Your Questions
Your Questions
Q: Dr. Eppley, I have been bothered by my ears since I was in grade school. I am noiw 21 years old. While they don’t stick out as bad as some ears I have seen, I just don’t like and I wish they were further back than they are now. What type of otoplasty procedure do I need? I have attached some pictures for you to see what I mean.
A: Thank you for sending your pictures. It appears you have a moderate case of protruding ears caused by some conchal hypertrophy as opposed to the more typical lack of an antihelical fold. Your antihelical fold is fairly well defined by the concha (the bowl around the ear canal) is a little too prominent which is why your ears protrude a little. Your ear position along the side of your head can be brought back by an otoplasty procedure in which the concha is weakened and then sutured closer to the mastoid fascia. This is done as a simple outpatient procedure that takes one hour to complete. There are few restrictions after surgery and a head dressing is only worn for the first night after surgery in adults.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, How is fat accurately determined and measured before suctioning it out by liposuction. I haven’t read anything about how body fat is measured to accurately determine how much might be safely suctioned out from each target area. How do doctors concretely know how much of fat to remove so the patient gets the best result and is even on both sides?
A: The reason you can’t find anything on this aspect of liposuction is because it does not exist. There is no way to know beforehand how much fat to remove from any area. That is and will likely always remain the ‘artistic’ side of liposuction. It is based on the surgeon’s experience and artistry to do the fat removal. The amount of liposuction aspirate is measured as it is removed and that does help in establishing some symmetry by taking equal amounts from any body area that is bilaterally treated…but this assumes that there is good symmetry beforehand which often is not the case. Thus liposuction remains an inexact surgical procedure and also explains the highly variable results seen in liposuction patients in general.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I had occipital neuralgia decompression surgery 5 weeks ago, My doctor also talked about decompressing the auriculotemporal nerve. I was nervous to have them done at the same time, so we were conservative and are waiting to see if it will be necessary after the 3 month mark from surgery. I have never suffered from migraines. I had a whiplash in my neck that had caused my neuralgia. I had mild temple pain on the right side, but my doctor said that could come from the greater occipital as well, so I wanted to wait see if that went away like the nerve pain has. What are your thoughts? I have been reading your website and wanted to get your input. I also wanted to know what the recovery time was for the auriculotemporal nerve. Is it the same as the occipital nerve decompression surgery. Also what are the percentages of success after auriculotemporal decompression.
A: Given that the origin of your head pain was from a whiplash injury and not a ‘traditional’ migraine trigger, I don’t think anyone can answer your question as to the success of auriculotemporal nerve decompression in your case. For refractory temporal pain it is also important to identify where the potential nerve source involved is the auriculotemporal or the zygomaticotemporal nerves. They are in different locations on the temple with one being in the hairline and the other between the hairline and the brow. If the pain location is between the hairline and the brow (the zygomaticotemporal nerve), this should first be tested by Botox injections which can predict the success of surgical nerve decompression/avulsion. There is no test for the auroiculotemporal nerve and whether its decompression will be successful.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I am interested in nose reshaping, but I also have been told that I would need nasal surgery. Do you do both at the same time?
A: I believe you are referring to needing improvements in your breathing inside the nose as well as external nose reshaping. It is most common to do both functional and cosmetic nasal surgery at the same time, a procedure better known as a Septorhinoplasty. It is always better done together as external nose reshaping often needs cartilage grafts which are most easily obtained with the septal straightening to improve the breathing. Thus the septorhinoplasty ends up after healing with better breathing as well as a more balance and pleasing external nasal shape.
You may feel free to send me some picture of your nose and I would be happy to do some computer imaging of them to see the possibilities of what can be done. A front and side view pictures are best for imaging purposes.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, Thank you for your information on temporal implants. I live in Los Angeles, and I have been getting fillers injected into my depressed temples for a couple year with limited and very short lived results. My hollow temples are genetic and non trauma related. I understand from your site that you perform a silicone temple implant procedure. I am however in Los Angeles, and wonder if you could recommend a surgeon here or in the Beverly Hills area who may also perform this procedure. Thank you for your help.
A: By your description of the temporal hollowing and lack of any sustaned results from the use of injectable fillers, you appear to be a good candidate for a permanent solution using subfascial placement of silicone temporal implants. Unfortunately due to the relative newness of the commercial availability of the the temporal implants, I am not in a position to know whom in Los Angeles or even California has yet performed this procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a 2 year-old daughter that had a lip laceration repaired in the emergency room earlier this week. They put in 3 sutures and I was told to follow up with a plastic surgeon later in the week to make arrangements for the sutures to be removed in five to seven days. Can you take tell me when to bring my baby in to your office to have the sutures removed?
