Your Questions
Your Questions
Q: Dr. Eppley,I am a transgender woman who is curious about procedures to narrow the width of my overall face. My face height (from hairline to bottom of the chin) is long, which by measurement seems to be around the female average, but my head looks wide due to the disproportionate width. The primary culprits seem to be the lateral projection of my zygomatic arches as well as a wider than average skull (lateral projection above the ears).
My understanding of male vs. female cheekbones is that male cheekbones tend to have more lateral projection, while female cheekbones tend to have more anterior projection. Would lateral cheek bone reduction combined with implants to give more anterior projection be a good solution to feminize this part of the face? And could this be combined with a reduction of the temporal muscles above the ears to achieve the effect of a less-wide head?
A: While I have not seen pictures of your face, your overall supposition seems aesthetically accurate. Posterior temporal reduction, posterior zygomatic arch reduction and anterior zygomatic (cheek) augmentation all seem like the correction combination to achieve a more feminine facial shape.
I wiould need to see some pictures of your face to provide a more qualified opinion in that regard.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have an atrophic abdominal scar, similar to a C-Section. It was due to surgery at an early age (I am male). There are two potential solutions to it. One is subcision to release the scar from being tethered to the underlying muscle fascia. The other is autologous stem cell injection at the scar site, something which I am not sure has been done before on this particular issue although I have seen nearly miraculous results on other injuries such as major burns.
With my scar, the surface of the scar is not bad, it is just tethered down. This creates a deformed appearance resulting in a major impact on quality of life. If it was level with the rest of my stomach then it would be hardly noticeable. However, stem cells could theoretically remove the scar permanently.
Please let me know if you can help.
A: Thank you for your inquiry. Let me provide some clarification on the concept of stem cell injections. Such a procedure in the purest sense of the term does not exist in the U.S. unless done under FDA-approved clinical trials for very specific study indications. Many people throw the term around like they are doing stem injections when they are not. It is strictly forbidden to harvest any cells from patients, modify them in any form and put them back into a patient. What is being done widely are fat injections which are erroneously touted, for marketing purposes, as ‘stem cell injections’ or even ‘stem cell enriched fat injections’. Fat coincidentally contains a lot of stem cells so all fat injections do have a high number of coincidental stem cells as part of it. How many are transferred with the fat, how many survive and what they do after transfer are all completely unknown. But to label fat injections as a true stem cell injections is misleading.
That being said fat injections can be done for scar releases in cases of contracted scars like yours. Their success, like all fat injections, depends on adequate scar release and a percent of the actual fat injectate surviving…whether that is due to some influence of its stem cell component can be debated.
Whether such an injection technique would be appropriate for your abdominal scar would require an assessment of pictures of it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a rhinoplasty to fix a retruded columella. I know a graft is needed to push out the base of the columella. One doctor told me that he would use septa cartilage. Isn’t the anterior nasal spine made of real bone, so wouldn’t you need something tougher than soft septal cartilage to do that? Would my nose lose structure/functionally feel weird if a piece of septum were missing? I’ve heard that some doctors use ears and ribs, what are your thoughts on that?
Also, do you feel that my nose tip need to be projected more forward and down, if the base will be lowered?
My other concern is about my nostrils. I think the outer corners droop down too much, hence I was asking about alar reduction (although that appearance could be exacerbated by the retruded columella).
A: In answer to your questions:
1) The anterior nasal spine is bone but you would never harvest a bone graft to place there nor would a bone graft persist. Cartilage is the correct choice, it is just a question of the quantity needed and the best donor site. Without question rib cartilage is best both in quantity and structural stiffness…if the patient does not mind a small chest scar to harvest it.
2) As the columella is rotated downward you are correct in that the tip projection will look less. As long as one has enough cartilage to graft, then the tip projection and rotation should adjusted accordingly. Like #1 the rib graft re-emerges and is essential if this nasal change is done. A rib graft rhinoplasty is the procedure you appear to be needing.
3) I think that the alar appearance is exacerbated by the retruded columella. Since any change to the alar rims requires an incision, I would not commit to the need for that change until one sees it in perspective of the columellar correction.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in chin reduction surgery. Unfortunately it seems that there are not that many Doctors in the US who do chin reduction. I even consulted two hospitals in Korea but I think I’ll skip. I don’t need anything major. Maybe just shorten and chisel it like 5 mm? Also I am 42 years old so I will need a facelift after? 🙁should we do the external approach to avoid the loose skin? I feel like there’s already too much tissue on my chin right now.
A: Thank you for sending all of your pictures and detailing your chin objectives. As you may know there are two methods to chin reduction, intraoral osteotomies and extra oral submental osteotomies. Because there are two methods it is not a surprise that there are some differences between them.
The intraoral approach uses bone cuts (osteotomies) where the a T-shaped pattern is done with both vertical and width bone reduction. It is then put back together with a small plate and screws. The soft tissues remain intact on the bottom and back side of the bone segments so there is not any resultant skin sag. (if there is too much soft tissue initially this won’t change) Its advantages are that it is scarless as everything is done from the inside. Its disadvantage is that the amount of bone reduction is usually a little more limited to protect the mental nerves and tooth roots since the actual vertical and transverse bone removal is done in the middle of the chin bone. There will be some temporary lower lip numbness as the mental nerve gets stretched with retractors to protect it during the bone cuts.
