Your Questions
Your Questions
Q: Dr. Eppley, About 2 years ago I had a chin implant put in during a rhinoplasty revision in Miami. It looks great BUT the lisp NEVER went away. It resolved to about 90% and continues to have good days and bad. The chin implant is a medium size. I’ve spoken to a neurologist as well and he does not feel this could have anything to do with mental nerve irritation as there is no area of numbness. At this point I’m quite frustrated and got a CT hoping to see some gross abnormality or slipping of the implant. The CT shows only a slight periosteal reaction (not-osteo per the radiologist) on the right and a .5cm asymmetry of implant riding posteriorly on the right. Could this be the cause of this? I do notice a corresponding limitation to my ability to retract my lower lip on right. Searching the internet, you seem to have the most facial implant experience so I wanted to get your opinion as general consensus thus far (including a speech pathologist) seems to think replacing it with an implant that projects less would be the answer.
A: This is not a postop problem with chin implants that I have personally seen before. I would not feel that the size of the chin implant nor its position is the problem. There are lots of chin implant patients with gross asymmetry of their implants and they don’t have any speech issues. Conversely there are patients with huge chin implants that don’t have a lisp either. It sounds like there is a mild weakness of the marginal mandibular branch of the facial nerve, which affects the retraction of the lower lip, which can be a source of a lisp. That is a lower lip problem that I have seen before. Recovery of a marginal mandibular nerve weakness, which is a monofasicular nerve, will have reach its potential by two years after surgery. Thus I would have no confidence that any manipulation of your indwelling chin implant would offer any improvement in your current speech issue. You can, of course, prove or disprove that conjecture by replacing the current implant that you have. But the chance of improvement to me would be very unlikely.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a chin and jaw reduction ten days ago. It went well except that I have had worsening swelling each day after surgery. Today, when I woke up with even larger swelling on the left, I went to the ER to check it out and the ER doc after examining me was concerned I had a hematoma or an infection and ordered a CT scan with contrast. When the doc came back to my room he said the CT showed a large abscess on the left and a smaller one on the right and said I needed to get them drained. Then he consulted another plastic surgeon in the ER who looked at the CT and then called my plastic surgeon to consult him. After consulting each other it was determined these were pockets of liquid that can be a complication of surgery and would eventually be reabsorbed so no need for drainage. One determining factor was my WBC was normal however I just finished up my antibiotics yesterday. Also the ER doc sent me home on another week of antibiotics so I am wondering if he isn’t still somewhat concerned about possibility of an infection. So nothing is going to be done about the liquid pockets and the large one on the left is particularly bothersome and really has me concerned not only about the possiblity of infection as well as it is delaying my progress with recovery (worsened the swelling, discomfort, etc).
I know that you do a lot of jaw reduction surgery and would so appreciate to get your opinion re: these pockets. Should at least the large one be drained to reduce chance of infection and speed up my recovery?
A: Since you are within the first few weeks after surgery, these fluid pockets are either blood, serous fluid or a combination of blood. Bone when it is cut can ooze after surgery since it is hard tissue that does not have the capability of soft tissue contraction around the oozing exposed blood ‘channels’ and relies on compression of the overlying soft tissue on the bone (external wrap), an indwelling drain to pull off the fluid or just naturally stopping on its own. (which it may do if the bone removed is fairly superficial) Probably every facial bone reduction procedure gets a little bit of fluid which just naturally resorbs on its own within the first month after surgery.
Large (and it can be debated as to what constitutes large) pockets of fluid do have an increased risk of infection (good bacterial culture medium), can be uncomfortable when big enough and can prolong the recovery of one’s appearance and the final result because of increased resorption time. Draining them by needle aspiration or opening the incision and suctioning the fluid out can provide a prompt resolution to these concerns.
I can not tell you what you should do since you are not my patient for this surgery and that is between you and your surgeon.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have some questions and concerns about skull implants and would really appreciate it if they can be answered in detail. I am very serious about this operation and would like to find out more about it.
1) Let’s say I will get this operation during this month, how long will it be approximately before the incision will become unnoticeable? Also, Will I need to be wearing a hat for a certain amount of time until everything clears out to conceal it or no?
2) In what place will the incision be made and is 9 cm going to be the maximum for the incision?
3) Just out of curiously, will the implant be detectable when doing an x-ray or any type of scan at any doctor’s office or will it read as a single part of the skull?
4) Would you say this is a fairly easy operation?
5) Are there going to be any chances of infection/ nerve damage or any complications in the future or during the procedure?
6) Also, once the implant is inserted is it somehow attached or no? Or is it just inserted and the opening is closed?
Do you have any photos of how the incision/scar looks like right after it is closed?
7) Is it true that the thinner the custom implant is or the less material there is, the smaller the incision that needs to be made? Also, is it the patient’s choice or no?
