Your Questions
Your Questions
Q: Dr. Eppley, I had a columellar strut from a rhinoplasty that caused a smile issue. I had the strut removed last year and my smile went “almost” to normal. It was a free floating strut. I am not sure if the doctor removed all of it or left a bit at the bottom. I am feeling some hard tissue there. Doctors say it is fibrotic tissue, but one said it is a strut remnant. The doctor who did it said he removed it all. Is there an imaging technique with which I can prove what is what? CT scan maybe?
A: No imaging can see a cartilage strut in the columella of the nose in any accurate way. If the doctor said he removed it I would believe him. I would expect that it will feel firm and fibrous as the anatomy has been disrupted…twice. At this point if your smile is ‘almost normal’ I would consider that a recovery that is as good as one could hope. Trying to take a 90% improvement to 100% is the surest way I know to probably make it worse…or at least end up with no improvement despite the effort.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had standard Implantech jaw angle implants placed three years ago, and although they are an improvement they are not the desired result. They appear quite bulky and have accentuated an asymmetric appearance. Furthermore, my right masseter muscle is now partially torn creating a large bulge around my cheek bone when I eat. Is this common with this surgery? I am reaching out to you with some questions:
1) Can Custom implants be placed after the removal of the current implants and the current state of the masseter?
2) Can the masseter be repaired at the same time as removal and placement of new implants or will it need to be two separate operations?
3) Can the masseter be repaired through intraoral approach? If not, what level of scaring will be present from an external approach?
Many thanks for answering my questions.
A: Thank you for your inquiry. In answer to your jaw angle and masseter muscle disinsertion questions:
1) Custom jaw implants can be used as replacements for your existing standard implants.
2) Masseter muscle disinsertion is a very difficult problem to correct. Surgical correction could be attempted at the time of implant replacements, provided the new implants are not substantially bigger than the ones you have.
3) Attempted correction of masseter muscle disinsertion is best done through an external approach, using a 2.5 cm incision below the jaw angle. With a disinsertion that is five years ago I would not be optimistic that it is improveable.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I want to do a brow bone reduction and scalp advancement, but first i need to ask you if its possible correct a irregular hairline (hole in the center) during the scalp advancement. I need to know if its possible to make that correction without hair transplant to the hole.I have a irregular hairline which is not common. i have a little lack of hair in the center front, like a little hole, fortunately its less than 1cm to the back. I need to know if you can align during hairline lowering to get a linear hairline.
A: While the entire scalp is mobilized for a hairline advancement, the edge of the hairline from side to side does not move equally. Because a scalp advancement (aka hairline advancement) gets the greatest movement in the center of the frontal hairline, it is likely that the hairline will become more linear afterwards. But that would depend on how much hairline advancement one is trying to achieve. Anything beyond a 1 cm to 1.5cms would likely end up with the hairline shape you now have. You may need to consider a hair transplantation after the scalp advancement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was recently diagnosed with a very mild case of Cutis Verticis Gyrata . I’m concerned with the size getting larger.I saw a dermatologist who diagnosed it and prescribed topical Ammonium Lactate 12% cream and 500mg of Vitamin C daily and said if it worsens there’s some laser type treatments that were possible but he was very confident it wasn’t going to worsen. I used to frequently get alopecia areola prior to going bald and would receive steroid injections which could be the cause?? I’m very open to having surgery/injections with someone who has done this in the past.
A: Thank you for your inquiry in regards to cutis verticis gyrata (CVG) and sending your pictures. From this information I can make the following statements:
1) No one knows or understands why CVG occurs.
2) Its natural course is completely unpredictable, it may stay the same or get worse over time. No one can predict what it will do in the future.
3) There are no proven treatment methods for CVG, either to treat it or prevent it from getting worse.
4) Topical treatments such as Ammonium Lactate or Vitamin C has no documented efficacy in the medical literature.
5) There are no laser treatments for it. This is a problem that emanates deep in the scalp tissues not on its surface at the skin level.
5) The only logical treatment for it is fat injections mixed with PRP. Since this is a condition of fibrosis, adding new tissue with stem cells and fibroblast activating factors makes the most biologic sense.
6) It is easier to treat CVG early when the fibrosis is less severe then when it is advanced when the tissues are as hard as concrete. (which is what occurs in its more advanced stages)
Dr. Barry Eppley
Q: Dr. Eppley, I want to do a direct necklift by cervical waveplasty or Z plasty. I have already tried liposuction and not much fat came out and my issue is loose skin so I thought of direct doing it. Attached are my photos. However I do shave my hair so please bear in mind the scars need to be able to be hidden.
