Your Questions
Your Questions
Q: Dr. Eppley, I found your website researching the vermilion advancement or gullwing lip lift and wonder if you could help me. I had a subnasal or bullhorn lip lift procedure done a month ago in order to show upper teeth when keeping my mouth open. I have always had a long philrum. Before surgery it was 20mm in length and now it is 13mm. Just like before, however, I do not show any upper teeth when my mouth is open or when I talk or when i smile. I do not have any more swelling at this point so I know this result is final and am considering a revision. Do you think a gull wing lip lift help me show my upper teeth?
A: With a central reduction of upper lip length from 20 to 13mms, that is a 1/3 reduction which is about the limits of this centrally-based upper lip shortening procedure. It is surprising that you have not made even a little upper tooth exposure with that reduction. But your anatomy and direction and vectors of lip movement may be working against you to achieve any better dental show. I would not be optimistic that a lip advancement would produce the desired dental uncovering. Lip advancements are great at making the lips bigger but I have never seen them result in any increased dental show of either the upper and lower lip. Lip lifts (bullhorn) are more effective at that than lip advancements. (gull wing) It may be possible but is not the primary intention of that procedure.
I would have to see pictures of your lips, both at rest and smiling,to give you a more qualified answer. It is also possible that you may benefit by an internal mucosal reduction which provides the ‘missing link’ in complete upper lip shortening.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am considering some facial surgery to improve my overall aesthetics. I have previously been through a rhinoplasty, chin implant and cheek implants. While these have been helpful, I still want to get better results. I am hesitant in doing any more surgeries, however, unless the results will be a significant improvement in facial aesthetics and symmetry. To help me visualize what I want I have used a facial aesthetic program which morphed the “ideal male ” with mine. The pictures seem to make the chin width smaller and less square and with an even jawline to the posterior angle of jaw. The images seem to downsize the cheek implants and to make the tip of nose more symmetrical and smaller with a raised nasion. I have attached a few of these pictures. The first two pictures are that of an ideal female face with mine. The last three are the ideal male face combined with mine. Thirty points on my face were used for my facial proportions to generate these pictures. Is it possible to achieve this morphed look since it seems the resulting face is more aesthetic.Your thoughts and concerns are greatly valued regarding what is achievable. If you have a software program regarding what the postop look will be regarding the different procedures I would be interested in seeing those results.
A: Thank you for sending your images and your thoughtful morphing overlays. While I think they are helpful to see what direction you ideally want to go, I do not find them realistic or that those type of results are achievable. Images like this set the standard of how the patient will judge their outcomes afterwards and it always leads to results that fail to hit the mark and are disappointing. Their greatest value lies in helping the patient determine whether surgery is worthwhile, particularly the patient who has been through previous surgeries and is in the ‘revision mode’. Quite frankly, I and probably most plastic surgeons shutter when a patient goes through this exercise because the results will always fall short. Since I do not feel your results would meet these imaging goals, at least in my hands, I would recommend that revisional plastic surgery may not be worth the expense and recovery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am wanting to get the size of mons pubis reduced. I am so ashamed of its size and it restricts me from doing many things in my life. I am not obese or grossly fat, just about 30 lbs overweight. I have been losing weight but the mons will just not go down in size to any significant degree. I will continue to diet and exercise but I have no confidence that it will get any smaller. The skin tone over the mound is good and not loose. It feels firm but can be pushed in so I feel certain that it is fat and not bone. If liposuction is done and the fat from the mons reduced will that in any way affect sensation in this area?
A: Liposuction of the mons pubis or suprapubic liposuction is a very successful spot area of fat removal. It can be surprising how much fat is in the mons and how much of a difference it can make when it is done. Like all body areas treated by liposuction, there will be some temporary numbness of the overlying skin for up to six to eight weeks after surgery. This loss of skin sensation will completely return. The procedure will not, however, affect any feeling of the clitoris or sexual sensation. I have even had a few patients who have told me that their sexual sensation was actually improved after mons reduction, presumably due to an uncovering of the clitoris. Suprapubic mound reduction in men can have a similar effect due to exposure of greater penile length.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like to ask if it is possible to reduce the width of head? The width of the upper part of my head above the ears is big on both sides. Is there any possibility to reduce it? I am 30 years old and it has bothered me my whole life. Thank you for taking the time to answer.
A: The thickness of the side of the heads is influenced by both bone and soft tissues. The area directly above the ears is part of the temporal area and the thickness of the underlying temporalis muscle can have a major role in its thickness. The influence of this muscle decreases as one gets closer to the transition of the skull from a vertical to a rounder more horizontal orientation as it thins out. Depending upon where the bulge or too wide portion of the side of the head is located, some reduction is possible. I have performed successful reduction in this area by releasing and resecting the posterior portion of the temporalis muscle and some outer table skull burring. This can make for a 5 to 7mm reduction per side, which could be mean up to a 1.5cm reduction in head width. If the extreme width of the head extends more superiorly, then not as much reduction can be done and the procedure may not be worthwhile to undergo.
Indianapolis, Indiana
Q: Dr. Eppley, I want to achieve a better face shape with a wider and higher jawline, higher cheek bones, a wider upper face and a less ‘pear shaped’ face. I have attached two pictures. In the second picture I tried to draw the changes I want to make, if possible. Thank you.
