Your Questions
Your Questions
Q: Dr. Eppley, as an expert in this facial surgery area I would like to take your opinion regarding bone resorption after placement of silicone jaw angle implants , I have noticed 2 to 3mm resorption after removal on an implant from two patients that didn’t like how they looked after placement. There was no infection or any other complaint.
Moreover, I would like to know if this resorption process is continuous or will stop at some point after placement and if you recommend a protocol for follow up or X-rays for a period of time.
Thanks for all your efforts.
A: What you are referring to is not bone resorption but passive bone remodeling. This is a very typical response to any facial implants placed under strong muscles and is largely only seen in the chin and jaw angles due to the influences (pressure) of the overlying mentalis and masseter muscles. It is a passive and self-limited tissue response and is to be expected. Also in the jaw angle area it is very common to see some bone overgrowth around the implant edges on the mandibular ramus due to the complete subperiosteal location of the implants. Passive bony remodeling and some bone overgrowth are common and benign bodily responses to an object who biologically was not intended to be there. There is no reason to followup the patient in this regard after the implants have been removed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was wondering which procedures you think could help my face become more photogenic? Some info about me/things that I’ve noticed: half asian, 5’7, 150 pounds, I’ve noticed that I have somewhat of a “flat nose” or middle section of my face but it’s only noticeable in certain lightings, something about my jaw maybe it’s too wide or could be my chin, and slightly puffy eye lids. Also, could losing a little weight help reduce my droopy/chubby lower jaw area? Or is this more of a bone structure issue that jaw surgery could correct? I also dislike the way my face looks when I smile, not sure what type of procedure could help to balance my face when I smile. Thanks for your time.
A: While beauty is truly in the eye of the beholder, I can make the following asian facial reshaping suggestions. An augmentation rhinoplasty, buccal lipectomies with perioral liposuction and bony jaw angle/masseter muscle reductions would have the greatest slimming effect in your face. (I would also defat your upper eyelid and make the upper eyelid crease more apparent…but I can’t computer image that type of change) This is not an issue with your jaw relationship or any orthognathic surgery needs. These procedures combined with 10 to 15 lb weight loss would maximize this type of facial change.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley,I went to plastic surgeon to get rid of those temporal artery frontal branches. The surgeon cut a 1 cm section off from both sides from the lowest part at the hairline. Even with the 1 cm section of the artery gone it is still bulging and pulsating. How can this be, is there some backflow from the scalp to this artery? The surgeon said that I should wait for a couple of days to see if it was success even though the artery is still bulging. This is just a nightmare, how can I get rid of these ugly bulging arteries.
A: I would need to see pictures of where your temporal artery ligations were done. A single point ligation (or even artery removal in that location) rarely works in my experience. It takes at least 2 and sometimes up to 4 ligations points to be effective in some patients due to the sinuous pattern of the superficial temporal artery. The takeoff of the anterior branch of the superficial temporal artery is variable not to mention the issue of back flow from an arterial system that extends into the scalp. It is a complex blood flow system that is not an easily reducible as one would think by just cutting off one point of inflow.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a reconstructive cranioplasty. I was involved in a car accident three years ago which resulted in me undergoing a craniotomy. They fitted titanium mesh to cover the area since the bone was crushed and couldn’t be sued.. As I have become older, I now see that the skull is indented over that area and therefore I wanna have a reconstructive cranioplasty. I have consulted with several neurosurgeons without much luck lately, because of concerns about further surgery.
Therefore I have a question related to cranioplasty. As I already have titanium mesh fitted, would it be a problem to remove that – does titanium mesh attach to the dura or tissue for that matter? That seems to be the question I can’t find a answer to, so hoping you can help me! Or would it be possible to just leave the mesh and cover the area with either PMMA filler or hydroxyapatite bone cement?
A: While it is possible to remove your titanium mesh in your reconstructive cranioplasty procedure and replace it with a custom implant, the risks of dural tears and a CSF leak is not worth that effort. It is far better to leave the mesh in place and cover it with any of the available bone cements of your choice.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley,I am very familiar with injectables and have been using Botox for over ten years and Juvederm for at least the past five years5\. My eyes are looking extremely tired and I wear glasses every day to cover up the line. I am aware that the tear trough can be treated but have heard it is only for the experienced. Can you please let me know if this is something common in your practice? Thank you
A: Placing injectable fillers into the tear trough is the hardest area on the face for getting good results in my experience which is considerable. It is a facial area fraught with aesthetic problems such as irregularities and over correction issues. It is also a very aesthetically scrutinized area since it is in the eye region. Anything less than a perfect result will be viewed by the patient as unacceptable.
