Your Questions
Your Questions
Q: Dr. Eppley, I have a very large and disproportionate face. My brows are hugely overgrown and my jawline is equally as big. I look like a Neanderthal! What type of facial reshaping or facial reduction surgery would be beneficial for me?
A: Thank you for sending your pictures and I can clearly see your brow and jawline overgrowth concerns. While reduction of these facial bones is certainly one part of the solution, it is not the complete or most effective approach for either area. For your brow bones, their prominence is partly contributed to by the recessed or backward sloping of your forehead. That would be become very apparent if the brow bones were reduced alone. The best result comes from a combination of an oteoplastic brow bone setback (not just shaving) and forehead augmentation above it. I have shown this type of result in the imaging attached. From the jawline standpoint, bone needs to be removed along the inferior border of the jawline from the angles to the chin. But the chin bone needs to be vertically lengthened and setback a bit to make the jawline more harmonious and smooth. I have attached imaging of this type of combined chin and jawline change. For all facial areas it is also important to not overdo them as your entire face is skeletally strong and any drastic change to one area would look out of proportion or even feminizing to your face.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in some form of cheek augmentation. I have a concave portion of my face that I would like augmented. From the semi profile view, I find the circled area below may have missing volume. I found someone that had a similar shape in this area and had it fixed with fillers (photo under mine). I assume the jaw implant would have no impact on this area? Assuming not, do you think putting fillers there would be appropriate to get a similar outcome as in the photo under mine in this area?
A: The volume deficient cheek area to which you refer is in what I call the ‘trampoline area of the face’ which is a non-bony supported area between the cheeks and the jawline. No form of an implant will improve that area so an injectable approach needs to be done for that lower type of midface or cheek augmentation procedure.. If one wasn’t having surgery then a synthetic injectable filler would be used. But since you would be having surgery then fat injections should be done. While fat injections are unpredictable in terms of retention they are a ‘surgical’ choice and are better than having a known temporary synthetic filler placed. Fat may or may not survive. But at least it has a chance unlike any synthetic filler.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have chin asymmetry and am looking to get it corrected. I am a 31 year old trans woman who has been on hormone therapy for about a year. The hormones have significantly feminized my face, however one thing that has been “revealed” in the softening and rounding of the jaw/chin is that one edge of the chin appears to come down a bit more than the other. The jaw is even And the chin “point” is even, it just seems like theres a bit of excess bone on one side. It’s very subtle and the goal would be for no one to notice i had surgery. Please let me know what options you might recommend for going about this in a way thats conservative, and would not affect overall facial proportions (I don’t want a shorter or more rounded chin!, and also i have a somewhat larger nose and wouldn’t want to have a surgery that then required an additional rhinoplasty) Here I have attached some photos to help you get a better idea. All I want fixed is the larger corner of my chin so that it be brought into balance with the other side. I don’t want a chin thats any more “round” OR “square” than what I already have, if that makes sense? In other words, I don’t want anything done to the smaller corner/mid point of the chin. Let me know what you think. Thank you so much!
A: Thank you for sending your pictures. I can clearly see that the one side of the chin is vertically lower than the other side. Your chin asymmetry could be reduced without touching the midline or good side of the chin through an intraoral approach. In doing this from an intraoral approach it would be important to resuspend the mentalis muscle back into place since to get to the very bottom edge of the bone requires some soft tissue elevation. Coming from below through a submental incision makes the surgery easier from a technical and recovery standpoint but there is always the issue of the fine line scar under the chin to do so.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, For the past year, I have been having frequent sometimes heavy nose bleeds three to five times a week. I wanted to mention this to you. Is this a cause for concern going into rhinoplasty surgery? It usually stops easily if I pinch the bridge of my nose. I’ve noticed it is somewhat related to stress in my life.
A: Having a history of nosebleeds before undergoing a rhinoplasty does not preclude you from having one. Having them at the frequency of three to five times a week and being heavy in nature is a cause for some concern about what would happen after a rhinoplasty and having to manipulate your nose to stop the bleeding. This may have adverse consequences on the ultimate aesthetic outcome of the rhinoplasty.
