Q: Dr. Eppley, I am interested in gynecomastia reduction surgery with nipple reduction at the same time. But did have one concern that another physician raised regarding a nipple reduction – specifically, the physician was very hesitant that such a procedure was worthwhile considering the risks (which he described as a 20% chance of necrosis of the nipple following such a procedure) – I would be curious to hear your assessment of this risk (or others) as pertains to a nipple reduction procedure before I make a decision.
A: I am not sure at all what is the origin of the statement by a surgeon of ‘there is a 20% risk of nipple necrosis when nipple reductions are performed with gynecomastia reduction’ for the following reasons:
1) Nipple reduction in a male almost always means nipple amputation, the complete removal of the projecting nipple, thus there is no nipple left to have any necrosis. I can only assume what this doctor is more likely referring to is ‘areolar necrosis’ or difficulty with the nipple reduction site healing. This has not been an issue that I have ever seen.
2) This ‘statistic’ is based on what I do not know since there has never been anything published in the plastic surgery literature in that regard or any other literature since the performance of male nipple reduction in gynecomastia reduction is so rarely done.
3) The relevancy of potential vascular compromise to the nipple-areolar complex is based on what type of gynecomastia reduction is being performed. If an open gynecomastia reduction is performed through an inferior areolar incision, where the nipple-areolar complex is left with a thin layer of tissue underneath it and it depends on vascular inflow from the surrounding dermis (where half has been cut off from the inferior areolar incision). then one would have reason to consider there may be the potential for vascular compromise from the healing nipple reduction site. But this issue becomes moot when the gynecomastia reduction is performed by liposuction without a direct areolar incision.
4) But when in doubt one can always delay the nipple reduction for a week or two after surgery since it can easily be done as an office procedure under local anesthesia. (where the chest is largely numb anyway for awhile)
Dr. Barry Eppley
Q: Dr. Eppley, I am wondering whether to get a chin implant or a sliding genioplasty for chin. I want my chin to be wider and square from the front view I want vertical and horizontal projection.
In terms of front view of face, can the sliding genioplasty provide as much chin widening as an implant can for that masculine look? And for the side profile, I am aware that the genioplasty provides more projection.
A: Thank for your inquiry and sending your picture. You have numerous misconceptions/misinformation about what are the dimensional effects of chin implant vs a sliding genioplasty. So let me provide you with some clarifications:
1) A sliding genioplasty can effectively create more horizontal and/or vertical increases in projection. It, however, does so at the expense of width. Depending upon the degree of horizontal advancement the chin will always get more narrow. It has NO ability to make the chin wider.
2) A standard chin implant can effectively create more horizontal projection and width but can only create very minimal vertical lengthening.
3) The amount of horizontal projection between a standard chin implant and a solidify genioplasty is equal out to 10mms. Beyond that only a sliding genioplasty can add greater horizontal projection.
4) A custom chin implant can create horizontal, vertical and transverse (width) increases. It is the only option that can create a 3D chin augmentation effect.
By your own description you are seeking every dimensional increase possible which can only ideally be met by #4, the custom chin implant.
There is also an amalgamated approach to achieving a 3D effect with the two basic chin augmentation methods, a sliding genioplasty for the horizontal and vertical increases combined with a chin implant overlay to create the width.
Dr. Barry Eppley
Will Shoulder Width Reduction Surgery (Clavicle Shortening) Cause Any Problems With Shoulder Movement?
Q: Dr. Eppley, Thanks for doing the imaging on my potential shoulder width reduction procedure. From the picture it looks like so much change. But I have the following questions.
If the clavicle is cut, will there be any backbone issues as I have to always have the shoulders moving forward? Will it not create a structural stress on my back in the future? How will my shoulder blades adjust to this pulling forward? Will it impact my range of motion?
A: As I discussed with your husband at length on the virtual consultation and to answer these questions to you directly:
1) Clavicle shortening of 2.5cms per side does not cause any spine or shoulder joint dysfunction. To potentially create such dysfunction it has been shown that it takes greater than 30% reduction in clavicle length to do so. With an average female clavicle length of around 14cms and a reduction of 2.5cms, this is only an 18% change in clavicle bone length….enough to make a visible difference in shoulder width but not enough to cause shoulder joint dysfunction.
2) The clavicle shortening is 90% horizontal reduction and 10% forward movement. Thus their is a very minimal anterior rotation which does not cause a substantial pulling of the shoulders forward.
Dr. Barry Eppley
Q: Dr. Eppley, Hello, I have been looking to have chin surgery for a while now. My chin is my biggest insecurity. I never smile due to the way my chin pulls down when I smile. I also dislike the dimple in my chin and how wide my chin looks when I smile.
A: Thank you for your inquiry, sending your pictures and detailing your concerns. You have two specific soft tissue chin concerns, 1) hyperdynamic chin ptosis and 2) a vertical chin cleft. They may be anatomically related as a vertical chin cleft occurs due to a midline soft tissue deficiency. For improvement/correction a submental approaches needed as the size of the chin pad must b reduced and the chin cleft managed by a muscle repair in your case. Such soft tissue chin repairs, while not technically challenging to perform, are difficult to predict the outcomes since surgery is done in a static setting while your chin issues mainly appear with dynamic motion. (smiling)
Dr. Barry Eppley
Q: Dr. Eppley, I have a Occipital Crown Deficiency in my skull that’s why I feel really bad about this. Is there any chances to reshape it without risks. So i will look normal as others.
