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Q: Dr. Eppley, I’m about 5’4 and roughly 115-120 pounds maybe a tad heavier. I’m considering buttock implants. I’m 23 soon to be 24 so I didn’t know what the options were? Time of surgery? Healing process ? Risks ? I’m hoping to hear from you very soon!
A: While I don’t know exactly what you body looks like, your height and weight measurements suggests that the use of fat for your buttock augmentation is unlikely to be inadequate. You may simply not have enough fat to harvest to do much of a buttock augmentation. I would really need to see some pictures of your body to answer that question better. if not that would then leave you with only the option of buttock implants. Whether implants would produce a satisfactory result depends on what your buttock augmentation goals. Implants generally produce a small to moderate buttock enlargement not a big buttock size increase.
Buttock implants can be very effective if one has a realistic understanding of what they can and can not do. Beyond this aesthetic issue, buttocks implants have a relatively long recovery time and it probably takes most patients a full month to get back to most of their normal activities.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Several years ago, I developed bulging temple veins and I had the superficial temporal artery ligation in my right temple with a single point ligation.I’ve had some potential complications and I’m looking for a second opinion.
For the most part, the surgery was a success. The bulging vessel is gone and any scarring was very minimal. A couple years after the surgery, I developed a very rare condition called Partial Third Nerve Palsy, most likely caused by lack of blood flow to my ocular motor nerve. As with most partial ocular nerve palsies, my condition improved within weeks.
Fast forward a couple years and it happened again. And just like the first time, I recovered completely. I had the top ophthalmologic docs stumped. I told them about my superficial temporal artery ligation and they brushed it off as insignificant. I’m relatively young and healthy and have no other conditions that typically would cause an ocular nerve palsy.
I was recently reading Men’s Health and there was an article about giant cell temporal arteritis and how it can cause double vision or blindness. So that tells me that there IS a possible connection between the superficial temporal artery ligation and vision, right?
But everything I read online said the procedure is safe and perhaps my recurring ocular nerve palsy is just a totally unrelated coincidence. As you seem like an expert in this field, I thought I would reach out to you and hope you can put my mind at ease.
Q: In short, I know of no connection between superficial temporal artery ligation and oculomotor nerve palsy. The superficial temporal artery is a terminal branch of the external carotid artery that supplies the forehead and anterior scalp. Conversely the oculomotor nerve receives its blood supply from the internal carotid artery through an intracranial course. Thus there is no apparent anatomic connection on the basis of arterial blood supply.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Wouldn’t a jaw implant have the same issues as chin implants where eventually the bone starts to become reabsorbed?
A: The belief that chin implants cause ‘bone erosion’ is both inaccurate and biologically misinterpreted. Some, but not all, chin implants develop passive settling into the bone as a biologic response to the tissue displacement pressures of the implanted device. This is a passive and natural process that occurs in many augmentation implants throughout the body that is self-limiting as a method of pressure relief. This should not be confused with an inflammatory process like bone erosion which develops as an adverse reaction to either a material’s composition or an infection from the implant material.
Such passive tissue remodeling responses to a facial implant is most commonly see in chin implants. It is probably because of the tight tissues of the projecting soft tissues of the chin stretched out over a projecting underlying bone. This puts a lot of pressure over a single bone point. (chin) This is not seen in larger jaw implants because the displacement forces are spread out over a much larger bone surface area and there is no one single pressure point or area.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, My primary cosmetic concern is actually very dark skin in the upper and lower lids as well as the sides of the nose. Unfortunately, without make-up this feature dominates my face. However, I am also aware of some structural issues that make this darkness look worse. My prominent brow bone casts a shadow over my deep-set eyes and that the radix of my nose is very narrow. Would you agree that these are contributing factors? (Photos, with make-up, are attached.) Would brow bone reduction and nasal augmentation help?
I had some fat transfer to the lower lids ten years ago with some lasting success. I would now like to correct the darkness in my upper lids and medial canthus and I’m researching two options. One option is fat transfer. The other is to address the structural issues through reduction of the brow bones and lateral augmentation of the radix of my nose. Ideally, I would pursue all of these (along with hairline lowering) but am hesitating to have such invasive procedures.
