Your Questions
Your Questions
Q: Dr. Eppley, thank you so much for taking the time to respond to my temporal artery ligation questions. I am wondering if you haven’t treated women for this condition before because (a) women usually have a higher body fat percentage than men and statistically are less likely to have this issue and (b) the women who do have it are able to cover it with their hair?
A: I haven’t treated women for temporal artery ligations before simply because one has never presented for the procedure. There is nothing inherently different in a woman vs a man on how the procedure would be done. But the most likely reason it is far more common in men is because they have larger arteries with thicker muscle layers which are more sensitive to stimulation, perhaps because of the hormonal differences between men and women. (higher testosterone levels)
In theory one would think that many women would be more susceptible than men because they have a thinner subcutaneous fat layer and the temporal arteries would be more exposed. But this is clearly not the case since I have yet to see a female ask to have the procedure done.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, How much volume addition is possible with a single skull implant surgery without a first stage scalp tissueexpander? In your article I read that the maximum addition is about 1.5 cm. A surgeon in Germany, who implants silicone for augmentation, told me that he can add up to 3 cm without using an expander before. In some cases he needs to scrape some mm of the head rind to avoid tension. What’s your opinion? I am really anxious that 1.5cm aren’t enough for me. Many thanks for taking your time.
A: Only by using a full coronal incision (from ear to ear) could more than 1.2 to 1.5 thickness of a skull implant be placed in a single stage procedure. But even a full coronal incision will not permit a 3cm thick skull implant to be placed. And even if it can be placed that is increasing the risks of complications. As an aside I never seen anyone that needs a 3cm thick skull implant. That would make any head too big. For safety sake you have to avoid being too ‘greedy’. It is far better to have 50% to 70% of the result you want that has no complications than 100% of the result that develops a complication. A complication in a skull implant (infection, wound dehiscence) means that the skull implant is coming out and all will be lost.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m considering a nose augmentation operation for central nasal depression with a closed technique. I’ll be using a silicone ePTFE coated nasal implant from Implantech company. (ePTFE Dorsal Nasal Implant) My plastic surgeon has never used such material, he has been mainly using cartilage or silicone, so I will be his first patient.Since you are an experienced plastic surgeon in the US, you have definitely done cases with similar material, what is your impression and opinion about using this type of implant on the bridge of the nose and what was your patients feedback. I have another question here, what if the implant is long and it’s needed to be cut little bit to fit my nose, can my plastic surgeon be able to cut the ePTFE coated silicone? The length of this kind of implant is similar for all sizes but the amount of height of the bridge only differs. I greatly appreciate your valuable reply.
A: Many of my writings on nasal implants as well as my recent reply to your prior email speaks to my favorable experience and opinion of the ePTFE Nasal Implant, whether it is the preformed style (ePTFE coated silicone) or a hand carved pure ePTFE nasal implant. I would trust that your surgeon would have enough preoperative knowledge of the nasal implant and its composition to know how to intraoperatively shape it for each individual rhinoplasty patient.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like to discuss forehead remodeling for a brow bone reduction revision. Attached is a photo from your website to a more masculine forehead. I would ask for the exact opposite. To do that, my angle between the forehead and nose would need to be altered. In addition, my frontal sinus would need to be reconstructed to alter shape and slope of forehead to make more feminine. You can see how protruded it is in my x-ray. Burring down the bone is not appropriate as my original surgery performed did that and it was not successful.
Unfortunately, from that surgery, my surgeon removed most of my frontalis muscle as outlined as the “diamond shape.” I would like something added to hopefully contribute to a more rounded forehead but also to decrease the hollowness when I lift my eyebrows. I am leaning more toward fat injection because it is the least invasive and you
could also take fat from my neck as I don’t have a well defined jawline and this bothers me a lot. I am basically asking you to do it to alter the forehead slope and decrease the visibility of the “diamond.”
A: With your frontal sinus anatomy, a burring reduction was never going to be successful so that is a peculiar brow bone reduction technique that was chosen. Even more peculiar was the removal of the galea/frontalis muscle of your forehead creating an expected soft tissue indentation along the entire excision pattern.
