Your Questions
Your Questions
Q: Dr. Eppley, Would a zygomatic osteotomy work on an individual with cheek asymmetry due to hemifacial microsomia? I am considering orthognathic surgery to fix my jaw and masseter muscle. I am also considering a procedure to enhance my cheek symmetry. I have heard implants can be unnatural when placed unilaterally even when custom made. I thought a zygomatic wedge osteotomy may be better. Because the eye and cheek are interrelated it could make eye look smaller?
A: What is best for your cheek symmetry would really require evaluation by pictures of your face and review of a 3D CT scan. But as a general statement, a zygomatic expansion osteotomy (which is what you mean by ‘zygomatic wedge”) only affects one dimension and that is cheek width. It can not change any other cheek dimension. In my experience in the hemifacial microsomia patients, the dimensional changes need to the cheek area are more than just that of width. Plus the bony edges of a zygomatic osteotomy and the plates and screws to hold it would ultimately be able to be felt and many be able to even be seen through the skin. It is not true that a custom implant would look unnatural and, because it is custom made and fits the bone in a smooth transition manner, would probably look more natural than any osteotomy/bone grafting procedure.
Any cheek augmentation procedure, by definition, may make the eye look smaller no matter what technique is used. Although that degree of orbital change may be aesthetically negligible.
These are general statements which are made with no specific knowledge about your case.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a problem with my lower floating ribs. They touch my pelvis bone and cause a lot of pain and discomfort. Typically they render me inactive for weeks, sometimes months at a time. I’ve been to countless physiotherapy sessions, and I have looked and looked for a doctor who would consider rib removals.. I just discovered you on YouTube, and I am wondering if you would consider this for me. Thank you for your time.
A: Thank you for your inquiry. It is very rare that the lower floating ribs actually touch the iliac crest of the hip with certain body movement…but I have had previous patients tell me this before. And it can be anatomically explained as ribs #11 and 12 actually point downward as opposed to the ribs above it which point more to the side. Also they are partial ribs and not complete ones so they do have a blunt end to them. The good news is that rib removals of them should be a cure for this type of anatomic impingement problem.
Rib removals of ribs #11 and 12 are done through small incisions on the back that parallel the direction of the ribs.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m interested in a reverse tummy tuck, I’m at my goal weight and I’m 48 years old. I’ve had previous liposuction to tummy, buttocks, and thighs. I’m interested in just tightening the skin in my upper abs. I do not want any liposuction as this has already caused uneven skin and a permanent wrinkle in my tummy. I don’t need my muscles to be tightened as they are already pretty tight. I just want to tighten the skin. When I pull the skin up under my breasts, it does miracles. I am not looking for perfection. Even if it protrudes a bit, I’m fine with it. I just want to fix the uneven skin and the permanent wrinkle that is there.
Can this be done with local anesthesia and twilight or IV sedation? I have a real hard time with general anesthesia. Also, where do you tether the incision? The rib or the muscle? To keep the scar from stretching or moving downward? Does the scar have to go across the breast bone? Can it be just under the breasts? I do have large breasts so they may hide the incisions which would be a bonus. Again, I am not looking for total flatness. Just get rid of the bumps or unevenness.
I’m also interested in skin removal from my buttocks and outer thighs. I don’t want a Brazilian butt lift. I don’t care if my butt is flat. I have lost weight in my lifetime and gained and lost again. This has left me with saggy skin and some dimples, maybe due to liposuction as well. I don’t want liposuction in this area. If you think it has to be done then that’s fine. I just want some even skin with no dimples. Can you suggest something for this area that I have not been able to find? The only thing I can think of that would help is a skin removal/tightening. If it can help my outer thighs then great. Please see my photos. I would also like this to be done without general anesthesia. Is this possible? Can this be done the same time as the reverse tummy tuck.
