Your Questions
Your Questions
Q: Dr. Eppley, My 5-year old daughter has protruding ears, and I was interested in looking into costs associated with having them fixed and if she is currently a candidate or if it is best to wait until she is a little older.
A: Thank you for your inquiry. Otoplasty surgery can really be done at any age after two years old from a biologic standpoint. Ear growth is not affected when performed after this age. Thus, otoplasty in children is done when the parent(s) feel that it is in the child’s best psychological interest to do so. It is historically common to perform the procedure before school formally starts which is where the ‘by age 6’ concept has its origin. Since some form of formal schooling is not occurring earlier than age 6, it would not be rare today to do the surgery by age 4 or 5. This is really a parental decision not a plastic surgery one.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I’m interested in cranioplasty augmentationsurgery but have a few more questions.
1. Is this correction permanent meaning is it reversible? is it expected to last a lifetime?
2. You mention PMMA is harder than hydroxyapatite, will i feel the difference?
3. Is the hardness of hydroxyapatite similar to real bone? Will it feel more natural to me?
4. Will I experience foreign body sensation with this “implant”
5. I’m not an expert on the anatomy of the skull but i’ve read that there are gaps between the bones of the skull even when they are fused. how will this type of correction subtle dynamics of contraction and expansion of my skull bones, once a material like hydroxyapetite is plastered onto them?
6. Is there potential for leakage/breakage of material and if so what are the health, carcinogenic, or risks.
7. Is there risk of allergic reaction to the material?
Thank you for the work that you do.
A: In answer to your questions:
1) All cranioplasty materials are permanent, meaning that they do not degrade, break down, and never need to be replaced because they wear out. They are, however, fairly easily removed so they are completely reversible.
2) There is no external feeling difference between PMMA and HA. Their biomechanical differences are largely that of laboratory testing.
3) There are no feel differences between PMMA and HA and they will feel both natural and just like your own bone.
4) Patients do not report that they feel like they have a skull implant in place. It feels just like bone.
5) There are no gaps between adult skull plates. That is an in utero and neonatal phenomenon.
6) Cranioplasty materials are fully polymerized and do not break down, leak, or degrade over time. There are no long-term health or carcinogenic risks.
7) While infection can occur from their surgical placement, there is no known risk of an allergic reaction to HA and very rare risk to PMMA.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am seriously interested in reducing size of my stomach/abdomen with minimal down time and invasion. Is this what laser liposuction can do? I am researching my options.
A: It would be good to talk you through many of your liposuction options and get a realistic understanding of how they work and what can be achieved. There is no such thing as any liposuction method that has any different amount of invasiveness or recovery. That is a misconception propagated on the internet by various marketing and promotional efforts as well as many device manufacturers. While there are numerous liposuction techniques that use different energies to achieve their effects, they all are invasive surgery, traumatic the tissues significantly and involve recovery that would not be considered quick or minimal particularly over a large area like the abdomen.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I’ve been browsing your website for a couple of weeks and it has proved a tremendously useful resource on rhinoplasty. This is something I’ve been thinking of getting for a while, but I would like your opinion on the options available. From what I’ve read, silicone implants tend to come with a risk of extrusion, which is why many surgeons recommend rib grafts. However, I would prefer to avoid the scar and a more invasive procedure. After posting on various forums, I have been recommended to get a silicone implant for the bridge, but to use ear cartilage to reinforce the tip and to further build up the bridge and radix. Do you think that this will be a viable alternative to rib grafting? Lastly, as I’m from out of the state, would you be able to perform a rhinoplasty on me, and how long should I expect to have to stay before flying back home?
A: It is understandable that many patients want to avoid the use of a rib graft for their rhinoplasty. The use of an implant makes the operation far less complex and much easier for recovery. But, as you have pointed out, the use of an implant for nasal augmentation must be carefully done to avoid its well known complications. For implant nasal augmentation, I currently prefer the use of a PTFE-coated silicone implant as it allows some better tissue adhesion than pure silicone alone but avoids the severe scar adherence of a Medpor implant. The key to prevent long-term complications is to avoid too much pressure on the overlying skin, particularly that of the tip. For this reason, many surgeons will cover the tip with an ear cartilage graft which is a perfectly valid approach. When possible, I prefer to place the end of the implant under the nasal dome cartilages which have been lifted, narrowed and sewn together over a columellar strut cartilage graft. This achieves the same purpose but buries the implant under more natural tissue. This can only be done when the nasal implant is a dorsal style only and not a dorso-columellar style implant. Many times the dorso-columellar style can be avoided with columellar strut grafts. It is unclear to me yet as to what your nasal augmentation needs are.
With a rhinoplasty that uses a nasal implant, the recovery is only a matter of days until one can return home.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, My surgeon indicated that he wants to perform a mandibular osteoplasty to reduce the squareness of my angles; this is why he would need to use screws. He told me that the bone is so hard to reach that he doesn’t use the angles osteotomy, he doesn’t know how to do that. He is a maxillofacial surgeon and not a facial feminization surgeon.