A: Thank you for sending your pictures. A direct neck lift of any pattern would not be appropriate for you. The scars would turn out to not only be visible but would also be of poor quality. Direct neck lifts in men are only appropriate in much older men (age 65 or older) who have the skin laxity to create scars that heal better. Between your age and ethnicity any form of direct necklift would be a terrible decision that would result in scars from which there would be no good recovery. The only neck contouring option to consider in your case is a submentoplasty where fat is directly excised from beneath the platysma muscle and he muscle edges are resected.This will create a neck contour that would be better than that from your prior liposuction efforts although undoubtably not the 90 degree cervicomental angle that you desire.
Dr. Barry Eppley
Indianapols, Indiana
Q: Dr. Eppley, i have some questions about temporal reduction surgery. They are as follows:
1How long will it take for the scars behind my ears to heals?
2 How long will the sugary last and how many days will I have to be in your care before I can be released?
3Will this temporal reduction make my head look normal and not as big as it is now?
4What risk can this have on me now or for the years to come…I mean in my old age like 55 or above?
5 How much will this cost me?
Hope to hear from you, take care and God bless.
A: in answer to your temporal reduction questions:
1) The incision behind the ear heals very quickly because it is in the natural skin crease where the ear is attached to the head.
2) Surgery takes 90 minutes.
3) You should be able to return home the following day after surgery.
4) The goal of posterior temporal reduction surgery is to reduce the bowing on the sides of the head above the ears…to make the sides of the head straighter.
5) This surgery does not have any age-related effects.
6) My assistant will pass along the cost of the procedure to you on Monday.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have some questions about orbital implants. They are the following:
1. Does the zygomatic arch implant give more of that model cheekbone look?
2 a.Would the inferior orbital rims be augmented with a tear trough/infraorbital rim implant?
b.Would the superior be augmented with a brow ridge implant?
3. Is there only one type of infraorbital implant? Or is there a customizable implant also?
A: In answer to your questions about orbital implants:
- The augmentation of the zygomatic arch back towards the ear does create a well defined facial feature that some may refer to as a model cheek look. It does seem to be an area of facial augmentation that provides a more angular facial appearance.
- a) Inferior orbital rim augmentation requires a complete infraorbital rim implant, not just one that augments the tear trough alone. b) A brow bone implant augments the superior orbital rim also known as the brow bone.
- There are no standard infraorbital rim implants, they all have to be custom made
In short orbital rim implants are a unique collection of facial implants for which there are few standard shaped implants to treat this facial area. The role of custom implant design is usually necessary for most implant augmentations in this facial area.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have had double jaw surgery in the past. Can I still have midface implants place after? In addition, what is the ‘duration’ of such implant, as in after how long might need to take it out? And what are the risks associated with such surgery?Thanks.
A: A variety of midface implant styles and sizes can be used to further enhance the effects of a prior LeFort I osteotomy. In answer to your midface implant questions:
1. Having a prior LeFort osteotomy does not preclude from having midfacial implants. A custom design can be done around any existing plates and screws. As a general rule I usually do not like to take out plates and screws in the maxilla as they often open up holes into the maxillary sinus which could be an infectious source for the implant.
2. As long as they achieve the desired aesthetic effect, midface implants are permanent. They will never degrade or need to be replaced because of a material problem such as breakdown or being ‘worn out’.
3. Like all implant surgery anywhere in the body the surgical risks are the same….infection, asymmetry and inability to achieve the desired aesthetic facial effect.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in the custom implants for the back of my head and both sides of my head which are flat. A few questions about 3D skull implants I have are:
1.What kind of materials are used for the 3d skull implant?
2.What type of screws are used (metal or plastic), and do they effect x-rays?
3.Assuming no infection, can these implants be rejected later in life like 20 years down the road?
4.How long does the procedure usually take(best case and worst case).
5.Is this reversible?
6.Can they be felt from outside the skin, meaning the corners of the implant.
A: Thank you for your inquiry. In answer to your 3D skull implant questions:
1) They are made of a Solid silicone material
2) Titanium microscrews are used to maintain early implant stability. They will not affect getting MRI studies later.
3) Infection of any skull implant can happen early after surgery (although I have yet to see it) but not delayed rejection.
4) The surgery time for the procedure is around two hours.
5) It is a completely reversible procedure. A silicone skull implant can easily be removed later if desired.
