Your Questions
Your Questions
Q: Dr. Eppley, I have a question about nasal airway obstruction surgery. I am a 25 year old female who ever since I can remember,I had difficulties breathing. My right nostril’s been doing almost all the job of breathing, while my left nostril had difficulties breathing and sometimes wouldn’t breathe at all, like it’s clogged. I thought it is a normal thing to do for a nose until recently someone told me that both nostrils are supposed to breathe at the equal intensity. I asked my mother if I ever broke my nose when I was a child, she said “no”. I recently found out from my father that I actually did fall on my face/nose more than once when I was six or seven years old (I vaguely recall the incident). He also told me that they never took me to see a doctor, although I had been bleeding from the nose, I had blue circles under the eyes and a swollen nose. As a result I am soon planing on getting my nose x-rayed to find out if it is broken or not. But even if it’s not broken, is there a way to enlarge nasal canals to make breathing easier (or maybe change the shape of the nose to help easier breathing)? I’ll greatly appreciate your response. Thank you for your time.
A: While nasal breathing may not always be completely equal between both sides of the nose, it is not normal to have a feeling of being completely blocked on one side. With your history and those symptoms, this strongly suggests that you do have an internal nasal obstruction either from a septal deviation, inferior turbinate hypertrophy, middle vault collapse or some combination from all of the above. While you can get an x-ray (CT scan) to see the complete anatomy of the internal nose, a good physical examination will can also make the diagnosis. Undoubtably some form of a septoplasty and inferior turbinate reduction may be beneficial at the least.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had gynecomastia reduction surgery and subsequently developed scar tissue under the nipples that has caused them to still stick out. I have been told it is scar tissue and will be getting some steroid injections to see if it will help. If that does not work and I were to get the scar tissue excised, would I be at risk of the scar tissue coming back again like this time and having the same issue?
A: In gynecomastia reduction revision surgery, the key to preventing this scar tissue problem is to eliminate the so-called ‘dead space’ that occurs after any tissue is removed from under the skin. If not it fills with some fluid and leaves a residual space where scar tissue can form. This dead space management is done by three different methods, suturing the space closed during the surgery, using drains for a few days if necessary, the wearing of a circumferential wrap for several weeks after surgery. Should it recur despite these maximal management methods, then the immediate use of steroid injections need to be done as soon as it occurs. (when they can actually be most effective)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had saline breast implants done 19 years ago. About 3 years ago I noticed my implants felt wrinkly and softer and had a more unnatural feel to them. I can even see dents in my breasts in the mirror. This as about the same time that I had lost some significant weight. My old plastic surgeon said he could fill them up with more saline. He said he can do an ultrasound to see if they can be refilled. Is this common?
A: The first thing to realize about breast implants is that they are not lifelong devices. Many breast augmentation patients have either never been told this or they did not hear it prior to their initial breast implant surgery. Most saline breast implants will last an average of 10 to 20 years, a few will spontaneously deflate in just a few years while a few others may last more than two decades. But none will last as long as over a long patient’s lifetime. At 17 years after their initial placement, your breast implants have served you well but they are coming to the end of the functional use. What you are feeling is not deflation but the rippling and folding of the implants as they have gotten older and you have had some natural breast tissue atrophy which makes the implant profiles more obvious. It is time to start thinking about their replacement whether it is with new saline implants or silicone implants who do not have some of the same aging concerns that saline implants do.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley,I am interested in a LeFort osteotomy. My bite relationship is significantly off, though, and I’m still wearing braces. I’d suspect my upper jaw exceeds my lower jaw by at least 7-10 mms. My orthodontist is under the impression that my bite relationship is fine, but I think that either extractions or upper jaw surgery would be necessary to shove my upper jaw back and even out my profile view. I think the jaw surgery might be a better bet than a chin implant, in this case, since i like my lower jaw position but not my upper jaw position. Do you perform upper jaw surgeries? Could you show me an image of what an upper jaw surgery might look like, in terms of shoving my jawline back?
A: I have performed many maxillary (LeFort osteotomy) upper jaw surgeries. You can not really push your upper jaw back more than 1 to 2mms. It may go significantly up (impaction) or forward but it can not be moved any significant amount back as a total jaw unit. You may have the first premolars removed and have the pr maxilla (bone that contains the front 6 teeth) moved back by orthodontics or even by a premaxillary osteotomy but whether that is a reasonable thing to debased on your tooth relationships and facial profile is a questions for your orthodontist and their participation in integral in this process.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, when it comes to lip reduction surgery I have one question for you that I have been thinking about lately. As you written previously with a lip reduction the dry vermilion on the lip is what is removed but how does this affect the lip’s functionality? Currently because the dry vermilion bothers me so much I peel it off as it begins to flake and after peeling it off it grows back hours late in a continuous cycle. Now if the dry vermilion is removed does that mean skin will never grow back in that area? And if this is the case what is left on the top lip in the area in which the dry vermilion has been removed?
