Your Questions
Your Questions
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
Q: Dr. Eppley, I am having facial feminization surgery by you in a few months. Is it possible for me to have breast augmentation at the time of my facial feminization surgery? Or will it need to be on a different day? How long after FFS would you recommend I wait to have it done?
A: The first thing to appreciate is That is too much surgery at one time. I don’t think you realize (understandably so) what is going to happen to your face and the recovery that is needed for that collection of facial procedures. Eight to ten hours of surgery is an extreme stress on both your face and body already. Adding breast augmentation to a facial feminization surgery can be done but let me give you several thoughts as to why that is not the best idea and how to think about staging it.
While a young person like yourself can undergo an extreme amount of stress (extensive surgery), there are numerous other issues that can develop from extensive surgeries that go well beyond 8 hours. Such potential medical issues such as blood clots (deep vein thrombosis) and the risk of infection increase significantly. With extensive facial surgeries that involve the nasal and oral cavities there is a bacteria load that is released into the blood stream from them. Placing a large synthetic implant at the same time becomes a great point of attachment for such bacteria floaring in the bloodstream and thus a potential source of implant infection.
When staging facial feminization surgery and breast augmentation there are numerous ways to do it. But the most practical one is to consider the risk of revisional surgery from the initial facial feminization surgery. While each procedure in a facial feminization surgery has its own inherent risks (mainly aesthetic outcomes) when all the procedures are put together that risk becomes additive or cumulative. So let’s say for example that each facial procedure has a 10% risk of revisional surgery, a combined ten procedures would then ensure a revisional surgery for at least one of them. Thus it is better to wait a few months to see the complete outcome of the facial feminization surgery and then combine breast augmentation with any revisional facial procedure if needed. This would be the prudent approach to lower the number of potential surgeries needed/desired.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in skull augmentation or skull reshaping, I don’t know which is the right term. I feel it’s from the back of my head circumferentially around the sides. When I push fthe ront of my hair up (to increase volume) I feel my face looks normally. But when I take my hair tightly I feel my head is smaller than my face.
I am really sad and frustrated. I feel there is no way that I can feel normal I even went to a good plastic surgeon for a consultation but after 5 minutes he said it’s genetics and not worth it to be corrected.The only doctor that I found is really supportive is you.
I think my problem is more than just cosmetic, I I don’t look normal and I cannot do normal activities like swimming. I always have to use many clips to push my hair up.
I really appreciate your kind support.
A: Your description of your skull/head shape problem is one that I have heard from female patients many times. The skull size descriptions and their aesthetic concerns and psychological effects are identical. Their is a solution to these skull size concerns and it involves a custom skull implant that adds volume to the head in exactly the areas you feel are most deficient. But there are two ways to use such a custom implant and they will create different results.
Having had patients just like you I have a good feel for the amount of additional skull volume you need. Thus the ideal approach is a two-stage one. The first stage is the placement of a tissue expander for 4 to 6 weeks to create the scalp stretch that is needed for the size of skull implant that will create the ideal result. The second approach is one-stage with the placement of a smaller skull implant without doing scalp expansion first. The way to think about choosing is what type of result are you willing to accept for the effort invested? If you can live with improvement and 50% to 75% of the ideal result then place a custom skull implant without scalp expansion. If only the ideal skull height/shape increase will do the do the two-stage approach. Be aware that once you have an implant placed you can do not do scalp expansion later. (should one decide afterwards that they want more volume. Obviously the one-stage approach is quicker and costs less…but you have to be prepared to accept improvement in skull size but not perfection.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Is it possible to do forehead lift to rid of horizontal wrinkle lines and raise the forehead but not move eyebrow position? Because I have many forehead wrinkles. I have tried Botox but I want a permanent result. I don’t want any movement position in eyebrows. How is it done?
A: What you are asking can not be done exactly the way you want it. You can not permanently paralyze the entire forehead even with extensive muscle stripping. And if you remove all the muscle between the eyebrows to try and achieve it you will need up with a dent or depression between the eyebrows. You definitely can weaken it considerably by muscle resection (glabellar area) but it should be combined with the placement of a dermal-fat graft in the resected area so that a depression is not created and it will inhibit any muscular reattachments as well.
