Your Questions
Your Questions
Q: Dr. Eppley, I am seeking a scalp scar revision. I had a hair transplant done five years ago which was supposed to leave me with a “pencil thin” scalp scar. What I ended up with is a far cry from such an optimistic prediction. So now I’m looking for best scar revision option, maybe combined with tissue expansion and w-plasty/ geometric broken line closure. I just want to laser my hairs out and be bald. I know scar will not disappear but i want just to improve it as much as possible. Do you think based on my attached picture that the scar can be reduced to an acceptable level on my scalp? Thanks.
A: In looking at your pictures, you have a modestly wide occipital scalp scar harvest site. Your assumption is correct in that only a scalp scar revision has any chance of making a lessening in its appearance. Only by cutting out the scar and getting back to unscarred scalp that contains hair follicles can make that improvement. Given the pattern of the scar a running w-plasty/modified geometric closure would be the preferred type of skin closure. The key to a scalp scar revision’s success is how much tension is on the closure. It doesn’t matter if the best interdigitating skin closure is done, if the tissues are tight some recurrent scar widening will occur. While there is no question that a scalp tissue expander is always going to be of great benefit, you obviously would not like to take it that far if it can be avoided. Since it has been five years and I assume that you had only one harvest procedure, there is a good chance enough scalp laxity is present to avoid tissue expansion. If you have had two strip harvests and the back of your head feels very tight then scalp expansion may be needed for more assured success.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley ,How many rhinoplasties have you performed? What is the percent of having to redo a rhinoplasty that did not come out as desired.
A: I have performed over 500 rhinoplasties in my career. The number of medical complications, such as infection, in rhinoplasty surgery is very low as I have seen only two. (both that involved the use of synthetic implants) Revisional surgery in rhinoplasty surgery, however, is not rare and in fact is actually common. These revisions are for aesthetic reasons and the national average is around 15% if not higher. That number is my rhinoplasty surgery experience is about right although it may be a bit lower. There are a large number of reasons for rhinoplasty revisions and some of that is driven by the patient themselves. Some patients can tolerate minor imperfections in their nose while other patients continue to seek absolute perfection and may go on to have multiple revisions. I have seen patients who are quite content with their result even if I has wished I could make some further improvements of it. Conversely there are other patients that desire a rhinoplasty revision when I would have preferred and thought more medically appropriate that they leave it alone. The point is that the risk of revisal surgery in rhinoplasty is real and not rare and one that every patient who undergoes the challenging operation of rhinoplasty must accept.
It is also important to differentiate the risk of revisional surgery based on the type of nose that is being treated. There is an enormous difference in the likelihood of needing a revision in a cleft rhinoplasty procedure that someone who only wants a small bump on their nose to be reduced.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had Permalip lip implants placed in the top and bottom lip. My smile is horrid. And can’t even open my mouth wide enough for the dentist. My lips are extremely tight. I still want larger lips but not tight distorted lips.
A: The most common complications from Permalip lip implants is that of implant asymmetry or an inability to achieve the lip size increase that one wants. I have not had the experience of these lip implants causing extreme lip tightness or significant interference with one’s smile. But based on your lip symptoms it is clear that these implants needs to be removed and should bone replaced by fat injections. You need to get rid of what is causing the tightness (the implants) and replace them with a material that can help relieve some of the tightness and still provide significant augmentation. While it is true that fat injections into the lips have variable amounts of take and unpredictable volume retention outcomes, they are the best solution for relieving lip scar contractures. The residual capsules from the lip implants do provide a more favorable site for fat placement and graft retention.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Two years ago I wanted a change and I got a Terino Square Chin implant. While I do think it made my chin look better, I would never wear my face without a full beard now. The implant is huge and I believe it did not address the vertical increase that I needed. The groove under my bottom lip looks way to big to be normal. I have also attached a current photo of myself with the full beard. I believe there were some irregularities under the implant with my chin that have now been pronounced since the implant was not custom.What should I do now? I feel that the sliding genioplasty with an implant) may have been my best option from the start but the recovery time is extremely long. My recovery time from this implant was over 10 days. I do not feel hideous or anything so this is not urgent but I really would like to understand if what I am looking for is even possible.
A: Given what you had hoped to achieve and looking at where you are now, the only option to consider is a custom chin or custom jawline implant. Compared to many patients who have gotten square chin implants your results would not be considered remotely huge or disproportionate. But that is clearly how you feel and that is all that matters. You desired results show a lower and more square chin but the width of the squareness is fairly normal and not at all what the Terino square chin implant can achieve. Only a custom chin implant can make that type of non-standard chin augmentation change. You have also shown on your ideal result some jaw angle changes as well. How important that is to you will determine whether you should have a custom chin implant or a custom total jawline implant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a genioplasty and jaw augmentation a little over a year ago. The jaw augmentation was performed using hydroxyapatite paste along the jawline and the results are pretty asymmetric and too bulky for my face. The surgeon who performed the procedure is in Belgium and if possible I’d rather have it corrected by someone closer to home. I’m hoping my jaw can be shaved down or contoured to better fit my face and correct the asymmetry. I really hope you can help me. Thanks and kind regards.
