Your Questions
Your Questions
Q: Dr. Eppley, I have questions about using rib grafts for rhinoplasty. How would the surgeon even determine if the rib graft he is going to take would be straight ‘enough’ for it to be placed directly to augment the bridge? What if the carving of the graft isn’t successful? Would you diced it instead and continue the surgery when the patient requested not to have the diced method done? After reading what you have written, a diced cartilage method is obviously better than a ‘single rib’ method right? But one question is that why many patients and surgeons are choosing the ‘single rib’ method instead of the diced method? Can I also know how much does a rib graft rhinoplasty cost? Does it include tiplasty and alarplasty too? Thanks Dr!
A: The quality and straightness of the rib graft is determined by the skill and experience of the surgeon taking it. There are a lot of rib choices on the lower end of the costal margin from the free floating #9 to the fixed ribs #s 6, 7 and 8. Usually a straight piece can be obtained as the longest rib graft that is needed does not usually exceed 4 cms.
If the patient does not want a diced graft method and does not consent to that option, then only the single piece method would be used.
The question of whether a diced vs a solid rib graft is better is a controversial one and every surgeon will have their own opinion on that matter. The answer would also depend on what the nose anatomy is and what one is trying to achieve. It is never that one method is always better than the other, it must be taken on an individual case basis.
A rib graft rhinoplasty can or cannot include tip and other work depending upon what needs to be done. I would view it as a comprehensive rhinoplasty with one fixed cost, no matter what needs to be done.
As a ball park figure, all costs included, the cost is in the range of $8,500 to $9,500.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have some questions about skull reshaping. I have a decent head shape, it’s just that when I cut my hair really short or shave off all of my hair my head shape looks distorted. I’ve been realizing lately that the two sides of my head tend to be larger than the rest of my face and my skull is too large above my ears. It makes me have a very awkward face structure almost like a balloon and was wondering if you had any ways to reduce the size. It isn’t a big reducement, just maybe 1/4 of an inch to make it symmetrical. But would there be any scars left after surgery that would be permanent? Thank you.
A: In a normal shaped head, the sides in the front view stay well within a vertical line that extends upward from the helical attachment of the ears. Any bowing out from this line can make it look disproportionate. The temporo-occipital region of the skull (sides of the head) are composed of a thick layer of temporalis muscle as well as bone. It can be reduced about a 1/4 inch per side. Skull reduction in this area is a combination of muscle and bone reduction. It is done through a small vertical incision on each side so there would be a small residual fine line vertical scar on each side.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am Asian and am interested in getting my jaw angles reduced. They make my lower face look too wide. How risky is the surgical reduction? And how long is the down time? Is it possible for me to undergo the procedure during spring break (2-3 weeks)?
A: This is not a procedure that I would consider risky. It is a cosmetic procedure that is about reducing the width and shape of the jaw angle. That being said, it does require the masseter muscle to be lifted off of the bone to do the procedure so there will be some significant swelling afterwards. The procedure is done by either burring down the width of the jaw angle (outer table reduction) or actually removing the jaw angle by an osteotomy. It takes about 3 weeks for most of the swelling to go down after this kind of facial bone surgery and about another month or so to see the lower facial width reduction benefits of having the operation. I tell patients that it takes 3 months to see the final results after jaw angle reduction surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, A friend of mine just had her upper and lower eyelids done. She said that on her lower eyelid, besides removing fat and pinching some skin out, that she also had her cheek muscles repositioned. Is it true that cheek muscle can be lifted with a lower eyelid procedure? If so, what is the cosmetic benefit for doing so?
