Your Questions
Your Questions
Q: Dr. Eppley, I have Caliber-Persistent Labial Artery (CPLA) in my lips with visible pulsating on middle upper lip on the right side. I am curious to know if you heard of the more conservative methods in treating CPLA? Would you be willing to try these two simple methods before doing a surgery?
A couple of doctors that have successfully treated CPLA in multiple patients by using triamcinolone (kenalog 40): “In view of the size of the lesion and concern over the functional and esthetic impairment that might result from surgery, the patient was treated with triamcinolone (40 mg/ml) injected at low pressure into the lesion, which caused the formation of deposits of colloidal particles within the lesion. The procedure was repeated twice at 2-week intervals. Subsequently, the lesion was found to have completely regressed. The favorable therapeutic results achieved”
A doctor has treated CPLA in multiple patients using high-frequency electrocautery. It is described that the successful use of a 30-gauge hypodermic needle to deliver a low-powered, high frequency electrical current from a hyfrecator. This inexpensive, simple approach was used in 8 patients.
A: I can not speak to these dermatologic approaches to CPLA as I have never done them nor would I have any confidence in their success despite what is reported. I simply do not believe they would be effective long term in a high flow lip artery. I think the only assured approach would be one of a double ligation encompassing two points to cut off the flow to it from both sides.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, i have arranged a surgery with you for bilateral posterior temporalis muscle removal later this year. I have asked you before if will have any problems with chewing or jaw movement after the surgery, your answer was no. When I am chewing food though, with my back teeth(mostly), I am feeling the movement of the muscles above my ear. Isn’t that the muscle we are going to remove? Or are those movements of muscle under the scalp bone? Did anyone of your patients of the same surgery report anything related to jaw movement or chewing problems?
Thanks so much for your time.
A: As I have stated previously there has not been a single case of postoperative jaw dysfunction or pain with posterior temporal muscle removal for head narrowing puroposes. This would be expected given that it is the posterior temporal muscle that is removed which makes a very minor contribution to jaw function. The reason it is hard for you to wrap your mind around the concept that removal of this portion of the temporal muscle causes no dysfunction is two-fold; 1) your anatomic understanding of the function of this muscle is understandably limited and 2) you have never performed this procedure and then followed patients afterward to see their outcomes.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a reverse frenulectomy procedure. About one month ago while my tooth was being filled a dentist without my knowledge and permission did lower a lower lip frenulectomy with laser. This has caused lower lip ptosis. My orofacial esthetics is altered in a very bad way. And since most of my mandibular teeth are missing I have lost the proper reinforcement for my temporary partial dentures. Do you do the frenulum reattachment procedure? If yes do have any experience in successfully restoring it?
A: The three frenal attachments in the mouth (maxillary, palatal and mandibular) are mucosal bands of tissue that connects a soft tissue mobile structure to a fixed bony non-mobile structure. In the case of the mandibular frenum it attaches the lower lip to the front part of the tooth-bearing part of the lower jawbone. (alveolus) Inside the mucosal frenal bands are thin muscle fibers which connect the orbicularis muscle to the bone. Cutting the frenum normally would not cause a lip ptosis or oral incompetence because it is done for high or abnormal frenal attachments. What may happen in more normal frenums that undergo release may be different.
There is no specific procedure for recreating the actual frenal band. (aka reverse frenulectomy) But the effect of doing so can come from two types of vestibular procedures. A horizontal vestibuloplasty can be performed that raises the level of the midline alveolus and brings the lip closer to the alveolus. The other approach is a midline vertical vestibular suspension where a suture attachment is done which most closely resembles a frenulectomy recreation. Either procedure is performed under local anesthesia.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in ear reconstruction. I got bit by a dog a year ago and lost the lower third of my ear. I have attached pictures for your review.
A: Thank you for your inquiry and sending your pictures. Your traumatic injury represents a classic case of reconstruction of the lower third of the ear…the hardest area of the ear to remake. To do so requires a two-step procedure with the first stage being to raise a skin flap from behind the ear and attach it to the visible edge of the missing ear section. After 8 weeks the attached skin has gotten a good blood supply of its own and it can be released from its base, rolled to make both a back side as well as front side of the missing area and closed over a cartilage graft or implant to support the lower helical rim and where the earlobe would be. This keeps moist of the scar to do within the shadow of the ear rim.
Both stages of this ear reconstruction could be performed as an outpatient procedure and each takes about an hour to complete under IV sedation or even local anesthesia.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have researched Coolsculpting and Smartlipo and feel that Smartlipo is better for me. I go to the gym three to five times a week and for years have been trying to get my abs looking better. I’ve tried many diets and working out but nothing works.
A: Thank you for the inquiry and your interest in Smartlipo. There are some standard misconceptions about Smartlipo. First there is no comparison between a non-surgical procedure like Coolsculpting and a surgical one like Smartlipo. They are radically different in both execution, recovery and results. The short version of the story is that a surgical fat removal procedure is always many fold more effective than a non-surgical one.
Smartlipo, while cleverly named and marketed, is not a non-surgical procedure. It is just as invasive as any form of liposuction, involves the same degree of trauma, and has the identical recovery. It is not a ‘minimally invasive’ procedure and does not create a shortened recovery time or superior results. Like all forms of energy-based liposuction it simply uses a different energy form to help break up the fat but this does not result in less trauma, bruising/swelling or recovery. It is also a procedure that does not usually go well if trying to do it under local anesthesia. It is far from a comfortable experience for the patient and the results subsequently suffer. The best liposuction results come from being done under general anesthesia unless the fat area being treated is vey small.
