Your Questions
Your Questions
Q: Dr. Eppley, Hi, I’m interested in improving vertical chin lengthening. Below are attached pictures of before and after application of 1 and then 2 syringes of Juvederm Volume below my chin to increase vertical projection. I like the result but considering a more permanent option. In my research it seems that most chin implants address mostly horizontal projection. My horizontal projection is fine but I would like to increase vertical projection to get more sharper look in profile. I’m in great shape and don’t think dieting and more exercise would greatly improve my facial profile or remove the appearance of double chin. Would like to get your opinion on options. Thanks.
A: When looking for vertical chin lengthening, there are two options. An opening wedge siding genioplasty would be the autologous option. The chin bone is cut and open vertically downward and then plated in its new vertical fashion. The other option is to make a custom chin implant that mainly adds a vertical dimension increase. The decision between the two would be based on how much vertical increase one seeks. Large amounts of vertical increase are best done with a vertical bony genioplasty since it carries the soft tissue downward with it as it remains attached to the bone. With a custom chin implant it is important that enough chin soft tissue is available to be mobilized over the implant.
Lastly, vertical chin lengthening is not going to be enough to completely eliminate the double chin. Liposuction of the submental region would need to be done as part of the chin procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a rhinoplasty and chin implant two years ago. But I am still not happy with shape of my nose, chin and face overall. I wish I can start over. I feel my nose is still too long and pinched and wish it was straighter and more refined. I also want a more angular facial shape with a masculine defined jawline and cheekbones. I think my chin implant has done only so much to help my desires. See my before and after pictures. Are my expectations and desires unrealistic? Can you help? Thanks so much.
A: Thank you for sending your before and after pictures. I think on both counts (rhinoplasty and chin augmentation) you have had good improvement and I would not agree that there would be any benefit to ‘starting over’…even if you could. You have reasonable results from both your rhinoplasty and chin augmentation. Your nose may be just a tad too long but that is a pretty good result. You are not going to be able to make any drastic changes to it other than perhaps some tip shortening. I do not know what you mean by being ‘pinched’. The refinement of any rhinoplasty is controlled by the thickness of the nasal skin. Having thicker skin there is a limit as to how much refinement can be obtained. You are likely as good as it can be. In that regard you probably do have some unrealistic expectations. Your chin implant has provided a substantial improvement and you would not want any further horizontal augmentation. What you are ‘missing’ from a facial skeletal standpoint is a lack of jaw angles and cheek prominence. The nose and chin have helped but they were not the sole solution to a more masculine face.
In short I would recommend some nasal tip shortening and cheek and jaw angle implants. This will then provide a more comprehensive approach to facial masculinization.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, How much do you charge for Selphyl? And how many cc’s are included in the Vampire Facelift? I did this procedure over 4 years ago and am interested in getting it done again.
A: You have asked about two similar but slightly different injectable facial rejuvenation procedures.
Selphyl is a kit or system where PRP (platelet-rich plasma) is added to PRFM to create a gel-like matrix for injection. By adding a calcium chloride solution, the Selphyl system converts PRP into an injectable gel. This fibrin matrix serves as a three dimensional scaffold to maintain the platelets at the site of injection. This PRP gel adds both volume to the injected facial areas and serves as a tissue stimulant onto which fibrous tissue can be created. The cost of a single Selphyl treatment is $1500.
The Vampire Facelift takes PRP and traditional hyaluronic-based injectable fillers and injects them separately into the facial areas. The injectable filler serves as the three-dimensional matrix in which PRP is secondarily injected. It is not a kit or system per se and is more of a technique that has been given a branding name. A single Vampire facelift may cost up to $2500 depending upon how much injectable filler is used.
The facial rejuvenative concepts between Selphyl and the Vampire facelift are similar even though their methods and materials are slightly different.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am contacting to find out more info about chin ptosis correction. I am 26 years old and had a chin implant that I strongly regretted. It was removed about six months ago. I notice that my chin has not returned to its original shape and size as I had been told that it would. There seems to be excess tissue underneath my chin and I miss the taut appearance that I used to have naturally. Just curious about what is involved to correct this issue and the potential cost. My incision was made underneath the chin, not intraorally. Thanks a lot for any info.
