Your Questions
Your Questions
Q: Dr. Eppley, I am interested in doing the scarless temporal reduction surgery in the next year. I am a 35 year old male with a normal sized face but large head – 58 cm circumference – which seems mostly due to protrusion above the ears from temples above the forehead back to the end of the skull. The sides of my head become sore if I wear glasses for a long time and hats tend to be tight.
I have had a few questions regarding the procedure:
1) what are the requirements for anesthesia and how long is the surgery?
2) based on the description, can I expect to have a good result? will the change in head width give a noticeable impression of a smaller face/head?
3) what are the potential side effects both functional and cosmetic you have seen in the past even if the chances are low?
4) will removal of the temporal muscle lead to drooping of the skin in the lower part of my face due to volume loss at the head?
5) what is the cost?
6) what are the pre and post operative considerations and requirements?
7) how many of these surgeries have you performed?
Looking forward to your advice!
A: In answer to your questions about temporal reduction surgery:
- Surgery is about 1 1’2 hours and general anesthesia is a requirement for it.
- Temporal reduction reduces the width or convexity of the side of the head. It would not have any effect on the face.
- I have seen no adverse side effects in any patient. The only questions is whether the result meets the patient’s aesthetic goals.
- Removal of the muscle does not cause a skin droop.
- My assistant will pass along the cost of the surgery to you.
- There are no special before and after surgery requirments or tests needed
- I invented this head reshaping procedure and have performed over 50 of them
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Will a reduction sliding genioplasty make my chin pointier or wider from front view? And who benefits from the double sliding genioplasty? Is it twice as expensive as a normal one? Lastly, if I opted for chin widening, where does the bone graft come from? Thanks a lot.
A: A sliding genioplasty is a procedure that can be done various ways to create numerous changes to the chin. It can make the chin wider or more narrow from the front view depending upon how it is done and the technique used. There is virtually no reason today for a double sliding genioplasty. That sliding genioplasty technique was used decades ago before plates and screw were used for bone fixation. When there was only wire bone fixation used, large horizontal chin movements were best stabilized by this double cut osteotomy technique. There is no need for that sliding genioplasty technique today. When widening the chin a bone graft can be harvested from the patient or a cadaveric bone graft can be used. If harvested from the patient the best source would be from the back part of the jaw from inside the mouth.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in skull reshaping for my son. He is 4 years old. I went to several doctors to exam his head, only to have them tell me his head was normal. I begged for the helmet when he was a baby and they said no he doesn’t need it. I’ve always noticed these large bulges above his ears and wanted to correct it before his head was done growing.
Now we are dealing with what seems to be the needing of temporal bone reduction. These bulges, in my opinion, gives him the illusions of having a football shaped head when his hair is cut really low. It also pushes his ears forward quite a bit. I do not want him to suffer frmo being bullied as he grows and enters elementary school.
Do you perform this procedure on children? If so, can he also get the local anesthesia instead of being put to sleep?
A: I would need to see pictures of your son’s head to give a more qualified answer. But by description it sounds like your son has temporal bulging above the ears as well as protruding ears which often accompanies that type of skull shape. At four years of age the skull bone is very thin in that area and is not thick enough to allow for any skull reshaping reduction procedure. He will need to grow a lot more before that can be considered. The ears, however, are different and can be reshaped/pinned back at this early age.
No craniofacial bone procedure in a child is ever performed under local anesthesia. All such procedures require a general anesthetic.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Congratulations on your great blog first of all particularly on rhinoplasty topics. I have been bothered by the appearance of my nose for quite a long time and it’s the lateral view of it that bothers me the most. I’ve read both online and on your blog about the importance or the radix/nasion in the appearance of the nose and in particular the nasal length. I believe that my nose makes my middle of the face look a bit long regardless of the fact that I have a short chin as well. But I can’t seem to understand if my own nasion is high or low set. Do I just have a dorsal hump ? A low nasion ? Or a combination of both?
Finally, do you think that some nose tip work would be enough for me if I don’t want to make it obvious that I had surgery? I’m attaching a lateral view image of my nose if you’re willing to do some computer imaging so I can understand what would you have in mind.
Thank you a lot for your time.
A: In looking at your nose the issues are a dorsal hump and a long hanging tip. Simultaneous correction of both nasal shape issues (dorsal hump reduction and tip elevation/rotation) reveals that your radix/nasion is neither too high or too low. The attaching imaging of your predicted rhinoplasty result from the side view reveals this effect.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have an additional question about my stomach and tummy tuck surgery. I don’t want a tummy tuck where I have a scar that goes around my hips. I was wondering if skin could just be pulled tighter towards the pelvic area so that the wrinkling and obvious bulge would look smoother. I had a lumbar disc replacement surgery some years back and the scar left my stomach lumped like that with the way the incision was done. I’ve heard of mini tummy tucks that only leave a bikini line scar – could that be done?