In my experience 50% of the patients treated have some issue that requires further injection treatment whether it be additional filler or hyaluronidase to reduce/remove the filler material. I would need to see some pictures of your face to determine what risk profile you have for tear trough injections in this difficult facial filler area.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a bone cement cranioplasty. You have previously told me that it would not be good idea to try and remove the titanium mesh. Maybe you can walk me a little through this. I thought the titanium mesh was placed above the hole in my head and mounted with screws in the skull. I don’t see how my dura could be teared when unscrewing the screws and lifting of the titanium mesh? Has the dura grown into the mesh?
According to bone cement, is there any specific one you would recommend or would any product do the trick? Its just that it is a somewhat bigger cranial defect, but maybe that doesn’t have anything to say? And will the bone cement attach to the mesh, and surrounding bone, holding it in place?
Thanks for your time!
A: Since I assume you have never performed skull surgery, it would be understandable why you would not know that scar tissue and dura adhesions have occurred into the mesh which is certainly not a smooth surface. While it can be removed there is a significant risk of dural tears and a postop CSF leak in doing so. It simply is not a risk that most patients and surgeons would take when the original problem has been solved.
For a bone cement cranioplasty, hydroxyapatite cement would be the preferred coverage material and the size of the cranial contour problem is not an issue. The cement will adhere to both the bone and the metal material. Adherence of the cement is not an issue.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in facial asymmetry surgery. The right side of my face looks completely different than my left side. I like the left side so I think it is the right side that is the problem, it just didn’t develop like my left side. Can you tell me what is wrong with the right side of my face and how it could be improved.
A: Thank you for sending your pictures and talking to you earlier today. In looking at your face you have a classic right-sided facial asymmetry that extends down from the brow bones to the jawline. Every single external structure is affected. I have taken your picture at numbered the 8 involves areas from the jawline as follows:
1) Low vertical jawline (still)
2) Downturning right corner of the mouth
3) Flat/hypoplastic infraorbital rim and cheek
4) Lower right lower eyelid position
5) Lower setting eyeball
6) Excess skin right upper eyelid skin
7) Lower/protrusive brow bone
8) Right Upper eyelid ptosis (which would be present if the eyeball was raised)
All of these issues are improbable and can be done in one facial asymmetry surgery. The right periorbital (eye area) would be treated through upper and lower eyelid incisions for #3 through #8. No scalp incisions are needed even for the brow bone reshaping.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a tummy tuck revision. I had complications from a tummy tuck procedure done almost two years ago. I have hardness of tissue below belly button but above incision which also sticks out. I have had multiple radio frequency treatments to try and soften it up but without any success. What options are available to me now for improvement.
A: While you did not state what your after surgery complications were, by your description and pictures that most likely problem would have been a recurrent seroma. When this does not get completely absorbed it can create an encapsulated seroma pocket which can feel firm as it creates skin adhesions down to the abdominal wall. It will also create a pooch to the skin area that overlies it. Its most common location to occur is between the belly button and the incision line…exactly where you have the firm feeling bulge.
The treatment for that is to go in and remove all of the scar tissue and seroma capsule. Some extra abdominal skin can also be removed at the same time. Your tummy tuck revision would really be called a secondary mini-tummy tuck.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in chin liposuction and I would like to know my options. I have attached pictures for your review.
A: Thank you for sending your pictures. As a matter of clarification, the term ‘chin liposuction’ is a misnomer. The chin is never actually treated by liposuction. It is actually the area under the chin that people are referring to known as the submental area. Thus the terms submental liposuction and submentoplasty would be more appropriate.
You have good chin projection so this is a matter of improving the neck only. You options are either liposuction or a submentoplasty. The difference is in both the outcomes and how the procedures are done. Liposuction removes some of the fat above the platysma muscle only. A submentoplasty removes fat both above and below the muscle as well as tightens the platysma muscle. While both are done through small incisions under the chin, a submentoplasty will create a better neck contour than just liposuction alone…as one would expect as it modifies more of the neck tissues. I will have my assistant Camille pass along the cost of the two neck contouring procedures to you later today.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, What are the complications involved with forehead augmentation? Is it it a fairly common surgery at this point? Is the scarring from the incision visible or does it completely disappear over time?
Please answer the same questions regarding chin/jaw enhancement as well.
Also, if it’s the marionette/Jowl area that needs to be enhanced, what do you recommend?
A: Forehead augmentation in my practice is common but it is not a commonly done by most plastic surgeons. The most common complication from it are aesthetic…did the result meet the patient’s expectations and is the result smooth. The incidence of such complications varies by the augmentation method used. (bone cements have highest risks, custom forehead implants have lower risks) Any forehead augmentation method requires a scalp incision to perform. The use of bone cements have longer incision lengths, custom implants have shorter incision lengths. While such scalp scars generally heal very well and can be well hidden, there is no such occurrence as the scars completely disappearing.
