Your Questions
Your Questions
Q: Dr. Eppley, I´m a patient who would like to have a rhinoplasty with you in your clinic. I have a big hump and also a big tip. I will make photos this week to send you, In the meantime I would like to know, Is that procedure very hard to perform? Should I worry that my nose won´t look natural after the first procedure?Is it usual to have more than one procedure?
A: Thank you for your inquiry. How difficult your rhinoplasty is and what that potential outcome may be will await the receipt of your pictures and my analysis of them. Seeing the magnitude of the nasal shape changes that are needed and what the thickness of your skin is goes a long way in determining how successful rhinoplasty surgery can be.
While the technical aspect of many rhinoplasty surgeries are not ‘difficult’, the outcomes of such efforts are not always completely predictable due to how the overlying skin contracts over the reshaped osteocartilaginous framework.
Rhinoplasty has well known risks of potential aesthetic issues that may require a subsequent revisional procedure. The usual stated risks is around 15%. Whether your surgery has a higher for lower risk of revisal surgery would depend on what type of shape changes you are seeking.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in an arm skin graft. I have multiple self-inflicted scars on my arm from when I was younger. I am in a much better place now and want to rid myself of their appearance from an earlier time. I have some questions about the procedure:
Where is the skin graft from? I’ve read thigh region.
Recovery time?
Will the stitches be visible after? And for how long? I had a scar revision done and the interior stitches are still noticeable, dark. It’s been about 1.5 years.
What is a procedure like this cost?
How soon can this be set up?
I was thinking of tattooing the area once healed, would this be a concern? How long would I need to wait?
Would it be possible/advisable to tan the area to be used as the graft to match the affected area prior?
That is all I can think of for now. It would be great to speak with you.
A: In answer to your arm skin graft questions:
1) The skin graft is harvested from the lateral thigh.
2) Ir depends on ow you define recovery…to work in a few days depending on what kind of work you do.
3) My assistant Camille will pass along the cost of the surgery to you on Wednesday.
4) You would have to ask my assistant Camille and let her know when is a good time for you.
5) You would have to wait a minimum of three to four months after the surgery.
6) Whether you tan the donor site or not before it is harvested does not affect graft take.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in brow bone reduction surgery for my prominent brows.
I have read your posts online and I see there are 2 different options for the scalp incision. What would you recommend for having it the least bit noticeable and the best chance of healing the best?
A: In a male, the scalp incision is usually going to be back further in the hair, rather than right at the hairline because you don’t know how stable the male frontal hairline is. The exceptions to this would be in a male if one wanted to do a hairline advancement at the same time as the brow bone reduction, one had a good familial history of hairline stabiity our one wanted to eliminate any risk at all of any hair damage along the incision line. Having used the hairline incisions in men numerous times for different indications I have not have any postoperative concerns about the scar or the recession of the front edge of the hairline behind it.
But both hairline and more posterior scalp incision can be successfully used and the scars heal well in both locations. But it is important to carefully these incision location choices in the male brow bone reduction patient.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am going through with custom infraorbital-malar implants from a CT scan. However, I am afraid that the prominence of the custom implant would be too much at 5mm.
1.Is there a general reference for when implants would be extreme when looking at the skull, similar to where mandible angle implant width is considered extreme if it extends pass the zygomatic bone/arch?
2. Is it a bad idea for a surgeon to custom shave down a cheek implant further if it looks too prominent during surgery, even thought the implant was custom designed/fitted already? (I.e good chance of creating an abnormal shaped cheekbone?
3. I heard that custom designed implants at 5mm are more similar to the projection of off shelf implants of 3-4mm, since they have no space between the bone and implant. In general, have you noticed a 5mm custom designed malar implant to be less noticeable/prominent than a 5mm off shelf implant?
4. How much do you charge for a custom infraorbital-malar implant with both the payment to moldhouse and the expense for you to place it?
A: In answer to your custom infraorbital-malar implant questions:
1) For the midface there are no specific skeletal landmarks to keep an implant’s projection inside the ‘aesthetic window’.
2) If the surgeon feels the implant looks too big or unnatural in the cheek area after it is placed, it would be prudent for an adjustment by shaving reduction to be done at that time. I have done that many times as it is far better to have an implant that may end up slightly too small thank one that is too big. The latter has a 100% chance of revision.
3) I have never seen nor have any biologic rationale to the cheek implant comparison you have referenced. In fact it is quite the converse, custom cheek implants can much more easily be oversized compared to standard cheek implants because they cover a much greater surface area and thus their volumetric effects are more profound.
4) I will have my assistant Camille pass along the cost of the surgery to you later today.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am researching for my 20 year old son. He had a large craniectomy done two years ago and the replacement was a plastic implant. They were not able to reattach his temporal muscles and it has left a bump at his temporal area above his ear and a drooping eyelid. Can this be fixed? Can the muscle be reattached? What are the future complications? Thank you for your help.
