Your Questions
Your Questions
Q: Dr. Eppley, I would like to get a consult on a scar revision on my shoulder. I had a small keloid scar (about .5cm) on her left back shoulder that a dermatologist tried to remove with elliptical excision a couple years ago. Unfortunately the healing process was disrupted by a complication infection that was caused by the technician not properly removing the sutures. Remaining suture fragments were later found embedded and removed by an urgent care physician. The excision expanded and the result is a much larger keloid scar. (about 3x3cm) I’m attaching two photographs for you to get the idea of its current size. You can vaguely make out the shape of the excision scar which is surrounded by the individual suture scars.
I am interested in a consult to determine if there is a revision option that would at worst leave her with a much less prominent scar.
A: Thank you for sending pictures of your shoulder scar. This is a very tough area for scar revision to make improvements due to the thickness of the skin and the continual tension that is on the shoulder area. Without surgery, of course, there will be no improvement. With surgery there is a chance for improvement but it is certainly no guarantee.
Because of the skin tension issues in this body area, the most prudent approach is a serial scar excision. What this means is to do an initial subtotal excision (inner two-thirds), let it heal and see what it looks like in three months. If it remains less in size then go for the completion excision with confidence that it will end up much smaller than it is now….with no risk that it can become bigger. This would be the safest approach to lessening the risk of making the scar no better in the end with further surgery or even making it bigger.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in an umbilicoplasty procedure. My belly button has turned into an outie after my pregnancies and looks abnormal. Why does it look this way and what can be done about it? How does the umbilicoplasty procedure work?
A: Thank you for sending your pictures. Your current umbilical shape is primarily because you have a disinsertion of the umbilical stalk from the abdominal wall. This is probably associated with a small defect in the abdominal wall although not necessarily a true hernia. This has allowed the entire umbilicus to come protruding outward which is why it looks like there is a ‘smaller ring inside a bigger outer ring. There are also issues with the overall diameter of the umbilicus and its length although these are more minor. What initially has to be done for your umbilicoplasty is to reattach the center of the extruded umbilicus back down to the abdominal wall to return its shape to that of a single inward funnel. The length of the funnel would also be shortened at the same time. Such a procedure would be done through an incision inside the umbilicus.
An actual physical examination may change this opinion which is based on your pictures only. (but probably won’t)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had to have the bottom half of my ear surgically removed as the result of cancer. Since radiation was tried but was unsuccessful, permanent replacement via a an ear bone attachment is not possible. I am interested in a permanent ear replacement using your technique of creating a mold, growing ear cells from an animal, implanting this into the back of a rat then permanently attaching this ear.
A: Thank you for your inquiry in regards to ear reconstruction. I am not sure where you got the impression of how ear reconstruction is done, but the concept of growing cartilage cells on an animal in the shape of an ear to be used in human ear reconstruction is an experimental study not a viable human surgical procedure as of yet. But even if it were, the key issue in any attempt at ear reconstruction in yourself in that you have had radiation. Such treatments have damaged the surrounding tissues and impaired their blood supply. Any form of reconstruction will require a vascularized soft tissue cover regardless of what is used for the underlying cartilaginous framework reconstruction.
I would be happy to look at current pictures of your ear to determine what type of ear reconstruction may be possible in your case.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley,I am writing to you to enquire as to the methods one could use to restore a chin after a failed chin reduction.I underwent a chin reduction surgery to correct the excessive vertical dimension of my chin. Supposedly a section of bone was removed from the center of my chin and the lower part was moved upward. However the results were not at all as expected. My chin is now uneven in every direction, has no tip, is much too small, and has no structure to support the soft tissue around it.
I am not completely sure what the surgeon actually did. Suffice tit o say that he can not simply re-cut the line and move it back into place as the chin is now a completely different shape from what it was.
My question is; is there a method, perhaps using HA, to rebuild my chin and restore its previous shape?
A: A plain view x-ray of your chin, such as a panorex, would answer the question as to what type of chin reduction procedure you had done. Usually for a purely vertical chin reduction a wedge reduction intraoral genioplasty would be done. The results you now have do not appear to be consistent with that approach. Knowing how it was done can influence how you might reverse it or perform the revision chin reduction procedure. If it was done by a true wedge reduction vertical genbioplasty than re-opening the osteotomy site and placing an interpositional graft would work. If the bottom part of the chin was just cut off or one desires to bypass an opening wedge genioplasty then building up the bottom part of the chin bone is needed. This would not be done by using HA as getting anatomic contour and shape would be impossible with this material. Rather an implant would be designed from a 3D CT scan which would provide the optimal vertical chin shape and smoothness as well as choosing before surgery the vertical dimension increase if any is desired.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’ve been surfacing on internet for quite some time now to seek the corrective options I’ve got for my facial asymmetry. The problem with my face is that the left side of my face is bigge r(overgrown) than the right side and my chin and lower lip seems to be drawn to the right. I’ve learned about jaw implants through your blogs on this website. Keeping in view my above stated complaints what would you suggest me for attaining a more symmetrical face?