But moving forward an osteoplastic bone flap method is now needed to create a more significant brow bone setback. Managing the forehead soft tissue defect is more challenging. While I would agree that fat injections as an isolated procedure would be reasonable, that is not possible to do during an open brow bone procedure as where the fat needs to go is completely open. The only thing that could be done during the open procedure is to remove a large galeal graft from the scalp behind the frontal hairline incision. The other option is to lay in a thick layer of allogeneic dermis, like Alloderm, as a composite collagen graft. Otherwise fat injections would have to wait 3 to 6 months after the brow bone reduction procedure. Also with fat injections your neck would not have remotely enough fat to do the procedure. It would have to be harvested from elsewhere, usually the abdomen.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley,the first thing I wanna say is thank you for the hard work you did to make those kind of cosmetic procedures (skull reshaping) available nowadays. And making people with skull shape self concerns happy and more confident about themselves . i have been following your great work since 2015 . So my problem is the lack of height of my head its like the top of the head curved downward to the back of the skull.
i have read that with a first-stage scalp tissue expansion the skull can be augmented up to 2.5 to 3 cms in many places…which is the perfect amount I’m seeking for the crown and vertex areas. I want the thickness of the implant to be reduced to 2 cm on the top of the head near the forehead area so the shape of the head looks harmonic. So is it possible to achieve these goals ? And if so how much is it gonna cost me ? Thank you for the interest and hope get some answer from you soon.
A: You are correct in that with tissue expansion it is possible to achieve up to 2 cm of added skull height using a custom skull implant. This is really the maximum amount that a skull implant should be.
I will have my assistant Camille pass along the cost of a two-stage skull augmentation procedure to you in the next day or two.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have problem with my masseter muscle.(Masseteric muscle hypertrophy). I heard about electrocauterization procedure in your clinic. Is that a permanent solution? What is the average cost of the treatment? Can i try to become pregnant soon after the procedure? or how long should I wait?
A: Electrocautery reduction of the masseter muscle is a permanent procedure as it shrinks part of the muscle due to the thermal injury. This is done through an intraoral approach with elevation of the muscle off of the mandibular ramus bone. Electrocautery is then applied to the internal surface of the muscle throughout its entire length and width. A portion of the muscle will then eventually shrink down as some percent of the muscle fibers/cells die due to necrosis. This is a process that will take a full three months to see the final result when the muscle atrophy is fully complete. This is a masseter muscle reduction procedure that is less commonly performed than Botox injections or external radio frequency treatments.
Trying to become pregnant immediately after a masseter muscle reductionprocedure is not a concern as the masseter muscle has nothing to do with that process.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a rib reshaping surgery question. I was just wondering if its possible to alter the total size of the ribcage, like to make it narrower or wider at the bust point? I’ve heard you perform rib removal surgeries, but as far as i’m aware that only affects the lower part of the ribcage towards the waist.
A: I have been asked that question may times over the years about ribcage modification or rib reshaping surgery and the answer is no. Rib removal surgery is done for either horizontal waistline reduction or vertical waistline elongation. But the middle and upper portions of the ribcage can neither be narrowed or augmented as this portion of the ribcage is important for lung function. Any ribs that lie below the apices of the lungs can be reduced for a body contouring effect. But any ribs that wrap around the lungs are needed for support to allow the lungs to expand and contract through the muscular action of the intercostal muscles and the diaphragm.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am wanting to do a Mommy Makeover. I would like to do the procedure the week of March 12th because my daughter will be home from grad school and will be able to help me. I am very serious about making this happen then because I have a lot of important events happening in my life this year and I want to look my best. I have the money so no financing will be needed. Please let me know as soon as possible what you have available for I am researching others. I would like to do the (gummy bear) implants and because of the size of my breast I am sure a re-positioning of my nipples will need to be done. As far as a tummy tuck I would love to have the least invasive procedure, however if that is not possible, I want the one that is recommended best for me.
A: Thank you for sending your pictures. In looking at them I can give you some specific insights and recommendations about the breast and abdominal procedures that you really need.
From a breast standpoint, you have significant breast ptosis (sagging) where the nipple sits below the lower breast fold. Your entire breast mound, including the nipple, needs to be repositioned back up on your chest wall. This is going to require a full breast lift with the resultant anchor pattern scars. You also have some significant breast tissue so, unless you are only looking for a very small breast implant to just create some greater upper pole fullness, you can not have implants placed at the asme time as the lift. A big breast lift with larger implants is a recipe for complications as a combined procedure. I do not know what you breast size goal is so this is an issue yet be be determined. (staged or immediate breast implant)
From an abdominal standpoint, you are in need of a full tummy tuck combined with flank/waistline liposuction. With your anatomy there are no effective less invasive procedures. You simply has too much fat and skin for anything less to make for a satisfying result.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Would you mind telling me if I am correct in thinking that a smile line lip reduction would basically work in the opposite way as a lip lift in the sense that during a subnasal lip lift, a cut is made and a portion of skin is removed which essentially pulls the upper lip up, closer to the base of the nose, and alternatively a smile line reduction would be cutting out a portion of the upper lip on the inside of the mouth, pulling the lip inward, and thus appearing smaller?