A: Thank you for your inquiry and sending his pictures. What your son has is a temporal muscle retraction which has no functional implications. It can not now be unraveled and lifted back up and repositioned due to muscle atrophy and scarring. To treat the contour defect my approach is to build up the temporal area with hydroxyapatite cement (temporal augmnentation) to replace the bulk that was once there from the muscle. This can be done through his existing scalp incision.
The drooping eyelid is a facial nerve issue for which there is restoration of the motor nerve function that was lost. That is treated like ptosis repair to lift up the eyelid to a better level to the upper rim of the iris of the eye.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in lip asymmetry surgery. I have upper and lower lip asymmetry. I have had it as long as I can remember. It is present when I am not smiling and becomes more so when I do smile. What can be done for it?
A: Thank you for sending your lip asymmetry pictures and lip asymmetry surgery objectives. In the rest position I can see a left upper lip asymmetry with less very vermilion exposure and the lower lip looks just fine. In animation the left upper lip asymmetry becomes more noticeable and the lower develops an asymmetry the left side of the lower lip staying in the same position while the right lower lip gets pulled down. (which is normal) The lower lip acts like a marginal mandibular nerve paresis where the depressor muscle is not working.
The two things you can do are a left upper lip vermilion advancement to correct the upper lip asymmetry. This will provide improvements at both rest and in animation. Since you can’t bring depressor muscle movement back into the left lower lip side, the initial treatment should be Botox injections into the right lower lip depressor muscle to se how much correction of the lower lip occurs in animation. If successful and the Botox proves that weakening the normal depressor action of the lower lip is effective, one can move on to having a subtotal depressor muscle resections done for a permanent effect.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in brow bone lowering. I would like a few changes on the upper eyelid or lower brow bone area of my face. I have attached an image below with the desired transformation. Do you believe that degree of change to be realistic for both eyes? If yes, would it be possible to do with some sort of upper eyelid filler? Would it be dangerous to inject in the inner eyelid corners as shown in the GIF image? Also, some eyelid surgeons claim filler in the upper eyelid tends to last for much longer time (2-3 years) compared to fillers injected in different areas of the face. Have you noticed so in your practice?
Thank you.
A: Your brow bone augmentation request is not rare in my young male facial reshaping experience. However brow bone (lowering via augmentatio is not possible with any method as you can not drive the eyebrows downward in any reliable and predictable fashion. This is not possible with filler, fat or even implants. That type of periorbital change is simply not an achievable goal. While brow bones can be augmented to create increased horizontal projection, make the soft tissues (eyebrow) to follow the augmented brow bone downward dress not happen
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Where are the incisions for lower eyelid surgery to remove excess skin? I’m 1/2 East Indian so culturally, I do not scar well. I had to get a complete hysterectomy a couple months ago and the scars on my stomach, albeit small, are darkened. I utilized silicon tape to flatten them but the 3 marks are still visible.I can’t have visible scars on my eyes. Just want to make sure this procedure can be done without leaving visible darkened marks.
A: Lower blepharoplasty incisions are placed right under the lashline of the lower eyelids. Regardless of ethnicity blepharoplasty incisions heal well because of the thinness of the skin and certainly can’t be compared to what happens in body areas below the neck like on the abdomen, back or extremities. Having made lower blepharoplasty incisions for a wide variety of reasons in darker skinned patinents, besides aging, I have not seen increased pigmentation of them. Nor have I see any adverse healing or hypertrophic scars from them. But your concerns are understandable as it would be with any incision on your face. But that being said, when in doubt, the safest course of action is to not make the incisions.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, For an endoscopic cranial cheeklift , is it possible to lift the cheeks vertically without an eyelid incision? My eyelid skin is quite thin and ideally I would not like them cut. How long is the cranial/temporal incision?
2) How many times have you performed this surgery on young individuals in the same situation? I’ve been consulting surgeons who have rejected me for any sort of resuspension or lifting due to my young age and have just been pointed to fillers, which is quite upsetting.
3) Are the sutures used in this surgery permanent or can dissolving sutures be used? Are they palpable in any way? I know endotine cheek lifts are an option but I do not think that work as well and am scared of the palpability due to my thin skin.
4) You’ve mentioned that two weeks would be the maximal recovery for swelling. I am planning to have this surgery done during my break which is just over a month and a couple weeks, but I would have limited time in Indiana as I am a non-American. Would it be possible for me to have the cheek resuspension surgery, wait out two weeks for majority of the swelling to dissolve, and then undergo a chin osteotomy procedure with my zygoma reduction surgeon back in my home country after the two weeks?
I understand it would be a lot of protracted swelling but is there any reason I cannot.