Can you advise me which of these procedures will make the most difference to the darkness in my eye area and my overall appearance? Also, what is the likelihood of a good result? Any advice you can offer is greatly appreciated.
A: Thank you for your inquiry and sending your pictures. While your structural issues may make a contribution to your periorbital dark skin appearance, you would never do structural surgery such as brow bone reduction or nasal augmentation in an effort for skin coloration improvement of the adjoining areas. The risks are simply too high. You do those surgeries for what they primary purpose is…creating a structural change not a potential secondary benefit.
This leaves you with the only treatment option of which you have had prior experience…fat grafting. Whether this would be effective to improve your periorbital skin discoloration is not precisely known.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’ve underwent a male breast reduction surgery five years ago. Everything went well. Months after my surgery,I had slight scar tissue build-up in my chest—nothing too concerning, absolutely livable. I massaged when I could but it was always so sore and I was too scared of messing up my results. I noticed the scar tissue in my left pec fluctuated slightly in size slightly over time. Massaging wasn’t helping, so at one year post op I went in for Kenalog shots to break up some of the tissue. It seemed to work but it also left a slight dent when I flex. Now, four years post op, the tissue seems to have grown again out of nowhere. I began massaging vigorously again. At first, the scar tissue seemed like it was breaking up and getting smaller. I was massaging just about everyday and then it started to harden. I even got some bruising around my left nipple. I tried to keep massaging, but I’m not seeing any progress. It only seems to be getting bigger, harder, and more noticeable—is that good or bad?
A: At this point the only effective option is going to be further gynecomastia reduction surgery. Whether it is scar tissue or actual breast tissue regrowth, further improvement is not going to come from massage or steroid injections. Secondary or revisional gynecomastia reduction surgery is not rare due to either the development of scar tissue or some breast tissue regrowth.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have had a Medpor chin implant placed last year. I am ok with the look although it is a bit big for my feminine small face and my chin looks a bit big and asymmetric when I smile. However my big problem is when I woke up after surgery with excrutinating pain on the right side, probably along the branch of the mental nerve that goes to the lip. And it still hurts a lot, focused on that groove between chin and lip on that side. It improves when lying down after a while and worse when I move my mouth, speak etc. What should I do?
The surgeons are very experienced but have never experienced this kind of problem before, and have never removed or performed a chin implant revision. I also have numbness in the same side of the lip and a bit problem with articulation.There is also pain in the lip when I stretch the lip. When I wake up in the morning the pain is almost gone and comes when I start moving around. I consulted a neurosurgeon who said there is nerve damage, not a cut nerve. The surgeons are willing to take out the whole thing but I think that is very drastic. What would be your advice, and where to find the best expertise for my problem, and how to fix it – the situation is kind of desperate as i do not function so well wit all that pain. Hope to hear from you soon.
A: Either the chin implant is impinging on the nerve (mental neuropraxia) or the nerves has beens stretched/injured during the making of the pocket to place the implant. Given the overall larger sizes of Medpor chin implants and their stiffness, it is likely that it is the former. I think the only way you can make improvement is to do a Medpor chin implant revision where the implant is removed, the right mental nerve checked/repaired/fat grafted and the implant modified in size and reinserted. It is unfortunate that this was not done a long time ago when an injury to the nerve had a much better chance of having a full recovery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in masseter muscle reduction via electrocautery for a permanent solution. I would also like to know if this method can be used for the upper trapezius muscle as well? Mine is way over developeddue to genetics as well as being top heavy…thank you.
