Your Questions
Your Questions
Q: Dr. Eppley, I want to get my forehead reduced so it can be the flattest it can be. However I’m not sure of which approach to take. I heard that with the burring its only a limit to how far you can take it but with the set back you can accomplish more with greater results. However from what I’m told the set back can’t be hidden well and you’ll be able to tell where your bone was broken removed and repaired with screws cements or whatever you guys use to hold it into its new position Is it an additional price from the average burring technique and do you also lift the bones of the eyebrows into a new place to heighten them or you just simply lift the muscle and skin around the bones to raise the brows.
A: Everything that you are saying or have heard about brow bone reduction is relatively true. It would be very rare that a burring technique alone can significantly reduce prominent brow bones or make them as flat as possible. Thus, the formal brow bone setback is the better procedure to do for maximal change.It is true that in the thinner-skinned forehead patient it may be possible to potentially see the outline of the brow bone work. But I have learned to lessen the likelihood of this problem by either avoiding or minimizing the use of any plates and screws (use mainly resorbable sutures if possible) , use only very miniature plates and screws (1mm profile) if they are used, be meticulous about contouring the surrounding bone into and around the setback area and using a thin film or overlay of hydroxyapatite cement over the setback area for smoothness. Whether a simultaneous internal browlift is done depends on the patient’s current eyebrow positions, the degree of brow bone reduction and the patient’s desires. The internal browlift is done by suturing the underside of the eyebrow area onto the bone of the osteotomized brow bone edges or to any fixation hardware used in the brow bone setback.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I want to know if I am a good candidate for liposuction. I have a stomach bulge but as I have been searching various internet sites I have seen bigger women than me that have only had the liposuction and show good results. I don’t want a tummy tuck because of the scar. I have never been pregnant and have no stretch marks just a big bulge. Will liposuction be the best option for me? Is losing a little bit of belly weight before a good idea for me?
A: The ideal candidates for abdominal liposuction is primarily defined by the quality of the overlying skin. Nice taut skin that has good elasticity without excess will always produce the best liposuction result, regardless of the liposuction technique used. Skin that has the natural abiity to tighten will do better than any method of skin tightening that various liposuction devices tout. Being a female and never having been pregnant, by definition, makes you a good liposuction candidate in most cases. It is always good to begin any weight loss efforts before liposuction so you will already been in the lifestyle change that will help ensure you enjoy the long-term benefits of the liposuction procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’ve read your articles on brow bone augmentation and was wondering if silicone implants could be used instead of hydroxyapatite or PMMA? Apart from the scalp incision, could the silicone implants be placed through any other incision (upper eyelid)?
A: Performed silicone brow bone implants could be placed either through an upper eyelid incisional approach or through an endoscopic technique through two small scalp incision. Because they would be made of a flexible silicone material, they can be inserted in two separate pieces and ‘assembled’ once inside. If this brow bone augmentation technique is done, it is best to make the preformed silicone implants beforehand using a 3D CT scan of the patient.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am wanting a breast lift and augmentation. I am 24 years old and my left breast is a cup size larger than my right. After having a baby a year ago and breast feeding for 6 months, the all around shape and liveliness has headed south. I want to get some information about a lift. I am interested I’m how much of a difference just a lift would make, is it better to do both augmentation and lift, and what is the likeliness of breast feeding if I were to have children in the future and would it bring the breast back down. Thank you
A: Breast asymmetry is always one of the most challenging of all breast reshaping surgeries to do. In interpreting your question, it sounds like you are just interested in doing something with the original larger left breast. That may be a reasonable approach if a lift can approximate the position or shape of the opposite right breast. In many cases of breast asymmetry, before or after pregnancies, it usually takes treating both breasts to get the best result. Whether this is done with implants, lifts or combinations depends on the size and shape of the initial breasts and their degree of asymmetry. Regardless of what is done, future pregnancies and breast feeding will negatively impact the surgical results that are obtained.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have read on your site about the injectable sternoplasty (bone cement) and read about successful operations correcting mild to moderate pectus excavatum. I have mild pectus excavatum and was wondering about the approximate cost of the whole operation.
