Your Questions
Your Questions
Q: Dr. Eppley, I am interested in getting breast implants but am uncertain if I need a breast lift also. I saw a breast augmentation patient you had done who looked somewhat similar to me and she was able to have a good result with large implants alone. I was wondering if I might obtain a similar result. I have attached some pictures of my breasts for your opinion on this matter.
A: Thank you for sending your pictures. I think you just have too much ptosis (sagging) to avoid a breast lift with your implants. The key is the level of the nipple to the inframammary fold. If the nipple is at or just a hair below the fold level, implants can create a bit of a lift or at least not create the appearance of breast tissue sagging off the front of the implant. But when the nipple is really below the inframammary fold (and in your vase it is by several centimeters), the implant will merely drive the already hanging breast tissue off the front if it…making a not so good breast appearance even worse. While I do many breast lifts, I really don’t like them for women due to the scars and try to avoid them when there is a good chance that a women may get by without it. But unfortunately I just don’t see that being a good option for you. (implants with no breast lift)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in facial plate removal as part of other cosmetic facial work being done. But I have four titanium plates in the left side of my face from a previous facial trauma. Can I have those facial plates removed at the same time as the cosmetic work as well.
A: Indwelling metal facial plates can be removed during any upcoming facial procedure. The only question is where these plates are located, what access would be needed for their removal and would the trauma of trying to remove them be worse than just leaving them alone. One never knows if the plates have bony overgrowth on them and whether the screw heads that have been used to place them have been stripped. (making them difficult for a screwdriver to get a good purchase on them) With four plates I can going to assume that the metal hardware is likely around the cheek and orbital area.
In most cases in which patients have no symptoms from their indwelling facial plates, facial plate removal is more for self-relief or are being removed because of surgical convenience. For these reasons I needs to think carefully as to whether the trauma induced by facial plate removal makes it worthwhile.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in occipital and forehead augmentation. I am aware of custom forehead and occipital implants but I have several questions for which iIhope to get answers.
1. I do know through research that there are alternative material called PMMA, how does this compare with pre fabricated silicone ?
2. Which one is cost effective?
3. Which one get less side effect and after-problems?
4. If I included my forehead, are we using the same materials?
A: In answer to your additional questions:
1) You are referring to PMMA, a born cement material which is applied like a putty, shaped and than allowed to harden. This is what I used a lot before custom skull implants of which has largely replaced PMMA bone cement in my practice.. A custom skull implant is always better because its shape and exact dimensions are made before surgery. Because it has a preformed shape it is also put in with a smaller incision and less operative time and with a much lower risk of revision due to irregularities or edge transitions.
2) A custom skull implant costs more but PMMA will exceed that cost of a revision surgery is needed due to irregularities or edge transitions.
3) A custom skull implant has much lower revisional surgery risks than PMMA bone cements. It is also much easier ti remove and revise if that need should arise.
4) The issues are the same in the forehead where a custom implant works better than PMMA bone cement.
But the differences between using a custom implant vs. PMMA bone cement may be greater or more similar depending upon the size of the front and back of the head augmentations desired and how much scar length one is willing to tolerate. I would really need to see pictures and do computer imaging of you to get a better idea as to these very important issues.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I just got buttock implants done (425cc), but they are no where near the size I want. I was wondering is there anyway for you to add to my hip/ butt area maybe with more implants? I can’t do a fat transfer as I am too thin.
A: Thank you for sending your pictures of your buttock implants result. While I do not know where you started, you have a very good result. It is not possible nor medially wise to seek that degree of buttock size change by larger buttock implants or adding other implants. Such implants in a thin frame like yours is asking for complications and risks losing what you have now. Surgery with implants anywhere in the body is like a roulette wheel. You have spun the wheel once with fairly large buttock implants for your frame and you have achieved good improvement without complications…at least up to this point early after surgery. Pushing all your chips for another spin at the roulette wheel (further implant surgery) risks losing everything with complications like infection, implant capsular contracture and lifelong buttock deformation. While you may have not achieved your ideal buttock enlargement goal, which was never a realistic goal with your body frame, you have reached what I would consider to be medically safe and the probably limits of what your body can tolerate.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am seeking vertical facial lengthening. I am told and agree, that my face is short and looks clamped. My dad has a bite issue and his face also is short but not as short as mine. I was told by an orthodontist that it was a borderline deformity. I have noticed strange looks from others and have caught some laughing at me. This is affecting my quality of life. I have heard of procedures to lengthen the jaw and was wandering if this falls under facial asymmetry or if it doesn’t if you could correct this?