A: What you are referring to is known as lifting the sagging cheek at the same time as a lower blepharoplasty. Some call this a midface lift or malar resuspension. It is not a true muscle lifting procedure but rather that of sagging cheek fat and skin. As the midface ages, the cheek tissues will slide off the cheek bone particularly if the cheek bone is naturally flat or not that prominent. This creates malar pads that can be seen as an additional fold of tissue below the lower eyelids. This sagging cheek tissue can be lifted through a standard open lower eyelid incision for a full lower blepharoplasty. This is convenient since both the lower eyelid and cheek issue can be addressed through the same incision. The operation you describing that your friend had was a more limited blepharoplasty known as a pinch lower blepharoplasty. Through this limited approach it would not be possible to do a true midface lift or malar resuspension.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have had several children and am wanting to get my stomach back in shape. I am only 26 years old and I don’t want to live the rest of my life with this stomach. I am too young for that! My question is what will happen to my pubic area after a tummy tuck. I noticed that it got bigger after having children and I would like to see that area flatter as well. Will it be taken care of if I get a tummy tuck? Also I have love handles that I would like to get rid of as well. Will a tummy tuck get rid of those as well?
A: A tummy tuck will only solve the problems that lie within its zone of tissue excision. When looking at the markings of a tummy tuck, you will see that the love handles and the pubic area lies outside the excision zone. However, the addition of flank liposuction is a part of most tummy tucks with the recognition that the goal is an extended waistline reshaping that wraps around to the back. Pubic or mons reduction, if needed, can be incorporated as part of the tummy tuck procedure whether it is reduced with liposuction or it is lifted as part of the tummy tuck design. You can see in planning a tummy tuck that the entire area must be taken into consideration to get the best overall result.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had breast augmentation eight months ago. They were Mentor 375cc moderate profile silicone gel implants. My problem is that the implants are too widely spaced apart. My plastic surgeon told me he could fix them by removing the implants, putting in stitches into the sides of the pockets to move them closer together and then put the implants back in. I would like to have more cleavage but don’t know if this procedure is worth it. Should I have this done and how long does it take to heal?
A: While repositioning implants through suturing of the surrounding capsule (capsulorraphy) can be done to push implants in any direction, the question is how effective would it be. This is particularly relevant when trying to make implant move closer to the sternum. If these are submuscular implants, and I have to assume that they area, you must know the edges of the pectoralis muscle will block the implants from moving very close to the sternum. The reason in my opinion to undergo the procedure is to move implants inward that you feel are too far to the side…not because you think will get more cleavage. Laterally displaced implants can be reliably moved back onto a better position on the chest wall. Moving breast implants with the primary intent of creating more cleavage is less certain to be able to achieve that goal. Either way, recovering from an implant repositioning procedure is much less than the original breast augmentation surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dear Dr. Eppley, Do you mind sharing some advises of yours regarding to diced cartilage for nose jobs? What is the main difference between a piece of rib cartilage being place directly to augment the bridge and injecting fine diced rib cartilage into the bridge as well? Are the side effects of using this ‘diced cartilage’ technique be higher too? Lastly, are there any limitations pertaining to nasal bone narrowing procedures and tiplasty?
A: Rib grafting of the nose is most commonly done for significant dorsal augmentation. Rib grafts offer the most volume to do the procedure and can be done either as an en bloc or a diced technique. There are advantages and disadvantages to either approach. If one can get a nice straight piece of rib cartilage, in which carving and shaping it will not induce warping, then a single en bloc graft method should be done. The problem is that often a good perfectly straight rib graft can be hard to obtain or carving it straight may not make it stay that way. Also, the tunnel or tissue pathway into which the graft is placed must be very tight so the solid one-piece graft does not slip from a straight midline position When the rib graft is not straight and/or there are concerns about midline graft security/fixation, then a diced cartilage approach is the solution. While this takes intraoperative time to do, the risks of graft warping, graft malposition and a crooked nose are virtually eliminated. A diced cartilage approach can also be used when one has multiple small pieces of cartilage, none of which are long and straight enough for a good dorsal augmentation.
The vast majority of diced cartilages grafts in rhinoplasty are placed through an open approach. The cartilage is diced and placed in a fascia or surgical wrap and inserted like a one-piece rib graft. The injectable cartilage approach is only used for very small defects of the nasal dorsum.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am pursing getting a rhinoplasty to make my nose look better. In fiddling with my own version of computer imaging, I have made some changes to my nose that I would like to get done. Are these type of nose changes possible? If so, Acne X Factor what type of rhinoplasty do I need? I know there are two types of nosejobs, a tip rhinoplasty and a full rhinoplasty. Which do you think is best for me?
