Your Questions
Your Questions
Q: Dr. Eppley,Is there a difference between submental liposuction and submental lipectomy? Do you perform both procedures if this is the case?
A:Technically there is a difference between submental liposuction and submental lipectomy. Submental liposuction, as the name implies, removes fat between the skin and the platysmal muscle by vacuum extraction using a cannula. (like any traditional lipouction only using a smaller cannula) Submental lipectomy is the direct excision of central fat beneath the platysmal muscle. in the midline The combination of submental lipectomy and submental liposuction is always part of the procedure known as a submentoplasty. A submentoplasty is a more aggressive form of neck contouring that also include platysma muscle tightening.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Regarding limitations in the size of facial implants, such as chin implants, would the skin not eventually stretch, gradually, to accomodate the implant? That is to say, have you ever had someone get an implant, wait a year, get a larger implant, or is this irrational? Would the tissues simply become too tight regardless of how long was waited? I know, for example, that as people get fat, their skin extends generally regardless of how fat they get. Is there not the same potential for cosmetic implants? Is there any experimental work being done in this area?
A:It is very common that patients unintentionally undergo a first stage tissue expansion procedure (placement of an initial implant) for a second larger facial implant later. They get one implant size today and then may decide later they want it bigger…which is not a problem to do.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am writing this email in regards to the query regarding the custom jaw implants. I had a V-line surgery done around 3 years ago in Korea and since then I have almost lost my jawline definition. I am looking to reverse this surgery dr. Probably around in coming 1-2 months or as soon as I get a leave from work.Actually my question is not regarding the custom jawline implant but regarding the possible implications of it on my future surgery. Actually I am scheduled to get a Lefort 1/ Upper jaw surgery. Its ONLY an upper jaw surgery but not a double jaw surgery. Currently I am undergoing orthodontics and it is scheduled for Summer, 2020. My maxillofacial surgeon is very confident that it is only going to be upper jaw surgery with some setback and Clockwise rotation with some posterior impaction. He said that he won’t touch my lower jaw at all. So my questions are:
1.Is it possible that I can get a custom jaw implant to reverse my V-line surgery and for jawline augmentation in upcoming August/September 2019 and then still in 2020 can go upper jaw surgery only for my maxilla without any compromising effects on my jaw implant.
2.Will the custom jaw implant create any hindrance if my maxilla is impacted/rotated or setback or if it has to be removed during my maxilla surgery.
3.Can I get a custom jaw implant now on my mandible but still in future can undergo ONLY upper jaw surgery without any problem.
Thank you so very much for your time Dr. I am really looking forward to get my custom jaw implant with you. My basis of this query is just that as I can get leave now from work and I would like to get my custom jaw implant with you now as I really dislike my un-defined jawline. Looking forward to hear from you soon.
A:Thank you for your inquiry and detailing your issues and upcoming maxillary surgery in 2020. I think all of your three questions revolve around the same issue…can a jawline implant interfere with any aspect of a subsequent LeFort 1 osteotomy? And the answer to that would be no. As long as you know that you are not going to need bimaxillary orthognathic surgery, then placing a custom jawline implant will be just fine.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Is a direct temple lift the same or different than an endoscopic browlift? Or I assume the direct temple lift pulls the tail vertically while the endoscopic browlift pulls the whole brow up to the hairline.
A: There are differences between a direct temple lift and an endoscopic browlift. An endoscopic browlift uses 4 scalp incisions (2 parasagittal and 2 temporal) to create a total brow lifting effect. Conversely a direct temple lift uses an incision either at the tail of the eyebrow hairline, at the edge of the temporal hairline or back in the temporal hairline to create a tail of the brow lift. Most commonly the incision is placed at the edge of the superior temporal hairline which lifts the tail of the brow in a 45 to 60 degree angulation upward.
The combination of a lateral cantoplasty and a direct temple lift is the most powerful technique for creating an upward sweep or angulation to the outer eye area.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, this is about mouth widening surgery, I saw online about a question about how mouth widening surgery can improve the length of the mouth and Dr. Eppley answered about 5mm on both sides of mouth, Is that right? I don’t see how wider the mouth can get without cutting too far into the muscle which can be dangerous.
