Your Questions
Your Questions
Q: Dr. Eppley, I was interested in the perioral and buccal lipectomies as well as a revision sliding genioplasty to add just a tiny bit more projection (3mm or so), as well as a platysmaplasty to refine the jawline. I was wondering if the chin were to be advanced more, could we fill in part of the labiomental fold with HA paste to prevent a deep crease there? Thanks!
A:Typically I would fill in the step of a sliding genioplasty with allogeneic bone particles which will ultimately become ingrown with bone. HA paste, an older form of bony augmentation which is synthetic, has largely been relegated to historical significance given the lack of manufacturers who make the particles. HA bone cements are also an option but due their high cost and lack of bony ingrowth would be inferior in my opinion to allogeneic (tissue bank) bone particles.
Dr. Barry Eppley
Indianapolis Indiana
Q: Dr. Eppley, I have noticed patients gaining shoulder width on each shoulder by 3cm using implants.
1) Do the implants stay in place during your entire life?
2) what happens when you gwt the implants done and then start exercising afterwards and start gaining muscle on the deltoids? will that not arise problems?
A: You are referring to deltoid implants, also known as shoulder widening implants, of which the most common widths are 1.5 cms or less per side. In answer to your questions:
1) Like all implants placed in the body, deltoid implants become surrounded by scar tissue (encapsulated) which holds the implant in position lifelong.
2) Like all muscle implants, most of which sit on top of the muscle and under its fascia, they are carried outward in an uncomplicated fashion with any increase in the size of the muscle.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have make bimaxillary and sliding genioplasty orthognathic surgery and you can see in the photo the final result.
When mouth is closed I can accept it, when I open the mouth and the TMJ work its like I don’t like my surgery result as it immediately appears with a double chin, superior lip have problem specially in the attachment with the nose, inferior lips don t have the necessary bone support and give me stupid expression, finally even the cheeks are floppy.
Thank you.
A: Thank you for sending your pictures and x-rays. As best as I can tell from them and reading your concerns, you have aesthetic satisfaction with the mouth closed but not with opening.This is completely normal as orthognathic surgery is done for the static closed mouth position as this helps set the jaws in alignment. Surgery is not done for how it may look in opening as the facial soft tissue changes with that movement. This is not abnormal nor is there anything wrong. You may benefit by other soft tissue procedures which were not meant to be done at they same time as your orthognathic surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Can I ask three questions about temporal reduction surgery? I have wide head.
1: Can you scrape the bones under the muscles of the temporal region? I learned temporal muscle reduction surgery by reading your articles as it will work for making head width more narrow.
https://exploreplasticsurgery.com/anterior-vs-posterior-temporal-reduction-for-head-width-narrowing/
To be honest my case is so severe that I wonder if scraping the bone as well as anterior and posterior muscle reduction is needed.
My back head (especially right side) is flat so here is needed to insert an implant. This is why my face bone is totally weird, not only back but also side,around the top of the head as well.
2. Can I take consultants with you face to face? I know I can take it with virtually but I hope I can take face to face consultation with you.
I never mind extra fees.
3: Do you use plastic surgery simulator for computer?
A: In answer to your temporal reduction questions:
1) Bore reduction can be done as well as muscles reduction but to do so that will change the location of the incision from behind the ear to the side of the head.
2) I will have my assistant Camille contact you to schedule an office face to face consultation time.
3) I always use computer imaging to try and demonstrate potential results.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Recently, I did a V line jaw reduction – an osteotomy and shaving of the mandible and a genioplasty. I had a fat graft to my temples too! However, I’ve been breaking out quite a bit. I was hoping to take Accutane to alleviate this. It has been almost a month since my surgery. I was wondering when it is safe for me to take it? I’m also really really afraid my bones are going to grow back after the jaw reduction as I’m very young.
Also, I’m interested in an Asian blepharoplasty + ptosis correction and an undereye fat graft with you. How long should I wait after I finish Accutane?