Having owned and used Smartlipo for over five years I can testify that, while theoretically appealing, it does not create improved clinical results in my hands. And at operative times that are twice that of other forms of liposuction, with associated increased costs, I have subsequently abandoned its use. My preferred form of liposuction today is power-assisted liposuction (PAL) done under general anesthesia.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I went to get a lower face lift. I felt like I was starting to look “loose” around my neck and jawline. The doctor suggested a genioplasty because he felt it would give me a better result than a lower facelift. I told him that I didn’t like the sharp edge of my chin where it meets the labiomental fold. He told me the procedure would soften it. I did not go into this surgery wanting to look “different”. I always felt like I was pretty and I liked my face, especially my smile. I just wanted to be tight under my chin again and soften the front of my chin if possible. I guess I was naive about what this surgery would actually do.
It’s been one year since the surgery and I am still unhappy with the results. I think I look ok as long as I’m not smiling, although my lower lip appears much smaller and seems to roll inward now. A lengthening of 10 mm was done. There was no chin advancement. The harsh edge of my chin below the labiomental fold is softened. However it appears that it was done by bringing the labiomental fold forward, not by actually changing that protruding edge of my chin. When I smile my chin gets quite large and prominent. Instead of starting under the fold, it bows out and starts at the bottom of my lip. My lower lip no longer pulls down in a straight smooth line. The center of my lower lip now curls inward towards my teeth, I assume because the labiomental fold is not as recessed anymore. If it weren’t for the lower lip being the way it is, the chin itself might not seem so big.
I feel like I took a chin I didn’t really like and exaggerated the size to make it the focal point of my face. In the process I lost the smile that had been the most attractive thing about me. Regardless, the recovery was so long that I had decided to try to live with it. Should I go ahead and have some sort of revision done ? Is it possible that the metal plate and screws are the reason for the labiomental fold not being as deep, and if so, will removing them allow my lip to roll forward instead of back? Is it possible to remove some of the length from the bottom of my chin bone as opposed to cutting through the center and resetting the bone? What would recovery for that be like compared to cutting through the bone and moving it? I’m attaching pictures “before” the surgery, an X-ray of the metal plate and screws, and “after” photos.
Thank you for your time.
A: Thank you for sending all of your pictures and detailing your concerns from which I can make the following comments about potential chin revisional surgery:
1) It appears you had a vertical lengthening bony genioplasty. Whether you were really a good candidate for that procedure initially can be debated but what it has done is take someone with a naturally pointy chin and now make it more pronounced with smiling with a 10 mm dropdown. It can be difficult to know how an expected chin will look before surgery in both a static and dynamic manner.
2) With every bony genioplasty that involves expansion of the bone, whether it be horizontal or vertically, there are going to be some changes to the lower lip and its function. Every one of those changes you have and they are largely irreversible. (Or some assume when you consider any type of revisional surgery)
3) I think it is clear that you should probably shorten your chin back down to at least 5mm two 7mms less.
4 ) Based on #3, the only way to shorten your chin, remove your hardware and put no hardware back in is to do a submental shave off the bottom of the chin. This submental chin surgery will have a much easier and shorter recovery than an intraoral chin osteotomy.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in extreme facial reshaping. I want a well defined chin and jawline with high cheekbones and sucked in cheeks between them. I have taken my pictures and did some computer imaging for the facial changes I am seeking. What are your thoughts?
A: Thank you for supplying your imaged results and a very detailed analysis of your desired outcomes. I can see that you have put a lot of thought into these changes. For this type of extreme facial change, and it is appropriate to call it an extreme change (from a surgical standpoint not a personal one), I can make the following comments:
1) You are correct is assuming that only a custom jawline and cheek implants can ever approximate this type of facial change.
2) It would be fair to say that your imaged results are not a completely realistic outcome for a variety of reasons including soft tissue tolerances and the inability for a 1:1 correlation between the implant design and the exterior desired outcome.
3) Having done over 500 custom facial implants, I can tell you there is no current technology that can take a photoshopped image and translate that into an implant design that will guarantee that outcome. Implants are designed on the 3D CT scan (bone) and it has to be estimated what type of implant shape, thickness and contours might create an outcome that would come close to the patient’s desires. Custom implant designing remains an art form and not an exact science.
4) The extreme indentation between the cheeks and the jawline is not realistic. While the size of the implants and your thin face will help a lot in that regard (and even buccal lipectomies will help also), it would be unlikely that such a contrast between the augmented skeletal contours and the unsupported soft areas between them will be that substantial in contrast.
5) By far and away the most common need for a revision in custom facial implants in general and in such extreme facial changes in particular is high. To not be subtle about this possibility, presume it is 50% or greater. This is particularly true in the patient who before surgery has done a vey detailed analysis and has a very specific facial outcome in mind. This is not a personal statement about you, as I have many such facial patients of which many are men, it speaks more to the imprecision and limitations of the surgical process. (Anything can be done on photoshop which may or may not be translated to the patient’s outcome) It is important to point out that patients assess their after surgery outcomes with the same zeal and analysis that they did before surgery. As a result it would be extremely unlikely that the patient’s exact aesthetic target will be achieved most of the time.