If this is the case, would it be fair to say that this procedure is not reversible? My only concern is that my lips at present are relatively thin, so how much smaller would you expect my upper lip to get? would it be comparable to the amount that appears to make a lip look larger during a subnasal lip lift?
Would lip fillers be an option after this procedure should a fuller lip be desired?
Also, if one had this procedure done, would a subnasal lip lift still be an option for the future at any point down the road?
Would it also be fair to say that you feel that I am not an ideal candidate for the more popular subnasal lip lift at my present age with my present facial aesthetics? As best as I can measure, I have figured that the length from the base of my nose to the lowermost part of my cupid’s bow (or at the center of my cupid’s bow) looks to be exactly 1.5 cm.
A: Your concept about the subnasal lip lift and the smile line reduction is correct. They both achieve some increased upper tooth show by removing tissue but do it at different ‘ends’ of the upper lip. The increased central upper lip size from a subnasal lip lift woule be equivalent to the upper lip reduction achieved by a smile line reduction. Any form of tissue removal on the upper lip is irreversible. Lip fillers can always be placed later into any such lip lift or reduction procedure.
Numbers aside whether one is a candidate for subnasal lip lift depends exclusively on whether the patient thinks they have too much skin between their nose and the upper lip.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in chin implant removal. I would like to have my RZ Extended Medpor chin implant (5mm projection) be removed that was implanted about 6 years ago. I’ve had three revision surgeries since then and the implant is still causing intermittent numbness of varying degrees and motor control problems on the right side of the chin due to excessive scaring (according to my surgeon). Cooling and other activities that cause vasoconstriction alleviate the sensory and motor problems whereas anything that causes vasodilation does the opposite. About four years ago a heavy intravenous cortisone regimen that I received for a facial infection almost entirely reversed all my problems. Unfortunately, the numbness and lack of motor control returned within several weeks. Nevertheless, this success with cortisone indicates that my problems could still be reversible after all these years and that in fact scarring could be the main culprit.
I should also note that I never tolerated intraoral incisions well. Each time they caused me at least 1 year of full numbness until sensation would return and I was unable to move my mentalis muscle for the same period of time. It was like glued to my chin. The last revision surgery was done through a submental incision and that didn’t cause any problems.
Do you advise me to have the chin implant removal done?
A: I think the simple answer is…you are never going to have the potential for significant in your symptoms unless you take the risk of doing it. While there are no guarantees in surgery, and every surgery has risks, your over 6 year history of issues since the implant placement strongly suggests that a more defintive solution should be pursued.
Dr. Barry Eppley
Indianpolis, Indiana
Q: Dr. Eppley, I am interested in occipital skull implant augmentation. The back of my head is flat, and I would like to explore the options of surgery. I currently live in Montana. I would like to know what the procedures are for out-of-state patients.? Thanks for your time. I look forward to hearing back from you.
A: All of my skull implant patients are from everywhere around the world so your discrepant geography is the norm for my unique practice. Skull augmentation is done today using a custom skull implant technique made from the patient’s 3D CT scan. This sac is obtained where the patient lives, is sent in and used to make the custom implant online and them manufactured for the surgery. This is a process that takes about a month to complete. The patient then only comes in one time for surgery, arriving the day before and leaving for home within 24 to 36 hours later.
Please send me some pictures of your head from the side view for my assessment for this procedure. From these I will be able to do computer imaging so I can determine how much occipital augmentation you may desire.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in breast implant revision. I currently have saline implants below the muscle. I believe they are around 350 to 400 cc. As you can see in the attached pictures my breasts are asymmetric. They increasingly got worst as the capsulation increased. My goal would be to improve this. I’m not young any more so I don’t expect the 25 year perky breast but if the right one could be freed up from the scar tissue to drop and better match the left, I would not be so embarrassed by them. Or, two new ones that matched and didn’t point down at my toes would work too.
A: Thank you for sending your pictures. You are correct in that you have a right breast implant contracture (Grade III) which is the major source of your breast asymmetry. But you also have a Grade III/IV ptosis. (breast sagging) The ptosis plays a major role in defining your two breast implant revision options.
