Your Questions
Your Questions
Q: Dr. Eppley, I have an active depressor septi muscle in a way my upper lip is very shortened during smiling. this muscle has been partially cut during a nose job and it was perfect, but after a few months it has reattached.
Therefore, i would like a permanent outcome… a complete cutting of the muscle. Can you do the incision from inside the mouth? Can you explain to me please the process of the surgery?
A: Since the depressor septi muscle can not grow back or reattach itself after surgery, the temporary improvement you saw was due to swelling and temporary muscle inactivity from the rhinoplasty surgery. Once the muscle recovered from the surrounding surgery, it recovered to full motion like that prior to the nasal procedure.
The depressor septi muscle can be cut from inside the nose or from inside the mouth. I find the intraoral approach to be the most assured at getting a complete release of the muscle. This also allows the best view of the muscle from its origin at the incisive fossa of the maxilla to its insertion on the nasal septum. By electrocautery the muscle can be visualized and released in a controlled fashion.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a custom skull implant.I have a flat back of the head, that I hide every day as much as I can with my hair (no hair loss). I am interested in the skull reshaping procedures using custom implants described in the page: http://eppleyplasticsurgery.com//skull-reshaping/. I am particularly interested by the computer designed flexible implants, and the example photographies of a skull with/without implant in the middle of the section ‘custom skull implant’ matches quite closely my situation. I believe that an additional 50cm3 volume would be largely sufficient to get the desire ’rounding’ effect, after testing with plasticine, however I do not know if this volume would fit under my scalp.
I have listed below my questions (I have a lot, but I am considering very seriously this surgery), I hope you can answer them either by mail or a scheduled interview, as you see fit (however I’m more comfortable writing english than speaking it):
1) what is the volume range of the implants that can be inserted?
2) what is the material used to 3d-print the implant? How long is it supposed to last?
3) what would be the size and position of the scar necessary to insert the implant?
4) can you give me the necessary details of the 3D imagery you need, so that I can already schedule the skull scanner in a nearby laboratory?
5) what would be the cost of such an intervention?
6) If the implant has to be removed, even a few years later. Iis the removal a simple process? Can the screws be removed?
Thank you for your time.
A: In answer to your questions about a custom occipital implant:
- I do think of skull implants in terms of volume. Rather I think about their maximal thickness and how the scalp can stretch to accomodate it. In general, a custom occipital implant of 10 to 12 mms thickness can be tolerated by most patients regardless of the surface area that it covers.
- The implants are made of solid silicone and will last forever.
- The implant is inserted through a low horizontal scalp incision on the back of the head.
- A high resolution (.1mm thocknes slices) skull 3D CT scan is needed.
- My assistant will pass along the cost of the surgery to you tomorrow.
- The implant can be easily removed later. I no longer use screws for implant fixation as they are not needed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a sliding genioplasty to correct my weak chin and create a longer jawline. I have fullness at my lower half of the jaw which is actually bone even though it looks like jowls. I have a bone notch half way down my jaw where the bone comes out so the jaw looks fuller and looks too masculine for my liking from the front. I’m not sure where the cut from a sliding genioplasty is but if it is quite far forward so this part of the jaw can be shaved down a bit in addition to moving my chin?
A: Your question is a good one as it relates to the width of the jaw behind the chin where the location of the sliding genioplasty is performed. The bone notch to which you refer is actually normal and is known as the antegonial notch. As the jaw bone descends from that area it can sometimes get a little wider. Whether it can be safely reduced depends on the exact location of the width and its relationship to the mental nerve from the bone which exits somewhere close to that area. While to may be aesthetically desired to reduce it you also don’t what to potentially cause permanent numbness to your lower lip and chin either. The bone cut from a sliding genioplasty is a horizontal one and usually goes back behind the location of the nerve. This bone segment moving usually creates a more narrowing effect to the jawline as it becomes longer. In some cases it may be possible to reduce some of the bone behind it but if I think that the mental nerve is at risk for injury I won’t do it. It all depends on where your mental nerve comes out of the bone in relationship to this area of bone width.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a chin implant revision or removal. I had my initial chin implant placed about one year ago. Immediately I know it was too big. The doctor talked me into a revision and now it’s pointy and not the shape of areal chin. I Only wanted subtle chin projection. Now I wish I never had it done at all. I am worried about chin ptosis if it is removed especially after reading your info online and I don’t know what to do.
