Your Questions
Your Questions
Q: Dr. Eppley, I am interested in rhinoplasty surgery. I guess my wish list is quite long, but I don’t want to look like a different person. I’d like to reduce or remove the hump and slightly shorten its length. Also, on front view it seems slightly crooked and very wide, especially when I smile. If you could magically decrease my excessive snoring, my husband would probably appreciate that too! I’ve spent a lot of time thinking about this and looking at pictures online. I think a lot of doctors go too far for my personal taste. One common thing I see online is when humps are removed and the nose ends up actually dipping down in the middle where the hump once was. I don’t care for that. I also think some take off too much length and drastically change the side profile. I am looking for something more subtle.
A:Thank you for sending your pictures in consideration of rhinoplasty surgery. The type of nose changes you are after is a straight nasal dorsum and decreased nasal tip length with minimal tip rotation upward. Trying to not make your nostrils flare when you smile is precarious as decreasing the action of those muscles to do that can also affect the way your upper lip moves when you smile…which would not be a good tradeoff. The best you can do in that regard is to minimize the amount that the nasal tip pulls down when you smile. As for breathing improvement that would depend on what the inside of your nose looks like and whether you have any significant airway impingement by septal deviation and/or inferior turbinate hypertrophy.
The best way to avoid having radical nose changes from rhinoplasty is to not over resect or remove too much cartilage or bone tissue. Knowing your nasal change desires as being a subtle change helps your surgeon know how aggressive or conservative to be when performing rhinoplasty surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in forehead reduction surgery. I have always had a high forehead and I have been embarrassed about it most of my life. I do my bangs everyday cause its all I can do to cover it and I get stares constantly everywhere. I wanna be like a normal person so I can get up out of bed and run out the door without having to do my hair. I don’t even get the mail unless I do my hair. I don’t even wanna go out and play with my kids unless my hair is done. I don’t get in the pool with them because I don’t want to get my hair wet around people. I want to know if I would be a good candidate for a one step procedure because I don’t want my head inflated with a balloon. Thanks so much!! (sorry my pics are horrible but I can’t do anything with my hair cutting wise or color)
A: Based on the picture you have sent, I can see your concerns about a high and broad forehead. While the picture may be somewhat distorted because of the fisheye lens effect from a cell phone camera, there is no question that you have a high hairline and what appears to be frontal bone bossing. I would need to see a side view that is not so close-up to have a better appreciation for the hairline position and how much true frontal bossing you really have.
You would definitely need a combined frontal bone reduction and frontal hairline (scalp) advancement. The key to whether a single stage procedure would offer enough benefit to make the effort worthwhile depends on how much your scalp can be advanced. That would be a function of how much natural flexibility it has (looseness) and how much it can be mobilized. There is also the question of how much hairline advancement do you need to make a difference and what is the location of your temporal hairline. (which is the most resistant to any significant forward movement. More pictures would help make those issues somewhat more clear.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in custom facial implants to correct asymmetry and deficiencies from previous corrective jaw surgery. My case is completed in that I have significant nerve damage on the left side and an existing Medpor jaw implant on the same side that doesn’t address the problem.
A: Your description of your mandible/chin concerns is complicated but that is what makes it only treatable by a custom implant approach. Using a 3D CT scan, the shape of the lower jaw can be clearly seen with all of its asymmetries and deficiencies as well as a clear view of the indwelling Medpor implant. An implant can then be designed, most likely as a single piece that wraps around the jawline, after the computer removes the Medpor implant. Surgeries like yours are challenging due to scar tissue and the never easy removal of Medpor but can be very successfully improved with the aid of a custom facial implant approach.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 20 year old male and am interested in forehead augmentation. I have a protruding occipital bone and a slightly sloped forehead. I would like to get my occipital bone reduced, and then have the bone transferred to my forehead to make it more vertical. I reckon my own bone would be a better and safer material for forehead augmentation than a foreign substance like methylmethacrylate. Is this possible? I have heard wonderful things about your expertise, and I am willing to fly all the way to the United States from Australia to get the procedure done.
