Your Questions
Your Questions
Q: Dr. Eppley, I am a plastic surgeon practicing in Slovakia. I recall that you place your buttock implants intramuscular…..I am seeing a patient soon interested in gluteal implants. If you have a moment I have a few questions for you since my experience was limited in buttock augmentation.
1. Must I have the tool that is used to split the muscle (pic attached attached)…..I don’t recall you using this tool…will a couple malleables, dever, and cautery work?
2. How long until you let your patients sit? Seems like a wide discrepancy in the literature.
3. I recall you using the incision technique according to Raul Gonzalez where the midline is depithelialized preserving the sacrocutaneous ligament….I will do the same.
4. How long until you let your patients sit on an airplane?
5. Do you place drains with the intramuscular approach?
6. How do you determine implant volume choice….do you use templates?
Thanks for your help!
A: Be aware that buttock implants are the hardest of all body implants to placed and when you do your first case you are likely to ask yourself why made you think it was a good idea to do this surgery. The other very important preoperative consideration is that the size of buttock implants that can be placed different dramatically from subfascial vs. intramuscular. You and the patient have to have a clear idea as to expectations. Intramuscular buttock implants will almost always be smaller than the patient wants, have a very long recovery and are very hard technically to do since there is no natural plane of of dissection. Subfascial buttock implants allow for much larger implant sizes, have a somewhat quicker recovery and are technically much easier to do. But to answer your intramuscular buttock implants questions:
- The duckbill dissector to which you refer is not absolutely essential as a wide malleable restractor can similarly be used. At at $850 for the instrument it really becomes non-essential.
- I let patients discomfort determine when they can sit…as they eventually have to do some sitting for certain functions
- Re-establishment of the sacrocutaneous ligament is essential in closure of the intergluteal incision.
- Same as answer #2
- There is no reason to use drains in the intramuscular buttock implant technique.
- With intramuscular buttock implants you are never going to get an implant in and satisfactorily covered with muscle over it that is bigger than 330cc. It just can’t be done. Your implant options are going to be either 270, 300 or 330cc. When in doubt choose the smaller implant size.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, The more I sit here the more I am feeling like I would just like to come and see you for a 3D CT scan of my face. The sliding genioplasty and lip issues is one thing but I am seeing marked asymmetry in my whole face (the one side literally looks like it is 1/2 inch out farther than the other side causing my cheek and jaw on the one side to be much much larger and lop sided.
To clarify what I had done:
Sliding genioplasty
Mid jaw implants
Back jaw implants
Cheek implants
Buccal fat removal
I know I would feel better if I saw you for a look over and a scan. My surgeon didn’t do a CT scan on me and claimed he did custom facial implants but from the very first day my one side has looked larger and it is now day 8 and doesn’t feel puffy – just hard like the implant yet it sticks out way way wider than the other side. I specifically asked for no width to be added to the face and for it to stay slim but I feel masculine and disfigured. Even if it just means taking things out for now I’m okay with it.
A: Having had all of these implants and bone work it would be very common at your early postoperative period to have facial swelling that was asymmetric. So I would not try to judge the symmetry of the results at this early juncture as that is really impossible to know. But if you really want to know how all the implants looks by position and size, then a 3D CT scan would answer those questions. As long as the implants are silicone they can clearly be seen on the scan. Medpor implants are much harder and often impossible to see. The sliding genioplasty of course can be seen very clearly. That is a scan you can get where you live. You just find a place to have it done and I can fax in the order to have it done. You do not need to come here to get the scan but can if you would like.
True custom facial implants require a 3D CT scan to fabricate but your surgeon may have been referring to just shaping standard implants at the time of surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting the masseter muscle reduction and the upper trapezius muscle reduction and I am looking for a more permanent solution. Here are a few of my questions…
– What to expect on results
– Recovery Time
– Healing and when can I leave to go back home to NJ
– Vitamins and meds to take to help with swelling and healing
Please also see my attached photos of a view of my side, front, and back and let me know if you need any more information from me…thank you.
A: Thank you for sending your facial pictures. In answer to your questions:
1) Surgical masseter muscle reduction is done through an intraoral approach by muscle release and electrocautery reduction. After surgery it would take a full three months to see how much muscle has been reduced. The trapezius muscle is done through an incision at the back of the occipital hairline. From this location a wedge of trapezium muscle is removed to reduce the raised contour of the line from the neck out to the shoulders.
