Your Questions
Your Questions
Q: Dr. Eppley, I was wondering about sliding genioplasty. is it possible to get sliding genioplasty that will heal without a stair step? For example this video shows that after the bone heals there is a ‘stair step’ in the chin.
Finally, I am looking to fly in next year for surgeries. Is it possible to get hooded fat grafting, rhinoplasty, and genioplasty all at once?
A: In answer to your questions:
1) Every sliding genioplasty has a bone step deformity whose magnitude depends on how much the chin is advanced. The only way to make that heal so there is not a step is to bone graft it at the same time.
2) It is common to combine upper blepharoplasty, rhinoplasty and sliding genioplasty all during the same surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have pockets of fat around my mouth that have been there since I was a kid. I’m 24 now and I have been self conscious about them for years. Could you help me? I read about Perioral Mound Microliposuction -could you perform this on me?
A: Thank you for your inquiry and sending those pictures. You do have some subcutaneous fat collections around the mouth area for which microcannula liposuction is one treatment option for it. Other non-surgical treatment options are Kybella injections and radiofrequency skin tightening treatments (e.g., Exilis, Ulthera) whose side effects are fat loss. (which in your case is their benefit) No matter which treatment approach is done it is not an easy problem to improve. Having done lots of perioral liposuction surgeries improvements are always seen but some patients (about 50%) may need a second procedure to maximize the result to improve any asymmetries or further reduction that is needed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I suffer from vertical orbital dystopia, my left eye being slightly lower than my right. I have been told bone contouring of the upper left eye orbit would help with the asymmetry, bringing both my upper orbits to to the same level. Also fillers and possibly an implant under the left eye, to bring the eye up slightly to more the same level.
This is an issue that has destroyed my whole life, please would it be possible to help. It is insane how no oculoplastic surgeons seem to offer the treatment you do and seem completely ignorant about it.
A: Thank you for your inquiry and sending your picture. With what appears to be about a 5mm vertical orbital dystopia, that is within the range of being treatable by orbital floor-rim implant augmentation as well as supraorbital rim bone reshaping. To determine the exact treatment plan you would need to get a 3D CT scan of your orbits which will provide the accurate information as to how to exactly proceed down to the millimeter level.
Having treated numerous cases just like yours, good improvement is possible. You may never get the eyes perfectly level (there are limits as to how much the eye can be safely raised) but visible improvement is possible nonetheless.
I will have my assistant pass along a document which will describe how to find a place locally to have the 3D CT scan for which we can then provide the order to the chosen facility for you to get the scan.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m interested in having rhinoplasty and am wondering if my goals for the procedure are achievable.
1 – My nose looks better when I flare my nostrils vs when they are at rest. When flared, my nostrils are lifted and take on more of a “v” shape than an “m” shape. I would like my nose to look like it does when flared but at rest. Aside from that, i would also like to have my nose made smaller while avoiding the typical things that can be seen in ethnic rhinoplasty, such as: triangular nostrils, a “pinched” tip, nostrils that are far bigger than the tip etc. In other words, i just want to look natural. I’m fine with just a modest size reduction, I’m more concerned with shape than size.
2 – I’d also like for the columella/bottom of the nose to be made fuller/longer and for the nose itself to be lengthened by a few millimeters. I’ve included one picture to illustrate the “ideal” nose and how the bottom part of it is fuller than mine. There is one more picture that shows a perfection mask based on the golden ratio placed over my nose. This is just to highlight the imperfections.
Are any of these things achievable through surgery? Would you mind creating a morph that illustrates how close my nose could be made to what I have described here?
Thank you for reading.
A: Thank you for your inquiry and sending your pictures. In terms of your aesthetic goals, some of them are incongruent with others. With your thick nasal skin the goals of making your nostrils more flared and the tip longer does not mesh with an overall goal of making the nose also smaller. You may be able to give it a better shape but not truly accomplish much of a size reduction. With your thick nasal skin there would never be a concern about having a pinched tip or sharp triangular shape to it..
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, As far as calf implants are concerned, is it going to be OK to walk in the airport to go home eight days after surgery? Just want to make sure? Is it OK to walk on calf implants 8 days later?