Are you aware of the mandibular osteoplasty surgery? Is that appropriate to reduce mandibular angles? Does that give a more natural result to the angles? One that causes less asymmetry or sagging skin? Is a maxillofacial surgeon appropriate for that type of surgery? (purely aesthetic as I have no functional problems)
A: The term, mandibular osteoplasty, is a generic term (means jaw bone reshaping) that does not imply any specifics about the surgical technique. You would have to ask him to draw exactly what this technique is to understand what is being proposed. However, I suspect he is talking about doing a sagittal split ramus osteotomy as this would be the only jaw angle procedure in which screws would be used to fix the bone back together. I do not see any reason or indication in this approach for what you are trying to achieve aesthetically. I suspect you are correct in that this particular maxillofacial surgeon is taking a functional rather than an aesthetic approach to your concerns.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I am a 28 years old transgender female. I would like to do a hip augmentation with implants and at the same time a liposuction and fat transfer to the butt or maybe butt implants and hip implants together. I would like to know what is the best solution to create more feminine curves in the butt and hips areas.
A: I would need to see some pictures of your body to see the dimensions of your hips and buttocks and see what the best solutions are. But I will assume for now that you do not have enough fat to successfully do any amount of fat injection transfer for augmentation. This usually requires at least 2500 to 3000cc of liposuction aspirate to get 300cc to 400cc of concentrated fat per buttock to inject…which will create a very modest buttock enlargement. This leaves the only options for either buttock and hip augmentation using implants. The decision for buttock implants is whether to go above or into the muscle. I usually prefer the intramuscular approach since this implant location has a lower risk of complications and better long-term results. Hip implants are always placed in the subfascial location and the size of implant that can be placed depends on the tightness of the pocket right below the level of the trochanteric prominence.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, there is something wrong with my face but I can’t figure it out. I used to think it was all because of my nose which is big but I think it is more than that. There is some other part of my face that just isn’t right that makes me look unbalanced or disproportionate. I have attached some pictures for your insights and recommendations.
A: Thank you for sending your pictures. What I see about your facial proportions are two things:
1) A nose that is very broad at the tip and middle 1/3 and a bridge/dorsal line that is low.
2) A forehead that is narrow and very flat.
Ideally a rhinoplasty with tip narrowing and dorsal line augmentation would make the nose more proportionate. Also a forehead augmentation to give it greater convexity from the brows up to the hairline would also be an aesthetic addition.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I need to know if I need liposuction, a mini-tummy tuck or a full tummy tuck? I am 28 years old and have had two children. I had breast augmentation done three years ago and go pregnant right afterwards. I have a big hard stomach and can’t seem to lose it even though I work out and try to eat right. I am 5’ 8” and weigh 190 lbs. I think surgery is only thing I can think of to help but I am not sure what I need, liposuction or some type of a tummy tuck. Please help!
A: With a relatively high BMI (body mass index) and a ‘hard and big’ stomach, I have concerns that any form of plastic surgery is appropriate for you at this time. You need to lose some weight by some method before considering any tummy reducing plastic surgery procedure. A hard stomach indicates that the skin is tight and a tummy tuck, while it can be done, would not produce a result that may be worth the effort. (the tight skin would not allow that much to be removed) A better yield on a tummy tuck would occur if you dropped 20lbs to 30 lbs, creating greater looseness of skin. Similarly liposuction would produce less of a result that expected as some of your fat is intraperitoneal (located behind the abdominal muscles) where it is inaccessible to a liposuction cannula.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I am Mexican-American and have large cheekbones. Would you do me the honor to address my affliction. Malarplasty and chin implant are my considerations. I have attached pictures in which I did not shave to accentuate jawline and chin. Hope I didn’t goof. Thank you very much for your time.
A: Thank you for sending your pictures…and you did just fine. In looking at them, the problem with your chin is that it is vertically short as the predominant issue with only a mild horizontal deficiency. I think when the chin/front part of the lower jaw is expanded by an extended vertical chin implant, it makes the more prominent cheek bones less signficant. Your cheek bones to me only seem large because the bottom 1/3 of your face is short. I have attached some predictive imaging illustrating what happens when the chin is vertically lengthened.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m contacting you as I am seeking some comments from yourself in relation to what I suspect is either unilateral coronal synostosis or plagiocephaly. Given the nature of the problems I present I am not to comfortable with sending photographs
If I were to describe my observable problems I would summarize them as follows:
1. Slight right-sided anterior ear displacement (very obvious asymmetry of the ears)
2. Mild right-sided occipital flattening
3. Frontal bossing with excessive protuberance of the upper portion of the squama frontalis over the supraorbital margin – slight right to left cant with the right being more forward
4. Vertical orbital dystopia – right side slightly higher than the left (I would say the entire zygomatico-orbital bone complex on the right is higher as I have an asymmetry and protuberance in the zygoma region)
5. Nasal root deviation to the right with deviated septum to the right (What I mean by this is that the entire nasal bone pyramid complex is off to the right)