A: It is perfectly fine to take Accutane one month after such facial hone surgery. I would wait until you are off Accutane for three months until proceeding with the blepharoplasty and fat grafting procedures. While Accutane primary affects the healing of epidermal wounds (and the evidence for this effect is questionable) in theory it does not affect they healing of tissues such as muscle, fat and bone. But it is always better to be conservative particularly in regards to elective facial surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m interested in reshaping my face with you making it more attractive and add angularity. I’ve been told I have thick soft tissue resulting in weak contours so I was wondering if I can thin the soft tissue. The side of my face is convex but I want more of a concave side, as shown in the picture because I heard the implant stretches the tissue. Would this be achievable with a jaw implant alone if widening the gonials. Thank you
A: Unless your face has that concave look initially, no form of jaw implant is going to have that effect. The tissue stretching effect of a jawline implant is on that of the neck not the face. That is where the pull off the soft tissues is affected. It may help a loose or saggy beck as it pulls the neck tissues up as the lower and outer border of the lower jaw is expanded.
Similarly any ability to get a more concave face requires direct defatting of it and some form of cheek augmentation above it to have any chance of that type of facial reshaping effect.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I saw your website allows free consultations/questions about plastic surgery. And I was curious about a singular calf implant.
I was born with club foot but after correction the mass in my right leg developed different from the left. It was much smaller but over the years I have made major progress but I know it will never be equal. I am in my mid 20’s and live a very active life. And wanted to know if a calf implant can handle such a lifestyle. From hiking, wakeboarding, marathons and mixed martial arts and things like of that nature; without risk of popping or shifting. I’ve read there are different types of implants such as soft and solid silicone etc and which would be better suited for activity.
I know the recovery time can be a little long but I would be willing to wait as long as possible to guarantee results.
A: Thank you for your inquiry. Clubfoot is the most common reason for the use of a unilateral or solitary calf implant. A calf implant is composed of an ultrasoft but solid silicone that will last a lifetime and can withstand any type of physical exertion or trauma.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m interested in undergoing a full skull reshaping procedure that would include brow reduction and forehead reshaping (with potentially a hairline advancement as well) as well as back of the skull implants for a flat back of the head. I would need to fly in for this procedure so I was wondering if the entire surgery from consultation to procedure could be done in one trip? If so, how many days would I be flying in for and when would appointments be available for the surgery? I was hoping I could get an overall cost estimate as well for the procedures I listed if possible. Thank you.
A: Thank you for your inquiry. I will have my assistant Camille contact you to schedule a virtual consultation time to review some basic concepts about your skull shape needs and how to achieve them.
The concept of a hairline advancement with any form of skull augmentation is contradictory. Hairline advancements base their success upon having the scalp mobility to shift the hairline forward/lower. Conversely occipital augmentation needs scalp to allow it to be expanded from underneath. Thus you can’t do both at the same time. To do all that you have mentioned would require a two stage approach with all frontal procedures done first and any occipital augmentation done later.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I recently had a lower jaw advancement but it did not change my chin like I thought it would. Can you look at my pictures and records and tell me what you would recommend for further facial/chin improvement.
A: Thank you for sending your records. What that show me is the following:
1) You have a Class II bite relationship with a horizontal and vertical lower jaw deficiency for which the lower jaw advancement (BSSO) was an indicated procedure.
2) While the BSSO brought the lower jaw forward it was unable to correct the vertical deficiency at the chin.
3) While you did not state what your aesthetic concerns were with the outcome my assumption is that that you feel the chin stick out too far and has bunched up the soft tissue chin pad. This is because the vertical shortness of the chin remains unaddressed.
4) I would think the correct approach would be to vertically lengthen your chin which would improve your facial balance, setback the chin back a bit and unravel the bunched up soft tissue chin pad. (vertical lengthening bony genioplasty)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am considering custom jawline implant with you that wraps around the whole including chin. I am wondering if widening my mandible would stretch the soft tissue and make my cheeks appear slightly hollow. Could you look at my photo and the model to see if my goal is possible with the jawline implant alone. Thank you.
A: That is an easy question to answer…which is no. A custom jawline implant by itself will not make the cheeks more hollow. Even with every cheek procedure that is available (buccal lipectomies and perioral liposuction) such a cheek effect is not going to happen in you. That is not a realistic goal with your natural facial shape. What those models have that you don’t have is cheeks. You have to have the facial defatting procedures and the addition of cheeks to get close to that type of facia shape change.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’ve seen your article about testicular wraparound implants.