In reality a forehead lift and a browllift are one and the same. A forehead lift can not be done without some browlifting effect. That effect can be made minimal but no change can be done in the forehead without some potential change occurring in the brow area riught below it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 28 year old male. I was always bothered by a flat spot on the back of my head. It has a profound effect on my confidence and makes me feel very self-conscious about myself. Even though it is not terribly bad, I would still like to get it corrected. Going through similar cases on your website, I would like to know if I will be a good candidate for the minimally invasive closed cranioplasty approach. What is the success rate of such a procedure? Are there any side effects? How long does it take for the scar to heal and will it be visible? How large of an incision will be needed? I have attached a photo of back of my head. Also, my hair is currently thinning on my crown area. I would like to get an FUE hair transplant. Is it recommended to do the hair transplant first prior to the cranioplasty or vice versa? Will cranioplasty have any effect on hair growth in general?
A: The best and only way I will do occipital augmentation today is using semi-custom or custom occipital implant placed through a low occipital incision. (general 9cms in length) This has a high rate of success (as long as one is not asking to achieve more than 10 to 15mms of augmentation) and a low rate of revision. A closed cranioplasty procedure has a high incidence of irregularities and asymmetry…which can only be revised then by an open cranioplasty approach.
Occipital implants do not cause hair loss. When it comes to hair transplantation, the impact of occipital augmentation depends on what method of FUE harvest is going to be done. If one is going to have a traditional linear strip harvest then one should have an occipital implant as least one year before the procedure to allow the scalp to relax. But one would be unlikely to get more than one harvest so ideally this FUR harvest method should not be used. If more contemporary methods of harvest are going to be used (Neograft, Artess) then the hair transplant procedure can be done six months after the occipital implant is placed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, why does plastic surgery get its name? Can I assume that most plastic surgery operations work by putting in some form of plastic or synthetic material?
A: While there are certainly some plastic surgery procedures that do employ the use of synthetic materials to create their effects, most commonly that of breast augmentation for example, the vast majority of plastic surgery procedures use the patient’s own natural tissues for either cosmetic and reconstructive efforts. The timeline of plastic surgery history will show that the surgical specialty name and that of synthetic material development are quite different.
By modern day perceptions of plastic surgery, most people would be surprised how old the field of plastic surgery really is. The term plastic surgery can be traced way back to the early 1800s in German surgical texts. This predates the development of synthetic plastic materials by more than one hundred years. India placed a major historic role in developing reconstructive plastic surgery techniques due to the need to rebuild lost noses and lips that had been cut off by local warlords to mark the people that had violated local customs and rules. But it was World War I that catapaulted plastic surgery into an organized and recognized surgical specialty due to trench warfare and the devastating facial and burn injuries that it created. This subsequently lead to the creation of the American Society of Plastic Surgeons in the late 1930s…which still predated the developement and commercial use of plastic materials.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am an Australian looking for someone who does head widening implants in Australia. I have been researching for some time but you are the only surgeon I can find who performs this surgery! Unfortunately, as a student, I don’t see myself being able to afford a trip to the US any time soon so I was really hoping that you may have an idea/possibly know a college here in Australia who may be able to perform this surgery. I would really appreciate any advice or recommendations you could give me.
A: The surgical concept and the implants used for head widening implants are those that I have developed. This is a new cosmetic temporal surgery that would be unknown to almost all surgeons in the world. Thus I am certain there is no one in Australia or anywhere else in the world at this time that performs this surgery. It uses as dual combination of anterior and posterior temporal implants placed in a subfascial location to create a widening effect from the lateral orbit and forehead all the way back to the anterior occipital region. Since the side of the head is largely made up of temporal muscle it makes sense to augment this large muscular surface area to create greater convexity to the side of the head.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am really feeling confident with what you have advised for other procedures and was wondering if after having everything we discussed whether I could possibly have marionette fold excision. I can’t stress enough how much I detest these lines. They are extremely prominent and appear to take over my face. I have researched my options and I’m not really sold on the filler injection as I would much prefer a permanent solution. And having typed in marionette fold excision your name came up. I have my fingers crossed this may be possible.