The submental approach uses a skin incision under the chin where the bone is shaved from the bottom up. The chin can be vertically reduced as well as the side bone cut down for reshaping. Because the bone removal is done from the ‘bottom up’ more bone reduction can be safely down particularly in regards to the mental nerve as well as the more direct linear access to the bone removal. There usually is little to no temporary lip numbness from this bottom up approach. Also any soft tissue redundancies can be addressed as most submental chin reductions get some form of a submentoplasty as a result. Its disadvantage is the fine line scar under the chin. This is why it is not popular in Asian countries where their skin types are more prone to adverse scarrring.
Having done a lot of each chin reduction approach, you have to choose which technique is most appropriate for the patient’s anatomy and aesthetic chin reshaping goals. It is not really a question of one being better than the other, they are just different with each one having their own distinct advantage and disadvantages.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have some questions in regard to temporal implants:
1. Are there standard implants for augmenting the whole temporal complex? or just the anterior portion?
2. What the procedure be should the implants become infected post operative or years later?
3. How many days would I need to stay in Indiana for recovery?
4. Could an endoscopic brow lift be preformed at the same time through the same incisions?
A: In answer to your temporal implant questions:
1) Standard temporal implants only exist for the anterior temporal region. There are special design or custom temporal implant options for the posterior temporal region.
2) I have never seen a temporal implant infection. But if it would ever occur, like all implants, it would occur within the first month or so after surgery. It would not occur years later. The standard treatment for implant infections is removal.
3) 1 to 2 days at most would be all the time you would need to be here before traveling home.
4) Endoscopic browlifts require more superior scalp incisions to perform not lateral temporal incisions. As a result an endoscopic browlift could be performed at the same time as the placement of temporal implants. In fact the same high temporal incision could be used to perform both of them.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m needing some information on the ultra-soft testicale implants you talk about in you blogs. I have had a semi-solid Promedom implant placed three weeks ago. Now I find it is a bit harder than my other natural one, so are the soft implants you mention softer and more natural feeling than the Promedom semi-solid elastomer ones? Are they silicon gel filled or just a much softer elastomer? Which company makes and supplies them and how could I purchase them here in my country?
A:I can not speak to how the Promedom testicle implant compares to the ultrasoft testicle implants that I use here in the U.S. since I have never felt that implant before. I also have no knowledge of its silicone composition or properties. But due to the lowest durometer silicone that is used in my custom testicle implants and I have yet to see a patient state that it is too firm, I would guess that it is a softer solid silicone material that what you have currently in place. The testicle implants that I use are exclusively provided to U.S. surgeons based on FDA requirements and guidelines. How to get them in your country is a question for the manufacturer.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, let’s say a patient is interested in permanent lip augmentation. From research, Ive found the only permanent options are a lip lift, fat graft to the lips (but it’s controversial as many have reported it deflating too soon) and the silikon 1000 injections. My concern with the lip lift is the scarring, especially because I have olive-dark tone skin and have read that those with darker pigmentation are more prone to keloid scarring. If I were to treat my skin to become lighter, does that help with the issue of dark skin = keloid scarring? I’d really like a lip lift as it seems the only permanent option.
A: For the sake of clarification, there is also two other permanent lip augmentation methods, a lip or vermilion advancement and internal mucosal V-Y advancements. So there are a few other options of which the concerns about scarring exist with the one (lip advancement) but not with the other. (mucosal rollout)
I have done many lip lifts on dark-skinned patients and I have never seen any adverse scarring issues such as keloids. So this would not be a major concern based on my lip lift experience.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in chin implant removal. I am currently 6 months after my rhinoplasty and chin implant and I am unfortunately more than disappointed with the results. I went in with my nose being my main concern and my plastic surgeon was very adamant about giving me a chin implant, as a lot of surgeons suggest doing with rhinoplasties. Because I trusted him and his work, I agreed to it. I wanted to wait to do the implant at a later time, thinking it would be too much all at once, but he thought it would be best to get it all over with at one time. Well, I should have stuck with my gut, because I was right- the results are too much. I wanted a new nose, not a new face- and with the two, I just don’t feel like myself anymore. I realize I had a small chin and maybe the way my chin is now, might be aesthetically perfect to others, but it is not me and I wish I could have loved myself for what I was. I went to my 3 month post-op appointment to voice my concerns with my plastic surgeon, because not only am I not pleased with my implant, but I am going to need a revision rhinoplasty. He looked at me in disbelief, telling me he was disappointed in me and that anyone else would be thrilled with their results- that what I’m seeing is psychological. I can assure you, I am not feeling good about myself, but I know I am not seeing things. When telling him I didn’t like my implant, he told me getting it out would be the biggest regret I would ever make and that the procedure is extensive and complicated. Right now, I just want to get back to feeling and looking like me again. Being that I am so early in my recovery for my nose, having this implant removed is all I can do and I really would love your input. I have done a good amount of research and I am terrified that I’ve made a huge mistake. I keep reading about people getting their implants removed and their lips/chins being permanently numb, hard, or they can’t move their mouth properly.. or they have the sagging skin, dimpling, etc. A big dislike I am having with this implant is that it has changed the way I talk, amongst other things. I had such a petite face/chin before and although this may be a small implant, it was enough to change my look completely. And to me, not for the better. I have tried to look into doctors who specialize in implant removal and did not have a lot of luck- it seems like a lot of doctors are able to put them in, but are not as experienced in taking them out. I just really want this done the right way, or not at all. I don’t want to be stuck like this for the rest of my life, but I really can’t handle dealing with anymore bad results. You were one of less than a handful of doctors that popped up right away in searching the removal of chin implants- Can you please give me some insight?
