Your Questions
Your Questions
Q: Dr. Eppley, I am interested in chin advancement surgery for my obstructive sleep apnea. (OSA) Let me explain that I had an extremely underdeveloped chin and I had a chin implant out in over twenty years ago. The OSA has always been present and I snore really loud. I have made a few attempts to have this corrected but I’m a mouth breather. I have a CPAP machine but it really puts a lot of pressure on the chin implant and it hurts me to wear that awful mask. I have had the machine for over five years. I’m ready for a surgical solution. Ive spoken to my sleep doctor but she is not qualified to answer the surgical question.
A: Thank you for your clarification on your OSA history. With an extremely short chin it is very likely that mandibular advancement would be the most beneficial approach or even bimaxillary advancement surgery.. But doing so would require pre surgical orthodontics and that is often not feasible or very desirable when one is older. The other option, albeit less effective, is a sliding genioplasty chin advancement. This can help to bring the tongue somewhat forward…although not as much as a total lower jaw advancement.
I aska about whom recommended surgery for your OSA because that may have meant that the sleep doctors had exhausted all they could do and detected a jaw bone deficiency in you.
I would need to see pictures of your face and your current bite to see whether these surgical options may be beneficial for you.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a custom jawline implant done by you last week. In looking at my result this week I feel that the chin is too big and the jaw angle look a bit asymmetric. I have talked to several close friends and they are in agreement. I am thinking that I need a revisional surgery and would like to do that as soon as possible.
A: I am gong to repeat now what I stated from the very beginning…as you are going down exactly the path to which I pointed out to you that many young men take in this type of facial surgery. You are just one week from surgery and have a long way to go before seeing the final results. Much will change in both appearance and your perception of it. You are already prematurely critiquing your results and trying to pass judgment on issues to which you are not yet close to seeing the final results. As we have previously discussed, your premature reactions are not uncommon, but it’s important that you understand they are indeed premature.
The advice that I am going to repeat to you now is that you must allow the healing and adjustment process to complete. I will not discuss any facial situation that is in an evolutionary state, as it is a ‘moving target’ and it is not in your best interest to do so until the final results are clear, in 8 to 12 weeks after surgery. It’s best not to entertain discussion at this point about pre-surgical implant design decisions and premature outcomes, as that would serve no purpose at this juncture.
This position may seem unduly harsh but it seems to be the only way in some patients to get them to understand the reality of the situation. I make it a priority before surgery to ensure patients understand how the process will unfold in these cases after surgery and, more importantly, how I will handle it after surgery. While your friends may offer their own opinions regarding your procedure and certainly know you on a personal level, it’s important to note that I have a great many years of experience in surgery, and am a specialist in this procedure. I have spent thousands of hours in surgery and am your best resource regarding the postoperative process, and as such, will offer you expert medical advice as opposed to uneducated opinions.
You came to me for a reason…if you are not willing to accept my advice and recommendations then I can not offer much further help. If the early results are too distressing to tolerate or do not permit one to allow for the allotted recovery time to see the true final outcome, then the only alternative option is removal of the implant. My advice again, is to allow the body time to heal and the postoperative process to resolve before any further considerations.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have some deep acne scarring and red pigmentation. I had Matrix laser done with 4 treatments. They promise at least 80% improvement. There was no change. Even they admitted to no improvement. But no offer to help any further. It was a complete waste of time and money. I read your testimonial and hope you can help. As I get older scars getting worse. I have watched about all types of acne scarring procedures on Youtube, excision and then follow up with deep laser seems to be my guess. But I’m not a doctor. I’ll send pictures.
A: Trying to improve acne scarring is a challenge to say the least. There are no magical treatments and modest improvement at best is really what is obtainable. You are correct in that excision without or without fat grafting of the deepest ones is the most effective. Fractional lasers and the newer HALO system offers some improvement of the more shallow ones. Older patients also have another treatment option as their loose facial skin contributes to the worsening acne appearance. Tightening the skin on the side of the face (mini-facelift) can also be effective as the scars get stretched out and more flattened by some doing.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Thank you very much for getting back to me. Please see attached, a few pictures. Two show the lower lip at rest. As you can see, there is virtually no display of the upper incisors and significant display of the lower incisors. Also the one showing me smiling shows some drooping of the lower lip on my right hand side (photos taken in selfie mode so it’s flipped). I have had a genioplasty done previously – the drooping may or may not have been related to that. I cannot remember if it was present prior to the genioplasty.
I don’t know if I am a suitable candidate for a lip lift but I was thinking of getting assessed for an upper and lower lip lift. In terms of a lower lip lift ,I am not sure if you do this particular procedure?