A: I think you have two chin implant revision or removal options:
1) Downsize the chin implant to a much smaller one with intraoral suspension. This still leaves some soft tissue support and has the lowest risk of chin ptosis, or
2) Remove the chin implant entirely and do an intraoral suspension and hope for the best. There is still a chance you may be able to avoid the chin ptosis problem. It is not always a 100% guarantee that it will always happen when a chin implant is removed. The risk is high but it is not 100%. There are successful ways to manage chin ptosis even it occurs.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, My knowledge about Smartlipo is limited. I have watched many tutorial videos and read information that has been posted on doctors websites. I understand that it is a procedure that uses a laser to help extract the fat. It seems to have less bruising, less downtime and less time one has to wear the compression garment than traditional liposuction.
Maybe Smart lipo is not the best procedure for the unwanted fat on my abdomen, flanks, back bra area, thighs and let’s throw in the chin area for good measure. But that is the reason for the consultation….for you to advise me on options that will best fit my needs.
A: The reason I ask about your perspective on Smartlipo is that it is highly misunderstood…which is not the patient’s fault. Many doctor’s marketing of it is false…or at the least a but understated. Smartlipo is not different in terms of invasiveness, amount of bruising, recovery or downtime than any other form of liposuction. It is just a different way to loosen up the fat to remove it but it is still a very invasive procedure just like every other form of liposuction.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting a skull implant. I have attached photos of my mutant head. As you can see I got this stupid bald ugly head, it is not very visible from behind but looks very bad from left or right side. It is not very much dented but it is enough and bothers me very much. So many people ask me what happened to my head or they just staring at my head like I came from another planet. Is there any way to fix it? This skin on my crazy head is kinda flexible and I thought it would be enough to pull that skin in a direction to make it less visible or apply some kind of implant under the skin to make my head more round on that flat area and cover that bump/dent. Any suggestions? How long does it take for such a surgery or some other kind of fixing it?
A: Thank you for your inquiry and sending all of your pictures. There is no question that the best and only way to get the back of head built out and smooth is with a custom made skull implant. This can be designed on the computer using a 3D CT scan of you and then inserted through a small low scalp incision to fit over the bone. I have done such skull augmentations many times. I have attached a recent back of the head case that shows how this technology works and how effective it can be.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a large congenital nevus on my left cheek. It has been bothering me all my life and at this point I just want it gone. Please see below for pictures. Would skin graft treatment be an option for me and would it have a lesser chance of scarring?
A: Thank you for sending your cheek nevus pictures. The best way to treat your congenital cheek nevus is through a process known as serial excisions. You can’t just cut the whole nevus out or skin graft it as that would end up making it look worse. To end up with the best final scar, one does subtotal removal of the nevus inside its existing margins for two stages spaced three months apart. This does not overstretch the surrounding skin (thus keeping the scar narrow) and keeps making the nevus smaller. After two stages only a thin one of nevus if any will be left for the third and final excision/scar revision. All of these procedures can be done in the office under local anesthesia. There will be a scar but the goal is to have it end up as small as possible without distorting the surrounding cheek tissues.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in eye asymmetry surgery. A few months ago I fainted and fell against a sink. The result was a left eye broken orbit (only the rim below, not a blow out fracture, no displacement). After a few weeks when the swelling was gone, I saw that the position of my left eye was different from the right side. Doctors measured a different of the position of the globe of 1.5 mm. Although it might not be much, in my case it is obvious. Doctors told me that it could be from fat atrophy. Do you think that an implant or so can help me to get my eyes more symmetric again? Many thanks for your response!
A: If an eye asymmetry has indeed developed after some type of orbital fracture, particularly if occurring within the first month after the injury, I would have it assume that this is due to a skeletal issue not fat atrophy. (as that would take many months or even years to be seen) But regardless of its cause a horizontal globe asymmetry can be treated by one of two methods, an implant or fat grafting. A small implant can be used to build up the orbital floor or a dermal-fat graft can also be so placed. (if you happen to have a c-section from your children) This is a simple surgery in which either material can be placed through a limited subciliary or transconjuncitival incision. The hard part is just deciding if such surgery is absolutely necessary and what material to use in doing it should it be so. Please send me a picture of your eyes showing their current state.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have an Inquiry regarding breast augmentation, I am wondering if my wife would be a candidate or should even consider a consultation. She had ovarian cancer in 2005 and then in 2014 was diagnosed with Stage 4 head and throat cancer. She is currently in remission. She has always wanted breast augmentation surgery but I wonder now if it would be too late.