A: The key in calf implant augmentation recovery is early mobilization and rehabilitation. Calf implants are just like breast or buttock implants….it is a surgery that causes muscle trauma/injury. Stretching the muscle out is how one recovers sooner rather than later. You can’t hurt the implant, it is just sitting on top of the muscle. It takes a few days after surgery before one starts the stretching when it becomes more comfortable to do so. So walking on them is started long before the one week after surgery time.
Knowing your physical condition I would say this would probably not be a big problem even when combined with hip implants.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, In doing some research on chin reduction, I discovered you are an expert and I’m hoping to get a second opinion on a chin reduction surgery. I had jaw realignment surgery and chin burring done over 10 years ago to address a problem with my bite, as well as the fact that my chin grew longer on one side. I’m very happy with the surgery and it did a lot to improve the asymmetry. However, there was still some leftover asymmetry in the chin, especially when viewed from underneath that continued to bother me. For that reason, about three years ago, I had a revision. The surgeon reviewed my case and recommended additional burring. I also asked him if it would be possible to narrow the chin slightly at the same time, as this was something I had also wanted for cosmetic reasons. However, since having the revision, I haven’t noticed an improvement in the asymmetry and my chin is now dimpled in areas (even when relaxed). I’ve been told to get filler as a correction, but since a reduction and narrowing was my initial goal, I’m reluctant to consider filler long term.
At this stage, I’m wondering two things. First, I’m wondering if my desired “after” goal was realistic (I’ve attached a photo of the before/desired and actual result). Perhaps the goal was never truly achievable, which would help me manage my expectations.
And second, I’m wondering if there’s anything apart from fillers that could help the dimpling at this stage.
I’m attaching photos because I had filler done about 8 months ago, that has masked the problem area, so I’m not sure to the extent a skype consultation would be helpful at this point. The filler is dissipating, but I’m unhappy with continuing it, as I my original goal was a smaller, narrower chin, rather than a larger one.
I really appreciate your help, and look forwarding to hearing from you.
A: Thank you for your inquiry, detailing your history and sending your pictures. In answer to your chin reduction revision questions:
1) Your original aesthetic goal was never achievable, at least by burring. That was the worst choice of all available chin reduction/reshaping techniques. They detaching of the soft tissues and the lost of support volume creates the soft tissue contraction….which you see as dimpling.
2) Other than fat grafting, which will make your chin bigger/wider, there is no permanent and effective cure for your chin dimpling.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 28 year-old female and have been struggling very hard from scarring after a too-harsh dermatologic treatment many, many years ago. As a red-blonde I was treated with TCA peeling 30% and prescribed Vitamin A creme. This must have been too much for my thin and sensitive skin. I ended up with scarring on my chin. The upper layer of skin has changed structurally. Really tough to treat and after having sought out help from renowned dermatologists, there is really nothing more we can do.
As the scarring is only in the lower third of chin I came up with an idea: couldn’t we first remove the scarred skin while performing a sort of chin reduction procedure and afterwards elongate it back to its former shape or even a bit longer (which would suit my round face shape)?
Is that even possible? I really don’t want to make things worse.
A: Thank you for your inquiry and detailed history on your chin scarring. What you are describing would be very ill-advised. The scarring that would result from excising the scarred skin segment would be far worse than whatever the chin looks like now. In addition, if that segment of chin pad was excised you could never re-establish the lost chin length.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had multiple custom PEEK facial implants with another surgeonI have soft tissue problems now. Attached are videos showing face now and implants used. My problems now are:
- chin ptosis/lip incompetence after implant removal
- masseter not attached to mandible border
- temple hollowing
- lateral canthus hollowing
Can you tell me what can you do to correct these problems?
A: In answer to your custom facial implant revision questions:
Besides the chin and lower lip incompetence issue, what you have in all three other areas is the almost expected sequelae of placing larger implants made out of a very stiff material that lacks feather edging…as the material does not permit it. It requires feather edging int the designs to not show the outline of the implants where they transition into the natural bone in the thinner tissues of the face above the jawline. Some of your issues are also a matter of implant design as they all look very bulky and lack a natural transition into the surrounding bone…a common design flaw. As a result you have the following:
1) Masseter Muscle Dehiscence – this is the result of over stripping of the soft tissue attachments which often needs to be done to place larger stiffer material jaw angle implants. This is also a risk when the implant design extends beyond the natural posterolateral jaw angle border. I ave seen it many times and trying to reposition the muscle back over the implant has a very low change of success and involves a neck scar. I have found it more productive to place a soft tissue jaw angle implant over the deficiency muscle area right under the skin in the subcutaneous plane.
