Your Questions
Your Questions
Q: Dr. Eppley, I would like to achieve a radical but natural look. My main problem is that I was born with a bad bone structure. I want a bigger chin, jaw implants to make my face more square, high cheekbones (but natural i´d like to know if fat grafting would be an option), and I see some irregulaties in the form of my forehead and i like to look uniform. Is it possible to correct it with a natural and safe filler? I also think that some liposuction under my chin will help me to create a better facial profile. I have attached some pictures of myself for imaging these changes. Thank you so much.
A: In reviewing your pictures I see that the deficient bone structure is really isolated to the short lower jaw/chin and a forehead that slopes backward. I would agree that a chin augmentation using a square chin implant, and jaw angle implants that both widen and lower the angle would compensate nicely for the lower facial bone deficiency. The jawline improvement would be enhanced by submental and neck liposuction. From a cheek standpoint you can certainly use fat injections. Another fat alternative is to remove part of the buccal fat pads and use this as a ‘cheek implant’, serving the dual purpose of malar augmentation and some submalar contouring. Fat injections could also be used as a forehead filler as well for any irregularities. The attached imaging illustrates some of these potential facial reshaping changes.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, My 3 year-old son fell and cut his lip in two places about 1 year ago. We did not get it stitched up and it healed on its own. I now find that he has 2 scars, obviously more noticeable when he smiles and the skin is taught. To describe the scar if you imagine placing a ruler into his mouth towards the edge of the mouth that would be the location and direction. They are on the bottom lip and go across the interface between lip and face and travel approx half way across the lip It is every parents worst nightmare to be responsible for their child’s suffering. I have spent a lot of time searching but found no helpful guidance until your site. Could you advise me as to what degree the scar will fade and become invisible, if we decided to pursue surgery of some form would this eradicate the visible scar and when would be the best time to operate i.e. soon or as a teenager for example?
A: Many lip lacerations fortunately occur along the vermilion lines or grooves which are the natural weak tissue planes in the lip mucosa. This is the equivalent to having a laceration along a natural skin crease anywhere else in the body. (e.g., horizontal lines in the forehead) This usually results in the best scar but also a perfect location to perform a linear scar revision if needed.
In looking at our child’s pictures, I can see that he has two such lip scars, the one closest to the corner of the mouth being wider and more noticeable. The one in the front of it is not as wide and hence less obvious. At one year after the injury, these scars are mature and will nto fade from what they appear today. Only excisional scar revisional can provide an opportunity for improvement in their appearance. The time to do such s scar revision is whenever you as parents or he decides that it is an appearance issue. The outcome from such a lip scar revision is not based on age. It can work well at any age.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a young girl who is scheduled to have a hysterectomy as part of my conversion to a male. I have seen some postoperative photos of this surgery after one year of healing, and there is a visible scar in most cases. Is it possible to remove this completely, and have you performed a surgery like this? Also, do you do a surgery which will accentuate the adam’s apple for a more male appearance? Thank you for giving me advice in advance.
A: All hysterectomies result on a low horizontal scar. That scar is permanent and there is no such thing as secondary scar removal or complete eradication. Some hysterectomy scars look quite good on their own and others benefit by a subsequent scar revision. Either way, there will be a scar. It is just a question of how diminuitive in appearance it will be. But there is no procedure than can produce a complete scar removal.
In regards to tracheal or adam’s apple augmentation, I have actually performed such a procedure. It is done with a specially-shaped implant that sits on top and in from of the tracheal cartilage. It has a v-shaped upper edge to it to resemble the typical appearance of the shape of the adam’s apple. It appears to work best in necks that are thin without a lot of subcutaneous fat so the new outline of the tracheal can be appreciated as opposed to just a larger neck bump.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have uneven eye sockets, my right eye is higher than the left, just at the top, making it so my eyebrow is up higher on that side. I was wondering if there is any way to fix this? And what would have to be done if so? I would just like for my brow on that side to be moved down and out just a tiny bit.
A: Brow bone asymmetry may be caused by differences in the position of the entire orbital box, but more commonly it is just differences in the brow bones themselves. The shape of the brow prominences or the underlying shape or pneumatization of the frontal sinuses may just be different. In a female, it is the actual brow bone shape or arch. This can be treated by brow bone reshaping by burring which can be done through an upper eyelid incision, provided that only the outer 2/3s of the brow bone needs to be changed. If the entire brow bone needs to be altered, then the best approach is through a scalp or coronal flap with turn down with complete brow bone access and preservation of the supraorbital and supratrochlear nerves. If the outer tail of the brow bone needs to be built up, this is best done by adding a small amount of hydroxyapatite cement. The combination of select burring and augmentation can change the shape or arch of the brow to a lower level with a more symmetric tail.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, My right leg and buttock is smaller then my left due to scleroderma. Is there anything that can be done to improve their appearance and make them look more symmetric?
