Your Questions
Your Questions
Q: Dr. Eppley, I wanted to know if the doctor preforms a surgery to fix a deformity of the ribcage like barrel shaped ribcage thanks I’m willing to go for a very aggressive risky approach as long as it provides a real change im tired of living with this deformity its impacting my quality of life in every single way my hurts from hunching it all the time trying to hide my protruding barrel chest it’s just unacceptable and very unappealing.
A:In the barrel chest deformity it would be necessary to do rib reduction osteotomies at multiple levels probably from rib # 5 down through #9. The question is not whether this can be done but how effective would be in doing so. To my knowledge no one has ever performed such a procedure before so knowing how effective it would be remains speculative. The unknown variable in removing lateral rib segment at this level of the rib cage is how much flexibility of the ribs exist, in other words can you close down the resected rib ends and put them back together and , if so, how large of a rib segment can be safely removed. I know from doing rib reduction osteotomies at rib #9 that at least one cm of rib bone can be removed and the two ends plated it back together. But does the same rib flexibility exist as you go higher up on the ribcage? For now we can only speculate that it does but until the surgery is attempted no one can answer that question with certainty.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley,I am considering facial contouring procedures and wanted to ask specifically about reducing the width of my face. Would it be possible for you to let me know if decreasing my face width is feasible in my case, and if so, by approximately how many millimeters it can realistically be reduced? I am planning to do around 5mm on each side, and I would like both bitemporal and bizygomatic length be reduced. Also, I would like to ask if buccal fat removal, alarplasty, epicanthoplasty+lateral canthoplasty, and lip lift/philtrum reduction can be done altogether in one surgery
A: Thank you for your inquiry and sending your pictures to which I can make the following comments:
1) in terms of bony facial width reduction, otherwise known as cheekbone reduction osteotomies, you certainly can get 5 mm per side of bizygomatic width reduction. When it comes to bitemporal width reduction that answer depends on whether you are referring to anterior or posterior temporal reductions. Most likely based on your desire for a facial with reduction you are referring to the anterior muscle compartment. Of that you cannot really reduce that area particularly above the zygomatic arch. There is no good method of anterior temporal muscle reduction particularly closer down to the level of the bony zygomatic arch we’re the greatest thickness of the muscle exists.
2) it is common for buccal lipectomies, nostril narrowing, lateral canthoplasties/epicanthoplasties and subnasal lip lifts to be performed in a single surgery.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I want to reduce he “vertical height” of the anterior nasal spine, which is what I was asking if could be reduced/shaved from the bottom. This would help reduce the total nose height of the face.However, this might reduce the bone support for the Nasal Columella. To which I proposed if, a bone graft or cartilage could be used on the top of the anterior nasal spine, hence increasing its vertical length again but this time on the top. And then a rhinoplasty is performed. In this way, theoretically, the nasal height was changed but the bone support and the nose shape etc are still ideal. This surgery also in turn could help us in improving other craniofacial measurements like the length of midface (this theoretical reduction of nose height will increase philtrum height which we can again decrease with a lip lift thus reducing the midface length).
I just wanted you to ask you if this is possibly even THEORETICALLY, I’m aware that no surgeons have ever done it officially.
