Your Questions
Your Questions
Q: Dr. Eppley, It’s been one month since my sliding genioplasty surgery and I am starting to feel that my results are just getting worse every day. I’ve attached some pictures for you to see. My whole right side of my face looks rotated upwards & even more crooked than before. Is there any chance this is going to get better? I have a dent and now I also have lines on my right side.
A: I think it is important to understand that four weeks, which seems like an eternity when one is the patient, is a very brief time after surgery and many issues have yet to resolve or become clear. In intraoral genioplasties I do not judge the aesthetic outcome and any functional issues for at least six months. When the mentalis muscle is disassembled, the bone cut and moved and the muscle then reassembled, many expected short-term issues will appear. Stiffness and aberrant movements (soft tissue distortions) of the chin pad will initially develop as it heals as one might expect from such disruption of the anatomy. These almost always resolve but it will take time and patience to get there. Until all swelling, numbs and stiffness of the tissues resolve, you are not close to what the final functional outcome may be. The resolution and complete adaptation of the soft tissues down to the bone always takes much longer than any patient thinks. It would be impossible that your face is more crooked than before surgery given exactly what was done. Again the six month time period is when the true final outcome can be determined.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley,I am mainly looking to improve my profile and get more projection from my chin although I think I would benefit from slight additional vertical length as well. I have done a fair amount of research about the various options for recessed chin (jaw surgery/ sliding genio/ chin aug) and understand chin aug to be the least invasive of them all. I have an overbite that was made slightly better with braces about 2 years ago, but during the process I had 4 teeth extracted which seems to me has made my jawline/ dental arch narrower(may be just in my head). My dentist has said that my overbite is not too bad but I want to make sure that a chin aug alone would be sufficient for my needs or should I be looking more at orthodontic options.
A: Thank you for sending your pictures. With your amount of horizontal chin deficiency and your dental/orthodontic history, there is on doubt that the origin of your chin concerns is a result of overall lower jaw growth deficiency. While major jaw surgery/orthognathic surgery would more ideally address that problem, it would be a very difficult and long road to go through orthodontics before and after surgery not to mention the actual jaw surgery itself. And you would still need some type of chin surgery done with the jaw surgery. Thus this leaves you with either a chin implant or a sliding genioplasty as more practical treatment options. To really add a vertical increase to you chin as well as a horizontal one, you ideally should have a sliding genioplasty. A chin implant to achieve that same type of result would almost have to be custom made to achieve similar dimensional changes.
Dr. Barry Eppley
Indianapolis, Indiana
Dr. Eppley, I am looking for temporal implants due to significant thinning of my face with age and weight loss. I would also be interested in possible fat transfer or other procedures to fill my cheeks in some. Would like to consult on what my options are. Here is one old photo of me 30 years ago, I don’t ever expect to look that young again, but I would like my face to be plump or full looking again like it used to be. I’ve lost a lot of weight and my face now looks sunken and sickly. Please help me. I am embarrassed by my appearance.
A: Thank you for sending your pictures. You have very classic panfacial soft tissue volume loss which is very common in significant weight loss particularly in an older person. It affects some individuals more so than others. This is most manifest in your temporal region where it has turned into a complete concavity from the zygomatic arch all the way up to the anterior temporal line on the forehead. It is seen less severely in the cheek area only because your naturally high cheek bones have preserved some of the volume. (there is no bone protecting the temple areas) For your temporal areas there is no question that an extended temporal implant is the preferred procedure as it will create a permanent volume solution to that problem. It requires an extended temporal implant as opposed to the standard one given that it needs to reach all the way up to the forehead. For the cheeks your options are submalar cheek implants or fat injections. Each one has their own merits. (fat is better at total area volume addition but its survival may not do well given your age and lack of natural fat in the area…an implant has assured permanent volume but only provides volume to one specific area) In facial volume lose cases like yours I will often combine submalar cheek implants with fat injections to get the best of what each has to offer.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in umbilicoplasty surgery. My belly button has been this way for about 10 years, ever since the birth of my son. It has been the source of my insecurity and I am so self-conscious about it that I can’t even wear a fitted shirt because it clings to my belly button and creates this weird looking indent. I hate it and fixing it would make me so incredibly relieved and ecstatic. I can’t afford a tummy tuck and even so I would hate to go thru all that just to fix one little thing. I really sincerely hope something can be done.
