Your Questions
Your Questions
Q: Dr. Eppley, I am asking you to ask about your experience with midface Medpor implants. How often do you use them, especially in men and is this your preferred material to work with? Do you have much experience in customizing the standard implants offered by the company that produces them?
I was wondering if you could take a minute or two and look at the pictures I’ve attached.
The first picture is of someone else that shows the area I’m trying to augment. This is not the malar or submalar area as such, but rather the cheekbone area high and laterally – my goal is augmenting laterally as much as possible along the zygomatic arch. The cheeks in attractive men are almost always perfectly flat or even hollow, as is the case with most/all fashion models.
The second picture is of me – I apologize for the low quality. I saw a plastic surgeon locally who said that I’m exactly the opposite of the man in the first picture. The area I marked in green is my main problem. This area (please notice the same at the opposite cheek) is very, very prominent, bulging, and very not-masculine, worsening the problem with my under-eye hollows and nasolabial folds. Someone recommended buccal fat removal, however, I don’t think this is at all right for me, as buccal fat will remove the area I marked in red, and that has little if any overlap with the problematic area on my face. Am I right in this? Or is there a way to remove the fat from the marked green area? I thought the best solution for me, instead of removing anything, would be building the upper-mid face, as I discussed above using the example of the man in the picture I’ve attached. I marked that area in black in my picture. This particular area looks depressed on my face (as you can see on the opposite, unmarked cheek), and the prominence of that diagonal strip on the cheeks (the green area) makes it much worse. Most people think i’m older than I actually am and I look tired all the time. Another surgeon suggested some sort of mid-face vertical lift, but I don’t think there is any effective way to do this. Most techniques result in short-term results and awfully lot of swelling for months.
So, I concluded my best option is building that area marked in black with medpor implants. This would balance the prominent bulging cheeks. I attach here their catalogue (please see pdf file). On page 6, I noticed the “extended malar shape” type that the company says extends laterally along the zygomatic arch. I think it also captures the infraorbital rim area, if I’m not mistaken, and I could really benefit from it, as the existing hollows under my eyes are also a problem.
If I could please ask you: Having seen my picture, would you say this implant is the right for me, or would there be a better type? As it is extremely important for me that the implant does not add to the problematic, already prominent diagonal stripe in the submalar area of my face (marked in green), can this part be cut off from the standard implant? Or will there be no need for that? I can’t judge at all how much vertically the implant drops, but the part below the infraorbital rim is where the bulk of it is. The more vertically it drops, the worse would the outcome be for me, because it will make the cheeks even more bulging.
I find it hard to believe that there aren’t any standard mid-face implants on the market that would cater to the needs of men. Even in this “extended” type, the extended part looks thin and stops prematurely, while the remaining malar part is quite bulky. I would probably have to go for the largest size and cut off much of the unwanted part to benefit the best. For illustration, I’ve attached here some pictures of models – in any beautiful male face the cheeks are always perfectly flat (most of malar and definitely submalar parts) and even hollow (the exact opposite of what 90% of the malar and submalar implant do!!!), but the cheekbones are high and the whole area is always built naturally well laterally along the zygomatic arch, all the way to the temporal process.
Yet another surgeon recommended the use of hydroxyappatite instead of implants to build the area of the face I’m interested in augmenting. However, I don’t think HA can achieve that much as implants can and I wonder if it does give so much flexibility and is safe, why more surgeon are not using it?
A: To answer your questions succinctly:
1) I use both silicone and Medpor facial extensively and have a lot of experience with both of them. I have no preferred fondness for either material as the body does not care what is implanted…it treats them all the same from a biologic response standpoint. I choose the implant material based on which one offers the best shape and size for what I am trying to achieve for the patient. In many cases the implants have to be modified during surgery to create the desired shape. In other cases, I make the implants before surgery (true custom designed implants) based on modifying existing implant styles or design my own shapes for a specific patient.
2) You are correct in that there is no current facial implant style, regardless of the manufacturer, that is designed to create the effect you are after. This will require a modified malar implant design to achieve.
3) The Medpor extended malar implant is the closest preformed shape but there is way too much material in the submalar area.