6) Your biggest risk of aesthetic ‘complications’ is in the jawline. Dropping down the jaw angle that much with such widening poses a real risk for masseter muscle disinsertion and retraction with ‘implant reveal’ over the jaw angle area.
7) While infection is the dreaded complication of any facial implant, that risk is fairly low. (< 5%) The real complications, as noted above, are aesthetic in nature.
8) Recovery from any form of facial reshaping surgery, such as implants, takes a lot longer than any patient thinks. You will look reasonable by two weeks or so after surgery but it takes up go two months after surgery to see the true final outcome.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m planning on doing a chin augmentation late this year and, for that reason, have some questions that if possible would like to be cleared out. My questions are:
1 – Judging by the photo attached, how much augmentation do you believe I’m going to need?
2 – Will the procedure change the front view of my face?
3 – How much time out will I need to take out of work after the procedure?
A: In answer to your chin augmentation questions:
1) Unless I do the actual imaging I can not tell you what millimeter change it would be.
2) Every chin augmentation procedure changes the front view to some degree. It is not realistic to expect only one dimensions of the chin to be changed when a 3D implant is placed.
3) Recovery is one of swelling and your tolerance for it. The surgery will create more swelling than you think and it will take longer to go down and become acceptable in appearance than you desire. Half of chin augmentation swelling goes down by ten days and 75% by three weeks. At one point in this time course you will find it socially acceptable but that varies amongst different patients.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, i come from Europe but would love to be your patient. I have a question about rib removal. Is it possible to remove all of the so called fake ribs? I can conclude that it is very extreme but wearing a corset would make up fort them missing since I don’t work out or lift heavy stuff. Thank you so much in advance.
A: When you use the term ‘fake ribs’, I assume you mean the unattached or free floating ribs which are traditionally #s 11 and 12. In some patients this can also include rib #10 which may not connect to the subcostal ribs. These are ribs that I remove all the time for horizontal waistline reduction. Their removal works for waistline narrowing because of their surprisingly vertical orientation. Rib removal is not extreme surgery in terms of being dangerous or exposing the patient to undue risks. Nor does the patient have to wear a corset afterwards for protection. Some women do wear a corset after rib removal but this is because they are trying to maximize their waistline narrowing. This is a common procedure in my practice that has no adverse medical sequelae other than the small back scars.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in brow bone reduction due to the overly prominent ridge which gives me a Neanderthal look. I have researched the different methods this is done, but I am hoping there is another option that does not leave a large scar since I will most likely experience hair loss.
I am not really bothered so much by the actual prominence, but by the transition to the upper forehead. Is there a way to blend this with some sort of filler or something else?
A: What you are referring to is to fill in the forehead area above the brow bone….a forehead augmentation approach rather than a brow bone reduction approach. This is one valid approach to the strong brow bone appearance in men. This is best done by making a custom implant for the forehead area that has a precise fit and contour to create a smooth and blended approach into the upper forehead. This is made from the patient’s 3D CT scan. Depending on its size it can be placed through very small scalp incisions using an endoscopic technique.
To determine if a brow bone reduction or an upper forehead augmentation should be done is determined preoperatively by computer imaging.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, My questions on facial plastic surgery:
1. I plan to go on a course of Accutane but I understand this impairs wound healing. As a result, it is advised not to have elective surgery for 12 yo 18 months after one finishes the medication. I cannot wait that long. Also I have the fistula under my neck (a large hole) it needs to heal first before I can start Accutane…as Accutane negatively affects wound healing.
Does Accutane only affect the epidermis or does it also affect the gums / intraoral incisions to place cheek and jaw implants? I understand that as part of placing the total jaw implant, you make a submental incision – would Accutane affect this healing if the surgery is carried out around 6 months before or after a course of Accutane?
2. Would having a hair transplant cause any problems for facial implants currently in place? For example, could it potentially trigger inflammation or an infection?
3. I need to have revision rhinoplasty – could I do this after having cheek and jaw implants or should I do it before inserting new implants? I’m thinking I might wait 12 months after the Accutane treatment to do this.
4. I was also thinking that perhaps I could have the revision rhinoplasty at the same time as cheek implant replacement and then have the jaw implant done later – is this feasible? After the damage caused by the previous jaw implant infection, I’m very weary and apprehensive about triggering infections. I lived with the previous implant for around 2 years. The remaining jaw implant is Goretex (screwed in) but I believe my current cheek implants are silicone/silastic and not screwed in.
The surgeon who removed my infected implant, only inserts silicone implants due to their ease of placement and removal. His comments concerned me so I want the ‘healthy’ remaining jaw implant removed as soon as possible (but I’ve read it’s best to have the replacement done at the time it’s removed but for me, that cannot be done until I heal fully from the infection.)
A: In answer to your questions:
1) Accutane primarily affects epithelial and dermal healing of which is most relevant to facial laser skin resurfacing. Its negative effects on deeper tissue healing is less certain. But that being said, it is still best to not undergo elective surgery for six months after it has been stopped.
2) Hair transplants have no known association with causing facial implant infections.
3) The timing of a revision rhinoplasty is one of convenience. It can be done in conjunction with other facial implant surgeries or done in isolation. This is not a medical decision.