A: First of all, any doctor or physician’s assistant that would put sutures in the face of a 2 year-old that need to be taken out later is not very thoughtful of the patient or the parents. You always use resorbable sutures in the skin in any child under the age of 8 because it is going to require a general anesthetic to remove them. While they may have wrapped the baby in a papoose board in the ER to put them in, you can be certain that is not going to happen in a plastic surgeon’s office. Nor are most plastic surgeons going to try it with the baby screaming at the top of their lungs which is exactly what is going to happen.
My suggestion is to send me a picture of the lip so I can see what it looks like. And be aware of the very distinct possibility of having to sedate the baby to do it in an operating room setting.
I am well aware that you will likely be stunned to find out that an anesthetic will be needed to remove the sutures. But anyone in the ER can say anything when they don’t actually have to remove them later. Trying to get sutures out of the lip when the baby is thrashing around is not a good experience for all involved and will likely do damage to the lip repair that was just done.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I am a 38 year old female. I had lap-banding in June 2012 and have since lost a lot of weight. I have gone from 339lbs to 268lbs. Currently, I am contacting you because I need help. I have always had large breasts. I have a 48E bra size at this time and despite my weight loss, have not decreased in bra size. My concern now, is that I have not been able to exercise properly because of the pain that my large breasts cause. In fact, in November of this last year I had an anterior cervical discectomy and fusion on an emergent basis due to a severely herniated c6-c7 disc- presumably caused by my large breasts. I have recently sought several consultations for a breast reduction due to this, but the consensus is that I need to have a lower BMI. I have very few comorbidities, so my surgical risk is minimal. Would it be reasonable to request a consultation from your office? I have Blue Cross Blue Shield and if deemed “medically necessary” breast reduction is a covered entity.
A: Thank you for your inquiry. While your weight may still be high by ‘ideal’ standards, the symptoms you experience with your breasts are not likely to be improve regardless of further weight loss. From that perspective, breast reduction at this point is not unreasonable. Sometimes the breast reduction just needs to be done regardless of the patient’s weight. This is more of getting the procedure approved through insurance at your weight than it is about the technical capability to do the procedure or in its ability to heal.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, Let me first give you some background information. About 6 years ago I had several procedures including a rhinoplasty. The dr. that did the rhinoplasty removed something under the base of my nose possibly part of the nasal spine. The result was a change in the angle under my nose. Also my top lip seems to come down lower than it did before. While I know I am not at the point of looking abnormal I would like to look more like myself before the rhinoplasty. When I push up under my nose it looks more like the way it did presurgery. I think this can be achieved with a peri-pyriform implant. I am not sure if silicone or meseline mesh would be the best material. I am attaching photos. the first in each set is with no expression the second ones are of me pushing up under my nose to show the look I want. I look forward to hearing your opinion.
A: Thank you for sending your pictures. What you are demonstrating is not what any type of nasal base/pyriform aperture augmentation will achieve. In fact, it will achieve the opposite effect…pushing out on the nasolabial angle…but it will not push it back up as you have demonstrated nor will it cause the tip to elevate/rotate.
The changes you are demonstrating can only be done by a revisional rhinoplasty in which lower caudal septal resection and suturing the lower ends of the medial footplates of the lower alar cartilages back to the resected caudal septal area is done. That is what needs to be done to drive teh base of the nasolabial angle in a more superior position.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, My son is 16 years old was born with a cleft lip It is now closed , but the scar is clear and the lip is not filled propwely. A fat transfer was done last December but the results are not satisfactory. Please advise if anything further could be done.
A: Without seeing pictures, it is would be impossible to make an accurate comment about any further potential improvements…although I have yet to see a cleft lip repair that could not stand some further efforts. I would not think that fat injections had any chance to offer improvement as the issue is one of proper alignment of the muscle, skin and vermilion not just a volume issue even though it may visually seem so.
