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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
Indianapolis, Indiana
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
Indianapolis, Indiana
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
Indianapolis, Indiana
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
Chin-Jawline Augmentation
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
Indianapolis, Indiana
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
Indianapolis, Indiana
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
Indianapolis, Indiana
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
Indianapolis, Indiana
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
Indianapolis, Indiana
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
Indianapolis, Indiana
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
Indianapolis, Indiana
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
Indianapolis, Indiana
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
Indianapolis, Indiana
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
Indianapolis, Indiana
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
Indianapolis, Indiana
Q: Dr. Eppley, Following a chin implant being removed via an intra-oral incision six years ago, I have lower lip incompetence and chin ptosis.Is it possible to have a successful outcome with mentalis muscle resuspension without inserting another chin implant? Also is it possible to achieve a good result with absorbable Mitek sutures as opposed to titanium screws?
Another doctor has advised he would insert another small chin implant and use titanium screws. I’m not comfortable putting another chin implant in or with titanium screws in my chin.
A: One can certainly have a mentalis muscle resuspension surgery without placing a new chin implant. But the success of the procedure drops when the lower chin support provided by a new chin implant is not added. This does nor mean that it can not work just that the long-term success rate will be lower.
Mitek absorbable bone anchors are my performed method of mentalis muscle resuspension. They come with an indwelling bone device (anchor) that is composed of either a small piece of metal (nitinol) or a reservable polymer composition that takes 6 months to go away. The sutures attached to the bone anchors however are permanent.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m about 5’4 and roughly 115-120 pounds maybe a tad heavier. I’m considering buttock implants. I’m 23 soon to be 24 so I didn’t know what the options were? Time of surgery? Healing process ? Risks ? I’m hoping to hear from you very soon!
A: While I don’t know exactly what you body looks like, your height and weight measurements suggests that the use of fat for your buttock augmentation is unlikely to be inadequate. You may simply not have enough fat to harvest to do much of a buttock augmentation. I would really need to see some pictures of your body to answer that question better. if not that would then leave you with only the option of buttock implants. Whether implants would produce a satisfactory result depends on what your buttock augmentation goals. Implants generally produce a small to moderate buttock enlargement not a big buttock size increase.
Buttock implants can be very effective if one has a realistic understanding of what they can and can not do. Beyond this aesthetic issue, buttocks implants have a relatively long recovery time and it probably takes most patients a full month to get back to most of their normal activities.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a question about what can be done with the sliding genioplasty technique without any implants. I am not to keen on implants as it’s not natural and I have read that it can lead to atrophy and infection and I am still young.
I have attached photos – I don’t like my chin I feel it is too thin and too short vertically in relation to my nose and face.Is it possible to add vertical length using sliding genioplasty in my case as I already have good horizontal projection? My chin is already narrow,
can something make it wider? Also will sliding make it look slimmer if it is increased vertically? I really want vertical increase without any future possible complications like with an implant. Thanks a lot for the help.
A: The most common technique to just vertically lengthen the chin is an opening genioplasty procedure. Rather than ‘sliding’ the bone forward it is just vertically dropped down. Be aware that this will not widen your chin. As the chin bone becomes longer it will by definition not become wider and may, in fact, look a little bit more narrow.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have orbital dystopia where my left eye sits further and lower than my right eye. My question is will the placement of orbital floor implants correct the misalignment and depth of my left eyeball?
A: Correction of orbital dystopia is very challenging for a variety of reasons. First one can not just move the eyeball anywhere one wants by changing the volume inside the orbit because of the optic nerve. Care must be taken to not put too much pressure on the eye as the low but real risk of visual loss is ever present. Secondly, the increase in interorbital volume is always multifactorial and changing the size of the interorbital space through implant augmentation affects just one of these factors. Lastly, there is no scientific method to know exactly how much to augment the orbital floor and where. All that can be done is to take measurements and make a 3D implant from them to match the other side.
