Your Questions
Your Questions
Q: Dr. Eppley, I have questions about jaw angle reduction and temporal implants. Here’s a list of my questions I want to ask:
1. My jaw is still growing and i have braces, will this affect anything? What possible complications can there be? I’m willing to take all the risks and complications. ( i am getting the braces removed soon)
2. If my jaw angle is vertically reduced to make its location higher, will this make it higher from the front view too? Can this be an possible result? By higher i mean close to the ear.
3. Is there any implant to make my head larger or my forehead larger? Since my face is long, i want to make it more proportionate. I have been reading about the temporalis muscle, any implant/augmentation surgery for that
4.what is the difference between having the jaw shaved with a ear incision, and inside mouth incision? Recovery time? Results? Damage? Risks?
5. Here comes the important part… How long is the recovery time? For the ear incision & inside mouth incision? Is there any massage or laser treaments i can take to dramatically reduce the swelling so i can look ‘normal’ after a week of recovery?( i’m willing to pay a lot for any treatments that’ll help ) please include the implant part as well!
6. is it possible to do implant and jaw reduction surgery together? If so how much time will it take and what risks are there?
A: In answer to your questions:
1) Having braces and undergoing orthodontic treatment has no impact on any type of jaw angle surgery.
2) The traditional method of jaw angle reduction surgery does exactly what you are describing. It removes the jaw angle so that the most posterior part of the jaw angle is at the same level as the earlobe. It is important to understand that is so doing the jaw angle will no longer have a square form but a more rounded or sloped angulation.
3) Forehead and mid-temporal augmentation can be done to achieve a larger more pronounced forehead and increase the bitemporal distance for a wider head as judged by its width above the ears.
4) The jaw angle can be reduced by two different surgical approaches. (incisions) The intraoral method is the historic and most common method still used but it does pose challenges for angling the bone cut in an ideal and symmetric manner. The external approach uses an incision behind the ear or just below the ear and provides a much better angle for the bone cut and a quicker recovery (by staying out of the mouth) but runs the risk of causing temporary or permanent facial nerve injury. (that risk is low but is not zero)
5) There is nothing a patient can do to expedite the recovery process which is largely about who long it takes the swelling to go away before one looks human (7 to 10 days) and for its complete resolution. (4 to 6 weeks)
6) It would be common to combine any number of aesthetic craniofacial procedures such as jaw angle reduction and temporal augmentation. The risks of such surgeries, besides infection, are largely aesthetic…symmetry, over/under correction of the desired goals.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I read somewhere about temporal implants for head augmentation which I assume is of the muscle. If you add an implant there, wouldn’t it widen my head? And if so, how is it done with what type of implant and location?
A: It depends on what part of the temporal region in which the implant is placed and what type of implant is used. A preformed anterior temporal implant is now available that augments the temporal hollow. (the region between between the anterior temporal hairline and the eyebrows/side of the eye) which often occurs from aging, genetics, drug therapy or neurosurgical approaches. A larger preformed or custom mid-temporal implant is also now available that when placed below the muscle on the side of the head above the ears will increase the bitemporal dimension or width of the head. This as you can see, it is important to know what temporal region of augmentation one desires to select the right temporal implant style and location of augmentation.
Using implants for temporal augmentation is one of the newest areas of craniofacial implant development that has extended the use of implants in the face upward to that of the skull.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like information about brow bone augmentation with calcium hydroxyapatite and customized implants from 3D CT scans. I had a rhinoplasty where the surgeon used transverse and medial osteotomies of the nasal pyramid, and nasal dorsum. I realized that the eyebrows lost support after surgery. The augmentation surgery in the region of the supra-orbital rim or brow ridges with customized implants are made of what material?
