Your Questions
Your Questions
Q: Dr. Eppley, I am interested in a corner of mouth lift. On one side of my mouth as I have an asymmetrical smile. The corner is low when I am not smiling but it gets worse when I smile. I have attached two pictures which show the asymmetry both smiling and not smiling.
A: Thank you for sending your two pictures. Your mouth at rest and when smiling show that the root cause of your mouth asymmetry is weakness of the zygomatic major facial muscle. This muscle is responsible for lifting up the corner of the mouth when smiling. Since the muscle is weaker on the one side, the corner of the mouth droops down slightly when not smiling but becomes really magnified when asked to animate. (smile) Thus the mouth asymmetry is much more apparent when smiling.
A corner of mouth lift is a static procedure that is done on a structure at rest. Since your problem is much more of a dynamic nature, a corner of the mouth lift will provide better symmetry at rest and less so when smiling. But despite its limitations a corner of the mouth is all you can do for your mouth asymmetry concerns.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am potentially interested in some form of a forehead augmentation procedure. So this is what I’m working with the last picture shows an example of what I’m looking for in regards to a forehead change . I’ve scheduled a hairline lowering procedure but my forehead will still “slope” backward obviously. I don’t know if this is because of my eyebrow bone or what but I have no clue where to start or what would be the best course of action. Hairline lowering and eyebrow bone shaving? Hair transplants? I really don’t want to do the whole cement implant thing and was hoping there were other options. I’d really like your honest opinion because I’m impressed with what I’ve seen on your website in regards to forehead augmentation. Thank you and best wishes. Let me know if you need better pictures please.
A: With you modest backward inclination to your forehead the result you demonstrating/seeking definitely involves upper forehead augmentation. There is no other way to augment the forehead without adding something to it.
The alternative is to reduce the brow bones (and leave the forehead alone) which in your case is actually a viable idea. With even 4 to 5mm brow bone reduction you will go a long way to achieving that look. Augmentation is still preferable but brow bone reduction is not a bad alternative if you are strongly opposed to any forehead augmentation material.
Either way, forehead augmentation or brow bone reduction, it is best to do it with the hairline lowering procedure. Otherwise you are going to have to go through the hairline scar twice which may not lead to the best scar outcome.
Dr. Barry Eppley
Indianapolis Indiana
Q: Dr. Eppley, I’m contacting you because I believe you may be able to offer some advice on my sliding genioplasty procedure.I recently went through with a revision genioplasty and I am currently recovering, it has been 1 week since the surgery. The surgery went well however I am concerned and merely certain that my surgeon did not move the chin forward enough to truly support the loose skin on my chin and the mentalis muscle. I specifically asked him to put the chin back in the same position that it was in prior to any revisions and I provided numerous X-rays and pictures, however I can see and feel that it’s not in that position. I raised my concerns to him but they are telling me to give it more time because it’s swollen and I cannot tell the final result right now.
I am aware that it is swollen, and I do have a follow up visit on Tuesday with the doctor where x-rays will be done. If I find for certain in the x-rays that the chin position is still off from the desired projection to support the mentalis muscle, what do you think is the best way to proceed forward to revise it? I would really like to get it revised immediately before the bone starts to heal back up. I’m just not sure about how to go about requesting this from the doctor and avoiding additional fees. My surgeon clearly mentioned that his precision will be within half a millimeter of the desired outcome. I’m concerned that it’s not but I do not know if I will be able to get them to correct it even if the X-rays prove that it’s further off. I believe it is about 2 millimeters from the projection of the original position but another issue is that I can feel that the chin bone points slightly up instead of down which would be inline with the rest of my jaw. A simple 2 millimeter plate increase seems like it will fix the angle and projection issue.
I understand that some of these questions don’t really have direct answers, but if you can offer me some advice/recommendations, that will be useful.
Also I’m wondering, if the doctor agrees to increase the projection and the surgery is done within say 3 weeks of this original surgery, do you think it would be possible to do it under local anesthesia? I’m wondering because it seems like it would be a easy procedure as no bone cutting should be necessary and just exchanging the plate size should suffice.
Thank you for your time, I will look forward to your response.
A: Thank you for the detailed information on your recent sliding genioplasty surgery. However I do not provide advice or recommendations on patients who are under the active care of another physician. That would be inappropriate as I can only comment on what I would do, not what another surgeon would or should do. Your questions are best handled by addressing then directly with your surgeon who I am sure would appreciate that you are having that discussion with him.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Hello, I had a fat transfer (fat grafting) procedure done in years ago where fat was removed by liposuction from my abdomen area and transferred to my buttocks. However, Since the procedure my abdomen area has never been the same. It now have lumpy, unappealing, uneven skin around my abdomen area due to the aggressive liposuction and would like to know what is the best treatment available for me to try and correct this irregularity and if you can help me? I do have pictures I can send to you of what my abdomen area now looks like.