A: Thank you for your inquiry and sending your pictures. As reverse tummy tucks go, you are about as perfect a candidate for it as I have seen. They are for women that have either had liposuction, a tummy tuck or weight loss where the tissues below the belly button are taut. But the skin above the belly button is loose and has some overhang exists onto the umbilicus. By simply pulling up on the abdominal skin a good improvement is seen. By definition a reverse tummy tuck is a more simpler form of a tummy tuck, does not involve muscle plication and is a skin excision only procedure.
The key in a reverse tiummy tuck is the incision location. I have done it either keeping the incisions limited to the inframammary folds or crossing the lower end of the sternum. When it crosses the sternum it produces a better skin lift/tightening (due to the central pull) but does have visible scar location in the very center. When the ellipitical skin excisions are limited to the inframammary folds, the effect is not quite as good but still apparent. One has to decide whether more upper abdominal skin tightening is worth the scar trade-off. The upper abdominal tissues are plicated to the fascia over the ribs at the inframammary fold level.
In regards to your buttocks and outer thighs, a partial solution exists. A lower buttock lift can tuck and tighten the lower buttocks through an elliptical excision along the infragluteal crease. It does flatten the lower buttocks a bit but this is not an issue for you as you have stated. The outer thighs is a more problematic area because any effective skin tightening/lift will create a visible scar that would only be an acceptable trade-off in the extreme weight loss patient.
As uncommon as reverse tummy tucks and lower buttock lifts are, they are not in my practice. I have performed them many times although their frequency is in the range of 3 to 4 per year for reverse tummy tucks and 10 to 12 times per year for lower buttock lifts. Both can be performed under IV sedation although, because of the prone position and airway security, the lower buttock lift should be done under local anesthesia if one is not having general anesthesia.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am looking for a doctor that has done brow bone augmentation. I came across Dr. Eppley and am considering both rhinoplasty and brow bone augmentation to improve my profile view. I want my forehead to come out further, as of right now my eyes are flush with my forehead and it’s very flat. I want more dimension in my face. I wanted to know what you would recommend and how confident yo are with Asian rhinoplasty. Thanks!
A: Thank you for your inquiry and sending your pictures. I have done many Asian forehead and brow augmentation and rhinoplasty procedures. The key question for both procedures are the materials to do them. In the forehead you have the option of either bone cement application through a near complete coronal incision or a custom forehead/brow bone implant placed through a smaller scalp incision. For the rhinoplasty, one of its key elements is the augmentation of the nasal bridge. This can be done using either a cartilage rib graft or a silicone nasal implant.
The use of these various materials for both forehead and brow bone augmentation and rhinoplasty affects numerous aspects of the procedures including cost and recovery. I would need further input from you on these choices.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am inquiring about a genioplasty revision.I originally had double jaw surgery and a genioplasty performed. The results of the jaw surgery were great and the genioplasty was not bad either however there was some asymmetry and the chin projected just a tad more then I preferred, so I had a revision on the chin to move it back very slightly, a total of 1.5mm back from the original 4mm that it was moved forward as well as correct the asymmetry.
The results of the revision were not satisfactory, I developed chin ptosis and loose skin. 8 months later I decided to have another revision surgery to move the chin forward by 1mm, nearly back to it’s original position of 4mm and the mentalis muscle resuspended. After recovering from this surgery I have realized that the chin was not moved forward enough to support the mentalis muscle and the loose skin. There has been some improvement, I have a slightly droopy smile and I still have loose skin. I believe that the surgeon used a different type of plate and therefore the measurements were not as accurate as expected.
My question to you is, what are my best options to correct this, I am okay with having a bigger chin at this point, so I am considering having a 4th genioplasty and utilizing my CBCT scans, images, etc to have it moved to exactly into the same position that it was in after the first surgery, but do you think that undergoing a 4th genioplasty would be okay to do? Also, if the chin is moved to the same position that it was prior to any revision and the mentalis muscle is suspended correctly, what do you think my chances are of achieving similar results of what I had prior to the revisions?