Please send me some pictures of your son’s lip at your convenience.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I am interested in having the surgery of gluteal crease correction. I do not need a buttock lift per se but a correction of buttock crease. I am 5 ‘9″ tall & very thin & had a thigh lift years ago which was not done very well & gave me a lower uneven shaped buttock crease which makes my buty look loger than it should and the crease needs to be higher. I want to make the crease more even and have it round and higher. I have sent you pictures to study. I just recently had the crease corrected three weeks ago but this surgeon made the same mistake and just followed the original surgeon’s incision marks which were completely wrong and so it has not been corrected and still pretty much looks the same and the right cheek is also lower than left. I should have much better results for what I paid. I am so very disappointed. The top portion of my butt looks normal and round, but now I have loose skin and square/pointy shape at side view hanging down lower than the butt. The incisions/scars needed to be redone in the right position and be made more even, rounder and higher and the bit of loose skin on back of thighs needs to be excised and lifted. Have you ever seen anything like this done before? Do you have experience correcting this issue and think you could correct it and make it look much better and completely normal? This disfigurement has made me very self conscious & sad.
A: Thank you for sending your pictures and describing your concerns. I think you are spot on and I am completely bewildered as to what was actually done doing your recent procedure. I am going to assume that the size of the fresh incisions/scars that I see are the extent of the skin resection/crease creation? I will assume for now they are. If so, they are far too limited to adequately address the creation of a more complete lower buttock crease, create a distinct break between the lower buttocks and the upper thighs, and get rid of the bulge or overhang that you have. Perhaps you were unreceptive to a more complete or longer incision ??? At any rate, the lack of a distinct buttock/thigh demarcation, improved lower buttock crease/shape symmetry and elimination of the transitional bulge can be done by a longer and more wide excision of skin and fat with a tuck down to the gluteal fascia. This can be trememdously effective for your type of problem provided you can accept a longer but well placed scar. One of the keys to a lower buttock lift/crease creation is to not have the side part of the scar extend into the visible lateral thigh area.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I’m 4 months out from having upper and lower jaw surgery. A 2.5mm upper advancement with a 4mm transverse expansion and 3mm posterior impaction to correct an anterior open bite, along with a 3.5mm lower advancement through a BSSO. In addition to this, I had a 7mm chin augmentation through sliding genioplasty. While everything else went perfectly well, unfortunately the genioplasty ended up asymmetrical.
I’ve attached both frontal and profile pictures for you here, as well as frontal and profile pictures from before the surgery. In addition, my latest panoramic x-ray is included as well. I’ve also included a picture of my sulcus as it was before surgery, and as it currently looks now, as well as a “relaxed lip” picture as I believe I show more lower incisors at rest than I used to. Forgive the photo quality…interestingly, I look much worse in photos than in 3-dimensions. I’ve never been terribly photogenic. In addition, I have a bit of residual swelling in my upper center face.
In any case, obviously, I’d like to have the asymmetry corrected (I think its very obvious). So, I have these questions:
1) How difficult is it to correct? My OMS seemed to be very reluctant to do a correction and implied it could be very difficult which is why I’m looking to you for correction based on several recommendations I’ve received about your work. Do you think I be better off with fillers or pre-jowl implants to mask the asymmetry rather than redoing the osteotomy? There are also those pesky “dents” on either side of my chin (pre-jowl)…
2) Is there a risk of more lower lip drop–greater than the first surgery? I did notice my lower lip dropped a little bit…perhaps 1-3mm though I can’t be completely sure as I never really looked at it before and don’t have any previous pictures of my lips in repose. It’s obviously not a devastating lip drop/incompetence issue as I’ve heard about. Do you see anything with the sulcus that looks abnormal in any way? Would an additional surgery in this area be more risky in this respect? If there is a problem…can it be corrected?
I’m planning on coming up there in the next 4-6 weeks for an in-person consult, but wanted to get an initial opinion from you as to what you believe needs to be done.
A: Thank for detailing your surgery and sending your pictures. Now that you are four months out from surgery, you can see largely see the effects of the surgery as all of the swelling has subsided and the tissues hav contracted back done to the bones. What I see is the chin asymmetry and the very typical notching at the back end of the osteotomy sites which can occur from a sliding genioplasty based on how it is cut. (angle) Your lower lip position is hard for me to judge since how you are now is all I know. But I will assyme that there is a slight lower lip sag/ptosis.