A: Unless the chin implant was fairly small and removed shortly after insertion, rarely do the chin soft tissues return to their exact shape as before surgery. All face and body implants are, to some degree, tissue expanders and they can create some overlying soft tissue changes no matter how small they may be. The approaches to chin ptosis repair are of two fundamental types, resuspension and excision. Sagging chin tissues can be resuspended, excess chin soft tissues can be removed. Which approach is best depends on the nature of the chin problem. I would need to see some pictures of your chin to make that chin ptosis repair determination. My suspicion is that you have a very small amount of soft tissue sag at the bottom of the chin that can be easily solved with a submental tuckup procedure. As long as the lower lip position is good any soft tissue sag off the chin bone is usually best treated by a chin ptosis repair using excision.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have had so much filler, including volume (five vials of Sculptra and Juvederm within the past year) and I still feel that my cheeks are not full enough. I had very high cheek bones when younger and I am now 52 years old. I used to do the IPL laser years ago and this thinned my face very much due to fat loss. I would like to have a consistently full face rather than be dependent on these costly fillers. When I do the filler the swelling makes me look fantastic, but once the swelling is over it is deflation all the way. I thought that cheek implants, even the smallest, would give me a foundation that I could be happy with.
A: injectable fillers play a major role in facial voluminization, particularly in the cheek area. But the reality is that it is not a long-term solution to one’s desire for fuller cheeks. Fillers are great long enough until one’s decides that they either want to ‘graduate’ to more permanent solutions or to stop their cheek augmentation efforts. While fat injections are one of the two more permanent options, cheek implants provide an assured method of permanent cheek augmentation. With the wide variety of cheek implants style and sizes, patients and plastic surgeons have a lot of good options to choose from for permanent cheek augmentation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a custom jawline implant. But before making this expensive decision I just want to make sure a sliding genioplasty is not something I should consider and living with a custom chin implant for life is 100% the best for me. I really think vertical length is one of the key factors with my chin being weak. I would appreciate your thoughts before I make this choice. Thanks so much.
A: In looking at your goals by your own imaging, you need chin and jaw angle changes. When it comes to vertical chin lengthening that can be done by either a sliding genioplasty or a custom implant. If you were just doing the chin alone and did not care about the rest of your jawline then the debate of a sliding genioplasty vs. implant has merit. But when you factor in the rest of the jawline for aesthetic improvement, where jaw angle implants would be needed and the only way to get that improvement, then a custom jawline implant makes the most sense. While a sliding genioplasty can be done with jaw angle implants, those areas will remain unconnected and not have a smooth line between them. A custom jawline implant creates all the chin and jaw angle changes one needs and connects them in a smooth wraparound fashion. In my experience this produces a far better result for almost all male jawline enhancements with lower risks of nerve injury/numbness. An even though the implant is more expensive to manufacture up front, it is done in less surgery time (so the costs differences are closed to a wash) with lower risks of revisional surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in forehead augmentation. I have very large brow ridges, and a sloping forehead with a prominent central bump in front of the coronal suture. I suffered a blow to the saggital region as a younger boy, and I have always believed that I suffer from premature suture closure. The saggital region is pointed, and my skull height is reduced. I read your procedure articles about plastic inserts in the forehead region to round the forehead and perhaps make it appear higher and more vertical, as well as similar inserts to widen and heighten the overall head shape. I am 68 years old, and have combed my hair over my forehead since I was a young man because I am embarrassed about my appearance. At my current age, and with thinner, receding hairline, this is becoming impossible. Can you help me?
A: Thank you for sending your pictures. I can clearly see your forehead concerns with a large flat area above your brow bones which slopes backward up into the skull. There is a relatively straightforward solution to our forehead deformity by building up the bone over the area of the depressed forehead region which is fairly well delineated. (forehead augmentation) This could be done using either a custom made silicone forehead implant from a 3D CT scan or using bone cement (PMMA) to do the forehead augmentation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting breast implants. I am in the process of losing weight (40 pounds to date) so would also like to consult with you regarding how much more weight loss would be ideal before having the breast augmentation surgery. Thanks!
A: In the face of future weight loss the standard answer would be to wait until one’s weight loss is maximized before getting breast implants. Like all standard answers, however, the specific response for any patient must be further qualified. If one has no existing breast ptosis or sagging and not much residual breast tissue (volume) then further weight loss will have no impact on current breast implant size selection or whether ones needs a breast lift or would affect what type of breast lift one might need. However if one already has some breast sagging and /or some significant breast volume, further weight loss will affect both. And, as a result, any breast implant/enhancement decisions made now may be adversely affected when further weight loss occurs.
The final variable is this decision is the amount of weight loss one believes they can achieve before getting breast implants. As you have stated you seek a 40lb weight which would be considered substantial in how it could potentially affect your breasts. If it was a 10 or 15lb weight loss that amount would be considered to have a negligible influence on the current state of your breast shape and position on the chest wall.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in cheekbone reduction or recontouring. I’m wondering if there is a possible solution to my low cheekbone contour, by this I mean the ‘hollow’ shadow line that you see in many male models or those with high cheekbones. From looking at my face at the front is the cheekbone insertion too low or are my cheekbones just too large in length size? I ask this because the cheekbone seems to start at a high position i.e. just under my eye but seems to extend a lot length wise down my face. Any possible solutions to this would be appreciated.