A: All mouth widening surgery involves removing a wedge of orbicularis oris muscle as that this is a necessity to help prevent relapse. There is nothing dangerous about such muscle manipulation/removal. This is a small wedge of the lateral aspect of the muscle which has no functional significance.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in eyelid surgery to correct negative canthal tilt. I know lateral canthopexy can be done to raise the lateral canthus but i also need the medial canthus to be lowered in both eyes. I talked to one doctor who told me it is impossible to do. I started researching this and found many articles on the topic that have been published throughout the years. All of them describe methods and techniques for reattaching the medial canthal tendon. When i sent one of those articles to the surgeon he told me those techniques do work but they’re only for “medical problems”. I even saw a video of of the procedure being done. I e-mailed another surgeon asking him if it is possible to do and i suggested cutting the bone to which the tendon is attached and moving it down then fixing it in that position. I asked him if that would work and he said that it would and that he’s done things like that before. I just don’t see any reason why this can be done for people who have severe skull fractures/shattered orbitals but not people who are perfectly normal? Is it possible to do or is it impossible? I’m confused and just looking for a real explanation.
A: Medial canthoplasty is a far more challenging procedure than lateral canthoplasty due to the more limited access of the inner eye and the very thin bones to which the tendon is attached. It is also a procedure that is far less successful as a result. While attempting to do it for reconstructive purposes has merit, manipulation of the medial canthal tendon for aesthetic purposes must be considered far more carefully. I would doubt that moving the inner corner of the eye down will be successful if attempted by trying to move the medial canthal tendon downward. The bones of the medial orbital wall are very thin due to the sinus cavity that lies on the other side. This makes secure fixation very difficult. If the goal is to move the inner corner of the eye downward boy a few millimeters it would far more sense to do so by skin manipulation such as a small z-plasty. It would be more effective and incur none of the risks of destabilizing the medial canthal tendon attachments.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m interested in jawline custom implants but what material does the you use?
A: A custom jawline implant can be made by a variety or materials from solid silicone, Medpor, PEEK or titanium. I am not married to any of them, ultimately that is the patient’s choice. However they are not all equal, meaning there are major differences in cost, how they would be placed (one piece or sectioned into multiple pieces) as well as the size of the incisions to place them. The reason solid silicone is chosen by most patients is its lower cost, ability be placed as a single unified implant and the smaller incisions used to place it. But I have had lots of patients who have chosen other more expensive materials and had equally satisfactory results.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Thank you for the detailed reply and the options therein. When considering the submentoplasty procedure for neck sagging problem, my questions/concerns are as follows:
Putting aside (for the mpment) the expense of the work needed, there is, for me, the more difficult or challenging elements of having the work done without it being readily identifiable as someone who’s ‘had some work done’.
Can the procedure described be done in stages so as to minimize its obviousness? In the closing paragraph of your last email it appears that you are alluding to a sequence of steps, could those steps be the thresholds for a series of successive procedures or are they too intrinsically woven to be approached separately ?
It’s important to me that my friends and family think I’ve just had a vacation, fallen in love, or gotten laid properly (or all three) when they first see me after the operation.
Additionally, I’d like to know what the pain management path is; would I be put out for the operation, is the time envelope for the work an hour or two, or significantly more? In terms of pain management history, I have had some oral surgery and dental implants over the course of a few decades and have always insisted on anesthesia – not the local variety, but rather being put out by an attendant Anesthesiologist.
Logistical speaking, do I need to be swaddled in bandages fo a day, or three, or a week or more ? Travel considerations ?Time of year ?
A: In answer to your submentoplasty questions:
1) The concept of someone wanting to have facial work down and not looking like work has been done is not an issue you should be concerned with given the type of procedure you are considering. By definition a submentoplasty procedure simply can not look overdone. Its real issue is whether it can fully address your neck concerns. So the potential issue is really the opposite of what you think….not looking overdone but can it do enough to satisfactorily improve the problem. If you remember my discussion of your options, the ideal treatment for your neck concerns is a lower facelift. You just may not be ready to undergo that effort at this time.
2) The submentoplasty includes all three components that I discussed which have to be done at the same time. There is no benefit to staging them from a result or recovery standpoint.
3) Changes in the neck are not really noticeable to other people as a specific identifiable change as people are not that perceptive. They may only ‘notice’ as some type of overlay beneficial change.
4) This is not an operation that is associated with much pain as most facial/neck procedures have low levels of discomfort.
5) Such procedures are done under general anesthesia.
6) There is a chin/neck strap applied for one day after surgery. Thereafter its use is optional.
