Your Questions
Your Questions
Q: Dr. Eppley, My question is what should type of chin procedure do I need to get the best possible aesthetic result. I had double jaw surgery six weeks ago, and also a medium size silicone implant placed intraorally and fixed with 2 screws. I think most of the swelling is gone now. I’m noticing that my mentalis muscle is acting up again, especially at the bottom of my chin. I thought the implant as well as reduction of my vertical maxillary excess and lower jaw advancement would have resolved the mentalis strain completely. The bumpy appearance is much better than before I had the implant, but I’m unhappy with any dimpling, and am worried that it will return in full force eventually. I also think my chin implant projects too far forward (for a female) and it looks too high. I would ideally like my chin to taper to a slight V in the frontal view rather than the flat U I have now. I also noticed my lower lip looks really asymmetric post-surgery, wondering if it has to do with the implant? What would be the best course of action? Reposition or replace the implant? Fillers? Botox the mentalis? Sliding genioplasty? Thank you for your time and consideration.
A: While an implant offers the simplest approach to chin augmentation, it is usually not ideal in the face of a functional mentalis strain and can produce an aesthetically undesireable widening in a female. From your profile picture, I would agree that it seems too highly positioned which can also place a strain on the mentalis muscle.
For substantative improvement, it now appears that the implant should be replaced by a sliding genioplasty whose dimensional movements I can not say just based in these pictures. That would not only improve the mentalis muscle position but the chin could be narrowed in the frontal view with a v-line reduction technique as well.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I read literature online that (if I comprehended it appropriately) that a sliding genioplasty can relapse. Meaning, the chin advancement goes back to the original placement over time. Is this really true? Also, can bone resorption and/or bone remodeling in the long run take away from the aesthetic appearance achieved from the initial sliding genioplasty procedure? I thought the results of this procedure were supposed to be permanent. Let me know what your thoughts are.
A: If a sliding genioplasty is rigidly plated into position, theres is zero chance of relapse. You are referencing old chin fixation techniques that only used wire fixation which are far less stable. While I doubt they could even then relapse back to the their original position, they were less secure the further the chin was advanced.
In extreme or large amounts of chin advancement (10mms or greater), bony remodeling may account for a negligible amount of reshaping over the pogonion area of about 1mm. This is not aesthetically noticeable.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, over a decade ago I approached a surgeon as my upper lip did not raise well when smiling and my appearance was edentulous and a little tight when I smiled. Rather than the more typical bull horn type sub nasal lip lift procedure, the surgeon performed an operation that he designed to raise the complete base of my nose and debulk the premaxillary area. He did this by taking a full thickness crescent of skin from the floor inside the nasal vestibule of each nostril as well as segment of the nasal spine lifting the nasal base and sill into the deficit on closure which also closed the naso labial angle. By lifting the nasal base the columella was slightly rotated inward. This left me with a flatter lip which gives the impression of being overly long rather than shortened. I understand that the current wisdom is that this is not surprising. For some reason it also left me with difficulties in balancing the facial expressions involving the central elevator muscles which seem unrestrained or supported seemingly due to the missing bulk of the premaxillary soft tissue. The result has been a hyperactivity of the depressor alae or alae nasalis pulling my nasal base and lip downwards (see attached pic) and my impression is that this is in compensatory opposing the levator labii muscle or alaequa nasi. I had Restylane injected into the premaxillary area some time ago which very temporarily helped moved the central lip forward rather than downwards looking noticeably odd. I believe that the original incision needs releasing to allow the nasal labial angle to fall back into place for the best function and cosmetically (ie a de-rotation). I am unsure how to proceed or better describe the subjective problems I have and any advice or help would be welcome. If I were to describe this in more approachable terms I am trying to lower the base of my nose to its previous position by nasal spine augmentation and soft tissue repositioning / release.
I have attached some pictures pre- and post- op which demonstrate the difficulty I have in expression and smiling. I am hoping that you might be able to offer operative help or advice.
A: Certainly the operation you had done was unusual and predictably problematic. The question now, however, is how to reverse its effects. The fundamental problem appears to be a scar contracture/tissue loss at the nasal base/spine area. I would agree that the original incision and underneath it need releasing but that alone would not be adequate as it would just scar back done. It would need to be filled/augmented (premaxillary augmentation) and that is probably best done by a dermal-fat graft not an implant. You need biologic tissue that can fill the released space and not just turn into hard scar. You could do the same thing with injectable fat grafting but it would take several injection sessions to achieve a good release and tissue fill. This is better done by an open approach and en bloc tissue grafting
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m having my cheek implants removed later in the week due to an infection. Just wondering, will there be an excessive amount of swelling like when I had them placed in or will the amount of swelling be more limited this time round? Also, I’ve had them in for a year and will be replacing them in 6 months. In the meantime though, should I expect any damage or deformity from their removal? Lastly, I will be having some fat grafting done to my brow ridge. Will there be a lot of swelling associated with fat grafts to that region? Thanks for taking the time to answer my queries and it is much appreciated!