A: The Kryptonite material is no longer commercially available so that treatment option no longer exists. Other injectable treatment options include hydroxyapatite granules and fat. The hydroxyapatite granules are mixed with platelet-rich plasma (PRP) and made into an injectable putty-like material. Fat injections can be done provided that one has enough fat to harvest, of which it usually takes about 100cc of aspiration harvest to get 20cc to 25cc of concentrated fat for injection. Whether either one of these would be appropriate for you depends on the size of the pectus and your body habitus. I would need to see some pictures of your chest to make that determination.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have noticed that my son who has just turned 21 years old has quite a prominent protruding brow. In fact, I noticed it a few years ago and I am quite positive that it has become larger in the past 12 months. He is 6ft 5in (195cm) tall – a very slim built person; a sports man. Other body features, such as face and head, are all normal in size and do not have the ‘giant syndrome’ disease – which I recall most people with a large protruding brows have. I am wondering – will the brow bone stop growing or could it become larger? Should we be concerned? Should he see a physician? Is this a particular condition or syndrome which needs investigation? Look forward to your early response. With sincere thanks.
A: In theory, frontal sinus development is almost always complete by the later teen or early 20s. Your son is a large man so his frontal sinus development may be normal for his size…or it could represent an underlying endocrinologic disorder of the pituitary gland or excessive growth hormone. I would recommend that he be initially seen by an endocrinologist to rule out this potential medical condition even though it may be unlikely. X-rays of his frontal sinus would also be helpful to determine its size. If there is not an endocrinologic basis for his frontal sinus development and it is an aesthetic concern, brow bone reduction/reshaping is a surgical option
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I see that you have a post on various implants that can be implanted in the body. My left thigh (inner part) is more curved and less developed than my right thigh. I have attached some pictures of my inner thighs. I’m wondering if you perform implants of this kind. Can you please let me know? I cannot find any surgeons in the U.S. who perform this kind of implant. Thank you.
A: I did get your pictures and can see the inner thigh difference in contour to which you refer. The question is whether an implant is the appropriate solution to that problem. I ask that question for two reasons. First there will be a noticeable scar in the inner thigh through the implant must be placed. While it is not a long scar (3 -4 cms), the inner thigh is a sensitive area in terms of less than ideal scarring. Secondly, the location of the implant would be between the sartorius and the vastus medialis muscles which is a good submuscular location. (although this is a superficial inner thigh muscle) Since there is no true thigh implant, the best body implant choice would be a calf implant which is long and slender and would seem to have an appropriate shape for this location and the overlying muscle. Current calf implant lengths are 15 cms (small) to 24 cms long.(large) It would be helpful for you to outline on your leg your perceived length of the contour area and what is lengths in cms. is.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 35 year-old male born with a significant facial asymmetry. I have a prominent left sided zygomatic prominence, a left ptosis and a slightly recessed left sided forehead. I also have prominent inverted-U shaped supra-orbital bossing, which divides my forehead into two, and cast unaesthetic shadows especially when I stand under light. I do understand that there are limitations to what could be corrected but I will like to explore what can be corrected. My surgical objectives would be; 1) repair of left ptosis, 2) reduction/shaving of the zygomatic prominence, 3) zygoma fossa augmentation and 4)
forehead contouring with burring/infracture of supra-orbital bossing +/- forehead augmentation. I have attached images for your review. I have also used a plastic surgery simulator to put my desire in a picture form. I would appreciate your review and consult.
A: I have taken a careful look at your pictures, including the simulations, as well as your goals and can make the following comments.
- The width of the zygomatic body/arch can be narrowed by an anterior and posterior osteotomies. (infracture method)
- The prominent brow bones could be reduced by osteotomy/infracture method. (brow bone reduction)
- #1 and #2 could be done through a coronal incisional approach. Since #2 mandates that this be used, #1 would take advantage of that approach also.
- You are showing a high temporal augmentation in the superior temporal zone. I believe you are incorrectly calling this area the zygoma fossa which I think you mean temporal fossa. This area could be augmented through the same incisional approach as #1 and #2. This would require an onlay augmentation using PMMA given the quantity of material needed as well as the size of the surface area.
- To optimally smooth out the forehead above the brow bones, some augmentation would need to be done as well above the brow bone infractured area.
- Your left upper eyelid ptosis appears to be in the 1mm to 2mm range which could be treated by an internal Mueller’s muscle resection.
- I also noticed that you have performed rhinoplasty for narrowing of your nose and lower lip reduction as well.
As you can see in the above description, the key to most of your desired changes is the need for a scalp or coronal incision to do them.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, My upper lip is big and hangs over my teeth. i am looking for a lip lift. I am in my mid 50s Am I good candidate for it. Will my upper lip look bigger or the same.