7) You could return home 1 to 2 days after surgery.
8) The best time to is such surgery is when it suits your schedule the best. Time of year and weather make no difference.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, My paranasal-premaxillary area is very recessed. I was wondering If is it possible to do paranasal-premaxillary augmentation with fat grafting. I know that peri-pyriform implants exist, but I want to know If fat grafting can achieve 4mm or more augmentation. Thank you Dr.
A:Thank you for your inquiry. Can fat grafting be done to the midface and can an initial 4mm paranasal-premaxillary augmentation be achieved….the answer would be yes. The question is not whether fat grafting can be done to the midface but whether it would be successful. (i.e., survive) My experience and the observation from patients who had it done by other doctors is that the survival rates are low. There is also the issue that, even if it survives with some reasonable volume, the look is often more of a bloated/full one and not that of a skeletal augmentation effect which is the source of the problem. Once fat grafts are in there should the look be undesired there is no good way to remove the fat.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have crater chest deformity. I had not long ago had gynecomastia reduction surgery and it’s gone horribly wrong. My nipples are caved in and they are partially black. I am devastated. What do I do now?
A: Thank you for the clarifications and sending your pictures. What you have is an over resection of tissue through an open gynecomastia reduction approach that has left both a crater deformity as well as partial nipple-areolar necrosis. While I don’t know exactly how long ago the surgery was I would suspect on the appearance of the nipple-areolar complexes that it as just a few weeks at longest.
Your options at this point are the following:
1) Let the extent of the crater deformity and nipple-areolar necrosis declare itself (the extent iof the contour deformity and how much the nipple-areolar complex will survive) over the next few months and then treat secondarily with fat grafting and nipple-areolar scar revision, or
2) Undergo immediate injectable fat grafting to help restore the contour and possibly limit the extent of the nipple-areolar tissue loss. (what is black is likely full-thickness tissue loss) This still may require some revision later but by adding healthy tissue back in with some stem cells it will expedite the healing process as well as provide some early contour improvement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m contacting youfAfter reading your answer on Real Self. I am very much worried as I had a terrible otoplasty that left my ears over pinned (3 months ago), it is a true nightmare as I asked the doctor not to do it!!! I am just curious about any possibility to make my ears stick out again. You wrote that the ears can stick out again trough an incisión of the scar tissue that is holding the ears folded. Is this enough or do we have to mold the cartílage again?What could you recommend me to do? Doctor used Stenstrom technique with one absorbable stitch per ear. Thank you.
A: It is unlikely that just release of the sutures will make the ear come back out as the memory of the cartilage is now lost at three months after surgery. That only works in the first few weeks after surgery. It now requires a tissue bank cartilage graft to hold the ear back out once it is released. That is the fundamental principle of a reverse otoplasty.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have had eyelid surgery before. I had festoons so to get rid of them the Dr. pulled my lower eyelids and now they bow. I look Asian now. I would like to put in an orbital rim implant and small lower cheek implant. I also have one eye that looks closed and i am not sure if because pulling on lower is forcing upper down. My questions are:
1) Can we add a orbital implant under eyes plus lower cheek bone implant to add fullness because I look caved in?
2) Can you make me look less Chinese and have an eye shape like I had before?
3) Can you work on upper lid so it doesn’t look like my eye is closing and maybe work on one or both upper lids? I have big scars and hopefully can reduce scars??? After surgeries and healing occurs can have scar reduction surgery???
A: Thank you for your inquiry and describing your eyelid concerns. By your description you had an aggressive lower eyelid procedure in an effort to ‘lift out’ the festoons. (which is very prone to lower eyelid ectropion problems) The bowing down is the rounding of the lower eyelids due to loss of vertical height. The upper eyelid issue is a bit unclear to me. But I will need to see pictures of your eye area to provide a more qualified opinion. Until then I can answer your questions as follows:
1) An infraorbital rim-malar combined implant can treat the caved in look which is the result of inadequate volume.
2) To get your eyes back to normal and less deformed, it will require a combination of #1 and lower eyelid reconstruction with spacer grafts for the lower lids and lateral canthopexy.