A: Masseter muscle reduction is surgically done using electocautery to treat the entire internal surface of the muscle from where it is lifted off the jaw bone. By so doing it causes some muscle cell atrophy, reducing the size of the overall muscle. Treating a much larger muscle like the trapezium is more analogous to that of the calf muscle. In calf muscle reduction a portion of the fibers of the muscle are released from its origin by electrocautery resulting in a different mechanism for muscle atrophy. This would how the trapezius muscle would similarly treated. What bothers you about the trapezius muscle would most likely be the upper third where it is seen gong from the back of the head down across to the shoulder. Such a trapezium release of the upper third of the muscle would have to be done where it attaches to the occipital skull bone.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have some questions about custom facial implants. I have attached a frontal shot of my face in harsh bright lighting. I have also attached a side profile shot along with an adjusted “goal” image of what I would like my profile to resemble. I have also attached a picture of a famous actor who has an incredibly angular and well defined jaw. It would be my dream to have a jaw like his. Is it achievable? My budget is considerable. My primary aim is to get rid of my round face front on and have something square and angular both in the chin and jaw angle regions.
I am also interested in what parts of my face are lacking and how I can improve it aesthetically. What are your thoughts, I’m open to suggestions. I seem to have quite a round face despite being low in body fat (my abs are visible and I have a “four pack”). I’m puzzled by what I need to enhance to get the look I desire. Is my lack of facial bone structure causing poor tissue distribution or is my poor tissue distribution hiding my bone structure. Interested in your thoughts and potential solutions, I like your intelligent approach that I’ve been reading in your blog.
A: Thank you for sending your pictures and describing your aesthetic goals. In reality you do not really have a round face. It may appear that way to you and is not to your liking but it is certainly not round. Your face is thin and you have decent facial bone structure. What you lack is the bone structure to get the ‘supernormal’ look you desire. With the right cheek and jawline implant designs such facial changes that you seek are possible. That type of facial change can really only be achieved in someone with a thinner face where the enhanced skeletal projections created by custom facial implants become more evident externally.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, With my custom midface implant I hope to be able to meet with the engineers to tell them how I want my implant designed in detail. I also wonder if I can have a midface lift at the same time as the placement of the custom midface implant.
A: In terms of custom midface implant design process, patients can not have a direct participation in the actual designing of the implants with the engineers. Since the patient is not a surgeon, direct manufacture and patient contact is prohibited by the FDA. The implant design process is done between myself and the engineers independent of the patient. Patients to get to see the implant designs and make comments and suggestions from the PDF file designs provided to them after each design session. Only three implant design sessions are done from which the final design must be completed. Final implant designs must be submitted a minimum of two weeks before the actual surgery date.
With the placement of any midface implant a midface lift can not be performed at the same time. A midface lift in a young person is also an unnecessary and ineffective procedure. This is an operation for older patients who actually have lose midface misses from aging and bone loss.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a question about what can be done with the sliding genioplasty technique without any implants. I am not to keen on implants as it’s not natural and I have read that it can lead to atrophy and infection and I am still young.
I have attached photos – I don’t like my chin I feel it is too thin and too short vertically in relation to my nose and face.Is it possible to add vertical length using sliding genioplasty in my case as I already have good horizontal projection? My chin is already narrow,
can something make it wider? Also will sliding make it look slimmer if it is increased vertically? I really want vertical increase without any future possible complications like with an implant. Thanks a lot for the help.
A: The most common technique to just vertically lengthen the chin is an opening genioplasty procedure. Rather than ‘sliding’ the bone forward it is just vertically dropped down. Be aware that this will not widen your chin. As the chin bone becomes longer it will by definition not become wider and may, in fact, look a little bit more narrow.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, So I don’t have a severe deformity, but the top of my head is basically flat. I have a big head but it’s very flat, it looks Cro-magnonish and it gives me a primitive look which I don’t like. Is there any option to add height to my skull? Just a few cms? Slightly reshaping it would really make a difference I think. My forehead is also very flat, so it looks really really bad. I would send pictures, but I don’t know how. Can this condition be treated somehow? Basically my goal is to add a little height to the top of my head so it won’t look flat. I await your answer.