A: Brow bone augmentation can be done by different materials which can also control the surgical approach to place them. (incisional access) The traditional and still most commonly performed technique for brow bone augmentation is through an open scalp incision using either PMMA or hydroxyapatite bone cements. When just the brow bone is being done, hydroxyapatite cement is the material of choice. But when the brow bone is being combined with total forehead augmentation, PMMA bone cement is used due to being a more lower cost material per amount of volume. Performed or custom implants can also obviously be placed through such a wide open exposure. Custom brow bone implants made from a 3D CT scan are always made of a silicone material, primarily due to ease of adaptation to the underlying brow bone and cost. Newer techniques of placing custom or preformed silicone brow bone implants are being developed to avoid the larger scalp incision. (endoscopic frontal and upper eyelid incision)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Dr. Eppley, I am 20 years old but have had prominent “tear troughs” all of my life, my left tear trough being more prominent than my right. I am very interested in getting injectable fillers for that area. I was wondering if you would be able answer a few questions for me. Would you recommend fillers for my tear troughs? If so, what kind and how much filler would you most likely use? How much would it cost? Is this something that you perform often? Thank you for your time.
A: Based on just the one side view picture you have shown, you do not have a true tear trough deformity. Rather you have pseudo or seemingly tear troughs when in fact it is caused by something else. What it appears you have is congenital herniated lower eyelid fat pads. This causes a fullness/bulging/bags of the lower eyelids which subsequently creates a tear trough appearance due to the bulge above an otherwise normal tissue area along the infraorbital rim. (lower eyelid socket) Injectable fillers would be contraindicated in this type of lower eyelid anatomy. Conversely you need removal and/or translocation of the lower eyelid fat pads. Some would be removed while a portion would be moved to drape over the infraorbital rim, thus eliminating both the lower eye bulge and the tear trough at the same time. This operation is known as transconjunctival lower blepharoplasty with fat transposition.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in fat injections (Lipodissolve) for my lower abdomen. I am done having children and have gained an excessive amount of weight during my pregnancies. I have lost the weight, but the aftermath is stretch marks, loose skin and a “pudge.” My upper abdomen has no stretch marks and is ok. I am trying to find an affordable procedure, that I can handle with minimal downtime, as I have 2 small children.
A: What you need, without even seeing a picture of you and based purely on your rather classic description, is not going to be achieved by an injectable fat reduction technique. Lipodissolve is intended for very small fat collections (like the neck) in which the overlying skin is of good quality. It is completely ineffective for the post pregnancy belly that you are describing. What you need is some form of a tummy tuck which can more effectively deal with the excess/loose skin and fat. With this type of abdominal problem, you either hold out for a tummy tuck one day or do nothing…as nothing will offer any acceptable level of improvement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in occipital augmentation. I have a flattened head at the back which is also assymetrical. It has been a major problem for me for many years. Isolation and depression are the main effects. I have a local surgeon who is tells me a PEEK onlay is the best option. Would you consider this to be better than a filler material. He tells me I will have a transcranial scar and will have to have my hair cut short, preferably shaved. The argument for the onlay is it is difficult to achieve a smooth transition with filler material. I should add he has never done this operation before. Could you give me any advice. I am a little nervous about head shave and a huge incision.
A: After having performed over 100 occipital augmentations with every known material (except PEEK) and method, I can tell you for certain I would never use a hard preformed material like PEEK. (or preformed HTR or preformed acrylic for that matter) The material on insertion is too hard and this requires a maximal incision to get it into place. That may be fine but I don’t know of too many patients that want a full coronal incision for their occipital augmentation.
The two most commonly used and preferred cranioplasty materials in my practice are either intraoperatively fashioned PMMA bone cement or a preformed silicone implant. Either of these materials can be placed with much smaller incisions and work well. I have not seen an infection with either cranial augmentation material to date. This does not mean these methods are perfect (PMMA can have some edge transition issues because of its intraoperative fashioning) but these issues are aesthetic and not of any major medical significance.