A: I would not as a patient get concerned about the different types of rhinoplasties. The differences between a tip and a full rhinoplasty is somewhat artificial. The basic difference that separates the two rhinoplasties is that a more complete technique involves osteotomies or the narrowing of the nasal bones due to hump reduction or bridge modification. A tip rhinoplasty by classic description does not go past the lower tip cartilages. Regardless, many rhinoplasties incorporate techniques that borrow from each basic type of rhinoplasty making the surgical changes that each patient’s nose needs unique. Your attempt at rhinoplasty imaging is pretty good and I think that it is a fairly achieveable outcome. Hump reduction and tip narrowing and elevation are fairly standard changes that can make many noses look better. Your lack of thick nasal skin makes it also realistic that the alterations to the underlying cartilage and bone will be seen on the outside when the swelling goes down. You may call the type of rhinoplasty that you need a more complete one.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a gullwing upper lip lift two years ago. I am very unhappy with the resulting scar. The surgeon who did the procedure said that the scar would end up invisible…it did not. The scar sits 2mm above my vermilion line and is very indented so even if I try to cover the scar with lip liner and concealer it still shows. The surgeon cut very deep and used only eight sutures on the whole of the top lip. Please give me your honest thoughts and whether it can be improved by scar revision. I have attached a picture of my upper lip so you can see how bad the scar is.
A: Thank you for sending your pictures. I think without a doubt that the scar and the upper lip shape can be improved. The indentation is so visible because the natural shape of the white roll (where the skin of the upper lip and the vermilion meet) is everted not inverted. While the eversion of the white roll is lost in every lip advancement, it should be flat and not inverted. I suspect that deeper sutures were not used in the closure so that inversion resulted. In addition, I see no definition of the cupid’s bow of the upper lip, which is one of the main benefits that a lip advancement can achieve. In looking at your before pictures, I think you had the wrong lip enhancement procedure from the beginning. You would have been better served with a subnasal or bullhorn lip lift not a vermilion or gullwing lip advancement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a belt lipectomy six months ago. The tummy tuck portion in the front did lift my pubic area a bit but it is still puffs out below the scar line compared to the tight abdomen above it. When I lay on my side, my abdomen is tight but the pubic area is puffy and sags like old wrinkled skin. While standing it just looks a bit puffy but no wrinkles. What pubic reduction method would work the best and can it be done under local anesthesia?
A: It is not uncommon that pubic or mons fullness becomes evident after a tummy tuck or curcumferential lower body lift. While this fullness was always there, it becomes apparent when the tightness of the scar above it is more narrow than the original projection of the pubic tissue. Every tummy tuck does create some degree of a pubic lift but it may not be enough to obscure the larger pubic mounds that exist in those that need a circumferential body lift. If this is diagnosed in advance, it can be incorporated into the frontal tummy tuck design or undergo liposuction for reduction. On a secondary basis, pubic reduction can be done liposuction alone or combined with a pubic lift skin excision pattern. Since it appears by your description that you need more than just liposuction, I would recommend a general anesthesia approach.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting an otoplasty but am concerned about how will the scars on the back of my ear look after surgery. I almost always wear my hair pulled behind my ears. I worry that my friends and others will be able to notice the scars from having my ears pinned back. How often do otoplasty scars need scar revision. Will laser resurfacing of the scars help if they look bad and how long after surgery can I have it done?
A: While I understand your concern about the scars on the back of the ears, it is not an issue that I have ever heard a patient who has had otoplasty have. Besides the fact that the scars on the back of ear heal really well, there are also essentially invisible because the ear is folded back obscuring the back of the ear skin completely. If you look at back of the head views of otoplasty patients, you will see that the outer helix of the ear hides most of the skin on the postauricular surface. I think your concern about poor or visible otoplasty scars should not be a significant one. Of all the otoplasties that I have ever performed, I have never done a scar revision on them.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I got jaw angle implant one year ago and want to get new ones. I have two problems with the ones I have. The first thing is that they did not give me the look that I wanted. They added very little width and did not make the jaw angle any more prominent. The second thing is that one of them has slipped and is starting to come through the incision as it is sore and I can see an edge of it inside my mouth. What do you recommend? I have a picture of me so you can see where I am now.