4) Hydroxyapatite granules are never going to create the look you are after as they will be flattened by the pressure of the overlying cheek tissues.
5) The cost of your malar implant surgery would be influenced by the material you want it composed (Medpor vs silicone) and how you want it prepared (intraoperative modification or custom premade).
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting jaw angle implants placed from the outside as opposed from inside the mouth. What is the size and length of incision if we went through outside? Are the scars predominately visible or dark? If I choose to go with the external incisions, would they be near the facial nerves and would the nerves be subject to damage? Can you direct me to before and after photos of your work with jaw angle implants please? And even better, any example photos that show what the external incision scar would look like.
A: If one was to place jaw angle implants through an external approach, the location of the incision would be in the classic Risdon location. This is the incisional approach through the neck to repair fractures of the mandibular angle which has been used for over fifty years. This classic mandibular angle incision is located two finger-breadths or about 3 cms. below the jaw angles in a horizontal neck skin crease. It’s length is also about 3 to 3.5 cms. It is placed in this location because that places it below the path of the marginal mandibular branch of the facial nerve which controls the depressor action of the lower lip. If well placed and executed the scar is very acceptable…although never as scarless as an intraoral approach.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, Many months ago, you responded via Real Self regarding my botched gull wing lip advancement. The plastic surgeon also did a v-y advancement under the cupid’s bow. It has ruined my cupid’s bow and my lips have taken on a very flat appearance. I’ve been to 3 plastic surgeons for consults and each one has told me that there is nothing that can be done to correct my problems. You had mentioned on Real Self that you could remove tissue (not skin) to give me a cupid’s bow which would also help with the flat look that I now have. Would you be so kind as to explain exactly what this tissue removal involves. I am somewhat concerned about more scarring. As of now I have scars (small) where the current cupid’s bow is. If you change the cupid’s bow to a more pleasant look, wouldn’t I have additional scars. I just hope that you can explain the procedure a bit more and inform me about any additional scarring. I have attached recent photos which are 6 months after the initial gull wing lip advancement. Thank you so much, and I look forward to hearing from you.
A: What you have, as you know, is a flat or absent cupid’s bow of the upper lip. This is due to a lack of an indentation or greater vertical skin between the normal peaks of the cupid’s bow. To create this normal feature of the cupid’s bow, a few millimeters of vermilion in a curved fashion needs to be removed between the height of the cupid’s bow. You already have a scar line at the skin-vermilion junction so the risk of more visible scarring is very low. How much the prolabial skin will stretch down is uncertain but this is the only lip revision treatment option.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have long been looking to improve my jawline and it seems, based upon my research, that you and your staff are a great fit for what I want to do! I have yet to find another doctor who has a lot of experience with jawline improvements. I am a 30-year-old male with a somewhat feminine/steep jawline. I am looking to improve it from both the front and the profile with a more masculine look. I have read your articles and am looking to get a consultation to get the ball rolling and want to inquire as to what my next step is. I have attached pictures of myself as well as pictures of the jawline I am looking for. As you can see from my profile, my jaw angles are steep and feminine. I am looking to get my jaw angles as square as possible, like the pictures I have attached after my own. Furthermore, my front view could use a bit of width on the mandible to provide a more masculine look; I guess a widening starting from the back of the jaw. In addition, my left-side jaw angle is better than on my right side, so I am sure that would slightly alter what you do with each side. You will be able to clearly see what I am looking for after viewing the pictures that come after my own. I will leave it up to you to determine if this look is possible for me.
A: Thank you for sending your pictures. My comments are as follows:
1) I believe you would get good improvement with off-the-shelf jaw angle implants that add about 10mms of vertical length and 7mms of width.
- Jaw angle asymmetry is common and it is virtually impossible using standard jaw angle implants to ever get perfect symmetry. There are too many variables involved and modifying one side over the the during surgery is just guessing about what to do and rarely creates much better symmetry. Custom-designed implants are the best option when significant asymmetry exists. But that adds considerable expense to the operation which your degree of asymmetry does not justify in my opinion.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am 37 yrs old and I have some wrinkles under and around my eyes I would like to get rid of and not sure if I should just do Botox or try and have surgery to remove them. I have attached some pictures for your review.