A: While hydroxyapatite granules are the most biocompatible material for only bone augmentation, they unfortunately do a poor job of establishing a smooth outer facial contour. I have revised numerous patients who have undergone hydroxyapatite facial augmentation by hydroxyapatite (HA) granules/paste and they all have the same lumpy irregular bone contours. The concept of injectable HA bone augmentations is appealing but it is prone to a high incidence of aesthetic contours problems just like you have. The good news is that these augmentation irregularities can be smoothed or modified to a better contour just like any bony outcropping. Interestingly many HA augmentations will have a fair amount of bone ingrowth into and around them which actually makes their modifications easier than if the granules were just on top of the bone by themselves. It would be very helpful to have a preoperative 3D CT scan to a clear idea as to the exact location of the HA augmentations and their size compared to where the excessive bulk/asymmetries are seen on the outside of the face.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I came across one of your publications on the Internet regarding cutis verticis gyrata scalp condition.You recommend fat grafting to treat this condition.
A doctor I have consulted (where I am living) also recommend me to try this procedure. But I am not sure about the efficiency of this procedure. Would you mind to advise if fat grafting technique could be a good option to solve my case ? I have attached pictures of my scalp so you can have look. I am looking forward to hearing from you.
A: Cutis verticis gyrata of the scalp is a very unique, peculiar and fairly rare scalp condition. Why it is occurs is not known and how to really effectively treat it is similarly not known. The vertical grooves or grata are scalp indentations (not bone) that become fibrotic and adhered down to the bone. This adherence is quite dense and unbelievably stiff. There is almost nothing but scar tissue between the skin of the scalp and the bone. The only really viable treatment option is injectable fat grafting. Having done that procedure it is really hard to get into and raise the grata to place the fat grafts. It takes an initial release with ‘picklefork’ instruments to get the tissue separated to create the tissue plane to place the fat. And it will likely take more than one fat grafting session to get the best result. But you would have a good idea after the first treatment session of the value of doing further fat injection treatments.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had brow augmentation by injectable fat grafting done ten days ago. I had a quick question about after care from the procedure. Should I be avoiding going into a sauna? I figured the heat would increase blood flow to the fat graft, but I just heard about how Vanquish destroys fat cells by warming them to 110 degrees.
A: While high heat is a known detriment to fat cell survival, the actual temperature at which that would occur is around 140 degrees F….not just 110 degrees. Vanquish does help destroy fat cells but that is by causing an internal temperature of the fat in the treatment to reach and be sustained around 45 degrees C. Therefore, I don’t believe the heat from a sauna would make any difference in fat graft survival. While the heat from a sauna may reach 145 degrees, your internal body temperature never rises more than a degree or two. Vanquish specifically creates temperatures at the subcutaneous tissue level of 45 Centigrade plus with the specific purpose of destroying fat cells. External sauna temperatures do not create the same subcutaneous level temperature changes. If they did you would be ‘cooked’ just like the fat cells that were placed by an injectable fat grating technique.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a question about mentalis resuspension and v-y inner lip plasty. I had a sliding genioplasty and no plate was used during my sliding genioplasty, just two screws which seem to have been placed quite low. Could this be part of why the mentalis muscle is not as high as it was? Thank you.
A: One of the methods in sliding genioplasty bone fixation is that of lag screws as opposed to a step fixation plate and screws. This is undoubtably the two low placed screws that you see. Placing lag screws does require more muscle and soft tissue stripped off of the chin to place them. But I do not think, based on this description alone, as to why you think the mentalis muscle is not as high as it once was. You are likely referring to the depth of the labiodental fold of which the mentalis muscle makes little contribution to it. The labiodental fold is a fixed structure that is an external indicator as to the depth of the vestibular sulcus intraorally. When the chin bone is advanced the depth of the labiomental fold will often appear deeper since its position did not change but the chin projection became greater. This is not usually a reflection of loss of mentalis muscle attachment, it is the natural deepening of the labiomental fold area which will occur despite having the mentalis muscle attached back into its original position. This deepening of the labiomental fold is a natural occurrence in many sliding genioplasty outcomes.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am in need of secondary chin surgery. I am a female and am 34 years old. One year ago this month I had a chin implant removed due to a number of reasons including bad positioning and shape. It was in for five years and was not replaced with another. It was inserted and removed orally and it was fixated with a screw. It has left me with soft tissue complications and still gives perception like the implant hasn’t been removed. I found the a link where you go into detail about chin implant complications nearly identical to what I have currently. It describes how you would tackle the problem and seems you have extensive experience in the procedure. It seems I’m finding it very difficult to find someone in my country who can tackle the issue. From my pictures would you class my soft tissue deformity as a mild case of Witch’s Chin?
A: Thank you for sending all of the pictures. You definitely do not have a Witch’s chin deformity. At rest you have a perfectly normal position of the soft tissue chin pad on the bone. Your deformity appears when you animate and the soft tissue contractions (dimpling deformity) appear. This is the result of the soft tissues being stretched out by the implant and then, with the implant being gone, its support is lost and there is now too much soft tissue. This will create an abnormality on contraction which you now have.
Treatment options include:
1) Doing nothing. It is not predictable that any improvement can be gained.