A: Thank you for your inquiry. It is always disheartening to hear of unsatisfactory aesthetic outcomes from any form of plastic surgery whether it is my patient or another…so I do feel your psychological pain. I always do preoperative imaging on any facial reshaping change to be certain that the patient likes their predicted new face. That may or may not have been done in your case. But either way it is irrelevant now. You have done the definitive test, you have worn this chin augmentation result long enough to know whether you like it or not.
A silicone chin implant removal is very straightforward and far less ‘complicated’ than putting it in. While the implant is small and has not been in for very long, and the risk of any soft tissue sag is low, it may be beneficial to do a little soft tissue tightening internally when it is removed. But based on how you feel, just get it removed ASAP and get back to the lower facial shape that you know.
The picture being painted that a chin implant removal is complicated and will lead to other adverse issues is not accurate.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I know that facial fat is a very difficult thing to address.
If you are young and have exhausted both options of Buccal fat removal and facial liposuction and still have an unacceptably fat and heavy face, how feasible would it be to get a face lift to address the deeper and superficial layers of fat by dissection? I know In older patients who get face lifts often everything is opened up and can be fully accessed and at times fat is taken out. I know the issue with taking out fat in the face is that it can’t be accessed easily since a lot of it is intermingled in different soft tissue layers. Wouldn’t a full face lift allow a surgeon easy access to all of it to dissect, remove and split carefully?
Can this be done with a younger patient who desperately wants a leaner face even at the expense of face lift scars?
Also what’s your opinion on Kybella for facial fatness beyond by chin?
A: In answers to your questions about facial fat reduction:
1) Kybella will be useless for our facial reshaping concerns.
2) A lower tuckup facelift will offer improvement. You are correct in that regard. But it is not really the result of fat removal, it exerts its effect by tissue lifting/tightening along and above the jawline.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was interested to read your comments regarding augmenting the skull area: ‘Kryptonite Bone Cement, can be injected through a very small incision (10mms) and shaped until set from the outside. ‘m (injectable cranioplasty) Would this procedure be suitable for expanding the cranium, beginning from above the forehead, top of the cranium ending at the back of the top of the head, as this is where I would require augmentation, the highest area to be approx 3cm in height? Also, what would be the cost? I look forward to hearing from you at your earliest convenience.
A: In answer to your question, both Kryptonite bone cement material and the concept of an injectable cranioplasty using it have been abandoned. While there may one a role for injectable cranioplasty for very small cranial defects, it is a technique that will not work for larger skull augmentations due to irregularities and lack of contour control.
While I commonly do large skull augmentations, this is done today using custom designed skull implants from the patient’s 3D CT scan. This ensures control of the surface area coverage and shape of the skull augmentation in a precise manner. In larger skull augmentation, like the 3cm thickness to which you refer, this would require a first stage scalp expander to generate the soft tissue coverage required of such a large skull augmentation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m interested in rib removal. I was wondering how much of the 11th and 12th ribs you remove during the procedure? Also, what is the risk of post-thoracotomy pain from the procedure? And what do you do with the intercostal nerves that run below the ribs when you do this procedure? Thanks very much.
A: In answer to your rib removal questions, the ribs are removed back to the lateral or outer border of the erector spine muscles. More medial resection towards right spine has no aesthetic benefit. There is zero risk of pneumothorax in removing ribs #11 and #12. The pleura of the lung sits higher than at these rib levels in most patients. I have only see the pleura one time during surgery at the level of the 11th rib. The intercostal neurovascular bundle, located on the inferior side of the rib in a bony groove, is dissected out and preserved throughout the extent of the rib resection out to their cartilaginous tips. Intercostal nerve blocks with Exparel anesthetic are administered at the end of the procedure prior to wound closure to help with decrease the immediate postoperative pain during the first few days after surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, in Europe and Australia, PEEK has recently come into use as a facial implant material, particularly being advertised for its ability to be custom manufactured/shaped for the patient.
One of the supposed benefits of this new material is that it is very similar in density and hardness to bone. However from reading your blog posts on Medpor vs silicone or ideas like titanium implants, it seems to me that this is irrelevant and that silicone remains both cheaper and easier for surgeons to use?