6. Chin deviation to the left
7. Asymmetry in the vertical height of the mandible – left side is higher than the left
8. Uneven cheek fullness – slightly greater degree of fullness on the right side.
9. Malocclusion – no functional occlusal contact left side and buccal crossbite right side in centric relation, posterior bilateral open bite in centric occlusion. Mandibular mid-symphysis deviates slightly to the right in centric relation, and slightly to the left in centric occlusion. Left condyle is both posterior and superior in the mandibular fossa compared the right. There is a slight transverse cant of the maxillary occlusal plane observable in frontal view, which gets more significant as you approach the region of which is inclined.
If I were to describe my visual appearance in worm-eye view I would say that there is a slight twisted effect to the skull from right to left, as can be seen looking at the frontal bone and the supraorbital margin, the nose, the zygoma’s, and the mandible.
I have looked at some photos of myself as a child and it seems quite apparent to me that I had a slight degree of vertical orbital dystopia. I do not believe however that I had the “harlequin eye” deformity looking at these photos.
Do you have any comments or advice, and what treatments may be available to tackle my asymmetry?
A: Your description is fairly classic for this deformational type of skull deformity. Usually the best camouflage approach is to level out the chin and jawline by osteotomy/implant, correction of lower orbital dystopia by cheek augmentation, building up the floor of the eye and adjusting the ipsilateral lateral canthus and possible brow bone contouring. Rhinoplasty to straighten a deviated nose may also be useful. If the ear sticks out on the more anteriorly positioned side, an otoplasty may also be done. Usually I leave the occipital skull deformity alone unless it is really flat.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I had orthognathic surgery to improve my bite and make my jaw more symmetrical. Even though my bite is better, I now realize that my jaw is too small and narrow. I have been researching to find an implant which is able to make my jaw both longer and wider from the chin all the way back to the angles, but can’t find any. Are there any off-the-shelf implants that can achieve my goal of back to a substantial and robust jawline? Can Medpor or silicone implants be custom made? I am more favourable towards Medpor because of its ability to form on to the bone and become incorporated in it, rather than silicone or any other materials. I really hope you will be able to help me with this jaw problem.
A: It is hard for me to know how much change you really need based on your description alone. But in cases that I have worked in the past who have had similar concerns they almost always have needed custom rather than stock or off-the-shelf implants. Custom made jawline implants off of a 3-D model which can be designed and manufactured in virtually any dimension so their versatility makes them always the most ideal choice for total jawline enhancement. They can only be made in silicone, custom made implants from Medpor is not an option because it is not offered by the manufacturer and they would be virtually impossible to place anyway. It is also a misconception that bone grows in Medpor which it does not really do. Rather fibrous or scar tissue is what grows into the material…which is why they can be very hard to remove later.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I hope you can help me. I had lipouction for a witches chin with jowls removed; jowls on advice of plastic surgeon. Chin is uneven with a “fat pad” remaining. Plastic surgeon said he would “fill it in” and used Belotero. I look 10 yrs. older; I am 61. Could you look me up on Facebook and you will see the before and after photos. Plastic surgeon said he will not redo. Have been to two other plastic surgeons for their advice; both said they would never have lipo’d the chin. What can you advise? I can’t afford to keep getting filler and feel foolish and depressed over this. Thank you for your valuable time and advice.
A: I will need to see some current pictures of your chin for my assessment, a front and side picture will suffice. (I don’t do Facebook) As a general statement, liposuction of the chin is not a good technique, will not correct and witch’s chin and usually will leave it uneven or bumpy…often worse than where the patient started. The preferred treatment of a witch’s chin deformity is a submental tuck-up where the overhang is removed and tucked under the chin. A witch’s chin problem is the full thickness of tissues that do not have bony support. It is not an isolated fat problem which is amenable to liposuction.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I am curious about having liposuction on my abdomen and thighs what is the average cost, I want to remove about 15lbs.
A: Thank you for your inquiry. While it would be helpful to see some pictures of your abdomen and thighs, let me ask you a few questions in regards both areas:
1) Is this your full abdomen?
2) Do you need the flanks or muffin tops t.reated as well as your abdomen?
3) Do the thighs include both sides, inner and outer? Knees?
When considering cost, knowing exactly what areas needs to be treated as this allows the time to do the procedure to be properly determined. Fundamentally, liposuction like all cosmetic surgery and its cost revolves around the timer to do it.