If you choose to live with the ptosis then you could have a right implant capsulectomy and the implant could be made to drop lower. This would be the simplest and most economical approach but also the least aesthetically pleasing one.
Conversely the complete opposite and more comprehensive approach would be to have full breast lifts done with new implants and the aforementioned capsulectomy. This is the most aesthetic approach but is also the most extensive.
As you can see your breast sagging plays a major role in your breast implant asymmetry correction decision.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in lip implant removal surgery. I would like to consider removal of my Gore-Tex lip implant. It is uneven and also tender. It was implanted around age 30 and I am now 49 years old. I would consider some type of plumping afterward as I suspect it will have a deflated look.
A: You undoubtably have in an old style Gore-tex lip implant that is probably multi strand in design. You or I would have no idea as to his many strands were actually implanted. (although it is almost always more than just one) These can be challenging to remove and you are correct in that some immediate volume restoration would be helpful. Concurrent fat injections with the lip implant removal would be the appropriate approach since it may add some volume. But it also be a good treatment to prevent adverse scarring/contracture that can occur from such lip implant removal procedures.
Today’s lip implants are far easier to remove as they are a single tubular implant that slides back out just as easily as it is implanted An enveloping capsule that does not adhere to the implant enables its much easier removal.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in facial reshaping surgery. I would like your opinion on what I should do to ”enhance” the harmony of my face. I’m referring to what procedures would make my face look better and what’s necessary to be done. I think I need a nose job at least but I’d also like an opinion on what other ”fix-ups” would be necessary because I don’t want to do the wrong thing and make mistakes.
A: Thank you for your facial reshaping surgery inquiry. When it comes to your face the first thing to realize is that you have a very good looking face with strong bone structure. There is no deficiencies or an obvious reshaping effort that needs to be done to normal your facial proportions.
That be said if you want to enhance the existing structure of your face the best thing to do is jaw angle augmentation which will help make your jawline stronger. Other areas like male model cheekbone augmentation is an option besides the rhinoplasty. But they probably carry less importance than that of your jawline for your facial reshaping surgery. Computer imaging will help you see if these facial changes would be aesthetically beneficial.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in facial reshaping surgery. I have attached some pictures of me. Some in fluorescent bathroom light and the others in regular day light from a window. I don’t want to try to “copy” someone’s looks , but I’d rather change my own features in order add as much harmony as possible. I think I would benefit from a nose job. However for the rest of the face things seem more complex and a lot can go wrong. That’s why going to a highly regarded surgeon such as yourself would be the optimal choice for me.
So my problems are that even with a nose job, I’ll still be left with with a face that lacks harmony. My midface is simply way too long. I seem to have a “recessed” maxilla, with little volume leading to a thinner looking face and lack of under eye support (in my case causing the appearance of slightly bulging eyes). Realistically I would like to widen / add more volume to my face. As well as fix my eyes, to give a more upward tired lateral eye shape. I’ve read a lot about different procedures such as infraorbital rim implants, as well as orbital decompression and even just regular fillers. As for the length of the midface, I think that perhaps it could be be made to appear shorter by either a rhinoplasty combined with a lip lift or perhaps extending my chin (which seems a bit recessed) and widening my jaw. I would absolutely like a more prominent/square jaw and chin. So I’m just wondering what options would give me a wider looking face with a more defined jaw/chin as well as under eye support.
I just need a plan or a list of recommend procedures. Something that would give me the best results.
A: Thank you for sending your pictures. Your midface looks long, and there is some component to that perception, but it is mainly because of your other facial features. Your nose is large and protruding and your mouth area is very small. (small lip size and lip width) When you add in some mild chin and infraorbital bony deficiency, this collection of facial features makes the middle part of your face looks too dominant. This would never be approached through a LeFort 1 impaction, besides the negative impact on your upper lip-tooth relationship, because that is simply not the main issue. There are many other facial features that could be changed to put your face into better proportion. They would be the following facial rehabbing surgery procedures in order of importance:
1) Reduction rhinoplasty
2) Chin/Jawline augmentation
3) Upper and lower Lip Advancements with possible mouth widening (I usually do not like to do these two lip changes together)
4) Infraorbital- Malar Augmentation
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have rib removal scar questions. First one is I saw Pixie Fox who had the rib removal procedure done already. But when I look at her back I see very large scars. So will my scars be similar to hers?? If you can clarify that a lil bit for me. I can make a better decision.