It seems to be a very interesting alternative to standard half curved implants that always looks to be a bit easy to detect.
How many patients have you already implanted that kind of implants?
No blood circulation issues or decrease of sperm due to maybe hotter testicle temperature du to implant?
How much did it will cost to have that surgery done?
Thank you in advance and have a nice day.
A: In answer to your custom testicular wraparound implant questions:
1) I have performed six such cases or twelve total implants.
2) Since the testicle is dissected out on its neurovascular pedicle before placing it inside the implant, no circulatory or testicular survival issues would be expected.
3) I can not speak to the issue of sperm counts as that is not a preoperative or postoperative test that is done. In any such patients that have been implanted they have all been older (greater than 50 years of age so viable sperm was not a concern to them)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, My height 5’1 weight 102 Ibs. I’m a short torso
want to get rid of hip dips and want to know which procedure is the best for me?
Questions:
1) How long should I stay in Indianapolis?
2.) If I had consultation for first time after that, how long does it take time to customize implant?
3.) Does hip implant and rib removal are the best way to give my body hourglass figure?
Thank you.
A: Thank you for your inquiry and sending your pictures to which I can make the following comments:
1) While it is good to have well defined goals, the ideal images you have provided are not ones that are realistic with your body or can be done in a safe manner. I have attached a realistic imaging prediction based on rib removal and custom hip implants of what can be achieved in the effort to give you more of an hourglass shape.
2) The lead time for manufacturing of custom hip implants is three weeks. What I do is have a virtual consultation with the patients where measurements are shown how to be done from which I develop the implant dimensions based on that discussion.
3) I would say give yourself 10 days to be here before returning home.
Dr. Barry Eppley
Indianapolis Indiana
Q: Dr. Eppley, First off, my desired surgery objective is still this: a more symmetrical, fuller, rounder head shape, with no (or very minimal) impact to hair follicles and craniofacial health.
With this aim, here are some questions I’d like to have your views on. I really appreciate your time to attend this email. Thank you Dr. Eppley!
1. About screws
I learned that in most cases, screws are used in order to stably attach an implant to one’s skull. These photos show how they look: https://exploreplasticsurgery.com/wp-content/uploads/2018/09/Screw-Fixation-of-Custom-Occipital-Plagiocephaly-Skull-Implant-intraop-Dr-Barry-Eppley-Indianapolis.jpg
What is the material of the screws, 100% titanium?
Are they screwed into the skull bone?
If so how deep do they go?
Are there chances that the way the screws are drilled does harm to one’s brain in particular, or to one’s health in general?
Are screws detectable when the person is going through a security check/scan, for example, at airport customs or other similar sort of checks in public places?
Is there other attachment methods that don’t use screws?
If using screw is the best option, why?
2. Implant material
In one of your articles, it says “Total skull enlargement and augmentation can be done using either bone cements or a custom implant”
Which method should I choose and why?
Will an implant with either method cause migraine and headache to a patient?
Does the procedure cause hair follicle damage (consequently causing hair loss) post-operation, in short-term or permanently?
Is there things that I can’t do due to having an implant on my skull, for example, some intense sports, pressure massage on the scalp, or other strength and movement placed on the head?
Will either material cause problems or discomfort feelings when I am in hot temperature, for example in a sauna, or tropical summer climate with 40+ degrees, and in icy cold environment, say winter in North Canada?
What is the worst case of side effect caused by implant material?
One of your articles talks about injectable bone cement. https://exploreplasticsurgery.com/product-review-osteovation-injectable-bone-cement-small-skull-contouring/
For my case, is there benefit of using injectable bone cement, compared to custom implant(s)? Why?
3. Pieces of implant
In one of your articles, it says “A large custom skull implant replacement requires a two piece design approach to keep the scalp incision more limited.”
For my case, would you recommend to have 1 or 2 pieces (known as geometric split implant insertion technique?)? Why or why not?
Where is recommended for the incision?
4. Design and desired shape
I could see this case study has some similarities to what my shape issue is and what the outcome could be. I may prefer a rounder shape outcome instead of square shape in this example though.
May I know what are the parts that I will be invovled during the design stage?
I know there requires doing 3D CT scan, discussing on a design, and maybe other parts?