Would there be any advantage at all to this material or is it just a case of people trying to reinvent the wheel?
A: PEEK and any other firm rigid polymers as a facial implant material have a role to play in reconstructive surgery but not so much in the aesthetic patient for two primary reasons. First and foremost there is the surgical access needed to place the material. A rigid implant requires wide open incisional access or, at the least, longer incisions and a much bigger implant pocket. This is a major disadvantage over more flexible materials like silicone which can be placed through smaller incisions and then acquire the feel of bone when the backing on which they rest is bone. Secondly, custom designing of a PEEK implant is far more expensive than that of other materials like silicone often being 2X to 3X more expensive.
In conclusion, there are numerous other technical issues than can overtake whatever theoretical material advantages a facial implant material. (ease of placement and removal as well as cost being major considerations) While feeling ‘like bone’ may seem advantageous, that very material property is equally if not more potentially disadvantageous.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, i had my chin implant revised last year as it had shifted after ten years. A surgeon repositioned the implant intraorally but i did not like the look. I subsequently had it removed a thereafter as it got infected as well. The surgeon who removed the implant saw fit to inject me with HA filler on my chin as i was afraid that it might lose its shape once the implants was removed. Another doctor gave me another injection of HA filler last year as well.
All in all everything seems to have been one mistake after another. I am now diagnosed with ptosis of the chin. i have good lip competency but it is not without some effort. i also feel the shape of my lip quite different from before and it feels sort of loose, like it’s been stretched out and is a little bit slack. It has been recommended that either a Medpor chin implant or a genioplasty should be done although all the doctors I have seen say they haven’t seen many cases like mine though.
So I went reading on the internet and it seems you have a lot of experience with cases similar to mine. Might you be able to help me with. chin implant replacement?
A: What you undoubtably have after having a chin implant removed is exactly what you described…a stretched out soft tissue chin pad. It is being partially supported now by the HA filler but that is not the same as a chin implant replacement as either a new chin implant or a sliding genioplasty.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m trying to decide if I should get a BSSO mandible advancement surgery or jaw/chin implants for my overbite and weak jawline. It is very hard to decide and I am not sure what to do.
A: Actually that jaw augmentation decision is much more straightforward than you think it is. First, I would need to see pictures of your face and your bite to make an assessment and any recommendations. Secondly, the BSSO mandibular or lower jaw advancement surgery requires pre- and post surgical orthodontics and is really an operation of a bite change whose result on the aesthetics of the jaw is controlled by how much occlusal change can be done. A BSSO is not really a primary jawline augmentation procedure. It may have some side benefits in that regard but that is not its primary objective. Whether it can achieve the chin projection aesthetic your desire can be determined by preoperative cephalometric tracings. But a mandibular advancement surgery will have no impact on jaw widening or jaw angle augmentation. At best it is mainly a jaw profile enhancement procedure that affects chin projection. Lastly, implants have a distinct 3D effect on the jawline but will not change your bite.
So you can see that the simple answer to your weak jawline quandry is whether your bite needs to be changes for functional purposes or not.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I appreciate the chin augmentation prediction imaging that you have sent me. I attached the image that I found more desirable. Doctor, if you could clear up some questions, I would hugely appreciate it. My questions are:
1 Is this chin augmentation result achievable?
2 Doctor, I really don’t want to make big changes to my front profile, would this procedure noticeably alter it?
3 Do you think I have a big or deep mentolabial sulcus? If so, would this be a problem?
A:In answer to your chin augmentation questions:
1) I only image results that I think are achieveable.
2) Every chin augmentation procedure affects every dimension of the chin to some degree. You can’t just change the profile view and not affect the front view. To minimize frontal view changes (not make the chin too wide), a certain style of implant must be chosen that augments mainly the central chin and not the sides.
3) The mentolabial or labiomental sulcus is a fixed anatomic structure while the chin point is not. Thus every chin augmentation procedure, by definition, will make the labiomental sulcus look deeper. The bigger the chin augmentation, the deeper the labiodental sulcus becomes.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Would it be possible to do the rhinoplasty to straighten asymmetry but keep some features of my nose? I would like to take down the small hump, but I honestly kind of like how the tip of my nose flicks upward. I know that is usually undesirable, but for some reason I’ve always been attracted to upturned noses and “ski-slope” noses versus a traditional straight nose. I feel like if the hump was reduced and kind of sloped inward more to match curvature of the tip of my nose, it would give my nose a “ski-slope” appearance from the side view. We can still even narrow the tip, as long as we keep a slight curvature versus having my nose look like a straight line from the side. I added a few pictures as examples of “ski-slope” type noses. Also my eyes are quite deep set, and I feel like reducing the bridge of my nose and maybe even a little up at the top of it between my eyes might make my eyes appear less shadowed. I like what you did with the chin however I’ve always felt self conscious because I have what people consider a “butt chin”. I was wondering if that too could even be smoothed out because we would already be doing work on my chin to correct the asymmetry. Thanks so much for your help! Sorry if I seem really nit picky, I just want to feel good in my skin.