A: Interestingly, while many men seek to obtain the cheek look that you have (and can’t) yours appears to be a question as to how to change your high and wide cheekbone prominence. Your cheek look is a function of both the high and wide shape of your cheek bones as well as the lack (or minimal amount) of facial fat. As a result you have a very classic pattern of ‘cut out’ cheek bones whose pattern can be seen very clearly on your face. Since a face like yours is very unlikely to maintain any injected fat, the only possible solution is to recontour your cheek bones. A reduction in your cheekbones (cheekbone reduction) to reduce its width, and possibly adding a small submalar implant (to fill out the submalar hollows), would be the one way I can see to modify your cheekbone shape.
Cheekbone reduction surgery is often about modifying the shape of the cheekbones as opposed to just pure bone removal.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in jaw asymmetry correction. I was referred to you by a friend and I would like to consult you over my concern. I have a slightly asymmetrical face with a swelling on the right side of my face. Based on the scan my right mandible is longer than the left side while it is more bended (curved) than left as well. To me the chin misalignment is not a big issue and doesn’t have that much impact on my look but rather the swelling on my right side of face is very noticeable and unpleasant. So my main concern is just getting rid of the swelling on the prominent side with the least manipulation on my face. Please note that I am not looking for a perfect face. More of a normal face is what I am asking for. I was wondering what options I have here to just get rid of swelling?
A: Thank you for your inquiry and sending your picture. What you refer to as right jawline swelling is not really swelling. This is reflection of your lower jaw asymmetry due to how it developed. As you appear to have had a CT scan it shows that the right jawbone is bigger and longer than that of the left side. This will also include the overlying soft tissues as well. In essence your entire lower jaw is shifted during development of which also consist of chin asymmetry and a left jawline/facial ‘shortness’.
It would be helpful to see the CT scan and hopefully it was a 3D type. But having seen many such jaw asymmetries before, the treatment approach is fairly straightforward. In an ideal world I wish just reducing the larger jaw on the right side would straighten out your face and give it substantial better symmetry. But this is unlikely to happen by itself. The reason is that you can not reduce the larger bone enough to make a big difference. (there are teeth and nerves in the bone so that is a limiting factor as to how much bone can be reduced) In addition it is not possible to reduce any of the thickness of the overlying soft tissues as it contains muscle and branches of the facial nerve.
For these reasons this is why many jaw asymmetry corrections must employ a ‘triple point’ approach. This means all three points of the jaw (chin and two jaw angles) are treated. Reducing the right jawline, straightening the chin and augmenting the left jaw angle provides the best method of jaw asymmetry correction. Even with this approach perfect lower facial symmetry is not usually possible. But it is usually the best approach to mask the lower facial disproportion which now exists.
In short, you have three options:
- Right jawbone reduction with the understanding that it will only produce a modest improvement,
- Right jawbone reduction and left jaw angle augmentation since you have stated that you are not bothered by the chin asymmetry, and
- Right jawbone reduction, left jaw angle augmentation and a leveling chin osteotomy for straightening.
With each treatment option the degree of jaw asymmetry improvement increases.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m trying to find out more about lateral epicanthoplasty, could you help me find more information about this before I take this procedure?
A: Unlike the better known medial epicanthoplasty, a lateral epicanthoplasty procedure also exists.The epicanthoplasty procedures can elongate the length of the eyes, increase the eye size, and improve the aesthetic results of double-eyelid surgery. In addition to focusing on the fold at the inner eye (medial epicanthoplasty), the lateral procedure also addresses the outer portion of the eye. Lateral epicanthoplasty is done to lengthen the eye and correct a slant that makes an eye appear droopy or tired. The most common misconception about lateral epicanthoplasty is that it is like its medial cousin when in fact it is not. The medial epicanthoplasty is about correcting the overhanging skin fold. The lateral epicanthoplasty, more accurately called a lateral canthoplasty, changes the position of the corner of the eye and is not an external skin removal procedure. It does require small skin incision to do but its objective is to elevate the outer corner of the eye by tightening the lateral canthal tendon. In short, a lateral epicanthopasty is not a unique procedure but is the well known lateral cantoplasty procedure which has been around for decades. In many cases it is not even a true lateral canthoplasty but is really a lateral canthopexy.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have rather under defined but wide cheeks. I’m interested in undergoing both Cheekbone Reduction and Cheek Implant surgeries. I saw your answers on RealSelf and wanted to know more about your experiences in these surgeries. Also, how much would it cost to perform both surgeries? Thank you a lot in advance.