4) The revision rhinoplasty, as indicated in answer #3, can be paired with any other aesthetic facial procedure. There would be no reason to have the remaining good jaw angle implant removed first before placing another one.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’ve been looking at getting some work done on my lower third for a few months now. After doing some research, I’ve heard I would best benefit from different two things, and I’m not sure which I would benefit more from:
1. Bimaxillary Osteotomies (Lefort 1+ BSSO) with CCW rotation and sliding genioplasty. This was due to both a recessed mandible as well as maxilla? I can’t tell whether my maxilla is recessed, although from my profile shots, my whole face just looks flat or potato like.
2. Facial Implants. Probably a full custom wraparound. For the chin, an emphasis on increasing width, height, and projection, and a more square shape.
So I’m at a huge crossroads here. I’m torn on whether I’d be better off with implants vs jaw surgery.
A: The fundamental answer to your question is that you are trying to compare apples to oranges. Orthognathic surgery and facial implants are not comparative procedures, they are done for different reasons with different outcomes. Orthognathic surgery is largely a functional operation whose main goal is to improve your bite. There may be aesthetic benefits to it but they will not remotely compare to what a custom jawline implant will do. Conversely a custom jawline implant is a completely aesthetic operation with no functional benefits. You have to prioritize as of what your primary goal is….then that decision becomes much easier.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like hip implants. I made a huge mistake and had silicone injected by a unlicensed injector several years ago that caused a bad reaction in my body. My hips turned black and became hard as a rock. Fast forward to last year where I had the material, hardness and discoloration removed. I had a BBL earlier this year to replace the large dips I had in my hips from the removal surgery. A lot of the fat died so I’m thinking due to me having the silicone in my hips for so long maybe fat will not survive in that area. Right now I have dips in my hips that I would like fixed. I would like to have silicone hip implants placed to build them out.
A: It is important to realize that placing implants anywhere in the human body requires normal healthy tissue around them to avoid infection and other implant problems. If fat has trouble surviving in the hip area due to the tissue quality this bodes very poorly for any attempt at implant placement. At the least further fat injections may be needed to improve the tissue quality of the hips before implants may be placed. The hip areas must feel soft and not hard to rigid if implants are even to be considered. I would need to see pictures of your hips to determine what this area looks like
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I need your opinion for my very specific facial implant selection needs describe d below. I also posted photos of my face (front – side view & oblique) in order for you to understand better my situation. The 3 photos are real, as I am (the before) and the modified photos are fake (modified in Photoshop) and show the desirable effects, what exactly I want to achieve after the aesthetic surgery.
As you can see, I want to achieve a more masculine facial structure, as well as a more prominent jaw line and reducing the roundness appearance of my face. I’ve decided to go on with 3D facial plastic surgery, in addition with buccal fat pad removal (I ‘m not interesting in typical, non-surgical methods). I know most of the basics and I am looking for the right doctor in order to proceed. But I have some questions to ask first.
1) Which chin implant would be better according to my needs, in order to achieve the effects in the modified photos? Conform™ Extended Anatomical Chin Implant, Extended Anatomical Chin Implant, Terino Extended Anatomical™ Chin Implant, Vertical Lengthening Chin, Mittelman Pre Jowl Chin™, Mittelman Pre Jowl®, Glasgold Wafer, or Terino Square Chin (All styles) ?
Chin Augmentation Goals: stronger – masculine chin, a little front, side and vertical widening, as photos show.
2) Again, which jaw angle implant would be better, the Conform™ Mandibular Angle Implant, the Widening/Vertical Mandibular Angle Implant, the Lateral Mandibular Angle™, or the Posterior Mandibular Angle™ ?
Jaw Augmentation Goals: The main point here is to enhance the vertical facial structure of the face and secondly the angular shape to be more prominent BUT without enhancing the roundness of the face.
3) In addition to these augmentations, do I need cheek augmentation to achieve the desirable effects? Or the buccal fat pad removal is enough according to my case? If I need, which of the three options would suit better in my case? Malar, Submalar, or the Combined Shell?
The goal here is to achieve more tight and high cheekbone effect and with no fill and volume, just like men models.
4) Would you suggest to go for temple augmentation too, in order to achieve a boarder/wider forehead and a more masculine effect? Or not?
Thanks!
A: In answer to your facial implant selection questions:
1) I can only provide specific implant recommendations to patients that I have consulted on and I am performing the procedure. It is ill-informed to do so otherwise.
2) Buccal fat removal can never achieve your imaged effects and always has to be combined with cheek augmentation to come close to that midfacial effect.
3) Augmenting the facial skeleton will only make the temporal hollows look more pronounced not less.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I read your article online regarding Fractora vs a facelift and you mentioned that you would review pictures. See below. Would I benefit from Fractora or perhaps an injectable filler? Not sure which way to go. Thank you for your time.
A: In answer to your facial aging treatment questions, this is a classic debate between fillers, fractional laser resurfacing (Fracture) or some type of lower facelift. It is important to understand that in this spectrum of facial aging treatment options they have very different effects and are used for different facial aging concerns. Your facial aging needs are beyond what fillers or laser resurfacing can really improve much and they would be considered a poor financial investment. Your only good choice is to have a lower facelift procedure which is the only economically worthwhile approach. You may opt for laser resurfacing because it is not surgery but with the understanding that its benefits will be very limited and not the equivalent of a facelift.
In reality in your case, fractional laser resurfacing is a good complement to be done after a facelift. But it is certainly not a substitute or an equivalent treatment for your facial aging concerns..
