because it is natural and could be tailored better to the entire shape of the deltoid deformity. Its disadvantage is that its volume retention is not always predictable.
From a biceps standpoint, I see no specific hypoplasia on the same side. They appear symmetric between the two sides. I am assuming that the request for biceps augmentation is to simply augment what you already have, not correct a deformity.
Indianapolis, Indiana
Q: Dr. Eppley, I am 54 years old and am interested in getting a facelift, rhinoplasty, and blepharoplasty surgery. I’m trying to achieve a more youthful look, less sagging, and not so tired looking appearance. I have attached some pictures of me so you can show me by imaging what the results may be like.
A: Thank you for sending your pictures. Here is some imaging for the following procedures; a facelift (neck-jowl lift) and a rhinoplasty.You could get a really significant improvement in your neck wattle as it is a large amount of loose hanging skin. That would dramatically change your neck-jawline profile. It is interesting as to why you have such a large amount of hanging neck skin even though it appears you are relatively thin. Perhaps you have lost a lot of weight ?? Regardless a full facelift will remove inches of skin from the neck and tighten up the entire jawline.
From a nose standpoint, you tip is wide and thick and turns down slightly. There is also a small bump higher up on the nose. A full rhinoplasty would take down the bump, shorten and narrow the tip with some lifting and narrow the size of the nostrils. This type of nose change at your age changes the structure of the nose and makes it look smoother and more refined, a look that has a more youthful quality.
The combination of these two procedures, as the imaging illiustrates, would make significant rejuvenative changes to your overall facial appearance
As an addendum, I did not do nor is it possible to do realistic blepharoplasty computer changes. It is clear from the pictures that you have some extra eyelid skin that can be removed as well as some herniated fat from the lower eyelid. Your lower eyelid shows no significant skin excess, however, other than a few millimeters. Together, this type of upper and lower blepahroplasties will make you look less tired.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am 22 years old and my breasts are more saggy than I would like. I have not even had kids yet and they sag. I have a good breast size but much of it just hangs low. I have read about the crescent and Benelli types of breast lifts and was wondering if these would work for me. I have attached a front and side view of my breasts so you can see what they look like.
A: The decision to undergo a breast lift is an aesthetic choice between breast sagging and better shaped breasts that have scars. For some patients with very saggy breasts this can be a relatively easy choice. For other patients with more minimal sagging, such as yourself, that choice is a more difficult one. You have asked about the Benelli (donut) and the crescent lifts because they have the least amount of scarring of all the breast lifts. In reality, they are not breast lifts at all but really nipple-areolar repositioning techniques. They do nothing for lifting or reshaping the breast mound. They work best in cases where an implant is needed to restore breast volume and a slightly higher nipple-areolar position is beneficial. In your case they would provide no breast lifting benefit. More substantial breast lifting techniques are needed to really lift your breasts and that would involve vertical and maybe even horizontal breast crease scars as well. Given the amount of sagging that your breasts have and your young age, the trade-offs for a breast lift are very questionable. Iwould not recommend this procedure at your age. Wait until after you have had children when the need will be greater and the scar trade-off will be more convincing.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am 59 years old with a younger looking face and body but an old, wrinkly neck. My neck does not match the rest of my face or body and makes me look old. From what I’ve read, a direct necklift may work to improve the appearance of my neck but would be of interest to me since it may cost less but I’d like to know what you think. I have attached some pictures which shows my wrinkly saggy neck.
A: Thank you for your inquiry and sending your photos. You have a most unusual amount of neck aging compared to that of your face. And the direction of your neck sagging is mainly horizontal and not vertical. Many men develop so called turkeynecks which are largely a vertical skin sagging problem. This is the typical direction that direct neck lifts treat which is a vertical neck skin removal with some minor horizontal skin removal at both ends of the vertical excision.