A: In answer to your endoscopic cranial cheeklift questions:
1) It is usually best to have a small incision at the eyelid so the subperiosteal dissection can be thoroughly completed and connect the tunnel between the skull and the intraoral incision for full cheek mobilization.
2) Most of these cranial suspended cheek lifts have been done on older patients. I have done only a handful on younger patients who have either had cheek implants removed or have had cheekbone reduction surgery.
3) The suspension sutures used are dissolvable.
4) I see no reason you can not have a chin osteotomy done two weeks after the procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was hoping to also ask you about paranasal implants. You are the only doctor I know of that does this surgery and I would be very interested to know if you think I might benefit from this? I have always disliked how the line between lips and the base of my nose recedes backwards. I have read a lot online about the maxilla bone and how this can grow forwards or down. My impression is faces are more attractive when the maxilla grows forward but mine seems to have grown down giving me a flatter face, but the surgery for shifting if forwards seems too serious for surgeons to do it for cosmetic reasons. Therefore I was very interested to read that you can place an implant in this area. Do you think this would work for me in addition to the other surgery we discussed?
A: In regards to midface augmentation at the paranasal level, you certainly have the face for it, meaning augmentation in this area of your faces would be aesthetically advantageous. Short of moving the teeth and upper lip forward, paranasal-maxillary augmentation (the proper term actually) creates the same effect as a LeFort 1 osteotomy advancement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have questions about skull implant scars. I need to discuss with you some concerns regarding the skull implant procedure, primarily I am worried about the size and position of the resulting scalp scar. Of course I understand that these probably won’t be known until you have the CT scans and design, however if you could provide an estimate of its size. Can measures be taken in the design to minimize the size of the incision and what effect would this have on the desired outcome? Just as a reminder, my desired outcome is to address the asymmetry of my head caused by the shallow depression down the right hand side.
A: It may or may not be a surprise to you that over 70% of all skull reshaping patients are men who either have thin hair, are bald, or shave their heads. As a result the location, size and methods used to close a scalp incision so the scar is as close to undetectable as possible is paramount in each and every one of them. No man wants to trade off one aesthetic head problem for another (scar) that would bother them just as much if not more than the original problem. Therefore, regardless of where the incision is located such attention to incisional detail is done in every case. The ultimate rest of that effort is determined by how many men who have had skull reshaping surgery in my experience have gone out to have a requested scalp scar revision…..zero.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, we communicated a few months ago and I wanted to give more time to heal from my sliding genioplasty that I had last year which was advanced 7mms. I still have substantial numbness on the right side of my chin/lip, though feeling seems to slowly be coming back. I’ve attached pictures to in attempt to illustrate my dislike of the results.
I am happy with the advancement, but feel I need some soft tissue repair. My chin drops below the bone when I smile, and feels tight at the incision. I have asymmetry with my bottom lip, left side lower, and lost volume. Lip feels stuck to gums, and mental labial fold too deep. All these issue also cause my chin to be too wide and round, and vertically long. I only had an advancement, no lengthening.
A: Thank you for sending all of your pictures. Your list of chin symptoms are the following:
Tight deeper labiomental fold
Incisional tightness
Lower lip asymmetry and less volume
Chin ptosis
Vertically long and rounder chin
I list these symptoms this way because some can be predicted for a sliding genioplasty and some can not.
All of the incisional and lower lip issues are not rare from an intraoral incision where the chin bone has been advanced and mechanically makes sense.
But when the chin bone is advanced the frontal appearance of the chin usually looks more narrow not more wide. It can become vertically longer if the bone was moved that way or can appear so because the chin is more narrow. Only a postop x-ray can determine the exact chin movement that was done.
I have never heard of or seen chin ptosis developing from a bony chin advancement because the chin tissues have never been detached from bottom of the bony chin and it is being advanced as well. I don’t think what you have is ptosis, just that with the chin bone being more prominent the soft tissues of the chin stick out more but they are not falling off of the bone so to speak.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in body contouring after weight loss of 75lbs after prior bariatric surgery. My desired breast look, which was once a size D cup, is to get back to the size I was before the weight loss. I want to get rid of the extra skin sag on stomach and belly button frowns. I do not want my inner thighs touching, thighs ripple and skin above knees. My butt sags and my back legs ripple. So I don’t know what procedure/ procedures would be best and most cost effective. The lower 360 degree lift? I’m 100% getting breast implants no matter what. The rest is just if I can afford. Thank You.
A:Thank you for sending all of your pictures, they are very helpful in determining what can and can not be done for your body contouring after weight loss. Based the description of your goals, I can make the following comments:
1) While breast implants will be needed to enlarge your breasts to the size you desire, the current state of your breast shape will require some form of a lift. They have sag and asymmetry and placing implants in them will just make them top heavy and drive the nipples down, a look that no patient will find very acceptable. Depending upon the size of implant needed, you would either have to have a breast lift first (with a larger implant) or a vertical lift can be done at the same time if a smaller implant is used.
