Your Questions
Your Questions
Q: Dr. Eppley, I had Botox injections for square jaw in the masseter muscles three months ago, 32 units each side. Now I dont like the way my face looks. It is heavy, not v-shaped with saggy skin and prominent cheeks. You are an expert. Is it reversible.? My jawline that was perfect is now like a jawline of an old person.
A: Botox in a reversible neuromuscular drug which achieves a temporary muscle thinning effect as the nerve input to it is decreased. However in the vast majority of patients the master muscles should return to its previous state of fullness once it has worn off in 3 to 4 months. I have yet to see Botox injections cause a permanent muscle thinning effect in just one injection treatment. This almost never happens or at least I have never seen it. Most patients who have this treatment for a square lower face or thick masseter muscles wish it would work with just one injection treatment,. I would need to see some pictures of your face to see what you looked like before Botox and now after for further commentary/recommendations.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am in desperate need of revisional facial slimming surgery. Two years ago I had cheek and jawline reduction in Thailand and it has turned out to be a disaster. It has left my cheeks sagging, my jawline has disappeared and I got a deep burn across my chin from a hot instrument during surgery. I have attached before and after pictures as well as x-rays. I do not look anything like I did before the surgery. This has been a nightmare and I need an expert like you to help me!
A: Thank you for your inquiry, sending all of your pictures and x-rays and describing a very unfortunate surgical outcome from a typical facial slimming procedures of cheek bone and jaw angle reduction surgery. My comments are as follows:
1) From a bony standpoint, you have the classic cheekbone reduction sag that occurs when the anterior osteotomies are not fixed by a plate and screws or has an osteotomy design that is self-retaining. While this effectively narrows the cheek bone, it causes a soft tissue sag as the attached soft tissues sink in and down with the bone.
2) Your jaw angles shows a complete amputation of the bony angles at a 60 degree angle. While this will also narrow the lower part of the face, the complete lack of any bony support causes the face to sink in and look prematurely aged. There is also asymmetry between the jaw angle cuts which is common.
3) Your lower lip/chin burn was a 3 degree burn injury undoubtably causing by the heat from the power equipment used to cut the bone inadvertently laying against the skin while in use. Based on its location and angle I would assume this was from the cheekbone cut. Such an extensive burn injury I have not see before from this type of facial procedure. It has gone on to heal with the expectant hypertrophic scar.
My recommendations for revisional facial slimming surgery that may be of benefit at this point:
1) Excision of hypertrophic burn scar and geometric skin closure.
2) Anterior zygomatic bone elevation/repositioning with plate fixation
3) Bilateral vertical jaw angle implants to put back some of the lost bony support.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Can a chin augmentation be done that doesn’t simply just push the bottom tip of the chin forward ?(but fills in below the lower lip as well)
A:In regards to your chin augmentation question, the depth of the labiomental fold (under the lower lip) can never be changed by any form of chin augmentation and it will always end up a little deeper with any form of increased chin projection. That is because the labiomental fold represents the attachment of the mentalis muscle above the chin bone. The attachment of the muscle can not be changed or removed for the obvious functional reason. That being said it can be treated at the same time as a chin augmentation by either fat injections (externally) or a dermal-fat graft. (internally) The latter is more effective at reducing the labiomental fold than the former.
The only facial bone procedure that can change the position of the lower lip as well as the depth of the labiodental fold is to advance the whole lower jaw. A mandibular advancement, unlike a more limited chin advancement (by implant or bone movement) carries with it the teeth and its attached bone. (dentoalveolar unit) This is what pushes the lower lip and labiodental fold forward.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am looking forward to have custom jaw and chin implants, but I’m located outside the us, and since I’m unmarried it would be nearly impossible for me to get a us visa in my country. So I was wondering if it would be possible to have the custom implants made for me without me having to visit your clinic personally. Like, I send you my 3D CT scan, we have a consultation over Skype, you get the implants made to custom fit my face and have them shipped to my location, and finally I have them implanted by a local surgeon in my country. Does that make sense? I wasn’t able to find any doctor doing custom facial implants here, they all have those made-to-fit all OTC implants which I don’t find appealing. So if what I suggested could be done, please let me know. I know it could be risky or maybe won’t give perfect results, but I’m willing to have it done regardless. Thanks. Looking forward to your reply.
A: Thank you for your inquiry. Essentially what you are asking is whether I could design your custom facial implants for you, have them made and then shipped directly from me to you so your surgeon of choice could implant them. That can not be done based on two fundamental issues: 1) I can take no responsibility nor should you assume that your surgeon has the knowledge and experience to successfully place them. Custom facial implants often require surgical technique modifications to be successfully placed, and 2) the regulation and legal issues with importing medical devices vary greatly amongst countries and I am certain shipping a medical device directly to a patient from an outside country violates many of those laws.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I just wanna start off by saying, I love your work! I wish I lived in the same state as you to visit your office for a consultation for facial reshaping but unfortunately I’m not. Anyway, I really would like to know if I am a good candidate for a chin implant and jaw implant. I have a round (moon) face and I desire a square face. is it possible for me to obtain that facial structure ? I know you can’t tell me if it’s possible or not because you haven’t seen my face yet but I’d like to email you some photos of my face for a virtual consultation , so please get back to me as soon as you can – thank you!
