Your Questions
Your Questions
Q: Dr. Eppley, I want to improve my face and have attached pictures which show my concerns. For some reason, the selfies make my face look longer than it really is. I have a very square face. I would like very much to have more of a heart shaped face… and to address the skin laxity that is showing my age. These pics are without makeup and do show a little of the perioral mound that keeps a heart shape away. I am wondering if that needs to be removed or if I would do better with a form of facelift to lift some of the fullness/wrinkles from my mouth area. By the way… I have had an upper bleph (love it!), but do wonder about a little brow lift as well. I have a very short forehead and low brows. It looks quite wrinkly when I try to keep them raised. Thank you.
A: Thank you for sending all of your pictures. Selfies do create facial distortions as your face is certainly not long but vertically short with its more square shape. Your pseudo perioral mounds are really caused by the skin laxity along the jawline. As the skin falls forward it ‘piles up’ against the corner of the mouth creating these tissue mounds. Ideally what you need is a small ‘tuck up’ lower facelift also known as a jowl lift. That will resolve the jowls and eliminate the buildup of tissue in the perioral mound area. To help make you face less square and more heart-shaped some vertical chin lengthening would go a long way in that regard. This can be most simply done by a small vertical lengthening chin implant but also by am opening bony genioplasty as well.
For the brows an endoscopic browlift would be beneficial as it would not only lift the eyebrows but would vertically lengthen the forehead as well.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was wondering if it’s possible to get a cheek augmentation at the same time as a rhinoplasty or would swelling from either interfere with the other. I also have a deviated septum. Do/can you fix that as part of a more general cosmetic rhinoplasty? Thanks.
A: Having a rhinoplasty and cheek augmentation at the same time is both common and not problematic. Even though they are anatomically close the tissue disruption of one does not affect the other. The swelling from these procedures does not start until after surgery so one procedure does affect obscure the visualization of the other.
In a rhinoplasty it it very common to perform and achieve dual benefits, changing the shape of the nose as well as improving one’s breathing. Known as a septorhinoplasty, it is both an internal and external nasal procedure. Besides being able to straighten a deviated septum, the cartilage from the septum can also serve as a support material for the cosmetic nose reshaping part of the operation. A septorhinoplasty is truly a synergistic procedure that for some patients absolutely has to be done together. In some cases the functional airway part of the operation may be covered by one’s health insurance.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like to enquire about lower blepharoplasty. I am a 45 year old male and have been suffering from eye bags getting worse over the last five years or so. (particularly the last year) I have been to see three plastic surgeons about this, but am confused as to the approach to take. All three plastic surgeons have confirmed it is herniating fat and not a tear trough or other problem that is causing the bags.
The first surgeon preferred a transcutaneous approach, though said I may benefit from a tiny skin excision, it may not be needed. The other two both said skin removal was not needed and both recommended the transconjunctival approach with no fat transfer or redraping. Now, since I have done quite a bit of research on this I realize that a transconjunctival approach is regarded to be less risky, due to not cutting through the lower eyelid muscle, especially since a skin excision is not required it seems a needless risk.
However, where the last two surgeons differ is that one said they rather be repairing the lower orbital septum, (he called it Transconjunctival Septal Suture Repair for Lower Lid Blepharoplasty) and that this would involve a miniscule fat removal as the septum would hold the fat pads in a more natural position. He said this would not only give better long term results in terms of preserving eye shape and lid level, but also prevent a common problem of a skeletal look that can arise from a basic transconjunctival approach, he even claimed that this marginally would improve the upper eye skin look, as the eye would be sitting more naturally in its socket – looking at before and after pictures I can see this is indeed a happy side effect.
What I would like to ask is:
1) Which approach would you take (I am happy to send in more photos)
2) Is it common with a basic transconjunctival approach to have a skeletal look long term or is this always simply caused by excess fat removal?
3) Would a transconjunctival approach, with septal suture repair produce more inherent risks or recovery time, and if so would the results be that much better that (2) such that the risk is worth it?
A: In looking at your pictures and your age, it is clear that you don’t need skin removal. Thus a transconjuncival approach to your lower blepharoplasty should be done rather than a transcutaneous one. Your debate is in how to handle the herniated fat pads…either subtotal removal or retrograde repositioning. (septal reset) The simple answer to this debate is if you can keep your fat and it can be brought back in (like a hernia repair) this is always better long term. However it is much more technically challenging than fat removal through the transconjunctival approach.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am looking to get augmentation of the brow ridge/supraorbital rim. I also have a backward sloped forehead which I was hoping to make more vertical at the same time. I have consulted with another surgeon who told me that my lack of supraorbital rim projection extends to the lateral orbital rim too. So I was wondering whether it would be possible to design a custom implant to cover all three of those areas at once? A couple of other issues are these;
– It appears as if my supraorbital rim is not only under projected but also that it sits at an upward angle ‘away’ from my eyeball itself. Is it possible to fashion an implant that both angles downwards and sits lower down on the supraorbital rim to ‘surround’ the eye?