2) A full tummy tuck is needed to get rid of the loose skin on the entire abdomen. This wold be combined with flank liposuction around the waistline into the back. The 360 circumferential tummy tuck is an option but the benefit of wrapping the skin cut out completely around your body is probably not worth the back part of it since its benefits on the back side would be very limited.
3) While thigh liposuction can be done, achieving an inner thigh gap is not possible. That is not a realistic goal for just about any patient whose thighs touch.
4) There are no effective treatments for thigh or back of leg rippling or skin above the knees, short of a knee lift. But that scar has to be considered very carefully.
In summary the two most effective procedures on you are your breasts and stomach. That is where the value of body contouring surgery is for you.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I see that skull-reshaping/augmentation is a specialty of ours. Can hairline lowering be done along with the skull augmentation. My complaints are: too high forehead as well as head shape too flat on top and in back. Concerns are that once scalp pulled forward, will there be enough room to actually add filler to skull area(s) in need.
A: It is not possible to perform skull augmentation and hairline lowering in the same patient, either together or separately. Skull augmentation needs more scalp to stretch over the implant and relies on scalp stretch to do so. Hairline lowering requires the scalp to stretch to move the hairline lower which also relies on scalp stretch. One procedure works directly against the other.They can not even be staged separately as again one works against the other. If you have a skull implant you will never be able to advance the hairline thereafter. If you have had a prior hairline advancement you will not be able to get even a small skull implant in place due to the tightness of the scalp tissues.. Both skull augmentations and hairline advancements need all the scalp stretch they can get to be effective.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have some questions about paranasal-maxillary implants.
1. Will the pyriform-paranasal implant offset the shadow created by my large (also high) cheekbones? My ultimate goal is to reduce the shadows on my face to a certain extent, if it can not be completely eliminate. During our consultation, I mentioned that I would like to have the ePTFE block carved into a shape not just cover the pyriform-paranasal area, but also slightly extend to the area that is around the bridge of my nose (not quite the whole cheek area but just a slight and natural extension).
2. If I decide not to get cheekbone reduction during the same surgery, can I still get it done after I am fully recovered from my pyriform-paranasal implant surgery? My main concern is the order of the surgery. I am fully aware of the risk of potential cheek sagging but wonder if getting pyriform-paranasal implant would have any negative impact on potentially getting further cheekbone reduction in the future?
3. If I decide to have the cheekbone reduction surgery at the same time, I wonder if you could share any before & after photos of patients who had done the same surgery with you? Do I need to speak with your patient concierge assistant to update the surgeries details and get an update quote? Or another virtual consultation needs to be done before that?
Thank you very much for your time in advance,
A: In newer to your paranasal-maxillary implants questions:
1) The paranasal-maxillary implant can be extended higher up along the pyriform aperture more towards the nose. That is one advantage of either preoperative custom designs or hand making the implants during surgery.
3) Having implants in does not preclude having a cheekbone reduction procedure later.
4) I will have my assistantpass along the updated quote.I have all the information I need to do so.. To respect patient confidentiality patient pictures are not passed out.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, As you are famous for your work with facial augmentation, I hope you can guide me in what to do in my current situation.
I underwent jaw shaving surgery overseas where my gonial angles were completely amputated. I could live with the results but I feel as if just a smidge more length would make me a lot happier with the results (not restoring the angle completely.) This is because from certain angles, especially in photographs, my jawline looks too unnaturally straight, the angle looks slightly too high, and makes my face shape slightly off-looking.
Specifically, I’m probably looking for no widening effect but maybe a vertical lengthening effect of between 0.5cm to 0.6cm at the very maximum. (I think this is small anyway)
In my home country, there is only one doctor who works with custom jaw implants but he lives on the other side of the country, and so I’m looking for alternatives before I decide whether or not it’s worth the effort to go there for such a small augmentation effect. The doctors who are closer to me do not offer jaw angle implants for the size I am looking for.
What options do I have to permanently achieve this augmentation without the use of custom/regular silicone implants? Are custom silicone implants the only way I can achieve the effect I am looking for? To be quite honest, I would just like a surgeon a bit more closer to home this time as not being close to my surgeon post-op after jaw shaving scared me quite a bit.
Is it possible for an ‘implant’ to be carved out of a hydroxyapatite block into shape that I need and stuck onto the bottom of the jawline?
Can granules be used for such a minor lengthening effect?