FYI, I do not have my patients shave any hair for their skull augmentation regardless of the material or approach.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, What is the difference between the composite facelift using the subSMAS spaces and your technique? Do you make those incisions inside the ear cartilage behind the tragus? Can you please explain the differences between the Deep Plane facelifts? I am basically looking for the most invasive change/longest lasting facial rejuvenation change.
A: Let me provide you with some further comments and my experience with composite acelifting since this is a topic about which you have inquired.
I do not claim to have originality or unique experiences with extended SMAS or sub-SMAS facelifting or composite facelift procedures. The principal motivation of a composite facelift is to bring a rejuvenative effort to more of the midface rather than just the neck and jowl areas. In other words, extending the lifting efforts to more of the central face area. A true composite facelift, in the purest sense of the term, works below the SMAS layer around the cheek, buccal fat pad and deep to the nasolabial fold area. The theory behind such a central dissection is that there is volume descent of the midfacial fat pads which has certainly been shown to be true by anatomic studies. This is not an area that any of the more traditional forms of facelifting strive to reach and treat. By dissecting the fat pad out and lifting and securing it vertically, midfacial descent of tissues is improved.
While this dissection can be done, and a few surgeons certainly tout it, more widespread experiences have been that the risk of injury to the buccal branches of the facial nerve, prolonged operative times, substantial and sustained edema and recovery and the sustainability of the midfacial results do not justify this type of effort in most patients. Other than a very few surgeons, the documented and proven long-term results simply do not justify that effort. The risk of buccal nerve injury, even if temporary, is very real and unsavory for any patient who sustains it.
If it is midface rejuvenation that one is striving for from a deep plane approach, there are more effective and less risky methods that can be combined with a good SMAS dissection. (e.g., subperiosteal midface lift through an eyelid approach)
Thus one should not confuse longevity of a facelift necessarily with the deepest plane approach. There is only so much one can do with the SMAS layer and the intent of a deep plane technique is not necessarily one that ensures a more sustained result because of its extensive SMAS manipulation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had the silicone micro-droplet injections initially done two years ago with no problems. Then I had a second silicone injection into my upper lip six months from which my lip has turned hard and tight. What can I do now to get my lip back to being soft again?
A: Silicone injections may have their role in facial soft tissue augmentation but the lips is the most precarious place to put such a material. When it works it is great but the risk of significant scar reaction/nodules in the lip poses a difficult problem. Whether it is possible to get your lip soft and supple again is hard to predict. Since it is virtually impossible to ever get the silicone material out of the lips, unless there are some distinct hard nodules, all that can be done are fat injections. The objective would be to break up some of the fibrotic scar tissue and layer in some healthy fat grafts that hopefully survive and act as a more supple interface amidst the silicone material which is encased in scar tissue.. This adds new healthy fat cells in and around the scar that would hopefully soften up the lips through the addition of new tissue.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am wondering if I am a candidate for an abdominal panniculectomy procedure. What I mean by being a good candidate is whether insurance will pay for the procedure. removal. I am not sure if I am a grade 2 or 3 pannus.
A: Only your insurance company can truly answer the question of whether an abdominal panniculectomy would be covered but the basic criteria are:
1) an abdominal pannus that covers the groin crease and hangs onto the thighs,
2) an abdominal pannus that is associated with recurrent groin crease skin infections that has a documented three month history of topical skin treatments (non-surgical therapy) that has failed,
3) a BMI of less than 30 or a body weight that in within 20% of their ideal body weight based on standard height and weight measurements.
If one does not fulfill all three criteria, my experience has been that approval for abdominal panniculectomy surgery will be denied. And in some cases, even if all three criteria are met, a denial will still be given. It is also important to check whether your insurance company has a policy exclusion for panniculectomy surgery, as many companies now do, so this may not be a surgical procedure that is even eligible for coverage.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I developed a depression/dent on the middle of my forehead that is circular after the birth of my second son. Whenever I bend over or pressure is applied to my abdominal area, the depression on my forehead fills up with fluid and a huge bump is visible. I have had a CT scan done and the results showed that it was not a dent on the skull surface, however it did not explain the cause. Why do I have it and will it ever go away?