For chin or total jaw augmentation, implants are the only effective treatment choice. Their complications are similarly aesthetic with over/undercorrection and asymmetry being the most common reasons for revision. Most chin and jaw implants are placed intramurally so external scar concerns are usually not an issue.
The marionette/jowl area is usually treated by fat injections. In some cases the jowl issues are solved along with the placement of a chin/jaw implant. But marionette lines require soft tissue augmentation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had pectoral implants done last week. i wanted to run by you what is going on. Obviously I know I am recovering and I’m assuming full swelling will take time to heal. My doctor ended up using the the Implantech Powerflex anatomical pectoral implants of 271cc in volume. I think it is the 3rd largest in that category. I was wondering if you could examine my pictures I have attached in this email as I have a couple of concerns.
Firstly I did request my surgeon to go quite large with the implants as I wanted them noticeable and on the bigger side. Gathering from the information I collected from online resources I assumed the anatomical implants are more suited to me. After having them in I currently do not like them. I always thought they would be placed differently to how they are now. I don’t know if its just me or if my surgeon has incorrectly used the wrong style and shape of implant.
I feel like I have a huge DeNT in the middle of my chest and based on the pictures I find the look i really enjoy is the cleavage look and the square cut shape of the pectoral implant. I feel like a human Ken doll where the implants look like two big circles on my chest almost breast like. So I didn’t know if this is because the anatomical shape was chosen. I’m assuming i should have gone with a slightly flatter square shape. I am feeling quite “booby” and the dip in the middle of my chest is bothering me. is there anyway of making the implants sit closer? or is that depending on my anatomy and genetics?
If you were my surgeon, is there any way i can solve these concerns and can u comment on which implant i should have had. I am aware I am one week post op is too soon to comment but I feel i am already seeing the shape of the implant expeically in the middle of my chest where volume is lacking. I also thought the anatomical implants only sat on the lower two thirds of the pectorals. i feel like my ones sit quite high up under the collar bone. Any help would be greatly appreciated. I just know in my heart something is not right and I don’t feel like this represents a muscle in the event i was able to build it myself. I don’t mind the side view but when front on i feel like they are placed very wide apart and feel like two circles on my chest.
The pictures I will send are from today and I will include pictures of the pectorals i like. Clearly they are models and I am not.
To summarize id like to know if
1 – my surgeon should have used a square cut implant to give me more medial augmentation and a square cut look
2- is it possible to close that gap in between my chest as it feels like a big dent
3- is the anatomical implant making me feel like i have breast like circles?
4- can my chest be made a similar style to the pectorals in the images shown? (obviously they are models and im not)
Thank you VERY much for taking your time to read this.
A: I am sorry to hear of your current dissatisfaction with pectoral implant surgery results. It is not professionally appropriate nor will I comment on what surgeon should or should not have done. Those discussions are between you and your surgeon whom you have entrusted to do the procedure.
What I can do is provide some insight about the two basic pectoral implant styles offers through Implantech. The Powerflex 1 pectoral implants is oval shaped and its effect is to accentuate the lower border of the pectoralis muscle and create a more rounded form to it. It provides no superomedial augmentation effect in most cases nor is it designed to do so. It is called the ‘anatomic’ pectoral implant because this is how most natural shaped male chests look.(non-body builders) as the bulk of pectoral muscle mass is in the lower two0-thirds of the muscle. The Powerflex 2 pectoral implant is rectangular-shaped with the specific intent of creating a more boxy-shape to the chest which includes, by definition, superomedial augmentation. It design allows the implants to be brought closer together and create some male ‘cleavage’. While this is not a natural or anatomic look, it is the desired chest look of many fitness and bodybuilders and is clearly the type of chest augmentation effect you are demonstrating in your male model pictures. How effective this design is in creating thirds desired look is also influenced by the dimensions of the implant as it requires a tight fit to see the full effect of the implant’s shape.
If you should seek a pectoral implants revision the Powerflex II pectoral implant is clearly the design you should have. What size requires measurements of the pectoral space and muscle borders.
Dr. Barry Eppley
Indianapolis, Indiana
Dr. Eppley, I have read almost your entire website and have learned a lot about implants! Thank you for keeping it so up to date. I had jaw implants in 2010, didn’t like my results, but kept them in because I looked better than before. Though last year, I found out I have sleep apnea and need double jaw surgery. I have the option to have my jaw implants kept in (if they can manage), they may be able to trim them in the places where it’s very wide, or have them removed. My major concern having them removed is that it will look horrible underneath when the swelling goes does. I think having them trimmed maybe the best option. I have attached my before and afters. In your expertise and experience could tell me what you would advise? Thank you so much for your time.