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a closed rhinoplasty correct some tip asymmetry. My questions are:
1. What will be my limitations post op? Can I play sports? Can I blow my nose? What happens if a ball or object hits my nose? Can I go swimming? Etc
2. Is there any possibility that the procedure would produce a more asymmetric nose tip? Or is it guaranteed that I will at least have more symmetry?
3. What will you actually be doing to my nose in order to achieve the more symmetric tip that I want?
4. How long will I have a cast over my nose?
5. What is your policy on revisions?
6. Will my nose have anything foreign in it ?
7. What are some potential complications or risks with a nose like mine?
8. What is your revision percentage for rhinoplasty?
9. About how many closed rhinoplasties have you performed?
10. Will you only be doing work on the asymmetric side of my nose or do both sides of my nose need work in order to achieve what I want?
11. I attached more realistic before and after photos where I do not use a mirror, but instead just used a morphing app to reduce the hump on the left side of my nose. How realistic is it that you can achieve this result for me?
Thanks in advance!
A: In answer to your closed rhinoplasty questions:
- Other than some compressive tapes on your nose for the first week after surgery, there are no physical restrictions…other than common sense ones like no contact sports for the first few months after the procedure.
- By removing some of the excessive lower alar cartilage on the fuller side, it would one hard to imagine that the surgical result would the worse than before. The very likely outcome is that the asymmetry would indeed be less.
- A cephalic trim of the left lower alert cartilage would be done.
- The tapes would stay in place for 5 to 7 days after surgery.
- The revision policy is written and is one in which you are already familiar since you have seen and signed that policy paper from your recent surgery.
- There will be no foreign materials used in your nose other than resorbable sutures.
- The risks of this surgery are exclusively aesthetic…how well does it meet your aesthetic nose reshaping goals.
- The usual stated revision rate for rhinoplasty is between 10% to 15% on a national basis for primary (first time) rhinoplasty. But that number is an average and does not take into account the type or complexity of the rhinoplasty being performed. Your proposed rhinoplasty would be considered ‘not complex’ and in theory should have a lower risk iof revision. But that would depend on the ‘perfectionist’ nature of the patient as that is what drives most revisional facial procedures.
- I have performed many closed and open rhinoplasties.
- Based on our own imaging, it is presumed that only reduction of the larger side is needed. But that depends on your nasal tip reshaping goals.
- Your imaged results appears realistic and is an achievable goal.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in secondary rib graft rhinoplasty. I had silicone rhinoplasty done seven years ago. (they used silicone for the bridge and septal cartilage for the tip).Although I am very happy with it aesthetically, I also started getting autoimmune problems shortly afterwards and now have full-blown Lupus. While the link between silicone and Lupus isn’t firmly stablished, I don’t want to take any chances and would like to swap out the silicone for rib. Is there any way I could do this via closed rhinoplasty?
A: You are correct in that there is no established connection between solid silicone implants and autoimmune diseases currently. But I can certainly understand what you would want to replace your silicone nasal implant. While I have no idea of your implant’s size and shape, it can certainly be replaced with a rib graft. Some general comments about rib graft rhinoplasty in your case would include the following. It may be possible to use a closed approach for the replacement as the implant has an established capsule/pocket. Whether the rib graft should be inserted as a solid piece or in a diced fashion would depend the shape of the harvested rib and its ability to be inserted through a closed approach. It would be important to realize that any form of a rib graft may not have the completely smooth and perfect shape as that of a preformed nasal implant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am seeking nasolabial fold correction. I wanted to see if you can help me. I have atrociously bad nasolabial folds by my mouth. I am young so I don’t know why, maybe weight loss. I wanted to ask your expert opinion. Do you think I have midface deficiency causing this or is it just that my cheeks have sagged a little bit? I need to know if I should do jaw surgery to correct an upper jaw deficiency or just have a facelifting skin procedure . I appreciating your opinion. Here my pictures.
A:Thank you for your inquiry and sending your pictures, Nasolabial folds remain a difficult challenge to treat on any permanent basis. I see no evidence in your face of a midface deficiency nor would upper jaw surgery ever be an effective treatment for nasolabial folds. They are not typically perceived to be a bone-based mid facial problem. They are a soft tissue problem not caused by a bone deficiency. Conversely a facelift of any form never effectively treats nasolabial folds in any sustained fashion. The best approach for nasolabial folds correction remains release with injectable therapy whether that be synthetic filler, fat or even implants.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a question regarding cheekbone reduction. I know that cheekbone reduction is often performed in patients seeking to reduce the width of the face. However my issue is slightly different. Essentially I have low set cheekbones that project, both forward and laterally. To me this gives a very feminine look, and the reason behind it is that the zygomatic prominence is too low down on the face, causing the ‘bulge’ of the cheek to be too low. So I was wondering whether it would be possible to reduce the projection of the cheek in not only both the forward and lateral directions but also in the vertical dimension. My thoughts are that we would flatten down the projecting part of the cheek and then remove the bone forming the inferior border of the zygoma. Will we be able to achieve these objectives? If it proves to be impossible what is the closest we can come to achieving them?
A concern I have is that the soft tissue may not react well to reducing the size of the bone. I am worried that reducing the bone would just leave hanging soft tissue. Are my concerns on this matter valid? If so, can we do anything to help such as a midface lift to reposition the soft tissue against the new bone contours?