A: Aggressive liposuction on the abdomen is prone to irregularities when the subcutaneous fat layer gets too thin. Trying to get enough fat for adequate volume for buttock augmentation often requires an aggressive liposuction approach.
Contour deformities have been around on the abdomen since liposuction was developed over forty years ago. They have always proven to be a difficult problem that often defies any significant contour improvement. Options includes secondary small cannula liposuction with adhesion releases alone or done in conjunction with fat grafting or some form of mini tummy tuck for skin tightening. I would need to see pictures of your abdomen to make an assessment and recommendations.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a L-shaped silicone nasal implant placed a year and a half ago. There have been no major complications, but I’m looking for a revision for a better aesthetic outcome. My biggest issue is that the implant seems too ‘narrow’, and I’m looking for a new implant that’s wider and longer to give me a more masculine nose. My questions are:
1) I know that many surgeons favor rib cartilage, but I’m honestly not fond of such an invasive procedure and lengthy recovery (especially the scar). If I only want a synthetic implant material, which one would you recommend (silicone, Gore-Tex etc.)?
2) Apart from my bridge, I’m hoping for a more pronounced radix and glabella. Could this procedure be done at the same time as the rhinoplasty?
3) Finally, I’m looking to increase my nasolabial angle. Could a small implant be placed under my nasal spine to bring the base of my nose forward?
A: Undoubtably your current nasal implant is too ‘small’ lacking both adequate height and width. That is a reflection of the nasal implant style and size. With silicone nasal implants there are many different styles and sizes that can likely fulfill your aesthetic nasal needs. With the right implant the radix and even up into the glabella can be augmented. At the same time as the revision nasal implant surgery is performed, a premaxillary implant can be placed on top of the nasal spine to help open up the nasolabial angle.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in coming for rhinoplasty surgery. I only want to change the bit from the nostril tip to the bit where it meets the lower lip. Currently my nose is like this. I want a shorter area from nose top to the top of lip and a nicer angle like this. I researched something can be done to make this area similar to above. Is that true? What kind of material can be placed where the green is in the diagram below to give this nicer angle? Do you know if it can be done?
A: As best as I can tell from your description of your nasal concern and objective, you want to change the nasolabial angl as well as the shape of the infralobular-columella region. It is a bit difficult to reconcile your description with the picture examples you have provided. But the rhinoplasty diagram you have provided shows a columellar strut graft. Depending where that cartilage graft is placedm the nasolabial angle and shape of the nasal tip can be changed. I would need to see a side picture of your nose and do some computer imaging to have a more clear idea of your desired rhinoplasty changes.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a crooked and prominent nose (dorsal hump, droopy tip) and I was wondering if there were any ways of making it more harmonious to my face, without having to go through a rhinoplasty surgery, since I kind of like its shape, but it definitely does not fit my current facial structure (weak midface. orbits and chin). I suppose this would be the hard way to create a harmonious face, but would facial implants ,for example, be an effective way for that matter? I was thinking about your Custom Midface Implant(http://eppleyplasticsurgery.com//custom-midface-implant) for this reason. Could it help make a nose appear less prominent?
A: Bringing the midface forward could potentially cause a slightly less protrusion of the nose through the illusion of the surrounding elevated base around it. This may create improved harmony of your face particularly in the presence of a deficient midface. I would go to the case study to which you refer and see if that made that patient’s nose look less protrusive. It is unlikely, however, that it would have a facial effect that would be as significant as a rhinoplasty which directly changes the shape of the nose.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I may be interested in custom facial implants in the future. But I have an unusual but relevant question about them. I have vertical orbital dystopia which makes my eye asymmetry pretty obvious. As far as I know, having consulted with some doctors in my area, correcting such an issue requires invasive craniofacial surgery and includes fixation with surgical plates around the orbital area and possibly the cheekbone. I’m not really sure I’m going to go through this operation in the future but in case I do, will it be able to have implants around my upper facial (supraorbital ridge, infraorbital rim implants, cheekbones) area ? To put it simply, can custom-made implants be created so they can fit over titanium plates connecting bones from a previous osteotomy?
A: In designing custom facial implants, the exact location of the plates and screws will be visible on the bone on the 3D CT scan. Any implant design can be made to fit over them and their presence will not cause any design or implant insertion issues. In fact in some cases the location of the fixation devices can act as a locater for the exact position of the custom facial implant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I wonder if there is a less invasive skull augmentation procedure that a custom small implant that will benefit my situation. I have also read about the use of tissue expanders and PMMA. Based on what I have seen, this seems to be less evasive and possibly more cost effective. How much of a lift be obtained at my Crown area from that type of procedure? Can you tell me the pros and cons of this versus the Bumpit implant? Are there any potential health risks more commonly associated with either procedure? Also, I’d like to know how long you’ve been performing these types of procedures and how many of these you have performed. I appreciate your help with this as it seems to be a huge undertaking and obviously something I’d like to explore at length prior to making a decision.