I understand that some of these questions can’t be truly answered with out a full examination but if you can answer them based on experience that would be helpful,
A: The short answer to your question is that approach would be the only viable option. Bony support has to be re-estabished to the soft tissue chin pad. Whether returning to its original advanced position is enough is unknown but it can only help. There certainly is no harm in doing a 4th genioplasty as the vascular quality of the tissues would not be impaired and the amount of scar tissue at this point is irrelevant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am considering a series of separate body feminizing procedures (transgender body contouring) in this sequence:
1. Butt Implants with body lipo/fat grafting to complete hip/butt shape.
2. Then take 3-6mo to regrow some fat for Breast Implants with body lipo/fat grafting for cleavage and more natural finished shape.
3. Ribs removal. Front and back. Im not sure of the exact rib #s, but Im referring to both protruding ribs in front, and lower floating ribs. Would you kindly advise what exactly is possible, safe, and effective?
4. Tummy tuck with plication and for “internal corset” effect.
My thinking is that doing rib removal as a separate procedure before tummy tuck, allows for removal of more ribs than if removing ribs at the same time as tummy tuck, and will create more potential for the tummy tuck to draw in/around the trunk, for an overall slimmer torso and waist.
Would you kindly let me know your thoughts?
Thank-you Dr!:)
A: Thanks for detailing your transgender body contouring sequence, I would make the following comments to them .
1) Buttock implants with overlay fat grafting is a good approach to these needs. Fat grafting can only be done if the buttock implants are placed in an intramuscular position and not in a subfascial location. This would really be based on implant size. Any buttock implant bigger than 330cc would have to be placed in a subfascial location. In thus case, fat grafting is done first followed by implants secondarily.
2) I doubt once you harvest fat the first time there would be enough for the second time. The concept of growing fat is not usually a good idea for fat grafting since any weight loss will simply make what has been transferred to go away. It is important to remember that grafted fat acts like where it comes from, it retains its donor sit characteristics. It would make the most sense to rely on implants to do the complete breast augmentation/reshaping.
3) For waistline narrowing, ribs #10, 11 and 12 are commonly removed with small incisions from the back. For anterior protruding ribs (ribs 8,and 9) that is done through either a low subcostal incision or through tummy tuck incision.
4) If one is having a tummy tuck then that would be the ideal time to remove the subcostal ribs #8 and 9.
With this information, I would make the following recommendations based on how to best put the body contouring program together in two stages.
#1 Rib removal #10, 11 and 12, intramuscular buttock implants (300cc) and waistline/abdominal liposuction with fat grafting to the hips and around the buttock implants.
#2 Six months later….breast augmentation with implants, tummy tuck with rib removals 8 and 9.
This, in my opinion, would be the best way to put in all together and is actually how it is commonly done.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have what to me is extreme facial asymmetry, and have wondered all of my life if anyone could correct my face. I destroy all pictures of myself I am so ashamed of what I look like. Is there anything you can do for me? If I take a reverse picture using a mirror, I look pretty normal ( pictures attached). Is there a way I can look like that without using a mirror to reverse my image? Thank you very much.
A: Thank you for your inquiry and sending your pictures for assessment of your facial asymmetry. In critically looking at your pictures, I see four very specific difference between the two sides of your face. They include the following and are based the way I am seeing the picture (which may well be reversed in real life based on how the picture was taken)
1) Cupid’s bow asymmetry of the upper lip. The right of the cupid’s bow is lower than the left. (correction – cupid’s bow vermilion advancement)
2 Nostril asymmetry. The left nasal base is wider and more elevated than that of the right side. (correction – left alar base lowering and inward relocation)
3) Left eye asymmetry. You have a significant left lower eyelid ectropion/sagging) This is probably the one facial feature that is the oat obvious. (correction – lateral canthoplasty and lower eyelid repositioning)
4) Left eyebrow asymmetry. The left eyebrow is lower than the right. (correction – left endoscopic browlift)
When these four facial asymmetries are out together it can create a rather significant facial asymmetry.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in brow bone augmentation as well as orbital floor augmentation. But I don’t want to use any synthetic implant materials to do so. Can Bio-oss (bovine hydroxyapatite) be used for orbital augmentation and brow bone augmentation?