Stress is not really a reason or cause of nosebleeds, there would have to be a more anatomic explanation. I would recommend that you have an evaluation by an ENT specialist to try and determine their source. You may or may not be able to do find a cause but it would be prudent to have that evaluation before undergoing any form of nasal surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’ve gotten a skull reconstruction cranioplasty done while on active duty following a stroke/craniectomy and I have 1) a concave dent on my left temple, 2) a bulging muscle underneath the dent (surgeon said the muscle couldn’t be reattached to the titanium plate, and 3) have an irregular protruding spot where the plate ends in my forehead, almost like it’s not fully connected to the bone, or the plate itself isn’t the right fit. Can plastic surgery fix this? Will it be a major operation, or dangerous? If so, do you think the benefits of the status quo outweigh the risks? Thanks
A: I would need to know two important pieces of information about your prior skull reconstruction surgery, 1) what type of cranioplasty was done and 2) a current 3D CT scan of your skull to fully know the anatomy of your skull and what the cranioplasty looks like and the area that it covers. That being said, most likely the corrective approach is going to be a bone cement only cranioplasty to recontour the area. I would not view this as a risky or dangerous procedure. Since you undoubtably already have a scalp scar the biggest aesthetic risk of such surgery is irrelevant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a brow bone reduction. Given the strong prominence of my forehead, and based on everything I have seen on Dr. Eppley’s website, my brow bone will probably need to be removed, reshaped, and reattached. If this is the case, how many days will I need to take off work and approximately how long will it take before there are little to no visual signs of surgery?
I still want a masculine forehead. I do think (based on editing the photos a little myself haha) that reducing the brow bone, and following the natural slope of my forehead, will still allow a little bossing in the brow region where it meets the bridge of my nose. Although not noticeable in the photos, my brow did not boss in the center between my eyebrows (though it may appear as such in attached photos) creating a hard “valley” between my eyebrows as if the frontal sinus did not fuse together properly during puberty (if that is even possible). Therefore, I am hoping the results of this procedure will (1) reduce the horizontal protrusion and in effect (2) eliminate the crevice in the center between my eyebrows.
A: Thank you for sending your pictures. I have done imaging to show what type of potential result is possible with a brow bone reduction procedure for you. It is very common to have the brow bone protrusion to be more evident on the sides as the air space of the frontal sinus is often not connected across the midline so the bone protrusion from enlarged sinus spaces is often less evident in the middle or globular region of the brow bones. Both of your brow bone reshaping goals are achievable.
The recovery from brow bone reduction is largely that of appearance. It probably takes about 10 days after surgery until one looks fairly reasonable and a full three weeks until one appears visually completely normal and does not have any signs of having the surgery. There are other physical issues that take longer to recover from such as forehead numbness and incisional healing but that is not an externally seen issue.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in scalp scar revision. This is a 37 cm by 2 mm scar by a hair transplant that was done 15 year ago. My main goal is to be able to cut my hair short so I can wear it like in the pictures without being noticed. It is slightly hypertrophic but more problematic is that it is white and that it is linearly straight. I have tried tattoos – it was not successful and injections didn’t help either. I would to see if we can revise this. How will you be able to handle the hairs that in and around it ?Would you be able to save the hairs? Thanks.
A:The only method that could offer any improvement is that of surgical scalp scar revision. The scar needs to be cut out in its entirety and then reclosed using either a straight line as it is or with a running w-plasty closure line. (preferred) Any hairs that are in the scar would be removed. Hairs that are around the scar would be preserved. I don;t know if it is every realistic that you can have the scar improved to the point where it would never be somewhat noticeable. Like all scar revisions, reduction in its appearance may be possible but complete invisibility is not a realistic goal.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am writing to enquire about chin lengthening surgery. I have a fairly round face which to me lacks length , I am hoping to achieve a more heart shaped appearance , I do not have a recessive chin although it is quite “round”. I’m not sure if that is the best way to describe it but I have attached pictures so you can get an idea of what I mean. Please would you be able to tell me if you feel I’m a candidate for this type of chin surgery.
A: What I see is that your chin is vertically short which makes your face overall more round in shape. A vertical chin lengthening procedure through an intraoral opening osteotomy will provide facial elongation and go a long way towards making your face more heart-shaped. In vertical chin lengthening the chin bone is cut and dropped down in a cantilever fashion so as to keep bone contact at the back end of the bony cuts. The vertical opening distance is maintained through the placement of a small spanning titanium plate. An interpositional cadaveric bone graft is used in the central part of the wedge for both stability and to expedite eventual bone healing into and through the gap.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley,I am looking to get double jaw surgery for functional reasons related to sleep apnea and I have been doing a lot of research on the aesthetic benefits that double jaw surgery can bring. I believe that if I am going to be getting double jaw surgery, I might as well maximzse the aesthetic outcome. I am currently searching for reputable surgeons to perform the surgery and your name cropped up as an aesthetically minded surgeon trained in both maxillofacial surgery and plastic surgery.
