Your Questions
Your Questions
Q: Dr. Eppley, I have had injectable fillers placed along the back side of my jaw to give me more of a sharper angle appearance. It was Radiesse and it took two full syringes to get a modest effect. The result was good but I wished it was stronger and more pronounced. I have heard that if you keep getting the fillers they will build up overtime and you will get a permanent effect. Is this true? If it is not, then do you think jaw angle implants will give me what I want?
A: There are no synthetic injectable fillers currently approved in the U.S. that are permanent. So it is not true that repeat treatments of any injectable filler will lead to a long-lasting build up of any facial bone site. Most certainly injectable fillers are not a substitute for the volume and permanency that can be provided by jaw angle implants. What your injectable filler treatment has done is to demonstrate that augmentation of the jaw angle region is aesthetically beneficial for you. That can be very helpful when uncertain if such a facial change is worthwhile. This should give you the confidence of proceeding forward with this implant surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am very unhappy with the result of a rhinoplasty that I had done two years ago. It was a closed rhinoplasty and I wanted to have a more refined and pretty nasal tip. It has ended up, however, being just a balled up fat tip with nostrils that now look bigger. What type of rhinoplasty do I need now to fix it? And can it be fixed?
A: Thank you for sending your pictures. What appears to have happened is that you have lost cartilaginous support of the tip due to overresection of the lower alar cartilages and the caudal end of the septum. The thick overlying tip skin has now just contracted inward without adequate support, resulting in a ball-like tip with excessive nostril show. Your nasal problem most definitely can not be fixed by any closed rhinoplasty method. It will need a rhinoplasty revision using an open approach and cartilage grafting to restore support for the tip to create a more natural shape and decrease nostril show. You will need a columellar strut graft and alar rim grafts to help correct the retraction as well as tip reshaping. These type grafts are best placed through an open rhinoplasty, particularly in the face of a nose that has scar from prior surgery. Presumably these cartilages grafts can be harvested from the septum and the ear.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a chin implant, neck liposuction and a submentoplasty with fat removed under the platysma muscle one month ago. I am 32 years old and had a double chin that could not be improved by any other method. I wore a neck compression garment faithfully for three weeks after surgery. Despite this, I have very visible lumps and creases which did not exist prior to surgery. Will this resolve? What else can I do to help?
A: A submentoplasty combined with liposuction is a very good but aggressive procedure for neck recontouring. There is no question that it can do a good job of removing fat and tightening muscle, significant anatomic changes to improve a neck profile, but it does not remove skin. Thus it relies on the elasticity of skin to shrink down and produce the final shape. It is not uncommon for this procedure in some patients to end up with skin redraping issues. (irregularities, indentations, creases) That is the one knock on the procedure in my experience. It is still early so some of these skin issues will definitely get better with time. Whether they will completely go away remains to be seen and I doubt if there will be 100% resolution. But this is an issue of time and you will know more by six months after surgery. You would probably benefit by neck treatments such as massage or Exilis treatments which can help with skin smoothing and now is the time to do them before a lot of scar sets in.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a question about Kryptonite bone cement. Can it be used to build up the jawline. I was born with hemifacial microsomia and my jaw on one side is short not very full. My bite has been corrected by a jaw osteotomy previously but the overall side of the jaw is still small and too thin. Would this be a good use for this type of bone cement material? Also what would happen it is got infected after surgery?
A: Kryptonite bone cement is FDA-approved for all craniomaxillofacial bone applications whether it is as an inlay, onlay or any combination thereof. Therefore, it is appropriate to use it as an onlay augmentative material for the mandible or any other facial bone for either reconstructive or cosmetic indications. So it could be safely used for jaw onlay augmentation.
Having 20 years experience as a craniofacial plastic surgeon with a lot of experience in biomaterials in the craniofacial region, Kryptonite has a very steep learning curve with its use. It handles completely different than every other bone cement material used in craniomaxillofacial surgery. It would also be a challenge in getting into a site with difficult access such as the jawline. What I have learned in complex cases like yours is to first get a 3-D craniofacial model made from a CT scan. Then use that either to premake the desired implant for other synthetic materials or use it sterilized during surgery to custom make an implant intraoperatively out of Kryptonite. This will help tremendously in getting the best contour shape and in its placement.