A: Thank you for sending your pictures. Your highlighting the changes you desire makes it very helpful to know exactly what you are looking for. Based on your face and those highlighted changes, I can make the following comments. These are said with the acknowledgement you have some significant facial asymmetry as seen most prominently in your jawline and eyebrow areas.
1) Your eyebrow asymmetry poses challenges as a high eyebrow can not be brought down. Only the lower eyebrow can be elevated to a more symmetric level to the higher one. Whether that is done by a unilateral endoscopic browlift or a hairline procedure that elevates the right brow and overall shortens the vertical length of the forehead depends on your other foreheads objectives.
2) Temporal implants can easily augment and widen the temporal area.
3) Your drawn concept of a lower eyelid lift is to raise the horizontal level of the lower eyelid. That is quite different than a typical lower blepharoplasty that removes excess skin but maintains the existing horizontal eyelid level. Raising the low horizontal lower eyelid with too much sclera show is not easy nor always predictable. To do so requires adding a spacer dermal graft in the internal lining (lamella) of the lower eyelid and tightening the lateral canthal tendon. It may be possible to raise the eyelid but not more than a few millimeters at best.
4) Your cheek implants are positioned on the underside of the cheek, indicating that submalar implants would be most beneficial.
5) Your nose changes shows expansion of the middle vault with spreader grafts, tip narrowing and shortening, and nostril narrowing. This can be done through an open rhinoplasty.
6) Your lip drawings show upper and lower lip vermilion advancements but I am not sure whether those fine line scars would be acceptable. But only vermilion advancements can produce the results you are showing.
7) Your jawline poses a bit of a challenge. It is not possible to make it as smooth from the chin back to the jaw angle as you have drawn. You can place lateral jaw angle implants, the right being bigger the left, to widen the lower face.
When it comes to changing the overall shape of one’s face, multiple procedures need to be done at the same time. Your composite drawings illustrate that well.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I want a consultation about my profile. I am confused as to what I may need. My bite is not bad and I have never had braces. My dentist told me my upper teeth forms a c-shape. I think my jaw line is asymmetric, my chin points to the left and my right side profile looks concave or flat. This had been bothering me for a while but I don’t know what will be the best to make my face look more symmetric and balanced. I have attached some pictures so you can see what I mean.
A: When looking at a face there are two views to consider. The patient themselves sees the frontal view and, understandably, often considers it to be the most important. The profile and oblique views are what other people see and how the patient will usually see themselves in photographs. In your description of concerns, you mention both the profile and frontal view concerns.
As you have described in your frontal view, the chin and jaw angles are asymmetric (right chin deviation and left angle deficiency), and the right cheek is flatter or less pronounced than the left. If you look at other features of your face, you will see that there is an overall right facial deviation compared to the cranial base. This rotation is also why the right facial profile seems flatter in the cheek area.
I can not speak for your bite (occlusion) as it is not contained in any of the pictures you have sent. However, I doubt if your bite is severely off or misaligned and I don’t think it has any contribution to your facial asymmetry.
To improve your facial asymmetry, you have to think of ‘camouflage’ procedures for improvement. I would recommend left jaw angle and right cheek implants and either an asymmetrically-placed chin implant (with minimal horizontal increase) or a chin osteotomy with rotation and shifting to bring the chin point in the midline.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a chin implant removed and my chin muscle sags now. Because the initial surgery was fraught with infections and complications, my chin muscle was cut into four more times after the first surgery. Doctors tell me now, 4 years later, that the chances that I could have my chin muscle reattached higher, where it used to be, is slim. Since there is very little of anything left to sew into, I’ve been told that they could try and drill screws near the nerves of my bottom teeth and try to attach something that way, but this is unlikely. Is there a surgeon out there who has dealt with this same issue successfully? I am desperate to get my face back. There must be some way to reattach my chin muscle!! Help, please!
A: Reattachment of the mentalis muscle is very possible. The key is to have a stable method and non-injurious place to attach the muscle/scar. This is best done with micro-suture anchors that are designed to be very small (1.5mms) and can be placed over (in between) the roots of the lower anterior incisor teeth. I have found this technique to be successful, regardless of how many times the mentalis muscle has been re-entered.
Despite re-attaching the mentalis muscle, complete improvement of the sagging chin pad may not still be obtained. The implant may have created some extra chin tissues through expansion that a combined submental tuck-up may be needed as well to get a tight redraping of all of the soft tissues over the convex chin bone. Whether this approach to you revisional chin surgery is needed would require photogtraphs and an examination to determine.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in having a rhinoplasty done but am uncertain as to whether the result would be worth it. I have a very big nose with very thick skin. It is way out of proportion to the rest of my face. No one else in my family looks like this so I don’t know where I got it. In looking online at a lot of rhinoplasty results, a lot of times I don’t see that much of a difference in many of them. I am worried that I might end up as one of those type of results. And when you have a nose like mine, you need a big change. I have attached some pictures for you to see. Tell me what you think, is a rhinoplasty worth it for me?