– The same issue seems to be apparent with the lateral orbital rim in that it sits too far away from the eyeball. Can the same be done here as with my question above?
– Not only is my forehead backward sloping and sagitally underprojected, but it is also horizontally convex. The sides of my forehead sit too far back relative to the centre of the forehead. Is this a fixable issue?
A: Using a custom forehead and brow bone implant concept, it can be designed to any desired shape and dimensions. The key issue is not whether an implant can be designed to accommodate your aesthetic desires, but whether your tissues can adequately stretch to accomodate the desired augmentation. This is of a particular issue as one tries to create augmentation on the lower aspect of the brow bone. Besides there being the supraorbital nerves (responsible for feeling sensation of the forehead) which exits through the brow bone and can become injured when an augmentation drops below the brow bone, this is also a brow bone area that is hard to expand as the tissues are very tight.
The other aesthetic issue is that it is potentially problematic when the forehead augmentation crosses the temporal lines at the side of the forehead. Unlike the bony forehead, the sides of the forehead (or the upper temporal region) is muscular and not bone. Any augmentation that crosses into this area can create an unnatural line of demarcation. (the temporal line is a natural line of demarcation)
In short, a custom forehead and brow bone implant can be designed to meet most of your aesthetic augmentations. But there are some aesthetic considerations that may not allow every aesthetic/forehead desire to be met.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, about three years ago I had a Mentor Coloplast prosthetic testicular implant put in. It is sooo hard and unnatural feeling. The good news is It isn’t sutured in and I do like having the mobility. I really want to know if they make a softer squisher testicle. I know a prosthetic testicle will never be 100% like the real thing, but this is sometimes causing me pain because it is so rock hard.
A: Saline-filled testicle implants (Mentor Coloplast) are by their very composition hard and quite unlike what a natural testicle feels like. Saline placed inside a silastic silicone shell creates a very firm prosthesis. It is fundamentally a flawed concept for a testicle implant not to mention the risk of deflation and need for eventual replacement. Very soft low durometer silicone testicle implants exist that feel very similar to a natural testicle. They are extremely soft and squishy and have no risk of eventual failure or need for replacement. This is because it is a solid implant material and not a fluid-filled bag.
With an existing testicle implant in place, it would be a straightforward surgery to remove the hard saline implant and replace it with a very soft silicone testicle implant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m inquiring about a cheekbone augmentation and possibly a bossing reduction. I’ve always been bothered by my side profile. To me, it looks more flat (or even mildly concave) than convex. I was seen by a craniofacial specialist about this concern, and he stated that my forehead shape and slope were fine, but I had very flat cheekbones and that it could be fixed. I’m not certain why I didn’t speak about a cheek augmentation procedure at the time.
I was wondering if a cheek augmentation, possibly a frontal bossing reduction, would help give the impression or a more convex profile. I’ve attached images. It may be hard to see in the images, but the areas under my eyes are completely flat, and vertical.
A: Thank you for your inquiry and sending your pictures. I would say that you are correct about your facial profile in regard to the lack of midface (cheek) projection and some frontal bossing protrusion. On a practical basis for a man, it is easier to undergo cheek augmentation than upper forehead reduction because of the incisional access and the resultant scar line.
Your cheek deficiency is really a more infraorbital-malar deficiency that encompasses from under the eye out to the sides of the cheeks. This is why you have a negative vector. (the cornea of the eye sticks out further horizontally than the projection of the cheeks.
This is not ideally treated by a standard cheek implant as this will provide no improvement to the under the eye area. This is best treated by a custom infraorbital-malar implant style.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley,I just want to receive more information on forehead reshaping procedure. I have always been very unhappy with my masculine looking forehead and although I am a male I have always wanted to obtain a more feminine looking forhead and eliminate my heavy brow ridge. I did have a procedure done abroad about 7 months ago and had my brow bone shaved off but to say the least the surgeon that did my surgery did not remove enough bone to make my forehead straighter and less slopped. Ideally I would like my forhead to be rounder but at the very least eliminate the bump on my eyebrows and make my forhead smoother. I would like to consult on forehad reshaping with possible upper forhead implant.