A: An upper lip lift, presumably through a subnasal incision location, would produce only a minimal amount of lip lift as it relates to improving tooth exposure. It would make the central part of the upper lip look bigger. If you are happy with the current size of your upper lip, a subnasal lip lift would not be the appropriate procedure. If you do not mind more vermilion upper lip enlargement, then it would be a reasonable procedure to do. But it may take a concurrent lip tuck-up done from the inside the lip as well to get the desired amount of improved tooth show.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I underwent mandible angle and cheekbone reduction surgery over a year ago. I am disappointed with the changes as it has feminized my previously masculine face. I find that the angle reduction from my jaw is unnaturally high and much too straight to be considered normal. What options could I consider to replace the previous bony structure? Another issue that I am faced with is substantial mid to low face sagging. Several areas seem to be affected such as the infra-orbital muscle (clearly visible, elevated on cheekbone), nasolabial folds, and soft tissue isolation (sides of mouth, fat cheek look). Could you explain the causes of these irregularities and possible procedures that I could undertake?
A: I have seen a few cases just like yours where the jaw angles have been completely amputated. The angular shape and the vertical height of the ramus of the mandible can be restored by jaw implant augmentation. But the implant shape can not be a standard jaw angle implant. it needs to be shaped to just have a vertical augmentation only that has an oblique superior shape to match the oblique cut. That can be done by either using one of the custom jaw angle implant shapes that I have previously used or have one made off of a 3D CT scan.
As for the other facial changes those are obviously a result of the cheekbone reduction. I am going to assume that this procedure was done intramurally with n obliquely oriented osteotomy of the zygomatic body and a posterior osteotomy of the zygomatic arch. That has caused loss of support of the surrounding cheek tissues which not sag creating an orbicular is muscle edge show, deepening of the nasolabial folds and sagging in the submalar area. Like the jaw angle issue, adding back some skeletal support would seem like a logical approach. That effectiveness, however, is not as clear as it would be in the jaw angle area.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, My 5-year old daughter has protruding ears, and I was interested in looking into costs associated with having them fixed and if she is currently a candidate or if it is best to wait until she is a little older.
A: Thank you for your inquiry. Otoplasty surgery can really be done at any age after two years old from a biologic standpoint. Ear growth is not affected when performed after this age. Thus, otoplasty in children is done when the parent(s) feel that it is in the child’s best psychological interest to do so. It is historically common to perform the procedure before school formally starts which is where the ‘by age 6’ concept has its origin. Since some form of formal schooling is not occurring earlier than age 6, it would not be rare today to do the surgery by age 4 or 5. This is really a parental decision not a plastic surgery one.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I’m interested in cranioplasty augmentationsurgery but have a few more questions.
1. Is this correction permanent meaning is it reversible? is it expected to last a lifetime?
2. You mention PMMA is harder than hydroxyapatite, will i feel the difference?
3. Is the hardness of hydroxyapatite similar to real bone? Will it feel more natural to me?
4. Will I experience foreign body sensation with this “implant”
5. I’m not an expert on the anatomy of the skull but i’ve read that there are gaps between the bones of the skull even when they are fused. how will this type of correction subtle dynamics of contraction and expansion of my skull bones, once a material like hydroxyapetite is plastered onto them?
6. Is there potential for leakage/breakage of material and if so what are the health, carcinogenic, or risks.
7. Is there risk of allergic reaction to the material?
Thank you for the work that you do.
A: In answer to your questions:
1) All cranioplasty materials are permanent, meaning that they do not degrade, break down, and never need to be replaced because they wear out. They are, however, fairly easily removed so they are completely reversible.
2) There is no external feeling difference between PMMA and HA. Their biomechanical differences are largely that of laboratory testing.
3) There are no feel differences between PMMA and HA and they will feel both natural and just like your own bone.
4) Patients do not report that they feel like they have a skull implant in place. It feels just like bone.
5) There are no gaps between adult skull plates. That is an in utero and neonatal phenomenon.
6) Cranioplasty materials are fully polymerized and do not break down, leak, or degrade over time. There are no long-term health or carcinogenic risks.
7) While infection can occur from their surgical placement, there is no known risk of an allergic reaction to HA and very rare risk to PMMA.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am seriously interested in reducing size of my stomach/abdomen with minimal down time and invasion. Is this what laser liposuction can do? I am researching my options.