A: Thank you for your inquiry and sending your pictures. What you have is most certainly a short lower third of the face due to the vertical height of the lower jaw. (and some jawline asymmetry) Many people that have this vertical jawline deficiency have a near 100% overbite and are over closed, thus creating that look. Since you have been clearly seen and evaluated by an orthodontist this is not the primary cause in your case.
Your vertically short lower jawline (lower facial height) can be best and only treated by a vertical facial lengthening surgery using a custom jawline implant that will lengthen the entire jawline from front to back. This is made from a 3D CT scan and is custom designed for each patient. This is aided by the use of computer imaging of pictures and computer design software, meshing the two together to create a much improved but not over corrected result. The custom jawline implant is inserted through incisions inside the mouth.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a sliding genioplasty done two months ago and I think that it has shifted. I am not sure if there is a gap on part of it because of the shift. I would like your opinion and evaluation.
A: Thank you for your inquiry. I understand that you think your sliding genioplasty has shifted. Did you have any x-rays after surgery or any now that would help understand if that is what has happened? It is also possible that as all swelling has finally subsided any asymmetries can become more apparent which are masked for the first 4 to 6 weeks after surgery due to the swelling. Please send me some pictures or anything that shows where you see the chin/jawline asymmetry. It is also more likely than not that the gap you see is the step-off at the tail end of the sliding genioplasty along the jawline behind the chin.
An under appreciated aspect of any sliding genioplasty is that it causes a disruption of the inferior border of the jawline. Depending upon the angle of the bone cut and the amount of forward advancement of the chin, the inferior border disruption may be minimal or significant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am seeking a skull implant. The crown of my head is flattened out in the back and I would like to have the back of my head have a more rounded shape to it. I’m bald and wear a hair system that’s adhered to my scalp right now. But I am considering having scalp micropigmentation to give me a buzzed haircut look and the appearance of the back of my head is the only thing that’s stopping me right now from doing this. the scar which would be created can be hidden somewhat with the micropigmentation. On your website, you have a pic of what the back of my head somewhat looks like but maybe not as extreme so I have attached it so you can see what it looks like. If you need a more detailed pic, I would have to remove my hair system which would take time to remove it but if its needed, please let me know. I am hoping to get an approximate cost for the procedure if its something that can be realistically done. I don’t have enough donor hair to consider having a hair transplant and this to me is the next best option as I’ve always wanted as I’ve always loved the buzzed cut hair look. I hope to hear from you soon, thank you for your time.
A: It is extremely common in men that they seek skull implant augmentation when they are either going bald, want to shave their head or permanently eliminate the need for a hair prosthesis. The fear of what their head shape looks like may drive them to seek skull shape correction. In short, I have heard your story and motivation for skull reshaping surgery numerous times.
The best approach for increasing the convexity of a flattened back of the head is a custom skull implant. This is made from a 3D CT scan. My assistant will pass along the cost of the surgery on Monday.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I need advice for facial reconstruction. I had surgery consisting of a left partial maxillectomy to remove a muco-epidermoid carcinoma. (intermediate grade).
Since then, my face have partially distorted as per current picture. Could you please suggest what type of procedure is good for me , to have a better natural handsome look. Could you please recommend the best option and how the procedures are carry out.
A: Thank your for your inquiry regarding facial reconstruction and sending your pictures. The key question is whether you have undergone any radiation treatments to your face after your cancer resection??
Your face is collapsed inward on that side due to lack of underlying bone support from the maxillectomy. Replacing that bone and rebuilding that side of your face would require a complex form of reconstruction known as a free flap as there is inadequate soft tissue to cover any bony reconstruction. This would be particularly necessary if you have had radiation treatments.
A simpler and less complex form of reconstruction would be to focus on building up the soft tissues through fat injections. This can be done whether you have had radiation treatments or not.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a breast reduction but my situation is a bit unusual. I currently have breast implants but gained weight after surgery with my third child. That was over ten years ago. I would like a breast reduction with my implants removed. I do not want to be bigger than B cup… I am currently a D/DD cup.
A: With breast implant removal and some significant breast tissue on top of them, a full breast lift may be likely needed. Due to concerns about blood supply to the nipples, the amount of breast reduction/lift that can be done may be more limited than going all the way down to a B cup may permit. Conversely, based on the size of your existing indwelling implants and their location (submuscular vs. subglandular), such a breast size reduction may be very possible. Larger breast implants that are in a submuscular position will safely permit more of a breast reduction/lift. I would need to see pictures of your breasts to help make that determination.