A: One of the main effects of scleroderma is the shrinking of all soft tissues in the skin dermatome that it involves. Why it causes significant subcutaneous fat atrophy and even skin thinning is not known but its effects are quite clear, particularly when its involvement is severe. The most effective treatment is to restore soft tissue volume through fat augmentation, most commonly through an injection technique. A fat injection approach allows large areas to be treated and substantial volumes to be added rather easily. Despite the uncertainty of how much fat will survive, it is very effective at the time of surgery. Repeat fat injections may be required for additional volumes or for touch-ups. The only limitation to using fat injections is whether one has enough fat to harvest. While not all scleroderma patients are thin, many are and this may preclude this treatment approach for them.
Indianapolis, Indiana
Q: Dr. Eppley, Thank you so very much for the information you have provided on blepharoplasty. I found you through a Google search hoping to find some information on whether insurance will cover surgery in severe cases. My hooding is genetic; insurance paid for my grandmothers surgery by the age of 50. Now at almost 50, I look 20 years older all because of my hooding. My huband doesn’t understand my desire to have surgery because he sees me as beautiful the way I am. After reading your information and seeing the images, I can see that perhaps someday there is hope for me as well. Thank your for your encouragement.
A: Hooding or extra skin that hangs on the upper eyelids is easily and often dramatically improved by the blepharoplasty procedure. Of all the anti-aging surgeries of the face, an upper blepharoplasty is one of the ‘simplest’ in terms of the results, short recovery and very low risk of any significant complications.
When it comes to medical coverage, things have changed dramatically since your grandmother’s time. Insurance rarely covers an upper blepharoplasty anymore and, even when they say they will, they often reverse their position when the procedure is done and the physician submits their charges. For this reason, many plastic surgeons no longer process a cosmetic or even a functional blepharoplasty as a medical procedure to an insurance company. It is done on a cosmetic fee basis only.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m currently seeking to get rid of a facial scar from trauma (long, hypotrophic, discolored, widened vertical cut on the cheek about 3cm long running perpendicular to the RSTL and a “v” shaped hypertrophic, discolored scar on the jaw line below) that’s over a year old now. Treatment thus far has been with silicone tape on and off. I’m not sure if w-plasty, z-plasty or laser resurfacing would be the best option? I’m not sure if you specialize in these types of cases. Any suggestions/advice/thoughts would be greatly appreciated. I was searching online and came across your website. Thank you.
A: There are two important features of your right vertically-oriented facial scars; they are both wide and they are actually parallel (not perpendicular) to the RSTL in that area of your face. Because the scars are wide, they are not improveable by any form of laser or skin resurfacing. Wide and depressed scars by definition need to excised and reclosed to be made more narrow. The only question is whether they should be closed in a straight vertical line or in an irregular pattern like a running w-plasty. The irregular scar revision pattern is aesthetically preferable for better camouflage.
As a final note, the concept of getting rid of a facial scar is not possible. The scar can be made less conspicuous but it can never be completely removed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a breast lift with implants 6 weeks ago. I have 3 spots on my right breast where the stitches were sticking out a little bit. A week ago I pulled these stitches out pretty easily and they seemed ok. A couple days ago, they had gotten some puss in them and kind of looked like an open sore. So I put neosporin on them and covered with a band aid. Well, now one of the spots around my areola is split open. It seems to have gotten worse as far as the skin opening up. But mostly just some clear, slightly bloody fluid in it. The other 2 spots aren’t as bad. Just wondering if I should leave everything alone, keep using neosporin and covering with a bandaid, or do I need to actually put a butterfly bandaid on it? I have a stitch slightly sticking out on my left breast but I’m not going to touch it. Is this normal and what can I do to make them heal up and go away.
A: These are very typical spitting sutures that almost always occur anywhere from 3 weeks to several months after this type of surgery with long incisional lines in thin breast skin. They are the result of dissolveable sutures being used in the dermis of the skin. Rather than the body resorbing them , which takes up to a year after surgery, it rejects or spits them out because they are so close to the surface of the skin. They appear as red, fluid-filled, or pussy spots along the incision lines. They confuse and concern patients because they appear long after one thinks they are completely healed. (this does not really occur until at least 3 months after surgery) The best thing, and the only curative technique, is to get the knot of the suture out. In the office, I will either squeeze them like a pimple until the knot pops out or pick out the knot or suture end with a fine pickups. They are easily resolved problems that will have no negative influence on the final scar. These are temporary nuisance problems that are the final hurdle to complete healing.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I came upon your case study thru google –Case Study: Secondary Liposuction After Tummy Tuck Surgery. I am 3 months post op for diastasis repair (to above button) and c-section scar revision . I did not have a full tummy tuck and no liposuction. The skin was pulled down at area of incision. I had a drain at upper abdomen below ribs for 5 days. There is persistent skin elevation there, like a bulge, delimiting the curvilinear path of the drain. Dr says it’s fibrosis and to massage area. I’ve done this daily and no change. I am now wondering if this is fat as you state in your case study. I am, and was, very thin, especially upper abdomen. The area is soft to touch and no fluid (ultrasound was done). It’s just so odd that it follows the path of the drain yet what you state in article makes a lot of sense. Any advice will be greatly appreciated as this is very disturbing for me to look at . Thanks!