From an aesthetic point of view, there are two main issues that I am having trouble wrapping my head around, and they both involve counter-clockwise rotation of the maxillo-mandibular complex. The first is the position of the dentoalveolar portion of the maxilla relative to the anterior nasal spine and the paranasal area. In the first image that I have attached, you can see how the mouth area of the patient in the ‘before’ is set-back relative to the base of the nose. In the after, you can see how the mouth area was moved forward relative to the base of the nose, reducing the nasolabial angle and creating a forward sloping upper lip. Is this a result that is achievable with CCW rotation in the general sense (barring any other preclusions)? In other words, given that an aggressive CCW rotation is able to be performed on a patient, is that the result that one would expect?
My second question is whether or not counter clockwise rotation of the maxilla around the anterior nasal spine, and thus the movement of the maxilla and mandible ‘forwards’ and ‘upwards’, may be able to reduce the perceived distance between the stomion point and the subnasale point on the face. I surmise this because – with CCW rotation around the ANS – the subnasale point is remaining constant whilst the maxillary incisor tip and the stomion point is not only being moved forwards but also *upwards* relative to the rest of the face. So the linear distance between subnasale and stomion will remain constant, but the perception of the distance by the onlooker will be shorter because of the new angulation created between the two points relative to the true vertical plane. Is this an accurate appraisal?
A: There is a reason you ‘can not wrap your head around’ the aesthetic changes that may occur from a counter clockwise rotation of the maxilla and mandible in double jaw surgery…it just isn’t that simple. How the overlying soft tissues respond with the bony changes is not completely reproducible and may be somewhat different in each patient. While cephalometric and even computerized prediction tracings make it look mathematical, it often doesn’t work as predictable as it looks. It is important to remember that this is surgery on live tissue not a linear drawing on an x-ray. No matter how you choose to view it, orthognathic surgery is a ‘gross’ bony movement procedure and is not really amenable to be critiqued by smaller millimeter measurements or such precise external facial changes. In short it is more than just geometry of bone movements.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am wondering if surgery could correct my facial asymmetry? I have multiple scars across my forehead, most notably over my right eye. I lost skin and underlying tissue in the area and the eyebrow sits higher and at an odd angle compared to the left eyebrow. Due to the lost skin and tissue, the eyebrow and forehead area on the right side of my face are uneven with the left. I had a skin graft four years ago so that I could close my right eye, but there was excess skin from the graft which is noticeable when the eye is open or closed. Can facial symmetry be achieved in my case, and if so how?
A: I see three facial asymmetry issues that you have: 1) a higher eyebrow, 2) an eyebrow/brow bone contour deficiency and 3) excess skin of the eyelid. Lowering a higher eyebrow is very challenging to do and is often resistant to surgical efforts due to the fundamental loss of tissue and the tethering of underlying scar in your case. But that doesn’t mean it is impossible. I would recommend three specific procedures to offer improvement to your orbit-brow asymmetry. An upper blepharoplasty to get rid of the redundant skin from the skin graft, 2) release of the eyebrow and 3) placement of a dermal-far graft on the brow bone. (to create better contour and help the brow release)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have for a few years been researching rib removal for cosmetic reasons, but was unable to find surgeons doing this procedure. The only surgeon I found with information about this procedure said the rib removal alone would not make the waist look smaller. I found you when reading about the model having rib removal with you last year. Is removal of the floating ribs likely to make a considerable difference on a slim woman? Is it possible to receive more information about the procedure? Particularly about aftercare and risks, it is hard to come by legitimate information about this procedure. I understand that it is an extreme procedure, and you have probably received many messages about this procedure after the story came out. Is this a procedure you will do? How does a patient go forward with this? Is an in-office consultation necessary? I’m located in Europe. Other than being a motivated and healthy patient, what makes for a fitting patient for rib removal?
A: The best way to get the most accurate information about rib removal for waistline narrowing is by have a virtual consultation. My assistant will contact you tomorrow to schedule a Skype consultation. Rib removal with waistline training can successfully narrow a waistline in my experience of close to twenty rib removal patients. Those women who get the best results are usually the ones that are already fairly thin where the effects are seen the best. Please send me some pictures of your waistline and any examples of what you want to achieve.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, About eight years ago I had a jaw implant that I was very happy with the result. However, as I’ve aged and my face has lost volume, I’m interested in slightly increasing the implants to (slightly) widen my face. I understand that one option may be to insert a “chip” underneath the existing implant. Is this correct? If so, what is the recovery period? Many thanks.