Once an implanted material gets infected, Kryptonite or otherwise, antibiotics will not usually solve it. The material must be removed to cure the infection. The material is simply inoculated, particularly a porous material, and you can’t get rid of the bacteria with drugs alone. They will only provide a temporary amelioration of the infection which will return as soon as the antibiotics are stopped. Clearly this is a problem to be avoided which is why I always mix in antibiotic powder with any bone cement material in the preparation process.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am 22 years old and am bothered by my small lower jaw. It is small with about a 1/2 inch discrepancy between my upper and lower teeth. I really dislike my profile. I had an appointment with an orthodontist last week and he recommended getting braces and then having a lower jaw advancement. This sounds too extreme to me. I was wondering if I can just get a chin implant if I’m that unhappy with my looks. If you were me what would you do?
A: Your dilemma is a classic one and the decision is ultimately affected by a patient’s age, whether they have any masticatory functional symptoms, the magnitude of the jaw discrepancy and what they are willing to go through. From a long-term standpoint at your young age, both functionally and aesthetically, you should have the combined orthodontic and jaw advancement surgery. It is most certainly not extreme and is a routinue maxillofacial surgical procedure. A chin implant, while comparatively simple and providing an immediate aesthetic benefit, would offer no functional improvement for your bite, jaw function and TMJ health.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a problem from a previous closed rhinoplasty. I am very unhappy with the tip of my nose. It has been lifted too high and this has exposed my nostrils unfavorably. It also makes my face look flat. What I want is correction through a closed rhinoplasty. Will that work for me and my nose problem?
A: When the nasal tip becomes too shortened after a rhinoplasty, it will produce a set of classic aesthetic issues including an obstuse nasolabial angle with excessive nostril exposure. It can be corrected through tip lengthening/de-rotation through cartilage grafting. This is not best done through a closed rhinoplasty. The grafts would be hard to place and secure through such limited visualization. An open rhinoplasty would provide much better exposure to accurate place tip grafts and/or septal extension grafts to create a de-rotation effect. The one exception to this approach is if the amount of tip lengthening needed is small. Then the placement of limited tip grafting could be done through a closed approach. I would need to see photos of your nose to determine which rhinoplasty approach may work for your revisional surgery. The only question I would ask is what is the basis for your deference to an open rhinoplasty? The scar is inconsequential and the results are more consistent and superior.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 27 year old man and I’m thinking to have a surgery to reduce the size of my brow bone. My question is if the look of my eyes would change. Because I have read in other forums that such surgery might change the deep of my eyes of which I love their appearance. I would appreciate very much your esteemed opinion to my concern. Is it justified or not? Thank you very much.
A: It has not been my experience that the depth of one’s eyes appears any different after brow bone reduction surgery. This is because brow bone reduction in men, in particular, is about changing the bulge or convexity of the anterior table bone of the frontal sinus. It does not change very much the lowest edge of the brow bone or reduce it posteriorly which would make the eyes look less deep. I would have to see some pictures of you, particularly from the side view, to make that determination more specifically however.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am having a tummy tuck later this spring and look forward to a beach vacation this summer with my new body! My question is how soon after surgery can I begin tanning? If I have my surgery in May could I get into the ocean by July? How much time should I allow between surgery and these activities? I don’t want to do them too soon and affect my results but I know I will be anxious to do them.