6) The edges of most 3D skull implants are usually not seen or easily felt.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have some questions about cheek and orbital implants.
1. What is the difference between an extended zygomatic arch implant and a cheekbone implant?
2. Besides brow ridge implants is there anything that can your eyes more deepset
3. Do lateral orbital rim implants make your eyes more deepset/what is the aesthetic Benefit of strong lateral orbital rims?
4. Are there only 3 main parts of the orbital rims that can be augmented? Supraorbital/infraorbital/lateral rims.
A: In answer to your facial implant questions:
1) An extended zygomatic arch implant is a special type of cheek implant which covers the arch posteriorly almost back to the ear. It is not a standard type of cheek implant. It can be part of a more anterior cheek implant or zygomatic arch implants can be done as a stand alone procedure without augmenting the cheek. A zygomatic arch implant creates a widening effect of the midface back to in front of the ears.
2), 3) and 4) Deep set eyes come from augmenting the superior, lateral and inferior orbital rims.This makes the bone around the eye more protrusive thus making the eye look deeper set. Whether one of these three area or all of these areas need to be augmented to have that effect must be determined on an individual patient basis.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like to know whether you, in principle, perform endoscopic surgery for the removal of forehead lipomas. This is because I understand that some doctors use the endoscopic method for the removal of osteomas only, believing that using the technique on lipomas cause too much tissue trauma. I wonder what is your position on this issue.
A: In answer to your question, most forehead lipomas can be removed with an indirect approach using a hairline incision if one wants to avoid a direct scar over it. While an endoscopic technique can be used, it usually offers little benefit and does require the elevation of much more forehead tissue off of the bone than the hairline approach does.
However the further forehead lipoma is from the hairline, like down at the eyebrow area for example, it may not be possible to remove it from a hairline incision. This is where the endoscopic can have a role in its removal. A guideline to use is if the lipoma is below the ‘equator’ of the forehead the endoscopic technique will be needed. But if it sits north of the imaginary horizontal line it can be removed through a hairline incision.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I underwent otoplasty surgery several years ago from which my ears got over corrected (pinned back too much). As a result it gives my face a weird and unbalanced look. My surgeon basically didn’t correct my ears based on my face shape. I recently consulted with him regarding a correction or undoing what he did. His response was that no cartilage was removed, it was just cut in places to weaken it so it could be bent and reshaped. Therefore he said he can undo it, however, the ear protrusion will not be 100% as it was before surgery, as surgery was performed long ago. I don’t want to go back to this surgeon after my initial experience with him. I am primarily looking to get my ears protruding out again (especially the middle portion which is almost not visible from the front. Please help as I really need to get them corrected. I have attached pictures for your review.
A: Thank you for sending all off your pictures. What you have is an overcorrection of the middle third of your ear as the outer helix is pulled back behind the antithetical fold. This is the most common form of overcorrection in otoplasty. (the so called telephone ear deformity) This is corrected by a postaurucular release of the cartilage folds and the placement of an interpositional cartilage graft, usually allogeneic in nature rather than harvested from the patient. (reverse otoplasty) This is a procedure that can be done under local anesthesia or IV sedation. Since there was a reason you had the surgery in the first place, I would assume you would not want to regain to their original protruding shape, just correct the overcorrection.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m a 27-yr old female. I have been thinking about having an occipital augmentation procedure done to correct for the flatness and asymmetry at the back of my head, due to bad sleeping position from when I was an infant.
Currently I have two questions regarding the procedure. I will be very grateful if you can give me some answers:
1) I’m hoping to achieve notable increase in the projection of my upper occipital region. I know this will depend on the laxity of my scalp. According to your experience, can you tell me that, for an average person in my age range, how much increase in projection (in cm) is realistically achievable? I’m thinking about using implant.
2) Will screws be needed for the fixation of the implant?
3) Is this performed under general anesthesia? Or local?
4) Is it possible to achieve notable increase in projection with bone cements?
5) What would the cost be for a typical occipital augmentation procedure?
6) After the procedure is already performed, how many days will it take for me to be able to go back to work?
Thank you in advance.
A:Thank you for your occipital augmentation inquiry. In answer to your questions:
1) Normal scalp laxity will permit a 10 to 15mm increase in central projection. More than that requires a first stage tissue expansion.
2) I always use two microscrews for early implant stability.
3) General anesthesia is required for the surgery.
4) Bone cements can not create the same outward push as an implant for a wide variety of reasons.
5) My assistant will pass along the cost of the surgery to you later today.