You asked for the picture of my face so here it is. I previously forgot to mention that I’ve got history of face trauma some 10 years ago over the right aspect of my nose forming a hump/scar (evident in pic). As far as i know facial asymmetry became more obvious to me after that. I was just wondering whether that accident has got anything to do with my facial asymmetry.
A: Thank you for sending your picture. Contrary to your perception your facial asymmetry is the result of an underdevelopment of the right side of your face and not an overgrowth on the left side. Hypoplasia is the cause of 95% of facial asymmetries. True facial hyperplasia is fairly rare.
Now it could be that you like the smaller side better but the actual pathology is on the right side. From an aesthetic correction standpoint what you have to decide is which side you like better so an established target is set…..either make the right side bigger to match better to the left or make the left side smaller to match better with the right. Either way the correct diagnostic step is to get a 3D CT scan to know the underlying skeletal anatomy.
Your facial asymmetry is congenital, it is not the result of your nasal trauma.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have had two mandible reductions and one full lower jaw sagittal split jaw procedure. These were done within about 5 months of each other. It has been about 9 months after the sagittal split procedure and I still have a problem with my lips.
I think the doctor burred too much and now my lip is similar to this.This is the area which has damage. My lip is not quite as bad as this but it is noticeable to a degree. Which part is this? Is it the inferior alveoli nerve damage? Is it likely that this is going to get better over longer period or is there no chance? When I chew it looks weird and also I dribble always when I drink and sometimes when my mouth is open. Even when I drink from a cup it dribbles from the middle for some reason. Is this type of overdone mandible burring and shaving possible to cause complete and utter permanent nerve death? I have a really tingly sensation if I tap it. It’s very hypersensitive. Some areas of the lip are numb though.
Would a particular facial exercises help?
Is there any way I will get back to normal or now not much chance? I worry Botox on other side will just mask problem and not help the dribbling issues.
A: While you have a lip problem, you are confusing the two nerves that can be affected in mandibular surgery. The inferior alveolar nerve is the sensory nerve that runs inside the jaw and comes out of the bone at the mental foramen below the roots of the first and second premolars. This nerve is at risk in both the SSRO procedure (sagittal split ramus osteotomy) and the mandibular reduction. This nerve is responsible for feeling and is why you have numbness of the lip and chin.
The lip looks like it does because the marginal mandibular branch of the facial nerve has been injured on your right side and is why the lower lip is higher than the left side. This undoubtably occurred during the mandibular reduction not the SSRO. This small nerve is responsible for innervating the depressor anguli muscle of the lower lip (it is a motor nerve) which is responsible for pulling the lip down with motion. When injured it does not move and the normal side pulls down while the paralyzed side rides up, thus creating the asymmetry most seen in activation.
At 9 months after the surgery (injury), while it is not impossible that some motor function of that nerve may return, I would not be optimistic. This is a single fascicular nerve branch so it has no cross-innervation, thus it has a poor recovery outcome. Facial exercises will not help. Botox may be helpful on the normal side so it does not pull down as much.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have some questions about standard temporal implants:
- How can a standard implant cover up the inner concave on the hollowing temple fully with perfect positive results? Won’t there be bulges, indents of pockets not covered by the standard implant?
- By standard, do you mean a one size fits all? Is this a standard procedure? Because I haven’t seen it aside from your practice.
- How far back does the imlant go? if you see in the pictures, I’m deficient a little back there behind temple above the ear along the ear. What do you think?
- How about Fillers instead? Ideally Permanent fillers? Or even better Fat? What’s your opinion on fillers instead of implants?
- Please to the best of your ability explain the procedure. Basically we make an incision (where) and push in the implant, fit it and close the incision? Is there something done to hold down the implant?
- How long is recovery from a pain perspective, bruising, swelling and going back to work perspective.
- How long do I stay in Indiana ideally? What if it becomes infected when I am home? Is flying with it in hard and painful? Or do you have a doctor you work with in my area.
- Is it irresponsible to do a surgery in another state?
- Are temporal implants reversible?
- What does it feel like to the touch?
- Aesthetic outcome: can we make it straight not rounded? I tend to get haircuts that make hollowing look straight, not rounded. Thats the best aesthetic. Can we aim for that?
- Can it ever come out of place?
- Please can I request before and after pictures? I’m from out of state and would really like a few before I commit to this long process.
A: In answer to your temporal implants questions:
1) Your temporal concavity concerns are classic and are exactly what standard temporal implants were made to augment. They would produce a smooth contour…although I am going to point out there are no perfect results in any facial implant procedure or surgery. If only perfection will do, then you should not have surgery as that never happens.