I’ve included a side view so you can see that I don’t need to reduce my size, it is just that lower bulge/wrinkled area that needs to be addressed. What are your recommendations?
A: Certainly a more limited tummy tuck can be performed to lessen the scar burden and just get rid of the loose tissue in the lower central abdominal area. This will not produce as dramatic a change in your overall stomach area since this solution is far less then the problem. But if the concern about a scar supersedes that of some loose abdominal tissue then the mini tummy tuck is the better procedure for your abdominal rehabbing.
Q: Dr. Eppley, I have had a bull horn lip lift. I think it makes my mouth a little bit “sad” as it only lifts in the middle and not the sides. My wish is to have a higher middle part to push down on the lower lip and make the middle line in the lips more straight again (The three arrows in the middle in the picture).
My secondary wish is to have the outer part of the upper lip a little bit bigger (the two arrows pointing downwards in my picture).
Would you recommend VY-plasty on the outer sides and fat transfer in the middle or some other technique?
A: Your result is exactly what a subnasal lip lift does and could have been predicted beforehand. To accomplish your two remaining upper lip goals, one technique is to drop the middle part of the upper lip by fat grafting through an injection method. Either that or a dermal-fat graft placed like an implant. The other option is an internal mucosal V-Y advancement. Raising the sides of the upper lip is far ore predictable with a vermilion advancement than an internal V-Y mucosal procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in jaw augmentation surgery but I don’t know what type of procedures I need. I believe my face really suffers from a weak lower third and I need to reshape it somehow. Could you please advise me on what type of surgeries I should get? I have attached some pictures of my face for your review.
A: Based on your pictures our chin is short with a high jaw angle. This means that there overall jaw is short and total or more complete jaw augmentation would provide the best aesthetic result. There are several methods for jawline augmentation based on how the chin and jaw angle are treated. These include: 1) a chin sliding genioplasty and vertical lengthening jaw angle implants, 2) a square chin implant and vertical lengthening jaw angle implants, or 3) a custom one-piece jaw implant that wraps around the entire jaw made from a 3D CT scan. Each approach has it own advantages and disadvantages and, to some degree, slightly different aesthetic effects. This is where the role of computer imaging is critical to determine what degree of aesthetic change that you seek. Stronger and more prominent jaw augmentation results are usually achieved by the use of a custom implant approach.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a very deep forehead line and am wondering what treatment options there are. I have attached pictures for you to see how deep this forehead lines is. Thanks in advance.
A: You have a very deep glabellar furrow. While there are a variety of synthetic fillers, implants and Botox injections as potential treatments, these would be ineffective with such a deep furrow caused by strong muscle action. The skin has become permanently etched and indented over time. The best treatment would be to treat it like a deep scar. (which to a large degree is what it is) I would excise the skin edges, implant a dermal-fat graft and close the skin in a broken line closure method. While you will always have a line/scar, the realistic goal is to make it less indented and have a more smooth outer contour.
While this approach may sound ‘radical’, a deep forehead line is an aesthetic problem that is resistant to every other injectable approach. It is now way beyond an expression line and has become a non-traumatic deeply indented scar. Substantial improvement in its depth can only come from surgical scar revision.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in thigh scar revision. I had fat transfer done a year ago and the fat was harvested from my thighs. This means that I have two incisions along both sides of the pelvic area. The issue is, I was a couple of weeks late in removing the stitches, and there’s now hypertrophic scarring where the incisions were.
They are not too big – 1 cm in length and rather narrow. The thing that bothers me is how raised and red they look as it becomes rather obvious due to my pale complexion.
I get that it was my fault for delaying removing the stitches, but are there any options to improve on the appearance of these scars? Cost is not an object, and I’m fine with a relatively invasion procedure if it can provide the best results.
Anyway, the scar has remained the same for the past 6 months, so that’s why I’m seeking a scar revision now. Any solution that you can provide will be much appreciated.
A: While I would need to see actual pictures of your scars, I suspect that only excision and reclosure of them (scar revision) would make any difference. This time all sutures should be placed under the skin and be dissolvable so no suture removal is needed and the risk of hypertrophic scarring is less.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Do you think the vertical maxillary excess surgery would change my face a lot or would I still mostly look like me still? And is this something you practice?
A: The answer to your critical questions can be summed up like this. You have a ‘modest’ vertical maxillary excess problem from which all of your aesthetic concerns emanate. The reality is that orthognathic surgery is ‘drastic’, and while solving all of your classic vertical maxillary excess problems, runs the aesthetic risk of changing the way you look and has it own set of risks and complications. The outcome may be great or could turn out that you wish you never had it done because you look different. That is the risk of having a ‘big operation for a proportionately smaller problem’. Conversely a less drastic approach (e.g., gummy smile lowering vestibuloplasty and sliding genioplasty which is what I would do if I was you) is aesthetically safer but will leave you slightly under corrected…but without the risk of changing your appearance so dramatically.