A: The simple answer to your question is that when you need to add length to the back of the jaw, you need a performed implant with a stable shape to do so. Small vertical lengthening jaw angle implants, which are preformed are exactly what you need to ‘cap’ the cut off part of the jaw angles.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I don’t think I want a reverse secondary tummy tuck, I really do not want the scar, so probably no need to come back in and have him evaluate that. I still want to fix the skin laxity above my belly button. You said we could do a full tummy tuck, but I want to get clarity on a few things before we go any further. During my last tummy tuck, the Dr cut my stalk and moved my belly button down, therefore I only have blood supply from my skin and because of that what complication can arise? Here are a few questions I have for you if you don’t mind passing along.
1. Since my belly button was cut from the stalk and moved, what are the chances of getting necrosis and my belly button dying ?
2. What can be done if it does die? What is the wound care process?
3. Can it be re-attached to the stalk during surgery?
4. What can be done to prevent my belly button dying?
5. If the risk of my belly button dying is too high, and I could be looking at months of wound care and belly button revisions, what are my other options to correct the aesthetics? Just liposuction and another mini?
6. I really want my loose skin fixed above the belly button, I just understandably do not want to lose my belly button. A: In answer to your belly button questions about further tummy tuck surgery
A: In answer to your secondary tummy tuck questions:
1) It is impossible to give an exact percentage of this potential risk. Suffice it to say it is not zero. But I would say it is more likely to survive than die
2) If it undergoes necrosis, the wound will have to go through the long healing process which will take a few months.
3) During a full tummy tuck, the existing outer belly button and its stalk are separated from the overlying skin which is removed and then a new hole made in the outer skin to bring it back through.
4) The only way to eliminate the risk of not having a belly button survival problem is to not do a full tummy tuck.
5) Liposuction and another mimi tummy tuck is the way to eliminate the risk of any belly button survival issues.
6) No one of course wants to lose their belly button. But given your prior tummy tuck history and your optimal aesthetic abdominal reshaping goals, that is the risk that has to be taken.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m a young male hoping to get some advice from you on a secondary genioplasty. I really respect your work and blog and appreciate you taking the time to inform the public on so many medical topics.
I’ve had a short chin growing up and by the time I was 21, I had saved enough to undergo a sliding genioplasty. The operation improved my profile by a mile. I wasn’t 100% happy with it but I could live with it, you know.
It’s been almost a year now, and I’ve lost a couple of pounds. I’ve lost some fat around the face and jaw and now I’m realizing that my chin is a lot narrower than I thought it was. I think the extra chub around my face was hiding the bony narrowness of the chin.
Now, I’m looking at this as a chance to undergo a secondary sliding genioplasty to maybe increase projection by just a couple more mm and widen the chin by maybe 6mm or so, so it isn’t as narrow.
I would like to stay away from implants and a submental approach wouldn’t work for me anyway. If I had to place an implant intraorally, I would much rather prefer just going through with a bony augmentation. Anyhow, I hope you can provide a response to my next questions as it would really easy the mind.
(1) Would it be safe to recut the mentalis muscle with a secondary sliding genioplasty and what are the risks? I know I shouldn’t be scarring the mentalis muscle if I can prevent it, but I would like further aesthetic improvement. I think I was one of the lucky ones to have no apparent aesthetic issues with my tissue and muscle after my surgery.
(2) My main worries are lip sagging, chin dimpling at rest, or mentalis muscle contracture. Am I at risk of this if I undergo a secondary procedure with the movements I am hoping for?
(3) If I were to widen my chin, logically there is excess bones at the side. Would this be palpable or can they be camouflaged with bone cement so it blends in with the jawline, instead of being burred down?
A: In answer to your secondary genioplasty questions:
1) The ideal and assisted method of changing the width of your chin would be a custom made implant to do it placed through an intraoral approach. This avoids a lot of potential contour problems from trying to make the chin bone do something that it can not do well. (widen the chin) It is the one dimensional change in a sliding genioplasty that the procedure does not do well because of the step-off created behind the wing and its widening effect will not flow evenly back along into the jawline.
2) That being said, a secondary genioplasty can be done to both bring it forward and widen the chin. While there is always a risk of some mentalis muscle or lower lip issues every time you do an intraoral approach, that seems to be more often caused by a technical issue not an inherent or inevitable part of the procedure.
3) In widening the chin with a sliding genioplasty it is important to angle the opening of the midline cut so that the side winds are placed more inward, this avoiding a major palpable step off. Bone cements are very difficult to make work inside a limited soft tissue tunnel. Such access does not favor their working properties.
Dr. Barry Eppley
Indianapolis Indiana
Q: Dr. Eppley, I am interested in a skull implant replacement., I have a question regarding a skull implant and the incision site. I had a silicone skull implant placed via a coronal incision last year. Unfortunately it hasn’t provided the desired aesthetic outcome for me. I am wanting it redone, I don’t feel it was big enough or the shape I want. However, I don’t want it to be placed via a coronal incision again, the scar and resultant hair loss is too noticeable. My question is, are you able to go in and remove and replace from a site lower on my head? Thank you.
