Your Questions
Your Questions
Q: Dr. Eppley, I had a saline testicle implant placed last year and I hate it. It feels hard as a rock and very unnatural. I would like to replace it with a softer but larger silicone testicle implant. In addition I would like to make the opposite testicle larger. I have read that there is a way to do this by wrapping it with an implant. Is that true? I read it on the internet so you never know how accurate that information is.
A: Saline testicle implants feel very firm because they are an overfilled water sac which is under tension. Conversely silicone testicle implants are very soft and squishy because they are made of a low durometer solid silicone material. There is no question that silicone testicle implants feel a whole lot softer than saline ones. I will have to compare the largest silicone implant with that of saline to make sure it is bigger. But I would have confidence that it would be since the largest silicone testicle implant is up to 4.5cms in length with an oblong shape.
Capping the existing testicle is how it is made bigger. You take a large silicone implant, cut in in half and then remove the inside of the implant leaving only a thinner outer shell. Then you put the two halfs together over the existing testicle and put it back together like a clamshell. A space needs to be left between the two calfs so that the vascular pedicle and cord that goes to the testicle is not pinched off.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in orthognathic surgery even though my bite (Class 1) normal. Thus any orthognactic surgery would be cosmetic and not functionally beneficial. It just appears to me that my face and the bones in it did not grow in an optimal aesthetic direction. It seems that my face is too long and has dropped to a gaunt look with a flat midface. Could this be due to a downwards grown maxilla or other bones? Can it be fixed with a maxillary impaction?
A: Your malocclusion is modest and within the confines of a general Class I occlusion. The point being is that it is not the source of your aesthetic facial concerns. The difference between your child face and your adult one is the relatively standard change between the 2/3s dominance of the upper face in childhood to the completion of facial growth in early adulthood with a reversal in that proportionate relationship. Whether your face is too long is a personal assessment and not a function of actual facial structure disproportions.
Changing your facial proportions is done by decreasing the vertical length and improving the midface projection width. This is usually best done by a vertical wedge reduction genioplasty (chin) and malar-submalar implant augmentation. Doing a maxillary impaction would bury your upper teeth under your upper lip and would also require a concurrent mandibular osteotomy to keep your bite relationship from changing unfavorably.
Dr. Barry Eppley
Indianapolis, Indiana
Dr. Eppley, I found your name on the American Society of Plastic Surgeons and also on the website, RealSelf.
I am experiencing pain and restrictions from an old c-section scar from 1985. The left end of the incision is indented and has adhered to the underneath muscle. I have tried many rounds of physical therapy to help it, but it now seems to be pulling so much that my hip flexor and groin area are becoming restricted and painful.
I have hated the look of it ever since the day I got it, but I can’t deal with the restrictions and pain. Had it looked at by a general surgeon where I live about 10 years ago and he said he didn’t ‘believe’ in scar adhesions.
Is a scar revision normally covered by insurance? Thank you for your time.
A: It is not rare that a c-section scar can create an adhesion down the abdominal wall, resulting in scar contracture pain. Whether the general surgeon you saw believed in scar adhesions or not, they do exist and they are real. Such c-section scar adhesions are easily solved by total excision of the scar down to the abdominal wall and bringing in fresh tissue to reconstruct the tissue layers from the bottom up to the skin. (C-section scar revision) Scar revisions are not usually covered by insurance but that is a determination they have to make not one that I can since they write the policy and make the decisions about coverage.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like to have v-line jaw surgery, a lower facelift and a subnasal lip lift. As far as the lower facelift and neck there is not too much laxticity today but the jaw reduction will likely increase it so a lower neck and facelift will be needed. Can these procedures be performed in a single surgery?