A: Based on this one picture, I believe your jaw angle goal can be achieved with an off-the-shelf implant as it appears that what you need is more width and jaw angle prominence. That can be done with either a silicone lateral augmentation style or a medpor inferolateral augmentation style (modified) based on your width desires. I know that you said you have jaw angle implants now but I don’t know how much they are adding to where you are at present. Besides one of them slipping (they should always be screwed in) they may not be big enough or placed low enough on the mandibular ramus to have the proper effect. This is both a sizing and placement issue. If you desire a much more prominent jaw angle, I would consider using a medpor RZ angle implant of the 11mm size. That will give you the most prominent jaw angle possible with a preformed jaw angle implant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a chin implant revision. I had a chin implant about six months ago and the doctor said it would look just like I wanted. Well it hasn’t and he appears to have chosen the wrong implant. What I wanted was a much wider and more square chin look and it doesn’t look that way at all. I have done some imaging on my picture to show you what chin look I am after. What is the best type of chin implant to achieve my desired look?
A: The imaged change that you desire in the width of your chin can not be made by almost any off-the-shelf preformed chin implant. Even square chin implants do not add that much width. If you look carefully, the widest part of the chin goes past a vertical line dropped down from the corners of the mouth. That is beyond the widths of most existing chin implants.
There is however a way to do it with one and only one preformed implant, the Medpor RZ extended square chin implant. It is possible to exceed its natural width because of its central connector. It is actually inserted in two separate pieces and then attached once in place. You can increase the width of the chin by a full centimeter by not snapping it together but by leaving the two pieces spaced apart and made ‘one-piece’ by only the thin bridge of the connector.
The other option is to make a one-piece design out of silicone that contains all the desired dimensions and is placed as a single piece implant. (aka custom chin implant)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a revision rhinoplasty about ten years ago. I had a Medpor nasal shell put in. It was a thicker shell which augmented my nose too much in width, but I’ve always liked the right side and the profile is good. However, the left side is too bulbous and makes my nose look too big. I have talked to two rhinoplasty surgeons who have given different opinions although both are very confident about working with Medpor. One suggests removing the shell and replacing it with a smaller implant or a rib graft. The other said to leave the implant in and just carve into it on the left side and make it smaller. What’s your opinion? What do you think will yield the best results, but also be the safest in preventing infection and is less intrusive?
A: The concept of narrowing your existing implant rather than replacing it with a new implant or a rib graft is a sound one to me. If you like most of what you have in place and just need a little tweaking of it, then you should just modify the existing implant. Doing so also has the advantage that it is really what I call an ‘autoimplant’ at this point. It is part implant and part autogenous since you have tissue ingrowth into it. I would also contend that using the existing implant has less of an infection risk than placing a new one, since the ability to get it inoculated with bacteria into its porous structure is less due to the existing tissue ingrowth.
Whether you carve it in place or take it out to reshape the existing implant is matter of nuances. Either way you have to do a complete dissection over the top and both sides of the implant. Even for in situ carving, you need the space to work. The only difference is that in removal you have to release it underneath from the cartilage-bony framework. Based on my experience, I could not tell you until I was in there which way I would do it. If I had good access with it in place, I would carve it down without removing it. If I could not get a space to work and was concerned about the overlying skin, then I would remove it, carve it down and re-insert. I don’t think any surgeon can tell you which exact method is best until they are in there. What matters is which way will give the best rhinoplasty revision result and not injure the overlying skin cover.
I have never found Medpor implants hard to remove. Surgeons say it is hard because they have never done it or are comparing it to silicone implants which slide out quite easily. Medpor implants require more care and finesse in their removal to not injure surrounding tissues but they can be removed even though they are more adherent to the tissues.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I need a sinus setback procedure. I think it is called the brow bone. but my brow bone is a bit asymmetric. Will a browlift be needed after this surgery? Is in the quoted price also the hospital care and everything? How many days should I stay in your town all together? Also is it possible to make some sort of insurance arrangement in case something goes wrong so that I am fully covered in this case? Finally have you not seen or have you also not heard of anybone resorption with this procedure? Long term consequences really scare the XXX out of me.