A: There are basically three treatments for aging eye issues, Botox, blepharoplasty surgery and skin resurfacing. (chemical peels vs. lasers) Botox is the only treatment for wrinkles that occur OUTSIDE of the eyelid area. (e.g. crow’s feet area) Blepharoplasty (eyelid) surgery is the only treatment that can remove excess skin and fat of or ON the eyelids. Skin resurfacing using either chemical peels or fractional laser resurfacing can be used for fine wrinkles ON and OUTSIDE of the eyelids. Given the nature of aging around the eyes, many people need a combination of these approaches to get the best result…not to mention the need for maintenance therapies such as Botox injections, topical skin creams and the avoidance of smoking and extreme sun exposure.
What I see in your pictures is hooding of upper eyelid skin and a roll of skin underneath the lashline of the lower eyelid. These are definitely surgical (blepharoplasty) issues. I suspect there is wrinkling beyond these areas but the quality of the pictures does not permit that assessment. These pictures are also only smiling which creates animated rolls of skin on the lower eyelid which may or may not be present when not smiling.
The short story is that you are likely in need of surgery for major improvement but I would not use the term ‘remove’ when it comes to eyelid aging changes as that is not realistic. You need to think improvement of them that is not going to be a permanent cure to them.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a flat back of the head that I think makes me look odd and I want to build it out. I have attached pictures from the side of my back of the head profile. How can this head change be done?
A: Thank you for sending your pictures and illustrating your desired back of the head change. Based on your goals and drawings, the first thing I would point out is that the skull bone actually stops at just about the level of the top of the ear, an area much higher than most people realize. Therefore, no type of skull bone augmentation can go that low. The lower half of your desired expanded area are the soft tissue of the neck not bone. Secondly, as a man who shaves his head any incision to do skull augmentation is a very treacherous aesthetic trade-off and I would not recommend it for most men. The only option I would consider would be fat injections to build up the back of the head. But the problem with fat injections is whether you nave enough fat to harvest to do the procedure and the unpredictability of how much would survive and how smooth it would be. But this is the safest aesthetic option with very little downside.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Can the silicone implants be inserted through an armpit incision? I’m looking into getting implants. Im 30 years old and have had 3 kids. I use to be a full C now I’m barely a B. I know by research that knowing what one to go with or how big to get the look I want is impossible via email but could you send me as much information as you could. Maybe a price range I would be looking at before I get my hopes up on finally getting it done. Thanks in advance.
A: Silicone implants can be placed through the armpit up to a certain size, usually in the maximum range of 400cc to 500ccs based on my experience. Beyond that size they need to be placed through an inframammary fold incision. Having had three children a very important consideration is if you have any significant breast sagging. If you do you may not be able to get by with just implants alone. I would have to see pictures of your breasts to better answer that question. One can anticipate the total cost of silicone breast implants to be in the $5,000 range.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I incurred a closed depressed skull fracture from a head-butt when I was 22. I am now 28. The depression in my skull has bothered me emotionally since it happened and I have some physical pain too (I feel like there is constant pressure on the area). When I participate in rigorous physical activity (such as running) I get severe head aches. I hope to get surgery to elevate the depression and was interested to know more about possible procedures.
A: If you are having symptoms of headaches and pain from your depressed skull fracture, the first thing you need to do is to consult a neurosurgeon to be certain that there is no undue pressure on the brain. While I would doubt that is the case after this many years, it would be an important first step to do. That is the only reason that the skull fracture would be elevated and that will require an open craniotomy to accomplish. If your neurosurgical work-up is negative then the depressed skull area can be treated for its cosmetic appearance by an onlay cranioplasty to build up the outside of the bone. A skull fracture is not elevated by craniotomy for a cosmetic change only.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I would like my chin made shorter, smaller, more even and to have fat removed from the chin where a plastic surgeon mistakenly added fat in my chin. I have outlined the fat I want removed in one picture. I also have sort of a balled chin and I believe it is weird and uneven in many ways including a minor balling problem. I want a normal, nondescript chin, as much as possible without putting in another chin implant. You can see that my chin is too long, uneven and overly prominent. In one picture I outlined in brown pencil where another plastic surgeon mistakenly injected fat. I would like to have this fat removed if possible. In another picture you can see my overly long chin in profile. In the last picture you can see me pinching the extra skin that resulted from 3 chin implants that were placed and later removed.
