Your Questions
Your Questions
Q: Dr. Eppley, I had an otoplasty done several years ago to correct my protruding ears. When I saw the results, I was disappointed and thought my ears were undercorrected. I decided that I wanted another operation. We did the operation again 3 months after the previous operation, which I think caused my antihelix to thicken. nI don’t mind that my antihelix is thick, I do mind how close my ears are to my head. I also developed a telephone ear deformity. All I would like to do is return back to how my ears looked before, but I know that might be difficult. How difficult would it be to return it the original shape and protrusion or something close to the original shape and protrusion?
A: I would need to see pictures of you ears, both now and before, to better answer your question. But I think the question is not whether your ears can return to their initial preoperative state, because they can’t, but how close or what type of result, could such an otoplasty reversal come to it. There is no going back home, so to speak, there is only how much closer to home can you get. Very few surgeries are ever 100% reversible.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, i am writing to you for some possible assistance. I was reading a thread just now that was posted a few years back about bulging temple veins. One of the gents on the forum talked about how he went to you for treatment for his” wiggly worms” on his temples. I have the same issue much more mild though on my right side, i thought i would ask you if you know anyone personally that resides in my area that does this procedure and is very good at it? It is a old post so i was curious, has treatments become more advanced since then? Like it can be done with lasers now or is done with just a trip to the surgeon office? I don’t know the first thing about all this and that is why i have come to you, i don’t mean to bother you. This gent spoke very highly of you and thought i would enquire.
A: What you are actually referring to are known as prominent temporal arteries, not veins. This is the type of prominent vasculature that occurs most commonly in men in the temples and forehead region. The only technique for their reduction/removal is my multipoint ligation technique. I could not tell you whom in your geographic area may perform this temporal artery ligation procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Thank you for the informative consultation a few days ago, I am currently in the process of narrowing my choices. I just had a few questions.
1.) What are the odds of long term side effects with genioplasty vs jaw implants? Is one significantly safer than the other?
2.) Would a custom jaw implant benefit my chin as well? If yes, would it benefit my chin to the extent a genioplasty would?
3.) Would a custom jaw implants be much better than standard implants in terms of symmetry?
A: In answer to your questions:
1) A genioplasty (chin) and jaw angle implants carry with them different risks. I am not sure I would ever say one is safer than the other but because the jaw angles involve an implant and the chin is done by moving one’s own bone, jaw angle implants carry a risk of infection than a bony genioplasty does not.
2) By definition a custom jawline implant wraps around the entire jawline from angle to angle and crosses the chin. An implant can create the same amount of horizontal augmentation that a sliding genioiplasty but also can widen the chin which a genioplasty can not do. (it actually makes the chin more narrow from the front view)
3) One of the benefits of a custom jawline implant approach is that it is one piece, using standard implants is a three implant approach. This reduces the potential risk of asymmetry both by its design and placement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a young female and 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
Dr. Eppley Q: Dr. Eppley, Can you please give me some information on custom facial implants? If I decide to go ahead with the procedure how much time do I need in the USA?
From the date that I arrive –
to have the CT scan,
to manufacture the jaw or skull model ?
To sit together and design the implant
To manufacture the implant
To operate
To leave hospital
To be able to leave USA ?
I am extremely concerned about infection – because I have just had cervical disc put into my neck. An infection my spread to them and create a big problem causing them to be removed.
Also extremely worried about pain – that is the one thing keeping me from going ahead – how can we totally control this ? Can I stay in hospital of the first couple of days so that I can get stronger IV pain medication \?
A: In answer to your custom facial implant questions:
1) The design and manufacture of custom facial implants is a 4 to 6 week process. Therefore patients get their 3D CT scan in their local geographic region and send it to me. I then take the scan and do the design process. Patients only come here for the surgery for the obvious practical reason.
2) The design process is done in sessions with engineers from 3D Systems. Patient do not directly participate in these actual sessions. I then take the design files and share it with the patients for their input. We have three design sessions to come up with the final approved implant designs.
3) The surgery time for a custom jawline implant is 2 hours.
4) If you are coming by yourself, and given your immediate pain concerns, you would stay overnight in the surgery center. This surgery is not performed in a hospital as that changes the cost of surgery significantly.