6) Most patients should be able to return to work in 7 to 10 days after the surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a facelift question. You did a secondary facelift on me from an initial facelift done one year ago by another surgery. While the terrible scars from around my ears are now gone, I noticed that the remaining horizontal scar across my sideburn (which we left along to manage later) has not really change in position much. I don’t understand the vectors of tissue lifted in facelift surgery. Is can you explain it to me.
A: In facelift surgery what happens to the SMAS does not translate in a 1:1 relationship to the skin. The whole purpose of SMAS manipulation is to take tension off of the skin to prevent scar widening and to hold up the results longer. Its purpose is not to allow a lot more skin to be removed particularly on a secondary basis. In fact it is quite the opposite. Its role is to allow facial tightening so that the scars can be removed with the least amount of skin removal that will not create recurrent adverse scarring or distort the hairline or earlobes. This is particularly relevant in a secondary facelift that was done in a relatively short time after the first. Your secondary facelift goals were to eliminate the wide scarring and prevent its recurrence and tighten the underlying tissues better to support that effort. Thus I would not expect the horizontal location of the preauricular back cut to change in any significant way. This would be very different if the secondary facelift is done 7 or 10 years later when significant skin laxity had returned and more aggressive skin removal was warranted. Being a male with thicker skin with more pigment you can see what happens when skin removal is done by itself when its elastic limits are exceeded and its movements are not supported underneath it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have some chin reduction recovery questions. I wish I came across your site before. I just had chin shaving and sliding genioplasty two weeks ago. I know it is early but I don’t think the incision was stitched together correctly. My lower lip hangs down and when I smile the lower lip now covers my top teeth. I also have no feeling on the left side of my chin. And the steps were not shaved off so I have large bumps on my jawline. I am so devistated so far. Is it possible to send you photos and get your opinion. Again, I’ve research this surgery for four years and never came across your site until now.
A: It is important to point out that at just several weeks after chin reduction surgery many of the symptoms that you describe are not uncommon. A month or two more of healing can make a big difference in much of what you are experiencing in the early phase of your chin reduction recovery. The final result can not be fully appreciated until three months after surgery with all swelling and tissue contractions and remodeling have occurred.
Lastly it is not appropriate that any physician comments on early surgical results when the patient remains under active care of the primary surgeon.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had custom chin implant surgery placed two days ago and I have noticed there is an indentation along the side of the chin on the right side that is not present on the left side. I am concerned that this may represent an implant malposition. I know you told me before surgery as well as our visit that day after surgery not to overanalyze or interpret what I am seeing now when there is a lot of swelling present.
A: You are correct in that I mentioned during your most recent postoperative visit (yesterday) to avoid making any preliminary assessments about how any facial implant looks in the short-term, particularly in the weeks to first month after the surgery.
But your question is understandable and I have the unique insight into how the implant was placed and positioned during your surgery and the great intraoperative attention that is paid to the placement of such implants. From that perspective I have confidence in its symmetric placement and there was certainly no evidence of any asymmetry when it was placed.
To provide you with some insight into why the placement of facial implants is often associated with asymmetry in the early healing process, it is necessary to understand how implants are placed and how the body heals around them. It is not just about swelling as a tissue reaction as, if that was true, all swelling around implants would be perfectly symmetric on both sides of the face.
To place an implant in the body, the tissues must be widely raised around it. (pocket creation)This pocket is always much bigger than the implant itself so the implant can be positioned properly without deformations of the implant’s shape. The elevation of the tissue pockets (the disinserting of tissues off of the bone) is never exactly the same on both side of the face and does not need to be…what matters is that there is enough room for the implant to be placed and positioned as desired. Because there is no swelling of tissues during surgery (just the release of the tissue attachments) the external result of the implant can be seen to be symmetric. (if it is properly placed) BUT…when the postoperative swelling ensues the tissues that swell the most are those that have been disinserted. (tissues swell more when they have lost their attachments than those that have not) THUS given that the raised tissue pockets are never completely identical on both sides of the face the external swelling that ensues is often asymmetric. In short, the swelling really represents the extent of pocket creation and not that of the implant’s shape or position.
Understanding this biologic response also provides insight into the recovery process. To see the final result around any implant, one must wait to see two healing processes be completed…resolution of swelling of the tissues AND the readapting of the tissues back around the implant. (the so called shrink wrap effect) This is a process that takes a full 6 to 8 weeks to be completely realized in both phases….and sometimes even longer.