8) Based on your experience, how likely is it that people around you will notice drastic changes of the shape of the head after the operation? Is it significantly noticeable or not noticeable at all?
9) It says on your website that the implants can be sectioned into 2 pieces and reassembled once inserted. Will this have an impact on the length of the incision or no?
10) After the surgery has already been done when can I see the incision disappear?
11) In the previous email you mentioned that it is better to do hair transplant using FUE in my crown area around 6 months after the surgery. Is there a particular reason why there is a need to wait for so long? If I decide to do the FUE before the surgery if it fine, how long must I wait before I can do this operation? Is there a specific time? Can I do it the next day?
12) Does the amount of silicone used affect the price in any way?
13) Is there going to be a significant difference in how it feels after the silicone is placed or no?
14) I am a casual smoker and I smoke very little. I would say I smoke around 1 pack per every two months or so. Also, I don’t smoke every day. Will this have any effect on the post op results such as healing time, etc?
Thank you and regards
A: In answer to your questions about skull implants:
- Provided one has hair for coverage the scalp incision would be fairly undetectable in short period of time. If one has a shaved head the incision will take several months before it fades considerably. The wearing of a hat or head wear is a personal choice, not one that I advocate either for or against.
- The incision placement would be based on what type of skull implant is used and its size. Without knowing these specifics I can not give a more specific answer. In general, however, most skull implant incisions are placed posterior more towards the crown of the skull area.
- Silicone skull implants are not detectable in plain x-rays. Their outline will be seen in CT or MRIs however.
- Placing skull implants can be a straightforward operation for those plastic surgeins who are very experienced in placing them.
- While infection is always a risk with any type of implant place in the body, it is not a problem I have yet seen in skull implants. Any other potential long-term concerns are related to the overall size of the implant but, in general, there is no risk of permanent nerve damage.
- I generally do place very small screws to secure the implant and use perfusion holes throughout the implant so tissue can grow through it between the overlying scalp and the underlyng bone. Thus making dosens of tissue connections through the implant.
- There is no question that the size and thickness of the skull implant affect how long the incision need to be to place it.
- I don’t think skull/head shapes are physical features that draw as much scrutiny as other facial features.
- While in some cases I do section very larges skull implants or are forced to based in their size or shape, it is not a preferred method as the integrity of the fit to the bone is most assured by placing them in the manner that they were fabricated.
- Incisions/scars do not disappear or go away completely. Their redness and visibility certainly improve with time and is a process of 3 to 6 months for maximal scar appearance improvement.
- When you induce changes to the scalp you do not want to put too close together traumatic (surgical) events. This stresses the blood flow to the scalp. This may cause hair shedding or, at worse, a devascularizing event where scalp loss may even occur. (I have not seen it but even the robust blood supply to the scalp is not immune to adverse vascular events) Therefore in elective scalp/skull surgery caution is prudent about the spacing of repeated surgeries.
- The cost of skull implants is not influenced by volume but by their method of manufacture.
- A silicone material placed on bone will feel like bone.
- You would be well advised to avoid any smoking for at least 3 weeks before and 3 weeks after surgery. Nicotine is a potent vasconstricting agent and carbon monoxide competes for space on the hemoglobin molecule with oxygen. Good blood vessel perfusion and oxygen levels provide for the best tissue healing possible and lowers the risk of infection.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I recently had jaw angle implants and the implants used were a medium sized lateral jaw angle implants. I can tell the implant does what it is supposed to do and looks good, but I’m afraid the Doctor placed the implant forward of where it should be. I can send you photos. The problem is that this is the 2nd time I’ve done this procedure with this Doctor. Last year we used a posterior angle implant and the result was quite bad. I thought it was because we used the wrong style of implant and should have gone with the lateral implant. However, I now realize that it was because that implant was also not placed correctly. I can’t imagine that a Doctor would intentionally misplace an implant, or that the doctor wouldn’t know where to correctly place the implant. Either way I am not comfortable seeing this Doctor anymore. I found your website and see that you are an expert on jaw augmentation. I am able to travel to Indiana. Are you able to fix my situation by simply going in and creating a new pocket for the implant to correctly place it, or would you have to use a new implant?