I currently live outside the U.S., but I can consider to come to the U.S. during the design stage, if this is necessary to help create a better design. Do you think this is necessary? Where is it better to do the required 3D CT Scan, in Australia or the U.S.?
5. About first stage scalp expansion
My understanding is that it is very similar (or just the same) to a regular augmentation procedure. The only difference is that by doing it, it is assumed that there will be a second time procedure with the aim to further enlarge the implant size/volume. Therefore, a “first stage scalp expansion” itself is a separate, complete skull reshaping procedure, and after that, whether or not one pursues a second surgery is optional.
Is my understanding correct?
As the ideal scenario is that my shape problem could be solved fully (or to a high level of satisfaction) through one single surgery, so I’d like to find out more specifications of the design during the design stage. I can’t wait to get to that stage : )
6. About potential removal
Are there common reasons that one needs to remove an implant during later stage in their lives?
If needed, can a removal be done, and is there major risk from a removal?
7. Other questions
How long do you suggest me to stay in the U.S., for best catering to the designing stage and recovering from surgery?
What is the earliest procedure date can be booked, if you have information on this?
Is there recommendations on budget accommodations?
Thank you for your attention. I really hope all goes well on your side. Speak soon!
A: In answer to your skull augmentation questions:
1) Screws are made of titanium and are self-drilled into the skull to a depth of about 2mms. They are not detectable by an airport scanner.
2) Custom skull implants made of solid silicone are the superior augmentation method because they are premade based on the patients’s 3D CT scan and can be placed through much smaller scalp incisions than the full coronal scalp incisions that bone cements require. Because they are placed down the bone level they have no adverse effects one the hair follicles or hair growth.
3) A first stage scalp expansion is needed of the patient requires more than a 125 to 150cc volume of implant augmentation.
4) The shape of the custom skull implant can be whatever the patient wants since it is predesigned from a 3D CT scan which the patient gets in their geographic location. All imlpant design planning can be done remotely.
5) Whether a first stage scalp expansion is needed is based on the patient’s aesthetic desires. (how much augmentation do they want and what are they willing to go through to get it)
6) A custom silicone skull implant is easily rempved/reversed if desired.
7) Most patients return home 2 to 3 days after surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Thanks again for all your help, Dr. Eppley. I just wanted to update you that I recently had an overnight sleep study. If I have sleep apnea, as the oral surgeon suspects due to my airway, we will move forward with jaw surgery to address the airway and also do a genioplasty. If I don’t have sleep apnea, then only genioplasty. He feels the lower jaw could be extended regardless, but double jaw surgery only if there is sleep apnea.
I just had a question, though, which you’re the expert in. Let’s say I have jaw surgery for the sleep apnea and combine the genioplasty with it. If I’m still not satisfied with the width of my lower jaw, are mandibular angle implants s even possible? I know you recommended a staged approach, but I wondered if it even possible to augment a jaw after it’s gone through jaw surgery. The narrowness of my lower jaw concerns me.
A: Yon can always do mandibular angle implants after BSSO surgery. That is very commonly done and up to 1/3 of jaw angle and custom jawline implant patients have had prior orthognathic surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a deformed forehead. My brow bones are sticking out and the bulge is very prominent.I am hereby sharing the photographs
I would like to know if it is possible to shave the brow bone partially through incision below the brows as I don’t want to go for scalp incision due to receding hair line and possible scar formation post surgery
My expectation from this surgery is reduction in the deformity and not to get a perfect look. Also, the bulge above left brow is more prominent than right which looks even worse. I would like to know if that can be shaved off to bring down to the size of right bone.
A: Thank you for your inquiry and sending your pictures. You have major brow bone protrusion. An effective reduction can not be done by just shaving the bone (it is too thin), it will require bone flap removal and setback. The more pertinent question, however, is the surgical access to it if any scalp incision is eliminated as an option. An incision would to be made at the eyebrow level. Whether that is made just at the hairline at the bottom or top edge of the brow bone can be debated but I would prefer the bottom edge of the eyebrow hairs.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have differences in the shape of my buttocks with the left being lower than the right. I was told that a buttock lift would be need to improve the asymmetry at the bottom.