A: The simple answer is I don’t know why you have it nor can I predict with any certainty if it will go away…but if I had to guess I would not think it is going to go away. Since the dent does to have a bone-basis for its presence, one can assume this is a soft tissue deficiency. That is predictable since if the dents as due to a bone issue, it would have been present essentially since birth. (short of some traumatic event) I have no doubt that the dent fill sour when you bend over but that is not because it fills with ‘fluid’ per se. That is probably due to blood vessel engorgement from the pressure which would be more obvious when the tissues are thinner.
What I would initially is to some temporary filler injections to make it more level and probably resistant to that bulging engorgement effect. If that us successful the you can eventually move on to a fat graft or fat injections for a more permanent result once you are assured that a soft tissue fill solves both problems.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had an endoscopic mid face lift two months ago. Actually I had minimal problem but I decided to go through this surgery. Actually it did not help me that much. I did not have any complication but it just was not very helpful for me. As my swelling went down I do not see any noticeable changes at all. Now the problem is that my upper lip is very stiff and it is hard for me to move it. I am at 2 months post surgery and it has only improved by about 30%. The approach was through my mouth. Is this caused by the Endotine device or because the dissection was through my mouth and temple. Is it normal to have a stiff upper lip after midface lift? Your answer will be very highly appreciated.
A: Most effective midface (cheek) lifts do involve a combined temple/scalp and mouth approach. While this does create some temporary mouth soreness and upper lip stiffness, it has not been my experience that the upper lip stiffness is prolonged out to months after surgery. The Endotine device is positioned up on the zygomatic bone so that device is not the source of prolonged upper lip stiffness…or should not be. It is the path of dissection and how much tissue was released in doing so that is the cause. This is an issue for which only time and further healing can provide a resolution.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have some questions about temporal reduction surgery.
1 What is the thickness of the temporalis muscle?
2. I have been searching for the this kind of surgery on the Internet and I have not found many surgeons who deal with this, why? Is it because it’s the most difficult operations of all or is it because there is no big demand for this procedure?
3. Do you have any materials (video, pictures) of this kind of operation?
4. When the temporalis muscle is removed , would it influence any other muscle or anything related to that section of head?
5. In your message to me you wrote : ” A vertical incision is made and the entire posterior temporalis muscle is removed and the underlying bone burred as much as possible” What is burred?
6. Is there any chance that you can make a picture for me of how I would look like after the surgery ?
7. This operation can not cause any damage to my brain?
A: In answer to your questions:
1) The thickness of the temporalis muscle differs depending on its location. The average thickness of the temporalis muscle above the ear is usually around 7mms or so.
2) Temporal muscle reduction surgery is not commonly practiced due to lack of awareness and patient demand, it is not complex surgery.
3) I do not have any videos of this type of surgery but do have intraoperative pictures of it.
4) Removal of the posterior portion of the temporalis muscle has no functional effects on the workings of the muscle and its jaw opening/closing function.
5) Some temporal bone burring is done is some cases.
6) I can do some computer imaging if I have a frontal view picture of you.
7) This is an extra cranial procedure not an intracranial one so there is no risk of any brain injury.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a question about my breast augmentation procedure that I forgot to ask about during my consultation. My left breast is slightly bigger than my right breast and I was wanting to know if this would affect the overall look of my breasts after getting implants? It is only a slight difference in size, and is only noticeable from a side view. I am just afraid that it will affect the look of my breast post surgery.