A: In regards to forehead augmentation, your concept of transferring bone from the back of your head to the forehead seems logical but unfortunately will not work for many different reasons. There would not be enough bone, it would have the wrong shape and part or all of it would be resorted. The safer, easier and highly predictable option are a variety of synthetic materials that maintain their shape, can be precisely shaped, and will not ever change shape after surgery. Options include PMMA, HA or a custom silicone implant, each either own unique advantages and disadvantages.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in mandibular plate and screw removal. I had a sagittal split mandibular advancement done in 2012 with the use of 4 hole titanium plates and screw on each side of the jaw. Because I am a fairly thin person, I can feel the plates on the side of the jaw and I think they are also making my jawline wider in this area. Bone may have grown on top of them (which I am told is common) or there is a lot of scar tissue around them. Either way they make my face feel fat and I think their removal would have a somewhat thinning effect on my jawline. I went back to my original surgeon and he told me they look fine (weren’t loose) and removing them would be difficult, if not impossible, and wouldn’t make ay difference in how my face would like. Do you agree with him? Could these plates and screws be removed?
A: Your surgeon has the advantage of seeing you and your x-rays so any answer I would give would be based on incomplete information. But what I can tell you is that I have removed many times titanium hardware on the lateral cortex of the mandible in the angle and body area form either orthognathic or trauma surgery. I have yet to see hardware that could not be removed although it is never as easy as ‘just untwisting the screws and removing the plates. Bone overgrowth is common and to be expected. Often a thin film of bone covers the hardware and fills the screw slots. Some screws occasionally may have had their heads stripped while being tightened. You just never know what you are going to get. Burring off the bone from the screws will often destroy the screwheads which can make it very difficult.
One technical aid I have used recently is the Sonopet system for bone cutting and removal. Using high energy sound waves can very effectively remove the bone layer on the plates and screws with less trauma to the metal screw heads. It can also precisely and carefully remove bone from around the plate to get under it.
Whether removing the hardware will make your face thinner is matter of how big the plates are and the bone coverage that they have. But up to 5mms of thickness can be reduced from where the hardware once was. This can help reduce some width along the jawline in that area.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, In 2010 I had vertical Medpor jaw angle implants implanted. I am not so pleased with the result so therefore I would like to remove them. Is this possible?
Also, I would like to replace them with lateral width jaw angle implants, this is what I wanted in the first place but there was a miscommunication between myself and my previous doctor. If possible, and I know that it differs from case to case, what is the average approx. cost for this procedure? I would be flying in from Eurpoe so I would like to do the consultation and surgery in one trip. I can send pics to help before the consultation. Thanks.
A: I have had the experience of removing numerous Medpor jaw angle implants and replacing them with silicone-based jaw angle implants of various dimensions. Medpor implants can certainly be removed successfully although it is somewhat tedious as the tissues can be very adherent to them. It often can be just as traumatic to the tissues as their initial placement…and sometimes more so. But it can be done without any damage to the bone. Once the implants are out, there is plenty of room (pocket space) for the new silicone lateral width implants. But because silicone is a smooth material and the tissue pocket will be much bigger than the implants, it would he critical to secure the new jaw angle implants in with screw fixation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have been an admirer of your work for some time & consider your website an invaluable resource for patients seeking to inform themselves in regard to cosmetic procedures.
I am a young male in my late twenties. My question relates to cheek implants. Specifically, I am looking to address two issues and I am hoping you might offer me some insight & the benefit of your expertise to provide advice as to what might be suitable choices. I have some asymmetry, my right cheekbone is less pronounced and has less anterior projection than my left side. I prefer the left side. I have also lost some weight & this has contributed to a loss of mid-face volume and deepened nasolabial folds. I do however have fairly good malar projection laterally, especially on my left side.
Would you advise me to address these issues with submalar implants of differing sizes or perhaps a combination implant on one side or both? I wish to avoid feminising my face through excessive lower cheek volume, but I am very keen to mitigate the asymmetry and restore lost volume in the midface. I would like to achieve the classic “v†shape model look if at all possible, but addressing the two issues I described is my priority.
Thank you for your time and attention.
