Your Questions
Your Questions
Q: Dr. Eppley, I have read through you pectoral implants case studies and wondering what your thoughts are on 230cc implants on a 60kg male with low body fat. I went and saw a surgeon for a consult today. However I am still confused as to which one is best for me. My surgeon did however state that the 190 cc would be too “natural ” for me as I am wanting a slightly aggressive approach to this. Another thing I noted is that he was adament that he use the square shape implant as opposed to the oval shaped for the look I am after. I always thought that i would be more suited to the oval shape as I don’t wish to look “meaty or body builder like” and enjoy more of a swimmers, athletic style of implant whilst keeping the aggressive approach and creating the bulge you mention on your notes. I have found it difficult to find information on this as I have noticed that most people on the internet and my doctors patients who have had pectorals done are all the complete opposite physique to me and are much older.
A: I will preface my comments by saying that since I don’t know what you look like now or your chest shape goals, all I can do is make some general statements about pectoral implants. There really is vritually no difference in size between 230cc and 190cc pectoral implants. If you don’t go up at least 100cc in implant volume you will see no external differences. You are correct in that there are differences in results between the more square shaped and oval pectoral implants. Given what you may want to achieve it certainly sounds like the oval shape pectoral implant styles would be more appropriate for your aesthetic chest shape goals.
Dr. Barry Eppley
Indianapolis Indiana
Q: Dr. Eppley, Will inserting maxillary implants on the maxilla (the entire maxilla, including the bits around the nose and up to the under eye sockets) be an effective solution to get rid of mild nasolabial folds? My folds are very present at even the slightest facial expression and the smile lines stay for a while after the expression. And if I look really closely I can see the smile lines even if I haven’t made an expression for a while. (so they will only get worse as I get older, I’m currently 22)
The actual smile lines at rest bother me more so than the folds during expression, as I can stop expressing if I really want to. Or is there another more effective procedures to get rid of these bothersome facial lines?
A: In short, I am not aware that underlying bone augmentation significantly impacts the depth of nasolabial folds at rest or prevents their occurrence with smiling. Maxillary implants are designed to augment the bone not to address the outer soft tissues.
Furthermore your concerns about the smile lines will be a lifelong one as there is no real solution to these superficial skin wrinkles. They are a normal and natural part of the sequelae of facial expression, a critical element in human interaction and communication.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a fat transfer to my arms/wrists area twice in the past and the fat did not survive – the result was very good at first but after nearly 4 months the fat has gone away. My concern is my small wrists and arms but especially the wrists. I would like to know if the arm implants can be used to augment the wrists to make them appear wider/bigger. I plan on having this surgery late this year.
A: It is no surprise that fat would not survive in the arms and wrists. As a general rule fat does not survive well in tissues where fat does not normally reside to any degree. Fat may survive is one area or spot but will not persist in an overall circumferential manner. That is just simply to going to work…as you now know times two.
It is not possible to place implants in the arms/wrist as there is not adequate soft tissue/muscular cover for them. Implants that are just covered by skin and are close to a moveable joint like the wrists would likely have a high incidence of complications. It is not a question of whether it can be done but whether it should be done.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, So I don’t have a severe deformity, but the top of my head is basically flat. I have a big head but it’s very flat, it looks Cro-magnonish and it gives me a primitive look which I don’t like. Is there any option to add height to my skull? Just a few cms? Slightly reshaping it would really make a difference I think. My forehead is also very flat, so it looks really really bad. I would send pictures, but I don’t know how. Can this condition be treated somehow? Basically my goal is to add a little height to the top of my head so it won’t look flat. I await your answer.