A: The question you are asking is whether at the time of your sagittal split ramus osteotomy (SSRO) of the mandible to move your jaw forward, should the jaw angle implants be put back in to not. (whether they are trimmed down or not. Clearly they will initially have to be removed as the first step in surgery to access the mandibular ramus to cut the osteotomy, move the distal mandibular segment forward and fix it in place with a plate and screws. At that point should the implants be put back in before the wound is closed?
While their are obvious aesthetic advantages in doing an immediate replacement jaw angle implant surgery, the question comes down to the risks in doing so. The risk is that of an infection occurring over the proximal mandibular ramus site which has been partially devascularized to do the osteotomy. Should that happen you could end up with osteomyelitis of the jaw…which would be a devastating complication to say the least. The odds are that it might not happen and all would heal well. But in the uncommon event it does happen it would be the biggest regret of your life.
In short, like many choices in surgery and life, it is all about how you want to ‘gamble’ so to speak. A second surgery to put new jaw angle implants six months later would be a safer bet than the risk of jaw infection and osetomyelitis. In my opinion it just isn’t worth the risk and paying an implant over and around a fresh osteotomy site which requires fairly wide subperiosteal undermining.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in cheek implant revision surgery. I would also like to ask you if you think I could change my submalar cheek implants out for a malar implant or combo one? I wanted the high cheek bone look not the heavy mid face cheekbones. I’ve had to compensate by using a lot of fillers. I know you use many different styles of cheek implants that you have designed. Some of them look like they augment my cheek area that I want augmented. Are they silicone? What is the difference between this and Implantech Terino shell? Do you use screws and how long would I have to stay in town if I had you perform this procedure? Lastly, can it be done with sedation not general? Sorry for all of the questions.
A: These are silicone cheek implants that differ from malar shell cheek implants by having an infraorbital and zygomatic arch extension, creating a higher and ore model like cheek look. A single microscrew is usually placed through the implant at the maxillary posterior buttress bone for assured stability in the easily healing phase while the implant pocket is forming. This is a facial augmentative procedure that can be done under a deeper form of IV sedation. However the anesthesia needs to be adequate enough to allow for the proper implant pocket creation and placement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had my implant placed three weeks ago. It was a silicone implant large size with wings. I can barely move my bottom lip up and I can’t speak well for that reason. I have strange nerve pain that goes through the left bottom lip when i move it. The sensitive pain comes from the left side where the end of the wing is placed. If I touch it I get a nerve reaction on my lip. Moving muscles around it causes it too. Note- I am still numb on my left lip and chin. What is your advice? Attached is my before and after picture. I don’t like how projected it is and the huge crease it creates on my bottom lip.
A: While it is fairly early after your chin implant procedure, you have several concerning symptoms that speak for an early intervention with a chin implant revision. First and foremost you should have never had a chin implant for your chin augmentation. Your horizontal chin/jaw deficiency was so severe that a very large implant would have to be used that places too much stress on the chin soft tissues and the lower lip. But that issue aside you also have nerve pain which suggests the mental nerve may be impinged on by the wing of the implant.
You have three options for your chin implant revision:
- Downsize the implant to a small size and better style,
- Remove the implant completely, or
- Remove the implant and replace with a sliding genioplasty which was the correct chin augmentation procedure from the beginning.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, One year ago I had a sliding genioplasty with 5mm advancement. I previously had iposuction under the chin ten years before the sliding genioplasty. I still have fullness under the chin and lower jaw region and lack 4mm or 5mm in chin projection to meet the lower lip and possibly 2mm in length.
I would greatly appreciate your views on the ideal way forward in considering these options:
1. Sliding Genioplasty revision to further advance 5mm and lengthen 2mm. Concerns mentalis muscle drooping, narrowing of chin from frontal view. Possible advantages of stretching muscles/skin to reduce that under chin/jaw fullness.
2. Custom medpor chin implant of 5mm with wings to add more width to chin. Concern won’t reduce the fullness concerns.
3. Neck lift, incision under chin tightening and or removing/shaving digastric muscles and submandibular glands. Concerns would need further incisions around ears to pull skin tort.
Would option 1, 2 or 3 be optimal or option 1 or 2 with option 3?
Ideally I’m after more chin identity and less fullness around that lower third of jaw/chin.
I have also had a CT scan which shows no chin fat as a concern and the submandibular glands are not abnormally large.
I have attached photo images and x-rays.
I would appreciate your opinion as to the most suitable surgical option to move forward and greatly appreciate your advice and time.
A: In looking at your pictures and video, the correct procedure for you is #1 and a modification of #3. A sliding genioplasty revision would be preferred over any form of an implant as it will stretch out the muscles and skin under the chin. That will help under the jawline and chin fullness.