A: Rhinoplasty in noses that have a very large and thick skin sleeve are very challenging. Not so much because of the technical execution of the surgery but in how the skin will respond and how much shrinkage of it will occur. One can make a significant change in the shape of the underlying cartilaginous strutcures but if this skin does not adapt to it well, then much of those changes will not be seen. In looking at your nose, you are correct in pointing out that the size of the tip in particular is way out of proportion to the upper nose and the rest of your face. At least half of the size of your nasal tip is skin which can not be removed but can only shrink to some degree.
The key to rhinoplasty in the thick-skinned male nose is the recognition and realistic expectation that you can never have a small or well-defined nose. That is not anatomically possible. Most likely, you can never have the type of nose change that you would ideally want. But some improvements can be made anmd could be very worthwhile. In your rhinoplasty, I would tnarrow and lift the tip cartilages, defat the nasal tip carefully, augment the dorsum with cartilage grafts, and do a significant nostril narrowing. I have done some computer imging for you to see what may be possible. I would also consider a chin augmentation which would help balance your facial profile and is a classic manuever to help make the nose appear a little ‘smaller’ by changing other facial proportions.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was 16 years old when I got my rhinoplasty done. I am Asian and I had what appears to be a very typical Asian rhinoplasty using an implant. I think it is a silicone L-shaped implant. I originally had a very flat nose with a low bridge. It is now 20 years later and I want to take it out. I have never liked the way it feels and the idea of having plastic in my face bothers me. I think the skin has also gotten thin over it as I think I can see the implant when out in bright sunshine. Can it be removed at this point? How will my nose look when it comes out?
A: Your indwelling nasal implant can be removed at any time. The question is not whether it can be removed but whether to do anything else to replace it at the time of its removal. Taking the implant out will deflate the nose so it will get flatter and shorter, perhaps close to what you were before. Certainly that is the easiest option but perhaps not the most esthetic. Replacing it with a rib cartilage graft is the most aesthetic but not the easiest. Intermediate options include placing layers of allogeneic dermis (e.g., alloderm) on the dorsum and a septal columellar strut graft. That would be a good revisional rhinoplasty compromise as it would produce an intermediate aesthetic result without the need for rib graft harvesting. I suspect you really won’t like the appearance of the nose when the implant is removed but may not really want to have a rib graft harvested either.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I don’t know if you are familiar with Groupon (if you are on this planet you must by now) but it has been a wonderful idea for me. I have participated in numerous Groupon deals for a variety of merchandise and restaurants and have saved a lot of money by doing so. i am interested in getting breast augmentation later this year and was wondering if you will ever have a Groupon for breast implants?
A: While Groupon may be very appropriate and a good consumer concept for meals, spa treatments and other conventional retail items, it is a poor idea when it comes to plastic surgery. This makes the very serious endeavor of human surgery a trivial matter and places it as a mere commodity. It brings it done to the level of money-off coupons, day long specials and competition prizes. Besides the very serious breach of ethics of the American Society of Plastic Surgeons, such business tactics belittles plastic surgery and the medical profession as a whole. But the real tragedy is in how it may affect patients who will undoubtably suffer complications and even lifelong injuries from such promotional activity. What corners are being cut to provide plastic surgery at such low prices? Equally importantly, what are the qualifications and experience of surgeons who must use this patient draw tactic to get surgery? Aesthetic plastic surgery should be a thoughtful decision that is driven by consideration of the benefits vs the risks of the procedure not by low pricing. You can return a dress you don’t like or never go back to that restaurant where the meal was not very good, but plastic surgery is not ‘returnable’ and often is not even reversible. While the economics of elective plastic surgery (e.g., breast augmentation) is always an important issue, it should never be the most significant one.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, assuming that all goes well when putting in a chin implant, what about the feeling of having it. (mandibular nerves and the touch receptors of the hands?) How physically light is the implant? Will it feel weighted? I’m sure that your own senses will eventually incorporate it into being a part of it, but what about others. Will it be discernible if say someone else touches your face (jaw)? I know this is a tricky question, coming from a post operational/personal standpoint, but thanks for taking the time to answer.
A: The question you are asking it one related to every type of face and body implant…that of incorporating it as part of yourself and no longer have it feeling foreign. And I think the answer is the same for a chin implant as it would be for a breast implant for example. Intially the implant feels different as the tissues are tight and swollen and the overlying skin is numb. It probably takes about 6 weeks after surgery until it begins to feel more natural and really 3 months until it becomes part of you. At this point, the overlying tissues are relaxed and normal feeling has largely returned to the skin. The chin implant can largely not be detected by yourself or anyone else at that point. While for a patient three months seems like a long time, it is actually relatively short and it is amazing how soon one incorporates the new contours of their face into their body image.
The weight of a chin implant is but a few ounces. It is lighter than bone of the same size.
Dr. Barry Eppley
Indianapolis Indiana
Q: Dear Dr. Eppley, I recently read, that a revision on a chin implant that has been inserted through an intraoral incision, can lead to distortion of the chin muscle because this muscle would be cut through twice. I don´t have a chin implant, but porex cheek implants (inserted through an intraoral incision) that need to be shaved down on the left side. Now I would like to know if an intraoral performed cheek implant surgery also involves cutting through a muscle what eventually could lead to distortion of the soft tissue if this muscle is cut through twice.Thank you in advance for your reply!
