Your Questions
Your Questions
Q: Dr. Eppley, I am interested in skull augmentation. I haven’t managed to find any possibility here for my skull flat shape and also smaller size, which is always a problem due to hiding its flatness in a puffy hair and that takes a lot of time and doesn’t allow me to wear the desired hair style. I’m 34 years old and I am struggling with such issue for a lifetime, and now I’m seriously looking for a permanent fix. My forehead is also flat and what I’ve lately done was to get injected fillers in my forehead, its corners and all over it, for creating a nicer curvature which is not a permanent but only temporary one, then within 1 year or a year and a half, I need to re-do this process which is not the most desirable fix, also only temporary. I’ve been reading about a latest discovery, Kryptonite, and also learning about you Dr Eppley from online and also searching your website, and I’ve noticed you’re extremely experienced and a specialist in such matters. I’d like to kindly ask about your opinion, if some injections with suitable bone adhesive (Kryptonite or otherwise) would solve my problem permanently, without any side effects or other later surprises? I’m aware the injections would be the quickest fix, especially when 1.5 cm to 2 cm height in my skull’s curvature would be perfect and also a bit at the top back, plus a bit on the laterals for creating more volume around, therefore in a nutshell needing some attached patches in the right spots of my skull. I’m also reading online that such injections would have some side effects and in the longer term may bring some problems, not sure if that’s correct or not? If possible, I’d appreciate it receiving your kind reply regarding such procedures, or if it’s better going for a whole skull patch addition through a more complex operation? Obviously, I’d prefer the simplest but most efficient procedure, but if such quick injectable permanent safe fixes don’t exist, please kindly elaborate about the best fit in my case, in order for my forehead to be considered as well and curved accordingly with no weird marks after a possible operation or implants.
A: The simple answer to your question is that no method injectable skull enlargement works well and has lots of complications. Kryptonite is no longer available and has been removed from clinical availability. The only effective method of significant skull augmentation (and a 1.5 to 2 cm enlargement would be considered significant) is a two-stage surgical procedure. The first stage is the placement of scalp tissue expander (to gain the room for the bone expansion) and the second stage is the placement of a custom skull implant made from a 3D CT scan. Like all surgical procedures, they are not risk free but this approach has had few complications in my experience.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was interested in removing the dimple or cleft in my chin. I have attached pictures of it so you can see if chin cleft removal will work for me. It is not a big chin cleft but it bothers me nonetheless.
A: Thank you for sending your pictures. What you have is a lower vertical chin cleft which is a direct manifestation of a notch in the chin bone. If you feel the chin bone under the cleft you will probably feel a notch or a groove in the middle of the chin bone. In this type of cleft it is important to fill in the bone ‘defect’ as well as add a little fat right into the soft tissue portion of the chin cleft since it also is making a contribution. This is done from inside the mouth with the placement of a very small mesh implant into the bony groove. The fat can be harvested from inside the bely button and injected into the soft tissue cleft or a small graft can be harvested from inside the mouth from the buccal fat pad and placed directly into the defect.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m 18 years old at height 5’4 and weigh 125lbs. I have breasts the size of 32DDD. I know I want to have a breast reduction sometime in life, and my question is if it’s worth having one before I have children?
A: When one undergoes breast reduction depends on how symptomatic one is from their large breasts. If they are heavy and painful and are interfering with your lifestyle then you do the procedure before children since you can get the benefits sooner rather than later. If they are large and not that uncomfortable then you wait and see what effect having children as on their sizes and the symptoms that are causing.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like to inquire about depressor septi release surgery for correcting a transverse crease above my upper lip just below my nose. I do not know of this is the right approach but ti seems like it might work.
A: The release/removal of the depressor septi nasii muscle is usually done to stop the top of the nose from pulling down while smiling. It may or may not have an effect on a transverse crease in the upper lip. The best way to find out if it does is to initially do Botox injections first and prove that the elimination of its action will make an improvement. If Botox is successful then you should consider depressor septi muscle release surgery
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a question about the genioplasty and v-line surgery. ( jaw reshaping) What’s a good prediction of what the recovery will be like two weeks forward in terms of speech, looks and smile?