In short, you do not have a perfect treatment choice. You basically to have to choose between these two approaches to vertical maxillary excess based on what risk tolerance you have. The only way to decide is how much do you want to change your bite. If it is of lower priority then don’t do the maxillary impaction surgery. If it is of high priority then maxillary impaction surgery is the only way to go and the risks would be worth it.
I can speak to these treatment choices well because I am trained and have performed many of each so I have a unique experience perspective.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, In regards to my custom facial implants (midface and jawline) I have soe design questions. 1) how much forwardness do you think my midface/premaxillary implant would need? 2) Would it look like the example photograph I sent you through Skype? 3) And how much vertical length would you think I’ll be getting in my chin and jaw angle implants? 4) Could the midface implant also give me natural looking high cheekbones in the process? Thank you Doc for you’re time.
A: IN ANSWER TO YOUR CUSTOM FACIAL IMPLANTS QUESTIONS. 1) I WOULD THINK SOMEWHERE BETWEEN 4 AND 6MMS OF MIDFACE AUGMENTATION IS NEEDED. I HAVE NOT SEEN ANYONE THAT NEEDS MORE THAN 7MMS. THERE IS ALSO THE ISSUE OF BEING ABLE TO HAVE A COMPETENT MAXILLARY VESTIBULAR INCISIONAL CLOSURE. IF THE IMPLANT IS TOO BIG TERE IS AN INCREASED RISK OF POSTOPERATIVE WOUND DEHISCENCE. 2) AS TO THE RESULT OBTAINABLE, YOU CAN’T MAKE ANYONE LIKE LOOK LIKE SOMEONE ELSE. YOI CAN ONLY MAKE YOU LOOK BETTER AND MORE PROPORTIONED. 3) YOUR CHIN PROBABLY NEEDS TO COME DOWN ABOUT 5MMS WHILE THE JAW ANGLES WOULD BE CLOSER TO 15MMS. 4) LIKE MOST MALES THEY ALL WANT A HIGH NOT A LOW CHEEK AUGMENTATION EFFECT SO YOUR REQUESTS ARE SIMILAR TO WHAT EVERY OTHER YOUNG MALE SEEKS.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I wanted to share these pictures to check if they would match the custom midface implant design. His face shares similar orbital vector and eye shape to mine. These faces are projected directly below the eyes. I prefer the look where the projection is high in the midface and hollows in the lower cheek segment giving an chiseled athletic look. I have seen many cheek implant results online where the lower cheek was filled and the upper cheek was left hollow giving the patient a chubby cheek appearance.
In regards to the implant would the given dimensions be suitable for this look? My infraorbital area appears very hollow even relative to my recessed cheeks. Ideally I’d like the result to look like the projected faces but I do understand that many factors go into the outcome. His cheek augmentation before and after is a result I’d want to avoid. He appears less masculine as the projection was lower in the cheek. His infraorbital augmentation is much better in my opinion, he looks sharper and masculine.
Like you have previously pointed out my orbital vector is negative and I’d like to augment it making it positive giving the deep set eye appearance, instead of a protruding eye appearance.
Thank you for your time and consideration.
A: Thank you for providing your pictorial examples and your goals. The reason you are having a custom midface implant is because no standard cheek implant can remotely create the type of midface augmentation that you, and every patient that has a negative orbital vector, requires. If one tries to use any standard cheek implant for your problem it would be an aesthetic disaster. Also most standard cheek implants are really made for women. While they are also routinely used in men, I find they are often aesthetically not optimal as what makes most male cheeks look better is a different zone of augmentation than that of the female. To no surprise male and female midface aesthetics and beauty are different. Most men do not want the ‘apple cheek’ look that some females want, they want a high malar augmentation result.
I am very well aware of your midface aesthetic needs and those will certainly be an integral concept in your custom midface implant design.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, i have been concerned with my big forehead. I did a hair transplant six month ago but the problem is that I still have a large forehead. I now know that it is because my forehead bone is so prominent.(forward) I was wondering if you do forehead reduction surgery where the bone is shaved down and is less forward and more symmetrical with my other features. On your website I saw that the you had done a lot of similar forehead reduction procedures. Attached are some pictures for your review.