2) Recovery time is based on swelling and level of discomfort. There is really no postoperative restrictions. The swelling of the jaw angles would be more noticeable than the trapezius and would take about 10 days before returning to its preoperative size and months before the final result is seen.
3) You could go home in 1 to 2 days after surgery, whenever you feel like traveling.
4) Vitamins are not helpful for the swelling. I will give you steroids during surgery as well as Medrol Dospak after surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Following a chin implant being removed via an intra-oral incision six years ago, I have lower lip incompetence and chin ptosis.Is it possible to have a successful outcome with mentalis muscle resuspension without inserting another chin implant? Also is it possible to achieve a good result with absorbable Mitek sutures as opposed to titanium screws?
Another doctor has advised he would insert another small chin implant and use titanium screws. I’m not comfortable putting another chin implant in or with titanium screws in my chin.
A: One can certainly have a mentalis muscle resuspension surgery without placing a new chin implant. But the success of the procedure drops when the lower chin support provided by a new chin implant is not added. This does nor mean that it can not work just that the long-term success rate will be lower.
Mitek absorbable bone anchors are my performed method of mentalis muscle resuspension. They come with an indwelling bone device (anchor) that is composed of either a small piece of metal (nitinol) or a reservable polymer composition that takes 6 months to go away. The sutures attached to the bone anchors however are permanent.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like to schedule an appointment to have something done to my undereye wrinkles. I have attached pictures of me smiling and not smiling and you can see the big difference as to how many undereye wrinkles occur when I am smiling.
A:Thank you for sending your pictures. Under eye wrinkles either are only present when one smiles or becomes much worse when one does smile. (have them at rest) Lower eyelid surgery really treats excess skin and wrinkles when one is not smiling. It is really an operation that treats a static problem since that is how the surgery is done. (patient not moving/smiling) More dynamic undereye wrinkles are treated by Botox injections as this injected agent treats a dynamic problem through muscle weakening. In other words, if your undereye wrinkles are mainly present when you are smiling that is a non-surgical Botox injection treatment issue. However, if a lot of undereye wrinkles are present when one is not smiling, and gets much worse when one does smile, then lower blepharoplasty surgery would be the most effective treatment. It is also important to point out that no treatment will completely get rid of undereye wrinkles, they can only reduce the number seen.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a skull widening procedure.I have a narrow skull/ head and was wondering if its possible to widen the sides of skull and forehead with Alloderm instead of implants? Im not comfortable with implants and was hoping instead that Alloderm could be used for such large areas. And if alloderm can be used for skull/head widening, does screws need to be used? Thank you.
A: While Alloderm can be placed on the sides of the skull for augmentation, there are several problems with its use for that application. Beyond the sheer cost of Alloderm (the material alone would probably costs $15,000 to $18,000 for a skull widening procedure that is at least 5 to 7mms thick) the material has a low propensity for persistence and a relatively high incidence of infection when stacked in layers which it would have to be for any skull augmentation procedure. I don’t think the use of Alloderm is a viable option for a skull augmentation material. If you are looking for a more ‘natural’ skull augmentation material, injected fat would be the most viable option as long as one is not looking for any major volumetric change.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, What is the maximum amount of projection in mm that off the shelf submalar cheek implants can give and how much projection can custom implants realistically give? I am looking for a pretty decent amount of projection in order to give me a more rounded apple cheek look.
A: The submalar cheek implant is designed to elect and reposition soft tissue in an anterior and superior position. It adds some lower mid facial fullness and may have a mild effect on softening the depth of the nasolabial fold in some patients. It can create the so called ‘apple cheek’ look which is usually more of a desired feminine facial trait.
In theory there is very little limit as the midface soft tissues can stretch fairly significantly. The only real limit is the thickness of the soft tissues ands can a competent and tension-free intraoral would closure be done. Standard submalar cheek implant sizes range from 4.5 to 6 mms. I have made custom cheek implants with up to 8mms in thickness in this area. Whether you would need more than 8mms would require an analysis of your pictures and computer imaging of your projected results. I would not think that you would as a general statement as a few millimeters in this facial area has much more powerful efefctr than one would think.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in arm lift surgery. I have attached two pictures for consideration of my possible candidacy for brachioplasty which I think is the formal name for an arm lift. There is loose skin on my forearm that I am interested in addressing as well. I am 20lbs. from my goal weight. Please let me know if you deem me qualified for arm lift surgery.