A: What you need is a skull augmentation procedure using a custom skull implant. How much skull augmentation on the top of the head that can be achieved is limited by how much the scalp will stretch to accommodate the implant. But up to 1 cm to 1.5cm of additional skull height can be safely achieved. The shape of the implant would provide a rounder shape as the height is increased and that is part of the implant’s design.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a male and I’m interested in a lip lift procedure. I say this because I feel as if the distance between the base of my nose and my upper lip is too long for my face and throws my facial balance out or proportion. As you know, a lip lift is able to reduce that distance which is exactly what I need. What you also know is that the lip lift pouts the upper lip, which is something that I’m not aiming for with this procedure; mainly because pouty lips on a male can look overly feminine . I know that this effect is unavoidable, it’s a question of whether the benefits of reducing the upper lip distance outweighs the drawbacks of a slightly poutier upper lip. However I feel that I’m unable to make a decision without knowing precisely how the procedure will effect my upper lip. So my question is: is there any way in which I can visualize the likely result of this procedure on my own face? I’ve tried morphing my upper lip to be slightly more full but it doesn’t seem to give the same effect that I’ve generally seen with lip lift before/afters which tend to alter the upper lip size, but not in a straightforward way as the morphing app is only capable of doing.
That brings me onto my next question about patient results. From the many before and afters that I have seen, some seem to really change the lip proportions whilst others don’t really drastically affect the upper lip proportions at all. I have noticed that this is even the case where the upper lip distance reduced in these comparable results isn’t hugely different! Obviously I would prefer a result like those in which the upper lip hasn’t been changed all that much. But how am I to tell which sort of case I would fall under?
The last question I had was whether a portion of the underside of the upper lip could be removed in order to thin the upper lip from the underside. And then have the lip lift performed on the thinner upper lip? I say this because my upper lip has a very slight tubercle hanging downwards (I am not sure if I’m decsribing it rightly, what I mean is that a sort of triangle hangs down from the centre of the upper lip, it’s quite common). If this tubercle could be removed and the upper lip therefore thinned, could that mitigate the increased upper lip thickness that may result from the lip lift? If it can, that would be great because it means that I’ll have the same net upper vermillion size with a shorter upper lip length?
A: In answer to your upper lip lift questions:
- There is now way to accurately show before surgery what the real effects of a lip lift would be on your areas of lip shape concerns.
- The factors that affect how much change a lip lift does to the upper lip is the amount or percent of upper lip skin distance that is excised as well as the natural elasticity of the upper lip tissues. Thus that really makes it impossible to compare lip lift results between patients as these two variables are not the same in any two patients. The most important factor is how much of the philtral length is horizontally removed
- A smile line vermilion edge resection can be done at the same time as an upper lip lift.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a strange aesthetic problem that has to do with my eyes, more specifically with my eyeballs. I feel that they’re too deep set into my skull and that makes them look tiny. The problem, however, is that not only I don’t have “heavy” or protruding brow bones but my whole orbital rims (upper and lower) are recessed , I can tell that from my profile view because I have a visible bulge under my eyes and I also have dark circles. Unfortunately, I do not have a camera with me so you can see what my eyes look like. But supposing that all my assumptions are correct, is there any way to move my eyeballs forward ? I was thinking if orbital floor augmentation or craniofacial surgery to this area can be effective. Are any of these options to be seriously considered?
A: In short, you can not move your eyeballs forward. They are on a tether known as the optic nerve. It is not a good idea to stretch the optic nerve as this could very well led to visual disturbances or blindness. Orbital floor augmentation can potentially move the eyeball up. Craniofacial surgery moves the orbital rims around the eyes. Neither of these are to be seriously considered, even if they would be effective, for an aesthetic eye concern.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m about 5’4 and roughly 115-120 pounds maybe a tad heavier. I’m considering buttock implants. I’m 23 soon to be 24 so I didn’t know what the options were? Time of surgery? Healing process ? Risks ? I’m hoping to hear from you very soon!
A: While I don’t know exactly what you body looks like, your height and weight measurements suggests that the use of fat for your buttock augmentation is unlikely to be inadequate. You may simply not have enough fat to harvest to do much of a buttock augmentation. I would really need to see some pictures of your body to answer that question better. if not that would then leave you with only the option of buttock implants. Whether implants would produce a satisfactory result depends on what your buttock augmentation goals. Implants generally produce a small to moderate buttock enlargement not a big buttock size increase.
Buttock implants can be very effective if one has a realistic understanding of what they can and can not do. Beyond this aesthetic issue, buttocks implants have a relatively long recovery time and it probably takes most patients a full month to get back to most of their normal activities.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Several years ago, I developed bulging temple veins and I had the superficial temporal artery ligation in my right temple with a single point ligation.I’ve had some potential complications and I’m looking for a second opinion.
