Your Questions
Your Questions
Q: Dr. Eppley, I have benign temporalis muscle hypertrophy on the sides of my forehead. It adds width to my forehead which gives my forehead a kind of alien shape. I know it is the temporalis muscles as when I fully open my mouth I achieve a very desirable atrophy which diminishes the odd looking alien shape. I would like to have this problem dealt with surgically as I want the problem fixed permanently. I am aware Botox is an option. However I have a few questions about the surgery.
1 )Does this surgery have a high satisfaction rate?
2) Is there a possibility that it could look un-even or potentially worse?
3 )Are there any potential side effects after the surgery?
4) The muscle hypertrophy is benign, does this make me a more suitable candidate even if it is the anterior part?
5 )Why do other surgeons not use the cauterisation technique you use and would that be necessary for my procedure?
I look forward to hearing back from you.
A: I am very familiar with the temporal shape issue which you have described. You are referring to a anterior temporal muscle reduction which is far less commonly done than that of posterior temporal muscle reduction for head narrowing. The anterior temporal reduction poses far greater challenges than that of posterior temporal reduction for the following reasons; 1) incisional access is more aesthetically challenging, 2) the muscle can only be partially reduced/released (unlike the posterior procedure where the entire muscle is removed. This poses technical challenges and 3) it is on an exposed non hair-bearing part of the face where the effects of the surgery can be readily seen.
Anterior temporal reduction is done somewhat similarly to that of the posterior temporal reduction technique that I developed. From a vertical incision back in the temporal hairline, a subfascial approach is used to release some of the superior muscle attachments to the anterior temporal bony line of the forehead. Then cauterization points are done along the length of the muscle from the forehead down to the zygomatic arch. Unlike the posterior temporal technique the muscle is not widely resected as that would leave to a major temporal hollowing effect. The anterior technique relies on muscle thinning and not resection.
In answer to your specific questions:
- The anterior temporal reduction technique has not been done as frequently as that of the posterior temporal area which has a near 100% satisfaction rate. I have only done it a handful of times from which I have not heard any issues about lack of effectiveness.
- I don’t know if it can be made to look worse. I think the risk lies more in its effectiveness, was enough of a reduction obtained.
- There will be some temporary jaw opening discomfort and stiffness on mouth opening.
- The origin of the temporalis muscle hypertrophy does not affect one’s candidacy for the procedure.
- I can not speak for what other surgeons do. My technique has been described above.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in jawline reduction surgery and rhinoplasty for a facial feminization effect. I am a female but I look too masculine. Perhaps this is a bit silly, but my friend photoshopped my face to look much more oval. I’d like to go for a more oval jaw (if possible) and smaller. He did nothing to the nose, but I’d still prefer a more refined nose and think the current nose would not fit well with a more refined jaw. I’d like my nose to be thinner all the way down and also more refined at the tip. I’m sending an example photo, which I realize might not be the best fit for my face (or maybe it would be). I hope this is helpful. If you need a side view of my nose, which is very straight, I can send that as well. Anyway, I’ve had a few people mistake me for a male when I’m not wearing make-up. To me that’s distressing and that’s the motive for seeking additional cosmetic surgery.
A: Thank you for sending your pictures and delineating your goals…which I completely understand and concur. My current comments are as follows:
1) I would agree that the nose and jawline are tied together in terms of the overall goal of facial femininization. Reducing one will make the other look bigger.
2) The nose and jawline are two of the three main keys to any form of facial feminization surgery. (the forehead is the other one)
3) Using the ideal morphed image (which I have attached a direct comparison) shows that the degree of jawline reduction would be hard to achieve. That is a 1 cm vertical reduction of the anterior jawline. The location of the tooth roots and nerve will not permit that much reduction. A panorex x-ray is needed to make measurements to see how much can be done.
4) Regardless of the amount of reduction, the issue in the ‘older’ patient is how will the overlying soft tissues adapt to a reduced bone structure. This is relevant as it makes for a critical decision in how the jawline reduction is approached. (intraoral vs submental) If you like carefully at most jawline reductions they are done in younger patients with good skin elasticity and contraction. The intraoral approach requires that such tissue contraction will occur. Because of your age and that you have already had a facelift, this raises the issue of whether a submental approach should be done which can better help with soft tissue reduction in the chin should that be needed. (and it is most certainly will)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in your suggestion as to whether micro fat injections might be able to break up Sculptra granulomas. I developed Sculptra bumps about 15 months after initial injections. My doctor has been injecting them with a mixture of Kenalog and 5 FU. They are improving slightly after 3 months of multiple injections but,they are still quite visible. Have you had success breaking up Sculptra granulomas with fat injections? Thank you.