A: In looking at your pictures the correct facial reshaping procedures for your moon face are a sliding genioplasty (not a chin implant) and jaw angle implants for skeletal augmentation and facial defatting through submental/neck and perioral liposuction as well as buccal lipectomies.
A chin implant would be the absolutely wrong procedure to do for your chin because you need both horizontal and vertical lower facial lengthening. This is a critical element of changing your facial shape. It will also help your neck contour by pulling out the underlying neck muscles.
Q: Dr. Eppley, We had previously discussed a facial reshaping surgery consisting of verical jaw angle implants, infraorbital-malar implants and a glabellar implant. Last week I had a second consult with another plastic surgeon that also specializes in facial implants as well. He offered very similar plan to you with only minor differences. I do have a few questions/confirmations i wanted to bring up after looking over the surgery plan:
1. The jaw implants for me would have both vertical and horizontal dimension?
2. Are the vertical and horizontal dimensions given in mm’s? if so, what are the ranges of each dimension? what size would you use for me?
3. The semi custom infraorbital-malar implants will be 5mm?
4. The other surgeon recommended a subperiosteal midface lift with the infraorbital-malar implants. Would you also do the subperiosteal midface lift?
5. How many screws to secure jaw implants? infraorbital-malar implants? the glabellar implant?
Thanks for your time and answers.
A: In answer to your questions:
1) Every standard jaw angle implant style offers both vertical and width augmentation changes. What makes the two basic styles different (vertical vs widening ) is the ratio of the vertical and width dimensions. Widening jaw angle implants provide more width than vertical length. Vertical jaw angle implants offer more vertical length than width.
2) Every facial implant, regardless of style and size, has very specific millimeter measurements which are provided by the manufacturer on their website complete with drawings and measurements. The best jaw angle implant style for you would be vertical jaw angle implants of the ‘large’ size. (11mm vertical, 5mms width)
3) The semi-custom infraorbital-malar implant will be 5mms at its thickest portion.
4) Every infraorbital-malar implant that is placed through a lower eyelid incisional approach is closed with a ‘subperiosteal midface lift’. Some surgeons chose to specifically call it as part of the procedure and even charge a separate fee for it. But, by definition, making the pocket for the implants requires raising a subperiosteal midface pocket to insert the implant. When the tissues are closed over the implant by sutures to the bone this is what constitutes the subperiosteal midface lift. It is an integral part of the procedure, some surgeons just chose to call it a separate procedure.
5) Jaw angle and glabellar implants generally only require one screw. The infraorbital-cheek implant may also only need one or possibly two. The judgment about the total number of screws is made at the time of surgery based on the stability and fit of the implants to the bone. Probably the correct number of screws will be 8 not 6.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in your orbital dystopia surgery. You can see my right eye is much lower positioned than the left one on the side view photo you can also see I don’t have prominent cheek bones. They’re really “hollow” and on the photo where I lift up my lower lids is how I kind of would like them to be (just bigger as on the photo) a lifted almond shape but you still can see that the right eye is positioned too low… so If I would just do lower lid tightening or something like that I can already tell you I won’t be happy because I’m just a perfectionist..I think my right eye needs to move up and then I need lower and upper eyelid correction and maybe some cheek implants or filler. what would you recommend me to get even, beautiful well shaped eyes?
A: Thank you for sending your pictures and I can clearly see the lower right eye. Orbital dystopia is a difficult problem to successfully treat and the concept of changing from your orbital dytopia problem to one of ‘beautiful well shaped eyes’ is not going to happen. You can not make that type of dramatic change in one surgery and have it perfect. You focus first and improving the orbital dystopia by raising the right eye and making some lid adjustments on that eye. Thereafter you focus on any additional adjustments that are needed and other cosmetic periorbital/cheek changes. As you can see this will require a series of operations but even in the end, perfectly symmetric and well shaoed eye results are not going to be possible.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m not sure what I need to help my face. I’m 54 years old and have been noticing sagging in my neck and the beginning of jowls. I had a “liquid facelift” in last year but it didn’t seem to help much. Just wanting to talk to you about what other options I have.
A: One of the many signs of facial aging is the development of lower facial changes including the appearance of jowls and a droopy neck. While many purported no-surgical therapies exist to treat these signs of facial aging, including the so called Liquid Facelift (pumping bunch of injectable fillers into the face), none of them can really lift up a truly sagging face. There are really for younger people who have only the earliest signs of aging. The only approach that will work is surgical and has the name, facelift.
Facelift surgery is one of the most misunderstood of all facial plastic surgery procedures. It is a spectrum of lower facial rejuvenation procedures that range from a limited jowl lift to a full lower facelift. The type of facelift surgery performed is adapted to the patient’s aesthetic needs. This is undoubtably the type of treatment you need. It is just questions of what type of facelift.