A: The type of cheekbone reduction you have described can be done and is known as a zygomatic-maxillary corner ostectomy. That would address the bony ‘deformity’ that you have astutely ascertained. The concern about soft tissue sag is not without its merits although the superior zygomatic bone structure remains intact. To proactively address this potential concern one would do a soft tissue bone suspension of the cheek tissues at the time of the ostectomies.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am searching for information on eye asymmetry surgery. I am interested in addressing my eye asymmetry as well as that of my face. I do not have any medical problems related to it as far as I know, but it is something that has caused me a lot of distress in my daily life and I worry it will worsen with time. One side of my face is more defined and lifted, including the eye, and other side of the face also looks more “pushed in” while viewed at 3/4 angle. I have attached my pictures for your review. I am interested in pursuing cosmetic surgery to fix these issues, and was wondering if your facility provided procedures that can do so. Thank you for your time and help, and I look forward to your response.
A: What you have is a vertical orbital dystopia that is part of an overall facial asymmetry. The eye area is always the most noticeable since that is what you ‘see’ the most. This asymmetry will not worsen over time since this is part of your natural facial development and is stable. The correction of such orbital dystopia (eye asymmetry surgery) is done through the placement of an orbital floor implant to raise the eye up. The eyelid will also need upward adjustment at the outer corner. A small cheek implant will also help to bring out that face ion that side next to the eye.
Ideally a 3D CT scan would show the degree of orbitofacial skeletal asymmetry and can be used to design the orbital floor implant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in arm scar revision. I have several self-inflicted arm scars from several years ago. The three arms scars are 2 inches, 1.5 inches and the smallest at one inch. I have some general questions about the procedure:
1.Is it possible for my arm scars to be improved?
2. Do you suggest any alternate solution?
3. How much would this cost me given that there are only three marks?
4. If this is surgery, how many days do I need to under your care? is it one time or do I need to come few times a year after surgery?
5. What potential side effects can occur?
A: Thank you for sending pictures of your arm scars. In answer to your arm scar revision questions:
1) The only benefit of scar revision would be if you think that the scars being narrowed would be of benefit. It is not possible to have the scars completely removed. There will always be scars, just more narrow with hopefully no white color.
2) There are no alternative solutions other than to cut them out and restore. Since they were original skin lacerations that were allowed to heal secondarily, the scar goes all the way through the thickness of the skin.
3) My assistant Camille will pass along the cost of the scar revision procedure to you tomorrow.
4) This is an office procedure done under local anesthesia. There is no aftercare needed and all sutures are placed under the skin and are dissolvable.
5) I would think that whatever scar improvement is possible with this type of scar revision, it would be seen after just one scar revision.
6) I see no side effects other than how much scar improvement is obtained.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am considering arm lift surgery to remove extra arm skin and was referred to you to possibly do arm implants. (bicep and tricep implants) My question is can the implants replace the surgery and will that stretch out the excess skin in my arm so it no longer hangs. I am 60 years old and in good health and shape. Thank you.
A:Thank you for sending your pictures. Your concept of adding volume to the arm muscles to fill out loose skin is not completely unfounded. But the success of arm ‘voluminization’ depends on how much loose arm skin is present. What your pictures show are arms like look like someone who has lost a lot of weight. The back of the arm shows a classic bat wing deformity with a lot of loose hanging skin.
A bicep implant would fill out some of the overlying upper arm skin which is always less than that on the back of the arm. But a triceps implant would provide no benefit to the larger amount of hanging posterior arm skin. An armlift is really the only way to get rid of the posterior arm hanging skin. It is possible to combine an arm lift with arm implants if desired as there is convenient surgical access due to the arm lift incision.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, My son, under the instruction of a general practitioner, was not given the green light for a helmet to treat plagiocephaly. We were told he would just grow out of it. He never did. One side of his forehead is more prominent than the other. It’s too late now as he is 4 years old. This raised my concerns, and after much research have come to find the rise of children and young adults effected by an uneven forehead due to the back to sleep programs of the 90’s.
There are hundred of parents that share the same concerns and numerous young adults seeking treatment of a lopsided forehead. My concern is that there are not enough surgeons worldwide with knowledge of correction techniques, such as custom made implants to even out this problem.
Please, if you have some sort of voice in the medical fields with other surgical professionals, could please bring light to these techniques. More training worldwide is needed. You are pretty much, the only surgeon that has any insight into this that I have come across. No one has ever heard of plagio forehead implants or treatment.
There needs to be much more research into this issue. Maybe you can train or help spread more awareness of how to surgically treat adults with plagiocephaly. Because, I guarantee ,now and in the future, it will help so many people.
I just Google about adults with plagiocephaly and many of them has felt suicidal, suffered depression or anxiety. This breaks my heart so much. Is there anything I can do to help spread awareness in the surgical community, please direct me how to go about it. Any information would be beyond welcome.
A: Thank you for your email. I certainly see and treat many patents with different forms of frontal and occipital plagiocephaly. I do find that the use of custom implants in teenagers and adults provides an effective improvement with a low risk of complications and aesthetic tradeoffs. Fortunately the internet provides the best forum for passing along this information as I try to do in my many blogs on this topic. I feel confident that what I do today, in time, will become well known and a more widely used surgical therapy for it. In surgery the adoption of newer surgical technique is often met with skepticism but successful outcomes eventually lead to it becoming an accepted and contemporary surgical approach.