A: When it comes to surgical access in the face for the placement of implants, they must be placed down at the bone level below the periosteum. This always requires cutting through attached muscle to get to the proper placement level. But there are significant differences between the lower jaw (mandible) and the rest of the face. The lower jaw is the only bone of the face that actually moves, the rest of the facial bones are fixed. This makes for significantly different types of muscular attachments.
The mentalis muscle of the lower jaw, while having no function in its opening and closing, covers the chin bone and affects the lower lip and soft tissue movements. When it becomes detached or scarred, one can develop lower lip and chin soft tissue sagging. While good soft tissue closure will avoid this problem it is always a risk. While there is nothing wrong with secondary intraoral chin surgery, the upper attachments of the mentalis muscle are being severed and reattached twice. This does increase the potential for secondary mentalis muscle problems.
The intraoral placement of cheek implants does not cut through any muscles of jaw motion or those responsible for any soft tissue support. There are no risks, therefore, for muscle scarring that would affect any facial function or appearance. The muscle issues of intraoral chin implant surgery do not apply to intraoral cheek implant surgery.
Dr. Barry Eppley
Indianapolis Indiana
Q: Dr. Eppley, I read your comment on floating belly button. I saw a plastic surgeon recently who said it would be best for me to repair my abdominal muscles all the way to top, float the belly button and then reattach it right where it was as I have almost no loose abdominal skin. (mini-tummy tuck) It sounds good in terms of a lower and smaller scar but the “cutting the cord” idea really bothers me and worse since I saw it on Youtube! Since the belly button is sort of the center of connection for mothers, I just want to know if it is ok and safe and if it can really be reattached? Thank you.
A: While I can appreciate your concern, you have nothing to fear. The umbilicus, or belly button, is really nothing more than a band of scar that runs from the midline of the union of the rectus abdominal muscles to the overlying skin. While it is a remnant or scar from the original umbilical cord, it serves no useful purpose other than its aesthetics….and that it would look weird if someone didn’t have one. In a mini-tummy tuck it is very common to release it from its attachment to the fascia of the muscles so it is out of the way for a complete vertical repair of the loose rectus muscles. It is easily sutured back down either to its original location or lower depending upon how much abdominal skin is removed. This is a perfectly safe procedure and I have never seen it to be a problem afterwards.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am interested in cheek implants and until now I have thought that this compared to other plastic surgery procedures would be a relatively simple procedure with a minimum of complication rate. Recently I have seen a scary video on Youtube that shows a patient who developed a bunch of complications a few weeks after this procedure. He isn´t able to smile on one side of his face. One implant moved the whole way down the cheekbone and the other implant developed some kind of air pocket between the cheekbone and implant.One of the implants got infected. This patient also mentioned in his video that the surgeon removed some bone of his cheekbones before he inserted the implants. I can imagine that you don´t like to comment on another surgeon´s work. Could you please tell me if these are complications that could have been easily avoided by a well trained surgeon?
A: You would be correct in assuming that I wouldn’t comment on any specifics about another surgeon’s work or results. That is not a protective maneuver for other surgeons but because many details of other patient’s surgeries and cases are not known to me and often how the information is presented may not be complete. There is also the old motto of ‘there are two sides to every story’.
But I can make some general comments about cheek implants and their potential outcomes and complications. I have never seen the type of complications from cheek augmentation that you have described. In my experience, the most common complications are aesthetic in nature. Asymmetry of cheek implant position or too large a size or incorrect implant style for the desired effect are more likely complications to be seen. These can be resolved by implant adjustment and/or replacement. Infection of the implant is also a potential complication but this is uncommon in my experience with cheek augmentation. I have done many cheek implants in combination with maxillary or LeFort osteotomies, where the implant sits directly over an open sinus cavity, and have yet to see an infectious outcome with its use in that ‘higher risk’ use. The best way to avoid many of these cheek implant problems is to secure them to the underlying bone with a screw and get a good two-layer soft tissue closure over them.
I have a hard time figuring out how any type of permanent facial nerve injury can occur from cheek augmentation as the terminal buccal branches of the facial nerve are well above the subperiosteal dissection used for the placement of the implants across the zygomatic bone surface.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am considering getting nipple reduction surgery if this is possible. I am a 19 year-old male college student who has a very athletic body type. I suspect I have always had nipples which stuck out and they didn’t used to bother me. But now they do and it has been giving me self-esteem issues. What type of surgery do I need to correct this problem, how is it done, and how long is the recovery?