Please send me some pictures of your face for my assessment and recommendations.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have attached two photos for your assessment for scar revision surgery. The scar is slanted towards the left at the top and slopes downwards towards the right. The scar healed flat at the top 2 inches and bottom 3 – 4 inches. It’s the section in the middle that healed wider and is slightly raised. Aside from silicone scar sheets and micro needling, I haven’t tried anything else to alter the scar. What I would like to achieve would be a flatter, less bumpy scar.
**I understand that area is prone to scarring badly, so I’m unsure if it is best to leave well enough alone.
A: Thank you for sending your scar pictures for possible start revision surgery. As midline chest and upper abdominal scars go, this is just typical scar widening that commonly occurs in this area. It is not a hypertrophic or keloid scar which is good. The only effective treatment would be to cut out the scars and reclose it in a finer line…and hope that it heals better this time. At this point treatments such as scar sheets and gels and microneedling are completely ineffective in an established scar like yours. The reason the middle part of the scar is the most irregular is due to the constant tension from the pull of the breasts. This is a very common adverse scar effect seen in women with larger breasts.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m concerned with my severe chin recession. Although in the attached photo I think I might have slightly tucked my jaw in my neck, it appears like I have a very full neck and almost a double chin. It really doesn’t have to do with body fat since I’m almost underweight at 130 lbs considering I’m 5’10” tall. After some research, I found that my particular neck appearance is due to the anatomy of the surrounding neck muscles and the hyoid bone. I’m also attaching a lateral X-Ray cephalogram in case it’s helpful to determine anything related to anatomy.
Is the image morphing that I have attached any realistic? I’ve thought of four possible routes to come close to it :
1) Sliding genioplasty combined with submentoplasty for a better cervicomental angle
2) A custom jawline implant designed to posteriorly extend the jaw as much as possible
3) Sliding genioplasty + custom jawline implant + submentoplasty
4) Lower jaw advancement surgery (BSSRO) , though I’m not sure if I am a candidate for it since my bite seems normal -except an overjet I have-
What do you think would be the best route for my goals? Feel free to do your own imaging if you think mine is not realistic.
A: The answer to your chin recession surgery and neck issues is #2, a custom jawline implant. Besides the fact that it would most likely resemble the computer imaging you have done, it provides a recruitment of tissue from the neck to create the definition along the jawline. Options #3 and 4 are not viable approaches for you for a variety of reasons. Your choice really comes down #1 and #2. The problem with #1 is that a sliding genioplasty will have no impact behind the chin and will make the chin more narrow from the front view.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m interested in a tummy tuck, liposuction and fat injection breast augmentation. (breast fat transfer) A breast implant augmentation wouldn’t be an option for me so I’m hoping to have the breast fat transfer but it doesn’t seem to be performed much in this area. I appreciate your thoughts!
A: The issue with fat transfer for breast augmentation is not whether you an do it…but whether it will remotely come close to the result you seek. Fat injection breast augmentation is not commonly done because most breast augmentation patients don’t have enough fat to do it and, even if they do, the usual outcome is about a 1/2 cup size increase. Such a breast size change will be inadequate for most patients seeking breast enhancement. If one takes the approach of ‘anything I get will be better that what I have’ then the result would be worthwhile for that patient. But if one seeks a defined breast size increase that is more than a half cup or so then the result will be disappointing.
I would need to see some pictures of your body to determine how this answer applies to you and your desire for fat injection breast augmentation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a plastic surgeon who has a patient that wants to do hip implants. I just want to confirm that you put them under vastus lateralis fascia, over muscle, like calf implants. Any tips as this is new to me? A Canadian plastic surgeon describes placing them under TFL muscle. This seems risky to me.
A: The options for placement of hip implants are limited and are really subcutaneous in location for most patients in my experience. If you look carefully where most people want them it is higher that the upper extent of the vastus lateralis muscle. It is either over the trochanteric depression or even slightly behind and above it. In theory the TFL is more anatomic to the hip augmentation region but placing them under it runs a real risk of chronic pain not to mention the limited augmentative effect that will result from the tight fascia over it. Using an incisional approach high and behind the augmentative site also avoids any risk of running into the lateral femoral cutaneous nerve.
While it is always nice to have an implant deeper in the tissues, the hip region doesn’t provide any good and safe options to employ that concept. The other important implant feature of the hip region is that it needs to be of composed of an ultrasoft silicone polymer. (solid but feels like an ultra cohesive breast implant) For this reason I have them all custom made to get the dimensions needed and the right implant feel. It also makes them easier to insert with a smaller incision.
I hope this is helpful,
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a facelift revision.I really feel in order to look more natural this surgery is essential. You would be basically restoring the thin skin to an area that “thick” skin has been pulled over. I understand that this could look patch work like, but I also feel like there would be a more natural looking appearance. Pulling the facial skin over the tragus gives the appearance of a wider face and on a man look really funny. Men have lines that are essential to a man’s look. If I was a doctor I would NEVER do this to men especially this being “hair bearing” skin.
1. It’s been 3 months since this facelift was performed. Is this enough time to do this?
2. Would this also loosen up the skin from your incision line to my nose in the mid face?
3. Your incision will basically be my new beard hair line which will go from under my sideburn to the bottom of my ear lobe, correct?