Removal of breast implants by itself causes an obvious breast reduction effect. But the now excess and potentially sagging overlying breast tissue must be managed to create a smaller and tighter breast mound.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in forehead recontouring but all of your case studies of the procedure show people with hair. I can see how an incision made for forehead recontouring along the hairline is great if you have hair and can hide the incision. But what if you don’t have hair, how would you handle that?
A: There is a reason you do not see pictures of almost any kind of forehead recontouring procedures in men who either do not have hair or have a shaved head…they do not do the surgery. The scar would not be a good tradeoff in the vast majority of men unless the forehead deformity is very noticeable or extreme. Having said that, I have done a handful of men who have no hair for forehead recontouring but they are extremely motivated and are willing to make the aesthetic tradeoff of a scalp scar.
In some cases of forehead recontouring a forehead incision through a prominent wrinkle line can be considered as an alternative to a scalp incision. This can be a more ‘natural’ and direct approach based on the age of the patient and the extent and depth of the forehead wrinkles.
Dr. Barry Eppley
Indianapolis, Indiana
Q: D. Eppley, I need advice on a facelift result. I am a 63 year old female, who has lost 125 lbs from gastric bypass surgery over two years ago and had a facelift done two months ago. Sadly, my neck wattle has partially returned and both I and my plastic surgeon are very disappointed. In reading my operative note the facelift technique done was a lower facelift/corset platysmaplasty, lateral spanning sutures in platysma, and SMAS plication, with extremely wide skin undermining.
I am at a loss of what I or my plastic surgeon could have done differently! I don’t want to go back to surgery with the same plan which has already failed once. My plastic surgeon suggested the option of a direct neck lift but I don’t want the visible scar.
Do you have any experience with facelift surgery in massive weight loss patients? Was I asking too much from this operation? I know my skin elasticity is terrible and there is some improvement but not a lot.
A: In my facelift experience with large neck wattle in extreme weight loss patients, the first thing I tell them is that their degree of neck laxity may require a secondary procedure due to rebound relaxation and an inability to adequately reposition all the neck skin up and back. What looks good on the operating room table may be inadequate or does not always hold up well. So plan the surgery as if it is a two-stage procedure.
The second issue is what I do during surgery…you will need a major back cut behind the ears that either extends well into the occipital hairline or goes along the occipital hairline down very low into the posterior neck. This is the only way you can find a place to redrape the neck skin and excise it. In necks like these it is all about incisional location and it is different than a more traditional facelift. This also applies to the anterior incision as well. Because so much skin is being moved, and I don’t want the preauricular tuft of hair to end up way above the ear, I do a blocking incision technique. This is where the incision is made not up into the temporal hairline but around the preauricular hair tuft in a Z-shaped pattern. Good mobilization and redraping of the skin with these incision patterns, will show intraoeratively that the entire ear is completely covered before you make pilot cuts and skin excision. If it is not, then the amount of neck skin redraping will be inadequate.
I would simply plan on doing a secondary facelift with these modified anterior and poster incision locations, doing skin only, and it will be much better than the first time. The reality is that this type of neck skin excess and poor elasticity defies a traditional facelift approach.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a severe tear trough deformity and am interested in the implant procedure. However there does not seem to be anyone in my area that will use implants for correction????
A: Thank you for your inquiry and seconding your picture. I think you are referring to a complete infraorbital rim implant not just a tear trough implant which just covers the inner half of the orbital tim. While most plastic surgeons prefer fat injection grafting for a deficient infraorbital rim, I prefer an implant rim augmentation technique which produces a more reliable, smooth and permanent result. This is a vey rare type of facial implant that is used only by experienced facial implant surgeons. While the technique to place them is the same (lower eyelid incision), the design of the infraorbital rim implant varies. It can be made as a custom implant from the patient’s 3D CT scan or can be used as a ‘semi-custom’ type implant which is a derivative from prior custom implant patients. (infraorbital rim anatomy/shape is not that different amongst most patients) There are no performed or standard off-the-shelf infraorbital rim implants for use…which is also why there are so few surgeons that use or have any knowledge about them.