A: V-line jaw surgery usually does not create excessive jowl or neck skin as it is really a redistribution of the bone shape not always a real total jaw reduction. If you do not have any skin laxity now I doubt any will be created after. There is simply not that much jaw bone removed to create substantial less skin support. But that is somewhat dependent on your age and natural skin elasticity. But for the sake of discussion let us assume that some neck-jowl tightening would be needed then a lower facelift can be performed at the same time as the V-line jaw surgery…or await and see if it is really necessary which would be the most practical approach. Certainly there is no problem doing a subnasal lip lift at the same time as the v-line jaw surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, do you do mole removals on the face? I have several raised moles on my face that I would like to see about removing. Is the cost for it per mole? I have one about the size of a pencil eraser and the others are smaller. Do you have before and after pictures of facial mole removal procedures? I’m worried about the scarring and not sure if it is worth it.
A: Every plastic surgeon does facial mole removal which is done in the office under local anesthesia in most cases. Your facial picture which makes it very clear as to your facial mole issues and their large number. I could easily identify three facial moles (right face, right nose and right upper lip) and probably six that would benefit by removal. While every faoial mole removal does leave a very fine scar in its wake, this would seem to be of less significance than what they are replacing based on your picture and the sized and location of the moles. In general a small flat scar is usually better than a raised darkly pigmented mole which often can have hair growth associated with it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had an otoplasty on my right ear, but unfortunately it was overdone and is causing a lot of problems. The surgeon removed a lot of cartilage and skin from my ear causing my ear to be set back a lot and completely attached to my head in some areas. This has affected my life greatly and now I am looking for a very experienced surgeon who can reverse this. I don’t have any stitches holding my ear to my head, so the only fix I believe is doing cartilage and skin grafts to separate my ear from my head and spring it back to match with the other one. Is this something you can do? And what is your experience with such reconstruction surgeries? I really appreciate you help.
A: Most otoplasty reversals require a method to spring the cartilage back out which can be done with a rib cartilage graft or a special metal spring that I use. If there is a true skin deficiency a skin graft will be initially needed prior to any effort at cartilage reshaping. However is some cases I have done a simultaneous fascial rotation flap after the ear is released and then skin graft on top of that at the same time as a cartilage graft. I would need to see pictures of your ear to see exactly what needs to be done. It may also be that a skin graft alone may suffice.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a very wide face and protruding cheek bones and it’s always been an insecurity of mine. I’ve also always has chubby lower cheeks.when I smile my cheeks tend to protrude a lot which makes my profile look very awkward. I really want to have a slimmer more masculine face/jawline. I’ve also been considering a lip lift to shorten the gap between my upper lip and nose, and a nose job for a slimmer less bulbous nose. What surgeries are right for me? And what combination of surgeries are safe to perform simultaneously?
A: When it comes to fullness of the lower cheeks, which are below the cheekbones and down closer to the side of the mouth, a defatting approach is needed. Given your pictures and the fullness that runs from just below the cheekbone almost down to the jawline, I would recommend the combination of a buccal lipectomy and perioral mound liposuction. These two together are the most you can do for helping change a round face to a more V-shape based on soft tissue changes only. It is also important to remember that the thickness and quantity of skin also plays a role so there are limits as to what facial defatting can do.
When it comes to a rhinoplasty and a subnasal lip lift, I do not recommend that these two procedures be done together. This has to do with ensuring good blood flow into the intervening columellar segment. They will need to be staged or done separately.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was just curious on the cost of the filler for forehead horns. My brow bone sticks out too far and I would like to have it filled like I see in the photos on the website. Do you know the cost roughly? Also, would you ever have to get this procedure done again in the future or will it be permanent once it’s done? Thanks in advance!!