4. Your incision will basically be a “section” of skin. What if this section of skin sits over some scar tissue? Will this scar tissue be completely removed so that the new graft has the ability to project the tragus?
5. Will the facial skin be thinned to connect the new thinner skin graft? To give a better transition.
6. You’ve said something about taking skin behind my ear which is NOT an option in my case. That is an area that has been completely exhausted. Could you take the skin from under my bicep between my arm pit to my elbow? If so, I think this scar could be hidden under my arm near my arm pit. Is this an option?
7. On one side part of my tragus was cut off. Can you rebuild this? If so where would you get the cartilage?
Thanks in advance.
A: In answer to your facelift revision questions:
1) Three months after the original procedure is an appropriate amount of time for any revisional surgery.
2) I don’t think a tragal release/skin graft would create any additional skin looseness between the nose and the ear. Time will eventually make that happen. Although some effort can be made to do some skin undermining and any plication suture releases which may be of benefit.
3) I am not sure I understand how you are envisioning the release. What I envision is to remove the beard/facial skin just off of the tragus and skin graft that area.
4) All skin including scar will be removed down to the cartilagious tragus.
5) You can’t thin the facial skin. The skin on the tragus is naturally a lot thinner anyway than the adjacent facial skin.
6) A skin graft can be taken from just about anywhere. I was suggesting behind the ear because that would probably be the closest color match. (technically the neck skin would be most ideal) You would be surprised how different skin color is from different parts of the body. While you certainly can take it from the armpit area that is will look remarkably whiter than your facial skin.
7) While you can rebuild the tragal cartilage you would have to use an ear graft to do it known as a composite cartilage-skin graft. It would probably better to put a little piece of cartilage in it later when the graft has healed. Then the cartilage can be taken inconspicuously from the ear as it doesn’t need any skin with it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I want to have forehead and skull reshaping surgery. I will fly to US at the end of February.
I have fat injection in my forehead 3 times. Each time interval is 1 year. The last time is 4 months ago. Now I have problem with the fat lump as you can see in the picture. The fat lump creates the ugly on my forehead.
1. I want to reshape my forehead and skull as the green line in the picture. I want to have a high and big forehead as in the picture. Which method is suitable to me?
2. I think I should have the brow shaving to achieve the result I want. I attach the desired result.
3. Is it possible to remove the fat which has been injected in my forehead to smooth my forehead?
4. How long I need to stay in Indiana for the surgery?
5. What is the cost for the surgery?
I hope to hear from you soon.
A:Thank you for sending all of your pictures and describing your forehead augmentation with fat injections outcome. Your forehead augmentation result speaks to why I don’t like this method of forehead augmentation. It can create a lump/bump appearance and the fat often drifts down lower closer to the brows rather than higher up in the forehead which most Asian women want. While it does not always create the result you have, I have seen it enough times that it is always a potential outcome. When fat injections in the forehead go awry, they can be very difficult to remove and runs the risk of forehead irregularities just like what can occur with liposuction anywhere on the body. But the use of liposuction on the forehead has a higher risk potential for these irregularities due to the higher skin tightness of the forehead and being able to see cannula lines.
In answer to your questions:
1) As you have discovered in your case, achieving your forehead shape result will; require bone augmentation. This can be done by bone cements or a custom forehead implant. The latter is always preferred when possible as it can can cover a broad surface area with the smoothest result possible.
2) I would agree that brow shaving would be a useful adjunct to your forehead shape goals.
3) As stated above the only fat in the forehead can be removed is with liposuction. And I think that has to be done as part of your forehead reshaping goals. BUT it should be not done at the same time as the aforementioned forehead procedures due to blood supply and healing concerns from the scalp incision and elevated forehead tissues. Any efforts at fat removal should be done first and allowed to heal. I can do that or the doctor who injected the fat should be able to perform it as well.
4) You would only be here for a day or two after surgery and then you could go home.
5) My assistant will pass along the cost of the surgery to you later today.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was interested in information about body shaping and fat grafting. I am transitioning and noticed you do facial feminization so wondered if you did body for transgender as well. One procedure I was most interested is is fat grafting breast augmentation. It seems this is not a extremely uncommon procedure at this point so wanted to check if this is something you could do. Thank you.
A: One of the most common transgender body reshaping surgeries for make to female is breast augmentation. I do breast augmentation by fat grafting (fat injection breast augmentation – FIBA) as well as the complete face and other body procedures for transgender body reshaping plastic surgery. The main reason that FIBA is not commonly done is not because it is technically difficult but that patient selection for it is very limited. One has to have enough fat to harvest to do the procedure and also be willing to accept the unpredictability of the outcome (how much fat will survive) as well as a more modest breast augmentation result. (1/2 cups size in most cases) Breast implants offer an immediate, sustained and more predictable result which is why FIBA is not commonly performed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Since my original temporal artery ligation operation I seem to have developed small vein grooves around the same area where the arteries ran. These are definitely from veins as they are sort of dents running straight down across the artery path, and when i put my head down low the veins bulge out there. These grooves were also present before, just to a lesser degree but seem to be worse since I had the original operation.
I am not sure how much this worsening is due to the original operation, and how much is just due to further fat loss/skin thinning which would have happened anyway. However, these areas don’t really bother me that much.