A: Removal of cheek implants is associated with far less swelling than their initial placement. Letting the tissues settle down and replacing the implants months later is not associated with any damage or deformity issues. Fat injections to anywhere on the face do not cause much tissue swelling.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am 42 years of age and have suffered all my life with what people around me have described as a square head. The head isn’t misshaped at the side or the back but is flat on top with a bit of a bump in the centre of the top. This has made all hair styles very difficult throughout my life and has affected me severely.
I wanted to know the following:
1) Is there any surgery available for this type of head shape?
2) How long would such surgery take and what kind of recovery is involved?
3) What are the results of such surgery?
4) What are the risks of this skull reshaping surgery?
5) Can you show images of what the likely results will look like before surgery?
A: Based on your description, it sounds like you need a convex augmentation across the top of your head for skull reshaping. In answer to your specific questions:
- Skull reshaping by onlay augmentation is a common surgery to buld up
- It is a 2 hour surgery under general anesthesia with about a week recovery at longest.
- The results of such surgeries are always successful in terms of improvement.
- Besides a fine line scalp incision needed to perform the surgery, the risks are generally aesthetic…shape and smoothness of the augmentation.
- I would need to see a front and side view pictures of your head to do predictive computer imaging.
Dr. Barry Eppley
Q: Dr. Eppley, I need your assistance with helping my doctor “get it right” when it comes to my jaw implants. Last year I had jaw angle implants placed which were lateral ones and they were the largest ones by Implantech. I then developed an infection on the right side and then I got one side taken out and then I was booked into have it reinserted two weeks later. However I found that although I loved the size of the implants it was the swelling that I enjoyed. So I asked my doctor when he put back the implant that I would like bigger implants. However he told me there were no larger sizes so what he did was simply place silicone block between the jaw bone and the current implant to push the jaw out more. Months passed and then I had another operation because what happened was that the silicone block was pushing out the contours on my cheeks and simply producing a very fat, large, round looking face. So the next operation involved cutting a portion of the implant between the jaw and cheekbone (near the ear) so that my face would ” dip in a bit”. I let that heal and now I’m still not happy with my jaw. Although it is okay I find that I never have reclaimed that lovely square contoured look I wanted when it was swollen from the first time I had it done.
So what my doctor has decided is to place Medpor instead of silicone during my next operation. He says that Medpor looks and feels more like bone and will produce a more better shape especially since i have thick soft tissues. He showed me the catalogue and i think the biggest one was 11mm. However I’m not sure if this time round it will work. I think my current implant combined with the silicone block is a lot bigger in width compared to the Medpor. Is Medpor better in my case? Will it give me more of a chiseled look? I’m concerned that my doctor isn’t looking into vertical augmentation as well.
A: When standard sized jaw angle implants are not sufficient because of their size or shape, trying to modify them or adding to them is usually not a satisfactory solution unless the changes needed are relatively minor. This is where the role of custom jaw angle or jawline implants have a very valuable role. Made from a patient’s 3D CT scan, implant dimensions can be made that best suits the patient rather than standard sizes that are made for ‘average’ amounts of facial augmentation.
Medpor does not look or feel more like bone than silicone. That is a completely false statement. More relevantly, any implant dimensions offered by Medpor are not really much different then silicone particularly in width.
Once you have been through two jaw angle implant surgeries with still unhappy results, you have to choose a different approach. Without taking a custom implant design approach, you would be best to leave what you have alone as continuing to use standard jaw angle implant sizes and shapes will still ‘not get it right’.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a nonsurgical injectable rhinoplasty last year but I believe the effect might be over. My question is do you think I should consider rhinoplasty because of the projection of my tip when I laugh and my bump on nose. Or should i just get another nonsurgical rhinoplasty because the tip is bothering me. The problem is my nasal profile from side could be adjusted with injection of the but it doesn’t do anything to the tip and it droops or falls down when I laugh. Please let me know thanks
A: I believe you have really answered your own question about the decision for a second injectable rhinoplasty vs. open surgical rhinoplasty. One of the benefits of any type of non-surgical aesthetic treatment is to determine if its effects can produce an equivalent result as that of surgery. While an injectable rhinoplasty can provide augmentation to a low radix or bridge of the upper nose, it will have no effect on any other areas of the nose other than that of an illusory effect on the overall nose shape. It will certainly not have an effect on an overly dynamic nasal tip that pulls down with smiling or laughing. Thus, some form of surgical rhinoplasty is the only treatment that can treat both both the bridge and tip problems.