For under the chin liposuction is often not completely adequate. What you need now is a submentoplasty. This is a procedure where a small incision is made under the chin, fat directly removed above and below the platysmal muscle and the platysmal muscle tightened. You do not need a formal necklift nor modification of the digastric muscles or the submandibular glands. This will work well and be synergistic with a secondary sliding genioplasty.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 21 year old college student. I’ve always been conscious about my side-profile, specifically the chin area being weak, and was thinking about pursuing a chin implant. In addition to whether you think a chin implant is appropriate, I was hoping you might be able to tell me with you expertise whether a chin implant would help reduce mentalis muscle strain or the dimple that appears from holding my bottom lip up when my mouth is mostly at rest. I have read online that it should, but have received mixed/unsure messages at consultations in my local area. In other words, I would like to have a smooth chin line at rest following the strengthening of the profile. Thanks!
A: Thank you for your inquiry and sending your pictures. A chin implant is exactly what you should NOT do. That is the wrong treatment strategy for your jaw problem. You have a very horizontally short and vertically long chin which is associated with lower lip incompetence and a mentalis strain. The correct treatment choices are either orthognathic surgery (braces and move the entire lower jaw forward) or a sliding genioplasty.
Assuming you do not want to change your bite, a sliding genioplasty moves the chin bone forward with vertical shortening AND improves lower lip competence and the mentalis strain. It is probably a fairly big movement (10 to 12mm maybe more) but a chin implant offer none of these important functional improvements.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, We had previously discussed a facial reshaping surgery consisting of verical jaw angle implants, infraorbital-malar implants and a glabellar implant. Last week I had a second consult with another plastic surgeon that also specializes in facial implants as well. He offered very similar plan to you with only minor differences. I do have a few questions/confirmations i wanted to bring up after looking over the surgery plan:
1. The jaw implants for me would have both vertical and horizontal dimension?
2. Are the vertical and horizontal dimensions given in mm’s? if so, what are the ranges of each dimension? what size would you use for me?
3. The semi custom infraorbital-malar implants will be 5mm?
4. The other surgeon recommended a subperiosteal midface lift with the infraorbital-malar implants. Would you also do the subperiosteal midface lift?
5. How many screws to secure jaw implants? infraorbital-malar implants? the glabellar implant?
Thanks for your time and answers.
A: In answer to your facial reshaping surgery questions:
1) Every standard jaw angle implant style offers both vertical and width augmentation changes. What makes the two basic styles different (vertical vs widening ) is the ratio of the vertical and width dimensions. Widening jaw angle implants provide more width than vertical length. Vertical jaw angle implants offer more vertical length than width.
2) Every facial implant, regardless of style and size, has very specific millimeter measurements which are provided by the manufacturer on their website complete with drawings and measurements. The best jaw angle implant style for you would be vertical jaw angle implants of the ‘large’ size. (11mm vertical, 5mms width)
3) The semi-custom infraorbital-malar implant will be 5mms at its thickest portion.
4) Every infraorbital-malar implant that is placed through a lower eyelid incisional approach is closed with a ‘subperiosteal midface lift’. Some surgeons chose to specifically call it as part of the procedure and even charge a separate fee for it. But, by definition, making the pocket for the implants requires raising a subperiosteal midface pocket to insert the implant. When the tissues are closed over the implant by sutures to the bone this is what constitutes the subperiosteal midface lift. It is an integral part of the procedure, some surgeons just chose to call it a separate procedure.
5) Jaw angle and glabellar implants generally only require one screw. The infraorbital-cheek implant may also only need one or possibly two. The judgment about the total number of screws is made at the time of surgery based on the stability and fit of the implants to the bone. Probably the correct number of screws will be 8 not 6.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in knowing more about the custom jawline implant recovery process. I was looking at some of the before and after photos of custom wrap around chin and jaw implants on your website/RealSelf, they look amazing. Part of me says, I should do the whole jaw and be done with it.
I would highly appreciate if you would explain to me one more time a detailed recovery timeline, progression of healing process such as what to expect in first few days to first few weeks and months, along with most common complications and possible worst complications.
A: I will sum up the custom jawline implant recovery process, which is largely related to facial swelling, by this phrase…‘There will be more swelling that you can imagine and it will take longer to go away that you ever want’. If you embrace this concept then you will be well prepared for the surgery. To put specifics to it, 50% of the swelling goes down by 10 days, 66% to 75% by three weeks and 90% to 95% by 6 weeks after surgery. I do not judge, nor do I ever do any revisions, until the final result is truly seen three months after the surgery when all swelling, tissue shrinkage and psychological adaptation to the new look has occurred. Most patients will feel comfortable going out in public somewhere between 10 to 14 days after surgery.