How familiar are you with the procedure? I’ve read that trying to fix something like my case is 85% more likely to make the problem worse due to fat distribution. I would just like your professional reassurance as to how you would avoid making the problem worse. Thank you.
A: Your right buttock has a lower infragluteal fold than that of the left. Thus a left infragluteal or buttock tuck is needed to raise the lower side to match better with the higher right side.
I have performed lower buttock tucks for almost 30 years. In so doing I have never seen or would understand how it is likely to create an ‘85% risk of making the problem worse’. That is not a pertinent question or a relevant likely outcome. The real question is whether the fine line scar along the new raised infragluteal crease is a worthy tradeoff in the correction of your buttock asymmetry.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, If you remove tons of facial bone and end up with sagging soft tissue, is there a limit to how much of that soft tissue you can “clean” up? Would any patient who is motivated and willing enough, eventually able to remove enough of the soft tissue to the point where it would nicely fit the new smaller facial bones?
A: Unlike removing bone, adjusting the soft tissue to fit the smaller bone is not so simple. All that can be done is a variety of facial lifting procedures to try and address it…which may our may not be as effective as one would like after facial bone reduction surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I know you’re one of the top surgeons in the USA for revision. I had my nose job (primary) about 1.5 years ago. I’m satisfied however I notice a bump – ball lump like feeling on the side of my nose tip. I do not know if this is common. I read that it isn’t cartilage coming out as usually does shows after 3-6 weeks post op and not 1 year post up and plus. Do your patients usually get these or have these and is it due to maybe an acne or thick pore build up? What’s the resolution that you would do for this. If I took a photo you wouldn’t see it as when I put my finger on the side of my nose tip I can feel like a small ball. I attached a photo to show the area.
However I’m thinking it could be a epidermoid cyst tip of nose. How do you remove these without any scarring?
A: Just based on this one picture it is more likely that you are seeing the cartilage underneath the skin. It can take 1 or 2 years sometimes after a rhinoplasty for the fine details of the shrink wrap effect of the the tissues to reveal the underlying osteocartilaginous anatomy particularly in the tip area. It would be very unlikely that a dermoid cyst could occur from an open rhinoplasty….not impossible but I have never seen it or heard of it occurring. Undermining the skin would not be a mechanism for its occurrence. Until proven otherwise I would assume this is due to the same of the underlying lower alar cartilage.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I think cheekbone reductions is tricky. I would like them a slimmer, but I also would like to maintain the current natural “curve” of the zygomatic body and arch I currently have. I am not intimately familiar with all the various cheekbone osteotomy procedures, but I know the ones popularized in Korea are the L and U shaped oseotomies. I have also attached photos of people I think who have gotten such reductions that reflect the results I would like to achieve. I think my overarching goal there being to maintain the natural “curve” and protrusion of the cheekbones despite the reduction. My questions here:
a) Which variation of cheekbone osteotomy would you recommend so I can do more research? Pointers to any publications would be appreciated!
b) Would your recommended procedure also affect my anterior cheekbone projection?
c) Is there imaging and preplanning here to plan the cuts as to protect the facial nerve?
As for risk factors In my research, the main complications seem to be facial sagging and bone integrity issues (non-union) after cheekbone osteotomy. So my questions here are:
a) As compared to genioplasty, how often do you perform of cheekbone osteotomies?
b) What is the relative complication/satisfaction rate for each?
c) Has the technique for cheekbone osteotomy been changing recently or has it been the same technique used for a number of years? Based on the literature, it seems cheekbone osteotomy is a relatively recent technique that’s constantly undergoing new innovations, which makes me concerned about the stability of the outcomes.
Sorry for all the questions, and thanks again for the time!
A: In answer to your cheekbone reduction questions:
1) In cheekbone reduction osteotomies you never lose the natural curve of the zygomatic arch as the osteotomies are done in front of and behind the curve of the arch.
2) The L-shaped anterior cheek bone reduction osteotomy is the most common osteotomy pattern used.
3) I have performed many cheekbone reduction osteotomy surgeries in both Asian and Non-Asian patients. But by comparison chin osteotomies are more commonly requested and performed.
6) While there are many subtle variations in technique whose clinical relevance can be debated, the fundamental concepts of anterior zygomatic body and posterior arch osteotomies with plate fixation has remained the same.