A: You have the classic wide cheekbones (technically zygomatic arches) that do not have much anterior projection over the body of the zygoma. (malar prominence) Hence your description of ‘underdefined but wide cheeks’. As you already know improving this type of cheekbone anatomy requires cheekbone reduction surgery (technically inward respositioning of the zygomatic arches) and implant augmentation. (anterior cheek augmentation) The most challenging aspect of this surgery is in the cheek implant design. There is no standard cheek implant made that achieves the type of cheek augmentation that you need. Fortunately I have treated enough Asian patients who desire this exact type of cheek change that I have designed specific cheek implants to achieve this anterior projection but which create no lateral projection or width increase.
I will have my assistant pass along the cost of the surgery to you on Monday.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in temporal artery ligation. There are a few pics of how it looks just about everyday when I exercise it gets about 3-4 times worse and throbs rapidly. I went to the doctors and they said that its common and since I’m a big guy at 6’4 and 240 lbs that it’s not uncommon and there really is no treatment. When researching online it suggests prednisone in a large dose along with other things. I’m not sure if I should seek another doctor opinion or if prednisone is something that is going to help with it.The arteries being prominent drive me a bit crazy I know they are super noticeable and I get a comment here and there about them which is frustrating to say the least. How much does surgery cost? And would it be wise to try out the prednisone if I can find a doctor who thinks that would help.
A: Your prominent temporal arteries show a very classic pattern along the squiggly pattern of the anterior branch of the temporal artery. I have not heard of using steroids for reducing the appearance of prominent temporal arteries. That is the type of treatment for temporal arteritis but that is not what you have. The only successful treatment for their reduction in multiple point ligation. That is a procedure done under local anesthesia in the office. I will have my assistant pass along the cost of the surgery to you on Monday.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’ve had a chin implant procedure. The photos are of me about a year after the procedure. I am not fully satisfied with the size. Do you think a sliding genioplasty (perhaps while keeping the implant I have) would help? I don’t think I look bad, but I would like to have a more masculine face.
A: Thank you for your inquiry and sending your pictures. I would agree that your chin projection is still inadequate and could be further improved. The question is whether this is best done by a new custom made implant or whether a sliding genioplasty should be done keeping the existing implant in place. The answer to that can not be completely derived from profile pictures. It would be helpful to know the size of your existing chin implant and where it is positioned on the bone. These pics of information you are not likely to know and are best determined from getting a 3D CT scan. That will provide invaluable treatment planning information. It is clear in your profile view that you need at least another 7mms of chin advancement and come vertical lengthening as well. But your front view pictures would also be helpful so see what your chin width is. A sliding genioplasty in the front view will usually make the chin more narrow and not wider so this is an important assessment to make.
Please send a front view picture for my assessment. We can help you get a 3D CT scan where you live. You simply find a facility where you want it done and we will fax the order to them for you to get it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a fractured cheekbone. In terms of cheek reconstruction will a fat injection be more beneficial than a cosmetic implant? Please email me your answer.
A: Assuming that you are not going to have the cheekbone fracture repaired acutely or that this is an old healed fracture, you are seeking cosmetic camouflage of the external deformity caused by displacement of the underlying bone. (cheek reconstruction) Both fat injections and an onlay bone implant are viable treatment options. But which one would be better depends on the location and extent of the external facial deformity. Each approach has its advantages and disadvantages. Fat injections are simpler to do with a very quick recovery but their survival is far from assured and, in most cases, requires more than single treatment session. A facial implant offers an assured augmentation result but is more invasive with a longer recovery. (swelling period) In some cases of secondary zygomatico-orbital reconstruction I have combined implants with fat grafting to get the best result.
It would be very helpful to see pictures of your face to determine the nature of your cheekbone fracture deformity. From that I could give you a better idea as to which approach may be best.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Interested in advice on upside and the downside of temporal artery ligation. I am a healthy 39 year old male and have these arteries near both temples that constantly bulge and have a pulse in the heat, under stress or when exercising. They look like squiggly worms on the side of my head!
A: Prominent temporal arteries are not rare and their presence becomes more noticeable when the need for increased blood flow occurs. (exercising, heat or just bending over) Temporal artery ligation for cosmetic purposes is done through very small incisions in the temporal hairline and usually one at the end of the visible arteries location. (which is usually somewhere close to the forehead) Always two separate points of ligation are done and occasionally three ligation points are required. These small incisions heal imperceptibly and are not a cosmetic problem. The procedure is done in the office under local anesthesia and there is no real recovery at all. One can resume all activities right after the surgery. the only potential downside to temporal artery ligation is in how well it works. The appearance of the temporal artery can definitely be reduced but not always completely eliminated.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m looking to obtain some information about posterior jaw or jaw angle implants. I had three surgeries approximately 20 years ago on my upper and lower jaw to correct the alignment and preserve my teeth. After I healed from my last surgery I was to have jaw inlays placed however I did not opt for it at that time due to the need for external incisions. Attached you will find several photos from today and one from (many years ago) just prior to my maxillofacial surgery to give you an idea of how my face once looked. What is the approximate cost for the entire procedure? I’m looking for an approximate amount for the entire process, from beginning to end. Does having previous maxillofacial surgery have an impact on this procedure?