When in doubt about using infraorbital rim implants, one should always try fat grafting first. There usually is little to lose by doing so as fat often completely resorbs in the infraorbital area. If it is overdone and too much fat persists then infraorbital rim implants can be placed and the extra fat removed at the same time.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in correcting my chin dimple. My chin really bothers me the most right now. Once we meet in person I think it will be easier to assess. I have researched for two years now the options to get rid of the dimple in the chin. I have read a lot about the injectable fillers to achieve a temporary fix, so again once we meet in person you can tell me what you think about that option. Anyways, attached are pictures where you can see the dimple a little bit. Pictures do not do it justice though! Attached you’ll see a recent pic I took where you can see the dimple. Also attached you will see a side profile where you can see the dimple in my chin and also the tip of my nose that irritates me! Thanks for your help!
A: Thank you for sending your pictures. What you have is really bit of a vertical chin cleft which you are calling a chin dimple. Those can be difficult to treat effectively. The simplest and the best injectable filler treatment is either fat injections or micro droplet silicone oil. (which is permanent) If you were having other types of surgery then fat injections would be worthwhile since you are already there. Otherwise you can try injectable fillers in the office and see how effective it is first before doing something permanent like silicone oil.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in temporal and brow bone augmentation. I was wondering what you would suggest for a 26 year old patient with weak temple and brown bones that make me look tired. I want the brow and temple area to be smoother and flatter and my eyes to look less protruding. I was reading about fat injections and was wondering if those can give me the results or would I need something more extreme like implants.
A: Thank you for sending your pictures. For the temporal region I can see where our extended anterior temporal implants will fill out the temporal areas nicely up to the temporal lines of the forehead. Building out the brow bones (supraorbital ridges across the top of the eyes would make the actual eyes look less protruding. The best way to achieve that look would be to make a custom brow bone implant for you off a 3D CT scan. Both procedures could be done concurrently. The temporal implants are placed through small (3.5 cm) vertical incisions back in the temporal hairline. The brow bone implants could be placed endoscopically through small scalp incisions.
The problem with fat injections, particularly for the brows, is that they are unpredictabe in terms of survival. In addition they produce very ‘soft’ push on the outside tissues which may be acceptable for the temples but not for the brows. But as an alternative and potentially more appealing treatment strategy this can certainly be done. And there is little to lose but doing so.
In reality, the placement of implants is not much traumatic than doing fat injections in these areas.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in lip reconstruction. Attached are photos of my lips. Two years ago, I had a vermillion lip advancement. However, the surgeon did a v/y to the central portion of my upper lip…something that was never discussed beforehand. I’m left with no cupid’s bow and no philtrum. My lower lip hangs down and there are ‘pouches’ just below the lower lip. What can you do to make my mouth look better, and most of important, what can be done to lift my lower lip so that my teeth don’t show and those pouches diminished. Thank you so much in advance.
A: Thank you for sending your lip pictures. Lip reconstruction efforts can be done on both the upper and lower lips. Certainly the upper lip vermilion advancement can be improved because that is straightforward redesign of the shape of the upper lip and advancing the vermilion edges according to the new pattern cut out. This is very predictable and will make a positive improvement. Raising the lower lip, however, is considerably more challenging, not easy, and very unpredictable. Regardless of the dubious success of raising the lower lip, the pooches that lie below and beyond the vermilion of the lower lip can not be improved. Techniques to try and raise the lower lip usually require a sling or suspension of tissue placed across the lower lip from one mouth corner to the other. (technically from a small incision at the end of each nasolabial fold crease to the sling can be threaded through) This sling could be comprised of your own tissue (abdominal fascia) or an allogeneic (cadaveric) sling of dermis can be used. (e.g., Alloderm)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had cheek implants placed two years ago. As a result, my cheeks are uneven and prominent in the wrong place. I want high cheekbones and also the uneveness of the current submalars makes one cheek look higher and more prominent and throws my jawline off making it look wider on one side. I want to correct this and obtain higher cheekbones instead of the cartoon character look. That’s why I want to swap them out for other cheek implants, either malars only or combo implants. Can you look at my pictures and give your recommendation?
A: Thank you for sending your pictures. It is very clear that the large submalar cheek implants is really not the right cheek implant style for you. It creates too much fullness below the cheek bone which does not work well in your face. I would recommend the following:
1) Remove existing submalar cheek implants.
2) Your new cheek implant style would be any form of a combo or one that has any submalar component at all.
3) You need ‘high’ malaria augmentation styles implant that also go back further onto the zygomatiuc arch. No such standard malar cheek implants exists, even amongst the standard malaria options. Ideally a custom cheek implant style is made that would fir your face precisely and create the augmentation exactly where it is needed. because your current implants have created loose cheek tissues, the new cheek implants really need to help lift up this tissue.