7) A preoperative 3D CT scan is required before any form of facial bone surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, If we were to impact the maxilla (LeFort 1), I understand the septum would also be trimmed by the corresponding amount. Wouldn’t this result in some shortening at least (perhaps not the full extent of the impacted amount )? Or is this largely variable and dependent mostly on how the soft tissue responds ? Even if post maxillary impaction, there is little or no shortening of the midface (brow to nose tip), if this is followed with rhinoplasty, does this actually increase the amount of shortening the nose can get (frontal view ) since the nasal cavity now is actually a little shorter ? (Septum trimmed by impacted amount and maxilla moved up wards )
Many thanks for your time
A: I am not sure I understand your question as it relates to ‘shortening’ whether this means midface shortening or nose shortening. But assuming it is the latter the nose will not shorten in height or length and make even make the nose look larger/longer. This is because no matter what is done wirh the underlying framework you still have the soft tissue coverage which is not changing. While it is tempting to view these concepts of facial change as a mathematical or from an engineering approach, that is not how the face will respond as it is not a 1:1 correlation. The soft tissue coverage must be accounted for and not being a hard structure its responses are not completely predictable.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m interested in custom midface implants, infraorbital malar implants, zygomatic arch process… etc. Whichever best suits my face. My midface is flat, cheeks sit low, and my under eye area is droopy. I want a fuller midface, higher cheeks, and support for my under eye area. A more youthful and prettier heart shaped face.
My questions are:
What is the estimated cost of custom implants like these?
Will they help support my cheeks from future sagging?
How much downtime is needed during recovery?
My age is 24, and I can provide pictures for reference.
Thank you.
A: Thank you for your inquiry. By your description it sounds like you need an infraorbital-malar-maxillary implant design to which I can make the following general responses to your questions:
1) My assistant Camille will pass along the cost of the surgery to you later today.
2) Such an implant will provided enhanced soft tissue support that will help decrease cheek sagging that would otherwise occur more severely without such added support.
3) Downtime from almost any facial surgery is primarily related to the postoperative swelling and its impact on your appearance. Most patients needs at least 10 to 14 days if not longer until they may feel more comfortable being in public. But the total resolution of all significant swelling really takes 6 to 8 weeks to occur at a minimum.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Approximately two years ago I had a rhinoplasty surgery at your clinic and the results are amazing. I love the way my nose now looks. However, a few months after the surgery, the skin around my nose (in all of the spots that sinuses are located) started to become inflamed. Every few weeks the skin becomes inflamed and peels off. I’ve been seeing many different doctors repeatedly and it has left them all baffled. They’ve decided it’s not acne or allergies, have tried treating me for bacterial infections and viruses as well as ran blood work and determined I don’t have HSV. Could my nose/body have possibly healed incorrectly and be causing the issue?
A: Thank you for your long-term followup. Having done many rhinoplasty procedures over the past 25 years, this is a postoperative development that I have never seen or heard of before. Problems in rhinoplasty healing, which is very rare due to the superb blood supply of the nose, affect the nasal skin directly…not off the nose to the sides. The fact that this developed months after the surgery also speaks to that it is not a nose healing issue as such problems would have developed right after surgery and appeared right on the nose. I wish I had a better answer for you that could solve your problem but I am like all the other doctors you have seen….baffled for an explanation as to the cause.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have 420cc silicone implants. I have had them in for 9 years. Before I had them done I was a B cup, I am now a DD/E cup. I am 27 and 5ft 7inches height, I have had one child breastfed for two months. I hate the size and want to go back to my natural breast but my main worry is will I have enough natural breast tissue and will the skin be extremely loose? I have gone from clothes size 8 to 12 over the years.
A: The most important concept to understand is that removal of breast implants in anyone is not going to return you to the breast shape that you had before they were implanted. Going from a B to DD cup and having a child that you breastfed all means that you will have exactly the problems that you fear….loose skin with less breast tissue that you had before these events. There are unavoidable sequelae of the tissue expansion effect created by the implant and having a pregnancy.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m 21 years old and I have been losing my hair rather dramatically in the last year or so. This wouldn’t bother me that much as I always knew I would, but my head is asymmetrical. The right side of my head above my ear extends further out than the left side, and the right side of my forehead extends forward more than the left. I was wondering what the cost of a temporal reduction surgery would be for just one side, and what surgery you would recommend for the front.
