Your Questions
Your Questions
Q: Dr. Eppley, I am interested in a custom jawline implant. Roughly what is the cost of a Custom Jawline Implant and the procedure if I want a very large implant enclosing the entire chin and jawline and angles, adding quite a lot around the angles, increasing chin projection up to 25mms?
A: A custom jawline implant is fabricated from a patient’s 3D scan. From this a completely customized implant is made from one jaw angle to the other. While any dimensions can be made on the model using design software (up to 25mms at the chin), there has to be enough soft tissue along the jawline so that the implant will actually fit into place. Realistically, having placed many custom wrap around jawline implants, a chin enlargement of 25mm horizontal advancement is likely more than the neck soft issues (which is where the skin must come from) can accommodate. This is too much soft tissue stretch when you factor in that the implant wraps the whole way around the jaw. A more reasonable approach is around 15mms or so of horizontal chin advancement. You must also factor in the lower lip position and the depth of the labiomental sulcus which will be severely left behind when the chin comes that far forward. The total cost of such an implant, all costs including fabrication and surgical placement, is in the range of $12,000 to $ 13,000.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in skull reshaping. The occipital bone on my skull is flat and I am interested in correcting this, preferably with an implant. Surprisingly, you and a Korean clinic are the only 2 places I have found so far for this procedure. I have already ready about the risks and complications for elective surgery, I have read some of your blogs and had a few other questions. How many skull implants have you preformed and what complications have you seen? Do you recommend the putty over implants or no? I would worry that the putty would cause more complications and would be harder to remove if something went wrong. How much do you charge of this surgery? How long does the surgery take and what is the procedure? Could a rhinoplasty be combined with tis surgery and at what additional cost? If I opt for a rhinoplasty, would it be better to do the skull reshaping first and base the amount rhinoplasty on the new skull shape or vice versa? Thank you for your time and consideration.
A: Skull reshaping surgery is commonly done for a flat back of the head. When it comes to occipital augmentation for a flat back of the head, there are different types of augmentation approaches as you have mentioned. Bone cement or bone putty (PMMA or HA) and a preformed silicone implant can be used. There are advantages and disadvantages to either approach. Bone cements offer materials that do bond to the bone and can be impregnated with antibiotics as they are mixed intraoperatively which are their advantages. I have yet to see an infection with a bone cement cranioplasty. Their disadvantages are that they must be molded and shaped as they are applied as a putty so they can have some irregularities and palpable edge demarcations which is the number one reason a revision on them may occasionally be done. A preformed silicone cranial implant is perfectly shaped and its flexible characteristics makes it very adaptable to the bone without edge demarcations. Its softer material also allows it to be placed through a smaller incision. But the material does not bond to the bone and ideally should be secured in place by a small titanium screw. Its infection risk is somewhat higher and it is the only cranial implant that I have ever seen develop an infection and had to be removed. (one case)
Regardless of the material, both are easy to remove and the actual material cost is not significantly different. Most occipital cranioplasties take between one to two hours to perform and total cost will be in the $8,000 to $9,000 range.
Rhinoplasty can certainly be done at the same time as any skull reshaping surgery and actually commonly done, regardless of the type of rhinoplasty needed. If one separated the two procedures, the order that are done on does not make a difference.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am looking to see if you can do a lip widening surgery technique. I have tried fillers and implants and nothing seems to work as my lips are just toooo small for my face. I look so disproportionate and really I am tired of it. I’m still single, and would really like the confidence to know that I have a beautiful smile.
A: Lip widening surgery, know as a lateral commissuroplasty, is done by opening up the corners of the mouth in a Y-V mucosal advancement procedure. The Y is in the incision pattern with the vertical aspect of the Y being the horizontal incision that determines how much the corners should be opened up. The V part of the Y are the incisions that then follow the natural border of the vermilion-cutaneous junction of the upper and lower lips. Small triangles of skin are then removed and the vermilion and mucosal are brought out from inside the mouth to make the new corner of mouth opening. This does result in very fine line scars that end up along the vermilion-cutaneous junction of the upper and lower lips at the mouth corners. This lip widening surgery is done under local anesthesia as an office procedure in most cases. Usually the width of the mout can be opened 5 to 7mms per side without causing any lip distortions. There will be a period of time when the mouth corners will feel a little tight and stretching exercises can be done beginning three weeks after surgery when the incisions are well healed to hasten the softening process.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in skull reshaping. I am a 25 year old male that has suffered from an odd shaped head. Its wide on the sides and irregular shaped on top. For years I’ve had a great insecurity every time I looked in the mirror. I have tried many different hairstyles to hide my head shape but none work for very long. I just feel like its the only part of me thats incomplete and if i have it fixed i will be so much happier and confident. I am determined to have it fixed even if i have to do it myself. I have attached a few pictures of my head.
