Your Questions
Your Questions
Q: Dr. Eppley, I had a chin advancement done several months ago due to my severe lower jaw deficiency. I just want to ask a question. I definitely feel there has been an improvement since having the chin moved, but I was wondering what your opinion is on whether moving my jaw itself would ever be possible in my case because I still feel that my lower jaw deficiency is problematic. I would assume as an oral surgeon it is a procedure you are familiar with. I have had a lot of dental work done which definitely complicates things unfortunately, but the appearance of my lower jaw is still something that bothers me. I am currently 24 years old and have been bothered by it tremendously for years now. I do realize that jaw surgery is very costly unfortunately, but the financial realities aside, I just wanted to hear your opinion about whether it even is a possibility given the dental work I have had done in your opinion. I definitely regret not taking better care of my teeth and would do it all over again if I could because of how much of a toll this problem has taken on me.
A: In looking at your x-rays, you do have an overall lower jaw deficiency with a Class II malocclusion. Your indwelling dental work aside, the question of whether you could ultimately have a sagittal split mandibular advancement first requires an orthodontic opinion. Such orthognathic surgery requires a period of orthodontic preparation and after surgery orthodontic fine tuning. While I suspect you are an orthodontic candidate, how much time that would require and the associated costs would have to be answered by an orthodontic evaluation. This orthodontic process is the rate-limiting step for any patient considering orthognathic surgery as the jaw(s) can not be moved without it in place and having the teeth realigned for such surgery. As an cosmetic camouflage alternative, that is why you have a chin osteotomy initially.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have big eyes and it looks like my eyeballs stick out from my upper eyelids and it makes me appear very scary to people. I even sometimes get mistaken for being an Egyptian even though I’m not. I searched over the net and found out that by having brow bone augmentation my eyes will look deeper . That could be the solution to my problem since I want to hide my eyeballs that stick out of my upper eyelids. Do you think brow bone augmentation surgery would help. The thing is that I’m in desperate need of this surgery but at the same time I’m really scared when it comes to surgeries around my eye area. So my question is how safe is brow bone augmentation surgery and what are the risks and the worst case scenario in terms of the surgery and could it ever effect my eyes negatively in any way in the long run? Thanks alot
A: When it comes to eyes that are too prominent, you want to first be sure that the cause is not some form of exorbitism due to intraorbital tumor or medical condition such as hyperthyroidism. But for the sake of answering your questions, I will assume that yours is natural condition of your anatomy. Therefore, brow bone auugmentation could help as it builds out the upper out eye socket rim, thus making the eye look more recessed. This is a perfectly safe surgery from an eye safety standpoint since it is done from above and does not involve entering the intraorbital space. The potential complications with it are mainly aesthetic, the scar from the coronal scalp incision to do it and whether the brow bone is built up too much or too little.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a tummy tuck six months. Although there is much improvement in the lower half of my stomach, the area above my belly button up to my ribs still seems too thick. I was wondering why liposuction wasn’t done to thin that area out at the same time as my tummy tuck. It was the perfect time to do it. Did my doctor overlook it or just forget to do it?
A: Liposuction is not done in the central upper abdomen at the time of a tummy tuck by many plastic surgeons in an effort to a avoid wound healing complications. While it may be viewed as an ideal treatment approach that offers more complete abdominal contouring, it does introduce risk of wound healing problems. By traumatizing the blood flow to the upper abdominal skin flap which may be also partially undermined, a partial necrotic skin flap can potentially develop below the belly button. Even it that develops and is small, you will then wish that liposuction component had been omitted from the procedure. It is much better to have a tummy tuck that heals well even if there is some residual fullness in the upper abdominal area. You can always undergo a secondary upper abdominal liposuction procedure later which is a much more tolerable ‘problem’ than to go through the time and tremendous inconvenience of a long healing process of an open wound…not to mention the ugly scar which will result. It was not an overlooked or forgotten procedure but one omitted for your safety.
Dr. Barry Eppley
Indianapolis, Indiana
Injectable fillers have come a long way since the approval of the first non-collagen based product in 2002. While once conceived as only a way to make lips bigger and nasolabial folds less deep, injectable fillers have evolved into a popular aesthetic technology that has a wide number of facial uses.
Injectable fillers are used for two aesthetic facial applications, spot filling and volumetric enhancement. It is the latter that is often coined as ‘non-surgical facial sculpting’. That term is probably more accurate than not as it definitely takes skill and a good eye to get pleasing facial results with fillers. There is more art to it than science.
When it comes to facial volumetric enhancement with fillers, they are often compared to and even viewed as a substitute for surgical solutions to the same problems. Some injectors view synthetic fillers as a better treatment choice as they are easier to do and have less risk of complications than surgery. While that is partially true, they rarely give better results than surgery or offer the best value for the money invested to do them. Fillers can be a quick non-surgical fix but the benefits will ultimately fade away.