2) Replace the implant and recreate the soft tissue support. (although placed from a submental position and tighten the mentalis muscle from below)
3) Do a submental approach to the mentalis muscle repair with excision and midline reapproximation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in facial feminization surgery but don’t know exactly what types of procedures I need. What are my options? Can they all be done at once> How much of a change to my face can they make?
A: Facial feminization surgery (FFS) involves a wide variety of bony and soft tissue changing procedures to create more of a feminine facial appearance. In a single surgery as few as one or two of these procedures can be done or as many as dozen or more . I have done as many as 15 procedures in a single patient. As a result FFS can produce subtle or major facial changes. Procedure options going from top to bottom of the craniofacial include: 1) skull augmentation, 2) hairline lowering (scalp advancement, forehead reduction), 3) forehead augmentation, 4) brow bone reduction, 5) lateral brow bone contouring, 6) browlift, 7) lateral canthopexy or corner of eye lift 8) rhinoplasty or nose reshaping, 9) cheek augmentation using either implants or fat injections, 10) lip lift or lip advancement, 11) corner of mouth lift, 12) lip augmentation with fat injections or Permalip implants, 13) chin reduction, 14) jawline/jaw angle reduction, 15) masseter muscle reduction by electrocautery or Botox injections, 16) submentoplasty (reshaping under the chin) and 17) adam’s apple reduction. (tracheal shave)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am in need of lip and earlobe reconstruction. A middle piece of my upper lip and my entire left earlobe were bitten off by a dog last year. Both my lip and ear have fully healed but I need reconstruction to get them to look better. I have attached some pictures of my lip and ear for your thoughts on best to reconstruct them.
A: Thank you for sending your excellent pictures. They show both the upper lip and left ear deformities well. Both of these pose some of the most difficult challenges in reconstruction of these areas. The upper lip lacks volume and also has a color mismatch of the vermilion of the surrounding lip. While the color and volume problem could be improved by excision of the defect and bringing good tissue in from the sides, that will result in a vertical scar extending up into the currently unscarred upper lip skin. Therefore I would prefer to build up the volume with a dermal-fat graft and then add color by micro pigmentation (tattooing) That would be [referable to me than a vertical upper lip scar. From an ear standpoint, earlobe reconstruction would need to be done by a two-stage procedure. The first stage would be the transfer of a skin flap from the tissue next to the earlobe and post auricular crease. The second stage would be the release of the skin flap and wrapping it around an ear cartilage graft to form the lobule.
Both upper lip and left earlobe reconstruction could be done at the same time under local or sedation anesthesia.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am trying to figure out if there is a cosmetic surgery that exist for skull reduction. I am a female with a 25.25 inch head circumference and it has been the joke of my life since birth. I already have to have jaw surgery because of my underbite, but I am praying that maybe there is some way to make my bobble head less noticeable. I tried gaining weight so that the weight could bring proportion, but unsuccessful. I know that this may sound silly to some, but this is my life and if I could change this, I will. I don’t expect to ever wear a hat, but I would at least like to face the public without having to cover my head with long hair or look down while walking.
A: There are a variety of skull reduction procedures that can done for just about anywhere on the skull. What is important to understand about them is that they treat selective areas which can be used to change some of the contours of the skull. In rare cases, there is even overall skull reduction by burring. These procedures can not, for example, take a 25 inch circumference of the skull and make it 21 inchs around. But in many cases they can make a visible difference which could provide a psychologically substantial improvement in how the patient sees the size of their head.
Whether these type of skull reduction procedures may be of benefit for you would require that you send me some pictures of your head for my assessment.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a female and interested in a “supermodel” jawline. (female jawline implants) I would most likely want the wrap around jawline style to create more length across my chin line but I don’t wish to create any additional definition to my actual chin. I’ve always been picked at, being told I have a long face so I do not wish to have a bigger more define chin. I am just looking to add length side to side. I’m attaching a pic of my favorite model. To me, when I flip through the pages of Vogue you can see the focal point of each woman’s beauty is her large jawline. Tell me if something close to this pic would be achievable on someone like me, and roughly how much a custom wrap around implant could potentially cost. Also wondering if I fly into Indiana for the procedure how many days/weeks would you recommend I stay there while I heal? Would you be able to link me up with a doctor in the my area who could treat me when I get back home? Flying back to Indiana would be a bit difficult. One more question…does the implant need to be switched out after a certain amount of years? I was told any implants need to be changed out every 10 to 20 years.
A: When one uses the term for a female of a ‘supermodel’ jaw width, they are referring to a well defined and very angular jawline. In female jawline implants one has to be careful, however, with your jaw width increase so that it does not become too wide for your face. Your long vertical facial length provides some limitations as to how wide you can make the jawline implant. As a general rule the width of the jawline/jaw angles should not exceed the width of the superior cheeks. The model that you favor has a shorter facial length and, as a result, can have a jaw width that actually makes her face almost square. But even in her the width of the jawline is equal to the width of her cheeks.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a hairline advancement (forehead reduction) surgery one month ago. I’m losing some hair on the scar and was wondering how long will it take before it grows back? Im still not too happy about my head. I don’t feel like I can wear my hair back. I still feel my hairline is high. My husband says it looks good however! Thanks.
