Your Questions
Your Questions
Q: Dr. Eppley, I am curious about nipple reduction. I am an athlete with only about 10-12% body fat but I have nipples that stick out. I have always been self-conscious about the kind of shirts I wear or even taking my shirt off. I would like more information on what is best for my situation.
A: When one is concerned about nipples that stick out, it is very important to differentiate between true nipple protrusion and areolar gynecomastia. Both can cause protrusion from the nipple area but they appear quite differently on close inspection anad are treated with different techniques.
The commonly called nipple is really better understood as the nipple-areolar complex. There is a central protruding nipple surrounded by a flat pigmented areola. In men, the nipples are smaller because the size (diameter) of the areola is very small. In nipple protrusion or hypertrophy, the small central nipple sticks out while the surrounding areola is flat. This makes for a small point that sticks out in shirts. It is treated by a simple nipple reduction done under local anesthesia in the office. Most of the nipple is removed so it lays flat and will never protrude again. In areolar gynecomastia, there is a mass of breast tissue that pushes out the whole nipple-areolar complex. This is better called a ‘puffy nipple’. It is treated by removing this mass of breast tissue through a small areolar incision. This is done as an outpatient procedure under IV sedation or general anesthesia.
Dr. Barry Eppley
Indianapolis Indiana
Q: Hello, I’m writing because I am in need of a tummy tuck. I have had four c-sections and I would like to know if I will be able to get a tummy tuck. I have a very large stomach pouch that I dislike and would like for it to be removed before I get too old. If not, it will be sitting in my lap. Will having these c-section scars interfere with having a tummy tuck? Can the entire stomach pouch be removed or can only some of it come off? Thanks for answering my questions!
A: The large stomach pouch to which you refer is a pannus, otherwise known as an apron of skin. (and fat) Between multiple children, c-sections and weight gain, the excessive abdominal skin and fat falls over the waistline. The scarred and indented c-section location accentuates this pannus by pulling in tightly underneath it. The solution to this pannus problem is a modification of a traditional tummy tuck known as an abdominal panniculectomy. It differs from the tummy tuck because the amount of tissue that is removed is larger. This makes for a longer low horizontal incision, often extending into the back area. The final result is often not as refined as that of a tummy tuck given the type of body on which it is performed. In its simplest form, an abdominal panniculectomy is an amputation of the pannus from along the waistline.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have previously had a tummy tuck and liposuction of my waistline and thighs last year. That went well and the results are really good. My remaining body issue is my lower legs. They are still so thick and they have no shape. I guess they are called ‘cankles’. I am embarrassed by them so I always wear pants. I wold love to be able to wear shorts and even a low hanging skirt. I have read that liposuction can be done for the lower legs. Do you think it will make enough of a difference? Will I be as satisfied with it as my tummy tuck and other liposuction?
A: Calf and ankle liposuction can be very gratifying and make a big difference in the shape (not the size) of the lower leg between the knees and the ankles. By selecting removing small fatty areas and making curves in the favorable silhouette areas of the inner knee, upper and lower calfs and ankles, the shape of the lower legs from the front can be made more pleasing. This is done with small cannulas and is really a form of liposculpture rather than volume reduction liposuction. The biggest issue with lower leg liposuction (cankle liposuction) is that there will be prolonged swelling in the lower leg. The changes may not even be apparent in the first few weeks after surgery adn your lower legs may even look fatter initially. It will take several months to really appreciate the final result. It always appears but it does take time. In my experience, patients have been happy with the results even though they do not end up with skinny legs, just more shapely thicker ones.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am interested in getting a complete mandibular implant and would like to know an approximate cost.
A: When people use the term, complete mandibular implant, their objective is to enhance along their jawline from the angles to the chin. To achieve that look, there are two different approaches. These different methods affect how the procedure is done and the cost. The first approach, and the most common, is to use three separate implants. This includes off-the-shelf chin and jaw angle implants placed through a submental and intraoral incisions. That total cost averages around $8500 to $9500. The other approach is a custom one-piece implant that is made off of a 3-D CT scan taken from the patient. It may or may not be put in as a one-piece implant but it is completely customized to the patient’s jaw anatomy and aesthetic desires. That total cost is in the range of about $15,000.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am interested in getting cheek implants as I think they would help my facial appearance. But I don’t really know if that is true. If it is, what type of cheek implant would be best? I know there are different types, like malar, submalar and shell styles, so which would be best for me? I have attached some pictures of my face for your opinion. Thanks and looking forward to your recommendations.
A: When looking at cheek augmentation, you must first determine whether and where any cheek bone (zygomatic or malar) deficiency exists. This requires looking for obvious bony deficiences of the midface, the relationship of the eye to the brow and cheek bones and the thickness of the overlying soft tissues. This must all be taken in context of the overall facial shape as well.