2) Standard temporal implants come in two styles and two sizes and are widely used.
3) Standard temporal implants do not go back that far.
4) There is nothing with fillers or fat injections…other than they are not permanent. When in doubt so those first.
5) The implant is placed in a subfascial pocket on top of the muscle. That si what holds it into place.
6) Pain is minimal, there usually is not bruising and there will be swelling.
7) You should be able to return home the next day. I have not seen a temporal implant infection.
8) Many patients have plastic surgery far away from home. It is commonly done.
9) Like all facial implants, it is completely reversible.
10) Feels like normal muscle. The implant is soft and squishy like muscle.
11) Making the temporal straight is best achieved by using small implants.
12) It can not become dislodged from the surgical pocket into which it is placed.
13) Due to patient confidentiality I can not pass out patient pictures.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am well from my brow bone reduction procedure. I am doing well. Again, overall pleased with the outcome of my procedure. I do hope I am not asking too many questions, but I am curious about something. Is it possible to have the plates and screws removed from my forehead? If so, would this require the same type of incision as my prior procedure, or could this be done with a much less invasive incision? There is a palpable bump where the screws and plates are and if they can be removed with a minimally invasive procedure, I would consider that. Basically, I don’t want to go through the same recocery I went througn before. If the plates and screws are still necessary for support, then I will not do it, but if they have done their job, and it is ok to have them removed, then I will consider it.
A: In answer to your after surgery brow bone reduction question:
1) The plate that was used has a very low profile, less than one millimeter. Thus it is not yet clear that the palpable bump to which you refer is the actual plate. I would need to see a picture with the area outlined on your forehead to match up to the intraoperative pictures to determine if what you are feeling is the plate.
2) The fixation plate should not be removed \before six months after surgery two ensure as much bone healing as possible.
3) Depending on how you define a minimally invasive procedure, the central part of the incision would need to be opened and an endoscope used for access to visualize the plate and screws and remove them. This is not close to what it was before but it does require a central endoscopic dissection.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in placing a chin implant on top of my sliding genioplasty. Maybe if my sliding genioplasty cut was made further back and moved in slight angle higher to make it look more square from front (losing some vertical height maybe). It is what it is – But I still think it was a clear improvement even with some compromises.
With an implant on top of the sliding genioploasty I want to achieve some more horizontal projection but at the same time some more width. All this must happen so that my chin doesn’t look longer (here I mean no additional vertical length). I also mean that not even optical illusion of looking so. I want to avoid deep sulcus but I don’t think it is a concern.
A: While the chin implant can be added into the sliding genioplasty, the relevant questions are:
1) Given the current shape of your chin after the sliding genioplasty, would a standard implant adapt well or is it best done with a custom implant made for the alerted shape of the chin bone.
2) While the additional amount of horizontal chin augmentation is not extreme, it will make the labiomental crease a little deeper. This may potentially be avoided with a custom chin implant.
3) Should this be done intraoral or from below from a submengtaol skin incision.
These are issues for you to ponder.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have interest in consulting regarding dermal fat drafting surgery . I have been researchimg for sooo long hoping to find something like this. I was diagnosed with linear scleroderma a few years ago and have noticed my top frontal area become more and more darker and indented. I am a 33 year old mother of three and since this diagnosis and physical apperance, it has caused great emotional damage and even depression. It has been an extremely difficult time understanding this and dealing with it, having to explain it to my friends and family. Please help. Thank you for your time,
A: Linear scleroderma is both a peculiar and frustrating craniofacial affliction. The first place to start is to send some pictures for my assessment and recommendations. By your description you appear to be in the active phase of the disease and it involves the forehead and up into the scalp undoubtably along the pathway of the supraorbital nerve. The classic teaching is that one should not treat the deformity until the disease process has abated and the tissue loss has stabilized. While that certainly makes the most sense from a reconstructive standpoint that is usually not very comforting to patients. I have often taken a different approach which is to try to stop the tissue deformation progression by early tissue grafting. Whether this should be done by the implantation of a dermal-fat graft from an abdominal harvest or fat injections with PRP (platelet-rich plasma) is up for discussion. With either fat grafting technique, it may take more than one treatment session to get sustained results.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have benign temporalis muscle hypertrophy on the sides of my forehead. It adds width to my forehead which gives my forehead a kind of alien shape. I know it is the temporalis muscles as when I fully open my mouth I achieve a very desirable atrophy which diminishes the odd looking alien shape. I would like to have this problem dealt with surgically as I want the problem fixed permanently. I am aware Botox is an option. However I have a few questions about the surgery.
1 )Does this surgery have a high satisfaction rate?
2) Is there a possibility that it could look un-even or potentially worse?
3 )Are there any potential side effects after the surgery?
4) The muscle hypertrophy is benign, does this make me a more suitable candidate even if it is the anterior part?