In terms of improvement, two out of three issues are straightforward. First, the jawline indents will need to be filled in which can be done with either a shaped mersilene mesh overlay implant or a wrap-around prejowl silicone implant. (1mm thick in the middle so it adds no further horizontal augmentation) Second, since an intraoral approach would be redone the mentallis muscle would just be repositioned and resuspended not only as a prevention of any further sag but may actually improve where your lower lip is now. Lastly, the bony chin asymmetry can be delt with two ways, eitehr reposition the genioplasty or shave down the large or more prominent side. Since you may be getting an overlay implant anyway I would think burring the bone is far simpler. The only reason to reposition the genioplasty is if there are other dimensions to it you want to change. I suspect what has happened is that with the typical central plate fixation used, one side got rotated a bit (no lateral stabilization) and the asymmetry resulted. The genioplasty can be recut and repositioned without a problem (never confuse can with want to) but you just should have a godo reason to do so and to make sure that something simpler may not work just as effectively.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am interested in making my face look thinner. Even though I am not fat (below the neck), my face makes me look like I am. I have read about the buccal lipectomy procedure and that seems like it would work for me. I am most interested in getting the lower part of my face thinner. Thank you for your help!
A: To treat the soft tissue facial triangle area (lines drawn between the cheek, chin and jaw angles), the procedures of buccal lipectomies and perioral mound liposuction may be useful for ‘facial derounding’. It is important to realize that these procedures are most effective for the areas below the cheek down to about the mouth level and not for fullness at the jaw angle or in the lower part of the face. Facial defatting procedures work best in areas that are not directly supported by bone where the fullness is more the result of the thickness of the fat and not the bone. A buccal lipectomy removes a very distinct large ball of fat that sits right below the cheek bone. It is done from a small incision inside the mouth. It is important to not totally remove it so one does not get a gaunt look later in life. But for someone with a really round ‘fat’ face this potential issue may be irrelevant. The perioral liposuction procedure removes fat from below the buccal fat pad that sits right under the skin opposite the mouth. It is done from a small incision inside the mouth. Done together these two distinctly different facial fat removal procedures can help create a facial thinning effect.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in having a direct neck lift and was wondering if i would be a good candidate for the procedure. Also, I was born with a cleft lip. I would like to fill in the hairs on my upper lip to cover the scars. Could you use the redundant neck skin as a source for the donor hairs, since they are facial like the lip or would you use scalp hairs? Thanks.
A: Whether one is a good candidate for a direct necklift is based on the degree of loose neck skin, age and one’s tolerance for a very fine vertical neck scar. The direct necklift tends to be a procedure most commonly done and accepted in men older than age 65…although that does preclude any man younger than that age if they meet all the other qualifications. You are absolutely correct in making the assumption that the neck skin could be the source of donor hairs for transplanting into the cleft lip scar.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I had the Mandibular Matrix system implanted in 2010 including the two 7cm jaw implants and a 7cm chin implant. However after three years, the two jaw implants have shrunken/settled into my bone so that my jaw corners are around the same size as they were before the surgery. I plan to have my jaw revised. From looking around, I can tell that you are one of the top-experts on male jaw enhancement. Do you recommend replacing the jaw implants or stacking a new implant on top? What are the risks of bone settling and how can I reduce them. Also, how can I schedule a consultation and surgery date? I can send you pictures. Thanks.
A: My first question is whether the jaw implants have really sunken into the bone. That would be very unlikely given how the Medpor material is treated by the underlying bone. The first thing I would do is have a 3D CT scan done and a model made to really look at the current relationship of your existing implants and the jaw bone. It would be impossible to give good advice/recommendations without knowing the answer to this very important question. It may also be likely that any new implants may have to be custom made whether they would be placed on top of or in replacement of your existing implants. Be aware that it would be very difficult to remove your existing implants…not impossible but very difficult.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I was wondering how much of an advancement in millimeters via either an implant or genioplasty to achieve a more masculine chin and does my deep groove effect the outcome. Thanks.
A: How much chin advancement any patient can obtain depends on their anatomy. For a sliding genioplasty it is usually up to 12mms based on the front to back distance of the thickness of the chin bone. An implant can do more as it is based on how the implantg is fabricated, how much the soft tissue can stretch and the placement of the submental incision to place it. Increases in horizontal projections with chin implants can be done up to 15 to 18mms. In some cases, a coimbination of a sliding geniplasty with an implant overlay can be done with increases up to 20mms.
Any amount of chin advancement, no matter how it will done, does not change the labiomental sulcus and, in cases of significant advancement, will make it deeper. In a genioplasty the ‘step’ in the bone can be filled in to help preventing worsening the depth of the sulcus. In chin implants, the best simultaneous treatment would be fat injections placed directly beneath the sulcus.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I had some type of chin reduction procedure 10 years ago (maybe burring down the bone?) but my neck and chin actually looks worse afterwards. I have attached some x-rays which show a single butterfly-type device with four screws, visible more so from the profile shots. Do you think the irregular bone shape underneath is contributing to any of this fullness? Or does this not matter? The wedge on the end looks like it is positioned a little high to me. Would something like F in the image below be a better option? I want my labiomental fold effaced more like the after-shot in F. Or could this also be achieved with bone burring? What are you thoughts about all this? I want to get rid of the bulbous shape and having small, short teeth doesn’t help matters out much.