A: There are limit to a one-stage hairline advancement surgery based on teh scalp’s elasticity and how much the forehead can be reduced. Hair shafts along the incision line will typically shed in the first few weeks to month after surgery due to the trauma of the surgery. (hair follicles do not like traumatic events) This still leaves the follicles underneath the skin/scar which will regrow hair, at the growth rate of 0.05mm per day (the follicle lies 6 to 8mms under the skin), which will take about 8 to 10 weeks to begin to appear at the skin surface. (1mm per 10 days or 3mms per month) Thus it will take around three months until some hair growth has occurred through the scar. This coincides with when the redness of the hairline scar begins to get better. (less red) Between the hair growth and the maturation of the frontal hairline scar, it will take about 6 months for the appearance to become more normal. It takes up to a year for the scar to fade as much as it is going to and to have enough hair growth length to see the final true hairline location and pattern.
While easy to stay, it takes patience and lot more healing time to really judge your final perception of the surgical result.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am seeking a witch’s chin correction. My chin sags down like a witch’s chin after my chin reduction ten years ago. Also I would like to remove the neck fat because my jaw is narrow and gets lost in my neck. I would like my profile to be more balanced, so I am hoping that Smart lipo will fix this. The attached x-ray was requested by a surgeon who does facial feminization, even though at this point, I only wanted my jawline and chin corrected. My chin and jaw are off balance, but I don’t want to go through any bone surgery if I don’t have to. My chin midline is slightly off per the surgeon who requested this x-ray.
A: Because you have a witch’s chin deformity from an intraoral chin reduction, your x-rays shows exactly what one would have predicted. You can see the chin reduction which was done which left behind the large chin soft tissue pad which is now unsupported. Your x-rays shows why an intraoral chin reduction does not achieve the desired effect and creates the witch’s chin deformity that you have. This type of chin reduction is ill-conceived and is not anatomically correct. A witch’c chin correction is not going to occur by any form of liposuction. Rather you need tissue resection through a submental incisional approach to make the chin pad tissue match the lesser amount of chin bone support that you now have.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I need information and various options of how to reduce a jawline. (jawline asymmetry correction) I am 23 year old and one side of my jaw bone is larger than the other. As a result my face appears crooked or more angular. I had orthognatic surgery two years ago because one side of myteeth was not meeting and as result I could only chew on the other side. Now I have function on both sides of my mouth to chew food properly. However, the bone on the side of the jaw is larger than the other side and it needs to be balanced. Needless to say, I am not happy with my face and have self confidence issues. I would appreciate it if you can provide any information on what can be done. Thank you.
A: For jawline asymmetry correction, I would need to see pictures of your face from the front and side views to do a proper assessment. However having reconstructed cases just like your description I can speak as to the general issues involved. The question becomes whether the longer side of the jawline needs to reduced, the shorter side needs to be lengthened or whether it is a combination of both to get the best aesthetic result. This can be aesthetically determined by computer imaging. Surgically, the key issue is the location of the inferior alveolar nerve in the bone which often is pulled down lower on the longer side and can limit how much vertical reduction can be done. This question is best answered by a simple panorex x-ray or more ideally by a 3D CT scan.
In most cases of significant jawline asymmetry the combination a vertical reduction on the longer side and a vertical augmentation (by a custom made implant) on the ‘shorter’ side is usually needed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have had injectable fillers in my cheeks with injections of several popular products over the course of three years now. It is costing a fortune since I metabolize it quickly. (so I’ve been told) I have used Radiesse, Juvederm, and most recently Voluma and love the results for correcting diagonal mid cheek lines and loss of fullness but they do not last more than 4 months. How do I find a surgeon who has sufficient experience in cheek implants ? What is cheek implant surgery downtime? Longevity? Any other cheek augmentation alternatives?
A: Your injectable filler story is not uncommon and many patients will be in your same situation in the years ahead. Injectable fillers are great at doing what they are intended to do most of the time. But despite the good results they provide, many patients have or will find out that the long-term costs of injectable filler ‘maintenance’ will become prohibitive for some patients. Thus seeking a permanent cheek augmentation solution has merits.
Cheek implants can provide a very satisfactory solution provided the proper implant style and size is chosen. Because the cheek area and the cheek implants chosen to augment it defy any exact method of measurement (unlike chin implants for example where the amount of horizontal augmentation needed can be measured) it takes a surgeon with a lot of cheek augmentation experience to get it right the first time. While the concept of cheek implants is simple, it can be difficult to get their placement anatomically correct with good symmetry. This difficulty is imposed on top of how to select the best cheek implant style and size for the patient.
Cheek implant recovery is largely about facial swelling and the time it takes for it to look acceptable. In reality expect that to be longer than one really wants. It takes about ten days to look socially acceptable, three weeks to ‘normal’ and really three months to judge the final result and how one feels about the facial change.