A:Thank you for your clarification on your surgical objectives. I don’t think the question is whether such an operation can be technically done as it is fairly straightforward as you have illustrated despite the fact that it probably has never been done in exactly the way you have described. My concern would not be whether it can technically be performed but whether in so doing the aesthetic outcome is exactly what you think it may be. The problem is you’re making a lot of assumptions about the aesthetic outcome based on drawing on a skeletal model. That is often a flawed concept as what happens at the bone level does not always translate to the outward aesthetic effect. One major consideration is that if the objective is to reduce mid facial length that is simply never going to happen no matter what you do at the bone level. Everyone fails to factor in to what happens to all the overlying soft tissue no matter what you do to the bone… It does not go away and thus external mid facial length is never really changed. The only effective mid facial length reducing procedures are sub nasal lip lift and reductive rhinoplasties that are associated with increased tip rotation. Nothing you can do at the bone level is ever going to decrease external midfacial length.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I had a genioplasty last year and then a revision earlier this year. I developed a deep mentolabial surcus that I never had before in my life. I’m so unhappy with the look of this sulcus or crease and I think it looks so masculine. I just hate how my chin looks in general. I think my chin looks unrefined and like a block. I think I was expecting it to look like an implant with a more elegant curvature and definition. Is there anything that can be done about A) the sulcus. Would it be possible to soften it? I also have developed chin ptosis and it looks just awful when I smile or talk. How is that treated permanently? Can a lower facelift get rid of all of that sagginess? Is it possible to surgically remove the extra soft tissue that has formed. I really appreciate your advice
A:Based on your postoperative pictures, and I have no idea what you look like before the surgery, this looks like a perfectly normal postoperative result from a sliding genioplasty. I don’t find the labiomental sulcus to be particularly deep and I don’t see any way to take that sulcus and make it less deep. As a general rule and a sliding genioplasty the shape of the chin from the front view usually gets a little bit more narrow but not wider. I suspect what you do not like about this result is that you probably were seeking a more V-shaped chin which could only really have ever been achieved by a V shaped chin implant that does not have any wings. While I obviously have no knowledge about your preoperative discussion with your surgeon but based upon this outcome and your issues with it this was simply not the best chin procedure for you given what your chin shape goals were. A sliding genioplasty is usually not a good choice when one wants a very controlled shape to the chin.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I wanted to inform myself about what you can do aesthetically to a skull. I am a 28-year-old man. I was born with a broad skull, or in medical terms, brachycephaly. My question is: what can I do about this later in life? I would like to have surgery. The reason is that this condition weighs heavily on my mental well-being. I don’t go out much anymore because I’m so insecure about it. I used to be able to partially hide this with long hair, but I started losing my hair a year ago, and it’s no longer hideble. My head is spread out to the sides and my head is flattened at the back Attached is a photo of what my skull looks like. I hope to hear from you. Thank you in advance!
A:Thank you for your inquiry and sending your pictures. You have a classic case of aesthetic brachycephaly with a flattened back of the head with a widened parietal – temporal sides of the head. The most practical procedures for improvement would be a custom scholar implant for the back of the head and reduction of the sides through a temporal reduction procedure. Ideally you would like to reduce the temporal– parietal bony eminences as well but I don’t think that aesthetically justifies a vertical incision over that area. The temporal reduction procedure is essentially scarless within an incision on the back of the ear in the crease.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, So my actual face is like the attached pictures.But I desire a look similar to this picture
My bite is perfect I just need the change for aesthetic purposes.. Do you think Bimax is the best solution or implants?
A:Based on your face now and your desired goals double tall surgery with absolutely not be the correct procedure. Your most major skeletal deficiency is in a very short chin with indistinct Jaw angles. That is best addressed by a sliding genioplasty combined with a wraparound custom jawline implant. Your chin deficiency is significant and is probably in the 12 to 14 mm range she’s beyond what an implant alone should do. The jawline behind it however can only be augmented with implants. Therefore you combine the two concepts into a sliding geniopolasty with the custom jawline implant that blends into it and creates a total overall jaw augmentation effect.
Your mid face only lacks some cheekbone prominence well the rest of it has adequate horizontal projection. Therefore this can only be addressed by an implant approach.
As you have already stated your bike is perfect and your concerns and not functional.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I am interested in getting implants for my very flat butt. I have attached pictures so you see what I mean?
A:Thank you for sending your pictures. You have a buttock shape that poses significant challenges for improvement. You have a very long buttocks with a low infragluteal crease but a flat shape. This cannot be treated by implants alone as implants only affect the top to middle portion of the buttocks and not the lower third. In the long buttocks patient with a very low infragluteal crease a lower buttock lift/tuck is initially needed to shorten it’s vertical length and provide a better demarcation between the buttocks in the posterior thighs. Buttock implants can then be done secondarily and will look better.. I have combined these two procedures in the past but inevitably it results in undesirable infragluteal scarring and I have learned that it is best to stage it in the vertically long and flat buttock patient.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I hope you’re doing well. A year later after the occipital skull reduction procedure I’ve finally shaved my head and I’m fully satisfied with the results – however, there is a persistent discolored red splotch of skin surrounding the left side of the incision scar – at first I thought I just irritated the skin shaving it, but it hasn’t gone away. Do you know what it could be and if so, is there anything I can do about it?