A: Thank you for sending the x-rays. What they demonstrate is that you had a reverse sliding genioplasty for your chin reduction, not just a simple burring of the bone. (like image F in the genioplasty illustrations) That is why there is a 4-hole metal fixation plate and screws. This also explains, as I suspected, the submental fullness that developed and never changed after the procedure.
Repeating the original reverse genioplasty is only going to make your neck/submental area worse…and will not reduce the depth of the labiomental fold. Do not let that illustration fool you, it does not work that way in real life on the effects of the soft tissue above the chin bone. (anything can happen on a drawing)
I do think that the bottom of the chin bone needs to be reshaped (narrowed and reduced in height) but, again, that is not going to change the depth of the labiomental fold. Fat injection grafting is the best procedure to try and make that happen.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I had chin reduction done when I was 13 (intraoral approach), however, there are still problems with it and it never has looked exactly right. I think it may be soft tissue issues? It still has a bulbous shape, and ever since the surgery, has this odd-looking submental fullness. The underneath side of my chin sags and looks very unnatural and strange from the side; it has looked like this every since I had the surgery. I don’t understand why this is…. is this fat or muscle or why doesn’t it look exactly right?
Also, my bottom lip positioning is incorrect. My bottom lip needs to come down and out (more everted), because when i smile my bottom lip goes in over my bottom teeth. What I am wanting is a more normal-looking profile, less of a labiomental fold with a bottom lip that everts (instead of inverts) like normal, and a more sculpted chin (less fleshy and bulbous on the end and a more smooth profile without all the submental fullness.
I talked to you before about soft tissue reduction of the chin, but I now have x-rays which might be more helpful. I have attached my digital pics and the x-rays of my mandible (DICOM files). Would only a soft tissue reduction/augmentation be able to address my problems? Or do you think I need something done to the bone? Another ostectomy or bone burring? I want to get rid of this fullness underneath and get a more sculpted, normal-looking chin, instead of a bulbous one. What type of procedure or procedures do I need to fix these problems and improve my profile? Thank you 🙂
A: Good to hear from you and I remember your case quite well. Let me dissect all your issues one by one. First the submental fullness is a soft tissue isseu of too much fat and loose skin, which often happens from an intraoral approach to horizontal chin reduction particulalry if done by an osteotomy. Just that alone could be corrected by a submentoplasty procedure to flatten out the submental fullness and tuck the tissues under the chin. Secondly, the files of the x-rays you sent me were text and not the images and I have no way of opening them in an imaged format. You will have to send me the x-rays actual jpeg files. But even without the x-rays I believe you need further chin bone reduction/reshaping to have a more sculpted chin shape. The value of the x-rays for me is to know whether there is any hardware in there and what the bone shape looks like. Thirdly, no chin procedure is going to change the depth of the labiomental fold. That has to be addressed directly by either fat injections or a subcutaneous implant to soften its depth. Lastly, the lip position and how it moves is not something that can be reliably changed by surgery. The only option is to do a v-y internal mucosal advancement to create more eversion but this will not in the long-run move the lip position lower.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley,I was thinking about have a nose job, I’ve been thinking about this for a long time! But i’ve made myself really paranoid buy looking at the bad points, but i am so insecure about my nose! I don’t know what to do?
A: The first place to start is to list what you do not like about your nose and what you would change if you could. Secondly it would then be important to see what is possible by rhinoplasty surgery by having some computer imaging done of realistic surgical outcomes. Then you can see if rhinoplasty surgery is worth the effort. If you send me some pictures and the changes you would like to see I can do that for you. This will give you good information to decide about what to do with your nose.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, do you perform Love Band eyelid surgery. I have lost the fat padding directly underneath my eyes, which I would like back. In Korea, they call these fat pads “love bands” and promote surgery to enhance that area via fat transfer in order to make the eyes appear bigger. Do you offer “love band surgery” as welland not just fat grafting for lower eyelid hollows? Thanks so much.