The intermediate step between injectable fillers and implants for cheek augmentation is fat injections. While far simpler and with a very quick recovery compared to cheek implants its issue is how well the fat will survive and how long it will persist. These are unpredictable and can be different for each patient.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in orbital asymmetry correction. I have attached several photos. I believe my right eyeball is smaller in size than my left. I also believe my right eyeball is further back in the eye socket and more deeply set than the left adding to the asymmetry I have. This is probably causing my right brow to drop a bit too. If you look at photos you will see my left eye looks different than in other photos. (same eye just pictures were taken at different times) This only happens from time to time, especially when am really tired I don’t know whether its the muscles in the eyelid reacting or what but as you can probably see it looks very odd. I know am never going to be symmetric but if I could find a solution to help minimize the orbital asymetrys then it would help me massively. Let me know what you think Doctor Eppley and thank you for your time.
A: Thank you for sending your pictures and describing your orbital asymmetry concerns. What you have is rather classic right sides facial asymmetry that affects the entire right orbito-malar region. Your right eyeball is likely not truly smaller than the left but it appears so for the following reasons: 1) the right brow bone sits lower than the left, 2) the right eyeball sits further back in the eye socket than the left, 3) the right upper eyelid has redundant eyelid skin (from the eyeball sitting back further), and 4) the right cheek/infraorbital rim one is smaller than that of the left. The skeletal components of your orbital asymmetry can be demonstrated/proven by a 3D CT scan.
When it comes to treating your orbital asymmetry, the most efficient approach would be the following: 1) right brow bone reduction (raise the lower rim of the brow bone by shaving it), 2) right upper blepharoplasty (use this same incision for the brow bone contouring), and 3) right cheek-infraorbital rim implant augmentation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in chin ptosis correction. I originally had a chin implant ten years ago. Following an accident in nine years later the implant moved and it was changed with a new implant last year. This new chin implant was much too large for my face and was removed six months later. Following the removal of the implant I developed chin ptosis with too much lower teeth show when I opened my mouth.
I subsequently had a chin ptosis corrective surgery three months ago with bone anchors. The result from the chin ptosis surgery is substantially the same as before the surgery but now my lower lip goes in on the right side when I smile or I speak or when I open my mouth my lower teeth sees too much. When I talk I have trouble to articulating my words, maybe because of the new position of my mouth. I saw the surgeon again last month for this problem again and he did Artecoll to correct the irregularity of the chin and offered me another surgery to remove the extra skin under the chin and to do Botox to correct the defect of the lower lip.
I did not accept these proposals because I want to have first your opinion and advice. The surgery to remove the extra skin under the chin makes me nervous because now when I open my mouth my lower teeth show too much and I fear that this problem will be accentuated with this surgery. Now I really need your advice and your help. I’m sure you could find a solution to restore my chin. I read your publications regarding chin ptosis and possible treatments could be a small implant or 2 or 3 mm osteotomy for support under the chin could help or neck lift. I have seen before and after pictures on your web site concerning this surgery in which you made all this women much more beautiful. Thank you very much for your answer.
A: The first thing is I would not rush into any surgery immediately. It has just been three months and your tissues are still healing. If too much lower tooth show is the primary concern any type of submental tissue removal would not help in that regard. Given your history of multiple chin implants and now being ‘implantless’, it appears that an important part of getting your lip back up may be the placement of a new smaller implant to help drive the tissues upward or possibly even making the vertical length of the chin shorter. Lower lip sag is a very difficult problem that is not easily solved.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting injectable fillers for nasal folds and vertical mouth lines I am allergic to many things and wanted to find out how common are allergic reactions and can a test be done prior to the actual full procedure?
A: The majority of injectable fillers today use hyaluronic acid-based materials (synthetic sugars) that are also present in many tissues of the body. Because of their very low risk of hypersensitivity reactions, skin testing has never been recommended or advised with their use in first time patients. This is quite unlike that of the now defunct bovine collagen injectble filler products (Zyderm and Zyplast) from the 1980s and 1990s. That being said the risk of hypersensitivity reactions (aka allergic reactions( is not zero although it is less than 1%.
When in doubt or in a patient with a lot of known allergies it can be convincingly argued that a skin test should be done before even a hyaluronic acid-based injectable filler is done. If there is any doubt or concern, I always perform a skin test which is simple and easy to do. It is done just like a TB test.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a question about gummy smile surgery. I’ve always had a long mid-face with significant gum in my smile (5mm with normal smile, 7-8mm with excessive smile). I would be interested in hearing your thoughts about mid-face reduction surgical options.
A: When it comes to gummy smile surgery there are two fundamental treatment approaches. The most common approach is a soft tissue one with a lowering maxillary vestibulopasty and legator myotomies with V-Y upper lip lengthening. This soft tissue approach prevents the lip from retracting upward as much and also drops it down a few millimeters at rest. This is by far the most common gummy smile surgery. The other approach, more historic but still of value in the proper selected patient, is a maxillary impaction surgery. (aka LeFort I impaction) This is the proper gummy smile surgery for those patients that have vertical maxillary excess which is evident by excessive tooth at rest and extreme gum show when smiling. It is not indicated when one does not have excessive tooth at rest. Otherwise a maxillary impaction will bury the upper teeth under the upper lip giving one an aged appearance.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a male to female transgender patient and I am interested in buttock implants. I have been on hormones for 2 years and have already had facial feminization surgery. I have a flat butt and large rib cage. I also have a little fat around my mid section and flanks. I inquired about a butt lift by fat injections but after an examination they said that I do not have enough body fat. They do not do implants and said that they are extremely painful. Your website said that you do them and that there is not so much pain. Any info would be helpful——Thanks !