It is best to think about improvement in the position of the eye rather than absolute correction. Raising the eye is one challenge but bringing the eye forward is even more so.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, After doing research on real self and looking at my own face, I’ve very open to anything you suggest that I have done! You responded to my question in detail on real self several days back which I really appreciated. The main procedures I would like to take a look into having done has to do with my chin, so possibly a chin implant…fat removal underneath the chin/neck (This is one thing I feel like I’m a great candidate for and really want done), and buccal fat pad removal in the cheeks because I have always noticed I have pretty thick cheeks. I do realize sometimes buccal fat removal isn’t possible based around if the cheek has fat that can be removed or if it is just the way it is genetically. My chin also points slightly to the left and I’m not sure if chin implants can fix that? Like I said I’m very open here! Also my whole life I’ve been able to give myself what looks like a facelift just by “flexing/pulling” back the muscles and skin on my face. Everyone who I’ve showed which has been a lot of people, always say they’ve never seen someone who can do it. Have you ever seen this before and what does it mean? In all the side by side pictures attached, on the left side of every pic is my face totally relaxed. And on the right is me “pulling my face back”. I’ve notice it makes all my facial features stand out more but the one thing I don’t like is it also raises my forehead line which makes my forehead look larger.
A: Thanks for your inquiry and sending your pictures. What happens when you pull the skin back is that you ‘skeletonize’ your face. The skin is tighter and the skeletal highlights (brow bone, cheeks, chin and jaw angles) become more prominent. That is why you like your face better this way. To try and replicate some of that effect you have to do a combination of skeletal augmentation and facial defatting. You will never replicate that loo surgically or naturally on its own but there are several procedures that will help. Chin implant augmentation with buccal lipectomy and neck liposuction are good selections. I would also add that small cheek implants can also help sculpt the midface better and are a complement to that of the buccal lipectomy. You natural chin/jaw asymmetry poses an issue for a standard chin implant as this really requires a custom chin implant to ideally correct but that will drive up the cost of surgery. The most economic approach would be to modify a standard chin implant (reduce the left side and position the right side of the implant lower) and hope for better albeit not perfect symmetry.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am dissatisfied with my facial profile and wonder if a sliding genioplasty would help. I feel my jaw is vertically too long, yet I can’t exactly put my finger on it. My maxilla/jaw just doesn’t match up. PIctures irritate me the most, because its so evident. Id like to achieve a better look, maybe with a sliding genioplasty and fat injections to the cheeksTake a look…. and thank you very much sir. You are by far the best Ive researched in this area. You surely are the right plastic surgeon for me.
A: Thank you for your inquiry and sending your pictures. Regardless of your current state of your occlusion (which are not going to be furthered modified by orthodontics), your maxillomandibular relationship shows a very mild mandibular retrusion and vertical elogation of the chin. There is also submental fullness below the jawline. A sliding genioplasty to bring the chin slightly forward (3 to 4mms) as well as vertically shorten it (5mms) combined with submental/neck liposuction would make the desired improvement in your profile. Fat Injections to the cheeks would help add some cheek highlights for otherwise flatter cheeks. Another consideration would be to transpose your buccal fat pads as ‘cheek implants’. That would create a better cheek contour result by increasing malar projection while decreasing submalar fullness.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I know you warned me that the jaw angle implant recovery would involve substantial swelling for a while. I am at the 2 week mark. I can tell I should not have gone with any ‘drop down’ with the implant. This change is a bit more than what I was looking for. I should have stuck with just 3 mm width, no vertical lengthening. I am wondering what is the next step to getting this fixed. Would I be able to get them replaced with smaller ones (or completely removed)? And, could this happen soon? I am sort of desperate at the moment, I am really sorry. I do need your help on this.
A: I am going to give you some advice on jaw angle implant recovery based on an enormous experience with them in young male patients. You may choose to take it or not and I will do whatever your decision may be.
- I have heard your concerns from innumerable young men who have had jaw angle implant surgery and it is always about the same time period…about two weeks out from surgery. At this point you are far from seeing the final result, both physically and psychologically. On average 50% of the swelling is gone in10 days, 75% in 3 weeks and 95% by 6 weeks after surgery. So while you may think you know what the final outcome will be, you do not. No one can say for sure at this point in the incomplete recovery process. There is also the ‘getting used to’ the new look which takes much longer. So any decision made today is a premature one that could result in an unnecessary surgery.
- The economically prudent and medically advised recommendation is to give the recovery process a minimum of 6 weeks and ideally one should not have revisional surgery for three months after any form of facial skeletal surgery. (temporal implants are NOT like facial skeletal surgery) Any surgery before that time period is really chasing a moving target from an aesthetic standpoint.