A: The reality is that any method of skull augmentation is similarly invasive as the fundament concept is the same. The more relevant question is what is the most effective method that has the least amount of risk or potential for revision. By far a custom implant surpasses every other skull augmentation method in my experience. It offers superior results and eliminates many of the problems from the use of bone cements and can get a more effective augmentation. There are no health risks for skull augmentation. All risks are local and confined to the site of implantation and would be typical for any implant placed in the body. (e.g., infection, overcorrection/undercorrection, asymmetry etc) I have been performing skull augmentations for over twenty years and have switched in the last five years to 90% being done by custom or semi-custom skull implants. I have performed over fifty custom skull implants during this more recent time period of skull augmentation surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m 25 years old and four years ago I underwent orthognathic surgery (lower jaw advancement) and a chin osteotomy because the lower part of my face was receded and short. In terms of proportions the surgery has been a relative success. However, since then my oral commissures (mouth corners) have been pulled downwards and are not in line with the middle part of my lips. To give you an idea, the mouth corners go as low as the gum area of my bottom teeth. The mentalis was re-suspended after surgery so perhaps that’s why the middle part of my lips has not been affected. As you can see the rest of my face has not yet aged so this pulled down mouth corners look very unnatural and give the illusion that my upper lip is very long whereas the actual distance between my nose and upper lip is normal.
I was wondering if there’s a solution for this? Something that can pull my mouth corners up to be in line with the middle part of my lips?
A: The only way that the corners of the mouth (and the sides of the lips) can be pulled up is through vermilion advancements and/or corner of the mouth lifts. This works by removing skin and moving up the vermilion border. This does create a very fine line scar at he vermilion-cutaneous junction which actually does better in men than women due to hair-containing skin.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I considered jaw angle implants a few years ago and was told that the maximum width on standard implants was 11mm. This is not wide enough for the correction I would need. What is the maximum width that one can do with custom implants?
A: The historic maximum width of standard or performed silicone jaw angle implants is 11mm and that remains true even today. When it comes to custom jaw angle implants there is no limit as to what can be designed or potentially inserted. The facial soft tissues can stretch a large amount and the only limitation to jaw angle width that can be done is aesthetic and not anatomical in nature.
It is critically important in jaw angle implants that the desired dimensional changes are carefully considered. Width has been the historic jaw angle dimension that can be augmented. But that has changed recently with the introduction of a vertical jaw angle implant line that is designed to specifically augment this jaw angle area as well. More patients need vertical rather than width increases as this dimension goes a long way to creating a more defined jaw angle shape.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had facial reshaping surgery consisting of rhinoplasty, chin reshaping and jaw angle implants done in Thailand three months ago. Whilst my facial structure has improved, I am not satisfied with my results and I think some of the the reasons why are that the Asian plastic surgeon is not as familiar with western faces and also males and I feel like I have obtained a more Asian female facial struxcture.
I am very happy with the new jaw angles that have been created and the slightly wider lower face. Generally I feel that my lower face has become a little too round and fat and not the square defined shape which I was looking for. Which I think is from the jaw angle implants that they have used.
– I believe you are so well written on the internet, that it makes me have confidence in you and what your doing compared to my other surgeon; i guess it is just about agree what needs to be done
For the chin I don’t really notice any difference and I still feel the chin is still quite round – I was hoping for a more squarer shaped chin. It should be noted that I lost nerve sensation on this for a period of time which is now starting to come back, but hope that I wouldn’t have a similar experience again. Would a square chin implant be more appropriate to create a more squarer chin?
I think the cheek implants used may have created a more of an Asian female facial structure with round cheeks. They used the combined submalar shell medium implant. I would Welcome your opinion in regards to this?
Therefore what would be your recommendations? Could I have revision facial surgery six months after the original procedure? Do you think this is advisable?
I have attach my current photos as well as some pics of other people that is more alike to the facial shape/desired look that I am trying to achieve. You will notice all of them have a more square chin, squarer shaped face and less round cheeks
I believe you are so well written on the internet, that it makes me have confidence in you and what your doing compared to my other surgeon; i guess it is just about agree what needs to be done.
A: Quite frankly for the chin, jaw angles and cheeks, you had the wrong facial reshaping procedure/wrong implants for what you were trying to achieve. I will say first that the facial goals you were seeking to achieve are probably not obtainable to the degree that you would like or have shown in the ideal pictures. But in aiming for that type of look the procedures done had no chance of even getting close to that look.