A: Quite frankly, your belly button concerns are due to the excessive surrounding tissues that are collapsing around it and engulfing it. This is not a belly button problem per se, it is due to excessive abdominal skin and fat. Thus there is no umbilicoplasty surgery that is going to correct it nor would it even be wise to spend any money trying it as it will not solve your concerns. What you need is a fully tummy tuck which will treat the real source of the belly button problem by removing all the excessive tissue and in the process create a new belly button. While you may not be able to afford it now, it is much better that you wait until the day you can and then have the correct operation. That is a far better financial decision as an umbilicoplasty surgery now would be a disappointment and waste of money.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting a cheek implant. I was in a car accident ten years ago and had reconstructive surgery on right side of face. You can see that my fave is fuller along the jawline and lacking fullness on the apple of my cheek. I’ve had fillers for years to temporarily fix the problem area but I hate it. I’m ready for a permanent fix so I can feel beautiful. You can see in my attached pictures my facial asymmetry problem.
A:Thank you for sending your pictures. You have the classic cheek deformity that often occurs after a zygomatico-maxillary (cheekbone) fracture where the projection of the cheek is ultimately lost from inward translocation of the arched cheek bone complex. Given your naturally very high cheekbones (as seen on your left side) it would be easy for such a fracture and even its repair to match the naturally high cheekbone projection that you have. You are correct in that there is a simple fix to that concern by placing a cheek implant on top of the most depressed portion of the bone. This is done through a small incision inside the mouth.The key is both the proper cheek implant shape and size.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a chin implant placed through a submental incision three months ago. I’m really in a tough spot with the chin implant because I really can’t live with this crooked smile I’ve had since post op, but no doctor knows what’s causing it or how to correct it. I’m seriously thinking of removing it without replacement in the hope that my smile will return, but I have concerns about post removal complications like witches chin deformity or scar tissue balling. If I remove it, it will be five to six months post op at the earliest. This was a large extended anatomical implant, and I’ve read doctor opinions on Real Self where they’ve expressed concerns about removing a large implant without replacement more than a few months post op. What is your take on all this? Should I only have a doctor perform this procedure if he does it a certain way? For example, only go with a plastic surgeon that can recognize, during surgery, if a submental tuck up is needed, as well as one that has me wear a chin compression sling post op? I wonder too if, since my jaw is on the smaller side, could this implant be ‘too tall’ and be limiting my mentalis muscle, in turn affecting my smile? If I were to go with another implant, should I be sure the doctor’s comfortable shaving it down to be no taller than say 1.0cm or even less than that? The large Terino implant is 1.3cm at its tallest point in the center. Please see the 2 attached 2 X-ray’s taken recently if they are of any help in your assessment.Thanks for your help!
A: With a chin implant that is only adding 6mms of horizontal projection, I would have no great concerns that removing it would create a witch’s chin deformity or a chin ptosis. If the implant is removed I would see no reason that a submental tuck would be needed. Simply putting back and tightening the mentalis muscle should be enough. When trying to solve a problem, don’t complicate it by adding too many variables. Either simply remove the implant or have the one you have now repositioned a bit lower on the bone. It is sitting just a tad high on the bone right now. While that may or may not solve issues, these are simple chin implant revision maneuvers that at the least will not create any further complications.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like your opinion on something. Over the past few months I have noticed deep ridges in my forehead which run a long the forehead veins. I went to see a dermatologist for fear it was en coup de sabre, but was told the skin didn’t seem like that. I’m 46 years old, thin and female. I am extremely depressed about it as it looks like I’m a Klingon when I look at myself in shadowy light. in bright light it is OK. I was thinking of having a face lift in the UK later in the years so don’t know if anything could be done about it then. Is this something you could address? I was wondering whether maybe forehead cement but then would that be possible with the veins where the ridges are and would that push the veins up to make them bulging instead. Yours desperately.
A: Thank you for your inquiry. I would have to see pictures of them but most likely it is forehead veins and not linear scleroderma. I have seen this quite a few times. These veins, when deflated, can leave long vertical grooves in the forehead which is often paired. How to treat them is challenging. The concept of bone cement on the surface makes sense but would likely leave raised ridges and may likely cause its own aesthetic problem. The other alternative is fat injections placed around them. Since fat is injected with blunt cannulas there is little risk of entering the veins or disrupting them.
The key issue is what these forehead grooves look like in three positions, when standing up, laying down and then with your head bent over. (head lower than your heart) This will make the diagnosis that this is indeed forehead veins. Those three pictures would be very helpful.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in rhinoplasty and have several specific concerns/goals I want to achieve.The only other thing about my nose that I am most uncomfortable with is the lower part of my nose. It appears that my columella is hanging or sagging. I really don’t like the way that part of my nose looks. The nostrils also appear higher than the bottom part of my nose and you can see the inside. I am not sure if this is because of natural Alar retraction or because the columella is hanging down? Both? Neither? The nostrils themselves are kind of “pinched”. They are very narrow and a lot of times I feel like they are the biggest cause of my breathing problems as they seem to collapse some even during normal breathing. Also, Is it possible to change the angle of the tip more upwards? It may just be the bottom part of my nose that makes it looks like its not angled up but I am really not sure? I know that you have said that anytime you make the nose smaller you risk making breathing problems worse. Is it possible to make the nose wider? Like the nostrils or the base itself? If so, would this help with breathing?