A surgical rhinoplasty for you would augment the bridge with either an implant or cartilage graft and resection of the depressor septi muscle if the only tip issue is its downward pulling.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, my clavicles on both sides stick up. Have you dealt with this surgery before – do you recommend anything (would deltoid implants resolve this)? I don’t want huge shoulders, just bones not so prevalent and I don’t want scars. Appreciate any feedback.
A: I have seen and treated prominent clavicles before and they are not rare. From an anatomical standpoint, the clavicle or collarbone is the only long bone in the body that lies horizontally as it connects the medial sternum to the lateral scapula. The knob at the acromial end of the bone can be felt in anyone but in some people this bony bump is very prominent as a bulge underneath the skin on top of the shoulder. This occurs due to either more bone in some people or less surrounding fat in others.
Cosmetic camouflage can be done by bony reduction by burring but this creates a scar which you have eliminated as an option. Deltoid implants are not appropriate for camouflage as this type of implant fits over the larger muscle belly of the deltoid which is more to the side of the shoulder. The only scarless treatment option would be injectable fat grafting. Since a thin fat layer is one reason why a prominent clavicular knob is seen, fat grafting around the knob and out into the deltoid muscle belly provides the best treatment option. While fat graft survival is unpredictable and survives least in areas of thin fat with tight overlying skin, it is the one true scarless camouflage method. What may be helpful is deltoid augmentation by fat grafting not implants.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, what scar revision procedure would you recommend to help improve this widened, red/pink, rough, indented scar above my upper lip? As you can see, the mustache hair follicles were killed in the car, so there is no hair growth. It is a year old and seems to be done improving on its own. Please help.
A: Your upper lip scar, as you know, is wide, indented and hairless. Fortunately it lies in a near vertical direction which is a perfect orientation for a straight line scar revision. The existing scar needs to be cut out and hair-bearing upper lip skin brought together after removing the indented scar. This brings healthy tissue back to healthy unscarred tissue. This alone may be sufficient and will make a big improvement. Depending upon beard hair growth around the scar afterwards, a few hair transplants could be done if there is not good hair density across the scar. But you don’t want to do any hair transplants before formally removing the scar as that would never look as good. This type of scar revision is an uncomplicated office procedure done under local anesthesia. By removing the lip scar the surrounding beard hair will be closer together and the lip depression removed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a revision rhinoplasty that lengthens my nose. I had a rhinoplasty several years that ended up shortening and lifting my nose too much. This is not a good look for a man. I have read that the best way to do the procedure is with cartilage grafts and the rib may be the best source if substantial lengthening is needed. Does the rib graft make the nose feel any different such as being very rigid?
A: When considering revision rhinoplasty for tip lengthening and derotation, it is important to understand the anatomy of the nasal tip cartilages. The nasal tip cartilages are the only structures in the nose that are ‘free floating’, they are not attached to the underlying septum or upper lateral cartilages by fixed rigid attachments. This is why one can move the tip of the nose around freely and it is compressible, unlike the upper nasal bones or cartilages for example. When any tip lengthening procedure is done, which requires cartilage grafts, by definition more structural support is added and it will become more rigid. It will never be as soft and compressible as when it has less cartilage support. How rigid it may become is a function of the type and amount of cartilage grafts that are needed and how they are placed.
The cartilage grafts needed for significant tip lengthening/derotation must be placed between the fixed structures of the nose and the free floating tip cartilages. This is the way you drive down the tip of the nose. In essence, you are building up the underlying support to push out and down the tip. The grafts can not merely be placed on top of the nasal tip cartilages, that is only effective if you need just a few millimeters of lengthening or derotation effect. To really be effective for tip lengthening, straight pieces of cartilage are needed that are placed in an almost tripod fashion behind the tip cartilages. The use of a rib graft ensures that an adequate amount of cartilage is available.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in removing my breast implants and doing fat grafting as a replacement. I’ve had two children and after their births, I lost a lot of volume and my areolas stretched quite a bit. Currently, I have 350 cc saline implants making me a full C-cup. I was hoping to get a donut lift with areola reduction and fat grafting. I don’t expect to be a full C-cup again but what type of volume replacement could I expect?