A: As incisional lengths go for rib removal surgery, the scars in Pixie Fox are actually quite good. Assume for the sake of decision that those scars would be similar. I do make them smaller than that today….but the scar decision is an important one and you have to be prepared to live with two scars of some length. It is not a scar free procedure. It is also important to realize that it takes 6 to 12 months for the scars to maximally lose their redness and obvious appearance.
My advice to any patient for any procedure in which a visible scar is a trade-off….you make a decision to do the procedure based on the worst that the scar can look…not on the best you hope the scar may look like. That way one will never be disappointed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in eye asymmetry surgery. I have problem with my appearance. I have plagiocephaly. In future I’ll want to correct my facial asymmetry using 3D implants, but before it I need to correct my eyes. Now my biggest problem is vertical asymmetry of my eyes, the right eye is higher than the left eye. The left eye is also smaller than the right eye. The left side of my forehead is concave, the right is convex. My eyebrows are asymmetric. Can you help me with my problem? If you need I can send you my 3D CT scan of my head. I have attached my pictures. I’m waiting for your reply.
A: Thank you for sending your facial pictures. What you have is the classic periorbital changes from plagiocephaly. You can not lower the ‘higher’ eye, actually that eye is the correct one. You have to focus on the ‘deformed’ side which is the left lower side. The left eye needs to be raised through orbital floor augmentation, left eyebrow elevation, and left inferior brow bone reduction. This is how I commonly treat this type of orbital or eye asymmetry. This may not create perfect symmetry but it will go a long way in making it better.
I am certain that if you look at the front view of your 3D CT scan you will see the lower left orbital skeletal box.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in jawline liposuction. I posted my concern on Real Self a week ago and you were one of the surgeons that responded. You had said I was not a good candidate for facial contouring due to my prominent cheeks and you did not seem to recommend the liposuction. I wanted to inquire about this further because I had another consultation a few days ago and I was told I would be a good candidate for SmartLipo of the chin and jawline and that they could remove close to 90% of the double chin fat. The Vectra image I am attaching is very general. They told me the imaging does now show shadows very well and the end result would look better than what the Vectra would show. They showed me a few before and after pictures of prior patients and the results were dramatic.
My concern with the procedure is really whether or not I will obtain dramatic results that would justify having the procedure. I am not at my ideal weight but I am currently dieting and exercising to lose 15 pounds. The pictures you see are me at 170 pounds. At 155 pounds, the cheeks do slim down somewhat but the stubborn neck fat still lingers. The double chin is hereditary as my father has it. He is in his early 60’s and it is still very noticeable so that was another reason for me to look into this procedure as I don’t think any of that fat will atrophy any time soon for me.
After doing some more research, I am leaning away from doing any work on the buccal fat pad as I think it’s really the double chin that is making my face look bigger and the buccal lipectomy probably will not give me the result I am really looking for.
My goals are to get a tapered jawline and to reduce the overall size of my face. I’m 5’6″ and I believe my face looks a lot larger than it should on my frame.
I look forward to speaking with you about this.
A: When it comes to contouring any face/jawline with liposuction, its effectiveness is determined by three factors. First what is the natural tissue thickness of the patient’s face. Thicker skinned patients with fuller faces will get some positive changes but it will never be ‘dramatic’. Secondly, how much is the existing fat actually making a contribution to the lack of a defined jawline. In other words, if the fat is reduced will the natural jawline become more apparent or will it just look a ‘little better’. If you don’t have a good jawline bone structure to start with you won’t end up with one even if some fat is removed around it. Thirdly, how does the patient define a ‘dramatic’ result? What constitutes in their mind what a dramatic change in their jawline is.
Applying those three factors to you and your jawline….you have a thick tissued face with an acceptable but not a naturally strong bony jawline. I believe the best jawline result you could possibly get with facial and neck liposuction is what is shown by the Vectra imaging. It will not end up any better than that and that imaging may even be a little optimistic. If that result is what you would describe as ‘dramaric’ and a satisfying result that you will be pleased with the outcome of the procedure. But if you undergo it and expect the outcome to be better with a well defined and visible jawline then you will likely be disappointed. The reality is that your thicker and heavier facial tissues have limits as to how much they can be reduced and show any jawline definition.
This is what I would counsel you on if you were my patient. It is always better in aesthetic surgery to expect the least. What is the minimum type of result you would find acceptable to justify your efforts? Anything result better than the least will then be a bonus and will make for a very satisfying experience.