A: Marionette fold excision can be done and is a permanent solution. But it is almost always reserved for older patients with really deep (inverted) marionette lines/folds who are more than willing to trade off a scar for the fold. That can be an easy tradeoff in much older people, usually 65 years or older since they already have many lines and wrinkles. That tradeoff may be more suspect in someone younger…or at least one should give very careful consideration of it. In addition an older person’s facial skin stretches more due to being thinner with less elastic fibers. Thus they scar much better. This is why skin cancer excision and reconstruction has such good results on older people.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m interested in masseter muscle reduction and am aware you offer electrocautery as a treatment. I have a few questions regarding this procedure :
1) Is it permanent? I understand Botox is used for this as well but it is temporary and radio frequency has also been used but lasts only for a couple years. I am looking for a permanent solution.
2) Are the effects significant? I have seen the effects of Botox for masseter reduction and I really liked it but as I previously mentioned the effects wear off. Will electrocautery provide the same effects or is it more subtle? If I find the result too subtle could I possibly come in for a second treatment?
3) Will there be any complications such as nerve damage, eating/movement limitations, premature sagging skin, or asymmetry?
4) Also, I have a dental Herbst appliance. Would that be an issue?
I look forward to your response. I apologize for the many questions.
A: Electrocautery is a form of surgical masseter muscle reduction. Somewhat similar to radiofrequency, it is a method of causing direct thermal injury to the muscle resulting in permanent loss of some muscle fibers. Unlike radiofrequency it it done through an open approach intraorally where the undersurface of the masseter muscle is treated. Through a combination of subperiosteal muscle release and direct electrocautery the size of the muscle mass is decreased as it heals. To answer your specific questions:
- Those muscle fibers that are directly thermally injured does result in their permanent loss. However, like liposuction which permanently removes some fat cells but weight gain can return by those fat cells that remain undergoing hypertrophy, the same can be said for muscle tissue. If the cause of the masseter muscle hypertrophy persists the remaining muscle fibers can become hypertrophic and muscle volume returns.
- Generally the effect masseter muscle reduction by electrocautery are similar to the effects of Botox injections. Further reductive treatments can be done.
- Other than some temporary muscle stiffness (trismus) there are no other adverse effects. It is just an aesthetic question of what degree does the overall muscle mass shrink.
- An indwelling oral appliance is not a preventative factor for having the procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have an odd question about testicle implants that I hope you will not think is too weird. I have had great loss of testicular size due to testosterone therapy. Is it possible to get two testicle implants and not disturb the small testicles that I have?
A: I think your question is whether you can add two testicle implants while keeping your existing small testicles. Provided there is adequate scrotal sac space, and there most likely is, the answer would be that you could. You would just have to be sure that you can get a testicle implant in the sac that is appreciably bigger than the existing smaller testicle. That way you could have two ‘dominant’ testicles and not just four smaller ones. (aka sac of marbles) The obvious assumption is that you are trying to have a more normal testicle size while keeping the simultaneous function of the existing testicles, small as they may be.
Testicle implants are placed through high scrotal incisions near the groin crease so the final resting place of the implant is not directly against the incisions. This is a procedure that is performed as an outpatient under general anesthesia.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I made a terrible mistake with my son’s otoplasty. I went with the less invasive procedure for his ears. I had a doctor perform an incisionless otoplasty six days ago. The bandages were removed this weekend and I am extremely unhappy with the results. There is virtually no change at all and it looks terrible. I am embarrassed that I made this choice and I now realize I should have gone with your approach at our initial consultation. Is there anything that you can do to help revise this now or should we wait a few months?
A: At just six days after an incisionless otoplasty it is possible that the ears are so distorted with swelling that you may not be really looking at any approximation of the final ear reshaping result. The incisionless otoplasty works on the principle of a closed cross hatching of the cartilage with a needle (to weaken it) and then passing multiple sutures under the skin using the same entrance points. This technique does cause a lot of trauma to ear so I would not rule out what you are seeing as temporary ear distortions due to swelling and bruising.
But it would be important at this early point after surgery to allow the swelling and bruising to subside and let healing take place for the next three months. At that point the ears will have their final shape and you will be in a better position to assess the result. The ears would also be healed enough at that point that I would consider converting to an open otoplasty to get a better result if that is needed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, What can be the most likely solution to my bulging eyes? You can see in my pictures that my eyes stick out. They have been this way since I was little girl.