A: While breast implants can be ‘replaced’ with fat grafting, it is important to appreciate several concepts about breast fat grafting. The success of any fat grafting procedure is dependent on the amount of fat one has to harvest and how much of the injected fat survives. Each part of the fat grafting process has a depreciating value. This means for example if 1000cc of fat aspirate can be harvested, when it is reduced (concentrated for each injection) the amount of fat available for grafting will be 1/3 to 1/2 of the harvest. (1000cc = 500cc) When the fat is injected only a percent of it will survive. While that percent can be quite variable for each patient (0 to 100%), let us assume the average take is 50% of the injected fat. (250cc) When you do this math for each breast, the final volume replacement of a 350cc implant will be 125cc of fat volume. (and this assumes that you would have 1000cc of fat to harvest) So you are correct in assuming that you would not be a full C cup with fat replacement but more likely a small to medium B cup. Thus it is easy to see that replacing implants with fat grafting is not close to a 1:1 exchange and the trade-off for a natural replacement will be loss of 50% to 75% of what the implant volume provided. Of course it is also possible that you may have greater than a 1000cc fat aspirate obtainable and then the volume replacement will be somewhat better.
Dr. Barry Eppley
Indianapolis, Indian
Q: Dr. Eppley, My problem is that my jaw line is low which gives me a rectangular/long face look. But honestly I don’t really mind that… I prefer having a softer angle. Mine is really low. If it was higher it would be good. But I’m wondering if you can actually do this surgery in several appointments? Like each time cut/thin off a tiny bit of the bone, so that it’s safer and faster… Honestly i’m scared that the results will be too drastic.
A: On a practical basis, you would really only go through a single jaw angle reduction procedure….and be certain that it is not too radically done. It is possible to do it in stages, and there is nothing wrong with that approach (and might end up that way anyway with a conservative reduction and if you like the improvement and want more), but most patients would only want one surgery. But the key in jaw angle reduction in general is too simply not over do it. It is somewhat easier to do more than to add back. Whether the jaw angle reduction procedure takes off a little or a lot, its safety, time to do the surgery and recovery would still be the same.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am seeking Facial Feminization Surgery (Rhinoplasty, Lip Lift, Chin Implant, Trachea shave, Brow shave). Please let me know if I am a good candidate. I am very serious/committed to doing this. What is the lead time between consultation and scheduled operation typically?
A: My definition of an ideal candidate for Facial Feminization Surgery (FFS) is a male who has the greatest chance of making a successful gender transformation based on their existing facial features. I would say you are about as ideal as it gets because you have a soft small thin face with a less distinct facial skeletal structure. With a few changes you would look quite feminine. The procedures you have chosen are the ones that I would agree are the only ones you need to make for a very successful FFS result. I will work on some computer imaging of these changes and get them back to you tomorrow.
As a general rule, I try and get patients into surgery as soon as they would like to have the procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’ve been reading about various types of facelifts and have a couple of questions and comments.
Questions:
1) Will he be tightening the muscles beneath the skin as well as cutting away skin?
2) Where will the fat injections go? I don’t want to look like Kim Novak did at the Oscars this year—so bloated my head seems too large for my body.
3) Can you send me pictures of previous facelifts you has performed on other people?
Comments:
1) I am not wanting to look 25 or 30 but to go back 10 to15 years would be nice.
2) I’ve attached 4 pictures of what I looked like from 1985 through 2005. I hope you’ll be able to get me back to 2000.
A: In answer to your queries:
Questions:
1) The only muscle that is tightened in a facelift is the plastysmal muscle in the midline of the neck. The SMAS layer on the sides of the face, which lies above the muscle, is lifted and tightened.
2) The only place fat injections go are in the nasolabial folds and the cheek pads.
3) There are many before and after pictures of facelifts on my website.
Comments:
1) Most facelift patients do turn the clock back by about p to 12 years. But it is important important to understand that a facelift only affects the neck and the jawline…and has not affect on the mouth area. To affect other areas of the face, other procedures needs to be added to areas such as the eyes and mouth. It is a common misconception that many people confuse a facelift with a more comprehensive total facial rejuvenation of which a facelift is just a part of it.