A: Just because one has cancer, or even a lifespan that looks limited, does not preclude one from undergoing breast augmentation surgery. I did a lady some time ago who a stage 4 liver cancer. She had always waned to have breast implants and finally fulfilled her wish. She lived for two years after the procedure. It is all about making patients happy. Some people in having a cancer diagnosis may take that trip around the world or climb up Machu Picchu…others may want to have breast implants. There is no medical reason to not do so if her cancer doctors approve and she is not on any active chemotherapy or immunosuppression drugs. Breast augmentation surgery would be comparatively ‘easy’ to go through compared to any of her other cancer surgeries.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in paranasal implants…again. I had jaw surgery five years ago which successfully corrected my under bite, but I still have mid-face concavity. I originally sent you pictures a couple of years ago and you said I was a good candidate for this procedure. A little over year ago I had the paranasal implant surgery done locally, but there were about 3 small tears that opened opened up along the incision line, which lead to infection less than 2 weeks after the surgery. The surgeon offered to redo the procedure after 6 months of healing at a discount, but I didn’t have much faith in him after that.
For the implants, we had selected the larger 7mm porous implants, and it completely eliminated the concavity, and it looked good despite the little bit of swelling that remained.
A:Thanks for providing your paranasal implants history. You obviously had Medpor paranasal implants which I don’t like since they have a higher rate of infection due to their porosity. Paranasal implants are unique amongst facial implants because they have the thinnest soft tissue cover over them being right under the lip. Unless one gets a two layer closure over the implants, which includes a good muscle layer, wound breakdown will occur. It sounds like you probably had a combination of both that lead to an early exit of the implants. Whether the 7mm thickness of the paranasal implants is really adequate is unknown because it really takes up to 6 weeks for all the swelling to be gone. But with your history of prior surgery and now scarred tissues, I would not push it beyond that thickness anyway.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, A while back I had some excess skin removed from under my chin along with some liposuction on the left side. This was done with a t-scar with decent results. (direct necklift) The skin on some of the upper neck is still a bit looses especially where the lipo was. It also pulls some when I look to the right. I would like to come in and have the t-scar extended a small amount in order to clean up more of the loose skin and get rid of the pull. Also, I would like to improve on the scar as it is a little wide where the lateral and horizontal incision meet. I’m not looking for any miracles but I am looking for a decent amount of improvement without extending the scar down to my Adams apple. I would like to be able to hide the scar behind a beard for a year or two and allow it to heal to an acceptable appearance. In April, I have a two to three week block of time in order to get this done. What are your thoughts?
A: In my experience with the direct necklift, the vertical scars can do well in older male patients. Such scars do not do very well in younger males that do not have a lot of loose neck skin. The lower that vertical scar becomes the more potential problematic it can be. (postoperative widening) ‘Significant’ results usually mean more skin excision, more tension on the scar line and some degree of lengthening of the vertical component of the T scar.
While such a procedure is easy to do in the office under local, I remain cautious about these vertical necklift scars in younger patients. (under age 60 to 65) Whether you can get significant improvement without substantially increasing your scar morbidity is not something I can comment on without seeing pictures or examining you in person.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in abdominal panniculectomy surgery although I am not exactly sure what it is but it sounds like what I need. I’m 45 and am about 510 lbs at 5’10.
I need help asap. I have a real bad overhanging belly and a scar from my belly button to waist that’s feel likes it’s ripping. I also have bad hernia that’s randomly pokes out and creates extreme pain.
A: While there is no question that some form of an abdominal panniculectomy could be incredibly helpful, at your level of weight it is also a surgical procedure that has a very high risk and will undoubtably have a 100% complication rate. This most certainly will be from a wound healing standpoint and potentially from medical risks as well. This is also a procedure that would have to be performed in a hospital that would likely need 5 to 7 days of hospitalization…and that is providing that no significant medical complications occur. You are going to have to get a medical reference from your physician who has been following you and has you in the best health as possible for this weight. He/she must also feel that the procedure is medically indicated and that your are cleared to have the procedure.