2) Temporal Hollowing – This has occurred because there is now a mismatch between the ends of the brow bone implants and the temples and may also have occurred as a result of some stripping of the termporalis fascia and muscle along the anterior temporal lines near the brows. To improve that the brow-temporal disproportion a combination of feathering of the tail of the brow bone implant with adjacent temporal augmentation is needed.
3) Infraorbital Hollows – This is a design flaw with lack of bringing the implant design further up along the lateral orbital rim. When you augment the infraorbital and cheek area that much, the implant design must go up into the lateral orbital rims to create a natural transition. Otherwise this will create an infraorbital hollows as you now have. That can be treated by adding a lateral orbital rim implant to fill in the ‘defect.
4) Lower Lip Incompetence – I am presuming you had = a chin implant removed and now have this problem. When the chin loses structural support, the vestibule and lower lip will contract down lower than its normal position. This may or may not be associated with actual chin pad ptosis.. Beyond replacing the chin implant, soft tissue treatment options include mentalis muscle resuspension and/or fat grafting.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have some questions about rib removal surgery and hip implants which are as follows:
Do you think the below change is achievable? (See photos, i would like the area circled in red reduced, not below)
Is there a risk of hitting any organs or key arteries?
Other than bleeding and infection, are there any other risks?
How long after until can work out my upper body and abs?
Would you combine rib removal with any liposuction ?
Hip implants – I have almost no fat on my hip dips – might the implants show through? Might hip implants interfere with my buttock implants? (I intend to augment the buttock implants in 9 months)
How common is hip implant migration?
How soon after rib & hip combined can I fly home?
Cost of rib removal alone, and rib + hip implants?
Thank you!
A: Thank you for sending your rib removal and hip implant questions:
1) I believe the result for rib removal surgery you have shown is exactly what can be accomplished. If I had to image it myself that is exactly what I would have shown.
2) There is no risk of hitting any organs or major arteries. They are nonsuch structures in the path of dissection, Rib removal surgery remains a highly misunderstood surgery.
3) I have never seen any complications from rib removal surgery, including infection and bleeding. Despite how the procedure seems to the uninformed, it is a very low risk surgery.
4) When you return to working out after rib removal or hip implants is going to be in the 3 to 4 week range…and this is more to prevent seroma formation from the hip implants and has nothing really to do with rib removal.
5) Many rib removals do also consist of flank liposuction since one is in the prone position for the surgery and this is a very advantageous position for maximizing flank liposuction.
6) The key to not showing edges in hip implants is a custom design so that hey have very feathered edging. If you just use standard buttock implants for the hips (as some surgeons do) you will see the outline of the implants in thin patients.
7) The pocket locations for hip and buttock implants are quite different and do not overlap or interfere with each other.
8) I have never seen hip implant migration. This is probable because of their custom design and the use of perfusion holes in them…design features which mitigate against that potential issue.
9) Returning home after these combined surgeries is merely a matter of comfort as well as whether you are by yourself or coming alone. But one average it would be 5 to 7 days after surgery.
10) My assistant Camille will pass along the cost of the surgery to you later today.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had an Implantech anatomical size small chin implant placed last year. It was placed off center and it is very noticeable. I had a sliding genioplasty more than ten years ago. The doctor blames my crooked implant on the brackets. He injected Juvaderm a few weeks ago on the left to make it look less crooked. It didn’t work. I like the height of the profile and the projection but from a front view it looks really bad. Do you think the vertically lengthening implant will also cover my prejowl sulcus and not look too boxy.
A: Thank you for sending your pictures and x-rays. Trying to place a standard chin implant on a bone based that is irregular is always a recipe for further aesthetic issues. if you look at your x-ray you can see that your original sliding genioplasty has uneven bone cuts on both sides. This combined with the indwelling metal plate and screws makes for an irregular bone surface to place any implant. While a chin implant can still be done it requires removing the existing plate and screws (if not overgrown with bone), shaving the sides of the chin bone to make it even and then placing an implant.