A: I would not call your columella a true hanging columella. This is controlled/treated by the reduction of the caudal end of the septum (which is necessary to tip rotation) and removal of any redundant columellar mucosa.
One of the hardest things to improve in any nose is nostril show. This will be potentially magnified with any degree of tip shortening/rotation that is done. Alar rim grafts are placed to combat it but there is no guarantee that it will not be a persistent issue. Pinched nostrils are treated through the use of batten grafts to provide improved lower alar cartilage support.
The best strategy to manage breasting difficulties in a rhinoplasty are middle vault spreader grafts to help open up the internal nasal valve.
The combination of extensive cartilage grafting (columellar strut, alar rims, batten and spreader grafts) is the most one can do to improve nasal tip support and open the anterior nasal airway as much as possible.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I got a 7mm Medpor Chin Implant put in on January 20, and I want it removed ASAP. Its too bulky and makes my face look less feminine than before. What are the chances of my face going back to the way it was before? Would another implant need to be put in? my doctor doesn’t do silicone chin implants for their tendency to drop overtime so Medpor it was. I’ve heard how difficult these implants can be to remove, what’s your experience with removing them? If I was to replace with a silicone implant, is it better to do it when removing the other or a few months later?
A: I am not surprised that a Medpor implant is too bulky for a female. While that implant needs to be removed, it is important to always remember that you had a chin implant placed for a reason and that was to correct a chin deficiency. This may be the wrong implant but that does not mean that there is no merit to having a chin implant at all. A better shaped and more feminine chin implant made from silicone would offer horizontal advancement with far less width if any at all. I would strongly consider replacing the implant rather than merely removing it. I have to see you throw away the complete effort.
I have removed many Medpor implants. While they are not as easy to remove as silicone it can be done. I have never heard of silicone implants ‘dropping over time’. There jus no biologic explanation for that and something I have never seen. It is better to remove and replace at the same time (with screw fixation of the new silicone implant) than to delay. The only reason to delay/stage it is if you are uncertain that you really want an implant at all. But that will change what is done during the implant removal. If you are just removing then you need to do a submental tightening of tissues since the tissues have been expanded to avoid a chin pad drop/ptosis.That ail not be necessary with a chin implant replacement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I contracted polio when I was an infant from a vaccination, which resulted in atrophy of my left leg. Would fat grafting or thigh and calf implants help to make my legs more symmetrical? I know the discrepancy looks severe so I don’t have expectations of perfection but I’m hoping something may be done to lessen.. possibly with the combination of both procedures.
A: Thank you for sending your pictures The easiest and less severe component of your leg asymmetry is that of the calf. One calf implant placed on the inner half would go a long way to improve symmetry below the knee. Two calf implants would produce near symmetry inj size to the other side.
The thigh deformity is the bigger part of the leg asymmetry and the more challenging to improve due to its magnitude. Injectable fat grafting would be the only treatment that can be done and its success is partially dependent on how much fat you have to harvest. This combined with how much fat survives determines that outcome. Based on the performance of the first procedure (and how much fat you have to harvest) you may need a second fat grafting session to get the best possible outcome.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, is there a chin implant that can make a cleft chin? I would like to get a cleft with my chin implant augmentation and I am told that cleft chin implants exist but do they work?
A: Contrary to popular belief, a chin implant that has a central cleft in it either manufactured that way or intraoperatively put in it will not create the appearance of an external chin cleft. It seems like that chin implant approach would work but it does not.
The key to making a vertical cleft in the chin when using an implant is to use/make a clefted chin implant but then the overlying soft tissue must be thinned out and then sewn down into the implant cleft or even all the way down to the bone. What makes it work is the suture technique down to the bone.
I wish it was as easy as putting in a cleft chin implant and creating a visible external chin cleft…but it is not.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I recently had rhinoplasty (4 weeks ago) and I am extremely unhappy with the result. I asked my surgeon to remove the bump on my nose but it is still there and also my nose looks extremely wide. I was wondering if this could still be due to swelling- and if so, how much can I hope for it to go down, and if not, how soon do you think I could get a revision – I really want to be able to feel comfortable with myself before I go to back to school in September. I’ve attached some photos – as you can see my bridge is very wide and there is still a noticeable bump- could these just be caused by swelling, is there a chance they could go down completely/a lot?