A: Love Band surgery is fat injection grafting done just under the lashline of the lower eyelids to create an elevated skin roll. This is done by placing small fat droplets in a linear fashion with a microcannula technique. It usually takes less than 1cc per eyelid to create the roll. This is viewed in some countries, particularly Korea, as enhancing the eye area and making it more attractive. It is a variation of contemporary fat injection grafting that is done just to one specific area of the lower eyelid in a very precise manner.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in cheek augmentation and an African-American rhinoplasty. I have fat cheeks and I want them smaller. I also want a more refined and less fat nose. I have attached a picture of me so you can see what needs to be done.
A: Thank you for sending your picture. This one view is not the best picture to judge the result but it is helpful. I believe you are looking for a buccal lipectomy to reduce the fullness under your relatively flat cheek bones. Or you could leave the buccal fat alone and augment the cheekbones which I think is a better alternative. (maybe just a little buccal fat removal. Your nose shows many of the typical ethnic features and that could be improved by an open rhinoplasty in which the nasal bridge is built up with an implant, the tip lengthened and narrowed and the nostril flaring/width reduced. I have just imaged the buccal lipectomy and the rhinoplasty.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a jaw/chin implant 14 weeks ago, it was two separate pieces that were screwed in. I would assume most of my swelling is gone but I have asymmetry as one side is lower….my Dr. is a reputable surgeon and is working with me, we meet approx every 5 weeks or so….he said if necessary he can go in to the one side, make a small incision and file it down some (not remove it)…he also put some filler in the area right where the implant starts at the jaw so you can see it….said there is permanent filler we can use down the road….I guess my question is how does this sound to you…..is filing down of an implant an option when there is tweeking to do?? I greatly appreciate your help….also is filler routinely used to help “fill in” near and around an implant for a more natural appearance and do you advise that. Thank you for your time!
A: Let me make sure I understand exactly what implant you have. Using the term jaw/chin implant could be either an isolated chin implant or a combination chin and jaw angle implants. I suspect you mean a chin implant because it is two-pieces which would also make it a Medpor two-piece chin implant. If there is asymmetry between the two positions of the two pieces and you are certain that it is not just swelling (more than 3 months after surgery), the best approach is to go in, unscrew the implant, reposition it higher and screw it back into place. There is nothing wrong with cutting down the lower side but that can be harder than it seems to do smoothly and evenly with the implant in place. As a general rule it is always better to fix the primary problem (implant) rather than investing in camouflaging the problem by injectable fillers.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, My goals are increased horizontal projection of my chin( no vertical lengthening)and a more square chin. Jaw angles flared out with augmentation of the angle itself and of the ramus but not the body? ( not necessarily a drop down of the angle itself as I think the angle is low enough currently). Rhinoplasty to decrease the hump in the nose possibly decreasing the width of the bony part of the nose when viewed from the front and the tip refined somewhat( picture with red hat)( My morph( lateral view of my nose in the blue shirt) I admittedly got a bit crazy/unrealistic with the tip of the nose. Finally, liposuction below the lower jaw/chin area to get rid of the adipose tissue that has always been there no matter my weight( a good 10-15 mm in various spots under the jaw/chin when I do a pinch test.) Also, wondering if the chin implant can be placed through an existing scar on my chin from my childhood.( picture added of scar 20 mm long and 10 mm long in the 2nd aspect and around 3 mm of width to the actual scar line( the scar is basically a T shape) Attached are some before and after pictures that I’ve done in photoshop as what I’m kind of looking for in general terms. I don’t know if this is even possible / what would be proportional for my face, but thought I would include them as a rough reference since I’m not there in person currently. My overall goals are increased balance in my face as I think the upper 1/3 of my face/ head is much larger then the lower 1/3. Also, I’m looking to do this with IV/ twilight sedation and not general. I’ve had septoplasty (2004) and a hernia operation in the past with just iv sedation(+ spinal for the hernia sx) and prefer this option. Thanks a lot.
A: Thank you for sending your pictures and doing the array of imaging. My review of the imaging matches fairly well with your goal descriptions and I would agree with much of it with the exception of a few minor variations.
For your chin you seek more horizontal projection, a more square shape in the frontal view and no change in its vertical length That would be possible using a square silicone chin implant, probably of at least 7mm to 9mms in thickness placed through a submental incision. It would not be wise to use your existing scar as it is too small, would become more prominent as the chin is pushed forward and would dive through the mentalis muscle in the process. A scar revision can be done on it but it would not be used to place the implant.
Your jaw angles show width expansion, a sharpening of the angles and no vertical lengthening. That could be accomplised by a 9mms silicone lateral augmentation implant placed directly over the existing angles.