Your neck, however, shows a substantial amount of horizontal skin laxity as seen by your many horizontal neck wrinkles. This indicates that a direct necklift for you must have a different excisional pattern. Using your horizontal neck wrinkles, two to three inches of neck skin can be removed across the width of the neck keeping the final scar in a horizontal neck wrinkle line. The only question is whether a vertical component to the skin excision needs to be done as well. I can not tell that from your photos since your face is tilted upwards in the photos you sent which may artificially make any neck wattle look better than it really is.
There is also the option of a more traditional facelift approach which will also work very effectively as well, albeit with more recovery and expense.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting rid of my lower abdominal pooch. The skin has some stretch marks which become really apparent when I lean over. The wrinkly skin really sags when I do this and it is very unattractive. I am wondering if I can just exercise this area away (my husband says I can) or whether this needs liposuction to make it better. (which I think it does) What are your thoughts?
A: Many women, who are not overweight, have developed a little pooch in their lower abdomen between their belly button and their pubis. Its relatively small size suggests that it is a non-surgical problem that can be exercised away. Usually I see women who come in after they have proven to themselves that they can not get rid of it on their own. Your wrinkled skin that sags when you bend over is the key in answering the question of whether this is a surgical or non-surgical problem. This tells you that there is too much skin and it will not shrink down on its own. Excess skin most certainly can not be exercised away. The only real solution is that of some form of a tummy tuck, particularly if you are using the criteria of how it looks when you bend over. Stretch marks are a sign that the elasticity of the skin has been destroyed and no recoil or shrinkage of it can occur. Only surgical removal will solve this loose saggy skin condition.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in breast augmentation. Iwant fuller breasts to eliminate the stretch marks and I would like to go one size bigger. I am a size B now. I have attached pictures so you can see what you have to work with.
A: Thank you for your inquiry and sending your pictures. I can see your concern about breast size and there is no question that implants would be beneficial to get you from a B cup to a C cup. However, no amount of increase in breast size will eliminate your stretch marks. With the expansion of skin from breast implants, stretch marks may become somewhat less noticeable as they are pushed out and stretched flatter. But the concept of stretch mark elimination should be erased from your mind as an expected outcome. The one concern that I have about your breasts is what degree of sagging they may have. The pictures are taken with your arms up which artifically lifts them and may camouflage the actual amount of sagging. Breast implants do not lift sagging breasts which is a common misconception. So whether you may or may not need some form of a breast lift with your implants remains uncertain. When you have the amount of stretch marks that your breasts do, this adds to that concern. If you can send me some new pictures with your arms at your sides, that would help answer that question.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I want to get rid of the little bump in my profile, and I’m wanting to smooth out my nose. It looks really bumpy in pictures and it usually looks bad in certain kinds of lighting. I would really love my nose to look anything like these celebrities: Carrie Underwood, Lauren Conrad or Blake Lively. I think their noses are great but I don’t know if they would look good with my face.
A: In looking at your pictures, your nose is bumpy because of the disproportion or asymmetries between the three regions of your nose. Your upper nose has wide nasal bones, the middle third or upper lateral cartilages of your nose is more narrow and the tip cartilages of your nose (lower alar cartilages) are separated or wide. When put together, this gives your nose an almost hourglass configuration in the frontal view as opposed to straight parallel dorsal lines. In the side view, this gives an uneven straight dorsal line with an upper hump and a downward dip in the middle third. This is why your nose appears bumpy and irregular to you. A full rhinoplasty is needed to reshape all three areas to create an overall more harmonious blending of the three regions to create a smoother nasal appearance. I have done some imaging to show what these changes may look like. In regards to the celebrity noses you have mentioned, it is important to realize that rhinoplasty can not make your nose look like that of another person. Rhinoplasty can only make your own nose look better.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Is there a procedure that includes both a breast enlargement and a tummy tuck together? Breastfeeding four babies and having had multiple c-sections has left me with a body that makes me feel insecure and unhappy with my belly and breasts. I’ve never been a heavy woman, I’m 5’5″ and weigh about 140lbs. I haven’t felt comfortable in my skin since having my first child at twenty and now I’m about to turn forty. It would be nice to be happy with myself and feel confident enough to wear a bikini again. Other than these two parts of my body, I’m completely ok with.everything else about myself. Hopefully, a physician will read this question and know exactly how I feel and and be able to help me achieve this type of procedure at an affordable rate before I get too old to enjoy it or even worry about it anymore. Thank you so much.