A: Based on your pictures If there was anyone that would get a lot of benefit out of an arm lift procedure, it would certainly be you. Removal of your large arm ‘bat wings’ would make a tremendous difference in your upper arm appearance as well as being able to get into clothes. Given the size of your arms, whether you have the procedure at your current weight or lose the additional twenty pounds, does not make any difference in the outcome of arm lift surgery. While loose tissue can be removed from the forearms as well at the same time, the tradeoff of the scars to do so must be considered very carefully. So called forearm lift scars are much more visible and do not do as well in appearance as upper arm scars do.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in rib removal surgery. I have a deformity on the bottom edge of my rib cage. It is on the front left side and it is about 2″ by 2″ in size. I was wondering if it would be a bad idea to have that deformity removed or to just leave it be. It does bother me functionally and causes mild pain on and off. The deformity is the result of a rib fracture (I believe chostochondral separation) that happened back seven years ago. It took a while for the deformity to develop but it seems to be permanent. Thank you.
A: With a history of trauma and a costochondral fracture/separation, what has happened is the development of excess cartilage/scar tissue at this bone-cartilage junction. This is the moveable part of the ribcage which is why it gives you some periodic discomfort. Whether you should have this area of the rib resected is a personal decision based on your level of both aesthetic and functional discomfort. Removal of the enlarged and protruding rib junction would be the treatment for it. Such small rib removal is done through a small incision directly over it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, My problem is the buttocks augmentation I did 10 years ago with permanent fillers. The plastic surgeon did an awkward shape, he filled the flanks and the upper buttocks, which as a consequence made may back look shorter. Before buttocks augmentation, I originally have shorter torso comparing to my long legs, even though, I used to have a proper and slim body. The permanent fillers are made of silicone. It is called pure gel if you have heard about it, it is made in the USA and it is banned now in my country. The problem about these fillers is when trying to remove them from the body, the body get infected. A friend tried to remove them and when she did the skin where the fillers were injected got burnt and became dark. She got a fever for almost a month and was taken to the hospital for treatment. If you have any background information about this kind of fillers and the proper way of removing them with out any side effects please advise me.
A: When it comes to trying silicone removal from prior oil injections, there is no approved injectable silicone filler in the U.S. of any kind. The removal of silicone oils are all problematic, have a high risk profile and there are no ‘proper ways’ to remove them since there are not supposed to be used for this aesthetic purpose. Like any form of a permanent synthetic filler, they can be very difficult to remove later.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Hi! i have been interested in vertical chin lengthening for awhile and I came across your site and liked your work. My chin is horizontally deficient but the vertical length bothers me the most. When I push my chin down about 5mm to 7mms I like the way my face looks. I understand you cant tell me if a sliding genioplasty is better than an implant without examination but what are the pros and the cons for each? I also like when my chin comes to a point, (a “v” line so to say) is that possible to achieve through surgery? I have pictures attached if that helps. Thanks!
A: When it comes to vertical chin lengthening, an opening bony genioplasty with an interpositional graft is best for most patients. This is a variation of the more well known sliding genioplasty. This is particularly true when the opening is 5 to 7mms. As the chin comes down and slightly forward in our case it will make the front part of the jaw look more narrow or v-shaped. Whether this will make your whole jawline look that way I can not say since you only provided a side view picture.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m interested in the custom midface implant (that looks like a “mask”) you’ve recently fabricated and posted about on your Explore Plastic Surgery blog and I’m also interested in a procedure to change the width of my lips. However, I have some questions about both procedures :
For the custom midface implant :
1) Can the portion of the implant that covers the infraorbital rim area be extended to cover the zygomatic arches?
2) Can the implant design be modified to cover the sides of the maxilla at the point where a hypothetical vertical line from the pupils and a horizontal line from the sides of the alar bases meet?
3) Can the portion of the implant that covers the infraorbital rim area be extended to cover the lateral orbital rims? If this design modification is possible, how is this going to affect the lateral canthal positioning? I struggle to see how the lateral orbital rim can be sagitally advanced without altering the lateral canthus because the lateral canthus is attached to it.
As far as lip widening is concerned , from the information that I’ve gathered online I think that a lateral commisurotomy is the best way to achieve a wider mouth appearance but I was also wondering if PermaLip implants can successfully widen the lips. What do you think?
Thanks a lot !
A: In answer to your custom midface implant questions:
1) Yes
2) No
3) Yes. The lateral canthus is attached inside the lateral orbital rim, not on the outside.