4) If I was ‘forced’ to use a standard cheek implant I would the malar shell style and modify it during surgery.
5) I would consider doing subtotal buccal lipectomies and perioral mound liposuction to contour in the area below the new higher malar augmentation to maximize the effect.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a gastric bypass surgery three years ago to lose weight. I have lost nearly 200 pounds. I am a 50 year-old female. My primary insurance is Medicare and my secondary is Champ VA. i did not have to pay a penny for my gastric bypass. I saw a story on my local news tonight about Cool Sculpting. A procedure that costs $1,500. by a doctor in California. One place locally here has given me a quote of $7,600 tor a tummy tuck, but there is no way I’ll ever be able to save that much money. I have no credit cards. I don’t even have a car or a phone. I cannot afford a monthly payment on a car much less the insurance. Nor can I afford a monthly payment on a phone. My car broke down last year with a cracked engine in January. I rent a car when I need to go out of town. Thank you.
A: When one has lost 200 lbs, the overall circumferential body problem is too much skin. Do not waste your time and money on anything other than a major tummy tuck operation. There is nothing less than a big operation to cut out the extra tissues that will work. You may have luck finding a plastic surgeon who takes Medicare to do your surgery (which is very scarce) or you may be able to have it done in a VA. But other than these unlikely options, being able to do a tummy tuck like you would undoubtably need at just $7,600 is a bargain. Whomever offered to do your surgery at that very low rate for a tummy tuck like you would need was doing you a major favor.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a sliding genioplasty done two months ago and I think that it has shifted. I am not sure if there is a gap on part of it because of the shift. I would like your opinion and evaluation.
A: Thank you for your inquiry. I understand that you think your sliding genioplasty has shifted. Did you have any x-rays after surgery or any now that would help understand if that is what has happened? It is also possible that as all the swelling has finally subsided any asymmetries can become more apparent which are masked for the first 4 to 6 weeks after surgery due to the swelling. Please send me some pictures or anything that shows where you see the chin/jawline asymmetry. It is also more likely than not that the gap you see is the step-off at the tail end of the sliding genioplasty along the jawline behind the chin. This can be more apparent on one side or the other and is more common if the sliding genioplasty movement was significant or the angle of the bone was at least 45 degrees or greater. The bigger the bony movement and the greater the angle of the bone cut, the more likely jawline indentations will appear after surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a sliding genioplasty and jaw recontouring (after I had upper and lower jaw surgery previously with a different doctor). After the sliding genioplasty and jaw recontouring my chin still wasn’t in the middle and I am unhappy with the shape of my jawline,. It seems to have a lot of dents after the surgery (see the before and after x-rays). Is it normal after jaw recontouring and sliding genioplasty to have this kind of irregularities and is it possible to get more symmetry? I hope you can help me with these questions.
A: Thank you for your inquiry and sending your x-rays. What I can see on the x-rays is that the left jawline looks very irregular from the chin on back to the jaw angle and has clearly been surgically manipulated. Curiously the right side of the jawline looks fairly pristine…almost as if it has never had surgery at all. I can not appreciate the chin asymmetry as the x-rays shows a bony chin that looks midline. The left lower border looks a little irregular. How this correlates to what you look like on the outside would be relevant to whether and want you should do next. In looking at your pictures of your past jaw recontouring efforts, you look just like your x-rays with a very irregular left jawline and chin asymmetry. I would recommend you get a 3D CT scan from which a custom inferior border implant that would extend from the chin back to the jaw angle to improve your jawline and chin asymmetry.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’ve been considering a breast augmentation but I have a few questions. I’m 21, and I’ve read that you cannot do silicone breast implants until you are 22. I’ve also read that it’s illegal to get silicone done under 22, but I’m not wanting to do saline. I’m curious if it’s possible to do silicone or not at my age. If it’s not how does that work. thank you for your time!