A: Thank you for your inquiry and I am sorry to hear of your lack of ideal results on your jaw angle implant surgeries. I do not believe your doctor intentionally misplaced the implants but jaw angle implants are the hardest facial implant to get positioned properly and in a symmetrical fashion. Releasing the tendinous muscular attachments can be difficult and is the key to proper jaw angle implant placement in most cases. Even with proper pocket development and implant placement if they are not secured with screws malposition is highly possible. Since there is so little different between Implantech’s posterior and lateral jaw angle implant styles, you are undoubtably correct in that implant positioning is the issue not the implant style. (as you have discovered after the second surgery)
If the jaw angle implants are providing the proper width increase in the jaw angles and are malpositioned anteriorly then repositioning and screw fixation would be the corrective approach. I obviously have no way of knowing where your jaw angle implants are and would prefer not to presume or guess where they may be. It would be ideal if we knew exactly where they were on the bone and this would best be determined by a 3D CT scan. That would provide unequivocal knowledge as to where they are and how far off from the ideal position on the jaw angles they may or may not be.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I briefly exchanged messages with you a couple of years back as I was quite distressed with certain aspects of my appearance, namely the extreme narrowness of my skull and length of my face. I tend to have a narrower skull/face than most, male or female. I have a very dolichocephalic skull, with all the usual signs; long midface, excessive occiput, narrow bitemporal area etc. I had a mild skull deformity and borderline long-face syndrome that caused vertical facial growth and heavy asymmetry of the face. I have subsequently had surgery with jaw angle implants and a genioplasty. I am very happy with the results as it has gone some way to adding width to my face and restoring an element of balance. However, I have been very impressed with your extensive information on the possibility of forehead/anterior temple widening. Or basically, overall widening of the face and skull. I think that could apply to my situation where I want to add masculinity and width to my face/head. I have attached some before and after pictures for you to hopefully take a look at. I have tried to find pictures that show similar camera angles in the before and afters.
The questions that I have are:
– Can you see potential for my forehead and temple area to be widened?
– I have always had a small mouth, but since having the jaw implants it has perhaps become a bit more apparent. Can anything be done to widen the lips?
– I believe that the surgery I have had has helped to balance my midface somewhat, but still think it is perhaps a bit too long. Can anything be done to shorten/balance the midface?
Thank you for taking the time to read this. As a potential foreign patient, naturally I have many questions to ask before hopefully flying over! Have a good day!
A: As I suspected back then shortening the chin and adding facial width by jaw angle implants will go a long way to make your face less long and a bit wider. Adding extended temporal implants that go all the way up to the side of the forehead as well as posterior temporal implants will add further benefit to this overall effect.
While you can widen the lips at the corners of the mouth, there would be small scars to do so.
There is nothing you can do to shorten the midface. That is a fixed structure that can not be changed without burying the upper teeth under the upper lip.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have heard that chin implants cause bone resorption. If this is true do they cause resorption under silicone nasal implants too? My nasal implant only extends to the dorsum. Also, how does one know if nasal implants cause scar tissue in the nose bridge? Thanks.
A: Silicone nasal implants do not cause bone or cartilage resorption of the underlying nasal structures. Chin implants settle into the chin bone because of the pressure and contraction of the overlying mentalis muscle. This is not active inflammatory resorption but simple passive settling of the implant a millimeter or two into the bone for a pressure release. It is a self-limiting problem whose concerns about it are way overblown. A nasal implant is placed under the skin and is not exposed to the same pressure phenomenon. In nasal implants the potential is not for bone or cartilage resorption but thinning of the skin over if they are big enough.
All implants placed in the body form scar tissue around them or become encapsulated. This is normal and occurs no matter where or what type of implant is placed, including nasal implants. This is a normal bodily response to an alloplastic (synthetic) material)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a silicone chin implant placed on June 12th and it has been discovered that the right wing was malpositioned, it protruded through my gum line. I have the revision done on June 18th, and there is no improvement whatsoever, the right wing is still siting very high above the jaw bone. What would be the best chin implant revision option?
A: I am sorry to hear of your unfortunate chin implant experience. It usually does not proceed down this complicated postoperative course. To have have had your type of chin implant complications would suggest two things. First the chin implant was placed through an intraoral incision. This is the most way chin implant wings get too high. Second, the implant was not secured to the bone with screw fixation. (which is ideally needed in intraorallly placed chin implants) Thus migration of the one wing of the implant into the mouth.(vestibule) The chin implant revision solution is to remove the implant, close the intraoral wound and immediately replace the chin implant through a submental skin incision and then rigidly secure it to the bone with a screw. With some form of fixation efforts at repositioning a chin implant in a slippery encapsulated pocket are prone to failure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, my facial problem is that I am very skinny. I have no volume in my face with flat cheekbones. The doctors say my maxilla is also very small and is retrusive by 6mms.has a reduction of 8mm. Even though my body is not skinny, I have talked with surgeons because I want more volume as my face is very flat/skinny. They placed implants in my maxilla on both side of the nose. Even tough my profile is good, my face still looks skinny and I cannot smile because the implants change my smile completely.
I want to remove these implants. I want to have my smile back and more volume in my face, but I’m afraid if I put new ones in, the result will be exactly the same. I want to talk with a new surgeon so I can get a more satisfactory facial profile result. I have attached numerous pictures of my face so you can see my deficient midface profile.