4) Permalip implants will NOT create a mouth widening effect.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in chin (vertical chin lengthening) and jaw augmentation surgery, particularly, adding vertical length by means of a sliding genioplasty. I have an overbite, however, I consciously usually just move my jaw forward so that is is properly aligned so I have included 3 pictures in which you can see the overbite and 3 pictures in which my jaw is in a normal position. My goal is to increase vertical length of my chin/jaw and perhaps add an appropriate amount of horizontal projection in order to have a more square jaw appearance as well as a less rounded face look. In terms of how many millimeters can be added vertically, about how many mms do you think would be possible or how many would you suggest?
A:Thank you for sending your pictures and doing the ‘surgical simulation.’ By moving your jaw forward you are creating a surgical type result of the chin through vertical chin lengthening. That would be the approximate effect on the appearance of the chin as moving the jaw forward provides a vertical chin lengthening. The amount the chin should be vertically opened is determined before surgery by measuring the distances between the upper and lower teeth as you go from having them together to the desired position of the jaw that creates the look you like. In most cases of vertical chin lengthening it is usually about 8 to 10mm of opening the chin osteotomy centrally to see a very noticeable chin appearance change in my experience. Two caveats about vertical chin lengthening and its effects on the appearance of the jawline. First it will not make the chin more square since it is just the natural chin shape that is being moved forward. Second, the appearance of the jawline will not change like it does when you bring your jaw down and forward too simulate the effect of vertical chin lengthening. Such a maneuver moves the entire jaw down which is not creates when you surgically just vertically length the chin.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, This is a general surgeon who practices in Iran whom I personally know. He asked me to correct his skull deformity. However I do not perform those procedures in my practice. I heard that you may be doing this kind of procedure. If so, can you guide me your process, so I can let him know. Again, he will be traveling from Iran.
A: I routinuely treat flatness of the back of the head using a custom implant approach from a 3D CT scan. The implant is placed through a low occipital small horizontal scalp incision in a simple 90 minute procedure. The amount of augmentation that can be obtained in a single stage skull augmentation depends on how much the scalp can stretch and is usually in the maximum rage of 12 to 15mms. But don’t let that number fool you as the effects of the implant are more impressive than just the number because of its surface area coverage. The manufacturing process takes about 3 to 4 weeks to get the implant ready for surgery. It is computer designed from the 3D CT scan. Patients can get the 3D CT scan in their country of origin and then just send it to me. They only need to come in one time for the surgery. The logistics of surgery care that the patient comes in the day before the surgery, has the surgery the next day and can return home in 1 to 2 days even for international patients.
For some patients who can not get a 3D CT scan, I do have ‘standard’ occipital skull implants that I occasionally use which actually come from other patient implant designs. (The shape of the back of the head is not all that different amongst some people)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley I had sliding genioplasty / buccal fat removal / jawline implants and cheek implants all done at once one week ago.mI understand I am very swollen and still healing but I am having severe issues with my smile mainly my lower lip and I would like a second opinion on it. My surgeon wants me to wait but from my reading I believe waiting could be a bad idea.
Before surgery, I loved my smile and it was my best feature. Now due to my sliding genioplasty my lower lip is tucked in too high and inwards to my lower teeth. Instead of a nice curve it is flat and tight. I can’t smile or talk properly. It almost feels like the surgeon placed the stitches too high and fixed the lip in a weird position. I would like your opinion on whether or not this should be reversed or if there is another option such as releasing the stitches from where they are placed.
My lower lip is continuing to tighten and cover up my upper teeth. Even tonight it has gotten worse. I can move the lower lip outward and inward but it will not move down at all and is covering more and more of my smile by the hour. If I could describe it, it feels like the stitches are placed too high on my chin/gum and it’s locking the lip into an unnatural position of laying flat/straight over my teeth. I feel like I jus want to get in there and snip the stitches to release it. My lower lip is laying flat across my teeth and ruining my smile. I can’t even physically move the lip down by pushing with my fingers to curve the way it did prior surgery due to how it’s secured in place. I can barely get a spoon into my mouth or talk because it’s locked into position so high and worsening. It very obviously has moved the resting position of the lip where it feels like it is being pushed up by an implant but I had sliding genio. It now curls in and tucks under my upper lip and sits much higher on my teeth making me look toothless on the bottom. It literally feels like there is just too much lip and it can’t move out of the way for my teeth. I can feel it held into position with the stitches that aren’t letting it free. I don’t want to wait to see if it resolves I just want the stitches in the front/chin released so they can move freely and then to do rehab with my lip to regain mobility and a normal bottom lip curve.