A: Thank you for sending your pictures. You will need a significant reduction of some bone and soft tissue to effect a visible chin change. You do not need an implant but a reduction in tissue volume that is best done from a submental chin reduction approach. The chin bone needs to vertically reduced, transversely reshaped and a large wedge of overlying soft tissue removed as well. The fat that was injected was placed in the labiomental fold area, a difficult if not impossible area to remove. Small cannula liposuction can be done but its effectiveness is uncertain.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I had liposuction done to my calfs out of state. My calves look great and I am happy with results but I’m not happy with the indented scars that are left. Three of the eight incisions are indented. The incisions were left open to drain and were not stitched up. I understand some docs do this and some don’t. I guess it’s a preference thing. They are very small incisions but I still do not like that they are indented. Because of the location on my calves, they show a lot. I feel like everyone will now know what I had done. I can’t enjoy the results because of this. I feel like I would have been better off if they were stitched up and became keloid scars this way I could flatten them with scar strips like I have done in the past. Even with scar revision, I know they will not go away completely. I am realistic about this but as indented as they are, they will attract more attention. I have had liposuction in the past on other body parts and the incisions were sutured up and now you cannot even see the scars. So I do have experience with this. That is what I was hoping for these too. Now there is nothing I can do to pull them out. I have included pictures. I would like to discuss what method you would use to pull them out or even cut out the scar and resuture. I heard some doctors make another incision and then loosen the connective tissue (with a needle) that is pulling it down and then suture it up. This is what I would be interested in. What would you charge per indentation? If this is something that you are comfortable doing or have experience with, please have your assistant contact me.
A: Indented scars from liposuction are common on the calfs if they are not sutured closed because the skin is so naturally tight and thick. This is particularly true on the back of the calfs. The best approach would be to a simple scar revision by excision, release the indentations by needle (subcision) and then reclose them. This would be a fairly simple procedure done in the office under local anesthesia.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, My forehead it’s very high and it also sticks out, I feel it takes the beauty away from my face. Is there a surgery to fix it and if there is I would like to know if it is too risky?
A: The high protruding forehead is usually due to a combination of a hairline that is set back too far and the forehead bone having some degree of protrusion to it as well. It can be treated through a combination hairline lowering (scalp advancement) and burring bone reduction of the upper forehead bone. This procedure is very safe and has no significant risks to it…other than a fine line scar along the frontal hairline. Whether you would be a good candidate for this procedure would depend on how much laxity is in your scalp and the pattern and hair density of your frontal hairline. A review of any pictures of your face/forehead from the front and side view would be very helpful in determining if you are a good candidate for this forehead reduction procedure.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, My daughter had craniosynostosis. After which she was left with plagiocephaly(right side). Was wondering what are the best options for her, she has 5mm deformity after wearing the helmet for 1 year. Now she is 9 years old. Need to know if the surgery can be done anytime or there is a certain period that is beneficial for the kids.
A: Once the skull has undergone much of its growth spurt and it is clear that ongoing growth is not improving the asymmetry, it is reasonable to consider an onlay skull augmentation. The decision to do so is based on an aesthetic judgment since there are no neurologic benefits to doing it. So the question is not whether it can be done but whether it should it be done. At 9 years of age, that is a decision for the parents to consider or to allow the child to decide for herself when she is old enough to do so.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I am 28 year old female.When I was12 whenever I opened my mouth very wide the left side of my face clicked under my ear. Therefter it became more painful to open and I had great difficulty in eating chewy foods. By the time I was 18 my face looked obviously asymmetric. My jaw is not properly aligned. I have been to an orthodontist and was told that I would need corrective jaw surgery which I can not afford and he also said it may not necessarily make my face look straight even if my jaws were better aligned. What can I do to straighten out my face?