A: Thank you for sending all of your pictures. If I understand your surgical history correctly, you currently have in certain types of midface implants. (malar and paranasal implants – four total implants) You mentioned malar but I wanted to be certain that you also have in paranasal (side of the nose) implants. Paranasal implants would be the culprit of affecting your smile, not the malar implants. Overall facial volume enhancement could be improved by fat injections which would provide a more global effect. Although I would not want to see you remove your existing malar implants as they are undoubtably providing some facial volume effect. I would have to know more about your paranasal implants as the style and size in place may be the problem not just paranasal implants per se.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, There is one other question that just occurred to me to ask you regarding jaw angle implants. I have noticed that when I clench my molars (I.e., bite down), my jaw looks wider and better-proportioned, which I’m assuming is due to having well-developed masseter muscles. Having said that, if someone’s jaw looks significantly wider when they clench their teeth, do you take this into consideration when designing a custom wraparound implant for them? Should the implant add only minimal width so that the patient’s jaw (after having the implant placed) doesn’t look too wide when they clench their teeth?
A: This is a good question but the simple answer is no, the prominence of one’s masseter muscles are not taken into consideration when selecting or designng jaw angle implants. The amount of time one spends clenching their teeth together or biting done is miniscule compared to the relaxed facial position. It is sort of like selecting clothes or an outfit taking into consideration what does one look like when they are flexing their chest or biceps. (although clearly some people do take that into account) You care much more about what one looks like naturally and not in a muscular contraction state.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, It’s been over a year since I had my frontotemporal skull implant surgery with you and I’m quite satisfied with how things have turned out. I have noticed however some hollowing near the eye brow roughly at the bottom edge of the temporal implants. This is very minor and I assume something like a filler or minor far transfer could smooth it out. In your opinion would it be safe to use fillers or fat around the skull implant site and its capsule?
A: Thank you for the followup and I am glad to hear that our custom skull implants efforts have come a largely satisfactory outcome. With such a large implant, particularly that extends far onto the temporal areas, it is not surprising that there might be a slight irregularity along one of the edges. I think it would be perfectly safe to use either injectable fillers or fat injections around the implant edges. As long as the capsule of the implant is not penetrated there should be no chance of infection. In order to eliminate the risk of implant capsule penetration any injection material should be done using a blunt-tipped cannula rather than a sharply beveled needle.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a question about the jaw angle implants that worries me, I consulted a few Maxillofacial surgeons in my country. Some of them said to me that implants under the masseters muscles (for aesthetic reasons, not deformity corrections) is a bad idea, one of them even called jaw implants malpractice. The main argument is that due do the fact the those are the strongest muscles in the body and are constantly active (and mine are even hypertrophied) and will apply constant pressure over the implants, sooner or later it will lead to complications, that the main of them is bone erosion which will lead to relapse at the the best or more severe bone loss at worse.
I’v also been told:
– The procedure is quite aggressive and the masseteric muscles never recover completely from it.
– The procedure will cause mouth closing/ opening problems and chewing problems.
– The scar tissue that will created from the procedure will add 5 mm~ of width to both sides of my face, which will lead to an unaesthetic result, even if the implants will designed for vertical length only.
– The implants will cause thinning of the masseters over time, which will cause further health complications (I don’t remember specifically).
I would appreciate your reply to those concerns. Is the procedure really that dangerous?
A: The simple answer to almost everyone of your jaw angle implants concerns is that none of them are true or are based in any biologic or clinical reality. While it is true that jaw angle implants are placed under the masseter muscles, this does not lead to chewing or muscular dysfunction, underlying bone erosion, or aesthetically undesireable scar tissue formation. The only negative masseter muscle issue that I have ever seen, and it is an aesthetic one is that the pterygomasseteric sling can be disrupted if one is not very careful in their placement. This can lead to bulging above the jaw angle when biting down as opposed to the bulge being over the jaw angle point normally. Other than this potential issue I have found having placed, modified and removed many jaw angle implants that they are as safe and effective as any other type of facial implant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Can you answer a technical question about lip lifts? Is there a difference between a corner mouth lift (smile surgery) and corner lip lift? Do you perform these type of lip lift surgeries?
A: In answer to your questions, a corner of the mouth lift and a corner lip lift sound very similar but there is a subtle difference. A corner of the mouth lift evens a downturned mouth corner by removing a small strangle of skin just outside of the mouth corner. A corner of the lip lift creates more visible vermilion at the tail of the upper lip (and can be combined with a corner of the mouth lift) by removing a small strip of skin kist above the lateral vermilion lip edge. Some people only need a corner of the mouth lift while other people only need a corner lip lift. Then there are some people who need a combined corner of the mouth lift combined with a corner lip lip lift because their whole side of the lip is turned down. I have performed a lot of both of these and you have to pick the right procedure for the lip problem. Often times I see patients who had the wrong type of lip lift performed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interesting in a skull reshaping procedure for a flat side to the back of my head. In my pictures you can see the difference between the two sides of the back of my head. I want to see if you could make the smaller side of my head (left side) look the same as the bigger side (right side). My ear on the flatter side also sticks out nore. Even though it would cause me to have a large looking skull I wish to find a sense of normalness.