One final comment….such face and jawline liposuction is all you can do with your face to get some improved definition. There are no other procedures to consider at this point. Just don’t expect it to be a dramatic result with a well defined and sculpted jawline….that is simply not going to happen.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Is it feasible to do a deep body chemical peel for arms, legs and back? Assuming all could not be done at one time (?) What would be the estimated cost. Everything I’ve read relates to facial peels. I would like to improve the appearance of my skin in these areas with long-term results. Thanks.
A: Skin resurfacing of body areas is completely different than that of the face. While the face has a great blood supply and can heal from even deep laser resurfacing, the rest of the body is not so tolerant. There is no such thing as a deep chemical peel for the body as that would result in delayed healing and terrible scarring. Body skin resurfacing must be approached much more conservatively (light to medium depth peels) and in sections. And even before that is done, skin test areas must be done to determine how the skin will react and heal. Therefore, while body skin rejuvenation can be done by skin resurfacing it must be done more conservatively and in stages unlike that of the face. There is a reason you can’t find much on a body chemical peel procedure…because it is a much more rare procedure than that of facial chemical peels.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 32 years old women coming from France. I ‘m interested about the rib removal surgery. Since 5 years ago I am focused on my large waistline. I have tried corset, diet and exercise but no result. I think is because I have a athletic body shape and no much fat in my body. That’s why I come to you to narrow my waist, the only way is the surgery. I would like to know the price of this surgery all inclusive and how long I have to stay before returning in France. As requested you will find my pictures.
1) I have also heard that rib can grow back so it’s reversible it is true?
2) I have a thick skin so would it impact the result of my waist?
Thank you in advance.
A:Thank you for sending your picture. In answer to your questions about rib removal surgery:
1) In an adult removed portions of ribs will NOT grow back. Regrowth of surgically removed ribs is an urban myth.
2) Your thicker skin will not negatively impact the result. I always combine waistline liposuction with rib removal to maximize the result.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in teenage gynecomastia reduction. My 14 year old son has gynecomastia and is very embarrassed about it to the point he doesn’t take of his shirt in public to swim and he wears a tight shirt under his t shirts to hide it. I was not sure if you would perform surgery on him since he is still going through puberty or if insurance would even cover the procedure? Thank you
A: Thank you for sending pictures of your son’s chest. This appears to be a ‘soft’ type of gynecomastia which should respond well to liposuction reduction. His skin and areola will shrink back down with the fibrofatty breast tissue removal.
When it comes to his age, the ‘standard’ thinking it is that this type pf gynecomastia will go away on its own and that he is too young to have surgery. In my experience I find that thinking of early juvenile gynecomastia completely flawed. It will not go away on its own and he is at a critical psychosocial point of development. I would choose to have it treated and reduced now so he can feel a lot better about his chest appearance. Whether it will regrow in the future is unknown but, even if it does, there will still be self-image benefits to having the surgery now.
As for insurance coverage, they would require a complete endocrinological workup to prove there is not a hormonal basis for his gynecomastia (and there is a 99.9% chance there is not) and the gynecomastia would have to be much bigger than his. They would view his problem as cosmetic and deny coverage for it.
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 am interested in facial asymmetry surgery. I have been diagnosed with a mild version of hemifacial microsomia. My asymmetry of the face seems to be more a soft tissue involvement. after some CT scan, the bone asymmetry is not as bad. I would like give my face symmetry with either fillers or fat grafting, what would you recommend?
A: Given the two facial asymmetry surgery treatment choices you have provided, you would never use injectable filler unless you just wanted to do a test to see if you like the result. Injectable fillers are temporary and will take a fair volume of them to have any facial augmentative effect. Injectable fat grafting would be the better soft tissue augmentation/reconstructivhe technique since the volume able to be injected is limitless and some of the fat will likely survive and persist.
I would also have to see your 3D CT facial scan to see his significant the underlying bony deficiencies are. Augmentation of any bony deformities, particularly along the jawline, can often be very beneficial and is an assured permanent volume result.
Many congenital facial deformities are often best treated by a combination of hard and soft tissue reconstruction techniques.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in migraine surgery. I have had migraine headaches for years and receive Botox injections for relief. My neurologists injectes them all over my head every four months from which I get good relief. My question is knowing that I get Botox placed all over my head, does that mean I will need surgical decompression of all four nerve zones?
A: Nerve decompression surgery for migraines works by treating the known area(s) of nerve impingement. While Botox has been effective for you, its injection all over the head does not provide a clue as to whether any of the known three migraine nerve sites (supraorbital, zygomaticotemporal and occipital) would be effectively improved by the surgery. In migraine surgery you never just decompress every available nerve site as that may end up doing unnecessary surgery.