For the chin, you can not make a chin more square by reducing it. That may seem to make theoretical sense but the soft tissue does not follow the bone shape in a reductive procedure. You would have to use a square style chin implant and, it would have to be modified, to create that near 90 degree turn back to the jawline to make it really it that square. Even the existing Implantech square chin implant is to soft/round at the corners to make it look ‘sharply’ square as you have shown in the goal pictures.
For the jaw angles that is a completely incorrect implant style. That widening style jaw angle implant, while widening the lower face, will just make it rounder/fatter. It will never create a sharply defined jaw angle shape as you desire. What you are deomstrating is a vertically longer and wider angles that has a 90 degree shape. Such a jaw angle shape does not exist and would have to be custom made to do so. The new vertical lengthening jaw angle implants would be a lot better than what you have and may be acceptable. This is a new style that is not yet in the catalog.
For the cheeks, you have gotten ‘female’ cheek implants which create an ‘apple cheek’ look and not a higher angular shape. This is a common mistake when it comes to doing cheek implants in males. A different style/shape of cheek implant is needed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I read on the internet that you specialize in mentalis muscle resuspension surgery in case of lower lip ptosis. I have developed ptosis as a result of revision jaw surgery and genioplasty and the result is that I’m showing approximately 4mm more of my lower incisors that I did before. In addition, my chin goes in a weird shape when I’m trying to close my lips (“witches chin deformity”) even though I do not have a deficient chin. (See attached photos) During the first surgery my doctor overdid the forward movement of the genioplasty and during the second surgery, the second surgeon burred the bone of the chine in order to reduce the forward projection again (he was not able to do a reduction genioplasty because the first genioplasty was too assymetric). This is what caused the problem.
I wondered what the approximate success rate of ptosis correction surgery is for cases such as mine. In how many % of the cases is such surgery successful? How many mm elevation of the lower lip can be achieved on average? Many thanks in advance.
A: Thank you for your inquiry. Correction of lower lip sag and a mentalis muscle deformity of the chin pad are very difficult problems to improve that often have low success rates. It was not very prudent of your surgeon to burr the chin bone down after the sliding geniplasty as this has caused a loss of bony support and soft tissue collapse. This is why you have chin pad deformity when trying to close your lips. The lack of chin projection and the lower lip sag are intimately related.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was looking to get an Endotine midface lift. Does the you use this technie? I’m young and had Ultherapy which caused my cheeks and nasolabial folds to droop. I would like to do a cheek lift but not through under eye incisions because I read there is risk of eye droop. And also don’t want the shelf look under my eyes. I saw on here the Endocrine midface lift was mentioned which is what I’m looking for! Thank you
A: Thank you for your inquiry. There are many different types of midface or cheek lifts that use different incisional approaches and tissue lifting techniques. The Endotine midface lift uses a resorbable device to help lift the cheek tissues. It is placed through a combined intraoral and temporal incisions. The intraoral incision allows access to lift the cheek tissues off of the bone. From inside the mouth the Endotine device is inserted and its prongs engage the loosened cheek tissues. It is then passed over the cheek bone and up into the temporal area where it is secured to create the cheek lift. You are correct in that no eyelid incisions are needed to do the procedure.
The operation is somewhat similar to that of placing cheek implants using much of the same dissection.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a Box Osteotomy procedure. I realize this is not a routine operation but I was wondering whether you have ever performed it before and what criteria a patient would need to have to be eligible for such an invasive procedure? I am a male, with no deformities or large abnormalties but my mid face ratio isn’t very good so was looking into ways to improve it as mid face shortening isn’t possible. My eyes are less than one eye width apart from one another. So I just wanted to know a little about the procedure and whether theres any possibility of me getting it, or if its too dangerous and only done on very deformed patients. Thank you.
A: Thank you for your inquiry. When you say ‘Box Osteotomy’ I assume you are referring to orbital osteotomies done in cases of congenital hypertelorism. This is an operation for severe craniofacial deformities and is not appropriate for aesthetic eye spacing issues. It is a major surgery that requires a frontal craniotomy to perform it. Just by the description alone you can see the the magnitude of the surgery far exceeds any aesthetic eye concerns.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am 35 years old and am seeking a unique transgender facial reshaping procedure. I had a chin reduction ten years ago and it was left slightly uneven. Last year I went to have it fixed along with my mandible contoured. Now I feel my face is too thin looking especially in the prejowl area. Its a very sharp contour somewhat V shaped. Before it was more U shaped and it looked better. I am seeking to widen my lower face. I am not sure if I would need a prejowl implant, a jaw implant or custom jaw implants. I am also a transsexual and being the reason why I had it reduced, I have lived very successfully as a female for many years. Have you worked on transsexual people before? Please see attached images. I am looking to restore to my old face.