A: Thank you for sending your pictures. I see nothing unusual, both visually and in the pictures, in your early sliding genioplasty results. That was clearly the correct procedure given your very severe horizontal chin shortness. It is important to understand that this procedure takes apart the chin muscle to be able to cut and move the bounce and then puts ti back together at the end. This combined with the stretch of the tissues from the bene advancement will make the lip feel very tight and your smile is not going to be normal for awhile. I have no knowledge of what preoperative education you were provided but what I tell all my patients is two things. 1) Surgery is not ‘instant oatmeal’. You are changing your natural tissue relationships and this is by very invasive trauma to those very tissues. This is going to cause a lot of distortion and it can be very psychologically disturbing in the early recovery process particularly in young patients. 2) Recovery is a process of months not weeks. It will take a full three months for recovery to be complete from the procedures you have had done.
That being said I would agree with your surgeon that staying the course and allowing the recovery process to unfold naturally would be the prudent course of action.
The only remote question I would even think about at this point is whether the chin may be advanced just little further than your chin/lower lip tissues ‘like’. That can cause a lot of chin and lip tightness in big advancements. But I don’t know the actual number of millimeters your chin was advanced.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in jawline augmentation.I’m really curious what is possible in my case and what procedure is needed to realize it. In my side picture, it might be a little hard to see because of the beard, but when I bite my teeth, I have a receding chin. On the front picture, it’s a bit odd, but my facial shape is quite narrow. This combination for me results in zero jawline definition, a double chin and an unbalanced face from both the side and front view. I really hope you could help!
A: Thank you for your inquiry and sending your pictures. Even with your beard in side profile, it is clear you have a very short jaw and a narrow jawline resulting in a thin v-shaped face with a convex profile. As part of this type of facial development your cheeks are also correspondingly flat. To adequately correct your facial shape a jawline augmentation can be done using either a custom jawline implant or you could have a combination of a sliding genioplasty with jaw angle implants. Your cheeks can be addressed using cheek implants that provide a high malar augmentation with an infraorbital extension.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in doing the scarless temporal reduction surgery in the next year. I am a 35 year old male with a normal sized face but large head – 58 cm circumference – which seems mostly due to protrusion above the ears from temples above the forehead back to the end of the skull. The sides of my head become sore if I wear glasses for a long time and hats tend to be tight.
I have had a few questions regarding the procedure:
1) what are the requirements for anesthesia and how long is the surgery?
2) based on the description, can I expect to have a good result? will the change in head width give a noticeable impression of a smaller face/head?
3) what are the potential side effects both functional and cosmetic you have seen in the past even if the chances are low?
4) will removal of the temporal muscle lead to drooping of the skin in the lower part of my face due to volume loss at the head?
5) what is the cost?
6) what are the pre and post operative considerations and requirements?
7) how many of these surgeries have you performed?
Looking forward to your advice!
A: In answer to your questions about temporal reduction surgery:
- Surgery is about 1 1’2 hours and general anesthesia is a requirement for it.
- Temporal reduction reduces the width or convexity of the side of the head. It would not have any effect on the face.
- I have seen no adverse side effects in any patient. The only questions is whether the result meets the patient’s aesthetic goals.
- Removal of the muscle does not cause a skin droop.
- My assistant will pass along the cost of the surgery to you.
- There are no special before and after surgery requirments or tests needed
- I invented this head reshaping procedure and have performed over 50 of them
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Will a reduction sliding genioplasty make my chin pointier or wider from front view? And who benefits from the double sliding genioplasty? Is it twice as expensive as a normal one? Lastly, if I opted for chin widening, where does the bone graft come from? Thanks a lot.
A: A sliding genioplasty is a procedure that can be done various ways to create numerous changes to the chin. It can make the chin wider or more narrow from the front view depending upon how it is done and the technique used. There is virtually no reason today for a double sliding genioplasty. That sliding genioplasty technique was used decades ago before plates and screw were used for bone fixation. When there was only wire bone fixation used, large horizontal chin movements were best stabilized by this double cut osteotomy technique. There is no need for that sliding genioplasty technique today. When widening the chin a bone graft can be harvested from the patient or a cadaveric bone graft can be used. If harvested from the patient the best source would be from the back part of the jaw from inside the mouth.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in skull reshaping for my son. He is 4 years old. I went to several doctors to exam his head, only to have them tell me his head was normal. I begged for the helmet when he was a baby and they said no he doesn’t need it. I’ve always noticed these large bulges above his ears and wanted to correct it before his head was done growing.