In short, while an abdominal panniculectomy would provide numerous medical benefits, it is not a procedure that should be approached lightly and with great preoperative consideration. I would assume you know that losing weight by bariatric surgery would be far preferred before undergoing such a procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in facial reshaping. I absolutely hate my face and how it looks different on both sides. What would I need done to make myself look more symmetrical. I only like the left side. I hate people even looking at my right side and I wont ever take face forward shots. I attached a picture to show you. I just really hate it and very insecure. I feel like everyone can notice that one side of my entire face is higher than the other and that one eye is bigger than the other.
A: Thank you for sending your picture and expressing concerns. I can clearly see the differences between the two sides of your face and most, if not all, of the asymmetry is in the periorbital region. (around the eye) Because the picture you sent may be inverted (mirror image) I am not sure which is the right or the left. But there is one side where the eye is bigger and the brow bone and cheek bone on that side are more developed. While the opposite side has a smaller eye and a slightly lower brow bone edge and smaller cheek.
When it comes to facial asymmetry and facial reshaping surgery that involves the eye, the bigger eye or higher side can not be lowered. Only the smaller side can be made more open or raised. Thus on the smaller side the brow bone can be shaved to raise it, the cheek augmented to make it fuller, the eyeball raised to make the pupil more even with the other side and the upper and lower eyelids raised to expose more of the white of the eye.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a skull implant question. In your experience how do these two materials perform in terms of edge transitions (edge of implant to the skull)? Is there a noticeable step off from the implants onto the skull on a shaved head?
A: In the shaved or bald male head, there is always a concern about a visible transition of a skull implant to the bone. Eventually any less than smooth transition will be seen no matter how thick the scalp is. PEEK implants can not be made with a feather edge to them because of the way they are manufactured. (machined) Furthermore they were never designed to be used an an onlay and the company will probably not make them knowing that it is to be used as an onlay since they are only FDA-approved as inlay skull implants for defects. Conversely silicone skull imlpants can be made with a fine feather edge by virtue of the way they are manufactured. (poured and oulled off of a mold)
In short, a silicone skull implant offers the best material capability for the smoothest implant to bone transition. In the exposed scalp patient a skull implant needs to have a virtual feather edge at its perimeter.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in cheekbone reduction. I am a 24years old female. I would like to have Zygoma reduction. (by intraoral route if its possible) I want to do this surgery to have more slim face. Do you do on the CT face scan analysis and do you use melting screw? Do you do Anterior segmental osteotomy surgery? Looking forward to hear from you. Thank you.
A: Cheekbone reduction osteotomies for facial narrowing is usually done with an intraoral anterior osteotomy of the posterior zygomatic body combined with a posterior osteotomy of the zygomatic arch where it connects to the temporal bone with a very small incision in the hairline. Small 1.5mm titanium plates and screws are used for bone fixation. While resorbable plate and screws can be used they are much more expensive than titanium and do not work as well. While an anterior osteotomy of the posterior zygomatic body can be done alone, it does not create as much facial slimming as when a posterior zygomatic arch osteotomy is done as well. I usually like to see a 3D CT scan before surgery to determine how much inward movement can be obtained with cheekbone reduction osteotomies.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in having blepharoplasty surgery to remove the extra skin of the upper eyelids and the skin and fat from my lower eyelids. The poor condition of my eyelids appears to have gotten worse in the past year when I was diagnosed with an IgA automimmune skin condition and have been on dapsone and tetracycline antibiotics which have helped tremendously get it under control. My question is whether this medical condition and my medications will adversely affect blepharoplasty surgery?
A: Dapsone, also known as diaminodiphenyl sulfone (DDS), is an antibiotic that is best known for its treatment for leprosy. It has had this use in leprosy since the early 1940s. Ss an antibiotic dapsone inhibits bacterial synthesis of dihydrofolic acid which is very similar to how sulfa antibiotics work. The most common side effect of dapsone is blood-related with the development of some degree of hemolysis in about 20% of patients on the drug. From a skin standpoint dapsone can cause mild skin irritation, redness and dryness and burning and itching. There is no evidence that it impairs the ability of skin to heal.