For the genioplasty, I definitely want to reduce the width. I think rather than projecting it forward to slightly bring in some height, I’d rather just lengthen it vertically right where it is. I prefer this because I don’t want dramatic length added so I wouldn’t think I want to do both, and I assume extending my chin bone downward will help change my chin profile from “slumping up” at the chine edge, to a more aesthetic look.
In other words, I assume bringing the chin forward wouldn’t help change my chin’s profile and hence, moving the bone downward would benefit me best. I think if anything perhaps my chin could be brought forward a millimeter, but again the real thing I’m looking for is to reduce the width and add a little height for the sake of creating a more v-line jaw line.
A: I think your insights into creating more of a V-line jaw shape are correct. (v-linje surgery) Chin width reduction and vertical lengthening will go a long way towards changing the shape of the front half of the jawline.
It will take a good three weeks to have about 75% recovery and a full 6 weeks to show 90% of the result from V-line surgery. This surgery does not affect speech or the ability to eat but is mainly an appearance issue due to swelling and temporal chin distortion. There is no doubt your chin will be very swollen the first 7 to 10 days after surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I wanted to have a chin implant and midface augmentation (orbital rim, paranasal and cheek implants). Recently, I discovered a question on Realself where you said that one big, custom midface implant would be the best choice. This looks like it would augment exactly what I want to be augmented! Wouldn’t this save me money and be the perfect option for a flat/droopy midface because the implant would be adapted to my bone structure? What I’m searching for is a chiseled, “bone” look, because I see many cheek augmentations that are too low or feminine on men! The chin implant is a standard design though, isn’t it?
A: There is no question that a single total midface augmentation by a custom made implant from a 3D CT scan would have the best and most comprehensive effect. (custom midface implant) Since there are no true preformed midface implants (cheeks and paranasal do exist but nothing for the maxilla or orbital rim), only a custom midface implant would work. This type of implant combines all the skeletal areas on the midface into a single implant, thus creating almost a LeFort III advancement effect. (minus the occlusion changes)
Chin implants, however, do come in a wide variety of styles and sizes so something ‘off the shelf’ may well work.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have extremely narrow clavicles which have caused years of insecurity. I’m very interested in the deltoid implant surgery that you offer. I think I read that the maximum amount that you can add to each shoulder in width is 1.5cm. Is this figure correct and does it apply to both the method of silicone implant as well as the fat grafting technique?
A: Deltoid augmentation (aka deltoid muscle augmentation) can be done by either fat injections or actual deltoid implants. If you have adequate fat, fat injections would be preferred since they are the most natural and are scarless to perform. While not all the fat will survive, fat injections would always be the first choice. If one does not have enough fat than only an implant can be used. This is placed through an incision in the skin crease at the back of the axilla (armpit) and the implant is placed in a subfascial location over the central segment of the deltoid muscle.
Both deltoid augmentation approaches take about the same amount of time in surgery and both have about the same recovery. Neither deltoid augmentation technique will create a full 1.5 cm per side, close but not always.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, what is the nest method for scar treatment after surgery? I know there are lots of topically applied products most which appear to be made of silicone gel or oil. I also see there are scar tapes. Are scar tapes better than the topical ones? How are they applied and where can get them?