A: Breaking up fSculptra granulomas with fat injections can be effective in some by two mechanisms. First you have to mechanically break up the granulomas with a small cannula. That is the first step in their treatment by fat injections in the procedure. Then the fat injections are placed to prevent the scar tissue from reforming or the granuloma recoalesing. So technically the fat injections do not break up the granulomas per se. But are the prequel to the fat injections.
But in looking at your pictures you have far too many garnulomas on the one side of your face for any form injectable therapy to be effective. The best approach in your case is to have them excised through an anterior facelift approach. One could also argue that a layer of allogeneic dermis (Alloderm) could applied over the excised area to ensure maximal contour smoothness.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in facial reshaping surgery. I want to remove my medium chin implant and get a sliding genioplasty. I want my chin to be a bit more squared. I also don’t want to sound like I am abnormal because I know I’m perfectly decent looking but I would also like some very subtle volume to my midface around the infraorbital-zygomatic area. And perhaps a bit more angularity on my jaw. I’m not dead set on any of this and I would like to listen to a professional. The last thing I want is something that looks fake, a plastic looking face or some disfigurement.
A: Thank you for sending your pictures. In answer to your desired facial reshaping surgery desires:
1) A sliding genioplasty will not give you a more square chin. While moving the chin bone can be effective for many chin dimensional changes, adding width or squareness is the one change it can not do. Only an implant can make an effective chin width shape change.
2) Augmentation to the undereye and cheek area is usually done by a special design infraorbital-malar implant design. The change can be subtle or more pronounced depending upon what look the patient is trying to achieve.
3) As for the jaw angle it is a bit hard to tell with a beard, but you do have thicker heavier skin. Whether adding some volume to the jaw angles would be beneficial has to be looked at carefully. The best jaw angle results come from patients with more lean faces where the implant definition can be more clearly seen
I understand what you are trying to achieve is to add some angularity to a face that is more round. More modest changes in multiple facial areas is what is needed to achieve that overall facial effect.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in forehead reshaping. I have mild to moderate metopic synostosis that was uncorrected as a baby. Because of this, the metopic ridge is prominent, starting about halfway down my forehead up to about 2″ behind my hairline. My entire forehead has the pointed appearance seen in trigonocephaly.
My question is: Is a reduction via bone burring enough to make my head more normally shaped? I will always have a… unique skull… but I’d like for it to be a little less unique! If not, is this something that could be corrected using a combination of bone burring and hydroxyapatite cement?
Thank you.
A: Thank you for your forehead reshaping inquiry. In the correction of the forehead, the bone burring has the least significance alone and would not produce a more normal forehead shape. In fact one could argue that the midline crest is the near normal projection of the forehead and it is the recession of the bone to the sides that is the bigger shape problem. Thus it is augmentation of the forehead using a custom made implant that offers the real improved shape to the forehead.
The problem with bone burring and the use of hydroxyapatite cement, which are both viable treatments methods is that they require a full coronal scalp incision from ear to ear to do. That is probably not an acceptable aesthetic tradeoff. A custom forehead implant offers a more predictable and symmetric shape result with a shorter scar to insert it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like to get a lip lift but I also will get a rhinoplasty with a different surgeon I have already paid to do. My question is should I get the lip lift first and then rhinoplasty or the opposite way?i don’t want to get them together. The surgeon will reduce nostril size during the nose surgery so is a bit more complex than a normal rhinoplasty. Thank you.
A: The debate of whether to do a lip lift with a rhinoplasty or to do to separately is a constant one for which there is no clear consensus. But since you are doing them separately there is also a debate about which order they should be done in. I am not convinced that which one is done first really matters. But since you are going to do nostril narrowing as part of your rhinoplasty (which is actually fairly common) I would do want the rhinoplasty first. Then have the lip lift 3 to 6 months later. The concept for this order is that the scars from the nostril narrowing can first be established which are usually just inside the alar base on each side.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a question about temporal artery ligation. Is the procedure you undertake similar to a traditional temporal artery biopsy? I wasn’t sure if a biopsy results in the artery being completely tied off, or if it is somehow reconnected after the sample section is removed. Just curious if there are any similarities between the two procedures — i.e. biopsy versus ligation.