A: Let me provide clarification about age and the insertion of silicone breast implants. Because the long and extensive clinical trials for the silicone breast implants used today consisted largely of women between the ages of 22 and 65 years of age, the FDA listed that age range as the recommended ages of silicone breast augmentation. While that is the FDA guidelines for the use of silicone breast implants, it is completely up to the plastic surgeon to use them as he/she sees medically appropriate. Thus it is perfectly legal and medically appropriate to use silicone breast implants at any age below 22 years old. This is up to the decision and informed discussion between the plastic surgeon and the patient.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a septorhinoplasty procedure. I previously have undergone balloon sinus surgery in order to correct breathing issues. I have been to an ENT doctor and he suggested further reduction of the turbinates. I also have a problem with the sides of my nose collapsing when I breath in heavily. I wanted to correct the breathing problems especially because my chosen career is very physically based, as well as reduce a bump on my nose. I am very interested in if you would have any additional things to add to aid my breathing as well as improve the appearance for my nose.
A: Having not seen any pictures on your nose or examined you, I can only make some speculative opinions based on your description of your nasal symptoms. While further reduction of your inferior turbinates may improve your breathing, collapse of the nasal sidewalls with inspiration suggests weakness of the lower alar cartilages and impingement of the internal nasal valves. Such nasal valve collapse can cause greater breathing difficulties than a mechanical obstruction of the inferior turbinates. Since you interested in taking down your existing nasal hump as part of a cosmetic change to your nose, the incorporation of middle vault spreaders to open up and stabilize the internal nasal valves as well as batten grafts to support the lower alar cartilages would be adjunctive nasal airway maneuvers in addition to the inferior turbinate reductions. This more comprehensive approach to your septorhinoplasty should provide some significant breathing improvement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in pectoral implants. I had gynecomastia reduction done twice in the last 10 years. I still have divets because I think too much tissue was removed on the outside areas of my pecs. I am also considering pectoral implants to even this out and provide a more contoured even look. I work out often and I still am not able to get my pecs looking good. I have read about your expertise with male cosmetic enhancements.
A: It sounds and looks like the combination of pectoral implants combined with some fat grafting to the nipple-areolar divots would create a more contoured chest result. It is hard to argue with the immediate and dramatic improvement in chest shape that pectoral implants can create. But they alone would not fix any indentations from over resection from gynecomastia surgery. That will need to be addressed directly with fat grafts put right into the soft tissue defects.
Gynecomastia reduction, particularly if done by liposuction, can often leave the chest looking deflated particularly in older men. Pectoral implants can make for an instant change in chest size through muscle enhancement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a jawline implant I am a 50 year old male in good shape. I had liposuction under my chin for the first time at age 35. About ten years ago I had a neck lift and liposuction under my chin. At 50 years of age, I am interested in a Jawline implant and tightening of the platysma muscles which seem to be sagging. Additionally, the skin under my neck is just a bit saggy. I would like a 90 degree cervico-mental angle, similar to Rob Lowe without the protruding chin. I would rather get this done while I am younger so it won’t look so dramatic after the surgery? Can anyone tell that one has had jaw implants?
A: I need to know whether you mean jaw angle implants or a total jawline implant. I believe you may be referring to a total wrap around jawline implant which can be combined with a submentoplasty procedure for the optimal jawline-neck shape change. Such jaw implants are not detectable unless they are overdone or look obviously disproportionate to the rest of the face. They require a preoperative 3D Ct scan for their custom fabrication.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in alar base repositioning. I read in a Real Self post you commented on regarding a lady who had one ala that was higher than the other side. You mentioned that you can lower the high alar sidewall through a simple technique. I have the same issue: my left ala is higher than the right, so my nasal sills/base seems it slants up toward the high side, my supra alar crease is 2-3 mm higher as well, and my upper lip also follows this upward slant. I have slight form of hemifacial microsomia where the left side of my face is smaller (and shorter) and less full than the right. Can you tell me what this alar repositioning technique is? How do you lower the higher alar side? I consulted with my local plastic surgeon and he considered an anchor suture technique to try and pull down the high side. The problem is, I had a prior surgery where a different surgeon put a Medpor implant (with screw) in my pyriform aperture and there is a screw there. My current plastic surgeon said he would need to put a screw for the anchor where that screw is currently in for the implant. Was the anchor suture method the method you spoke of in that lady’s post? Can the Medpor implant that I have be removed? And can the anchor be put in its place, using the same screw hole to fasten it?
Just thought I’d ask because you’re the only plastic surgeon that has also mentioned this technique to lower an alar sidewall that is a higher than the other side. You also mentioned in another post of using this method to raise the ala (the opposite), has this been successful? I’d appreciate your advice and information on which technique you were referring to, in order to lower or pull down one alar sidewall that is higher than the other side. I would like to have my higher ala/nasal sill, and upper lip lowered for better symmetry. It seems that when I pull the skin down next to my supra alar crease, everything else goes down with it, and it looks more symmetrical, how I want it. I have yet to find a doctor who can actually do all this, as my asymmetry is due to my facial bones. It sounds like the anchor suture thing would be the thing to do, but then again, I am not a Dr. by any means, so I wanted to ask you since you mentioned a technique to the lady who has the same problem I have.