5) You would fly home when you are comfortable doing so. Each patient is different but I would give yourself at least 5 days after surgery before leaving.
6) While infection is always a concern in jawline implant surgery, I would have no concern about it spreading to your cervical disc implants should it occur. When occurring it remains localized to the implant pocket.
7) While the most common postoperative custom facial implant issues are aesthetic in nature, infection is the one medical issue that we pay a lot of attention to try and avoid through a host of strategies. But infection is not something that ever occurs immediately, its occurrence is always in the range of 3 to 6 weeks after surgery…a time that surprises patients as they think they are well past it at that point.
8) While every patient is different about pain, that has never been a postoperative issue that has been a problem with any custom facial implant patient. You may every well be different in this regard although I would think your cervical disc surgery would have been far more painful than jawline important. While one would receive IV pain medication in the overnight stay int the surgery center, there is no capability to go to a hospital for IV pain medication after the first night after surgery.
9) Pain is not something I worry about in any patient as that seems to be well controlled by standard pain medication. What I do worry about is that few patients are psychologically prepared for the large amount of facial swelling that will occur (from the patient’s perspective) and the duration of time that it takes to go away. This can be very psychologically destabilizing for some patients…and they are always the male patients that have the most difficulty with it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a couple questions about some problems I have with the lower third of my face and lip area. To begin with, I’ve noticed that my lips have begun to age. My upper lip looks quite long, and I’ve always had a downturned mouth and aging has exacerbated it. I look extremely sad/angry, even when I’m not. I have vertical maxillary excess, causing bite problems and lip incompetence too.
Is there anything I can do to fix all this? I was thinking a combination of a corner lip lift, upper lip lift and facelift would address the lip problems, but I would still need something done for my maxilla, to shorten it and help with the lip incompetence.
Thank you very much for your attention.
A: If you have maxillary excess that needs to be treated and would be beneficial to do so, that is what you need to treat first. All the external changes of the lips and face need to await that fundamental skeletal change. You would only do the lip and facelift procedures first if you knew that you were never going to have a maxillary impaction procedure. I would need to see pictures of your face to provide a more qualified answer.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like to ask are cheekbone reductions always bound to have some sort of sagging of the midface area or incur premature aging?I thought I had done enough research on zygoma reduction before deciding to undergo the procedure. I knew there would be risks or trade offs, but I didn’t know it would be this bad.The L-osteotomy surgery I had included a 4mm removal of bone on each side. My front and 45 degree cheekbone was not prominent. Only the lateral of my cheekbones was quite prominent, giving me a strange wide and manly face shape. Why is it that my front cheeks sagged so much after the surgery?
A: When the whole cheek bone has been moved in, depending on the facial type, the risk of soft tissue sagging is a real one. That is whole skeletal support for the midfacial soft tissues, particularly the front part of the cheeks. By your own admission the front part of your cheekbones was fine but it was the back part (posterior zygomatic arch) that created the issue. Thus it would been better to just have the posterior arch osteotomies done with inward positioning as that would have caused no soft tissue sagging at all.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a lip lift in early December 2017. The surgeon took out 7mm of skin in the center of the upper lip. And now it seems that the nasolabial area looks bigger and mouth corners look down turned. I would like to know if the Double Duck would be a good option for me, when can I get the surgery and if you could perform this surgery, how much would it be ?
A: Thank you for sending your pictures, particularly that of the preoperative markings. When this amount of skin resection is done with a flat inferior border in a subnasal lip lift, it can cause an apparent over corrected appearance to the central upper lip and the sides of the lip are left ‘behind’. This creates an upper lip central to side vermilion disproportion and can also cause a downturning of the corners of the mouth. (too much central lip pull)
A strategy to improve to improve your upper lip shape could include the following:
1) Extended corner of mouth lifts with lateral vermilion advancements
2) Subnasal scar revision to try and move the scar line inside the nostril on each side of the columella (this is really a modification of the Double Duck Lip lift procedure)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I hope I can ask you this: I just had a Facial fat transfer 2 weeks ago. My surgeon is on holiday now. Please help me. I was walking today and I came into a storm with around 38 km/h of wind. Often the wind blew directly in my face for around 20 minutes. Do you think that killed some of the 2 weeks old fat? Thank you so much and warm regards.