The most common complication after a custom jawline implant is the inability of some patients to tolerate the necessary recovery process. They can feel it is ‘too big’ and want to rush to an early revision. (downsizing or removal) While this does not happen to all patients it probably occurs in about 25% of them and can pose a stressful recovery process for both surgeon and patient.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a male interested in brow bone reduction. i have actually seen five surgeons….I vaguely talked to a plastic surgeon about it while I was getting basal cell removed from my nose. You mentioned the incision and that great thought needs to be put into it being done in a male. After talking to surgeons I am a little confused about the scar. One surgeon suggested either one of two things, a cut around the whole top of my head or multiple smaller incisions called endoscopy. He told me the same thing that we need to really think about it but he was referring more to male pattern baldness which is unknown. Then I went back years later and he told me he wouldn’t work on me. Another surgeon said he’d make an incision so thin that I could be bald and it wouldn’t be noticeable. Another surgeon said the same thing but I believe he said he’d just make two incisions at the top of my forehead and kinda do an endoscopy type thing and pull up my brow…burr it down and remove calcium deposits. He said the way they were going to do it was that my forehead would appear smaller because my hairline would come down which sounded good to me. I think when I was a baby and since my head is large…I know there was a problem with me crowning when I was born…I think since my head was soft like all babies are it affected the way my hair grows to…..my hair grows down not straight up…..so I can’t grow it very long at all…matter of fact I generally have it shaved on the sides at a 1 or 2 guard….I am afraid that you would see the scar. I am also aware that there are hair grafts and I am wondering if that could be useful in my case. Make no mistake the biggest problem is my brow…..its just two low, kinda grows downwards, and just looks extremely heavy. I only get one life and I really need this done. I don’t want to make a mistake and fix something, but look unnatural or have a scar I have to worry about. I’m not looking for a miracle…..before I turned 16 my brow wasn’t developed like it is now but my head was still wide…..i just want a more normal, natural, attractive, and vibrant appearance.
Thank you so much.
A: Let me help clarify the thought process for you about the approach and the scar that would need to be used to adequately perform your male brow bone reductiono surgery. First the procedure. The only approach to brow reduction that is going to work for you is not just simple shaving, that simply will not be enough and will not create enough of a difference. So throw out any suggestions about an endoscopic or limited incisional approach through your scalp. Your brow bone reduction needs to be an osteoplastic brow bone setback technique. Nothing short of this going to work. Second the incision. A osteoplastic brow bone setback technique needs wide open surgical exposure to perform adequately. Your incisional choices are either a full coronal scalp incision from above (almost ear to ear) or a mid-forehead incision through the deepest horizontal skin wrinkle that you have. The surgeon who told that a full coronal scalp incision could heal so well that it would be invisible if you are bald…is flat out wrong. That is complete fantasy and misinformation. While they can heal well and look good with hair, the scars often get widest in the temporal area and would never be well hidden with thinning hair or if one is bald. Given your concerns about the scalp scar I do not consider this a good option for you. This leaves with the mid-forehead incision which I consider to be the safest aesthetic choice. You already have horizontal forehead wrinkles so a scar that would look like one of them is a wider choice.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have just read your comment about “Nasal Depressor Septi Muscle Release for Nasal Tip Animation Deformity”, I was wondering if separating the depressor septi muscle would not only stop a nasal tip droop when smile but also stop the tip from being pulled downwards while talking?
A: Nasal depressor septi muscle release, in theory, should also help somewhat with nasal tip deformity from talking as well. Although a more qualified answer would require seeing videos of your face while you are smiling as well a talking to look at the nasal tip movement that occurs.
It is also important to realize that there are two other muscles that also attach to the base of the nose, the nasal alas dilator and the superior quadratus, which can also create muscle movements that affect the base of the nose and how the tip may move.
The appropriate approach to your nasal tip concerns should be Botox injections. First treat the depressor septi muscle alone and see what happens with smiling and talking. If this is not completely effective than the lateral nostril bases should be injected to see if this produces a more complete elimination of nasal tip movement.
However
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had cheekbone reduction surgery three years ago and I was left with these gaps/non unions. Of course, the gaps need to be closed and the bones repositioned and plates need to be used to hold the bones together. I have heard that I need to do this ASAP because the bones become dead. Right now I cannot afford surgery and I am saving money for a reconstructive surgery in the next year or so. How would you fix the problem and is it true that the bones become dead? How urgent it is? My face is sagging too.
A: It is certainly not true that the zygoma/zygomatic arch would become ‘dead’ if it is not reattached to bone segments urgently after the cheekbone reduction surgery. The bone does not become dead per se, it remains alive but it will lose some bone mass/volume since it is no longer performing a supportive function.