A: If I understand what you had done…a muscle repair to a level above the umbilicus and some form of a mini-abdominoplasty. (c-section scar revision) The key in determining why this bulge exists has to do with the muscle repair and how the abdominal skin was elevated to do it. I suspect that the muscle repair was done through a ‘tunnel approach’ above the belly button given that a mini-abdminoplasty incision was used. This means a tunnel of abdominal skin and fat was raised above the belly button to perform the muscle repair rather than a wide undermining of the upper abdominal skin flap. When the muscle was sewn together, this creates a midline bunching or bulge because the side tissues remained attached to the muscle. As the muscle is brought in by suturing, so is the side tissues pushing them together in middle. The fact that a drain was temporarily there is coincidental not causatory. (I have never seen a drain cause a raised skin tract) In essence, this is an ‘excess‘ of abdominal skin and fat that has created the bulge. The best treatment would be for some small cannula liposuction to reduce the underlying fat thickness and the overlying bulge.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a chin osteotomy several years ago but still feel my chin is short. Do you think another chin osteotomy can be done. I do not want an implant for more chin if I can avoid it. I have attached an x-ray so you can see what my chin looks like now.
A: Your x-ray shows that you had a sliding genioplasty fixed together with cerclage wires. What this means and shows is that the back cortex of the chin segment has been brought forward enough to be attached to the front cortex of the mandible. This means that the chin segment has been brought forward as far as it can go. This is an older genioplasty technique that dates back to a time when only wires were available for facial bone fixation. Since the wires can only attach to the cortices of the bone, the chin is brought forward whatever distance the back end of the chin and the front edge of the upper bone will allow as they match together. In today’s genioplasty bone fixation techniques, plates are used that move and hold the chin together at any desired distance horizontally as well as vertically.
In theory, you should not be able to get any more advancement out of the chin segment once a ‘maximal’ bony genioplasty has been performed. But there is one thing that is a bit unusual in the way your chin osteotomy was performed. The x-ray shows that it was cut at a very low horizontal level. This has left a lot of bone height between the lower end of your incisor teeth and the top edge of the bony cut. This suggests that a new osteotomy could be done above the old one, bringing more of the chin forward. This would create a ‘stairstep’ chin osteotomy approach which I have done at the same time but never as a staged procedure which is actually safer. So I do think a repeat chin osteotomy is possible to gain more chin projection. In stairstep chin osteotomies, I do recommend the use of hydroxyapatite granules or demineralized bone to fill in the steps at the end of the procedure for maximal bony healing.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am looking into working for the Medicis company and was wondering what you could tell me about their two aesthetic products, Restylane and Dysport.
A: All I can say about the company’s products is that Restylane is one of the most popular and well known names in injectable fillers The injectable filler market, however, is a crowded one with nearly a dozen other competitors. The name recognition in the market is not only because it is product that works well with very few complications but also because they were the first to enter the modern-day injectable filler era as a hyaluron-based material. Dysport lags far behind Botox as an injectable facial expression reducer and probably has less than 10% of the U.S. market. They just don’t don’t have the advertising and name recognition that Botox does and as a late entry into the field never established any clinical advantages over Botox. For all intent and purposes, it works the same and has very similar patient costs. As a result, it has had a tough time finding widespread traction in the market place. One day, at best, it may become Pepsi compared to Coke…but it is far from even that now.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have had deformity to my face due to scleroderma. I am now in remission, but the damage is done. Tightening around the mouth and jowls make me appear to be so much older than I am. I see you have replied to several people who have the same disease. Have you helped people with scleroderma and what type of procedures do feel would help me? Thank you.
A: I have seen many variations of the effects of scleroderma on the face from a small area to an entire hemifacial region. In the facial areas of scleroderma involvement, the subcutaneous fat is lost, the overlying skin is thinner, and in severe cases even the underlying bone can be notched or atrophic. In the treatment of scleroderma, the fundamental principle is to add volume which almost always is fat. Because it is injectable and can be placed anywhere, liposuction-aspirated fat is a mainstay of treatment today. While it’s success (survival) is not always assured, and scleroderma defects are more challenging than normal tissues due to less vascularity, the versatility of fat injections makes it a preferred method in most cases. There are indications for other augmentation methods, such as dermal-fat grafts, allogeneic grafts, and onlay bone implants, but there use is more limited.