A: In a lip reduction procedure, whether it is for size reduction or for the treatment of chronic dry/chapped lips, a portion of the dry vermilion is removed in front of the wet-dry line. The dry vermilion removed is ‘replaced’ by the wet mucosa which advances forward from the inside of the lip. The wet mucosa is very soft and supple and thus its replacement of a portion of the dry vermilion poses no functional limitations to the lip.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, first thank you for offering such great jaw angle and chin implant surgery to patients. I have found your website on the internet, as I have been looking for Medpor RZ angle implants and chin implants for years and I definitely intend to do that surgery. Of course a final recommendation can only be done personally in your office, but I would be very thankful for your first indication based on a picture of my current jaw line and chin position attached.
My initial questions prior to the surgery would be:
1. JAW ANGLES:
a. Which Medpor RZ angle implant size would you suggest to achieve a projection like on the celebrity pictures and my computer animated picture, assuming that I augmented my cheek and cheekbone prior to the jaw implant surgery? 7mm or 11mm or 11mm shaved down to 9mm?
b. What is the horizontal width of the 7mm and 11mm Medpor RZ mandibular angle implants?
2. CHIN: which mm size of the chin implant would you suggest for a masculine chin projection, 6mm or 8mm?
A: In answer to your questions:
1) The vast majority of jaw angle implants rarely need to be more than 7mm. An 11mm implant, when both sides are factored in, increases the bigonial width by 22mm which is considerable. The numbers 3, 7 and 11mms refers to the width or horizontal dimensions of the implant. It is a standard 10mm vertical drop with these style of jaw angle implants.
2) I would have to see your pictures and see what degree of chin horizontal shortness you have, but generally 8mms is going to be a better choice than 6mms for most men.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had gynecomastia reduction surgery performed back in March of this year. The results immediately afterwards were amazing, everything was completely flat. A month or so after I started developing scar tissue which hasn’t gone away and has made my nipple area protrude once again. My plastic surgeon said I probably needed a steroid injection to help with the scar tissue. Since it is much further to travel back to him I went to a local plastic surgeon, but he thought it was just some leftover breast tissue and didn’t want to do the Kenalog injection. No offense to him, but I don’t feel like he had much experience with gynecomastia and I definitely feel like it is scar tissue since the results after surgery were a completely flat chest with no feeling of any tissue whatsoever. That led me to come across your website where some people had asked about Kenalog injections for scar tissue after gynecomastia surgery. Based off what I have told you, does it sound like scar tissue to you or is it possible that the gynecomastia has actually grown back? I would be interested in seeing you for Kenalog injections if you believe they would be beneficial. I have attached a picture of the before and immediately after surgery. I would really appreciate any information you could give me so I can get this behind me for good.
A: I have done a lot of open areolar gynecomastia reduction surgeries in young men just like yours. What you are experiencing is not uncommon. It looks really flat in the beginning but a slow nipple protrusion develops. The tissue under the nipple-arolar complex feel firm, sometimes harder than before the initial surgery. You are correct is that it is scar tissue and not breast tissue. But often considerable scar tissue develops and the mass effect is almost like it was before surgery in some cases. I have done my fair share of steroid injections into this scar tissue and that seems to be the logical approach to do. But I have yet to see a case in which the steroid injections were successful, particularly at over six months after the initial procedure. My experience is that the only thing that solves the problem is to surgically remove the scar tissue, very much like the original surgery. While there is no harm in doing steroid injections, and the protocol would be a series of three injections spaced three weeks apart, I have little optimism that it will lead to a complete resolution of the problem.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have attached some pictures of my stomach pannus. Please let me know if I would be a good candidate for an abdominal panniculectomy. It is the most troubled part of my body. I have backaches and some times irritation underneath due to my jeans. I wear a size16 in pants but that is underneath my pannus. If I got pants to go over my pannus they would not fit my legs and hips properly. I hate this stomach!! 🙁
A: Thank you for sending your pictures. I do believe you are a good candidate now for an abdominal panniculectomy. The size of overhang of your pannus is significant and much functional improvement would come from its removal. You are not going to have a flat stomach from the procedure, however, and of this you should be aware. It will still be round due to the amount of intra-abdominal fat but there will be no overhang. In preparation for an abdominal panniculectomy, hopefully in the near future, I would still continue to make efforts to lose weight no matter how slight it may be. That will only enable as much stomach tissue to be removed as possible.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am in need of mouth opening surgery. I’ve been to all the doctors in my area but not one of them can solve my mouth problem. I’ve had all my teeth pulled out, which was very hard for me because my mouth cannot open widely. It cannot stretch as big as normal mouths can. I wanted to make my dentures but I couldn’t because they couldn’t measure my gums because the measurement thing cannot fit into my mouth. I’m so so sad because I am ashamed to talk like I used to because I have no teeth. Can you give me some advice please. One doctor said that he could cut the sides of my mouth but there will be scars afterwards. I hope that you can help me with some advice. I cannot go on with my life like this, a toothless 34 year old and i cannot even fix my dentures. Thank you for your time.