A: What you are referring to is a very common procedure in plastic surgery known as a Mommy Makeover. This name tells both what the procedures achieve as well as serve as a marketing approach. The Mommy Makeover is a combination of breast and abdominal reshaping, the two body parts that are usually most affected by pregnancies. Breast reshaping options include size enlargement with an implant and correction of sagging with some form of a lift. More times than not a breast lift is needed with the implant. It is uncommon that an implant alone will suffice for breast enhancement in the ‘pregnancy-induced’ breast deformity. Abdominal reshaping always involves some amount of skin removal, known as a tummy tuck. Whether it is a full or mini-tummy tuck depends on how much loose skin exists. Liposuction of the abdomen alone has little role in the post-pregnancy tummy.
The most common scenario is that both breast and abdominal procedures are performed during the same operation. But some patients, due to financial or recovery concerns, may do them in two separate stages.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am very interested in skull contouring for the back of the head using acrylic, although I do have a couple of questions. What is the maximum thickness that can be added? Where is the incision to put it in located? I have a scar running horizontal across the back of my head from a hair transplant several years back. Can the incision be placed in the existing scar line or is it a must that it be vertical? Thanks for your time.
A: When building up the back of the head (occiput), the limiting factors on the thickness of the augmentation is the scalp and the incisional approach. How much the scalp will stretch is important as its expansion is what creates the space for the material. Usually the augmentation can be anywhere from 10 to 20mms at the greatest point of the arc of convexity. (midline occiput) Where the incision is located and how long it is always influences the shape and volume of the augmentation. While a traditional bicoronal incision provides unparalleled access for any location of skull augmentation, that scar is aesthetically unacceptable. For this reason, I use a vertical incision for an occipital cranioplasty. It provides good exposure over the most important part of the occiput where the buildup needs to be the greatest. Whether your existing horizontal scar can be used depends on where it is located. Most hair transplant harvest sites are usually fairly low but I would need to see a picture of the scar location to tell if it can be used for incisional access. I would certainly be motivated to try and use it if possible for the obvious aesthetic benefit.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, This is a micropigmentation inquiry. I have a rather pronounced scar of 3 to 4mm width above the left eye, in the middle of my forehead, from a car accident many years ago. Will micropigmentation be effective in hiding the scar? Will the sun still reveal it if the skin around it tans? Thanks.
A: As a general rule, tattooing a scar is almost never a good technique for scar camouflage. It is very difficult, if not close to impossible, to match the surrounding skin color with any implantable pigments. It would always appear different in color to that of the skin and risks actually making the scar more noticeable. Tattoo pigments are also not very stable and are probe to fading and needing re-treatment. Lastly, as you have pointed out, the skin around the scar will tan and the tattooed scar will not creating a noticeable color mismatch. For these reasons, you need to think more about excisional scar revision as it will narrow the scar and bring naturally-colored skin that will tan closer together.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have migraines which are predominantly left sided. A few weeks ago I received injections to both the left corrugator and temporalis muscles. There has been a reduction in migraine attack intensity but no reduction in attack frequency. But there is a definite change in pain pattern as the forehead and cheek are considerably less involved but the temporal headache persists. Would you consider this to be indication of the injected sides being trigger points or just a part of a pain pattern, triggered elsewhere? What would be your next step in the diagnostic process in my case? Local anesthetics into the pain site or a botox injection to the occipital area?