A: I am not surprised that just shaving the brow bone in a male did not give adequate forehead reshaping and reduction. Almost all males with really prominent brow bones need an osteoplastic setback procedure rather than simple shaving. A few millimeters of reduction in a male is just going to be inadequate. In addition some males with prominent brow bones have a significant backward slope to their forehead which often needs to be augmented at the same time as the brow bone reduction to get a much improved forehead shape.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 28 yr old who was born with a unilateral cleft lip and palate and have undergone a diced rib cartilage rhinoplasty within the past 6 months. Although I am very happy with the rhinoplasty, I feel a midface augmentation would very much improve any midface deficiency caused by the cleft. I am also interested in a potential forehead augmentation as my forehead slopes back quite a bit with a prominent browbone. Can this all potentially be done in one visit,? I am looking to have this done within the next couple of years. I would like to schedule a Skype consultation to get a better idea of what can/cannot be done in my case. My main concern lies with potential extrusion of any silicone implants in the midface. I have heard some horror stories of infection and extrusion of non-autologous/man-made material implanted into the face, especially into an area with a lot of muscle movement. I look forward to your response.
A: All facial clefts cause some degree of midface deficiency on the clefted side which may become more apparent with an augmentative rhinoplasty. Building up the deficient paranasal/midface area can be very beneficial in the cleft patient and there are lots of ways to do it using various autologous and alloplastic materials. It is a shame this was not done during your rhinoplasty since you had access to one of the best long-term materials to do such midface augmentation…rib cartilage. Since you still have the chest wall scar from the harvest this probably remains a possibility. But considering other options, a wide variety of implant materials exist to do the job. While synthetic implants have a risk of infection, particularly when placed through the mouth, it is fortunately very low. I have put in thousands of facial implants over the past 30 years and these risks are incredibly low in my experience. However it is important to acknowledge that they are not zero. Only the use of your own tissues poses the lowest risk exposure to infection. (and even that is not zero)
I would need to see some pictures of your face for a more detailed assessment of your midface and forehead for further recommendations.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in rib shave surgery. I think what I have what is called costal cartilage protrusion on my left ribcage. My right ribcage is normal. I have done some research and some say it can be shaved down. If possible, I would like to have my rib shaved down so it looks normal like my right side. I would also like to know the downtime for such a procedure. Attached are some pictures. Thank you for your time.
A: Thank you for sending your excellent pictures. You are correct as that is protrusion of the lateral cartilaginous portions of ribs # 8,9 and maybe a bit of #7. A cartilage shave procedure of this protrusion would be the appropriate procedure through a 3.5 cm long skin incision right underneath it. Because the dissection passes through the rectus muscle (split vertically) there will be some soreness for awhile. This is ameliorated for the first few days through the use of Exparel injections placed at the time of surgery into the muscle as well as intercostal nerve blocks. This is a local anesthetic that will last for up to three days after surgery. Some soreness will persist for about a month after surgery as one would expect. When you could return to work depends on what type of work you would be doing and when you feel comfortable doing it.
Dr. Barry Eppley
Indianapolis, In
Q: Dr. Eppley, I am interested in occipital augmentation. The back of my head looks exactly like the picture that I have attached and the issue is the protruding occipital bun at the back of the head of which I am concerned. However my skull is quite small or a man (22.5 inches circumference) and I do not want to reduce it anymore than it already is. I was doing some computer morphing and I found that the result that I want can be obtained (on the morph) by augmenting the area at the bottom of the back of the head (the concave curvature underneath the occipital bone to the neck). I understand that the area is complex and that it is partly muscular. Is there any way to augment this area either by custom implants, custom soft tissue implants (similar to those used for temporal augmentation), fat transfer, fillers etc.?
A: As you have correctly perceived, the area on the back of the head that you are interested in augmenting is not a bony structure. Unknown to most people is that the bottom edge of the occipital bone sits at above the level of a horizontal line drawn across the top of the ears. There is no effective way to do occipital augmentation in what is essentially the top part of the back of the neck. This is tight skin over muscle with little fat in the subcutaneous plane. Neither an implant, fat transfer or any synthetic filler can provide any significant augmentation in this non-skull area.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have had small cheek implants placed last year, but they are definitely too small. I’m looking to get some fillers for further augmentation. I just have a couple of questions:
1) Can a filler like Radiesse be placed over the implant safely?
2) My malar deficiency seems to be causing some mid-face sag and folds. Would adding fillers to the cheeks help address these concerns?
Thank you!
A: Any form of synthetic injectable fillers or injected fat can be placed over cheek implants. No complications will occur unless the injectate ends up violating the cheek implant capsule. This is where the role of using blunt-tipped cannulas for fillers are better than injecting using a needle.
