Your Questions
Your Questions
Q: Dr. Eppley, I have questions about a recent subnasal lip procedure that I just had four days ago. Here are some pictures of me, I took them today. Sorry for this miserable face but I didn’t go out since the day of the operation and I can’t stop crying all day.
I don’t look normal in pictures and I don’t know why. But I swear in real it is not normal. It doesn’t fit my face and I look horrible. I just look like a bunny now and I can’t handle it. The shape of my mouth is like a triangle, I didn’t asked to change the shape of my mouth.
I saw my surgeon but he said he can’t correct it because it is beautiful and I just need time to accept it. I just wanted a small change because I was tired of my small mouth but didn’t want to have fillers anymore because it turns in a duck mouth. But even the duck mouth was 100 times better. Now I just lost my identity with this surgery… I changed so much, I can’t recognize me, I am so so so desperate.
I just want to go back to my normal face please, please please please I am begging you to help me.
A: Thank you for sending your pictures. I have performed many subnasal lip lifts and yours looks perfectly normal at this early time after surgery. There is nothing wrong with the way it was done and it does not look overdone or that too much skin was removed. A subnasal lip lift will always look a little high right afterwards and the swelling can distort the nose along with it. It is important that any patient that has this procedure know BEFORE surgery that there is no reversing it. You can not go back. Skin has been removed and it can not be replaced. The scarring from placing a skin graft under the nose would look terrible and be far worse than what you have now.
It is also important to know that a subnasal lip lift will relax or relapse over the first few months after surgery. The amount of relapse can be as much as 25% to 33%. Thus waiting out the recovery period and allowing the lip and nose to settle is a prudent strategy. It is also the only thing you can do.
It is important that you understand that healing and tissue relaxation will make changes that will be different than what you are seeing now. You should not judge the final result from this type of procedure until you are three months out from surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in breast augmentation and a tummy tuck. I have had two consults which were slightly different. My concerns are dog ears from the tummy tuck and scarring from performing a lollipop breast lift. After discussing it with my husband I don’t want to get a lift as I am not comfortable with the scarring. I would like to look good in a bathing suit and have a full C. Right now I am a deflated A. I am 5’4″ 139lbs. Last question, regarding my flanks, both doctors agreed that it is mostly loose skin on my flanks, is there much I can do about that if I got a tummy tuck to make a more contoured waistline all around?
Looking forward to hearing from you.
A: Thank you for sending your pictures. What I can tell you is the following:
1) You can not have breast implants without a lift. You have too much sagging breast tissue and breast implants alone will produce a poor result with breast tissue hanging off the end of the implants. Breast implants do not have any lifting properties. They merely take what you have and make it bigger…or in your case will make the sagging look even worse. Your options are to either live with what you have or to accept the scars that are needed from a combined breast implants with a lift procedure.
2) The only way to improve the loose skin in the flanks is to carry the tummy tuck incision further back to cut out this tissue as well. This creates another scar concern. Thus you either leave the loose flanks alone or accept the longer scar to get tighten that area as well.
You face a classic dilemma that many breast and abdominal contouring patients face…whether a scar is more aesthetically acceptable than the original loose skin problem.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in using fat grafting for a breast augmentation. (fat injection breast augmentation) Am I right in understanding that you can perform this procedure? If so, what do I need to do find out how I can find out more information? What qualifies one for this type of breast augmentation?
A: Thank you for your inquiry. The critical questions about fat injection breast augmentation by fat injection are the following:
1) Do you have enough fat to make the operation worthwhile? It takes a lot more fat than you think as the fat has to be processed and concentrated for injection and only about 50% will survive the transfer process.
2) What is your breast size expectation? Fat grafting for most patients can increase breast size by about 1/2 cup.
3) What is the patient’s breast shape and current volume? Small to little breast tissue makes for poor fat take.
Unlike implants, the selection of women for breast fat grafting is much more selective as the outcomes are less in size and the outcome not as predictable. The reality is that of all the women who request fat injection breast augmentation, less than 5% of them qualify for that form of breast augmentation surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am seeking gynecomastia reduction revision surgery. had a perfect chest, and put on some weight and thought gynecomastia reduction surgery would be the answer for puffy nipples and getting it more defined. Well the surgery went wrong and I ended up with a nipple indent, scarring, hepatoma and a crater deformity. I then went to another doctor who does revision gynecomastia reductions who said no to pectoral implants but could fix the crater and make it look good. But he ended up over doing liposuction leaving me with less tissue, a caved in look and puffy nipple on the left side which looks still like I have gynecomastia.