- Any surgery before this time period has elapsed is really an emotional one that is not based on logical thinking. I will do it but I need to make clear I do not think it is a wise choice. After three months you may still come to the same conclusion (or not) but at least you will know an undisputable clear idea of the result and how you really feel about it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am seeking a revision rhinoplasty. I had my primary rhinoplasty done six months ago. The method used was diced ear cartilage wrapped in fascia to increase bridge and tip height. What I’ve noticed in my bridge is that it slightly decreased in height possibly due to swelling going away. With the swelling gone, the bridge height isn’t as augmented as I had wanted. For a revision,I wanted to know if Dr. Eppley would consider using the diced cartilage injection technique.Looking for very slight increase in bridge height.I feel that cartilage injection best suits my case.That minor change can make a huge difference. As I have read in some of your articles concerning revision rhinoplasty, many patients desire a revision rhinoplasty because they may be seeking the optimal look for themselves and may not be a result of aesthetic unhappiness with what their previous surgeon performed. In my case, I feel as if my surgeon did an excellent job with my rhinoplasty. My only issue now is that I was extremely gratified in the first three to four weeks with my nose but failed to realize that the swelling played a role in that. Now that the swelling has almost subsided completely, I am looking to add enough bridge height to replicate what it looked like in the first month post surgery. I can’t stress to you enough how little of an increase in bridge height I am desiring, but it’s enough of a change to make a huge difference for me.
A: Thank you for our detailed rhinoplasty history. For a modest increase in dorsal height, I would agree that an injection of diced cartilage, done through an intercartlaginous incision, should be appropriate.While the concept of an injection always sound simple, it is important to note that cartilage must be harvested, prepared and then injected. The question is where that cartilage should come from…the contralateral ear or the septum? Either way this usually requires more than a local anesthetic in most cases.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a forehead widening and brow bone implant. Is it possible to get a wider forehead like in the attached picture and a brow bone similar to the one in the second atached picture in one combined procedure?
A: Such forehead and brow bone changes are possible under the following two circumstances;
1) a custom forehead implant with a brow bone extension must be used which is designed off of a 3D CT scan of the patient, and
2) a coronal scalp incision would be needed and the resultant fine line scar for its placement.
While smaller brow bone implants can be placed through small scalp incisions using an endoscopic technique, as soon as the larger forehead component is needed a much larger open scalp incision is needed to ensure proper placement.
The wider forehead comes from making the custom forehead implant extend beyond the anterior temporal lines on the side of the forehead. In essence the the implant creates a new temporal line more lateral to the existing one. This also requires that the implant extend down inferiorly on top of the temporalis fascia into a fine feathered edge so that there is no visible implant edge transition.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in pubic liposuction. I had a tummy tuck over ten years ago and my pubic area is rather puffy and i would like to get liposuction to remove the fat that completely sticks out on each side of the seam in my pants or it is disgusting in my bathing suit. I have an appointment with another plastic surgeon but I like all that you have said about this after tummy tuck problem so you seem to be experienced in what I am looking for.
A: It is very common after a tummy tuck that residual fullness of the pubic region is seen. This is because the fat content of the pubic region has not changed (tissue thickness) while what lies above it has. Since the narrowest portion of a tummy tuck is usually the scar line this makes the unaltered pubic region more evident after surgery. While many patients think that the pubic fullness is persistent swelling from the tummy tuck, this potential cause can be eliminated once one is six months after their tummy tuck. Pubic liposuction is the solution to the puffy mons and is tremendously effective at reducing its profile and making it flatter.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a facial artery pulsation on my face near my nose that has been bothering me for quite some time now. After reading your case study of facial artery ligation, I would like to get it ligated if possible. It is around the region of my cheek near my nose. I do have a hard time believing its possible to ligate such an important artery as it supplies blood to the skin and tissue of the cheek. If ligation is not possible, I would love to explore the alternatives. Maybe a fat transfer over the artery might work? I would be grateful for you opinion.
A: Please show me a picture of the area on the face where the pulsations exist. The facial tissues have such an extensive blood supply that any single artery ligation does not have a compromising effect. It is more of an issue of how easy is it to get to and would a single point of ligation be effective. Most likely you are talking about a branch of the facial artery as it courses upward around the mouth and the side of the nose. While it can be safely ligated there is the issue of back flow from the tissues that it supplies. Fat transfer for coverage is a good alternative consideration.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Thank you for your website which provides an extremely useful series of information on most areas of plastic surgery.
In relation to custom jaw angle implants, I understand there are a number of choices of material including MEDPOR and Silicone. If one is going to carve custom lateral jaw angle implants, to account for hemifacial microsomia, what sort of durometer of silicone is the best to use in this area – soft, medium or firm? Clearly, one would not want the same sort of flexibility or softness that one would expect of a breast implant for example, in the jaw area. Also, which material is better to use, silicone or MEDPOR?