A: The answer to both questions resolves around the tummy tuck scar and making sure it is healed enough to not be affected by these activities. Getting into ocean water, which will have organisms in it that do not occur in chlorinated water, should be deferred until 6 to 8 weeks after tummy tuck surgery. At this point, you should be well healed including any small areas of potential suture extrusions. The effects of tanning and sun exposure on your tummy tuck incision, however, is a much different concern. Both tanning bed and sun rays can adversely effect how the scar may eventually look so such exposure should be deferred until it is well healed for at least three months after surgery. If you must use the tanning bed, I would cover the tummy tuck scar with tape until then to block these undesired rays.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have saline breast implants placed under the muscle now 11 years ago. I have been very happy with them and have had no problems at all. I was originally told by my plastic surgeon that they will last anywhere from ten to twenty years. Now that I am past the ten year mark, I am wondering if I should just have them replaced now since a deflation could happen anytime now.
A: It is important to realize that breast implants are not life-long devices. They will eventually fail, which means the containment bag will develop a leak. With saline this means the fluid is coming out and the implant will deflate with an external flattening of the involved breast. How long saline breast implants will last and when they will deflate can not be accurately determined. While your breast implants are living on borrowed time, I see no reason to preemptively just replace them. You might as well get the value out of them for as long as you can. While this will someday result in a breast implant ‘emergency’, it can be replaced within a matter of days with no significant recovery. (unlike the first time)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I need your help as I have no jawline. My chin is very short, the neck seems to be missing and it appears as I almost have no lower jaw. This gives a profile that I am very self-conscious about. I make every effort so people don’t see me from the side. I know you are an expert in facial surgery based on your writings and patient photos so what do you recommend?
A: Lack of a well defined jawline and neck angle can be due to any one or combination of the following; chin/lower jaw bone prominence, fullness/fat in the neck and loose neck and jowl skin. Most commonly, the combination of a chin implant and neck liposuction can make a dramatic difference in the younger patient who often has a short chin and full neck. In older patients the sagging skin factors in significantly and some form of a jowl or necklift may be needed. There are exception to these two categories, such as the early aging facial patient with a good chin prominence who just needs some neck contouring through a procedure known as submentoplasty. But when someone describes themselves as having ‘no jaw’, this would indicate the problem is more than just one of the three anatomic components that make up the neck angle and jawline.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, on your website you mentioned orbital implants. I have deep set eyes. Can these orbital implants be placed in the upper eye area to fill in the hollowness. Thank you.
A: No they can not. There is no easily accessible superior bone space above the eye to access without significant risk. Actual implants can only be placed on the floor of the eye socket in which that space is more easily accessible without risk of eye muscle injury. Hollowness of the eyes, however, is rarely treated by implants anyway. It is better treated by fat injections/grafting which is placed between the skin and the underlying muscle. This is far easier to do and more effective. Its risks are largely cosmetic, how well does the fat survive and how smooth is its outward appearance.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, are there any good non-surgical treatments for sagging jowls. I am 56 years old and my neck isn’t too bad. But my jowls make me look like I have a bulldog face. I am not afraid of surgery but am worried about the cost and the recovery.
A: Jowling is always a major facial aging concern for many people as they hit 50 years old and beyond. There are some reasonably good treatments for jowls which are device or energy-based approaches. My current preferred approach is Exilis. This is a treatment based on radiofrequency waves which heat up the jowl fat and skin. This causes some fat atrophy and skin tightening. It requires a series of treatments, at least four spaced two weeks apart, to get the best result. While not as effective as surgery, it can make a very visible difference in the right patient who jowls have not developed beyond what a non-surgical approach can treat. The most effective approach, however, is a jowl lift. Your concerns about recovery are excessive when it comes to this tuckup procedure as it is a quick turnaround from the procedure until you are back into your regular routinue. While sugery is never appealing if it can be avoided, solving the problem in a single setting of an hour’s time can change one’s perception of it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I want to have a more shapely and manly chest. I have worked out a lot and simply can’t build up my pectoral muscles very much. It almost seems like I have a muscular deficiency in this area, they just won’t build up to my liking no matter how much iron I pump. I think the only way I am going to get there is with chest implants. Can you tell about how the operation is done and what type of implants are used? I assume it is pretty much like breast implants for women.