A: There are also multiple scar tapes most of which have silicone in them. But my preferred scar tape is the Micropore tape. It is from 3M, flesh colored and is microporous so moisture can escape from them. The regimen I use for my patients for just about any type of surgical scar is as follows. The tape should be applied to your scars immediately after surgery and left on until they fall off on their own (usually about 7 days). The tape can then be reapplied. It is important to ‘shingle’ the tape, using short 2″ pieces that overlap slightly. The tape must be worn continuously for several months until all signs of inflammation are gone (no residual redness, swelling etc). When the scar is white, you can discontinue the tape. There are more expensive tapes and wound support technologies available and under development, but the tape technique is very economical and probably equally effective to other scar treatment methods.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had braces when I was about 18 years old and that was my second time for them. My first time was a few years before my second time. The reason I went back again was because I had a problem closing my mouth. It’s either because I didn’t really wear my retainer or because of my protruding jaw. So I went to the doctor and what I had in mind was just that I wanted to close my lips without looking like they are protruding. The doctor took off 4 of my teeth, 2 upper and 2 lower on each side. And as a result, now I realized that it’s been narrowed down too much. Both front part and side part being forced inwards and so I find that when I smile, my cheekbone is more obvious, I have lines besides my nose, and my teeth doesn’t look as good since it’s way inside, not showing like before. Also, the part above my upper lips under my nose look like it’s went further inside and I think it’s because the orthodontist pushed it backwards quite a lot.
I’m not sure if the solution years ago about my protruding lips was to rearrange my teeth without extracting those 4 teeth or there is actually the need to take them off. (I went to the first dentist and he insisted that he wouldn’t take off my teeth, since I didn’t want my lips to look like that I went to other dentist and he said it was fine to take them off).
So the bottom line is, is there any solution to this ? Is it possible to move my upper jaw a bit forward so that I don’t look like an old lady whose teeth’s all gone since they are way hidden inside?
A: What you had done was extraction of four premolars to allow all remaining front teeth to be moved back, thus reducing the prominence of the lips. You are correct in that is a source of premaxillary/midface retrusion. While doing a maxillary advancement would reverse these effects it is important to realize that if you move the upper jaw forward you must move the lower jaw forward as well. (bimaxillary surgery or double jaw surgery) This will maintain the occlusion you now have. Otherwise you will create a substantial bite discrepancy.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have recently lost 100 pounds. I still want to loose another 50 pounds but would like to get some information about doing an extreme tummy tuck since my skin and fat hang by my mid thighs. I would also like to get information about a breast lift.
A: Thank you for your inquiry. Congratulations on your success at such a significant amount of weight loss. I would agree that you should maximize your weight loss before any body contouring surgery is done to get the best benefit from the procedure. It his likely that the next 50 lbs will be harder to lose than the last 100lbs but the effort will still be worth it.
Anytime a female loses more than 75lbs there are always going to be the sequelae of loose redundant skin on the abdomen and waistline and the development of breast sagging. While weight loss causes the reduction of fat, no skin is lost and how much skin redundancy remains depends on its natural elasticity and its ability to contract which is often very poor. (men do much better in this regard with large amounts of weight loss) In the extreme weight loss patient, a standard type of tummy tuck is always inadequate so you are correct in that an ‘extreme tummy tuck’ is needed. At the least this is an extended tummy tuck but may be a flour-de-lis type of even a circumferential body lift to create the greatest degree of redundant tissue removal. I would need to see smoke pictures to provide you with a more accurate answer as to the type of tummy tuck you need. For the breasts, the vast majority of time one needs a full or anchor style breast lift. Whether implants would be needed to restore volume is the only issue to be determined.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Can I get a hair line lowering procedure, forehead contouring, and shaving of the brow browsing, lip lift, lip augmentation, corner lip lift and maybe jaw implants all during the same surgery? My goal is to feminize my forehead, the distance between my lips and nose is extremely far a lip lift would feminize my lips, and I’d like a heart shaped face and girls with heart shaped faces always have a nice feminine jawline.