A: In trying to answer your questions, I am at a significant disadvantage. I do not know what your nose looked like originally and know no details of how your rhinoplasty was done. These pieces of information are critical to know as to whether the eventual resolution of swelling will produce a favorable outcome or not.
But let us assume that the outcome of your primary rhinoplasty is not favorable, the timing of any revision rhinoplasty would depend on what needed to be done. This would not be before three months at the minimum and likely six months after the original rhinoplasty procedure. The nasal tissues need time to heal and have all the swelling fully subside.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have this terrible vertical line in the middle of my forehead and I really want it gone. Can you help me?
A: Vertical wrinkles in the forehead are a result of overactivity of the corrugator supercilii muscles. These are small muscles that run obliquely from the inner aspect of the eyebrow under the more superficial frontalis muscle and pass inward towards the central area between the eyebrows to insert to the underside of the skin. When these muscle contract they pull the inner half of the eyebrow inward. With both sides pulling inward together this creates the vertical lines between the eyebrows that many people have. This is why the name corrugator supercilii, which comes from Latin, means the ‘wrinkler of the eyebrows’.
The corrugator muscles are known as the frowning muscles and they produce a variety of vertical line patterns between the eyebrows. The most common are a pair of vertical lines, known as the 11s, and is the basis for the use of Botox injections to reduce their prominence. In some people a single deep vertical line appears, just like the one you have. They are often very deep and are the hardest of all vertical forehead lines to treat.
This is definitely not scleroderma which appears more liken shallow groove and does not appear in the midline. This is a deep expressive wrinkle (deep vertical line) which shows deep inversion. I would not think some much of fixing it as it is not that simple…but treating it to make it less noticeable. This is caused by excessive muscle action but not has become a deep etched vertical line which will not be resolved by simply weakening the muscle. (e.g., Botox injections) The hardest part of its treatment is to get the deep indentation back up and level with the surrounding skin. The simplest and most effective approach, but the least appealing, is to cut out the indentation and put it back together in a geometric closure pattern. (small running w-plasty like forehead scar revision) There is no more effective long-term skin leveling strategy than this approach but it is like trading one scar pattern (indented and vertical) for another pattern. (smooth and small irregular line) One could certainly argue that this is probably a much better ‘scar pattern’ than what you have now. The alternative non-excisional treatment would be to place something under the indented scar such as fat injections, a small dermal-fat graft or temporalis fascia. This would create less of an indentation that would not be quite as deep.
As you can see, the ‘fixing it’ strategy is not what can be achieved. It can only be improved and it is just a question of how one feels about either the options of a smoother fine line scar or simply less of a vertical indentation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m wanting to do a Brazilian Butt Lift lift. Can that be done at the same time as with a Mommy Makeover?
A: A Mommy Makeover (breast and abdominal reshaping) and a BBL (Brazilian Butt Lift) can be done at the same time but it create a very difficult recovery. It would all depend on what the exact Mommy Makeover procedures need to be and whether such a combination may negatively impact the results of any of the three procedures. For example if the Mommy Makeover needs to include a full tummy tuck there will be less fat that can be harvested for the BBL to avoid compromising the healing of the tummy tuck incision. I would need to make that evaluation during an actual consultation or you can send me pictures of your body type for a preliminary evaluation.
While it is always desirous to maximize the number of operations one can do in a single setting for economy of recovery and economic resources, there are operative combinations that can ‘fight’ against each other and may even compromise their results. This needs to be looked are carefully in these type of body contouring procedures.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in orbital rim implants. I am 23 years old with severe depressions under my eyes. I’ve had them since I can remember. I’ve tried everything. Special vitamins, creams, makeup, nothing works. I also have dark colors as well. I am more concerned with the depressions though. You can cover up color, but not hollowness. I went to see a local plastic surgeon and he basically told me nothing could be done. “Try our cream, and makeup” is basically all they said is necessary. I am tired of looking this way. How much does the implant surgery cost? I am so desperate. Thank you.
A: When it comes to infraorbital hollowness/tear troughs, this is an anatomic problem of either lack of soft tissue volume or inadequate bone projection. These are most commonly treated today through the use of temporary injectable fillers. In my opinion, however, these should only be used a trial method to see if soft tissue voluminazation would be effective. They are certainly not a long term strategy particularly when ine is very young and this is a congenital anatomic issue.
