Your Questions
Your Questions
Q: Dr. Eppley, I am attaching some facial photos for assessment for perioral mound liposuction The area I am concerned with is particularly visible in a 3/4 facial profile, but it also shows up in straight-on shots as weird shadowing around and below the corners of my mouth. Ideally, I would like this area to flatten, so that I can have a straighter profile. However, I am worried that fat removal in this area could cause laxness or drooping of the skin. I would like to avoid jowling!
I also have dimples in my cheeks when I smile — not sure if this makes any kind of difference, but I thought I would let you know. Thank you!
A: Thank you for sending your pictures. Your area of concern would be considered the perioral mound region and yours is a classic case of it. It is really only treatable by very small cannula liposuction through a small incision inside the corner of the mouth. I have not seen loose and lax skin develop afterwards as almost every perioral mound liposuction procedure I have done is in younger patients.
Having cheek dimples does not affect the results of perioral mound liposuction either positively or negatively.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am seeking extra large breast implants. I was a natural 34H and then got 800cc silicone implants under the muscle. the dr had said it would double my size. However it didn’t change my size at all, it only gave me a tiny bit more upper pole fullness was all. So I was very disappointed with spending all this money to not be bigger which was what I wanted. I have been told by a couple of Dr’s I could go up to 2000cc with overfilled saline. Is that something you would do? Or will you not go that large on patients? I want a good plastic surgeon with good ratings like you have. I am not a tiny framed lady, I do have a curvy build. Please let me know, thanks.
A: If 800ccs breast implants did not come close to your breast size goal, then at least twice that would be needed to make a more visible difference. Overfilled saline implants would be the only way to achieve that type of volume. Where the final volume might be on the spectrum of 1600 to 2000cc depends on how it looks and feels during surgery.
Please send me some pictures of your breasts for my assessment for these extra large breast implants.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I heard about you when I was researching Knee Lifts. After reading more about you ,watching your YouTube and reading your Bio as well as looking at your website I think you are indeed incredibly and uniquely qualified. Unfortunately I saw nothing on your website about my problem so I will ask you directly.
I believe I have stage 1 Lipedema,. After a few years of research I believe its Lipedema, based on my symptoms, age onset and process of elimination. The only treatment for Lipedema is liposuction from what I have read and spoken to surgeons about. I am planning to get my calves and ankles treated by liposuction but the surgeon I’ve spoken to doesn’t want to touch my awful, fat, disfigured knees as he says “knees are tricky”. He also isn’t too keen on my thighs as most of the disproportionate fat is right above my knees, which he says will make my knees much worse than they already are. I am not overweight, I am healthy, athletic and in shape. I would like to know what you know about Lipedema,and what your thoughts are about this type of surgery.
Thank you for taking your time to read this and reply.
A: As you know there are differences between lipedema and lymphedema by which you have come to the conclusion that you have the latter. Some improvements in true lipedema can be obtained by liposuction as you have stated. When it comes to using liposuction for its treatment I would be more concerned about prolonged edema from the calfs and ankles but not the knees. There is nothing ‘tricky’ about the knees and there is not any anatomic feature that makes them different for liposuction surgery. What the skin will do when the fat is reduced can not be precisely predicted anywhere on the lower extremities but most likely it is not going to shrink in a perfectly smooth manner. That would be an expected tradeoff for the size reduction.
Those are the general comments I can make without having any specific visual knowledge of your lower extremity problem.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, what are the differences between lip ‘advancement’ and lip ‘enhancement’ and lip ‘lift’? I’m specifically looking to augment my upper lift for more fuller appearance.
A: In answer to your questions, lip enhancement is a global term that refers to any type of lip augmentation procedure, albeit injection or surgical.
A lip advancement, also known as a vermilion advancement or ‘gull wing’ procedure removes skin just above the upper lip and the vermilion or red part of the lip is moved up to cover the removed skin area. This increases vermilion show from one mouth corner to the other. In essence it pushes the vermilion towards from below.
A lip lift, also known as a subnasal lip lift or ‘bullhorn’ lip lift removes skin from below the nose and lifts the lip upward. It shortens the distance between the nose and the upper lip and improves the central vermilion fullness of the upper lip. It does not have any effect on the sides of the upper lip.