A: Thank you for sending your pictures. The first question to answer is whether this is exophthalmos due to a medical condition such as hyperthyroidism. But since your eyes have always been ‘buggy’ it would be reasonable to assume that this is their natural appearance. It looks like you have what is known as pseudoproptosis. (appears like eye bulging when in fact it is not) This is due to a lack of bony rim/fullness around the eye particularly in the superior and lateral orbital rim areas. When the bony rims are recessed or not adequately projected the eyeball will look like it is sticking out when in fact its position is normal within the orbital box. The fact that they have been this way your whole life would support that this is just the way your face developed. Placing custom made superior and lateral orbital rim implants through an eyelid incision or doing it from above through a scalp incision would be the only way to improve this bulging eye appearance.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, . I have seen you have had experience with temporal artery ligation and success dealing with this procedure in the past which is why I am contacting you. Attached is a picture of my problem. The artery gets larger if my heart rate is up or its hot outside. I have another one that is not as bad on my left side as well that I would like to deal with at some point if the initial procedure works. Is the success rate of this procedure pretty high, in terms of greatly minimizing the size of the entire artery? I am very interested in having this procedure done.
A: The success rate of temporal artery ligation in my experience is always 100% or very close. That would be expected when you shut down both ends of the pipe so to speak. That is actually not the question that is the most relevant. The more relevant question is…does collateralization or shunting of flow occur? This means if you shut down one section of the pipe way will other previously invisible sections of the pipeline appear later. It is important to remember that all the arteries in the scalp and forehead are very extensive and interconnected. So in theory the blood flow that went to the vessel that was shut down could be shunted and cause vessel dilation elsewhere. I only mention this point in cases of men that shave their head where the entire scalp can be seen. I have had a few patients contact me over the years who had their temporal arteries ligated elsewhere and they developed visible dilated vessels elsewhere in the scalp weeks to months later which they felt was a worse aesthetic problem than the one they had treated. This shunting is not a problem that I have seen with temporal arerty ligation but it is one of which to be aware and a potential risk of the surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Dr. Eppley, I have just learned of fat injections to help narrow small shoulders. Could you help me learn more about it? I have a lot of fat around my abdomen and obliques. Could that fat be used to make my shoulders bigger (broader and thicker)? If I were to diet, does that mean I would lose fat in the shoulders and they would shrink and I would have to repeat the fat transfer procedure? A lot of stomach fat has been something I always had. Even at 125 lbs. even when I do lose weight, I still have a big stomach. Would that fat be as difficult to lose in my shoulders as it is my stomach? How much broader could I make my shoulders with the fat transfer procedure (half inch, full inch)? Sorry to bombard you with questions.
A: Deltoid augmentation by fat injections can be a successful method for shoulder enhancement. The key is whether one really has enough fat to do the procedure or, more relevantly, to make it worthwhile. While you may think that you have enough fat, and you may very well do, that is somewhat hard to imagine at a 125lb weight. Whatever stomach fat you think you may have by appearance, that protrusion may be from an intraperitoneal basis (behind the abdominal muscles) rather than in front of it. (intraperitoneal fat is inaccessible from liposuction) This is obviously an issue that requires further assessment/examination even if only by pictures.
But for the sake of discussion let us assume you could have the procedure. Abdominal fat transfer to the shoulders (or anywhere else) is going to behave like the donor site and not the recipient site. Meaning if you lose weight the fat cells will get smaller as well as the reverse. These transferred abdominal fat cells have depot behavior with higher metabolic activity. Thus they are more sensitive to weight changes that normal shoulder subcutaneous fat would be. How much increased shoulder definition you could get would completely depend on how much fat is capable of being transferred…and how much survives the transfer process. Thus it could be anywhere from a very modest change to a more robust 1/2 inch or so.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 29 year old female who four years ago had silicone injections done into my buttocks. Now I’m having some issues with pain and uncomfortability. I am trying to find a doctor who can help me but I have not found one yet. Do you remove these silicone buttock injections?
A:No one can completely remove silicone oil injections from the buttocks unless major excisions (cut outs) are done. While curative the aesthetic trade-off is a resultant disfiguring buttock deformity. So the concept of complete removal by excision is very rarely ever done.