A: We have a significant number of transgender facial reshaping patients in my practice. Just based on the two pictures you provided the difference seems to be largely in the jawline behind the chin. While I have not yet viewed a side profile, the horizontal projection of the chin does not seem to be changed very much if at all. I suspect that the lower facial restoration would involved bone augmentation from just behind the chin (prejowl area) all the way back to the jaw angles. Whether just widening the prejowl alone would be enough I can not say just based on these two pictures alone. I would have to see some more pictures from different angles and then do computer imaging on them to see exactly what type of lower facial change looks best to you.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have questions about a recent subnasal lip procedure that I just had four days ago. Here are some pictures of me, I took them today. Sorry for this miserable face but I didn’t go out since the day of the operation and I can’t stop crying all day.
I don’t look normal in pictures and I don’t know why. But I swear in real it is not normal. It doesn’t fit my face and I look horrible. I just look like a bunny now and I can’t handle it. The shape of my mouth is like a triangle, I didn’t asked to change the shape of my mouth.
I saw my surgeon but he said he can’t correct it because it is beautiful and I just need time to accept it. I just wanted a small change because I was tired of my small mouth but didn’t want to have fillers anymore because it turns in a duck mouth. But even the duck mouth was 100 times better. Now I just lost my identity with this surgery… I changed so much, I can’t recognize me, I am so so so desperate.
I just want to go back to my normal face please, please please please I am begging you to help me.
A: Thank you for sending your pictures. I have performed many subnasal lip lifts and yours looks perfectly normal at this early time after surgery. There is nothing wrong with the way it was done and it does not look overdone or that too much skin was removed. A subnasal lip lift will always look a little high right afterwards and the swelling can distort the nose along with it. It is important that any patient that has this procedure know BEFORE surgery that there is no reversing it. You can not go back. Skin has been removed and it can not be replaced. The scarring from placing a skin graft under the nose would look terrible and be far worse than what you have now.
It is also important to know that a subnasal lip lift will relax or relapse over the first few months after surgery. The amount of relapse can be as much as 25% to 33%. Thus waiting out the recovery period and allowing the lip and nose to settle is a prudent strategy. It is also the only thing you can do.
It is important that you understand that healing and tissue relaxation will make changes that will be different than what you are seeing now. You should not judge the final result from this type of procedure until you are three months out from surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in breast augmentation and a tummy tuck. I have had two consults which were slightly different. My concerns are dog ears from the tummy tuck and scarring from performing a lollipop breast lift. After discussing it with my husband I don’t want to get a lift as I am not comfortable with the scarring. I would like to look good in a bathing suit and have a full C. Right now I am a deflated A. I am 5’4″ 139lbs. Last question, regarding my flanks, both doctors agreed that it is mostly loose skin on my flanks, is there much I can do about that if I got a tummy tuck to make a more contoured waistline all around?
Looking forward to hearing from you.
A: Thank you for sending your pictures. What I can tell you is the following:
1) You can not have breast implants without a lift. You have too much sagging breast tissue and breast implants alone will produce a poor result with breast tissue hanging off the end of the implants. Breast implants do not have any lifting properties. They merely take what you have and make it bigger…or in your case will make the sagging look even worse. Your options are to either live with what you have or to accept the scars that are needed from a combined breast implants with a lift procedure.
2) The only way to improve the loose skin in the flanks is to carry the tummy tuck incision further back to cut out this tissue as well. This creates another scar concern. Thus you either leave the loose flanks alone or accept the longer scar to get tighten that area as well.
You face a classic dilemma that many breast and abdominal contouring patients face…whether a scar is more aesthetically acceptable than the original loose skin problem.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in using fat grafting for a breast augmentation. (fat injection breast augmentation) Am I right in understanding that you can perform this procedure? If so, what do I need to do find out how I can find out more information? What qualifies one for this type of breast augmentation?
A: Thank you for your inquiry. The critical questions about fat injection breast augmentation by fat injection are the following:
1) Do you have enough fat to make the operation worthwhile? It takes a lot more fat than you think as the fat has to be processed and concentrated for injection and only about 50% will survive the transfer process.
2) What is your breast size expectation? Fat grafting for most patients can increase breast size by about 1/2 cup.
3) What is the patient’s breast shape and current volume? Small to little breast tissue makes for poor fat take.
Unlike implants, the selection of women for breast fat grafting is much more selective as the outcomes are less in size and the outcome not as predictable. The reality is that of all the women who request fat injection breast augmentation, less than 5% of them qualify for that form of breast augmentation surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am seeking gynecomastia reduction revision surgery. had a perfect chest, and put on some weight and thought gynecomastia reduction surgery would be the answer for puffy nipples and getting it more defined. Well the surgery went wrong and I ended up with a nipple indent, scarring, hepatoma and a crater deformity. I then went to another doctor who does revision gynecomastia reductions who said no to pectoral implants but could fix the crater and make it look good. But he ended up over doing liposuction leaving me with less tissue, a caved in look and puffy nipple on the left side which looks still like I have gynecomastia.