A: What you are referring to is the concept of adding a wafer of material under an existing implant or even placing an overlay on top of the implant. The latter is usually more effective as its effects are more directly translated to the overlying soft tissues. For widening jaw angle implants which appears to be what you have, adding a wafer (shaved down implant) under the existing one would certainly be relatively atraumatic to do and would add just a slight bit of more width. However the complication rate is higher when two implants are stacked on top of each other. Thus while the wafer concept seems simple, it is probably better to just replace the jaw angle implants with new ones. This is really not much more traumatic than placing a wafer underneath them.i
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Please see CT scans for my current face bones of the right and left side. Also, photos before surgery and after surgery.
I went for jaw reduction but the doctor talked me into also having cheekbone reduction. The results were a strange shape face from the outside and deep burns from surgical instruments down my chin.
1. Please look at my CT scans and tell me what you can see has happened to my jaw bones.
2. Please look at my CT and tell me what you can see has happened to my cheek bones.
3. Please let me know if the cheek bones can be repairable and tell me the procedures to fix the cheek bones.
4. Please let me know if the jaw bones are repairable, also the procedures to fix the jaw bones.
Something has gone wrong from this surgery and I am looking for help.
Please kindly help or advise in any way, I really need help.
A: Thank you for sending your CT scans of the jaw and cheekbone reduction procedures you had done. What the 3D CT scan shows is:
1) Complete amputation of the jaw angles
2) Cheekbone osteotomies with wide displacement of the anterior osteotomies with no obvious fixation of the bones and a downward rotation/internal collapse of the cheekbones
Just based on the CT scan you would need the following for reconstruction:
1) Vertical lengthening jaw angle implants to remake the amputated jaw angles
2) Repositioning and plate and screw fixation of the anterior cheekbone osteotomies.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a plastic surgeon practicing in Slovakia. I recall that you place your buttock implants intramuscular…..I am seeing a patient soon interested in gluteal implants. If you have a moment I have a few questions for you since my experience was limited in buttock augmentation.
1. Must I have the tool that is used to split the muscle (pic attached attached)…..I don’t recall you using this tool…will a couple malleables, dever, and cautery work?
2. How long until you let your patients sit? Seems like a wide discrepancy in the literature.
3. I recall you using the incision technique according to Raul Gonzalez where the midline is depithelialized preserving the sacrocutaneous ligament….I will do the same.
4. How long until you let your patients sit on an airplane?
5. Do you place drains with the intramuscular approach?
6. How do you determine implant volume choice….do you use templates?
Thanks for your help!
A: Be aware that buttock implants are the hardest of all body implants to placed and when you do your first case you are likely to ask yourself why made you think it was a good idea to do this surgery. The other very important preoperative consideration is that the size of buttock implants that can be placed different dramatically from subfascial vs. intramuscular. You and the patient have to have a clear idea as to expectations. Intramuscular buttock implants will almost always be smaller than the patient wants, have a very long recovery and are very hard technically to do since there is no natural plane of of dissection. Subfascial buttock implants allow for much larger implant sizes, have a somewhat quicker recovery and are technically much easier to do. But to answer your intramuscular buttock implants questions:
- The duckbill dissector to which you refer is not absolutely essential as a wide malleable restractor can similarly be used. At at $850 for the instrument it really becomes non-essential.
- I let patients discomfort determine when they can sit…as they eventually have to do some sitting for certain functions
- Re-establishment of the sacrocutaneous ligament is essential in closure of the intergluteal incision.
- Same as answer #2
- There is no reason to use drains in the intramuscular buttock implant technique.
- With intramuscular buttock implants you are never going to get an implant in and satisfactorily covered with muscle over it that is bigger than 330cc. It just can’t be done. Your implant options are going to be either 270, 300 or 330cc. When in doubt choose the smaller implant size.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, The more I sit here the more I am feeling like I would just like to come and see you for a 3D CT scan of my face. The sliding genioplasty and lip issues is one thing but I am seeing marked asymmetry in my whole face (the one side literally looks like it is 1/2 inch out farther than the other side causing my cheek and jaw on the one side to be much much larger and lop sided.
To clarify what I had done:
Sliding genioplasty
Mid jaw implants
Back jaw implants
Cheek implants
Buccal fat removal
I know I would feel better if I saw you for a look over and a scan. My surgeon didn’t do a CT scan on me and claimed he did custom facial implants but from the very first day my one side has looked larger and it is now day 8 and doesn’t feel puffy – just hard like the implant yet it sticks out way way wider than the other side. I specifically asked for no width to be added to the face and for it to stay slim but I feel masculine and disfigured. Even if it just means taking things out for now I’m okay with it.