I hope this explanation provides insight into why, at this early postoperative time period, I am not concerned. I have seen these early facial asymmetries around implants many times. While the final result awaits to be seen, the healing process around the implant must be allowed to play out.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’ve been reading up on your custom jawline implant work, and I’m thinking about getting it done. I had a few questions.
1) Will you continue offering custom jawline enhancement into late 2018? Time constraints at the moment make it unlikely that I will be able to undergo significant surgery until at least summer 2018; ideally winter 2018.
2) If I am in ketosis (as part of a ketogenic diet, not diabetic ketoacidosis), will the considerations for my anesthesia be different? Can I safely go under general anesthesia while in ketosis? Or will I have to eat high carb before the surgery so my body is not in ketosis anymore?
3) Can a custom jawline implant be combined with a buccal fat removal to maximize the chiselled look? Can a rhinoplasty be added on top of a jawline implant and buccal fat removal?
I look forward to hearing from you soon. Thanks so much.
A: In answer to your custom jawline implant questions:
1) I will be operating far into the foreseeable future.
2) I am not aware of any negative effects of someone on a ketogenic diet having general anesthesia. But I will check with my chief anesthesiologist to be certain of that statement.
3) It is common to perform buccal lipectomy with many other types of jawline enhancement surgeries, particularly a custom jawline implant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in electrocautery for masseter muscle reduction. My questions are:
1. How long does the procedure take?
2 . Is it painful?
3. What is the recovery time?
4. Will I have to be on a liquid diet for some time after the procedure?
5. How long do results last?
6. Do you have any before and after pictures of this electrocautery procedure?
7. What is the cost for an electrocautery procedure?
8. If one of the masseters is larger than the other, does it require subsequent sessions of electrocautery, or can it be done in one session?
Thank you.
A: In answer to your masseter muscle reduction questions:
1) The procedure takes an hour under general anesthesia.
2) Like all procedures that manipulate the masseter muscles, there will be some temporary discomfort and tightness of jaw opening for a few weeks after the procedure.
3) Like #2 above there will also be some temporal swelling which should resolve in 7 to 10 days after the procedure.
4) You can eat whatever feels comfortable after the procedure. There are no dietary restrictions…although it will be a week or so until you will return to a completely normal diet.
5) It will take 3 months to see the final muscle atrophy from which those results will be permanent.
6) Due to patient confidentiality, patients pictures can not be released.
7) I will have my assistant pass along the cost of the procedure to you tomorrow.
8) It may but that is hard to predict based on how much muscle atrophy will occur from the thermal injury to it.
Dr Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I remain very interested in having skull augmentation and reduction of a bump done in the next year. I am wondering whether you could help alleviate a concern I have regarding the custom skull implant option. I have donea lot of my own research as sort of a hobby and came across some information regarding a potential risk/association between silicone breast implants and cancer (which was determined to possibly be a result of chronic inflammation).
Is this a risk with a custom skull implant or is the skull less susceptible if at all to such inflammation due to the fact that it’s bone? Also, would drilling screws at various places help reduce any chafing? You mentioned the implant and burring can occur at the same location/incision but figured additional tiny incisions for drilling the implant in place would also make sense.
A: There is no biologic response correlation between silicone gel breast implants and solid silicone skull implants. (or any other solid silicone implant) These are different forms of silicone. That issue aside, there has never been any proven association between breast implants and cancer. You may be confusing that with another unproven association between autoimmune diseases and older silicone breast implants. This has been conclusively shown to have no such effects and was the basis for the FDA releasing silicone breast implants for clinical use again back in 2006.
There is no chronic inflammatory reaction with a custom skull implant made of solid silicone and thus your issue about ‘chafing’ is not relevant as no such tissue reaction occurs.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a very masculine jawline implant. I have currently had silicone implants from implantech. Medium lateral jaw and medium square chin implant. I’m two months out and I still feel that my face looks very round and swollen. Maybe I haven’t waited long enough. The custom jaw/chin one piece implant looks very chiseled and unbelievably real. I have attached a photo of me now and what I was trying to achieve. If I need to wait another six months to a year I will but I am on a mission to get this very extreme masculine jawline.