A:Thank you for the long term follow-up which is now over one year from your occipital skull reduction. In looking at your picture the actual scar line is so minimal that it really cannot even be seen. There is, as you have pointed out, and overall reddish discoloration to some of the surrounding scalp skin. This is not really part of the scar per se but is some generalized scalp skin vascular dilatation. That is not a postoperative phenomenon that I have ever seen before or has been reported to me before from any type of scalp incision from skull reshaping surgery. Despite its rarity the treatment of it is not rare. Such vascular skin issues are typically treated with a tunable or pulse dye laser adjusted for the wavelength and color of the lesion to be treated. Such tunable wavelength lasers have been around for over 30 years and their initial introduction of use in the 1990s was for a more severe type of vascular anomaly, the port wine stain. Whether it be a port wine stain, telangiectasias for a generalized vascular rash this type of laser treatment can be very effective at reduction of the color.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I have a question pertaining to facial implants and specifically medpor cheek implants, if someone were to have these types of cheek implants, can they then have fat grafting on top?
A: Yes, provided the injector knows they are there and doesn’t inject into them.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, Hello, I am considering undergoing mouth widening surgery sometime within the next year, along with some other procedures. I would like to know how much scarring to expect and the probability that I will need scar revision surgery.
A:It is always wise in a procedure like mouth widening surgery to be aware of the scar and that potential need For scar revision surgery. I talk about it all the time because the corner of the mouth is a particularly challenging area for scars due the intersection of the upper and lower lips. This results in stretching of these lip corners that results from mouth opening particularly when that corner is expanded as in mouth widening surgery. It is also important to remember this is not just one surgery but there are two separate mouth corners which really makes it a bilateral or double procedure. This elevates any potential risk for adverse scarring x 2. Invariably when there is a scar issue it is almost always on just one side and the other side is acceptable.
That being said having done many mouth widening surgeries the actual number of patients who request or go through scar revisions is relatively low. Butt low should never be misconstrued as never can happen as that is the risk of the surgery. Attached is a representative example of a mouth corner scar in which the patient had no concerns.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I came across your name while researching online. I am living with multiple familial lipomatosis. My lipomas started appearing about ten years ago, and their number and size have gradually increased over the years. The largest and most bothersome ones are located on my thighs.I am currently followed by my general practitioner, but according to him, there is nothing to be done as this condition is benign.
It is becoming increasingly difficult for me to live with this condition and carry out daily activities. I read that you offer solutions such as SmartLipo or other less invasive methods than conventional surgery to remove or reduce the size of lipomas. If you can help me with this condition, or refer me to a plastic surgeon in Canada who could perform the same type of procedure, I will pay for your services and advice.
Thank you, and have a great day.
A:Thank you for your inquiry and describing your lipoma condition. Having treated numerous familial lipomatosis patients it is a symptomatic approach rather than a cure. In most cases you try to do as many as you can, in which I have done up to 100 lipomas excisions in a single patient. While non-excisional methods may be used in the patient with discreet lipomas whose primary goal just to avoid scar this is not an approach that I will use in the familial lipomatosis patient. There are simply too many of them and such non excisional approaches leave behind some of the fatty tumor and most importantly, its vascular pedicle, which only means the risk of recurrence is high. Well I never like to place multiple small scars in a single area the familial lipomatosis patient is a lot more accepting of such scars given their condition.
This type of excisional surgery is tedious and I am not as enthusiastic about doing it as I have done in the past. But I need to take a look at the assignment to see how extensive it is. Since the most problematic ones are on your thighs please send me some pictures of your thighs at your convenience for my consideration.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, My goal would be to fill in my undereye to a natural degree after getting cheek implants.? My eyes are very hollow so I happy with my cheeks that I have now have volume there. My surgeon said that the cheek went up to my under eyes and should fill it, which was the main reason I did it, but I’m still hollow. My surgeon said he could fill it in other ways at three months post op, but I tried filler years ago and it didn’t do much to fix the hollowness.