In looking at your face, you have a longer face that is fairly skeletonized. Your eyes do not have a lot of fat around them which makes them more deep-set. This is magnified by prominent brow bones and heavy eyebrow hair density. Your malar area shows good width but there is anterior malar and infraorbital rim deficiency. This is why your cheeks appear flat to you in a side or three-quarter view. When considering cheek implants, therefore, it is important that you avoid submalar and any malar implant that adds much zygomatic arch width. Augmenting these areas are not helpful to your face. Malar implants that add some anterior fullness along the suborbital groove and front end of the cheek is where your augmentation needs to be. This cold be done with either a modified malar shell implant or an extended tear trough style. Either way the volume should not be much greater than about 5mms. Too big of a cheek implant size will make the eyes even more deep-set or hollow in appearance.
Dr. Barry Eppley
Indianapolis Indiana
Q: Dr. Eppley, I had a rhinoplasty done three years of which I am very unhappy from the results. I am of Middle eastern ethnicity and initially had a big hump on my nose that I wanted to get rid of. I just wanted my nose to look more proportionate and not be so big. Right after ther surgery it did look better but as the swelling went down after a few months it didn’t look as good. While the hump is gone, my nose is now twisted and somewhat deformed. My breathing got worse after surgery too. It seem like it is getting worse with each passing year, is that possible? i have attached some pictures so you can see what I mean. I know I need a redo rhinoplasty but what do you recommend to make it better?
A: Your nose has some of the classic problems from an over-resected or radical reductive rhinoplasty. I suspect this was done through a closed technique and you may have initially had a large dorsal hump. Your nose shows middle vault collapse, indentations at the osseo-cartilaginous junctions, a pollybeak tip deformity and alar rim retraction. The upper nose deformity can happen when a large dorsal hump is taken down and the resultant open roof is closed with osteotomies that get infractured too far. This causes disruption of the upper lateral cartilages from the nasal bones creating an ‘hourglass’ deformity where the hump used to be. The middle vault constriction (pinched middle third of the nose) is the result of too much of the height of the upper lateral cartilages being removed causing collapse and possible breathing difficulties from pinching of the internal nasal valves. The tip deformity is marked by a hump in the supratip area and alar rim retraction with excessive nostril show. This occurs when too much cartilage is taken away and the tip is no longer supported. It then collapses and retracts so that the upper end of caudal end of the septum (septal angle) is now more prominent than the tip.
Your revisional rhinoplasty would be done through an open technique using spreader grafts for the middle vault, rasping of the dorsum, lowering of the lower end of the septal height, and columellar and alar rim grafts to the tip. In essence, cartilage support need to be put back into your nose to improve its appearance as well as your breathing.
Dr. Barry Eppley
Indianapolis Indiana
If you ever consider having plastic surgery, qualifying the doctor is an important first step. Are they the right doctor for you and what you need? Many magazine articles and other sources will give you a list of good questions to ask when you have an in-office consultation such as (1) are they board-certified, (2) how many years have them been in practice, and (3) how many procedures of your interest have they done?
While these are certainly good questions and the answers are extremely relevant, such questions today can be answered long before you ever pull into the parking lot of the doctor’s office. If you walk in with these types of questions for your consultation, you must not have a computer in your house or have never done a Google search. It is hard to imagine that such a person exists today, except maybe my 95 year-old grandmother.
While these were once good questions for prospective patients to ask during an office visit, they have gone the way of the bag phone. Such answers are relatively easy to find at the click of a mouse from home. Whether we as plastic surgeon’s like it or not, our websites and the information that they provide is a lot more relevant to patients than any number of diplomas hanging on the wall. If a plastic surgeon doesn’t have an up-to-date website that easily provides this basic information, patients will quickly move on to another surgeon that does. Today’s internet-based society makes it essential that these once basic qualifying questions are easily answered with minimal research effort.
With today’s electronic informational access, photo and video acquisition, and numerous locations for postings, contemporary plastic surgery qualifiers are different and more meaningful. Today, the more relevant checklist in finding the right plastic surgeon for your needs is procedure education, photographic examples and patient testimonials.
Traditional office print pieces, such as brochures and flyers, are historic methods of education in every plastic surgery practice. While they are still useful, so many are tempate-derived that they provide generic and virtually useless information…other than to say this service is provided. You want to know what this specific plastic surgeon does, not what most plastic surgeons do. This has spilled over now into websites as well. They all look pretty but what about their content? Is it meaningly and relevant to your needs? Look for brochure and website information that provides current and updated procedure information. This also suggests an interest in ongoing patient education which is most manifest in some type of website blog.
We have image overload everyday. Whether it is on Facebook or on your cell phone, we are surrounded by pictures. Plastic surgeons are without question the most advanced and proficient of all medical specialities in taking pictures. Therefore, patients should expect a good demonstration of a plastic surgeon’s most valued asset, their before and after patient photographs. While it is true that the best results will be posted, at the least you need to see a handful of actual patient before and after photographs. The more, the better.
Patient testimonials carry a lot of weight. Who doesn’t want to hear about a happy patient when you are considering going to that plastic surgery practice. But don’t just rely on what is posted, ask to talk to at least one patient who has had your similar procedure. But a patient who had surgery a long time ago is not as useful as one who has had surgery in the past weeks to months. Fresh experiences are what you need as these patients have the best recall of what it was like right after surgery.. Having a recent patient also suggests that the procedure is performed more than just a few times a year.