A: The correct procedure for increasing mouth opening (oral aperture) is the oral commissurotomy or mouth opening surgery. The sides of the mouth are opened by making an incision in the skin away from the corners of the mouth and the lining of the inside of the mouth is moved out to cover the new opening. While this does create scars, they are along the new lip margins…not ending up in the skin in a line running away from the corner of the mouth. This is a favorable location for the scars along a natural tissue border. This would provide improvement provided that the reason you can not get into your mouth is tight skin at the corners of the mouth.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had cheek implants placed over 25 years I have lost weight and would like to know if facial fillers can be used close to the implant. Is there and increased chance of infection? Thank You
A: Cheek implants that have been in place for 25 years had to have been some of the first cheek implants every put in, usually of a small ovoid shape that were positioned on the anterior end of the cheekbone. This location creates that ‘apple cheek’ look that is very appropriate for many women. While the bony augmentation has remained stable, over the years the soft tissue around the implants has undoubtably changed becoming thinner and developing some malar sag. Thus the impetus for injectable fillers to recreate some lost cheek highlights due to aging. Generally it should be no problem to place injectable fillers in the tissues overlying such ‘old’ cheek implants. Having removed several cheek implants of a similar age, the scar capsule that surrounds them can be incredibly tough and even partially calcified. It would be probably be unlikely that a needle could even penetrate the capsule should it inadvertently come into contact with it. This is also a good use of the microcannula method of injectable filler placement which has a blunt tip and would have zero chance of breaking through the cheek implant capsule and inadvertently injecting into the implant itself.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am seeking gynecomastia reduction by liposuction only. I am 24 years old with a body mass index of 26. I have developed glandular gynecomastia with enlarged areolas. All my endocrine labs are normal. Can I have Smarttlipo done using the axilla as access for the probe? Will this work for male breast reduction? I have attached pictures for your review.
A: This is one of the more challenging types of gynecomastia to treat because of the enlarged areolas and the skin excess on the chest. Trying to do gynecomastia reduction with liposuction only, regardless if the incisional access is not likely to result in the best outcome. With glandular tissue present under the areolas, any form of liposuction is not going to be able to completely remove it. I would do a combined open gynecomastia excision with liposuction and see what happens with the areolas and skin excess. (how much shrinkage occurs) One has to be prepared for the potential of the need for a secondary procedure that may involved a periareolar reduction with scars around the areola. One could argue that should be combined with the intial procedure but that would depend on he patient accepting those scars from the beginning.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am lookin into abdominal panniculectomy surgery. I have a large pannus that goe to my sides. It hangs below the pubic line but not completely covering the pubis. I am a larger woman but my stomach is the largest problem I have and I am interested in getting it removed. I am currently 290lbs but if you see me you wouldn’t think that because I have large muscle mass also. Do you operate on larger patients? I am currently eating healthier and it seems that my stomach has shrunk a few inches but will not go away. Please help.
A: The decision to undergo an abdominal panniculectomy is largely based on how large the pannus is and how much can be removed given the tightness of the abdominal skin. The one problem with the removal of any pannus near 300lbs is that only a limited amount can be removed given the tightness of the abdominal skin due to the distention from the underlying weight. A much more effective and larger abdominal panniculectomy could be performed when one’s weight is 50 to 75 lbs less as this loosens up the skin’s tightness. This doesn’t mean that at 290 lbs you can’t have the pannus removed, it just means it is a more effective procedure if you weighed less. I would need to see some pictures of your abdominal area to give a further assessment about whether it is a good idea to have the procedure at your current weight.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had my jaw fractured and repaired several years ago. Even though it is fully healed, it has never been quite right. I have attached multiple photos. When my jaw is relaxed, my bottom teeth show fully. I don’t know off hand what type of mentalis muscle resuspension surgeries were done. However, both were done making use of screws but the first one made use of multiple screws. That one completely failed after about 4-6 months. The second one which I underwent only about 3 months ago, the surgeon removed the other screws and used only screw where he went in under the chin with small incision and also sewed the soft tissue below the bottom lip to my inside gumline. where I have a dental bridge and no teeth blocking (also as result of trauma). Both of these surgeries seemed to focus on central part of the chin and muscle.