A: Your question is a good one as both procedures operate on the anterior branch of the superficial temporal artery. But that is where the similarities end. A temporal artery biopsy uses a single long incision just behind the hairline before the artery heads out into the forehead. A one cm section of the artery is removed since it is sent off to pathology for histologic evaluation. The ends are tied off and the gap remains between the two ends. Its intent is to get a specimen and not to treat vessel prominence.
Conversely temporal artery ligation, or more properly called ligations, involves the placement of numerous small incisions ( 5mm to 7mm) both in the hairline and out on the forehead. Its goal is to shut off both forward and backward flow into the visible artery so it is no longer seen. The vessels are tied off at these various skin locations but no section of the artery is removed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am attaching some photos for assessment for perioral mound liposuction The area I am concerned with is particularly visible in a 3/4 facial profile, but it also shows up in straight-on shots as weird shadowing around and below the corners of my mouth. Ideally, I would like this area to flatten, so that I can have a straighter profile. However, I am worried that fat removal in this area could cause laxness or drooping of the skin. I would like to avoid jowling!
I also have dimples in my cheeks when I smile — not sure if this makes any kind of difference, but I thought I would let you know. Thank you!
A: Thank you for sending your picture for consideration for personal mound liposuction. Your area of concern would be considered the perioral mound region. It is really only treatable by very small cannula liposuction through a small incision inside the corner of the mouth. I have not seen loose and lax skin develop afterwards as almost every perioral mound liposuction procedure I have done is in younger patients. But even in the older patients I have treated this has not been an issue that has occurred.
Having cheek dimples does not affect the result, positively or negatively.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in chin implant removal. I had a chin implant placed three years ago.I feel that it looks too rounded and full when I smile especially since my teeth do not show when I smile. It looks out of proportion. The Doctor who did it is fantastic and I really wanted it at the time but now feel that I do not want it. I have also lost some weight since it was inserted. My face does not seem to support the look of it. Attached are 2 pictures – one before and one after the implant. When I smile the implant looks even more odd.
The chin implant is Goretex and porous so I am not sure how easy it would be to remove. It is a rounded implant. Would you be able to remove it – and also would the possibility of a lower face/skin lift around that area be a good idea in order to tighten up the space/area ?
Thanks very much in advance.
A: Thank you for your inquiry in regards to chin implant removal. Goretex chin implants can be removed even though they will have more tissue adherence. In terms of tissue adherence, they are about halfway between a silicone and Medpor chin implant.
The issue is not whether it can be removed but what to do to prevent soft tissue chin ptosis which will likely occur once the support is removed. The chin is a central facial prominence for which a lower facelift of any kind will not affect it. A lower facelift is not a prevention or treatment for chin ptosis. Your options include leaving some partial support (downsize to a smaller chin implant) or perform a submental tuck with muscle tightening to readapt the tissues over the chin bone.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in cheekbone reduction reversal. I had my cheekbones reduced and am unhappy with the result. Is it possible to rebuild the cheekbones up with calvarial bone grafting on defected cheekbones or use a bone substitute such as hydroxyapatite? What is the best way? Thank you.
A: Cheekbone reduction reversal surgery can be done by one of two ways. Trie reversal consists of opening up the osteotomy cuts and bringing the cheekbones back out through an interpositional graft and plate fixation. The most common technique to reverse cheekbone reduction largely depends on the osteotomy pattern through the malar body. If it was a straight line cut (which would be the most common technique) the bone can be brought back out and a small natural bone graft placed like a calvarial bone graft as you have mentioned. This is the most ideal way as you’re then assured it will fully heal. The interpositional graft could also be a cadaveric bone graft or a synthetic bone graft like hydroxyapatite.
The other method of cheekbone reduction reversal is to leave the infractured cheekbones where they are and placed an implant on top of them. Such cheek implants are ideally made from the patient’s 3D CT scan.
Each cheekbone reduction reversal method has its advantages and disadvantages. A 3D CT scan should be obtained for preoperative evaluation to help in this decision process.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in jaw implants and have some questions:
1. My problem is a narrow jaw and a recessed chin topped off with a assymetric mandible to the right, pulling on one side of mouth, is this presenting a problem since it would require an assymetric implant?