A: Thank you for sending your pictures. You have a classic case of plagiocephaly with left occipital flattening and contralateral right frontal flattening. (cranioscoliosis) The skull reshaping treatment for it is an occipital augmentation on the flatter side. The protrusive ear can be set back in a more traditional setback otoplasty with conchs-mastoid sutures. I assume when you mean ‘make the smaller left side of my head look the same as the bigger right side’ you are referring to using a standard/semi-custom implant or bone cement to do so. I think I would use one of my preformed occipital implants that I use for plagiocephaly cases. It is not as perfect as a truly made custom implant from a 3D CT scan but it can make for a major improvement and lowers the cost of this skull reshaping surgery somewhat.
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?
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. This is because the best mobility of the scalp comes the center where the maximal its release is done down the middle all the way to the back of the head. This is due to the limits of the incision and resultant scar. In order to keep the scar from extending all the way down to the ears, most hairline advancements cut back no further than the high temporal region. As one gets closer to the end of the scar the amount of scalp advancement disappears.
Given where you have put the markings for the desired hairline end point 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.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in rib removal surgery to get rid of my lower ribcage which sticks out. I do have a few questions about the surgery.
1. I know rib removal isn’t as common of a procedure as tummy tucks or breast augmentations, how many of them have been done?
2. What are the reasonable cosmetic expectations?
3. I’ve done some research and have read that in some patients it creates permanent pain. Is this sometimes the case?
4. Also, is there a chance of uncontrolled bleeding from the operation?
5. What are some common complications?
A: Rib removal surgery can be done to be used for grafts in various facial reconstuctions (usually rhinoplasty) or for cosmetic contouring of various ribcage protrusions. The fundamental difference between these two types of rib removal are the length of ribs removed and the number and location of them. In answer to your specific questions:
- Ribcage contouring by rib removal is a very uncommon cosmetic procedure but i do about 3 to 3 case of it per year. I do many more rib removals for rhinoplasty and jaw reconstructive procedures.
- The success of rib removal for improved ribcage shape depends on the exact ribcage anamoly. How many ribs and what areas can be removed vs. what is the source of the problem, and how well these match up, determines how successful the procedure can be.
- I have not seen a rib removal patient who has permanent pain and this most likely relates to rib removal for chest surgery which is done differently. (and at a higher rib level since they are interested in entering the chest cavity….a goal that is the exact opposite of aesthetic ribcage reshaping) This usually involves rib bone removal not rib cartilage removal in lower ribcage reshaping. In cosmetic rib removal or any rib graft harvest great effort is made to preserve the neurovascular bundle which runs along the bottom of each rib. Nerve injury or neuromas can be a source of chronic pain.The lack of permanent pain in aesthetic rib removal should not be confused, however, with the fact that there is some significant pain after the procedure. I attempt to limit this immediate postsurgical pain with the injection of Exparel long acting local anesthetic into the surrounding tissues as well as intecostal nerve blocks which usually lasts about 72 hours
- There is no chance of uncontrolled bleeding from this type of surgery.
- The complications from this type of surgery are essentially aesthetic….how does the scar look and how effectively has the ribcage protrusion been eliminated.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m interested in having brow bone augmentation to give it a deeper and more masculine appearance. I understand that there are various materials available, and I was wondering if you could kindly answer these few questions:
1) Which material would allow for the smallest scar?
2) I understand that custom silicone implants will provide the most dependable results, but will hydroxyapatite (HA) be able to provide a similar augmentation?
3) Which would also have the cheapest overall surgical cost – silicone, HA or PMMA?
4) As I’m leaning towards HA, could you also provide the cost of getting this procedure?
Thank you!
A: When it comes to your questions on brow bone augmentation the answers are as follows:
- A silicone brow bone implant can be placed with the smallest scar. Because of its preformed shape it can be inserted and positioned with a limited incision or endoscopic technique. All other forms of brow bone augmentation (except fat injections) require a wide open scalp incision technique with a long scalp scar.
- Hydroxyapatite can provide a good brow bone augmentation if one can tolerate the coronal incision to have it placed. This is a liquid and powder mixture that must be carefully applied and shaped. To do so requires wide open visibility.
- A preformed silicone implant would provide the most economical approach since it has the shortest operative time to complete.