A: Your face is significantly asymmetric due to an underdeveloped left side. That extends from the cheek bone down to the jawline with a significant left chin deviation.Your non-major orthognathic surgery options include a combined procedure by repositioning the chin bone (opening wedge genioplasty), a left cheek implant and fat injections to the left side of the face. These three procedures will help fill out the left side of the face and straighten it by aligning the chin with the midline of the face.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Hi, I currently have mandibular implants, off the shelf from Implantech. I am unhappy with the off the shelf size and contours and have decided I need custom implants to reach the desired look. My question is can the implants be placed from and outside incision, rather than intra-orally? My current implants were placed from inside of my mouth and that was the WORSE part of the surgery. Not being able to open my mouth for 3 weeks = not eating for 3 weeks. Plus the pain on the inside was very bad. I believe by placing the custom implants from the outside incision would be much more generous when it comes to pain and downtime. Is this possible, opposed to intra-orally placing the implants? Any feedback would be greatly appreciated.
A: Jaw angle implants can certainly be placed from external skin incisions although in an aesthetic facial operation it is hard to imagine that the resultant neck scars might not be a concern. You should know that any replacement of your existing implants would likely be easier the second time around since the pocket under the muscle has already been partially created. Also, what is done on the side or below the jaw bone is the same whether one comes from inside the mouth or below in the neck (jaw opening restriction), the incisional approach is just a means to get there to do it.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I’m considering cheek implants to address the following problem. I have a wide round face with a flat midface and I want to avoid implants that make my face look wider or rounder. Should I go for malars without edges (so ones that only address the cheekbone) what part of the cheek contributes the most at creating forward projection? My main goal is to achieve a less wide face with more projection. Thank you so much!
A: When it comes to increasing midface projection without making the face wider, all implants have to remain inside of a vertical line drawn down from outside of the lateral orbital rim. This means the options of using orbital rim implants with small malar extensions relegated to the anterior cheekbone surface, paranasal, and premaxillary implants. These are the implants that can increase midfacial projection without creating width.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, Hi, I have a weird shaped head where the back of my head really sticks out so it looks long from a side view. Are there any implants that can be inserted to give it a more rounded normal shape or can the skull be reduced slightly at the back. Thanks.
A: Some reduction of an occipital skull prominence can be done which is usually about 7mms. The bone above the prominence can also be augmented to make the top part more round as it goes into the top of the skull and beyond. If done together this will create a better skull reshaping of the back of the head than either procedure done alone.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, There is no much information out there on paranasal implants. You are such treasure trove of knowledge so I will ask you this question. Someone on realself asked me whether my paranasal implants were uncomfortable, and I told her that they aren’t. This got me wondering, what exactly is the difference between a paranasal and premaxillary implant? Is the reason why my paranasal implants feel comfortable because they don’t sit on the nasal base?
A: Paranasal implants sit on the side of the nose under the nostrils along the side of the bony pyriform apertures. A premaxillary implant goes across the base of the nose under the columella and below the bony anterior nasal spine. In some cases a premaxillary implant can include the paranasal area as well or can be limited to just under the anterior nasal spine area. If properly placed at the bone level and not oversized, a premaxillary implant should be no more uncomfortable than paranasal implants. Premaxillary implants are placed by some surgeons through the nose into the soft tissues above the bone, potentially creating abnormal fullness and stiffness of the upper lip when smiling. This is not my recommended tissue location for a premaxillary implant.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, In reading about gynecomastia surgery, there seems to be an issue about the doctor removing too much tissue thus developing a “crater” look to the chest with fat pockets under the breast. How does the doctor address this?
A: The best way to avoid that problem to be aware of it and not create it. When deciding how much breast tissue to remove in an open gynecomastia operation, it is a matter of pure judgment. There is no scientific way to really know how it will look until it heals based on how much tissue is removed. Because an open procedure has the potential to remove more of the breast tissue in a central position (under the nipple) than around the perimeter, it is important to not over resect (remove too much) from this area.Since solving the gynecomastia crater deformity is more challenging than having to take more should a revision be needed, it is always better to use caution rather than indiscriminate aggression in gynecomastia reduction.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, for my chin and jaw angle implant surgery I have couple of questions. I had originally mentioned the idea of some liposuction below the Jaw line/ chin and wanted to see if you thought that was still an option( especially if it could be done through the chin implant incision.) Finally, any ideas of a realistic downtime from work? Would 3 weeks be enough to be off work and able to go back without looking extremely swollen? Also can the surgery be done under IV/ twilight sedation? Thanks again for your time. Thanks again
A: In answer to your questions:
1) Submental liposuction can certainly be done at the same time with access through the same incision as that of the chin implant.