Now we are dealing with what seems to be the needing of temporal bone reduction. These bulges, in my opinion, gives him the illusions of having a football shaped head when his hair is cut really low. It also pushes his ears forward quite a bit. I do not want him to suffer frmo being bullied as he grows and enters elementary school.
Do you perform this procedure on children? If so, can he also get the local anesthesia instead of being put to sleep?
A: I would need to see pictures of your son’s head to give a more qualified answer. But by description it sounds like your son has temporal bulging above the ears as well as protruding ears which often accompanies that type of skull shape. At four years of age the skull bone is very thin in that area and is not thick enough to allow for any skull reshaping reduction procedure. He will need to grow a lot more before that can be considered. The ears, however, are different and can be reshaped/pinned back at this early age.
No craniofacial bone procedure in a child is ever performed under local anesthesia. All such procedures require a general anesthetic.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Congratulations on your great blog first of all particularly on rhinoplasty topics. I have been bothered by the appearance of my nose for quite a long time and it’s the lateral view of it that bothers me the most. I’ve read both online and on your blog about the importance or the radix/nasion in the appearance of the nose and in particular the nasal length. I believe that my nose makes my middle of the face look a bit long regardless of the fact that I have a short chin as well. But I can’t seem to understand if my own nasion is high or low set. Do I just have a dorsal hump ? A low nasion ? Or a combination of both?
Finally, do you think that some nose tip work would be enough for me if I don’t want to make it obvious that I had surgery? I’m attaching a lateral view image of my nose if you’re willing to do some computer imaging so I can understand what would you have in mind.
Thank you a lot for your time.
A: In looking at your nose the issues are a dorsal hump and a long hanging tip. Simultaneous correction of both nasal shape issues (dorsal hump reduction and tip elevation/rotation) reveals that your radix/nasion is neither too high or too low. The attaching imaging of your predicted rhinoplasty result from the side view reveals this effect.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have an additional question about my stomach and tummy tuck surgery. I don’t want a tummy tuck where I have a scar that goes around my hips. I was wondering if skin could just be pulled tighter towards the pelvic area so that the wrinkling and obvious bulge would look smoother. I had a lumbar disc replacement surgery some years back and the scar left my stomach lumped like that with the way the incision was done. I’ve heard of mini tummy tucks that only leave a bikini line scar – could that be done?
I’ve included a side view so you can see that I don’t need to reduce my size, it is just that lower bulge/wrinkled area that needs to be addressed. What are your recommendations?
A: Certainly a more limited tummy tuck can be performed to lessen the scar burden and just get rid of the loose tissue in the lower central abdominal area. This will not produce as dramatic a change in your overall stomach area since this solution is far less then the problem. But if the concern about a scar supersedes that of some loose abdominal tissue then the mini tummy tuck is the better procedure for your abdominal rehabbing.
Q: Dr. Eppley, I have had a bull horn lip lift. I think it makes my mouth a little bit “sad” as it only lifts in the middle and not the sides. My wish is to have a higher middle part to push down on the lower lip and make the middle line in the lips more straight again (The three arrows in the middle in the picture).
My secondary wish is to have the outer part of the upper lip a little bit bigger (the two arrows pointing downwards in my picture).
Would you recommend VY-plasty on the outer sides and fat transfer in the middle or some other technique?
A: Your result is exactly what a subnasal lip lift does and could have been predicted beforehand. To accomplish your two remaining upper lip goals, one technique is to drop the middle part of the upper lip by fat grafting through an injection method. Either that or a dermal-fat graft placed like an implant. The other option is an internal mucosal V-Y advancement. Raising the sides of the upper lip is far ore predictable with a vermilion advancement than an internal V-Y mucosal procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in jaw augmentation surgery but I don’t know what type of procedures I need. I believe my face really suffers from a weak lower third and I need to reshape it somehow. Could you please advise me on what type of surgeries I should get? I have attached some pictures of my face for your review.
A: Based on your pictures our chin is short with a high jaw angle. This means that there overall jaw is short and total or more complete jaw augmentation would provide the best aesthetic result. There are several methods for jawline augmentation based on how the chin and jaw angle are treated. These include: 1) a chin sliding genioplasty and vertical lengthening jaw angle implants, 2) a square chin implant and vertical lengthening jaw angle implants, or 3) a custom one-piece jaw implant that wraps around the entire jaw made from a 3D CT scan. Each approach has it own advantages and disadvantages and, to some degree, slightly different aesthetic effects. This is where the role of computer imaging is critical to determine what degree of aesthetic change that you seek. Stronger and more prominent jaw augmentation results are usually achieved by the use of a custom implant approach.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a very deep forehead line and am wondering what treatment options there are. I have attached pictures for you to see how deep this forehead lines is. Thanks in advance.