The lower right side where mandible was most severely fractured and had the most work done to it seems to be where the suspension needs to be done and muscle reattached. Left side is now and always has been slightly higher than right leaving smile looking crooked and chin with no definition but just hanging below. It looks as if I have a much larger chin or even an implant when in fact it’s just unattached muscle hanging. However, it’s more than just the looks but the sensation and placement of nerves as both times recently after resuspension, it feels good and right and then after time goes by and starts slipping again then feels as if I am sucking on my lower jaw because the muscle has slipped below chin and lower teeth and jaw gives feeling as if further inside my mouth (If that makes any sense).
Do you think there is anything that can be done to attain a semi permanent resolution to this matter that has plagued me for the past two years or am I stuck with what I have currently? I don’t want to keep undergoing more surgery for no added benefit but just to accumulate further edema and added scar tissue.
A: The low hanging lip, regardless of the cause, is always a difficult problem to correct. Having had two ‘failed’ attempts at chin pad/mentalis muscle suspension is not an encouraging history and would suggest that any further efforts would meet a similar fate. You have even had the ultimate mentalis resuspension surgery procedure which is only possible when there are no teeth in the central alveolus. With that not working, there are no other suspension techniques available. I didn’t see mention of a V-Y mucosal lip advancement with the suspension although this alone is not the magical missing piece.
The right side of the chin/jawline issue is not really a muscular problem as there are no significant muscles that attach there. It is a soft tissue sag although not muscular per se. That is a difficult area to try and reattached because of the mental nerve and the potential of any existing metal hardware in the area. Do you have any x-rays that show the lower jaw and the repaired fracture?
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting a custom chin/jawline implant. I’ve been doing some more research into cheek and chin implants and wanted to ask your advice. Based on my photos do you think a standard chin implant modified to fit just the left side would be adequate? Or is it best to stick with the plan for a custom implant? I know a custom implant would be pretty pricey and since I’ll be needing lots of other work done to correct my Parry Rhomberg syndrome so I’m just trying to figure out the best options. I also wanted to get your thoughts on cheek implants. One surgeon I spoke to thought I only need a cheek implant on the left side and that the right side could be built up with fat or filler. However another surgeon insisted that I needed implants on both cheeks, so now I am confused. Would you suggest a cheek implant just on the left side or both sides to make things as symmetrical as possible? I’ve attached the other surgeons photo simulations of a standard chin implant, fat transfer, and left side cheek implants. Do these simulations seem like attainable results to you? Any feed back would be greatly appreciated.
A: With facial bone asymmetry, it is a given that a custom jawline implant would be superior to any off-the-shelf implant. There is no question about that. The question you are asking, understandably, is there something that would cost less that could do a reasonably similar job as a custom implant. When it comes to any existing standard chin implants I would say no because the bone deficiency extends all the way back to the jaw angle. However, I have been using a new wrap around jawline implant for men and women that I believe would work that is not yet available to the general public. (sold by the manufacturer) I think half of this implant could be added from your left chin back to the jaw angle and would do a great job of building out your deficient chin-jawline. (the custom implant would probably look somewhat similar) This would reduce the cost of the procedure considerably over a custom jawline implant.
As for the cheek areas, go with cheek implants on both sides. The cheek implants would not be the same size of course. But never try to compensate for a skeletal deficiency with unpredictable fat grafts when you are already committing to doing a cheek implant on one side. You may still need some fat grafting but just don’t try to make it work for the bone part of the facial problem when there are more predictable solutions.
When it comes to computer prediction imaging, understand that it is not a guarantee of how the surgery will turn out. It is Photoshop where anything is possible by moving pixels around. It is the surgeon’s estimate of what he/she hopes is accomplished and is the goal to aim for but whether that is completely attainable is determined by the surgeons skill and ability and how realistic the imaging has been done.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am looking for a consultation on breast augmentation. I have asymmetry issues and would be curious about not only evening out, but enlarging both breasts from a small B to a full C. I am not familiar with what a price would be for such a procedure, but I would appreciate a range/estimate to know what I’m getting into.
A: Breast asymmetry comes in many forms but your description suggests that it is a volume issue as opposed to one breast being smaller and sagging as well. (which poses different considerations) If it is a pure volume issue, then breast augmentation surgery alone may suffice…just using different implant sizes to make the mound ssomewhat more symmetric. While one can never achieve more symmetry or evening them out perfectly, breast enlargement with two mounds that are more symmetric is possible. This, then, other than having two different sized implants is a straightforward breast augmentation procedure. The cost of breast augmentation is dependent on what type of implants are used. (saline vs silicone) and not on the implant size so knowing your implant choice would be helpful in answering the cost question.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am 41 years old and weight 96 lbs. I have sagging, wrinkled loose skin at elbows and knees and was wondering if an elbow/knee lifts would be an option. I’ve never had a large weight loss but did lose 10 lbs about 2 years ago. Thanks so much for any info.