A: Thank you for sending your pictures. As for the upper lip, a subnasal lip lift would help with the show of the central and lateral incisors a bit. The other alternative would be an upper lip horizontal mucosal resection, a more direct approach, if one also thought their vermilion show of the upper lip was excessive. Your central lower lip droop reminds me of what can occur after a genioplasty procedure. Raising up the lower lip is very challenging and often not that successful as there are not anatomic structures to fix it to like that of the upper lip. I have used the V-Y advancement many times on the lower lip for that purpose and have found the improvement obtained is usually moderate and not a complete correction.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, After having read your in depth knowledge on jaw implants I wanted to get your opinion on what has happened to me. I have recently had jaw implants removed and I feel as though the masseter muscles have not been reattached correctly – they do not wrap around the angle of the mandible, instead they just go straight down. This has led to a strange look when I clench my teeth – a distinct difference of the masseter muscle and and bone angle itself. Can this be remedied? Will it resolve by itself over time? The implants I had were Medpor RZ. Thank you for your time.
A: What you have is disinsertion of the masseter muscle from the jaw angle. This is why when you clench your teeth the muscle bulges above the lower border of the mandible higher up on the ramus. While there is a procedure to try and reattach the muscle back down lower onto the edge of the bone, it has a low rate of success and leaves an external neck scar to do it. It is probably best to accept that this new position of the masseter muscle as permanent.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a sliding geniplasty reversal. It was supposed to be a 2mm sliding genioplasty, but ended up being moved forward 4mm. I had the hardware removed thinking it would soften my chin, but really didn’t do anything. I feel like my chin looks entirely too strong for my face, and it also has some places that the bone grew back weird leaving an indention. I also have to regularly get Botox in my chin because it gets dimpled whenever I contract the muscle, and makes it look even more pronounced. Overall, since the surgery I have just been very unhappy with the aesthetic of my face and it constantly draws my attention there.
A: A 2 or 4mm genioplasty is certainly a small chin bone movement that is rarely done because it is hard to justify the magnitude of the procedure with that small amount of chin change. But that it irrelevant now. The critical question is whether moving the bone back (sliding genioplasty reversal) will improve the adverse symptoms you now have. I think it would soften the aesthetic strength of your chin and may even help the classic notch/indentation deformities along the inferior border. But I doubt very highly that it will improve your chin dimpling and mentalis muscle irregularities that you now have. Whether a sliding genioplasty reversal is worth doing depends on whether one can accept a partial improvement of their symptoms but not a complete resolution. In essence you can not return your chin back exactly to what it was before the sliding genioplasty.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Is it possible to have MAC anesthesia instead of a general anesthetic while performing breast augmentation surgery as I have a fear of being fully asleep?
A: The answer of whether breast augmentation could be performed under anything less than a general anesthetic depends on three factors. The first and most important consideration is whether the implants are to be placed above (subglandular) or below the pectoralis muscles. (submuscular) Subglandular breast augmentation can be performed under IV sedation fairly comfortably as there is no muscle dissection. Submuscular breast augmentation is a completely different story, as you might imagine, as lifting the pectoralis major muscle off of the rib cage would not be considered an innocuous procedure. While there may be some plastic surgeons that would do such a procedure under local/Iv sedation, I would not. There is no great comfort level that can be achieved with this muscular maneuver and lack of a supple muscle can limit how well the breast implants can be placed. Secondly there is the unknown variable of patient tolerance. I have see many a patient who says they are ‘tough’ and do not require much anesthesia. In most of these cases this does turn out to be accurate and the execution of the procedure ends up as both challening and very time consuming. Lastly the size of the breast implants play a role. Larger implants can be more uncomfortable to place without a general anesthetic due to the tissue stretch involved.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in chin implant revision. I contacted you many years ago regarding a few questions about jaw implants. I never proceeded as I live in another continent and the expenses plus travel were too much for me at the time. It seems I may have to pay you a visit after all. I recently underwent a Rhinoplasty and Chin implant combo with a domestic surgeon here no less than a week ago and it went poorly.
Long story short I was told after surgery the implant I wanted wouldn’t fit my mandible and would slide up with time. Instead another implant with wings was added which not only lengthened but widened my petite face considerably. I requested only a tiny bit of anterior only projection and the results horrified me.
If you don’t mind, my questions for you are:
– Will there be any ptosis or sagging if this implant is removed within a week? I don’t know whether to trust my surgeon now.
– Have you ever had this same complication with a patient who just wanted a little anterior projection? Were you able to solve it?