I would need to see pictures of your lip to determine which lip enhancement procedure may be best for you. Most patients graduate to surgical lip enhancement after trying injectable lip enhancement methods.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in correcting my jawline asymmetry. I’ve always hated taking pictures head on or from the right side of my face because of the asymmetry of my chin and the angle of my jaw on the right side. It’s almost as if my jaw has shifted down and has caused my chin to shift and protrude forward on one side. This has been the case for as long as I can remember and I almost feel as if it’s getting worse. Probably because my skin is thinning and I can see the outline of the chin a little more. I’ve never had any dental issues or braces and no dentist has ever told me my bite needed to be corrected. I just wanted to find out my options-and see if this was actually possible to fix. Thank you so much in advance!
A: Thank you for sending your pictures and describing your lower jawline asymmetry concerns. What you have is an overgrowth of the right lower jaw that makes the jaw angle slightly bigger, the right jawline lower and the chin shift to the left. Usually with such jaw overgrowth there would be associated bite and occlusal plane asymmetry…but you seem to have largely avoided that typical accompanying issue. The treatment would be one of a chin and jawline bone shave from the left side of the chin all the way back to the jaw angle. This would be done through a submental incision approach. The amount of bone to remove would be determined from a simple panorex x-ray based on millimeter comparative measurements of he height of the mandible from midline chin to the ramus.
Dr. Barry Eppley
Inianaopolis, Indiana
Q: Dr. Eppley, I have consulted with you many times about my facial structure and have plans to do the jaw implant. I’m just wondering if I already have surgeries on my chin (1st surgery sliding genioplasty. 2nd surgery reverse sliding genioplasty 3rd surgery shaved the corner of the chin from expansion as it made my chin becomes square) will it be safe to do the jawline implant? Not doing anything with the chin but maybe will be the same area that got cut several times. Will it increase the risk of infection? I don’t plan to do jaw inplant with any doctor in Korea or anywhere as I think a doctor with experience is the best. And I had to save up again and again after my previous failure for other parts.
I really plan to do it but will be about a year or two from now since I have to finish my braces first in another country.
A: Regardless of your prior chin surgeries, that does not preclude you from getting a jaw implant in the future. The custom jawline implant is made from a current 3D CT scan so this will show your current bony anatomy. That happened to the chin bone in the past does not affect placing an implant across it in the future.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a custom jawline implant. I am attaching a few photos of my face and you will see that my lower third is narrow. My general interest is in a wraparound jaw implant in order to widen the face, tighten up the submental, improve aesthetics of the face and protrude the chin to balance the protrusion of the nose. What does your aesthetic eye think of this possibility judging by my photos?
Do the custom made implants have a high success rate as in the forum for plastic surgery knowledge I frequent there is a patient from Western Europe of yours that has had 2 revisions to his jaw implants in the span of 7 months? He says its “finetuning to look natural”. I am not extremely interested in having it revised because I dont want to endure the whole ordeal again.
A: If you are looking for increased lower facial width and dimensions of the chin and jaw angles that has a smooth linear connection than a custom jawline would be the preferred choice.
It is not uncommon for many patients to have revisions of custom facial implants including custom jawline implants. This is primarily because they often don’t know what they really want until they wear it to so speak. In the case you so described the patient himself chose the dimensions and that was what was exactly provided to him…only later to decide he wanted a different look. (Less strong)
The key in any custom jawline implant is that less is more. It is always to better to go smaller in dimensions as its effect is more substantial than a patient can anticipate. In looking at your face that its exactly what you…a smaller custom jawline implant. I cll this type a ‘jawline defining implant’ as it just adds angularity and a little width.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have put some thought into those measurements you told me about regarding zygomatic arch implants. I have made some research of my own and I have a found a cheek implant from Stryker that is not far from being a zygomatic arch implant. It’s measurements are close to the ones you suggested for me and my aesthetic goals (yours: 5cm length / 6-8mm width / 5mm projection height) which I assume can be carved/cut to meet your measurements even more.
Despite doing all of that sizing modification, the implant isn’t originally designed to sit on top of the zygomatic arch only. (This implant is also slightly bent in its shape). In the sample photo above, you can see that it is positioned in a way that starts just halfway on the zygomatic arch, going further over the malar prominence, whereas it ends at the maxillary buttress.
My question is; after the surgeon have carved/cut this implant to meet the sizing recommendations you sort of suggested, is it even acceptable to position this implant on the entire zygomatic arch?