My area of concern is I seem to have a groove that runs up the side of the temple and along the top of the front path of the head – around the coronal suture path. Again I am fairly sure this is a vein, as it seems to branch off and also when i put my head down it fills out pretty flush. I also have this to a lesser degree on the other side. Being balding, i can see the two lines will meet up in the middle leaving me with a nice dent across my head !
I have attached a picture here, i have caught it in the worst possible light – i have gone back through lots of old pics and can’t see this at all, but the angle has to be right to see it like this.
My questions are:-
-Firstly is this actually an artery and so would the operation somehow help it (though I can’t see how reducing something that is a dent would help)
-Is it possible that this can have been caused by the original temporal artery ligation operation somehow
-If so, would a further tie off to close the remaining lower bulge potentially make this problem worse
-If so, is there any other alternative at all – i did note you mentioned on another question about temporal implants – would they be suitable for hiding the lower grooves and whats leftt of the bulging artery
-Is there any way at all to fill in the groove that has developed going across my head.
Thank you very much indeed.
A: In answers to your temporal artery ligation questions:
1) I can not say just based on a picture as to the anatomic basis of the groove to which you refer. But I doubt very highly that it is an artery. However I have seen many grooves along the coronal suture line in the skull that look like yours as they represent depressions/dent in the underlying bone/suture lines
2) Temporal artery ligation is not going to cause a sutural bone indentation.
3) Nothing done to the superficial temporal vascular system below should affect, positively or negatively, the dent along the suture line.
4) and 5) Fat injections is the simplest and likely most effective approach for filling in these skull dents/grooves.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in silicone removal and reconstructive lip surgery. Could you tell me what would be reasonable and safely doable during surgery at the same time:
1) Get rid of the silicone on the white part of both lips, debulk the philtrum columns that were injected as well with silicone after the lips were injected (this silicone was not injected deep, it’s more on the superficial layer of the skin, but since you is the specialist, I need your advise on this…)
2) Get rid of the silicone bumps and scar tissue I still have on the wet lip inside of both lips.
3) Make upper teeth shown again, since all this bulkiness is weighting down and making my teeth to be hidden. I guess this could be accomplished by removing tissue from the inside, and also making the lip advancement. Lip advancement I guess will be also more appropriate to raise the lip than a lip lift in my case? (since if he has to do an incision there, I think would be more appropriate to raise it from there and not causing a new scar (bull horn)?
4) Re-shape the cupid’s bow, vermilion border and philtrum
5) Re-shape the lower lip, correct the great asymmetry I have (specially on the right side), make it thinner on the edges and fuller in the middle of the lip. Raise the lip with the V-Y plasty so the lower teeth don’t show that much, since right now I have exactly the way around as it should be (only lower teeth are shown 🙁
6) And he said something about a fat grafting to prevent the scars to become hard and bulky again.
Obviously an in person consultation will be the best, but at least I guess this might help a lot, since I’m showing him also the mucosa inside of both lips. Besides the concern of looking aesthetically much better, I’m concerned about not causing more damage and keep the natural functionality of the lips.
A: ‘I have a very clear understanding of the lip issues due to the silicone material as well as the objectives as has been outlined. I can see the issues very clearly in pictures as well as the Skype consultations. Seeing the lips in person will not change the silicone lip removal and reconstructive surgery plan or, most significantly, what I consider to be the single most important concept to understand about the lip problem and any proposed method to treat it. Trying to remove/debulk and improve the shape of the lips that has been distorted by silicone injections is both very challenging and the results will always be less than desired. There is no completely satisfying solution that will meet all the patient’s aesthetic lip/perioral shape desires. Silicone oil causes permanent damage and shape deformation for which only partial improvement is possible. It is this concept about treating adverse reactions to silicone injected lips that the patient must understand.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley,I’m interested in doing a mouth widening surgery combined with a chin implant.
I was just wondering what can I expect from getting a mouth widening surgery, in terms of post surgery scars. Will the visibility of the scars be like this?
http://exploreplasticsurgery.com/wp-content/uploads/2015/12/Subnasal-Lip-Lift-and-Mouth-Widening-Procedure-immediate-result-front-view-Dr-Barry-Eppley-Indianapolis.jpg
Will they be isolated to the corners of the both or below the nose as well ala above. Also, will the scars always remain as prominent as in the picture above? or will they gradually dissipate (not to become invisible but barely visible)? If the prominence of the scars do reduce over time, why are there so many doctors (on real self) against doing this surgery for cosmetic purposes?
Thanks for taking your time to answer my questions.
A: In regards to mouth widening surgery scars, the picture you have linked is an immediate right after surgery result. (and it also includes a concurrent subnasal lip lift which has nothing to do with the mouth widening) While it is very important to be aware of the risk of hypertrophic scars that may require a revision with any corner of the mouth procedure (lifts, narrowing or widening), my experience has been that there is a low rate of adverse scarring for the mouth widening procedure. As to your question about other surgeon’s comments about the mouth widening procedure, I can not speak for their experience in performing it. Such comments matter if they are qualified opinions…meaning have they really performed the procedure and personally seen actual outcomes.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, as an expert in this facial surgery area I would like to take your opinion regarding bone resorption after placement of silicone jaw angle implants , I have noticed 2 to 3mm resorption after removal on an implant from two patients that didn’t like how they looked after placement. There was no infection or any other complaint.