A: For filling in the central depression of the forehead, I really don’t use an injectable filler technique for it in most cases. Synthetic injectable fillers are only very temporary (a few months) while the fate of fat injections is uncertain as well as its permanency. I have used injectable bone cement as a form of injectable filler but it is difficult to get it perfectly smooth and, if it does not become smooth, a secondary revision of it is going to a larger incision to access it to even it out. The most successful strategy in my experience has been the use of a wall custom implant made from a 3D CT scan. This fills in the depression nicely and is permanent. I would need to see some pictures of your forehead to provide a more specific answer as to what work best for you. But central forehead augmentation to fill in a depression between the brow bones and the upper forehead prominences is usually best done with a custom forehead implant approach.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 39 year old male who was born with a noticeable asymmetry in my face. This is most pronounced on my right lower which is not as full/pronounced as my left side. It has always bothered me for as long as I can remember so I finally decided to do something about it. In January of this year I consulted with a local facial plastic surgeon who seemed confident that he would be able to eliminate the asymmetry with an off-the-shelf implant and so I ended up scheduling surgery a week later. I had some initial concerns because the consultation only took about 15 minutes and no details of the surgery or what my options were was presented. The doctor sent me out for a 3D CT scan prior we did not look at the scan and measure out where the asymmetry was and what areas needed to be augmented and by how much. I reluctantly decided to proceed regardless of my intuition telling me not to and this ended up being a costly mistake. About a month after surgery when the swelling began to subside, I noticed that the implant he choose actually ended up causing more asymmetry than I originally had. The implant he chose was a Medpor type implant that under augmented my horizontal deficiency by 50% and over augmented my vertical deficiency by 100% as well as changing the mandibular angle (something that I didn’t want to do as the angles matched before surgery).
During my follow-up visit the doctor agreed that this was not a good outcome and said he would redo the surgery with a custom jaw implant. However he has now abandoned me and has left me now with this Medpor implant that needs to be removed immediately. Thus I am looking for a doctor to help me out in this situation. I would like my current implant removed and a new custom implant put in in its place.
A: I am sorry to hear of your unfortunate outcome. In treating facial asymmetry, ‘winging it’ throws multiple variables into an already difficult problem and that usually never works out well. There is no doubt that a 3D CT scan needs to be done at the minimum for diagnostic assessment. But in 2015 designing a custom implant for facial bone asymmetry gives one the best chance for substantially improving facial symmetry. Since you already have a 3D CT scan you can proceed expeditiously to beginning the custom jaw implant design.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in breast implant replacements with or without a breast lift. I have saline implants that are 18 years old. I was a small B and the implants brought me to a small D. I’ve had two children and breast fed without complications. I feel like the implants stayed in place and my breasts didn’t. I don’t really want them this large anymore anyways but I’m unsure if I should take them out and get a lift or get them smaller with a lift. It would partly depend on cost but also on which one will look better. I just want a normal size and breasts that are perky.
A: It is not rare that pregnancy causes the existing breast tissue over implants to sag off of them after becoming enlarged and then deflated. This indicates that some form of a breast lift is absolutely needed, the only question is whether smaller implants are still needed to maintain persistent upper pole fullness of the breasts. A breast lift, while moving the nipple back up and tightening the breast mound around it will not maintain long-term upper pole breast mound fullness. This it is very likely that a small implant may still be needed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I may be interested in skull reshaping surgery. I am contacting you because I have been searching for a professional opinion relating to some worries I have concerning the shape of my head, and I thought that you might be able to help. I have noticed that there is a clear ridge sloping outwards, and above that, the shape seems to be flatter than when compared to many other people I have seen.
I never used to be so preoccupied, but this changed when I recently saw my head in profile. I have begun thinking that it is not ‘standard’, and I’ve been wondering whether there may be a reason for this.
I believe that some attitudes of people towards me, in the past, have been influenced by its shape. Do you think that undertaking cosmetic surgery to correct this would be possible/advisable, based on the images provided?
I realize it’s probably nothing, but I think it’s best to be certain about something like this.
A: I can tell you whether your skull shape should be a concern to you or not, that is a personal judgment. Beauty is in the eye of the beholder so speak…in this case an abnormality is also.
What I do see is a skull shape that has a flat occiput which has resulted in the posterior sagittal ridge area being raised up and sloping downwards toward the forehead. These skull shape issues are all interconnected and they are a well known type of skull abnormality.