A: I am not sure of the reason that a skull implant needs to be placed by a coronal incision as I have never found that necessary. But that issue aside, once you have the coronal incision there is no reason to use another incision as that just makes it a lot more difficult that it needs to be particularly with a larger implant. (you have to break through the scar capsule to expand the implant base) There should be no reason that hair loss occurs around a coronal incision and that undoubtably is a function of technique not an expected part of making a coronal incision. The second time you can also do a scar revision and make it look a lot better.
Usually one can double the size of the original skull implant the second time in a skull implant replacement procedure. But I would need to see the original design drawings of the first implant to provide a more qualified answer in that regard.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had varicocelectomy in 2014 and after swelling went down the scrotal skin never fully retracted. As a result I ended up with a small residual right hydrocele and a saggy scrotum. I am interested in getting the scrotal lift procedure. Does the fact that I have a small right hydrocele preclude me from getting the procedure done? Will it make sense to have a right hydrocelectomy first and then the scrotal lift?
A: You could have a scrotal lift with an indwelling hydrocoele. But if you knew that you were going to get a hydrocelectomy anyway, it would make the most sense to get it done first and do the scrotal lift second. Such surgery with the additional swelling may cause some additional skin stretch which may affect a scrotal lift adversely if it was done afterwards.
A scrotal lift is done by a midline frappe excision of tissues and brought together to create an upward lift and an overall tightening effect.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a graft taken from my left ear for nose reconstruction. While the left ear has healed well, it has left it deformed now being smaller and more bent in. Can anything be done to make it look more normal again. I have attached pictures comparing my left versus right ears.
A: Thank you for sending your ear pictures. You appear to have originally had a full thickness chondrocutaneous graft harvested from the root of the superior helical attachment of the left ear. This will create a expected vertical shortening of the height of the ear when it is put back together. While recreating that defect by reopening it and grafting it with a full thickness chondrocutaneous graft from the opposite ear is what ideally is needed for your ear reconstruction, the combination of creating a patch look to the reconstructed side and a similar defect on the other ear makes that approach completely undesirable/unacceptable.
Another ear reconstuction option is to add more vertical height to the superior helix just above the defect through either a small chondrocutaneous graft taken from the back of the normal ear which will leave no defect in its wake. Releasing the skin on the back of the helix and placing the graft from behind will raise up the height of the shortened superior helix to give the ear a more normal helical root appearance. The other option is to place a small cartilage graft our even a tubular implant under the helical rim skin to give it more height.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in liposuction for my man boobs, stomach and neck. I have several questions about the procedure.
1)Will removing fat cashew loose skin to develop after.
2) How long is the recovery?
3) When can I fly home?
4) How long do I have to wear the compression wrap?
5) When can I get back to working out?
6) How soon could I leave town after the surgery?
7) Well liposuction get rid of my man boobs?
Thank you!
A: In answer to your questions:
1) I don’t think you will on your chest and probably not in the waistline either.
2) Depending upon how you define recovery, I would say a few weeks. Although full aesthetic recovery takes (when the complete final aesthetic outcome is seen) takes about 2 months for any form of liposuction.
3) If you had some assistant you could get on the plane the next day after the surgery.
4) You wear the compression wrap until you feel they no longer are of any comfort benefit.
5) You return to working out when you feel comfortable to do. This will likely be about 3 weeks after the procedure.
6) You should be able to go home the following day if you are so motivated.
7) Liposuction is very good at getting rid of man boobs just like you have.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I need scar revision surgery. I have already had one procedure on my forehead to improve the look of the scar, but following the revision surgery (which was over two years ago) scar tissue slowly developed creating a deep crevice in the middle of my forehead. The crease is perfectly straight, which is very noticeable. My kids refer to it as the “butt crack” on my face. Attached are some photos.
My biggest concern is the “butt crack.” I am not sure if you can revise the scar to minimize the crease. I would actually prefer to have someone create a new incision where the crease is, remove some of the underlying bulging scar tissue, and then sew it up in a zig-zag pattern so that it is not so straight and noticeable and to prevent it from getting deeper in the future. IT would not bother me at all if some scar tissue developed under the “butt crack” to keep it from becoming a deep crease on my face again.
A: Thank you for sending your pictures. That is the type of glabellar forehead scar I have treated numerous times before. The reality is it is deceptively more difficult to make improvement than it seems because of its depth and the muscle contraction that runs perpendicular to it. Simple scar revision will not work as your own experience indicates. While a geometric excision and closure is needed for the skin, it is what is done underneath that will make the real difference in improvement. Volume needs to be added as well as muscle rearrangement. I usually do this by augmenting the bone with an ePTFE implant and excising and rearranging the muscle before the skin part of the scar revision procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 32 year old female. I have had bariatric surgery and have successfully lost 120lbs. 320 to 200 at 5’8 tall. And while I am very happy with my weight loss, I am left with a large amount of sagging skin in multiple areas, arms, back, breast, abdomen, and thighs. I believe that I would like to eventually seek an arm lift, breast lift with aug, TT with muscle repair, and thigh lift, possible liposuction to these areas, if needed to achieve best results. My question is, which of these procedures can be combined? What would you suggest as an approach. What is the consultation fee? Do you suggest I lose more weight?