I doubt that injectable cheek augmentation will do much for soft tissue elimination of your midface sagging. Larger cheek implants would be more effective in that regard but even they will not significantly improve your nasolabial folds. But an injectable approach to the cheeks and nasolabial folds would be a good initial approach to see how much improvement may be possible. I would not be optimistic about this approach but at least it is reversible if ineffective.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a very large and disproportionate face. My brows are hugely overgrown and my jawline is equally as big. I look like a Neanderthal! What type of facial reshaping or facial reduction surgery would be beneficial for me?
A: Thank you for sending your pictures and I can clearly see your brow and jawline overgrowth concerns. While reduction of these facial bones is certainly one part of the solution, it is not the complete or most effective approach for either area. For your brow bones, their prominence is partly contributed to by the recessed or backward sloping of your forehead. That would be become very apparent if the brow bones were reduced alone. The best result comes from a combination of an oteoplastic brow bone setback (not just shaving) and forehead augmentation above it. I have shown this type of result in the imaging attached. From the jawline standpoint, bone needs to be removed along the inferior border of the jawline from the angles to the chin. But the chin bone needs to be vertically lengthened and setback a bit to make the jawline more harmonious and smooth. I have attached imaging of this type of combined chin and jawline change. For all facial areas it is also important to not overdo them as your entire face is skeletally strong and any drastic change to one area would look out of proportion or even feminizing to your face.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in some form of cheek augmentation. I have a concave portion of my face that I would like augmented. From the semi profile view, I find the circled area below may have missing volume. I found someone that had a similar shape in this area and had it fixed with fillers (photo under mine). I assume the jaw implant would have no impact on this area? Assuming not, do you think putting fillers there would be appropriate to get a similar outcome as in the photo under mine in this area?
A: The volume deficient cheek area to which you refer is in what I call the ‘trampoline area of the face’ which is a non-bony supported area between the cheeks and the jawline. No form of an implant will improve that area so an injectable approach needs to be done for that lower type of midface or cheek augmentation procedure.. If one wasn’t having surgery then a synthetic injectable filler would be used. But since you would be having surgery then fat injections should be done. While fat injections are unpredictable in terms of retention they are a ‘surgical’ choice and are better than having a known temporary synthetic filler placed. Fat may or may not survive. But at least it has a chance unlike any synthetic filler.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have chin asymmetry and am looking to get it corrected. I am a 31 year old trans woman who has been on hormone therapy for about a year. The hormones have significantly feminized my face, however one thing that has been “revealed” in the softening and rounding of the jaw/chin is that one edge of the chin appears to come down a bit more than the other. The jaw is even And the chin “point” is even, it just seems like theres a bit of excess bone on one side. It’s very subtle and the goal would be for no one to notice i had surgery. Please let me know what options you might recommend for going about this in a way thats conservative, and would not affect overall facial proportions (I don’t want a shorter or more rounded chin!, and also i have a somewhat larger nose and wouldn’t want to have a surgery that then required an additional rhinoplasty) Here I have attached some photos to help you get a better idea. All I want fixed is the larger corner of my chin so that it be brought into balance with the other side. I don’t want a chin thats any more “round” OR “square” than what I already have, if that makes sense? In other words, I don’t want anything done to the smaller corner/mid point of the chin. Let me know what you think. Thank you so much!
A: Thank you for sending your pictures. I can clearly see that the one side of the chin is vertically lower than the other side. Your chin asymmetry could be reduced without touching the midline or good side of the chin through an intraoral approach. In doing this from an intraoral approach it would be important to resuspend the mentalis muscle back into place since to get to the very bottom edge of the bone requires some soft tissue elevation. Coming from below through a submental incision makes the surgery easier from a technical and recovery standpoint but there is always the issue of the fine line scar under the chin to do so.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, For the past year, I have been having frequent sometimes heavy nose bleeds three to five times a week. I wanted to mention this to you. Is this a cause for concern going into rhinoplasty surgery? It usually stops easily if I pinch the bridge of my nose. I’ve noticed it is somewhat related to stress in my life.
A: Having a history of nosebleeds before undergoing a rhinoplasty does not preclude you from having one. Having them at the frequency of three to five times a week and being heavy in nature is a cause for some concern about what would happen after a rhinoplasty and having to manipulate your nose to stop the bleeding. This may have adverse consequences on the ultimate aesthetic outcome of the rhinoplasty.