But the for the sake of argument let us make the assumption that the bone did die if it is not reattached. At three years after the surgery this would have already happened and fixing it now would be an irrelevant issue. Therefore I don’t see the urgency to undergo ‘urgent’ zygomatic reconstruction at this point.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have jawline reduction surgery scheduled for next month. Could you answer a couple questions about the surgery? Can you have a look at the CT once more. The root of the last tooth on left mandible seems to be pretty close to the outer border of mandible.
1)How many millimeters would it be safe to reduce on that point? Considering the nerves and risk of fracture in the future?
2)So the cortex parts of the bone seem to be the thickest. Will the bone adapt (create more cortex bone after part of it is shaved off? (afraid of fractures…)
A: In answer to your jawline reduction questions:
1) The bone that is removed in your type of jawline reduction is from the inferior border of the jaw not the lateral border.
2) 4 to 5mms would be safe from a nerve protection standpoint. None of this bone removal places the bone at risk for future fracture. Not enough bone is being removed for that to be an issue.
3) The bone will not grow a new or thicker cortex. As stated in #2 above, this is not a surgery that places the bone at risk for fracture.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had mid facelift and a temporal cranioplasty area several years ago. I was filled all up the side from each ear to the temple area and about 3 inches in depth. I did not like the result as it felt monstrous so I asked for it to be removed. My surgeon asked if I wanted it removed or burred down and I specified removed. However, it feels as if quite a bit of the implant material is still in there and, several years down the line apart from still feeling like Frankenstein, I have a widened hairless scar on each side. More recently my hair seems to be thinning on the sides of my head in the area above the implant only. I have just got to menopause so this is evidently in part hormonal but it is definitely only in a specific area. I am really worried I am going to lose my hair. Please can you tell me if you have come across this issue before. I really look forward to hearing from you.
A: It is not uncommon to have widened temporal scars but this does not really have anything to do with the temporal cranioplasty implant material. It is just the nature of putting a vertical incision in the temporal area for some patients. It is also be partially related to how the incision was handled both in its making as well as its closure. Even if there is any residual implant material there it is not a known source of hair loss and has never been in my cranioplasty experience.
If you have residual implant material and would like it removed and well as performed temporal scar revision, I can certainly do that at the same time.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a horizontally short chin and not very well defined jawline. Having made some very rudimentary measurements I would say I would like my chin advanced horizontally forward about 12 – 15mm. Due to the distance a sliding genioplasty seems out as an option. As I would be quite happy to have a better jawline as well as more prominent chin a wrap around jaw implant sounds like a good option to research.
I have a few questions:
1. How many wrap around Jaw implants has you done?
2. How many of these led to complications?
3. What is the mean full recovery time?
4. What is the mean recovery time to reach the point where I would not look post op anymore eg should be happy going out in public.
5. What would be a full ballpark cost for the procedure both with a standard and custom wrap around implant? I would like this to include everything eg implant, hospital fees, Mr Eppley’s procedure cost, anaesthetists cost, screws etc.
A: Thank you for your inquiry about a custom wrap around jawline implant. Bringing the chin out 15mms with any type of implant is a ‘stretch’. (no pun intended) The tightness of the chin soft tissues would safely permit a 10 to 12mms change more ideally. In answer to your questions:
- I have done over 50 custom wrap around jawline implants.
- In terms of medical complications, I have not yet seen an infection or permanet nerve injury. However, such implants do end getting revised at the rate of 10% to 20% due to postoperative aesthetic size or shape issues.
- Full recovery in most cases is 6 to 8 weeks.
- Most people look reasonable by two weeks after surgery
- My assistant will pass along the total cost of the surgery to you later this week.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a plastic surgeon who has a patient that wants to do hip implants. I just want to confirm that you put them under vastus lateralis fascia, over muscle, like calf implants. Any tips as this is new to me? A Canadian plastic surgeon describes placing them under TFL muscle. This seems risky to me.
A: The options for placement of hip implants are limited and are really subcutaneous in location for most patients in my experience. If you look carefully where most people want them it is higher that the upper extent of the vastus lateralis. It is either over the trochanteric depression or even slightly behind and above it. In theory the TFL is more anatomic to the hip augmentation region but placing them under it runs a real risk of chronic pain not to mention the limited augmentative effect that will result from the tight fascia over it. Using an incisional approach high and behind the augmentative site also avoids any risk of running into the lateral femoral cutaneous nerve.
While it is always nice to have an implant deeper in the tissues, the hip region doesn’t provide any good and safe options to employ that concept. The other important implant feature of the hip region is that it needs to be of composed of an ultrasoft silicone polymer. (solid but feels like an ultra cohesive breast implant) For this reason I have them all custom made to get the dimensions needed and the right implant feel. It also makes them easier to insert with a small incision.