2. Would a wraparound implant provide lateral width like implants under the masseter or only downward and anterior?
3. Is “jaw implants” to be understood as the wraparound jaw implant?
4. Is silicone the best material for this, is titanium possible?
5. How many years would a silicone implant last?
6. Is bone erosion a danger to the final look?
7. How can the final look be predicted? Am i able to choose different implant dimensions?
8. Is it possible to achieve a mandible like that of actor Colton Haynes with this procedure?
A: In order to answer most of your questions I would need to see pictures of your face. But in answer to some of them:
1) Custom jawline implants often are made with corrections to the jaw asymmetries
2) Custom implants are designed to any dimensions that are needed
3) Jaw implants is a general term. A wrap around implant is just one type of jaw implant
4) Silicone is the only material used for custom implants. Titanium is too stiff to use and would be extremely expensive
5) Such solid implants last forever
6) Jaw implants are not known to have any appreciable bone erosion
7) While you can choose the implant dimensions, there is no way to know for sure how that will look on the outside
8) You can make your jawline better or more enhanced but I would never say you can achieve anyone else’s jawline.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am attaching some facial photos for assessment for perioral mound liposuction The area I am concerned with is particularly visible in a 3/4 facial profile, but it also shows up in straight-on shots as weird shadowing around and below the corners of my mouth. Ideally, I would like this area to flatten, so that I can have a straighter profile. However, I am worried that fat removal in this area could cause laxness or drooping of the skin. I would like to avoid jowling!
I also have dimples in my cheeks when I smile — not sure if this makes any kind of difference, but I thought I would let you know. Thank you!
A: Thank you for sending your pictures. Your area of concern would be considered the perioral mound region and yours is a classic case of it. It is really only treatable by very small cannula liposuction through a small incision inside the corner of the mouth. I have not seen loose and lax skin develop afterwards as almost every perioral mound liposuction procedure I have done is in younger patients.
Having cheek dimples does not affect the results of perioral mound liposuction either positively or negatively.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am seeking extra large breast implants. I was a natural 34H and then got 800cc silicone implants under the muscle. the dr had said it would double my size. However it didn’t change my size at all, it only gave me a tiny bit more upper pole fullness was all. So I was very disappointed with spending all this money to not be bigger which was what I wanted. I have been told by a couple of Dr’s I could go up to 2000cc with overfilled saline. Is that something you would do? Or will you not go that large on patients? I want a good plastic surgeon with good ratings like you have. I am not a tiny framed lady, I do have a curvy build. Please let me know, thanks.
A: If 800ccs breast implants did not come close to your breast size goal, then at least twice that would be needed to make a more visible difference. Overfilled saline implants would be the only way to achieve that type of volume. Where the final volume might be on the spectrum of 1600 to 2000cc depends on how it looks and feels during surgery.
Please send me some pictures of your breasts for my assessment for these extra large breast implants.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I heard about you when I was researching Knee Lifts. After reading more about you ,watching your YouTube and reading your Bio as well as looking at your website I think you are indeed incredibly and uniquely qualified. Unfortunately I saw nothing on your website about my problem so I will ask you directly.
I believe I have stage 1 Lipedema,. After a few years of research I believe its Lipedema, based on my symptoms, age onset and process of elimination. The only treatment for Lipedema is liposuction from what I have read and spoken to surgeons about. I am planning to get my calves and ankles treated by liposuction but the surgeon I’ve spoken to doesn’t want to touch my awful, fat, disfigured knees as he says “knees are tricky”. He also isn’t too keen on my thighs as most of the disproportionate fat is right above my knees, which he says will make my knees much worse than they already are. I am not overweight, I am healthy, athletic and in shape. I would like to know what you know about Lipedema,and what your thoughts are about this type of surgery.
Thank you for taking your time to read this and reply.
A: As you know there are differences between lipedema and lymphedema by which you have come to the conclusion that you have the latter. Some improvements in true lipedema can be obtained by liposuction as you have stated. When it comes to using liposuction for its treatment I would be more concerned about prolonged edema from the calfs and ankles but not the knees. There is nothing ‘tricky’ about the knees and there is not any anatomic feature that makes them different for liposuction surgery. What the skin will do when the fat is reduced can not be precisely predicted anywhere on the lower extremities but most likely it is not going to shrink in a perfectly smooth manner. That would be an expected tradeoff for the size reduction.
Those are the general comments I can make without having any specific visual knowledge of your lower extremity problem.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, what are the differences between lip ‘advancement’ and lip ‘enhancement’ and lip ‘lift’? I’m specifically looking to augment my upper lift for more fuller appearance.
A: In answer to your questions, lip enhancement is a global term that refers to any type of lip augmentation procedure, albeit injection or surgical.