Silicone injections can be treated, however, through liposuction and fat injections. The liposuction removes some of the oil and, more importantly, breaks up the scar tissue/granulomas. The fat injections add fresh cellular elements and encourages new tissue ingrowth as well as maintaining one’s existing buttock size. This will usually relieve most of the symptoms caused by silicone granulomas in my experience. But complete removal of silicone buttock injections is not possible. Think treatment and symptopmatic improvement instead.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a skull implant placed six days ago. I have a question about the result of my surgery so far. I have noticed the areas on the top front of either side of my forehead are really soft (squishy). When I press on these areas it feels like I am pressing against a small water balloon. The squishy points are along side the implant edges on the front sides of my head where I do not have any hair. This might also be the case in other parts along the edge of the implant, but I can not tell as much because I have growing hair on rest of my skull. I believe the implant is noticeable from underneath the skin at this point in the healing process. Can you please explain to me what this may indicate? Is this an expected thing at this point? or is this an indication that my implant my not be concealed and will remain noticeable going forward? Thank you.
A:This is all normal at this point in your skull implant recovery. Remember I said it will take 6 weeks for all swelling and internal fluids to be absorbed. You are not seeing the edges of the implant. Rather you are seeing the limits of the tissue dissection where the scalp has been lifted up from the bone. This goes well beyond where the implant sits on the bone. (implant pocket creation) The edges are where the scalp tissue is tightly adherent to the bone. With swelling and fluid it creates a ‘perimeter’. For this visible perimeter to go away this requires swelling and the fluid to be absorbed so the tissues stick back down. This is an issue for 6 weeks to resolve, not 6 days.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have had multiple chin bone surgeries (sliding genioplasty) and my mentalis muscle now droops and dimples badly upon lip closure. (which I never had initially. The first surgery lengthened my chin inadvertently which made my face more gaunt looking. A second surgery was done to reverse the sliding genioplasty but that was not really done. The chin bone was not pushed back anywhere near as much as needed and it was asymmetrical. It appears the surgeon actually burred down the chin rather than a true sliding genioplasty reversal. Now I have step-offs that are astronomically different in size. What would you suggest to fix this all?
A: As best as I can determine from your description, you initially had a sliding genioplasty and then had it reversed. Rather than a complete osteotomy reversal, the bone was burred down to create part or all of the ‘reversal’. This has left you with bony irregularities and a soft tissue chin sag with dimpling. Comparing your preop x-rays to now I would assume that your goal would be to vertically shorten the chin and get it back as close as possible to your original chin position. This still will require an osteotomy (true sliding genioplasty reversal) as your chin is vertically longer than before. The mentalis muscle/chin pad could be resuspended at the same time. The chin dimpling is a more vexing issue as this is a result of multiple surgeries and aberrant muscle movements due to scar contracture. I would probably inject a little fat into the mentalis muscle to try and soften some of the scar contracture which may or may not be effective.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a very flat back of my head. I’ve never had any problems but as a female I can only wear my hair down and I puff it up everyday so you can’t see it. But by me doing that it is causing hair loss around that area. It is honestly very embarrassing and I am very insecure about it. Also my forehead is flat and the way my nose is shaped does not help at all. So I’m talking maybe three surgeries but I’m not sure how that all works. I have attached a series of pictures so you can see the scope of my concerns. Please reply I would amazingly appreciate it.
A: Thank you for sending your pictures. It is a very classic and common type of occipital-vertex deficiency that I see in women. While it can be very effectively augmented by a custom made implant (custom occipital implant) the question is how much augmentation do you seek…which defines whether it can be done as a single stage or requires a first stage scalp expansion by a tissue expander. Essentially a first stage can augmented the entire area by about 12 to 15mms maximum. A two-stage approach can augment the skull by 25 to 30mms. This is an important consideration up front. Ultimately the question is whether one wants a modest augmentation (one-stage) or a more significant one (two-stage) when it comes to designing a custom occipital implant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am scheduled to have an old cheekbone fracture reapir procedure by you in a few weeks. The two procedures you will perform on me are: (21407) treatment of fracture of orbit except blowout with implant Left side and (21270) augmentation of cheekbone left side. My questions are what exactly will you be doing as far the actual repairs? Will it require breaking the bone? If screws are used anytime in the procedure, will that negate my ability to have an MRI of the head region in the future because of the metal? Will I feel the implants and screws in my face when I rub it? Lastly, how durable will the implants be if I get hit in the face playing basketball? Thank you for being able to help me restore my features after so long of an injury. I trust you and your reputation and I feel I am in the best competent hands possible.Thank you for your time.