Dr. Barry Eppley
Indianapolis, Indiana
Liposuction is a very popular body contouring surgery largely because it works. It is an immediate method to remove certain areas of unwanted fat that you just haven’t been able to budge by your best efforts. With this fat removal method, may people expect to lose weight as well. It is no wonder many people think this when you see such advertisements such as ‘Lose 10 lbs In A Few Hours’ or ‘Get The Body You Always Wanted’. I have seen many such liposuction promotions in magazines and on the internet and it begs the question of aggressive advertising vs . medical fact.
Can you lose weight by liposuction? The simple answer is yes…in the short term. When advertisements promote how much weight is removed with liposuction, they are referring to what is suctioned out at the time of surgery. This is known as the fat aspirate and and is collected in a canister. It can be both measured in cubic centimeters or millimeters (always is) and weighed. (sometimes is) The weight of the aspirate can be closely approximated by its measured volume. Since a gallon of water weights 8 lbs and a gallon contains 2.2 liters (2200cc), then a liter (1000cc) of fat will approximately weigh 3 1/2lbs. Therefore if you have had liposuction surgery and had 2000ccs removed, for example, then you would have had a surgical weight loss of about 7lbs.
While this seems impressive, and one did have this 7lb weight loss in a hour or two, it is actually a bit misleading. The reason is that prior to the actual liposuction being done, a large amount of fluid is first put into the fat known as tumescent fluid. This is essential to liposuction to not only lessen the pain after surgery but, of equal importance, to reduce any bleeding that the procedure will cause. This fluid has both volume and weight and the actual fat aspirate will contain up to 1/3 of this by content. So the actual amount of fat removed and weight that has come off has to be toned down a bit. When you see large weight loss claims from liposuction, it is because large amounts of tumescent fluid have been initially placed….and then removed as well.
While liposuction may cause some weight loss immediately (surgical weight loss), a more significant drop may actually occur afterwards. In the healing phase for several weeks after surgery, most people are not motivated to eat normally. When combined with the increased caloric demands of healing, a metabolic weight loss often happens. This will usually equal the surgical weight loss by four to six weeks after surgery. So if 5lbs of fat aspirate has been removed during surgery, one can usually expect to be down 10lbs in another month or so. Whether one sustain this weight loss over time is affected by many factors, not the least of which is one’s lifestyle habits.
While liposuction and weight loss will be forever linked, one should view the association as incidental and a side benefit. Weight loss is not the reason to have liposuction…spot body contouring is. Some weight loss will happen for almost all patients. The amount varies on one’s body and how much fat was removed. Some view liposuction as a jump start method for their weight loss approach and, in the short term, that is what will happen.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was involved in a car accident in 2009 and sustained what is called a subcondylar jaw fracture. I was told by the doctors that it was not bad enough to fix so they let it heal without surgery. After a few months when I could open my jaw better, I noticed an obvious difference between the two sides of my jaw. My left jaw angle appears to have disappeared. It now makes my face appear crooked. I was wondering if some type of implant may help cover up this lost part of my jaw. What do you suggest?
A: When the neck of the jaw is broken, the thin connecting bone between the condylar head and the big ramus of the back part of the jaw, the vertical length or height of the jaw can shorten. A subcondylar fracture, if unrepaired, can make for a shorter posterior jaw height and apparent ‘loss’ of the distinctive jaw angle. This is because the jaw angle moves upward as the jaw height shortens. Provided that you have good jaw function and the only issue is a cosmetic one of the jaw angle, that could be camouflaged and made more symmetric by a jaw angle implant. It would be important that the right jaw angle implant be used. It needs to be one that doesn’t just widen the jaw angle (lateral augmentation) but rather provides a lengthening to the jaw angle. (inferolateral augmentation). These type of jaw angle implant can provide up to a centimeter of vertical length increase.
Dr. Barry Eppley
Indianapolis Indiana
Q: Hello Dr. Eppley, I am an Asian male and want to know if alar plasty can reduce the size my nostrils and reshape my nose? It kind of looks like Eddie Murphy as it is really flared. I want my nose to look like Justin Biebers nose , straight and pointed and not very flared. Can rhinoplasty make this happen?
A: When I hear these type of goals from a rhinoplasty, it brings me to a discussion of expectations and reality of what can be achieved from surgery. The simple answer to the question of whether you can have a nose like Justin Biebers is no. That is not surgically possible. Justin Biebers is Caucasian, you are Asian. The underlying anatomy of the nose stucture is different and, of equal importance, the overlying skin thickness and texture is not the same. This makes it impossible to achieve what is essentially transracial changes. Even if you were Caucasian, you still could not have his nose. Rhinoplasty can not make you look like someone else or give you someone else’s nose. Pictures of famous or other people faces are helpful, as they help to convey what one’s nose shape goals are, but they can not be surgically duplicated. One of the most challenging aspects of rhinoplasty surgery is to meet a patient’s expectations. When patients bring out celebrity or model photos to say what they want, it is always is a concern that their expectations may not be able to be realized.