Dr. Barry Eppley
Indianapolis, Indiana
Dr. Eppley, I am considering custom infraorbital-malar implants. Currently I have orbital rim implants that are of silicone material but they are not fixated with screws and are an off shell product. I think it gives a good improvement of my flatness under my eyes, but they are a bit uneven because of the different sides of my face as they are not completely symmetric. The right implant is actually perfect, but the left is kind of strange as it seems like it sits a bit lower and it has a lump that goes outward close to my nose, and there is a gap between the implant and the lump that creates a crease. Its almost like the implant are in two parts on this side.
I have a couple of questions to you regarding the custom infraorbital-malar implants that I was hoping you could answer.
1. Have you done a lot of these implant operations before? Are you very experienced in it?
2. As I have two sides of my face that are not completely symmetric, would you custom make the implant to the different sides to try to achieve more symmetry?
3. What kind of material are the implants of?
4. How long is the surgery time expected for this?
Looking forward to your answer, as I’m very pleased with the orbital rim implant I have, but I don’t like that they are not fixated and they are a bit asymmetric with the crease and lump on left side. I want a permanent safer, smoother solution that also will cover more of my malar region as well.
A: My first comment would be that if you are largely satisfied with your current standard orbital rim implants, I would be cautious about making any change. As a general plastic surgery philosophy, ‘perfection can be the enemy of good.’ That being said, if you were to consider a change the only way you should do it is with a custom implant approach as this would be the only method that has any chance of taking a result that is largely good and trying to make it better. In answer to your custom infraorbital-malar implant questions:
1) I am very experienced with custom facial implants including having done many custom infraorbital, malar and combined infraorbital-malar implants. (the latter is the most common when using a custom implant approach)
2) In using a custom implant approach, symmetry is exactly one of its benefits. The computer can see the differences on your 3D CT scan in bone between the two sides as well as your current implant positions and shape and take all of that into consideration when designing the implants.
3) The custom implants I use are made of silicone.
4) My assistant will pass along the cost of the procedure to you on Monday.
5) This surgery takes 1 1/2 hours to complete.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in custom infraorbital-malar implants to replace my existing tear trough implants. Your initial statement about that I have to be careful when the result is “good enough”.But there is a couple of things that bother me with the current orbital rim implant.I already described the uneveness of the implants on the sides, but there is also this concern that the implant is not fixed. I’m a bit afraid that the fact that its not fixed could lead to some erosion,and that it would be better if it was fixed.
When you talk about the making of the custom implant, are you saying that a x-ray scan can detect the underlaying bone structure I have under the implant? So this would mean that there is no need to take the implant out first and then take pictures, but you can actually detect the structure under the implant and make a custom implant out of that information? If thats the case it would be a relief.
The surgeon that put in my current orbital rim implant said to me that he would not advice me to do another cheek implant surgery as this would be risky.
Again. thank you for being such a great doctor and giving me such detailed informative answers.
A: Custom infraorbital-malar implants are made from a 3D CT scan of the patient. From this scan the current size/shape/position of the orbital rim implants can be seen as well as that of the underlying bone. To make the custom implants the old implants are digitally removed for the new designs. Thus you do not need to have your old implants removed first, the computer program does it. The really informative thing is then the new implant designs are overlaid digitally on top of the old implants. (in different colors) By so doing the two implants can be compared and one can see both the differences as well as to keep the good things about the current implants and have the new implants cover the areas that the old one don’t.
There is nothing medically risky about a second surgery to remove and replace your current implants. The risks are really aesthetic in nature. But you can see that the custom implant approach would be the only way to lessen/eliminate those risks and give you the best chance to go from a good result to a better one.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in skull reduction surgery. I would like to get the right side of my skull reduced. Its so bigger than the left side which is itself normal in size. This makes me look like big headed and I feel very uncomfortable with it.
So is there a possible way to do this surgery ?
What are the risks associated with it ?
How much can it cost ?
Will there be any scars after the surgery ?
A: Thank you for your inquiry and sending your pictures. In answer to your skull reduction questions:
1) The right posterior temporal region can be reduced through muscle resection. This is a far more effective procedure for head width reduction than trying to reduce the bone.
2) In my extensive experience with this type of head reshaping surgery, there are no medical risks that I have seen or can envision. The aesthetic risk is how effective it will be and how much more symmetrical it will be to the other side.
3) The incision is made behind the ear in the sulcus area so there is visible scar at all.
4) My assistant will pass along the cost of the surgery to you tomorrow.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m a 24 year old male and, due to an untreated positional plagiocephaly in early infancy, the right posterior part of my skull is flattened showing the typical pattern of occipital postural plagiocephaly with an asymmetry of 6 mm between the two cranial vault diagonals. Since I got my hair shaved because of the incipient baldness, this flattening is more obvious.Thanks to the complete and invaluable information you provide on your website I think I have found a solution for my problem, a custom occipital skull implant, but I have doubts due to the particularities of my case.
The flattened area extends on the right side (viewed from the back), partially over the occipital and parietal bones, and slightly over the more posterior portion of the temporal bone. On the occipital zone, this causes a depression in the area surrounding the superior nuchal line where the occipitalis, trapezius, semispinalis capitis, splenius capitis and sternocleidomastoid muscles are attached. This is the area my question is about.
I understand that in cases of prominent nuchal ridge reduction these muscles of the superior nuchal line are detached for burring the nuchal ridge. I have also seen in the Web this kind of detachment in cases of anterior and lateral foramen magnum meningiomas surgeries where an extreme-lateral transcondylar and retrocondylar approaches respectively are performed, as well as in mastoidectomies.