A lip advancement, also known as a vermilion advancement or ‘gull wing’ procedure removes skin just above the upper lip and the vermilion or red part of the lip is moved up to cover the removed skin area. This increases vermilion show from one mouth corner to the other. In essence it pushes the vermilion towards from below.
A lip lift, also known as a subnasal lip lift or ‘bullhorn’ lip lift removes skin from below the nose and lifts the lip upward. It shortens the distance between the nose and the upper lip and improves the central vermilion fullness of the upper lip. It does not have any effect on the sides of the upper lip.
I would need to see pictures of your lip to determine which lip enhancement procedure may be best for you. Most patients graduate to surgical lip enhancement after trying injectable lip enhancement methods.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in correcting my jawline asymmetry. I’ve always hated taking pictures head on or from the right side of my face because of the asymmetry of my chin and the angle of my jaw on the right side. It’s almost as if my jaw has shifted down and has caused my chin to shift and protrude forward on one side. This has been the case for as long as I can remember and I almost feel as if it’s getting worse. Probably because my skin is thinning and I can see the outline of the chin a little more. I’ve never had any dental issues or braces and no dentist has ever told me my bite needed to be corrected. I just wanted to find out my options-and see if this was actually possible to fix. Thank you so much in advance!
A: Thank you for sending your pictures and describing your lower jawline asymmetry concerns. What you have is an overgrowth of the right lower jaw that makes the jaw angle slightly bigger, the right jawline lower and the chin shift to the left. Usually with such jaw overgrowth there would be associated bite and occlusal plane asymmetry…but you seem to have largely avoided that typical accompanying issue. The treatment would be one of a chin and jawline bone shave from the left side of the chin all the way back to the jaw angle. This would be done through a submental incision approach. The amount of bone to remove would be determined from a simple panorex x-ray based on millimeter comparative measurements of he height of the mandible from midline chin to the ramus.
Dr. Barry Eppley
Inianaopolis, Indiana
Q: Dr. Eppley, I have consulted with you many times about my facial structure and have plans to do the jaw implant. I’m just wondering if I already have surgeries on my chin (1st surgery sliding genioplasty. 2nd surgery reverse sliding genioplasty 3rd surgery shaved the corner of the chin from expansion as it made my chin becomes square) will it be safe to do the jawline implant? Not doing anything with the chin but maybe will be the same area that got cut several times. Will it increase the risk of infection? I don’t plan to do jaw inplant with any doctor in Korea or anywhere as I think a doctor with experience is the best. And I had to save up again and again after my previous failure for other parts.
I really plan to do it but will be about a year or two from now since I have to finish my braces first in another country.
A: Regardless of your prior chin surgeries, that does not preclude you from getting a jaw implant in the future. The custom jawline implant is made from a current 3D CT scan so this will show your current bony anatomy. That happened to the chin bone in the past does not affect placing an implant across it in the future.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a custom jawline implant. I am attaching a few photos of my face and you will see that my lower third is narrow. My general interest is in a wraparound jaw implant in order to widen the face, tighten up the submental, improve aesthetics of the face and protrude the chin to balance the protrusion of the nose. What does your aesthetic eye think of this possibility judging by my photos?
Do the custom made implants have a high success rate as in the forum for plastic surgery knowledge I frequent there is a patient from Western Europe of yours that has had 2 revisions to his jaw implants in the span of 7 months? He says its “finetuning to look natural”. I am not extremely interested in having it revised because I dont want to endure the whole ordeal again.
A: If you are looking for increased lower facial width and dimensions of the chin and jaw angles that has a smooth linear connection than a custom jawline would be the preferred choice.
It is not uncommon for many patients to have revisions of custom facial implants including custom jawline implants. This is primarily because they often don’t know what they really want until they wear it to so speak. In the case you so described the patient himself chose the dimensions and that was what was exactly provided to him…only later to decide he wanted a different look. (Less strong)
The key in any custom jawline implant is that less is more. It is always to better to go smaller in dimensions as its effect is more substantial than a patient can anticipate. In looking at your face that its exactly what you…a smaller custom jawline implant. I cll this type a ‘jawline defining implant’ as it just adds angularity and a little width.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have put some thought into those measurements you told me about regarding zygomatic arch implants. I have made some research of my own and I have a found a cheek implant from Stryker that is not far from being a zygomatic arch implant. It’s measurements are close to the ones you suggested for me and my aesthetic goals (yours: 5cm length / 6-8mm width / 5mm projection height) which I assume can be carved/cut to meet your measurements even more.