A: In answer to your questions:
1) Generally, a browlift is not needed after a brow bone reduction. It does not usually cause the brow bone to fall.
2) Any price estimates given to you is all-inclusive of the surgeon’s fee, OR and anesthesia costs. A formal price quote can be given based on reviewing pictures of the patient. Most patients return home 48 to 72 hours after the procedure.
3) I can not think of anything that could go wrong with this type of surgery that would require hospitalizations. But most insurances will cover medical problems, regardless of the origin of the problem.
4) I have not seen or heard of any bone resorption afterwards with this operation.When properly done with good surgical technique, brow bone reduction should not result in any long-term bone resorption problems.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dear Dr. Eppley, i have really hollowed temporal areas and I have heard that there are temporal implants which can correct this. So can an implant be placed under the skin of the temporal regions? Also, can the implant be misplaced or is it screwed in place to stay there? Thanks a lot doctor 🙂
A: There are very specific temporal implants for the correction of different degrees of hollowing. These temporal implants can be used in the various sizes or can be custom carved to fit any shape or size of the hollowing. They are placed through a small vertical hairline incision and their flexibility (silicone rubber) makes them capable of being inserted through a much smaller incision than one would think possible based on the size of the implant. They are not bone-based implants so they can not be screwed in to any of the surrounding bone. Rather, they are placed right underneath the temporalis fascia in a tight pocket so there is no chance that they can migrate or move from this position. It is a procedure that is associated with virtually no pain afterwards and very little swelling.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley I have a question. I did open rhinoplasty and now I’m 3 months post op. I have stopped taping my nose but now I feel like my tip is more bulbous than it used to be. When I was taping it was more rounded and big. Now it feels firm with slight pain if I try to move it. Is that swelling? Will this shape change with time? I’m so confuced and I don’t want to undergo a revision.
A: Your questions are the most common concerns that most patients have after rhinoplasty. While I obviously don’t know anything about before surgery nose or what exact rhinoplasty maneuver were done, I can make some general comments. If you have read my four phases of rhinoplasty recovery blog, you will see that you are currently entering phase 3. Tip swelling is very common in this phase and often the tip may even appear bigger than before. The fact that it is firm and slightly painful indicates that you still have significant tip swelling. What you can know for sure is that the tip is going to get smaller. How much smaller and whether it will end up better than before surgery remains to be seen. You will know that all the tip swelling is gone when it feels soft again and can be freely moved without discomfort. The consideration of a potential rhinoplasty revision is a long way off and you must wait a year after surgery to be certain you are really looking at the final result.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I want a rhinoplasty to change the shape of my nose. I have attached a picture of the type of changes that I want done to my nose. This is my effort at a little computer imaging with Photoshop. The first plastic surgeon I saw told me that all I need is tip work while another plastic surgeon told me I have to do a complete rhinoplasty to get that look. Please let me know what you think as I am confused.
A: The first thing I would say is to not get confused trying to decide whether you need a limited or full rhinoplasty. There are fee and recovery differences between a tip rhinoplasty and a full rhinoplasty but the most important issue is what rhinoplasty techniques will give you the best result. The fundamental difference that separates the two rhinoplasties is that a more complete technique involves osteotomies or the narrowing of the nasal bones due to significant hump reduction. When you have a difference of opinion between two board-certified plastic surgeons on a limited vs a full technique it is usually because you could go either way. This is computer imaging can be so useful. Imaging allows discussion about different changes and how they might affect the overall look. The techniques used to achieve those goals are up to the surgeon at that point. You have shown only one photo of your nose from an oblique angle. It is impossible to say for sure what you may need from just this one angle. A front and side view would also be very helpful as the nose must be considered from numerous angles when considering a rhinoplasty change.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 22 year old female who is 5’6″ and weighs 165 lbs. I used to weigh 220lbs. I seem to be at a plateau for weight loss over the past year of which I am comfortable with that. But I have a remaining overhanging stomach pouch (I think it is called a pannus ??) that has not really gone away that much with the weight loss. It has gotten less full but now hangs down more. I have very large breasts and thick thighs and butt so I know I will never be tiny, but I would like my overhang gone and to have a flatter stomach area. Should I get liposuction or have a tummy tuck?