Longer-term surgical treatment options would be either the use of injectable fat grafting or infraorbital rim implants. (sometimes called tear trough implants although these are not necessarily the same) Each has their role and the choice between the two would depend on what your depressions under the eyes look like. I would need to see some pictures of your eyes to make a more definitive recommendation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in breast reduction surgery. I am 24 years old, 5 feet tall and pregnant. I was a 32C before and am currently a 32G. You have high reviews on Real Self. I struggle with stretch marks on my breasts and have no faith in my breasts shrinking after because of them. I am interested in a combined breast reduction and lift.
A: While you may ultimately need some combination of a breast reduction/lift, it would be important that you wait a full six months after delivery before having the procedure. You want your breasts to fully shrink down and be a stable size with whatever sagging may ensue. In essence you want to have a ‘stable target’ to operate on so the breast reduction result does not change appreciably afterwards due to still evolving changes in your breasts.
You may also be surprised how much your breasts will shrink after delivery. What seems like a breast size that can never go down adequately can actually even end up too small later. The sagging will not improve with time and a breast lift may ultimately be needed but it is way too early to say that you need a breast reduction as of yet.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, We are interested in chin reduction for our daughter. She is now 17 years of age. Through her orthodontist we have been told that she wiuld need a chin reduction. We have been to visit a plastic surgeon in our local area who is willing to operate on her but we would like to find someone with your level of expertise. We would like to what your thoughts are on what type of chin reduction surgery should be done. I have attached some pictures of her for your assessment. Many thanks.
A: That you for sending your daughter’s pictures which is extremely helpful. She has an unusual excessive chin problem as it is very horizontally protrusive but also vertically short. This creates a prominent chin ‘knob’ deformity. While I don’t know what the bone looks like underneath (it would be helpful to see a lateral cephalometric x-rays from her orthodontist who undoubtably has one) her excessive chin problem is both a bone and soft tissue issue. Both have to be addressed to produce a satisfactory chin reduction result, removing soft tissue alone will not work. While the bone may be horizontally excessive, her chin is also vertically short. Her entire lower face is actually vertically short compared to the rest of her face. Ideally you would want to convert the excessive horizontal bone to increased vertical chin height. This would stretch out some of the horizontally excessive soft tissue which is just following where the bone is. Then any excessive soft tissue could be removed. While this may be the ideal approach, it would entail two stages to do so. The other approach would be a one-stage submental chin reduction with removal of excessive horizontal bone which would then allow some of the excessive soft tissue chin pad to be removed and tucked under. This would still leave the chin vertically short but would offer significant improvement in a single surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I recently had scalp expansion (last surgery two weeks ago) and it looked great. Now two weeks later, I am losing most of my hair next to the suture line and where the expander at the top of my scalp was. Is this normal or will I now need yet another surgery to repair this damage?
A: Le me explain the infrequent phenomenon of scalp expansion hair loss. It is not rare to have hair ‘shedding’ (temporary condition) from the stress of a tissue expander if the amount of scalp expansion is large or is being done in the presence of existing scalp scars and tissue loss. This should to be confused, which is an understandable confusion, with actual hair follicle loss. (permanent condition) Hair is very sensitive to stress since it easily be changed into the telogen phase where the hair shaft separates from the hair follicle. Once the stress period is over (after the scalp surgery is complete) the hair follicles will resume growth at some point and new external hair will begin to appear. There may or may to be some scar widening from the tissue expander insertion site.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have had two chin reductions, a sliding genioplasty and bone burring and a chin lipectomy. Now my chin has collapsed, please help me to know what to do for a chin reduction revision?
A: Based on your history of two intraoral bony chin reductions, the overlying soft tissue appears to have ‘collapsed’ or become completely balled up over the chin. This is what can happen when intraoral approaches are done for horizontal chin excess. Intraoral bony chin reduction relies on the excess soft tissue chin pad to somehow shrink down and become less over a reduced bony chin prominence. While that may work for a very small horizontal chin excess, larger reductions result in the chin soft tissues just contracting down into a mass of distorted and indented soft tissue. This is why a submental approach which reduces bony and soft tissue is the better choice as it prevents what appears to have happened in your case by reducing the soft tissue as well as the bone.
The question is how best to release the contracted chin tissues and restore their volume. There are two basic approaches. First, if one is happy with the horizontal chin projection fat injections can be done to expand out the soft tissue a bit and try to soften it. The second approach is if one can tolerate a little more horizontal chin projection, the soft tissues can be released through a submental approach and a small chin implant can be used possibly with a little bit of fat injections.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a custom occipital implant three months ago. While I was initially thrilled with the results, I now feel that I wish it was bigger. Do you think it is too soon to consider a revision? Also my scalp is still somewhat numb, less numb than right after surgery, but somewhat still numb. Is this normal?