For the most part, the surgery was a success. The bulging vessel is gone and any scarring was very minimal. A couple years after the surgery, I developed a very rare condition called Partial Third Nerve Palsy, most likely caused by lack of blood flow to my ocular motor nerve. As with most partial ocular nerve palsies, my condition improved within weeks.
Fast forward a couple years and it happened again. And just like the first time, I recovered completely. I had the top ophthalmologic docs stumped. I told them about my superficial temporal artery ligation and they brushed it off as insignificant. I’m relatively young and healthy and have no other conditions that typically would cause an ocular nerve palsy.
I was recently reading Men’s Health and there was an article about giant cell temporal arteritis and how it can cause double vision or blindness. So that tells me that there IS a possible connection between the superficial temporal artery ligation and vision, right?
But everything I read online said the procedure is safe and perhaps my recurring ocular nerve palsy is just a totally unrelated coincidence. As you seem like an expert in this field, I thought I would reach out to you and hope you can put my mind at ease.
Q: In short, I know of no connection between superficial temporal artery ligation and oculomotor nerve palsy. The superficial temporal artery is a terminal branch of the external carotid artery that supplies the forehead and anterior scalp. Conversely the oculomotor nerve receives its blood supply from the internal carotid artery through an intracranial course. Thus there is no apparent anatomic connection on the basis of arterial blood supply.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Wouldn’t a jaw implant have the same issues as chin implants where eventually the bone starts to become reabsorbed?
A: The belief that chin implants cause ‘bone erosion’ is both inaccurate and biologically misinterpreted. Some, but not all, chin implants develop passive settling into the bone as a biologic response to the tissue displacement pressures of the implanted device. This is a passive and natural process that occurs in many augmentation implants throughout the body that is self-limiting as a method of pressure relief. This should not be confused with an inflammatory process like bone erosion which develops as an adverse reaction to either a material’s composition or an infection from the implant material.
Such passive tissue remodeling responses to a facial implant is most commonly see in chin implants. It is probably because of the tight tissues of the projecting soft tissues of the chin stretched out over a projecting underlying bone. This puts a lot of pressure over a single bone point. (chin) This is not seen in larger jaw implants because the displacement forces are spread out over a much larger bone surface area and there is no one single pressure point or area.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, My primary cosmetic concern is actually very dark skin in the upper and lower lids as well as the sides of the nose. Unfortunately, without make-up this feature dominates my face. However, I am also aware of some structural issues that make this darkness look worse. My prominent brow bone casts a shadow over my deep-set eyes and that the radix of my nose is very narrow. Would you agree that these are contributing factors? (Photos, with make-up, are attached.) Would brow bone reduction and nasal augmentation help?
I had some fat transfer to the lower lids ten years ago with some lasting success. I would now like to correct the darkness in my upper lids and medial canthus and I’m researching two options. One option is fat transfer. The other is to address the structural issues through reduction of the brow bones and lateral augmentation of the radix of my nose. Ideally, I would pursue all of these (along with hairline lowering) but am hesitating to have such invasive procedures.
Can you advise me which of these procedures will make the most difference to the darkness in my eye area and my overall appearance? Also, what is the likelihood of a good result? Any advice you can offer is greatly appreciated.
A: Thank you for your inquiry and sending your pictures. While your structural issues may make a contribution to your periorbital dark skin appearance, you would never do structural surgery such as brow bone reduction or nasal augmentation in an effort for skin coloration improvement of the adjoining areas. The risks are simply too high. You do those surgeries for what they primary purpose is…creating a structural change not a potential secondary benefit.
This leaves you with the only treatment option of which you have had prior experience…fat grafting. Whether this would be effective to improve your periorbital skin discoloration is not precisely known.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’ve underwent a male breast reduction surgery five years ago. Everything went well. Months after my surgery,I had slight scar tissue build-up in my chest—nothing too concerning, absolutely livable. I massaged when I could but it was always so sore and I was too scared of messing up my results. I noticed the scar tissue in my left pec fluctuated slightly in size slightly over time. Massaging wasn’t helping, so at one year post op I went in for Kenalog shots to break up some of the tissue. It seemed to work but it also left a slight dent when I flex. Now, four years post op, the tissue seems to have grown again out of nowhere. I began massaging vigorously again. At first, the scar tissue seemed like it was breaking up and getting smaller. I was massaging just about everyday and then it started to harden. I even got some bruising around my left nipple. I tried to keep massaging, but I’m not seeing any progress. It only seems to be getting bigger, harder, and more noticeable—is that good or bad?
