Your Questions
Your Questions
Q: Dr. Eppley, I may need a revisional rhinoplasty? I did not have breathing problems before I had a rhinoplasty? When I went back for a six month follow up I was told I had a deviated septum and needed more surgery. I was told I did not have one before surgery but that it has grown back that way now. Could the rhinoplasty have caused the deviated septum? Or was the deviated septum there before and it was just missed during the initial rhinoplasty?
A: One of the most common reasons for revisional rhinoplasty surgery is nasal airway obstruction. A recent published study of revisional rhinoplasty reported that up to 70% of patients had some degree of airway obstruction and was a main motivating factor for the surgery. There are many potential causes of breathing problems after rhinoplasty of which a deviated septum is but one. Usually, however, a deviated septum is diagnosed before or during the initial rhinoplasty and only ‘recurs’ because it was inadequately corrected. If there were no breathing problems before surgery, it would be unlikely that a deviated septum has developed now. With cartilage graft harvest, presuming that was done, septal deviation is less likely to occur.
One of the most common causes from the initial rhinoplasty is if osteotomies or breaking of the nasal bones was done, particularly if a low-to-low or even a low-to-high osteotomy pattern was done. A low initial starting point for the osteotomy can partially close down the airway. Another common reason is collapse or pinching of the middle vault which narrows the internal nasal valve, a critical point for airway passage in the nose. Both of these sources of nasal airway obstruction come from the common aesthetic manuever of taking down a hump or bump in the nose particularly if it is large. This can cause collapse of nasal structures which have to be recognized during the initial procedure to enable preventitive manuevers to be done.
The short answer to your question is that there may be other causes of airway obstruction besides a deviated septum that must be taken into consideration.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had gynecomastia reduction surgery 2 months ago and I am not happy with the results. It was initially very flat right after surgery but I have subsequently developed hard lumps under the nipples that now make them stick out a bit. This makes me mad since I paid good money to have a flat chest. What can I do about it now?
A: What you are describing is very common after gynecomastia reduction surgery in young men. Many open gynecomastia patients will develop a scar lump under the nipple after their procedure even though it looked initially quite fat. Whether this scar lump will go away or not takes time to see and two months after surgery is too early to tell. About 10% of open gynecomastia reduction in young men will develop these persistent scar lumps that may require a revision to remove and make completely flat if it persists. This is not reflective of a poor surgical technique or even a poor surgical result but is the unknown and uncontrolled variable of how one forms scar tissue in the space where a small or large lump of tissue had been removed. What I would recommend now is to have either Kenalog (steroid), 5-FU or combination kenalog/5-FU injections to try and soften the scar and make it go flat. Now is the time to do this, not 6 months after surgery where it would be much less effective when the scar tissue is mature. Whether this will be completely effective can not be predicted but at least this provides a chance for success. If not, you are going to require a revisional gynecomastia reduction procedure to remove the scar that has developed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have an unusual tummy tuck question. Can a tummy tuck be performed at the same time as when one is delivering a child? I have never heard of this before but it just seems to make sense to me. I have had two children by c-section and am thinking about having a third and with the excess skin already present this just seems like a perfect time to do it. Is this a crazy time to do a tummy tuck? Or should I just wait and do it after? How much weight should I lose before doing it after delivery?
A: Having performed three tummy tucks at the time of delivery I can speak to the fact that it can be done. While a tummy tuck can be done at the time of delivery, it is not going to be the traditional or full tummy tuck procedure. Because of the enlarged uterus, muscle repair is not done in the traditional fashion (hard to close over a big uterus) and the tummy tuck is limited to the amount of skin that can be easily removed without too much tension. The scar will end up being much longer than that of the c-section scar you have now. While producing a significant improvement, it is never as good as a tummy tuck that is done six months or later after delivery. When done well after pregnancy, it is a good idea to lose as much weight as possible to get the best benefit from the tummy tuck procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in an umbilicoplasty procedure. I hate the look of my bellybutton as it sticks out and want a prettier bellybutton that turns in like most people. How is the procedure done and was is the approximate cost of turning an ‘outie’ into an ‘innie’. Thank you.
A: The bellybutton or umbilicus is the residual attachment of the umbilical cord. It forms a visible depression in a very constant and central location on the abdomen. Underneath it lies the midline union of the paired vertical rectus muscles which will also have a depression or concavity in it, making it a structural point of potential weakness and the potential for a hernia. Most commonly the navel appears as a depression or innie which occurs in about 90% of people. In the minority (10%) an outie belly button is present which can either just be from extra skin left over from the umbilical cord or exists because the skin at the base of the belly button is pushed outward from a protruding hernia.