A: First, it really takes a good six months to have all normal feelings return to the scalp and to really ‘forget’ that one has a custom occipital implant on top of their head. It also takes one about the same amount of time to psychologically adjust to an extended body part and to put it in perspective. Thus you really are not there yet and what one feels today may or may not change later. So in the interim the following comments may be helpful to gain some further perspective.
It is extremely common, and almost expected, that every occipital implant augmentation patient eventually feels that they could have used more of an augmentation or some change in the augmentation location. They may feel that maybe the implant should have been designed bigger or placed differently or may even consider having a second implant done. This is known in the plastic surgery world as another ‘spin at the roulette table’ or ‘another bite of the apple’ to use a few common American phrases. I sum it up more psychologically as ‘cosmetic accommodation’.
This is common in this type of surgery because the reality is that a one stage approach can usually only achieve about 60% to 70% of the ideal augmentation one wants due to the limits of the scalp’s ability to stretch. The most ideal results always come from a two stage approach with a much larger implant. This is a discussion to have up front as one has to choose between the more efficient one stage approach that produces less than one ultimately probably wants or a more costly two stage approach for the ideal result. Besides the initial expansion phase, a two-stage also requires a change in the incision to across the top of the head rather than low in the occipital hairline.
Your preoperative situation with an already existing occipital scar throws a variable into the occipital augmentation planning….as it becomes the only way to place an implant as any incision across the top of the head places the stretched and/or expanded skin between the two incisions at risk for skin or hair loss. You always only had the option of the use of your existing occipital scar whether you had tissue expansion or not.
From the occipital scar location, it would have never been possible to get an implant any further forward than where it is right now. You simply can’t get around the curve of the skull to make a pocket from an incision that low in the hairline. You should take some solace in that you have had the maximum thickness of implant placed as far forward as was possible given the constraints of the incisional access. (15mm height)
In a few cases I have had occipital implant patients who really want to go for a second implant to get an even greater result. Without tissue expansion this is usually not possible. But even it were I would caution any implant patient to resist the temptation to take an initial uncomplicated surgical result that is good, but perhaps not perfect, and try to make it better. The next time around they may not be so fortunate.
Hopefully these comments will provide some additional perspective on your recovery process and the final result as you eventually gain full perspective on it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have 2 questions about a custom jawline implant. Recently I tried to find photos of celebrities with similar skull width and face shape as me, but I noticed that among people with similar midface width, the shape of the jawline can be very different. I can basically tell 2 different types, and what I’m trying to achieve is the Type I effect. That is the “long sharp chin” effect while the jawline still looks 3-dimensional. My current chin implant is sharp, but the size of it is too small and still short and the weight of the entire lower face looks very unbalanced (jaw body vertically short and flat). Also my jawline looks very 2-dimensional.
I really don’t like an over-masculine jawline like a “squared jaw” that protrudes in lateral direction like a lot of bodybuilders might request…). I prefer a neutral but a little more “boyish” one as type I. But almost all results of jaw implants I’ve seen are sort of similar to Type II (it’s big and wide), so
1. I just want to ask whether it is possible to achieve Type I effect with a wrapped-around vertical custom jawline implant?
2. Although it’s obvious that they are different, but I can’t tell exactly what contributed to the differences… Can you tell me some differences between Type I and Type II jawlines?
A: The short answer to your question is that the ONLY way to achieve a more vertical jawline enhancement is with a custom implant approach. No standard or preformed off-the-shelf are designed for that effect, they are all width based implants because they are all sitting completely on the bone. That is why you see many ‘type II’ jawline enhancement results and not your desired ‘type I’ jawline augmentation result.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 33 year old male and am interested in skull reshaping of the back of my head. (occipital bone reduction) My occipital bone has always been really noticeable. Now I am quite bald it’s even more noticeable now. I often get remarks about it, people tend to touch the back of head to feel it, and I’ve heard people talking about it behind my back. Is it possible to reduce it? I’ve seen a similar case on your webpage.
A: The occipital bone prominence can definitely be reduced. It is only a question of how much and that would be based on the bilaminar thickness of the occipital bone.This is best determined by a simple lateral skull x-ray which will show its entire thickness and the thickness of the outer cortical table of the bone. A tracing of the occipital profile can be done on the x-rays to show what the realistic outcome would be from the procedure in the profile view.
The horizontal prominence of the occipital bone is a very common skull reshaping surgery in my experience. It involves making a small horizontal incision on the back of the head from which the occipital bone is burred down as much as possible. It is usually not possible to over reduce or due too much of an occipital bone reduction.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in some form of breast reshaping surgery I am torn as to whether a breast lift or a breast reduction is the right option for me. I have attached some pictures so you can help me decide between the two options.