5 )Why do other surgeons not use the cauterisation technique you use and would that be necessary for my procedure?
I look forward to hearing back from you.
A: I am very familiar with the temporal shape issue which you have described. You are referring to a anterior temporal muscle reduction which is far less commonly done than that of posterior temporal muscle reduction for head narrowing. The anterior temporal reduction poses far greater challenges than that of posterior temporal reduction for the following reasons; 1) incisional access is more aesthetically challenging, 2) the muscle can only be partially reduced/released (unlike the posterior procedure where the entire muscle is removed. This poses technical challenges and 3) it is on an exposed non hair-bearing part of the face where the effects of the surgery can be readily seen.
Anterior temporal reduction is done somewhat similarly to that of the posterior temporal reduction technique that I developed. From a vertical incision back in the temporal hairline, a subfascial approach is used to release some of the superior muscle attachments to the anterior temporal bony line of the forehead. Then cauterization points are done along the length of the muscle from the forehead down to the zygomatic arch. Unlike the posterior temporal technique the muscle is not widely resected as that would leave to a major temporal hollowing effect. The anterior technique relies on muscle thinning and not resection.
In answer to your specific questions:
- The anterior temporal reduction technique has not been done as frequently as that of the posterior temporal area which has a near 100% satisfaction rate. I have only done it a handful of times from which I have not heard any issues about lack of effectiveness.
- I don’t know if it can be made to look worse. I think the risk lies more in its effectiveness, was enough of a reduction obtained.
- There will be some temporary jaw opening discomfort and stiffness on mouth opening.
- The origin of the temporalis muscle hypertrophy does not affect one’s candidacy for the procedure.
- I can not speak for what other surgeons do. My technique has been described above.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in jawline reduction surgery and rhinoplasty for a facial feminization effect. I am a female but I look too masculine. Perhaps this is a bit silly, but my friend photoshopped my face to look much more oval. I’d like to go for a more oval jaw (if possible) and smaller. He did nothing to the nose, but I’d still prefer a more refined nose and think the current nose would not fit well with a more refined jaw. I’d like my nose to be thinner all the way down and also more refined at the tip. I’m sending an example photo, which I realize might not be the best fit for my face (or maybe it would be). I hope this is helpful. If you need a side view of my nose, which is very straight, I can send that as well. Anyway, I’ve had a few people mistake me for a male when I’m not wearing make-up. To me that’s distressing and that’s the motive for seeking additional cosmetic surgery.
A: Thank you for sending your pictures and delineating your goals…which I completely understand and concur. My current comments are as follows:
1) I would agree that the nose and jawline are tied together in terms of the overall goal of facial femininization. Reducing one will make the other look bigger.
2) The nose and jawline are two of the three main keys to any form of facial feminization surgery. (the forehead is the other one)
3) Using the ideal morphed image (which I have attached a direct comparison) shows that the degree of jawline reduction would be hard to achieve. That is a 1 cm vertical reduction of the anterior jawline. The location of the tooth roots and nerve will not permit that much reduction. A panorex x-ray is needed to make measurements to see how much can be done.
4) Regardless of the amount of reduction, the issue in the ‘older’ patient is how will the overlying soft tissues adapt to a reduced bone structure. This is relevant as it makes for a critical decision in how the jawline reduction is approached. (intraoral vs submental) If you like carefully at most jawline reductions they are done in younger patients with good skin elasticity and contraction. The intraoral approach requires that such tissue contraction will occur. Because of your age and that you have already had a facelift, this raises the issue of whether a submental approach should be done which can better help with soft tissue reduction in the chin should that be needed. (and it is most certainly will)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in your suggestion as to whether micro fat injections might be able to break up Sculptra granulomas. I developed Sculptra bumps about 15 months after initial injections. My doctor has been injecting them with a mixture of Kenalog and 5 FU. They are improving slightly after 3 months of multiple injections but,they are still quite visible. Have you had success breaking up Sculptra granulomas with fat injections? Thank you.
A: Breaking up fSculptra granulomas with fat injections can be effective in some by two mechanisms. First you have to mechanically break up the granulomas with a small cannula. That is the first step in their treatment by fat injections in the procedure. Then the fat injections are placed to prevent the scar tissue from reforming or the granuloma recoalesing. So technically the fat injections do not break up the granulomas per se. But are the prequel to the fat injections.
But in looking at your pictures you have far too many garnulomas on the one side of your face for any form injectable therapy to be effective. The best approach in your case is to have them excised through an anterior facelift approach. One could also argue that a layer of allogeneic dermis (Alloderm) could applied over the excised area to ensure maximal contour smoothness.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in facial reshaping surgery. I want to remove my medium chin implant and get a sliding genioplasty. I want my chin to be a bit more squared. I also don’t want to sound like I am abnormal because I know I’m perfectly decent looking but I would also like some very subtle volume to my midface around the infraorbital-zygomatic area. And perhaps a bit more angularity on my jaw. I’m not dead set on any of this and I would like to listen to a professional. The last thing I want is something that looks fake, a plastic looking face or some disfigurement.