A: What you are referring to is known as facial feminization surgery and in the classic use of that plastic surgery term refers to a type of transgender surgery. By your inquiry it does not appear that you are a transgender patient. But the concept is really the same and there is nothing unique or different in terms of the number of facial reshaping procedures that can be done on a male to female or a female patient. It is very common to perform up to a dozen or more different facial operations during facial feminization surgery. These are perfectly safe and are well tolerated to be done all at the same time. It does create the need for significant recovery, however, as the more facial procedures you do the more swelling that occurs as you might imagine.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a vermilion lip advancement a few years ago and am not too happy with the results. My scars are healed but it is too large which makes the distance between my nose and upper lip too close. My bottom lip is also too large that makes opening and stretching my lips difficult. Overall, my lips look unnatural and is too big for my face. My question is: is it possible to cut the vermilion again to bring it down making the size of the lips smaller and improve the shape? I don’t think a lip reduction will work because my vermilion will still sit to high. What would you recommend? Thank you.
A: Once skin is removed from the upper lip, whether it is from below the nasal base in a subnasal lip lift or above the upper lip in a lip advancement, there is no way to put the skin back. These are permanent lip enhancement procedures that change the skin-vermilion relationship by excision. The vermilion can not be moved back down, short of a skin graft which would look like a patch and be aesthetically worse than before.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am 32 years old with a full 34C cup breast size.. I went for a plastic surger consult last week and I figured I would need a breast lift because my breasts were very saggy. I also wanted a breast lift with implants as I want perky very round (ok to look fake) looking breasts. I wouldn’t mind being bigger even a DD cup. My plastic surgeron said he won’t do a lift and breast implants at the same time. I was shocked that he would not do them at the same time as this ultimately means more money, recovery and longer to finally get the breasts that I want. Why won’t he do them together? And do you think just a lift will give me the perky round look I want?
A: It is important to understand the combination of breast lift and breast implants is a ‘ying and yang’ type or procedure where want (how much) is done in one will usually adversely affect the other. If I needs a big breast lift (lifts and tightens the breast skin) it will be impossible to put in very big implants at the same time. Conversely if one wants big breast implants the amount of lift obtained will be small and you will likely end up with some residual sagging.
When one needs a lot of breast lifting and also wants larger breast implants, it is best that the procedures are staged. That way you can get the maximal breast lift and then secondarily (3 months later) you can put in implants of the size needed to obtained the amount of fullness that you want. Trying to both at the asme time dramatically increases the your risks of complications and has a very high incidence of the need for revisional surgery. If you are going to get two surgeries anyway it is far better to have the second surgery on your terms…not managing complications from the first procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, You said that there is no deltoid implants but I found on internet that there is. I know about people get implants to their arms and belly to have muscles and six packs. so what kind of implants is it and can it be used for implants for the deltoid? o beside fat transfer/fat implants to the deltoid, is there any implants for the deltoid? Thank you.
A: What I said was that there are no preformed off-the-shelf deltoid implants that are made specifically for the deltoid/shoulder area. This is the same for other arm implants as well such as the biceps and triceps. The only body implants besides breasts that are commerically made are for pectoral, buttock and calf implants. It is unlikely that other body implants will be commercially made in the near future given their low demand. That does not mean that deltoid, bicep or tricep implants are not done as they are and I have done them as well. What is used for all arm and shoulder implants are the different sizes for calf implants. They are soft long and oblong and usually the small or medium size works well for the deltoid area. There soft silicone elastomer helps simulate muscle tissue which they are designed to augment.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a rhinoplasty done and ever since something about it has been bothering me since I have done it. I’m not sure what the doctor called it since it’s been 4 years ago. I was concerned that the side of my nose was big. It was the bone beside the bridge of the nose. I originally thought I wanted it to be smaller. I just realized after that what I was after wasn’t to get rid of that but I wanted my bridge to be smaller. I feel like now there is a hollow line of a downward from under eye to about 3-4 cm. And the width is about from the bridge to the side around 1-2 cm. I only remember him saying that he has made the bone in that area less thick. I think as a result, it leaves some kind of hollow, especially when taking picture that area seems to be looking deep and I don’t think it was like that before I did it. I think it’s not supposed to look like this. I think the doctor wasn’t skillful enough and removed too much bone and now I look kind of old. When I smile it’s the most obvious.