For involvement around the mouth and jowl area, the use of fat injections would be the best treatment choice. It may require more than one injection session to get the ideal result but adding volume will relieve that tight feeling and make it look rejuvenated as well.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in two facial procedures and I believe you are the right doctor to do them. I already have a chin implant in place but it is not ideal. I would like to have a sliding genioplasty to correct my underbite and have a slightly more balanced chin. Also I want buccal fat removal. I have a heavy lower face with full cheeks that I would like to look slightly more sculpted.
A: Based on the procedures you desire and your objectives, I would make the following comments and clarifications.
A sliding genioplasty is an alternative, and is sometimes better than a chin implant for more severe cases of chin deficiency. It will not, however, correct any occlusal problems as it is a chin procedure and not a total jaw advancement. The correction of one’s underbite requires a sagittal split ramus osteotomy jaw procedure (done in the back part of the lower jaw) which moves the tooth-bearing portion of the jaw bone. This requires pre- and post-surgical orthodontics. It fixes the bite as well as produces an amount of chin augmentation in millimeters that matches how far the lower teeth have moved to fit better to the upper teeth. Do not confuse a sliding genioplasty and a sagittal split mandibular osteotomy.
A buccal lipectomy removes fat and its associated fullness right under the cheek bone (submalar region) It does not create any slimming effect below this area. Most patients envision the entire cheek area done to and past the corner of the mouth when they refer to making their face less full. For this reason, many buccal lipectomies (done from a small incision inside the mouth) are combined with small cannula liposuction of the perioral mounds. (mound or fullness to the sides if the mouth or lower cheek region) This combination creates a better overall slimming effect.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had my earlobes reconstructed after several years of having them expanded by gauges. I was not completely happy with how they looked so the doctor has done a few revisions on them of which I am still not completely happy. Could you take a look at these pictures and tell me what you think. The left earlobe is a little red due to some recent laser resurfacing and I am ok with that side. It is the right side that does not look good to me. Is there any type of scar revision that would be further beneficial?
A: Thank you for sending your pictures. The left earlobe is in good shape and has a reasonably good connection to the face given there there is a deficiency of earlobe tissue. It does not appear to me that it would be improved by any form of further scar revision. (although I can’t really see the scar given its recent laser resurfacing but the connection to the face looks natural) The right earlobe shows some scar widening but it has less of a good connection to the face with some obvious tethering and pull down. This is undoubtably a reflection that it may have had even less earlobe tissue to start with than that on the left side. Can this be improved by scar revision? The fundamentral problem is that there is not enough earlobe tissue. So to get the tissue closed during the prior procedure some facial tissue was ‘recruited’. This is why the connection is more unnatural as facial skin has been pulled into the earlobe area and this is a completely different type of skin than that of the earlobe. Simply cutting out the scar and reclosing it will not improve the underlying problem. However, a z-plasty through the scar or even a v-y advancement type scar revision at the lower edge of the earlobe should be able to improve the look of the earlobe-face connection.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was born with cleft lip and palate and am now 28 years of age. I would like to have more symmetry of my profile, which could be improved by either a bigger upper lip or smaller lower lip. I just feel as though I could look better than I do now now.
A: Thank you for sending your pictures. I do believe you are correct in that there is room for further facial improvement and symmetry. You have all of the typical lip and nose manifestations that I have seen in just about every adult patient affected by a cleft. By your pictures, you had a unilateral cleft lip and palate on the right side. The one thing that you don’t want to do is to make the lower lip smaller. That is the normal lip and it is better to focus on making the upper lip (the abnormal one) larger and more aligned to match better to the lower lip. In paired facial structures, it is rarely a good idea in the pursuit of symmetry to try and make the normal half look like the abnormal half. While I don’t have a good frontal view of your face, I suspect that the upper lip needs to be taken apart along the scar lines and reassembled with emphasis on achieving a better vermilion roll and pout. (cleft lip revision) There may even be some benefit to adding some upper lip volume through a dermal-fat graft or allogeneic dermis at the same time. It would also be possible to do a complete septorhinoplasty during the same procedure to treat the nasal component of the cleft as well.