A In many ways, you are correct about the similarities between male pectoral implants and female breast implants. Like saline breast implants, pectoral implants are put in through an armpit incision (transaxillary approach) and are placed under the pectoral muscle. Unlike breast implants, however, the positrion of pectoral implants does not extend below the lower border of the muscle. This is a subtle but important placement issue to get the best increase in pectoral muscle outline. The biggest different is in the type of implant used. Pectoral implants are made of a solid (non-fluid filled) silicone elastomer material. It is very soft and has a spongy feel. They can not rupture or ever degrade and will never need to be replaced, which is very different from breast implants which have a limited lifespan.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have read recently about a procedure that lifts up the cheeks using an implantable device. It is supposed to go away after it is implanted. This sounds appealing but I don’t understand how it works and what happens to it after it is put in. How can something create a permanent effect when it goes away? Since it is used and put in by plastic surgeons and is sold commercially, it obviously is legitimate but I am confused as to how it works. Can you explain it to me?
A: What you are specifically referring to is the Endotine Midface Lift Device. This is a small platform with small angled spikes on its outer surface that is made of a well known resorbable material known as poly-lactic acid. Many dissolveable sutures are made of the same material. The concept is that the sagging cheek tissues are lifted up back onto the cheek bones and are held there by this device. The device is attached to the bone and the small spikes face upward. The cheek tissues are lifted up on top of the device and are held in place by the angle of the small spikes. This repositions/resuspends sagging cheek tissues back up higher on the bone. The procedure is done through a small incision from inside the mouth. The device resorbs within a year after surgery and is replaced by scar tissue. In theory, the scar tissue then acts to hold the cheek tissues in place.
The nice thing about this device approach to a midface lift is that is fairly simple to perform and is done without scar from inside the mouth. Unlike a traditional midface lift, it does not disrupt the lower eyelid tissues and eliminates the risk of ectropion or lower eyelid sag. For the right patient if performed well, it can be a good midface lift operation. Understand, however, that no form of facelifting is permanent. As the device goes away and with time and aging, some cheek sagging will return.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I can’t figure out whether I need a full or a mini-tummy tuck. After having two children what bothers me most about my stomach is the little bit of loose skin and the stretch marks between my belly button and my mons. Interestingly, there is no loose skin when I am standing straight but it appears when I am bending over. I am 32 years old and in very good physical shape at 5’ 2” and 106 lbs. My abdominal muscles feel very taut and I don’t think they are separated at all. I also have a hole on the upper part of my belly button from a prior piercing that I would like removed.
A: Your description of your abdominal concerns is a common one and you are what I call a plastic surgery ‘tweener’. This means one is stuck between two procedures and can go either way. Either type of tummy tuck can be done on you.l Understanding which way to go requires an understanding of the trade-offs of making either choice. A full tummy tuck, removing an ellipse of skin from above the belly button down to the pubis, will eliminate all loose skin and will avoid the sag you now see when you bend over. But the final scar will be horizontally long and will end up high, about halfway between the new belly button and the pubic region. A mini-tummy tuck will result in a smaller scar that can be kept down quite low but will result in less skin removed and there will remain some small sag when you bend over. The decision comes down to whether you value the most amount of skin tightening or the best scar location and size.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had breast augmentation three years and had PIP breast implants placed. Since the scandal about PIP implants has been reported, I am concerned about whether my breast implants are safe to have in my body. I don’t want some inferior low-grade silicone material inside my body. Besides getting the implants out and replaced, I also want to go a little smaller. I currently have 475cc implants in and want to downsize them to 400cc, maybe 375cc. Do you think I will develop any sagginess of my breasts if I do so?
A: The answer to what happens to your breast tissue when implants are downsized is not straightforward. There are numerous factors that can affect what happens when the size of the balloon is deflated somewhat. The most important factors are the elasticity of your breast skin and what it actually looked like before the breast implants were placed. Also, whether the implants are positioned above or below the muscle also plays a role. Given that you are considering an implant downsizing of 75cc to 100cc, or 16% to 21% total implant volume, the overlying breast tissue will lose significant support. Sagging could develop with this implant volume reduction if your breast skin has limited elasticity or you had some loose breast skin previously. This is an issue to consider when determining what your new breast implant size should be.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Hello, I am 25 years old and have had twelve IPL treatments. It has disfigured my face, somewhat like a thermage side effect. I have lost all collagen, subcutaneous tissue, and tissue and facial padding. My skin just sags, there is no elasticity or tightness or shape in my face any more, just very thin skin. Would cheek, chin, forehead, and temporal implants help bring my face back? Or can that all regenerate and grow back after time?