A: What your pictures show is that the shape of your head is due to a minor variant of sagittal craniosynostosis. This is why the shape of your head has a sagittal ridge or crest from front to back and is a little elongated. Accompanying this is a parasagittal deficiency, which with the sagittal crest, gives your head a peaked or more triangular shape. The typical skull reshaping strategy is to burr as much of the sagittal crest as possible and buildup the sides to create a less peaked and more rounded skull shape.
While this is surgically possible, and a major improvement can be obtained, this has to be done through an ear to ear scalp incision. This must always be considered careful in any man who shaves his head.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a form of scalp scar revision I had hair plugs done many years ago which has left me with a lot of ‘bumps’ on my head since I now shave my head. Can these be reduced in any way so that my scalp is more smooth and not so bumpy and irregular?
A: Your scalp issue does represent an unusual form of hair transplant scar revision. Most commonly this issue relates to the donor site scar on the back of the head. But old style large follicular unit plugs can certainly be an issue if one is now shaving their head or wants to. Trying to get good improvement in your scalp situation is not an easy one even though the techniques to do it are not hard per se. Ideally what you should do is a ‘test patch’ of a scalp area with dermabrasion to see how improvement you can get before launching forward on your whole scalp. If a small area done under local anesthesia shows good improvement then you could do your whole scalp under anesthesia. On the one hand this is not the most efficient way to do it but there would be little sense in doing your whole scalp if the amount of improvement would not be worth it. This issue applies to both the donor and recipient areas. It is just hard to predict what the level of improvement would be had with dermabrasion for your hair transplant scar revision so you want gauge the depth of your efforts by testing first.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had cheek and jaw angle implants four months ago. I see that you are ubiquitous on the Internet for cheek and jaw angle implants. My question: my right jaw has been very swollen to the point where I had an MRI that shows unusual swelling. As a result I’m scheduled to have that jaw area opened up and cleaned out with hopes of immediate replacement of implant. I was hopeful that during this same procedure I would have the cheek implants replaced with smaller ones and located a bit higher in my cheek area with more emphasis on the enhancement of the upper cheekbone. My surgeon said its not a good idea to work on the cheeks because of the inflammation in the right jaw. Is this true? If I’m going to be under sedation I would prefer to have the cheek implants adjusted. It would save me a third flight and money for sedation in the future. Your thoughts?
A: In regards to the simultaneous management of your cheek and jaw angle implants, I see no problem with doing them together. The ‘cleaner’ cheek implants should be downsized first and then the presumably infected right jaw angle implant should be opened and managed. I do not necessarily believe that one infected implant will affect unaffected ones of the sequencing in surgery is done in the right order.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in scalp scar revision. I see you have extensive experience on scars from hair transplantation. Nearly twenty years ago, I had the old hair plugs and have about 1,000 elevated plugs on top of my scalp that look like mosquito bites. I tried to shave my head and get micro pigmentation to conceal them so I could wear my hair short. Unfortunately the bumps are noticeable in the bright light. I would like to have them flattened as much as possible but have received mixed reviews from Doctors. Some recommend laser resurfacing, others say kenalog injections, others say dermabrasion. What would you recommend if there is anything? My goal is to keep my hair buzzed so I would need to improve the 1,000 circular scars in the back of the scalp as well as a strip scar on the sides and back. Any recommendations?
A: When it comes to reducing the raised hair plugs, it is best to think of it as a scar revision of a hypertrophic scar…as this is essentially what it is. This requires an aggressive form of skin resurfacing.. This is not an indication for steroid injections. Dermabrasion would be the best approach as it can create the greatest amount of selective reduction of each plug site. Laser resurfacing could also be used but it would have less of an effect and may take longer to heal due to the thermal injury.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in forehead reduction and hairline lowering. I would like to know if Im a great candidate for the forehead reduction and hairline lowering. I hit a brick wall when I was younger and that is how I have bumps on my forehead. Can you please respond back to me thank you!