A: What you need is a skull augmentation procedure using a custom skull implant. How much skull augmentation on the top of the head that can be achieved is limited by how much the scalp will stretch to accommodate the implant. But up to 1 cm to 1.5 cms of additional skull height can be safely achieved in most patients. The shape of the implant would provide a rounder shape as well as the skull height is increased. This is known as a skull cap implant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Recently had a mini facelift. I’m 3 weeks post op and I’m concerned about the areas of what appears to be fat next to my mouth. It gives me a bit of a “joke smile” look quite frankly. I spoke to my doc about it and he said photos were in bad light and area might calm down but I’m looking for a second opinion and wondering if these fat line areas can be removed with micro liposuction or should I use fillers to make less noticeable. I wonder if these areas are the fat that was previously along my jawline, or is it swelling still I cant seem to get a clear answer so I’m looking elsewhere.
A: It is important to note that you are just three weeks after your mini facelift surgery. The tightening along the jawline makes the perioral region look puffy or at least has exacerbated what it was before surgery. This is the effect of a mini facelift where minimal skin undermining is done. It may be that with more healing time and the jawline skin relaxes a bit that its appearance may decrease. I would give it at least 6 weeks after surgery to see how it looks then. If it has not improved substantially by then small cannula liposuction should be used to reduce the perioral mounds which has become unmasked. Trying to place injectable fillers around it is likely to make look worse.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have had confidence problems for well over a decade now due to my odd looking skull. I was thrilled to learn that skull reshaping is now a tried and tested method. Looking at the different cases, I think my problem is a sagittal crest skull deformity – marked by a high midline crest of bone surrounded by adjoining areas of skull deficiencies.
The procedure of choice would probably include the use of custom parasagittal skull implants. My question now is if this procedure would affect the position of my eyebrows, since the scalp and forehead skin will be stretched a fair bit. Which made me fear that said procedure might have the undesired side effect of leaving me with a permanent “shocked look” on my face. So, does this procedure affect the positioning of the eyebrows?
A: I have not seen any cases of eyebrow elevation long-term with any form of skull implants. Nor has any patient so mentioned it. But the specific combination of sagittal crest reduction combined with parasagittal augmentation has not been seen to have any impact on eyebrow position. This is because for the most part the amount of skull augmentation and upward scalp push is not that great.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in lip fat injections. I am 33 years old and starting to age and I feel it especially shows in my overly thin lips. I like more volume. I don’t like how long my upper lip is also. Id like to look more feminine and soft looking for a sexy more dramatic look. I wish I had more lip to show and some tooth show. However I am terrified of scars with lip lift. I want a more permanent solution over fillers. Also I have some asymmetry on the right side where I have less upper lip. I would like more sultry lips.
A: Thank you for sending your pictures for consideration for lip fat injections. With you thinner lips there are several realities that you need to know about lip augmentation with fat:
1) The best and most permanent augmentation result is going to come from a vermilion advancement. (not a subnasal lip lift) But since you are terrified of scars your best lip augmentation treatment is not an option.
2) Fat injections are unreliable in terms of retention and permanency. They rarely are permanent with a single injection session.
3) In thinner lips any type of injectable volume augmentation makes them fuller but may or may not create the lip shape you desire. As a general rule, any injected volume to the lips makes them bigger but usually maintains the same overall shape.
40 More tooth show is not going to come from adding volume to the lips, only lip lifts and advancements can achieve that effect.
5) It would be in you interest to have a synthetic injectable filler treatment first before trying surgical fat injections. You want to know if an injectable approach can achieve the look you desire. As if you do fat injectionks and it does not create the look you like and it persists, there is no reversing it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am pretty set on getting a custom jaw implant done but I have a few questions. Do I need to do anything in order to prep for this type of implant? I imagine I wouldn’t even need a custom fit but one side of my jaw has gotten noticeably smaller due to having the two back teeth on the bottom of one side removed. Would I need to get these replaced with a tooth implant before surgery to prevent any additional bone loss? Would replacing these teeth with an implant spur bone growth? Also, my periodontist said that my bite is slightly off (I feel like it would be about an eighth of an inch or less maybe) as my top teeth stick out a tiny bit further than the bottom, does this need to be fixed?
First I am going to get a fat transfer done to replace some facial volume loss. Is having a jaw implant going to effect this? I’d imagine the skin would have to stretch a bit due to the added volume. And will the implant increase chin projection? Looking for both projection and vertical height in that area.