I would like to reduce the bridge/dorsum and radix. I don’t really want anything done with the tip except whatever has to be done to correct the asymmetry. Maybe making the tip a bit smaller because making the bridge of my nose smaller might make the tip appear large… It’s weird I’m okay with my nose from a front facing view with a neutral expression, but whenever I smile it seems to appear at least twice as wide… maybe we should do something about that as well but I’m not sure what it would be. I want my nose to look like my nose afterwards, just a more visually pleasing version. I don’t want it to look completely different. As for the chin goes I don’t want any implants or fat grafting. I think my butt chin is caused mostly by bone, although you’re probably right that there is also soft tissue causing it. I think if we dealt with the bone though it would help, I am okay with having a slight butt chin but anything we can do to reduce it through the bone would be helpful.
A: In interpreting your nose shape change objectives I have attached an imaging prediction of what you want. This would be reduction of the dorsal line and bridge including the radix. This will create an increased concavity to the dorsal line. Without changing the tip of the nose this will give it a more scooped out appearance. Without changing anything the tip this will make the nose tip see longer and more upwardly rotated. While this nose shape change would not be common, I believe that is what you want and the patient’s aesthetic goals is all that really matters.
For the chin what you have imaged is a vertical reduction of the chin and back along the jawline. This is best done through a submental approach. Some of the bone that is removed can be placed over the cleft in the chin one as a graft to help minimize the cleft chin look.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in the skull reshaping procedure. My skull is pretty oddly shaped and I’m not sure what can be done. I have attached several pictures from various angles. I’m most interested in reducing the bump on the top of my head and correcting why my head looks odd from some angles. I noticed I have a flat spot on the back/ right side of my head, and a bulge on back left side. I understand this is informational and consultation is still needed, I just want to get a better understanding of what to expect. I have a few questions:
1) What kind of procedures do you think could be done and is it worth doing?
2) How long is the heal time for a procedure like this?
3) How many sessions do you think it might take? (I would be coming from out of town )
4) How bad could the scaring be, I’m interested in keeping my hair short or shaving it completely
5) What is a rough estimate of the cost for this procedure?
6) Are there any significant concerns about complications or infection?
A: Thank you for your inquiry and sending your pictures. What I see on your skull is a high posterior sagittal ride, flattening on the back of the head on one side and some generalized skull irregularities. In answer to your questions:
1) The procedure would be a combined posterior sagittal ridge reduction and a custom skull implant to fix the flatter back side of the head as wells to cover other areas of irregularities for a smoother overall head shape.
2) Swelling is a process that takes about 2 weeks for most of it to be gone.
3) This is a one time surgery.
4) A single fine line 9 cm long curved incision is used on the upper back of the head.
5) My assistant will pass making the cost of the procedure to you later today.
6) I have never seen a skull reshaping infection even with implants. The only potential issues are aesthetic…how does it look, is it smooth etc.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a cleft septorhinoplasty or at least I think that is what it is called. These are all photos within the last year taken with my phone. So the right side of my face will appear on the left. I’m not to worried about the deviated septum. I was wondering about possibly making the right nostril smaller and making both nostrils look symmetrical. Possibly pull the nose towards the right a little as well. I think that might also hide the septum a bit too. Let me know what you think. Thank you very much!
A: Thank you for sending all of your pictures. Cleft noses are the hardest of all rhinoplasties to do and you can’t just ‘piecemeal’ it, meaning do one small thing on the nostrils for example and they will turn out better…because they won’t. There are so many anatomic aberrations in the cleft nose that you have it to do a complete cleft septorhinoplasty procedure and go for trying to fix everything about it. Even then ideal symmetry and shape will never be obtained. But it takes a full septorhinoplasty effort in the cleft nose to even make small improvements as the tissues are deranged and abnormal.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had two subdural hematomas removed five years ago and one hole to remove a bone flap was done on my temple and has left a indentation to my face shape. Is there a possibility of an implant being set there because of the injury. I am going to talk to my neurologist about this and see how they feel about it. Very interested if it is a possiblity.
A: Thank you for sending your pictures. I have seen such temporal indentation deformities many times after temporal craniotomies. While they may be an underlying craniotomy flap indentation that accounts for some of the concavity, most of it is caused by the loss and retraction of temporalis muscle. The muscle has retracted from its superior attachments and is now sitting like a ball down above the zygomatic arch all shrunken up so to speak. This accounts for the severe temporal indentation (loss of muscle and sinking of the bone flap) as well as the excessive width by the eye. (contracted temporal muscle)
There are two approaches to treating your temporal craniotomy defect reconstruction:
1) Building up the temporal hollow with bone cement and thinning out the overly thick muscle mass by the eye through an open scalp approach, or
2) Doing fat injections into the temporal indentation. (closed approach, only requires small external puncture sites, may require multiple fat injection surgeries)
Either temporal craniotomy defect reconstruction approach has their advantages and disadvantages. I have attached a result from the open application of bone cement for your review.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, what are some ways that you can bring deep set eyes forward? I have eyes that sink back more than normal giving the appearance of enophthalmos. I’ve read about orbital floor implants, injections to prop eyeball up and more forward to protrude. This is my biggest insecurity is that my eyes are sunken in and if they were protruding the eyelid would be stretched out more and not deflated and flat because of how retruded my eyes are. Also I’ve read about shaving the zygomatic bone and brow bone to make the eye look more protruded, is that a surgery you preform? Retruded eyes makes my nose look even longer than it is. My nose bridge is a bit too narrow and long. I do want the nose shortened and the entire bridge as well as between my eyes widened wether that’s done with bone cement, fat grafting, cartilage grafting to give my eyes the illusion of being even more further apart. What are your thoughts on this?