Moreover, I would like to know if this resorption process is continuous or will stop at some point after placement and if you recommend a protocol for follow up or X-rays for a period of time.
Thanks for all your efforts.
A: What you are referring to is not bone resorption but passive bone remodeling. This is a very typical response to any facial implants placed under strong muscles and is largely only seen in the chin and jaw angles due to the influences (pressure) of the overlying mentalis and masseter muscles. It is a passive and self-limited tissue response and is to be expected. Also in the jaw angle area it is very common to see some bone overgrowth around the implant edges on the mandibular ramus due to the complete subperiosteal location of the implants. Passive bony remodeling and some bone overgrowth are common and benign bodily responses to an object who biologically was not intended to be there. There is no reason to followup the patient in this regard after the implants have been removed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was wondering which procedures you think could help my face become more photogenic? Some info about me/things that I’ve noticed: half asian, 5’7, 150 pounds, I’ve noticed that I have somewhat of a “flat nose” or middle section of my face but it’s only noticeable in certain lightings, something about my jaw maybe it’s too wide or could be my chin, and slightly puffy eye lids. Also, could losing a little weight help reduce my droopy/chubby lower jaw area? Or is this more of a bone structure issue that jaw surgery could correct? I also dislike the way my face looks when I smile, not sure what type of procedure could help to balance my face when I smile. Thanks for your time.
A: While beauty is truly in the eye of the beholder, I can make the following asian facial reshaping suggestions. An augmentation rhinoplasty, buccal lipectomies with perioral liposuction and bony jaw angle/masseter muscle reductions would have the greatest slimming effect in your face. (I would also defat your upper eyelid and make the upper eyelid crease more apparent…but I can’t computer image that type of change) This is not an issue with your jaw relationship or any orthognathic surgery needs. These procedures combined with 10 to 15 lb weight loss would maximize this type of facial change.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley,I went to plastic surgeon to get rid of those temporal artery frontal branches. The surgeon cut a 1 cm section off from both sides from the lowest part at the hairline. Even with the 1 cm section of the artery gone it is still bulging and pulsating. How can this be, is there some backflow from the scalp to this artery? The surgeon said that I should wait for a couple of days to see if it was success even though the artery is still bulging. This is just a nightmare, how can I get rid of these ugly bulging arteries.
A: I would need to see pictures of where your temporal artery ligations were done. A single point ligation (or even artery removal in that location) rarely works in my experience. It takes at least 2 and sometimes up to 4 ligations points to be effective in some patients due to the sinuous pattern of the superficial temporal artery. The takeoff of the anterior branch of the superficial temporal artery is variable not to mention the issue of back flow from an arterial system that extends into the scalp. It is a complex blood flow system that is not an easily reducible as one would think by just cutting off one point of inflow.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a reconstructive cranioplasty. I was involved in a car accident three years ago which resulted in me undergoing a craniotomy. They fitted titanium mesh to cover the area since the bone was crushed and couldn’t be sued.. As I have become older, I now see that the skull is indented over that area and therefore I wanna have a reconstructive cranioplasty. I have consulted with several neurosurgeons without much luck lately, because of concerns about further surgery.
Therefore I have a question related to cranioplasty. As I already have titanium mesh fitted, would it be a problem to remove that – does titanium mesh attach to the dura or tissue for that matter? That seems to be the question I can’t find a answer to, so hoping you can help me! Or would it be possible to just leave the mesh and cover the area with either PMMA filler or hydroxyapatite bone cement?
A: While it is possible to remove your titanium mesh in your reconstructive cranioplasty procedure and replace it with a custom implant, the risks of dural tears and a CSF leak is not worth that effort. It is far better to leave the mesh in place and cover it with any of the available bone cements of your choice.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley,I am very familiar with injectables and have been using Botox for over ten years and Juvederm for at least the past five years5\. My eyes are looking extremely tired and I wear glasses every day to cover up the line. I am aware that the tear trough can be treated but have heard it is only for the experienced. Can you please let me know if this is something common in your practice? Thank you
A: Placing injectable fillers into the tear trough is the hardest area on the face for getting good results in my experience which is considerable. It is a facial area fraught with aesthetic problems such as irregularities and over correction issues. It is also a very aesthetically scrutinized area since it is in the eye region. Anything less than a perfect result will be viewed by the patient as unacceptable.
In my experience 50% of the patients treated have some issue that requires further injection treatment whether it be additional filler or hyaluronidase to reduce/remove the filler material. I would need to see some pictures of your face to determine what risk profile you have for tear trough injections in this difficult facial filler area.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a bone cement cranioplasty. You have previously told me that it would not be good idea to try and remove the titanium mesh. Maybe you can walk me a little through this. I thought the titanium mesh was placed above the hole in my head and mounted with screws in the skull. I don’t see how my dura could be teared when unscrewing the screws and lifting of the titanium mesh? Has the dura grown into the mesh?