Perhaps custom implants would be the solution? You seem to be the only surgeon offering this.
Overall I would love to hear your opinion.
A: I am sorry to hear of your current situation and your desire for chin implant revision. While all chin augmentation procedures cause a lot of swelling initially (which can seem horrifying) given what you wanted and the implant you got there appears to be a mismatch. With someone wanting only central chin augmentation there are chin implants that just do that exact effect. I almost always screw them into place to avoid any shifting/rotation of them since they are so small. Usually central projecting chin implants are used in women but occasionally men may only want a small chin projection change that does not increase the width of the chin. I don’t see that you have to go the route of a custom chin implant to achieve the chin change that you want. Attached is the type of chin implant you probably would do well with using the 6.5mm horizontal projection size.
It would be ideal of you could just swap out your chin implant immediately. But if not get what you have out immediately and let the tissues settle down and heal for a few months. Then place the new chin implant style and size.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am 48 years old and have lost about 60 lbs over the past year with diet and exercise. I am now three months from a facelift and neck lift. While my face did improve, I haven’t seen the results that I was expecting. I still have a round face. I was expecting a sharp cheek shape and sharp definition of jaw line. There’s still loose skin in mid face which I was hoping that a face ift would address. I understand that there is still swelling in lateral mid face and and around jaw line. My very specific goal prior to face lift was to get rid of double chin, which I still have. I also wanted to have the buccal fad pads removed which the surgeon determined intraoperatively that it was not necessary. My surgeon said that he can do redo the liposuction of neck and face. I also had lower transconjunctival blepharoplasty, which improved the bags. However, I still have residual bags. He said he took out minimal fat to avoid sunken eyes which I agree. However, I still don’t like the residual eye bags. He said he can now remove the buccal fat pads and also perform subcutaneous midface liposuction along with fat grafting around the cheeks to create a prominence and blend into the eye bags. He mentioned that cheek implants are out of favor now as it is difficult to achieve bilateral symmetry and they have a high incidence of nerve impingement at inferior orbital canal. He also has offered to tighten the facial skin. He said the SMAS and platysma muscles have been maximally tightened and there is no room to further tighten it.
I am just very confused as to what should be best approach to address my facial reshaping goals. I was very happy to come across your reviews as you specifically address men’s faces.
A: Thank you for providing all of the pictures and your more recent surgical history. From this information I can make the following comments:
1) No form of a facelift/necklift is going to create a more defined facial skeletal structure. Without adding volume to the cheeks or jawline their appearance is not going to be enhanced.
2) In looking at the pattern of the incisions for your face (which are often appropriate for some men) the effect of the lower facelift/necklift is going to be limited. Limited incision means limited results in many cases. The good outcome from that approach is that the incisions will be well hidden and will not create any secondary aesthetic issues. The bad news from that approach is that the neck will be left with some excessive tissue and the midface tissues will not change. The double chin can only be improved by a platysmaplasty and incisions on the back of the ear that allow for more tissue rotation.
3) A transconjunctival lower blepharoplasty can not create optimal correction of your lower eye bags. This requires a subciliary external incisional technique.
4) Fat grafting will not create any lasting cheek augmentation effect in your type of tissues. And even if it could it would create a rounded effect not an angular effect. Only a cheek implant can create that more defined cheek look.
5) Cheek implants have not fallen out of favor. They are used more today than ever before and they do not cause infraorbital nerve problems or a high risk of asymmetry when well placed. It is true that many plastic surgeons rush to use fat grafting because it is simpler and requires less surgical skill and experience over any form of facial implants. And for many patients this is more appealing and is easier to accept. But for cheek augmentation in men in particular fat grafting does not create the same effect as cheek implants.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in waistline reduction by rib removal surgery. I have the following questions about this surgery.
1) What is the recovery?
2) How many inches can I stand to lose?
3) Will this effect my ability to do any movements in the gym permanently as a competitive athlete?
4) What are the possible complications?
5) Can I schedule an online consult since I am an out of town patient.
A: In answer to your questions about rib removal for waistline narrowing:
1) Recovery from rib removal usually takes about 2 to 3 weeks until you are back to normal activities.
2) I don’t like to predict what exact waistline circumference measurement this procedure will create. That is highly variable. The reason one should consider it is because they have exhausted every other means to reduce their waistline and whatever change they get will be seen as s desirable improvement.
3) This procedure will have no negative effect or restrictions on any athletic activity.
4) Your consult can be online as I do with almost all out of town patients.
Dr. Barry Eppley
Indianapolis, Indiana