Stress is not really a reason or cause of nosebleeds, there would have to be a more anatomic explanation. I would recommend that you have an evaluation by an ENT specialist to try and determine their source. You may or may not be able to do find a cause but it would be prudent to have that evaluation before undergoing any form of nasal surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’ve gotten a skull reconstruction cranioplasty done while on active duty following a stroke/craniectomy and I have 1) a concave dent on my left temple, 2) a bulging muscle underneath the dent (surgeon said the muscle couldn’t be reattached to the titanium plate, and 3) have an irregular protruding spot where the plate ends in my forehead, almost like it’s not fully connected to the bone, or the plate itself isn’t the right fit. Can plastic surgery fix this? Will it be a major operation, or dangerous? If so, do you think the benefits of the status quo outweigh the risks? Thanks
A: I would need to know two important pieces of information about your prior skull reconstruction surgery, 1) what type of cranioplasty was done and 2) a current 3D CT scan of your skull to fully know the anatomy of your skull and what the cranioplasty looks like and the area that it covers. That being said, most likely the corrective approach is going to be a bone cement only cranioplasty to recontour the area. I would not view this as a risky or dangerous procedure. Since you undoubtably already have a scalp scar the biggest aesthetic risk of such surgery is irrelevant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a brow bone reduction. Given the strong prominence of my forehead, and based on everything I have seen on Dr. Eppley’s website, my brow bone will probably need to be removed, reshaped, and reattached. If this is the case, how many days will I need to take off work and approximately how long will it take before there are little to no visual signs of surgery?
I still want a masculine forehead. I do think (based on editing the photos a little myself haha) that reducing the brow bone, and following the natural slope of my forehead, will still allow a little bossing in the brow region where it meets the bridge of my nose. Although not noticeable in the photos, my brow did not boss in the center between my eyebrows (though it may appear as such in attached photos) creating a hard “valley” between my eyebrows as if the frontal sinus did not fuse together properly during puberty (if that is even possible). Therefore, I am hoping the results of this procedure will (1) reduce the horizontal protrusion and in effect (2) eliminate the crevice in the center between my eyebrows.
A: Thank you for sending your pictures. I have done imaging to show what type of potential result is possible with a brow bone reduction procedure for you. It is very common to have the brow bone protrusion to be more evident on the sides as the air space of the frontal sinus is often not connected across the midline so the bone protrusion from enlarged sinus spaces is often less evident in the middle or globular region of the brow bones. Both of your brow bone reshaping goals are achievable.
The recovery from brow bone reduction is largely that of appearance. It probably takes about 10 days after surgery until one looks fairly reasonable and a full three weeks until one appears visually completely normal and does not have any signs of having the surgery. There are other physical issues that take longer to recover from such as forehead numbness and incisional healing but that is not an externally seen issue.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in scalp scar revision. This is a 37 cm by 2 mm scar by a hair transplant that was done 15 year ago. My main goal is to be able to cut my hair short so I can wear it like in the pictures without being noticed. It is slightly hypertrophic but more problematic is that it is white and that it is linearly straight. I have tried tattoos – it was not successful and injections didn’t help either. I would to see if we can revise this. How will you be able to handle the hairs that in and around it ?Would you be able to save the hairs? Thanks.
A:The only method that could offer any improvement is that of surgical scalp scar revision. The scar needs to be cut out in its entirety and then reclosed using either a straight line as it is or with a running w-plasty closure line. (preferred) Any hairs that are in the scar would be removed. Hairs that are around the scar would be preserved. I don;t know if it is every realistic that you can have the scar improved to the point where it would never be somewhat noticeable. Like all scar revisions, reduction in its appearance may be possible but complete invisibility is not a realistic goal.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am writing to enquire about chin lengthening surgery. I have a fairly round face which to me lacks length , I am hoping to achieve a more heart shaped appearance , I do not have a recessive chin although it is quite “round”. I’m not sure if that is the best way to describe it but I have attached pictures so you can get an idea of what I mean. Please would you be able to tell me if you feel I’m a candidate for this type of chin surgery.
A: What I see is that your chin is vertically short which makes your face overall more round in shape. A vertical chin lengthening procedure through an intraoral opening osteotomy will provide facial elongation and go a long way towards making your face more heart-shaped. In vertical chin lengthening the chin bone is cut and dropped down in a cantilever fashion so as to keep bone contact at the back end of the bony cuts. The vertical opening distance is maintained through the placement of a small spanning titanium plate. An interpositional cadaveric bone graft is used in the central part of the wedge for both stability and to expedite eventual bone healing into and through the gap.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley,I am looking to get double jaw surgery for functional reasons related to sleep apnea and I have been doing a lot of research on the aesthetic benefits that double jaw surgery can bring. I believe that if I am going to be getting double jaw surgery, I might as well maximzse the aesthetic outcome. I am currently searching for reputable surgeons to perform the surgery and your name cropped up as an aesthetically minded surgeon trained in both maxillofacial surgery and plastic surgery.