A: You have a very deep glabellar furrow. While there are a variety of synthetic fillers, implants and Botox injections as potential treatments, these would be ineffective with such a deep furrow caused by strong muscle action. The skin has become permanently etched and indented over time. The best treatment would be to treat it like a deep scar. (which to a large degree is what it is) I would excise the skin edges, implant a dermal-fat graft and close the skin in a broken line closure method. While you will always have a line/scar, the realistic goal is to make it less indented and have a more smooth outer contour.
While this approach may sound ‘radical’, a deep forehead line is an aesthetic problem that is resistant to every other injectable approach. It is now way beyond an expression line and has become a non-traumatic deeply indented scar. Substantial improvement in its depth can only come from surgical scar revision.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in thigh scar revision. I had fat transfer done a year ago and the fat was harvested from my thighs. This means that I have two incisions along both sides of the pelvic area. The issue is, I was a couple of weeks late in removing the stitches, and there’s now hypertrophic scarring where the incisions were.
They are not too big – 1 cm in length and rather narrow. The thing that bothers me is how raised and red they look as it becomes rather obvious due to my pale complexion.
I get that it was my fault for delaying removing the stitches, but are there any options to improve on the appearance of these scars? Cost is not an object, and I’m fine with a relatively invasion procedure if it can provide the best results.
Anyway, the scar has remained the same for the past 6 months, so that’s why I’m seeking a scar revision now. Any solution that you can provide will be much appreciated.
A: While I would need to see actual pictures of your scars, I suspect that only excision and reclosure of them (scar revision) would make any difference. This time all sutures should be placed under the skin and be dissolvable so no suture removal is needed and the risk of hypertrophic scarring is less.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Do you think the vertical maxillary excess surgery would change my face a lot or would I still mostly look like me still? And is this something you practice?
A: The answer to your critical questions can be summed up like this. You have a ‘modest’ vertical maxillary excess problem from which all of your aesthetic concerns emanate. The reality is that orthognathic surgery is ‘drastic’, and while solving all of your classic vertical maxillary excess problems, runs the aesthetic risk of changing the way you look and has it own set of risks and complications. The outcome may be great or could turn out that you wish you never had it done because you look different. That is the risk of having a ‘big operation for a proportionately smaller problem’. Conversely a less drastic approach (e.g., gummy smile lowering vestibuloplasty and sliding genioplasty which is what I would do if I was you) is aesthetically safer but will leave you slightly under corrected…but without the risk of changing your appearance so dramatically.
In short, you do not have a perfect treatment choice. You basically to have to choose between these two approaches to vertical maxillary excess based on what risk tolerance you have. The only way to decide is how much do you want to change your bite. If it is of lower priority then don’t do the maxillary impaction surgery. If it is of high priority then maxillary impaction surgery is the only way to go and the risks would be worth it.
I can speak to these treatment choices well because I am trained and have performed many of each so I have a unique experience perspective.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, In regards to my custom facial implants (midface and jawline) I have soe design questions. 1) how much forwardness do you think my midface/premaxillary implant would need? 2) Would it look like the example photograph I sent you through Skype? 3) And how much vertical length would you think I’ll be getting in my chin and jaw angle implants? 4) Could the midface implant also give me natural looking high cheekbones in the process? Thank you Doc for you’re time.
A: IN ANSWER TO YOUR CUSTOM FACIAL IMPLANTS QUESTIONS. 1) I WOULD THINK SOMEWHERE BETWEEN 4 AND 6MMS OF MIDFACE AUGMENTATION IS NEEDED. I HAVE NOT SEEN ANYONE THAT NEEDS MORE THAN 7MMS. THERE IS ALSO THE ISSUE OF BEING ABLE TO HAVE A COMPETENT MAXILLARY VESTIBULAR INCISIONAL CLOSURE. IF THE IMPLANT IS TOO BIG TERE IS AN INCREASED RISK OF POSTOPERATIVE WOUND DEHISCENCE. 2) AS TO THE RESULT OBTAINABLE, YOU CAN’T MAKE ANYONE LIKE LOOK LIKE SOMEONE ELSE. YOI CAN ONLY MAKE YOU LOOK BETTER AND MORE PROPORTIONED. 3) YOUR CHIN PROBABLY NEEDS TO COME DOWN ABOUT 5MMS WHILE THE JAW ANGLES WOULD BE CLOSER TO 15MMS. 4) LIKE MOST MALES THEY ALL WANT A HIGH NOT A LOW CHEEK AUGMENTATION EFFECT SO YOUR REQUESTS ARE SIMILAR TO WHAT EVERY OTHER YOUNG MALE SEEKS.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I wanted to share these pictures to check if they would match the custom midface implant design. His face shares similar orbital vector and eye shape to mine. These faces are projected directly below the eyes. I prefer the look where the projection is high in the midface and hollows in the lower cheek segment giving an chiseled athletic look. I have seen many cheek implant results online where the lower cheek was filled and the upper cheek was left hollow giving the patient a chubby cheek appearance.