A: Thank you for sending your pictures. In answer to your desired facial reshaping surgery desires:
1) A sliding genioplasty will not give you a more square chin. While moving the chin bone can be effective for many chin dimensional changes, adding width or squareness is the one change it can not do. Only an implant can make an effective chin width shape change.
2) Augmentation to the undereye and cheek area is usually done by a special design infraorbital-malar implant design. The change can be subtle or more pronounced depending upon what look the patient is trying to achieve.
3) As for the jaw angle it is a bit hard to tell with a beard, but you do have thicker heavier skin. Whether adding some volume to the jaw angles would be beneficial has to be looked at carefully. The best jaw angle results come from patients with more lean faces where the implant definition can be more clearly seen
I understand what you are trying to achieve is to add some angularity to a face that is more round. More modest changes in multiple facial areas is what is needed to achieve that overall facial effect.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in forehead reshaping. I have mild to moderate metopic synostosis that was uncorrected as a baby. Because of this, the metopic ridge is prominent, starting about halfway down my forehead up to about 2″ behind my hairline. My entire forehead has the pointed appearance seen in trigonocephaly.
My question is: Is a reduction via bone burring enough to make my head more normally shaped? I will always have a… unique skull… but I’d like for it to be a little less unique! If not, is this something that could be corrected using a combination of bone burring and hydroxyapatite cement?
Thank you.
A: Thank you for your forehead reshaping inquiry. In the correction of the forehead, the bone burring has the least significance alone and would not produce a more normal forehead shape. In fact one could argue that the midline crest is the near normal projection of the forehead and it is the recession of the bone to the sides that is the bigger shape problem. Thus it is augmentation of the forehead using a custom made implant that offers the real improved shape to the forehead.
The problem with bone burring and the use of hydroxyapatite cement, which are both viable treatments methods is that they require a full coronal scalp incision from ear to ear to do. That is probably not an acceptable aesthetic tradeoff. A custom forehead implant offers a more predictable and symmetric shape result with a shorter scar to insert it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like to get a lip lift but I also will get a rhinoplasty with a different surgeon I have already paid to do. My question is should I get the lip lift first and then rhinoplasty or the opposite way?i don’t want to get them together. The surgeon will reduce nostril size during the nose surgery so is a bit more complex than a normal rhinoplasty. Thank you.
A: The debate of whether to do a lip lift with a rhinoplasty or to do to separately is a constant one for which there is no clear consensus. But since you are doing them separately there is also a debate about which order they should be done in. I am not convinced that which one is done first really matters. But since you are going to do nostril narrowing as part of your rhinoplasty (which is actually fairly common) I would do want the rhinoplasty first. Then have the lip lift 3 to 6 months later. The concept for this order is that the scars from the nostril narrowing can first be established which are usually just inside the alar base on each side.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a question about temporal artery ligation. Is the procedure you undertake similar to a traditional temporal artery biopsy? I wasn’t sure if a biopsy results in the artery being completely tied off, or if it is somehow reconnected after the sample section is removed. Just curious if there are any similarities between the two procedures — i.e. biopsy versus ligation.
A: Your question is a good one as both procedures operate on the anterior branch of the superficial temporal artery. But that is where the similarities end. A temporal artery biopsy uses a single long incision just behind the hairline before the artery heads out into the forehead. A one cm section of the artery is removed since it is sent off to pathology for histologic evaluation. The ends are tied off and the gap remains between the two ends. Its intent is to get a specimen and not to treat vessel prominence.
Conversely temporal artery ligation, or more properly called ligations, involves the placement of numerous small incisions ( 5mm to 7mm) both in the hairline and out on the forehead. Its goal is to shut off both forward and backward flow into the visible artery so it is no longer seen. The vessels are tied off at these various skin locations but no section of the artery is removed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am attaching some photos for assessment for perioral mound liposuction The area I am concerned with is particularly visible in a 3/4 facial profile, but it also shows up in straight-on shots as weird shadowing around and below the corners of my mouth. Ideally, I would like this area to flatten, so that I can have a straighter profile. However, I am worried that fat removal in this area could cause laxness or drooping of the skin. I would like to avoid jowling!
I also have dimples in my cheeks when I smile — not sure if this makes any kind of difference, but I thought I would let you know. Thank you!
A: Thank you for sending your picture for consideration for personal mound liposuction. Your area of concern would be considered the perioral mound region. It is really only treatable by very small cannula liposuction through a small incision inside the corner of the mouth. I have not seen loose and lax skin develop afterwards as almost every perioral mound liposuction procedure I have done is in younger patients. But even in the older patients I have treated this has not been an issue that has occurred.