While 15 lbs of aspirate (1 liter of liposuction aspirate roughly equals 8 lbs) may be removed in surgery, this does not necessarily mean that will translate into 15 lbs of actual body weight lost.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I have a few questions regarding facial implants. I did not see this addressed on your blog so thought I would ask. My question is regarding the known/ suspected long term effects of having facial implants if any. While I understand that for instance solid silicone implants such as the jaw/ chin implants I’m interested in will last a lifetime; however, what does the aging process hold for those that have such implants? Does placing an implant under the largest muscle (of the jaw) have drawbacks as I age. ( only in my 30’s now) Will jowls/ sagging skin etc show up faster since the muscle is now stretched over this new ( larger jaw)? How will chewing be effected if at all due to this as I age. Or will aging and its various processes just march on as if I never had anything done and just as if I was born with this new wider jaw and more pronounced chin? Thanks again for your time.
A: Facial implants, of any location, have no negative impact of facial aging and may actually have the reverse effect. As implants add volume by addition to the bone, they may prevent some tissue sag, or delay it, that will inevitably occur with aging. Jaw angle implants have no negative effect on chewing other than the initial discomfort and stiffness in mouth opening right after surgery that persists for a few weeks.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I am seriously contemplating having chin revision surgery done by you due to a persistent unilateral numbness on the right side of my chin and lower lip area. This has been causing me a lot of distress for almost 2 years. On top of this, my right mentalis muscle doesn’t contract properly which causes a very noticable crooked smile and asymmetries in other facial expressions.
Here is a short history of what was done on my chin. About 3 years ago a plastic surgeon placed a Medpor chin implant with a 5mm projection via intraoral incision. It was the implant shown in this photo, but with a fair amount of custom reshaping. There were several issues after the first surgery though. While the left side seemed to be alright, the right side wasn’t. The implant was shaped assymmetrically (less prominent on the right angle. The right wing protruded about 2mm from the chin bone, i.e. it didn’t touch the bone which resulted in a bad transition as well as serious irritation and pain that wouldn’t resolve. The implant appeared to protrude slightly more on the right frontal part than on the left. Therefore my surgeon injected hyaluronic acid on the left frontal part to temporarily ameliorate this assymmetry until revision surgery. There was also numbness and lack of motor control of the chin and lower lip. The numbness and lack of motor control eventually fully resolved, but it took a whole year! However, the other problems made a revision surgery necessary. In this surgery the following was done. An intraoral incision merely on the right side (only the right muscle was cut through!), taking away the back part of the right wing to ease the irritation and pain, placing additional MedPor material on the right angle of the chin implant to make it more prominent and placing additional MedPor material on the left frontal part of the chin implant. The revision surgery took care of the irritation and ameliorated the assymmetries, meaning the chin now looked more symmetrically although still not perfect.
Unfortunately, the revision surgery brought more bad than good things. Now the major issue is that even after almost 2 years since revision surgery I still have unilateral numbness in my right chin and lower lip area and serious lack of motor control of my right mentalis muscle. This all became gradually better, but the progress has long halted and I am pretty certain that the remaining numbness and lack of motor control won’t improve any further with time. My surgeon said the odd behaviour of my right mentalis is caused by scar tissue located on the left frontal part pulling on the right side. I have no idea if this is possible. I rather think that the problem is not the scar tissue, but the mentalis muscle itself. Maybe it was not properly resuspended. This is were I need your opinion the most. I attached some images and a video so you can get a better idea of my problems. Among the images is an xray scan that faintly shows the chin implant. Maybe this helps you determine if the implant impinges on some nerve. Also, would you say that my chin is sagging somewhat? Can this be fixed? As a side note I should mention that I have a tendency for scarring and fairly bad wound healing.
Based on my description I have several question that you can hopefully answer:
– What would be your general advise in a situation like this?
– How would you approach another revision surgery? Does the mentalis muscle have to be resuspended? Is there hope it will return to normal functioning?
– Was it a sound approach to only make an incision through the right mentalis muscle? Wasn’t this screaming for a muscle dysbalance later on?
– Would it make sense to make an incision under the chin and not inside the mouth should a revision surgery be necessary again? It seems like cutting through my muscles is causing a lot of complications. But I guess the intraoral approach is necessary if the mentalis muscle has to be resuspended, right?
– Do you think the implant is aesthetically OK?
– Is it a good idea to take out the old implant and place a new and maybe smaller one? I suspect the current one might be slightly too large.
I’d like to thank you very much in advance for taking the time to read and respond to my email. Hopefully you have some encouraging news for me.
A: Thank you for your inquiry. I have reviewed your history, pictures and video and can make the following comments:
1) Your case illustrates why placing a firm and inflexible Medpor chin implant through the mouth is generally a bad idea, it is associated with a significant risk of all the complications that you have experienced. But that is water over the dam now.
2) I find the aesthetics of your chin result very acceptable and certainly don’t think it is too big.
3) I would NEVER think at this point of trying to remove and replace your chin implant. That is a disaster waiting to happen. Given what has transpired up to the present and the difficult with removing Medpor implants, the risk of worse nerve and muscle problems is very likely. It may not be perfect but a perfect chin result for you is no longer a reasonable goal. I would advise that you accept a reasonable aesthetic outcome. Revisional surgery for you, as you have learned, has a lot more risk of problems than it does in making things better.