The right side is more natural and fuller but left side just doesn’t match it. These doctors were supposedly the best and I am left deformed. I wondering if you looked at my pics and get your opinion. I find the left side the worst with the puffy nipple and more fat missing as this is the side I did’t have the hematoma.
Was wondering if you were able to make my chest more defined again and both sides even looking. thanks
A: Thank you for your inquiry and sending all of your pictures. I am not quite sure how you started out with a relatively small gynecomastia problem and ended up where you are now after multiple surgeries. But that is irrelevant now as all that matters is where you can go from here. I think your gynecomastic revision surgery options depends on how much restoration you want and how much effort you want to put into it. This means the following:
1) With your complicated gynecomastia reduction/liposuction history it would be perfectly understandable that you would want to do the least amount of further surgery that has the lowest risk possible. In that case I would only treat the left side with either fat transfer or a dermal-fat graft. Fat injections have the lowest risk as the worst case scenario is that it doesn’t work well. I don’t know if you really need to put on weight as even in thinner males enough fat can be harvested from the inner thighs to do a small area like the left nipple/lower chest. This would produce the least aesthetic improvement with the only goal being to make the left side look closer to that of the right.
or
- On the opposite end of the treatment spectrum are pectoral implants. Both sides of the chest are really deflated with loose skin. This loose tissue exacerbates any soft tissue deficiency between the two sides. Pectoral implants would expand both sides of the chest and would offer the best chest improvement. Whether some additional work needs done on the nipples at the same time remains to be determined. But with the option for best overall chest improvement comes this ‘bigger’ surgery with its own attendant risks. At this point with your surgical history, this concept make be too much to consider even if it offers the best aesthetic improvement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m interested in finding out how much would it be to have liposuction done to get my buttock injections removed. I’m having a lot of pain and discomfort and it seems as though the sillicone is moving down my leg and there is a lot of pressure being put on my tail bone when I sit and it’s causing a lot of pain. Can you please help? Do you all offer these services?
A: The long-term sequelae from silicone oil injections into the buttocks can include chronic inflammatory reactions known as granulomas. They can cause pain, hard lumps, skin discoloration and even open draining areas.
The typical treatment for silicone oil buttock injections is a combination of liposuction and fat injections. Buttock injection liposuction alone can not remove all of the silicone oil material. There is no surgical treatment that can accomplish complete removal. Fat injections add healthy cells and improve vascularity of the treated site to reduce scarring and buttock contour deformities. It has been shown that the combination of both treatments work best for silicone granulomas of the buttocks.
I would need to see some pictures of your buttocks to get an idea as to the size and location of the problematic buttock areas.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was wondering what aesthetic procedures can be done to push the lower lip forward slightly and improve the aesthetics of the labiomental sulcus? I was reading one of your case studies where a man got implants put in in his upper lip, lower lip and labiomental fold. So I was wondering whether a Permalip implant could be placed in the lower lip to give it some more horizontal projection? My lower lip is slightly setback compared to the upper but its not very significant; if this is possible what is the maximum amount of horizontal projection that can be achieved? I only need around 4mm at most. That said I have a very slight overbite where my upper teeth cover around 85% of my lower when biting down. Do you think orthodontics to correct my bite, combined with a Permalip implant could do the trick for a lower lip that is set back roughly 5mm and the above circumstances are taken into account? If I jut my lower jaw forward to the optimal bite position), my lips line up roughly accurately. But I don’t want to go through with lower jaw surgery for such a minor discrepancy.
Also, my concern is that if I push the lower lip forward, my labiomental sulcus and chin will look too set back in comparison. The chin is fine as I am happy to get an implant placed there. More importantly, I am concerned about how the labiomental groove will appear in two ways. First, the chin advancement will make the groove look more set back. Second, if you think about it on a profile view, the lower lip advancement will pull the tissue forward and make the angle between the border of the lower lip and the middle of the sulcus more acute. My sulcus isn’t very deep, but I would like to have an implant placed there and possibly fillers or fat grafting over the top at the same time. If a custom implant is used can the labiomental augmentation be almost unlimited?
As a side question, is it possible to give the illusion of a higher or more vertically short labiomental sulcus by strategic augmentation in the lower part of the sulcus, or through any other techniques?
A: In answer to your labiomental sulcus surgery questions, let me first make the following general statements:
- The true position of the lower lip is controlled by the position of the teeth. Thus the single most effective method of increasing the horizontal position of the lower lip is by lower jaw advancement. Understandable that is a lot of effort to obtain that relatively small amount of aesthetic change.
- Manipulation of the labiomental sulcus is not easily done and any such manuevers do not always produce predictable outcomes. It is a tight tissue area which has limited potential for change in its depth. This is a fixed tissue area for which there is a reason that an indentation exists there.