Linear IgA bullous disease (LABD) is an autoimmune skin disorder in which blisters form in the skin and mucous membranes. Blistering occurs because of the development of a split between the epidermis and the dermis, where IgA autoantibodies react to components of the hemidesmosome and basement membrane. Linear IgA bullous dermatosis improves or clears with the use of dapsone. Dapsone is often combined with a tetracycline antibiotic for maximal effect. I find no evidence that wound healing is impaired in linear IgA bullous disease. While there are rare cases of eye involvement in LABD, wound healing impairment of the eyelid skin has not been described.
In conclusion, having LABD and being on dapsone medication does not appear in any way to be a contraindication to having eyelid or blepharoplasty surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I suffer from an upper labial artery aneurysm. I also have the visible pulsating happening in the center right of my lower lip too but its in the inside of my lip so it isn’t visible to people that see me. I’ve been suffering with this humiliation for the past ten years.
You can literally see the artery in my upper lip pulsating in the center right part of my upper lip(extremely noticeable to other people). The entire artery through out the right side of my upper lip is so swollen that I can bite it and feel it against my teeth.
But on the same day this happened ten years ago, even though the pulsating on my bottom lip is harder to see, the right side of my bottom lip became severely discolored. The discoloration on the bottom lip is on the right side as well and stops right were the pulsating blood vessel is on my bottom lip. and where there pulsating is on my bottom lip there is a small lump. Do you think that is the source of the pulsating/swollen upper and lower labial artery? At the time all the doctors after all the scans and blood test weren’t able to help me. Just recently did I find out myself that this is a medial condition that other people suffer from. I thought I was alone suffered with this problem.
Will laser therapy work in hiding the pulsating artery?
A: The surgical treatment for an upper labial artery aneurysm or prominent labial artery is ligation. This almost always has to be done through at least two ligation points. In your case it may actually require three given the upper and lower labial artery involvement. In a true aneurysm the protruding sac may also need to be removed as well.
Laser treatments are not going to be remotely effective for this type of vascular problem.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 43 year old female and suffering from a flat back of my head. I was born with normal head BUT at a very young age (talking 10-15) I have been applying metal rollers to my head and in order to make the curls tight I would tighten up the rollers on maximum and then slept on them – EVERY NIGHT and I remember my head used to hurt in the morning. This was going on for a long period of time because I used to hate my straight hair and wanted them curly….. Then, at later stage as a teenager it became clear that I have destroyed my head shape. The back of my head is very flat.
I understand this would have to be a surgery. I have heard of an implants that could be placed under the scalp to help to improve the shape of the head and I would appreciate if you could let me know whether you have experience in this procedure.
Many thanks in advance.
A: There is no question that the definitive treatment for a flat back of the head is a custom occipital skull implant. I am an international authority on this procedure and have performed it many times. It is done ideally using a 3D CT scan from which the implant is designed and fabricated. Most custom occipital skull implants are placed through a low horizontal incision on the bottom of the hairline on the back of the head. The only question is whether there is enough scalp to stretch over the size of the occipital skull implant that one desires. I would need to see pictures of the back of your head to determine your degree of flatness and how much skull augmentation you need.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I found a picture below on your site, and i wanted to ask you what exactly has been done here.It looks like lip lift but it has been lifted not only in the middle, but on the sides too!I wanted to do a lip lift, but i always was aware that it lifts only the middle part, which makes lips look unnatural, but doctors who I’ve asked said that it is not true. You are the first one who confirmed my suspicions, so I kind of trust your opinion now.
A: You are correct about a lip lift, it can never do more than lift the central part of the lip. (cupid’s bow) It can look natural if it is not overdone. Some surgeons do overdo them because they believe that the more one pulls up in the center that it will somehow lift up the sides. But this, as you have surmised, is incorrect. The lady in the pictures had a lip or vermilion advancement which moves (‘lifts’) the entire vermilion or lip edge upward from mouth corner to mouth corner. This is done by removing a strip of skin at the lip edge.
The lip advancement is a close cousin to the lip lift but is much ore effective and is the only good lip enhancement option in very thin lips. The trade-off for its effectiveness is that it creates a very fine scar at the lip-skin junction. But in properly selected patients this does not turn out to be a concern.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Would the custom forehead implant also augment the temporal regions that require augmentation or would I need separate temporal implants?