The right side is more natural and fuller but left side just doesn’t match it. These doctors were supposedly the best and I am left deformed. I wondering if you looked at my pics and get your opinion. I find the left side the worst with the puffy nipple and more fat missing as this is the side I did’t have the hematoma.
Was wondering if you were able to make my chest more defined again and both sides even looking. thanks
A: Thank you for your inquiry and sending all of your pictures. I am not quite sure how you started out with a relatively small gynecomastia problem and ended up where you are now after multiple surgeries. But that is irrelevant now as all that matters is where you can go from here. I think your gynecomastic revision surgery options depends on how much restoration you want and how much effort you want to put into it. This means the following:
1) With your complicated gynecomastia reduction/liposuction history it would be perfectly understandable that you would want to do the least amount of further surgery that has the lowest risk possible. In that case I would only treat the left side with either fat transfer or a dermal-fat graft. Fat injections have the lowest risk as the worst case scenario is that it doesn’t work well. I don’t know if you really need to put on weight as even in thinner males enough fat can be harvested from the inner thighs to do a small area like the left nipple/lower chest. This would produce the least aesthetic improvement with the only goal being to make the left side look closer to that of the right.
or
- On the opposite end of the treatment spectrum are pectoral implants. Both sides of the chest are really deflated with loose skin. This loose tissue exacerbates any soft tissue deficiency between the two sides. Pectoral implants would expand both sides of the chest and would offer the best chest improvement. Whether some additional work needs done on the nipples at the same time remains to be determined. But with the option for best overall chest improvement comes this ‘bigger’ surgery with its own attendant risks. At this point with your surgical history, this concept make be too much to consider even if it offers the best aesthetic improvement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m interested in finding out how much would it be to have liposuction done to get my buttock injections removed. I’m having a lot of pain and discomfort and it seems as though the sillicone is moving down my leg and there is a lot of pressure being put on my tail bone when I sit and it’s causing a lot of pain. Can you please help? Do you all offer these services?
A: The long-term sequelae from silicone oil injections into the buttocks can include chronic inflammatory reactions known as granulomas. They can cause pain, hard lumps, skin discoloration and even open draining areas.
The typical treatment for silicone oil buttock injections is a combination of liposuction and fat injections. Buttock injection liposuction alone can not remove all of the silicone oil material. There is no surgical treatment that can accomplish complete removal. Fat injections add healthy cells and improve vascularity of the treated site to reduce scarring and buttock contour deformities. It has been shown that the combination of both treatments work best for silicone granulomas of the buttocks.
I would need to see some pictures of your buttocks to get an idea as to the size and location of the problematic buttock areas.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was wondering what aesthetic procedures can be done to push the lower lip forward slightly and improve the aesthetics of the labiomental sulcus? I was reading one of your case studies where a man got implants put in in his upper lip, lower lip and labiomental fold. So I was wondering whether a Permalip implant could be placed in the lower lip to give it some more horizontal projection? My lower lip is slightly setback compared to the upper but its not very significant; if this is possible what is the maximum amount of horizontal projection that can be achieved? I only need around 4mm at most. That said I have a very slight overbite where my upper teeth cover around 85% of my lower when biting down. Do you think orthodontics to correct my bite, combined with a Permalip implant could do the trick for a lower lip that is set back roughly 5mm and the above circumstances are taken into account? If I jut my lower jaw forward to the optimal bite position), my lips line up roughly accurately. But I don’t want to go through with lower jaw surgery for such a minor discrepancy.
Also, my concern is that if I push the lower lip forward, my labiomental sulcus and chin will look too set back in comparison. The chin is fine as I am happy to get an implant placed there. More importantly, I am concerned about how the labiomental groove will appear in two ways. First, the chin advancement will make the groove look more set back. Second, if you think about it on a profile view, the lower lip advancement will pull the tissue forward and make the angle between the border of the lower lip and the middle of the sulcus more acute. My sulcus isn’t very deep, but I would like to have an implant placed there and possibly fillers or fat grafting over the top at the same time. If a custom implant is used can the labiomental augmentation be almost unlimited?
As a side question, is it possible to give the illusion of a higher or more vertically short labiomental sulcus by strategic augmentation in the lower part of the sulcus, or through any other techniques?