A: Having had all of these implants and bone work it would be very common at your early postoperative period to have facial swelling that was asymmetric. So I would not try to judge the symmetry of the results at this early juncture as that is really impossible to know. But if you really want to know how all the implants looks by position and size, then a 3D CT scan would answer those questions. As long as the implants are silicone they can clearly be seen on the scan. Medpor implants are much harder and often impossible to see. The sliding genioplasty of course can be seen very clearly. That is a scan you can get where you live. You just find a place to have it done and I can fax in the order to have it done. You do not need to come here to get the scan but can if you would like.
True custom facial implants require a 3D CT scan to fabricate but your surgeon may have been referring to just shaping standard implants at the time of surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting the masseter muscle reduction and the upper trapezius muscle reduction and I am looking for a more permanent solution. Here are a few of my questions…
– What to expect on results
– Recovery Time
– Healing and when can I leave to go back home to NJ
– Vitamins and meds to take to help with swelling and healing
Please also see my attached photos of a view of my side, front, and back and let me know if you need any more information from me…thank you.
A: Thank you for sending your facial pictures. In answer to your questions:
1) Surgical masseter muscle reduction is done through an intraoral approach by muscle release and electrocautery reduction. After surgery it would take a full three months to see how much muscle has been reduced. The trapezius muscle is done through an incision at the back of the occipital hairline. From this location a wedge of trapezium muscle is removed to reduce the raised contour of the line from the neck out to the shoulders.
2) Recovery time is based on swelling and level of discomfort. There is really no postoperative restrictions. The swelling of the jaw angles would be more noticeable than the trapezius and would take about 10 days before returning to its preoperative size and months before the final result is seen.
3) You could go home in 1 to 2 days after surgery, whenever you feel like traveling.
4) Vitamins are not helpful for the swelling. I will give you steroids during surgery as well as Medrol Dospak after surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Following a chin implant being removed via an intra-oral incision six years ago, I have lower lip incompetence and chin ptosis.Is it possible to have a successful outcome with mentalis muscle resuspension without inserting another chin implant? Also is it possible to achieve a good result with absorbable Mitek sutures as opposed to titanium screws?
Another doctor has advised he would insert another small chin implant and use titanium screws. I’m not comfortable putting another chin implant in or with titanium screws in my chin.
A: One can certainly have a mentalis muscle resuspension surgery without placing a new chin implant. But the success of the procedure drops when the lower chin support provided by a new chin implant is not added. This does nor mean that it can not work just that the long-term success rate will be lower.
Mitek absorbable bone anchors are my performed method of mentalis muscle resuspension. They come with an indwelling bone device (anchor) that is composed of either a small piece of metal (nitinol) or a reservable polymer composition that takes 6 months to go away. The sutures attached to the bone anchors however are permanent.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like to schedule an appointment to have something done to my undereye wrinkles. I have attached pictures of me smiling and not smiling and you can see the big difference as to how many undereye wrinkles occur when I am smiling.
A:Thank you for sending your pictures. Under eye wrinkles either are only present when one smiles or becomes much worse when one does smile. (have them at rest) Lower eyelid surgery really treats excess skin and wrinkles when one is not smiling. It is really an operation that treats a static problem since that is how the surgery is done. (patient not moving/smiling) More dynamic undereye wrinkles are treated by Botox injections as this injected agent treats a dynamic problem through muscle weakening. In other words, if your undereye wrinkles are mainly present when you are smiling that is a non-surgical Botox injection treatment issue. However, if a lot of undereye wrinkles are present when one is not smiling, and gets much worse when one does smile, then lower blepharoplasty surgery would be the most effective treatment. It is also important to point out that no treatment will completely get rid of undereye wrinkles, they can only reduce the number seen.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a skull widening procedure.I have a narrow skull/ head and was wondering if its possible to widen the sides of skull and forehead with Alloderm instead of implants? Im not comfortable with implants and was hoping instead that Alloderm could be used for such large areas. And if alloderm can be used for skull/head widening, does screws need to be used? Thank you.
A: While Alloderm can be placed on the sides of the skull for augmentation, there are several problems with its use for that application. Beyond the sheer cost of Alloderm (the material alone would probably costs $15,000 to $18,000 for a skull widening procedure that is at least 5 to 7mms thick) the material has a low propensity for persistence and a relatively high incidence of infection when stacked in layers which it would have to be for any skull augmentation procedure. I don’t think the use of Alloderm is a viable option for a skull augmentation material. If you are looking for a more ‘natural’ skull augmentation material, injected fat would be the most viable option as long as one is not looking for any major volumetric change.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, What is the maximum amount of projection in mm that off the shelf submalar cheek implants can give and how much projection can custom implants realistically give? I am looking for a pretty decent amount of projection in order to give me a more rounded apple cheek look.