The only comments about potential results with these implants is that the angularity of them (point of the angles and sharpness of the chin corner) may or may not be as sharp/pronounced as you have shown. The other issue is the continuity or smoothness of the jawline from the chin back to the angle. While the ends of a square chin and jaw angle implants will overlap, these overlapping areas are not as thick as the other parts of the implants. This it is not clear that the jawline will be as perfectly smooth from front to back as you have imaged.
The nose can be changed through an open rhinoplasty with a hump reduction and tip narrowing and some mild lift. I think those results are very achieveable.
Lastly, this collection of combined facial structura procedures can be done very well under just IV sedation. These are operations that are best performed under general anesthetic to get the best result.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I had an operation on my forehead almost 16 years ago that changed my life. My frontal sinus was backed up causing me to have had my forehead bone removed and replaced with my hip bone in fear that it was infected. I have a cut along my hair line but my forehead does not look the way I wish. How much does a reconstruction cost to have some material to over lay the bone for a more normal look? Thanks!
A: I am assuming based on your description that you originally had a frontal sinus obliteration procedure in which the sinus lining was removed and filled in with an iliac marrow graft. This undoubtably healed in a very irregular fashion, leaving the brow bone area with an uneven contour that may even be a bit sunken in. The brow bone/forehead contour can be significantly improved by an onlay frontal cranioplasty using hydroxyapatite cement. That can be done using your existing hairline scar. In order to properly estimate costs, please send me a picture of your forehead for my assessment so I can see how much cement may be needed which can highly influence costs.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, have had surgery for migranes the first one was 2012 all four trigger points and deviated septum. about 4 months later I developed a very suttle yet painfull pressure pain in my right temple. It was relentless. feb 2013 the surgeon went back in and removed an artery. for a week I was sure it was better then it came back again. since then I have had steroid injection and anestetic injected in the temple.. no help then botox injected.for two days after I felt great accually thought I might have a life. then the pain came back and remains and it sometimes triggers a full blown migrane, yesterday I got a shot for a migrane I was given demerol toradol and benadryl and phenigan. It helped in all areas but not in the area in the temple I still had the pain.. I cant live like this. the surgeron removed a portion of the zygomatic nerve.
A: Based on your description it sounds like you have had every migraine surgery approach for your right temporal migraines. The zygomaticotemporal nerve has been avulsed and the anterior branch of the temporal artery has been ligated/removed. Short of a temporalis fasciectomy, there are not other surgical options that I know. The fact that Botox had little to no sustained effect does not bode well that any further surgical manipulation would have a high chance of being effective.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like to get the upside frown surgery. Can you please tell me how much this would cost? How long would recovery take? Is the surgery painful? How long does it take to get an appointment?
A: Thank you for your inquiry. It appears that you have an ‘upside down froen’ issue. In looking at your pictures what i see in a level smile line but an overhang of the mouth corners turning into deep marionette lines. This is not a problem that will respond well to a more simple corner of mouth lift alone. While that will get rid of the overhang at the corners of the mouth it will not improve the deep marionette lines. That problem can be simultaneously treated with either fat injections or (ideally) a jowl line lift to pull back the tissues that are falling forward.
For the sake of providing some sort of a cost quote, let me for now assume it would be a combined corner of mouth lift with marionette line fat injections. I will have my assistant pass along the cost of that procedure to you later today. This is not a painful procedure with minimal recovery. (just some mild swelling) Surgery can be scheduled as soon as your schedule permits.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I can not seem to find any surgeon who performs shaving or burring of the jaw angles! They all do osteotomies of the angles and the results look awful and unnatural. Would you know why most facial feminization surgeons do not shave the jawline? They cut off the bone (angle resection) instead. I am wondering if it is a typical technique used by FFS surgeons? Because they operate men to become women so they go extreme. I am already a woman and just want a softer jaw. Would you know how many mm can be shaved off the angles? and how many mm off the jaw close to the chin? maybe it is so limited that they rather cut so they can remove 1 to 2 cms, which to me, seems a lot on a face. I wonder if I should go to a maxillofacial surgeon instead?