Despite doing all of that sizing modification, the implant isn’t originally designed to sit on top of the zygomatic arch only. (This implant is also slightly bent in its shape). In the sample photo above, you can see that it is positioned in a way that starts just halfway on the zygomatic arch, going further over the malar prominence, whereas it ends at the maxillary buttress.
My question is; after the surgeon have carved/cut this implant to meet the sizing recommendations you sort of suggested, is it even acceptable to position this implant on the entire zygomatic arch?
A: I would be very cautious about using a Medpor material as a zygomatic arch implant. Besides the issue of its natural underlying shape (curved), the tissue ingrowth from this material will make it virtually impossible to ever remove or revise it later. There is a branch of the facial nerve that crosses over the posterior zygomatic arch that supplies movement to the forehead. While there is a very low risk of injuring this nerve during the insertion of the implant, trying to remove a Medpor zygomatic arc implant later due to the tissue ingrowth will almost certainly increase that risk considerably. If injured there will be some paralysis of the forehead. Thus this is not a material I can endorse as a zygomatic arch implant. Easy reversibility of a facial implant can be an important feature whose importance varies based on the anatomic facial location of placement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I hate to say it but I’m second guessing my decision about rhinoplasty surgery the more I read online. Perhaps I shouldn’t be reading online but I’m reading things like “nose job is the worst possible procedure to have done for a male.”. And that the problem is a lack of facial bone growth, not a big nose, which in my case is certainly true as I have a narrow face and underdeveloped lower third. So I’m wondering will a rhinoplasty simply be a regression for me, further feminizing my face? I know ultimately it’s my decision but obviously you understand aesthetics better than I do and could offer some sort of assurance as to why a rhinoplasty would be beneficial for me.
A: The psychological preparedness of a patient before any aesthetic surgery is of great relevance. A patient’s behavior will follow after surgery the exact pattern that they had before surgery. This is a plastic surgery experience that we see on a near daily basis.
It is one thing to be anxious about the surgical process, which most people normally are, but to be questioning whether one should have surgery at all based upon an uncertainty about the facial changes speaks to a different level of anxiety. It is important to realize that almost every patient after elective aesthetic facial surgery goes through a point in their recovery where they question the wisdom of their choice. For those who have few doubts before surgery they get past it at some point in their recovery. For those that were internally questioning whether such facial changes would be beneficial at all, they may never get past it and may recover to regret having had surgery. This is relevant since rhinoplasty is an irreversible change. It is not like a cheek or chin implant which can be pulled out later. This its why computer imaging should always be done before rhinoplasty which can help the patient visually determine if the surgery is worth it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a lateral commissuroplasty (mouth widening surgery) as I have a small mouth. How risky is this procedure in terms of end results? Does it always leave visible scars? And how visible are these scars? Will the scars heal evenly on both corners of the mouth? I’m curious to see some before and after photos of this procedure as I could not find any online.
I am also wondering about functionality after the procedure. How will smiling, eating, talking potentially be affected? Will there be a problem with drooling?
Thank you for your time!
A: Thank you for your inquiry. An opening lateral commissuroplasty or mouth widening procedure works because it removes a triangular segment of skin at the sides of the mouth and moves the vermilion of the mouth corner outward. By definition this leaves a v-shaped incision line at the mouth corner and a resultant fine line scar at the vermilion-cutaneous border. How discrete that mouth corner scar looks can vary but does well most of the time. Regardless of how they heal they cause no functional issues and do not interfere with eating, talking or smiling.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in eye widening surgery. My eyes are too close set together. I am looking for a way to widen them apart.Is there any chance getting the so called “box orbital osteotomy” surgery? Do you perform it? I understand this is a major cranofacial surgery but nowadays these types of procedures can be done safely. Could it increase the interpupillary distance for a few millimeters without looking deformed? Appreciate your help and time.
A:As an adult orbital box osteotomies are not appropriate for aesthetic eye spacing issues or is a form of eye widening surgery. I only perform orbital hypertelorism repair in young children. This is major cranofacial surgery of which its safety is not the issue. It is that it requires a craniotomy and the creation of numerous other aesthetic trade-offs (scalp scars, bony step-offs etc) that do not justify this type of orbital surgery for a few millimeters of inter pupillary distance increase.