A: The submalar cheek implant is designed to elect and reposition soft tissue in an anterior and superior position. It adds some lower mid facial fullness and may have a mild effect on softening the depth of the nasolabial fold in some patients. It can create the so called ‘apple cheek’ look which is usually more of a desired feminine facial trait.
In theory there is very little limit as the midface soft tissues can stretch fairly significantly. The only real limit is the thickness of the soft tissues ands can a competent and tension-free intraoral would closure be done. Standard submalar cheek implant sizes range from 4.5 to 6 mms. I have made custom cheek implants with up to 8mms in thickness in this area. Whether you would need more than 8mms would require an analysis of your pictures and computer imaging of your projected results. I would not think that you would as a general statement as a few millimeters in this facial area has much more powerful efefctr than one would think.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in arm lift surgery. I have attached two pictures for consideration of my possible candidacy for brachioplasty which I think is the formal name for an arm lift. There is loose skin on my forearm that I am interested in addressing as well. I am 20lbs. from my goal weight. Please let me know if you deem me qualified for arm lift surgery.
A: Based on your pictures If there was anyone that would get a lot of benefit out of an arm lift procedure, it would certainly be you. Removal of your large arm ‘bat wings’ would make a tremendous difference in your upper arm appearance as well as being able to get into clothes. Given the size of your arms, whether you have the procedure at your current weight or lose the additional twenty pounds, does not make any difference in the outcome of arm lift surgery. While loose tissue can be removed from the forearms as well at the same time, the tradeoff of the scars to do so must be considered very carefully. So called forearm lift scars are much more visible and do not do as well in appearance as upper arm scars do.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in rib removal surgery. I have a deformity on the bottom edge of my rib cage. It is on the front left side and it is about 2″ by 2″ in size. I was wondering if it would be a bad idea to have that deformity removed or to just leave it be. It does bother me functionally and causes mild pain on and off. The deformity is the result of a rib fracture (I believe chostochondral separation) that happened back seven years ago. It took a while for the deformity to develop but it seems to be permanent. Thank you.
A: With a history of trauma and a costochondral fracture/separation, what has happened is the development of excess cartilage/scar tissue at this bone-cartilage junction. This is the moveable part of the ribcage which is why it gives you some periodic discomfort. Whether you should have this area of the rib resected is a personal decision based on your level of both aesthetic and functional discomfort. Removal of the enlarged and protruding rib junction would be the treatment for it. Such small rib removal is done through a small incision directly over it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, My problem is the buttocks augmentation I did 10 years ago with permanent fillers. The plastic surgeon did an awkward shape, he filled the flanks and the upper buttocks, which as a consequence made may back look shorter. Before buttocks augmentation, I originally have shorter torso comparing to my long legs, even though, I used to have a proper and slim body. The permanent fillers are made of silicone. It is called pure gel if you have heard about it, it is made in the USA and it is banned now in my country. The problem about these fillers is when trying to remove them from the body, the body get infected. A friend tried to remove them and when she did the skin where the fillers were injected got burnt and became dark. She got a fever for almost a month and was taken to the hospital for treatment. If you have any background information about this kind of fillers and the proper way of removing them with out any side effects please advise me.
A: When it comes to trying silicone removal from prior oil injections, there is no approved injectable silicone filler in the U.S. of any kind. The removal of silicone oils are all problematic, have a high risk profile and there are no ‘proper ways’ to remove them since there are not supposed to be used for this aesthetic purpose. Like any form of a permanent synthetic filler, they can be very difficult to remove later.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Hi! i have been interested in vertical chin lengthening for awhile and I came across your site and liked your work. My chin is horizontally deficient but the vertical length bothers me the most. When I push my chin down about 5mm to 7mms I like the way my face looks. I understand you cant tell me if a sliding genioplasty is better than an implant without examination but what are the pros and the cons for each? I also like when my chin comes to a point, (a “v” line so to say) is that possible to achieve through surgery? I have pictures attached if that helps. Thanks!
A: When it comes to vertical chin lengthening, an opening bony genioplasty with an interpositional graft is best for most patients. This is a variation of the more well known sliding genioplasty. This is particularly true when the opening is 5 to 7mms. As the chin comes down and slightly forward in our case it will make the front part of the jaw look more narrow or v-shaped. Whether this will make your whole jawline look that way I can not say since you only provided a side view picture.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m interested in the custom midface implant (that looks like a “mask”) you’ve recently fabricated and posted about on your Explore Plastic Surgery blog and I’m also interested in a procedure to change the width of my lips. However, I have some questions about both procedures :
For the custom midface implant :
1) Can the portion of the implant that covers the infraorbital rim area be extended to cover the zygomatic arches?