A: You did not say why you had the IPL treatments, for what condition, and why so many. But that issue aside, IPL does create a subcutaneous heating effect. When done enough times it is possible to cause to cause subcutaneous fat loss. You are not the first person that I have heard that has had this effect. I would wait up to a full year after the last IPL treatment to see if any regeneration of tissue substance will occur. While I would not be optimistic that it will happen, time will answer that question. If not, then the first thing to consider is injectable fat grafting, perhaps even using a stem cell-enhanced method. You should try and replace what is lost as the first approach. While facial implants are bone-based methods of facial contour augmentation, and they may be appropriate for some facial areas, I would think fat replacement first by facial fat injection. Some combination of the two may also be considered. But I would need to see some pictures of your face for further assessment to provide more detailed recommendations.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am having breast augmentation surgery and am having trouble trying to decide between two different implant sizes. I can’t decide between 375cc and 400ccs silicone gel implants. They seem to look different when putting the implants in my bra. Also, which size will give better cleavage.
A: The difference in volume between 375cc and 400cc is 25ccs or a 6% total volume difference between the two breast implant sizes. This is an insignificant difference that is not visible and is one you should waste o further time thinkingabout. When in doubt between two implants sizes that are so close, always go with the slightly bigger implant. This is because here is no chance that it will make you too big but there is a very real chance that you will have wished you went bigger later. Also understand that stuffing a round implant into one’s bra is not a very good method of implant sizing even though it is done all the time. A much more accurate method is the Mentor Volume Sizing System where the sizers have shapes that actually fit over one’s natural breast, rather than simply smashing it flat with a round breast implant. This provides a much more realistic volume result. Lastly, also understand that cleavage is rarely created by breast implants unless one’s natural breast mounds are fairly close together beforehand. Implants make bras much more effective at creating good cleavage.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting liposuction for my belly area. I am 36 years old and had very successful breast reduction surgery seven years ago. While I was put to sleep for my breast reduction and had no problems, I am more anxious now considering it since I have two small children. Do you think it would be better to have regular liposuction under general anesthesia or Smartlipo under local anesthesia? I think I want to flatten my hips area as well. It is time to get ready for the summer!
A: You are under a classic misconception that Smartlipo is a liposuction procedure done only under local anesthesia. While it can be done in some smaller areas under local anesthesia, the reality is so can regular liposuction. The type of anesthesia has little to do with what type of liposuction can be performed. But it often controls how good a result one can get from any type of liposuction procedure. How thoroughly fat can be removed from multiple areas largely depends on a patient’s comfort to do so. In my experience, better liposuction results are almost always obtained under general anesthesia. More body areas can be concurrently treated and a more aggressive approach can be taken with how much fat is removed. While Smartlipo can be done under local anesthesia, I have found in many cases that patient comfort and the desire to treat more than one body area make it less than an ideal approach to liposuction fat reduction.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have previously sent you photos of me for consideration of a rhinoplasty and a chin augmentation. You sent back some imaging results and, after reviewing them, I have a few questions:
1) Rhinoplasty – I like the overall effect! I just wanted to ask if there was anyway you could make the bridge a little more concave, and if it would also be narrower from the frontal view, and if the tip might be narrowed as well? I know you said that you usually provide an image of the minimum effect that could be achieved, and if this is it, that’s great – I’d still be happy with the improvement.
2) Chin – I think I like the implant a little more than I like the osteotomy, though of course it doesn’t fix the underlying skeletal problem. I might still consider the implant but I haven’t decided.