A: Thank you for sending your pictures. In regards to your breasts it is important to remember that every breast reduction involves a breast lift and the associated breast lift is always a full anchor pattern lift. Thus the breast lift part does not change, the only variable in breast reduction surgery is in how much breast tissue should be removed (reduced) if at all.
Also every breast lift when done alone will reduce the size of the breast by almost one cup…and this is without taking out any breast tissue. (the removed skin is to lift and reshape the breast mound) In looking at your breasts I really see largely a breast lift with only enough breast tissue removed to ‘fit’ the remaining breast tissue into the lifted and reshaped overlying breast mound skin. Most likely you could get away with a full breast lift with no breast tissue removed at all.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I met with you for a breast augmentation consultation last week. Before I schedule my surgery, I have a few more questions about specific brands of implants. I believe you recommended Sientra, but I’ve been looking into Mentor implants. Specifically, the Mentor MemoryGel Siltex round implants. I’ m interested in the textured surface versus the smooth because the (perhaps dubious) Internet research done suggests textured surfaces lead to a lower rate of capsular contracture. And, Mentor appeals to me because of the enhanced warranty available for purchase. If my logic and/or research are wrong, please do correct me. If I did choose to go with Mentor, would there be a price difference from the original quote I received?
A: Thank you for the additional questions about breast augmentation and specifically about breast implants. Let me preface my comments with the understanding that it does not make any difference to me what brand of breast implants a patient uses. From my perspective, the three major breast implant manufacturers offer comparable devices for surgical implantation. The manufacturers, of course, see it differently and often promote and advertise relatively miniscule purported advantages to their devices.
When it comes to smooth and textured breast implants, it is important to understand what their advantages as well as their disadvantages are …as you will pay more to use them. (they are more expensive because it takes an extra step in their manufacture to add the textured surface onto the implant) Textured breast implants have only been shown to reduce the risk of capsular contracture when the implants are placed above the muscle. There has never been shown any differences in capsular contracture rates when they are placed below the muscle. The greatest reduction in capsular contracture, what was once a common breast augmentation problem, was the change in implant location from above to below the muscle. The type or surface of the implant is irrelevant when placed in the submuscular position. In my breast augmentation experience, which spans over 20 years and over 800 breast augmentations, I had yet to see a capsular contracture from a primary breast augmentation. In that time I have only performed a single above the muscle breast augmentation. All the surgeries have been done using smooth breast implant devices. This is a testament to the value and importance of the submuscular (technically the partial submuscuar or dual plane location.
It is also important to be aware that textured breast implants, besides costing more, require a slightly bigger incision to place and have a slightly higher risk of infection as any textured surfaced implant does. (the rough surface offers greater opportunity for bacterial adhesion than a smooth surface does) Due to their thicker shells they will feel more firm and will move less freely (due to tissue adhesion) than smooth breast implants.
Today, all breast implant manufacturers offer the identical warranty…lifelong implant replacement and a 10 year for surgery warranty of new implants plus $3500 towards the cost of surgery to replace them. (technically Sientra offers $3600 towards the surgery cost on the first ten years and also has a capaulat contarcture warranty so one could argue their warranty is better than Mentor and Allergan)
Again, it does not matter to me what breast implant manufacturer, style or size any patient desires. I will surgically place whatever they want. The only thing I do care about is that patients make an educated choice and that they understand the advantages and disadvantages of those choices.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’ve had 3 syringes of Restylane Silk and 1 syringe of Radiesse over the past year placed under my eyes and on the cheeks. The injections were placed down deep on the bone. When these fillers dissolve would there be any side effects? The reason I am emailing you is because I was so impressed by your answers on many plastic surgery boards. Is there no risk of underlying tissue or muscle becoming ‘lax’ from fillers especially with four ccs. of injectable fillers in just 12 months? I appreciate your time in answering my concerns.
A: All of the mentioned fillers are completely resorbable and they are not known to cause any long-term problems because of their relatively short duration of effects. Your question, however, is a good one but I am not aware of such injectable filler volumes causing lax skin or muscle tissues. That is because, while the injection volume creation process is acute, the resorption process is very slow giving the tissues time to recover due to its natural elasticity. Once the tissues deflate after such volume, however, I could understand how one could believe they are more lax because of the getting used to the volume that had been present.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m interested in cheeckbone reduction and maybe jaw reduction to make my face smaller and oval shape. My question is, do I need a jaw reduction or the cheeckbone reduction is enough to slimmer my face? Also, I had a rhinoplasty done about ten years ago. The tip is very visible. It looks like a small pimple on my nose, probably because my skin was thin. I’d like to have a revision. Please let me know what you recommend.