I hope this is helpful,
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in brow bone reduction surgery. My brow bones are way too low. The ends of my brow don’t curve back behind my eyes much, they are more horizontal. Also I don’t know if you would call it my mastoid process or what but the part of my skull where the ears connect to skull and downward and upwards from there is too wide and it makes my face look wide. Basically I’ve noticed that most peoples ears are back set behind their cheek bones while mine are actually out a little further which gives my face a very wide look and makes my neck look too big for my face. Also since my head is so wide in the back it almost appears that it is my hair …it’s deceiving. I don’t know what all can be done but I also have calcium deposits on my forehead one of which gives me a pretty bad looking knot.
A: From a forehead standpoint, your brow bones can be reduced and reshaped and the entire forehead can be smoothed out. That can be done very effectively. The only question is the surgical access to do so. This will require some form of incision either on the forehead, at the hairline or back in the hairline. Such a decision to do so must be weighed very carefully in a male.
From a mastoid standpoint, I do not think that its impact is creating the effects that you think. I think your entire skull base is wide and this is what is creating the excess width issues. While the prominence of the mastoid bones can be reduced it will not create the facial and neck narrowing effects that you seek.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in tailbone fat grafting. I am very thin and have a prominent tailbone. It sticks out and is painful to sit for any period of time. I have seen an orthopedic surgeon who suggested I have it removed or reduced but that procedure scares me and i hear it is very painful afterwards.
A: I have done numerous cases of soft tissue augmentation to the coccygeal area for coccygeal pain (coccydynea) using fat. There are two fat grafting approaches to adding fat to the tailbone, injection fat grafting and the placement of a dermal-fat graft. The type of fat graft chosen depends on the coccygeal area one is trying to build up. If it is directly over the tailbone prominence then a dermal-fat graft is best used. That may or may not be combined with some end of the tailbone reduction. If one is trying to buildup in the peri-coccygeal area (around the tailbone) then fat injections would be better as they can cover a broader coccygeal area.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in cheekbone reduction reversal surgery. I had the procedure done last year and do not like the way it looks now. Is the zygomatic arch after being reduced reversible? if not would a cranial facial reconstruction surgeon be able to reconstruct the zygomatic arch with plates to widen the midface to support the soft tissue? I have attached two photos of what I look like before and one photo of what happened to me after surgery. I had my cheekbone and jawline reduced which was a HUGE mistake and now looking to rebuild my face.
Thank You.
A: I have seen and treated numerous women and men who have had facial bone slimming surgery, such as cheekbone reduction, and wanted to reverse it. In short, cheekbone reduction reversal is very difficult to get the zygomatic body elevated back out and fixed into position with plates and screws…difficult but not impossible in some cases. But whether this is possible is best determined by getting a 3D CT scan to see exactly where the zygomatic bones look like. As for the jaw angles the only treatment option is vertically lengthening jaw angle implants for restoration to replace the missing bone.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a breast implant and lift revision. I got breast implants with a lift six months ago. My biggest issue now is how they look when I bend over. That was the whole reason I got implants. I nursed for a year and went from a D to less than an A. They looked very odd and fleshy. Now I am much bigger and they still look fleshy and saggy.
A: Thank you for sending your pictures. While I have no idea what you looked like before your breast surgery, you have a reasonable breast lift and implant surgical result. The implants may be slightly high or the lift is slightly low and one could argue for some improvement by adjustments of either one or both. The implants could be lowered or the lift can be redone to move the nipples higher up on the breast mounds and tighten some more breast skin. But either way, it is common and expected that when you bend over the natural breast tissue will fall off/pulls away from the implants. That occurs in most breast augmentation results whether they have had a lift or not. Expecting the implant and breast tissue to move together as a unit when you bend over is not a realistic result for most women.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have some facial reshaping questions. Are cheekbone and v-line surgery (zygomatic arch reduction + jawline reduction + genioplasty) the only ways to reduce the size of the face? How much would temporalis muscle reduction help? I am a Korean-American female looking to reduce the size and change the shape of my face.
A: Facial reshaping surgery to reduce or thin the face consists of a variety of bone and fat procedures. From a facial bone standpoint, cheekbone and jawline reduction (chin to angles) are the acknowledged facial reduction procedures. They do no necessarily reduce facial size per se that much but does reshape it or make it look more narrow.They are other companion fat reduction procedures of the neck and midface as well. (buccal lipectomies, perioral liposuction, neck liposuction.
Reduction of the posterior tenporalis muscle above the ear makes the profile of the head more narrow and less convex in the frontal view. While it is not a facial procedure per se, it can be effective at making the entire craniofacial shape more narrow. It can be a good complement to the other aforementioned facial reshaping procedures.
Dr. Barry Eppley
Indianapolis, Indiana