Dr. Barry Eppley
Indianapolis, Indiana
The stomach area is the number one region that almost all women, and some men, would like to improve. Many have discovered, however, that improving that body area is not as easy as one would like. Many people work hard at it but eventually ‘hit the wall’, get frustrated and may even quit their diet and exercise routinue with no more changes are seen. But the fault may not be your own. Loose stomach skin and fatty bulges at the waistline from pregnancy or significant weight loss are not amenable to internal calorie or fat burning. This brings some to the conclusion that the only way to a more shapely torso is a surgical one.
Everyone knows that a tummy tuck is the removal of skin and fat with muscle tightening to get a flatter stomach and better waistline. While it is almost always a very satisfying procedure, and many patients say afterwards they wish they had done it sooner, it is major surgery and is not just a weekend recovery. When considering a tummy tuck, be aware of the following considerations.
There are two basic types of tummy tucks. If your excess skin and fat is mostly located below the belly button, you may do just fine with a mini tummy tuck. Because the skin and fat removal is done below the belly button, there is a shorter incision that can be placed very low and the belly button is not moved. There is also a slightly shorter recovery with emphasis on the word ‘slightly’. If the loose skin and stretch marks are above the belly button, only a full tummy tuck will do. With that comes a longer scar, a bellybutton scar and a longer recovery.
I have seen recent treatment approaches, particularly online, that tout a ‘scar-free tummy tuck’. There is no such thing and this is just marketing spin to say they are offering stomach liposuction. That raises a question that many people would like to pursue…liposuction instead of a tummy tuck for their flabby and sagging stomachs. That has become a popular request, particularly since Smartlipo (laser liposuction) technology has become available. While it is true that Smartlipo does have some skin tightening ability, it is quantitatively different than what many people need. Smartlipo tightens skin as measured in millimeters, most people need stomach skin tightening as measured in centimeters. With this understanding, it is easy to see that liposuction is not a substitute for a tummy tuck.
Liposuction, however, is very often a part of a tummy tuck. But it isn’t necessarily used to make the tummy part looking better. It is used to shape the areas outside of where the effects of the tummy tuck occur…the outer waistline and back. (i.e. muffin tops) A tummy tuck alone is a 180 degree or frontal torso change. By adding waistline and back contouring with liposuction, the results becomes more of a 270 degree torso change.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a chin advancement by osteotomy last year but I am not happy with the result. My chin is still too short. I would like you to perform another chin osteotomy for further advancement. I still prefer the chin osteotomy because of its permanent result. I have attached some pictures for you to review. How much further do you think you can bring out my chin?
A: Thank you for sending your pictures. I can see by your side view photo that you still do not have optimal horizontal projection as you know. The key question in determining how much more horizontal advancement can be done with an osteotomy needs to be determined through a lateral cephalometric x-ray. The sliding genioplasty is based on the principle that as the lower chin bone segment moves forward, its back end or cortical segment maintains contact with the front edge or cortex of the attached upper chin segment. Some bone contact must remain between the two bone segments for it to survive and not resorb. It may be entirely possible that your chin was moved as far forward as the bone would permit. (unlikely) The real question in my mind is how much further can the chin bone be moved. That is where the value of the x-ray is so important. If it can only be moved 2 or 3mms further forward, an osteotomy approach may not be worth it. (I suspect it can be moved at least 5mms but I need to be sure) The x-ray will also show what type of bone fixation was used so there are no surprises during surgery. One would not want to run across some method of fixation that is very hard or impossible to fully remove and allow the bone to be mobilized. (e.g., lag screw fixation)
The x-ray ultimately needed is a simple lateral cephalometric or facial film view. That can be gotten at any orthodontist and most oral surgery offices.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have had five previous rhinoplasties to get my nose built up the way I want it. At the last surgery, the doctor put in a silicone implant. While that make it look better, it is still inadequate. What I want to know is whether diced cartilage can be used to make my nose bigger as it is still too small. What are the side effects of diced cartilage in the nose?
A: If I understand your question correctly, you are asking whether a diced rib cartilage graft will make for a bigger nasal dorsal augmentation that an exiting silicone implant. The answer might be yes although a more accurate answer would come from knowing exactly what type and size implant is in your nose and what you looked like before it was placed. In most cases, a rib cartilage graft offers more volume than an implant given the amount of rib cartilage that can be harvested. A diced rib cartilage graft can also be molded and shaped much better than an implant without the risks of warping or external deformity. That is the value of dicing a solid rib, it because moldable like clay material when placed in a sheath of surgical or fascia. With any rib graft, there would also be no long-term risk of infection or displacement which is always a potential issue with a synthetic implant. Also understand that the silicone implant must be removed and replaced by a cartilage graft, you can not or should not add a cartilage graft over an indwelling synthetic nasal implant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had saline breast implants of 375ccs filled to 425ccs last year. They were placed through incision in the lower breast crease and placed under the muscle. While I am happy with the size, I noticed about 6 months ago that I can feel a ridge approximately the size of a quarter to the right of my nipple on my right breast and it’s smooth in the center. What do you think this is? Is it a breast mass or lump or is it something on the implant?