According to bone cement, is there any specific one you would recommend or would any product do the trick? Its just that it is a somewhat bigger cranial defect, but maybe that doesn’t have anything to say? And will the bone cement attach to the mesh, and surrounding bone, holding it in place?
Thanks for your time!
A: Since I assume you have never performed skull surgery, it would be understandable why you would not know that scar tissue and dura adhesions have occurred into the mesh which is certainly not a smooth surface. While it can be removed there is a significant risk of dural tears and a postop CSF leak in doing so. It simply is not a risk that most patients and surgeons would take when the original problem has been solved.
For a bone cement cranioplasty, hydroxyapatite cement would be the preferred coverage material and the size of the cranial contour problem is not an issue. The cement will adhere to both the bone and the metal material. Adherence of the cement is not an issue.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in facial asymmetry surgery. The right side of my face looks completely different than my left side. I like the left side so I think it is the right side that is the problem, it just didn’t develop like my left side. Can you tell me what is wrong with the right side of my face and how it could be improved.
A: Thank you for sending your pictures and talking to you earlier today. In looking at your face you have a classic right-sided facial asymmetry that extends down from the brow bones to the jawline. Every single external structure is affected. I have taken your picture at numbered the 8 involves areas from the jawline as follows:
1) Low vertical jawline (still)
2) Downturning right corner of the mouth
3) Flat/hypoplastic infraorbital rim and cheek
4) Lower right lower eyelid position
5) Lower setting eyeball
6) Excess skin right upper eyelid skin
7) Lower/protrusive brow bone
8) Right Upper eyelid ptosis (which would be present if the eyeball was raised)
All of these issues are improbable and can be done in one facial asymmetry surgery. The right periorbital (eye area) would be treated through upper and lower eyelid incisions for #3 through #8. No scalp incisions are needed even for the brow bone reshaping.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a tummy tuck revision. I had complications from a tummy tuck procedure done almost two years ago. I have hardness of tissue below belly button but above incision which also sticks out. I have had multiple radio frequency treatments to try and soften it up but without any success. What options are available to me now for improvement.
A: While you did not state what your after surgery complications were, by your description and pictures that most likely problem would have been a recurrent seroma. When this does not get completely absorbed it can create an encapsulated seroma pocket which can feel firm as it creates skin adhesions down to the abdominal wall. It will also create a pooch to the skin area that overlies it. Its most common location to occur is between the belly button and the incision line…exactly where you have the firm feeling bulge.
The treatment for that is to go in and remove all of the scar tissue and seroma capsule. Some extra abdominal skin can also be removed at the same time. Your tummy tuck revision would really be called a secondary mini-tummy tuck.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in chin liposuction and I would like to know my options. I have attached pictures for your review.
A: Thank you for sending your pictures. As a matter of clarification, the term ‘chin liposuction’ is a misnomer. The chin is never actually treated by liposuction. It is actually the area under the chin that people are referring to known as the submental area. Thus the terms submental liposuction and submentoplasty would be more appropriate.
You have good chin projection so this is a matter of improving the neck only. You options are either liposuction or a submentoplasty. The difference is in both the outcomes and how the procedures are done. Liposuction removes some of the fat above the platysma muscle only. A submentoplasty removes fat both above and below the muscle as well as tightens the platysma muscle. While both are done through small incisions under the chin, a submentoplasty will create a better neck contour than just liposuction alone…as one would expect as it modifies more of the neck tissues. I will have my assistant Camille pass along the cost of the two neck contouring procedures to you later today.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, What are the complications involved with forehead augmentation? Is it it a fairly common surgery at this point? Is the scarring from the incision visible or does it completely disappear over time?
Please answer the same questions regarding chin/jaw enhancement as well.
Also, if it’s the marionette/Jowl area that needs to be enhanced, what do you recommend?
A: Forehead augmentation in my practice is common but it is not a commonly done by most plastic surgeons. The most common complication from it are aesthetic…did the result meet the patient’s expectations and is the result smooth. The incidence of such complications varies by the augmentation method used. (bone cements have highest risks, custom forehead implants have lower risks) Any forehead augmentation method requires a scalp incision to perform. The use of bone cements have longer incision lengths, custom implants have shorter incision lengths. While such scalp scars generally heal very well and can be well hidden, there is no such occurrence as the scars completely disappearing.
For chin or total jaw augmentation, implants are the only effective treatment choice. Their complications are similarly aesthetic with over/undercorrection and asymmetry being the most common reasons for revision. Most chin and jaw implants are placed intramurally so external scar concerns are usually not an issue.
The marionette/jowl area is usually treated by fat injections. In some cases the jowl issues are solved along with the placement of a chin/jaw implant. But marionette lines require soft tissue augmentation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had pectoral implants done last week. i wanted to run by you what is going on. Obviously I know I am recovering and I’m assuming full swelling will take time to heal. My doctor ended up using the the Implantech Powerflex anatomical pectoral implants of 271cc in volume. I think it is the 3rd largest in that category. I was wondering if you could examine my pictures I have attached in this email as I have a couple of concerns.