A: I would need to see some pictures of your occipital crown deficiency to determine whether a custom skull implant would be the correct solution. By description alone certainly sounds like it would. While no surgery is not without risks, skull reshaping surgery in general and custom skull implants in particular have the lowest risk of almost any plastic surgery that I know.
Dr. Barry Eppley
Q: Dr. Eppley, I hope this finds you well! I learned that my 3D CT scan copy is received and we will be able to move on to implant design process very soon, which is exciting.
At the same time, I was meaning to find out the following, if you may share your input, that would be great.
1. The following link from your blog shows that this case achieved a 15mm-20mm of augmentation, without a 1st stage augmentation involved. Is this amount of augmentation achievable in my surgery?
|Case Study: Flat Back of the Head Correction by Augmentation Cranioplasty – Explore Plastic Surgery – Explore Plastic Surgery – Dr. Barry Eppley – Plastic Surgeon|
Background: The shape of the skull is affected by numerous factors including genetics, in utero skull pressures, post delivery head positioning and growth of the brain. In general, the skull has an oblong shape that is slightly wider in the back than the front. While there is no uniform aesthetic standard for a pleasing skull Read More…
2. During the design process, how can we figure out what is the maximal augmentation level that is right below unduly tense (too tight) level while it is at a largest viable stretched amount?
3. For augmentation of the areas on which the head is in contact with a pillow while sleeping, e.g. the back of the head, the sides of the head, what are the chances for the implant be moved or loosened, caused by the weight from my head and neck pressuring on the implant approximately 8 hours a night over many years?
If this is a real concern, can we address to this risk during the design stage?
If implant loosening does occur at some point in the future, due to the weight from the head and neck during sleep, how will we handle it?
4. I highly regard your input in the design process of the implant. I replied Dawn’s email on what surgery outcome I would pursue. Please don’t hesitate to share your advice.
5. After surgery, I may choose to have a shaved head style some point in the future. When there is no any hair bearing for camouflage, will the skull shape still look natural and smooth, especially at the edge area where the implant ends and connects to my original skull area?
What makes a smooth and natural transition at the edge of implant possible?
6. Will the implant cause infection many years after the surgery is done?
7. Is an augmentation implant supposed to last all a life-time long?
If not, in what circumstances does the implant require what form of maintenance in the future?
8. After surgery, will it be ok to receive head massage? E.g. finger pressuring on scalp, which is provided by a regular message therapy store.
9. Will I need an additional revisional surgery? If one is needed, how long after the surgery will this happen?
Thanks for your attention Dr. Eppley : )
A: In answer to his custom skull implant questions:
1) No. That was done with a full open coronal incision which allows for some added expansion due to the mobilization of tissues.
2) There is no exact science as to how to know when the implant is too big or the tissues would be too tight to allow it to be placed and the incision safely closed. My design estimates are based on my experience of placing such implants.
3) Zero. While an understandable question it is never been a postoperative concern., I have never seen a custom skull implant move after surgery.
4) I still need to know what skull areas we are going to cover…back only, front only or both?
5) Due to the feather edging in the design there is a smooth transition from implant to bone.
6) No. Infection risks are in the perioperative period. (up two three months after surgery) Once last this time period the infection risk is negligible.
7) Custom skull implants are made of a solid silicone material which will never degrade or breakdown…thus no need for future replacement due to material failure.
8) Head massages are not needed or advised after surgery.
9) Revisional skull implant surgery would only be needed if you determine you want a bigger implant or a different design later. This is not done until six months after the initial surgery.
Dr. Barry Eppley
Should I Wait Until The Injectable Filler Has Dissolved In My Chin Before Getting A Sliding Genioplasty?
Q: Dr. Eppley, do I need to wait until the Radiesse filler in my chin is fully dissolved before getting a sliding genioplasty in order to minimize risks?
A: You do not have to wait until the Radiesse completely dissolves which could take a year or longer. In addition there is no reversal agent for the type of filler Radiesse is. There are no adverse consequences of having an injectable filler in the chin to performing a sliding genioplasty. Most, if not all, of the injectable filler is mainly in the soft tissue with a minimal amount on the bone. Whatever is on the bone will simply be removed as part of the surgery. I have seen lots of different fillers on the chin in performing this surgery and it has never been a problem during or after surgery.
Dr. Barry Eppley
Q: Dr. Eppley, My daughter is 2.5 years old and I have been worried about her head shape since she was 10 weeks old. I brought it up at every wellness check but was dismissed by her pediatrician saying it was fine. Now it’s too late and I live with guilt and regret daily. I was reading on your site about the skull augmentation implants on toddlers. How invasive of a procedure is this and what are the risks? How many cases have you done on toddlers and what is the success rate? I have attached some photos of her head.
A: Skull augmentation is not an appropriate procedure for infants. The skull needs to grow a lot more and the earliest I could consider it is 4 or 5 years of age….but likely even later than that age.
Dr. Barry Eppley
Q: Dr. Eppley, I had a surgery to correct my inverted nipples ten years ago and it did not work. It just left me with scarring. I read some reviews on your success with the surgery and wanted to get more information about how I go about scheduling a surgery living out of state.
A: I have found the best method for inverted nipple correction is to do a release and simultaneous placement of an interpositional graft. (e.g., stacked Alloderm wafers, dermal-fat graft) Whether that would be effective now for scarred down inverted nipples of long duration after a prior effort can not be predicted before surgery. It could only really be known by doing it. A prior procedure and scarring makes it more difficult than it would otherwise be. One test that could be help is whether you can manually make the nipple come out by gently squeeing on it. If so that is a very positive sign whether you have had prior surgery or not. I suspect, however, that yours does not even your prior surgery. That does not mean, however, that subsequent surgery may not be more successful.