Whether this skull shape should be of concern to you and whether it should be corrected is a personal and aesthetic judgement on your behalf. But it can be done through aesthetic skull reshaping surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m considering getting facial feminization surgery but I want to know the cost, recovery time and the amount of pain to be expected. I want to get the most change of my face that I can but am not sure how much I can really achieve. You are the facial feminization surgery expert so I would need your guidance as to what would be best for me.
A: Facial feminization surgery is a broad collection of hard and soft tissue procedures that are individually selected for each patient based on what has the best value to help change the shape of their face. There is no standard FFS surgery where everyone gets exactly the same procedures. I would need to see pictures of your face to make an assessment with computer imaging to see what works best for you before any cost quote can be given. Regardless of the exact procedures, FFS is always a compilation of numerous procedures that will cause a lot of swelling and takes about three weeks until one looks fairly normal and non-surgical…but really complete recovery from this type of facial reshaping surgery takes up to three months for everything to completely normalize.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley,I’ve recently e-mailed you inquiring about deltoid implants/fat grafting and I was wondering what other areas of the body that fat grafting can be applied to?
I’m 24 years old and have a very thin and bony structure, thin wrists, narrow shoulders, and thin neck which has led to years of insecurity, yet at the same time I have a decent amount of fat on my stomach and chest.Due to severe tendonitis and several joint problems – accompanied with a muscular dystrophic disease in earlier life, I’m entirely unable to engage in hypertrophy training so the option to increase muscle mass through weight lifting isn’t possible, though I have tried for many years to work around it.
I was wondering if somewhat of a comprehensive fat grafting/contouring upper body transformation (increasing forearm, upper arm, deltoid, and neck thickness) is possible. Could it be done and look natural? or is there an alternative surgery that could be more suitable? I just want to feel/look like a normal person.
Thank you.
A: I think the key issue in you, who is very thin most everywhere, is that fat grafting is very unlikely to be successful. This is because most likely you do not have enough fat to harvest to be used and in very thin people the injected fat rarely stays or stays so little that it does not make much difference. The only option for arms, shoulders, chest and calfs are body implants which can look natural as long as they are not overdone. (too big) There is no procedure that can make your neck thicker.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m a 32 yo man going for a sliding genioplasty. .I have lip incomptence therefore the surgeon is planning to remove a 5mm wedge of bone and I asked him to move the chin 10mm forward. However I’m a bit afraid of removing that amount of bone. I’ve read that with an angled genioplasty is also possible for height reduction but he seems reluctant because of the notch left on the jaw. I don’t know if these two procedures give the same result. The second picture is approximately what I expect and since I’ve had time I ‘simulated’ it on the x ray. Even though I rely on him, I’m looking for the best result that’s why I’m asking for another thought on it. Thanks for reading.
A:Please send me pictures of your face from the side view. That will be helpful to see how much vertical chin height reduction is needed if any in your sliding genioplasty procedure. If you really need vertical height reduction it is better to do it by a vertical wedge resection than a severely angled bone cut. That is the more assured method of achieving adequate vertical chin height reduction. Ideally seeing pictures of your lateral cephalometric x-ray would also be most helpful.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, a year ago I made a big mistake, I had a buccal fat removal operation (buccal lipectomy) and now I’m really sad about the results. My cheeks are too sunken and this makes me look older. I was reading an article you had written where you said that there two solutions for the buccal lipectomy defect. To add volume where my buccal fat was is it better a dermal-fat graft or fat injections? Will this leave scars on my face?
A: To restore lost volume from an over aggressive buccal lipectomy you can either do fat injections into the buccal space or place an actual dermal-fat graft into the original buccal space. One harvests the fat by liposuction (injection) while the other by an excision. (dermal-fat graft) A dermal-fat graft creates more assured volume but does leave a scar somewhere in your body to harvest it. For this reason many patients may initially opt for the fat injections. Either approach will leave no scars on the face as they are done from inside the mouth….just like your buccal lipectomy was done. In short, restoration of a buccal space defect must replace like with like…or fat lost with fat grafting.
Dr. Barry Eppley
Indianapolis, Indiana