A: There are two basic ways to lower a higher ala (alar base repositioning), either a skin excision alarplasty or a suture anchor fixation method to the underlying pyriform aperture. I would need to see pictures of your face to determine which may be more appropriate. Your indwelling Medpor implant does not pose a problem for the internal anchor technique. The implant can be maintained.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had sliding genioplasty surgery couple of days ago and moved forward 8-9mm.I hate my bottom lip got 1/4 size of my original one! It’s a heart attack and I loved my lips! Did you see any improvement in lip’s size after a while? Should I reverse the surgery?Attached are some picture of before and after 4days surgery. I really liked my bottom lip and I feel the suture are tok high that locked my lower lip and I doubt if it loose even after it heals. The reason might be because of the 8-9mm projection on my chin or the surgent personal desire to balance my lower lip without letting me know in advance. As I know he moved my chin 8mm out and little down. Now I can’t accept new round face and nice bottom lips are gone! What I wanted to have was a little projection! What do you recommend? I am thinking to revise partially before my bone get heal! Although I am worry because it might not give my pervious face and lips back! So appreciated for the help.
A: Thank you for sending your before and after sliding genioplasty pictures. I think it is extremely important to realize that you are just 4 days after surgery and the chin always gets tremendous swelling…which is why your face seems round right now. That will change over the next three weeks as some of the swelling subsides. I see no evidence that your chin is ‘overdone’ or been advanced too far. I think from an augmentation standpoint that you should wait much longer as it takes a good 6 weeks to really appreciate the final result. As for the your lower lip, it is very common that it feels very tight. This will always loosen up much more than it is now.
I think right now you are going through ‘buyer’s regret’ which is not uncommon with all the swelling and tightness and the uncertainty of what will be the final outcome. It is not rare that one yearns for what they look like previously when going through the early recovery period after many forms of facial structural surgery such as a sliding genioplasty.
I would urge you at this point to have more patience and give it two to three more weeks to see how you feel then. The osteotomy can be easily partially or fully reversed even months after the initial surgery date.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m wanting to have jaw angle reduction to make the face slimmer.
1.Is it correct that if the jaw angles get cut; then the periosteum that covers the jaw angles will also get detached or cut, correct?
2. The “standard “ jaw reduction surgery would ensure that the periosteum is intact to the jaw bone throughout the procedure. Not to cut the jaw angles which will also result in loss of shape and bone support. Therefore it is best to do a sagittal reduction to make the jaw slimmer?
3. For the sagittal reduction, does it mean that the periosteum does not get detached? I read that a standard procedure would be to keep the periosteum intact and have a sagittal reduction, not cut the jaw angles ? But I don’t understand why the periosteum does not get detached in a sagittal reduction?)
A: The periosteum must be elevated (detached) from the bone in any jaw angle (mandibular ramus) procedure. That is not what is important in preventing soft tissue sag after jaw reduction surgery. The relevant issue is the preservation of the bone angle shape. A traditional jaw angle reduction obliquely removes the full thickness of the angle where various ligaments attach. It will dramatically make the width of the angle less but do so at the loss of angular shape and potentially soft tissue support. The sagittal reduction method preserves the angular shape and soft tissue support although the width reduction will be less.
Either jaw angle reduction technique has its place. It depends on the natural jaw angle shape and thickness of each patien and what one is aesthetically trying to achieve.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have some questions about rhinoplasty and how it it planned and performed. How do cosmetic surgeons measure the profile of the face? From where to where? Is there a ratio that is considered perfect? Was it derived from the great medieval sculptors?
A: Contrary to popular perception, plastic surgeons do not use specific anthropometric measurements in planning and subsequently performing rhinoplasty surgery. While there are many known angle and measurements of the nose, and plastic surgeons are well aware of them, they are only roughly applied in performing the procedure. Surgeons use a gestalt about these anthropometric values and measurements rather than a precise application of them. Plastic surgeon may learn these measurements in their training or through experience but they do not use such precise measurements in surgery. This is because actual surgery does not translate well to afew millimeters or degrees of angulation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I got my chin implant because it looked receded in the profile view . But i think it looks large when you look at it from the front and it looks boxy and square from its width. As i grow older, i’m afraid that my chin will stand out where as the rest of my face thins out. I was thinking about a smaller implant but also considering genioplasty. I still want projection but not the width that the implant adds.