Trying to use an implant to cover up the prejowl sulcus or bony indentation from the sliding genioplasty, by definition, will make your chin wider.
Those comments aside before you do any further surgery you should have a 3D CT scan done on your chin/lower jaw (CBCT scan) so that it is very clear what the bone, metal hardware and current chin implant look like and how they all translate to your outer appearance. One should not guess or eyeball it when the the bony anatomy has been previously altered. You are proof of what seems like a simple chin augmentation procedure can create an ‘unexpected’ asymmetric result.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Speaking hypothetically, if one wanted to augment a part of their jawline or even their whole jawline with Mimix hydroxyapatite bone cement, would that be an issue,from a vascular standpoint? Would the blood supply to the bone be jeopardized?
A: Concerns about the blood supply to the bone by performing jawline augmentation with bone cement is irrelevant as it has a rich blood supply from its endosteal intrabony source. What would be a concern, and a 100% probability of problems, would be the irregularities and overall lack of a successful and smooth jawline augmentation result from trying to apply a bone paste through the limited exposure of acceptable extra- and intraoral incisions.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Please note I have breast implants, butt implants (2 months ago, revision operation) and liposuction to the lower back. I want the hourglass shape of small waist and rounded hips, but don’t have enough fat for transfer. Perhaps hip implants could be an option to fill the dips?
A: Thank you for sending all of your pictures. Given your slender frame it is certainly true that the only options for further waistline reduction and hip augmentation would be rib removal and implants for the hip dips which could be done at the same time.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have been treated for facial asymmetry due to hemifacial microsomia with a cheek and eye implant, browlift and a jaw implant and genioplasty for the left side of my face. Despite these efforts, there is still some asymmetry which is not insignificant, particularly around the left brow, forehead, temple and cheek area.
I have spoken to a number of cosmetic and reconstructive surgeons who have said that there is not much that they can do except for soft tissue fillers which I don’t think will address the underlying skeletal asymmetry.
I was hoping to get your opinion and perhaps, given you area of expertise, this would be something you can help with.
A: Thank you for your inquiry and detailing your surgical history. To provide a qualified opinion it would require an assessment of a combination of current facial pictures with a 3D CT scan. No one could say what is possible by merely looking at you on the outside. It requires knowing what your underlying facial skeletal structure looks like, particularly given what has been done previously, and matching that with your external appearance. Then a fully informed recommendation can be given for further facial asymmetry correction.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m a 31 year-old mother of 3. I’ve been quite unhappy with my body for awhile now, mainly my butt (or lack-thereof) and have been dreaming of the day that I’d be able to get a procedure done that would make my butt more plump & round… and today’s that day! I’m so excited to make the first step towards happiness! I’m extremely interested in getting a butt augmentation done and would love to meet with you and see what options I have.
Here are some pictures of my buttocks from different angles as well as a picture of my tummy. I’m not sure if I mentioned it but instead of just inquiring about a buttock augmentation, I now would much rather prefer the Mommy Makeover! Although instead of a breast augmentation , I just want to downsize from 36D to 36 full C & would probably need a breast lift as well. But you know best, so I’ll let you make that decision. I have included a front and side picture of those as well. I look forward to getting a consultation date set, as well as hearing your opinion on what procedure you think would work best for my body.
A: Thank you for sending all of your body pictures to which I can make the following body contouring (Mommy Makeover) comments:
1) BREASTS – while you certainly can have a small breast reduction/lift, I would carefully consider whether the scars that would result in doing so. That is your personal decision but I would look carefully at these scars in other patients to be sure the breast shape change is worth that aesthetic tradeoff.
2) BUTTOCKS – you don’t have enough fat to harvest to do a significant or reliable buttock augmentation. Thus you would need to have buttock implants. Whether the size they could achieve would meet your aesthetic expectations remains to be determined and would need further input from you in that regard.
3) ABDOMEN – you would best be served by a mini-abdominoplasty with umbilical float and flank liposuction as your abdominal reshaping procedure.
My assistant Camille will contact you on Monday to schedule an office consultation time.
Dr. Barry Eppley
Indianapolis, Indiana