A: What you are likely feeling is the valve of the implant. Saline breast implants are manufactured with an indwelling valve so they can be filled at the time of implantation. During surgery, the flat saline implant has a long tube attached to it at this valve. After the implant is positioned in the breast pocket, it is filled with saline through this long tube. Once filled to the desired volume, this tube is removed from the implant by detaching it from the valve by pulling on it. The valve has an attached cover which then snaps closed over the valve opening. This cover creates a very low profile bump or nipple on the implant’s surface. Usually the valve ends up on the underside of the implant by the way the implant is initially placed in the pocket. But it is possible that an implant can flip or be placed ‘valve up’. In breasts with very thin tissue, the valve may be able to be felt and it would be close to being around the nipple area. It poses no concerns other than being able to be felt.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I suffer from bruxism along time. I have broken teeth from the grinding and suffer from much jaw pain. In the last month I have gotten Botox injections for it. It provided some significant relief but it only lasted just over a month. Ccan you advice me if it is possible to get another botox treatment or maybe it is not my solution. Thanks for your helping.
A: Botox injections into the masseter muscles can be tremendously effective in the treatment of refractory and very painful bruxism. In my experience it lasts about as long as it does when used for cosmetic applications on the face…about 4 months. If it only worked for one month, there are several explanations. The first possibility is that simply not enough Botox (dose) was injected. The minimum effective dose is 25 units per side and 50 units per side is more ideal. Less than this dose will either have minimal effect or it will wear off very quickly. A second possibility is that the Botox used was ‘weak’, either being reconstituted days or weeks before injection, or being reconstituted with an overdilution of saline. Both can result in minimal or a very short duration of any benefit. Since you had some significant symptomatic improvement, I would repeat the Botox injections with these issues in mind. Unfortunately being the patient, the only one of these you have any control over is the actual dose.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in an onlay cranioplasty for back of my head. It is true that hydroxyapatite would be very light and much more like my bone than PMMA materials. Is PMMA heavier than hydroxyapatite? Would I feel the heaviness in my back of my head if I choose PMMA for the surgery? I know that PMMA would work to make my head round, What are the pros and cons of using PMMA? Are there any side effects of PMMA to my body? Thanks.
A: There is no real weight differences between PMMA and hydroxyapatite (HA), so that is not a concern. The differences between them is three fold. First, PMMA is a plastic material and it just as hard as bone if not actually harder. Secondly, it is a well tolerated and commonly used cranioplasty material. But it is not bone so, like a breast implant, it is well tolerated and accepted by the body but it never truly becomes part of the breast. It is simply walled off (encapsulated or surrounded by scar) HA is a lot more like bone biologically since it is the inorganic mineral content of bone. Because it it more like bone, the body actually grows into it and integrates into it. It is not as strong as PMMA or bone and is more ‘brittle’ much like a ceramic. The risk of fracture is greater on hard impact although I have yet to see fracture of the material as ever having occurred or being a problem that I have heard of. Lastly, there are cost differences betwene the two in terms of volume used. PMMA has a flat rate cost that is substantially less than that of HA as it comes in 40 gram packets. HA is charged by volume in grams per 10 grams used. So the equivalent material cost for, let’s say 40 grams of material, is about 4X the cost over PMMA. That is a several thousand dollar cost difference between the use of the two materials.
As you can see, the choice between PMMA and HA offers certain advantages and disadvantages for each material.
Indianapolis, Indiana
Q: Dr. Eppley, I am committed to undergoing chin augmentation with an implant but I am a little anxious. I just have a few questions. What do you see as the risks involved with a chin implant procedure, if any? Do your predictive photos mirror actual results? Thanks for taking the time to answer my nervous questions.
A: In answer to your presurgical jitters:
1) There are always some risks with any surgery and chin implant augmentation is no exception. Fortunately those risks with chin implants are few and very low. The ones that I have observed are infection (1% to 2%) and asymmetry of the wings of the implant. (2% to 3%) Both are very correctable, albeit with a revisional surgery. There is always the risk of too little or too much chin augmentation with an improper size implant but that is not a very common problem in my experience.
2) Computer imaging is an estimate and not an exact predictor of the final outcome from any plastic surgery procedure. Its predictive ability varies based on the type of procedure being performed. Of all the facial cosmetic procedures, chin augmentation is one of the more accurate in terms of predicting the outcome as it is a profile or silhouette facial feature.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am interested in getting implants for my deep tear troughs. I have a few questions about them. What is the recovery time? Will there be any bruising or swelling? What are the aftercare instructions? ( i.e., how long are bandages worn, how long do I wear sunglasses?) Can I apply Latisse on my eyes? What kind of anesthesia is used and what are the side effects associated with this? Is there a possibility that this will affect my vision? Are there any negative outcomes or side effects of tear trough implants?