That being said, they may be other more minor eye procedures that may be of benefit but I would need to see a frontal view picture of your eyes to determine if they may be successful.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had lip surgery last year with an asymmetric outcome. My mouth even got smaller (horizontal) which is a problem. Another thing is, that I’d like to reduce the red part of the lip with white skin. Now I wanted to know upfront if a correction is possible and if it is possible to reduce about 2mm of the red lip. (but not from the lip inside)
A: What you have done were lip advancements, also known as vermilion advancements. (An upper lip advancement is also known as a gull wing procedure) Your mouth got smaller and probably a but tighter because the advancements were carried out to the very corners of your mouth at both the upper and lower ends, thus creating a scar line around the corners. Lip advancements should never be connected at the corners to prevent creating a circumferential scar contracture which acts like a drawstring around the mouth as it heals. This can be corrected by doing a scar release at the corners and advancing the mucosa back out. This will also increase the horizontal distance between the mouth corners as well.
I am certain what you mean by ‘reduce the red part of the lip with white skin’. I assume you mean sort of reverse lip advancement? If that is what you mean, that is not possible to do. While the vermilion of the lip can be brought out by removing skin, the reverse can not be done.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m a 23 year old male who suffers from severe flatness of the back of my head. It has bothered me immensely for my entire life and has seriously affected my self esteem and my overall satisfaction out of life and the way I look. It’s very difficult for me to open up about this to anyone, but I am absolutely desperate to change my appearance. I was wondering what your suggestion would be in terms of what kind of skull augmentation procedure could be done. Thank you very much for your time and consideration. I cannot express the relief I felt when I discovered you and your practice online.
A: Back of head augmentation is one of the most common skull reshaping procedures that I perform. A custom occipital skull implant is made to fit the back of the head from the patient’s 3D CT scan. Whether this is a one-stage procedure or requires a first-stage scalp tissue expander depends on how much skull augmentation is needed/desired. For most men a one-stage skull augmentation procedure is usually done, although in rare cases I have seen a few men choose a two-stage approach.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in cheekbone reduction reversal. I had cheekbone reduction surgery done five years ago in south Korea. One year after the operation, I developed right cheekbone pain which often persists all day and I realized I can’t chew anything on the right side of jaw. In addition, I could hear sounds from both of my cheekbones every time when I’m swallowing. Recently, my right cheekbone pain is getting worse, the pain prevents me from opening my month, and I can’t even speak normally because of the pain from my right cheekbone.
I have been doing some research on cheekbone reduction, and try to find the cause of my pain. It seems like the cause of my pain could be the improper fixation on cheekbone so that the screws get loosed. Since I have heard a lot of recommendations about you, I want to ask you is there anyway can fix my cheekbone and relieve my pain? I can send you my CT scan if you need it. I would greatly appreciate it if you kindly give me a short reply on my problem.
A: Thank you for your inquiry. By your description of symptoms, it sounds like that you either have a non-union of the cheekbone osteotomy, malposition of the cheekbone position or a combination of both. X-rays would establish that diagnosis. A 3D CT scan would be ideal but the CT scan you have may also be adequate.
Secondary surgery can certainly be done with repositioning of the bone segments and rigid plate fixation. Given that it has been a year, the bone edges will also need to be freshened up and an allogeneic bone graft placed probably. The difficulty with opening your mouth indicates that the coronoid process may be impinged and this may also need to be released.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a double jaw surgery one month ago to advance my lower jaw about 8mms. I also had a chin implant placed more than ten years ago. After the surgery, as the swelling goes away, I can tell the advancement was not sufficient and my chin is still a bit recessed. I’m considering getting a sliding genioplasty to get more advancement. Also the sliding genioplasty would replace the chin implant as it does not look very natural when I smile. When would be a good time to do the chin bone movement after lower jaw advancement?
A: You can certainly do a sliding genioplasty with a chin implant in place. Or you can remove the chin implant and do the sliding genioplasty at the same time. The amount of additional horizontal chin bone movement equals the width of the chin implant to be removed plus the advancement needed for improved chin projection as determined by external chin measurements. I would wait a full three months after the double jaw surgery to let all the swelling go away and have a full recovery from that surgery before proceeding with the bony chin advancement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a buttock implant revision. About ten years ago I got tear drop shaped buttock implants. I had very little fat on my butt, so it was a bit disappointing after surgery. I did have some augmentation, but my rear looked kind of pointed in the center. I went back for some fat grafting towards the bottom to blend them in a bit, and it did help, but it was a so so result. I figured it was better than having a completely flat butt, so lived with them for the next five years. I had occasional soreness after exercise and sitting for long periods of time, but nothing unbearable.