In regards to the implant would the given dimensions be suitable for this look? My infraorbital area appears very hollow even relative to my recessed cheeks. Ideally I’d like the result to look like the projected faces but I do understand that many factors go into the outcome. His cheek augmentation before and after is a result I’d want to avoid. He appears less masculine as the projection was lower in the cheek. His infraorbital augmentation is much better in my opinion, he looks sharper and masculine.
Like you have previously pointed out my orbital vector is negative and I’d like to augment it making it positive giving the deep set eye appearance, instead of a protruding eye appearance.
Thank you for your time and consideration.
A: Thank you for providing your pictorial examples and your goals. The reason you are having a custom midface implant is because no standard cheek implant can remotely create the type of midface augmentation that you, and every patient that has a negative orbital vector, requires. If one tries to use any standard cheek implant for your problem it would be an aesthetic disaster. Also most standard cheek implants are really made for women. While they are also routinely used in men, I find they are often aesthetically not optimal as what makes most male cheeks look better is a different zone of augmentation than that of the female. To no surprise male and female midface aesthetics and beauty are different. Most men do not want the ‘apple cheek’ look that some females want, they want a high malar augmentation result.
I am very well aware of your midface aesthetic needs and those will certainly be an integral concept in your custom midface implant design.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, i have been concerned with my big forehead. I did a hair transplant six month ago but the problem is that I still have a large forehead. I now know that it is because my forehead bone is so prominent.(forward) I was wondering if you do forehead reduction surgery where the bone is shaved down and is less forward and more symmetrical with my other features. On your website I saw that the you had done a lot of similar forehead reduction procedures. Attached are some pictures for your review.
A: You have a frontal bossing issue on your forehead which could only be hidden if the hair transplant came down low enough. (which would also look unusual) Frontal bossing forehead reduction is done by a bone burring technique whose result is controlled by how much the bone can be reduced. (down into the diploid space.) That is usually around 5mms but many be more in some patients based on the thickness of their bone. If one really wanted to know much the outer table of the forehead bone can be reduced, a lateral skull x-ray will clearly show the thee layers of the skull and the outer table thickness can be measured.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have moderate vertical maxillary excess which causes me to have a gummy smile when laughing, a long lower/mid face and slight lip incompetence that causes slight chin dimpling/strain when I close my mouth. My chin is also slightly recessed. I dislike my downwards angled jawline which I think is the cause of the recessed chin and vertical maxillary execss that makes it harder for mandible to auto rotate. I also have a deep overbite and excessive overjet. My orthodontist and jaw surgeon suggested jaw surgery with maxillary impaction with slight advancement along with slight mandibular advancement to fix my concerns. I also had the orthodontic option to intrude my upper front teeth followed by gum laser removal. (although I don’t want my teeth looking long, i like the length of my teeth) I had braces when I was younger. They extracted 4 bicuspids which make my smile more narrow.
I would like to get rid of my gummy smile and long midface and have a relaxed looking mouth when I close it. I know my case is not severe but I would like to fix my concerns the right way. I do not want to look like a whole new person. I think I am good looking but I would just love to fix the things I mentioned that bother me. Would the surgical way make me look too different or would I still look like me?
A: Given all of your vertical maxillary excess symptoms, the best long-term treatment would be maxillary impaction possibly combined with mandibular advancement or a sliding genioplasty. Whether the lower jaw needs to go with the maxillary impaction depends on what the pre surgical orthodontic workup shows for the skeletal movements based on the needed occlusal changes. This is the long but the right way. Anything short of this approach will produce some partial improvement but will probably always leave you wishing for more improvement.
Dr. Barry Eppley
Indianapolis, Indiana