A: Undoubtably you have as one of your orthognathic surgery procedures sagittal split of the mandibular ramus (SSRO) osteotomies. In some cases this can cause some partial resorption of the jaw angle particularly if it was done more than once. You can clearly see in your before and after pictures that have lost the shape in the back part of the lower jaw. (loss of angles) While jaw angle implants is the correct procedure for jaw angle restoration, your prior surgeries have undoubtably caused some uncommon and uneven posterior jaw anatomy. To get the best result in terms of shape and symmetry you would be best served by custom jaw angle implants made from a 3D CT scan. That would not only show the shapes of your two jaw angles before surgery but would allow the computer design to make right and left angles that would match. While standard jaw angle implants would be better than nothing there at all, there undoubtably would be some persistent asymmetry. What is unique about restoring lost jaw angles is that a significant portion of the implants has to lie off of the bone. So custom making and fitting of the implants to the altered anatomy (with the use of microscrew fixation) would be invaluable in terms of implant stability.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am just finishing nursing our fourth baby and am looking into getting breast augmentation done. How long do I need to wait after finishing nursing? Also, we are military stationed overseas so would be flying in. How soon is the follow-up appointment? About how many nights should we plan to stay in a nearby hotel? Thank you!
A: The first question after having nursed four babies is whether you just need implants alone? Do you have any sagging and is the nipple above the lower breast crease/fold. if sagging is present, as defined by the nipple being at or below the lower breast fold, then a lift will be needed with the implants. As a general rule it is good to wait three moths after nursing to have the breasts shrink back down to reveal the amount of true sagging, if any, and to have a good appreciation of the desired implant size needed for the desired breast size result.
Since the real time to judge the results of breast augmentation is that of months and no sutures are placed that would need to be removed. One could leave for home fairly quickly after the breast augmentation procedure when one feels comfortable traveling.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m interested in having a number of surgeries at the same time including hairline lowering, brow lift, lip lift, cheek augmentation, V line jaw surgery, browbone/forehead implant, lip v/y plasty, corner lip lift, cupids bow augmentation, chin osteotomy, under eye fat grafting, marionette line fat grafting, love band surgery, and tongue tie surgery for the face. As far as the body I would like calf/knee/thigh liposuction with transfer to to buttocks and breast, and hip implants. I was wondering if all of these would be possible to do at the same time?
A: In the world of ‘extreme plastic surgery’, such a collection of procedures would bypass this term and really be excessive. It would not be possible nor advised to do all of these face and body surgeries at one surgical session. Besides taking as long as 12 hours to perform, the physical recovery from this prolonged surgery would be extremely difficult and exposes you to a lot of medical risks. This is a large amount of induced trauma to the human body. The face and body surgeries should be done separately and spaced about three months apart. Even when done separately the face and body surgeries would be considered extensive in and of themselves.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in facial reshaping surgery. I would like to make a great change on my odd facial appearance. I would like to have a facial reshaping on my interpupillary distance (IPD) and innerouterintercanthal distance (IOICD) because I think I got hypertelorism. I have 4.5cm telecanthus, 3.6cm intercanthal distance, 3cm orbit, 7.5cm interpupillary distance (IPD), around 14.5-15 cm facial width and around 19.5 cm facial length. What surgery should I do at this stage? Decrease interpupillary distance (IPD) by Facial bipartition or increase bitemporal distance and by custom implants? Thanks for your time. I am looking forward to your reply!