A: It would be good to talk you through many of your liposuction options and get a realistic understanding of how they work and what can be achieved. There is no such thing as any liposuction method that has any different amount of invasiveness or recovery. That is a misconception propagated on the internet by various marketing and promotional efforts as well as many device manufacturers. While there are numerous liposuction techniques that use different energies to achieve their effects, they all are invasive surgery, traumatic the tissues significantly and involve recovery that would not be considered quick or minimal particularly over a large area like the abdomen.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I’ve been browsing your website for a couple of weeks and it has proved a tremendously useful resource on rhinoplasty. This is something I’ve been thinking of getting for a while, but I would like your opinion on the options available. From what I’ve read, silicone implants tend to come with a risk of extrusion, which is why many surgeons recommend rib grafts. However, I would prefer to avoid the scar and a more invasive procedure. After posting on various forums, I have been recommended to get a silicone implant for the bridge, but to use ear cartilage to reinforce the tip and to further build up the bridge and radix. Do you think that this will be a viable alternative to rib grafting? Lastly, as I’m from out of the state, would you be able to perform a rhinoplasty on me, and how long should I expect to have to stay before flying back home?
A: It is understandable that many patients want to avoid the use of a rib graft for their rhinoplasty. The use of an implant makes the operation far less complex and much easier for recovery. But, as you have pointed out, the use of an implant for nasal augmentation must be carefully done to avoid its well known complications. For implant nasal augmentation, I currently prefer the use of a PTFE-coated silicone implant as it allows some better tissue adhesion than pure silicone alone but avoids the severe scar adherence of a Medpor implant. The key to prevent long-term complications is to avoid too much pressure on the overlying skin, particularly that of the tip. For this reason, many surgeons will cover the tip with an ear cartilage graft which is a perfectly valid approach. When possible, I prefer to place the end of the implant under the nasal dome cartilages which have been lifted, narrowed and sewn together over a columellar strut cartilage graft. This achieves the same purpose but buries the implant under more natural tissue. This can only be done when the nasal implant is a dorsal style only and not a dorso-columellar style implant. Many times the dorso-columellar style can be avoided with columellar strut grafts. It is unclear to me yet as to what your nasal augmentation needs are.
With a rhinoplasty that uses a nasal implant, the recovery is only a matter of days until one can return home.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, My surgeon indicated that he wants to perform a mandibular osteoplasty to reduce the squareness of my angles; this is why he would need to use screws. He told me that the bone is so hard to reach that he doesn’t use the angles osteotomy, he doesn’t know how to do that. He is a maxillofacial surgeon and not a facial feminization surgeon.
Are you aware of the mandibular osteoplasty surgery? Is that appropriate to reduce mandibular angles? Does that give a more natural result to the angles? One that causes less asymmetry or sagging skin? Is a maxillofacial surgeon appropriate for that type of surgery? (purely aesthetic as I have no functional problems)
A: The term, mandibular osteoplasty, is a generic term (means jaw bone reshaping) that does not imply any specifics about the surgical technique. You would have to ask him to draw exactly what this technique is to understand what is being proposed. However, I suspect he is talking about doing a sagittal split ramus osteotomy as this would be the only jaw angle procedure in which screws would be used to fix the bone back together. I do not see any reason or indication in this approach for what you are trying to achieve aesthetically. I suspect you are correct in that this particular maxillofacial surgeon is taking a functional rather than an aesthetic approach to your concerns.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I am a 28 years old transgender female. I would like to do a hip augmentation with implants and at the same time a liposuction and fat transfer to the butt or maybe butt implants and hip implants together. I would like to know what is the best solution to create more feminine curves in the butt and hips areas.
A: I would need to see some pictures of your body to see the dimensions of your hips and buttocks and see what the best solutions are. But I will assume for now that you do not have enough fat to successfully do any amount of fat injection transfer for augmentation. This usually requires at least 2500 to 3000cc of liposuction aspirate to get 300cc to 400cc of concentrated fat per buttock to inject…which will create a very modest buttock enlargement. This leaves the only options for either buttock and hip augmentation using implants. The decision for buttock implants is whether to go above or into the muscle. I usually prefer the intramuscular approach since this implant location has a lower risk of complications and better long-term results. Hip implants are always placed in the subfascial location and the size of implant that can be placed depends on the tightness of the pocket right below the level of the trochanteric prominence.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, there is something wrong with my face but I can’t figure it out. I used to think it was all because of my nose which is big but I think it is more than that. There is some other part of my face that just isn’t right that makes me look unbalanced or disproportionate. I have attached some pictures for your insights and recommendations.
A: Thank you for sending your pictures. What I see about your facial proportions are two things:
1) A nose that is very broad at the tip and middle 1/3 and a bridge/dorsal line that is low.
2) A forehead that is narrow and very flat.