A: At this point the only effective option is going to be further gynecomastia reduction surgery. Whether it is scar tissue or actual breast tissue regrowth, further improvement is not going to come from massage or steroid injections. Secondary or revisional gynecomastia reduction surgery is not rare due to either the development of scar tissue or some breast tissue regrowth.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have had a Medpor chin implant placed last year. I am ok with the look although it is a bit big for my feminine small face and my chin looks a bit big and asymmetric when I smile. However my big problem is when I woke up after surgery with excrutinating pain on the right side, probably along the branch of the mental nerve that goes to the lip. And it still hurts a lot, focused on that groove between chin and lip on that side. It improves when lying down after a while and worse when I move my mouth, speak etc. What should I do?
The surgeons are very experienced but have never experienced this kind of problem before, and have never removed or performed a chin implant revision. I also have numbness in the same side of the lip and a bit problem with articulation.There is also pain in the lip when I stretch the lip. When I wake up in the morning the pain is almost gone and comes when I start moving around. I consulted a neurosurgeon who said there is nerve damage, not a cut nerve. The surgeons are willing to take out the whole thing but I think that is very drastic. What would be your advice, and where to find the best expertise for my problem, and how to fix it – the situation is kind of desperate as i do not function so well wit all that pain. Hope to hear from you soon.
A: Either the chin implant is impinging on the nerve (mental neuropraxia) or the nerves has beens stretched/injured during the making of the pocket to place the implant. Given the overall larger sizes of Medpor chin implants and their stiffness, it is likely that it is the former. I think the only way you can make improvement is to do a Medpor chin implant revision where the implant is removed, the right mental nerve checked/repaired/fat grafted and the implant modified in size and reinserted. It is unfortunate that this was not done a long time ago when an injury to the nerve had a much better chance of having a full recovery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in masseter muscle reduction via electrocautery for a permanent solution. I would also like to know if this method can be used for the upper trapezius muscle as well? Mine is way over developeddue to genetics as well as being top heavy…thank you.
A: Masseter muscle reduction is surgically done using electocautery to treat the entire internal surface of the muscle from where it is lifted off the jaw bone. By so doing it causes some muscle cell atrophy, reducing the size of the overall muscle. Treating a much larger muscle like the trapezium is more analogous to that of the calf muscle. In calf muscle reduction a portion of the fibers of the muscle are released from its origin by electrocautery resulting in a different mechanism for muscle atrophy. This would how the trapezius muscle would similarly treated. What bothers you about the trapezius muscle would most likely be the upper third where it is seen gong from the back of the head down across to the shoulder. Such a trapezium release of the upper third of the muscle would have to be done where it attaches to the occipital skull bone.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have some questions about custom facial implants. I have attached a frontal shot of my face in harsh bright lighting. I have also attached a side profile shot along with an adjusted “goal” image of what I would like my profile to resemble. I have also attached a picture of a famous actor who has an incredibly angular and well defined jaw. It would be my dream to have a jaw like his. Is it achievable? My budget is considerable. My primary aim is to get rid of my round face front on and have something square and angular both in the chin and jaw angle regions.
I am also interested in what parts of my face are lacking and how I can improve it aesthetically. What are your thoughts, I’m open to suggestions. I seem to have quite a round face despite being low in body fat (my abs are visible and I have a “four pack”). I’m puzzled by what I need to enhance to get the look I desire. Is my lack of facial bone structure causing poor tissue distribution or is my poor tissue distribution hiding my bone structure. Interested in your thoughts and potential solutions, I like your intelligent approach that I’ve been reading in your blog.
A: Thank you for sending your pictures and describing your aesthetic goals. In reality you do not really have a round face. It may appear that way to you and is not to your liking but it is certainly not round. Your face is thin and you have decent facial bone structure. What you lack is the bone structure to get the ‘supernormal’ look you desire. With the right cheek and jawline implant designs such facial changes that you seek are possible. That type of facial change can really only be achieved in someone with a thinner face where the enhanced skeletal projections created by custom facial implants become more evident externally.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, With my custom midface implant I hope to be able to meet with the engineers to tell them how I want my implant designed in detail. I also wonder if I can have a midface lift at the same time as the placement of the custom midface implant.