A: When I get requests for ‘nipple reduction’ surgery, it is important for me to discern exactly what the problem is. Nipples can stick out from two causes and the difference is in understanding the anatomy of the nipple-areolar complex.. The first is true nipple protrusion or hypertrophy. This is where the small central raised nipple sticks out too far, either all the time or when it becomes temporarily erect. This creates a small almost sharp point that can be seen through shirts or makes for a non-smooth chest profile. Nipple reduction is essentially a wedge amputation, is done in the office under local anesthesia, and will produce a permanently flat nipple. There is no recovery at all. The other cause of the entire nipple-areolar complex sticking, also mistakenly called a protruding nipple, is gynecomastia. When the size of the gynecomastia is small, it can push out the entire nipple-areolar complex. This makes a ‘nipple mound’. This areolar gynecomastia reduction is removed through a lower areolar incision and is done in the operating room under general anesthesia as an outpatient procedure. The enlarged and firm mass of breast tissue is removed to bring the profile of the nipple-areolar complex back to a smooth chest contour. There is about 7 to 10 days of recovery in which the patient wears a circumferential chest wrap to reduce the chance of any fluid collection in the space where the breast tissue was removed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have had three hair transplants performed over the past 18 months. While I definitely have more hair, the results of these surgeries do match what I paid to get them. I have a couple of donor scars which when I cut my hair very short, show quite obviously and leave an unsightly scars at the back of my scalp. I would like to reduce the appearance of these as it is otherwise very difficult to be able to buzz my hair short without feeling self conscious about the scars.
A: Scalp donor scars for hair transplants can become wide, particularly when the same donor site is used more than once. This is a function of tension on the scar line which widens and leaves a gap between the sides of the hair-bearing scalp. Any scar widening, or ‘hair gap’, in the scalp is easily seen. Scar revision of hair transplant donor scars can be successful at narrowing their width based on total excision of non-hearing scar/scalp and deep suture support at the galeal level. Any tension on the skin will result in new scar widening. In some cases, I have done a geometric (running w-plasty) scalp scar excision to distribute the tension at the skin level and break up an otherwise straight line scar. Every manuever of tension reduction is important in scalp scar revision, particularly in those from hair transplants in the low occipital horizontal orientation.
Dr. Barry Eppley
Indianapolis Indiana
Q: Dr. Eppley, I am interested in a subnasal lip lift. I have had other minor plastic surgery procedures which were done with very good results, little scarring and very little down time. My upper lip is my greatest area of facial concern due to the length of my upper lip. It actually seems to be getting longer as I get older. It was always a little long even when I was younger but time is not making it shorter! I can send you pictures if you like. I live out of the states so please let me know if this procedure is something that could be accomplished with an out of town surgery visit. Thanks so much!
A: Thank you for your inquiry. A subnasal lip lift is a relatively simple procedure that can be performed in an office setting under local anesthesia. It is a delicate and precise lip procedure but the process to do it and the recovery is the simple part. It is a common procedure that patients from far away come into Indianapolis for me to perform. There is no physical recovery required with minimal swelling and virtually no bruising. One could have it done and leave for home whenever they want. There is no reason to stay here afterwards. I always use tiny dissolveable for the skin closure so the patient has no need to return for their removal. Please send me a picture of your lips for my assessment to determine if a subnasal lip lift procedure is for you.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have a minor case of pectus excavatum on the bottom of my sternum, although I do not believe it is causing me any physical problems such as breathing. I find its indentation to be very disturbing and affects my self-image. I was reading about the case study: Injectable Sternoplasty with Kryptonite Cone Cement on one of your websites and was wondering if this is the treatment would be good for me as I have about the same level of severity as shown in that person. I have had quite a difficult time researching any relevant plastic surgery options for treating this problem.
A: It is no surprise that you have had a difficult time finding any treatment options for minor to moderate sternal contour deformities as they really don’t exist. Short of treatment for more significant cases of pectus excavatum with the Nuss procedure or the older radical method of rib resection, there is no reported methods for sternal ‘augmentation’. In the past, plastic surgeons have occasionally used custom or carved implants for sternal augmentation but these required large incisions to place and were often associated with postoperatuve problems of seromas, infection or implant mobility. Whatever is placed on the sternum, it must be fixed and adhere to the bone to prevent these problems. This is why I have applied a cranioplasty approach to the sternum, specifically a Kryptonite injection approach. This material bonds to the bone and can flow through a very small tube for placement. In my experience with it I have learned that it takes less material than one thinks to fill a lower sternal indentation, usually less than 5 grams due to the expansion of the material
Indianapolis Indiana
Q: Dr. Eppley, I am interested in improving the shape of my forehead. It slants backward rather significantly and I would like it to be more vertical as it goes upward from my brows into my hairline. Can this be done with Kryptonite foreheasd augmentation? How much filler would be needed and what would be the cost?
A: I have done a side view imaging prediction to show that forehead augmentation can make a real difference in eliminating the backwards slope of your forehead by incrementally increasing adding volume from above the brows to the top of the skull. While there is no question this procedure can be done very effectively and get your desired aesthetic result, there are several important issues about the technique to do it. While an injectable or endoscopic Kryptonite procedure is very desireable due to its minimal scar approach, this would not be the best method to do it for several reasons. The volume of material needed is likely 40 grams or more to add the necessary amount of augmentation. That makes the use of Kryptonite prohibitively expensive, making the cost of the material alone for the procedure in excess of $12,000. When it comes to this volume of material needed for forehead augmentation, acrylic or PMMA is far more cost effective with a material cost that is about 1/10 that of Kryptonite. Secondly, and of equal importance, is that a smooth contour of the forehead augmentation is absolutely essential. It is often assumed that the thickness of the forehead and scalp tissues makes slight asymmetries or unevenness aesthetically tolerable, but this is only true when the augmentation is in the hair-bearing scalp. On the forehead, every irregularity will eventually be seen and most certainly felt when the swelling goes down and the overlying tissues adapt to the new forehead contour. With the current use if injectable Kryptonite, it is not possible to get as smooth of a result as that with an open PMMA frontal cranioplasty or forehead augmentation.