A: This is classic question posed by many patients who have some amount of a stomach overhang. By definition, the description of an overhang signifies that there is a skin excess problem as well as too much fat. Liposuction alone will only magnify the prior result of what weight loss has done, it will deflate the overhang (aka pannus) further but it will still leave a flap of skin. You need this cut off by a tummy tuck. Liposuction is only useful in your case when combined with a tummy tuck, as it may help contour the waistline better to the sides where the tummy tuck excision does not go.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a breast augmentation done seven years ago. Just last week I had a deflation and went back to my plastic surgeon. I am having both redone due to wanting to go fuller. I was an A cup before first surgery and now a C cup using a 350cc MP saline implant. I want a full D and he suggested a 550cc HP saline implants. I am m looking for a much fuller breast with less sagging. I want to make sure that when I go through this again that I get what I want. Does this size implant sound like enough?
A: When changing breast implant size to go bigger, you want to make sure that you are getting at least a 30% to 40% increase over your prior implant size. Anything less will likely not be that visible. That means going from a 350cc implant, you need to go at least 150cc bigger if not more. Thus the 550cc implant size sounds good to me. I have no doubt you will be visibly bigger and rounder. Whether your sagging will be improved to your liking, however, may be a different matter. Getting bigger does not always mean your breasts will be more uplifted, as defined by the nipple getting higher and more centered on the breast mound. Make sure you discuss this with your plastic surgeon beforehand to be certain you may not simultaneously benefit by some form of a nipple (areolar) lift with your breast implant exchange.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, You have some great results for jaw augmentation! For the man pictured below, what biomaterial did you insert and were they custom made implants? If not, what kind and shape of implants did you use? And how many mm width and length? My facial shape is somewhat similar to the man below after a botched jaw reduction surgery. By the way, since there is bone erosion over time with these kind of implants, I was wondering if this will be more of an issue since I had my outer bone removed, leaving the marrow or softer bone inside exposed. Also, since my softer bone is exposed, would there be higher chances of infection?
A: Those are preformed lateral augmentation silicone jaw angle implants. Although in someone with missing angles from a jaw reduction, you may be better off with an inferolateral style (Medpor) which is better at creating a more defined jaw angle. Otherwise, I am not aware that there is any bony erosion with jaw angle implants. I have removed many from other surgeons over the years and have never seen that issue. Having had jaw angle reduction previously, this does not increase your risk of infection or difficulty with jaw angle implant placement in my experience.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had liposuction of my stomach done three weeks ago. A total of nearly 1500cc of fat was removed. The very next day I looked great and my stomach was flat. But by the next few days, my stomach got bloated and bigger. Then I got my period and got even more bloated. For now my belly pouch is back although it is smaller. Is this normal and will it ever go flat again?
A: What you are describing is a very typical sequence of events after liposuction. When you see yourself the next day due to the compression applied by the garment and with no real swelling yet present, the amount of improvement created by the fat removal is seen. Then the swelling and the temporary impairment of lymphatic outflow occurs and some of the improvement appears to be lost. What I tell my patients is that what they see the next day will eventually return but it will take at least 4 to 6 weeks to get back to that. This is the time needed for all swelling to go away and much of the normal lymphatic circulation to return. So you will get to where you want to be but it requires more time and patience. This is a normal part of the recovery process from liposuction.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a facelift just one week ago. I expected to be a little swollen and bruised but not like this. I was told before surgery that I could return to work two weeks after the surgery. I was also told that by that time I would not be completely healed but that no one will notice that I would have had surgery. Based on the way I look now, I can’t see how this will be true in just another week. I am a bit panicky now because I can’t go to work remotely looking like this. I’d have to quit my job if I went in looking like the monster that I do now. Any suggestions or advice on how to make this swelling and bruising go away faster?