A:I have done many buttock implants and the key decisions are implant pocket placement (subfascial vs intramuscular) and the implant size and style. Implant pocket placement has a lot to do with the desired size one is after and the type of recovery what is prepared to got through. I am not sure where you read that buttock implants are not that painful as that would be untrue, particularly the intramuscular location. They do have a modestly long recovery since you do have to sit on the result at some point after surgery. They are uniquely different than breast implants for example because of their anatomic location and their functional significance in the short term. In short, buttock implants can provide a successful buttock enhancement result but it requires a motivated patient who can tolerate the 3 to 4 week total recovery process.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had jaw angle implants and they appear to be asymmetric. My gut feeling was that the implants were not placed correctly. I could see quite precisely where each implant was. It is beyond my comprehension how my doctor (or any doctor who does this procedure) could not know how to correctly place the implants. My fear going into the surgery was that the final result might look quite good, but possibly be a little more or little less augmentation than I was wanting and that I would have wished that I had gone with a larger or smaller implant. Many plastic surgeons don’t do jaw implants so when I found one who did I just figured he would have the training and experience to know how to do it. And they did show me some before/after photos of a couple jaw implants they did. One guy was young like me and had an excellent result so I figured I would too.
As far as fixing this, how difficult is it to go in and reposition it correctly and attach it with a screw? I also must say that I am considering going up to a large. I held the medium implant in my hand and it seemed like it would provide a lot of augmentation, but in reality it doesn’t. I was worried the medium could actually be too much, but now I actually think I need a bit more than what the medium gives. When you do the revision jaw angle implants surgery can you just remove my current implant and then put in a large implant (correctly) in one surgery? Or if I stick with the medium can you go in and just reposition it correctly and attach it with a screw?
A: I think you are being a little harsh in your surgeon. Jaw angle implants are hard to do and implant asymmetry is not rare. I have a tremendous experience doing this type of facial implant surgery and it will occasionally happen to me as well despite my best efforts. The overall need for jaw angle implant revision surgery is about 15%. Whether you keep you existing jaw angle implants or go up a size, the effort is the same to reposition it and screw it into place.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a question that has made me a bit nervous about a custom jawline implant Originally, i was going to have just jaw implants, but after talking to Dr eppley, I decided to do the full jawline including chin, for a more symmetric look. I was wondering a bit about the implant insertion. With just the jaw, I know that the implants were put in from the inside of the mouth, being placed gently under the muscle. But with the full jawline/chin implant, I didn’t know how it would be inserted and if there are complications. From what I understand, under the chin will be the incision. will the implant be one big piece and slid back on both sides to its final location. Are there any complication with the muscles by inserting this way? Is it easy and safe. Also, is it one piece, or is it 3 pieces that are created together that will be re-attached together at the end (2 jawlines and chin). I’m just looking for a more in depth explanation. Any videos of the surgery you could recommend. Let me know if you have any details you could share for me.
A: A custom jawline implant is put in usually as a single piece implant. But it requires three incisions to properly place…two inside the mouth and a front incision done either inside the mouth or from under the chin. The effects on the mentalis and master muscles are the same whether one has a total wraparound custom jawline implant or three separate implants. (chin and two jaw angles) In either case the same subperiosteal pocket must be made.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a frontal hairline advancement. I have no issues with hair loss. My hair hairline simply dips back into in the middle and that’s where I drew a line if that was eliminated on my picture. I have some breakage on the edges from hats and headbands, but nothing permanent. It grows back instantly. Is this possible? I know you are the best at this procedure so I thought I would ask you.
A: Thank you for sending your picture. Where a hairline advancement works the best is exactly where your hairline issue is….in the center of the frontal hairline. Given where you have put the markings for the desired hairline edge I think is a very achievable goal. Scalp elasticity always determines how much the hairline can be moved but a 1 to 2 cm forward movement is possible in most people. It is at the sides of the hairline advancement, the temporal region, where a hairline advancement has the least effect…unless the incision is placed right at the edge of the hairline which would usually not be desirable for most patients. This is a procedure that has a very quick recovery so expect to be back into a normal life within 7o to 10 days after surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had jaw angle implants placed earlier this year and they are asymmetric. I can tell the left implant is way forward of where it should be but I think the right implant is a little forward of where it should be as well. With a revisional surgeryI am actually thinking about going up to the large implant as the medium doesn’t really add that much. Whatever is done, the implant MUST be placed correctly, that I know now. I had no idea jaw implants were so difficult to place correctly. I did ask my Doctor about the placement and he said it’s tough to place them further back because the muscles and tendons tend to push them forward. And he said that it’s not wise to attach the silicone implants with a screw because they are soft and can tear if there’s too much pressure from the muscles. I don’t know if he just made all that up or what to believe now. Do you use implants made of different material if you are going to attach them with a screw?