2) Whether you can get back to what you looked like in 2000 depends on an understanding of exactly the facial areas you want to improve and what procedures you want to do to get there.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Will a sliding genioplasty improve my lip incompetence? I would like my chin moved forward. My chin also looks long when I force my lower lip up to close my mouth. Would a slight vertical reduction be beneficial as well? First picture shows my lip incompetence (my teeth are touching) and second picture shows the increase in vertical length. Thanks for your time.
A: Besides a change in the horizontal position of the chin, you are describing what a sliding genioplasty can do really well…vertically shorten the chin and improve lip competence. By bring the chin forward and making it vertically shorter, the position of the mentalis muscle is changed and an upward push occurs on the lower lip. Together this produces improvement or complete elimination of any non-iatrogenic lower lip incompetence problem. It is now just a question of the different millimeters of movement, how much horizontal movement (probably 4 to 5mms) and how much vertically shorter (probably 3mms) in just looking at your profile picture.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have researched the Brazilian But Lift procedure for quite awhile and have been to two doctors for consultation. One discussed the Aqualipo option but they could only show me two pictures and the results were slight. I have attached some photos of myself to give you a better idea and to see if it is feasible. I do want a noticeable result–the more the better! Lastly, I am getting married at the end of the month and will leave immediately on a cruise. I am trying to find the most feasible option for me right now to where I could be healed up enough for the honeymoon, possibly a surgery date the first week of June. Thank you for your time!
A: Based on your pictures, I could not see you getting a significant buttock augmentation effect with fat injections alone. (Brazilian Butt Lift) You have to have enough fat to harvest to inject and then there is the variable of how much of the injected fat will survive. Between these two issues, you are more likely than not to end up with a moderate augmentation effect at best. While everyone’s definition of a dramatic outcome is different, my experience is what most patients want as dramatic is not what you would be able to achieve. Unless you combined the fat injections with an intramuscular implant, I do not see a dramatic result occurring.
That issue aside on a realistic basis, it would be very close to having this kind of procedure and being ready to go on a honeymoon (and enjoy it) just three weeks after the procedure. Six weeks of recovery is best in advance of this type of body operation. The liposuction harvest portion would be extensive (you would need every cc of fat you could get) and your body will be enduring a fair amount of trauma in so doing.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a recessed chin (no overbite as orthodontics aligned my bite) and a very deep labiomental crease. My question is, am I a candidate for a chin implant? I feel like I am not a good candidate as an implant would only exaggerate my pre-existing issue. Please see attached pictures.
A: Almost anyone can undergo a chin implant if their chin is deficient enough. The real question is whether someone is a good candidate for the procedure. Since you appear to be using the criteria of any deepening of the labiomental fold as not being a good candidate, then you would likely be correct. If the depth of the labiomental fold bothers you know, then it may bother you more after chin augmentation. Any chin implant procedure changes the pogonion position of the lower chin but leaves the depth of the nasolabial fold unchanged as it is not a bony supported structure. Whether it would be significantly deeper depends on the size of the chin implant, the shape of the implant and whether the labiomental fold is augmented at the same time. Since your chin augmentation needs do not appear to be large, the labiomental fold may not be changed significantly.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I admire your plastic surgery work. Your lip reduction procedures are amazing. I had one back in December of last year and I am not pleased. Having your hand along another journey of having my 2nd lip reduction procedure would be great.
A: Lip reduction surgery is relatively straightforward and there is a limited number of ways to do them. What about your prior lip reduction surgery was not satisfactory…amount of reduction? scar location? Please send me some pictures of your lips both before and presently of your lips for my assessment. It would not be rare that secondary or revisional procedures are needed for lip reductions to get the maximal amount of lip reduction and symmetry. The lip tissues are unique and are different than skin. They are very flexible, swell more, are composed of two different types of tissues (mucosa and vermilion), are a surface that is exposed to immediate trauma after surgery (eating) and has a white background behind it. (teeth) These factors make lip reduction surgery somewhat unpredictable and highly prone to exacting scrutiny. In my experience, the risk of revisional surgery with this operation is as high as 50% for optimal results.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in one-stage frontal hairline lowering? How big will the scar be? As long as the scar isn’t noticeable, I’m definitely interested. How long is surgery? How long is recovery? Will I have to take any medication before surgery? Will I be completely out? Will I accomplish what I’ve wanted all my life, to be able to wear my hair off my face/forehead immediately?