A: There really is no way to bring the eyeball forward. It is important to remember that the eye is tethered like a string by the optic nerve. So the concept of trying to bring it forward puts tension on the optic nerve and may risk blindness. While the eye can be made to be raised or lowered, these are vertical changes that do not stretch the optic nerve.
What can be done to make the eye more prominent is to reduce the bone around it. The brow bones and lateral orbital rims can be reduced to set back the bone which can make the eye look a few more millimeters forward.
To make the eyes look further apart I would not think that widening the nasal bones would create that look. If anything that would make them look closer together as the distance between the inner corner of the eyes and the nasal bone is becoming shorter. Widening the nasal bones does not push the eye outward.
In short, while orbital bone reshaping can be done its effects on making the eyes look more forward would probably be negligible.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like to get a consult on a scar revision on my shoulder. I had a small keloid scar (about .5cm) on her left back shoulder that a dermatologist tried to remove with elliptical excision a couple years ago. Unfortunately the healing process was disrupted by a complication infection that was caused by the technician not properly removing the sutures. Remaining suture fragments were later found embedded and removed by an urgent care physician. The excision expanded and the result is a much larger keloid scar. (about 3x3cm) I’m attaching two photographs for you to get the idea of its current size. You can vaguely make out the shape of the excision scar which is surrounded by the individual suture scars.
I am interested in a consult to determine if there is a revision option that would at worst leave her with a much less prominent scar.
A: Thank you for sending pictures of your shoulder scar. This is a very tough area for scar revision to make improvements due to the thickness of the skin and the continual tension that is on the shoulder area. Without surgery, of course, there will be no improvement. With surgery there is a chance for improvement but it is certainly no guarantee.
Because of the skin tension issues in this body area, the most prudent approach is a serial scar excision. What this means is to do an initial subtotal excision (inner two-thirds), let it heal and see what it looks like in three months. If it remains less in size then go for the completion excision with confidence that it will end up much smaller than it is now….with no risk that it can become bigger. This would be the safest approach to lessening the risk of making the scar no better in the end with further surgery or even making it bigger.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in an umbilicoplasty procedure. My belly button has turned into an outie after my pregnancies and looks abnormal. Why does it look this way and what can be done about it? How does the umbilicoplasty procedure work?
A: Thank you for sending your pictures. Your current umbilical shape is primarily because you have a disinsertion of the umbilical stalk from the abdominal wall. This is probably associated with a small defect in the abdominal wall although not necessarily a true hernia. This has allowed the entire umbilicus to come protruding outward which is why it looks like there is a ‘smaller ring inside a bigger outer ring. There are also issues with the overall diameter of the umbilicus and its length although these are more minor. What initially has to be done for your umbilicoplasty is to reattach the center of the extruded umbilicus back down to the abdominal wall to return its shape to that of a single inward funnel. The length of the funnel would also be shortened at the same time. Such a procedure would be done through an incision inside the umbilicus.
An actual physical examination may change this opinion which is based on your pictures only. (but probably won’t)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had to have the bottom half of my ear surgically removed as the result of cancer. Since radiation was tried but was unsuccessful, permanent replacement via a an ear bone attachment is not possible. I am interested in a permanent ear replacement using your technique of creating a mold, growing ear cells from an animal, implanting this into the back of a rat then permanently attaching this ear.
A: Thank you for your inquiry in regards to ear reconstruction. I am not sure where you got the impression of how ear reconstruction is done, but the concept of growing cartilage cells on an animal in the shape of an ear to be used in human ear reconstruction is an experimental study not a viable human surgical procedure as of yet. But even if it were, the key issue in any attempt at ear reconstruction in yourself in that you have had radiation. Such treatments have damaged the surrounding tissues and impaired their blood supply. Any form of reconstruction will require a vascularized soft tissue cover regardless of what is used for the underlying cartilaginous framework reconstruction.
I would be happy to look at current pictures of your ear to determine what type of ear reconstruction may be possible in your case.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley,I am writing to you to enquire as to the methods one could use to restore a chin after a failed chin reduction.I underwent a chin reduction surgery to correct the excessive vertical dimension of my chin. Supposedly a section of bone was removed from the center of my chin and the lower part was moved upward. However the results were not at all as expected. My chin is now uneven in every direction, has no tip, is much too small, and has no structure to support the soft tissue around it.
I am not completely sure what the surgeon actually did. Suffice tit o say that he can not simply re-cut the line and move it back into place as the chin is now a completely different shape from what it was.