A: In answer to your labiomental sulcus surgery questions, let me first make the following general statements:
- The true position of the lower lip is controlled by the position of the teeth. Thus the single most effective method of increasing the horizontal position of the lower lip is by lower jaw advancement. Understandable that is a lot of effort to obtain that relatively small amount of aesthetic change.
- Manipulation of the labiomental sulcus is not easily done and any such manuevers do not always produce predictable outcomes. It is a tight tissue area which has limited potential for change in its depth. This is a fixed tissue area for which there is a reason that an indentation exists there.
In answer to your specific labiomental sulcus surgery questions:
- A Permalip implant provide some horizontal increase in the lower lip but probably not as much as 4mms.
- I would find it hard to imagine that even a 4mm horizontal lower lip increase would make either the labiomental sulcus and particularly the chin look recessive.
- You are overestimating/over thinking the effect of the lower lip on the labiomental sulcus. The effects just aren’t that simple or as profound as you are believing them to be.
- You can not change the vertical height of the labiomental sulcus.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in facial liposuction. I just had a revision mini facelift with fat transfer to nasal folds and high cheeks and Neck lipo. I’m unhappy with the appearance of the corners of my mouth. They have a downward slant which is extremely visible and I believe this started when I began to get fat transfer to my face to correct acne scars and facial hollow. Well after gaining weight my face gained double and my mouth is now turned downward. Please left me know if liposuction is the answer to my facial problem?
A: Without seeing pictures of your face I can not give a very informed answer. But conceptually fat removal in the face through liposuction is not going to raise up the corners of your mouth. Downward slanting mouth corners are difficult problems that do not usually respond well to lifts and increased facial volume. Many of them have to be treated directly through corner of the mouth lifts.
While it may seem like the addition of volume to your face through fat transfer was the source of this problem, and it may very well be, I can not say with any assurance that the reverse would be effective. Some fat removal by facial liposuction can be done but whether ti would be enough to change this mouth feature can not be predicted.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had orthognathic surgery ten years ago to correct a class II malocclusion. I had a LeFort I osteotomy, sagittal split mandibular osteotomies and a sliding genioplasty. I am very happy with my bite. My teeth meet and my quality of life has been greatly improved. There are a few things that I am unhappy about that have gotten worse as I have aged and my face is getting thinner. The deep mentolabial sulcus I have that makes me look like I have a tiny stuck on chin, my high angle jaws, and my super long philtrum. I’d love to resolve all three of these issues but, if I were to pick the most important to me they would be my chin and my long philtrum. I am not looking to transform into a new person. I want to continue looking like myself but, with some improvement.
Please tell me if I am off base with my assessment of my deficiencies. I’d love to have your professional opinion.
A: I would agree completely with your assessment from the concerns of a deep labiomental sulcus, the long philtrum and the high jaw angles.
Your chin shows a classic long-term sliding genioplasty outcome in which the labiomental sulcus has gotten deeper in the step of the bone cut. This can be improved by a dual approach of placing a labiomental implant on the bone and possible fat grafting at a more superficial level. (although filling in the step of the bone usually suffices) The long philtrum can be treated by either a subnasal lip lift or a more complete upper lip vermilion advancement. That choice depends on how you want to see the lip change. The high jaw angles can be treated by small vertical jaw angle implants.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am writing to you because you seem to be the de facto expert when it comes to brow ridge augmentation. This will be a rather lengthy and complicated post, and I do hope to be able to get your expert advice.
Basically, I had fat grafting done to my brow ridge 3 years ago, but the issue is that the end result was asymmetric brow ridges (my right brow has slightly more remaining fat than the left). Not only that, the central brow region (radix/glabella) was not augmented enough. As a result of this, I sought a more permanent way to augment my brow ridges, and I had a PMMA forehead/brow ridge implant placed earlier this year. While this did give me more pronounced brows and fixed the issue slightly, it still hasn’t solved some of the contouring issues caused by the fat graft.
I have since been getting fillers to correct the defect, but it is cost prohibitive and I’m not a fan of getting repeated injections to this region due to the small but catastrophic risk involved.
Anyway, I’ve been researching custom brow ridge implants, and I have a few questions:
1) I understand that they are customized to fit on the underlying bone. Would having an existing PMMA implant be an issue?