A: Thank you for inquiry and sending your pictures. For your facial concerns no major craniofacial surgery such as a hypertelorism or facial bipartition repairs would be appropriate. These are major intracranial surgeries with some significant risks that would not be justified for a cosmetic issue such as type 1 hypertelorism or mild increased intercanthal distances. Instead you want to think of other smaller facial reshaping procedures that can help improve that appearance. You have a low nasal bridge and epicanthal folds. Reducing the epicanthal fold appearance and augmenting the height of the nasal bridge (augmentation rhinoplasty) are well known manuevers that will help make the eyes looks somewhat closer. Making the adjoining areas wider (temporal augmentation) is another option to consider also. When you put all three of these facial procedures together they will do a lot to decrease your perception of the eyes being too far apart.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a facial scar revision. I have a long grooved scar on my left cheek from a two layer Moh’s operation performed three years ago. I have had several consultations from Plastic Surgeons and now am confused. The plastic surgeons said the original doctor did not evert the edges during closure therefore this is why it looks like it does now. The last plastic surgeon I consulted stated he would place deep sutures and not evert and do zero top stitching, placing just a fine stitch running over and over and than taken out in a week to prevent stitch marks. When I asked if he would evert the skin edges he stated no. Is not eversion the only way to give the best possible outcome with a atrophic scar apart from tension on the inner layers? How do you do it .. The first, Vertical mattress no dissolvable sutures and evert….the next zero eversion and deep sutures. I though eversion was the way to go? Thank you for your time and consideration.
A: When it comes to facial scar revision the various techniques can be confusing. One has to look at the original problem, understand it and then devise a strategy which will improve the outcome. You have classic inverted scar, not because the right wound closure technique was not done, but because this was a wound closed over an area of tissue excision under some degree of tension. That combination is doomed to result in a wider inverted scar no matter how it was closed. Skin under tension closed over an area of deeper tissue deficiency is bound to sink in as it heals over time.
Your scar revision now is different. The wound edges will not be under such tension and there be no deeper area of tissue deficiency since nothing is being removed. Therefore, release of the skin edges and the deeper tissues with reapproximation of tissue layers will solve the inversion issues. There really is not need to do specific skin edge eversion. Providing deeper tissue support or buildup is the key. How the skin is closed is really irrelevant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am hoping you can give me your professional opinion about my problem. I have been bothered by a fairly flat back of my head for decades now and I am at that point that I really want something done about it. Some stories sounds promising which make me hopeful but I am not even sure I am a ‘suitable’ client. What do you think as far as you can tell from a picture? How long will the procedure take (from intake to recovery) as I need to travel to the States. Thanks for your time.
A: When it comes to determining a good candidate for back of the head augmentation (occipital augmentation), pictures can go a long way in answering that question. Please send some to me at your convenience. The issue is not likely going to be whether you can have the procedure done but whether it is a one-stage vs a two-stage procedure based on your back of head shape goals and your natural scalp laxity to accommodate that change.
Back of the head or occipital augmentation is usually best done by a custom implant made from a 3D CT scan. Although I have done enough of these surgeries to have a ‘stock’ set of implanted designs from prior patients that can be used which does not require a preoperative 3D CT scan. Either way it takes about 3 weeks to have the implant made and ready for surgery.
Patients from other states or countries usually return home within 48 to 72 hours after occipital augmentation surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a v-line jaw surgery in Seoul, Korea and feel that it doesn’t suit my face. Is there a way to reverse it? I fear that it will cause me to prematurely age…it has already given me jowls.
A: While V-line jaw surgery can be very effective at making the jawline/chin smaller, it does create the potential for loss of skeletal support to the overlying tissues. Usually in young people this is not a major concern because the have very good elastic properties of the soft tissue which can adequately shrink down to the reduced jawline bone structure. But if overdone or in some older patients a jawline reduction can result in a soft tissue sag most commonly seen in the jowl area. A V-line jawline reduction can be reversed and requires a custom jawline implant to do so. I have done several of these procedures and the implant is designed based on a 3D CT scan. In some patients I have been fortunate enough that the patient had an original 3D CT scan prior to their jawline reduction surgery so the new and old 3D CT scans could be overlaid and an exact replica of their original jawline structure recreated. In other cases no such prior 3D CT scan existed so the custom jawline implant design had to be based on what was believed to be the original jawline bone structure. In one case, a male patent even went as far as augmenting his jawline far further that what his original jawline structure was like before the jawline reduction.
In short, a V-line jawline surgery can be reversed by a custom jawline implant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Can you do lip reduction surgery for me?? I suffer from neurofibromatosis which makes me produce a significant amount of tumors and makes my face look abnormal. I had a botched surgery when I was 9 to remove a tumor on my top lip. When I became of age i tried (with no luck) to find the surgeon responsible for leaving me with the lips I have now. He removed a tumor from my top lip but never restored a natural shape to them. They are huge uneven and unsightly. They make it hard to form words and I have no ability to form a proper smile. I am at a lost. I’m sorry if this is a long explanation, but no one has been able to help me. I just want to know is it possible to reshape and make my lips fit my face.My surgeon didn’t do a very good job of removing the whole tumor because it slightly grew back. You can see where it tried to come back thus giving me a protruding top lip and explanation of how it affects everything else. The surgery I seek isn’t listed but from what I mentioned its yet another tumor removal with hopes of restoration of lip shape.