A: The simple answer to your question is that I doubt external cold wind could adversely affect the volume retention of a facial fat transfer procedure…at least on a limited time exposue. You are undoubtably drawing this potential analogy from technologies such as CoolSculpting where cold temperatures are used to aid in some fat reduction. While seemingly a relevant analogy it is not. These are devices that are applied directly to the skin and held there for a duration of time to really lower the temperatures of the tissues under the skin. That is quite different than an external wind chill, which while dropping the skin surface temperature, would have a much harder time dropping the temperature of the deeper subcutaneous tissues if only ‘applied’ for a relatively short period of time. Much longer exposures, however, would be likely to do it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, In Korea, there are few clinic that offers posterior cheekbone reduction with 5mm sideburn and cut inside the hair (the posterior cheekbone reduction.) Many clinic in Korea also do not offer this method of surgery.
What are the risks of this method of surgery as I am interested in making my face smaller? The clinics I have consultations with told me that there are many revision case because people can feel and see the broken arch bone at the hairline or there is non connection of bone. Is this true? What other risks??
A: Thank you for our inquiry. I have done many isolated posterior zygomatic arch osteotomies (posterior cheekbone reduction) to narrow the width of the face on the sides. (but leaving the anterior cheek bone alone) I have not yet seen the complications which has been told to you such as bone edge visibility or palpability. By definition with plate fixation there is a non-connection to the bone but that is irrelevant as the bone is stabilized and there is always a non-connection of the bones no matter whether it is done in isolation or with anterior cheekbone reduction osteotomies.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in V-line facial contouring. There is a popular procedure in South Korea that offers a procedure called V line which slims the jaw and chin to make it doll like and I am very interested in getting it done in June 2018. I contacted several clinics in Korea and the procedure is much cheaper there when compared to USA. However, I am nervous going to a country I have never been before by myself. Before making a decision, I want to know my options for the in state surgeons. How much would facial contouring cost at Eppley Plastic Surgery Clinic?
A:Thank you for your inquiry. What you are referring is known as V-line facial contouring or V line jaw surgery of which I am very familiar. Whether you are a good candidate for that procedure depends on your pictures, x-rays and aesthetic goals. Be aware that when you go to South Korea they are going to do the procedure whether you are a good candidate or not. They treat everyone the same whether they are Asian for not or whether their bone structure can benefit from the procedure or not I have treated many Caucasian US women who went there only to have a result they did not want and then had to be secondarily reconstructed. Cost aside I would first determine if what you want to achieve is even possible with your facial structure. It will be a difficult problem to secondarily correct if the operation has never had a chance to achieve what you want.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in tear trough injections using injectable fillers. I have deep tear troughs that I think would benefit by them. I have attached some pictures for your review and recommendations.
A:Thank you for sending your pictures. Fillers or fat is not a proper procedure for your under eye concerns. What you have is overall fat protrusion of the lower eyelids with tear troughs. (medial orbital rim indentations) These are really pseudo tear troughs that are magnified by surrounding infraorbital fat protrusion. Any attempt at filling the tear troughs will likely just make your overall lower eyelids look even more puffy than they are now. The correct approach is lower blepharoplasties to remove the herniated fat and transpose it into the tear troughs with some lower eyelid skin removal/tightening.
In my opinion the only role for an injectable approach to your lower eyelids is to ‘prove’ that lower blepharoplasties are the better treatment. Given that injectable fillers in the eyelid can take a long time to resorb I would be hesitant to even try such a treatment as you would have to have puffy eyes for some time. It would be better to just proceed with lower blepharoplasty surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting a Peri-Pyriform Implant. As shown in my X-rays, I had Lefort1 osteotomy last year. I also had cheekbone reduction, mandibular reduction, and chin augmentation back before that. I am planning to remove the titanium screws before I get the Peri-Pyriform Implant. I do not know if that is necessary and I would love to hear your professional opinion regarding removing the titanium screws. I am also interested in getting cheekbone implant. I found a surgeon in Asia who places a Medpor implant below the lower eyelid area (the dark circle area, rather than the actual cheekbone area which is located below the outer eye corners) to give the patient a more convex midface and a more youthful look. I am wondering if we could discuss the possibility of getting the same implant along with the Peri-Pyriform Implant during our virtual consultation. Thank you very much for your time and consideration. I look forward to speaking with you soon.