Firstly I did request my surgeon to go quite large with the implants as I wanted them noticeable and on the bigger side. Gathering from the information I collected from online resources I assumed the anatomical implants are more suited to me. After having them in I currently do not like them. I always thought they would be placed differently to how they are now. I don’t know if its just me or if my surgeon has incorrectly used the wrong style and shape of implant.
I feel like I have a huge DeNT in the middle of my chest and based on the pictures I find the look i really enjoy is the cleavage look and the square cut shape of the pectoral implant. I feel like a human Ken doll where the implants look like two big circles on my chest almost breast like. So I didn’t know if this is because the anatomical shape was chosen. I’m assuming i should have gone with a slightly flatter square shape. I am feeling quite “booby” and the dip in the middle of my chest is bothering me. is there anyway of making the implants sit closer? or is that depending on my anatomy and genetics?
If you were my surgeon, is there any way i can solve these concerns and can u comment on which implant i should have had. I am aware I am one week post op is too soon to comment but I feel i am already seeing the shape of the implant expeically in the middle of my chest where volume is lacking. I also thought the anatomical implants only sat on the lower two thirds of the pectorals. i feel like my ones sit quite high up under the collar bone. Any help would be greatly appreciated. I just know in my heart something is not right and I don’t feel like this represents a muscle in the event i was able to build it myself. I don’t mind the side view but when front on i feel like they are placed very wide apart and feel like two circles on my chest.
The pictures I will send are from today and I will include pictures of the pectorals i like. Clearly they are models and I am not.
To summarize id like to know if
1 – my surgeon should have used a square cut implant to give me more medial augmentation and a square cut look
2- is it possible to close that gap in between my chest as it feels like a big dent
3- is the anatomical implant making me feel like i have breast like circles?
4- can my chest be made a similar style to the pectorals in the images shown? (obviously they are models and im not)
Thank you VERY much for taking your time to read this.
A: I am sorry to hear of your current dissatisfaction with pectoral implant surgery results. It is not professionally appropriate nor will I comment on what surgeon should or should not have done. Those discussions are between you and your surgeon whom you have entrusted to do the procedure.
What I can do is provide some insight about the two basic pectoral implant styles offers through Implantech. The Powerflex 1 pectoral implants is oval shaped and its effect is to accentuate the lower border of the pectoralis muscle and create a more rounded form to it. It provides no superomedial augmentation effect in most cases nor is it designed to do so. It is called the ‘anatomic’ pectoral implant because this is how most natural shaped male chests look.(non-body builders) as the bulk of pectoral muscle mass is in the lower two0-thirds of the muscle. The Powerflex 2 pectoral implant is rectangular-shaped with the specific intent of creating a more boxy-shape to the chest which includes, by definition, superomedial augmentation. It design allows the implants to be brought closer together and create some male ‘cleavage’. While this is not a natural or anatomic look, it is the desired chest look of many fitness and bodybuilders and is clearly the type of chest augmentation effect you are demonstrating in your male model pictures. How effective this design is in creating thirds desired look is also influenced by the dimensions of the implant as it requires a tight fit to see the full effect of the implant’s shape.
If you should seek a pectoral implants revision the Powerflex II pectoral implant is clearly the design you should have. What size requires measurements of the pectoral space and muscle borders.
Dr. Barry Eppley
Indianapolis, Indiana
Dr. Eppley, I have read almost your entire website and have learned a lot about implants! Thank you for keeping it so up to date. I had jaw implants in 2010, didn’t like my results, but kept them in because I looked better than before. Though last year, I found out I have sleep apnea and need double jaw surgery. I have the option to have my jaw implants kept in (if they can manage), they may be able to trim them in the places where it’s very wide, or have them removed. My major concern having them removed is that it will look horrible underneath when the swelling goes does. I think having them trimmed maybe the best option. I have attached my before and afters. In your expertise and experience could tell me what you would advise? Thank you so much for your time.
A: The question you are asking is whether at the time of your sagittal split ramus osteotomy (SSRO) of the mandible to move your jaw forward, should the jaw angle implants be put back in to not. (whether they are trimmed down or not. Clearly they will initially have to be removed as the first step in surgery to access the mandibular ramus to cut the osteotomy, move the distal mandibular segment forward and fix it in place with a plate and screws. At that point should the implants be put back in before the wound is closed?
While their are obvious aesthetic advantages in doing an immediate replacement jaw angle implant surgery, the question comes down to the risks in doing so. The risk is that of an infection occurring over the proximal mandibular ramus site which has been partially devascularized to do the osteotomy. Should that happen you could end up with osteomyelitis of the jaw…which would be a devastating complication to say the least. The odds are that it might not happen and all would heal well. But in the uncommon event it does happen it would be the biggest regret of your life.
In short, like many choices in surgery and life, it is all about how you want to ‘gamble’ so to speak. A second surgery to put new jaw angle implants six months later would be a safer bet than the risk of jaw infection and osetomyelitis. In my opinion it just isn’t worth the risk and paying an implant over and around a fresh osteotomy site which requires fairly wide subperiosteal undermining.
Dr. Barry Eppley
Indianapolis, Indiana