A: In terms of custom midface implant design process, patients can not have a direct participation in the actual designing of the implants with the engineers. Since the patient is not a surgeon, direct manufacture and patient contact is prohibited by the FDA. The implant design process is done between myself and the engineers independent of the patient. Patients to get to see the implant designs and make comments and suggestions from the PDF file designs provided to them after each design session. Only three implant design sessions are done from which the final design must be completed. Final implant designs must be submitted a minimum of two weeks before the actual surgery date.
With the placement of any midface implant a midface lift can not be performed at the same time. A midface lift in a young person is also an unnecessary and ineffective procedure. This is an operation for older patients who actually have lose midface misses from aging and bone loss.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a question about what can be done with the sliding genioplasty technique without any implants. I am not to keen on implants as it’s not natural and I have read that it can lead to atrophy and infection and I am still young.
I have attached photos – I don’t like my chin I feel it is too thin and too short vertically in relation to my nose and face.Is it possible to add vertical length using sliding genioplasty in my case as I already have good horizontal projection? My chin is already narrow,
can something make it wider? Also will sliding make it look slimmer if it is increased vertically? I really want vertical increase without any future possible complications like with an implant. Thanks a lot for the help.
A: The most common technique to just vertically lengthen the chin is an opening genioplasty procedure. Rather than ‘sliding’ the bone forward it is just vertically dropped down. Be aware that this will not widen your chin. As the chin bone becomes longer it will by definition not become wider and may, in fact, look a little bit more narrow.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, So I don’t have a severe deformity, but the top of my head is basically flat. I have a big head but it’s very flat, it looks Cro-magnonish and it gives me a primitive look which I don’t like. Is there any option to add height to my skull? Just a few cms? Slightly reshaping it would really make a difference I think. My forehead is also very flat, so it looks really really bad. I would send pictures, but I don’t know how. Can this condition be treated somehow? Basically my goal is to add a little height to the top of my head so it won’t look flat. I await your answer.
A: What you need is a skull augmentation procedure using a custom skull implant. How much skull augmentation on the top of the head that can be achieved is limited by how much the scalp will stretch to accommodate the implant. But up to 1 cm to 1.5 cms of additional skull height can be safely achieved in most patients. The shape of the implant would provide a rounder shape as well as the skull height is increased. This is known as a skull cap implant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Recently had a mini facelift. I’m 3 weeks post op and I’m concerned about the areas of what appears to be fat next to my mouth. It gives me a bit of a “joke smile” look quite frankly. I spoke to my doc about it and he said photos were in bad light and area might calm down but I’m looking for a second opinion and wondering if these fat line areas can be removed with micro liposuction or should I use fillers to make less noticeable. I wonder if these areas are the fat that was previously along my jawline, or is it swelling still I cant seem to get a clear answer so I’m looking elsewhere.
A: It is important to note that you are just three weeks after your mini facelift surgery. The tightening along the jawline makes the perioral region look puffy or at least has exacerbated what it was before surgery. This is the effect of a mini facelift where minimal skin undermining is done. It may be that with more healing time and the jawline skin relaxes a bit that its appearance may decrease. I would give it at least 6 weeks after surgery to see how it looks then. If it has not improved substantially by then small cannula liposuction should be used to reduce the perioral mounds which has become unmasked. Trying to place injectable fillers around it is likely to make look worse.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have had confidence problems for well over a decade now due to my odd looking skull. I was thrilled to learn that skull reshaping is now a tried and tested method. Looking at the different cases, I think my problem is a sagittal crest skull deformity – marked by a high midline crest of bone surrounded by adjoining areas of skull deficiencies.
The procedure of choice would probably include the use of custom parasagittal skull implants. My question now is if this procedure would affect the position of my eyebrows, since the scalp and forehead skin will be stretched a fair bit. Which made me fear that said procedure might have the undesired side effect of leaving me with a permanent “shocked look” on my face. So, does this procedure affect the positioning of the eyebrows?