A: Thank you for sending your pictures. It is important to realize that with the use of standard cheek implants they are not going to provide any infraorbital or under eye augmentation. In the patient who has under eye hollowing who gets cheek implants it is going to magnify the existing under eye hollowing by virtue of augmentation around and below it leaving the under eye hollowing behind so to speak. Infraorbital augmentation can certainly be done with indwelling cheek implants in place. This requires a custom infraorbital implant design to both augment the infraorbital area as well as to blend over and merge with the existing cheek implants which will be seen in a 3-D CT scan which is necessary for the implant designs.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley,I came across your webpage on temporal width and zygoma reduction surgeries and had 4 questions about these procedures.
I am looking to reduce my bizygomatic width as well as the width of my face above the zygomatic arches, and saw that you previously wrote 7.5mm per side maximum can be reduced in the zygomatic arches so I was wondering what might affect this maximum between individual skulls, since I am concerned that in my case it may not be possible to achieve the reduction in width I want (roughly 7-8mm both sides) as well as if moving the arches inwards too much would cause issues with the temporalis or masseter muscles below.
I was also wondering with regard to the temporal width surgery, if you ever reduce the bone underneath, since my temporal fossa bulges more in comparison to the typical flat shape (I attached an image from my CT scan to demonstrate this), as well as if you are limited to reducing the posterior part of the temporalis.
A:In answer to your questions about facial with reduction:
1) I have yet to see any impingement on the temporal muscle from cheekbone reduction osteotomies no matter how much it is moved inward. I suspect this is due to the overlying fascia of the temporal muscle. The bone can be pushed inward as far as being up against the fascia but it can move no further. The temporal muscle lies inside the fascia, as a gliding muscle, is therefore not impinged. This is very different from zygomatic arch fractures in which the sharp end of the fractured bone penetrates the temporal fascia and induces muscle pain and the potential for mobility restrictions.
2) the facial/head width reduction surgery almost never is the temporal bone reduced. This is for one main reason and that is of access. Short of a bicoronal scalp incision there is no way to easily access the bone to do so. So even if one may benefit from temporal bone reduction the trade-off would be the fine line scalp scar from ear to ear across the top of the head. The scar issue aside coming from above would certainly maximize the movement of the zygomatic arch inward, perform some reduction of the thickness f the temporal muscle as well as reduce the thickness of the temporal bone.
In summary the scarless technique, coming externally with arch osteotomies and some muscle reduction, may achieve your desired results but let’s assume that while improved it cannot reach your ideal goal. Conversely the coronal scalp approach maximizes what is obtainable and would be much more likely to hit your ideal aesthetic target. In the end it comes down to how much effort are you willing to put in for what type of aesthetic outcome.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, My nerve was damaged in my shoulder and killed my front deltoid muscles. I would like to get this to match my other shoulder.
A:Thank you for your inquiry and sending your picture. What you have is a classic example of deltoid muscle atrophy due to a motor nerve injury. It appears based on this one picture that only two of the heads of the deltoid muscle or involved (anterior and central) and that the posterior deltoid muscle head may have been spared. This is why you referred to it as the ‘front’ deltoid muscle.
That being said an implant would be the only way to restore as much as possible the volume from the lost muscle. Such implants can be designed several ways but the most common method, given your geographic separation, is by having you take measurements of its length and width from which I can make the computer design for the implant.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I am scheduled to have clavicle lengthening surgery next month. I wanted to ask about the possibility of permanent loss of motion and function in my arms. An orthopedic surgeon friend recently warned us against this surgery, stating “this does not ‘simply make your shoulders wider’–it permanently rotates your shoulders into an abnormal position and you will loose motion and function.
A:Thank you for your question. In my experience that statement by the orthopedic surgeon is unfounded. That might be true if the clavicles were significantly lengthened by many inches per side, which I doubt that would happen even then, but that is not the amount of lengthening which can be done. I don’t know the basis of the orthopedic surgeon’s statement but unless he has done the actual surgery and seen that happen that is a conjecture and not a documented outcome.
Rather than that expressed concern the real potential complications of the surgery are nonunion of the lengthened bone, hardware loosening, and secondary surgery for these potential problems. Clavicle lengthening is very different from clavicle reduction due to the limitations the soft tissues of the shoulder. Thus the gains to be had, with a low risk of potential complications, is not to try to do too much lengthening. This means keeping the lengthening per side 2 cm or less based on how much the soft tissues of the shoulder will allow the bone to be lengthened. I suspect the basis of the orthopedic surgeon’s comments come from the belief that much more clavicle lengthening can be accomplished then what can actually be done.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley ,Hello! I have tear trough implants that are not the same size. I was wondering if there was a way to have these implants removed and replaced with cheek implants.