2) The vast majority of the swelling from this type of surgery is from the jaw angles and you are correct to assume that 2 to 3 weeks is enough time for you to look normal, even though the final details of the result will take months to fully emerge.
3) This is not a procedure that is done under sedation anesthesia. Lifting the large masseter muscles off of the mandible is less than a pleasant experience to place the jaw angle implants. This is a procedure that requires general anesthesia to be done correctly.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, Thank you for your follow up on my questions about reshaping the top of my skull.. I realize that you are a surgeon in high demand and you taking the time to follow up is very impressive and kind. The cost is fair given the amount of work that needs to be done. The 10″ incision is my only concern. How large would the incision need to be if we simply build up the uneven side and leave the bump untouched. What would the cost be if we went this alternative route?
A: Understandably a long incision in your scalp is a concern, even to me given your young age and for the correction of only an aesthetic skull shape concern. But the same length of the incision is needed whether one merely reduces the high midline sagittal ridge or does a concomitant build along the side of it. The reason it needs to be of that length is that the hardest part of the skull reshaping procedure is getting the implanted material to have feather edges and blend into the surrounding skull smoothly and without a visible or palpable edge to it.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, First, do you have a web site I can look at? And second, knowing you do not have a crystal ball, how long can the average person anticipate a traditional breast lift to last? Thank you.
A: All breast lift results ‘last’ but it is important to realize that they will change or settle over time during the first six months after surgery. This is known as tissue relaxation as seen by changes in the lower pole of the breast. Since the skin has to support the uplifted breast tissue, some stretching or relaxation of the bottom part of the breast will occur in most patients. This is why it is important that the way the operation is done has the breast initially looking a little ‘upside down’. (the top part of the breast looks too full, the bottom part of the breast looks cut off or too short) This factors in the settling that will occur in the first few months after surgery as the mound drops and more round or tear drop breast shape results. In essence, one has to heal into the proper breast shape. But once a breast lift is healed and settled (3 to 6 months after surgery), there should be no major changes thereafter. The nipple position always stays in the new uplifted position, it is just that the breast mound settles around it.
I make these statements assuming that one does not get pregnant after a breast lift, gain or lose a lot of weight, or is having implants placed at the same time as a breast lift. Any of these can modify the aforementioned commentary on the stability of breast lift results.
You may go to my website, www.eppleyplasticsurgery.com/breast-lift/ for more information and patient results on breast lifts.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, Attached are the pictures of my scar on my cheek. What bothers me the most is the indentation. I would like to get surgical scar revision as I’ve tried lasers etc and nothing has worked. Do you think I’d be a candidate for scar revision? My scar is 6 years old or so. It looks red in some photos as I had a tca peel done a few months ago, which didn’t help with the indentation. I was interested in finding out what you would think would help? I read up about geometric line closure correction do you think this would be more favorable than a single line surgical scar? Let me know your thoughts, Thanks so much.
A: Thank you for sending your pictures. Given your scar’s appearance, I would think the only possible improvement for it would be geometric scar revision. Scar indentations can never be improved by very superficial skin treatments like chemical peels or even laser resurfacing. The entire scar must be excised and normal tissue brought together over the indented area. By the perimeter shape of the scar, it would be brought together in a geometric pattern, merely its irregular shape from the beginning. While one could make an argument to do a wider elliptical excision of it and close it in a linear or straight line fashion given is parallel orientation to the nasolabial fold, I would initially prefer a geometric approach which would also produce less total scar size.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I have had TMJ problems for years and have had just about everything under the sun to treat the condition with no success. I read Botox might be a solution to the symptoms. What type of success have you had in this area and should I come in for consult?