A: Thank you for your inquiry and sending your pictures. I can clearly see your motivation for the forehead reduction and hairline lowering procedures with a long and high forehead and a large protrusion of the frontal bone. You are correct in making the assumption that these two procedures would be of benefit. A less protruding forehead and a lower hairline would be very aesthetically advantageous. The key procedure of these two is actually the hairline lowering as a hairline that was 2 to 3 cms lower would help disguise the forehead protrusion significantly even though it can be reduced by burring somewhat. However, your scalp skin looks fairly tight, as most high foreheads are, and no more than about 1 to 1.5 cms of advancement could be obtained by simple loosening it up and bringing it forward. You would be better served by a first-stage scalp tissue expansion to create more hair-bearing scalp to bring forward. Then the second stage could be a large scalp advancement and bony forehead reduction. This would produce a much better result than a single stage procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in rhinoplasty surgery. I have always hated my nose. It has a large bump on it and it slopes down at the tip. I have always wanted a smaller and more shapely nose. What type of rhinoplasty do I need?
A: Based on a review of your pictures, you are an ideal candidate a good rhinoplasty result. This is based on your pictures which show the type of nasal anatomy which is very favorable for surgical change to get near ideal nasal proportions and shape.
Patients with nasal nasal skin have the capacity after surgery to show quite quickly and completely the changes that have been done to the cartilaginous/bony framework. In addition, thinner nasal skin does not get as much swelling after surgery and it does not take as long for most of the swelling to subside. Such is the type of nasal skin that you have.
A very common and favorable type of nasal problem is the convex dorsum which patients know as a nasal hump or bump. This overgrowth of the cartilage always makes the tip of the nose look like it is pushed downward, even if it is not. Reduction of this hump completely changes the shape of the nose and the profile, which make the nose looks smaller and more proportionate. The tip of the nose can also be narrowed at the same time. The other consideration in your rhinoplasty is the potential benefit of a small chin augmentation at the same time. Your chin is naturally shorter which is common in a nose with a hump. Reducing the size of the nose (dorsal reduction) and bringing the chin forward creates a diametric change in the facial profile which makes it more balanced overall.
Computer imaging will demonstrate these rhinoplasty and chin changes and I will get those prediction to you tomorrow.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in breast augmentation. After having two children I have lost all of my breast tissue, I am completely flat, the proverbial straight as a board chest look. I desperately need breast implants. What size and style of breast implant would you suggest?
A: Based on a review of your pictures, you are an ideal candidate for breast augmentation. Let me detail what makes one an ‘ideal candidate’ . An ideal candidate for any plastic surgery procedure is the one that is most likely to get the best result based on their natural anatomy and the anticipated changes from the surgery.
The best breast augmentation results come from small breasts that have no sagging and with the nipples centered on the diminuitive breast mound. Thus when the mound gets expanded by an underlying implant the resultant shape assumes completely the shape of the implant with firm skin and a perfectly positioned nipple-areolar complex. Your pictures demonstrate that you have an ideal presurgical breast mound by this description.
When choosing a breast implant, the first thing to decide is between saline or silicone-filled. With your lack of any breast tissue, silicone would be a better choice to avoid the rippling of saline implants which would be revealed without a thick layer of breast tissue to disguise it. Implant size is a matter of personal choice but the volume of the implant should generally not exceeded your natural breast base width. The final implant decision is whether the implant should have a round or teardrop shape. That is a personal choice of whether you want an augmented breast look that is round (full upper pole) or a more natural or sloped breast shape. (lower pole fuller than the upper breast pole)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had skull reshaping with bone cement last year in South Korea as my back of head was pretty flat. Since then I wasnt told that much information and may have put pressure on the left side of the back of my head, and now the left side is flat. can you fix this and is it safe to re apply more bone cement on top?
A: Since skull reshaping bone cement is permanent and does not move or degrade, the appearance of flatness on one side of the back of your head has nothing to do with what you did. (put pressure on it) This flatness has likely reappeared because all of the swelling has finally gone done and the complete result of the skull augmentation procedure is not evident. In other words, the application of the bone cement was likely not symmetric. When correcting a total flattening of the back of the head, the hardest thing to do surgically is to get both sides even. (symmetry) This is not a rare postoperative problem.
The good news is that this is a very correctable skull problem through the application of more bone cement on the flatter side. There is no problem with placing new bone cement on top of older or pre-existing bone cement in skull reshaping surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting breast implants. I have been wanting bigger breasts since I was 16 years old, I am 26 years old. I am currently a very small B cup and want to be a full D cup using gummy bear breast implants. I am 5’ 4” and weigh 135 lbs. I have attached a picture. Based on my picture and height and weight, what size implant should I get?