A: In answer to your questions about the Peri-Pyriform implant::
1) It is not necessary to do a separate maxillary plate and screw removal if you do not want to. I can do that at the time of the implant placement.
2) The subcheek and peri-pyriform aperture implants can be done all in one procedure with the same surgical access.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in cheekbone reduction reversal. I am a 21 year old Asian girl who thoughtlessly underwent cheekbone reduction surgery and jawbone reduction surgery in Korea. After six months of healing, I’m finding that my cheeks are sagging and it is making me look a lot older than I am.
I’m not sure what to do. I’m depressed and regretful of my decisions. The cheekbone reduction was conducted via L osteotomy, with an oral and sideburn incisions. I’m hesitant about cheek implants as I’m not very keen on putting foreign objects in my body. Even though I am young, I am desperate. Would a cheeklift/soft tissue cheeklift be beneficial in my case.
A: Thank you for your inquiry. Your cheekbone reduction reversal options are limited. You have to re-establish bone support to lift the soft tissues back up, a cheeklift is not going to work. You either reverse the osteotomies or place some form of a cheek implant. But either way you have to build the bone back out somehow, you can not lift the tissues around it successfully in a young person. Implants are easier but revise osteotomies are more ‘natural’.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have three questions regarding the titanium screws for may custom jawline implant.
1. Are they custom-made to different lengths, since they will be penetrating at three different spots of varying thickness along the mandible? (Ie. 14mm/12mm at the gonial angle, ?mm at middle of mandible, and 4mm at chin, so they don’t over-penetrate or under-penetrate)
2. Is there a torque limiter on your drill to prevent fracturing the bone?
3. Can we place the six screws as follows?(on pages 6 and 7 of the pdf file below, which I have marked up)
A: In answer to your screw fixation questions for your custom jawline implant:
1) These are 1.6mm diameter self-drilling screws whose maximal length is 8mms. They are placed through portions of the implant were it is thinnest to accommodate the screw lengths.
2) These screws are smaller in size than Abraham Lincoln’s jaw on a penny. Thus the risk of bone fracture is not a concern.
3) All of the potential screws locations you have indicated are not viable options as either the implant is too thick or there is no point of access to do it. (center one) I have attached an imaging picture of what are the locations that can be used based on implant thickness and available screw lengths.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I recently had a rhinoplasty and lip lift procedure that I am unhappy with. I wanted my nose to be narrowed and instead the surgeon rotated it up and shortened it. It now looks wider at the tip. I want it to be much more narrow. I think a slight alar base reduction would look nice in conjunction with narrowing the tip and de-rotating the tip. Also, the lip lift did not lift my upper lip enough. I am hesitant to pursue another lip lift procedure as it may complicate the revision rhinoplasty and make the tip appear more upturned by pulling the columella and nostrils down. I’ve consulted with several surgeons who have advised me that this will be a very complicated procedure. I would love to know your thoughts on what, if anything, should be done. Do you think you could narrow my nose (possibly alar base) and bring the tip down to look this way? This was the “projected outcome” photo. Thank you very much for your time!
A: I think the first concept you have to grasp in that after a primary rhinoplasty the obtaining of a dream or ideal nasal outcome is probably not realistic. Whether it was ever a realistic goal initially I can not say as I wasn’t involved in that process. Now you are looking to recover from an over correction in a nose that is now scarred and is short of cartilage structure. Getting the tip of the nose back down is a lofty goal in itself and will require significant cartilage grafts to do so. That will be an accomplishment by itself. Making the more narrow is probably not going to happen as much as you would like. For a revision rhinoplasty, now a reconstruction project, one’s goals should be more modest.