A: My best answer is that is just a lack of experience and knowing the different options that can be done. Also total jaw angle removal is easier to technically perform than outer cortical reduction with jaw angle preservation. It is important to apply the right operation to the patient rather than just the one operation you know to every patient. Most likely you can get about 5mms reduced from each jaw angle reduction, tapering to about 3mms behind the mental nerve.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I have had a open rhinoplasty during June of 2012. My nose in the beginning looked great, but gradually it got a bit more but it went down gradually in time, though it is still swollen on the tip. But approximately two months ago I was washing my face and pressed on my nose and I heard a “click” and some blood came out. Since then I always get a bit of blood from my nose in my snot. I put vaseline inside my nose, which made the blood to stop coming, I guess it was dry on the inside. A month after the “click” in my nose, it became really swollen. Even though people don’t see a swollen nose, I know that my nose don’t look like this. Ive cleansed my nose with salt and water on the inside, I’ve used cortisone nasal spray, I’ve got antibiotics and cortisone tablets. The cortisone tablets really helped but only for a day or so, after that my nose went back being swollen. I do not know what to do, and would really appreciate your help.
A: I am going to assume that your open rhinoplasty was done using your own cartilage and no synthetic implants. In an open rhinoplasty a columellar strut graft is often used and this is really the only thing that can cause any clicking after a rhinoplasty if you move the nasal tip. But this is a natural material and not a source of infection or would cause an open areas inside the nose where the incisions where. At 10 months after surgery you are rapidly approaching the time when you are reaching the final result although I would not pass final judgment until a year from surgery. You may consider doing some low dose kenalog injections in the nose to get some further nasal tip refinement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr Eppley,I was interested in getting a chemical peel or something for my skin type to help reduce/get rid of acne scars, melasma, freckles on my face. I am half asian/white and I am concerned about scarring and hyperpigmentation from doing such a procedure. I wanted to know your experience has been with asian patients and the success you have had with them.
A: I am not very enthusiastic about treating patients with intermediate skin pigments for discoloration issues because, as you know, those skin types are very problematic and often as many problems are created as are solved. Acne scars are problematic in any skin type in terms of the degree of improvement and the concept of completely getting rid of them is not usually possible. The fractional laser can help but, again, in intermediate skin types one has to balance the depth of treatment with the risks of hyperpigmentation. Scarring is not a concern in my experience.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in having the following procedures done:
* Ear surgery – ear pinning + fix right ear that sits lower than left ear or fix left ear that sits higher than right ear + improve general appearance of ear cartilage
* Blepharoplasty – lower eyelid of my left eye (when I smile, it creates a prominent bag under the eye – not the case with my right eye though)
* Septoplasty – nose veers a little bit to right (possibly due to deviated septum)
* Rhinoplasty – remove slight bump & also looking to have a thinner nose
* Lip augmentation – improve general appearance
* Liposuction under chin – just to get rid of dreaded dubble chin
* Other possible procedures (if doctor recommend them): cheek implants, jaw implants and chin implant – I would like to have more masculine facial structure
Other possible procedures, if you offer them: tear trough implants, cheek lift
PICTURES:
First pic: how I actually look
Second pic: alterations I made to my face on your website (not perfect, just played around).
A: In answer to the facial procedures:
1) It is possible to raise an ear .5 to .75 cms but it is not possible to lower an ear. Ear pinning or antihelical fold setback can effectively reshape the outer ear cartilage.
2) The ‘bag’ of the left lower eyelid is hard to appreciate in your non-smiling views so I am not sure if it is a skin issue or a fat issue.
3 and 4) A septorhinoplasty is needed to straighten the nose, reduce the bump and have a thinner tip.
5) To make that amount of lip augmentation change, you would have to think about fat injections even though their survival in the lips is anything but assured.
6) Submental liposuction can be done but, more importantly, significant chin augmentation will eliminate that concern on its own. Cheek and jaw angle implants would be complementary to the chin and, in your thin face, would make it very sculpted and angular.
7) Cheek implants will obviate the need for a cheek lift. Tear trough implants can be done to fill out the under eye hollows.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I want to put something inside my upper lip, a piece of jewelry I have. I also have big lips so this should work. What I’m using is a tiny Christian cross. I want to litterally implant it into my lip through the pink part of the lip, meaning you would not see it at all as it would be inside my upper lip. Could you do that or would having a piece of metal jewelry inside my lip cause an infection like tetanus?
A: A small metal implant can be implanted inside the lip as long as it is not too big and is placed in a sterile fashion. This also means that the implant must be sterilized before its surgical implantation as well. There is always the lifelong risk of infection or extrusion as long as the lip implant is in place although it is impossible to predict exactly how significant that risk is. That would be based on how deep or superficial it is placed and what the metal composition of the implant is.
Dr. Barry Eppley
Indianapolis,Indiana