4) It would be highly unlikely at this point that, even if the implant was impinging on the nerve (which I doubt) that relieving it is going to cause return of feeling. The nerve fibers have atrophied and the damage is irreversible at this point.
5) I do not think you have chin ptosis or sagging.
6) As for mentalis muscle dysfunction, I would have a very low level of confidence that any efforts at trying to resuspend the muscle would end up in the long run giving you a better result than you have now.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I am planning on having a scar revision for a vertical scar on the bridge of my nose. At the same time I want to correct sinus problems: turbinoplasty, septoplasty as well as rhinoplasty for some minor aesthetic improvements. I’m hoping the minor nose humps can be grinded so they won’t exaggerate the contours of the scar. How can I minimize the new scar on the bridge from becoming widened over time, developing little arterioles, or the skin getting too thin? What laser should I plan for post-surgery?
A: Based on your question, I would need to have a better idea as to the type of external rhinoplasty you would be having. Will this involve rasping of the bridge or will it require osteotomies as well? Either way, however, I would not perform a scar revision directly over the nasal skin that is being raised during the rhinoplasty. This is not a blood supply concern but one of scar healing. The swelling of the nasal tissues after a rhinoplasty will work directly against having a good scar result. You would be much better to delay the scar revision to after the rhinoplasty, preferably 3 to 6 months later. Scar revision on raised rhinoplasty skin is not a good simultaneous idea if you want the best scar result.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a depressed cheek scar above my nasolabial fold from a previous skin cancer removal using a Moh’s technique. If you inject fat do you utilize the Coleman technique with micro droplets to ensure the tissue becomes a graft and not just a temporary filler? Anyhow, I do not like the dynamic feature when I move the facial muscle as well as when the sight catches the groove of the scar. I have attached some pictures showing the scar. Thank you for your time.
A: Thank you for sending your pictures. I did not realize how young you were given that you have had Moh’s. It is actually a reasonable result in a difficult aesthetic area. The only modification I would make to my previous statement is that I would perform a geometric scar revision at the same time as microdroplet fat injections underneath. Even though the scar is well placed and has about as much narrowness as could be hoped for, there is always going to be a ‘groove effect’. That is just an unavoidable phenomenon in linear scar in that area. The scar line may need to changed from a pure straight line to get a better scar effect. Options include either fat injections with concurrent laser resurfacing (#1) or fat injections with a concurrent geometric broken line scar revision. (GBLSR) The conservative approach would be # 1 as GBLSR can always be done later based on the scar outcome. The more aggressive approach would be #2.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I went to see a maxillofacial surgeon to get jaw reduction (my jaw is too square and X rays show that my angles do stick out). He told me that he needed to do a small resection of the angles (osteotomy) because my angles were too square to burr them. and with the burring technique, only 2 or 3mm could be burred which would barely show. Is it possible to round off the angles with the osteotomy technique? or will it be a straight cut leaving the angles straight looking cut and unnatural? is it possible to preserve some angles with that technique? Also, what really surprised me is that he said that since the bone is so far and hard to get to due to the muscles, he might need to put some screws; I did not understand why. I thought that screws were used to put bones back into a new position; which would not be the case with angles osteotomy? I am confused. Thank you for your answers.
A: I can only speak for what I do, I can not explain what your surgeon said or their technique. When you cut off the angles, no matter how small, there will be a rounding effect created. Burring in the jaw angle area can be difficult because of the surgical access. Therefore, I choose to use a reciprocating saw and perform an outer table ostectomy, which thins the bone but preserves most of the angle’s shape. I have never used screws for this technique nor can I envision why they would be needed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a Moh’s surgery on my right cheek Dec. 27th 2012. I am unhappy about the indentation on the mid to lower half of the scar especially when I speak. I have photos I can send. Would like to know if you think I would need a revision, subcision, or laser, or this will subside in the months. Also, if revised, do you agree with the theory of lasering 4 to 8wks after sutures are removed to reconfigure the modeling of the tissues resulting in superior results, rather than waiting the full year of the old theory. I am not interested in temporary fillers.
A: I am assuming that you had a primary closure of your original Moh’s defect. The reason you have an indentation is that there is tissue missing over a dynamic area. As such, no amount of release or scar revision is going to improve its appearance. This is a tissue loss problem and releasing underneath or cutting out the scar/indentation from above does not address the biology of why it is there. I would take a reverse approach to conventional wisdom by doing fat injections under the indented area. This will provide both a release and adds volume at the same time. While fat may be unpredictable in survival, this natural form of tissue volume expansion better addresses the cause of the problem. This would be more effective done early in the healing process (months) rather than later. (year or longer) The overlying scar in the face of underlying tissue expansion should wait for further healing.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, three weeks ago I underwent surgery for brachioplasty on my arms. As the tape was coming off the incision looked great. There was no redness, it was perfect. As more of the tape started falling of I noticed that on the surface of a section of my incision, an opening, or blister, was forming. I was told to gently remove the rest of the tape down my arms. Now instead of seeing my original clean incision, I have a few blisters with a bit of pus along the incision line, and it is now read and bleeding slightly in some areas. Is this normal? I stopped wearing my compression shirt as were my doctors orders, but he said if it were to start swelling again to put it back on so I did. Does all of this sound normal?