A: Your old cheekbone/infraorbital rim fracture is going to be treated by a camouflage technique to build out the depressed bone and lower eyelid and cheek facial areas. This would be a combined cheek implant and infraorbital rim implant. Any implants used would be screwed into place with very small titanium screws. (about the size of eyeglass screws) They do not interfere with any type of x-rays. With such an old and healed facial fracture there is no benefit to breaking the bone and repositioning it. That would be very traumatic and less effective at this point that building out and filling in the obvious facial indentations/asymmetry. These implants are very durable and would pose no problems playing contact sports. In some ways you can think of them like placing protective bumpers on the bone.
Dr. Barry Eppley
Indianapolis, Indiana
Q; Dr. Eppley, I was born with club foot and now my right leg is slightly smaller than the left. I’ve attached two pictures. Let me know if you need another. My basic concern is having to do multiple implants and have also been thinking about fat transfer. I believe to make my right leg look symmetrical I will need one of the longer implants, because it would need to follow down to very bottom of my leg if possible. I have no Achilles tendon and your able to see my fibula bone if I flex my leg.
A: Your best obtainable result is going to come from a combination of calf implants and fat transfer. Calf implants do not go all the way to the ankle nor can any implant go past midway between the knee and the ankle. (can not go past the gastrocnemius muscle/fascia) Below this level any augmentation has to be done with fat transfer although it is important to be aware that fat grafting below the calf survives very poorly due to the tight tissues. Given the small size of your calf you will need both medial and lateral calf implants.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dear Dr Eppley, After a rhinoplasty I was left with a big space between my nose and lips. My surgery was 6 days ago. Do you think this might still change and I should wait longer until considering a subnasal lip lift? Thank you so much!
A: It would be entirely premature to judge what effect your rhinoplasty will have on your upper lip length at just six days after surgery. While it is unknown to me as to what type of rhinoplasty you have had, any rhinoplasty surgery that results in tip rotation and/or tip shortening is going to initially create the perception that the upper lip is longer. In reality it be now more exposed with the change (opening) of the nasolabial angle…or it is possible that it may have indeed become lengthened. But until all the swelling from the rhinoplasty surgery has resolved and the tissues have fully settled, any aesthetic judgment on upper lip length can not truly be appreciated. I would not perform an upper lip lift on a rhinoplasty until they are six months out from the procedure, not only because of the uncertainty of the aesthetics, but because of the intervening skin between an open rhinoplasty incision and that of the subnasal lip lift.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a full wrap around custom jaw implant as it seems to be exactly what I need for the look I am interested in. When making the wrap around it it possible to make the side ends thick to get an end result like I have illustrated in this example but also build in the chin implant on the wrap around to make my chin longer and more aesthetic? With my current chin implant I feel like the chin implant was placed too high and has altered my smile, so fixing it all in one go would be great. I am from around Loa Angeles so could I fly out prior to surgery and get a 3D CT scan and show you exactly the type of implant I wanted? Also would I need to get my wisdom teeth removed before the surgery? I talked to another doctor who required it.
A: The wrap around custom jaw implant is the only way you can get that continuous jawline look that goes from side to side. That jawline implant look (large wide jaw angles) can be designed although many patients would consider the look to which you reference as being excessively wide in the jaw angle area. Vertically lengthening of the chin as part of the design is commonly done for many custom jawline implant proedures.
The 3D CT scan which is needed can be done where you live so there is no need to come here to get that done. The design part is done from afar with you and it takes about three weeks from design to having the implant ready for surgery.
Whether your wisdom teeth should be removed depends on whether they fully erupted or partially or full bony impacted and whether they have ever been symptomatic. (e.g., developed pericoronitis) If they are full erupted and are asymptomatic then it does not matter if they are in place or not. But if they are less than fully erupted they should be removed 3 months prior to the custom jawline implant procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a saline testicle implant placed last year and I hate it. It feels hard as a rock and very unnatural. I would like to replace it with a softer but larger silicone testicle implant. In addition I would like to make the opposite testicle larger. I have read that there is a way to do this by wrapping it with an implant. Is that true? I read it on the internet so you never know how accurate that information is.