A: For forehead reduction/frontal hairline lowering, there are two techniques based on how much advancement of the frontal hairline is needed. If the amount of advancement is in the 1 to 1.5 cm range, then it can be done in a single operation. Larger amounts (> 2.5 cms) would require a first stage placement of a tissue expander to create the amount of scalp needed to move forward. Frontal hairline lowering is done through a hairline or pretrichial incision and is best thought of as a ‘reverse browlift’. Instead of the forehead skin being lifted from the pretrichial incision, the scalp behind is advanced forward and forehead skin removed where the new hairline will be. While this does place the incision/scar right at the new hairline, it usually heals very well and is barely detectable in patients with little pigment in their skin. (Caucasians) It is a procedure performed under general anesthesia and takes about an hour and a half to complete and is done as an outpatient. Recovery is very quick and there is no swelling of the eyes that is usually seen. One can shower and wash their hair the next day.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I lost of a lot of weight and my face is asymmetrical. I have small jowls and not sure if I need a facelift or just a necklift and if face implants would be an alternative to a facelift. I want to look prettier and have a long, narrow face with high cheek bones but hollow cheeks underneath and nasolabial folds. I have tried to have my own fat injected into the nasolabial folds but it does not last very long. I also have very thin skin. Would you recommend a regular face lift or a smart lift? Thank you
A: In looking at your face and objectives, I see three procedures that would be simultaneously beneficial. Higher cheekbones are only going to be obtained by cheek implants. While chin or chin-prejowl augmentation is not a substitute for what some form of a facelift can do, a small vertically lengthening chin implant can help the jowls somewhat but more importantly contribute towards a longer more narrow face. Facelifts go by many names and their name sometimes indicates the extent of the procedure. You need more of a jowl lift type procedure which often carries the name of short scar facelift, Lifestyle Lift, Smartlift etc. Regardless of the name it is designed primarily to lift and eliminate the jowls. When done together with the chin augmentation your jawline should be fairly smooth.
Improving the nasolabial folds is difficult and fat injections, while worth a try, are rarely successful. The only technique that I have found consistently effective are dermal-fat grafts which are essentially autologous implants but they require a harvest site to use.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I recently had a tummy tuck and have noticed something unusual (at least for me) afterwards. I am experiencing intense increased sexual desire. This is far beyond what I would normally feel this way. Since it is very early in my recovery ( five weeks) I can’t attribute to the fact that my body has changed and I am experiencing increased libido because of my new body shape. Is it possible that loss of weight or the removal of fat has caused some hormonal change that would account for my increased sex drive?
A: This is not the first time that I have heard from a tummy tuck patient of an increased libido after surgery. I would agree with you that it is not simply caused by a change in your appearance or hormonal levels. The most likely explanation is the coincidental pubic lift effect that results from many tummy tuck surgeries. To close the large open wound from tissue excision in a tummy tuck, the upper abdominal skin flap and the lower pubic region are moved to close over it. This lifts and tightens the pubic region and may change the exposure or angulation of the clitoris. It may also be that that the tissue shift and increased clitoral exposure may allow its increased exposure to be more directly stimulated by the rubbing on clothes. The occasional increased sex drive in a postoperative tummy tuck patient, therefore, may be a simple mechanical effect.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a question about temporal artery ligation. You have mentioned that the ligation of the temporal arteries would not cause hair loss. So, I’m 18 years old and I started to get a receding hairline and some slight thinning. Is it possible that these ligations don’t cause immediate hair loss, but accelerate the process of male pattern baldness? The internet says weird things, some sites claim that you should increase oxygen in the scalp and that bald people have less blood circulation/oxygen in their scalp. On the other hand, I came across a study that claims that ligation of the temporal arteries would stop male pattern baldness. I’m very confused and I was interested if you’d have an answer.
A: Hair loss, in general, is genetically driven. There is no medical evidence in an otherwise normal scalp that changing oxygen levels affects how the hair grows or how long it is retained. The scalp is so richly oxygenated by an extensive vascular system that it is impervious to varying oxygen levels throughout the body. A simple example of that concept is the effect seen in smokers who have lower blood oxygenation levels but often have very full heads of hair throughout their life. In addition, if oxygenating the scalp was beneficial for hair loss prevention there would be many scalp treatments available that offer that exact therapy. While the topical drug Minoxidil (Rogaine) does improve hair growth and hair loss prevention, it has a very specific vasodilatory effect on the hair follicle itself.