A: From the one picture you have sent, there is no question you would be a good candidate for breast implants. Having no sagging of the breasts with good tight overlying skin and centrally positioned nipples is the definition of an ideal breast augmentation candidate. Since implants largely just take what you have and make it bigger, the better-shaped breast (small as it is ) will always create the best looking breast augmentation result. Since you are young and do not have any sagging you should be able to have your breast implants placed beneath the muscle which is the best option for a young person for the long-term.
When it comes to choosing breast implant size,m it is not as simple as looking at a picture and knowing your height and weight. What counts is what volume will create the look of a full D cup on you. That, of course, is also open to your interpretation of what that is exactly. This is why I prefer the use of volume sizers for the patient to try on and see how it looks. It is also important to know what your natural breast base width is. With that being said, an experienced estimate would be 400c to 450ccs breast implant size for you, probably of a high profile style.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a rib graft rhinoplasty. I am a 32 year-old Asian woman that has a bad nose problem now. I had a silicone implant rhinoplasty done severn years ago. It looked good and was fine until about six months ago when my nose got really red and the implant got infected for no apparent reason. It had to be removed.:( Now my nose is sunken in and the tip is really short, it looks worse now than beforeI had the implant put in. Based on what I have read, it appears that a cartilage graft from the rib would be needed to get my nose back to the way I want it to look.
A: A rib graft rhinoplasty is the best choice for you now without question. The short nose of Asians can pose a real challenge when complications have occurred from a prior rhinoplasty. Unlike Caucasians rhinoplasty problems which are often the result of too much supportive cartilage removal, revisional Asian rhinoplasty problems result from augmentation problems from implants or grafts. When nasal implants get removed due to either infection or skin thinning, scar contracture will cause the tip to rotate upward as well as lower the height of the bridge due to the implant removal. This accentuates the naturally short nose of most Asians not to mention the scar tissue that has been created.
How effectively the Asian nose can be effectively built back up and lengthened is the result the result of the cartilage donor source. (an implant is obviously not a good choice when a prior implant has had to be removed) The amount of cartilage then controls what type of structural support and lengthening manuevers can be done. Rib grafts provide the most amount of cartilage one can use allows long straight grafts to be made for septal extension, columellar strut and extended spreader grafts as well as dorsal onlay grafts. No amount of tip or dorsal grafting from the ear or septum can produce the effects of what a rib graft can provide.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am possibly interested in skull reshaping surgery. I have occipital plagiocephaly. My head is clearly flat on the back left side of my head. I am 67 years old and losing my hair which makes it more noticeable. Can surgery correct this at my age or is it too late?
A: Age is not a physical issue for this skull reshaping procedure as long as one is in good health for the surgery. Since the procedure is an extra cranial procedure (onlay augmentation), it is no more complicated to go through than many other cosmetic facial surgeries. Age is only a limitation if one decides that they are too old to care about it…then it is too late.
I would be happy to look at any pictures that show the flatness on the left side of the back of your head.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m interested in getting buttock implants and fat grafting to my hips and butt. I know I don’t have much fat but I really want a much bigger butt. I have attached some pictures of me and a picture of my dream butt. How possible is this result?
A: Thank you for sending your pictures. You clearly have little fat to contribute to your buttock or hip augmentation. Your buttock augmentation result will come largely (95%) from the effect of the buttock implants. The ideal picture you have shown is not a realistic result. That is not going to be achievable no matter what implant size is placed. With an intramuscular implant approach with a maximal volume of 300 to 350cc, that result will be about 33% to 40% of your ideal buttock size result. If the implant is placed above the muscle (subfascial) with a maximal volume of 500 to 550ccs, you will get about 60% to 65% of your ideal result. Any addition of a small amount of fat will add little to the implant-created result.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am quite determined to have temporal reduction surgery done (head width reduction), but there is still a couple of lingering question I need answered. I have attached several CT scans of my head to get a better visualization on the width of my muscle as well as my skull. I was born with positional plagiocephaly. This has caused my head to be misshaped and one side of my face is wider than the other side. Initially, I was thinking about getting the head width reduction for both side of my face, however, after a careful consideration I want to focus the head width reduction on just the right side of the face on the wider side. If the result of the reduction is significant, I might consider a reduction on the other side of face as well as jaw and chin bone reduction on the wider side of the face. One of my main concern of the reduction is how much the width can be reduced. I recently took a CT scan of my head and I found that the size of the temporalis muscle at the widest area of my head isn’t very thick being about 6mm. Thus I felt through only muscle reduction there might not be as significance of reduction compare to when if both muscle and bone reduction is performed at some region of my head. Also I recalled last time we talked that you told me that you are not gonna remove a lot of muscle you simply reattach it and let it shrink. Since the temporalis muscle at some of widest regions of my head is only 6mm, I felt the shrinkage of muscle won’t likely achieve my desire width of reduction which is between 5mm to 7mm on the right side. Thus, I wanted to see if I can completely remove the temporalis muscle on that side above the ear.