Having cheek dimples does not affect the result, positively or negatively.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in chin implant removal. I had a chin implant placed three years ago.I feel that it looks too rounded and full when I smile especially since my teeth do not show when I smile. It looks out of proportion. The Doctor who did it is fantastic and I really wanted it at the time but now feel that I do not want it. I have also lost some weight since it was inserted. My face does not seem to support the look of it. Attached are 2 pictures – one before and one after the implant. When I smile the implant looks even more odd.
The chin implant is Goretex and porous so I am not sure how easy it would be to remove. It is a rounded implant. Would you be able to remove it – and also would the possibility of a lower face/skin lift around that area be a good idea in order to tighten up the space/area ?
Thanks very much in advance.
A: Thank you for your inquiry in regards to chin implant removal. Goretex chin implants can be removed even though they will have more tissue adherence. In terms of tissue adherence, they are about halfway between a silicone and Medpor chin implant.
The issue is not whether it can be removed but what to do to prevent soft tissue chin ptosis which will likely occur once the support is removed. The chin is a central facial prominence for which a lower facelift of any kind will not affect it. A lower facelift is not a prevention or treatment for chin ptosis. Your options include leaving some partial support (downsize to a smaller chin implant) or perform a submental tuck with muscle tightening to readapt the tissues over the chin bone.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in cheekbone reduction reversal. I had my cheekbones reduced and am unhappy with the result. Is it possible to rebuild the cheekbones up with calvarial bone grafting on defected cheekbones or use a bone substitute such as hydroxyapatite? What is the best way? Thank you.
A: Cheekbone reduction reversal surgery can be done by one of two ways. Trie reversal consists of opening up the osteotomy cuts and bringing the cheekbones back out through an interpositional graft and plate fixation. The most common technique to reverse cheekbone reduction largely depends on the osteotomy pattern through the malar body. If it was a straight line cut (which would be the most common technique) the bone can be brought back out and a small natural bone graft placed like a calvarial bone graft as you have mentioned. This is the most ideal way as you’re then assured it will fully heal. The interpositional graft could also be a cadaveric bone graft or a synthetic bone graft like hydroxyapatite.
The other method of cheekbone reduction reversal is to leave the infractured cheekbones where they are and placed an implant on top of them. Such cheek implants are ideally made from the patient’s 3D CT scan.
Each cheekbone reduction reversal method has its advantages and disadvantages. A 3D CT scan should be obtained for preoperative evaluation to help in this decision process.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in jaw implants and have some questions:
1. My problem is a narrow jaw and a recessed chin topped off with a assymetric mandible to the right, pulling on one side of mouth, is this presenting a problem since it would require an assymetric implant?
2. Would a wraparound implant provide lateral width like implants under the masseter or only downward and anterior?
3. Is “jaw implants” to be understood as the wraparound jaw implant?
4. Is silicone the best material for this, is titanium possible?
5. How many years would a silicone implant last?
6. Is bone erosion a danger to the final look?
7. How can the final look be predicted? Am i able to choose different implant dimensions?
8. Is it possible to achieve a mandible like that of actor Colton Haynes with this procedure?
A: In order to answer most of your questions I would need to see pictures of your face. But in answer to some of them:
1) Custom jawline implants often are made with corrections to the jaw asymmetries
2) Custom implants are designed to any dimensions that are needed
3) Jaw implants is a general term. A wrap around implant is just one type of jaw implant
4) Silicone is the only material used for custom implants. Titanium is too stiff to use and would be extremely expensive
5) Such solid implants last forever
6) Jaw implants are not known to have any appreciable bone erosion
7) While you can choose the implant dimensions, there is no way to know for sure how that will look on the outside
8) You can make your jawline better or more enhanced but I would never say you can achieve anyone else’s jawline.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am attaching some facial photos for assessment for perioral mound liposuction The area I am concerned with is particularly visible in a 3/4 facial profile, but it also shows up in straight-on shots as weird shadowing around and below the corners of my mouth. Ideally, I would like this area to flatten, so that I can have a straighter profile. However, I am worried that fat removal in this area could cause laxness or drooping of the skin. I would like to avoid jowling!
I also have dimples in my cheeks when I smile — not sure if this makes any kind of difference, but I thought I would let you know. Thank you!
A: Thank you for sending your pictures. Your area of concern would be considered the perioral mound region and yours is a classic case of it. It is really only treatable by very small cannula liposuction through a small incision inside the corner of the mouth. I have not seen loose and lax skin develop afterwards as almost every perioral mound liposuction procedure I have done is in younger patients.
Having cheek dimples does not affect the results of perioral mound liposuction either positively or negatively.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am seeking extra large breast implants. I was a natural 34H and then got 800cc silicone implants under the muscle. the dr had said it would double my size. However it didn’t change my size at all, it only gave me a tiny bit more upper pole fullness was all. So I was very disappointed with spending all this money to not be bigger which was what I wanted. I have been told by a couple of Dr’s I could go up to 2000cc with overfilled saline. Is that something you would do? Or will you not go that large on patients? I want a good plastic surgeon with good ratings like you have. I am not a tiny framed lady, I do have a curvy build. Please let me know, thanks.