Dr. Barry Eppley
Q: Dr. Eppley, I need your consultation. I’m a female and I had three previous rhinoplasties. In the last nose job in 2012, my nose was implanted with double grafts of mersilene mesh on dorsom. I have a lot of side effects because of the mesh implant. The mersilene mesh shows through the skin and makes it red as well as difficulty breathing at night; the mesh is attaching my immune system causing me a lot of diseases osteopenia, high Rheumatoid factor, unable to digest food, pain, cramps, etc. Besides, I hate the look cause it looks bigger with hump and deformities and does not make me breath well while sleeping and I hate everything about the change of my nose and would like to undo everything, remove all those implants. What is the complications and risks of nose mesh removal specifically after 7 years and is it possible to revise the nose at the same time removing the mesh implant? Can you perform such complicated surgery? Please advise
Looking forward to hear from you.
A: While mersilene mesh allows tissue ingrowth and is harder to remove than some implanted materials, it is not impossible to remove and it can be done so. Because the mersilene mesh removal will result in some soft tissue loss and tissue thinning, it is important to realizer that the tissues over the dorsum will not return to what they were before they were implanted. Thus you should probably consider having a thin allogeneic dermal graft (0.5mm thickness) placed in its replacement to compensate for the thinning of the overlying skin.
Dr. Barry Eppley
Q: Dr. Eppley, I’m interested in getting augmentation for my upper midface: infraorbital rims and the area lateral to it (upper part of the zygoma?). I don’t want pre-formed implants if the cheek is involved, because I believe that everybody’s anatomy is different. Especially the cheek area where shape is highly variable. I would be open to pre-formed implants solely for the infraorbitals if the other options aren’t suitable.
Your blog mentions that there are several ‘custom’ options. 1) Fully customised implant from 3D CT Scan. 2) Implant based off of another patient’s design. 3) Intraoperative hand carving of an implant.
Ideally I would get a fully customised implant, but I just don’t have the money for it. So I was wondering the prices of your other two options? Would I be correct in saying that the hand carved implant is about the same cost as a standard pre-formed implant?
Regarding the hand-carved implant, I wanted to ask how reliable it is in terms of creating an aesthetic effect? For instance, if I wanted to project my infraorbital rim, and also have the implant taper around onto the zygomatic arch, would this be possible or would this be asking too much? I have seen hand-carved results that extend out to the very top of the zygoma area (beneath the outside corner of the eye), and they look good. But I’m not sure how much further these hand-carved implants can be taken. If it’s not possible, I would settle for a basic hand carved design involving the infraorbital rim and the top part of the zygoma.
It is frustrating that the fully custom design is much more expensive, as it would really be the best choice. I have bilateral asymmetry involving the width of my zygomatic arches. It makes my face look narrow on one side. But this is a secondary issue to the infraorbital deficiency, and perhaps I could get the full custom implant some years down the line. I don’t know whether to wait and save up for the full implant, but I’m just not clear on whether it would be significantly better than a semi-custom version. I would appreciate any advice you may have on this matter. For what it’s worth I have thin skin and a lean face.
Thanks, and great blog by the way! Best resource for plastic surgery on the internet. I wouldn’t have found you without it.
A: In answer to your questions:
1) I would generally advise doing custom implants for the complex anatomy of the infraorbital-malar areas.
2) In some uncommon cases, I may use what we call ‘special design implants’ which are custom designs from other patients that I think can be modified to work for the patient who can not afford the ideal custom implant. These cost about halfway between regular and custom implants.
3) There are no standard implant styles for the infraorbital areas so that is not an option.
Dr. Barry Eppley
Q: Dr. Eppley, I first wanted to thank you for the detail that you’ve provided in each of your case studies. They are extremely informative.
I had a few questions regarding the Occipital Skull Reduction case study (https://exploreplasticsurgery.com/case-study-occipital-skull-reduction-2/)
I am in a very similar situation as the subject of the case study, except that the sides (more like, upper corners) protrude as well, and my overall head size is probably larger.
I am currently in my early 30s. I have very slight thinning on the crown, but my hairline has receded a decent amount. I plan on getting a hair transplant (FUE not a strip, so there will be no strip scar) for the hair line within the next year, perhaps prior to undergoing skull reduction surgery.
I believe I may have communicated with several years ago. At the time, you were very straightforward that there would be a very noticeable scar resulting from a reduction surgery, and compared it to a strip surgery / hair transplant scar. Is that still the case? I read a case study you posted on March 25, 2018 (https://exploreplasticsurgery.com/making-pleasing-scalp-scars-aesthetic-skull-reshaping-surgery/) regarding scars, and it seemed very promising. Have there been new developments, or are the scars still expected to be very noticeable?
For instance, how noticeable is the subject’s scar in the Occipital Skull Reduction case study? I would wear my hair around the same length.
Also, if I were to just flatten the top without doing anything to the back or sides, were would the incision need to be?
Lastly, what would pricing be for a similar operation as the one in the case study? Thank you in advance.
A: Good to hear from you again. In answer to your occipital skull reduction questions:
1) Any type of skull shaping surgery should be done before hair transplantation procedures.
2) The incision used for many occipital reduction procedures are far shorter in length and lower on the back of the head than the traditional strip harvest scars for hair transplantation. The length of the scar is related to how much skull reduction needs to be done in terms of location and surface area treated. Without knowing this exact details int your case I can not comment on what your scalp incision would be in terms of length.