3) Cheeks – One more question regarding my “chipmunk cheeks”. While my friends and family call them “endearing”, I”ve always wondered if I couldn’t have a little less of a balloony cheek especially right below the corner of the mouth. Is there any way of filling in the tissue right at that spot, or (I guess) of removing fat from the cheek (though I do like my dimples!
Thank you for taking the time to answer my questions and being patient with me!
A: In answer to your questions:
1) Ideally I would like the front view rhinoplasty result to be more narrow, and it may be possible, but your thicker skin may preclude that from happening. For this reason, I have imaged it so that the amount of narrowing will reflect what I believe will happen… but I am pulling for more.
2) I would agree that the implamt effect, while not providing as much horizontal advancement as an osteotomy, seems to be more ‘natural’ looking. It is always best in chin augmentation in a female to be less rather than more. That still preserves a feminine look.
3) You are referring to what is known as the perioral mounds. a cheek fat area that is below the buccal fat pad. That can be effectively treated by small cannula liposuction done from inside the mouth.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have had five pregnancies and my muscles are separated as well as I have a skin flap that hangs down. My back hurts all the time since my stomach muscles are so weak. My skin flap hangs down and rubs on my thighs. I have done physical therapy but it doesn’t help. My insurance says they won’t cover it and I can’t afford to get it fixed on my own. Being in this plight, how can I get my insurance company to pay? It seems like they should but they just don’t understand. What do you suggest?
A: The reality of medical insurance today is that coverage will not be provided for ‘muscle separation’, medically known as a rectus diastasis. While this is a common occurrence after multiple pregnancies, it is not interpreted as medically necessary to repair by the insurance industry. There is no getting around this ruling nor do such symptoms as muscle weakness make it possible for insurance to pay for surgery. It is different if an umbilical hernia is present as this is a true defect in the abdominal wall. The same consideration applies to abdominal skin flap surgery, known as an abdominal panniculectomy. Only in large abdominal pannuses that hang way down onto the thigh and have associated chronic skin infections underneath will insurance consider coverage for its removal.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Hi. My jaw points down and my chin is very weak. I would like my jaw to appear more square shaped. I don’t think this is a problem with the growth of my jaw as my bite is excellent and I wouldn’t want to mess with it anyway. I considered a chin implant but that seem to just make my jaw longer as it would sit on a backward angled segment of bone. Also, my nose has a high bridge, so I am wondering if rhinoplasty might off set the look of the jaw. Right now, my jaw line and the bridge of my nose are almost parallel lines. What is your suggestions?
A: In looking at your pictures, your mandibular plane angle does parallel the dorsal line of your nose. This is not a nose problem as its shape and size looks good. A rhinoplasty you most certainly do not need. You need to reorient the plane of your mandible. This would be best done by a combined chin osteotomy and jaw angle implants. The chin osteotomy would bring the chin forward but would also bring it upward due to the angle of the osteotomy cut. This will actually shorten the vertical length of the face. The jaw angle implants will bring down or lengthen the ramus of the mandible of posterior length of the face. These two procedures together will create a counter clockwise rotation of the mandibular plane angle.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, my labiomental crease is very deep and I don’t like it. When you look at me you would first think that I have a big chin. But then when you look at the rest of my face you see that compared to everything else my chin is fine. My labiomental crease is so deep probably because my teeth are located far back in my head. And it looks like I have an overbite, but I really do not have one. I would be very interested to hear what you could do to improve this. I know that fat transfers do not last in this area, so I am looking for some kind of implant for a permanent result.
A: Based on your side profile, one reason your labiomental crease is deep is because of your prominent chin. The more chin projection one has, the deeper the crease will be. Otherwise, a Class II malocclusion can be a cause due to the overprojecting front teeth and the recessed lower teeth…but this does not seem to the case in you.