A: If 800ccs breast implants did not come close to your breast size goal, then at least twice that would be needed to make a more visible difference. Overfilled saline implants would be the only way to achieve that type of volume. Where the final volume might be on the spectrum of 1600 to 2000cc depends on how it looks and feels during surgery.
Please send me some pictures of your breasts for my assessment for these extra large breast implants.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I heard about you when I was researching Knee Lifts. After reading more about you ,watching your YouTube and reading your Bio as well as looking at your website I think you are indeed incredibly and uniquely qualified. Unfortunately I saw nothing on your website about my problem so I will ask you directly.
I believe I have stage 1 Lipedema,. After a few years of research I believe its Lipedema, based on my symptoms, age onset and process of elimination. The only treatment for Lipedema is liposuction from what I have read and spoken to surgeons about. I am planning to get my calves and ankles treated by liposuction but the surgeon I’ve spoken to doesn’t want to touch my awful, fat, disfigured knees as he says “knees are tricky”. He also isn’t too keen on my thighs as most of the disproportionate fat is right above my knees, which he says will make my knees much worse than they already are. I am not overweight, I am healthy, athletic and in shape. I would like to know what you know about Lipedema,and what your thoughts are about this type of surgery.
Thank you for taking your time to read this and reply.
A: As you know there are differences between lipedema and lymphedema by which you have come to the conclusion that you have the latter. Some improvements in true lipedema can be obtained by liposuction as you have stated. When it comes to using liposuction for its treatment I would be more concerned about prolonged edema from the calfs and ankles but not the knees. There is nothing ‘tricky’ about the knees and there is not any anatomic feature that makes them different for liposuction surgery. What the skin will do when the fat is reduced can not be precisely predicted anywhere on the lower extremities but most likely it is not going to shrink in a perfectly smooth manner. That would be an expected tradeoff for the size reduction.
Those are the general comments I can make without having any specific visual knowledge of your lower extremity problem.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, what are the differences between lip ‘advancement’ and lip ‘enhancement’ and lip ‘lift’? I’m specifically looking to augment my upper lift for more fuller appearance.
A: In answer to your questions, lip enhancement is a global term that refers to any type of lip augmentation procedure, albeit injection or surgical.
A lip advancement, also known as a vermilion advancement or ‘gull wing’ procedure removes skin just above the upper lip and the vermilion or red part of the lip is moved up to cover the removed skin area. This increases vermilion show from one mouth corner to the other. In essence it pushes the vermilion towards from below.
A lip lift, also known as a subnasal lip lift or ‘bullhorn’ lip lift removes skin from below the nose and lifts the lip upward. It shortens the distance between the nose and the upper lip and improves the central vermilion fullness of the upper lip. It does not have any effect on the sides of the upper lip.
I would need to see pictures of your lip to determine which lip enhancement procedure may be best for you. Most patients graduate to surgical lip enhancement after trying injectable lip enhancement methods.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in correcting my jawline asymmetry. I’ve always hated taking pictures head on or from the right side of my face because of the asymmetry of my chin and the angle of my jaw on the right side. It’s almost as if my jaw has shifted down and has caused my chin to shift and protrude forward on one side. This has been the case for as long as I can remember and I almost feel as if it’s getting worse. Probably because my skin is thinning and I can see the outline of the chin a little more. I’ve never had any dental issues or braces and no dentist has ever told me my bite needed to be corrected. I just wanted to find out my options-and see if this was actually possible to fix. Thank you so much in advance!
A: Thank you for sending your pictures and describing your lower jawline asymmetry concerns. What you have is an overgrowth of the right lower jaw that makes the jaw angle slightly bigger, the right jawline lower and the chin shift to the left. Usually with such jaw overgrowth there would be associated bite and occlusal plane asymmetry…but you seem to have largely avoided that typical accompanying issue. The treatment would be one of a chin and jawline bone shave from the left side of the chin all the way back to the jaw angle. This would be done through a submental incision approach. The amount of bone to remove would be determined from a simple panorex x-ray based on millimeter comparative measurements of he height of the mandible from midline chin to the ramus.
Dr. Barry Eppley
Inianaopolis, Indiana
Q: Dr. Eppley, I have consulted with you many times about my facial structure and have plans to do the jaw implant. I’m just wondering if I already have surgeries on my chin (1st surgery sliding genioplasty. 2nd surgery reverse sliding genioplasty 3rd surgery shaved the corner of the chin from expansion as it made my chin becomes square) will it be safe to do the jawline implant? Not doing anything with the chin but maybe will be the same area that got cut several times. Will it increase the risk of infection? I don’t plan to do jaw inplant with any doctor in Korea or anywhere as I think a doctor with experience is the best. And I had to save up again and again after my previous failure for other parts.