Do you find the local anesthetic nerve block to be a good predictor of a successful vascular decompression?
A: The identification of potential loci for migraines can be difficult. While Botox injections can identify trigger points, they are technique-dependent. The corrugators is fairly easy to inject because it is a small area of muscle that is discretely located. The temporalis, however, is a very broad muscle and there is no well-defined injection point. Not knowing where your tenporalis muscle was injected or with what dose, it is impossible to say whether that area has been properly tested. It must be injected around the zygomaticotemporal nerve lateral to the orbit or in the temporal hairline near the area of the course of the auriculotemporal nerve. Until that area is adequately injected, I would not proceed to the occipital site unless it is a very specific pain site that can be definitely palpated. While local anesthetics can be a limited substitute for Botox, it is not helpful at all to determine any potential role of vascular compression.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I think that I need my chin lengthened downward. I have a very deep overbite. I have attached a variety of photos as I wanted to show you my face shape when my teeth are closed together (I have a deep overbite) and when they are not. Most of my teeth are bridges and crowns and I have recently been advised to have all of them removed and implants put in place and that would help my overbite and give me a lovely smile. I don’t know if this would help as it is unclear to me if my overbite is dental or skeletal. I am under the assumption that my problem is skeletal as I thought my overbite would be addressed when all my teeth were replaced around 6 years ago but this wasn’t the case. Unfortunately it isn’t really a financially viable option for me to now have all my teeth removed and replaced. I also sought advice a couple of years ago and although I was only 45 at the time, I was advised to have a facelift and nose job to improve my jowling and small chin. I did so but I don’t feel the real problem has been solved. I would appreciate your professional advice on how an improvement can be made.
A: Thank you for sending your pictures. I can see that you have a 100% overbite, which means your lower jaw is over rotated on closure thus shortening the entire lower face. This is a skeletal problem that is manifest by the presence of the occlusal discrepancy. But because of the arc of rotation, the vertical shortening is greatest anteriorly at the chin. As a general rule, the amount of vertical shortening in a 100% overbite can be calculated at the vertical height of the incisor teeth. (crown length) That would be somewhere between 10 and 15mms in most patients. So you are absolutely correct in desiring a vertical chin lengthening osteotomy. That would provide the greatest benefit in terms of improving lower facial height and overall facial balance. I have done some computer imaging which shows the predicted outcomes from that procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am trying to decide on whether forehead augmentation is right for me. If this procedure turns out right I would be beyond grateful but the size of the scalp scar does make me think about whether I should reconsider having this procedure done. But what concerns me most is the risk of asymmetry. I don’t want to have an asymmetrical hair line or forehead in general. I don’t know, however, if that’s a possible negative outcome when getting forehead augmentation. I also don’t want this procedure to change my eye shape. I simply want to add fullness to the area in between my brow bone and hair line. I usually wear hats or head bands at times to give my face an over all nicer flow. In this message I am attaching a frontal pic and an oblique view., I hate taking profile pictures so much but of course its necessary so I can be better evaluated.
A: I obviously can not tell you on a personal level whether forehead augmentation is right for you. All I can speak to are the potential risks and benefits. What I can tell is that through the open scalp approach, the forehead shape can be perfectly built up and be smooth. That is the advantage of seeing completely what one is doing. A nice buildup can be done between the brow ridge and the frontal hairline. It is quite clear were the buildup would be based on your profile view. This would in no way affect your eye shape nor would the forehead or hairline be asymmetrical.
I would say there is a very good chance that your need to wear hats may be eliminated…at least if this is the reason you are wearing them.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I read your explanation of the temporal migraine with a vascular component rather than a muscular one caught my attention. Are there any research into the effectiveness of this kind of surgery or do you have a personal experience with it´s alleviation of migraines? Do you have a personal experience of local anesthetic as a diagnostic test? I am currently undergoing Botox injections into triggers points to determine how best to help my migraines.