A:The tear trough implants that you have are undoubtably made of silicon which makes their removal fairly straightforward. They can be removed by the same pathway in which they were placed. It is possible if they were sutured into place and not screwed into place that they can be removed intraorally. This would be compatible with your stated desire of cheek implants replacements in which most standard cheek implants are done intraorally. However if it is a custom infraorbital-malar implant, which is a typical midface augmentation area for men, it would need to be done through the lower eyelid which is probably how was your original teardrop implants replaced.
These are some general comments in regards to your questions but more specifics as they apply to your exact aesthetic midface needs requires a picture of analysis and further discussion.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, Hello, I have a jaw contouring/ jaw reshaping concern. My right side lower jaw is bigger and draws the right side of my face downward. This is clear when seeing my lips, as the right side of the lips are pulled in a downward angle. It’s fairly clear to me that the right-side lower-jaw is overly large and extends excessively downward. Please let me know your thoughts!
A:As you have correctly surmised your jaw asymmetry is due to the right side being lower. This is a very typical form of Joel asymmetry and, for whatever reason it is usually the right side which is lower. The only effective treatment is an inferior border shave on the right side. This requires some x-rays for proper planning. At the least a Panorex X-ray will clearly show how much lower the right side is from the left as well as the location of the nerve as it runs through the lower jaw. This is known as the inferior alveolar nerve which supplies the feeling to the lower lip and teeth. This runs directly through the bone in the middle of the lower jaw and exits anteriorly through the mental foramen. Usually when the Joel is lower so is the nerve in the bone and we have to know exactly where that is to avoid injuring it in any type of bone removal. Most likely given where your jaw overgrowth is the nerve is probably got a safe distance away. But it is obviously important to know rather than to guess.
That issue aside the more relevant issue is the approach needed to remove the jawbone. The Jolla angle poses considerable technical challenges for proper access. Since what is needed is a specific linear cut of bone from the back of the jawline forward to the point where it matches better to the opposite side the only way to do that is an external approach. This requires an incision at the back end of the jaw angle. The alternative is an intraoral approach but this places the bone cut at an odd angle, a nonlinear cut, and it is very hard to be exactly specific as to the resultant bone shape that is created. It creates a curved shape unless the bone cut is placed very high which would then make your right side higher than the left and just cause the reverse problem.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I’m interested in paranasal implants. My goal is to normalize the central part of my face having an aesthetic outcome.
A:Thank you for sending your pictures. I would need to know exactly what you are hoping that paranasal implants can improve or resolve. When one says normalize the central part of my face that suggests to me to provide some additional projection around the lower central mid face which paranasal implants can certainly do. If the goal is to sit softener significantly reduce the presence of the nasolabial folds in that regard I would not be as optimistic in terms of the effects.
That being said, provided the primary goal is increased projection for undergoing the procedure, is whether one should use standard or custom implants. That decision requires a more in-depth conversation.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I need to know if taking bisphosphonates (alendronic acid, specifically) would be a problem when it comes to getting an otoplasty done, even if it’s just an upper ear setback via sulcus reduction, as well as a head width reduction procedure, whether it be by removing muscle or bone.
A:Biphosphanates potentially affects bone healing from surgery not cartilage (otoplasty) or muscle tissue (temporal reduction).
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I was thinking of having a facial augmentation, which would include the zygomas and the chin. I tried to make some implants to get an idea of what the result might look like. What does the doctor think of the ones I made. Could the design and thickness be like this.
The goal is to have more projection and width of the lower midface; I would like to know if the doctor could digitally place the implants I have designed onto my skeletal scan/model.
Or better I have already made a physical project of the implants on a skeletal model. What I need now is for this project to be transferred into a digital format, like a 3D simulation, so it can be used for further development of the implants.
So that I can see the project in a professional and more clear way.
A:What your pictures demonstrate is how I used to make custom facial implants prior to 2010. Back then I made the implant design using plaster or wax on the patient’s 3-D skeletal model. Since 2010 this method has become obsolete since I now design implants by computer design on their 3-D CT scan.