- I will have my assistant pass along the cost of the different brow bone augmentation procedures to you on Monday.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am seeking a sliding genioplasty or chin reduction revision. After a sliding genioplasty 18 months ago and two bone burring operations to reverse it (6 and 12 months after the original surgery) there are still areas of bone, on either side of my chin, that were not shaved back to create my original narrow shape. I am left with a wide bulky chin, the excess skin and tissue have sagged from over the past year. Now, after my most recent operation, I have even more tissue. I am always advised to go back to the trio of surgeons who did it but after this I really do not want to. There is a huge miscommunication and when they discuss things in Spanish, in front of me, I no longer trust them. I just want to have my normal looking chin back. Do you perform this type of revision and reconstruction surgery? How often?
A: While you did not state exactly the method by which your two chin revisional procedures were done, I suspect they were by an intraoral bone burring method. While you should have had the sliding genioplasty reversed by redoing the osteotomy and setting back where it once was, intraoral bone burring was destined to create exactly what you have now…a broader flat chin with soft tissue excess. The proper solution now is a submental chin reduction technique where the chin bone can be narrowed and the excessive chin soft tissue removed.
This is a sliding genioplasty and chin reduction problem that I see and treat regularly. It would be helpful to see some picture of your chin and to know the exact details of all three of your prior surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in rib removal surgery to reduce my protruding ribcage. How risky is this procedure? What are the complications/healing time? What would the results look like? How much, on average, would this cost? What other medical issues would be affected by the surgery? Sorry so many questions! Also, I live in Idaho how do you work with out-of-state patients?
A: Rib removal is not a dangerous surgery but, like any surgery that involves rib manipulation, it does cause some considerable discomfort. This is magnified when both sides of the ribcage are operated on at the same time. The best method of postoperative pain management I have found is the use of Exparel injections as intercostal nerve blocks done during the surgery. This is a local anesthetic that lasts for 72 hours after its placement. One could expect that it would take up to month after surgery until one has fully recovered. There will be a scar for the incision needed on both sides which would be about 6 to 7 cms long. The goal of the surgery is to remove ribs number 8 and 9 to reduce the subcostal protrusion.
My practice has many patients from all over the world for various types of plastic surgery. Patients usually come in the day before the surgery to have a face to face consultation and have surgery the next day. Whether you would stay overnite in the facility depends on whether you are traveling alone or with someone. I would anticipate your stay here to be no more than 2 or 3 days after rib removal surgery before returning home.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting breast implants. However I’m terrified of losing sensation in my boobs and not be able to breast feed. What are the chances I will lose sensation? Also I’m worried my implants won’t look symmetrical, what are the chances this will occur. Because of these concerns that’s why I’m trying to find a doctor that I know cares about my results and does the best job that they possibly can!
A: Breast implants are placed in a partial submuscular position which means there is no chance of any interference with the ability to breastfeed. Loss of nipple sensation, while a risk of breast augmentation surgery, is very uncommon in my experience and only patient in the past twenty years has reported it to me. The biggest reason for revision in breast augmentation surgery in my experience is implant asymmetry. That risk is about 5% to 7% and is highly influenced by how much breast asymmetry one has initially and whether there is any existing breast ptosis. (sagging)
An important consideration in having breast implant surgery is that there are risks like any surgery and one should have a full understanding of them before undergoing the procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have had a Mentor saline-filled testicular implant for approximately three years. While the implant has been relatively trouble-free, I do have some issues with it. I tend to get some occasional soreness due to the hardness of the implant. Also, as you might imagine, it is somewhat akin to having a nerd ball on one side and a superball on the other. Additionally, the implant, even though it was the largest size available, is perhaps one-third to one-half the size of my natural one. In other words, it’s far from a matched set. What options are available to me? Thank you very much for your help.
A: Soft silicone testicle implants feel a lot more natural than saline implants for sure. As for size I obviously do not know exactly what size your existing saline implant is by dimensional measurements. (saline is done by volume instillation) But the largest silicone testicle implants is 4.5 x 3.5 cms which would seem to be more than adequately large. It would be hard to imagine you would need a testicle implant bigger than that. (although custom ones can be made of any dimension) The pocket for the silicone implant replacement will need to be bigger than your current pocket but it should be no problem expanding the existing scrotal capsule.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a necklift to get rid of my turkey waddle. What would be the best surgical option to do so? I have attached a side view picture of my neck so you can assess the waddle. What type of recovery would be needed?
A: Thank you for sending your picture. Your turkey neck poses a bit of a challenge given your hairstyle. Normally a more traditional lower facelift (neck-jowl lift) would be the preferred treatment. But with no hair cover around your ears, this makes it challenging for incision placement to get the optimal neck contouring which is needed most in the center of the neck. This leaves us with the alternative option of a direct necklift with a fine line neck scar down the center of the neck between the underside of the chin and the adam’s apple. You situation is actually common in today’s world as so many men now just shave their heads.