A: Breast asymmetry is very common amongst many women undergoing breast augmentation and is a very important aesthetic issue to identify before surgery. As a general statement, all implants do is to take the breasts you have and make them bigger. They are nothing more than a mound enlarging device. Thus whatever breast shapes one has when they are small will become bigger. This means that for some women a small breast asymmetry may become more noticeable afterwards. (i.e., the breast asymmetry becomes bigger) In other cases, enlarging the mounds may make the slight breast asymmetry go away completely. The difference in what may make breast asymmetry more or less noticeable after augmentation is whether the asymmetry is due to mound size differences or whether it is due to a difference in the horizontal position of the nipples. Slight mound size differences will usually go away even with equally sized implants on both sides. (the key is the term ‘slight’ mound size differences) Conversely, horizontal nipple level differences will usually get worse with implant enlargement as the mounds enlarge. For this reason if I see such differences I point that out to patients during their consultation and usually recommend a small nipple lift at the time of breast augmentation to even out the horizontal nipple levels to avoid the so-called ‘cock-eyed’ breast look when nipples are at different levels on the breast mounds.
I don’t specifically remember any significant asymmetries in your breast mounds that would justify either a nipple lift on one side or the use of different implant volumes. But since you have noticed a slight asymmetry in your breasts and it is of concern to you, I would lastly mention an old breast augmentation adage…‘breasts are not twins but sisters’. This means that if they are slightly different before breast augmentation surgery, they will continue to be different after surgery. One should not expect perfect symmetry from surgery when the breasts are exactly perfectly similar before surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Is it possible to correct mild midface hypoplasia with fillers? Will it be a result that is approximate to what facial implants can do?
A: If you add enough volume of injectable fillers in the cheeks, orbital rim and paranasal regions, some midface hypoplasia correction (increased projection) could be achieved. But no filler is permanent and substantial filler volume would be needed. It is also important to remember that gel-like hyaluronic acid-based fillers (e.g., Juvederm Voluma) do not provide the same type of push on the soft tissues that implants do.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am 29 years old and I have 3 kids. They are all good size and I’m small build so therefore my skin has stretched out bad!!! Also as a result in having kids I have an umbilical hernia. Can that be taken care of as well at the same time as the tummy tuck?
A: It would be very common in tummy tucks and abdominal panniculectomies for a woman to have a concurrent umbilical hernia. The hernia can be repaired at the same time as the tummy tuck procedure and is an ideal time to do given the very open exposure. In some cases there is a risk of loss of the umbilical stalk with the hernia repair dependent on the size of the umbilical hernia.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Can oval shape buttock implants rotate? Is there an amount of time that goes by that rotation is no longer a concern because they are now in their permanent place? If so, how long until that happens? If they rotate can you push them back manually without another surgery?
A: Oval, sometimes called natural, shape buttocks implants can certainly rotate if they are placed in the subfascial location rather than the intramuscular position. That risk is greatest during the first several months after surgery but the risk is lifelong since they are not textured implants but have a smooth surface. You may be able to push them around back into the place but they can just as easily rotate again. But if the buttock implants are placed in an intramuscular pocket, the chances of inadvertent rotation are significantly reduced because of the more constricted pocket space.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had upper jaw surgery and a sliding genioplasty done four years ago when I was 18 years old. I have never been happy with the results on my chin and would like it reversed, is this possible? The surgery left indention’s on the sides of my chin and a upturned appearance to the chin.
A: A Sliding genioplasty can be reversed in the same fashion as it was done originally…the bone is cut and moved back to its original position. I suspect based on your description of the chin issues (notch deformities on the distal ends of the cuts and an upturned chin) that the angle of the genioplasty cuts was too steep. This moves the chin as much upward as it brings it forward and leaves a v-shaped notch on the lower edge of the jawline where the chin bone moved forward.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was searching for the information regarding facial sagging after cheek bone reduction surgery. I suffer from facial sagging after cheek reduction surgery that I had four months ago. Even though my bone is tightly fixed, sagging is quite severe and it keeps getting worse. I think it might be because of the loss of skeletal support. He didn’t reposition the unit of my cheek bone but removed part of my front cheekbone by dissecting it as an ‘L-shape’. The worst part is that only the right side of my face is sagging and I don’t know what to do. I’ve been searching for some doctors who are renowned for face lifting. They said that they need to release the zygomatic ligaments and lift the SMAS up as well as the skin. I can see that you are the one who understand the right reason and solution of this problem. So I will be truly thankful if you spare some time to give me some advice. Thank you so much.