A: When it comes to the term ‘TMJ’, that is a highly variable and diverse term. I would need to know specifically what are your exact symptoms. Botox may be able to help with certain masticatory problems that are primarily muscular in origin. But true intracapsular joint issues require other treatments than muscle modulation.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I have had nasal congestion bilaterally for years since I was young. So I think it make my flabby upper eyelids and lower eyelid bags is related to that nasal congestion. If I remove the the lower eye bags without treating the nasal congestion, can the eye bag regrow again after surgery?
A: It is a common misconception that puffiness of the lower eyelid is related or caused by nasal and sinus congestion. Actually, there is no correlation between nasal congestion and excess tissue on the upper eyelid or bags in the lower eyelid. They may be close in anatomic proximity but one’s genetics, aging and environmental factors is what makes for such changes in the upper and lower eyelids Thus the results of eyelid surgery, like a lower blepharoplasty with bag (fat) removal will not be affected by persistent nasal congestion after surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in jaw implants for my weak chin. I would like to know what the implants are made from and how durable they are. I do martial arts and blows to the face are quite common, so I wonder how well the implants will endure against physical trauma? Also do you believe there might be a possibility that corrective orthognathic surgery might help me, both cosmetically and in terms of snoring/breathing issues? Thank you.
A: The chin and jaw angle implants are made from silicone of a firmness slightly less than bone. I screw the implants into the bone that they will never move from their implanted position. It will require a force great enough to break the bone to ever dislodge them. And they might actually be a buffer against traumatic forces, ultimately protecting the bone to some degree. Whether you would benefit by orthognathic surgery instead of jawline implants is not a question I can answer based on the information you have provided the best way to answer that important question would be to get and orthodontic evaluation and see if the process of pre- and postsurgical orthodontics and orthognathic surgery would be a more appealing alternative that at least partially address the underlying bone problem of your weak jawline. You owe it to yourself for the sake of educational completeness to get such an evaluation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Wow. Information about dents on a persons head is next to impossible to find on the internet. I have about dent on the very top of my head that is about 2 inches in diameter, so it is a fairly large dent. After an accident, some skin was literally ripped from the top of my skull. Eventually, the skin did grow back, but I have no hair there now as the hair follicles went with the skin when it was ripped from my skull. The main problem is though I have a dent in my head there too. At first I thought that all the tissue ( the matter under the skin ) didn’t grow back even though the skin did. Recently, a CT scan showed that part of my skull was thin, so now I don’t know if I have the dent because I need tissue or if it’s because of my skull. Is there any way to determine what the actual cause of this dent is, and if it’s the skull, would anything procedure done to the skull raise the tissue so that it is flush with the rest of my head?
A: While I don’t know the details of your original injury, it strikes me as unlikely that you would have pushed in your skull or removed the outer layer of cranial bone with an avulsion type injury. My suspicion is that this is more of soft tissue defect than bone. the scalp is incredibly thick in many patients particularly of your ethnicity. If you lost enough scalp to remove the hair what is healed is now a partial thickness of scalp which can certainly create an ‘indentation’. The definitive answer, however, would be the CT scan which should clearly show what the bone looks like underneath of the scalp…if the scan was done using coronal images and not just axial slices. I would need to see the the scan and pictures of your scalp defect to definitively determine the anatomic basis of your head indentation.
If it is just soft tissue you can have the defect excised and the hair-bearing scalp defect loosened and used to repair the defect. If there is a loss of bone component to it this can be simply filled in with hydroxyapatite cement (cranioplasty) and the hair-bearing scalp tissue closed over it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Do you do a suture suspension breast lift? If so, can you please tell me how it is done, and what are the associated risks. Thank you.
A: The concept of a suture suspension breast lift can take many forms. In theory, many of the traditional forms of breast lifts use sutures for support whether they are skin-only or whether the breast pillars are sewn together to create an uplifted mound. Even more recently the use of GalaFLEX mesh (a resorbable mesh) can be implanted along the lower breast pole. All of these approaches are still an open method with scars and the objective is to try and prevent long-term bottoming out of the breast mound.