A: My guess is at your age and relatively stable weight, this is simply loose skin due to lose of elasticity of thin skin. This is very common at the elbows and knees due to the frequent flexion movements across the joints. It is not really question of whether elbow and knee lifts can be done…but should they be done. There is the aesthetic trade-off of a fine line scar which I consider more of a potential issue in the knees than the elbows due to the visibility. The good news is that thin skin usually scars the best, so this is a consideration not necessarily an impediment to doing it. I would need to see some pictures of the knees and elbows in the straight position (extended) to judge how much loose skin is present. It is that determination that makes the decision about whether elbow and knee lifts (so called ‘joint lifts’) are worthy of that scar trade-off.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am 42 years old and have had 600cc implants for over a decade. While the number makes them seem big, and they are not small, I am 5’9” and weight 140 lbs. I now would like to go up to 1000ccs or even 1250ccs. What do you think?
A: When one considers very large breast implants (at least based on the volume measurement), the most important long-term issue is whether the breast tissue will hold up and support them. If not, the implants will eventually drop (bottom out) and this will become a really difficult problem to correct. For most women going to that size initially would be impossible given the amount of breast skin that they have. But in someone with existing implants there has already been some significant expansion. So the concern then becomes where releasing the existing capsule to enable a larger size to be placed will exceed the surrounding soft tissue support. The other issue is that such a larger implant size will have a larger base width to it so one shoudl expect that the sides of the implant will go past the outer chest wall area and closer into the swing of the arms. (which many women do not like) The last consideration is that these will have to be saline implants as the largest prefilled silicone breast implant size only goes to 800cc. The largest saline implant size is 960cc but that can be overfilled up to 1100ccs if desired.
All of that being said, it is not a question of whether it can be technically done but whether it should be done. Having breast implants in place, you are in a good position to make an educated decision about what new size breast implants you want.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a rhinoplasty. I am 50 years old and was originally born with cleft lip and palate. I have had two previous rhinoplasties for my cleft nose, the last being over a decade ago. I have never really liked the results and was hoping to have one more go at it in my older years. Just recently had a consultation about my nose with a surgeon who is basically a cosmetic surgeon. He looked me in the face and said that due to my anatomy and blood supply, his major concern was that he wasn’t sure if he could correct anything. His concern was necrosis. I have great blood supply and have never heard of that possible complication before. As a matter of fact that remark caused me to realize that I needed an expert in cleft nose deformities. Please tell me what you think.
A: While open rhinoplasty always has the potential for nasal tip skin necrosis, this would be a very rare problem. The surgeon would have been better to say ‘I am not interested in doing your nose’, ‘this is hard and not worth my effort’ or even ‘this is beyond my skill level’ but the idea that the blood supply to your nose is compromised and can’t be operated on is not a valid biologic concept. If that were true, the vast majority of revisional rhinoplasties would never be done, not withstanding the secondary cleft rhinoplasty.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’d like to inquire about getting injectable fillers under my eyes. What product do you use, what are the risks and what does it cost? What is the general satisfaction with patients having this procedure. I am excited about having it done but also nervous since it is around the eyes.
A: Under eye hollows, tear troughs and malar creases are becoming a popular treatment site for injectable fillers. When done well they can provide significant visual improvement of problems areas that previously were only treatable by surgery. For under the eye hollows, I generally use Juvederm placed with a microcannula technique. This usually eliminates any risk of bruising. The biggest concern in injecting under the eyes is that it is not overdone and that it is as smooth as possible. This means that it is injected down at the bone level along the infraorbital rim Of all the facial areas to treat with injectable fillers, this requires the most careful and skilled technique and a comfort zone with the surrounding orbital anatomy. The biggest risk is lumpiness or unevenness of the lower eyelids. The cost of treatment, which will usually last a year or more is around $550.
Q: Dr. Eppley, I am interested in getting facial implants and am gathering information about getting plastic surgery. My intention is to improve my facial features with facial implants and cosmetic plastic surgery. I would like to get your professional impression and advice to enhance my look.
The areas that I would like to improve are:
– Jawline. I think I have an elongated face. So, I am looking for a more square and strong jaw.
– Cheeks and Eye Hollows. I am starting to notice some eye hollows. I think I do not have a strong features in this area, they are somehow “flat”. At this time, it is not bad, but I believe with time they will get more pronounced.
– Upper Eyelids. I notice that I have extra skin on my eyes lids, especially on my left eye.