I would certainly agree that any further lip lift efforts should be delayed until well after the revision rhinoplasty.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, thank you for your presurgical consultation today regarding my rhinoplasty tomorrow. I know we have been over my nose surgery numerous times and you have done a lot of computer imaging for me. I know that no surgery can create perfection but I still need to know if my nasal tip projection will really be shortened by the 2mms that i need. I also need to make sure my nostrils shape will not change in any way. I don’t want to seem pedantic at this point but I am concerned.
A: I would not use the word ‘pedantic’ or even over analytical. Those are patient behavior’s that are common and largely understandable. The concern that I always have with such behaviors is what may lie behind them…unrealistic expectations.
It is important to really understand that surgery is not Photoshop or any other completely predictable method of facial manipulation. Such efforts are important preoperatively but what they really represent is a method of communication as to what the patient’s goals are. Surgeons need goals to try and accomplish what the patient wants. They are, however, not completely accurate representations of what the results may be even though that is the goal. The manipulation of tissues, how they respond in surgery and how they heal afterwards, is not like manipulating images on a computer screen. It is far less predictable and no result will end up perfect or completely symmetric no matter how hard the surgeon tries. Patients who are most satisfied with their plastic surgery have an inherent understanding of realistic and not always predictable outcomes.
As an additional note I must make reference to the type of patient who is at greatest risk of having unrealistic expectations in plastic surgery and one of which I have an enormous experience…the young male patient who is having elective facial surgery. Often times an overanalytical preoperative behavior is a set up for postoperative disappointment…as any result can not withstand the scrutiny and degree of perfection such patients often seeks.
I pass along these thoughts as a note of caution as you are about to proceed into rhinoplasty surgery and hope that your expectations fall in line with what surgery can actually achieve…improvement but never perfection.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m seeking your opinion on my chin, neck and jaw. I’m open to all options. My chin is further back than it should be. I would like to know the pros and cons of the sliding genioplasty operation. I would also like to know if the simpler silicone chin implant would give me good results in your professional opinion.
A: Thank you for sending your facial pictures. With a chin deficiency of close to 9 or 10mms, both a chin implant and a sliding genioplasty will offer improvement as assessed in the side view. They probably can’t be differentiated from that viewpoint. But from the fontal and oblique views is where they will be aesthetically different. A sliding genioplasty will usually narrow the chin as it comes forward particularly in the prejowl area. Conversely a chin implant will widen the chin with the increased horizontal projection. In addition a sliding genioplasty can make the chin vertically longer if desired while most chin implants can not. These aesthetic differences in their chin augmentation effects need to be considered for a true 3D chin augmentation surgery.
There is also the consideration of how one feels about an indwelling implant vs using one’s own bone for the surgery. Unlike the logical aspects of their different aesthetic effects this consideration is emotional and personal but may be of no less importance in this decision between the two chin augmentation options.
Lastly, chin augmentation no matter how it is done does not affect the back part of the jaw, only its front part.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am seeking information about the management of a fat grafted breast infection. I came across a question that someone sent to you and your answer to it in regards to infection during fat grafting to breast. Here is the link to it: http://eppleyplasticsurgery.com//why-did-one-of-my-breasts-after-fat-injections-become-infected/. I was wondering if by chance you know what happened to that person and how their issue was solved because I seem to be in an exactly the same situation and wondering what the best and fastest way to fix it. Please let me know if you know how that patient’s case got resolved or if you had a similar one or know of a similar one and what it took to fix it: number of injections to correct, amount of cc-s injected each time and the timing – how long it took between procedures. I really appreciate your help. Thank you.
A: When it comes to treatment of an infection that has occurred in an injected fat graft site, the treatments are oral antibiotics (possibly IV as the breast is a big site with a probably big fat load) and possible needle or small incisional drainage. Having no knowledge of your fat grafted breast infection specifics (what does it look like, how long after the surgery did it occur, how much fat as injected) I could not provide specific recommendations as to your case. But as a general statement such infections should be treated aggressively combining antibiotics and some form of drainage. It is important to realize there is a large amount of dead tissue in there (injected fat with little to no blood supply) so all that can be done should be done right up front. If it is not too ‘severe’ oral antibiotics and needle aspiration may be fine. If it is more ‘severe’, IV antibiotics and incisional drainage may be needed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have linked you to an article you wrote in 2015 dealing with injecting fat into the scalp. I was under the impression that by injecting anything (fat) to a tight scalp it would make it more tight. However you state that introducing adipose tissue is actually beneficial for the scalp. Can you elaborate on this? I am interested in a solution to a thin/tight scalp. Thank you.