Ideally a rhinoplasty with tip narrowing and dorsal line augmentation would make the nose more proportionate. Also a forehead augmentation to give it greater convexity from the brows up to the hairline would also be an aesthetic addition.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I need to know if I need liposuction, a mini-tummy tuck or a full tummy tuck? I am 28 years old and have had two children. I had breast augmentation done three years ago and go pregnant right afterwards. I have a big hard stomach and can’t seem to lose it even though I work out and try to eat right. I am 5’ 8” and weigh 190 lbs. I think surgery is only thing I can think of to help but I am not sure what I need, liposuction or some type of a tummy tuck. Please help!
A: With a relatively high BMI (body mass index) and a ‘hard and big’ stomach, I have concerns that any form of plastic surgery is appropriate for you at this time. You need to lose some weight by some method before considering any tummy reducing plastic surgery procedure. A hard stomach indicates that the skin is tight and a tummy tuck, while it can be done, would not produce a result that may be worth the effort. (the tight skin would not allow that much to be removed) A better yield on a tummy tuck would occur if you dropped 20lbs to 30 lbs, creating greater looseness of skin. Similarly liposuction would produce less of a result that expected as some of your fat is intraperitoneal (located behind the abdominal muscles) where it is inaccessible to a liposuction cannula.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I am Mexican-American and have large cheekbones. Would you do me the honor to address my affliction. Malarplasty and chin implant are my considerations. I have attached pictures in which I did not shave to accentuate jawline and chin. Hope I didn’t goof. Thank you very much for your time.
A: Thank you for sending your pictures…and you did just fine. In looking at them, the problem with your chin is that it is vertically short as the predominant issue with only a mild horizontal deficiency. I think when the chin/front part of the lower jaw is expanded by an extended vertical chin implant, it makes the more prominent cheek bones less signficant. Your cheek bones to me only seem large because the bottom 1/3 of your face is short. I have attached some predictive imaging illustrating what happens when the chin is vertically lengthened.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m contacting you as I am seeking some comments from yourself in relation to what I suspect is either unilateral coronal synostosis or plagiocephaly. Given the nature of the problems I present I am not to comfortable with sending photographs
If I were to describe my observable problems I would summarize them as follows:
1. Slight right-sided anterior ear displacement (very obvious asymmetry of the ears)
2. Mild right-sided occipital flattening
3. Frontal bossing with excessive protuberance of the upper portion of the squama frontalis over the supraorbital margin – slight right to left cant with the right being more forward
4. Vertical orbital dystopia – right side slightly higher than the left (I would say the entire zygomatico-orbital bone complex on the right is higher as I have an asymmetry and protuberance in the zygoma region)
5. Nasal root deviation to the right with deviated septum to the right (What I mean by this is that the entire nasal bone pyramid complex is off to the right)
6. Chin deviation to the left
7. Asymmetry in the vertical height of the mandible – left side is higher than the left
8. Uneven cheek fullness – slightly greater degree of fullness on the right side.
9. Malocclusion – no functional occlusal contact left side and buccal crossbite right side in centric relation, posterior bilateral open bite in centric occlusion. Mandibular mid-symphysis deviates slightly to the right in centric relation, and slightly to the left in centric occlusion. Left condyle is both posterior and superior in the mandibular fossa compared the right. There is a slight transverse cant of the maxillary occlusal plane observable in frontal view, which gets more significant as you approach the region of which is inclined.
If I were to describe my visual appearance in worm-eye view I would say that there is a slight twisted effect to the skull from right to left, as can be seen looking at the frontal bone and the supraorbital margin, the nose, the zygoma’s, and the mandible.
I have looked at some photos of myself as a child and it seems quite apparent to me that I had a slight degree of vertical orbital dystopia. I do not believe however that I had the “harlequin eye” deformity looking at these photos.
Do you have any comments or advice, and what treatments may be available to tackle my asymmetry?
A: Your description is fairly classic for this deformational type of skull deformity. Usually the best camouflage approach is to level out the chin and jawline by osteotomy/implant, correction of lower orbital dystopia by cheek augmentation, building up the floor of the eye and adjusting the ipsilateral lateral canthus and possible brow bone contouring. Rhinoplasty to straighten a deviated nose may also be useful. If the ear sticks out on the more anteriorly positioned side, an otoplasty may also be done. Usually I leave the occipital skull deformity alone unless it is really flat.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I had orthognathic surgery to improve my bite and make my jaw more symmetrical. Even though my bite is better, I now realize that my jaw is too small and narrow. I have been researching to find an implant which is able to make my jaw both longer and wider from the chin all the way back to the angles, but can’t find any. Are there any off-the-shelf implants that can achieve my goal of back to a substantial and robust jawline? Can Medpor or silicone implants be custom made? I am more favourable towards Medpor because of its ability to form on to the bone and become incorporated in it, rather than silicone or any other materials. I really hope you will be able to help me with this jaw problem.