– Any suggestions to make the face more aesthetically balanced and harmonious with the rest of the face.
Concerns:
– I am concerned about the scars and the surgery around the eyes. I do not mind internal scars but external incisions concern me.
– What is the material used for the facial implants? I read about Silicone, Medpor and Gore-Tex. I would like to know your impressions about these materials, and their pros and cons, and why you use ones over the others.
– Asymmetry, implant shifting and/or misplacement (due to position, scarring, etc.)
– Final look. I would like to look natural and not “done”.
– Revisions. What is your policy in case of revisions?
– Complications during and/or after surgery. What is your policy in case of complications during the surgery and/or after the surgery? nerve damage?, secondary effects?, responsibility, cost, etc.
– Bone erosion with implants over time. What is going to happen with the implants when I get older. I am 30 years old at this time. What is going to happen with the implants and the bones when I am 85-90 years old? the implant, the screw, the bone. Is there any research done about this?
Ideal:
– I can imagine you have heard this before, but I would like to get the “model” look. Strong, symmetrical, pleasing features. I attached some photos of some ideal looks, by all means I don’t want to look exactly like a specific “celebrity” or “model”, it is just an idea of the look I am looking for.
Questions:
– Could you provide me with your professional impressions about the surgery/ies that I will be benefiting from, their related costs and results?
– Do you provide any imaging about the possible results. I attached photos of my face in different angles.
– What are the difference between conventional and custom designed implants? what are their costs?
– How long will I have to stay in Indianapolis after the surgery?
– When would I be able to return to my normal life work, exercise, being in public, etc?
– How much discomfort should I be expecting in the surgery?
A: I have done some computer imaging on your face for the various facial implants for the following procedures:
1) Square chin augmentation
2) Vertical lengthening as a well as width expansion jaw angle implants
3) Cheek implants
4) Fat injections to the lower eye hollows/tear troughs
In answer to your questions:
CONCERNS
– there would be no external incision with fat injections
– implants would be silicone, best because of better shapes and easily reversible or modifieable
– all implants would be screwed into place
– natural comes from not using too big of implants, particularly when multiple implants are being used.
– we have a complete page of the revision policy which you would get to read before surgery.
– bone erosion is a non-issue. The implants will look the same decades from now as they will one year after surgery.
IDEAL
– you are correct in assuming that every male who wants this kind of surgery wants the ‘male model’ look. Those who have a chance to come close to that look have to have thinner faces and some decent underlying facial bone structure…you are the uncommon one that actually fulfills these criteria.
QUESTIONS
– I have attached some imaging predictions for your review. I will have my assistant pass along the costs to you in a day or two.
– you should be fine with standard implants. Custom implants are always ideal but at the additional costs of $7500 they had better provide a real difference…which in your case they do not.
– 2 to 3 days, all based on how you feel.
– that is based on how you feel and look, somewhere between 10 and 21 days after surgery.
– jaw angle implants provide the most discomfort, the other procedures are much less.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I did an upper and lower jaw surgery five months ago. Unfortunately a genioplasty with bone graft was also done. See before and after X-rays attached. I’m very happy with my upper and lower jaw surgery but not the genioplasty with bone graft because now I’m unable to close my lower lip without forcing the lips together. It looks like the lower lip is being pulled down.
Is it possible to redo the genioplasty so Im able to close my mouth more easily. The secondary problem is that my face also look too long now. I added some before and after X rays. Is it possible to recut the bone and slid it back upwards half the distance it was slid downwards?. Or is it better to remove the bone graft and make the chin as it was originally?
A: Given that it has been nearly six months from the original procedure, there is no concern at this point about revisiting the genioplasty site. You can simply redo the genioplasty and either remove entirely the length that was added by the bone graft or shorten to whatever vertical distance you want. It is just as straightforward to do it either way.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 19 year old considering a buccal lipectomy and wondering if I am a good candidate for it. I feel that there is some roundness to my cheeks that make the lower half of my face disproportionate to the upper half. I was wondering if the procedure would benefit me or if it wouldn’t make much of a difference. And if it does, whether I might not look too gaunt. I’ve seen a lot of regrets online but I wonder if it’s just a vocal minority. Thanks for the opportunity to gain some nice insight! Truly appreciated.
A: In looking at your your pictures and your young age, you would not be a good candidate for a buccal lipectomy procedure. While the initial result would meet your objectives, the long-term of it in your case would leave you looking gaunt and end up along with those that you have read that has regrets online. It is not that a buccal lipectomy is a bad procedure, as it can be very effective and successful in the right patient, but your face is not one of them. You do not have a ‘fat face’ or even a round face. Your level of fat lipodystrophy is very modest and the buccal lipectomy is too aggressive for your facial fat concerns.