A: I would be very cautious about using a Medpor material as a zygomatic arch implant. Besides the issue of its natural underlying shape (curved), the tissue ingrowth from this material will make it virtually impossible to ever remove or revise it later. There is a branch of the facial nerve that crosses over the posterior zygomatic arch that supplies movement to the forehead. While there is a very low risk of injuring this nerve during the insertion of the implant, trying to remove a Medpor zygomatic arc implant later due to the tissue ingrowth will almost certainly increase that risk considerably. If injured there will be some paralysis of the forehead. Thus this is not a material I can endorse as a zygomatic arch implant. Easy reversibility of a facial implant can be an important feature whose importance varies based on the anatomic facial location of placement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I hate to say it but I’m second guessing my decision about rhinoplasty surgery the more I read online. Perhaps I shouldn’t be reading online but I’m reading things like “nose job is the worst possible procedure to have done for a male.”. And that the problem is a lack of facial bone growth, not a big nose, which in my case is certainly true as I have a narrow face and underdeveloped lower third. So I’m wondering will a rhinoplasty simply be a regression for me, further feminizing my face? I know ultimately it’s my decision but obviously you understand aesthetics better than I do and could offer some sort of assurance as to why a rhinoplasty would be beneficial for me.
A: The psychological preparedness of a patient before any aesthetic surgery is of great relevance. A patient’s behavior will follow after surgery the exact pattern that they had before surgery. This is a plastic surgery experience that we see on a near daily basis.
It is one thing to be anxious about the surgical process, which most people normally are, but to be questioning whether one should have surgery at all based upon an uncertainty about the facial changes speaks to a different level of anxiety. It is important to realize that almost every patient after elective aesthetic facial surgery goes through a point in their recovery where they question the wisdom of their choice. For those who have few doubts before surgery they get past it at some point in their recovery. For those that were internally questioning whether such facial changes would be beneficial at all, they may never get past it and may recover to regret having had surgery. This is relevant since rhinoplasty is an irreversible change. It is not like a cheek or chin implant which can be pulled out later. This its why computer imaging should always be done before rhinoplasty which can help the patient visually determine if the surgery is worth it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a lateral commissuroplasty (mouth widening surgery) as I have a small mouth. How risky is this procedure in terms of end results? Does it always leave visible scars? And how visible are these scars? Will the scars heal evenly on both corners of the mouth? I’m curious to see some before and after photos of this procedure as I could not find any online.
I am also wondering about functionality after the procedure. How will smiling, eating, talking potentially be affected? Will there be a problem with drooling?
Thank you for your time!
A: Thank you for your inquiry. An opening lateral commissuroplasty or mouth widening procedure works because it removes a triangular segment of skin at the sides of the mouth and moves the vermilion of the mouth corner outward. By definition this leaves a v-shaped incision line at the mouth corner and a resultant fine line scar at the vermilion-cutaneous border. How discrete that mouth corner scar looks can vary but does well most of the time. Regardless of how they heal they cause no functional issues and do not interfere with eating, talking or smiling.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in eye widening surgery. My eyes are too close set together. I am looking for a way to widen them apart.Is there any chance getting the so called “box orbital osteotomy” surgery? Do you perform it? I understand this is a major cranofacial surgery but nowadays these types of procedures can be done safely. Could it increase the interpupillary distance for a few millimeters without looking deformed? Appreciate your help and time.
A:As an adult orbital box osteotomies are not appropriate for aesthetic eye spacing issues or is a form of eye widening surgery. I only perform orbital hypertelorism repair in young children. This is major cranofacial surgery of which its safety is not the issue. It is that it requires a craniotomy and the creation of numerous other aesthetic trade-offs (scalp scars, bony step-offs etc) that do not justify this type of orbital surgery for a few millimeters of inter pupillary distance increase.
That being said, they may be other more minor eye procedures that may be of benefit but I would need to see a frontal view picture of your eyes to determine if they may be successful.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had lip surgery last year with an asymmetric outcome. My mouth even got smaller (horizontal) which is a problem. Another thing is, that I’d like to reduce the red part of the lip with white skin. Now I wanted to know upfront if a correction is possible and if it is possible to reduce about 2mm of the red lip. (but not from the lip inside)
A: What you have done were lip advancements, also known as vermilion advancements. (An upper lip advancement is also known as a gull wing procedure) Your mouth got smaller and probably a but tighter because the advancements were carried out to the very corners of your mouth at both the upper and lower ends, thus creating a scar line around the corners. Lip advancements should never be connected at the corners to prevent creating a circumferential scar contracture which acts like a drawstring around the mouth as it heals. This can be corrected by doing a scar release at the corners and advancing the mucosa back out. This will also increase the horizontal distance between the mouth corners as well.