A: It is hard for me to know how much change you really need based on your description alone. But in cases that I have worked in the past who have had similar concerns they almost always have needed custom rather than stock or off-the-shelf implants. Custom made jawline implants off of a 3-D model which can be designed and manufactured in virtually any dimension so their versatility makes them always the most ideal choice for total jawline enhancement. They can only be made in silicone, custom made implants from Medpor is not an option because it is not offered by the manufacturer and they would be virtually impossible to place anyway. It is also a misconception that bone grows in Medpor which it does not really do. Rather fibrous or scar tissue is what grows into the material…which is why they can be very hard to remove later.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I hope you can help me. I had lipouction for a witches chin with jowls removed; jowls on advice of plastic surgeon. Chin is uneven with a “fat pad” remaining. Plastic surgeon said he would “fill it in” and used Belotero. I look 10 yrs. older; I am 61. Could you look me up on Facebook and you will see the before and after photos. Plastic surgeon said he will not redo. Have been to two other plastic surgeons for their advice; both said they would never have lipo’d the chin. What can you advise? I can’t afford to keep getting filler and feel foolish and depressed over this. Thank you for your valuable time and advice.
A: I will need to see some current pictures of your chin for my assessment, a front and side picture will suffice. (I don’t do Facebook) As a general statement, liposuction of the chin is not a good technique, will not correct and witch’s chin and usually will leave it uneven or bumpy…often worse than where the patient started. The preferred treatment of a witch’s chin deformity is a submental tuck-up where the overhang is removed and tucked under the chin. A witch’s chin problem is the full thickness of tissues that do not have bony support. It is not an isolated fat problem which is amenable to liposuction.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I am curious about having liposuction on my abdomen and thighs what is the average cost, I want to remove about 15lbs.
A: Thank you for your inquiry. While it would be helpful to see some pictures of your abdomen and thighs, let me ask you a few questions in regards both areas:
1) Is this your full abdomen?
2) Do you need the flanks or muffin tops t.reated as well as your abdomen?
3) Do the thighs include both sides, inner and outer? Knees?
When considering cost, knowing exactly what areas needs to be treated as this allows the time to do the procedure to be properly determined. Fundamentally, liposuction like all cosmetic surgery and its cost revolves around the timer to do it.
While 15 lbs of aspirate (1 liter of liposuction aspirate roughly equals 8 lbs) may be removed in surgery, this does not necessarily mean that will translate into 15 lbs of actual body weight lost.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I have a few questions regarding facial implants. I did not see this addressed on your blog so thought I would ask. My question is regarding the known/ suspected long term effects of having facial implants if any. While I understand that for instance solid silicone implants such as the jaw/ chin implants I’m interested in will last a lifetime; however, what does the aging process hold for those that have such implants? Does placing an implant under the largest muscle (of the jaw) have drawbacks as I age. ( only in my 30’s now) Will jowls/ sagging skin etc show up faster since the muscle is now stretched over this new ( larger jaw)? How will chewing be effected if at all due to this as I age. Or will aging and its various processes just march on as if I never had anything done and just as if I was born with this new wider jaw and more pronounced chin? Thanks again for your time.
A: Facial implants, of any location, have no negative impact of facial aging and may actually have the reverse effect. As implants add volume by addition to the bone, they may prevent some tissue sag, or delay it, that will inevitably occur with aging. Jaw angle implants have no negative effect on chewing other than the initial discomfort and stiffness in mouth opening right after surgery that persists for a few weeks.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I am seriously contemplating having chin revision surgery done by you due to a persistent unilateral numbness on the right side of my chin and lower lip area. This has been causing me a lot of distress for almost 2 years. On top of this, my right mentalis muscle doesn’t contract properly which causes a very noticable crooked smile and asymmetries in other facial expressions.