In answer to your specific labiomental sulcus surgery questions:
- A Permalip implant provide some horizontal increase in the lower lip but probably not as much as 4mms.
- I would find it hard to imagine that even a 4mm horizontal lower lip increase would make either the labiomental sulcus and particularly the chin look recessive.
- You are overestimating/over thinking the effect of the lower lip on the labiomental sulcus. The effects just aren’t that simple or as profound as you are believing them to be.
- You can not change the vertical height of the labiomental sulcus.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in facial liposuction. I just had a revision mini facelift with fat transfer to nasal folds and high cheeks and Neck lipo. I’m unhappy with the appearance of the corners of my mouth. They have a downward slant which is extremely visible and I believe this started when I began to get fat transfer to my face to correct acne scars and facial hollow. Well after gaining weight my face gained double and my mouth is now turned downward. Please left me know if liposuction is the answer to my facial problem?
A: Without seeing pictures of your face I can not give a very informed answer. But conceptually fat removal in the face through liposuction is not going to raise up the corners of your mouth. Downward slanting mouth corners are difficult problems that do not usually respond well to lifts and increased facial volume. Many of them have to be treated directly through corner of the mouth lifts.
While it may seem like the addition of volume to your face through fat transfer was the source of this problem, and it may very well be, I can not say with any assurance that the reverse would be effective. Some fat removal by facial liposuction can be done but whether ti would be enough to change this mouth feature can not be predicted.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had orthognathic surgery ten years ago to correct a class II malocclusion. I had a LeFort I osteotomy, sagittal split mandibular osteotomies and a sliding genioplasty. I am very happy with my bite. My teeth meet and my quality of life has been greatly improved. There are a few things that I am unhappy about that have gotten worse as I have aged and my face is getting thinner. The deep mentolabial sulcus I have that makes me look like I have a tiny stuck on chin, my high angle jaws, and my super long philtrum. I’d love to resolve all three of these issues but, if I were to pick the most important to me they would be my chin and my long philtrum. I am not looking to transform into a new person. I want to continue looking like myself but, with some improvement.
Please tell me if I am off base with my assessment of my deficiencies. I’d love to have your professional opinion.
A: I would agree completely with your assessment from the concerns of a deep labiomental sulcus, the long philtrum and the high jaw angles.
Your chin shows a classic long-term sliding genioplasty outcome in which the labiomental sulcus has gotten deeper in the step of the bone cut. This can be improved by a dual approach of placing a labiomental implant on the bone and possible fat grafting at a more superficial level. (although filling in the step of the bone usually suffices) The long philtrum can be treated by either a subnasal lip lift or a more complete upper lip vermilion advancement. That choice depends on how you want to see the lip change. The high jaw angles can be treated by small vertical jaw angle implants.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am writing to you because you seem to be the de facto expert when it comes to brow ridge augmentation. This will be a rather lengthy and complicated post, and I do hope to be able to get your expert advice.
Basically, I had fat grafting done to my brow ridge 3 years ago, but the issue is that the end result was asymmetric brow ridges (my right brow has slightly more remaining fat than the left). Not only that, the central brow region (radix/glabella) was not augmented enough. As a result of this, I sought a more permanent way to augment my brow ridges, and I had a PMMA forehead/brow ridge implant placed earlier this year. While this did give me more pronounced brows and fixed the issue slightly, it still hasn’t solved some of the contouring issues caused by the fat graft.
I have since been getting fillers to correct the defect, but it is cost prohibitive and I’m not a fan of getting repeated injections to this region due to the small but catastrophic risk involved.
Anyway, I’ve been researching custom brow ridge implants, and I have a few questions:
1) I understand that they are customized to fit on the underlying bone. Would having an existing PMMA implant be an issue?
2) Could the outer side of the implant (the side that gives the soft tissue push) be customized to accommodate for the previous fat graft? Again, would the PMMA implant interfere with this design process?
3) The one area that the PMMA implant did not augment were the sides of my forehead and I was told that it is because PMMA can not be placed too far out near the temples. Hence, could a silicone implant extend to the temples to create a wider and more ‘rectangular’ forehead?
I’m sorry for the trouble, and I’m sincerely hoping that you will be able to help me.
Thank you!
A: Thank you for your inquiry. The fundamental question you are asking is whether a custom silicone brow bone/forehead implant can be placed on top of the existing PMMA implant and whether such a brow bone implant can extend up onto the forehead and out past the anterior temporal lines onto the temporalis fascia. The simple answer is yes to both questions. My only additional insight is why bother to make a custom implant to fit in top of the existing PMMA implant. if you are going to make the effort to make a custom brow bone-forehead implant, you may as well remove the PMMS and make the entire augmentation out of one implant material.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley,I was wondering whether you agree with my assessment that my philtrum (distance between bottom of nose and upper lip) is a bit too long for the best aesthetic outcome? I’ve been thinking about this because I feel like it throws off my facial proportions a bit. The thing is I don’t feel like a lip lift would suit me because it would make my lips look very downswung, as if they are frowning, and would create a very feminine Cupid’s bow appearance. I was thinking about mabye moving the entire base of the nose (including the nostrils) downwards one or two millimetres to make up for it that way? My nose is quite short and I think it would benefit my overall proportions to have this done. I’m not sure how possible it is though? Im sure it’s very rare but I doubt if it is impossible to do with a satisfying aesthetic outcome?