There may be some clue as to whether you have specific trigger zone involvement by a description of your migraine pattern. Does it start in one specific area? It is on one side or both sides? Can you put your finger on an area that is most tender or where it seems to come from? Such information would indicate which nerve site(s) should be decompressed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have given up my search looking for a surgeon to preform distraction osteogenesis to widen my clavicle. I have heard you preform deltoid implants and have seen it on this website. Is it possible for the implants to add 2 CM of width on each clavicle and does it look natural for the most part? Also I can’t do fat grafting because I am not overweight at all. I just want wider shoulders in width and you seem to know much about this procedure.
Is this procedure becoming more popular, are your patients usually satisfied with the results?
Thank you doctor Eppley for reading this I hope to hear from you soon.
A: You are correct in that no one is going to perform distraction osteogenesis to increase your shoulder width. That is a concept that simply is not going to work for a number of reasons. While deltoid implants are your only option, the question is whether it is a good option.
Deltoid implants are not going to be able to increase your shoulder width by 2 cms or more per side. The skin over the shoulder is simply too tight to tolerate that amount of augmentation. There is also the issue of the incision/scar to place it which is usually done from the posterior axillary skin fold.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a chin implant revision. I had a chin implant done 15 years ago. The chin implant that was used at the time was too big, roundish and squarish for my heart-shaped face. I needed more chin projection than chin width. The chin implant was also put in crooked, one side was higher then the other. The doctor at the time also put in an additional implant shaped like a matchstick in the depression of my chin and at the bottom of the chin to offset the fact that it was crooked which I was not aware of until after the surgery. Within a week he took out the small implant from the center of the chin which then left a line scar. It was a terrible experience needless to say so I just left the big implant in and the scar until two years ago.
Finally I had the courage to get the chin corrected. I had several different consultations and finally decided on a plastic surgeon that supposedly had expertise in chin implants. We reviewed all the details with many photos and discussions. I finally had the surgery last year. Basically the plastic surgeon decided to use the original implant that I already had in instead of a custom one. He basically just went in and moved the implant downwards and that was it. The result was that it was still too round and big and now way too low. One side had already fallen after one week. The plastic surgeon said I needed a revision and they scheduled it a month later. I again explained to the plastic surgeon prior to the revision that the chin implant was too big and squarish for my heart shaped face. Again we reviewed photos etc…After the surgery the implant was the same. The plastic surgeon had just repositioned the implant slightly higher but it was still wide and squarish and very crooked. I was devastated to say the least.
One month later they scheduled me for another revision. I again voiced my concerns with the plastic surgeon and was assured that he understood what had to be done this time and that the implant had to be carved and shaped to my heart shaped face. After the surgery the implant had finally been reduced in size but was completely carved in a square shape and completely crooked.
Finally I was again scheduled for another revision two months later. Again more photos more discussion etc…The plastic surgeob finally carved the implant smaller and narrower to suit my heart shaped face. However it’s been carved unevenly and positioned off center and there’s a lot of puffiness formed in a wave on the top of the chin and it’s spongy and puffy. It’s a year next month since the last surgery so not sure if this is all scar tissue. I went for a followup last week out of concern with the total result and the plastic surgeon suggested cortisone shots which I did not want to do. I don’t believe that doing a patch up job of cortisone shots or fillers will correct this issue and it’s been very disheartening to think that this is the final result after all these surgeries. I am now considering doing another revision with a custom made chin implant to correct this once and for all. I came upon your profile on RealSelf and went through your website/blog/reviews and feel that you have considerable experience and knowledge in the chin area.
I have attached several photos for you to view and I look forward to speaking with you and thank you for your time in reviewing my situation.
A: Thank you for sending all of your pictures and detailing out your multiple chin surgery history. This is a tragic tale of chin implant augmentation surgery that was both ill-conceived and poorly performed. The fundamental problem, in my opinion, is that you really had the wrong type of chin augmentation surgery. When you have the natural chin anatomy that you have, placing an implant will be hard pressed to create a very satisfying result. Your chin is very horizontally short and subsequently vertically long. Your chin has a 45 to 60 degree angulation backward of the slope of the bone from it normal inclination. Any type of chin implant, particularly one that is placed low on the bone, is going to create vertical elongation and limited horizontal projection. This issue is compounded by the typical narrow width that such a chin shape will have in a female. Any standard chin implant that has wings will end up creating a long and wide chin. (squarish) You have experienced every problematic variation of trying to make a chin implant work in an anatomic situation where it just won’t do well.