Short of a chin reduction, reduction of the depth of the labiomental fold can only be done by some type of implant. But the implant can not be primarily bone-based because the labiomental fold is not influenced much by bone augmentation as it is a soft tissue structure situated just in front of the anterior mandibular vestibule. Over the years, I haved used many types of implants from fat injections, intraoral dermal-fat grafts, mersilene mesh bone augmentation, and Advanta (Gore-ex) tubular implants. Of all of these, I have found that Advanta implants work best because they are placed directly under the skin and have permanent volume.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting a forehead augmentation. I know that there are different materials to use, one of which is PMMA. I have a few questions about PMMA. Does PMMA bone cement have a risk of granulomas like PMMA injections? Are the outlines of it visible? Does it have a risk of extrusion? Thank you!
A: In answer to your questions:
1) PMMA cranioplasty material does not cause granulomatous reactions. That is a unique phenomenon of small PMMA particles in soft tissue
2) Besides getting getting the right contour and amount of augmentation, one of the major objectives of any form of cranioplasty is to get a smooth transition form the material to the surrounding bone. This usually requires intraoperative burring of the edges after the material is set to have feather edges so there are not visible outlines after surgery.
3) There is no risk of extrusion of a PMMA cranioplasty. Extrusion of any implant material occurs because it is either placing excessive pressure on the overlying soft tissues or is infected and it is being pushed out by the pressure of the purulent fluid build-up. A PMMA cranioplasty is rigidly fixed to the underlying bone by microscrews prior to it being placed as a rebar method. This prevents any micromotion or displacement after surgery. The material is also impregnated with antibiotics which provides several weeks of antibiotic release after surgery for infection prevention.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have had a problem since I was in 10 years old. I have visited many doctors but none have had a proper remedy. Ever since I have started feeling it, I am been taking medicines. And right now I am frustrated with taking medicines. The problem is that my face clamps down suddenly on my right upper and lower jaw while I am talking, eating, brushing or even when I am not doing anything. I have visited many neurologists and finally visited orthopedic surgeons but nothing works. I was just going through some internet sites and visited yours and would be very kind if you could help me out. Thank you.
A: While I don’t have the insights that would be provided by an actual examination or knowing what treatments you have had, your description sounds like a condition known as hemifacial spasm. This is caused by involuntary contractions of the muscles of mastication, the temporalis and masseter muscles. Since you have visited neurologists I will assume that causes of intracranial pathology (brain tumors, vascular lesions) has been excluded. I would recommend a series of Botox injections into those muscles which exhibit spasm. Botox is very effective for masseteric spasm in the treatment of bruxism and myofascial pain disorders.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I got punched in the face a year ago and my eyeball has been sinking since. I am pretty sure that I fractured my eye socket but it was never treated. I didn’t go to the hospital when it happened at the time. My eye got very bruised and swollen afterwards and it took about three weeks for all of it to go away. I’d like to know if my eye will keep sinking. Please see the photo and let me know if you think this problem can be fixed. Thank you.
A: The description of your facial injury most certainly sounds like an orbital floor fracture. This is classic for orbital trauma as the thin bone of the floor of the eye blows out and downward as a decompression mechanism for protection of the eyeball. When displaced and untreated, the eyeball will sink downward afterwards as the floor that supports it is lower. After a year, the eyeball should sink no lower as the soft tissues under the eyeball has fully settled into the hole in the orbital floor. The level of your eyeball can be restored by orbital floor reconstruction. The scarred soft tissues under the eye can be freed up and the bony hole rebuilt/covered with either thin synthetic materials or bone grafts. This will bring the horizontal level of the eyeball up to its preinjury position.
Indianapolis, Indiana
Q: Dr. Eppley, I am 52 years old and had eyelid surgery, both uppers and lowers, a month ago. My problem is my right lower eyelid droops. It is not level with the other lower eyelid and a lot of white is showing. It was worse the first week after surgery and then it got a bit better. But it has not improved anymore since then. My doctor told me to be patient and keep ointment in the eye at night, massage it several times a day, and keep it taped up at night. My doctor said he can fix it later by tightening the corner if it does not improve. How long should I wait before having it fixed?