A: Injected fat is a soft tissue expander/relaxer even if none or only some of the fat survives. It is a simple volumetric principle of stretching the connective tissue between the dermis of the scalp and the underlying galea against the bone. Any fat that survives has to displace/stretch the existing scalp tissues. Any fat that survives pushes the scalp outward and, because it is fat, the scalp will eventually become softer with its survival since it is adding a tissue the that is softer than what most of the scalp is naturally composed.
The key in injecting fat into the scalp is to place it above the galea and right under the skin. This is the easiest tissue plane to enter with a blunt cannula.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am male but my facial appearance lacks masculinity. My eyebrows shape is not straight but arched, the overall vertical extension of the eye area is high, and the forward protrusion of the brow bone is minimal. Could my brow bone be augmented in such a way that the base for the eyebrow moves down, and the eyebrow repositioned downwards and forming a straight line appearance. How close to that could my eyebrows get fixed? Thanks a lot.
A: This is a common question from young men who seek brow bone augmentation. The simple answer to your question is….no. Brow bone augmentation will push the eyebrows forward but not down. No surgical procedure can make your eyebrows go lower…short of a tissue expander placed first in the forehead to create more skin and then a brow bone implant placed. This is because the forehead/brow soft tissues are too tight and the amount of tissue that is available has been ‘made’ based on how the bone has developed. You would have to free up the tissues and create some excess to have the brows be driven further downward. But this would not likely create a straight eyebrow shape from a natural arched one.
Dr. Barry Eppley
Indianapolis, Indiana
Dr. Eppley, I’ve had buccal fat pad removal two year ago and it derounded my fat considerably. I am happy with the results. However, it did no good to my perioral mounds. I came across the your name online while looking for perioral mound liposuction. I wonder how much the procedure costs, its duration and recovery time. I saw three doctors and none of them were familiar with the procedure and they all discourage me to have it done. Note this is a genetic thing, my father and my brother also have it.
A: As you observed by your own experience, buccal lipectomies do not address the perioral mound area. That is a separate subcutaneous fat layer that sits below the encapsulated fat of the buccal space. Perioral mound liposuction is done through small incisions inside the mouth. Other than some swelling there is no real other recovery issues. I would correlate its recovery to that of your prior buccal lipectomy experience. Because it is a small amount of fat removal it will take longer to see the final result than that of a buccal lipectomy, roughly 6 to 8 weeks to see the very final effect on the shape of the face in that area.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Do you preform breast injections with a Sculptra, or a similar lactic acid polymerized substance. And would you be willing to try a breast injection procedure?
A: Breast augmentation by resorbable synthetic fillers, like Sculptra, is quite frankly a problem waiting to happen. (Sculptra breast injections) Such fillers in significant volumes create soft tissue reactions such as lumps and even granulomas. This creates breast lumps and scar tissue which is the antithesis of what a soft breast should feel like. In addition, creates such soft tissue reactions in a bodily structure in which lifelong cancer surveillance is important is not the best medical decision.. Detecting breast cancer would be made more difficult in such an injected breast and these soft tissue reaction would make breast cancer detection challenging.
In addition, the volume of material needed and the need for repeat injection would make it a very costly endeavor. This cost factor is magnified when one realizes that such injections are not a long-term solution to a sustained increase in breast size.
A safer and more medically sound approach to non-implant breast augmentation than Sculptra breast injections is to use fat injections…provided one has enough fat to do so.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a repeat full tummy tuck with mesh reinforcement in conjunction with rib removal of the lower 3 ribs. I had a full tummy tuck done a decade ago and at the time the doctor did say that it most likely would need to be repeated with mesh reinforcement given the how well he thought the plication sutures would hold. He was advocating the use of well anchored mesh to supply the long term results that the procedure should provide. I am 5’5” and the lower part of the rib cage does present lower in the torso minimizing any desired hourglass result. At the time the doctor did feel that I would be a good candidate for rib removal if the procedure were to repeated. Since that time this doctor has retired but your name has come up as an expert in these types of surgery.