Dr. Barry Eppley
Indianapolis Indiana
Q: I have a steep angle from the back of my jaw straight to the chin. It looks very odd to me although no one else seems to notice strangely enough. I know it is not very common in women but I think a jaw angle implant would work well to make this look better and give my face more balance in profile.
I also have issues with a very bad rhinoplasty as you will see in the attached pictures. If you could simulate a nice straight nose with a nice narrow tip and not so ‘turned up’ I would very much appreciate it Out of interest, is it possible to make the sides of the nostils narrower to give the appearance of a narrow nose or is that not really worth it?
Attached are a couple of pictures they are not great but I don’ t have any digital pics. Thanks for giving me an opinion.
A: As you surmised, on reviewing your pictures, you do have a high jaw angle and a steep mandibular plane. I have done some imaging which demonstrates the effect of a vertical lengthening jaw angle implant.
From a rhinoplasty standpoint, your nose shows a bulbous tip, a pinched middle vault and a still wide nasal bone area. The side view shows too much upturning of the nose and some nostril rim retraction. I have done some imaging with a rhinoplasty that includes nasal bone narrowing, middle vault spreader grafts, tip narrowing, tip derotation, alar rim grafting and nostril narrowing. This will give you a more balanced and narrow-appearing nose.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I would like to get a tummy tuck, but I scar really bad. Will the scar be just a bad as and noticeable? All the scars I have are big and bold and dark. I am Puerto Rican.
A: The issue of scar appearance after surgery due to hyperpigmentation (darkening of the scar) is always a potential issue in patients who have intermediate pigmentation. This captures those ethnic groups of Hispanic, Asian, and Middle Eastern descent. African-American patients, even though they have more pigment ironically do not pose the same level of scar hyperpigmentation risk. Not knowing what your other scars look like makes it impossible to compare how a tummy tuck scar may turn out to them. Scars can look ‘bad’ for numerous reasons such as how they were caused and whether they were surgically managed. At least in tummy tuck surgery, the scar that is created is caused by a gentle cutting and closure technique which is the ultimate form of controlled trauma. I had done many Hispanic tummy tucks and have not seen what I would consider a really bad scar. Nor have I heard of patient complaints about the scar. It may re slightly more noticeable than the tummy tuck scar in a Caucasian patient but I would not classify them as ‘bad’.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am interested in RZ Mandibular Angle Implants for cosmetic purposes – the smallest size. Approximately how much do they cost? Also, could Dr. Eppley do a consult via photographs or Skype?
A: The smallest size of the RZ Mandibular Angle implants adds 3mms in width (this can be shaved down even further during surgery) and about 10mms in vertical length. That is a good implant if one is interested in both vertical lengthening and an increase in jaw angle width. If not then one needs to go with a lateral augmentation jaw angle implant only. These are the two basic styles of this type of facial implant. Regardless of the jaw angle implant type, the general cost quote for all expenses is around $6500. I regularly perform Skype or phone consults and that can be arranged anytime. Please send some pictures for my assessment in advance of either a phone or Skype plastic surgery consult. Dr. Barry Eppley Indianapolis, Indiana
Q: Hi there. I tried to send a photo over for the 3d imaging but it didnt send unfortunately – said I hadn’t filled in all fields but they were all complete.Was after some advice really. I have had maxillofacial surgery because I had an under developed bottom jaw. This included a genioplasty too. However, since having the genioplasty my chin looks really long to me when I smile, especially from the side. My jaw bone is only a cm under my ear. Would jaw implants in this area improve the look of the length of chin do you think and widen the lower face a little?
A: When an osteoplastic or sliding genioplasty is done, the vertical dimension of the chin almost always increases. That is because as the chin is brought forward there is a natural tendency to open the ‘wedge’ of the osteotomy or it may be deliberately done to actually lengthen the chin as well. That is part of the presurgical planning. If a genioplasty is done with a mandibular advancement osteotomy (jaw brought forward) that may leave the posterior height and width of the mandible deficient. This would be evident by a steep mandibular plane angle between the bottom of the jaw angles and the bottom of the chin. In these cases, I have done jaw angle implants whose primary goal is to increase the vertical dimension of the jaw angles more so than adding width. Much jaw angle width is rarely needed in most females.
Dr. Barry Eppley
Indianapolis Indiana
Q: I have a keloid on both sides of my right earlobe and it was at the back before I’ve tried operation back in 2008. Last year I went back to the hospital and they told me they would have to cut my whole earlobe off and that’s when I asked them to discharge me. I now want to know if it could be fixed?