A: What you have is ectropion or lower eyelid drooping at the outside corner due to loss of structural support from the transcutaneous lower blepharoplasty. This is one of the known potential complications from this surgery. You are following management instructions which are what should be done in the first month or two after surgery. As long as the lower eyelid position is slowly improving and/or eye symptoms such as dryness, itchiness or excessive tearing are not too severe, the more healing time the better. Improvements in ectropion can continue to improve several months after it has occurred. A full three months should be allowed to pass before undergoing lateral canthal/eyelid resuspension, which is the definite answer to ectropion. This can be done earlier if eye symptoms warrant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had gynecomastia reduction surgery two years ago. Breast tissue was removed through incisions on the underhalf side of the areola. No liposuction was done. The incisions healed well and, while it looks a lot better than it was, my nipples are still a bit puffy. My doctor said it was swelling for several months after surgery but it never got better. I want my nipples completely flat with no puffiness at all. I don’t want to see them poking out through a shirt. I can not feel any hard lumps under the nipples so I think it is just fat. The puffiness has a soft feel to it. It pushes in easily. I am thinking this residual fat may be able to be gotten rid of by exercise or losing some weight. Do you think this will work?
A: Gynecomastia surgery, when done through an open resection of glandular breast tissue, is an art form in terms of how much tissue to remove. There is no precise method during surgery, when the patient is laying horizontal on the operating room table, to determine if the nipples will lay completely flat afterwards. The one thing a plastic surgeon wants to avoid is over-resection or removing too much breast tissue. This will create a crater deformity after surgery. To avoid this problem, surgeons will be more conservative rather than aggressive in tissue removal. This means that in some cases after surgery that most of the nipple protrusion is gone but it does not lay completely flat. This is due to residual breast tissue or incomplete resection not fat. This can only be improved by secondary gynecomastia reduction surgery to remove more breast tissue. It will not respond to any method of fat burning or weight loss.
Dr. Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I don’t like the shape of my jawline as it goes from front to back. I would like the front of the jaw profile to be less angular and also look deeper. I think this would improve my face shape and make it look more symmetric. I have attached a few pictures. What type of operation do I need to make this improvement?
A: I am not sure I understand what you mean by the desire to have the ‘jaw front profile less angular and also deeper’. I would need a better explanation to be sure what you see. But looking at your pictures, I think you mean that the chin is pointy (rather than square) and the jawline from the chin angles back sharply as opposed to being more square and vertically longer. The angular chin/jaw line is more associated with females while the square and broader chin is associated with a stronger male look. This could be improved by geniomandibular groove implants that fit on the bottom of the chin and go back to the anterior body of the mandible. They can be used to widen the chin as well as provide structure at the turn of the chin into the jawline so that there is a stronger jawline appearance. This is done through a submental incision and the two implant halfs are assembled into a unified implant with screws once into place. How close or separated they are in the midline affects how much the chin width is increased.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in trying to make my face more symmetric. My main problem is around my eyes and they are not even. One eye is definitely higher than the other one or it could be that one eye is lower than the other. I am not sure which eye is the right one, all I know is that they are different. I think though that the left eye is too high as I like where the right eye is as it sits on my face. I have attached a front picture for you see what I mean. Is there anyway to make the eyes more even?
A:I would have to say that the vast majority of your facial asymmetry is based in the eye area as you know by looking at your pictures. The position of the two orbits/eyes is the most striking issue. Either eye position is acceptable but it is just that they are different and they are side by side. While one can have a debate about which one is the ‘goal’ to achieve (the good looking one), that discussion is largely irrelevant since you really can not correct one fully to be level with the other. Their differences are too great. The left eye can not really be brought down as far as the right and the right can not be brought up as far as the left. They are also lid issues with those movements, particularly the position of the medial and lateral canthi.
That being said, the only approach I envision that could work is a combination of making changes on both eyes, build up the floor on the right orbit and drop the left eye down. Each could be moved 2 to 3mms and together this ‘ying and yang’ approach could overcome the 5 to 5mm difference that currently exists in the horizontal pupillary levels. This may not create perfect orbital symmetry but it would be an improvement.
Indianapolis, Indiana