But regardless of the method used to obtain any implant design there is no method to determine exactly what the external facial effect will be… which I believe is what you’re asking. That is as of yet an impossibility with any accuracy. Whether it is the old method or the new method custom facial implant designing is done to make the best guess of what the result may be. The basis for any implant design should be morphed pictures of the patients before and after desired result… at least then the implants are designed based on a specific target. What it appears you have done is make an implant design and ask what aesthetic effect it would have. Besides being an impossible question to answer, as I have already stated, this approach is doing it backwards. The implant design should be based on a known target which is the patients morphed desired outcome.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, A year ago, I had Medpor infraorbital implants placed to correct hollowing under my eyes. Unfortunately, I feel that the implants were not well suited – my facial proportions have changed, and the implants are visible beneath the thin skin of the lower eyelids. I have also noticed a deepening of the nasolabial folds, which I suspect may be related to their position being too close to the inner corners of the orbits.
Later, I underwent a temporal lift intended to cover the implants with soft tissue, but it did not bring the expected results – the implants are still visible. Another maxillofacial surgeon suggested that the best solution would be to remove the implants through an intraoral approach, the same way they were originally inserted. After the implant surgery, I also experienced prolonged swelling in the nasolabial fold area, which still concerns me.
I would like to know, after reviewing the photos of my face, whether the best solution in my case would be complete removal of the implants, or possibly replacing them with a different type positioned more laterally – in the zygomatic area. I am also concerned about the removal procedure itself, although I understand that it is performed in another tissue layer and should not lead to skin loosening.
It is very important to me to receive professional guidance, and I am considering entrusting this procedure to you, given your experience with similar cases. I am attaching photos taken before the surgery as well as recent ones, along with CT scan images (unfortunately, the implants are not visible there). In two weeks, I will also have an MRI done, and I would be glad to send you those results for additional assessment.
Thank you very much for your time and opinion.
A:Thank you for your inquiry and sending all of your pictures. I have seen this problem many times and it typically occurs with the more bulky Medpor or PEEK implants because they are machined and do not have fine edges or contours. I don’t know whether these are standard and custom Medpor implants but the issue is the same as you have already correctly surmised… they are not well fitted for your face. The lower eyelid is a very unforgiving area due to the thin tissues and it doesn’t take much implant excess to have them appear as they do in you. You are, however, incorrect about the reason deepening of the nasolabial folds. It has nothing to do with implant location but in rigid Medpor implants it takes extended soft tissue tissue detachments for them to be placed. The need to detach all of the surrounding tissues has resulted in heir subsequent soft tissue descent resulting in the now more apparent nasolabial folds.
The concept of performing a temporal lift to provide more soft tissue cover over the implants was a flawed concept from the beginning…it never had any chance to be successful. The problem lies in the implant shape and design not the lack of adequate soft tissue cover.
When it comes for how to move forward there too obvious options. First there is complete removal of the implants which would solve the protruding appearance of them but I would have concerns that there will be more significant hollowing then you had initially. There undoubtably was a reason they were put in, which I assume was due to undereye hollowing, and that problem will likely be worse due to the trauma to the tissues as well as the stretch and detachment of them. A good rule to remember about implants placed anywhere in the face and body is that once removed one never returns completely back to what it was before they placed. I do not know where your concept comes from for implant removal as it is performed in the exact tissue layer in which they were placed and it will definitely lead to more skin loosening due to the expanded stretch of the tissues. The question is not whether there will be more skin loosing but only how significant it may or may not be
The second option would be to have better design and implants with improved contours and edging. Ideally it would be helpful to see the implants on a 3-D CT scan as then a custom design could be made using that information… As the old motto in facial implants goes…. when you know why something doesn’t work you know how to make it work better the second time. In other words if you could see the implants you have in place it would be easy to design something better to solve the current problems you have. However the Medpor implant material can simply not be seen on a CT or MRI imaging from a 3-D viewpoint which is the only information that would be helpful. I would not waste the effort on getting an MRI. I do not understand why that would be ordered or what is to be gained by getting it.
The most important imformation would be o know exactly the Implants that are in you which would be obtained from your surgeon by the operative note and/or a record of the implant style and size. The operative record is usually the most helpful.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I had a bimaxillary osteotomy to fix my bite 2 years ago. My bite is now fixed and both jaws have been moved forward and up but I feel like my midface is still pretty flat. The screws in my upper jaw have been removed already. (photo is older) Is there a possibility to add volume only under my nose to lift the base of my nose and around it?