A: When it comes to custom jaw angle implants, there is currently only material that is available to be used…silicone. It is my understanding that custom facial implants are no longer available as the manufacturer has chosen not to provide that service anymore. In using silicone for facial implants, the standard durometer would be firm or extra firm. Even the softest durometer for facial implants is much firmer than what is used in silicone gel breast implants. (that is for a soft tissue reconstruction not a bone reconstruction)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, These are a few pictures of my crown and a short video of my head. The hair on the ridges is sparse but in the furrows there is some. I’m not sure if I’m losing hair in this area due to mail pattern baldness or the cutis verticis gyrata. I just want to know my options for conceiving this. Wether it be a hair transplant over it or cutting it out.
A: Thank you for sending your pictures and the video. What you should do is based on how large of an area is involved in your scalp and how progressive or stable the cutis vertices gyrate is. If the area is small and stable and is not causing any other symptoms, it be left alone. I do not think it necessarily is causing hair loss but may just be spreading the follicles out further as it expands. (although I can not say for sure whether it is) The involved scalp area should only be excised if it can all be removed and should first have tissue expansion. The scalp is not very flexible and will leave a wide scar if it is all removed at once. If the scalp area is larger and it seems to be growing, then excision would not be advised. You may consider fat injections or PRP injections in an effort to treat it although such treatment is theoretically beneficial but not yet proven.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have read about your custom jawline implants (wrap-around style) on exploreplasticsurgery.com and was wondering if these implants can increase the width of the jaw angle as well as the vertical height or is it just the vertical height that these can change? I’m also trying to establish the drawbacks (apart from cost) of these wrap around implants over the separate jaw/chin implants.
A: Custom jawline implants can be made to any dimension that is aesthetically desired in either height, width or shape. The actual cost difference between a custom implant and standard implants is much less than one would think, with only about a 20% cost difference at best. While the cost of the custom implant is higher, it takes only 1/2 of the operative time to do…thus explaining why the cost difference is not that extreme. Having done hundreds of combination chin and jaw angle implants, I now find that single custom jawline implant produces a better aesthetic result with a very low risk of malposition/asymmetry compared to using three separate pieces. (1 chin and 2 jaw angles) In fact, it is virtually impossible to have a malposition of a custom implant because of the precision fit and design.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was wondering if you have and do perform surgery on cutis verticis gyrata. If so I was wondering some of the details and and maybe some idea of the length and width of a post op scar.
A: I have performed surgery on this exact scalp condition in the past and can make the following comments about it.
Cutis verticis gyrate (CVG) is a most unusual although not rare scalp condition of which its cause is unknown. But how it presents with ridges and creases is well known and that the scalp tissue thickens to create it. Treatment options are very limited with the most common approach in limited scalp areas of excision. This may be satisfactory if the rolls are limited to the back of the scalp in a horizontal orientation. But for many cases of cutis verticis gyrata the scarring is likely prohibitive. A more innovative approach is the use of subcision (release) of the creases combined with fat injections. This ‘scarless’ approach has no real downside other than its effectiveness and would be the preferred approach in larger areas of scalp involvement in which excision is not an option.
I would need to see some pictures of your scalp CVG to see which, if any treatment options, may be worthwhile for you.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am currently looking to have a rhinoplasty later this year. I had a discussion with an anesthesiologist about my needle phobia who advised I speak to the anesthesiologist who will be taking care of me during the procedure. As much as I want to say I don’t have a problem with my needle phobia I do. The last time I had my blood drawn I panicked and passed out. Obviously I don’t want any of that to happen which would make my surgeon’s job harder. He suggested maybe a prescription of Valium before the procedure or something of that nature. I will let you give me your professional advise on this matter. Looking forward to hearing from you.
A: Needle phobia issues are not uncommon in surgery. Known as trypanophobia, it is estimated that about 10% of people have it. While having to get a needle sick is unavoidable since an IV will be needed for your rhinoplasty surgery, there are numerous ways to get past this fear. Your apprehension can be remedied by taking 10mgs of Valium and 25 mgs of Phenergan orally orally one hour before arriving for your surgery. (as there will be someone driving you to and from surgery) Your surgeon can write that prescription for you. Make sure that you have signed your operative consents and had all your questions answered days before the surgery as consent can not be obtained from a mildly sedated patient.
The other management issue that can be done is to apply a topical numbing cream prior to actually putting in the needle. This will minimize needle insertion discomfort.
Dr. Barry Eppley
Indianapolis, Indiana