Thanks for your time.
A: In answer to your custom jaw implant questions:
1) If you have jaw asymmetry you would be better served by a custom implant approach. If not then expect the use of regular implants will still have some asymmetry afterwords.
2) Whether you get a dental implant or not that will have not impact on the jaw angle area.
3) Any bite issues you have are irrelevant for this surgery unless they are significant enough to require jaw surgery for correction.
4) If you are gong to get a fat transfer it should be done after jaw implant surgery. The trauma and swelling from jaw implant surgery will have a negative impact on fat graft retention.
5) Your dimensional needs of your jaw implant is determined before surgery but of you want both increased chin height band projection you are speaking to a custom implant design to create that type of change.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have lost over 150 pounds and have loose skin in my abdomen however do not have a large pannus flap my skin is just loose and like melted wax which is causing me to have significant vaginal pain and prevents me from doing many activities such as exercise. My insurance says an abdominoplasty can be considered reconstructive rather than cosmetic if a surgeon will submit for medical necessity. I would like to know if you deal with insurance on this type of issue? I am looking at needing other cosmetic procedures as well but right now the pain has made the abdominoplasty a priority because I need to exercise.
A: Getting abdominal surgery covered by insurance is not as simple as the ‘doctor stating it is medically necessary.’ All elective surgeries must go through a predetermination process with a very specific set of criteria that determines whether they would be eligible. The only abdominal procedure that can be approved for health insurance coverage is an abdominal panniculectomy not an abdominoplasty. To get approved for an abdominal panniculectomy there is a very specific set of approval criteria that must be met including: 1)photographic documentation of an abdominal pannus that hangs over the groins and onto the thighs, 2) photographic evidence that the pannus is causing a medical problem (chronic skin infections) and 3) documentation of at least 3 months of non-surgical therapies to treat the dermatitis that has not worked.
If a patient is unable to have an abdominal condition that does not have these three criteria met, a predetermination letter will not be submitted as its denial will be assured.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was wondering if metal wires was used to stabilize the bone after a cheekbone reduction, can this cause a systemic body rash or highly unlikely? If so, can the wires be removed? What are the risks? Thank you.
A: Wires used in facial skeletal bone fixation are highly unlikely to cause a systemic reaction like a body rash or other tissue reactions. They are made of stainless steel which, unlike titanium plate screws which are now more commonly used in the face for such procedures as cheekbone reduction, do not a higher risk of allergic reactions. However, I have never heard of or read of such reactions occurring in facial bone fixation with stainless steel wires.
Regardless wire ligatures can usually be removed in any facial bone where they are located. They would be removed through the same incision by which they were put in. As long as the bones are well healed they should be no risk in doing so other than the temporary swelling that results from the removal procedure. Most cheek bone reductions heal very quickly, as do most facial bone fractures/osteotomies, so I would not think that cheekbone positioning would be affected.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m interested in having a custom jaw implant to have a wider, more symmetrical and defined jawline.
I however don’t live in Indianapolis so am unsure as to the process of getting this done. Do I need to come to Indianapolis more than once? Or can I just send the CT scan that I have already done, have Skype consults and only come in once?
In terms of timing I have a tight schedule with uni. Ideally I would be hoping to get this done in January but am unsure if this is realistic with your schedule and time required for everything to be ready? How long does it take for the designing and the printing of the implants? When would your next availability for such surgery be?
I understand that the price of custom implants can vary considerably but what would be an estimate for the total cost (including your fee, the implant production, the GA fee, hospital fee etc..)?
A: In answer to your questions:
1) You only need to come here once for the surgery. You send the 3D CT scan to me from which your custom jaw implant will be designed. All preoperative consultations will be done by Skype.
2) The design and fabrication of a custom jaw implant takes from 4 to 6 weeks to complete. So January surgery is very possible.