I really plan to do it but will be about a year or two from now since I have to finish my braces first in another country.
A: Regardless of your prior chin surgeries, that does not preclude you from getting a jaw implant in the future. The custom jawline implant is made from a current 3D CT scan so this will show your current bony anatomy. That happened to the chin bone in the past does not affect placing an implant across it in the future.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a custom jawline implant. I am attaching a few photos of my face and you will see that my lower third is narrow. My general interest is in a wraparound jaw implant in order to widen the face, tighten up the submental, improve aesthetics of the face and protrude the chin to balance the protrusion of the nose. What does your aesthetic eye think of this possibility judging by my photos?
Do the custom made implants have a high success rate as in the forum for plastic surgery knowledge I frequent there is a patient from Western Europe of yours that has had 2 revisions to his jaw implants in the span of 7 months? He says its “finetuning to look natural”. I am not extremely interested in having it revised because I dont want to endure the whole ordeal again.
A: If you are looking for increased lower facial width and dimensions of the chin and jaw angles that has a smooth linear connection than a custom jawline would be the preferred choice.
It is not uncommon for many patients to have revisions of custom facial implants including custom jawline implants. This is primarily because they often don’t know what they really want until they wear it to so speak. In the case you so described the patient himself chose the dimensions and that was what was exactly provided to him…only later to decide he wanted a different look. (Less strong)
The key in any custom jawline implant is that less is more. It is always to better to go smaller in dimensions as its effect is more substantial than a patient can anticipate. In looking at your face that its exactly what you…a smaller custom jawline implant. I cll this type a ‘jawline defining implant’ as it just adds angularity and a little width.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have put some thought into those measurements you told me about regarding zygomatic arch implants. I have made some research of my own and I have a found a cheek implant from Stryker that is not far from being a zygomatic arch implant. It’s measurements are close to the ones you suggested for me and my aesthetic goals (yours: 5cm length / 6-8mm width / 5mm projection height) which I assume can be carved/cut to meet your measurements even more.
Despite doing all of that sizing modification, the implant isn’t originally designed to sit on top of the zygomatic arch only. (This implant is also slightly bent in its shape). In the sample photo above, you can see that it is positioned in a way that starts just halfway on the zygomatic arch, going further over the malar prominence, whereas it ends at the maxillary buttress.
My question is; after the surgeon have carved/cut this implant to meet the sizing recommendations you sort of suggested, is it even acceptable to position this implant on the entire zygomatic arch?
A: I would be very cautious about using a Medpor material as a zygomatic arch implant. Besides the issue of its natural underlying shape (curved), the tissue ingrowth from this material will make it virtually impossible to ever remove or revise it later. There is a branch of the facial nerve that crosses over the posterior zygomatic arch that supplies movement to the forehead. While there is a very low risk of injuring this nerve during the insertion of the implant, trying to remove a Medpor zygomatic arc implant later due to the tissue ingrowth will almost certainly increase that risk considerably. If injured there will be some paralysis of the forehead. Thus this is not a material I can endorse as a zygomatic arch implant. Easy reversibility of a facial implant can be an important feature whose importance varies based on the anatomic facial location of placement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I hate to say it but I’m second guessing my decision about rhinoplasty surgery the more I read online. Perhaps I shouldn’t be reading online but I’m reading things like “nose job is the worst possible procedure to have done for a male.”. And that the problem is a lack of facial bone growth, not a big nose, which in my case is certainly true as I have a narrow face and underdeveloped lower third. So I’m wondering will a rhinoplasty simply be a regression for me, further feminizing my face? I know ultimately it’s my decision but obviously you understand aesthetics better than I do and could offer some sort of assurance as to why a rhinoplasty would be beneficial for me.
A: The psychological preparedness of a patient before any aesthetic surgery is of great relevance. A patient’s behavior will follow after surgery the exact pattern that they had before surgery. This is a plastic surgery experience that we see on a near daily basis.
It is one thing to be anxious about the surgical process, which most people normally are, but to be questioning whether one should have surgery at all based upon an uncertainty about the facial changes speaks to a different level of anxiety. It is important to realize that almost every patient after elective aesthetic facial surgery goes through a point in their recovery where they question the wisdom of their choice. For those who have few doubts before surgery they get past it at some point in their recovery. For those that were internally questioning whether such facial changes would be beneficial at all, they may never get past it and may recover to regret having had surgery. This is relevant since rhinoplasty is an irreversible change. It is not like a cheek or chin implant which can be pulled out later. This its why computer imaging should always be done before rhinoplasty which can help the patient visually determine if the surgery is worth it.
Dr. Barry Eppley
Indianapolis, Indiana