A: While chin implants provide good lateral projection in a wide view, they also add width in the front view. That will happen no matter what size chin implants is used because of the extended lateral wings on them. While this provides a smooth and more natural blending into the jawline behind the chin, it do so by adding some width to the chin.
The choice is to either remove the wings in your existing implant or remove it and replace it with a sliding genioplasty. A sliding genioplasty as it brings the chin forward will not add any width and, based on how much forward movement is done, may make the chin sightly more narrow.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I originally sought rhinoplasty due to great discomfort concerning the projection of my nose. The tip feels enlarged and out of proportion to the rest of my face as well as deviating to one side. However, after speaking with a surgeon, I have come to learn that my jaw is retrusive which makes my nose look larger. I would like to know whether or not you think I would benefit from both jaw and rhinoplasty surgery, or whether you think one or the other would be enough to balance my face. I have attached some photographs in this email.
A: Thank you for sending your pictures. I think it is quite clear that in looking at them that the short chin/jaw is a far greater contributor to your profile concerns than that of the nose. Like many profile concerns, it is really a ratio of the nose:chin in looking at the deficiency and where the greatest improvement may come from what procedure. In your case I would put it at 80:20, jaw:chin. While chin augmentation will make a major difference, a rhinoplasty where the tip is thinned and a bit shortened will make for an even better result.
In many cases of rhinoplasty, the chin augmentation that may be done with it is complementary to the nose changes. But in your case it is the reverse…the rhinoplasty would be complementary to the chin augmentation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m contacting you in order to get some information on my recent zygomatic reconstruction. I had zygomatic bone (whole complex) reposition after overlooked fracture. The bone healed in wrong position and it had to be cut then repositioned. CAS (computer assisted surgery) was performed.
It’s 5 weeks since surgery and my masseter muscle looks strange when I open my mouth. I wonder why ? My surgeon only says me “wait, wait it will go away”. There is 0% of improvement. I’m not sure if the problem its gonna resolve itself. I’m afraid of TMJ since this muscle works improperly now. I feel some restriction in my occlusion (mouth opening) but not big. I can eat normally with little discomfort. My occlusion amplitude is about 3cm. Before surgery I had about 4cm. I realized that after fracture I didn’t have such problem because the displaced bone adjusted to muscles. Hence they were working perfectly.
IMPORTANT: After surgery new position is forced. My logic thinking says me, there may be not proper angle and eventually “distance between 2 parts of zygomatic arch, what gives strange position for different parts of masseter muscle. I never had symmetry .. I wonder what if my surgeon was focused too much on symmetry and set the bone in the position very uncomfortable for my muscles. What if waiting will not help and it’s gonna stay like this and some irreversible complications will occur.
Is it due to wrong position of the zygoma bone including zygomatic arch ?
swelling.? I do not see swelling there. I have mostly little swelling on the cheek, but no on the side of the face near the muscle Too big change ? Muscle need more time to adjust ?
A: Thank you for your inquiry and sending your pictures. As I interpret your current situation, you have a right zygomatic osteotomy done about 5 weeks for an initial displaced ZMC fracture. Your current symptoms are that of some persistent limited oral opening and right facial masseter ‘asymmetry’. As a general statement at this point after this major facial surgery, what you are experiencing is very common and expected. It will take you a full six months to achieve a full recovery…and this includes to have all of the facial swelling to go away. (I believe the masseter muscle/facial asymmetry you are seeing is still some swelling) At the least five weeks after surgery is not a complete resolution time for all facial swelling to go away.
I would also expect you to not have complete normal oral range of opening just yet. You should certainly begin oral range of motion exercises at this point to workout the muscle stiffness and increase the amount of opening that will be comfortable=y achieved. It will take a full three months to get back the normal range of interincisal opening. You didn’t have these symptoms after the injury because all of the masseter muscle attachments to the zygoma were not disrupted, but to reposition the zygomatic bone some of them must be. The reconstruction effort causes greater internal trauma to the area than that of the original injury.
Such zygomatic reconstruction is always done based on ideal bone positioning. It is never done based on any consideration for the exposure and partial release of a few anterior attachments of the masseter muscle that are needed.
Dr. Barry Eppley
Indianapolis, Indiana