My question is; is there a method, perhaps using HA, to rebuild my chin and restore its previous shape?
A: A plain view x-ray of your chin, such as a panorex, would answer the question as to what type of chin reduction procedure you had done. Usually for a purely vertical chin reduction a wedge reduction intraoral genioplasty would be done. The results you now have do not appear to be consistent with that approach. Knowing how it was done can influence how you might reverse it or perform the revision chin reduction procedure. If it was done by a true wedge reduction vertical genbioplasty than re-opening the osteotomy site and placing an interpositional graft would work. If the bottom part of the chin was just cut off or one desires to bypass an opening wedge genioplasty then building up the bottom part of the chin bone is needed. This would not be done by using HA as getting anatomic contour and shape would be impossible with this material. Rather an implant would be designed from a 3D CT scan which would provide the optimal vertical chin shape and smoothness as well as choosing before surgery the vertical dimension increase if any is desired.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’ve been surfacing on internet for quite some time now to seek the corrective options I’ve got for my facial asymmetry. The problem with my face is that the left side of my face is bigge r(overgrown) than the right side and my chin and lower lip seems to be drawn to the right. I’ve learned about jaw implants through your blogs on this website. Keeping in view my above stated complaints what would you suggest me for attaining a more symmetrical face?
You asked for the picture of my face so here it is. I previously forgot to mention that I’ve got history of face trauma some 10 years ago over the right aspect of my nose forming a hump/scar (evident in pic). As far as i know facial asymmetry became more obvious to me after that. I was just wondering whether that accident has got anything to do with my facial asymmetry.
A: Thank you for sending your picture. Contrary to your perception your facial asymmetry is the result of an underdevelopment of the right side of your face and not an overgrowth on the left side. Hypoplasia is the cause of 95% of facial asymmetries. True facial hyperplasia is fairly rare.
Now it could be that you like the smaller side better but the actual pathology is on the right side. From an aesthetic correction standpoint what you have to decide is which side you like better so an established target is set…..either make the right side bigger to match better to the left or make the left side smaller to match better with the right. Either way the correct diagnostic step is to get a 3D CT scan to know the underlying skeletal anatomy.
Your facial asymmetry is congenital, it is not the result of your nasal trauma.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have had two mandible reductions and one full lower jaw sagittal split jaw procedure. These were done within about 5 months of each other. It has been about 9 months after the sagittal split procedure and I still have a problem with my lips.
I think the doctor burred too much and now my lip is similar to this.This is the area which has damage. My lip is not quite as bad as this but it is noticeable to a degree. Which part is this? Is it the inferior alveoli nerve damage? Is it likely that this is going to get better over longer period or is there no chance? When I chew it looks weird and also I dribble always when I drink and sometimes when my mouth is open. Even when I drink from a cup it dribbles from the middle for some reason. Is this type of overdone mandible burring and shaving possible to cause complete and utter permanent nerve death? I have a really tingly sensation if I tap it. It’s very hypersensitive. Some areas of the lip are numb though.
Would a particular facial exercises help?
Is there any way I will get back to normal or now not much chance? I worry Botox on other side will just mask problem and not help the dribbling issues.
A: While you have a lip problem, you are confusing the two nerves that can be affected in mandibular surgery. The inferior alveolar nerve is the sensory nerve that runs inside the jaw and comes out of the bone at the mental foramen below the roots of the first and second premolars. This nerve is at risk in both the SSRO procedure (sagittal split ramus osteotomy) and the mandibular reduction. This nerve is responsible for feeling and is why you have numbness of the lip and chin.
The lip looks like it does because the marginal mandibular branch of the facial nerve has been injured on your right side and is why the lower lip is higher than the left side. This undoubtably occurred during the mandibular reduction not the SSRO. This small nerve is responsible for innervating the depressor anguli muscle of the lower lip (it is a motor nerve) which is responsible for pulling the lip down with motion. When injured it does not move and the normal side pulls down while the paralyzed side rides up, thus creating the asymmetry most seen in activation.
At 9 months after the surgery (injury), while it is not impossible that some motor function of that nerve may return, I would not be optimistic. This is a single fascicular nerve branch so it has no cross-innervation, thus it has a poor recovery outcome. Facial exercises will not help. Botox may be helpful on the normal side so it does not pull down as much.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have some questions about standard temporal implants:
- How can a standard implant cover up the inner concave on the hollowing temple fully with perfect positive results? Won’t there be bulges, indents of pockets not covered by the standard implant?
- By standard, do you mean a one size fits all? Is this a standard procedure? Because I haven’t seen it aside from your practice.
- How far back does the imlant go? if you see in the pictures, I’m deficient a little back there behind temple above the ear along the ear. What do you think?
- How about Fillers instead? Ideally Permanent fillers? Or even better Fat? What’s your opinion on fillers instead of implants?
- Please to the best of your ability explain the procedure. Basically we make an incision (where) and push in the implant, fit it and close the incision? Is there something done to hold down the implant?
- How long is recovery from a pain perspective, bruising, swelling and going back to work perspective.