A: Neurofibromatosis of the face is a very difficult problem for which there is no real cure. Surgical efforts attempts to remove any neurofibroma tumors and restore as much shape to facial structures as possible. But it is not easy and certainly restoring any type of shape or function to a delicate facial structure like the lips is challenging. For whatever result your lips now have I would not fault the original surgeon. He took on a difficult challenge for which there is really no ideal result. Having operated on many neurofibromatosis patients I can testify to the challenge. Neurofibroma tumors recur or grow new ones and surgery causes considerable scar tissue. This combination leaves the delicate and sensitive lip structure as bound to have some degree of residual deformity.
Hopefully further improvement is possible for lip reduction surgery. I would need to see pictures of your lips to see what possibly may be done now.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting hip implants. When coming in for hip implants, can you determine how big you want your hip implant of is there just one size?
A: The size of hip implants one can have is dependent on multiple factors including hip location implantation site, how thick/thin the overlying tissue are and what type of hip augmentation results one expect. There is no such thing as a preformed hip implant as the patient demand is too low for any manufacturer to make true hip implants in standard sizes. Hip implants are done using either standard buttock implants or buttock implants that have been custom carved at the time of surgery to fit the patient. Before surgery the location of the desired hip augmentation is measured and those dimensions are used in picking or making the hip implants to be used.
I would need to see some pictures of your hips and your location of your desired hip augmentation site to determine if this is a procedure that might be beneficial for you. One key factor in qualifying the patient for hip implants is whether they can tolerate the location and length of the incision needed to place them.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Just wanted to follow-up with you regarding my Mentalis Muscle Resuspension Surgery. I wanted to makes sure I understood what you told me during our consultation. You made the following points:
1) That my chin and lower lip sag are “fixable”.
2) Based on my chin x-ray, you said that the screws were placed
way too low to fix my issue. You would place screws much higher
between tooth roots
3) Also you would dissect a much larger area (under and around
the chin) to get enough lose skin to pull up and overcorrect issue as
there will be some sagging after surgery
4) And during the operation you would be able to place my head in
an upright position so you can confirm that my lower lips are way
above my bottom teeth before you attach the anchor then after
attachment confirm it has been raised high enough.
5) Lastly you recommended a V-Y lower lip mucosal
advancement.
What kind of results have you had with similar situation as mine? Do you usually have good luck?
A: Correction of a sagging chin and lower lip is challenging and the best results come when every available technique is done for it. The entire chin tissues must be mobilized and the anchorage point for the muscle must be high with a screw(s) placed between the tooth roots. While this can lift sagging chin tissues, it does not always guarantee that the lower lip will end up elevated. Raising the lower lip is very difficult to sustain and that is why I usually perform a soft tissue elevation/roll out of the lower lip as well. Reattaching the mentalis muscle higher is no guarantee that it will push up the lower lip. It may seem that way when one pushes the chin tissue up on the outside with their fingers but it does not work that way in surgery.
My experience has been with these techniques that everyone gets improvement but it is the lower lip position that can remain the most incomplete part of the repair.
Dr. Barr Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had liposuction of my stomach, love handles, pubic mound and back rolls one week ago. The doctor said he removed almost 3.5 liters of fat. I am very concerned because I have such massive swelling in my pelvic area that feels so hard that I know there’s blockage of my lymphatic system. I feel nauseated, toxic and the hardness in pelvic feels like rigor mortis. Not sure of spelling. The rock hard mass that I feel in my crotch can’t be normal for liposuction. It feels like deadening of my torso and tissues inside. I am very scared. Yes, I rejected most of the pain medication becasue I’d rather gauge how I feel instead of covering it up. Outside of my 8 hours sitting at my desk, all I do is bed rest. All week I have been like a hospital patient.
My job is stressful and may have caused the collection of cortisol in my midsection in the first place, but I think I can’t eliminate because of medication, stress, constipation and a very compromised lymphatic system. Not sure if I have lymphedema, but I am very sick. I drink plenty of water, but told nurse that I stay moving 3 times a week to keep my blood flowing (typically walking on treadmill 20 minutes regular pace). I eliminated my arm/muscle training and refrained from squats.
Please help me with the rock hard blockage in my pelvic area, primarily. Massage doesn’t work. What’s good?
A: Everything you are experiencing is perfectly normal and expected with the liposuction you have had. Every patient who has aggressive liposuction of the torso gets every symptom that you have. It is, in fact, a lot of temporary lymphedema as liposuction of any type disrupts normal lymphatic outflow initially.
There is nothing to be scared about with how the tissues feel. All patients do not realize, and now you do, that liposuction is a very traumatic operation and creates a lot of subcutaneous tissue injury. This creates lots of swelling, fluid and overall lymphatic congestion. The solution is simply time. It will takes months for the tissues to fully recover and feel normal again. Unfortunately there is no magic solution or method to hurry this process…and that is certainly true at just one week after surgery.