Here is a short history of what was done on my chin. About 3 years ago a plastic surgeon placed a Medpor chin implant with a 5mm projection via intraoral incision. It was the implant shown in this photo, but with a fair amount of custom reshaping. There were several issues after the first surgery though. While the left side seemed to be alright, the right side wasn’t. The implant was shaped assymmetrically (less prominent on the right angle. The right wing protruded about 2mm from the chin bone, i.e. it didn’t touch the bone which resulted in a bad transition as well as serious irritation and pain that wouldn’t resolve. The implant appeared to protrude slightly more on the right frontal part than on the left. Therefore my surgeon injected hyaluronic acid on the left frontal part to temporarily ameliorate this assymmetry until revision surgery. There was also numbness and lack of motor control of the chin and lower lip. The numbness and lack of motor control eventually fully resolved, but it took a whole year! However, the other problems made a revision surgery necessary. In this surgery the following was done. An intraoral incision merely on the right side (only the right muscle was cut through!), taking away the back part of the right wing to ease the irritation and pain, placing additional MedPor material on the right angle of the chin implant to make it more prominent and placing additional MedPor material on the left frontal part of the chin implant. The revision surgery took care of the irritation and ameliorated the assymmetries, meaning the chin now looked more symmetrically although still not perfect.
Unfortunately, the revision surgery brought more bad than good things. Now the major issue is that even after almost 2 years since revision surgery I still have unilateral numbness in my right chin and lower lip area and serious lack of motor control of my right mentalis muscle. This all became gradually better, but the progress has long halted and I am pretty certain that the remaining numbness and lack of motor control won’t improve any further with time. My surgeon said the odd behaviour of my right mentalis is caused by scar tissue located on the left frontal part pulling on the right side. I have no idea if this is possible. I rather think that the problem is not the scar tissue, but the mentalis muscle itself. Maybe it was not properly resuspended. This is were I need your opinion the most. I attached some images and a video so you can get a better idea of my problems. Among the images is an xray scan that faintly shows the chin implant. Maybe this helps you determine if the implant impinges on some nerve. Also, would you say that my chin is sagging somewhat? Can this be fixed? As a side note I should mention that I have a tendency for scarring and fairly bad wound healing.
Based on my description I have several question that you can hopefully answer:
– What would be your general advise in a situation like this?
– How would you approach another revision surgery? Does the mentalis muscle have to be resuspended? Is there hope it will return to normal functioning?
– Was it a sound approach to only make an incision through the right mentalis muscle? Wasn’t this screaming for a muscle dysbalance later on?
– Would it make sense to make an incision under the chin and not inside the mouth should a revision surgery be necessary again? It seems like cutting through my muscles is causing a lot of complications. But I guess the intraoral approach is necessary if the mentalis muscle has to be resuspended, right?
– Do you think the implant is aesthetically OK?
– Is it a good idea to take out the old implant and place a new and maybe smaller one? I suspect the current one might be slightly too large.
I’d like to thank you very much in advance for taking the time to read and respond to my email. Hopefully you have some encouraging news for me.
A: Thank you for your inquiry. I have reviewed your history, pictures and video and can make the following comments:
1) Your case illustrates why placing a firm and inflexible Medpor chin implant through the mouth is generally a bad idea, it is associated with a significant risk of all the complications that you have experienced. But that is water over the dam now.
2) I find the aesthetics of your chin result very acceptable and certainly don’t think it is too big.
3) I would NEVER think at this point of trying to remove and replace your chin implant. That is a disaster waiting to happen. Given what has transpired up to the present and the difficult with removing Medpor implants, the risk of worse nerve and muscle problems is very likely. It may not be perfect but a perfect chin result for you is no longer a reasonable goal. I would advise that you accept a reasonable aesthetic outcome. Revisional surgery for you, as you have learned, has a lot more risk of problems than it does in making things better.
4) It would be highly unlikely at this point that, even if the implant was impinging on the nerve (which I doubt) that relieving it is going to cause return of feeling. The nerve fibers have atrophied and the damage is irreversible at this point.
5) I do not think you have chin ptosis or sagging.
6) As for mentalis muscle dysfunction, I would have a very low level of confidence that any efforts at trying to resuspend the muscle would end up in the long run giving you a better result than you have now.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I am planning on having a scar revision for a vertical scar on the bridge of my nose. At the same time I want to correct sinus problems: turbinoplasty, septoplasty as well as rhinoplasty for some minor aesthetic improvements. I’m hoping the minor nose humps can be grinded so they won’t exaggerate the contours of the scar. How can I minimize the new scar on the bridge from becoming widened over time, developing little arterioles, or the skin getting too thin? What laser should I plan for post-surgery?
A: Based on your question, I would need to have a better idea as to the type of external rhinoplasty you would be having. Will this involve rasping of the bridge or will it require osteotomies as well? Either way, however, I would not perform a scar revision directly over the nasal skin that is being raised during the rhinoplasty. This is not a blood supply concern but one of scar healing. The swelling of the nasal tissues after a rhinoplasty will work directly against having a good scar result. You would be much better to delay the scar revision to after the rhinoplasty, preferably 3 to 6 months later. Scar revision on raised rhinoplasty skin is not a good simultaneous idea if you want the best scar result.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a depressed cheek scar above my nasolabial fold from a previous skin cancer removal using a Moh’s technique. If you inject fat do you utilize the Coleman technique with micro droplets to ensure the tissue becomes a graft and not just a temporary filler? Anyhow, I do not like the dynamic feature when I move the facial muscle as well as when the sight catches the groove of the scar. I have attached some pictures showing the scar. Thank you for your time.