From an aesthetic point of view, there are two main issues that I am having trouble wrapping my head around, and they both involve counter-clockwise rotation of the maxillo-mandibular complex. The first is the position of the dentoalveolar portion of the maxilla relative to the anterior nasal spine and the paranasal area. In the first image that I have attached, you can see how the mouth area of the patient in the ‘before’ is set-back relative to the base of the nose. In the after, you can see how the mouth area was moved forward relative to the base of the nose, reducing the nasolabial angle and creating a forward sloping upper lip. Is this a result that is achievable with CCW rotation in the general sense (barring any other preclusions)? In other words, given that an aggressive CCW rotation is able to be performed on a patient, is that the result that one would expect?
My second question is whether or not counter clockwise rotation of the maxilla around the anterior nasal spine, and thus the movement of the maxilla and mandible ‘forwards’ and ‘upwards’, may be able to reduce the perceived distance between the stomion point and the subnasale point on the face. I surmise this because – with CCW rotation around the ANS – the subnasale point is remaining constant whilst the maxillary incisor tip and the stomion point is not only being moved forwards but also *upwards* relative to the rest of the face. So the linear distance between subnasale and stomion will remain constant, but the perception of the distance by the onlooker will be shorter because of the new angulation created between the two points relative to the true vertical plane. Is this an accurate appraisal?
A: There is a reason you ‘can not wrap your head around’ the aesthetic changes that may occur from a counter clockwise rotation of the maxilla and mandible in double jaw surgery…it just isn’t that simple. How the overlying soft tissues respond with the bony changes is not completely reproducible and may be somewhat different in each patient. While cephalometric and even computerized prediction tracings make it look mathematical, it often doesn’t work as predictable as it looks. It is important to remember that this is surgery on live tissue not a linear drawing on an x-ray. No matter how you choose to view it, orthognathic surgery is a ‘gross’ bony movement procedure and is not really amenable to be critiqued by smaller millimeter measurements or such precise external facial changes. In short it is more than just geometry of bone movements.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am wondering if surgery could correct my facial asymmetry? I have multiple scars across my forehead, most notably over my right eye. I lost skin and underlying tissue in the area and the eyebrow sits higher and at an odd angle compared to the left eyebrow. Due to the lost skin and tissue, the eyebrow and forehead area on the right side of my face are uneven with the left. I had a skin graft four years ago so that I could close my right eye, but there was excess skin from the graft which is noticeable when the eye is open or closed. Can facial symmetry be achieved in my case, and if so how?
A: I see three facial asymmetry issues that you have: 1) a higher eyebrow, 2) an eyebrow/brow bone contour deficiency and 3) excess skin of the eyelid. Lowering a higher eyebrow is very challenging to do and is often resistant to surgical efforts due to the fundamental loss of tissue and the tethering of underlying scar in your case. But that doesn’t mean it is impossible. I would recommend three specific procedures to offer improvement to your orbit-brow asymmetry. An upper blepharoplasty to get rid of the redundant skin from the skin graft, 2) release of the eyebrow and 3) placement of a dermal-far graft on the brow bone. (to create better contour and help the brow release)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have for a few years been researching rib removal for cosmetic reasons, but was unable to find surgeons doing this procedure. The only surgeon I found with information about this procedure said the rib removal alone would not make the waist look smaller. I found you when reading about the model having rib removal with you last year. Is removal of the floating ribs likely to make a considerable difference on a slim woman? Is it possible to receive more information about the procedure? Particularly about aftercare and risks, it is hard to come by legitimate information about this procedure. I understand that it is an extreme procedure, and you have probably received many messages about this procedure after the story came out. Is this a procedure you will do? How does a patient go forward with this? Is an in-office consultation necessary? I’m located in Europe. Other than being a motivated and healthy patient, what makes for a fitting patient for rib removal?
A: The best way to get the most accurate information about rib removal for waistline narrowing is by have a virtual consultation. My assistant will contact you tomorrow to schedule a Skype consultation. Rib removal with waistline training can successfully narrow a waistline in my experience of close to twenty rib removal patients. Those women who get the best results are usually the ones that are already fairly thin where the effects are seen the best. Please send me some pictures of your waistline and any examples of what you want to achieve.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, About eight years ago I had a jaw implant that I was very happy with the result. However, as I’ve aged and my face has lost volume, I’m interested in slightly increasing the implants to (slightly) widen my face. I understand that one option may be to insert a “chip” underneath the existing implant. Is this correct? If so, what is the recovery period? Many thanks.