2) Could the outer side of the implant (the side that gives the soft tissue push) be customized to accommodate for the previous fat graft? Again, would the PMMA implant interfere with this design process?
3) The one area that the PMMA implant did not augment were the sides of my forehead and I was told that it is because PMMA can not be placed too far out near the temples. Hence, could a silicone implant extend to the temples to create a wider and more ‘rectangular’ forehead?
I’m sorry for the trouble, and I’m sincerely hoping that you will be able to help me.
Thank you!
A: Thank you for your inquiry. The fundamental question you are asking is whether a custom silicone brow bone/forehead implant can be placed on top of the existing PMMA implant and whether such a brow bone implant can extend up onto the forehead and out past the anterior temporal lines onto the temporalis fascia. The simple answer is yes to both questions. My only additional insight is why bother to make a custom implant to fit in top of the existing PMMA implant. if you are going to make the effort to make a custom brow bone-forehead implant, you may as well remove the PMMS and make the entire augmentation out of one implant material.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley,I was wondering whether you agree with my assessment that my philtrum (distance between bottom of nose and upper lip) is a bit too long for the best aesthetic outcome? I’ve been thinking about this because I feel like it throws off my facial proportions a bit. The thing is I don’t feel like a lip lift would suit me because it would make my lips look very downswung, as if they are frowning, and would create a very feminine Cupid’s bow appearance. I was thinking about mabye moving the entire base of the nose (including the nostrils) downwards one or two millimetres to make up for it that way? My nose is quite short and I think it would benefit my overall proportions to have this done. I’m not sure how possible it is though? Im sure it’s very rare but I doubt if it is impossible to do with a satisfying aesthetic outcome?
A:I would not disagree with your assessment of a long upper lip. It is possible, and I have done so, to bring the nostrils down a few millimeters. Otherwise known as nostril lowering. It is an infrequently requested and done procedure but that does not mean it can not be satisfactorily done.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, i have a few questions about my mouth. The width of my mouth is extremely short it is about the size of my nose i have been thinking of getting a surgery to fix this issue. Before i go on with the surgery i have a couple of question that i want to know. First question is i have read online about this surgery as much as i could and almost everywhere they have told me that this is not a cosmetic surgery as it can leave scars so my question is how bad are the scars and am I able to reduce it with laser? My second question is how much can the surgery widen my mouth i have measured my mouth and it is approximately 4cm and when i look at other people their mouths can be measured up to 5 or 6cms. Now my question is how much can you widen my mouth with this procedure. i want my mouth at least like the pic i have provided. if you could respond as soon as you can that would be great so I can make my decision.
A: While mouth widening can be done here are tradeoffs of scars for it. Generally they are fairly acceptable when the mouth width increase is small. (5mms or less) But larger increases are associated with increased scarring and the need for scar revisional procedures. Given your mouth widening goals I would say this is not a procedure for you.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Over one year ago I had a facelift and damage occurred in both great auricular nerves. My ears have been horrible since then. I have trouble sleeping on them and I am aware of the pain on most days. Do you do a repair on the nerves? I would like to see if the nerves can be repaired through surgery. I am in great discomfort all of the time.
A: What you have is a greater auricular nerve injury from your facelift that is likely due to a complete transection and the proximal end of the nerve now has a neuroma. With this nerve condition there are two nerve treatment options.
1) Resection of the neuroma and place the nerve end into the muscle or wrap it in a fat graft. This would be the most common treatment approach.
2) Actual repair or nerve grafting to reconnect the two ends of the nerve. This is less common as finding the distal cut end of the nerve can be very difficult or impossible in the scar tissue. If both ends are found a small nerve graft may be needed if they can not be stretched and brought together.
Given your degree of symptoms it is clear that something needs to be done.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had forehead/brow ridge and cheek implants placed a year ago with satisfactory results. I am looking for a surgeon for injectable fillers. While I am mostly happy with the implants, I’m hoping to get some fillers to ‘top up’ the aesthetic results.Anyway, I’m hoping to have the fillers injected to 3 areas – the cheeks, the radix and gabella/supero-medial orbital rims and the deep pyriform aperture space. My questions are:
1) Would it be safe to inject fillers over my implants?
2) What fillers would you recommend for these regions? I’m leaning towards Voluma or Radiesse since they seem to be the longer lasting fillers with good soft tissue push.