In addition, where your facial fat concerns are is actually below of where the buccal fat pad actually is. It is situated just under the cheekbone and not down by the side of the mouth.
If you were to consider any facial thinning procedure, perioral mound liposuction is a better choice as it helps reduce the fat thickness at the lower end of the cheek and is a procedure that cannot really be overdone and has no long-term ‘gaunt face’ consequences.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had fat injection breast augmentation done six months that had a lot of problems afterward. There was drainage from under the left breast for three weeks after the procedure. I was put on antibiotics to treat it but was told the rubbing of my bra on it was the cause. Then a month later my right breast developed a large painful lump that turned out to be an abscess which required more antibiotics and needle drainage. I am now left with one breast bigger than the other and one of them is lumpy. The doctor now wants to do the procedure again but this time using the Brava device. Will this make a difference and make it more likely that the fat grafts will take? My doctor is an ObGyn who specializes in cosmetic surgery but my first experience has now made me nervous.
A: Unlike breast implants, the use of fat injections for breast augmentation is not an assured outcome. As you know and have experienced, the take of injected fat is subject to a wide variety of factors not all of which is completely understood. The take of injected fat is highly dependent on the harvesting, method of preparation and the injection technique. While the injection of fat seems like, just like the liposuction of fat, successful results ultimately depend on surgeon experience and attention to technique details.
The concept of using the Brava device is a good initial approach for small breasts with a tight skin envelope. Whether that would have been advised for your first fat grafting surgery is now irrelevant but should probably be considered for any second stage. But it is important to remember that the Brava device is an adjunctive procedure to prepare the recipient breast bed, it is not the magical solution or a substitute for adhering to sound fat graft harvest, preparation and injection principles.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am an Asian female who is 27 years old and want to have a more narrow face. I’m interested in jaw reduction, chin reduction(v-line) and cheekbone reduction surgeries. What are the possibilities of side-effects such as nerve damage and sagging skin? Is it possible to do all 3 surgeries at once?
A: As you undoubtably know, narrowing of the Asian face by bone reduction is a common request and collection of procedures. All three facial bone reduction procedures are commonly done together including cheek bone reduction and jawline narrowing. The most common side effect, albeit not a complication, is the protracted facial swelling (4 to 6 weeks) until you see the beginnings of the results of the procedure. Generally permanent nerve damage (sensory nerves, infraorbital and mental nerves) does not occur although there will be a period of some lip numbness. The bigger risk is with the mental nerve as the jawline reduction goes right beneath it and some stretch on the nerve does occur. Sagging skin is also not usually an issue either and this is more of a concern in the cheek area rather than the jawline.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have cheek implants placed and had an infection after surgery. It was drained and reclosed, that was three months ago. While some of the cheek swelling has gone down there is a noticeable asymmetry between the two sides of my face. I had a CT scan done which shows no ongoing abscess and my doctor wants to do liposuction on the cheek to try and make the two sides more even. This does not quote make sense to me. Can you review the CT scan and tell me what you think.
A: I have received your CT scans and reviewed them in detail. While I would agree with the radiologist’s report that there is no obvious abscess/large fluid collection, the scan does show some significant asymmetry in the cheek implant positions and there is an encapsulated area around the left cheek implant with the infection history. You can see in the attached cropped images of your CT scans to what I am referring. Knowing that you did not have significant facial asymmetry before surgery and you had an infection of one cheek implant with secondary manipulation, your current significant facial asymmetry can not be explained by a fatty tissue problem. If you were my patient with these similar findings, the only course of action I would recommend is to re-explore the left cheek implant, remove any scar tissue and either reposition or just leave out the implant and let the tissues settle down. I would not rule out the possibility that this is a chronic inflammatory reaction from an originally infected implant. What you do know is the opposite right cheek implant reflects what it should look like. Thus the facial asymmetry on the left side is implant-related in some fashion. It would have to prove to me otherwise.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting cheek and paranasal implants. What is the best procedure to correct a deficient (flat) mid face? I’ve always hated my facial profile. I have attached some photos which I realize probably are not the quality needed for computer imaging but I was hoping you would be able to gauge if and how you might be able to correct my facial features.
A: The photos you have sent show you smiling in both of them so they not only are not useful for computer imaging but have distorted the midface due to the soft tissues changes. Unfortunately if I can’t image them to see the visual change then it is difficult to say such procedures are aesthetically productive…because what ultimately counts is what you think not what I think about the potential facial look change.
Having said that, cheek and paranasal implants are useful for improving the facial profile that has some midface deficiency…which may apply to you but smiling photos pull the soft tissue up (at least on the cheeks) and make them look fuller than they really might be. I can see the paranasal deficiency which smiling actually accentuates rather than improves.