A: The amount of swelling and bruising after a facelift that any patient gets will vary and is most affected by the type of facelift that one has. Unless it is a very limited type, I would never tell a patient that they will comfortably be able to go back to work in just two weeks. Three weeks after a more complete facelift is more realistic. That is now water under the bridge so to speak so what can you do now? Largely the speed of the improvement you are going to get is by your won natural healing process. But the use of Arnica tablets and topical gel for the bruising, don’t sleep completely flat (head up) and taking some bromelain (for swelling) may be of help. You may also be surprised what another week of recovery will do. I suspect you will be much better by next week and with a little makeup you will be largely ‘undetected’ for having a facelift.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dear Dr. Eppley, I had liposuction six months on my stomach, saddle bags, flanks and inner thighs. The doctor told me he removed 4 liters of fat. I am very happy with the results with the exception of my inner thighs. I now have some saggy skin and irregularities of the inner thighs. Is this common afterwards? Can some form of non-surgical skin tightening be done to make it better?
A: Liposuction can be tremendously effective for many body areas and the inner thighs are no exception. But inner thigh skin does not usually have much ability to contract so only conservative fat removal should be done in this area and patient expectations should be tempered as to how much size reduction can be done. If too much fat is suctioned out, the inner thigh skin can be made to sag with irregularities. There are numerous non-surgical skin tightening devices that can be tried and they have all have some effect. My current favorite device is Exilis which uses monopolar radiofrequency energy to create skin tightening through a series of treatments. If this is not successful, you may need a definite inner thigh lift which will solve this concern.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dear Dr. Eppley, I am an amateur bodybuilder and I have very large pectoral muscles as you can see in my photos. I feel I have achieved as much size as I can through exercise and that my only options for increased size are implants or anabolic steroids. Since steroids are illegal, I am interested in knowing whether I would be considered for pectoral implants and what amount of size and projection increase I could expect.
A: The common use of pectoral implants is for men who either need reconstruction for congenital pectoral/chest asymmetry or cosmetic chest enhancement for those that have not had good success with pectoral enlargement. Your chest shows considerable pectoral muscle enlargement as you have mentioned and your picture shows. The question is not whether you can have pectoral implants but whether the sizes that are commercially available will make enough of a difference to justify the effort. The typical size of the largest pectoral implants is around 350ccs with maximal projection of about 3 cms. How much of a difference that will make in your chest size in not exactly predictable. Knowing your exact chest dimensions in height, width and thickness for each perctoral area would be helpful in answering this important question. Based on the picture alone, I would estimate that the change would be in the range of a 20% to 30% increase…but that should be interpreted as a guess based on inadequate information as of yet.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dear Dr. Eppley, I would like to get Medpor malar and paranasal implants. However I am a bit concerned about the possibility of implant infection. Although I know that impregnating these porous implants in an antibiotic solution prior to implantation combined with good oral hygiene usually works well, I also would like to go for a dental dam that limits the contact of the implant to the mucosa during surgery. Would you use a dental dam if the patient asks for this? Do you think a dental dam can lower the risk of implant infection if the implant is placed through the mouth?
I know that malar and paranasal implants are inserted into the same pocket through the same incision. Considering this, do you usually charge for the combined malar and paranasal procedure like this would be two separate facial implant procedures or do you charge only a bit more than for a malar procedure alone plus additional cost of the implant material? Thank you in advance for your reply
A: Porous implants like those comprised of Medpor material do have a higher risk of infection in my experience. Thus everything that can be done to limit this potential problem is done from antibiotic soaking and irrigation, limited insertion and removal for try-ins, and a change in gloves when the implants are finally inserted. You are correct in assuming in assuming that the risk of infection is highest when placed through an intraoral approach due to potential contamination from the oral mucosa. The dental dam is an interesting but impractical method of recipient site isolation. The dental dam is used in tooth restoration because it wraps around the neck of the tooth being worked on so the rest of the mouth is covered. This places the tooth in front of the covered mouth. It can not be used effectively in reverse because the inside of the lips and the maxillary vestibular mucosa is still exposed to the recipient site even if the teeth are not. So no I do not think it would be an effective method for reducing the risk of implant infecrion.