A: I wrote that migraine surgery blog based on my clinical experience in doing it. While temporal migraines can usually be relieved by avulsion of the zygomaticotemporal nerve just outside the lateral orbit, it is not always completely effective. That is why I often will ligate/decompress the anterior branch of the superficial temporal artery as it courses along with the auriculotemporal nerve in the scalp portion of the temporal region. Through a single vertical temporal incision both procedures can be done simultaneously. Since there is no harm is eliminating this vascular element, it is often a part of my temporal migraine surgical approach. The use of local anesthetics would not be effective in determing if there is a vascular component to your temporal migraines. Like Botox, local anesthetics only provide insight into a muscular compression source of a migraine.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in permanent lip augmentation with Advanta. I have read about the split technique. What can you tell me about this procedure in terms of effectiveness and potential complications.
A: Advanta, in my experience, has been a good permanent method for lip augmentation. While it is an implant in the soft and moveable tissues of the lip, the material is a double porosity tubed construct that has the feel of a marshmellow. While most patient can feel the implant, I have not had a patient who has ever wanted it removed yet due to palpability. if removal should be desired or necessary, it is easy to slide out as it has a surrounding capsule without any real tissue ingrowth. Because of the capsular tunnel left behind, that could be filled with fat injections which would probably take well in an established capsular space. (backup plan or salvage procedure)
The key to placing Advanta for lip augmentation is two-fold. First the lip must be immediately stretched out after the implant is placed so that there is no bunching of it prior to the ends being trimmed and the small corner of the mouth incisions closed. Secondly, I find it a good idea to do a partial central implant split so that the potential risk of banding or tightness across the lip is reduced. But the entire implant should not be sectioned in the middle as that will cause it to widely separate in the middle and each piece migrate towards the corner of the mouth, losing any augmentative benefit in the central third of the lip.
Advanta lip augmentation is a fairly simple and effective procedure, particularly for those patients who are tired of repeat injectable filler treatments or do not want to run the risk of volume unpredictability with fat injections.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am planning on removing silicone malar implants without replacement that I had done 8 years ago. I am hoping that my skin will contract down once the imlant is removed. However, I realize that sagging is a possibility due to the stretching of my soft tissues from the cheek implants. I do not want any kind of implant again and a subperiosteal resuspension surgery is something that I would want to avoid at my age. Therefore, I was wondering if surgical adhesives, like a fibrin glue sealant would be useful in preventing or at least minimizing sagging and would help the tissues to better redrape the face. Would there be any potential complications from using surgical adhesives?
A: Your concern and questions about cheek implant removal are good ones. Like all implants in the body that push off of the underlying bone, their effects are seen by the stretching of the overlying tissues. Whether this soft tissue stretch is significant, and would result in malar tissue sagging after their removal, depends on how large an implant was originally used and how much elastic deformation of the skin was created. For some patients with smaller cheek implants, no significant malar sagging will occur. For other patients with larger implants and more significant cheek hypoplasia to begin with, the sagging may very well be noticeable.
Regardless of the size of the implant, the question is whether any surgical manuever (from the intraoral approach) during cheek implant removal surgery can prevent sagging and maintain a better soft tissue position on the underlying cheek bones. I think there are two options. As you have mentioned, tissue adhesives can be used. Whether they can really glue the outer capsular lining to the inner capsular lining on the bone is debatable (the surrounding cheek implant capsule is not removed so these two layers are present) But there are no risks to doing so. I would use an autologous tissue adhesive made from the patients’s own blood, like that obtained from the GPS III system. (Biomet) Another option is to place several sutures between the capsular layers to prevent the outer capsular lining, of which the cheek soft tissue are attached, from sliding off of the inner capsular lining and bone below. This is, in reality, a subperiosteal suspension done from below. That is a more likely effective manuever that would be more secure than tissue adhesives.
Dr. Barry Eppley
Indianapolis, Indiana