Is it possible at all to fill it up with something permanent fixed to my bone beside the bridge(basically to make the bone on that area thicker) that wouldn’t move when I smile? I don’t want a fat graft which doesn’t last and would move or get pushed up when I smile. Or any other material ? I’m aware that there would be a curve at the bridge down to the sides. But I’m really not sure where exactly the doctor got rid of my bones. But it wasn’t by squeezing the bone, he literally kind of use some tools to get rid of the bone.
A: I can not tell from your description whether this high paranasal deficiency is the result of nasal bone infracturing done at the time of a rhinoplasty or whether this area was directly burred from an incision inside the mouth. Regardless of its origin, the paranasal/medial maxillary process region can be built up using a variety of different material from an inside the mouth approach. (paranasal augmentation) Having built up this area before, it is a highly sensitive areas to augmentation and it only takes a few millimeters to make a very visible difference. Whatever material is used the upper edges need to have fine tapered edges ti avoid any visible external transition areas.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have an umbilical hernia and have been told that a general surgeon would be needed for this procedure. In addition to needing a mesh piece placed in the hernia, I would like the resulting belly button to be aesthetically pleasing. I also have a c-section scar with some loose abdominal skin. Can you address all my concerns during a single procedure without an additional general surgeon in the OR at the same time?
A: What you are specifically asking is to have a tummy tuck done with an umbilical hernia repair at the same time. This is not a rare situation for a plastic surgeon to encounter and manage. During an open tummy tuck procedure most umbilical hernias are repaired by using your own natural tissue through midline muscle plication. It would be very uncommon for a plastic surgeon to have to resort to the placement of a synthetic mesh for hernia repair during a tummy tuck. The only concern is the fate of the belly button during an open tummy tuck operation. Many umbilical hernias have disrupted the attachment of the belly button to the abdominal wall. During a full tummy tuck the outer connection of the belly button is removed from the surrounding skin. If the umbilical hernia has also separated the base of the belly button, it may not have adequate blood supply to survive afterwards and be lost. So the objective of obtaining a better looking belly button may be a difficult challenge when a full tummy tuck is done with a concomitant umbilical hernia repair. This does not mean that the two should not be done together, as they should, but one has to appreciate the potential implications for the belly button and its postoperative fate.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I contacted you last year about liposuction. I’m finally ready to get the right procedure cause I’m not sure what would be best. I’m 5ft 7inchs tall and weight 283 pounds. I would like to lose as much as possible. Can you tell how much I might be able to lose just so I have an idea. I would like to get down to 195 pounds but I don’t know if that is possible or if that is dangerous. Can you please help me pick the safe and best procedure. thank you for your time.
A: I am afraid that you have the wrong idea about liposuction surgery and what it can accomplish. It is not a weight loss method nor would it be appropriate at your current weight of 283 lbs. Liposuction is a body contouring surgery to remove select areas of fat that are diet and exercise resistant.The only way you are going to lose 75 to 100 lbs through surgery is by a bariatric surgery approach with either a lap band or a gastric bypass. Liposuction at 283 lbs is not only dangerous but would be ineffective at making any substantive body shape or weight loss changes.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have mild muscular dystrophy that has left my right leg and ankle much smaller than my left. I have two calf implants in now but my ankle and the inside of my leg are still much smaller. Is there any way you think you could help?
A: Calf implants do a good job of increasing the size of the upper half of the lower leg between the knee and ankle. But its augmentation effect stops where the gastrocnemius and soleus muscle meets which is about halfway between the knee and ankle. One way to augment the lower half of the leg and continue the effects created by the calf implants are fat injections. As long as one has enough fat to harvest, fat injection augmentation can be done in the lower half of the leg. (leg fat grafting) Its biggest problem is in how well the fat will survive which can be difficult in the tight tissues of the lower half of the lower leg. Multiple fat injection sessions may be required.