3) I will have my assistant Camille pass along the cost of the surgery to you later today.
Dr. Barry Eppley
Q: Dr. Eppley, I am ten days after my custom jawline implant and, while all has gone well and it looks good, I desire just a little more vertical chin lengthening. I think now would be the time to do it while I am still healing. My gut feeling before surgery was that it was not vertically long enough in the design and my feeling now is that it is just a bit short. What are your thoughts on an early custom jawline implant revision?
A: When considering an early custom jawline implant revision, let me pass along my thoughts based on an enormous experience with facial implants, particularly larger ones that are often done in young men:
1) it is critically important to wait for the true final aesthetic result to be seen and appreciated, which takes a full three months, before judging the final result from which one can make accurate and well thought decisions as to what to do next, if anything. Sitting in a hotel room alone in a different country thousands of miles from home at ten days after surgery does not really qualify as a reasoned perspective on which to make sound surgical judgments. Just because it may be convenient to consider improving an early perceived result does not make it a sound medical decision to do so.
2) Every new surgical procedure around an implant involves additional infection risks, particularly when an intraoral incision is used. You are not even beyond the initial set of infection risks from the first surgery. (6 to 8 weeks) Having additional surgery within this time frame essentially doubles the infection risks from the first surgery.
3) I have seen patients in face and body implants who had a ‘90%’ result, and in the pursuit of a more perfect result, incurred complications that ended up with an outcome that was far less than had they just left the 90% result alone.
4) It is important to remember that when it comes to placing implants in the body, we are creating an unnatural situation. Implants are not meant to be there and it is a marvel of the human body that they tolerate them as well as they do most of the time with a relatively low rate of complications. But every time you manipulate an implant, particularly one that seems to be doing well, you risk tipping the delicate balance between tolerance and intolerance.
May this experienced perspective add some additional insight to your early surgical recovery,
Dr. Barry Eppley
Q: Dr. Eppley, I am interested in hip and thigh implants. I have the following questions:
- My one hip is a bit flat, would it be possible to have a small hip implant on one side as well and a larger hip implant on the side that needs more volume?
- Do you see any issues with putting a thigh implant on my thigh where I have a skin graft? I touch the skin and seems it would stretch. I wanted to get your thoughts on that.
- After the procedure, when can I start:
a.- Walking a bit (around the room)
b.- Walking normally without pain
c.- Doing exercises in the gym
d.- Lift weight?
4. How many check-ups do I need after the procedure? I live out of town, I would like to start planning how long I should plan to be in Indianapolis.
5. Are implants going to be positioned under the muscle or over?
6. Can muscles still grow with exercise having an implant in there? Would this affect the shape of the area?
7. How long does it take to get custom implants?
8. Should I meet with you in person to take measurements and finalize everything before scheduling the procedure?
A: In answer to your hip and thigh implants questions:
1) Since the hip implants are custom designed, they can be made to any reasonable dimension on either side of the hips even if they are different.
2) I do not envision any issue with placing a thigh implant around/under the skin graft site.
3) Your recovery would, of course, be a progressive one but you need to begin walking and moving around immediately. Back to unlimited exercise is going to take up to 6 weeks after surgery.
4) You should be able to go home within a few days after the procedure. Followups would be done in a virtual fashion.
5) In the hip area implants are placed one top of the TFL fascia. (above the muscle) In the thigh area, if possible, they are placed under the muscle.
6) Muscle hypertrophy through exercise is still possible even with an implant in place.
7) Most custom can be made, sterilized and shipped for surgery in about three weeks.
8) The method that I use to design custom hip and thigh implants is to mark the patient where their desired areas of augmentation are, make a paper template and then determine what their surface projection and contour would be. Sometimes a silicone moulage model is made. In many cases the patient can do the former paper template method and we can discuss vis Skype to work out the details. But certainly seeing you in person would be ideal but is not always completely necessary based on the complexity of the implant shapes needed.
Dr. Barry Eppley
Q: Dr. Eppley ,I might just take this moment to get a full understanding of the silicone custom jawline implant by asking some questions:
1. The common problem of bone erosion with silastic implants is eliminated if the silastic implant is customized and fixed with screws?
2. Custom made silastic implants are made to last a lifetime inside the patient? In other words, there is no need to replace them unless the patient desires to do so.
3. In my case the silastic implant would be inserted intraorally since the PEEK implant will be extracted this way?
4. You would let me be involved in the designing process from start to finish and will show drafts and answer emails if the patient tries to engage you in the design?
5. You are willing to design implants that do not just provide volume in the right places but also correct asymmetries between the facial halves?
6. Do you have any computer program that could reasonably project how a finished implant design (for both the cheekbones and the mandible) would make my face look before we manufacture the implant?
7. Your finished implant design can be scrutinized and revised, if necessary, until we are both satisfied that it would fulfill my aesthetic wishes?
8. Implants are made well in advance and would only be manufactured with my explicit consent?
A: In answer to your silicone custom jawline implant questions:
1) All implants on the jawline, regardless of their composition, create some degree of passive implant settling and even bony overgrowth particularly back at the jaw angle area. These are natural phenomenon when placing implants on bone that is most manifest on the mandible. The concept of ‘bone erosion from silicone implants’ is both misunderstood and erroneous.
2) All implants for the jawline (silicone, Medpor, PEEK etc) are permanent materials that do not undergo degradation of the material over time. From a material standpoint they are lifelong devices.
3) If your PEEK implants were inserted intraorally then silicone implants can be done as well.