A: It appears you have misinterpreted how I do the temporal reduction surgery. I initially detach and remove the posterior muscle in its entirety, then detach the rest from the temporal crest, shorten it and reattach it lower. So the entire posterior muscle is removed. That is critical to get a very visible width reduction from 5 to 7mms based on the thickness of the muscle present. Bone reduction is done based on what the CT scan shows although it is never as significant usually as the muscle reduction, but it is an additive component to the overall width reduction. Certainly only one side can be done if desired and, in cases of asymmetry, met be the best initial approach.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, If I went with buttock implants under the muscle what is the largest size I could go?Here are a few photos I would like to know your thoughts about the previous question and what would get me to my dream buttocks. I know my butt is very flat. But is there anyway to see how different sizes would look with out coming to the office since I do live out of town?What would you think the safe option is? I don’t have to have a butt like the pictures but I do want one that I can be proud of and wear certain clothes and feel good about myself. But I also want it to look natural and be a size that fits my body and my new additions up top.
A: When buttock implants are placed intramuscular (inside the muscle, not under it), the largest size for most patients is usually in the 300 to 350cc range. (which is likely not what you are demonstrating in these pictures) From your pictures, I can certainly see why you seek buttock augmentation given that your buttocks has no projection. (flat) There is no question intramuscular implants (you’re only choice since you have no real fat to harvest) will make a significant difference just not to the degree of projection like the pictures of celebrities you are demonstrating. That can more likely be obtained with buttock implants above the muscle where implants of much larger size can be placed (up to 600ccs) but there is the potential for a higher risk of complications in that location. (although an easier recovery) When it comes to intramuscular buttock augmentation, the rule of thumb is you just put in the biggest size implant possible. (e.g., 350 – 400ccs) Why?…because it will never be too big as that is the limitation of that buttock augmentation approach. The intramuscular pocket will only allow so much volume. In some cases, and you might be one, you can also inject some fat in the subcutaneous space under the buttock skin at the same time. That adds a little extra volume (50cc to 100ccs) and gets one a little body contouring as well.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am really interested in one of the facial procedures (cheek augmentation I think) to improve my smile. I make an effort to smile only to find out that people don’t find it compelling. I am confused and this makes my self-esteem very low. I have small(weak) cheek bones which some how make me look like I am frowning all the time. It was after me noticing my self-consciousness that I started being aware of all the people I found very approachable or had friendly faces, in other words their cheek bones were gently protruding and noticeable from a profile(side view of the face). This, them having strong cheek bones, really made them appear to be ‘ever smiling’ and smile effortlessly even when it is just a grin their evoking. I looked at myself talking in the mirror lately and was evidently stunned, because I would say things but my facial expression was not corresponding with what I say or the way in which I respond to things I said to myself. For instance, when I am surprised my eyebrows don’t rise and no lines on my forehead show, because my eyebrow bone is also flat and I seem not to send my messages across to others other than verbally. A stronger cheek bone with lines on the corners of my lips and bigger eyebrow bones will make my smile sensible.
A: It sounds like you have a good grasp on how to improve your facial appearance. By your own description you know that cheek augmentation by implants, possibly combined with brow bone augmentation, would help your smile both outside and in.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in abdominal scar revision. I had a panniculectomy done six years ago and an original tummy tuck approximately 11 years ago. I’ve been unhappy that the scar is so high. As you can see in the photos there are 2 scars. The one on the bottom was from my first tummy tuck. Do you think another surgery to lower the top scar could be done? There’s not a whole lot of skin to work with but low cut bathing suits are what I like to wear. I’m very self-conscious about my scar. Your thoughts are appreciated.