A: I am sorry to hear of your unfortunate unilateral outcome from your cheek bone reduction surgery. The obvious origin of the problem is the loss of ligamentous attachments of the overlying soft tissues to the cheek bone as well as the loss of skeletal support for them. It is interesting, assuming that the same bone reduction techniques were done on both sides, that only one side of your face has this tissue sagging problem. This shows how precarious the soft tissue attachments are to the bone and how slight differences in dissection techniques can make a big difference in their outcomes. As has been pointed out to you, the key to improvement is not just the skin shifting but the need for deeper soft tissue repositioning. The only tissues that possible to relocate are the SMAS layer. But moving the SMAS layer without giving it skeletal support will not provide a significant improvement. The first place to start is to have a good idea of what the underlying bone support looks like between the two sides. I would recommend that you get a 3D CT scan to visualize your cheek bone anatomy as it is now. Then with that information a more complete surgical plan can be devised as to how to manage the bone and the soft tissues.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in jaw angle reduction surgery. 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 on 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 doing smaller amounts does not result in a faster recovery…as the same dissection is needed to reach the jaw angles. The amount of jaw angle bone removal has nothing to do with the length of the recovery period.
The key to a successful jaw angle reduction in is too simply not over do it. (remove too much bone at too steep of an angle) It is somewhat easier to do more than to add back jaw angle height that has been removed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, My desire for rhinoplasty surgery is purely a cosmetic one. I am a healthy and active 25 year old who has never had any complication or surgeries before. That being said I’ve also wanted this procedure done for some time now but never had the opportunity to speak to a physician about it. I have a very typical Arab/Roman nose with a bump on a wide bridge and somewhat bulbous drooping tip. Which with my slender face it looks disproportionate I believe. Furthermore I have a deviated septum which is not noticeable but make the tip look bigger and the hook worse from the right than from the left. I will attach pictures of my nose which will show that from one side nose looks more straight than the other. All in all I would like my nose to be a tad smaller yet still maintain a natural look to my ethnicity (I believe it’s called a ethnic rhinoplasty?). What do you think can be achieved with my nose? Thank you for your time I hope to hear from you soon!
A: When one uses the term ‘ethnic rhinoplasty’ that could mean one of two things. An ethnic rhinoplasty could be any non-Caucasian patient that has nasal features typical for their race and they want a more ‘westernized’ nose change or a radically different nose look.. Or an ethnic rhinoplasty could mean a non-Caucasian patient that wants to undergo rhinoplasty but with changes that still fit their face and to not lose most of their natural ethnic look. I believe you are referring to the latter with the term ethnic rhinoplasty and that is how I usually interpret it and attempt to achieve for my non-Caucasian patients. Whaty this translates in your nose is that some of the bump would be reduced and the nasal narrowed and the tip would be straightened and lifted somewhat so that the nasolabial us closer to 90 degrees rather than the 75 degree angulation you now have. It is very important in a male to keep the dorsal line straight (or even maintain a avery small bump) and that the tip is not overlhy rotated upward.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in ethnic rhinoplasty. I have a very flat noseand would like to narrow bridge significantly to enhance my facial features as well as narrow the tip. My ideal nose features are those of Halle Berry, Beyonce and Vanessa Williams. Can you achieve this finish by reshaping my nose?
A: The first issue about ethnic rhinoplasty, and any rhinoplasty for that matter, is that trying to have the nose of someone can never be achieved. It is good to have a desired rhinoplasty goal. But in the end, no matter how well executed a rhinoplasty is done, factors such as the thickness of the overlying nasal skin will have a major influence on the final nose shape result.