3) My assistant will pass along the cost of the surgery to you next week.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in chin ptosis surgery. Three years ago I had a chin implant placed through the mouth and then it was removed a few weeks later because it was causing dynamic ptosis. My chin and lower lip are lower than they were before and my oral vestibule seems really low in my mouth. My doctor said it was because of scar tissue and there was nothing he could do. I realize now that my mentalis muscle needed to be resuspended. Have I waited too long to have this done and have any chance of success?
A: The timing from the onset of the implant removal/chin ptosis does not really affect the success of the surgery when it is performed. The success of the surgery depends on many technical factors, one of which it is higher when a small chin implant is placed to support the uplifted chin tissues. Besides resuspending the mentalis muscle, the other very effective technique in my experience is to raise the height of the vestibule. This would be of particular benefit in your case as you have already described that it seems too low since the original chin implant surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in chin ptosis correction. Part of the reason I’ve put off having the surgery is because the success rate seems really low. I haven’t found anyone who has had this done sucessfully. I’ve read everything about mentalis resuspension that you’ve posted on your website and some of the information is conflicting. In an older article you state that everyone who undergoes the procedure has some degree of improvement, But elsewear you state that the surgery completely fails more times that it is successful. I’d like to know what your opinion is now, I don’t what my expections to be unrealistic.
A: Chin ptosis correction surgery can incorporate one or several techniques. Mentalis muscle resuspension alone, while initially effective, often disappoints with more healing time. When multiple techniques are done (muscle suspension, V-Y mucosal closure, elevating vestibulopasty and a chin implant) the results are much better and more sustained.
But you undergo the surgery with the knowledge that chin ptosis is a difficult problem to correct and results are far from assured. Usually the actual chin ptosis ends up corrected but the more visible issue, the sagging lower lip, can prove to be the challenge for sustained improvement.
Dr. Barry Eppley
Indianapolis, Indiana
Q:Dr. Eppley, I am a 28 year old male and i have a question about forehead bone reduction procedure. I’ve had these two lumps on my forehead for as long as i can remember. I always thought I got them from hitting my head when I was a kid. Recently these lumps started to bother me more and more so I decided to see a plastic surgeon that specializes in reconstructive plastic surgery in my home country and ask what he thinks about it.
He gave me a diagnosis of ’eminenta frontalis’, which I interpret as just a bone shape that is somehow normal but just a bit more prominent. He did not think this is something that should be bothering me nor could it be fixed due to the underlying sinus cavity and relatively thin bone thickness (no xrays were taken)
The thing is, this is bothering me and I would like to know what are my options.
A: If I am interpreting correctly as to what your foreheads concerns are based on the pictures you have sent, I see a pair of forehead prominences that are often called forehead horns. They are a natural development of the forehead that does occur in some males. They are not located over the frontal sinus but above it. These forehead bone humps can be very safely burred down. This would be done through a frontal hairline incisional approach. Forehead horn reduction is a procedure in my experience that exclusively occurs in men much like large or overdeveloped frontal sinuses/brow bones.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a female with a cleft chin and overactive/large mentalis muscle which creates pitting or orange peel texture in the chin area. If I have my cleft chin surgery to get it corrected, can it also correct the orange peel texture so I don’t have to keep getting Botox injections every 2 months? I am missing a little piece of bone at bottom of my chin due to the cleft chin. So I wouldn’t want a regular chin implant, but just something to fill in this dent. I don’t want to have to keep getting Botox or filler injections. I want something permanent.
A: You have two chin issues which are independent of each other. Cleft chin surgery for removing the cleft is not really based on putting a modified chin implant onto the bone. That is just a minor part of the correction. Most of the chin cleft resides in the overlying soft tissue which requires fat injections in addition to the bone implant.
The mentalis muscle irregularities/dimpling are a different issue which is not going to be improved by a chin cleft surgery. Short of Botox injections they are few other effective treatments. Fat injections into the dynamic dimpled areas would be the only other treatment option whose effectiveness can not be assured.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have several custom facial implants questions. I would like to visit you later this year for a custom midface implant and custom chin implant. Is it possible that I can have both surgeries at the same visit or would I have to wait for the first one to recover? Also what is the recovery time of a custom midface implant that covers the areas from the infraorbital rims to the ears?