A: My first reaction is that I am stunned that the intervening skin between the two abdominal scars actually lived and not died. That was a very risky procedure from a skin necrosis standpoint. But it did work although the logic of two such displaced scars remains a mystery.
If the goal is to lower the upper abdominal scar (via an upper abdominal skin flap elevation) and bring it down to the lower one, that is not going to be possible. There likely is not enough skin looseness to allow that much downward mobility after having had two excisional abdominal procedures. I do think it is possible that the skin between the two scars can be removed and made into one scar, but that will only happen because some of the closure will come from the lower pubic tissue being elevated. This will then place the new scar about halfway between where the two scars are now. That will not meet your low cut bathing suit criteria. Unfortunately I do not believe your abdominal scar situation can be improved to meet your aesthetic criteria.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, will a buccal lipectomy make a noticeable difference in the shape of my face? I am trying to get a shadowing effect below my cheek bones so I will have more of a male model look.
A: While the buccal lipectomy procedure has a controversial side as to its long-term facial aging effects (creation of the gaunt face), it is also importanbt to look at their upfront effectiveness as well. In most cases, a buccal lipectomy is a complementary facial reshaping procedure whose magnitude of effects differ based on one’s facial make-up. In a thinner and more skeletonized face, its effects are more visible but this is also the patient who is most predisposed to have sunken in cheeks later in life. In a heavier rounder face, buccal lipectomies often have a more minor effect and other procedures must be done around it to create a more visible facial reshaping effect. These are also the same patients that will not have a sunken in cheek look later in life. Opting for buccal lipectomies in facial reshaping must take into consideration the balance of early facial shape improvement versus potential detrimental long-term facial shape changes.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in knee lifts. I am 50 years old and am very active but my knees look like an 80 year old women. I need a knee lift to regain my KNEE self-esteem. I am in disbelief as active as I am that my knees have aged so horribly. I have an adverse reaction to most anesthetics so hopefully this is a procedure which could be done under a local anesthetic.
A: The knees, like any other structure on the body, are not immune to the aging process. the constant motion across the knee joint requires moveable flexible skin. But for some people (usually thinner and very active ones) that constant motion results in the development of loose skin. This loose skin appears as folds above the knees, often having two or three small skin folds that have ‘piled up’ above the knee cap.
The procedure of a knee lift can remove these skin folds by excising a crescent of skin above the patella. It must be marked and removed carefully so that enough skin is left for the knee to bend 90 degrees of greater without undue pulling on the wound closure/scar. It is a fairly simple outpatient procedure that for the very motivated could be done under local anesthesia. It does result in a fine line scar above the knee and this must be considered carefully as a worthwhile aesthetic trade-off for the removal of the suprapatellar skin folds.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like to get a buried penis repair done. How exactly is it done?
A: When you use the term ‘buried penis’ that unfortunately does not tell me what type of tissue problem there is and what needs to be done to make it better. Is it a short penis only, an isolated large suprapubic mound, is there an abdominal overhang or some combination of two or all of them? There are different plastic surgery techniques that are done for the buried penis problem with varying degrees of success. These could include pubic liposuction, a pubic lift, penile release and lengthening or some combination of all of them. Having a picture of the pubic area, ideally from the front and side views, would help me understand the buried penis problem and give you some recommendations on whether plastic surgery would provide a positive improvement. (increased penile show)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I know I need rhinoplasty but am not sure what else I need. I would like you to analyze the attached photos in order to determine the ideal procedures to bring better balance to my face. These are my own assumptions about my facial appearance, both what I see as out of proportion and how to go about fixing it along with the objectives I hope to achieve
1. Droopy asymmetrical nose – It would be optimal to both straighten the entire nose and strengthen the tip (add cartilage). The tip would look best projecting forward more. I would still want to keep a high strong nasal bridge, so little shaving should be done there. Tip should still be turned down slightly a few degrees further than perpendicular to the face.
2. My eyes are too prominent relative to my other features and I would like a stronger, masculine look to eyes. I have looked at everything from malar to inferior, lateral, and superior orbital rim implants. I am less sure what would prove ideal for this issue, so your own suggestions here would be much appreciated (though if you think it is a bad area for me to augment please let me know as I want your complete objective opinion). Be as specific as possible, referencing both the individual anatomy and procedures that are possible.
A: Based on the one side view picture that you have provided, I did some imaging for the rhinoplasty based exclusively on tip rotation and elongation with minimal reduction of the middle vault height and no reduction of the nasal bridge bone. With this change I see no reason for chin augmentation which is the first other facial feature to think of when the nose becomes derotated.