3) I am as yet unclear about your upper eyelids so I shall wait to comment until I have seen pictures of them.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 55 year-old make and I am interested in reducing the sagging underneath my chin (upper neck area – below the jaw)
A: Thank you for sending your pictures. You have the classic beginning of a neck sag with a central band of tissue running down the center of the neck between the chin and close to the sternal notch. Of all the tissues in the neck that can sag, this type of neck band is largely skin. This is a what I call a ‘tweener’ neck contouring problem. Meaning if was more severe you would absolutely need a lower facelift/necklift and if it was less severe perhaps liposuction alone may be adequate.
While it is important to point out that a lower facelift/necklift is the definitive treatment for your neck problem, I will make the assumption that you may not be committed to going quite that ‘far’ just yet. A direct necklift would also be tremendously effective but you are too young to do well with a central vertical neck scar in place of the central neck band.
Thus this leaves the submentoplasty procedure as the most viable option. One trough a small incision under the chin it is a three level central neck contouring procedure consisting of a combined liposuction above the platysma muscle, direct removal of subplatysmal fat and plastyma muscle plication or corseting…all done with the neck reshaping intent of improving the cervicomental angle.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a very tiny 28 year old who is constantly mistaken for being 15. I have a 32AA cup size, and my torso goes straight up and down with no curves. My hips do not curve out more than my waist. In addition, I am also 5ft tall so my ribs are only about 3/4 of an inch above my iliac crest. Because of this, I believe I have no inward curve of my waist. Rather than implanting silicone to fill my bust, I feel I would be more confident with a rib removal to enhance a curve and make my waist skinnier than my hips. I do not believe I need a tummy tuck. I have a tiny bit of fat on my rectus abdominus, external obliques, and lower back combined. But my waist circumference is 29 and my hips are 33. I only weigh 103 lbs while I am 5ft0in tall so I do not have a lot of fat. My stomach does protrude past my flat chest into a bit of what looks like bloating, but I always have this shape. I have visible abdominal muscles below my tiny bit of fat, which is why I don’t think I would need a tummy tuck.
Two questions:
1) Do you think rib removal without a tummy tuck would give me more of a womanly shape (smaller waist to hip ratio)? Where would the scars be and how big without a tummy tuck?
2) Do you think I am chronically bloated or store more fat internally (greater omentum) rather than on top of my abs? Like I said I am only 103 lbs, 5ft. 29 inch waist and 33inch hips. but my stomach protrudes almost looking like I am 3 months pregnant perhaps. I have also been told by my parents that this “protruded stomach body shape” runs in the family and is thought to be Lordosis. Could this really be the case?
A: Thank you for your inquiry and providing the details of your body shape and objectives to which I can make the following comments:
1) Rib removal for horizontal waistline reduction is done through small (4.5 cms) oblique back incisions and removes ribs #11 and 12 and usually #10 as well. This is never performed through a tummy tuck as these ribs are not reachable from that anterior approach.
2) The type of rib removals done through a tummy tuck approach are the anterior subcostal rib cage margins of ribs #7, 8 and 9 and is done for subcostal rib protrusions not horizontal waistline reduction.
3) Very thin and petite women are one of the major patient groups that seek out rib removal surgery for the exact reasons you have described….to provide some inward curve to an otherwise straight torso.
4) Being thin and virtually having no breast tissue, even low weight females can have a pseudo abdominal pooch. It would be exacerbated by a lordotic condition for sure. Whether that applies to you I can say since I do not know what your body exactly looks like.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, My face has a lot of asymmetry to it. One eyebrow is significantly higher than the other. My chin points more in one direction. It almost appears as though one part of my face stopped growing with the other half. I had braces a while back, and I remember having a pretty dramatic shift in my teeth (bracket came out of holder). My TMJ worsened, and I believe it all goes hand in hand. I was told this couldn’t be fixed because it was a vertical bony orbit asymmetry.
A: Thank you for your inquiry and sending your pictures. You have a right-sided facial hypoplasia which is most manifest at the north (eye) and south (chin) ends. The most significant component of your facial asymmetry is your vertical orbital dystopia (VOD) and the surrounding changes that come with it from a lower orbital box. (lower brow bone and eyebrows, lower upper eyelid, lower globe position, lower orbital rim and smaller cheek)
It is not an accurate statement that it ‘can’t be fixed’. While perfect eye symmetry may not be achievable, significant improvements can usually be obtained. The first step in the diagnosis and treatment planning process is a 3D CT scan which will clearly show the bony differences and what can be done to improve them.
Dr. Barry Eppley
Indianapolis, Indiana