3) Specifically, would Radiesse be safe to inject over the implants since they’re supposedly injected quite deep?
Thank you for taking the time to answer my queries.
A: In answer to your facial injectable filler questions:
- It is safe to inject fillers over the implants. The operative word being ‘over’ and not into the implant capsules.
- I would recommend Volume since you don’t want to be deep and this has the last chance of being lumpy or irregular which is a known issue with Radiesse and why it is recommended to be injected down at the bone level if possible.
- as per #2
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in injectable filler stop build up my brows and glabellar areas. My only concern is the risk of blindness when injecting the filler into the radix/glabella region. A few questions:
1) Would using a micro-cannula help mitigate these risks?
2) Would using a thinner filler like Restylane be recommended, or is Voluma just as safe?
3) Could a small amount of botox help lift the ‘inner’ eyebrows so that they appear straighter? I’ve read that combining botox and fillers in this region helps the fillers last longer – is this true?
4) Finally, how many syringes of Voluma total for my cheeks and radix/glabella is needed?
Thank you for your time!
A: Injectable fillers for brow augmentation can be vert effective even if it is not permanent. I would recommend Volume to get the longest lasting effect. In answer to your questions:
I have used microcannulas exclusively for years to do all injectable fillers treatments. They not only reduce the risk of intravascular injection but also decrease/eliminatent the risk of bruising and make the procedure much more comfortable.
Voluma with a microcannula technique would be safe for brow injections.
Eliminating the muscle action from the brow muscles using Botox can only help the persistence of the filler.
I would recommend 3 syringes of Volume for the brow and cheek areas.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a male with two enlarged bony frontal sinus and recessed forehead above it, creating a dramatic big V above my mid brow. When I was younger I would grow my hair to cover it, but now that my hairline has receded, I can no longer hide these horrible forehead bumps and lines. While I’d like to get it burred and smoothed, I am horrified of the thought of a huge hairline scar. My forehead slopes back quite a lot and I would like to know if a custom forehead implant can be inserted to cover it with minimal scarring. Please find photos of the my face. The sinus bumps can be seen clearly in these, creating a V shape depression toward my widows peak. It is really obvious when I am thinner and when the sun casts shadows across my face. Because they are so close to the centre of my forehead, that they tend to make my forehead look narrow and my face thinner and longer when viewed front on and make it look like I’m always frowning unless I raise both my eyebrows. I have considered many options including fat grafting, fillers, botox, implants and of course full forehead recontouring. When I am overweight, the extra layer of fat in my face tends to make them a little less obvious, but at the moment I am very thin and they are always visible.
A: Thank you for sending all of your pictures. You do not really have brow bone protrusion and your brow position is actually good for a man. What you have is a central forehead indentation/recession which makes you think you brow bones are bigger than they really are. I have seen and treated such cases just like yours before. The best and most effective mechanism is to make a custom central forehead implant that fits right into the depressed area. I have attached a custom forehead implant design from a near identical case like yours. (yours would be more V-shaped) This is slipped in through a small incision just behind the hairline. It is the best approach because it is permanent and is custom made to augment the exact area of deficiency. This is a very straightforward procedure to do with very minimal recovery. The key is in the implant design which is made from a 3D CT scan of your forehead.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley,I am interested in facial reshaping of multiple areas. I have some questions:
1) Ideally which order should the following operations be done?
– genioplasty
– custom jaw implants
– rhinoplasty
– custom midface implant
– brow bone/forehead implant (mimic deep set eyes with lower brow)
2) Also state which procedures can be done at the same sitting?
3) With the custom midface implant, does it obviate the need for paranasal implants, infra-orbital rims etc
4) Do you do sliding genioplasty? If so do you “deglove” or not while doing genioplasty?
A: In answer to your facial reshaping questions:
- All of these facial procedures could be done at the same time. But if you were to stage them, and I would advise one to do so, then they could be grouped into two operations. (Group I = Genioplasty/Jaw Angle Implants/Rhinoplasty and Group II = Forehead/Brow Bone/Midface) Group II should be done first and they will have some influence on the rhinoplasty both at the radix and nasal base levels.
- A custom midface implant covers the entire midface so it includes the paranasal and infraorbital rim areas.
- I do perform genioplasty surgery. (chin osteotomies) In doing the procedure I strive to main as much periosteal/soft tissue attachments as is possible.
Dr. Barry Eppley
Indianapolis, Indiana