My questions are:
1. The area corresponding to the attachment of the superior nuchal line muscles (the area delimited by the red line in the images) can also be augmented through a 3D custom-made silicone implant, or is there a maximum occipital inferior border to place the lower edge of the implant?
2. In which layer would the implant be placed? It will be directly placed on the skull bone and below the periosteum?
3. If the placement is subperiosteal and the nuchal ridge muscles are detached, how do the muscles are reattached to the skull if there is a piece of silicone underneath where they should be reattached? Does it have anything to do with the access being subperiosteal and lifting all the layers above the cranium like a flap?
4. Would detaching and reattaching the muscles cause muscle atrophy and, therefore, a reduction in its volume? If so, how can this unwanted effect can be camouflaged? Can detachment/reattachment affect the functionality of these muscles?
5. Can the implant be extended in one-single piece from the area of the upper nuchal line up towards the parietal bone?
6. Will the implant be fix to the bone with titanium screws?
7. Where will the incision be located in order to access the affected area?
8. The fact there is so little offer for cosmetic skull reshaping procedures around the world has something to do with the complexity of the procedure (technique, 3D custom implant supply,…), the lack of knowledge by the plastic surgeon about the existence of this procedure, the need for training as a craniofacial surgeon or maybe it is the little demand for this kind of cosmetic “job” (even when there is an increasing rate of people affected by plagiocephaly because of the “Back to sleep” campaign)?
Thank you very much in advance for your response.
A: Thank you for your inquiry and providing your specific skull shape concerns. Having done hundreds of skull implants of which the back of the head makes up half of them (of which those half are done for plagiocephaly), I can provide you the following answers to your occipital implant questions:
1) Augmentation of the occipital skull is NOT going to be done below the superior nuchal line. The contour below that line comes from the muscle not the bone and any detaching the muscle to have an implant extend below that line is counterproductive.
2) All skull implants are placed in the subperiosteal layer directly against the bone.
3) Once neck muscles are detached, they do not reattach nor can they be reattached regardless of whether there is an implant there or not.
4) Since the neck muscle can not be reattached and will cause some slight volume loss if so done, they should not be detached in any significant way. Hence why augmentation is not done below the superior nuchal line.
5) A custom skull implant can be designed to easily cover any contiguous skull area.
6) Most custom skull implants are secured with titanium microscrews.
7) A horizontal scalp incision, usually in the range of 7cm to 9 cms, is placed at the location of the nuchal judge in the hairline.
8) This does not appear to be a question but a statement for which I have no answer.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a small mouth and it makes me very uncomfortable especially when I talk I feel like people are always judging me. Anyway I heard that you can do a procedure know as lateral commissuroplasty or mouth widening. Now I am aware of the trade off of scars and am not worried about it. What I am worried about is if it will look normal. I have never seen any before and after pics and I’m quite skeptical about it. If you could provide me with some information about the procedure to make up my mind. So my questions are, 1.will it look normal or will you be able to tell that its not 2. How successful is these procedure. Thank you very much.
A: Mouth widening surgery produces less visible scar formation than mouth narrowing surgery so it is a more favorable procedure in that regard. The procedure always makes the mouth wider, it is just a question of how much. The goal is to increase the width of the mouth by 5 to 7mms per side. It is really no different than an upper or lower lip vermilion advancement. It is just done on the normal corners of the mouth rather than the ‘north or south’ lip borders.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, is the laser used for eyelid lift? (aka Laser Eyelid Lift) Is this a real procedure?
A: The simple answer to your question is largely no. The concept of a ‘Laser Eyelid Lift’ is one that is more of a marketing concept and not an improved or contemporary blepharoplasty technique. Using lasers in surgery always sounds like it would be better but the reality is often very different. Using lasers to cut skin causes a thermal injury and a much worse potential scar than if ‘cold steel scalpel’ is used. Beside the worse scar outcome it does not make the surgery faster, cause less bruising/swelling nor expedite the recovery in any way. Due to the thermal injury to the skin’s edges they are also associated with an increased risk of after surgery skin edge separation (wound dehiscence) due to a delayed wound healing response. While lasers have a valuable role to play in facial skin resurfacing, they are not a useful technique for any facial surgery in which they are applied to cut the skin. They can be used to cauterize bleeding points and even help cut out fat during a blepharoplasty procedure, but they do not offer any real advantages over the traditional use of needlepoint electrocautery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a young Asian male whose brow bones are flat, and is seeking to get them stick out through brow bone implant surgery. Would there be any long and short term side effects through implants, considering the amount of delicate nerves that lies in close proximity?
A:The nerves to which you refer (supraorbital and supratrochlear nerves along the brow ridge) are neither sensitive nor are they motor nerves. They are sensory nerves from the first division of the trigeminal nerve that exit out the brow bones and head north to supply the feeling to the forehead and the front of the scalp. They are very hardy nerves that are manipulated quite frequently in many forehead/brow bone procedures. In placing any brow bone implant around these nerves the implant design must consider their location so they are not compressed as a result of the implant’s placement. But this is usually an avoidable problem. This becomes a very relevant issue in the implant’s design if one is trying to drop down the brow bone edge inferiorly or desires a lot of horizontal (forward) projection. But fir the typical forehead/brow bone implant, a notch is made in the design of the nerve foramina based on the patient’s 3D CT scan.
Dr. Barry Eppley
Indianapolis, Indiana