A: Saline testicle implants feel very firm because they are an overfilled water sac which is under tension. Conversely silicone testicle implants are very soft and squishy because they are made of a low durometer solid silicone material. There is no question that silicone testicle implants feel a whole lot softer than saline ones. I will have to compare the largest silicone implant with that of saline to make sure it is bigger. But I would have confidence that it would be since the largest silicone testicle implant is up to 4.5cms in length with an oblong shape.
Capping the existing testicle is how it is made bigger. You take a large silicone implant, cut in in half and then remove the inside of the implant leaving only a thinner outer shell. Then you put the two halfs together over the existing testicle and put it back together like a clamshell. A space needs to be left between the two calfs so that the vascular pedicle and cord that goes to the testicle is not pinched off.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in orthognathic surgery even though my bite (Class 1) normal. Thus any orthognactic surgery would be cosmetic and not functionally beneficial. It just appears to me that my face and the bones in it did not grow in an optimal aesthetic direction. It seems that my face is too long and has dropped to a gaunt look with a flat midface. Could this be due to a downwards grown maxilla or other bones? Can it be fixed with a maxillary impaction?
A: Your malocclusion is modest and within the confines of a general Class I occlusion. The point being is that it is not the source of your aesthetic facial concerns. The difference between your child face and your adult one is the relatively standard change between the 2/3s dominance of the upper face in childhood to the completion of facial growth in early adulthood with a reversal in that proportionate relationship. Whether your face is too long is a personal assessment and not a function of actual facial structure disproportions.
Changing your facial proportions is done by decreasing the vertical length and improving the midface projection width. This is usually best done by a vertical wedge reduction genioplasty (chin) and malar-submalar implant augmentation. Doing a maxillary impaction would bury your upper teeth under your upper lip and would also require a concurrent mandibular osteotomy to keep your bite relationship from changing unfavorably.
Dr. Barry Eppley
Indianapolis, Indiana
Dr. Eppley, I found your name on the American Society of Plastic Surgeons and also on the website, RealSelf.
I am experiencing pain and restrictions from an old c-section scar from 1985. The left end of the incision is indented and has adhered to the underneath muscle. I have tried many rounds of physical therapy to help it, but it now seems to be pulling so much that my hip flexor and groin area are becoming restricted and painful.
I have hated the look of it ever since the day I got it, but I can’t deal with the restrictions and pain. Had it looked at by a general surgeon where I live about 10 years ago and he said he didn’t ‘believe’ in scar adhesions.
Is a scar revision normally covered by insurance? Thank you for your time.
A: It is not rare that a c-section scar can create an adhesion down the abdominal wall, resulting in scar contracture pain. Whether the general surgeon you saw believed in scar adhesions or not, they do exist and they are real. Such c-section scar adhesions are easily solved by total excision of the scar down to the abdominal wall and bringing in fresh tissue to reconstruct the tissue layers from the bottom up to the skin. (C-section scar revision) Scar revisions are not usually covered by insurance but that is a determination they have to make not one that I can since they write the policy and make the decisions about coverage.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like to have v-line jaw surgery, a lower facelift and a subnasal lip lift. As far as the lower facelift and neck there is not too much laxticity today but the jaw reduction will likely increase it so a lower neck and facelift will be needed. Can these procedures be performed in a single surgery?
A: V-line jaw surgery usually does not create excessive jowl or neck skin as it is really a redistribution of the bone shape not always a real total jaw reduction. If you do not have any skin laxity now I doubt any will be created after. There is simply not that much jaw bone removed to create substantial less skin support. But that is somewhat dependent on your age and natural skin elasticity. But for the sake of discussion let us assume that some neck-jowl tightening would be needed then a lower facelift can be performed at the same time as the V-line jaw surgery…or await and see if it is really necessary which would be the most practical approach. Certainly there is no problem doing a subnasal lip lift at the same time as the v-line jaw surgery.
Dr. Barry Eppley
Indianapolis, Indiana