2) Can the implant design be modified to cover the sides of the maxilla at the point where a hypothetical vertical line from the pupils and a horizontal line from the sides of the alar bases meet?
3) Can the portion of the implant that covers the infraorbital rim area be extended to cover the lateral orbital rims? If this design modification is possible, how is this going to affect the lateral canthal positioning? I struggle to see how the lateral orbital rim can be sagitally advanced without altering the lateral canthus because the lateral canthus is attached to it.
As far as lip widening is concerned , from the information that I’ve gathered online I think that a lateral commisurotomy is the best way to achieve a wider mouth appearance but I was also wondering if PermaLip implants can successfully widen the lips. What do you think?
Thanks a lot !
A: In answer to your custom midface implant questions:
1) Yes
2) No
3) Yes. The lateral canthus is attached inside the lateral orbital rim, not on the outside.
4) Permalip implants will NOT create a mouth widening effect.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in chin (vertical chin lengthening) and jaw augmentation surgery, particularly, adding vertical length by means of a sliding genioplasty. I have an overbite, however, I consciously usually just move my jaw forward so that is is properly aligned so I have included 3 pictures in which you can see the overbite and 3 pictures in which my jaw is in a normal position. My goal is to increase vertical length of my chin/jaw and perhaps add an appropriate amount of horizontal projection in order to have a more square jaw appearance as well as a less rounded face look. In terms of how many millimeters can be added vertically, about how many mms do you think would be possible or how many would you suggest?
A:Thank you for sending your pictures and doing the ‘surgical simulation.’ By moving your jaw forward you are creating a surgical type result of the chin through vertical chin lengthening. That would be the approximate effect on the appearance of the chin as moving the jaw forward provides a vertical chin lengthening. The amount the chin should be vertically opened is determined before surgery by measuring the distances between the upper and lower teeth as you go from having them together to the desired position of the jaw that creates the look you like. In most cases of vertical chin lengthening it is usually about 8 to 10mm of opening the chin osteotomy centrally to see a very noticeable chin appearance change in my experience. Two caveats about vertical chin lengthening and its effects on the appearance of the jawline. First it will not make the chin more square since it is just the natural chin shape that is being moved forward. Second, the appearance of the jawline will not change like it does when you bring your jaw down and forward too simulate the effect of vertical chin lengthening. Such a maneuver moves the entire jaw down which is not creates when you surgically just vertically length the chin.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, This is a general surgeon who practices in Iran whom I personally know. He asked me to correct his skull deformity. However I do not perform those procedures in my practice. I heard that you may be doing this kind of procedure. If so, can you guide me your process, so I can let him know. Again, he will be traveling from Iran.
A: I routinuely treat flatness of the back of the head using a custom implant approach from a 3D CT scan. The implant is placed through a low occipital small horizontal scalp incision in a simple 90 minute procedure. The amount of augmentation that can be obtained in a single stage skull augmentation depends on how much the scalp can stretch and is usually in the maximum rage of 12 to 15mms. But don’t let that number fool you as the effects of the implant are more impressive than just the number because of its surface area coverage. The manufacturing process takes about 3 to 4 weeks to get the implant ready for surgery. It is computer designed from the 3D CT scan. Patients can get the 3D CT scan in their country of origin and then just send it to me. They only need to come in one time for the surgery. The logistics of surgery care that the patient comes in the day before the surgery, has the surgery the next day and can return home in 1 to 2 days even for international patients.
For some patients who can not get a 3D CT scan, I do have ‘standard’ occipital skull implants that I occasionally use which actually come from other patient implant designs. (The shape of the back of the head is not all that different amongst some people)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley I had sliding genioplasty / buccal fat removal / jawline implants and cheek implants all done at once one week ago.mI understand I am very swollen and still healing but I am having severe issues with my smile mainly my lower lip and I would like a second opinion on it. My surgeon wants me to wait but from my reading I believe waiting could be a bad idea.
Before surgery, I loved my smile and it was my best feature. Now due to my sliding genioplasty my lower lip is tucked in too high and inwards to my lower teeth. Instead of a nice curve it is flat and tight. I can’t smile or talk properly. It almost feels like the surgeon placed the stitches too high and fixed the lip in a weird position. I would like your opinion on whether or not this should be reversed or if there is another option such as releasing the stitches from where they are placed.