I have done some imaging work on your pictures. The picture quality is not great but they are useable. Your nose is interesting because it looks the way it does because the nose has little cartilage support from the underlying septum which is why the tip is flat, the bridge is low and the nostrils are flared/wide. This is not unusual in African-American noses who often has weak septal support and widely splayed nasal cartilages with short nasal bones.
To make any significant changes to your nose, you would need an L-shape cartilage graft to both build up the tip and the bridge. Much like making a roof on a house, underlying support is need to build up your nose to give it more projection which is what will make it look more narrow and refined. This amount of support can only come from a shaped rib cartilage graft. Your nostrils would also need to be reduced/narrowed at the same time. The imaging predictions show some of the changes but be aware the frontal view image does not do justice to what would really happen when the entire bridge and nose comes forward as the computer software can not really show what happens as the nose is pulled forward. In short, the real result would look much better from the front that the imaging shows. I don’t know if your nose would look exactly like Vanessa Williams but it would be a lot closer than it is now.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in combining a chin implant and facial liposuction for making a round face thinner. I want to have normal shaped face, but also would like a skinnier face overall if possible? And are results permanent because I can get puffy just by taking a shower, so I am worried that my face is not stable and will that interfere with my surgery results. Thanks for any advice 🙂
A: Your desire for a slimmer face is actually based on a deficiency in your lower face not too much fat. You have little little fat throughout your face as you can see your cheek area is fairly thin and flat. The facial shape problem is that your chin is both horizontally and VERTICALLY short. As you can see in the attached imaging , when the chin is brought forward and lengthened, your face overall looks thinner. Thus making you have a thinner face is not based on liposuction fat removal but a very elongation of the lower face done through either a chin implant (vertical lengthening chin style) or a sliding genioplasty. (opening wedge type)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley,I was considering getting an injectable filler for my cheeks like Voluma that supposedly last for wo years. Would I be able to get rhinoplasty a couple of months after having the Voluma or should I just wait until I have rhinoplasty?
A: Your question about the use of Voluma Injectable filler is a frequent one that is posed by patient prior to some form of facial plastic surgery. If one knows they are going to eventually undergo surgery (rhinoplasty for example) then doing more permanent for the cheeks (fat grafts or implants) should be considered since one is in the operating room anyway. However, if one is uncertain that cheek augmentation is beneficial then an injectable filler can be done as a ‘trial’ method to judge the results and see if it what you like. But in that case you would use a short acting injectable filler so it goes away by the time of surgery. In short, if you were having rhinoplasty, for example three months from now, then you would use a quickly absorbing filler so in the event that the result is very positive you can then have a more permanent approach done with your rhinoplasty. But if your rhinoplasty was going to be done next year , or never, then you would use an injectable filler like Voluma due to its longer lastng effects
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had brow bone augmentation by fat grafting done yesterday, and I think my surgeon placed 8cc per side. I told my surgeon not to be aggressive, but I’m worried that he might have overdone it. It currently looks like an excessive amount of augmentation. Do you think this is what the final look will be, or will the amount of augmentation decrease to a reasonable amount with time?
A: Fat grafting to the face, by injection, is unfortunately not uniform in its outcomes or how well they survive. While there are a lot of variables in what makes an injected fat graft survive, and one can not assume that every surgeon does every step of fat grafting the same, the face has variable rates of fat graft take by region. The brow area has only a moderate fat graft take between 20% to 30%. Thus overinjection is commonly done knowing that much of the injected fat will take. That is why your surgeon uses 8ccs per side with the outcome likely to be only 1cc to 2ccs of fat that will actually take. So what you are seeing today will change and will go down substantially over the first month after brow fat grafting surgery. Ironically the concern you have today (too much) may turn into the opposite concern (too little) six weeks from now.
Dr. Barry Eppley
Indianapolis, Indiana
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