Differentiating the type of outie bellybutton is important as that determines how it is done and the cost of the surgical techniques to do it. An outie that is just a stump of skin (no hernia) can be done in the office under local anesthesia. The stump of skin is removed and the edges sewn down to create the innie look at a cost of $1500. If the outie has a palpable hernia, it will need to be repaired in the outpatient operating room under IV sedation. The umbilical hernia needs to be repaired at the same time with a total cost of between $2500 to $3000.
How do you know if your outie has a hernia? Push inward and see if you can feel a ring or hole underneath. Also an outie that is just a stump of skin can not be displaced inward. (the stump gets pushed in but the stump keeps its shape) The outie that can easily be pushed inward through the inner ring or hole has a hernia.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am considering jaw angle implants. I have been considering your reply to me about the possible unaesthetic fullness of my lower face due to the horizontal impact of the implant. I was wondering if this is a set figure or if some of the width could be “shaved” off prior to insertion? I am anxious not to have a “chipmunk” roundness I am truly very aware that I am by no means a beauty, far far from it, but my reasons for the jaw angle option was that I could get rid of the prominence of the jaw in my profile. I think you can see that there is quite a difference in my profile looking left and right. There is also a slight asymmetric difference in my jaw angles as the right appears to be higher. If this is to proceed then I am wondering about the length of time that I should set aside for a visit to you , consultation and surgery and recovery. I should mention that my current weight is 83kg and I understand that my proper weight should be closer to 77kg. Would dropping this weight have any affect on the procedure? I ask this as I am currently working very hard to reduce my weight with diet and lots of exersize.
Many many thanks.
A: JAW ANGLE IMPLANTS COME IN A WIDE VARIETY OF VERTICAL AND WIDTH NUMBERS AND ANY OF THEM CAN BE ADJUSTED DURING SURGERY. THE BEST WAY FOR YOU TO AVOID AN UNAESTHETIC ROUNDNESS IS TO SHAVE THE JAW ANGLE IMPLANT sO THAT IT ACTUALLY COMES TO A VERY SHARP FLARE. WITH YOUR THICKER TISSUES THIS WILL THEN NOT MAKE IT LOOK ROUND BUT RATHER PROVIDE A HINT OF ‘ANGULARITY’. THE POTENTIAL UNAESTHETIC FULLNESS IS CONTROLLED PRIMARILY BY HOW THICK THE SOFT TISSUES ARE AND THE HEIGHT OF THE JAW ANGLE. MOST PATIENTS COME IN THE DAY BEFORE SURGERY, HAVE SURGERY THE NEXT DAY AND RETURN HOME IN 48 HOURS BASED ON THEIR COMFORT TO TRAVEL. I DON’T THINK THAT RELATIVELY SMALL AMOUNT OF WEIGHT MAKES ANY DIFFERENCE FOR THIS FACIAL SURGERY. I BELIEVE YOU HAVE EXPLAINED IT VERY WELL. THE KEY IS TO CUSTOM CARVE AN IMPLANT FOR YOU THAT REALLY ACCENTUATES THE ANGULARITY OF THE JAW ANGLES. MOST JAW ANGLE IMPLANTS HAVE ROUND ANGLES WHICH IN YOUR CASE MUST BE MODIFIED.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in having superficial temporal artery ligation done. I’m a 30 year old male who over the past year I’ve lost weight and workout very frequently, which I believe has caused the superficial temporal artery on one side of my forehead to become very prominent. I’ve been checked out by a vascular surgeon and there is nothing medically wrong that is causing this. I’ve subsequently consulted with two plastic surgeons who’ve both said they don’t recommend having this removed. It’s really become bothersome to me. In searching, I found that you have provided information about performing this procedure. Do you consider this procedure safe or what are the possible risks? I guess I’m wondering why other plastic surgeons seem so reluctant to do this. Is there a possibility I could travel to your location to have this procedure done? I greatly appreciate any help you can provide. I’d really to do something about this issue and am hoping you can help.
A: Superficial temporal artery (STA) ligation is a fairly simple procedure that is often done under local anesthesia. There are no significant risks in doing it other than the small scars needed to access the artery to tie it off. Generally there needs to be at least two points of ligation to prevent backflow and return of the visible pulsations. One of these small incisions is always in the hairline and the other one or two is determined by the course of the artery beyond the temporal hairline. STA ligation is done under local or IV sedation anesthesia. There is no real recovery from the procedure as no swelling or bruising usually occurs. As this is an uncommon aesthetic facial procedure and patient request, most plastic surgeons have most likely not performed it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in scalp scar revision. I see you have extensive experience on scars from hair transplantation. Nearly twenty years ago, I had the old hair plugs and have about 1,000 elevated plugs on top of my scalp that look like mosquito bites. I tried to shave my head and get micro pigmentation to conceal them so I could wear my hair short. Unfortunately the bumps are noticeable in the bright light. I would like to have them flattened as much as possible but have received mixed reviews from Doctors. Some recommend laser resurfacing, others say kenalog injections, others say dermabrasion. What would you recommend if there is anything? My goal is to keep my hair buzzed so I would need to improve the 1,000 circular scars in the back of the scalp as well as a strip scar on the sides and back. Any recommendations?