A: While the final facial shape takes three to four months to be fully appreciated after any implant procedure, it is fair to say that the result you now have is not going to undergo dramatic change. While I have no idea what you looked like initially, the use of standard chin and jaw angle implants was never going to achieve the type of ideal or masculine jawline result you have shown in your examples. In fact not even a custom masculine jawline implant, no matter how it is designed can ever achieve that result. You simply don’t have the facial anatomy to make that happen. That is not a realistic surgical goal or a mission that you can ever fully complete. A more realistic result would be about halfway between where you are now and your dream jawline shape with a custom one-piece jawline implant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have sent you some photos in previous two emails of my skull shape and protruding temporal area with convex appearance. The muscle bulge is palpable and visual and creates a bilateral bulge just above my ears which is hugely increased in size and convexity when I frown (it’s like the facial frown muscles are connected to this bulge). For me it creates the appearance of a wide head which further draws attention to my oddly shaped skull in particular a long sharply angled, flat occipital region. I am unable to wear most sunglasses as my head appears so wide and if I attempt to place/rest glasses on my head they will crack due to intense pressure from sitting on the bulges. If you require any more pictures, angles please let me know. I am determined to fix this and create a more aesthetic appearance. I was completely unaware until I came across your revolutionary work in skull aesthetics. Thank you so much!
A: Your very description of your symptoms and pictures speaks to a large posterior belly of the temporalis muscle, exactly what the posterior temporal reduction procedure addresses. It’s goal is to change the convex shape of the head above the ears to more of a straight line. This becomes possible because the thickness of this muscle, particularly above the ears, is as much as 7mm to 9mms per side. Done through a postauricular incision, it removes the full thickness of this muscle creating an immediate elimination of the temporal bulge.
Dr. Barry Eppley
Indianapolis, Indiana
Dr. Eppley, I have lower facial asymmetry that increased after advancement surgery for the lower jaw. My lower jaw was fixed in a tilted manner, which led to the displacement of the chin also. I want to fix it but I don’t now what is the best procedure. I found reviews about you, and I am hopeful you can help. Thank you.
A: Thank you for sending all of your pictures and x-rays. What they show, as you probably know, is that your lower facial asymmetry is due to the shape and position of the lower jaw. While the right side of the face is also smaller as you move up from the lower jaw, it is less so and is primarily due to the soft tissues.
Assuming that your prefer the left side of the face better (more full), the most effective approach would be a right jawline implant to build out the right side of the lower mandible that also wraps around the chin. This would create better symmetry and some increase in chin projection as well. There may also be a role for a small cheek implant combined with fat injections between the jawline and the cheeks to build out the soft tissue as well.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, after a previous rhinoplasty procedure, all is well except that my nose leans to one side. If I apply pressure, my nose will be perfectly straight for a few seconds. I wonder if there’s some brace I can wear at night or internal splint or other option just for a slight straightening. Thanks.
A: Cartilage has memory so if that memory and position of the nasal structures did not get changed during the original rhinoplasty you can not manipulate it externally after surgery to do so. Nose cartilage is not like orthodontics where you can work out its memory. No internal or external device/splint will do so. Only a secondary or revisional rhinoplasty will work to actually changing the shape and position of the involved cartilages.
While there are devices out there that promote non-surgical rhinoplasties, they do not really work. They fall under the category of ‘hope lives eternal as for a few dollars many encouraged use them and see what happens. You may fall into that same category as well as there is no harm in using these nasal clip devices.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had double jaw surgery three years ago to fix sleep apnea. But it caused some unwanted aesthetic changes. I saw a local plastic surgeon and he suggested the following after voicing my facial concerns;
1) Alar Base Reduction. I told him that my nose is wider now and he said it’s a side effect of the double jaw surgery. He said alar base reduction will fix it.
2) Chin Reduction. My chin seems too far forward and a little wide. He didn’t recommend reducing size of chin but he thought sliding it back would suffice. (reverse sliding genioplasty)
3) Lower Facelift. I told him my cheeks are quite saggy. This surgeon said lower facelift fixes saggy cheeks.
4) In addition, is it possible to add on nose tip reduction to all of the above and do together? Double jaw surgery also made my nose tip markedly bigger.
Thanks for your input. Just trying to get my face back to where it was before double jaw surgery.
A:In answer to managing the adverse soft tissue effects of double jaw surgery questions:
1) Nostril widening is very common after a LeFort 1 osteotomy due to the subperiosteal release of all midface muscle attachments to do the procedure. Nostril width reduction by Weir wedges will restore bialar width.
2) Chin reduction by a reverse sliding genioplasty is usually not a good idea. It will cause some increased submental fullness (it pushes back and down the attached submental tissues) and bony notch deformities along the interior border of the jawline. It will also keep the chin wide or make it wider. The more effective approach is a submental chin reduction by bony reshaping which can reduce both horizontal projection and width of the chin with a few far easier recovery.