Another option would be a custom made implant for the lower leg. But this has a much higher risk of complications than calf implants do because of its subcutaneous location as opposed to that of a subfascial one.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in your assessment of my jawline issues. and what you would recommend for surgical improvement. I have a weak jaw but a fairly good bite. Had orthodontics as a teenager and they never recommended any surgery. The other issue which may be helpful is that I have obstructive sleep apnea (OSA) and wear a mouth piece at night to push my chin forward. I am tall and thin so I do not fit the ‘typical’ body type for many OSA patients. I have attached pictures for your review. I have been to several plastic surgery consults but each one suggests a chin implant. While that might be somewhat helpful it just seems that it is an inadequate solution for my problem.
A: Thank you for sending your pictures. My assessment is that you have an overall short lower third of our face as evidenced by a horizontal and vertical deficiency of your entire jawline. (mandible) Besides the visually apparent facial third discrepancy, the fact that you have OSA and require the use of nighttime CPAP speaks to the potential contribution of a short jaw as a contributing factor.
The optional treatment for this type of jaw deficiency is a custom jawline implant that can augment smoothly the entire jawline in a wraparound fashion from jaw angle to jaw angle including the chin with tridimensional changes including increased vertical, horizontal and some width changes. (see attached predictive imaging) Having significant OSA, however, throws a variable into such a plan however as it would provide no functional improvement in your airway….and that seems like a shame given its potential lifelong occurrence.
A variation on the custom jawline implant would be to combine a sliding genioplasty to bring the chin down and forward (carrying the anterior attachment of the tongue muscles with it and potentially offering some OSA symptom improvement) combined with a pre made custom implant that would augment the rest of the jaw. This would be the only way to have a completely smooth transition from the posterior edges of the sliding genioplasty osteotomy line to the body and angle of the jaw behind it from an augmentative standpoint. Like the total custom wraparound jawline implant it would need to be made from a 3D CT scan from which the osteotomy and implant design would be done.
The ‘simplest’ option would be to just have a sliding genioplasty with standard off-the-shelf vertical lengthening jaw angle implants. While offering aesthetic and functional jawline improvement, it would not create a perfectly smooth jawline from front to back.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a breast lift and tummy tuck. I’ve been thinking about the specifics of the breast lift and I’m hoping you can help with some questions. Attached are some images that will help guide our discussion. At the consultation we discussed the Wise pattern breast lifts with lateral extensions – Image1 is a quick sketch I did that represents my body type and my interpretation of what we discussed. What I’m unsure about is how much “pull” of excess lateral skin there will be with the breast lift and how much remaining fat will be left afterward. Also, would the lateral extension be an extension of deepithelialization from the breast lift or would there be skin and fat removal as is done in the tummy tuck?
If you take a look at attached images A and B you can see evidence of a pouch of fat lateral to the breasts post-surgery– this is what I’m hoping to avoid! Is this due to deepithelialization without fat removal? Images C, D, and E represent the flat appearance I’m hoping to achieve, all with different techniques. Image C is of a spiral flap procedure and this is the outcome I’m most fond of– though I’m not really interested in relocating the fat, just removing it from that lateral position! I’m wondering if this is the technique/outcome you had in mind or if this is something completely different.
A: Thank you for your questions about breast lift surgery. The issue at hand is how best to manage the excess tissue at the side of breast over the chest wall into the back. The Wise pattern breast lift procedure does provide some pull and tissue reduction to this area but will not produce a complete elimination of it. When the chest sidewall tissue excess is considerable, some direct management will be needed. Liposuction offers a ‘scarless’ method when fat is the main issue and one has good skin elasticity to allow for skin retraction. When there is a prominent skin roll extending the cut out from the breast lift into the sidewall and into the back is the most effective method for its reduction. But as your examples show it occurs with a price to be paid in terms of extended scars and scars that may not do as well as those of the breast lift or tummy tuck. But skin and fat needs to be removed from the side chest wall to be most effective.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a custom implant in the subnuchal region of my occipital skull. I know that fat grafting is another options to augment this area due to the neck muscles attaching to the skull there. My questions are what are the possible complications could be, and if you have seen these types of complications in any of the other skull shaping patients you’ve operated on. Hypothetically, in my case, I believe that such an operation could involve clearing/removing a 2cm width band under and parallel to the nuchal ridge on one side before in order to have the implant attached. Would this have a severe effect on head and neck movement and/or cause long term pain?