A: There is a natural evolution of incisional healing that understandably confuses most patients as it relates to body contouring surgery. All incisions look fantastic the first 10 days or so after surgery because the wounds have not started to really heal yet and the normal inflammatory process has not set in. Then the incision line begins to look worse…gets red and inflamed in some areas and make even have a few sutures that work their way through the skin. This process will continue for up to about 8 weeks after surgery when the incision line is finally healed and the inflammatory process has subsided. What you are observing is perfectly normal and armlifts are one body area where this process can often be more exaggerated due to the thinness of the arm skin.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I have some questions about jaw angle implant surgery.
1) If I have a jaw implant surgery, do you custom make the jaw implant for my specific jaw? Is custom making an abnormal activity for jaw augmentation practitioners or something that is done with regularity at most clinics?
2. Which material do you normally use as implant and from which brand? Why do you do this type or these types of implants?
3. What are the best/worst properties with these type of implants?
4. Approx. how many jaw implants have you done in 2012 and 2013 and what are the total number of jaw implants you have done?
5. If you were to say a number of the total people that have underwent jaw implant surgery, how many have come back of the total number and been displeased with the result?
6. What were they not happy about? and what do you do in such an situation?
A: In answer to your questions:
1) I would need to see photos of your face to make an assessment of whether you need standard or custom jaw angle implants. It has been awhile since I have seen your pictures. Regardless, using custom jaw angle implants is done by a very few surgeons in the world.
2) Depending upon what dimensional changes need to be done, the implants could be made from either silicone (widening the jaw angle only) or Medpor if vertical lengthening of the jaw angle is needed.
3) I do dozens of cases of standard and custom jaw angle implants every year.
4) To you on the outside, the different materials of the implants are irrelevant. Your current choices of jaw angle implants is based on what dimensional changes you need so you really don’t have much choice when it comes to vertical lengthening jaw angle implants because only one manufacturer (Medpor) makes them.
5) The revision rate of jaw angle implants is not insignificant and averages around 20%. This is the hardest facial implant to surgically place.
6) Asymmetry is the biggest reason for revision of jaw angle implants. In some cases, the result may be too much or too little for their aesthetic liking.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have further questions in regards to Temporalis reduction please. The area I want reduced is around squama temporal and the parietal area near the temporal line. In anatomical images, the temporalis muscle shows up white in that region, so is there very little muscle mass there? Will Temporalis muscle show up on CT scans? Also, would the surgery involve having to sever my temporal arteries? If so, will there be side-effects later in life? As temporal concavity is dependent on muscle mass, is that why elderly people appear to have narrower temples due to muscle degeneration? If so, will temporalis reduction increase wrinkles around that area and make me look older? I know you said it won’t affect mastication processes, but would it impede speech and pronunciation, since it involves jaw movement too? Will temporal muscle reduction make me unable to play soccer or tennis for the rest of my life?
A: To answer your further questions on temporalis muscle reduction:
1) The muscle is thinner near the anterior temporal line.
2) The muscle will show up on a CT scan.
3) The superficial temporal artery is not cut during muscle reduction.
4) The fullness of the temporal region is prinicpally controlled by muscle mass and an underlying extension of the buccal fat pad. As people age the fat resorbs and the area becomes more concave. The temporalis muscle does not really atrophy with age.
5) Temporal muscle reduction will not affect chewing or speech.
6) I see no physical restriction after such surgeries for either tennis or soccer.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have had multiple jaw implants that have left me with an unsatisfactory result. My jaw is naturally asymmetrical so it was hard for the surgeon to match left side to right side I suppose. He tried to fix the asymmetry by shaving down the implants, then another surgery to add implant on the right side which just made it bumpy and stuff. I think I just need to start over with newly designed implants. In addition I also want a reverse sliding genioplasty, my chin sticks out too far and looks unnatural. I can get a 3D print of my skull and a physical 3D exact model from a computer, so that new implants can be made to make my face sides perfectly symmetrical. I have attached a video which described in detail exactly what I don’t like about my jaw result.
A: I have seen your video and your problem is one I have seen many times. I can make the following comments:
1) Jaw angle implant asymmetry is not uncommon and is a result, most of the time, from different placements on the jaw angle rather than some inherent bony asymmetry. Bony asymmetry does not help but it is actually very difficult to get perfect symmetry (alignment of flare) between two jaw angle implants.