4) to 7) I have a very specific protocol on how custom implants are designed with patient participation. I have attached a document which explains the details of this process that every custom implant patient is required to read and sign before the implant design process is ever started.
Dr. Barry Eppley
Q: Dr. Eppley, I am still considering having the buttock implant removal. I really wish I had done it at the same time as the facial implant removal.
1. Have you removed many subfascial buttock implants?
2. If so, are there many potential complications with this surgery?
3. Will I need drains?
4. Is there much pain afterwards?
5. Would I need to stay in Indiana long? It would be great if I could just stay 3 days or so. Or would I need to stay to have stitches removed?
In answer to your buttock implant removal questions:
1) I fortunately have rarely just removed buttock implants without some form of replacement. So I certainly have not done ‘many’ and never hope that I have to.
2) Like all implants removals anywhere on the face or body, there is going to be generalized tissue deflation/flattening effect. Your cheeks are a good example fo what happens when you remove the underling support from a projecting prominence.
3) A drain is not needed.
4) Any postoperative discomfort will be a fraction of what its as to place them. Your facial implants are a good example of what ti expect.
5) You should be able to go home in one to two days at worst. All sutures are under the skin and are dissolveable.
Dr. Barry Eppley
Q: Dr. Eppley, I am a young female from Montana. I am interested in lip advancements. I just have a few questions about the lip advancement procedure. I have pretty full lips. I have lip implants in currently and I like them. However, I would like my lip size to be a lot bigger. I don’t like fillers at all and, after reviewing what is offered, I am most interested in the vermillion advancement. My questions are:
1) Would this option of lip enhancement be good for a young person who dislikes lip fillers?
2) Can I have a vermillion advancement with Permalip implants in?
3) How big would I be able to make my lips with the vermillion advancement? I would want a big difference.
4) Would I lose any current lip projection (volume forward/pout), after the advancement?
A: In answer to your lip advancement questions:
1) Short of injectable fillers and implants, a surgical lip advancement procedure is the only option for making one’s lips bigger.
2) A vermilion advancement can be done with lip implants in place.
3) As a general rule, lip advancements can increase the vermilion show of the lips by 4 to 5mms on the upper lip and 3 – 4mm on the lower lip. Lip advancement are very powerful procedures for increasing lip vermilion show and their perceived size.
4) Lip advancements will not decrease the forward projection of the lips.
Dr. Barry Eppley
Q: Dr. Eppley, I have a custom midface implant procedure and canthoplasty done by you last year. The recovery went well and there hasn’t been any sign of infection. Immediately after the surgery i was very happy with the result. After my face became swollen and recovered the look was different as the lower portion of my cheek had swollen. I thought it was swelling and that it would subside but almost a year later its still prominent.
Although I had the infraorbital implant placed there is a large shelf like gap between my eye and implant which appears sunken. Last time we spoke you said the best approach would be tat grafting and retraction of the eyelids to address the drooping and hollowness.
I had fillers done to the undereyes which did help the hollowness up until the implant. The doctors said they could not place filler between the undereye implant and eyeball. Which leaves a large hollow gap.Besides from augmenting the implant is it possible to liposuction the lower cheek fat beside the philtrum? Whats the best solution the address the fullness?
A: Good hearing from you and thanks you for the long-term followup. As per the attached pictures one can see that the implant did exactly what it was designed to do. It added forward projection and fullness to the infraorbital-midface based on the areas of its design. Like all facial implants and surgery in general, it is never going to be perfect and it can not completely augment all areas of your non-skeletal deficiencies. What you are seeing now and asking about are those areas of imperfections that such an implant either creates or could not adequately treat.
In answer to your custom midface implant questions:
1) The fullness you see in the lower cheeks is the result of the implant pushing out the soft tissues. While this is an area that can be treated by microliposuction it is not very effective. It would make more sense to treat the basis of the aesthetic problem….remove the section of the implant beneath it and let the tissue fall back.
2) The gap between your eye and the implant is because the implant can only go so high particularly given that it was designed to be placed from an intraoral approach. (see attached picture with arrows) The issue is that the entire infraorbital rim needs to be elevated from the tear trough area out to the lateral orbital rim. Even if so done there will always be some sort of visible transition zone as your soft tissue anatomy is made for the underlying shape/volume of the bone. Fat injections is an option but its success would be based on how well the fat survives… which would be dubious in a young man with a high metabolism and a low percentage of body fat. Adding more implant through either ePTFE sheets or an implant ‘extension’ is another option of which lower eyelid approach would be needed. The other approach is to smooth out the implant over the lateral infraorbital rim/cheek so the transition is smoother/less obvious.
Dr. Barry Eppley
Q: Dr. Eppley, I had jaw surgery to correct my overbite and gummy smile which got fixed. I still however feel I have a long face and want to shorten it a bit even more. I feel as if my nose and chin are vertically too long and I would love to shorten and make them smaller. I would also like to add filler to my lips and cheeks to give me more width volume. I feel as if my chin reduction would be hard to do because I don’t need a lot and it would have to be precise to get a good result and not look odd or throw off any facial balance. My nose also is a bit droopy at base and long. I would like to shorten my nose from the bottom without it looking “piggy” and then add some upper lip filler to keep my philtrum still looking short and in balance. Do you think my picture results are realistic and do you think my genioplasty result could turn out the way I want it. You are probably the best at genioplasty as many doctors can’t seem to have nice feminine results when I see their after pics. What procedures would I need to get the “what I want” result in my pictures. What procedures would you recommend to give my face a more compact feminine look.