A: Keloids of the earlobe are common problems for certain ethnic groups as a reaction or problem from ear ring wear. I have seen it in both men and women and they come in all sizes. They usually do involve both sides of the earlobe eventually since they are the result of a piercing. When ear keloids become very large, it does appear that the earlobe would need to be completely amputated to get rid of it. In actuality this is not true. A keloid acts very much like a gauged earlobe. There is a central keloid expansion, as opposed to a metal gauge, and the earlobe around it expands and thins. This means there is always earlobe tissue to use that can reconstruct a new earlobe. It may be smaller than one’s original earlobe but an earlobe can always be made. The best approach is a modified wedge excision, tapering the outer aspect of the wedge down to preserve as much earlobe tissue as possible. This usually leaves more than enought tissue for earlobe reconstruction. It is also important to not leave behind any keloid tissue in the resection and to do some type recurrence prevention therapy with the surgery, whether it be serial steroid injections or immediate low dose radiation.
Dr. Barry Eppley
Indianapolis Indiana
Q: I have a quick question…I got liposuction last year and I recently had to have it touched up in March. I noticed these “indentions” on the side of my back so I googled to see if it is normal and I ran across your post on Explore Plastic Surgery. I was just wondering if you could tell me if my back looks normal or if it is something that I should be concerned about? I never noticed this before I had the surgery and it is driving me crazy now because I am not sure if it looks right. I really appreciate your time. Thank you!
A: What you have is linear indentations from the liposuction cannulas. That has created a groove or inward depression in this portion of your back. This is due to the amount of fat that has been removed in that one area compared to the surrounding back areas. This gives your upper back that V-shape look. It is not an issue of medical concern only one of aesthetic judgment. Whether this tapered look is considered aesthetically pleasing or not is a personal one. Some would consider that this aggressive liposuction has created an improved back contour. Others may feel that these indentations have created an undesired back contour.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am interested in getting bigger fuller breasts with cleavage. I have attached a front picture of my breasts for you to see what shape they are in. Do you think this is possible to achieve?
A: Thank you for sending your picture. There is no question that your breasts can be made bigger by implants. But certain features of your breasts and chest may temper some of your desired breast goals. In looking at your breasts, they have obvious deflated volume and a sagging condition known as pseudoptosis. This means that the skin on the underside of your breasts hangs over your lower breast crease but your nipple remains at or slightly above the breast fold. This condition creates a problem in using implants alone to get bigger breasts. Some form of a breast lift is needed so that you do not end up afterwards with breast tissue and a nipple that hangs off of the edge of the implant. Whether a nipple lift (superior crescent mastopexy) or a periareolar (donut) lift would be best can not be predicted based on the one picture that you have sent. The other issue is that you have very widely spaced breasts with a large gap between them. Breast implants can not be placed so that they will create cleavage on their own. You will always have a gap between any type of breast augmentation/lift and this can not be prevented. Bras make cleavage in augmented breast cases like yours.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had silicone chin, cheek and jaw implants placed.Within a month, the jaw implants and the chin implant had shifted. The right jaw angle implant actually shifted through the incision into my mouth.The doctor repositioned both implants in a revision surgery. I asked him about fixating the implants with screws, but he insisted that a stay suture would hold them. Despite the stay suture, this time the left implant shifted — through the incision and into my mouth. The right implant seemed to be fine. In a third surgery, the doctor repositioned the left implant, with a stay suture again. Lo and behold, I discovered this afternoon that the right jaw angle implant has again shifted through the incision. A tiny sliver of it is poking through sutures which I thought would have dissolved by now, but which have not. I would like to have both implants repositioned and fixed with a screw. Can you do this type of revision?
A: Thank you for sharing your story. I am very familiar with why you have had recurring problems and it is not a mystery as you undoubtably know. Smooth silicone jaw angle implants are easy to put in which is why many surgeons use them. But unless they are positioned properly down at the inferior border of the mandible and secured there by a screw, there is always the risk of extrusion. While many such placed silicone jaw angle implants do not migrate and extrude, it is not rare when it happens. I have seen numerous patients just in the past few years who have had an identical problem. I experienced it myself when I placed my first set of silicone jaw angle implants over ten years ago…and vowed never to go through the endless revisions again which always ended up with recurrent extrusion. There is nothing wrong with silicone jaw angle implants, and placing a screw in them is not easy, but the avoidance of an extrusion risk is well worth it.
Given that you may not have the opportunity to revise your jaw angle implants for months, I would strongly advise getting them out so the open wounds can heal. These openings cause the posterior mandibular vestibule to deepen and make less tissue available for a competent closure over any new implants that are placed which increases the infection risk in replacement surgery. This also allows the incision edges to heal and hold sutures better down the road.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am interested in getting chin and jaw angle implants. I would like the chin implant to be lengthened (to the most extent) and squared (to the most extent) being in the category of the latest style available on the market. The jawline height should be lengthened and widened to its proportionate maximum possibly by having a “wrap around” implant and/or separated combination of implants. Do the latest style chin implants stating the above written factors of width and length fit the “wrap around” implant or separate implants more accordantly? Thank You.