I am certain what you mean by ‘reduce the red part of the lip with white skin’. I assume you mean sort of reverse lip advancement? If that is what you mean, that is not possible to do. While the vermilion of the lip can be brought out by removing skin, the reverse can not be done.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m a 23 year old male who suffers from severe flatness of the back of my head. It has bothered me immensely for my entire life and has seriously affected my self esteem and my overall satisfaction out of life and the way I look. It’s very difficult for me to open up about this to anyone, but I am absolutely desperate to change my appearance. I was wondering what your suggestion would be in terms of what kind of skull augmentation procedure could be done. Thank you very much for your time and consideration. I cannot express the relief I felt when I discovered you and your practice online.
A: Back of head augmentation is one of the most common skull reshaping procedures that I perform. A custom occipital skull implant is made to fit the back of the head from the patient’s 3D CT scan. Whether this is a one-stage procedure or requires a first-stage scalp tissue expander depends on how much skull augmentation is needed/desired. For most men a one-stage skull augmentation procedure is usually done, although in rare cases I have seen a few men choose a two-stage approach.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in cheekbone reduction reversal. I had cheekbone reduction surgery done five years ago in south Korea. One year after the operation, I developed right cheekbone pain which often persists all day and I realized I can’t chew anything on the right side of jaw. In addition, I could hear sounds from both of my cheekbones every time when I’m swallowing. Recently, my right cheekbone pain is getting worse, the pain prevents me from opening my month, and I can’t even speak normally because of the pain from my right cheekbone.
I have been doing some research on cheekbone reduction, and try to find the cause of my pain. It seems like the cause of my pain could be the improper fixation on cheekbone so that the screws get loosed. Since I have heard a lot of recommendations about you, I want to ask you is there anyway can fix my cheekbone and relieve my pain? I can send you my CT scan if you need it. I would greatly appreciate it if you kindly give me a short reply on my problem.
A: Thank you for your inquiry. By your description of symptoms, it sounds like that you either have a non-union of the cheekbone osteotomy, malposition of the cheekbone position or a combination of both. X-rays would establish that diagnosis. A 3D CT scan would be ideal but the CT scan you have may also be adequate.
Secondary surgery can certainly be done with repositioning of the bone segments and rigid plate fixation. Given that it has been a year, the bone edges will also need to be freshened up and an allogeneic bone graft placed probably. The difficulty with opening your mouth indicates that the coronoid process may be impinged and this may also need to be released.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a double jaw surgery one month ago to advance my lower jaw about 8mms. I also had a chin implant placed more than ten years ago. After the surgery, as the swelling goes away, I can tell the advancement was not sufficient and my chin is still a bit recessed. I’m considering getting a sliding genioplasty to get more advancement. Also the sliding genioplasty would replace the chin implant as it does not look very natural when I smile. When would be a good time to do the chin bone movement after lower jaw advancement?
A: You can certainly do a sliding genioplasty with a chin implant in place. Or you can remove the chin implant and do the sliding genioplasty at the same time. The amount of additional horizontal chin bone movement equals the width of the chin implant to be removed plus the advancement needed for improved chin projection as determined by external chin measurements. I would wait a full three months after the double jaw surgery to let all the swelling go away and have a full recovery from that surgery before proceeding with the bony chin advancement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a buttock implant revision. About ten years ago I got tear drop shaped buttock implants. I had very little fat on my butt, so it was a bit disappointing after surgery. I did have some augmentation, but my rear looked kind of pointed in the center. I went back for some fat grafting towards the bottom to blend them in a bit, and it did help, but it was a so so result. I figured it was better than having a completely flat butt, so lived with them for the next five years. I had occasional soreness after exercise and sitting for long periods of time, but nothing unbearable.