A: It would be very common to have more than one area of the face augmented with implants during the same surgery. This is just as true with custom facial implants as standard facial implants. The most common such combination would be custom jawline and custom midface or forehead/skull implants, treating distinctly different craniofacial regions.
The recovery time for just about any custom facial implants procedure is primarily related to the swelling that occurs in the face. One usually starts to look ‘reasonable’ in about 10 to 14 days after surgery. But full recovery to see the final results of the facial implant surgery can take up to six weeks after the procedure. As a general rule there his always more facial swelling that one expects and it will last longer than one wants.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have had three forehead contouring procedures starting with a PMMA forehead augmentation ten years ago. After some time a ridge across my forehead became more pronounced and I had two more procedures which involved removal of the PMMA implant and some adding of hydroxyapatite cement. I am lnow eft with strong indents in both sides of upper forehead, a lack of any real brow bones, and eyebrows became more propped up in corners. I would like to fill in and smooth the upper forehead and possibly build up the brows, which I think would improve/flatten eyebrows by getting them closer to their original position. I am wondering with three procedures done, and scar tissue removed, would I have enough elasticity to attempt to do this. I would love to not open the coronal scar and try to utilize less invasive methods. However, I understand the need to do this for better access to the forehead and brow bones. It has been five years since the last procedure. (second and third procedure were performed over a 6 month period with the same surgeon)
A: With having multiple forehead contouring procedures done you are correct in being suspect of how your forehead tissues would respond to further efforts at augmentation/expansion. That tissue issue is overcome, should it exist, with galeal releases done on the underside of the scalp flap. Between the need to very specifically apply further forehead augmentation materials and to potentially need to release the galea, an open approach using your existing coronal incision would be required. Limited incisional techniques in the face of your forehead circumstances is a setup for additional forehead contour issues. In essence the result will only be as good as what the surgeon can see. As you have observed in forehead augmentation even the slightest contour issue is eventually seen as the forehead tissues contract around it. It is surprising that even thick forehead tissues eventually reveal even the slightest irregularity beneath it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, f a person would like to reduce the brow bone and the nose size, wouldn’t it be best to have them done on the same day of surgery? I ask this because if a brow bone surgery is performed and them the nose after, it is possible that the brow has to be reduced again . i think I’m not explaining very well. Anyway my question is can you perform rhinoplasty and brow bone reduction together ? I’m also interested in chin reduction.
A: There would be no technical or medical reason why rhinoplasty, brow bone reduction and chin reduction surgery could not all be performed at the same time as a single surgery. The combination of these procedures is not all that uncommon. I think the origin of your question is the concern that one procedure may aesthetically affect the other. This doing them together would allow for a more harmonious result. While this concept is not as relevant as one may think, there is a relationship between a brow bone reduction and rhinoplasty at the radix where the two procedures ‘meet’. Depending upon the type of rhinoplasty performed and how much dorsal hump reduction may be done there can be a real impact of how one procedure affects the other and how the details of it would be performed. Such a relationship at the upper nose and central brow bone area, and how much reduction should be done, would be determined before surgery using computer imaging.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a scrotal reduction procedure. I have a testicular implant on my right side. There is a lot more scrotal skin on the left side than the right. I need it reduced using I think a lateral incision. Would you also if I wanted put in an incision on the right side just for aesthetics, so that it looks as if both sides have been reduced? Do you ever do that. Just create a scar for aesthetics? For symmetry?
A: A scrotal reduction can be done on the larger left side. Your unique situation of having a testicular implant on the opposite has created this unilateral need. If you prefer to have a scar made on the right side, without any skin incision for the sake of scar symmetry, that can be done as well. Usually a scrotal reduction or scrotal lift is done by making a midline excision of skin along the natural raphe between the two sides of the scrotum. But there is no reason that the reduction approach can not be down on the side as opposed to the midline. In your case this would likely create a better and more symmetric scrotal reduction result.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in Botox injections for migraines. My son has had persistent migraine headaches for the past two years. I can tell you his headaches/migraines are always in his forehead area above his eyebrows. He never has pain in the back of his head. I have done extensive research and it seems that neurologists always do shots over the entire head and neck, like 31 injections! That just doesn’t seem right to me. His current neurologist recommended another neurologist, but I am hesitant to use him for this reason, even though it would probably be covered with insurance. Any information you can provide is greatly appreciated.