A: Thank you for your inquiry and sending your imaged pictures. What you are showing is a vertical reduction of the chin extending back into the jawline but not back all the way to the jaw angles. That could be done by two types of jawline reduction techniques, (intraoral vs submental) each with their own distinct advantages or disadvantages. While the submental approach is the ‘easiest’ method to do, needing just a little reduction (to quote you…although that looks at least 5mms reduction to me, maybe even 7mms) would suggest that the intraoral osteotomy method may be acceptable because it is scarless. Certainly the combination of chin reduction, rhinoplasty, and filler injection to the lips and cheeks can also be done at the same time for a comprehensive facial reshaping approach.
Dr. Barry Eppley
Q: Dr. Eppley, I am interested in facial reshaping surgery. I really don’t like my face and want to change pretty much everything like jaw/chin, browbone/forehead and nose. But the things I don’t like most is the chin/jawline, the nose and brow bone. I would like to have a bigger jaw and the chin and bottom lip to be pushed forward a bit. The small hump on my nose removed and to have a bit wider nose. And the brow bone I would like to be more prominent and cover my eyes more, something similar to what you did on a guy in one of the photos in the photo gallery on your website. And the forehead to be more square and straight. Do you think its to much, what would you change? How big are the risks of the end results looking weird? Is there a way to predict what i would look like without having to meet you personally and do a 3D facial scan?
A: Thank you for your inquiry and sending your facial reshaping pictures. Many of the changes you have indicated can be done (forehead/brow bone, nose, and jawline) but a few of those changes can not be accomplished. (lower lip coming forward which only happens with an advancement of the entire lower jaw since that is tooth-driven and the nasal widening with hump removal)
I have done some imaging looking at the following:
Forehead-Brow Bone Augmentation
Infraorbital-Cheek Augmentation (it wasn’t on your list)
Hump Reduction Rhinoplasty
The key about ‘not ending up looking weird or unnatural’ is based on the degree of facial changes being done. This becomes particularly relevant when multiple facial structures are being augmented.
Dr. Barry Eppley
Q: Dr. Eppley, Everything is going exactly as you described with my chin implant recovery and I love it. It’s been about 6 weeks since surgery and the numbness in my lip is almost entirely gone. The left side of the implant felt good right away. The right side of the implant took longer to settle in. Now both sides feel symmetrical and completely natural!
The only question I have is about the scar itself. How long does it take for the stitches to dissolve? I can still feel some stitches and there are some puss-filled bumps/abscesses along the scar. One spot in particular has been a little red/swollen and I’ve had to drain it a couple times. Please advise if I should do anything for this.
I haven’t shaved my beard yet since I’ve been waiting for the scar to heal. When I do, I will send you some pictures of my new chin.
Thank you again, Dr. Eppley.
A: Thank you for the followup and the good report. Such small suture abscesses are very common in the submental area of men after any chin procedure with beard hair. They are not due to the external dissolveable sutures (which go away in a few weeks but due to the internal dissolveable sutures which take much longer to go away. (months) Because of the hair follicles, these are the sutures that can create some stitch abscesses that you have developed. The one recurring stitch abscess is because the dissolveable suture is still there and infected and needs to come out for a complete resolution. The one method that can help solve it is to squeeze it like a pimple and see of you can force it out when it is at its most inflamed. That often will allow the knot of the suture to come out and then it will be a resolved issue.
Dr. Barry Eppley
Q: Dr. Eppley, I am interested in breast implants but have some questions. I am 4′ 10″ tall and weight about 115 pounds and I’m currently a 34D. I don’t really want to go any bigger but I want implants to fill in the loose skin I have after having 3 children. (BTW you did tongue reconstruction surgery on my 19 year old son when he was 7 months old) Is there a way to get implants without making my breast much bigger? I feel like at my size if I go too big it just won’t look good at all.
A: While I would ideally have to see pictures of your breasts to provide an informed answer, adding implants to breasts that have loose skin and some sag to fill them out will, by definition, make them bigger. That postoperative outcome would be unavoidable…like filling up a deflated balloon so to speak. I suspect you are trying to fill out loose sagging breasts which is likely not a good strategy. Breast implants can not fill out a sagging breast nor can it lift them. Rather it will make the breasts look worse by pushing the sagging breast mound even lower. Sagging breasts usually need to be lifted first before any consideration of volume additions should be considered.
Dr. Barry Eppley
Q: Dr. Eppley,I have a question regarding shoulder widening surgery. Have you ever performed a clavicle osteotomy or know of anyone having this done? Would widening of the clavicle in turn move the scapula? I know its extreme but do you think this is safe and effective? I’ve been researching on surgeries to broaden shoulders and I’m very interested in the clavicle osteotomy but there is hardly any information on it. You are the only expert in this field that has at least talked about this procedure. Please could you shed light on this operation.Thank you.
A: There is very little information in regards to clavicular osteotomy because it would be considered an ‘extreme’ surgery in the quest for wider shoulders. There are other more conventional forms of shoulder widening that would be considered equally effective including deltoid (shoulder) implants and fat injections.
Clavicular osteotomies would be considered only for the most of motivated of men for the following:
1) Only one shoulder is done at a time with a 3 to 6 month spacing between the two sides.
2) Recovery would be considered similar to that of a fractured clavicle.
3) It requires plate and screw fixation with an interpositional allogeneic bone graft.
4) There will be a resultant scar over the clavicular osteotomy site.
5) Clavicular gap widening would be 2 to 2.5 cms maximum.