As it relates to temporal artery ligation, there again is no evidence that it has any effect on hair growth patterns…either a positive or negative effect. However, because of its collateral circulatory effects and employing the principle of choke vessels, a conservative approach to temporal artery ligation would be to do one side at a time. This is more an approach to ensure there is no negative effect on scalp skin survival and not necessarily for its effect on hair growth.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like to know if I would benefit from a lip scar revision? I had a laceration on my right upper lip that goes from the mid lip to just a hair past the vermilion border. I had 2, absorbing 4-0 sutures put in. And it’s been just a year and the scar seems more pronounced… When I’m not smiling it’s not as bad. But when I talk and smile, it’s definitely noticeable. It’s bumpy and from time to time .i get self conscious when in interacting with people, they tend to stare at scar…The scar is not straight, it has a slight curve. Thank you in advance!
A: Thank you for your inquiry and sending your picture. If the scar is over a year old and is pronounced and bumpy then there is some hypertrophic scar present. This often present as a white scar line that is raised, firm and may offset the vermilion-skin lip border. The only improvement that can be obtained at this point would be an elliptical scar revision pretty much along the line that it lies. Fortunately the scar parallels fairly well the natural vertical lines of the vermilion. This is a simple office procedure done under local anesthesia.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I want to get the ligation of the temporal arteries done. I’ve heard from you from a forum on the internet with lots of success stories. But I still have a couple of questions. If you tie off the artery at several locations, isn’t it possible that there appear ‘new’ artery or that the capillary system ‘feeds’ the tied off artery, so blood returns to the artery? Is there any chance of hair loss? My temporal arteries bulge beyond my hairline, how can you determine to ligate it in the hair bearing region? How big are the scars? On my right there’s just ‘one’ artery, while the one on the left splits into three arteries, of whom 2 splits into 2 other very little arteries, so I’d need a lot of ligations on this side.
A: When it comes to temporal artery ligation, the key is to perform proximal ligation to cut off the very high anterograde flow and distal ligations of any identifiable branches to eliminate any retrograde flow. If all lines that feed into the visible ‘pipes’ are tied off, there is no way any blood flow can return to the artery. There is no capillary system that feeds into the arteries. This always requires an incision (10mms) in the temporal hairline and small incisions (5 – 7mms) beyond it in the forehead area wherever the distal and feeder branches cab be identified. There is no risk of hair loss with this procedure. The blood flow to the scalp is extensive and has many other feeder vessels for scalp and hair survival. If ever in doubt, you only do one side at a time.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Can you do liposuction on the pubic area of a woman? The mons pubis I believe? I have attachments some photos of mine which is oversized tremendously. (as you can see in the attached pictures) How much would a procedure like this cost? How is it performed? What is the recovery?
A: It is very common to do liposuction on the mons area (pubic liposuction) and it can provide a significant reduction. However, your mons problem is going to require more than just liposuction due to the excess skin. You need a combined pubic lift to remove and tighten the loose mons skin that will result from it being deflated of fat at the time of the liposuction. Think of it as a reverse mini tummy with an incision in the skin fold at the upper end of the pubic region. This combined liposuction and lift of the mons area is technically know as a monsplasty. This is a one hour outpatient procedure done under general anesthesia. Its total cost is in the range of $4500. There is usually swelling and bruising of the pubic region and mild discomfort and it will take a full six weeks until the true final resut will be seen.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 25 year old male who currently has braces. Wondering if I should have BSSO mandibular advancement or sliding genioplasty. My jaw is strong but my chin is weak especially when biting.
A: The answer to the choice between a mandibular advancement or a sliding genioplasty to improve your profile is literally ‘between your teeth’. Since you are in braces, the key question is what is your bite relationship and what does your orthodontist to tell you? Is your bite correctable by orthodontics alone or is the discrepancy between your upper and lower teeth significant enough that the lower jaw needs to be brought forward to put your bite together properly and, if so, how much does it need to be moved forward.
There are three possibilities. #1 Your bite is going to be corrected by orthodontics alone and then a sliding genioplasty is needed. #2 Your bite is far enough apart that the lower jaw need to come forward significantly (7 to 10mms) and the profile will be corrected completely by that movement alone. #3 Your bite correction requires a small amount of mandibular advancement and a small sliding genioplasty will be needed as well.
Regardless of the type of mandibular or chin movement needed, I have attached a prediction of the type of change needed for normalizing your facial profile.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Do you do liposuction on “cankles” and calves?