A: I have not seen any cases of eyebrow elevation long-term with any form of skull implants. Nor has any patient so mentioned it. But the specific combination of sagittal crest reduction combined with parasagittal augmentation has not been seen to have any impact on eyebrow position. This is because for the most part the amount of skull augmentation and upward scalp push is not that great.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in lip fat injections. I am 33 years old and starting to age and I feel it especially shows in my overly thin lips. I like more volume. I don’t like how long my upper lip is also. Id like to look more feminine and soft looking for a sexy more dramatic look. I wish I had more lip to show and some tooth show. However I am terrified of scars with lip lift. I want a more permanent solution over fillers. Also I have some asymmetry on the right side where I have less upper lip. I would like more sultry lips.
A: Thank you for sending your pictures for consideration for lip fat injections. With you thinner lips there are several realities that you need to know about lip augmentation with fat:
1) The best and most permanent augmentation result is going to come from a vermilion advancement. (not a subnasal lip lift) But since you are terrified of scars your best lip augmentation treatment is not an option.
2) Fat injections are unreliable in terms of retention and permanency. They rarely are permanent with a single injection session.
3) In thinner lips any type of injectable volume augmentation makes them fuller but may or may not create the lip shape you desire. As a general rule, any injected volume to the lips makes them bigger but usually maintains the same overall shape.
40 More tooth show is not going to come from adding volume to the lips, only lip lifts and advancements can achieve that effect.
5) It would be in you interest to have a synthetic injectable filler treatment first before trying surgical fat injections. You want to know if an injectable approach can achieve the look you desire. As if you do fat injectionks and it does not create the look you like and it persists, there is no reversing it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am pretty set on getting a custom jaw implant done but I have a few questions. Do I need to do anything in order to prep for this type of implant? I imagine I wouldn’t even need a custom fit but one side of my jaw has gotten noticeably smaller due to having the two back teeth on the bottom of one side removed. Would I need to get these replaced with a tooth implant before surgery to prevent any additional bone loss? Would replacing these teeth with an implant spur bone growth? Also, my periodontist said that my bite is slightly off (I feel like it would be about an eighth of an inch or less maybe) as my top teeth stick out a tiny bit further than the bottom, does this need to be fixed?
First I am going to get a fat transfer done to replace some facial volume loss. Is having a jaw implant going to effect this? I’d imagine the skin would have to stretch a bit due to the added volume. And will the implant increase chin projection? Looking for both projection and vertical height in that area.
Thanks for your time.
A: In answer to your custom jaw implant questions:
1) If you have jaw asymmetry you would be better served by a custom implant approach. If not then expect the use of regular implants will still have some asymmetry afterwords.
2) Whether you get a dental implant or not that will have not impact on the jaw angle area.
3) Any bite issues you have are irrelevant for this surgery unless they are significant enough to require jaw surgery for correction.
4) If you are gong to get a fat transfer it should be done after jaw implant surgery. The trauma and swelling from jaw implant surgery will have a negative impact on fat graft retention.
5) Your dimensional needs of your jaw implant is determined before surgery but of you want both increased chin height band projection you are speaking to a custom implant design to create that type of change.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have lost over 150 pounds and have loose skin in my abdomen however do not have a large pannus flap my skin is just loose and like melted wax which is causing me to have significant vaginal pain and prevents me from doing many activities such as exercise. My insurance says an abdominoplasty can be considered reconstructive rather than cosmetic if a surgeon will submit for medical necessity. I would like to know if you deal with insurance on this type of issue? I am looking at needing other cosmetic procedures as well but right now the pain has made the abdominoplasty a priority because I need to exercise.
A: Getting abdominal surgery covered by insurance is not as simple as the ‘doctor stating it is medically necessary.’ All elective surgeries must go through a predetermination process with a very specific set of criteria that determines whether they would be eligible. The only abdominal procedure that can be approved for health insurance coverage is an abdominal panniculectomy not an abdominoplasty. To get approved for an abdominal panniculectomy there is a very specific set of approval criteria that must be met including: 1)photographic documentation of an abdominal pannus that hangs over the groins and onto the thighs, 2) photographic evidence that the pannus is causing a medical problem (chronic skin infections) and 3) documentation of at least 3 months of non-surgical therapies to treat the dermatitis that has not worked.