A: Any hydroxyapatite granular material can be used to augment a confined space like the orbital floor or a more open surface like that of the brow bones. Whether a bovine hydroxyapatite will persist or develop any significant bone ingrowth as an onlay material is a matter of debate. (it works best as an inlay bone substitute material) But from a handling standpoint, it can be used for either craniofacial application. Applying the material to the orbital floor is very straightforward. Applying to the brow bones, however, is a bit challenging because access to the brow bones is more restrictive. The ideal way to use it in brow bone augmentation would be an injection technique that uses a brow incision to do so.
While the concept of hydroxyapatite granules is understandably appealing, there are prone to irregularities and asymmetry when applied as an onlay graft. This would be particularly evident when introduced as an injection as the material does not have a smooth linear flow when injected out of a syringe.
Dr. Barry Eppley
Q: Dr. Eppley, After doing research on real self and looking at my own face, I’ve very open to anything you suggest that I have done! You responded to my question in detail on real self several days back which I really appreciated. The main procedures I would like to take a look into having done has to do with my chin, so possibly a chin implant…fat removal underneath the chin/neck (This is one thing I feel like I’m a great candidate for and really want done), and buccal fat pad removal in the cheeks because I have always noticed I have pretty thick cheeks. I do realize sometimes buccal fat removal isn’t possible based around if the cheek has fat that can be removed or if it is just the way it is genetically. My chin also points slightly to the left and I’m not sure if chin implants can fix that? Like I said I’m very open here! Also my whole life I’ve been able to give myself what looks like a facelift just by “flexing/pulling” back the muscles and skin on my face. Everyone who I’ve showed which has been a lot of people, always say they’ve never seen someone who can do it. Have you ever seen this before and what does it mean? In all the side by side pictures attached, on the left side of every pic is my face totally relaxed. And on the right is me “pulling my face back”. I’ve notice it makes all my facial features stand out more but the one thing I don’t like is it also raises my forehead line which makes my forehead look larger.
A: Thanks for your inquiry and sending your pictures. What happens when you pull the skin back is that you ‘skeletonize’ your face. The skin is tighter and the skeletal highlights (brow bone, cheeks, chin and jaw angles) become more prominent. That is why you like your face better this way. To try and replicate some of that effect you have to do a combination of skeletal augmentation and facial defatting. You will never replicate that loo surgically or naturally on its own but there are several procedures that will help. Chin implant augmentation with buccal lipectomy and neck liposuction are good selections. I would also add that small cheek implants can also help sculpt the midface better and are a complement to that of the buccal lipectomy. You natural chin/jaw asymmetry poses an issue for a standard chin implant as this really requires a custom chin implant to ideally correct but that will drive up the cost of surgery. The most economic approach would be to modify a standard chin implant (reduce the left side and position the right side of the implant lower) and hope for better albeit not perfect symmetry.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in multiple facial reshaping procedures. I have a long face with a vertically long chin. The last time you said you would take it back and wouldn’t shorten it. I disagree.I f I set it back I have not enough forward projection, I need to shorten it. My jaw is too long too. I need to change the mandibular angle to make it look rounder it is not soft looking. Next thing is my forehead goes backwards a little, I want it rounder and filled with nothing permanent.
A: Good to hear from you again. I must confess that I do not remember our prior emails. about your desired facial reshaping goals. The projection of one’s chin is open to personal opinion so if you prefer the anterior projection you have then vertical chin reduction should only be done. The jaw angles can be made more round by removing at a 45 degree angle their back end. The only non-permanent method of forehead augmentation would be either synthetic fillers. It can be argued that fat injections may not be permanent but they are best thought of as having some amount of permanent retention. The problem with synthetic injectable fillers is the volume that would be needed to augment a large area like the forehead.
Dr. Barry Eppley
Indianapolis, Indiana