That being said, when you ask about suture suspension breast lift you are likely referring to a true suture suspension that is being used to support the lower breast pole by lifting it toward the collarbone (clavicle)…without removing lower pole breast skin. This is done by making a incision next to the clavicle and attaching a small metal screw into the underside of the collarbone. To this scres is attached a very large permanent polymer suture. The suture is passed by a curved needle under the skin the whole way around the breast and back up to the collarbone. By tightening the suture and typing it down to the collarbone screw, the breast mound is ‘lifted’ and suspended upward. Having done this procedure what I can say about it is that it is a technique in evolution (not perfected) and only applies to a certain type of sagging breast. It is a breast where the nipple is in a reasonably good position and it largely needs a tightening of the lower pole only to get a good shape. This can be done in breasts that also need more volume by a simultaneous implant placement. For those breasts in which the nipple sits at or below the lower breast fold, a more traditional excisional breast lift approach needs to be done.
The risks of a suture suspension breast lift include a small scar over the midportion of the collarbone, palpability of the large knot under the collarbone scar, unknown longevity of this breast lift method, potential palpability of the suture under the skin along the perimeter of the breast, and risk of further breast sagging long-term.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was treated by a “#1 Migraine Specialist” in my state. I had been seeing this Dr. for 1 yr. and 4 months before he suggested Botox and I finally did the treatment because my insurance paid for it! YAY! I finally did the treatment in November 2012 and it was so painful! There was no spot left untouched. It helped the headache I had then so I was sure it was going to prevent the future ones! And low and behold just days later I get a Migraine and been having them as usual! I never had migraines until I had my stroke on May 10, 2010. When I get them they stay until i have to go to the emergency room for relief. Ten dr.’s later and I still have no relief. I have taken over 50 different types of meds and STILL NO RELIEF! I am so disappointed! I cannot live like this anymore! What can I do???
A: I am so sorry to hear about your terrible migraine history and current condition. Just based on your description I comment on your Botox experience. First, it should not have been that painful. When skillfully done wirth a small 30 gauge needle, it is at best of minimal discomfort. Secondly, when Botox is used for migraines it is not done ‘all over the head’. It needs to be placed specifically into known trigger point areas of which there are three very specific locations. This does not sound like what was done. Whether you have the type of migraine headaches that may be improved by Botox is unknown…as of yet. I would suggest that you have the Botox injections repeated at the identified trigger points based on your headache pattern. This will the tell you if you may be a good candidate for surgical decompression which is what, as a plastic surgeon, I can offer for your potential migraine headache relief.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have had two kidney transplants and now my stomach looks like a smiley face im very embarrassed lost 85 lbs in 6 months working off my body fat and eating healthier. No matter what I do it never can get smaller. I’ve recently gone through a divorce and with all my weight loss, i would really like to be happy with my body overall and not feel embarrassed to be naked in the bedroom. I’m writing because I would like to know what my options are for me.
A: Just because you have had kidney transplants does not preclude you a tummy tuck surgery. It is important to know, however, as to what type of immunosuppression drugs you are on (if any), where exactly is the kidney located in the abdomen and have you had any healing problems in the past. You would also need to get clearance from your nephrologist/transplant doctor for surgery. Having done tummy tucks in the past on kidney transplant patients, the one difference is that you rarely do any rectus muscle plication or abdominal wall liposuction. It is a primarily an excess skin removal procedure (skin-only tummy tuck) in which the excisional pattern must be carefully designed give the ‘smiley face’ scar you already have and the risk of skin necrosis.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a chin implant done intra orally which gave me a strange double chin when I smiled. I had it removed 2 weeks later after the doctor told me removing it would make my chin go back to normal. My chin did not go back, it’s still deformed.
A: Intraoral chin implant placement is associated with a higher incidence of mentalis muscle deformity, particularly when the implant is removed if the muscle is not adequately resuspended/repositioned. In theory, a quick removal of an implant should not have allowed time for the overlying soft tissues to become stretched (past their elastic deformation state) and this is undoubtably what your surgeon meant by ‘it would go back to normal’. But that does not factor in the malposition of the muscle which it sounds like you have. Depending upon how long ago the chin implant removal was and what your chin looks like now, it may be improveable with a muscle resuspension procedure. Please send me some pictures at your convenience so I can see exactly the chin problem you now have.
Dr. Barry Eppley
Indianapolis, Indiana