A: Mesh reinforcement on a repeat tummy tuck can be done. The only question is what type of mesh. There are lots of option but they fundamentally come down to non-resorbable polymer ones vs. slowly resorbable polymer ones that get replaced by considerable scar tissues over several years. Each has their advantages and disadvantages. Rib removal can be done at the same time although that requires small incisions in the back from the prone position. Ribs #10 through # can only be removed from behind. Only the subcostal ribs #7 through #9 can be removed from the tummy tuck approach.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’ve attached a few photos of my face/jaw. I would describe it as one side of my jaw being longer than the other and where the two halves meet at my chin, there’s a sort of deviation to one side. I’m curious what kind of effect an implant placed over my jaw/chin could achieve.
A: Thank you for sending your pictures. You do have a jawline asymmetry and the deviation of the chin reflects how one side is different than the other. Such jawline asymmetries would traditionally be difficult to make a lot better because ‘spot’ reduction or augmentations along the jawline by just using he surgeon’s eye/judgment often ends up magnifying the problem rather than improving it. A better approach for jawline asymmetries that are not going to be managed by orhognathic surgery is a custom jawline implant. A custom jawline offers the best approach because it creates an outer zone of augmentation that is symmetric on both sides (and straightens the chin) and then it just matches the asymmetric jawline bone underneath it. Thus it is based on creating an outer jawline symmetry first (as well as whatever jawline augmentation the patient desires) and then makes it match its underlying asymmetric bone.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, One week ago I had an otoplasty done and my earlobes protrude quite a bit. My surgeon has declined a revision as he states it can”t be fixed due to there being no cartilage in the earlobe. I would like to hear from Doctor Eppley who has experience surgically setting back earlobes as part of otoplasty according to Real Self. what specific procedure do you use and what is your % success rate with earlobes to avoid telephone ear deformity? Also, how soon can the earlobe be revised after my otoplasty?
A: When doing an otoplasty it is important to consider the position of the earlobe when the cartilage manipulations are done. (cartilaginous otoplasty) If the earlobe now sticks out beyond the lateral projection of the repositioned helical rim then it needs to be setback as well at the same time. (earlobe reshaping otoplasty) This is done by a fishtail skin excision on the back of the earlobes. (soft tissue otoplasty) This then creates a complete otoplasty. It is well known that the earlobe does not contain cartilage but that has no impact one whether it can be repositioned.
As a secondary procedure an earlobe reshaping setback can be done and it really could be done at any time after the original otoplasty procedure.
FYI a telephone ear deformity is when the cartilage of the ear is pulled back too far. (the helical rim sits back further than the antihelical rim, it has nothing to do with the earlobe.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I appreciate that you take the time to educate the public on plastic surgery, and I want to thank you for that. I’m planning on going to you this summer for temporal width reduction, cheekbone reduction, and chin/jaw reduction as my face is wide.
I had an intraoral chin reduction which I immediately regretted from a less experienced surgeon. He did a sliding genioplasty to move the chin backwards to reduce the horizontal projection, and also did some intraoral burring on the sides to reduce the width. The end result is that I still had a very wide chin. It was a bit less square, but still very wide. I was also left with drooping under my chin.
I had a revision with another surgeon in December in which he did a submental tuck-up which seems to have fixed the droopy chin problem, and he also did submental burring to reduce the width. It did reduce the width, but not as much as I would have liked.
I just want a more feminine, tapered lower face but my chin still looks a bit wide and full. I asked you in a previous question about if an intraoral wedge narrowing approach would produced a more significant narrowing effect than a submental approach, and you said it shouldn’t matter. So I’m wondering:
1) For chin narrowing, are burring-only approaches not as effective as tubercle ostectomy approaches?
2) What is the ultimate limitation of how much the chin can be narrowed? Is it because of the mental nerve? Since the mental nerve is located on either side, could an intraoral wedge reduction approach allow for more width reduction because it’s between the mental nerves?
Thank you so much!
A: In answer to your chin reduction questions:
1) In reality the submental shaving reduction technique is the most effective technique as it provides the best visual access and can take the bone removal back far along the jawline. The intraoral wedge reduction technique is more limited because it is a superior approach that is limited by the location of the mental nerves.