A: When it come to narrowing the wide Asian face, one procedure or changing one facial area is rarely enough to have a significant effect. Combining cheekbone reduction with jawline reduction (jaw angle, masseter muscle and chin elongation) is the most effective approach. Of course each patient must be individually assessed to determine if one of these facial changes would be the most dominant and, in your case, there most certainly is. The width of your cheek bones is by far the widest part of your face and would be the one procedure (cheekbone reduction) you would absolutely do if there was only one procedure you wanted to do.
From a visible nasal tip standpoint, which I assume may be from prior tip graft or implant,the tip can be either modified (tip point reduced) or over grafted. (cartlage graft on top of the tip) It would be helpful to know what exactly was done from your rhinoplasty now 10 years ago.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I read on your website that you are able to perform Adam’s Apple Augmentation (as opposed to the usual reduction) and I was wondering what the approximate cost would be for this surgery, and what the cost and recovery differences would be if the patient opts to use the intercostal cartilage rather than synthetic materials?
A: Adam’s apple augmentation or tracheal sugmentation can be done used either a Medpor nasal shell style implant or carved rib cartilage. There are advantages and disadvantages with either approach. An implant is preformed, requires no donor site harvest and easily shaped to overlay on top of the existing thyroid cartilages. Because the implant is performed, the operative time is shorter and this costs less. It is an implant, however, so theoretically the risk of potential infection is higher. (although I have not seen that occur) Rib cartilage requites a donor site harvest, is harder to shape and adapt to the existing thyroid cartilages and costs more to perform. It is, however, a natural material and this would suffer a lower risk of infection.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in temporal augmentation but I have questions regarding it and how it may be used for hollowed temples and cheeks on one side of the face. It appears to myself that the areas where the buccal fat pad would sit on one side of the face is abnormally thin. This contributes to a visibly old-like or sick appearance one one side of the face, but the other half looks healthy and normal for a young adult. My concern is more so on the temples than the cheeks. Is there enough protection of the temples on that side? (are there concerns regarding temple injuries) It also concerns me that I look “unhealthy” and abnormal because of it. What do you suggest for my temporal augmentation? Thank you for your time.
A: Temporal augmentation surgery is very safe and there are no concerns about ‘temple injuries’. Temple augmentation is about developing an increased muscular appearance using either implants placed in the subfascial location or fat injections directly into the muscle. Each temporal augmentation method has advantages and disadvantages with the primary difference being one has an assured permanence (temporal implant) while the long-term fate of fat injections can be more variable.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have some questions about implant rhinoplasty for my Asian nose. The original surgeon who performed my first rhinoplasty knew that I did not want an implant initially but sold me on the implant because the only thing that he offered that would be equivalent in terms of withstanding the test of time is fascia. He described it as a thin piece of skin from the scalp area that would show little difference. He never mentioned anything about rib grafts or diced cartilage wrapped in fascia. I feel that I was mislead purposely. Is it common for plastic surgeons in the United States to do this to make a buck and is this medically ethical?
A: There are numerous approaches to augmentation of the Asian nose including implants and rib cartilage grafts as you have mentioned. It is certainly true that fascia alone would provide no nasal augmentation at all due to its very thin and pliable tissue characteristics. It is good to encase a diced cartilage graft but is not an augmentation material per se.
Surgeons naturally present and offer to patients for any surgical procedure what they know and are comfortable performing. Presumably what they have to offer for any cosmetic condition is what they feel will work well and is in the best interest of the patient. It is also far easier for surgeons to offer implant rhinoplasty over rib grafts for nasal augmentation because it is simpler, easier to perform and costs the patient less. Even if presented with the rib graft option, many patients initially choose implants for all of those reasons also.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have along protruding chin and am interested in chin reduction surgery. What is the best way to reduce/reshape it so it looks smaller and more proportionate to the rest of my face?
A: In chins that are both vertically long and horizontally protrusive, there are two surgical approaches. A submental chin reduction technique is done from an incision below the chin where the bony chin can be vertically and horizontally reduced and any excess soft tissue removed. This is the best technique for bony chin reduction but does leave a fine line scar under the chin. That is somewhat of a concern with your ethnicity and skin type. The alternative approach would be an intraoral one where a vertical wedge bony genioplasty is done with horizontal setback. This leaves the question of what happens to any soft tissue excess, which may or may not contract back down but it is an externally scarless surgery.
As you can see, each chin reduction approach as its advantages and disadvantages. It all comes down to how the patient perceives the submental scar and what the risk of a redundant chin pad is after the bone is reduced.
Dr. Barry Eppley
Indianapolis, Indiana