Dr. Barry Eppley
Indianapolis Indiana
Q: Dr Eppley, I am in need of help. I had upper and lower lip lift surgery about three months ago for my very thin lips. I am not happy with the result. It looked very off-center and cock-eyed from the beginning. I could see right after the surgery that it was not even or symmetric. My doctor told me that it was just swelling but I knew it wasn’t right. Now that the swelling has long gone down, it looks the same just not swollen. My doctor keep saying it will even out but I don’t see how this is possible. I think his drawings were off from the beginning. He didn’t measure anything and just eye-balled with a drawing pen. Can any type of revision improve the way the lips look? I have attached a picture for your review.
A: For the sake of proper terminology, you had a lip or vermiliona advancemeent, not a lip lift which is just a central upper lip procedure done from under the nose. Beyond those semantics, however, your picture shows unnatural-looking lips for a variety of reasons. This would include the following; upper and lower lip asymmetry due to the cupid’s bow of the upper lip being off center and the left lower lip vermilion being vertically shorter than the left, the peaks of the cupid’s bow are too sharp (pointed), the tail ends of the lower lip vermilion into the mouth corners tails off too sharply (not enough vermilion exposure) and the arch of the upper lip vermilion in mid-portion (between the corner of the mouth and the cupid’s bow) is a little too high. I believe the lips could be improved by making some vermilion and skin adjustments to all of these areas. This is precision work so precise markings with calipers under loupe magnification is essential. These lip advancement revisions could be done as an office procedure under local anesthesia.
Dr. Barry Eppley
Indianapolis Indiana
Q: I had a breast augmentation about 10 years ago. I felt that they were too big right after surgery but my doctor somehow convinced me to keep them at the time. I would them either downsized or completed removed with some type of lift done at the same time. My question is what are the chances of my insurance covering a breast reduction or at least part of it? Have you ever dealt with a situation like this?
A: The simple answer is that this is not a procedure that would be covered by one’s health insurance. While the breasts are being downsized, this does not constitute a medically necessary breast reduction as implants are being removed, not breast tissue. The premise of a true breast reduction is that there is too much breast tissue present and a certain amount must be taken out. A medically necessary procedure has at its origin a health or medical cause. Prior breast augmentation is a cosmetic cause not a medical one. Breast implant removal and any lift that may be associated with it to reshape the loose and sagging breast skin is a cosmetic procedure.
Dr. Barry Eppley
Indianapolis Indiana
Q: Dr. Eppley, about six months ago I had a medpor chin implant inserted through an intraoral incision and secured with screws. Unfortunately, the wings were too large and malpositioned. I had a revision one month ago in which the implant was removed, trimmed and re-inserted. Now the implant is the right shape and size, but my lower lip feels shorter and tighter. The top halves of my lower teeth show with the lip at rest, and I can barely raise it enough to cover them. When raised, the lip is lower in the center than at the sides. After the original surgery I had the same problem but not as bad, and the lip eventually went back to normal. This time the lip seems worse, and I’m worried it might stay this way. My Dr. said getting the medpor implant out was “very difficult” and it took twice as long as he expected. The implant actually broke when he took it out and he added 2 extra screws to hold it together when he re-inserted it. My chin and lower lip where very swollen for two weeks afterward and the center of the lip is still slightly numb. I’m worried I might have a problem with my mentalis muscle. Does my lip issue sound like something that will go back to normal on its own or like something that will require correction? Thanks for any advice.
A: In your history you have said the key words…intraoral incision. When using this approach for chin augmentation, the superior bone attachments of the mentalis muscle are cut and have to be resutured at the end of the procedure. Besides the numbness,, it is common to have some lower lip tightening and little tethering until the tissues heal and relax again. Going through the muscle twice, particularly in a more extensive revisional procedure, traumatizes and scars the muscle again…making symptoms of tethering and lower lip retraction more significant. It is too early to tell whether this problem is temporary or permanent. If it has not significantly improved by three months after surgery then I would recommend a mentalis muscle v-y lengthening and resuspension procedure.
Dr. Barry Eppley
Indianapolis Indiana
Q: Dr. Eppley, about six months ago I had a medpor chin implant inserted through an intraoral incision and secured with screws. Unfortunately, the wings were too large and malpositioned. I had a revision one month ago in which the implant was removed, trimmed and re-inserted. Now the implant is the right shape and size, but my lower lip feels shorter and tighter. The top halves of my lower teeth show with the lip at rest, and I can barely raise it enough to cover them. When raised, the lip is lower in the center than at the sides. After the original surgery I had the same problem but not as bad, and the lip eventually went back to normal. This time the lip seems worse, and I’m worried it might stay this way. My Dr. said getting the medpor implant out was “very difficult” and it took twice as long as he expected. The implant actually broke when he took it out and he added 2 extra screws to hold it together when he re-inserted it. My chin and lower lip where very swollen for two weeks afterward and the center of the lip is still slightly numb. I’m worried I might have a problem with my mentalis muscle. Does my lip issue sound like something that will go back to normal on its own or like something that will require correction? Thanks for any advice.