About three years ago I noticed the upper right side of my left buttock seemed sore pretty frequently. I also wanted to investigate a different type of implant, so I found a doctor that preferred round implants. He inserted a fairly large round implant that aesthetically was more pleasing and natural looking. I’ve found that I have much more soreness with this pair. After exercise, after sitting for long periods of time, even laying flat in bed for a long time (if I’m sick) can cause discomfort for days afterwards even weeks. It seems to be more around the “edges” of the implants or the implant pockets, but they are generally sore all over. Especially that upper right corner again. Occasionally, it seems to radiate down the back of my legs, but this is rare. It seems to be getting progressively worse.
They actually look pretty good. There is nothing that unusual or unnatural looking about them. I don’t think the average person would ever know..so that part is not the issue..it’s the discomfort about 50% of the time.
I’m really tempted to just remove them, but I’m afraid of being disfigured without them. It would be some period of time (6 mo’s- year) before I could do some fat grafting or anything else to remedy the issue.
Any thoughts on what’s going on and what I should do?
A: In answer to your buttock implant quandary, there are some critical pieces of information missing in your description. Are the implants in the subfascial or intramuscular position? What is the volume size of the implants? Who is the manufacturer and what is their durometer? (durometer = degree of firmness of a silicone material)
That information aside I can make the following general comments:
1) I think you would feel deformed if they were removed. It is no different than having breast implants and then taking them out…the resultant appearance will not be like what it was before they were put in.
2) It is hard to justify doing a buttock implant revision with an implant result that looks good even with some discomfort symptoms. The only reason to do so is if the buttock implant you have could be improved by new buttock implants that have much lower durometer. (much softer)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Ive had jaw angle lengthening implant surgery 5 weeks ago. But the masseter muscle didn’t come down with the lower edge ofthe implant. So I had Botox yesterday in order to downsize the relatively large upper muscle. But I am now really regreting that this was a bad idea because I heard this type of surgery needs at least 3 months of recovery time.
Can these Botox injections make my final look worse than it should be? And if so what can I do from now?I would have had Botox anyway but it was too premature.
A: You are correct in that one should wait a full three months after any facial implant surgery to have a full and accurate appraisal of the final result. Doing Botox at 5 weeks after surgery was not only premature but you ran the risk of inadvertently inoculating the implants and causing an infection. That alone should have given everyone pause for reflection on the merits of these early injections.
While Botox is a valid treatment for masseteric muscle disinsertion, waiting for the full recovery and then evaluating the merits of Botox injections, masseteric muscle resuspension or a change in the jaw angle implant style could be more prudently done.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a custom jawline implant placed last year. I’m currently dealing with a bout of bacterial acute tonsillitis for which I’m taking antibiotics for. Yesterday I noticed my right side of my face, notably the upper part of the mandible, below the ramus, is feeling tender and a bit swollen. This could just be swollen glands, as other glands around my neck are swollen too due to infection, but I wonder if there’s a chance the bacteria from my tonsilitis could lead to an infection of my implant as well? Have you ever seen this before? Anything in particular I should watch out for or do?
A: While it is theoretically possible that a facial implant could become inoculated by any distant or contiguous infection in the body, this is not something I have seen. If infection of the jawline implant was present it would have swelling with at the angle and further forward along the body of the jaw to the chin.
Most what you have are swollen lymph nodes in the neck which are the filters of infection from upstream. As long as you are on antibiotics until the tonsillar infection is resolved, I would think you will be fine.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a follow-up question pertaining to something you had mentioned at my rhinoplasty consultation the other day. So you said I have very thick nasal skin. I’m reading that thick skin often does not shrink as well as thinner skin so it might not conform properly to the reduced nasal size. Also that it leads to scar tissue buildup in those open areas where the skin did not shrink sufficiently, resulting in a squishy, shapeless nose. Should I be at all concerned about my thick skin or would you consider it a non issue? Thanks much.
A: The well known issue with thicker nasal skin is how much it will shrink down to reflect any changes to the underlying bone or cartilage that has been modified. This is really only a concern in the nasal tip where the skin is the thickest. As long as the nasal tip cartilages are not aggressively reduced (which is not needed in your case) then the concern of the amorphous (shapeless) nose is not an issue. I mention it in every rhinoplasty patient who has thick nasal skin of the tip, whether it is male or female, to temper any expectation that they are going to get a small or thin-shaped nasal tip as thicker nasal skin will prevent that from being a realistic result.
Dr. Barry Eppley
Indianapolis, Indiana