For all of these reasons it takes a very highly motivated person to consider this approach to shoulder widening surgery.
Dr. Barry Eppley
Q: Dr. Eppley, I am interested in ear reconstruction. I got bit by a dog a year ago and lost the lower third of my ear. I have attached pictures for your review.
A: Thank you for your inquiry and sending your pictures. Your traumatic injury represents a classic case of reconstruction of the lower third of the ear…the hardest area of the ear to remake. To do so requires a two-step procedure with the first stage being to raise a skin flap from behind the ear and attach it to the visible edge of the missing ear section. After 8 weeks the attached skin has gotten a good blood supply of its own and it can be released from its base, rolled to make both a back side as well as front side of the missing area and closed over a cartilage graft or implant to support the lower helical rim and where the earlobe would be. This keeps moist of the scar to do within the shadow of the ear rim.
Both stages of this ear reconstruction could be performed as an outpatient procedure and each takes about an hour to complete under IV sedation or even local anesthesia.
Dr. Barry Eppley
Q: Dr. Eppley, I initially consulted a doctor for orthognathic surgery for treating obstructive sleep apnea. He gave me the option to do the orthodontics and straighten the teeth before surgery or just do the surgery and only fix the apnea. The only instruction that he ever gave to my orthodontist is to maximize the overjet. My orthodontist is currently trying to move it into two defined arches as per his plan.
I reached out to you as I have been researching orthognathic surgery and other things related to it. My major concern is appearance and elimination of sleep apnea. Reading around I saw that cheek implants and jaw implants could enhance the appearance and started wondering if that would be something that I could do to have a great aesthetic outcome in addition to the functional improvement. I could certainly use some guidance here.
A: What you need to focus join first are the maxillomandibular advancements for the treatment of your sleep apnea. This will involve moving the underlying bones and it will change your appearance. But implants can not be put in at the same time for a variety of reasons. You need to fix the bone first, see what you look like after and then consider any aesthetic changes that may, if any, be determined to be beneficial. In short you can’t perform orthognathic surgery and facial implant surgery at the same time for functional and aesthetic reasons.
Dr. Barry Eppley
Q: Dr. Eppley, I wanted to ask you some quetsions about my jaw after a sliding genioplasty. There is a significant gapping on the right side, I can feel underneath the chin )at the sliding genioplasty fracture site. There is slight gapping on the left. First, do you have any suggestions. I would like for my jaw to be more substantial for dental reasons. I have a 11 year old dental implant on the right side in the back and there is a tooth in the right canine area that may require extraction. I think part of the reason that the osteotomy sight didn’t heal well on the right is because I grind my teeth. (i.e the right dental implant didn’t absorb that stress very well) I now wear a guard at night.
I am considering getting prolotherapy or similar treatment in hopes of stimulating bone growth to fill in the non union areas. Would bone cement or fat interfere if bone is attempting to fill in. How long do we need to wait to do surgery?
A: If you are more than three to six months after the original surgery, you are not going to stimulate any bone to grow into the sliding genioplasty defect areas. It will not matter what type of therapy you undergo. Real bone is going to require a bone graft, every other implantable material is a filler/contour material. Anything placed into the bone ago that isn’t bone will prohibit any bone growth into it. The sooner you bone graft it, the sooner it will heal with real bone although I don’t think real bone is absolutely necessary in this common sliding genioplasty step off areas.
Dr. Barry Eppley
Q: Dr. Eppley, I want to have forehead and skull reshaping surgery. I will fly to US at the end of February.
I have fat injection in my forehead 3 times. Each time interval is 1 year. The last time is 4 months ago. Now I have problem with the fat lump as you can see in the picture. The fat lump creates the ugly on my forehead.
1. I want to reshape my forehead and skull as the green line in the picture. I want to have a high and big forehead as in the picture. Which method is suitable to me?
2. I think I should have the brow shaving to achieve the result I want. I attach the desired result.
3. Is it possible to remove the fat which has been injected in my forehead to smooth my forehead?
4. How long I need to stay in Indiana for the surgery?
5. What is the cost for the surgery?
I hope to hear from you soon.
A:Thank you for sending all of your pictures and describing your forehead augmentation with fat injections outcome. Your forehead augmentation result speaks to why I don’t like this method of forehead augmentation. It can create a lump/bump appearance and the fat often drifts down lower closer to the brows rather than higher up in the forehead which most Asian women want. While it does not always create the result you have, I have seen it enough times that it is always a potential outcome. When fat injections in the forehead go awry, they can be very difficult to remove and runs the risk of forehead irregularities just like what can occur with liposuction anywhere on the body. But the use of liposuction on the forehead has a higher risk potential for these irregularities due to the higher skin tightness of the forehead and being able to see cannula lines.
In answer to your questions:
1) As you have discovered in your case, achieving your forehead shape result will; require bone augmentation. This can be done by bone cements or a custom forehead implant. The latter is always preferred when possible as it can can cover a broad surface area with the smoothest result possible.
2) I would agree that brow shaving would be a useful adjunct to your forehead shape goals.
3) As stated above the only fat in the forehead can be removed is with liposuction. And I think that has to be done as part of your forehead reshaping goals. BUT it should be not done at the same time as the aforementioned forehead procedures due to blood supply and healing concerns from the scalp incision and elevated forehead tissues. Any efforts at fat removal should be done first and allowed to heal. I can do that or the doctor who injected the fat should be able to perform it as well.
4) You would only be here for a day or two after surgery and then you could go home.