If this is not a viable option I’m curious as to whether an implant could be placed in a pocket over the muscles/tendons and not directly against the skull. I have read that implants used in other areas (ie. breast implants) are at times placed within or over muscles and are not secured to any hard body structure. Could an implant be placed in the subnuchal area over the tendons, thus avoiding their separation from the skull? Subsequently if there was an implant placed this way, and if a portion of the implant extended to an area of the skull without/ not covered in tendons, could it then be attached there? Alternatively is there a method of fixation to the skull that could occur through the tendons (i.e., with screws) to secure an implant in place. I ask this after reading of non-secured implants causing erosion of tissue with micro-movement over time.
At this time I am willing and able to pursue a surgery if there could be an intervention that was safe effective visually and that is stable over time. I would be grateful for any input you may have.
A: Placement of a subnuchal skull implant for low occipital/upper neck augmentation would have to be placed on top of the muscular fascia as opposed to under it against the bone. Stripping the muscular attachments off the bone is associated significant discomfort and recovery of neck motion. Once in the subcutaneous tissue plane between the skin and the fascia the implant will generate a layer of scar around it which will keep it in placed. (much like a breast implant)
The only anatomic risk of placing an implant in this area is the greater occipital nerve. Fortunately this nerve lies under the muscular fascia and does not common through until higher up over the bone.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, First of all, I want to thank you for the time that you took and will take to analyze my case, I’ll be eternally grateful for any help that you can provide to me in order to improve my condition.I have been really traumatized over the years for this mistake on a surgery that was made to me when I was 17 years old (I’m 39 years old now) Please see photos attached, I’ll be waiting anxiously your answer.
A: Thank you for sending your pictures. You have a very classic gynecomastia ‘crater’ deformity from over resection of the breast tissue. This has left no intervening tissue between the nipples and the pectoralis muscle fascia, thus allowing the nipple to contract inward and scar down. Its appearance may have gotten a little worse as you have aged because the chest tissue around it (fat) may have gotten bigger allowing the inward nipple retraction look worse.
The correction of nipple retraction after gynecomastia reduction depends on the degree of severity and requires tissue grafting for release and improvement. Your case is fairly severe and you would ideally need an open release and dermal-fat grafts to level out the nipple contours. Dermal-fat grafts do require a harvest site somewhere which is usually done in the lower abdomen. Injectable fat grafting could also be done but that would definitely require multiple treatments to get the best result. There may also be a role for liposuction of the chest around the nipples to help optimize the chest contour also.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have always felt that the areas right inferior to my zygomatic archs are way too thick and hard and widened.I am not sure about the specific name of that muscle, but pretty sure it is not due to bone.I know that Botox is commonly used to reduce jaw angle, but I don’t even have an angle so I don’t know whether it will help, as it is like the area above masseter muscles (or it really is upper masseter muscle?).
A: Botox will not be an effective or prudent treatment for the area you have highlighted for the following reasons:
1) There is a significant risk that Botox injections placed in this area will inadvertently paralyze the frontal and buccal branches of the facial nerve, thus rendering your forehead, eye and upper lip areas paralyzed for the duration of the effects of Botox. (around 4 months)
2) The upper masseter muscle in this area is largely more fascia than muscle thus making it far less responsive to reduction than that of the jaw angles
The effective method of reduction would be check bone reduction (zygomatic arch reduction) to carry the attachment of the soft tissue inward with the bone.
Dr. Barry Eppley
Indianapolis, Indiana