Thanks!
A: By your description the temporal reduction procedures sounds appropriate for the right protrusion above your ears. While the forehead can be reduced by bone reduction, the problem is the need for a more visible scalp[ incision to do so. Whether that is a worthy tradeoff would depend on the magnitude of the right frontal protrusion.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I recently read about masseter muscle reattachment after mandibular angle surgery as one of my own patients has presented with masseter muscle disinsertion on the right side after revision of his mandibular angle implants performed in January of this year.
Recognizing your expertise in jaw implant surgery, I am hoping that you can help me by commenting on whether you are using a similar operative repair technique as what I read in the article and/or or whether you have any additional pearls of wisdom for successfully performing this reconstructive surgery.
In your experience, how often does masseter muscle retraction occur following mandibular angle implant placement and how can I prevent this from occurring in the future?
Have you generally found it necessary to remove the existing implant at the time of masseter muscle reattachment?
How many (and what type of) sutures do you generally place in order to resecure the masseter muscle to the mandibular bone?
Do you augment the repair with Alloderm or temporalis fascia?
Is botox treatment of the retracted masseter muscle a possible alternative to surgery?
A: In answer to your questions:
1) I have not found the masseter muscle reattachment procedure particularly effective. When combined with having to place a neck scar to do so, I rarely ever perform it anymore.
2) I treat the soft tissue jaw angle defect today with either the subcutaneous placement of thick Alloderm, perforated ePTFE sheeting or custom made ultrasoft silicone jaw angle implants. This camouflage approach has proven to be far more effective in my hands. This can be done through a less than 1 cm skin incision right over the angle edge.
3) Some patients may merit treatment of the retracted bulge of the muscle with Botox.
4) In terms of prevention, very careful subperiosteal elevation along the inferior border beginning anteriorly at the body of the mandible back around the angle is needed. This technique is far more gentler than the standard stripping done for a sagittal split osteotomy. This will prevent most masseter muscle detachment issues.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, My face looks swollen and fatter. How can I achieve a chiseled face look and get better defined facial look. I have attached some pictures of me to review.
A: Thank you for sending your pictures. Compared to many patients with darker skin pigmentation your tissues are not quite as thick as I suspected they would be. What you do have is vertical facial shortening of the lower third of your face with a flat mandibular plane. As a result there are some positive things you can do to your face including vertical chin lengthening and/or total jawline vertical lengthening combined with buccal lipectomies and possibly cheek augmentation. Stretching out the lower third of the face and adding highlights at the ‘five corners’ (cheeks, chin and jaw angles) is what can make a face more angular.
Many men seek a more chiseled face. But surgically achieving it in the way now may want it is often not possible. The men who get closer to a more chiseled face are those that already have a thin face where skeletal augmentation of the cheeks, chin and jaw angles is best revealed. Defatting a face alone rarely if ever achieve much increased definition. Facial defatting should be looked at as a complementary procedure to changing the shape of the facial bones.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’d writing to inquire about a few procedures with Dr. Eppley. I’m wondering if you can tell me the cost of each as well as answer some questions I have. I am transsexual so have to plan these around some other surgeries, both time-wise and financially. I expect I wouldn’t be able to do this probably until early next year, hopefully as my last surgery.
1)Clavicle reduction. How much length can you take off? What is involved with recovery?
2) Rib removal. Can you estimate how much it takes off the circumference of the waist Are there ever issues with soft tissue laxity?
3) Lateral Orbital Rim Reduction. I read on your website this can be done using an intraoral incision. I’ve already had a hairline incision during FFS and one hair transplant with another coming soon so would rather not have a coronal incision on top of it, especially because I would expect shock loss. I’m planning on having fat transferred to my temples soon as they’re very depressed. Do you think this will also reduce the appearance of the lateral orbit? I’ve attached a photo where the light catches it on one side and you can see the silhouette of it on the other.
A: Thank you for your inquiry. In answer to your questions:
1) In shoulder reduction surgery a 2 cm (one inch) segment is taken fro each clavicle. Recovery is somewhat similar to a broken clavicle with the exception that there is two of them.