A: In your history you have said the key words…intraoral incision. When using this approach for chin augmentation, the superior bone attachments of the mentalis muscle are cut and have to be resutured at the end of the procedure. Besides the numbness,, it is common to have some lower lip tightening and little tethering until the tissues heal and relax again. Going through the muscle twice, particularly in a more extensive revisional procedure, traumatizes and scars the muscle again…making symptoms of tethering and lower lip retraction more significant. It is too early to tell whether this problem is temporary or permanent. If it has not significantly improved by three months after surgery then I would recommend a mentalis muscle v-y lengthening and resuspension procedure.
Dr. Barry Eppley
Indianapolis Indiana
Q: Dr. Eppley, I am interested in breast augmentation but am concerned about the possibility of bad scarring. As a small child I had chicken pox and developed many of the typical pustules. While they went on to heal, I developed keloid scars scattered across my body. Although I do not feel that I still scar this way, I am concerned that I might and these would look terrible in my breasts! Do you think it will happen from the breast augmentation incisions?
A: Having had a terrible scar situation at an early age, it is understandable why you would be concerned about it occurring again from an entirely elective cosmetic procedure. However, and fortunately, these are not comparable scar circumstances. Chicken pox scars are the result of secondary healing of open wounds. They have a high propensity of resulting in hypertrophic scars which appears as wide as the original wound and are heaped up higher than the surrounding skin. This is not a keloid scar (whose growth goes beyond the boundaries of the original wound edges and often keeps growing) with which hypertrophic scars are often confused. The incision from breast augmentation ,whether it is around the nipple, along the inframammary fold, or in the armpit, is a controlled narrow skin injury which heals by primary healing. Primary healing almost always results in much better scars than from secondary healing. I have never seen a wide hypertrophic scars from any breast augmentation incision. Therefore, I would have no fear about developing the type of scars from any breast augmentation incision that would remotely be close to your existing chicken pox scars.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dear Dr. Eppley , I had chin augmentation about two years ago with terino square chin imlpants, style 1. It looked for about two years but it has disappeared somewhat. I would like to know if it is possible to place another square chin implant, a Terino square chin implant style 2 on the top of the existing one and have it secureed with screws to add some more definition, squarnes and some more anterior projection. I think it makes sense to place the bigger one on the the top of the smaller and according to the dimensions on the Implantech website they would fit perfectly. Would you please express your opinion on this matter? I would greatly appreciate it.
A: In regards to your existing chin implant disappearing, that impression is likely a combination of two factors. Many patients after face and body augmentations suffer what I call ‘cosmetic accomodation’. They simply have gotten used to the look and it no longer looks as good or as big as it used to. Secondly, the implant may have suffered a little settling into the underlying bone of a fedw millimeters which is not uncommon particularly if the implant is not directly over the lowest edge of the basal bone. These two issues combined have likely resulted in your implant ‘disappearing’.
In regards to placing a style 2 directly over a style 1 silicone square chin implant, your assumptions fro a chin implant revision based on measurements are correct. There is a 10mm difference in the square width of the implants so a style 2 does fit rather nicely over a style 1. That would also add an additional 8mms of anterior projection as well. They would absolutely have to be secured with at least two screws placed on their lateral edges to prevent the shifting of one smooth surface against the other. The only contour concern is on the edge of the lateral wings where a more noticeable step-off may occur as the transition back to the bone will have a double-thick edge. I would advise the wings of the overlay implant to be trimmed and feathered about 10mms short of the underlying implant to avoid this problem.
Dr. Barry Eppley
Indianapolis Indiana
Q: Dr. Eppley, how much is the laser removal for scars for burns?
A: There are several problems with your request. There is no such thing as ‘scar removal’ by any method. Scars can be treated so that they may be less noticeable but there is no such thing as scar removal. Scars can only be improved but never are they able to be removed, hence the term ‘scar revision’. The treatment for burn scars is variable given the very diverse presentation of burn scars. It is fair to say that laser resurfacing is often the only option for many burn scars given the large surface area that many burns have. Whether that approach would even be worthwhile or effective would require a visual inspection of the scars. Until this is done, no reasonable assessment of potential effectiveness or cost can be given.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am going to have a breast augmentation done next month. I also wanted my right nipple to be lifted and brought up to the level of my left side. My doctor said that I didn’t need to have it done and that it would put a scar around my nipple and down the breast if I did it. In my reading of nipple lifts this doesn’t make sense to me. Why does my doctor say it can’t be done without a lot of scar and I have read that it can. Can you explain this to me?
A: In solving this discrepancy for you, there are numerous types of breast lift techniques. Which one is best for any particular patient depends on numerous factors including how much sagging the breast has (how low does the nipple hang) and how much scar can the patient tolerate. The most limited scar technique is that of a nipple lift, also known as a superior crescent mastopexy. By removing a small crescent of skin from the top of the nipple, the nipple position can be elevated about 1 cm. For very minor breast lifts with small amounts of sagging this may be all that is needed. I suspect this is what you have been reading about or are referring to. The next type of breast lifts are the circumareolar or donut lift (scar around the whole nipple) and the vertical breast lift. (scar around the nipple and down to the fold, the one to which your doctor is referring) Both of these will move the nipple up higher but with more scar.