My lower lip is continuing to tighten and cover up my upper teeth. Even tonight it has gotten worse. I can move the lower lip outward and inward but it will not move down at all and is covering more and more of my smile by the hour. If I could describe it, it feels like the stitches are placed too high on my chin/gum and it’s locking the lip into an unnatural position of laying flat/straight over my teeth. I feel like I jus want to get in there and snip the stitches to release it. My lower lip is laying flat across my teeth and ruining my smile. I can’t even physically move the lip down by pushing with my fingers to curve the way it did prior surgery due to how it’s secured in place. I can barely get a spoon into my mouth or talk because it’s locked into position so high and worsening. It very obviously has moved the resting position of the lip where it feels like it is being pushed up by an implant but I had sliding genio. It now curls in and tucks under my upper lip and sits much higher on my teeth making me look toothless on the bottom. It literally feels like there is just too much lip and it can’t move out of the way for my teeth. I can feel it held into position with the stitches that aren’t letting it free. I don’t want to wait to see if it resolves I just want the stitches in the front/chin released so they can move freely and then to do rehab with my lip to regain mobility and a normal bottom lip curve.
A: Thank you for sending your pictures. I see nothing unusual, both visually and in the pictures, in your early sliding genioplasty results. That was clearly the correct procedure given your very severe horizontal chin shortness. It is important to understand that this procedure takes apart the chin muscle to be able to cut and move the bounce and then puts ti back together at the end. This combined with the stretch of the tissues from the bene advancement will make the lip feel very tight and your smile is not going to be normal for awhile. I have no knowledge of what preoperative education you were provided but what I tell all my patients is two things. 1) Surgery is not ‘instant oatmeal’. You are changing your natural tissue relationships and this is by very invasive trauma to those very tissues. This is going to cause a lot of distortion and it can be very psychologically disturbing in the early recovery process particularly in young patients. 2) Recovery is a process of months not weeks. It will take a full three months for recovery to be complete from the procedures you have had done.
That being said I would agree with your surgeon that staying the course and allowing the recovery process to unfold naturally would be the prudent course of action.
The only remote question I would even think about at this point is whether the chin may be advanced just little further than your chin/lower lip tissues ‘like’. That can cause a lot of chin and lip tightness in big advancements. But I don’t know the actual number of millimeters your chin was advanced.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in jawline augmentation.I’m really curious what is possible in my case and what procedure is needed to realize it. In my side picture, it might be a little hard to see because of the beard, but when I bite my teeth, I have a receding chin. On the front picture, it’s a bit odd, but my facial shape is quite narrow. This combination for me results in zero jawline definition, a double chin and an unbalanced face from both the side and front view. I really hope you could help!
A: Thank you for your inquiry and sending your pictures. Even with your beard in side profile, it is clear you have a very short jaw and a narrow jawline resulting in a thin v-shaped face with a convex profile. As part of this type of facial development your cheeks are also correspondingly flat. To adequately correct your facial shape a jawline augmentation can be done using either a custom jawline implant or you could have a combination of a sliding genioplasty with jaw angle implants. Your cheeks can be addressed using cheek implants that provide a high malar augmentation with an infraorbital extension.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in doing the scarless temporal reduction surgery in the next year. I am a 35 year old male with a normal sized face but large head – 58 cm circumference – which seems mostly due to protrusion above the ears from temples above the forehead back to the end of the skull. The sides of my head become sore if I wear glasses for a long time and hats tend to be tight.
I have had a few questions regarding the procedure:
1) what are the requirements for anesthesia and how long is the surgery?
2) based on the description, can I expect to have a good result? will the change in head width give a noticeable impression of a smaller face/head?
3) what are the potential side effects both functional and cosmetic you have seen in the past even if the chances are low?
4) will removal of the temporal muscle lead to drooping of the skin in the lower part of my face due to volume loss at the head?
5) what is the cost?
6) what are the pre and post operative considerations and requirements?
7) how many of these surgeries have you performed?
Looking forward to your advice!
A: In answer to your questions about temporal reduction surgery:
- Surgery is about 1 1’2 hours and general anesthesia is a requirement for it.
- Temporal reduction reduces the width or convexity of the side of the head. It would not have any effect on the face.
- I have seen no adverse side effects in any patient. The only questions is whether the result meets the patient’s aesthetic goals.
- Removal of the muscle does not cause a skin droop.
- My assistant will pass along the cost of the surgery to you.
- There are no special before and after surgery requirments or tests needed
- I invented this head reshaping procedure and have performed over 50 of them
Dr. Barry Eppley
Indianapolis, Indiana