A:I would not disagree with your assessment of a long upper lip. It is possible, and I have done so, to bring the nostrils down a few millimeters. Otherwise known as nostril lowering. It is an infrequently requested and done procedure but that does not mean it can not be satisfactorily done.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, i have a few questions about my mouth. The width of my mouth is extremely short it is about the size of my nose i have been thinking of getting a surgery to fix this issue. Before i go on with the surgery i have a couple of question that i want to know. First question is i have read online about this surgery as much as i could and almost everywhere they have told me that this is not a cosmetic surgery as it can leave scars so my question is how bad are the scars and am I able to reduce it with laser? My second question is how much can the surgery widen my mouth i have measured my mouth and it is approximately 4cm and when i look at other people their mouths can be measured up to 5 or 6cms. Now my question is how much can you widen my mouth with this procedure. i want my mouth at least like the pic i have provided. if you could respond as soon as you can that would be great so I can make my decision.
A: While mouth widening can be done here are tradeoffs of scars for it. Generally they are fairly acceptable when the mouth width increase is small. (5mms or less) But larger increases are associated with increased scarring and the need for scar revisional procedures. Given your mouth widening goals I would say this is not a procedure for you.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Over one year ago I had a facelift and damage occurred in both great auricular nerves. My ears have been horrible since then. I have trouble sleeping on them and I am aware of the pain on most days. Do you do a repair on the nerves? I would like to see if the nerves can be repaired through surgery. I am in great discomfort all of the time.
A: What you have is a greater auricular nerve injury from your facelift that is likely due to a complete transection and the proximal end of the nerve now has a neuroma. With this nerve condition there are two nerve treatment options.
1) Resection of the neuroma and place the nerve end into the muscle or wrap it in a fat graft. This would be the most common treatment approach.
2) Actual repair or nerve grafting to reconnect the two ends of the nerve. This is less common as finding the distal cut end of the nerve can be very difficult or impossible in the scar tissue. If both ends are found a small nerve graft may be needed if they can not be stretched and brought together.
Given your degree of symptoms it is clear that something needs to be done.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had forehead/brow ridge and cheek implants placed a year ago with satisfactory results. I am looking for a surgeon for injectable fillers. While I am mostly happy with the implants, I’m hoping to get some fillers to ‘top up’ the aesthetic results.Anyway, I’m hoping to have the fillers injected to 3 areas – the cheeks, the radix and gabella/supero-medial orbital rims and the deep pyriform aperture space. My questions are:
1) Would it be safe to inject fillers over my implants?
2) What fillers would you recommend for these regions? I’m leaning towards Voluma or Radiesse since they seem to be the longer lasting fillers with good soft tissue push.
3) Specifically, would Radiesse be safe to inject over the implants since they’re supposedly injected quite deep?
Thank you for taking the time to answer my queries.
A: In answer to your facial injectable filler questions:
- It is safe to inject fillers over the implants. The operative word being ‘over’ and not into the implant capsules.
- I would recommend Volume since you don’t want to be deep and this has the last chance of being lumpy or irregular which is a known issue with Radiesse and why it is recommended to be injected down at the bone level if possible.
- as per #2
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in injectable filler stop build up my brows and glabellar areas. My only concern is the risk of blindness when injecting the filler into the radix/glabella region. A few questions:
1) Would using a micro-cannula help mitigate these risks?
2) Would using a thinner filler like Restylane be recommended, or is Voluma just as safe?
3) Could a small amount of botox help lift the ‘inner’ eyebrows so that they appear straighter? I’ve read that combining botox and fillers in this region helps the fillers last longer – is this true?
4) Finally, how many syringes of Voluma total for my cheeks and radix/glabella is needed?
Thank you for your time!
A: Injectable fillers for brow augmentation can be vert effective even if it is not permanent. I would recommend Volume to get the longest lasting effect. In answer to your questions:
I have used microcannulas exclusively for years to do all injectable fillers treatments. They not only reduce the risk of intravascular injection but also decrease/eliminatent the risk of bruising and make the procedure much more comfortable.
Voluma with a microcannula technique would be safe for brow injections.
Eliminating the muscle action from the brow muscles using Botox can only help the persistence of the filler.
I would recommend 3 syringes of Volume for the brow and cheek areas.
Dr. Barry Eppley
Indianapolis, Indiana