For skeletal augmentation of the three facial highlights, chin, cheek and jaw angles, injectable fillers can be used to create a visible external effect. When placed down at the bone level, I prefer Radiesse. Its calcium hydroxyapatite composition makes it the most viscous filler which provides a better push of the overlying soft tissues per cc of volume. But when comparing it to synthetic facial implants that have been used for decades, it has several disadvantages. It takes a fair amount of syringe volume to get a visible effect, often at least two or three syringes depending upon the area. The effect will never be as significant as a surgical implant and the filler material will go away by about one year after injection. This makes using an injectable filler for bony augmentation very patient selective. Filler are best used when one is uncertain about how a surgical implant may look (trial ‘implant’) or if the effect is time dependent based on an upcoming event and one doesn’t have the time to recover from surgery.
The face is also made up areas whose shape is not dependent on the underlying bone. These include two large areas in the lateral face and the temples. In the triangular area between the cheeks, chin and jaw angles, lies the lateral facial region. This area has garnered a lot of attention in facial aging as it becomes more concave in some people as they age due to fat atrophy. Plumping it up with fillers has become popular as a rejuvenative manuever. I prefer Sculptra for the lateral facial triangle because of the volume of material needed. Using an 8cc reconsitution of Sculptra in an almost pure watery form, it is easy to get a good amount of material over this large area. Sculptra does not work immediately and it takes time and three total injection sessions to get a result. But its effect may last for up to two years.
Q: Dr. Eppley, I have an interest in a revision rhinoplasty. I had a prior rhinoplasty to try and make my nose thinner and smaller. But unfortunately that has not been how it has worked out. As you have previously written on your blogs, the more skeletal framework we take away from a thick nose such as mine, the more shapeless it may become. I have finally come to accept that my nose will never be small, but I am hoping that the tip can be a bit more defined. Also, I noticed that my nose exhibits lots of nostril show since the surgery. Would it be possible to make my nose longer, so that the nostrils will be less noticeable along with further nostril size reduction? Maybe you can see that my nose kind of looks like a pig’s snout similar to the “before” picture of the lady’s picture I have attached. I’ve attached a picture of myself along with a before and after picture I found online.
A: What you are talking about is that you have a bit of an overrotated nasal tip from the prior procedure, resulting in excessive nostril show. This can definitely be improved by a revisional rhinoplasty procedure using a derotation manuever with a tip lengthening graft (to push it down and forward) and nostril rim grafts to lower the outer alar rims. This would require a septal cartilage graft, which although some has been taken from the prior procedure, most likely enough may exist to do these extension tip grafts. This is an unknown variable that can only be determined at the time of surgery. As a secondary option, we would have to be prepared to use ear cartilage if necessary. Septal grafts are preferred because they are straight and more stiff.
Dr. Barry Eppley
Indianapolis, Indiana
The concept of facelifting has evolved considerably in the past fifteen years. Not only has the techniques of facelift surgery changed, but how it has become markerted and advertised has changed as well. When you throw in the media coverage of celebrities and some of their results, understanding facelift surgery becomes even more muddled.
The options in facelift surgery are, however, far simpler than it appears. Facelift surgery traditionally speaks to correction of aging of the lower face only, the neck and jowls. As we age, jowling develops first which then leads to neck sagging and eventually the dreaded neck wattle. At its most simplist form, facelifts can either correct the jowls only, the neck only or both.. Thus facelifts can be done either as a partial (aka mini-facelift) or a full version.
The partial facelift is done when jowling is the main problem and any neck issues are either non-existant or minor. A full facelift is needed when the neck problem is the main issue or just as prominent a concern as that of the jowls. Thus, partial or limited facelifts are usually done on younger patients (less than age 55 or so) who have yet to develop significant neck sagging. The recovery from mini-facelifts is quicker because the operation is shorter and less technical manevers and tissue manipulations are done.. These are also the type of facelifts that have become very popular, largely driven by people in the workface trying to look younger and refreshed to remain competitive. They have been given a lot of different marketing names that imply less surgery and faster surgery and recovery, all of which is true. But don’t let the names fool you, they are all very much the same surgery.
A full facelift is usually needed in patients 55 to 60 years and older when the neck is a noticeable aging feature and either flaps or gets in the way of shirts and neck wear. In these more complete facelift patients, other procedures may be beneficial and are combined with it such as eyelid tucks and browlift surgeries. It is these combination procedures that give the impression that a facelift is a very extensive operation from which it takes a month to recover.
In between the mini- and full facelift patients lies an almost third category. This is where a partial facelift is not enough and a full facelift maybe more than what is needed. This may be perceived as a 3/4 facelift whose level of invasiveness and recovery is somewhere between a partial and full facelift.
Dr. Barry Eppley
Indianapolis, Indiana