- How long do I stay in Indiana ideally? What if it becomes infected when I am home? Is flying with it in hard and painful? Or do you have a doctor you work with in my area.
- Is it irresponsible to do a surgery in another state?
- Are temporal implants reversible?
- What does it feel like to the touch?
- Aesthetic outcome: can we make it straight not rounded? I tend to get haircuts that make hollowing look straight, not rounded. Thats the best aesthetic. Can we aim for that?
- Can it ever come out of place?
- Please can I request before and after pictures? I’m from out of state and would really like a few before I commit to this long process.
A: In answer to your temporal implants questions:
1) Your temporal concavity concerns are classic and are exactly what standard temporal implants were made to augment. They would produce a smooth contour…although I am going to point out there are no perfect results in any facial implant procedure or surgery. If only perfection will do, then you should not have surgery as that never happens.
2) Standard temporal implants come in two styles and two sizes and are widely used.
3) Standard temporal implants do not go back that far.
4) There is nothing with fillers or fat injections…other than they are not permanent. When in doubt so those first.
5) The implant is placed in a subfascial pocket on top of the muscle. That si what holds it into place.
6) Pain is minimal, there usually is not bruising and there will be swelling.
7) You should be able to return home the next day. I have not seen a temporal implant infection.
8) Many patients have plastic surgery far away from home. It is commonly done.
9) Like all facial implants, it is completely reversible.
10) Feels like normal muscle. The implant is soft and squishy like muscle.
11) Making the temporal straight is best achieved by using small implants.
12) It can not become dislodged from the surgical pocket into which it is placed.
13) Due to patient confidentiality I can not pass out patient pictures.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am well from my brow bone reduction procedure. I am doing well. Again, overall pleased with the outcome of my procedure. I do hope I am not asking too many questions, but I am curious about something. Is it possible to have the plates and screws removed from my forehead? If so, would this require the same type of incision as my prior procedure, or could this be done with a much less invasive incision? There is a palpable bump where the screws and plates are and if they can be removed with a minimally invasive procedure, I would consider that. Basically, I don’t want to go through the same recocery I went througn before. If the plates and screws are still necessary for support, then I will not do it, but if they have done their job, and it is ok to have them removed, then I will consider it.
A: In answer to your after surgery brow bone reduction question:
1) The plate that was used has a very low profile, less than one millimeter. Thus it is not yet clear that the palpable bump to which you refer is the actual plate. I would need to see a picture with the area outlined on your forehead to match up to the intraoperative pictures to determine if what you are feeling is the plate.
2) The fixation plate should not be removed \before six months after surgery two ensure as much bone healing as possible.
3) Depending on how you define a minimally invasive procedure, the central part of the incision would need to be opened and an endoscope used for access to visualize the plate and screws and remove them. This is not close to what it was before but it does require a central endoscopic dissection.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in placing a chin implant on top of my sliding genioplasty. Maybe if my sliding genioplasty cut was made further back and moved in slight angle higher to make it look more square from front (losing some vertical height maybe). It is what it is – But I still think it was a clear improvement even with some compromises.
With an implant on top of the sliding genioploasty I want to achieve some more horizontal projection but at the same time some more width. All this must happen so that my chin doesn’t look longer (here I mean no additional vertical length). I also mean that not even optical illusion of looking so. I want to avoid deep sulcus but I don’t think it is a concern.
A: While the chin implant can be added into the sliding genioplasty, the relevant questions are:
1) Given the current shape of your chin after the sliding genioplasty, would a standard implant adapt well or is it best done with a custom implant made for the alerted shape of the chin bone.
2) While the additional amount of horizontal chin augmentation is not extreme, it will make the labiomental crease a little deeper. This may potentially be avoided with a custom chin implant.
3) Should this be done intraoral or from below from a submengtaol skin incision.
These are issues for you to ponder.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have interest in consulting regarding dermal fat drafting surgery . I have been researchimg for sooo long hoping to find something like this. I was diagnosed with linear scleroderma a few years ago and have noticed my top frontal area become more and more darker and indented. I am a 33 year old mother of three and since this diagnosis and physical apperance, it has caused great emotional damage and even depression. It has been an extremely difficult time understanding this and dealing with it, having to explain it to my friends and family. Please help. Thank you for your time,
A: Linear scleroderma is both a peculiar and frustrating craniofacial affliction. The first place to start is to send some pictures for my assessment and recommendations. By your description you appear to be in the active phase of the disease and it involves the forehead and up into the scalp undoubtably along the pathway of the supraorbital nerve. The classic teaching is that one should not treat the deformity until the disease process has abated and the tissue loss has stabilized. While that certainly makes the most sense from a reconstructive standpoint that is usually not very comforting to patients. I have often taken a different approach which is to try to stop the tissue deformation progression by early tissue grafting. Whether this should be done by the implantation of a dermal-fat graft from an abdominal harvest or fat injections with PRP (platelet-rich plasma) is up for discussion. With either fat grafting technique, it may take more than one treatment session to get sustained results.
Dr. Barry Eppley
Indianapolis, Indiana