A: In regards to your cheek asymmetry, the issue is whether you should just correct the right side to better match the left or do both sides with differing size and shaped cheek implants. The issue with either approach is how to best obtain symmetry. To do so you have to have a stable target so to speak. It is more predictable with standard preformed implants to just do the right side to try and match the left. But when it comes to implanting both cheeks that are already very different, it is pure guesswork with preformed implants. And such guesswork will undoubtably lead to improved cheek and midface volume but persistent asymmetry of some degree. If you are going to both cheeks, it is probably best to consider custom designed implants to get the best coverage and volume with the best shot at achieving much improved symmetry.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a sliding genioplasty reversal. I had a 6-7 mm sliding advancement genio a little over four months ago (no vertical change, just a straightforward Sagittal advancement secured with a single titanium bone plate). From the beginning, I hated it. Even as the swelling has gone down I think it makes me look masculine, old, and like I have gained weight. I regret it so much and cry every day. I know I can’t go on like this but I am worried that reversing the procedure completely will give me jowls, which I never had to begin with. I understand you have some experience with reversing the procedure and I’m wondering if you think I will ever look like I used to. Thanks and please write back as soon as possible, I am becoming extremely depressed.
A: Sliding genioplasty reversal surgery can be successfully done. I have done two such procedures just in the last month. I do not have a picture of what you looked like before to see if you can return to your previous look. But that issue aside, if you put the chin back form whence it came I see no reason why you wouldn’t return to your preop appearance. You are obviously young with good skin elasticity so you should return without a high risk of jowling. The way to hedge that risk of howling in a setback genioplasty is to just go back 4 or 5mms and end up with an overall 1 – 2mm advancement change from the original. There is some reason you had the genioplasty and this may be a good compromise approach.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a question regarding capsule formation that I was hoping you could clarify. I have heard what I believe is misinformation that the material of Medpor facial implants produces a different aesthetic outcome than silicone facial implants in terms of chin/jaw implants . The reasoning this individual used was that silicone implants form a capsule and therefore the appearance of such an implant will always appear “off”, and that Medpor implants will not result in such a capsule.
Correct me if I’m wrong, but I believe that Medpor also forms a scar capsule (albeit a smaller one) and that while silicone forms a capsule, it is not one that has any significant or noticeable aesthetic impact. Capsular contracture can form aesthetic complications, but that is a actually rare complication not common to chin or jaw implants.
Is my understanding correct? If one were to make a custom silicone implant the exact same size and shape as a Medpor implant, wouldn’t the aesthetic outcome be identical?
I would appreciate any clarification you could provide on this topic.
A: All implants placed in the body produce a surrounding scar, whether it is a facial implant or a breast implant, regardless of the material. This is a natural protective reaction of the body. (self vs non-self) Thus both silicone and Medpor facial implants produce a surrounding scar (capsule) with the only difference being is that the capsule produced around a Medpor implant will be more adherent or stuck due to the irregular semiporous surface of the implant. The scar capsule will also be slightly thicker as a result.The internal surface of a silicone implant capsule will be very smooth (and thinner) since the implant surface is smooth. But beyond that, the biology and make-up of both implant material’s capsules are similar.
From the outside and its aesthetic results, identically shaped and sizes of Medpor and Silicone facial implants will look the same.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a consultation with a plastic surgeon last year who had all my personal information prior to the visit. Within two minutes they told me they don’t do any surgeries of any kind on cancer patients who had received radiation. I was upset, mad and disappointed because they knew all my history. Then I was charged $125.00 to be told that. Are plastic surgeons not doing surgeries on cancer patients? I do not need reconstructive work. I only had a lumpectomy but I would like smaller breasts and a lift. Any information would be greatly appreciated.
A: Reconstructive and cosmetic surgery can be done on the irradiated breast but it requires different considerations and surgical approaches. The irradiated breast, which may appear quite normal, is not. Its ability to heal is compromised by the negative effects of radiation on the blood vessels that supply the breast tissue, skin and nipple-areolar complex. A surgical procedure will likely unmask its limited healing ability resulting in incision separation, skin necrosis and partial or complete loss of the nipple.
In reconstruction of the irradiated breast, this well known compromised blood supply is managed by bringing in normal tissue that has a good blood supply through tissue flaps such as the LD, TRAM and DIEP. Such drastic’measures in cosmetic breast surgery, however, are obviously not warranted.