2) Patients report a 1 to 3 inch reduction in circumferential waistline measurements. No on has ever indicated that it has caused a soft tissue laxity problem.
3) Lateral orbital rim reduction can not be done using an intraoral incision, that requires a more direct eyelid incision. There is always a chance that temporal augmentation can make the lateral orbital rims either diminished or no longer visible.
4) I will have my assistant Camille pass along the cost of these surgeries to you tomorrow.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m trying to gather information and plan out a few procedures to improve my figure. I would like to inquire about shoulder narrowing, custom hip implants and rib removal.
1. What is the recovery like for shoulder narrowing? I read that full recovery takes 6-8 weeks. But how long would I need to wait before traveling? I live in europe, so I have quite a distance to travel.
2. How long do hip implants last? Will they need to be replaced eventually, or are they considered permanent?
3. Can any of these procedures be combined, i.e. done at the same time?
4. What is the price for these three procedures?
Thank you for your time!
A: Thank you for your inquiry on multiple body contouring procedures. In answer to your questions:
1) In regards to shoulder narrowing surgery, you should be able to fly home a week after the surgery.
2) Hip implants are not like breast implants, they are soft solid silicone that will last forever and never need to be replaced due to device failure.
3) The logical staging of these procedure would be a combination of hip implants and rib removal and doing shoulder narrowing surgery as a separate procedure. Which order these two groupings are done in does not matter.
4) My assistant Camille will pass along the cost of these procedures .
Dr. Barry Eppley
Indianapolis, Indana
Q: Dr. Eppley, I have been doing some research into possible solutions for my area of concern, I have very very deep set eyes that appear quite small in comparison to my face. Do you perform oculoplastic surgery? I have heard of something called orbital implants that act to push the eyes into a more forward position, is this something you have any opinion on, or know of any patients who have had this sort of procedure. I am a young woman in her twenties , I don’t have any issues with loose skin around or above the eyes, just very deep set, an almost beady eye appearance. I have looked into plastic surgery for many years seeking to enhance my facial appearance to look more feminine . My eyes are a really big concern for me.
Thank you in advance for reading
A: For the deep set eye there is no procedures that can physically move the eye forward. It is important to remember that the eye is attached by the optic nerve of a certain length that goes through the apex of the orbit. You can not bring the eye further forward that what the natural given length of the optic nerve is…without risking blindness
The only potential procedure is to reduce the orbital bone that surrounds the eye. Whether this would be of benefit depends on what your periorbital structures looks like ad whether such reduction would make a visible difference.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I recently had a titanium jaw implant fitted to my left side and v-line surgery including genioplasty. unfortunately I am feeling very remorseful for shortening my chin it was a bad decision which makes my profile too weak with a terrible double chin. I am 38 years old and the surgery was meant to correct asymmetry issues caused from mandibular advancement surgery from 4.5 years ago.
I have included my before and after X-rays for you to see, please can you tell me if there is a way to reverse the chin via genioplasty, I am not keen on the idea of another implant in my face. I had the plates removed from the advancement surgery which is why there are no plates in the before images I have attached.
I have also included an X-ray of a genioplasty I found on the Internet and one that I have photoshopped my my own chin to ask if this is possible? Another surgeon said this was only possible with a bone graft from my mandible but I am not keen to lose any more bone from my jaw since the recent surgery already removed more than I would of liked. So I am hoping that you might have some ideas.
I have attached images of my side profile and front face and photoshopped versions to show how I would like my face to look. I had to hold the skin on my chin so that you could see the shape of it.
I would be very grateful to hear from you as I am desperate to restore my face. Please let me know if you think this is something that you would be able to achieve.
A: Thank you for your inquiry and detailing your history and sending your pictures and x-rays. From what I can interpret from your photoshopped imaging, your goal is to bring your previous genioplasty down and forward which movements that appear to be about 3mm and 3mms respectively. I see no reason that could not be done and, while an autologous bone graft may be ideal, allogeneic bone particulate or solid graft would also work just fine. The key is the bone fixation used, grafting is of secondary importance.
Dr. Barry Eppley
Indianapolis, Indiana