A: The migraines types that respond best to either Botox injections or surgery are those that are focal. This means there is one specific focus or location where the origin of the migraine can be identified. There are four well known extracranial foci of migraines, one of which is the supraorbital region of the brows where the nerve exits the bone. This sounds precisely as to what type of migraine your son has.
Botox injections for frontal-based migraines should be directly around the supraorbital nerve….and not anywhere else. I would agree that neurologists tend to use a shotgun approach and put it all around the head. This is not the injection approach for your son to determine the effect of chemodenervation and it is certainly not a cost-effective one either.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in buttock implants. I have an incredibly small butt given my body size. I don’t really have that much fat so a BBL procedure is probably out. I would also like to get rid of my hip indents. Will buttock implants take care of that as well?
A: Thank you for sending your pictures. I can see your buttock concerns as their size is very small compared to the rest of your body. The traditional placement of buttock implants inside the muscle allows for only a small size of implant to be placed (around 300cc) which is about the size of your hand. I believe this would be inadequate for you. Buttock implants that are placed above the muscle allow for much larger implant sizes but have a higher rate of potential complications because they are not in the muscle and your buttock fat layer is thin under the skin.
Putting these two buttock implant issues together for you means that ideally you should have a two-stage buttock augmentation procedure., Your first stage should be fat transfer to your buttocks. While the amount of fat you have to transfer is not enough to make a big difference it will thicken up the fat layer under the skin and help get rid of your hip dimples. (which implants will not) This will then allow buttock implants to be placed more safely above the muscle as a second stage procedure 3 to 4 months later.
You have a very challenging buttock size problem that is not easily remedied by more traditional one-stage buttock augmentation procedures.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting a deltoid implant. I am a 22 years old son and had a nerve injury from high school football that atrophied my left shoulder and deltoid muscle. I would like to explore an implant that could give back some muscle bulk and maybe a more natural look back. I am very sensitive to the appearance of my shoulder now. Although I have insurance, I’m certain a cosmetic surgery would not be covered. Could you give me an idea of the cost, how quickly I could get an appointment for surgery, the recovery time, and the physical therapy needs. (if any)
A: I will have my assistant pass along the cost of deltoid implant augmentation surgery. Presumably because you are young and thin, injectable fat grafting is probably not an option due to low body weight. Thus a deltoid implant implant offers the most reliable method of long-term shoulder augmentation. The only question in that regard is whether this is best done by a standard or custom made deltoid implant. I would need to see pictures of his shoulder from different angles to make a better assessment in that regard. Recovery from a one-sided deltoid implant is fairly rapid since the muscle is atrophied. There is no need for postoperative physical therapy.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a church choir singer. Would a tracheal shave operation affect my voice?
A: The concern about the impact of tracheal shave surgery on one’s voice is common. Whether it be a singer or radio announcer this is an understandable concern as air passes through the voice box. Everyone knows what their own voice ounds like and no one really wants to have their voice changed if it is integral to their profession.
Tracheal shave surgery should not and has not affected patient’s voices in my experience in the voice-sensitive patient population. But it is one of the known risks of the procedure because one is operating on the voice box. (thyroid cartilage) The key to avoiding that risk is to not get too aggressive. Too much cartilage reduction could theoretically weaken the paired thyroid cartilages thus theoretically changing the tension on the vocal cords. This is avoided by being more conservative and not trying to make the prominence of the Adam’s Apple completely flat. The thyroid cartilages need to maintain some integrity to support the internal attachments of the vocal cords. The risk is not of voice cord avulsion but of loss of cartilaginous support.
Dr. Barry Eppley
Indianapolis, Indiana