The choice in the irradiated breast patient that wants to undergo a cosmetic procedure like a breast lift is to either take the risk that no such complications will occur or to improve its healing capabilities. Improving the blood supply of the irradiated breast is done by initially doing first stage fat injection therapy. Through liposuction harvest, fat is concentrated and injected through the breasts implanting fat and stem cells. This approach has been well shown to obviate many of the negative effects on the tissues caused by radiation. Three months after the injection therapy, a breast lift/reduction can be more safely done. It may seem counterintuitive to initially make the breasts a little bigger by fat injections but this therapy completely changes the vascularity of the tissues which is essential to heal from any tissue injury.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’ve been perusing through your blog and I’m curious about forehead augmentation. I would like a more masculine brow bone and forehead. I feel like mine is flat. I’ve attached a profile view. Do you think it would be beneficial to my appearance. What I don’t like is my forehead starts to slope back starting from the brows. I would like it to be more square as if a stick was held against the forehead, more of the forehead would touch the stick instead of only the brow bone. From what I gather, the most economical option is using PMMA bone cement, correct?
A: Forehead augmentation can be done by using either intraoperatively applied PMMA bone cement or a custom forehead implant. The cost differences between PMMA and a custom implant are not really that different. While PMMA bone cement cost less (the material) than a custom implant, most of that material cost savings is offset by the increased time too place and shape the material. A custom implant costs more than the PMMA material to fabricate but is done in half the operative time, with smaller incision and a lower risk of potential revision due to shape. In the end, both forehead augmentation techniques cost about the same.
In the past, PMMA bone cement was the only forehead augmentation option available. But computer design technology is now making custom implant designs not only possible but affordable.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in the brazilian butt lift. I originally booked the procedure with another doctor. However, he will not be available for the procedure now and he mentioned you as one of the doctors I should see. I am hoping to get the same service as he was providing, which was liposuction of the arms, back, abdomen, flanks and inner thighs with a minimum 1000cc injected into each buttock.
A: I certainly do a fair number of Brazilian Butt Lifts. The key question, however, is whether you have enough fat to harvest that could be filtered and concentrated to be able to inject 1000ccs per buttock. That would be exceptionally unusual. To be able to get 2000cc of injectable fat, you would have to have close to 6,000cc (6 liters) of fat to harvest. That may be possible in you but since I have never seen your body I could not tell if that was so. What most patients don’t understand is that only concentrated fat should be injected not just the liposuction aspirate. Taking the liposuction aspirate and getting rid of the blood, broken fat cells, free lipids and the tumescent solution usually results in a 60% to 70% shrinkage of volume of ‘fat’ that has been harvested. Thus only about 1/3 to 40% of the lipsuction harvest ends up being useable for injection.
For most Brazilian Butt Lift patients, the maximal amount of fat that can be harvested and injected is done as most patients have an overall deficiency of fat for the procedure (based on their goals) rather than an excess. For this reason, I do not promise any patient that a specific amount of fat will be injected as that is an unpredictable number until the fat is harvested. I would have a good feel for an approximate amount that could be done in looking at one’s body and thus an estimate could be given before surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley,I’ve had a bad experience with a primary rhinoplasty making my nose too thin, specially in the upper area where my eyes are (T shaped). I believe the cause of this is overly aggressive osteotomies. I have morphed a picture where I make the upper third of the nose wider (Y shaped). Would you mind telling me if this is possible with a revision? Thank you for your time. Looking forward to hearing from you.
A: The nasal bones can not be recut and expanded to create that shape in the upper nose. A revision rhinoplasty using outward osteotomies is not stable and will not hold even if they could be cut to make that shape. Widening the nasal bones is hard enough but to make the nose have a T-shape (or return to it) would be impossible by just moving the nasal bones. The only way to create that shape would be by adding a material or graft to the outside of the nasal bone. That could most easily and assuredly be done by making a small custom implant to fit over the radix to create that exact shape using a 3D CT scan. This is a perfectly safe place for a small nasal implant. It could also be done using graft materials such as cartilage, bone or acelluar dermis but there are shaping/contour concerns with this type of revisional approach and issues of symmetry and smoothness would be a concern.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had jaw surgery two times and now have lip damage. Bottom lip seems paralyzed or damaged. (lower lip asymmetry) I saw online and seems others have had the same problem. I have seen it may be hyperplasia of depressor orbis lip muscle or paralysis of lower lip nerve. I don’t know what it is. Do you think it is nerve damage or muscle damage? Is it likely to be permanent damage after jaw surgery or temporary? I has been one year now and still no change. It is less obvious when relaxed but when make ‘O’ shape with lips or kiss shape with lips or smile it pulls down to one side on my right. The left side doesn’t pull down. I did think it was the right side which shows lower teeth when smile which is the problem side but actually I think after research it is the left side which doesn’t show any teeth when smile which is the problem side. I have seen certain solutions are to use Botox but are there any other options? I want something permanent. Can a surgeon correct it with more invasive surgery? Can they maybe correct the problem side or maybe damage the other side so both don’t show lower teeth when smile because personally I think that looks better to only show upper teeth. I really need your help doctor. Please help thanks.