With regard to the labiomental scar that is not the approach I would have utilized in your or any situation for the placement/removal of any form of labiomental implant.
Moving forward you have two chin implant revision options. The best option is to convert your chin augmentation to a sliding genioplasty and abandon the implant approach. Your chin needs to come forward and up. (vertically shortened) This is not what a chin implant can do. (as you now know well) The other approach is to make a true custom chin implant BUT shorten the length of the chin bone at the same time so that you still create the important vertical shortening effect.
I am sorry that you have had the outcomes which have occurred and I remain sympathetic about your chin surgery experience.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had custom facial implants placed about 3 years ago and I am wondering if they may be too big. You can see in one photo that I have some trouble smiling. My cheeks just kind of bunch up. I am considering replacing them and I would appreciate your opinion. They are cheek implants that extend to the paranasal area, chin implant, and jaw implants. Thanks for your time.
A: As I understand by your description you have custom cheek, chin and jaw angle implants. As the old saying goes…beauty is in the eye of the beholder. The fact that you ask the question indicates that you feel the implants are too big. In looking at the pictures you have sent with your initial inquiry, I think there is no question that the chin implant is way too big for your face from an aesthetic standpoint. If your smile feels stiff then the cheek implant size or style may not be quite right for your face also. The question now is whether your current existing implants can be resized or whether you would need new ones. There is also the question for some of them, like the chin implant, as to whether it is needed at all.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in midface shortening. I am interested in the LeFort 1 procedure. However I do not have a gummy smile, so would that be an issue? Perhaps there are better ways to solve the midface ratio by playing around with facial/jaw width. Is there a way to send pictures and get a professional opinion?
A: You are correct in that doing a LeFort I impaction without a gummy smile will have adverse effects on the upper lip-tooth relationship and is not a good idea. Burying the upper teeth under the upper lip has a negative facial effect and creates more of an aging appearance. Searching for other facial options would be what needs to be explored. Please send me some pictures of your face for my assessment and computer imaging of other potential facial reshaping options. Rhinoplasty, midface and/or jaw augmentation and lip enhancements can all be potential facial reshaping procedures that can change the disproportionate appearance of a long or strong middle third of the face.
True midface shortening can only be done through a LeFort 1 impaction as a vertical shortening of a bony vertical maxillary excess.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I consulted with a plastic surgeon in January and he told me that I have an unusually low set zygomatic prominence. He suggested a custom malar implant. From your response I understand that it is indeed reasonable to reconstitute the malar prominence higher up on the face using a custom malar implant approach..
What I want to clarify in particular is what happens to the current zygomatic prominence? As you know it is important to maintain a natural shape to the cheekbones to avoid them looking fake. Assuming that I am not looking for any alteration to the frontal and lateral projection to the zygoma, would two malar prominences not look odd on the face? If it is contended that the custom implant would taper into the former malar prominence, I can envisage this creating an excessively large malar prominence which would run counter to the objective of a sharp, high set malar prominence.
A similar concern arises with respect to the lower border of the zygoma which would ordinarily sit beneath the ‘old’ zygomatic prominence. Can we literally remove this part of the zygoma by burring/shaving in order to raise that border to sit directly under the ‘new’ malar prominence?
A: I can only tell you what I would do…make a custom malar implant that sits high with an anterior infraorbital and posterior arch extension combined with an inferior triangular ostectomy of the lower portion of the zygomatic prominence combined with a buccal lipectomy. This is the most assured approach to maximize the likelihood that an inframalar concavity facial contour is created along with a higher cheekbone appearance.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in bicep implant revision. One of my bicep implants is outside the fascia and the surgeon only sutured it to other tissue as a solution. Can it be re-implanted correctly? My surgery was five months ago. It is too late to fix? What has been your experience with this problem?
A: Whether you can have a successful bicep implant revision depends on the reason your implant currently sits outside of the proper subfascial pocket. If the fascia has not been torn or disrupted, then the implant should be able to be placed into the subfascial position. This would presumably have occurred because the surgeon intentionally placed it above the fascia for whatever reason. This would be favorable for a successful subfascial repositioning. If the implant ended up outside of the pocket because the fascia was torn or disrupted during its initial placement, then repositioning would not likely be successful because surgical repair of the fascia is very difficult due to limited surgical access. This does not mean it is impossible but an intact fascia along the longitudinal axis of the implant location is important to maintain the implant in the pocket.
Dr. Barry Eppley
Indianapolis, Indiana