A: In answer to your questions about chin and jaw angle implants, here is the following dimensions:
Square Chin implant (Style 2 Terino), Implantech = 6.5mm anterior projection in the middle, 10mm projection on the square portion (transition corner) of the implant, 9cms long (4.5 cms back from the middle on each side)
or
RZ Extended Square Chin, Medpor = 7mm in anterior projection, 11mm projection on the square portion of the implant. Because of the central connector, the implant can be expanded and made more square which also allows for the creation of central cleft
RZ Mandibular Angle Implants, Medpor = 11mm width expansion, 10 mm vertical elongation
These three implants must be put together to create a ‘wraparound effect’ but there will be a depression between the two along the jawline because their edges are feathered where they come together. They were never made to be used to create a completely smooth wrap around jawline effect. What you may really be searching for is a custom one piece wrap-around jawline implant that can be made to almost any shape and dimension.
Dr. Barry Eppley
Indianapolis Indiana
Q: Dear Dr. Eppley, I wanted to send you my pictures to review. I had a childhood scar which I had revised in 1995 and the result was this elongated revision which I have not been too happy with. It has been about 16 years since then and I was hoping to find out if can have anything done to make it less visible. I am currently 30 years old and of Asian decent. If you have few minutes, I would appreciate your input on a few of the questions as it will help me be more knowledgeable.
1. I realize that the scar revision is replacing one scar with a less visible one. Would you consider the revision for this vertical midline scar to be GBLC, serial W-plasty or a simple vertical excision?
2. I know there may be a bandage or silicone gel sheet after the procedure. Any idea of how long I need to wear one and the down time in general?
3. Following the revision, would there be any additional resurfacing required? If so, would you recommend dermabrasion? And any idea of total number of follow-ups required?
A: Thank you for sending your pictures and reviwing your scar history. Your forehead is a relatively flat wide scar that runs vertically right down the middle of your forehead. In answer to your questions:
- As this scar runs completely perpendicular to the relaxed skin tension lines of the forehead, which run horizontal, any successful scar revision should nto be a straight line. Some form of irregular pattern needs to be used. Given that the scar is absolutely vertical, I would use a running or serial w-plasty type of scar revision.
- I would apply just some glued brown tapes for a week after the procedure over the sutures. Thereafter, one would apply a light antibiotic ointmnent for an additional week and then change to a topical scar gel. Scarguard is my preference.
- I suspect that some light laser resurfacing may be beneficial done once about 6 to 8 weeks after the procedure. That would depend on how the scar appears. Definitely not dermabrasion as that is too deep. With your Asian skin I would be very conservative with any type of scar treatments that use heat due to the risk of pigmentation changes.
Dr. Barry Eppley
Indianapolis Indiana
Q: Hi Dr. Eppley, I don’t like the look of my mouth. Can you help me to look like every other normal people and to make my mouth so that it isn;t so big. Because now I look like a monkey. I really don’t like my look and nobody else likes it either. Please send me a picture if you can do something about me. Big thanks!
A: Thank you for sending your pictures and stating your concerns. What you are referring to is known as macrostomia. This is where the horizontal length of the mouth, from one corner to the other, is too long or wide. Technically, the upper and lower lips are too long but it is where they join (called the commissures) where the mouth width is judged. By standard anthropometric measurements (created largely from Caucasian study populations), the width of the mouth should not exceed a vertical line drawn down from the pupil of the eyes. While this is a measurement it has to be taken in perspective of the patients overall facial aesthetics to determine if it is really abnormal or bothersome. It can seen in your one frontal photograph that your mouth corners extend beyond this area.
An excessively wide mouth can be horizontally shortened through a procedure known as a commissuroplasty or corner of mouth tuck. While this is more commonly used in the treatment of the reverse mouth problem, microstomia (too small a mouth), it can be used to make a wide mouth more narrow. While this could easily reduce your mouth width by 5 or 6mms a side (reducing total mouth width by a cm.), there is a trade-off of a fine line scar that goes a short distance in the skin outward from the corner of the mouth. One has to consider this scar trade-off carefully.
Dr. Barry Eppley
Indianapolis Indiana
Q: Dr. Eppley I am just wondering how I am able to fix the dent in my forehead above my brow bone? I want a more smoother look. How much would the procedure cost?
A: You are referring to the area above the brow ridges where you would like it to be more smooth and confluent as it goes upward into the upper forehead. That is a common request amongst females that I get. This involves adding material above the brow bone so that it creates a flatter, or even a convex shape, to the forehesad area. This has to be done through an open scalp (coronal incision) That cost for this type of frontal cranioplasty procedure is in the range of $8500. Several features influence the cost of the procedure including the type of material used for the cranioplasty procedure. (hydroxyapatite vs. kryptonite vs acrylic) This is an outpatient procedure that usually takes about 2 hours to complete. There would be some swelling of the eyes afterward as gravity pulls swelling downward. The trade-off for this forehead improvement is a permanent fine line scar in the hairline and some slight permanent numbness of the scalp near the incision line.