A: Thank you for sending your pictures. I did not realize how young you were given that you have had Moh’s. It is actually a reasonable result in a difficult aesthetic area. The only modification I would make to my previous statement is that I would perform a geometric scar revision at the same time as microdroplet fat injections underneath. Even though the scar is well placed and has about as much narrowness as could be hoped for, there is always going to be a ‘groove effect’. That is just an unavoidable phenomenon in linear scar in that area. The scar line may need to changed from a pure straight line to get a better scar effect. Options include either fat injections with concurrent laser resurfacing (#1) or fat injections with a concurrent geometric broken line scar revision. (GBLSR) The conservative approach would be # 1 as GBLSR can always be done later based on the scar outcome. The more aggressive approach would be #2.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I went to see a maxillofacial surgeon to get jaw reduction (my jaw is too square and X rays show that my angles do stick out). He told me that he needed to do a small resection of the angles (osteotomy) because my angles were too square to burr them. and with the burring technique, only 2 or 3mm could be burred which would barely show. Is it possible to round off the angles with the osteotomy technique? or will it be a straight cut leaving the angles straight looking cut and unnatural? is it possible to preserve some angles with that technique? Also, what really surprised me is that he said that since the bone is so far and hard to get to due to the muscles, he might need to put some screws; I did not understand why. I thought that screws were used to put bones back into a new position; which would not be the case with angles osteotomy? I am confused. Thank you for your answers.
A: I can only speak for what I do, I can not explain what your surgeon said or their technique. When you cut off the angles, no matter how small, there will be a rounding effect created. Burring in the jaw angle area can be difficult because of the surgical access. Therefore, I choose to use a reciprocating saw and perform an outer table ostectomy, which thins the bone but preserves most of the angle’s shape. I have never used screws for this technique nor can I envision why they would be needed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a Moh’s surgery on my right cheek Dec. 27th 2012. I am unhappy about the indentation on the mid to lower half of the scar especially when I speak. I have photos I can send. Would like to know if you think I would need a revision, subcision, or laser, or this will subside in the months. Also, if revised, do you agree with the theory of lasering 4 to 8wks after sutures are removed to reconfigure the modeling of the tissues resulting in superior results, rather than waiting the full year of the old theory. I am not interested in temporary fillers.
A: I am assuming that you had a primary closure of your original Moh’s defect. The reason you have an indentation is that there is tissue missing over a dynamic area. As such, no amount of release or scar revision is going to improve its appearance. This is a tissue loss problem and releasing underneath or cutting out the scar/indentation from above does not address the biology of why it is there. I would take a reverse approach to conventional wisdom by doing fat injections under the indented area. This will provide both a release and adds volume at the same time. While fat may be unpredictable in survival, this natural form of tissue volume expansion better addresses the cause of the problem. This would be more effective done early in the healing process (months) rather than later. (year or longer) The overlying scar in the face of underlying tissue expansion should wait for further healing.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, three weeks ago I underwent surgery for brachioplasty on my arms. As the tape was coming off the incision looked great. There was no redness, it was perfect. As more of the tape started falling of I noticed that on the surface of a section of my incision, an opening, or blister, was forming. I was told to gently remove the rest of the tape down my arms. Now instead of seeing my original clean incision, I have a few blisters with a bit of pus along the incision line, and it is now read and bleeding slightly in some areas. Is this normal? I stopped wearing my compression shirt as were my doctors orders, but he said if it were to start swelling again to put it back on so I did. Does all of this sound normal?
A: There is a natural evolution of incisional healing that understandably confuses most patients as it relates to body contouring surgery. All incisions look fantastic the first 10 days or so after surgery because the wounds have not started to really heal yet and the normal inflammatory process has not set in. Then the incision line begins to look worse…gets red and inflamed in some areas and make even have a few sutures that work their way through the skin. This process will continue for up to about 8 weeks after surgery when the incision line is finally healed and the inflammatory process has subsided. What you are observing is perfectly normal and armlifts are one body area where this process can often be more exaggerated due to the thinness of the arm skin.
Dr. Barry Eppley
Indianapolis,Indiana