Thank you for your input,
A: In answer to your post bariatric body contouring questions:
1) You want to maximize your weight loss before having any body contouring done…this always goes without saying. A weight loss of 120lbs is very impressive and you are to be congratulated. If significant more weight loss is your goal then you should do so. But if you are only going to lose another 10 or 20lbs at best then you can go ahead anytime with the surgery. In other words if you are at 85% to 90% of your weight loss goal, then it is Ok to process with surgery as that process will carry you the rest of the way with the final weight loss.
2) Many body contouring procedures can be combined. But for the purposes of recovery and to limit surgical risks, no one is going to have all their desired procedures in a single setting. Thus I tell patients to pick their top two procedures of most importance and do those first. In the last majority of cases patients often choose an extended tummy tuck and armlets as their top priorities. Your most important procedures may or may be the same.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a mini tummy tuck, I think. I am thin but after two pregnancies I have a lot of loose skin round my belly button. I also need a diastase’s muscle repair and possibly fixing an umbilical hernia as well. I have attached pictures for your review and recommendations.
A: Thank you for sending your pictures. While you may be small and thin, your abdominal problem is not ‘small’ and a mini-tummy tuck is not going to provide the type of improvement you probably seek.
You abdominal problem is a classic ‘tweaner’, meaning a mini-tummy tuck is inadequate and a full tummy tuck to really correct the problem has its own aesthetic distraction. What defines a mini vs a full tummy tuck is the decisional pattern of the skin/fat segment removed.This is illustrated in the attached images based own your abdomen. A mini tummy tuck removes a horizontal ellipse of tissue BELOW the belly button. This keeps the belly button attached to the skin, so no scar occurs around it but leaves all the loose skin and stretch marks around it or above the cut out area. While the pull down to close the tummy tuck does stretch out the tissue around there all still be stretch marks and some loose skin around the belly button in the end. The one advantage of the mini tummy tuck is that the scar is shorter and can sit lower, well within your pant or underwear line…but it does NOT correct the full extent o the abdominal problems.
The full tummy tuck provides the definite treatment by removing all of the loose skin and stretch marks by having the cut out pattern extend above the belly button. While providing the optimal removal of loose tissue, it does result in a scar around the belly button and a higher positioned and longer transverse tummy tuck.
As you can see there is no perfect tummy tuck for your abdominal concerns. You have to which of their liabilities is most acceptable to you….incomplete tissue removal of the mini tummy tuck or more scar from a full tummy tuck.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in secondary genioplasty surgery. I really hope you can help me out. I had jaw reduction in South Korea two months ago, where only the outer layer of my bone was cut off. I am grateful to myself that no bone angles were cut off but a problem I didn’t think I would encounter has arisen.
The back outer cortex part of the jaw was cut pretty evenly but I’m afraid I cant say the same for the sides of my chin. The right side is perfect and exactly the way I wanted it. However, the left side has been slightly more overshaven, and dents inwards, especially when I smile and the tissues are stretched back.
It’s especially visible in photos and makes my lower face look asymmetrical. I think if it was just slightly more built out, it would have been perfect. What options do I have to do this?
Is there some sort of permanent injectible filler or bone filler that could be used to just to build out this area very very slightly. It’s not a major augmentation but I would feel so much more at peace if it could be slightly more build out.
I know they use some sort of paste in sliding genioplastyto hide the notch or dent in the jawline. Can the same material be used to slightly build out the overshaven jaw cortex in this area?
A: To answer your question about secondary genioplasty surgery, a variety of materials can be used to fill in the dent behind the left side of your chin. An injectable approach will not work for a permanent effect since there are no truly effective and completely safe permanent injectable fillers. Hydroxyapatie cements or ePTFE sheets can be placed intraorally to build out the overshaved chin area.
Dr. Barry Eppley
Indianapolisk Indiana
Q: Dr. Eppley, I am roughly 8 weeks post op from zygoma reduction, buccal fat reduction, and genioplasty to reduce the width of my chin. I really hope you can help me out with some questions because my original surgeon is not being very helpful and is now unresponsive.
Prior to the surgeries, one of my cheekbones protruded more than the other, causing some facial asymmetry. But my doctor removed a wedge of bone of the same length from both sides of my face. Is it normal to reduce the left and right zygoma by the same length when the original cheekbones are obviously asymmetrical? Would this not just keep the asymmetry and push them in, so that it’s pushed in and asymmetric. Why wouldn’t different widths have been taken out.