2) Chin reduction reshaping is done below the level of the mental nerve so there is no restriction in the amount of bone reduction that can be done. The limits are what the soft tissue can allow without resulting in ptosis or sagging.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a few quick questions concerning chin surgery, or more specifically sliding genioplasty.
1) Is 18 years old to young to consider such a procedure? (my pediatrician expects me to continue growing until 22)
2) I had read that some surgeons remove the hardware once the two bones fuse together usually around 9-12 months post-op. What’s your take on this?
3) I was hoping to stay away from implants due to possible bone erosion. Do you perform procedures where you cut the lower chin into two or three parts, in order to widen the chin? (I believe some people call it an Expanding Genioplasty)
4) Chin surgery usually gets lumped with chin implants on Real Self showing an average price of around $5,000. Without diving to much into financing, would it make sense to expect an average price of $10-12k for a Sliding Genioplasty, and perhaps even more for one that attempts to widen the chin?
The goal would be to masculinize the chin by advancing it in all 3 directions. Sorry for all the questions and thank you for your advice!
A: In answer to your sliding genioplasty questions:
- 18 years of age is not too young for a sliding genioplasty chin augmentation procedure.
- There is no reason to remove the hardware later, I have never done it.
- While your concept of chin implant and ‘bone erosion’ is erroneous, you are referring to a widening bony geniplasty with a midline split of the down fractured segment and the placement of an interpoitional graft. Like a narrowing any genioplasty where a central segment of bone is removed, the central slit can be grafted to widen the chin as well.
- I will have my assistant pass along the actual cost of the surgery to you next week.
Dr. Barry Eppley
Indianapols, Indiana
Q: Dr. Eppley, Orthognathic surgery is a more dangerous and time-consuming surgery than jawline augmentation and if it’s possible to have an ideal aesthetic jaw without going through the more complicated surgery, that would be nice. I do have an overbite but I was under the impression (although this may be wrong) that it could be corrected/compensated for with just braces/invisalign attachments and bands without surgery. I’ve never had any pain or other functional issues from my jaw alignment, so it’s mostly an aesthetic worry.
If orthognathic surgery is the only way to get an ideal jawline and chin with my current bone structure, (and perhaps getting implants afterwards) then I’ll do it, otherwise getting just a wraparound jawline implant would be ideal. I’ve looked at before/after pictures of jawline and chin implants and it seems as though there’s a limit for how much projection can be added, and I’d also like a natural look.
Is there any way I could get a consult with my pictures to see what my projected outcome would be with just jawline implants? Are jawline implants never recommended if there’s any overbite?
Thank you.
A: You have thus answered the question about the need for orthognathic surgery…it is not for you as your primary problem is the aesthetics of the jawline and not its function. That is good because orthognathic surgery in most cases can not approximate what a custom jawline implant can do.
You are, however, inaccurate about the limits of a custom jawline implants. The aesthetic risk with their use is far and away that they can easily be created too big rather than being too small.
I would need to see your facial pictures as well as have an idea as to what your jawline goals are to answer the question of whether a custom jawline implant would be aesthetically effective for you.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m an out of town patient looking to surgically enhance my jawline. I’m not sure if a wraparound custom jawline implant or even a genioplasty would be enough to have an aesthetic jawline and chin or if I should be pursuing a bilateral sagittal split ramps osteotomy (BSSO) or other orthognathic surgery. Is there any way I could see an approximation of what my jawline would look like with these augmentations and/or get a professional opinion?
A: The answer to your question about orthognathic surgery vs. jawline bone augmentation is fairly simple…orthognathic surgery is only indicated when you have a malocclusion. If you don’t a bite issue that needs to be corrected then only jawline augmentation will work to achieve it. The most effective form of jawline augmentation, if it is more than just a chin issue, is a custom jawline implant. In general orthognathic surgery and custom jawline implants are not equivalent procedures, they have different jawline effects. But orthognathic surgery should never be considered a jawline enhancement procedure even if it can create some greater chin prominence. But it certainly does not improve the shape or size of the jaw angles.
Dr. Barry Eppley
Indianapolis, Indiana