A: It is quite common to have some residual midface projection issues after an isolated LeFort I osteotomy or double jaw surgery advancement. In these instances nasal base augmentation by implants would be the method to do s o now that the bone position has been maximized.
The only debate is how much more nasal nose projection is needed and what is the best implant method to do so…standard or custom implant designs.
Dr. Barry Eppley
World Renowned Plastic Surgeon
Q: Dr. Eppley, Id like to ask about a step off after genioplasty. I had 2 step off sites right after my sliding genioplasty (6mm forward only) one side is worse than the other. I did a revision 7 weeks post-op to set the bone back to its original position but the step offs are still there. They are better but still there. I’m very stressed now. I thought that a revision would fix this problem. Could you please advise if these step off will go away with time or I need some sort of surgery to fix it? How to fix it please? I’m really stress about it and you seems to be the most knowledgeable doctor about genioplasty . Thank you very much in advance.
A: If you really wanted to know now, rather giving it months, to determine if the bony stepoffs willl go away or persist, you get a 3D CT scan which will provide the definitive answer. Such a visual assessment will also explain why they are there if they do persist.
The only reason they would persist is if the bone was not set back all the way. But A 3D CT scan will answer that supposition accurately.
Dr. Barry Eppley
World Renowned Plastic Surgeon
Q: Dr. Eppley, Hello doctor, in skull aesthetics, screws are used. What happens if these screws get infected, and is it a risky surgery?
A: Skull reshaping is as safe as any other aesthetic surgery.
Screws don’t get infected, never seen it in 35 years of doing the surgery.
Dr. Barry Eppley
World Renowned Plastic Surgeon
Q: Dr. Eppley, I have had perioral mounds since I was a kid. I had micro liposuction and it made some difference but did not get rid of them as much as I would like. I tried device skin tightening but it didn’t make any further change. Several surgeons have suggested a deep plane facelift for any further improvement as they say there are anatomic constraints for doing liposuction. What do you think?
A:I have never been impressed with the results for any device skin tightening treatments and I don’t really know what exactly is done with ‘microliposuction’ of the perioral mounds. In other words what size cannula was used, how aggressive and how much surface area was done in the procedure etc. I simply don’t know how thorough the liposuction was done. Microliposuction could mean an aggressive and extensive area was done using a miniature cannula to do so. It could also mean a very limited amount of area which treated hence the term micro.
When it comes to perioral mounds there really are no anatomic constraints. Anatomic constraints in the face typically means where are the branches of the facial nerve. But in the perioral mounds in the lateral facial area on a line between the mouth corner to the ear and down to the jawline there are no facial nerve branches in this area. While this is basic facial anatomy it seems to escape many plastic surgeons as they frequently tout anatomic constraints as to why it cannot be treated or or not treated much beyond the area right at the corners of the mouth.
That being said the real question is whether you would benefit by a more thorough treatment of your area of facial concern. It is hard for me to say, not knowing exactly what was done previously, as to whether further liposuction efforts have merit. I can only make the comment in reverse in relation to considering a deep plane facelift at your age. That is a bit like using a shotgun to remove an annoying fly in your house. The solution seems to be far greater than the problem. In that regard it may be worth trying something far less in magnitude before committing to that type of effort and scar tradeoffs..
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, Interested in midface augmentation to address some recession and rhinoplasty. Possibly minor bone reduction and implants to resolve some asymmetry. Attached a mockup of what I’m looking for, but it looks kinda unnatural in the eyes.
A:Thank you for your inquiry and sending your pictures. I have toggled back-and-forth between the before and afters and your perception of why it looks unnatural around the eyes is that it’s augmentation effect is greater than that of the midface below creating an aesthetic mismatch. It’s not that there is not benefit to infraorbital-malar augmentation, just a balancing that with her mid face augmentation below it can be challenging.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I am very interested in learning more about the Iliac Crest Reduction procedure that your clinic offers. I would greatly appreciate it if you could provide me with information regarding the following:.).
- The expected recovery time and any lifestyle restrictions following the procedure.