A: What you have is paralysis of the left marginal mandibular branch of the facial nerve. This tiny nerve branch supplies movement to the depressor muscle of the lower lip. With the nerve being paralyzed that side of the lip does not move down normally while the opposite right side does. With no lower lip movement on the left, the normal righth lower lip retraction looks exaggerated and overly pulled down. This lower lip appearance can make one think the side of the lip that moves is the problem when in fact the th higher lower lip side is the culprit of the lower lip asymmetry.
At one year from the injury with no movement, there is no reason for optimism that the paralyzed nerve will start working again. I wouldn’t say it is impossible but very unlikely. There is no method to make the nerve work again other than natural healing. Thus the treatment for lower lip asymmetry from permanent marginal mandibular nerve paralysis is to weaken the opposite side whose muscular movements are exaggerated. This can be done by Botox injections (temporary) or by partial resection of the depressor muscle from an intraoral approach. (permanent)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am looking to get cheek implants soon. I am also interested in having a hair transplant about 6 months after I have cheek implant surgery. My question to you is do you think it is safe to have a hair transplant after cheek implants? …. Is there any risk of infection to my cheeks implants? … during the hair transplant they will poke the front of my hairline hundreds of times. Can this in any way effect my cheek implants ??
A: This is a thoughtful question that speaks to the potential of bacterial seeding of any implant in the body due to bacteremia (release of bacteria in the bloodstream) after any invasive procedure. I think as long as your cheek implants are well healed and have an intact mature capsule, this potential risk is very low to negligible. It can easily be compared to having a dental cleaning in which one has any implant in their body. This is clearly not a problem of any magnitude given the millions of people who get their teeth cleaned or undergo any dental work and have surgical implants of many varieties and anatomic locations. But to be safe, and this would be done anyway, take an antibiotic starting one hour before the surgery and then for a few days after.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had chin implant replacement done 3 months ago. I had a Medpor chin implant replaced by a silicone square chin implant as I wanted more squareness to my chin and wanted it wider. Today is officially 3 months after surgery and it’s been frustrating for me. Two sides of my chin where the previous wing were removed are still presenting irregularity and swelling. When I touch it it feels kinda soft and tissue like. I’m not sure it’s the capsule or scar tissue still remaining there. It makes the two side of chin still look like swollen and the jawline is not straight at all. But it is definitey improved since the first month after surgery .I’m just really anxious about it everyday now and I’m wondering when will it fully healed? I have searched online and some people says steroid injection can be done. Should I do that? I’m pretty sure the implant placement itself is fine but the capsule or scar tissue is making it look bad. I hope you can help me 🙂
A: Full and complete healing after any facial skeletal surgery can take up to 6 to 12 months after surgery to see and feel the final result. This can certainly be true for revisional chin implant surgery where one iimplant (that is well scarred in) is replaced by another chin implant. The important question is whether the fullness that you see is do to scar tissue/healing or that the implant is simply too wide/big. If it feels soft and tissue like then I would say there is still healing going on and more time would be the appropriate answer. I would not advise steroids as that is an uncontrolled drug treatment that can have adverse soft tissue effects (atrophy and indentations) and thus it can create just as many problems as it may solve. The only injectable treatment to consider is 5-FU injections which can help settle scar tissue but has no soft tissue atrophy effects. Otherwise, if the sides of the chin feel hard, then this is an implant issue where it may be too big or wide
The steps to take now are either 5-FU injections and/or continue to give it more time. At the minimum I would give it at least six months from the last surgery before contemplating anything invasive.
Dr. Barry Eppley
Indianapolis, Indiana