A: Cankle liposuction is more than a myth, It is very real surgical procedure! Reshaping the legs from the thighs down to the ankles are liposuction procedures that I commonly do. Do not think of reshaping the lower extremities as a 360 degree circumferential procedure as that is not the approach that is taken. The most effective thigh, knee, calf and ankle liposuction technique is known as ‘silhouetting’. This is done by selectively changing the inner and outer contours to give the entire leg more shape as seen from the front. This means that the inner and outer thighs are done, the knees from across the top, inner aspect and curving below the knee into the upper calf and tapering the lower calf above the ankle area above both areas of the ankle bones. This is how one uses liposuction to make the leg more shapely from top to bottom.
While effective, cankle liposuction invokes a lot of persistent swelling around the ankles that takes months to completely go away and see the final result.
Dr. Barry Eppley
Indianapolis, Indiana
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in revisional rhinoplasty. I have had two reputable doctors turn me down for revision saying that I do not have enough natural cartilage left to build up the nose and that I have too much scar tissue preventing the tip definition and bridge length and height I desire. Please let me me know whether you can revert my current nose to my birth nose – longer, more heightened bridge and defined tip.
A: In revisional rhinoplasty, having adequate building materials (cartilage) is often the key to any degree of success. When it comes to using cartilage for the nose, there are three sources…septum, ear and rib. One is never out of enough natural cartilage because the ribs are an endless source for the amount needed in any nose. The issue may be that your septum and ear from prior surgeries has been used or the cartilage volume demand exceeds what they can supply. While I don’t know your prior rhinoplasty surgery history, most likely they were more reductive procedures so your septal and ear cartilage sources may still be available. But in augmenting your nose throughout its length, the amount of cartilage needed probably exceeds these sources. Thus you do have enough natural cartilage to use but you may not prefer or your other surgeons do not do rib cartilage harvests. But to get nice straight pieces of cartilage that are needed for this type of augmentation rhinoplasty, rib graft cartilage would be best.
While your nose undoubtably has scar tissue, that would not be a limiting factor in increasing dorsal height and bridge length. It can very well be a limiting factor in improving tip definition however.
One important realization is that you at never going back completely to your original nose. You may get close but it will never be able to return exactly to what it was before surgery. That well may be exactly what your two doctors were really saying…they may have felt that what you wanted to achieve is not possible and for what can be achieved may leave you wanting and disappointed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like to explore a lip lift and corner lip lift. I have an unusually long upper lift (distance from bottom of nose to top lip) and would look much more balanced if that distance could be shortened. However, I have an over rotated upturned nose from previous rhinoplasty. This means there is no crease or space in the shadow of a nose that a scar could hide and it would mean that if there was nostril distortion, it would be very visible and unattractive. Given how little room for error my nose allows for this lip lip and corner lip lift, should I consider this surgery or let it go?
A: When it comes to a subnasal lip and corner of the mouth lifts, the most important issues are the potential scars and not overdoing either type of lift. Prominent scars or an overcorrection (which is virtually impossible to correction since you can not add back skin) are aesthetic tradeoffs that one needs to avoid. While I have not seen a picture of you, you may have answered your own question…if there is little to no room for error…why take the chance? I have never seen nostril distortion and have only rarely revised a subnasal lip lift scar but your concerns do have merit.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had an hydroxyapatite chin augmentation several years ago. The hydroxyapatite was semi-solid or loose when implanted- mixed I believe with some fluids, but it was not cut from a block. It was implanted intraorally. Besides not doing much from my chin, it appears that the chin tissues are more loose now and hanging somewhat. I would like to see if we could perhaps fix this problem as much as possible. The tissue also appears more red in color that the rest of my face after surgery. I have attached some pictures of my face for you. I did take them myself from short distance so they do appear a tiny bit distorted, but they give you a good look at the chin and jaw angles in particular. In terms of enhancement to my jaw, I am not necessarily looking for a massively dramatic distal increase in size- just a moderate one to give a sharper look to the lower part of my face and to help with structure as I age.
A: Thank you for sending your pictures. I can’t say that I see any significant soft tissue detachment of looseness per se but the chin is horizontally short. It may feel somewhat looser as the hydroxyapatite granules are not structurally supportive. The hydroxapatite paste put in the chin usually have very little push to it so its augmentative effect is very minimal and often can be very irregular. I am not sure why the chin button area is slightly red as hydroxyapatite is usually very biocompatible. Certainly the hydroxyapatite granules can be removed and other forms of chin augmentation done. A more stouter form of chin augmentation will do a better job of picking up the loose chin tissues as well as providing more of an augmentative effect. At the same time, jaw angle augmentation focusing primarily on vertical length can be done as part of an overall jaw enhancement strategy.
Dr. Barry Eppley
Indianapolis, Indiana