A direct necklift has a much simpler recovery than a more traditional lower facelift as the loose neck skin is excised directly rather than being loosened and being shifted to another location (ears) for removal. One can look pretty good in a week after surgery other than a healing neck scar.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a facial scar is approximately three years old completely severing lip and chin tissues. An excellent alignment repair was done at the time. But over time the chin repair changed from a raised scar to an indention. What type of scar revision procedure would be used to correct it? Will this be a permanent correction?
A: Many facial laceration repairs look great early, become raised secondarily and then eventually become wider depressed type scars over time. This is due to the different phases of healing that occur from early inflammation, intermediate collagen deposition to late effects of scar contracture and collagen/fat resorption.
Given its facial location in which it completely violates the relaxed skin tension lines of the skin, a geometric type scar revision is needed. It would be either a running W-plasty or another form of broken like type scar revision. When the scar limbs interdigitate there is less chance of recurrent widening or depression of the scar. Most facial scar revisions do end up better in the long run but it is a process that will also go through the similar phases of healing that the original injury did.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am contemplating seeing you for sagittal ridge reduction surgery. My understanding is that the resultant scar will be 5 to 7cm in length, from left to right, at the crown of my skull. I am Caucasian with “medium” toned skin. While the prominence of the sagittal ridge bothers me tremendously, I’d like to get an idea of how well the scar will heal in order to determine whether surgery will be worth it. I’ve done an Internet image search for “scalp scars” and the search returns pictures from hair transplantation surgeries, brain surgeries, etc… A lot of these scars are quite prominent, and it’s difficult for me to figure out what a “fine line” scar actually means in my case. So my questions for you are:
1) How well do sagittal ridge surgical scars heal compared to other cosmetic surgical scalp scars? Since the surrounding skin is tight at the crown region of the skull, I’d expect there to be tension on the scar, which would make it wider. Is that true?
2) What can be done, if anything, to improve the scar once healing has occurred. Is Fraxel effective? What about other dermatological techniques? Are there concealer creams that can be used on a daily basis to hide the scar?
3) Do you have more before/after pictures of scars that you can post?
A: Your questions and concerns about the scalp scar from skull reshaping surgery is understandable and appropriate given the elective aesthetic nature of the surgery. Searching the internet will not be helpful since just about every surgical scalp scar you see is not what scars from this type of surgery will turn out. There is no comparable other skull/scalp surgery to which this applies. In answer to your questions:
These type of scalp incision usually heal remarkably well and ion many patients can be very hard to detect. These are not scars in which there is any tension since this is a reductive operation not an augmentative one.
There will be no scar treatments that are needed. I have yet to do a scalp scar revision from one of these surgeries as they heal so well. I do many skull recalling surgeries on bald/shaved men and the scar is usually very slight at worst.
Attached see an example of a scalp scar in a shaved head male who had sagittal ridge skull reduction.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in breast implant removal. If I have complete removal do you take out the capsule? Do you check for fungal or bacterial infection? With breast lift create risks of deformities? How many removals have you done? If the implants are not removed is there a concern of future surgery at my age. My primary care Dr will contact you for a consultation. Thank you.
A: In answer to your questions:
1) There is no compelling medical reason to remove the capsules. They will shrink away on their own with time. It can be done if the patient wants.
2) Without evidence of an active or chronic infection, there is no reason to do bacterial or fungal cultures.
3) Concurrent breast lifts will create their own aesthetic deformities known as scars. How extensive they would be depends on the type of breast lift needed.
4) While breast implant removals without replacement are fairly rare, I have done dozens of them over the years. About half the time a breast lift is needed with their removal.
5) If you replace the implant with silicone devices that would be the most assured approach to keeping implants and have the lowest risk of of any future implant-related problems.
It is not necessary to have your primary care doctor arrange for a consultation. These are not procedures that would be covered by insurance unless there original placement was for breast reconstruction due to cancer. Otherwise this is a cosmetic procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in cheekbone reduction. I have been very insecure about my face structure. I feel like if I get cheek bone reduction it would really change my life because I am tired of thinking about it all over again everyday, it really frustrates me and depresses me. So for my cheek bone reduction would I have any visible scar? And how stable would the cheek be? Would it be stable as before? Would it be able to take a punch? Because I’m really worried. I have attached pictures so you can see how prominent my cheek bones are.
A: Thanks for sending all the pictures. Cheekbone reduction surgery is done mainly from inside the mouth. There is a very small external skin incision on the backside of the sideburn area to get to the posterior tail of the zygomatic arch but it is very small and heals well. The bones are put together with small plates and screws for stabilization afterwards. Once the bones are healed, like any facial fracture, they can resist trauma such as taking a punch in the face. You also have to remember that the cheekbones will already be broken (moved inward) so their ability it get fractured is less anyway.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m looking to have liposuction. My main concern is being put to sleep. Ive watched a few YouTube videos and noticed that the Smartlipo procedure was done without general anesthesia, all while awake.