A: What you are referring to is the concept of adding a wafer of material under an existing implant or even placing an overlay on top of the implant. The latter is usually more effective as its effects are more directly translated to the overlying soft tissues. For widening jaw angle implants which appears to be what you have, adding a wafer (shaved down implant) under the existing one would certainly be relatively atraumatic to do and would add just a slight bit of more width. However the complication rate is higher when two implants are stacked on top of each other. Thus while the wafer concept seems simple, it is probably better to just replace the jaw angle implants with new ones. This is really not much more traumatic than placing a wafer underneath them.i
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Please see CT scans for my current face bones of the right and left side. Also, photos before surgery and after surgery.
I went for jaw reduction but the doctor talked me into also having cheekbone reduction. The results were a strange shape face from the outside and deep burns from surgical instruments down my chin.
1. Please look at my CT scans and tell me what you can see has happened to my jaw bones.
2. Please look at my CT and tell me what you can see has happened to my cheek bones.
3. Please let me know if the cheek bones can be repairable and tell me the procedures to fix the cheek bones.
4. Please let me know if the jaw bones are repairable, also the procedures to fix the jaw bones.
Something has gone wrong from this surgery and I am looking for help.
Please kindly help or advise in any way, I really need help.
A: Thank you for sending your CT scans of the jaw and cheekbone reduction procedures you had done. What the 3D CT scan shows is:
1) Complete amputation of the jaw angles
2) Cheekbone osteotomies with wide displacement of the anterior osteotomies with no obvious fixation of the bones and a downward rotation/internal collapse of the cheekbones
Just based on the CT scan you would need the following for reconstruction:
1) Vertical lengthening jaw angle implants to remake the amputated jaw angles
2) Repositioning and plate and screw fixation of the anterior cheekbone osteotomies.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a plastic surgeon practicing in Slovakia. I recall that you place your buttock implants intramuscular…..I am seeing a patient soon interested in gluteal implants. If you have a moment I have a few questions for you since my experience was limited in buttock augmentation.
1. Must I have the tool that is used to split the muscle (pic attached attached)…..I don’t recall you using this tool…will a couple malleables, dever, and cautery work?
2. How long until you let your patients sit? Seems like a wide discrepancy in the literature.
3. I recall you using the incision technique according to Raul Gonzalez where the midline is depithelialized preserving the sacrocutaneous ligament….I will do the same.
4. How long until you let your patients sit on an airplane?
5. Do you place drains with the intramuscular approach?
6. How do you determine implant volume choice….do you use templates?
Thanks for your help!
A: Be aware that buttock implants are the hardest of all body implants to placed and when you do your first case you are likely to ask yourself why made you think it was a good idea to do this surgery. The other very important preoperative consideration is that the size of buttock implants that can be placed different dramatically from subfascial vs. intramuscular. You and the patient have to have a clear idea as to expectations. Intramuscular buttock implants will almost always be smaller than the patient wants, have a very long recovery and are very hard technically to do since there is no natural plane of of dissection. Subfascial buttock implants allow for much larger implant sizes, have a somewhat quicker recovery and are technically much easier to do. But to answer your intramuscular buttock implants questions:
- The duckbill dissector to which you refer is not absolutely essential as a wide malleable restractor can similarly be used. At at $850 for the instrument it really becomes non-essential.
- I let patients discomfort determine when they can sit…as they eventually have to do some sitting for certain functions
- Re-establishment of the sacrocutaneous ligament is essential in closure of the intergluteal incision.
- Same as answer #2
- There is no reason to use drains in the intramuscular buttock implant technique.
- With intramuscular buttock implants you are never going to get an implant in and satisfactorily covered with muscle over it that is bigger than 330cc. It just can’t be done. Your implant options are going to be either 270, 300 or 330cc. When in doubt choose the smaller implant size.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, The more I sit here the more I am feeling like I would just like to come and see you for a 3D CT scan of my face. The sliding genioplasty and lip issues is one thing but I am seeing marked asymmetry in my whole face (the one side literally looks like it is 1/2 inch out farther than the other side causing my cheek and jaw on the one side to be much much larger and lop sided.
To clarify what I had done:
Sliding genioplasty
Mid jaw implants
Back jaw implants
Cheek implants
Buccal fat removal
I know I would feel better if I saw you for a look over and a scan. My surgeon didn’t do a CT scan on me and claimed he did custom facial implants but from the very first day my one side has looked larger and it is now day 8 and doesn’t feel puffy – just hard like the implant yet it sticks out way way wider than the other side. I specifically asked for no width to be added to the face and for it to stay slim but I feel masculine and disfigured. Even if it just means taking things out for now I’m okay with it.