A: When it comes to reducing the raised hair plug areas, it is best to think of it as reduction of a hypertrophic scar…as this is essentially what it is. This requires an aggressive form of skin resurfacing.. This is not an indication for steroid injections. Dermabrasion would be the best approach as it can create the greatest amount of selective reduction of each plug site. Laser resurfacing could also be used but it would have less of an effect and may take longer to heal due to the thermal injury.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in breast augmentation revision. I had breast augmentation three years ago. Right after I had major issues with my right breast implant. It was smaller and now moves around a lot, almost like its not even in place now. In addition, it is painful. My previous surgeon went through my armpit to place them and whatever he tied his suture to it is no longer attached. And he doesn’t see an issue after multiple visits. I just want to cry. I have decided to move forward and have heard multiple positive reviews from patients that came to see Dr. Eppley. Very excited to see the light at the end of the tunnel!!!
A: It is hard to tell based on your description as to the exact nature of the problem with your right breast implant. Besides being smaller and moving around more, the source of the pain is not clear. Usually pain with breast implants is associated with either a tight pocket, capsular contracture or a ruptured silicone implant. I am going to assume that since your implants were placed through the armpit that they are saline implants.
Regardless at least a right breast implant revision is going to be needed. That will have to be done through a new inframammary fold incision. You talked about ‘ a suture that was tied that is no longer attached’ but such an entity during transaxillary breast augmentation surgery does not exist so that is an irrevelant issue. The question is whether this is a pocket adjustment with more volume added to the existing implant or whether a new implant is needed. This will require a physical examination to determine exactly what needs to be done.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a custom jawline implant. Roughly what is the cost of a Custom Jawline Implant and the procedure if I want a very large implant enclosing the entire chin and jawline and angles, adding quite a lot around the angles, increasing chin projection up to 25mms?
A: A custom jawline implant is fabricated from a patient’s 3D scan. From this a completely customized implant is made from one jaw angle to the other. While any dimensions can be made on the model using design software (up to 25mms at the chin), there has to be enough soft tissue along the jawline so that the implant will actually fit into place. Realistically, having placed many custom wrap around jawline implants, a chin enlargement of 25mm horizontal advancement is likely more than the neck soft issues (which is where the skin must come from) can accommodate. This is too much soft tissue stretch when you factor in that the implant wraps the whole way around the jaw. A more reasonable approach is around 15mms or so of horizontal chin advancement. You must also factor in the lower lip position and the depth of the labiomental sulcus which will be severely left behind when the chin comes that far forward. The total cost of such an implant, all costs including fabrication and surgical placement, is in the range of $12,000 to $ 13,000.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in skull reshaping. The occipital bone on my skull is flat and I am interested in correcting this, preferably with an implant. Surprisingly, you and a Korean clinic are the only 2 places I have found so far for this procedure. I have already ready about the risks and complications for elective surgery, I have read some of your blogs and had a few other questions. How many skull implants have you preformed and what complications have you seen? Do you recommend the putty over implants or no? I would worry that the putty would cause more complications and would be harder to remove if something went wrong. How much do you charge of this surgery? How long does the surgery take and what is the procedure? Could a rhinoplasty be combined with tis surgery and at what additional cost? If I opt for a rhinoplasty, would it be better to do the skull reshaping first and base the amount rhinoplasty on the new skull shape or vice versa? Thank you for your time and consideration.
A: Skull reshaping surgery is commonly done for a flat back of the head. When it comes to occipital augmentation for a flat back of the head, there are different types of augmentation approaches as you have mentioned. Bone cement or bone putty (PMMA or HA) and a preformed silicone implant can be used. There are advantages and disadvantages to either approach. Bone cements offer materials that do bond to the bone and can be impregnated with antibiotics as they are mixed intraoperatively which are their advantages. I have yet to see an infection with a bone cement cranioplasty. Their disadvantages are that they must be molded and shaped as they are applied as a putty so they can have some irregularities and palpable edge demarcations which is the number one reason a revision on them may occasionally be done. A preformed silicone cranial implant is perfectly shaped and its flexible characteristics makes it very adaptable to the bone without edge demarcations. Its softer material also allows it to be placed through a smaller incision. But the material does not bond to the bone and ideally should be secured in place by a small titanium screw. Its infection risk is somewhat higher and it is the only cranial implant that I have ever seen develop an infection and had to be removed. (one case)
Regardless of the material, both are easy to remove and the actual material cost is not significantly different. Most occipital cranioplasties take between one to two hours to perform and total cost will be in the $8,000 to $9,000 range.