I have seen surgeries performed where the implant is rolled up and inserted via a small (4 cm) incision that runs from front to back of the scalp versus side to side. Is this possible regarding the implants you use? Thank you.
A: A custom forehead implant can be made to any dimensions and size including incorporating the temporal region. Whether it should extend past the anterior temporal line at the sides of the forehead into the temporal region depends on where you are looking to achieve temporal augmentation.
The concept of using only a 4 cm long scalp incision to place a forehead implant only applies to small round central forehead implants usually used in women. Men that get a larger custom forehead implant that includes the brow and temporal regions need a longer scalp incision despite the fact that they may be rolled for insertion. A custom forehead implant covers a large surface area and, as as result, need a longer scalp incision for insertion that does a smaller more central forehead implant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’ve been googling all night and saw a picture of my butt! When I followed the link it led me to your site. I have suffered with them embarrassment of my saggy butt for most of my life. Even in my late teens when I got down to 95lbs due to working out three times day I still had a saggy butt! I’ve researched butt implants and fat transfer to my butt (I don’t have enough fat) but I really don’t need a bigger butt. I just don’t want the sag. How many of these procedures have you done? How long would I have to stay in Indianapolis after surgery before I could fly home?
A: You are referring to a lower buttock lift or tuck. I have done many lower buttock lifts and it does work well to correct a lower buttock skin sag. Please send me some pictures of your buttocks for my assessment for this procedure. I will have my assistant Camille pass along the cost of the procedure to you later today. You could return home the following day as this is a procedure which is not associated with much pain and all sutures are placed under the skin so there is no need for suture removal later.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in revision rhinoplasty. With rhinoplasty surgery my surgeon shortened my nostrils, cut my hump on my bridge, and my nose tip didn’t cut at all, just is rotated upward. I need to know how to reduce with revision rhinoplasty that distance between upper lip and nose and the fat philtrum and how to narrow nose like it was before. Can nose be longer like it was before and narrow with all size. I’ve heard that by lengthening nose with cartilage graft, nose can get wider. I must say again, that I don’t won’t to go with a lip lift, just thinking about revision rhinoplasty.
A: No revision rhinoplasty can reduce the distance between the base of your nose and your lip. Only a lip lift can make that change. There is no procedure of the lip that can reduce or thin out a ‘fat’ philtrum. The only way to narrow the nostrils is by lengthening the nasal tip and this will require a cartilage graft to do so. But this will make the tip longer which may be an undesired aesthetic change. You may instead consider shortening the tip and use alar rim grafts to help wide the nostrils.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am writing concerning liposuction and fat grafting into my breasts. (fat injection breast augmentation) I am curious as to if this surgery could be performed by mid April if I were to schedule immediately. I am 18 and my high school prom is April 30, so I was wanting this as soon as possible. Also, can liposuction incisions be made through previously existing laparoscopic scars? Thank you.
A: The first question about your potential procedure is whether you are a good candidate for breast augmentation by fat injections. The key question is whether you have enough fat to harvest to create enough of a breast size increase to justify the procedure. While the operation is understandably appealing, few women are actually good candidates for it…they either don’t have enough fat to harvest (it takes a lot more than most people think) or their breast size increase goals are not realistic with what fat grafting can achieve. (usually about a half cup size is the typical outcome) Thus it it important to understand that breast implants and fat grafting are not really interchangeable procedures in terms of their outcome.
There are a variety of secondary issues that are also relevant. If you have the procedure by mid-April you would be barely recovered to go to a prom by April 30th. Also more small incisions would be needed to harvest fat than just that from laparoscopic scars. That is because abdominal liposuction alone is unlikely to have enough fat in most people to do a worthwhile fat injection breast augmentation procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a recessed premaxilla even after jaw surgery, and I’m looking to ‘rotate” the base of my nose forward as per the image without increasing the volume at the side of my nose. Just wondering, does such an implant exist, and if not, how much will it cost to have it custom made?
A: What you are looking to do is increase the projection of the anterior-inferior portion of the pyriform aperture area, known as the premaxilla. There is, as you may know, a facial implant known as a peri-pyriform implant. This is really a combined premaxillary-paranasal implant. One could either remove the paranasal portion of the existing off-the shelf implant, hand carve the exact design from a carving block or have a custom premaxillary implant made. It is really all about how much projection (thickness) that the implant needs to have.