3) A lower face lift addresses the jowls and neck but will not satisfactorily improve the cheeks. That requires a more direct cheek lift approach. Although I would have to see where you are seeing the cheek sagging.
4) Tip rhinoplasty can be done with any other combination of facial surgeries.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had bone grafts done for my jaw angles about twenty years ago and they have really disappeared. I should have done jaw angle implants as they are permanent. Can you still do jaw angle implants if I had bone grafts placed there previously?
A: Having had prior bone grafts to the jaw angles does not preclude having jaw angle implants later. Onlay bone grafts always undergo irregular but near complete resorption. This has been a lesson learned in craniofacial surgery decades ago. Because the bone graft pushes out the biologic boundary of the bone and is not functionally loaded, it has no reason to persist so it largely resorbs over time.
But the prior placement of bone grafts and any asymmetry that they now cause to the jaw angle bone may indicate the need for custom made jaw angle implants to fit the irregular shape and surface of the bony angles. A 3D CT scan would be good idea to determine the shape and contours of your bony jaw angles now. That would help make the determination as to the best approach to your jaw angle augmentation needs now. By your history with the bone grafts, this would indicate that you only need a widening jaw angle implant approach.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in total jawline augmentation. I can show you the change that I am looking for when I jut my jaw down and forward as shown in the attached picture. Do you think this type of jawline change is possible?
A: In looking at your own prediction imaging by moving your jaw down and forward, it creates two artifacts that will not happen from a surgical procedure like a custom jawline implant for total jawline augmentation.
First, the depth of the labiomental fold will not be pushed forward or become more shallow. The depth of the labiomental fold can only be changed by bring the teeth forward (lower jaw advancement) not by any jawline implant augmentation. It sits above the level of the bony chin so any form of chin augmentation will not change it and may make it a bit deeper.
Second, the jaw angle area will be come more obvious or angular with implant augmentation. Jurtung the jaw forward actually blunts the jaw angles as they come down and forward. An implant will actually make the jaw angle more pronounced or stronger as your ideal pictures demonstrate.
I have attached an adjusted imaging picture which I think is more realistic of the actual result in profile view.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am considering chin implant revision. I got an Implantech medium anatomical chin implant through a submental approach six months ago.
Before I list my questions/concerns, I would like to say I’m extremely happy with the way the implant looks and prefer to keep it than to remove it but the tightness on the right side of my lower lip is very bothersome. I received a few doses of Botox to see if it would relieve the tightness and it has but I’m afraid this is only masking the feeling and not really taking care of the problem. I would love to think it would solve the problem with the tightness but I know Botox is only a temporary fix. And I wouldn’t want to wait too much longer as I feel my nerve might be compressed and have some hope perhaps I could get some feeling back and relief of the tightness if I were to remove it. The reason I think I’m hopeful on my nerve having some feeling back is because when I stretch my mouth downward (as if I were yawning), I feel immediate relief. Also, when I push the right side of my lip outward with my tongue, I feel lots of tingling on my right lower lip as if there was still some nerve messaging going on there.
This is why I needed a second opinion on what I should do. I’ve heard of numbness sometimes being permanent but is this true with tightness as well? If I were to remove the chin implant, will the recovery be as when I put the implant in? Can tightness still be a problem even after removal? Does scar tissue cause problems after removal?
Thank you for your time and consideration as this has been an emotional rollercoaster for me. I don’t think I can go through a revision either as I have heard that those who have had it done usually opt to remove it anyhow due to other issues. I appreciate any guidance.
A: Thank you for supplying your additional information. The most important thing to know with your symptoms and considering a chin implant revision is what is the actual position of the implant on the bone. Is the implant placed symmetrically? Is an implant wing up against the mental nerve? Are your symptoms due to the implant position or just from the soft tissue alone? Your symptom description implies the former.
Tightness issues can be different than nerve issues but it is important to know where the implant is actually sitting on the bone which can only be obtained from a 3D CT scan. If you didn’t like the aesthetics of the chin implant then such a study would be irrelevant. But since you do, first establishing that the implant is in a good and symmetric position and its wight wing is not compressing up against the mental nerve would be a critical piece of information in how to proceed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a middle-aged male and I recently noticed that I have bulging temporal arteries (can feel a pulse) on both temples, which look like squiggly worms from my ear arcing up to my (receding) hairline. These arteries are visible at rest but really ‘pop’ when I get hot, drink alcohol, or workout. I did not have these (or at least they were not noticeable enough) several months ago. I went to a Rheumatologist, who ruled out GCA/temporal arteritis. I am now exploring options to reduce the visibility of these, one of which is arterial ligation and I have a few questions:
1) In lieu of GCA/temporal arteritis, what causes the temporal artery to suddenly swell and become permanently visible (I’ve read about others who have experienced the same thing)?