You may feel free to send me some pictures of your forehead for my assessment and your suitability for this procedure.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am requesting male masculinization including cheek and jaw implants. I want a “wrap around” jaw implant with a very good cleft in the chin portion.. I would like a widened, elongated and very distinctive jawline angle and very shapely square chin, preferably the most square chin implant. I would also like that fine line of distinction between the lower part of the jaw implant and the chin implant. A line that is located on the sides of the mouth maybe about an inch from the corners giving the jaw and chin a very strong look when implants are placed together. I’m hoping this can be accomplished by using a “wrap around” implant without too many additional implants. Can this be done and with what type of implants? I have attached some photos for you to see my jawline.
A: When it comes to your jaw, I understand what you want to achieve as far as jawline enhancement is concerned. While your jawline and chin is by no means weak, it appears you want it to be more pronounced. When it comes to doing a complete jawline enhancement or ‘wrap-around’ augmentation, there are two fundamental implant approaches. The first is to use three or a triple implant approach. This would be a chin and two jaw angle implants. The weakness or flaw to this approach is that the union of the wings of the chin implant and those of the front edges of the jaw angle implants is a weak contour area. It is never filled in as well as the chin and jaw angle prominences, particularly when the chin is more square in design and the jaw angle are more pronounced. The other approach is to make a custom jaw implant as a one-piece unit. (even though it may be put in as two separate halfs and combined in situ) This avoids the body of the mandible contour defect from the triple implant approach. Its one drawback is that this is a more expensive method as the custom implant has to be made off of a 3-D mandibular model prior to surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am interested in getting a revisional rhinoplasty but honestly this is a difficult decision. Overall I’m not eager to go through the whole process again. I’m trying to determine if my gain in appearance is worth putting myself through it again. I’m 43 years old now and somewhat concerned about my body healing as quickly or as well. As a side note, I am in good physical condition for my age as I do lots of exercise. I figure if I’m going to do anything more with respect to my appearance, now is the time. I may be having a bit of a mid-life crisis I suspect. I do have an appointment to see about Botox/filler/collagen and/or fraxel laser treatment in attempt to back-off the aging process which is now in full-swing.
A: It is always a difficult decision as to whether to revise a rhinoplasty or not. Having experienced the recovery once gives one pause to really assess the the benefit:risk ratio for round two. Given the fact that your rhinoplasty result may be very reasonable (no major complications or deformity) and you are shooting for a more advanced aesthetic outcome also makes one ponder it carefully. In the end, the appeal of the potential benefits has to outweigh the understandable disdain for the process to get there.
One potential advantage of a revisional rhinoplasty, besides that of the nose, is whether there are any other facial procedures that could be combined with it. These might include fat injections for fillers or any type of laser skin resurfacing. This is what I call an opportunity factor given that being in the operating room under anesthesia is a very rare occurrence.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting liposuction. I thought I would never even consider this but times have changed. My main concern is my hips. I’ve tried for years to lose this area. I am really having a problem finding clothes to fit me due to this problem. I usually have to buy a size bigger to accommodate my hips, which in turn causes the rest to not fit properly. So, my need is my hips. As most women go, I’m sure I could find other areas that I’d like done, but this is what I really need and I emphasize the need to get my hips done. This is just my personal desire and goal for myself. How well does liposuction work for hip reduction?
A: Usually when patients are referring to the hips, they means an area between the upper waistline and down to the outer thighs. (saddle bags) Whether this is just a small hip roll or a much larger area depends on whom is asking and their body type.That is an area that responds pretty well to liposuction and significant improvement can usually be obtained. Depending upon the size of the hip area, one can usually drop a clothes size which would work out well for you given how you have to buy your clothes now to accomodate your larger hips. The only real complication to hip or thigh liposuction is the potential for contour irregularities or dimpling. As this area often has some degree of cellulite in many women, making it perfectly smooth after surgery may not always be possible.
Dr. Barry Eppley
Indianapolis, Indiana
While women have always made up the majority of plastic surgery patients, the percentage of men is steadily increasing. More men today acknowledge what women have known all along…appearance does matter regardless of age.
While the goals are always the same, to look as good as one can, a man’s age influences why it matters. Younger men are motivated by optimal attractiveness or to correct features that they consider embarrassing. Older men are motivated by divorce, job competitiveness and countering the effects of time. The common procedures that men choose, not surprisingly, are also influenced by age. Droopy eyelid skin and neck wattles are the concerns of older men while the removal of excessive body fat and reshaping noses, ears and chins captivate younger men.
While age may make a difference in what plastic surgery procedures men desire, there is one characteristic that they all share. Men are less patient than women, particularly when it comes to appearance issues. This means that cosmetic treatments that require regular maintenance, like Botox and injectable fillers, are not that appealing. Men prefer more of an immediate fix like what surgery does. And men do not want a lot of recovery or downtime after surgery if possible. Discretion is paramount in male cosmetic surgery. While everyone knows that men having plastic surgery is not rare, the male patient does not really want to broadcast it.