The premaxillary implant is placed through an intraoral incision across the lower edge of the pyriform aperture and across the anterior nasal spine of the maxilla in the midline. I would place two micros crews on each small wing of the premaxillary implant to ensure its positional stabilization after surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have 2 questions about injectable brow augmentation and chin asymmetry.
1. Is it possible to create a more deep set (masculine) brow via fillers?
2. the bottom of my chin is a bit asymmetric. Can filler be used to even this out? Thank you for your time.
A: Inejctable brow augmentation and correction of chin asymmetry can certainly be done by using injectable fillers. It takes a fair amount of injectable filler to augment the brows, usually about 2 syringes. But it can create a significant brow augmentation effect. The improvement of chin asymmetry will take far less volume. While effective, like all injectable fillers, its effects will be temporary in the range of 6 to 9 months at best.
Injectable brow augmentation can be a very good initial ‘test’ to determine if overall brow augmentation produces a good result. If not it can always be easily reversed by hyaluronidase injections or simple the passage of time to let the filler resorb naturally. If one likes the result, one may progress to the use of fat injections or to a permanent brow bone implant. Permanent brow bone implants are made from the patient’s 3D CT scan and are usually placed through an endoscopic approach.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in chin ptosis correction. I had a rhinoplastymin my early 20’s to correct a deviated septum and reduce a nasal hump. My surgeon suggested a chin implant to improve my profile since my nose was over projected. He added a button type chin implant intra-orally. However it did not seem to make much of a difference aesthetically and actually hardly showed at all. To be honest, in hindsight, I’m glad it didn’t because I have come to realize that I didn’t really need a chin implant anyway.
As the years progressed, I started noticing that my chin began to droop, especially when smiling. With research I learned that this is supposedly quite common with intra-oral chin procedures? More recently I had my nose and chin corrected by another surgeon. This time a young plastic surgeon seemed confident that he could correct the chin ptosis…he did not. Through some sort of “miscommunication”, after removing the button type implant which was supposedly placed in a strange upper region of my chin and on a slant, he added a larger implant with wings!! Needless to say it was not a good look but I tried to give him the benefit of the doubt and lived with it for 6 months. I finally decided to have it removed. The same surgeon performed the explant and tried once again to correct the ptosis. He failed once again- hence me reaching out to you. He also agreed that the chin implant was a mistake and that I looked much better without one. Thanks.
Also, he left me with superficial numbing on the left side of my chin- from my bottom lip down to chin. He does’t understand why this is, because he said that he clearly saw the nerves and that they weren’t cut. He thinks that perhaps scar tissue might be putting pressure on the nerve(s). He offered to correct it but I don’t have faith or trust in him anymore. I’ve been living with the numbness ever since.
In conclusion, after many google filled evenings researching chin specialists, I came across your website. I’m hoping that you could help me.
I’m worried that excising tissue might change my appearance or my smile and i’m afraid of more numbing. The ptosis is only visible by profile view. I don’t want to change my frontal appearance. Your advice and expertise would be greatly appreciated.
A: Thank you for providing your detailed history and pictures. With your degree of chin ptosis, I would have zero confidence that any intraoral approach would correct it. You have extra chin pad tissue now from two implants and their subsequent removal. (like have breast implants removed) That extra tissue is not going to be able to be lifted back up onto the chin….unless there is the support added to it by an implant. Since you do not need an implant, and never did, your only option now is a submental chin tuck. This is where the redundant chin tissue is removed from below. This is a very effective procedure that will not cause any pulling of the lip downward, affect one’s smile nor cause additional nerve numbness. It is a different and simpler experience because the whole intraoral approach to its execution is avoided.
The sensory nerve numbness that you have occurred from the placement of the winged chin implant. Whether the numbness is the result of nerve stretch or some other injury during the surgery will never be known. But I know of no procedure that could reliably and safely return the feeling to the mental nerve distribution which is now affected.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a PMMA forehead implant placed a few years back, but I’m looking for more augmentation still. I would like to go with the custom silicone implant route, but I have a couple of questions. Is it possible to remove the PMMA implant and design the silicone implant from scratch? I’ve heard some surgeons say that bone cement is impossible to remove, much like Medpor. Can the incisions used for the previous implant be used again for the new silicone implant? I would like to avoid additional scarring if possible.