Rhinoplasty can certainly be done at the same time as any skull reshaping surgery and actually commonly done, regardless of the type of rhinoplasty needed. If one separated the two procedures, the order that are done on does not make a difference.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am looking to see if you can do a lip widening surgery technique. I have tried fillers and implants and nothing seems to work as my lips are just toooo small for my face. I look so disproportionate and really I am tired of it. I’m still single, and would really like the confidence to know that I have a beautiful smile.
A: Lip widening surgery, know as a lateral commissuroplasty, is done by opening up the corners of the mouth in a Y-V mucosal advancement procedure. The Y is in the incision pattern with the vertical aspect of the Y being the horizontal incision that determines how much the corners should be opened up. The V part of the Y are the incisions that then follow the natural border of the vermilion-cutaneous junction of the upper and lower lips. Small triangles of skin are then removed and the vermilion and mucosal are brought out from inside the mouth to make the new corner of mouth opening. This does result in very fine line scars that end up along the vermilion-cutaneous junction of the upper and lower lips at the mouth corners. This lip widening surgery is done under local anesthesia as an office procedure in most cases. Usually the width of the mout can be opened 5 to 7mms per side without causing any lip distortions. There will be a period of time when the mouth corners will feel a little tight and stretching exercises can be done beginning three weeks after surgery when the incisions are well healed to hasten the softening process.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in skull reshaping. I am a 25 year old male that has suffered from an odd shaped head. Its wide on the sides and irregular shaped on top. For years I’ve had a great insecurity every time I looked in the mirror. I have tried many different hairstyles to hide my head shape but none work for very long. I just feel like its the only part of me thats incomplete and if i have it fixed i will be so much happier and confident. I am determined to have it fixed even if i have to do it myself. I have attached a few pictures of my head.
A: What your pictures show is that the shape of your head is due to a minor variant of sagittal craniosynostosis. This is why the shape of your head has a sagittal ridge or crest from front to back and is a little elongated. Accompanying this is a parasagittal deficiency, which with the sagittal crest, gives your head a peaked or more triangular shape. The typical skull reshaping strategy is to burr as much of the sagittal crest as possible and buildup the sides to create a less peaked and more rounded skull shape.
While this is surgically possible, and a major improvement can be obtained, this has to be done through an ear to ear scalp incision. This must always be considered careful in any man who shaves his head.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a form of scalp scar revision I had hair plugs done many years ago which has left me with a lot of ‘bumps’ on my head since I now shave my head. Can these be reduced in any way so that my scalp is more smooth and not so bumpy and irregular?
A: Your scalp issue does represent an unusual form of hair transplant scar revision. Most commonly this issue relates to the donor site scar on the back of the head. But old style large follicular unit plugs can certainly be an issue if one is now shaving their head or wants to. Trying to get good improvement in your scalp situation is not an easy one even though the techniques to do it are not hard per se. Ideally what you should do is a ‘test patch’ of a scalp area with dermabrasion to see how improvement you can get before launching forward on your whole scalp. If a small area done under local anesthesia shows good improvement then you could do your whole scalp under anesthesia. On the one hand this is not the most efficient way to do it but there would be little sense in doing your whole scalp if the amount of improvement would not be worth it. This issue applies to both the donor and recipient areas. It is just hard to predict what the level of improvement would be had with dermabrasion for your hair transplant scar revision so you want gauge the depth of your efforts by testing first.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had cheek and jaw angle implants four months ago. I see that you are ubiquitous on the Internet for cheek and jaw angle implants. My question: my right jaw has been very swollen to the point where I had an MRI that shows unusual swelling. As a result I’m scheduled to have that jaw area opened up and cleaned out with hopes of immediate replacement of implant. I was hopeful that during this same procedure I would have the cheek implants replaced with smaller ones and located a bit higher in my cheek area with more emphasis on the enhancement of the upper cheekbone. My surgeon said its not a good idea to work on the cheeks because of the inflammation in the right jaw. Is this true? If I’m going to be under sedation I would prefer to have the cheek implants adjusted. It would save me a third flight and money for sedation in the future. Your thoughts?
A: In regards to the simultaneous management of your cheek and jaw angle implants, I see no problem with doing them together. The ‘cleaner’ cheek implants should be downsized first and then the presumably infected right jaw angle implant should be opened and managed. I do not necessarily believe that one infected implant will affect unaffected ones of the sequencing in surgery is done in the right order.
Dr. Barry Eppley
Indianapolis, Indiana