2. How many of these temporal artery ligations have you performed? How many needed follow-up procedures?
3. My biggest fear by far with this procedure is damaging the facial nerve, which from pictures I’ve seen, runs extremely close to the temporal artery. I know plastic surgeons study where the nerves are but I assume the location of the facial nerve differs in everyone. Any damage to this nerve would becatastrophic and would be 100x worse than the bulging temporal arteries. How would you respond to this?
4. How do you ‘map’ these arteries to determine if there are ‘feeder branches’ that would circumvent the ligation – do you use some type of ultrasound?
5. Could ligating the temporal arteries cause the arteries that run from the eye to the hairline (or other facial arteries) to swell and turn into the ‘squiggly worms’ (I read about a guy who this happened to 3 years after he got a temporal artery ligation).
6. Which arteries would supply the scalp / forehead if the temporal arteries no longer function?
7. Does the temporal artery supply blood to anything else (besides the scalp / forehead)
8. How big are the incisions? \I’ve read that dissolving stitches leave a bigger scar than removable stitches – is this true?
9. Do you tie off the arteries or sever them? I read that you don’t drain them – how does that remove the bulging effect as the blood would be trapped within the temporal arteries (I picture a water balloon – you can tie off the end but all that does is trap the water in, making the balloon swell).
10. I assume it is local anesthesia, correct?
11. What is the recovery time? What is expected post-op as far as swelling / bruising / scarring / time until return to work / exercise / etc?
12. Do you perform this procedure on Saturdays for out-of-towners?
A: In answer to your temporal artery ligation questions:
- It is unknown.
- I have performed over 50 temporal artery ligation v]cases which has resulted in about 10% to 15% needing a touchup for additional ligations.
- The frontal branch of the facial nerve is not in the same areas as the ligation points
- Visual and digital assessment is the method used to map out the arterial patterns.
- This is not something I have seen. With multipoint ligation this risk is lowered significantly.
- There are many other arteries that supply the scalp.
- No.
- 5 to 6mms for the incisions size. Dissolveable sutures do not leave a bigger scar.
- The arteries are double tied but not cut. The blood is stripped between the ligation points to prevent postoperative bulging.
- Local anesthesia is correct.
- There is very minimal recovery time, no real recovery actually
- I only operate during the weekdays.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley,I’d like your opionion on having a chin prejowl implant, or just a pre jowl sulcus implant. My concern is not the anterior projection of my chin, but the verical height. I think an implant that can add around 3 mm of vertical height below my chin, and widen or treat the prejowl area (maybe make it more square, as well) would be my best option. My goal with the implant is to disquise my double chin line underneath my chin (already treated with liposuction and Ulthera), and maybe to improve jowling if I have it. Of the off the shelf implants, what would be my best choice? Thank you very much!!
A: Thank you for your inquiry. If the vertical height is the main objective with your chin augmentation, with the addition of some squareness, no standard chin implant has those dimensions to make those changes. Certainly a chin prejowl implant can not accomplish those changes. That would require a custom chin implant design. In addition your neck should ideally be treated with a submentoplasty as your main problem now is the fat that lies below the muscle, that combined with some muscle tightening will take the results of the prior neck liposuction to another level of improvement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in plagiocephaly surgery. I was wondering what procedure would be better to reshape the plagiocephaly of my head. I have seen that there is a procedure done in South Korea where they use bone cement to remodel the shape of the head. I was wondering what opinion you had about that procedure or the use of an implant. what are the pros and cons? I really appreciate it and thanks in advance Dr. Eppley.
A: A custom skull implant is almost always better than bone cement for almost any form of skull augmentation for the following reasons:
1) it can be put int through a smaller scalp incision,
2) it can cover a broader surface area in a smoother fashion,
3) the shape of the augmentation and all of its details is determined before surgery and is not left up to the ‘artistry’ and hands of the surgeon,
4) it has a much lower rate of revision due to inadequate augmentation, irregularities or visible implant edge transitions that are far more common with bone cements, and
5) it is very easily reversible if needed. A silicone skull implant be fairly easily removed.
Dr. Barry Eppley
Indianapolis, Indiana