2) The problem you have on our left side is that the two implants (chin and jaw angle) do not meet, thus leaving a depression or lack of smoothness between the two. That, again, is reflective of the asymmetrical placement of the jaw angle implant on the left which is further back and higher than the right one. Note that your right side is smooth probably due to the better position of the right jaw angle implant.
3) Correcting jaw angle asymmetry, in my experience, rarely works by just shaving down the implants while they are in place. The implant almost always has to be removed, modified if necessary and then reinserted in a better position. Modifying it while in the patient is treating implant malposition by adjusting the shape or thickness of the implant, potentially worsening the problem or at the least ending up no better for the efforts.
4) You are correct in now assuming that the best approach to the problem is to get a 3D model of your jaw, see exactly where the implants are and make new implants if needed.
5) As for your chin, I do not have the advantage of knowing what you looked like before. But your chin result is not particularly abnormal or unexpected. It may be more projection than you want but many chin implants when placed on a smaller chin will end up with that result. It may look like it is sticking out and the labiomental sulcus will deepen. Medpor chin implants are thicker and more bulky than other materials and this may also be part of the aesthetic problem. You may simply benefit from a smaller projecting chin implant design.
In conclusion, making a completely symmetric 3-piece chin and angle jawline enhancement is not as easy as it looks on a skeletal model and you, unfortunately, are reflective of some of the problems which can occur. But your next step of getting a 3D analysis of what you have and why it looks that way is the only effective way to move forward.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I was wondering if when I got a breast lift plus augmentation if I can get the scar around only the areola. Who is the best candidate for it? I have doubleDD breast size and a lot if sagging since having my son who is almost a year. And I am 19. Thanks so much!!!
A: Having DD size breasts suggests that you definitely do not need an implant but a significant breast lift. A periareolar type breast lift only provides a very limited lifting effect and is almost used exclusively in the small sagging breast when the effect of the implants helps considerably in filling out the loose breast skin and providing a lifting effect of its own. As a stand alone procedure a periareolar breast lift, also known as a donut mastopexy, does not create a significant breast lift. By your description you are in need of a full breast lift that involves a horizontal and vertical tightening and creates the classic anchor scar pattern. While every woman would like a breast lift with limited scarring, that does not appear to be an option in your case.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I had a serious head injury in 1994 that left me with a skull indentation on the right side of my upper forehead and it looks like I still have swelling in the temporal area. Would it be possible to flatten that temporal area and fill in the dent in my forehead to make my face symmetrical?
A: At this point nearly 20 years after your injury, I can assure you that the bulge or fullness in the temporal area is not swelling. It is either a perception of a bulge due to the forehead indentation or an alteration (uprising) of the temporal bone as the forehead area became indented. Regardless, I am certain both areas are improveable at the same time. I would need to see some pictures to get an idea of the magnitude of the problem and see exactly what needs to be done. The forehead indentation can be filled in with bone cement (frontal cranioplasty) to match the other side as best as possible and the temporal bone or muscle can also be reduced if needed.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I am having a facelift two weeks from today and want things to go as well as they can. I have read about taking arnica and bromelain supplements to speed healing and make my recovery quicker. Would these be good to take before surgery?
A: These are common non-pharmaceutical supplements for healing that some plastic surgeons endorse and prescribe for surgery including facelift surgery. Arnica is a well-known extract of the mountain lily flower that has been used for decades to prevent or clear bruising related to any form of trauma. Taken one week before and one week after surgery, it helps prevent some of the bruising that will occur as well as speeds its resolution after surgery. Arnica is most commonly used as an oral tablet but can also be applied directly to the bruised site as a topical ointment. Bromelain is an extract in oral or liquid form from the pineapple fruit that has anti-inflammatory properties. It is commonly used for sports injury, trauma and surgery to decrease swelling. Contrary to popular belief, eating pineapple will not increase your levels of bromelain as it exists mainly in the stem of the fruit. My feeling on both supplements is that they do no harm, are relatively inexpensive, and may provide some recovery benefit so I do advise my patients to take them particularly for any facial surgery.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I am a 32 Chinese female who is interested in cheekbone reduction. More specifically, I find that my left zygomatic arch sticks out more than my right, so I want to reduce by a little bit to balance out my face. Can I you send you pictures to see if I am a good candidate for this procedure?
Also I have a couple of questions:
1) I am very worried of sagging of the soft cheek tissue, what is the risk of this and what type of procedure is done to avoid this.
2) Is this surgery common at your office? How much experience do you have doing cheekbone reduction?
3) Will is be possible to see pictures of your previous patients that have undergone cheekbone reduction at your office?
4) Since I am an out of town patient, how long will I have to stay in town for this procedure?
I have been contemplating this surgery for a very long time and I am very keen to do it.
Thank you for taking the time to answer my questions.