From an eye standpoint, the only consideration you want to make is for infraorbital rim-malar augmentation. While superior and lateral orbital rim augmentation can be done, the effort to do does not justify the minimal benefits and risks. The focus for making the eyes less prominent should be on the recessed infraorbital-malar complex. I have factored this into the imaging.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like to possibly get temporal zone migraine surgery or Botox injections. I have been diagnosed with chronic daily headache (migraine) and believe this would be beneficial. I have had it for approximately 3 1/2 years and normal medications and treatments do not correct the issue. The issue developed approximately 2 to 3 months after returning home from overseas. I do wear a TMJ mouth guard for bruxism and have daily muscle tension type headaches in both temples and above the ears. Since medications and the mouth guard do not fix the problem I believe that this procedure may provide some more permanent relief. Please feel free to email or send any additional information. Thank you.
A: By your description, it appears you have symptoms that involved both temporal and masseteric muscles. This, to me, more likely suggests myofascial pain syndrome of these muscles and fascia rather than a specific trigeminal nerve compression issue. The first place to start is with Botox injections into either the temporal or masseter muscles or both. Then see what the response is which, in my experience, I have yet to see a patient who does not get some significant reduction in their symptoms. Migraine surgery is reserved for those patients in which a specific peripheral neurovascular trigger can be found rather than overall masticatory muscle pain/headaches. That is the first place to start and is what should be done during the first visit.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in skull reshaping to reduce the width of my head. I have a large head and I’m embarrassed about it. I have to buy larger hats than everybody else and it’s a hassle to wear sunglasses or prescription glasses because my head is so large that it squeezes and gives me a headache. I have to order special made ones if I want them to be comfortable. I understand that it’s not really a problem, but I’ve been self conscious about it for years and I want something done to stop constantly thinking about it. I would like a procedure that would make my head smaller in width. What could you do?
A: Skull reshaping can provide numerous skull shape changes and one of those is in the reduction of its width. In looking at your head shape, it easy to see your concerns with a fair amount of temporal convexity, bulging of the anterior temporal lines and a general side to side large cranial outline. While there are limits to how much the skull be reduced, there are some visible changes that can be achieved. The bulging on the sides of your head (temporal area above the ears) can be reduced by temporal muscle reduction/shortening and the anterior temporal lines (transition between the sides of the head and the top) can be reduced by about 5 to 7mms. These manuevers will never make your head width as small as you would like but they can make a visible difference.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in jaw implants to give me a more defined jawline. I can see from your computer imaging that adding the chin implant to the jaw angle implants really does make a difference. I have a couple questions. Are the implants silicone? Do the size and type of the implants determine how chiseled my face would look? I’m trying to get as close to the ‘male model’ look as possible. I’m not sure if any other procedures would make as much of a difference as these.
A: Chin and jaw angle implants (jaw implants) are made of either Medpor or silicone material and I have used both extensively. However I much prefer silicone because implants made of this material can inserted much easier, shaped intraoperatively much better if needed and are far easier to revise/remove if needed. A good saying about silicone facial implants is…easy in, easy out and easy back in if needed.
The size and the shape of the implants play a major role in the look of the final jawline result, provided one has a fairly lean facial look to start. The thicker the overlying soft tissues are, the less defined the outline of the implants becomes.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in orbital floor augmentation to raise up my eye which is about 2 to 3mms lower than the other side. Regarding the graft material, I’d prefer to go with natural ear cartilage if that’s something you’re comfortable using. Have you used ear cartilage for orbital floor augmentations before? I also have several more questions about this procedure…
1. Could raising the eyeball via the orbital floor (as opposed to reconstructing the entire orbit in a different position) result in pressure on the upper part of my eye?
2. Is there any chance of this procedure affecting my vision?
3. How long would I have to abstain from wearing my contact lenses?
4. Could this result in unintentional horizontal movement, in addition to vertical movement? Is there any chance of ending up with a cross-eyed look?
5. Approximately how long will it take for my eye to settle in its final position, about 2mm higher than where it is now?
6. Approximately how long will the procedure take and how long will I be under anesthesia for?
7. Is there any way to do before/after 3-D imaging for this procedure? I think what I’m seeing in my head is a complete relocation of my entire eye – I’m having some trouble visualizing what it would look like just to have my left eyeball raised, while my eyelids, lashes, etc. remain in the same position.