So my incomplete assessment at this point suggests that you may be correct that your midface profile could be improved by these types of implant augmentations.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting a lip advancement procedure that would make my upper lip at least equal to my lower lip. My lips are significantly out of proportion. I have sent 3 pictures as references. Would you be willing to make such a drastic lip change to make them equal in size/appearance. I really would not be happy with the results if this outcome isn’t achievable. I live out of state and would have to fly in the night before the surgery and then fly out the day after. Would that cause any problems with the procedure and healing process. I am a very healthy 38 year old male with no health conditions. I have had anesthesia for a prior procedure. I am in the health field so I could perform most of the post care protocols. Thanks for your help.
A: Through a lip advancement your upper lip could be made almost even, if not completely even, to that of your lower lip. This is a procedure that could be performed under either local anesthesia (office) or IV sedation (procedure room) Many lip reshaping patients of mine come from afar so distance is not a concern in terms of healing or a cause of any after surgery problems. As you undoubtably know, the only issue with the lip advancement is the fine line scar along the vermilion border which is why it is not as commonly done in men as in women…although this does not mean the scar is any different. I don’t know of you are going to have upper lip hair or not after the procedure so the scar may or may not be of significant consideration.
Dr. Barry Eppley
Indianapolis Indiana
Q: Dr. Eppley, I need with a chin implant revision or a chin implant removal. I had a chin implant done about 10 months ago and I am still experiencing numbness and a slightly crooked smile on the left side. The most alarming part is that smile does not “go down” as much as it used to. My smile feels tight and almost like I am fighting against my chin to smile. Am I just still recovering from the numbness or should I get it removed? I liked my smile before and now it is too small and strained looking…I have a round face and sometime’s I think the implant makes it look rounder (and not thinner/ more defined which is what I wanted). My entire lower left side was numb after surgery so it has come back significantly…but still so slow in 10 months. Do you have any suggestions?
A: You are describing symptoms of a chin implant that is too ‘big’. The feeling of tightness in the chin and the stiffness from it is either due to a very tight pocket or an implant that is a little too big for the tissues. The fact that your chin looks rounder also indicated that it is ill-shaped for a female which should have more of a triangular-shape and not rounded like the implant that is in there. Given that you had the chin augmentation procedure for a reason, I would suggest a chin implant revision rather than a chin implant removal. The implant needs to removed, reshaped and then repositioned rather than just throwing away the entire effort. You did not say which way the chin implant was put in (intraoral vs. submental) but I am going to guess it was placed intraorally which can often be a source of these type of symptoms.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in forehead reduction/hairline advancement surgery. I am a 20 year old female, and I wanted to ask about forehead recontouring. I would like to know more information. I am self-conscious about my forehead as it curves/bulges outwardly. I’m not sure if this is applicable to this, but I have included a picture to get a better opinion. I also want my hairline lowered. Will a tissue expander be needed?
A: The success of frontal hairline advancement depends on the tightness of one’s scalp and how much forward movement of the hairline one desires. If the scalp has some looseness and the amount of hairline advancement in not greater than 10 to 15mms, then a scalp expander will not usually be needed. Although I have seen some patients whose scalp is so tight that is barely moves even with full release.
A hairline lowering will help but will not get rid of the bulge appearance completely. The two procedures are often done together for maximal effect.
Based on this profile picture you have sent, I think your rounder forehead can be made flatter. The relevant question is how much? Generally up to 4 or 5mms can be taken from the most central prominent area. But I alway check a simple skull x-ray first to see how thick the bone is in that area.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, My son needs skull reshaping surgery. He is currently six yearrs old and will turn seven later this year. I have many concerns for my son. My son has never had a hair cut in his entire life. I braid his hair down in efforts to try to disguise the deformity located on the right side of his head. We are African-American and one day, after my son graduates from college, he will need to be appropriate to interview for jobs. No one will want to hire my son with braids in his hair. He needs to be able to cut his hair and wear suits proudly. Also, both his grandfather and father are bald. What happens to my son if his hair pattern follows in that same direction? When my son was born, his head shape was absolutely perfect. I want my son to be able to fit in with society and not be ashamed or judged on his deformity. My son is an innocent child and if there were anyway I could take his place I would. Please help us.
A: Skull reshaping surgery by an onlay cranioplasty is most commonly performed for flat areas on the back of the head. I am assuming that his flatness is on one side of his head in the back of his head. Such a skull deformity is very amenable to being built up by an onlay cranioplasty procedure by putting material on top of the bone. This does require a scalp incision to do it, located more to the back of his head. He does not have to shave his head or unbraid his hair to do it. In fact, having braids in his hair is the best hair management for the procedure.
Dr. Barry Eppley
Indianapolis, Indiana