If a patient is unable to have an abdominal condition that does not have these three criteria met, a predetermination letter will not be submitted as its denial will be assured.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was wondering if metal wires was used to stabilize the bone after a cheekbone reduction, can this cause a systemic body rash or highly unlikely? If so, can the wires be removed? What are the risks? Thank you.
A: Wires used in facial skeletal bone fixation are highly unlikely to cause a systemic reaction like a body rash or other tissue reactions. They are made of stainless steel which, unlike titanium plate screws which are now more commonly used in the face for such procedures as cheekbone reduction, do not a higher risk of allergic reactions. However, I have never heard of or read of such reactions occurring in facial bone fixation with stainless steel wires.
Regardless wire ligatures can usually be removed in any facial bone where they are located. They would be removed through the same incision by which they were put in. As long as the bones are well healed they should be no risk in doing so other than the temporary swelling that results from the removal procedure. Most cheek bone reductions heal very quickly, as do most facial bone fractures/osteotomies, so I would not think that cheekbone positioning would be affected.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m interested in having a custom jaw implant to have a wider, more symmetrical and defined jawline.
I however don’t live in Indianapolis so am unsure as to the process of getting this done. Do I need to come to Indianapolis more than once? Or can I just send the CT scan that I have already done, have Skype consults and only come in once?
In terms of timing I have a tight schedule with uni. Ideally I would be hoping to get this done in January but am unsure if this is realistic with your schedule and time required for everything to be ready? How long does it take for the designing and the printing of the implants? When would your next availability for such surgery be?
I understand that the price of custom implants can vary considerably but what would be an estimate for the total cost (including your fee, the implant production, the GA fee, hospital fee etc..)?
A: In answer to your questions:
1) You only need to come here once for the surgery. You send the 3D CT scan to me from which your custom jaw implant will be designed. All preoperative consultations will be done by Skype.
2) The design and fabrication of a custom jaw implant takes from 4 to 6 weeks to complete. So January surgery is very possible.
3) My assistant will pass along the cost of the surgery to you next week.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in chin ptosis surgery. Three years ago I had a chin implant placed through the mouth and then it was removed a few weeks later because it was causing dynamic ptosis. My chin and lower lip are lower than they were before and my oral vestibule seems really low in my mouth. My doctor said it was because of scar tissue and there was nothing he could do. I realize now that my mentalis muscle needed to be resuspended. Have I waited too long to have this done and have any chance of success?
A: The timing from the onset of the implant removal/chin ptosis does not really affect the success of the surgery when it is performed. The success of the surgery depends on many technical factors, one of which it is higher when a small chin implant is placed to support the uplifted chin tissues. Besides resuspending the mentalis muscle, the other very effective technique in my experience is to raise the height of the vestibule. This would be of particular benefit in your case as you have already described that it seems too low since the original chin implant surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in chin ptosis correction. Part of the reason I’ve put off having the surgery is because the success rate seems really low. I haven’t found anyone who has had this done sucessfully. I’ve read everything about mentalis resuspension that you’ve posted on your website and some of the information is conflicting. In an older article you state that everyone who undergoes the procedure has some degree of improvement, But elsewear you state that the surgery completely fails more times that it is successful. I’d like to know what your opinion is now, I don’t what my expections to be unrealistic.
A: Chin ptosis correction surgery can incorporate one or several techniques. Mentalis muscle resuspension alone, while initially effective, often disappoints with more healing time. When multiple techniques are done (muscle suspension, V-Y mucosal closure, elevating vestibulopasty and a chin implant) the results are much better and more sustained.
But you undergo the surgery with the knowledge that chin ptosis is a difficult problem to correct and results are far from assured. Usually the actual chin ptosis ends up corrected but the more visible issue, the sagging lower lip, can prove to be the challenge for sustained improvement.
Dr. Barry Eppley
Indianapolis, Indiana
Q:Dr. Eppley, I am a 28 year old male and i have a question about forehead bone reduction procedure. I’ve had these two lumps on my forehead for as long as i can remember. I always thought I got them from hitting my head when I was a kid. Recently these lumps started to bother me more and more so I decided to see a plastic surgeon that specializes in reconstructive plastic surgery in my home country and ask what he thinks about it.