A:In all due respect to your surgeon, he/she is inaccurate on both assertions about jaw angle implants. To properly position jaw angle implants, muscle and tendons must be elevated to make the pocket. Not releasing these attachments will result in the implant being positioned too far forward. Secondly I screw in every jaw angle implant and 95% of what I put in is silicone. Screws will not tear or disrupt the implant. Without securing them in with a screw the risk is high that they will become displaced or moved from the position/pocket that is made for them.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in chin ptosis correction. I originally had a chin implant ten years ago. Following an accident in nine years later the implant moved and it was changed with a new implant last year. This new chin implant was much too large for my face and was removed six months later. Following the removal of the implant I developed chin ptosis with too much lower teeth show when I opened my mouth.
I subsequently had a chin ptosis corrective surgery three months ago with bone anchors. The result from the chin ptosis surgery is substantially the same as before the surgery but now my lower lip goes in on the right side when I smile or I speak or when I open my mouth my lower teeth sees too much. When I talk I have trouble to articulating my words, maybe because of the new position of my mouth. I saw the surgeon again last month for this problem again and he did Artecoll to correct the irregularity of the chin and offered me another surgery to remove the extra skin under the chin and to do Botox to correct the defect of the lower lip.
I did not accept these proposals because I want to have first your opinion and advice. The surgery to remove the extra skin under the chin makes me nervous because now when I open my mouth my lower teeth show too much and I fear that this problem will be accentuated with this surgery. Now I really need your advice and your help. I’m sure you could find a solution to restore my chin. I read your publications regarding chin ptosis and possible treatments could be a small implant or 2 or 3 mm osteotomy for support under the chin could help or neck lift. I have seen before and after pictures on your web site concerning this surgery in which you made all this women much more beautiful. Thank you very much for your answer.
A: The first thing is I would not rush into any surgery immediately. It has just been three months and your tissues are still healing. It would be helpful to see pictures from different angles for a more complete assessment. If too much lower tooth show is the primary concern any type of submental tissue removal would not help in that regard. Given your history of multiple chin implants and now being ‘implantless’, it appears that an important part of getting your lip back up may be the placement of a new smaller implant to help drive the tissues upward. Soft tissue suspension alone appears to have been inadequate.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a reversal otoplasty. I know you have used s small metal spring/clip to help hold the released ear out as an integral part of the procedure’s success. While I know that metal device works I feel uncomfortable with even a very small pieve of metal in my ear. I know you have tremendous experience with resorbable LactoSorb devices and you have probably used that in the past for a similar procedure as a spacer. In an article from 1999, it mentions the use of LactoSorb in rabbit ear cartilage where in 50 percent of the study rabbits suffered auricular skin degradation due to the thinness of the skin and tension on the wound. However it does mention that in order to decrease tissue tension at the implant site, thinner, low-profile more pliable bioresorbable plates have been designed for the nasal septum and are now available for clinical trial.” This article was from 1999 so I hope these other plates have been designed and tested. My questions is this: Would this be a concern for you in this procedure? Also would you know what the thinner, more pliable material discussed would be and if that would be a viable option as well? On a side note I bent the LactoSorb implant you let me take with me to test the pliability and with little pressure, it snapped. This could be a concern if I were to sleep on or press on the implant while healing is taking place. What are your thoughts on this matter? I would love to hear your thoughts on these questions and concerns I have.
A: In answer to your questions about the use of LactoSorb in a reversal otoplasty procedure:
- Such an animal study with that plate size is irrelevant to the human condition. In a mass to tissue ratio that would be the equivalent of putting a 2 x 4 in your arm. That is an enormous polymer load in a small tissue space. With a large load of biodegradable material per surface area of tissue I would expect to see soft tissue changes around the plate. If they really wanted to test it for ‘septal use’, they should have known to use a much smaller polymer load. Therefore, the observed concerns about plate effects on the soft tissue are both misguided and of poor scientific quality. If you want to make a comparative analogy to your clinical situation a LactoSorb device that is .1mm thick, 1mm wide and 5mm long would need to be used in such a study.
- Polymer plates stand little deformation and they will react from a biomechanical perspective like a piece of plastic. They have little room for elastic deformation when acute loading forces are placed on them. That being said, bending them between your fingers is not an analogous situation to being implanted in human tissue. In human tissue that are somewhat mechanically protected by the tissues that are attached to and they develop greater resistance to deformation through hydrophilic nature. (water absorption) However as I mentioned in the office this is a concern that is completely obviated through the use of a metal spacer technique.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a facelift and jaw angle implants. Does it make a difference if they are done together or separately? If they need to be done separately which one should be done first? I have already scheduled my facelift but my gut feeling says that the jaw angle implants should be initially done first. My questions are:
1. Since I should have the implants first…how long after should I schedule my facelift?
2. Do you do jaw angle implants and facelift at the same time? (If I decided to have the facelift with the implants).
3. Would submitting pictures help decide which way to go/
Thanks for your help!