One observation that has reverberated amongst plastic surgeons for decades is that men can be difficult to please and are less satisfied than women after surgery. They also are more prone to want revisional surgery. That has not been my experience…with the exception of the younger male patient. Facelifts and eyelid surgery in the middle to older-aged male gets good results and satisfaction is just as good as women. When it comes to structural changes in the face or body contouring surgery in the younger male patient, there is some definite truth to that belief. Younger men today grow up today playing with action figures, looking at men’s magazines and seeing great emphasis placed on exercise and sports which exposes them to more pressure to have a very masculine face and body. This makes managing the expectations from surgery in younger men extremely important.
One male quality that seems to be true…and most women will probably second it as well… is that many men are not very tolerant of pain. They are less comfortable with after surgery discomfort and that is to be expected as men have never endured pregnancy and child delivery. That gives women a decisive advantage in the early after effects of many plastic surgery procedures. This is not to say that men are not tough, just not as tough as women when it comes to appearance alteration.
Last year over one million men underwent some form of cosmetic alteration in the U.S. The stigma of men paying more attention to their appearance and grooming habits has changed alot in the past ten years. The beauty gap between men and women is closing to some degree as an increase in the desire of men to use their improved looks to remain competitive professionally and personally is on the rise.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley I am interested in revisional surgery. Over a year ago I had a rhinoplasty done. While there have been some improvements, there are numerous features about it of which I am not happy. I would like tip size reduced/refined to reduce the overall size. I might be intereted in some more narrowing of the bridge depending on upon complexity and down-time. I have attached some pictures for you to review of where I am now.
A: Thank you for sending your pictures. I can tell by the appearance of your nose and your description that you have had prior rhinoplasty surgery. Based on your desires, I see an upper third (bridge area) which can be further narrowed by osteotomies, an indentation of the right osteo-cartilaginous junction between the right nasal bone and right upper lateral cartilage, and a tip that is a little too wide and with a slight amount of over-projection. The nose has a fairly good dorsal profile and tip rotation. (nasolabial angle) These are features that you don’t want to change. For a revisional rhinoplasty, I would do low lateral narrowing osteotomies for the bridge small cartilage graft for the right upper middle vault indentation, and tip shortening and narrowing. This would be done through an open rhinoplasty which I assume is how your first rhinoplasty was done. I have attached come projected imaging. Since it has been over a year since your first rhinoplasty it is reasonable to critique the result and consider any revisional rhinoplasty at this time.
Dr. Barry Eppley
Indianapolis Indiana
Q: What is the cost of tummy liposuction?
A: This seemingly simple question is actually more complex that it appears. When people request liposuction of their stomachs, and its associated fees, they often are under a false perception that this is what will work for them. About half of the patients that I see for tummy liposuction do not need or do not get that procedure. Many actually need a tummy tuck due to their excess and loose tummy skin. But assuming that liposuction of the stomach is the right procedure, there are other variables that will affect the time and cost of performing the procedure. Does the whole stomach need to be done or just the lower half? Does the flanks or muffin tops along the waistline need to be done in addition to the stomach to get a better overall result? All of these affects both the results and cost of the liposuction procedure. This makes for a cost range of between $4000 to $5500 depending upon how much work needs to be done.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am interested in doing a ” Brow ridge reduction “, at least that is what I think it is. Also I would like a chin reduction. So my questions are; Are these types of surgeriess even possible? How far in advance do I have to schedule them? Have you ever done similar work to this? I have attached some pictures for you to see what I mean. Sorry as they are not the best quality.
A: Thank you for sending your pictures. Your requests for brow bone and chin reduction surgery is not uncommon and these are established procedures. I am very familiar with doing them and get requests for them all the time. Brow bone reduction (technically frontal sinus reduction since the brow bones are largely sinus cavities not solid bone) is done through a scalp incision. The outer table of the frontal sinus is removed and set back which makes the brow bone less prominent. It is a very effective surgery and the only significant issue in men (which are by far those who request the procedure) is the need for a scalp incision and the resultant fine line scar in the scalp to access the forehead and brow areas. Chin reduction surgery is done different ways based on which dimension of the chin one wants to shorten. If it is a vertical chin shortening that is done by an intraoral osteotomy and bony wedge resection. If both a horizontal and a vertical chin reduction is needed that is usually done by a submental (under the chin) incisional approach and the bone is burred down and the soft tissues shortened and tightened to the smaller bone.
This will give you a general overview of your requests. Both surgeries are possible and are part of cosmetic craniofacial reshaping surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hi, I have one very prominent ear that is a big source of embarrassment for me. I am fifteen and this is a huge deal for me. I would love to get this fixed but I am worried about cost.
A: First, it is important to know that I, nor any plastic surgeon, can communicate or have any medical discussion with a minor. It is critical that all minors have parental consent before any discussion can be done even by e-mail. An e-mail communication is no different than an office visit when it comes to providing medical advice to any patient. This can be done by having your parents fill out a form and return it to us so that we have confirmation of their knowledge of any future medical communications between my office and you. This issue would eventually be crossed at some point if surgery ever becomes a reality, not only for consent for the operation but for payment as well.
Indianapolis, Indiana