- Whether this surgery can be combined with other contouring procedures (such as liposuction or body sculpting).
- Potential risks or limitations that patients should be aware of before undergoing this operation.
Thank you very much for your time and assistance. I look forward to your reply.
A:In answer to your questions about iliac crest reduction surgery;
1) Recovery from iliac crest reduction involves some stiffness with walking in the first few weeks which then completely goes away due to the trauma to the TFL fascia which has its attachments to the iliac crest. Once full recovery is achieved there are no physical limitations.
2) iliac crest reduction can be combined with other body contouring procedures.
3) in my experience other than a small scar I am not seen any other significant risk or limitations from the surgery.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I’m emailing you wondering if I would at all be a candidate for cosmetic skull reshaping. When I was born I was delivered with forceps that unfortunately shaped my head in an odd way. There’s an indent on the back left side of my head that has pushed the front right side forward. Making my skull look ‘pointy’ when viewed head on. I’m curious to know if there is any kind of surgery to make it look more rounded and not a point ridge like it is now?
Thank you for taking the time to read this.
A:Thank you for your inquiry and sending your picture. Regardless of the origin, at least seen in this one front view, you have a classic scaphocephalic head shape….meaning the top has a midline peak and the sides of the head are narrow. One can argue which of these two issues are the greatest, the the midline top of the head is too high or the sides of the head are too narrow, and it is a combination of both but the narrowness of the head shape is really the majority of the problem.
When it comes to treating this type of head shaped there are three options based on how far does one want to go for what degree of correction. These options include: 1) sagittal crest reduction alone, 2) sagittal crest reduction with para sagittal augmentation (between the sagittal crest and the bony temporal line, or 3) sagittal crest reduction with para sagittal and temporal (side of the head) augmentation. As can be seen in the attached three images there is a progressive improvement in the head shape the greater the surface area of the problem is treated.
There is considerations for these options given the shaved nature of your head (incisional access). But initially it is important to consider which aesthetic outcome looks the most favorable to you.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I had cheek implants that I initially liked and then replaced them with new cheek implants that I thought would be better…but they weren’t. I now realize that I like my original cheek implants much better. I would also like some paranasal augmentation as well. My question is whether I should go back to my original I should go back to my original standard cheek implants or, because of the desire for paranasal augmentation, go with a completely custom midface implants approach.
A:I think the debate is whether to replace your current implants with the standard ones that you had previously of which you have good aesthetic satisfaction, along with new standard paranasal implants, or to take a completely customized approach to the midface area. That decision, quite frankly, is an economic one. One could make arguments for either approach. For standard implants, which will be the most economic approach, you were happy with a standard style previously and the paranasal area generally works well with a standard paranasal implant. Conversely a custom implant approach can be done where implant designs are made specifically for your bony anatomy to cover these areas. When one is in a position to have a viable debate between standard and custom implants the ultimate question is how much better will the aesthetic result be with a custom approach versus a standard one. For example if you could accomplish 90% of your desired asthetic results with standard implants why would you pay more for custom? However if you could only achieve 50% or less of your desired results with standard implants then the more economic approach would not be prudent in the long run.
That being said the other argument for a custom implant approach, which I have seen many times in patients where standard implants will produce an acceptable result, is that the patient feels better with implant designs in which they can see what they are beforehand and have confidence about what they look like and where they are going to be placed. This is almost always true in the patient who has had one or two prior standard implant surgeries.
The other decision that may sway a patient towards the custom implant approach is if they are having another facial area where a custom design is absolutely needed. This may be applicable to you since for your chin, in which a prior bony genioplasty has been done, a custom implant approach would be the most assured method to achieve very specific augmentative changes.
This is a long answer to a short question, I’ll be at an important one, which implant approach do to take?
Q:Dr. Eppley, What is your experience with treating negative orbital vectors with custom implants. Is it favorable? Also I want enough of a result to be seen but I don’t want to look unnatural so something conservative.
A: In answer to your questions:
1) My experience is favorable one. Compared to any other treatment methods it is the most effective. I didn’t say perfect but it produces a positive improvement
2) I understand the basis of the question but the fundamental principles to understand are the following: to get a significant aesthetic result you could not be conservative in designing the implant. As a general rule significant problems require significant effort. Conservative approaches work best when you don’t have much of a problem.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