A: While jaw angle implants and a facelift can be done at the same time, I think it is better to stage them doing the jaw angle implants first followed by the facelift three months later. Jaw angle implants cause a fair amount of swelling in front of the ear and jaw angle area. That swelling would seem counterproductive to the pull of a facelift and would work against what the facelift is trying to accomplish. You do not want to stretch out the very skin and tissues that have just been pulled up. (if the facelift is done before and at the same time as jaw angle implants) While I think the two procedures are complementary (both help create a much better jawline), they just should not be done together and the sequence of the staging (implants before lift) is important.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am writing a paper for my school on becoming a plastic surgeon and I need your help.Thank you so much for taking your time to do this…especially so promptly. Out of five plastic surgeons surgeons in my area all of them have practice managers who are like guard dogs to their doctors. I could not get a single one to return my calls or emails. You are amazing for doing this for me. You’ve definitely helped to save my grade and sanity! I am only in my second year to starting my path towards this career. I have a lot to learn yet on what all it will take, but I have my mind set to be a plastic surgeon regardless. If you have any other words of advice I am all ears!
Thank you SOOO much! You are a lifesaver! Alright here we go…
1. What made you chose this profession? Did you know before med school that this is what you wanted to do?
2. What are some of the benefits and drawbacks of your position?
3. Your experience with all of your schooling is really impressive! How long did it take you to complete all of it?
4. What are some of the benefits to becoming board certified? Would you recommend it? and what is involved in doing so?
5. If you had to do it over again would you still become a reconstructive surgeon?
6. What are the most important skills to obtain for this career?
7. What advice or information do you wish you had known when you were premed?
8. Is the compensation worth all of the expenses that it took to become a surgeon?
9. Was money coming in slow when you first started your career? Or were you able to start right out of school at a comfortable pay?
10. What was is like when you first tried to find a job? How long did it take you to become comfortable performing different procedures?
11. What is your typical day like?
12. About how many surgeries do you perform in a week? What are the most common procedures?
13. Are there ever any surgeries that make you nervous? if so, which one(s)?
14. What was the hardest part to becoming a surgeon?
15. What do you think about the current status and future of this occupation?
16. Would you recommend this career to someone who was interested?
For my own personal information…was it hard to get accepted to medical school? I think that is my biggest fear. I stink at interviews and I am scared that they will pick me apart and I won’t know how to respond to their questions. One last question, so my absolute dream is to make money doing the elective surgeries then be able to do pro bono work for individuals who have been in accidents or have had something happen and are not able to afford to “be fixed” is that a completely unrealistic thought? Or is it something that I could expect to be able to afford to do while still living quite comfortably myself?
A: In answer to your questions:
1) My background is different than most plastic surgeons. I went to dental school first and then medical school. I was trained as an oral surgeon and then progressed through further training to become a plastic surgeon. So yes by the time I was in medical school I knew I wanted to be a plastic surgeon.
2) Like all surgeons, the personal and financial rewards are high but it is a lifetime commitment that can be all consuming being responsible for patients and the surgery they have.
3) Leaving high school until entering plastic surgery practice was 20 years.
4) You have to be board-certified today, it is not an option to not be. You will not be paid by insurance companies for surgery performed if you are not board-certified. Board certification is an additional written and oral testing after have you have completed plastic surgery training.
5) Life is full of many interesting vocations. While plastic surgery island has been my life, it would always be interesting to see what else would have been out there to do for a living.
6) Like all careers, persistence and focus are the keys to success. Nothing succeeds more than persistence dedication to a focused goal.
7) Nothing really. Education and the creation of a career is an evolving process than often takes one down different roads than one envisions. Keep focused on getting the best education with a propose is what I knew then and is what I would tell any college student today, a medical career notwithstanding.
8) Money is only a measure of educational costs and the services ultimately provided from using it. The worth of that education and career is really based on the joy one gets by the process of achieving it and then using it. One should never measure their success in life by a monetary yardstick. The value of the process is what it makes you as a person.
9) Comfortable pay is a relative concept. As long as the money coming is ore than your expenses, one should be comfortable. But yes working is more financially comfortable than training is.
10) I never had trouble find a job. Work was available as soon as I finished my training.
11) I start the day at 5:30AM in the office and usually get home by 7PM at night.
12) I perform between 10 to 15 surgeries per week. Since I do such a varied number of aesthetic and reconstructive plastic surgery procedures there is not really one common procedure. The procedures range anywhere from cleft lip and palate repairs, cosmetic breast augmentations to custom skull and facial implants.
13) No surgery makes me nervous anymore ayer having seen and done thousands of plastic surgery procedures. The only thing that makes me ‘nervous’ is my hope that each patient gets the best result and the outcome takes them to a better place.
14) Working when you feel too tired to do so.
15) Plastic surgery is such a diverse surgical specialty that it will always have a bright future. When the possibilities are so endless the future is only limited by the imagination and creativity of those who are trained to do it.
16) Interest in plastic surgery alone is not enough to make it a career. Passion about it is what is important. For that is what it takes to get through the process to becoming a plastic surgeon.
Getting into medical school has little to do with how one interviews. Just like college it is really all about the numerics, the grades and test scores.
While it it is not completely unrealistic to be able to do pro bono surgery, the reality is the medicolegal and social media risks of so doing will usually make that thought secondary in the real world of practicing surgery.
Dr. Barry Eppley
Indianapolis, Indiana