A: Thank you for your inquiry. In answer tho your questions, a PMMA forehead implant can be removed quote easily. So the surgeons who have said it is difficult or impossible to remove must have no experience with it. A silicone custom forehead implant is designed off of a 3D CT scan. During the deign process the PMMA implant is digitally removed so only the bone is seen. Thus it is no problem to design a forehead implant with an existing PMMA implant in place. I will use the ghost image of the PMMA implant to design the new implant since it serves as a useful reference for how much more augmentation can be achieved. The identical scalp incision used to place the PMMA implant would be used for the new custom forehead implant so no new scarring would be created.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m 370 lbs with 52N size breasts, with severe ptosis and painful sagging breast tissue, I have severe back pain from supporting such pendulous heavy breasts for years, will you reject me as a candidate for the surgery?
A: As you have surmised, at your current weight you are not a good candidate for breast reduction surgery. While there is no doubt you would benefit by such surgery, your current weight increases your surgical risks and poses several logistical issues which I will enumerate for you.
1) Any patient over 300 lbs has to be done in a hospital setting. This is not only because of the more comprehensive medical setting and your increased risk of medical problems, but you also need to be conserved overnight after a 3 to 4 hours surgery done under general anesthesia.
2) The other reason a hospital setting is essential is that they have the operative beds that can handle any weight over 300 lbs, most outpatient surgery centers do not.
3) Due to the cost of surgery in a hospital, it is only economically feasible if the cost of surgery is done through insurance.
4) No health insurance will approve a breast reduction with one’s weight being over 300lbs. One of their criteria for coverage is that one’s weight should not be more than 30% of their ideal body weight. At the least they expect to see that the patient has a documented history of substantial weight loss efforts. While we know that weight loss is not going to be the cure for the symptoms of your large breasts, it is an insurance criteria they use.
For all of these reasons, you are not a good candidate for breast reduction surgery at this time. What you need to do kids get your weight under 300lbs which would help lower your medical and surgical risks and give you a better chance to have your surgery approved by insurance.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m interested about rib removal surgery for a smaller waistline. What are the qualifications for this type of body contouring surgery. mIf I qualify, how long will I stay in the hospital? When can I get back to work? My work requires a lot of standing and some walking. Thanks a lot 🙂
A: Rib removal surgery is best done in patients that have a reasonably thin body frame (not lot of fat around the waistline) in which the anatomic waistline is not well-defined. It is also important that liposuction of the abdomen and waistline will not help to create the more defined wasitline and that the ‘obstruction’ is caused by the flare of the lower ribcage.
For most patients, rib removal surgery can be performed as an outpatient if you have someone to take you from the surgery center and be with you. (the procedure is done in a surgery center not a hospital) If not, then it will be an overnight stay. One can return to work when one feels capable. That will vary amongst different people and could be anywhere from 10 days to three weeks for a semi-strenuous type of work. One can not hurt the surgery sites by anything that they physically do.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am dissatisfied with my facial profile and wonder if a sliding genioplasty would help. I feel my jaw is vertically too long, yet I can’t exactly put my finger on it. My maxilla/jaw just doesn’t match up. PIctures irritate me the most, because its so evident. Id like to achieve a better look, maybe with a sliding genioplasty and fat injections to the cheeksTake a look…. and thank you very much sir. You are by far the best Ive researched in this area. You surely are the right plastic surgeon for me.
A: Thank you for your inquiry and sending your pictures. Regardless of your current state of your occlusion (which are not going to be furthered modified by orthodontics), your maxillomandibular relationship shows a very mild mandibular retrusion and vertical elogation of the chin. There is also submental fullness below the jawline. A sliding genioplasty to bring the chin slightly forward (3 to 4mms) as well as vertically shorten it (5mms) combined with submental/neck liposuction would make the desired improvement in your profile. Fat Injections to the cheeks would help add some cheek highlights for otherwise flatter cheeks. Another consideration would be to transpose your buccal fat pads as ‘cheek implants’. That would create a better cheek contour result by increasing malar projection while decreasing submalar fullness.
Dr. Barry Eppley
Indianapolis, Indiana