With abdominal liposuction women and men will develop substantial swelling at the ‘bottom of the well’ over the pubic and down into the genital area. This effect is magnified when pubic mound liposuction is concurrently done.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am having abdominal etching liposuction next week. How defined do you think you can get for me as well as removing my love handles? I know this guy is 28 and I’m 52 but I really want to get some definition with the abdominal etching.
A: I believe your answer comes from what you have stated after your initial question. Your observation that the model is 28 while you are age 52 speaks volumes in terms of result expectations….that is not an achievable goal. Three factors come into play in any type of body contouring that will define the result…1) How toned and defined are the underlying muscles, 2) how thick is the fat layer between the muscle and the outer skin and, of equal if not greater importance, 3) how much elasticity of the skin exists to shrink down around the reduced fat areas. The older one gets the loss of skin elasticity plays a major limiting factor. I have seen goal pictures like the one you have provided many times and I have yet to see any patient get that type of abdominal etching result no matter how much fat is removed.
In short I think we should temper our expectations to an abdominal result that has some definition but never as defined as we would like.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am getting jaw angle implants that are of a standard vertical lengthening size that you have designed. The look that I am trying to achieve is a jaw that isn’t “high up”. One that is not quite lined up with my chin but low enough. So I’m just concerned that this will leave me with just a “slight” change and still leaving me with a high jaw line. From your experience and knowledge what is your expectation? I just payed for everything and set for our consultation, I apologize for the questions and concerns, but this is so important to me and Im spending my savings. So all I want to know is, what to expect. Can you not give me some assurances as to the results?
A: The reason I am being nebulous with the answer to your question is two-fold. First it is an accurate statement that no one can predict what the final results will truly look like. Will it be better than what you have now…absolutely yes. Will it meet your expectations….unknown. This is no different that a woman getting 350cc breast implants and asking will it meet her expectations. It is certainly going to be better but whether they are big enough or have the right shape can be hard to answer with absolute certainly. Secondly, the very question you keep repeatedly posing is exactly the reason why your surgery, and any young male who is getting facial bone augmentation, makes me nervous. As I have said before, you are aiming and probably expecting a result that is only going to be achieved by custom made jaw angle implants. But because that it not a viable financial option for you, you are hoping that any non-custom approach will produce satisfactory and fairly assured results. The importance of that to you is further emphasized by your statement that you are spending your savings for the surgery. Patients who put themselves in this financial position, particularly young male patients, often end up with unsatisfactory outcomes.
I would like to emphasize that this is not the type of assurance I can give you. As I have said previously the only way you should have this type of jaw angle implant surgery is by the following guidelines:
1) You view an acceptable result as one that provides any improvement at all to your existing high jaw angles. I can provide no assurance that an 11mm vertical length will be ‘low enough’.
2) If you are seeking a specific target length or certain jaw look, as shown by model or other celerity pictures, and that is the only result that will make you happy…then you should not have the surgery. This is what custom jaw implants are used to create.
3) An understanding that there is a relatively high incidence of jaw angle implant asymmetry when using non-custom jaw angle implants that provide vertical lengthening. When half the implant needs to be positioned off the bone the difficulty in getting symmetry between the two facial sides escalates considerably over any other type of facial implant which is positioned entirely on the bone.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am getting a nasal implant for my rhinoplasty but I am very leary of necrosis and the aesthetic results and safety of a Shirakabe vs. Dorsal nasal implant. I would like to ask you whether the Shirakabe or Dorsal nasal is best for avoiding necrosis. Which one? or does it not matter? Would a dorsal nasal implant have good results since I have a bulbous tip? Aren’t Shirakabe’s better for Black/Afro American? Could you define my nasal tip more (having a dorsal nasal implant in comparison to a Shirakabe) without necrosis developing? Thanks.
A: I think in general one has to be very leery of having any type of synthetic material under the skin across the nasal tip. A nasal implant that puts any pressure on the nasal tip skin is destined for long-term problems. The issue is not immediate skin necrosis but long-term skin thinning, implant visibility and/or infection. Synthetic implants that cross the nasal tip area have a significant long-term risk of these issues. While implants work well for the nasal dorsum and have a much lower incidence of problems, the same can not be said for the nasal tip. The best ‘implant’ for the nasal tip is your own cartilage, particularly that of rib cartilage. If you were asking me what is the best to use both in terms of results and the lowest risk of potential complications, I would choose cartilage over an implant every time in rhinoplasty surgery.
Dr. Barry Eppley
Indianapolis, Indiana