A: There will be swelling and maybe some bruising for a few weeks. Recovery is all about how you look not how you feel. There is no aftercare or anything that you need to do other than to ice the eye area for the first night after surgery. There are no bandages. You may continue to apply Latisse to your upper eyelid lashes as normal if you desire. General anesthesia is used as the lower eyelids and orbital bones are impossible for anyone to stay still except if they are asleep. This surgery will have no effect on your vision. The biggest risk of tear trough implants is getting the right size and position on the bone so you do not feel them, see them and they do not move after surgery. Implants can be used for tear troughs but so can fat injections which is another good option. Fat injections, like tear trough implants, is an operation that is done under general anesthesia as well.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a chin implant done approximately 10 years ago. I have only mildly been satisfied with the results. I believe the implant was put too far down on my chin bone to lengthen it vertically. Shortly after surgery, the implant slipped off on one side making my chin appear uneven. But it is from the profile view that I dislike my chin the most. My chin and neck are not separated by much horizontal distance. I think I may be a candidate for the vertical lengthening jaw implant that is done with the CT scan. My question is..is there a way to do a consult visit without me physically coming to Indiana? Or is an office visit required to make a determination if I am a candidate for this procedure?
A: When considering lengthening the anterior lower face vertically, the decision is between a chin osteotomy or a custom chin implant. For the sake of this answer, I will assume that the implant choice is the better option for you. Since there are no off-the-shelf chin implants that have any significant vertical component to it, a custom implant will need to be fabricated. This is a process that requires the following steps. First, a 3-D CT scan must be obtained. This can be gotten at most CT scanning facilities in your geographic location. That scan is then sent to a model manufacturer which creates an actual mandibular (jaw) model that is an exact replica of your own lower jaw. I then take this model and hand-carve a chin implant out of a special clay material that matches your exact aesthetic needs. That custom chin implant is then sent to a manufacturer who makes and sterilizes a silicone implant from the clay mock-up. All of this can be done without you ever leaving your home. Your candidacy for any custom facial implant is determined from afar by phone, photographic and Skype video consultations. One only has to appear for the actual surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in the combination of a browlift and a hairline advancement. My brows are now sagging too low and I have always had a high forehead. With a browlift alone I fear that the front part of my hairline will go back further with some of the browlift methods. I visited a plastic surgeon and he told me that both could not be done at the same time. But I have also read in your articles that it can be done simultaneously. I am confused. If they can be done at the same time, how does it work? And why would this plastic surgeon say it can’t be done?
A: Just like a browlift loosens and lifts the forehead tissues upward, the scalp can be loosened and moved forward. They key to these procedures is that when done independently, they rely on having a fixed point onto which the loosened tissues are fixed. For the browlift, it is the frontal hairline, For a frontal hairline advancement, it is the forehead tissues as the fixed point. When doing a hairline (pretrichial) browlift and frontal hairline advancement at the same time, which can easily and most conveniently be done together, the key is to create a point onto which both can be used for stabilization. There are different ways to achieve the fixation of the two flaps but I prefer to use outer cranial table drill holes with galeal suture fixation. This not only provides good fixation but keeps the tension off of the suture line so the hairline scar does not widen and excessively show. For the right patient, this combination can produce excellent results and achieve a more total forehead rejuvenation. I can understand why some plastic surgeons would not combine these two procedures as their movements seem to be working against each other. But that is a matter of preference and experience, not an issue of technical feasibility.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am interested in the corner of the mouth surgery to lift up my downturned and sad looking mouth. What are the risks, recovery time, and success rate of this procedure? Is the procedure an office visit? What number of follow up procedures are required?
A: The corner of the mouth (COM) lift is an office procedure done under local anesthesia. Dissolveable sutures are used so no return visit is necessary for out of town patients. I would say there is really any true recovery, just some redness in the corners of the mouth for several weeks and time to let the scars fade. There are no dietary or oral hygiene restrictions afterward. It is always a successful procedure as the corners are always leveled out rather than downturned. The key is not to overdo it so the corners are turned up or give someone a ‘joker’s smile’. There will be a very fine line scar that emanates out from the corner of the mouth about 5 to 7mms, but it is very small. Sometimes there may be a need or it is of benefit to do some other minor procedures around the corners of the mouth. (e.g., fillers to marionette lines) This is why it is a good idea for me to see a picture of your mouth in a non-smiling position to determine if this is the corner of the mouth lift procedure for you.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley,I am interested in liposuction of the perioral mounds. The effect I am going for is what happens when I suck in my cheeks. Would the procedure produce such an effect? However, I have read that it is difficult to do liposuction in this area and that scars and asymmetric results are common. Could you also tell me more about the risks? Thank you!