What I’ve also noticed is that the side with the originally less protruded zygoma, is some asymmetric cheek fullness as well. When I smile it becomes very obvious. There is this deeply sunken in part right underneath the arch area of the zygoma and right in front of ear tragus and on the mandible area. Would this be from the zygoma reduction or the buccal fat pad removal?
I understand that there is definitely some residual swelling left but this has been extremely distressing. If this sunken in area persists, what should I do?
I’m not sure about whether I should fat graft the area, but I’m also worried about spending money on a procedure that can’t guarantee fat retention. Or is there some sort of permanent injectable that can be used to build out the area. I don’t need a specific shape like a cheek implant, but just like a slight pushing out of the area.
A: In answer to your after surgery zygoma reduction questions:
1) The specifics of your surgery are only known to your surgeon. That is his responsibility to explain what was done and why.
2) It will take a full is months to see the final result of your reshaped face and that should be taken into consideration when considering any revision.
3) Buccal fat removal will not cause any indentations back by the ear or underneath the zygomatic arch, that is caused by the bone reduction.
3) Fat injections, while not always predictable, are the safest soft tissue volumizing filler to use.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, My rhinoplasty questions are the following :
-Would my case be done with open or closed rhinoplasty?
-I think the tip is a very prominent part of the face and Im scared about the tip looking stitched or asymmetric. Is it possible to deproject the nose without touching the tip with the surgical knife? With tip I mean the part that is colored in pink in the photo “tip photo”.
-Which are the chances that a second surgery would be needed?
-Is it possible to achieve a reduction like the modified photo compared to the original photo?
-Would it be necessary in my case a graft in the tip or in another part?In which part?
A: Thank you for your inquiry. Unfortunately all of your pictures dd not come through so I can not make an assessment of how realistic an imaging or ideal goals are. But to answer your specific rhinoplasty questions:
1) Am open rhinoplasty approach is needed. Deprojecting any nose is not a rhinoplasty technique that lends itself to favorable closed rhinoplasty results.
2) I do not know what you mean by ‘deprojecting the tip without touching it with a knife’. That statement is an oxymoron as only surgery can change the projection of the tip of the nose.
3) With most forms of tip modification it is almost always best to at least place a columellar strut graft to maintain the shape and projection of the reshaped tip.
4) The general revision rate in rhinoplasty averages around 15% but that number is influenced by what type of rhinoplasty or nasal shape changes are being done.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am very interested in a custom skull implant done. It has been bothering for as long as I can remember. I do have a few general questions for you (I hope that you don’t mind):
1) What is the recovery time?
2) Can the entire procedure be done in one session? I live in California, as you know, and it would be difficult for me to travel back to Indianapolis for follow-up treatment(s) or visit(s).
3) How big will the prospective scar be on the back of my head?
4) any potential hair loss?
5) will my head be shaved for the procedure?
6) any side effects or potential issues that I should be aware of?
7) will the implant be secure — if for example, I fall, etc., is it prone to move if significant pressure is placed on it?
8) is 15 mm a decent sized implant? I.e., will my head be round.
9) How much does the procedure cost — total?
10) will the implant last long / forever?
A: In answer to your custom skull implant questions:
1) Most patients are well recovered in two weeks or less.
2) Patients get their 3D CT scan where they live. They only come in one time for the actual surgery.
3) It is a fine line incision usually about 9 cms long placed low in the occipital hairline.
4) These scalp scars usually heal remarkably well with no hair loss.
5) No hair shaving is necessary.
6) No adverse side effects have yet be seen.
7) The implant is never going to move from its healed position on the skull.
8) a 15mm is the maximum projection that can be achieved given the limits of the scalp to stretch in a single procedure. It certainly be a lot more round than it is now.
9) My assistant has been instructed to pass the cost of the surgery on to you.
10) The implant will last forever, it can never degrade or break down or need to be replaced.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I received a large chin implant about 5 months ago, but I am still not quite happy with the projection. I’m looking to achieve a more angular, masculine face and feel I could use some length at the bottom of my face in addition to projection. Attached are my before and after pictures.
I’d like to explore a sliding genioplasty in addition to buccal fat removal and would love your opinion.
A: While a sliding genioplasty will bring your chin further forward and even provide some vertical lengthening, be aware that will make your chin look more narrow in the front view. This would be contradictory to your goals of a more angular/masculine lower facial appearance, you need to see the side profile changes as well as a chin/jawline widening effect in the front view. This is not what a sliding genioplasty can do. While a sliding genioplasty is a very versatile chin reshaping procedure, it can not address all dimensional changes of the chin.
Dr. Barry Eppley
Indianapolis, Indiana