5) My assistant will pass along the cost of the surgery to you later today.
Dr. Barry Eppley
Q: Dr. Eppley, Since my original temporal artery ligation operation I seem to have developed small vein grooves around the same area where the arteries ran. These are definitely from veins as they are sort of dents running straight down across the artery path, and when i put my head down low the veins bulge out there. These grooves were also present before, just to a lesser degree but seem to be worse since I had the original operation.
I am not sure how much this worsening is due to the original operation, and how much is just due to further fat loss/skin thinning which would have happened anyway. However, these areas don’t really bother me that much.
My area of concern is I seem to have a groove that runs up the side of the temple and along the top of the front path of the head – around the coronal suture path. Again I am fairly sure this is a vein, as it seems to branch off and also when i put my head down it fills out pretty flush. I also have this to a lesser degree on the other side. Being balding, i can see the two lines will meet up in the middle leaving me with a nice dent across my head !
I have attached a picture here, i have caught it in the worst possible light – i have gone back through lots of old pics and can’t see this at all, but the angle has to be right to see it like this.
My questions are:-
-Firstly is this actually an artery and so would the operation somehow help it (though I can’t see how reducing something that is a dent would help)
-Is it possible that this can have been caused by the original temporal artery ligation operation somehow
-If so, would a further tie off to close the remaining lower bulge potentially make this problem worse
-If so, is there any other alternative at all – i did note you mentioned on another question about temporal implants – would they be suitable for hiding the lower grooves and whats leftt of the bulging artery
-Is there any way at all to fill in the groove that has developed going across my head.
Thank you very much indeed.
A: In answers to your temporal artery ligation questions:
1) I can not say just based on a picture as to the anatomic basis of the groove to which you refer. But I doubt very highly that it is an artery. However I have seen many grooves along the coronal suture line in the skull that look like yours as they represent depressions/dent in the underlying bone/suture lines
2) Temporal artery ligation is not going to cause a sutural bone indentation.
3) Nothing done to the superficial temporal vascular system below should affect, positively or negatively, the dent along the suture line.
4) and 5) Fat injections is the simplest and likely most effective approach for filling in these skull dents/grooves.
Dr. Barry Eppley
Q: Dr. Eppley, I am interested in silicone removal and reconstructive lip surgery. Could you tell me what would be reasonable and safely doable during surgery at the same time:
1) Get rid of the silicone on the white part of both lips, debulk the philtrum columns that were injected as well with silicone after the lips were injected (this silicone was not injected deep, it’s more on the superficial layer of the skin, but since you is the specialist, I need your advise on this…)
2) Get rid of the silicone bumps and scar tissue I still have on the wet lip inside of both lips.
3) Make upper teeth shown again, since all this bulkiness is weighting down and making my teeth to be hidden. I guess this could be accomplished by removing tissue from the inside, and also making the lip advancement. Lip advancement I guess will be also more appropriate to raise the lip than a lip lift in my case? (since if he has to do an incision there, I think would be more appropriate to raise it from there and not causing a new scar (bull horn)?
4) Re-shape the cupid’s bow, vermilion border and philtrum
5) Re-shape the lower lip, correct the great asymmetry I have (specially on the right side), make it thinner on the edges and fuller in the middle of the lip. Raise the lip with the V-Y plasty so the lower teeth don’t show that much, since right now I have exactly the way around as it should be (only lower teeth are shown 🙁
6) And he said something about a fat grafting to prevent the scars to become hard and bulky again.
Obviously an in person consultation will be the best, but at least I guess this might help a lot, since I’m showing him also the mucosa inside of both lips. Besides the concern of looking aesthetically much better, I’m concerned about not causing more damage and keep the natural functionality of the lips.
A: ‘I have a very clear understanding of the lip issues due to the silicone material as well as the objectives as has been outlined. I can see the issues very clearly in pictures as well as the Skype consultations. Seeing the lips in person will not change the silicone lip removal and reconstructive surgery plan or, most significantly, what I consider to be the single most important concept to understand about the lip problem and any proposed method to treat it. Trying to remove/debulk and improve the shape of the lips that has been distorted by silicone injections is both very challenging and the results will always be less than desired. There is no completely satisfying solution that will meet all the patient’s aesthetic lip/perioral shape desires. Silicone oil causes permanent damage and shape deformation for which only partial improvement is possible. It is this concept about treating adverse reactions to silicone injected lips that the patient must understand.
Dr. Barry Eppley
Q: Dr. Eppley, I had an injectable cranioplasty procedure done last year by another doctor. The results were less than stellar. The size is small, approx 1″ x 3/4″. I have the following questions:
1) is it possible to burr the implant down through the original 1/2″ incision
2) will the rasping damage the hairs above the site
3) is there risk of cracking the implant
Thanks in advance for your response.
A: An Injectable cranioplasty, even when small, is prone to irregularities and edging. It takes a lot of practice and negative outcomes to work the kinks out of this procedure because it is done in a blind fashion. What material was injected? (I will assume PMMA)
In answer to your questions:
1) It is not possible too smooth out the material through the small incision by which it was placed. That is the downside to an injectable cranioplasty. If the result isn’t perfectly smooth the incision will have to be enlarged to modify/remove it.
2) If it is PMMA or even hydroxyapatite (HA), you can not rasp it or smooth it. PMMA is too hard and HA is too brittle for rasping. They have to be burred down for further contouring. In many cases, you are better off removing it and replacing it.
3) The implant will fracture/crack with any type of closed manipulation such as rasping or burring.
Dr. Barry Eppley