While the malar and paranasal implantation sites can be done through the same incision, the work to place the implants is still doubled. Shaping, placing and fixating the implants is the bulk of the operation. Four implants require twice as much work as two implants. Making the incision and closing it is but a minimal amount of time for either operation. Some cost reduction is seen when both types of facial implants are done together based on the time saved as it relates to incisional management.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dear Dr. Eppley, I was born with a condition known as right hemifacial atrophy, also known as Romberg’s syndrome. I was operated on two years ago with corrective orthognathic surgery. Both my upper and lower jaws were cut, leveled and my bite put back together. The result is good but I still have some right facial asymmetry. I want to reshape my right cheek bone, nose and orbital region. I would appreciate if you can give me some advice on what procedures I need. I have attached some pictures and x-rays from my surgery.
A: Thank you for sending your pictures. You have made good improvement from your orthognathic surgery. To further improve your hemifacial hypoplasia/asymmetry, I would recommend the following right-sided facial reshaping/augmentation procedures:
1) Right orbital floor-infraorbital rim implant
2) Right lateral canthoplasty
3) Right cheek implant
4) Rhinoplasty
5) Right jaw angle implant
6) Opening wedge genioplasty (right side lengthening) – I was little surprised they did not do this during your orthognathic surgery
This would be my optimal plan to address all of your right facial issues. While all of these procedures do is to lengthen and expand the shorter right side of your face. I think you would get as good, if not even better, aesthetic improvement than you have had from your prior orthognathic surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dear Dr. Eppley, I consulted with a board-certified plastic surgeon who says he can round the corners of my chin and reduce about 5mms of projection without any ptosis or deformity. I have seen his before and after pictures and they are stunning. Best I’ve seen. Should I still be concerned about sagging. Also he wants to put me on a course of antibiotics, steroids and put a drainage tube in my chin to make sure no fluid collects for several days. What are your thoughts?
A: There is no chin reduction procedure of any significance in which the risk of soft tissue sagging does not exist. By definition when you make the supporting bone structure smaller, you have an excess of overlying soft tissue. With proper soft tissue management and suspension this potential concern can be avoided whether it is done from an intraoral or submental approach. The use of antibiotics and steroids are standard practice. The use of a drain is surgeon’s preference. It is not something that I have ever used for any chin procedure but I know there are some surgeons that do.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a nose job six months ago from which I am not at all happy. It was a closed septorhinoplasty with the objective of lifting the tip of my nose and narrowing it. While right after surgery the tip was up, it fell down just weeks later. My nose is now not only pointing downward but is bent to the right to boot. I am very unhappy. The doctor told me that the stitches either became loose and weren’t strong enough to hold it up. What should I do now?
A: One of the problems with a closed rhinoplasty is that it can be more difficult to get idelal tip shaping and rotation. This is not to say that it can not be done but it takes more experience to do so than in the more commonly used open rhinoplasty. There are numerous reasons why a tip does not get or sustain adequate rotation including a suture retention issue, inadequate caudal septal reduction, inadequate columellar tip support or some combination. Regardless a revisional rhinoplasty procedure will need to be done through an open technique now because of internal scarring and a failed first procedure. As long as this approach is used, you should be confident that you still can get the end result that you initially desired.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am very disappointed with my Smartlipo results. Over four months ago, I had the procedure on my abdomen and flanks to try and improve my waistline. The laser was used but no suctioning of the fat was done. While everytime I go back the doctor tells me to be patient, I surely would have thought I would have seen some improvement by now. I am getting frustrated as I spent all this money and have yet to have anything to show for it?
A: I am afraid to tell you that if you have not seen results by now, you are not going to. It is not common practice, nor do I think it is even reasonable, to perform Smartlipo without simultaneous aspiration. While there is some heat-related effect to Smartlipo, you simply can’t rely on that effect alone to create a result. The main benefit of Smartlipo is that it makes the fat easier to suction out and enables better fat removal. Smartlipo is not a Star Wars game where you shoot and vaporize the fat instantly. Nor does it cause enough fat release that lymphatic drainage will remove enough to make a visible difference. Without simultaneous liposuction, it is not possible to make a significant improvement. It pains me to see some practitioners use this non-suction approach to Smartlipo and its lack of results which makes people unhappy as well as gives Smartlipo a bad name. This is a doctor problem not a device-related one.
Dr. Barry Eppley
Indianapolis, Indiana