A: Cartilage can be used for orbital floor augmentation and certainly would be a natural material. I am all for using a natural material when possible. Cartilage has the advantage somewhat similar to a synthetic implants in that it should not undergo any resorption. The only issue with ear cartilage is that the amount of graft material is fairly limited. Ear cartilage is great for the nose but the front part of the orbital floor is much bigger. Thus the only caveat is that the ear graft size may be somewhat insufficient for its intended purpose. In answer to other questions:
- This amount of orbital floor augmentation will not put any undue pressure on the eye.
- There is no risk of vision loss with this procedure.
- You can wear your contacts as soon as you feel comfortable and can get them in.
- The procedure will not result in any unintended horizontal movement.
- The final results from orbital floor augmentation can be critically judged 6 weeks later. Always the eye will look a little higher than the ‘normal’ eye for awhile.
- This is a one hour procedure done under general anesthesia.
- Computer imaging can be done of the eye moving up but it will create a distorted view. Computer imaging can only show more or less of what is already present. Thus moving the eye up should show a similar amount of iris exposure but it will look elongated and will not show a natural iris to lower lid margin relationship. I am happy to do it but you will probably not find it helpful.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in some form of facial freshaping. I have some issues regarding a long face, and more importantly a long midface. It’s just been seriously bothering me for years to the point where it is causing problems. If you could take a look at these pics and just figure out what is so wrong with it, i would really appreciate it.
A: While I would not disagree that your face is a little long and the guilty component is your midface, there are other facial structural issues that are magnifing that impression. A horizontally short chin and a long nose with an acute nasolabial angle make the midface loo longer than it already. When you combine that with a very skeletonized face (little facial fat), the effect becomes even more so. There really are no true midface shortening procedures other than a maxillary impaction which is only used for vertical maxillary excess that has a gumkmy smile. (which does not apply to you) But what you can do is change some of the other factors that are accentuating the midface elongation effect. This includes a sliding genioplasty to bring the chin forward, a rhinoplasty to rotate the tip and decrease its length and submalar cheek augmentation to procide some more width to the midface. Together, these facial structural procedures can help shorten a long midface appearance.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’ve been wanting to get a rhinoplasty for awhile to augment my radix and glabella. My goals are to widen and raise the radix so that there’s a smoother transition between the nose and the brow ridge. Anyway, I have two questions:
1) Will I be able to achieve this through cartilage grafting, and if so, how long a recovery should I expect?
2) I’m hoping to get it done next year. As such, could fillers be injected into the radix and glabella in the interim? It would also serve the purpose of giving me an idea of the kind of augmentation that can be achieved. Also. if fillers can be used, how much filler will actually be required? Thanks!
A: The long-term solution to a deep radix is augmentation, albeit done with a synthetic implant or a cartilage graft. There are arguments to be made for either an implant or a graft but I will leave that subject alone for now. If that is the only thing that is being done to the nose, there is a very short recovery since such augmentation can be done through a closed rhinoplasty technique. If one is uncertain as to how one would look with radix augmentation, one could do either computer imaging or place injectable fillers as a ‘surgical test’. Usually most injectable radix augmentations take about .3 to .4cc of material to create the desired effect. While there are many different type of injectable fillers, one should use those that are composed of hyaluronic acid as these can be placed in the smoothest fashion and the timing of their resorbability can be adjusted based on the specific product used.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a revision rhinoplasty. Do yout have experience in removing medpor L shaped implants? This nose has become tight and hard.
A: Revision rhinoplasty often involves removal of synthetic implanted materials. I have removed more than my fair share of Medpor implants all over the face. I am assuming when you say an L-shaped Medpor implant you are referring to its use in the nose for dorso-columellar augmentation. Contrary to common perception, medpor implants can be removed without undue difficult even though they get fibrous tissue ingrowth into them and can be quite adherent. Their removal from the nose is the ‘trickiest’ area to do it because of the naturally thinner tissues of the overlying skin. The tissues may be very carefully lifted off of the implant so as not to damage the blood supply to the overlying skin. I have removed such nasal implants numerous times over the years but the key questions is…what do you want to do to replace it? Depending upon its size, the tissues can contract and become distorted after its removal. In other words, your nasal skin and its shape is not going to return to what it was before the initial implant surgery. This is the more important concept to consider in your revisional rhinoplasty.
Dr. Barry Eppley
Indianapolis, Indiana