A: Having had all of these implants and bone work it would be very common at your early postoperative period to have facial swelling that was asymmetric. So I would not try to judge the symmetry of the results at this early juncture as that is really impossible to know. But if you really want to know how all the implants looks by position and size, then a 3D CT scan would answer those questions. As long as the implants are silicone they can clearly be seen on the scan. Medpor implants are much harder and often impossible to see. The sliding genioplasty of course can be seen very clearly. That is a scan you can get where you live. You just find a place to have it done and I can fax in the order to have it done. You do not need to come here to get the scan but can if you would like.
True custom facial implants require a 3D CT scan to fabricate but your surgeon may have been referring to just shaping standard implants at the time of surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting the masseter muscle reduction and the upper trapezius muscle reduction and I am looking for a more permanent solution. Here are a few of my questions…
– What to expect on results
– Recovery Time
– Healing and when can I leave to go back home to NJ
– Vitamins and meds to take to help with swelling and healing
Please also see my attached photos of a view of my side, front, and back and let me know if you need any more information from me…thank you.
A: Thank you for sending your facial pictures. In answer to your questions:
1) Surgical masseter muscle reduction is done through an intraoral approach by muscle release and electrocautery reduction. After surgery it would take a full three months to see how much muscle has been reduced. The trapezius muscle is done through an incision at the back of the occipital hairline. From this location a wedge of trapezium muscle is removed to reduce the raised contour of the line from the neck out to the shoulders.
2) Recovery time is based on swelling and level of discomfort. There is really no postoperative restrictions. The swelling of the jaw angles would be more noticeable than the trapezius and would take about 10 days before returning to its preoperative size and months before the final result is seen.
3) You could go home in 1 to 2 days after surgery, whenever you feel like traveling.
4) Vitamins are not helpful for the swelling. I will give you steroids during surgery as well as Medrol Dospak after surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Following a chin implant being removed via an intra-oral incision six years ago, I have lower lip incompetence and chin ptosis.Is it possible to have a successful outcome with mentalis muscle resuspension without inserting another chin implant? Also is it possible to achieve a good result with absorbable Mitek sutures as opposed to titanium screws?
Another doctor has advised he would insert another small chin implant and use titanium screws. I’m not comfortable putting another chin implant in or with titanium screws in my chin.
A: One can certainly have a mentalis muscle resuspension surgery without placing a new chin implant. But the success of the procedure drops when the lower chin support provided by a new chin implant is not added. This does nor mean that it can not work just that the long-term success rate will be lower.
Mitek absorbable bone anchors are my performed method of mentalis muscle resuspension. They come with an indwelling bone device (anchor) that is composed of either a small piece of metal (nitinol) or a reservable polymer composition that takes 6 months to go away. The sutures attached to the bone anchors however are permanent.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like to schedule an appointment to have something done to my undereye wrinkles. I have attached pictures of me smiling and not smiling and you can see the big difference as to how many undereye wrinkles occur when I am smiling.
A:Thank you for sending your pictures. Under eye wrinkles either are only present when one smiles or becomes much worse when one does smile. (have them at rest) Lower eyelid surgery really treats excess skin and wrinkles when one is not smiling. It is really an operation that treats a static problem since that is how the surgery is done. (patient not moving/smiling) More dynamic undereye wrinkles are treated by Botox injections as this injected agent treats a dynamic problem through muscle weakening. In other words, if your undereye wrinkles are mainly present when you are smiling that is a non-surgical Botox injection treatment issue. However, if a lot of undereye wrinkles are present when one is not smiling, and gets much worse when one does smile, then lower blepharoplasty surgery would be the most effective treatment. It is also important to point out that no treatment will completely get rid of undereye wrinkles, they can only reduce the number seen.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a skull widening procedure.I have a narrow skull/ head and was wondering if its possible to widen the sides of skull and forehead with Alloderm instead of implants? Im not comfortable with implants and was hoping instead that Alloderm could be used for such large areas. And if alloderm can be used for skull/head widening, does screws need to be used? Thank you.
A: While Alloderm can be placed on the sides of the skull for augmentation, there are several problems with its use for that application. Beyond the sheer cost of Alloderm (the material alone would probably costs $15,000 to $18,000 for a skull widening procedure that is at least 5 to 7mms thick) the material has a low propensity for persistence and a relatively high incidence of infection when stacked in layers which it would have to be for any skull augmentation procedure. I don’t think the use of Alloderm is a viable option for a skull augmentation material. If you are looking for a more ‘natural’ skull augmentation material, injected fat would be the most viable option as long as one is not looking for any major volumetric change.
Dr. Barry Eppley
Indianapolis, Indiana