Which type of breast lift you may need depends on the difference in the horizontal levels of your two breast nipples. Without knowing that information, I can not recommend what lifting method may be needed in your case.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hello Dr. Eppley, I was reading some of the information on your site about the use of Matristem (Acell) in scar revision. I was wondering if the several scars on my face from a previous auto accident, including a small raised scar (keloid?) would benefit by this treatment. In my readings I see that it has been used on fingertips and other body areas but it is not clear to me how useful it would be in the face. I really want to do something about these scars on my face and lessen their appearance. Thanks for your time in answering my question.
A: I think it is important to understand that Matristem, nor any known agent, has magical properties in either wound healing or in preventing scar formation. It should be perceived as a potential adjunctive material that can be incorporated into other scar revision strategies. Because it comes in powder form, it can easily be used in traditional open scar revisions done by excision with or without some type of geometric arrangement. Its benefit is that it encourages healing with less scar formation than may otherwise occur. Whether it would produce a better result (scar appearance) than scar revision alone is theoretical but appealing nonetheless. I have used it in numerous types of face and body scars and some open wound problems. Since it is has no known side effects or negative issues with its use, there are no drawbacks to adding it to the scar revision approach. When it comes to problematic scars, every available advantage is needed to get the best result.
Dr. Barry Eppley
Indianapolis, Indiana
The concept of non-surgical fat reduction has been around for over a century. From belt machine devices in the early 1900s to the infomercial weight loss supplements of today, hope is eternal when it comes to getting rid of unwanted fat. Without question, the definitive way to lose spot areas of fat is liposuction. Liposuction is a proven surgical method to trim down specific body areas, but it is an operation and involves recovery.
Non-surgical fat removal, no matter what the method, will never be as effective as surgery for spot reduction. However, newer non-surgical methods of fat melting have appeared in the past few years. One of these is Zerona, or specifically the Zerona laser treatment program. It is touted as a painless body slimming method that is proven to remove fat and inches without surgery with zero pain and downtime. Does it really work? Is it hype or hope?
Zerona works by using a low frequency ‘cold’ laser that passes through the skin without injury and targets the fat cells. The laser energy targets the fat cells through a photochemical process. Not to be confused with a photothermal (heat) or photoacoustic (vibration) method, this non-heat generating process makes the fat cells ‘leaky’. The fat cells shed their liquid fat content, now known as free-fatty acids, which is then absorbed through your lymphatic system. The lymphatic system transports it to the liver where it is processed and broken down, and most importantly, not re-circulated and stored again as fat.
Zerona is more than just a machine, it is a process. Treatment sessions number six to nine and have been shown to be able to take off three to five inches in the hips, waist and thigh in two to three weeks. But to aid the lymphatic clearing process, one must significantly increase their water intake and take a twice-daily niacin supplement (Curva) or HCG (human chorionic gonadotropin) during the treatment process. The treatment sessions require a commitment and must be done every two to three days to really be effective. Once the fat cells get leaky, you can’t let them heal themselves by missing treatments or having them too far apart. Each treatment session takes just under an hour and is painless. You literally get up and go afterwards. Daily exercise (such as brisk walking, light running, or other cardio training) can increase the final results by aiding in lymphatic clearance and an increased metabolism.
Is Zerona fat reduction too good to be true? It depends on your expectations and how much fat you have from the beginning. We do screen our patients and select those that we think, based on our experience, have the best chance for success. That has resulted in about a 70% satisfaction rating from our treated patients. This means that those patients saw enough of a difference, both visually and by measurements, that they rated the treatment a worthwhile investment. Thus, as part of a jumpstart on the front end of some body slimming or as part of an overall weight loss program, Zerona can make for very visible body changs.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dear Dr. Eppley, I would like to have those chiseled high cheekbones. I have looked at some implant styles online and it seems that the Medpor extended malar implant may work for me. The picture on the website product catalog shows the implant in a high and lateral position and the implant is described to augment the malar region. My surgeon told me that this kind of implant can only be placed under the cheekbone (submalar) and more towards the nose than towards the zygomatic arch and that the picture on this website shows the wrong placement of this implant design. I really don´t want submalar augmentation! Is it true that this implant design is actually a submalar implant and therefore not used for malar augmentation or can it be used for both malar and submalar augmentation? What is your experience with this kind of implant design?
A: Choosing the correct implant design and size is obviously critical for any type of facial implant procedure. This is particularly true in the cheek or malar region as this area has the most complex three-dimensional anatomy to it. It contains five zones of potential augmentation including anterior, lateral, oblique, orbital rim and submalar. Any cheek implant will affect at least three of these zones in any single design. For those interested in more ‘chiseled’ cheeks, by definition this means that the oblique and lateral zones are most important. The submalar zone should absolutely not be augmented as part of this type of cheek implant because it will create more of a rounded full cheek look rather than making higher and more ‘chiseled’ cheekbones. The type of cheek implant to which you refer will not help create the look you are after. That type of cheek implant design creates fullness on the lower or submalar cheek zone and will not achieve that higher angular cheek look.
Dr. Barry Eppley
Indianapolis, Indiana