A: If the principle concern about liposuction surgery is being put to sleep (local anesthesia liposuction), then I am not the surgeon for you. My experience with any form of liposuction done under local anesthesia (unless it is a very small area) is not very good with suboptimal results, patient discomfort during the procedure and an experience that the patient and I would usually not like to repeat in most cases. In my experience when a patient chooses local anesthesia for an invasive liposuction procedure, they have to be willing to accept a limited result and that they may need multiple treatment sessions to ultimately get the best result. Such an approach will also cost more than if done one time under general anesthesia. Regardless of what you see on the internet and how it is promoted, liposuction is a very invasive procedure that covers large body surface areas and is a completely effort dependent process. When this surgical effort becomes compromised by an anesthetic choice that limits these efforts, the surgeon’s hands becomes ’tied’ and the result and experience ultimately suffers. At least this has been my liposuction under local anesthesia experience.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a healthy 50 year old male. I have had liposuction and fat transfer to my buttocks two years ago along with fat removal from my chest area. I am happy with the results of these body contouring procedures. I have however put on more weight and I am wanting to have fat transfer now to my shoulders along with sculpting of the waist, lower back and flanks. My question is will this give me a more athletic look. And is fat transfer to shoulders a successful procedure. How much fat will be saved in the shoulders as the shoulders are my first priority. If I have fat left I want my buttocks still a little more fuller. So in a nut shell I am trying to get a V shape look. Is this possible?
A: Fat transfer to the shoulders (fat injection shoulder augmentation) is just as successful as most other area of fat grafting such as the buttocks. The argument can be made that it may be a more favorable area for fat injections since the recipient site is largely muscle, always the most preferred site for optimal fat take. I almost always mix the harvested fat with platelet rich plasma (PRP) to optimize fat graft take. The real rate-limiting step in any fat grafting procedure is the amount of donor material one has to harvest and process for injection. All one can do in any patient, particularly a male, is to harvest as much fat as possible from the abdomen and flanks for injection. This should certainly help in obtaining more of a V body shape.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’ve had saline breast implants for approximately 19 yrs. One has recently deflated. I am wanting to see what my options are as far as saline or silicone replacement.
A: You have gotten good use out of the original breast implants as most saline implants from twenty years ago did not last this long. The options for managing a saline breast implant deflation (saline breast implant replacements) are three fold. First you could just replace the deflated implant which would be the simplest and most economical option. But at nearly twenty years out the opposite breast implant is running on borrowed time and most people would be concerned that the other implant would deflate shortly after the replacement surgery. Thus most women are going to opt to replace both implants which could be either saline (option #2) or switch to silicone gel implants. (option #3) Whether one elects to stay the same size, go bigger or go smaller can be done with either saline or silicone implant replacements. There are arguments to be had for either choice but many women would choose silicone replacements so they would never have another implant deflation in their lifetime. A few women given the long-term success and lack of any problems until the deflation many opt to keep saline filled implants.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a sliding genioplasty three months ago and now my left lower lip is paralyzed. It affects my smile and when I open my mouth. What surgical procedure can I do to make it better. What type of nerve repair is needed and how is it done?
A:The most common nerve injury from a sliding genioplasty is that of the mental nerve, a sensory nerve that controls the feeling of the lip and chin. Injury to a branch of the facial nerve is different as this is a motor nerve that controls the depressor anguli oris (DAO) muscle which provides a depressor or pull down of the lower lip when smiling.
If you have developed marginal mandibular nerve weakness from a sliding genioplasty (or any other chin surgery), which is a very rare complication from this type of surgery, the only potential resolution is time. This is a monofascicular branch of the facial nerve that has no interconnections with other facial nerve branches so its recovery will be slow. It is not likely that it is cut or torn but stretched. Even if it was inadvertently cut it is too small to find and repair. This is why time is all that can be done with marginal mandibular facial nerve injuries. Many do resolve satusfactorily with time.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in calf implants. I have thought about it for years. I am tired of being self-conscious in shorts. I’m almost 40 years of age and want to do something about it now. Here are some photos. In my opinion my calves do not match my body frame. Despite working them out daily, they refuse to grow.
A: Thank you for sending your pictures. Calf muscles are the hardest of all body muscles to increase in size due to their dense compact type of muscle fibers. Calf implants are the immediate cure for that problem. Placed through a small incision in the popliteal crease behind the knee, they are placed underneath the fascia on top of the calf muscles providing an instant augmentation. In looking at your calf pictures I would recommend medium size calf implants for the medial calf muscle and small calf implants for the lateral calf muscle for a total of four calf implants.
While calf implants are instantly effective (just like breast implants) there is a substantial recovery from them. The calf muscles will be tight and sore and walking can be initially difficult for the first few days after surgery. It takes about three weeks to have a near full recovery from calf implant surgery.
Dr. Barry Eppley
Indianapolis, Indiana