About three years ago I noticed the upper right side of my left buttock seemed sore pretty frequently. I also wanted to investigate a different type of implant, so I found a doctor that preferred round implants. He inserted a fairly large round implant that aesthetically was more pleasing and natural looking. I’ve found that I have much more soreness with this pair. After exercise, after sitting for long periods of time, even laying flat in bed for a long time (if I’m sick) can cause discomfort for days afterwards even weeks. It seems to be more around the “edges” of the implants or the implant pockets, but they are generally sore all over. Especially that upper right corner again. Occasionally, it seems to radiate down the back of my legs, but this is rare. It seems to be getting progressively worse.
They actually look pretty good. There is nothing that unusual or unnatural looking about them. I don’t think the average person would ever know..so that part is not the issue..it’s the discomfort about 50% of the time.
I’m really tempted to just remove them, but I’m afraid of being disfigured without them. It would be some period of time (6 mo’s- year) before I could do some fat grafting or anything else to remedy the issue.
Any thoughts on what’s going on and what I should do?
A: In answer to your buttock implant quandary, there are some critical pieces of information missing in your description. Are the implants in the subfascial or intramuscular position? What is the volume size of the implants? Who is the manufacturer and what is their durometer? (durometer = degree of firmness of a silicone material)
That information aside I can make the following general comments:
1) I think you would feel deformed if they were removed. It is no different than having breast implants and then taking them out…the resultant appearance will not be like what it was before they were put in.
2) It is hard to justify doing a buttock implant revision with an implant result that looks good even with some discomfort symptoms. The only reason to do so is if the buttock implant you have could be improved by new buttock implants that have much lower durometer. (much softer)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Ive had jaw angle lengthening implant surgery 5 weeks ago. But the masseter muscle didn’t come down with the lower edge ofthe implant. So I had Botox yesterday in order to downsize the relatively large upper muscle. But I am now really regreting that this was a bad idea because I heard this type of surgery needs at least 3 months of recovery time.
Can these Botox injections make my final look worse than it should be? And if so what can I do from now?I would have had Botox anyway but it was too premature.
A: You are correct in that one should wait a full three months after any facial implant surgery to have a full and accurate appraisal of the final result. Doing Botox at 5 weeks after surgery was not only premature but you ran the risk of inadvertently inoculating the implants and causing an infection. That alone should have given everyone pause for reflection on the merits of these early injections.
While Botox is a valid treatment for masseteric muscle disinsertion, waiting for the full recovery and then evaluating the merits of Botox injections, masseteric muscle resuspension or a change in the jaw angle implant style could be more prudently done.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a custom jawline implant placed last year. I’m currently dealing with a bout of bacterial acute tonsillitis for which I’m taking antibiotics for. Yesterday I noticed my right side of my face, notably the upper part of the mandible, below the ramus, is feeling tender and a bit swollen. This could just be swollen glands, as other glands around my neck are swollen too due to infection, but I wonder if there’s a chance the bacteria from my tonsilitis could lead to an infection of my implant as well? Have you ever seen this before? Anything in particular I should watch out for or do?
A: While it is theoretically possible that a facial implant could become inoculated by any distant or contiguous infection in the body, this is not something I have seen. If infection of the jawline implant was present it would have swelling with at the angle and further forward along the body of the jaw to the chin.
Most what you have are swollen lymph nodes in the neck which are the filters of infection from upstream. As long as you are on antibiotics until the tonsillar infection is resolved, I would think you will be fine.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a follow-up question pertaining to something you had mentioned at my rhinoplasty consultation the other day. So you said I have very thick nasal skin. I’m reading that thick skin often does not shrink as well as thinner skin so it might not conform properly to the reduced nasal size. Also that it leads to scar tissue buildup in those open areas where the skin did not shrink sufficiently, resulting in a squishy, shapeless nose. Should I be at all concerned about my thick skin or would you consider it a non issue? Thanks much.
A: The well known issue with thicker nasal skin is how much it will shrink down to reflect any changes to the underlying bone or cartilage that has been modified. This is really only a concern in the nasal tip where the skin is the thickest. As long as the nasal tip cartilages are not aggressively reduced (which is not needed in your case) then the concern of the amorphous (shapeless) nose is not an issue. I mention it in every rhinoplasty patient who has thick nasal skin of the tip, whether it is male or female, to temper any expectation that they are going to get a small or thin-shaped nasal tip as thicker nasal skin will prevent that from being a realistic result.
Dr. Barry Eppley
Indianapolis, Indiana