A: Thank you for your inquiry. Please send me some pictures of your face for my assessment. Cheek osteotomy reduction, specifically that of the zygomatic arch, is done by a combined anterior zygomatic osteotomy (from inside the mouth) and a posterior zygomatic arch osteotomy where it attaches to the temporal bone. (from a small temporal scalp incision) In answer to your questions:
1) Soft tissue sagging is not a concern with this type of cheek osteotomy because the soft tissues are not detached from the arc bone during the procedure. They simply move inward with the medial movement of the zygomatic arch.
2) This is a common aesthetic craniofacial procedure in my practice. It is done almost exclusively for Asian patients.
3) Out of respect for patient privacy and their confidentiality, we do not send out patient photographs to prospective patients.
4) This is a type of facial osteotomy procedure in which you could return home within 48 hours after surgery.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I have a facial scar below my left cheek that I want revised by a geometric broken closure. One question I have is that I had Silikon 1000 injected under the scar to try and raise it several years ago. The material has migrated around the scar making the scar look even more indented as the surrounded tissue is raised. So I know the scar I have is around 2.2cm but I’m not sure how wide it is including the surrounding skin. Would you be able to remove the Silikon 1000 filler or at least the raised skin around the scar? If so could you still do geometric broken line excision or would you have to do a straight line scar. I REALLY want to get rid of this Silikon 1000 but not if it leaves me looking like one side of my face is way thinner or not symmetrical to the other side. What would be your advice with this? Warm regards.
A: Once silicone oil droplets are in the tissues there is no way to get it out unless it is part of the actual scar revision. I would treat the fact that there is silicone in the tissues as irrelevant. It would not change how I would do the scar revision or the amount of tissue removed. Trying to go beyond the actual scar borders in an effort to achieve the ancillary goal of silicone material excision is fraught with causing additional scar problems. It is best to treat the scar as if it was not there.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, You suggested 10mm of vertical projection for both my jaw and chin. However, when I measured my face with a ruler, I determined that in order to achieve the 1/3 1/3 1/3 ratio, I would need between 15-20mm vertical lengthening. I am hoping we can design a chin implant that has close to 15mm of vertical length. In my experience am more worried about undershooting than overshooting. Is a 15mm vertical chin possible? If so, does it carry increased risk?
2) Can we use computer imaging to figure out the ideal dimensions? My left jaw projects significantly more than my right jaw.
3) With a custom 3-piece chin + jaw set that includes both vertical and horizontal projection, will there be a smooth transition in the space between the chin and jaw(body)
4) In terms of safety, what is the difference between my current Medpor implants and silicone? I heard that silicone breast implants may rupture.
5) Can silicone be flexibly shaped to my jaw contour using hot sterile saline the way Medpor can? And if so, would that mean that the easiest approach is to use a previous patient’s custom implants, and skip the CT scan?
6) How much vertical lengthening do my 7mm Mandibular Matrix jaw and chin implants already have? I can’t find the vertical jaw dimension online.
7) Since my current Medpor implants have been screwed in, how will you remove them? Do you “unscrew” them? I believe there are two screws anchoring each one of the pieces.
8) How many custom combined jaw+chin procedures have you done in the past? Are you the only one who does this?
A: In answer to your questions:
1) The vertical length of the jaw angles can be lengthened in the range of 15 to 20mms. The chin can not be done as much because of the lack of adequate soft tissue to recruit for coverage. A more realistic lengthening in 8 to 10 mms.
2) 2) Computer imaging is great to provide a general concept or trend but it would not be an accurate way to determine the desired millimeters of change. Unless the picture is taken so that the computer recognizes its size, it can not be used for estimating exact changes.
3) One of the main purposes of a custom 3-piece jawline implant system is to have a smooth transition between the chin and the jaw angles.
4) There is no danger is using silicone as a
facial implant material. It is a solid material unlike silicone breast implants. I ma not sure where you would get the concept that a silicone facial implant would rupture.
5) Silicone always adapts better to the bone than medpor. Medpor is a very stiff material that is minimally adaptable using ‘hot water’. This is not necessary with a silicone material.
6) It is impossible for me to say how much vertical lengthening your current implants provide since that is highly influenced by how they were placed in addition to their design.
7) Your current implants have to be unscrewed…that is the easy part in trying to remove them.
8) I have been making custom facial implants for 20 years. I can’t speak for who else may use this approach around the world.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I have wide temporal areas between the sides of my eyes and my hairline that I want reduced. Is the temporalis muscle the reason why some people have bulged temples that are wider than their cheekbones, and some with troughed temples as wide as, or narrower than their cheekbones? Or has it also got something to do with the cranium itself? Is this feature genetic at all? My mother has troughed temples that are slightly narrower than her cheekbones, and my dad has bulged temples wider than his cheekbones. So have I carried my father’s genes for that particular feature? Thank you.
A: The shape of the temporal region, whether it is a convexity or a concavity, is largely controlled by the thickness of the temporalis muscle mass, not bone. Only very rarely, in cases of a temporal bone tumor, is a temporal convexity driven by the size of the bone. This feature appears to be completely genetically derived.
Dr. Barry Eppley
Indianapolis,Indiana