He gave me a diagnosis of ’eminenta frontalis’, which I interpret as just a bone shape that is somehow normal but just a bit more prominent. He did not think this is something that should be bothering me nor could it be fixed due to the underlying sinus cavity and relatively thin bone thickness (no xrays were taken)
The thing is, this is bothering me and I would like to know what are my options.
A: If I am interpreting correctly as to what your foreheads concerns are based on the pictures you have sent, I see a pair of forehead prominences that are often called forehead horns. They are a natural development of the forehead that does occur in some males. They are not located over the frontal sinus but above it. These forehead bone humps can be very safely burred down. This would be done through a frontal hairline incisional approach. Forehead horn reduction is a procedure in my experience that exclusively occurs in men much like large or overdeveloped frontal sinuses/brow bones.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a female with a cleft chin and overactive/large mentalis muscle which creates pitting or orange peel texture in the chin area. If I have my cleft chin surgery to get it corrected, can it also correct the orange peel texture so I don’t have to keep getting Botox injections every 2 months? I am missing a little piece of bone at bottom of my chin due to the cleft chin. So I wouldn’t want a regular chin implant, but just something to fill in this dent. I don’t want to have to keep getting Botox or filler injections. I want something permanent.
A: You have two chin issues which are independent of each other. Cleft chin surgery for removing the cleft is not really based on putting a modified chin implant onto the bone. That is just a minor part of the correction. Most of the chin cleft resides in the overlying soft tissue which requires fat injections in addition to the bone implant.
The mentalis muscle irregularities/dimpling are a different issue which is not going to be improved by a chin cleft surgery. Short of Botox injections they are few other effective treatments. Fat injections into the dynamic dimpled areas would be the only other treatment option whose effectiveness can not be assured.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have several custom facial implants questions. I would like to visit you later this year for a custom midface implant and custom chin implant. Is it possible that I can have both surgeries at the same visit or would I have to wait for the first one to recover? Also what is the recovery time of a custom midface implant that covers the areas from the infraorbital rims to the ears?
A: It would be very common to have more than one area of the face augmented with implants during the same surgery. This is just as true with custom facial implants as standard facial implants. The most common such combination would be custom jawline and custom midface or forehead/skull implants, treating distinctly different craniofacial regions.
The recovery time for just about any custom facial implants procedure is primarily related to the swelling that occurs in the face. One usually starts to look ‘reasonable’ in about 10 to 14 days after surgery. But full recovery to see the final results of the facial implant surgery can take up to six weeks after the procedure. As a general rule there his always more facial swelling that one expects and it will last longer than one wants.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have had three forehead contouring procedures starting with a PMMA forehead augmentation ten years ago. After some time a ridge across my forehead became more pronounced and I had two more procedures which involved removal of the PMMA implant and some adding of hydroxyapatite cement. I am lnow eft with strong indents in both sides of upper forehead, a lack of any real brow bones, and eyebrows became more propped up in corners. I would like to fill in and smooth the upper forehead and possibly build up the brows, which I think would improve/flatten eyebrows by getting them closer to their original position. I am wondering with three procedures done, and scar tissue removed, would I have enough elasticity to attempt to do this. I would love to not open the coronal scar and try to utilize less invasive methods. However, I understand the need to do this for better access to the forehead and brow bones. It has been five years since the last procedure. (second and third procedure were performed over a 6 month period with the same surgeon)
A: With having multiple forehead contouring procedures done you are correct in being suspect of how your forehead tissues would respond to further efforts at augmentation/expansion. That tissue issue is overcome, should it exist, with galeal releases done on the underside of the scalp flap. Between the need to very specifically apply further forehead augmentation materials and to potentially need to release the galea, an open approach using your existing coronal incision would be required. Limited incisional techniques in the face of your forehead circumstances is a setup for additional forehead contour issues. In essence the result will only be as good as what the surgeon can see. As you have observed in forehead augmentation even the slightest contour issue is eventually seen as the forehead tissues contract around it. It is surprising that even thick forehead tissues eventually reveal even the slightest irregularity beneath it.
Dr. Barry Eppley
Indianapolis, Indiana