A: The perioral mounds are small fat collections that lie outside of the corner of the mouth and on the lower end of the cheek area. They are not part of the buccal fat pads, as is commonly thought, but is a less defined area of subcutaneous fat between the skin and the buccinator muscle. A prominent perioral mound can be reduced by small cannula liposuction. The entrance site is just inside the corner of the mouth in the mucosa so there are not resultant scars. Generally 2 to 3 cc of fat can be aspirated from each side. I have not seen that asymmetry or skin irregularities are a problem afterwards. The only real risk of the surgery is that the effect it creates is not significant enough. While I have always seen a reduction of the perioral mounds with liposuction, it will not create the look of sucking in your cheeks. That look results because the soft tissues of the cheek are like a trampoline being suspended between the bony supports of the cheek and jawline. They can easily be pulled inward with suction but no amount of facial fat removal can create that same effect. Perioral mound liposuction is best done as part of buccal fat pad removal to create an overall better facial thinning effect.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in Botox for hand hyperhydrosis. What is your fee for both hands? How much time is involved? Is a nerve block involved due to pain issues?
A: Botox for excessive sweating of the hands, like everywhere else it is used, is done based on the number of units injected. While the effective dose differs for each individual, the minimum dose for each hand should start at 25 units. (50 units for both hands) If one has had Botox before, they they will have a baseline for the number of units that are most effective. If they have never had it before, then this is a good starting place although maximal effectiveness may require more units. The goal with Botox, like all drugs, is to determine the least dose that is most effective. The cost of Botox is done by the unit. Each practitioner may have slightly different unit pricings so you have to inquire at each specific office for their Botox charges. No doubt the palmar surface of the hand is a very sensitive area to inject. I have managed the injections multiple ways including patients ‘taking it straight’, topical numbing creams and nerve blocks done at the wrist level for the radial, median and ulnar nerves. Bilateral wrist blocks are difficult on a patient when it comes to walking out and expecting to drive home. Treatment time for the Botox injections can vary from 15 to 45 minutes based on what type of anesthesia is done.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, do saline implants only last for 5 years? And is it true that you have to be 22 to get silicone breast implants? Im really interested in silicone implants because I’ve heard they last longer but I just recently heard that you have to be 22 to get them.
A: The longevity of breast implants is both unknown and variable. No one can predict with any accuracy how long any breast implant will last. When speaking of the longevity of breast implants one is referring to when it will fail. Failure is defined as when the bag or shell that contains the filler (saline or silicone gel) gets a hole or tear in it. When that happens with saline implants, the detection of failure is immediate as the implant develops an obvious deflation with visible loss of breast size. (i.e., flat tire) When failure occurs in silicone implants, the detection is not immediate and may not be known for a long time as deflation does not occur. This is because silicone gel material can not be absorbed and much of the material may stay in the shell because of its thicker non-liquid material properties. This is why failure in silicone gel breast implants is known as silent rupture. Detection of silicone implant failure may be only found on a mammogram or can be suspected if one breast develops some discomfort or hardening. These differences in how the two types of breast implants fail is why silicone breast implants ‘last longer’ than saline implants.
According to the FDA regulations imposed on breast implant manufacturers (based on the clinical studies for them which did not include patients 21 years or younger), the recommended guidelines for use of silicone breast implants is for patients 22 years or older. What any specific plastic surgeon will do in terms of implantation is between the doctor and the patient.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like to get my ears reshaped. I think they are too big at the earlobes and they stick out a bit. My earlobes seem too big for a younger male and I have always been self-conscious about how my ears stick out. Can my ears be pinned back and the earlobes reduced in size at the same surgery? I haved attached some pictures of me from the front so you can see what I mean. It is hard to look at anything else but my ears in these pictures!
A: Thank you for sending your pictures. I can see your concerns about earlobe reduction and a little bit of ear pinning. The combination of the two would solve those concerns and make your ears blend in naturally along the side of your head. Ears should blend into the side of the face and not be a dominant facial feature. The ear can be put back a little further by adjustment of the concha through mastoid sutures from an incision on the backside on the backside of the ear. The earlobe can be reduced by half its current size. The only question there is scar location. There are three different methods of earlobe reduction with changing locations of the scar. Regardless of how earlobe reduction is done, it can be combined with ear pinning (otoplasty) at the same time and are fairly easy to undergo. There is really no significant recovery other than some slight external ear swelling.
Dr. Barry Eppley
Indianapolis, Indiana