A: You have a frontal bossing issue on your forehead which could only be hidden if the hair transplant came down low enough. (which would also look unusual) Frontal bossing forehead reduction is done by a bone burring technique whose result is controlled by how much the bone can be reduced. (down into the diploid space.) That is usually around 5mms but many be more in some patients based on the thickness of their bone. If one really wanted to know much the outer table of the forehead bone can be reduced, a lateral skull x-ray will clearly show the thee layers of the skull and the outer table thickness can be measured.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have moderate vertical maxillary excess which causes me to have a gummy smile when laughing, a long lower/mid face and slight lip incompetence that causes slight chin dimpling/strain when I close my mouth. My chin is also slightly recessed. I dislike my downwards angled jawline which I think is the cause of the recessed chin and vertical maxillary execss that makes it harder for mandible to auto rotate. I also have a deep overbite and excessive overjet. My orthodontist and jaw surgeon suggested jaw surgery with maxillary impaction with slight advancement along with slight mandibular advancement to fix my concerns. I also had the orthodontic option to intrude my upper front teeth followed by gum laser removal. (although I don’t want my teeth looking long, i like the length of my teeth) I had braces when I was younger. They extracted 4 bicuspids which make my smile more narrow.
I would like to get rid of my gummy smile and long midface and have a relaxed looking mouth when I close it. I know my case is not severe but I would like to fix my concerns the right way. I do not want to look like a whole new person. I think I am good looking but I would just love to fix the things I mentioned that bother me. Would the surgical way make me look too different or would I still look like me?
A: Given all of your vertical maxillary excess symptoms, the best long-term treatment would be maxillary impaction possibly combined with mandibular advancement or a sliding genioplasty. Whether the lower jaw needs to go with the maxillary impaction depends on what the pre surgical orthodontic workup shows for the skeletal movements based on the needed occlusal changes. This is the long but the right way. Anything short of this approach will produce some partial improvement but will probably always leave you wishing for more improvement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have read through you pectoral implants case studies and wondering what your thoughts are on 230cc implants on a 60kg male with low body fat. I went and saw a surgeon for a consult today. However I am still confused as to which one is best for me. My surgeon did however state that the 190 cc would be too “natural ” for me as I am wanting a slightly aggressive approach to this. Another thing I noted is that he was adament that he use the square shape implant as opposed to the oval shaped for the look I am after. I always thought that i would be more suited to the oval shape as I don’t wish to look “meaty or body builder like” and enjoy more of a swimmers, athletic style of implant whilst keeping the aggressive approach and creating the bulge you mention on your notes. I have found it difficult to find information on this as I have noticed that most people on the internet and my doctors patients who have had pectorals done are all the complete opposite physique to me and are much older.
A: I will preface my comments by saying that since I don’t know what you look like now or your chest shape goals, all I can do is make some general statements about pectoral implants. There really is vritually no difference in size between 230cc and 190cc pectoral implants. If you don’t go up at least 100cc in implant volume you will see no external differences. You are correct in that there are differences in results between the more square shaped and oval pectoral implants. Given what you may want to achieve it certainly sounds like the oval shape pectoral implant styles would be more appropriate for your aesthetic chest shape goals.
Dr. Barry Eppley
Indianapolis Indiana
Q: Dr. Eppley, Will inserting maxillary implants on the maxilla (the entire maxilla, including the bits around the nose and up to the under eye sockets) be an effective solution to get rid of mild nasolabial folds? My folds are very present at even the slightest facial expression and the smile lines stay for a while after the expression. And if I look really closely I can see the smile lines even if I haven’t made an expression for a while. (so they will only get worse as I get older, I’m currently 22)
The actual smile lines at rest bother me more so than the folds during expression, as I can stop expressing if I really want to. Or is there another more effective procedures to get rid of these bothersome facial lines?
A: In short, I am not aware that underlying bone augmentation significantly impacts the depth of nasolabial folds at rest or prevents their occurrence with smiling. Maxillary implants are designed to augment the bone not to address the outer soft tissues.
Furthermore your concerns about the smile lines will be a lifelong one as there is no real solution to these superficial skin wrinkles. They are a normal and natural part of the sequelae of facial expression, a critical element in human interaction and communication.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a fat transfer to my arms/wrists area twice in the past and the fat did not survive – the result was very good at first but after nearly 4 months the fat has gone away. My concern is my small wrists and arms but especially the wrists. I would like to know if the arm implants can be used to augment the wrists to make them appear wider/bigger. I plan on having this surgery late this year.
A: It is no surprise that fat would not survive in the arms and wrists. As a general rule fat does not survive well in tissues where fat does not normally reside to any degree. Fat may survive is one area or spot but will not persist in an overall circumferential manner. That is just simply to going to work…as you now know times two.
It is not possible to place implants in the arms/wrist as there is not adequate soft tissue/muscular cover for them. Implants that are just covered by skin and are close to a moveable joint like the wrists would likely have a high incidence of complications. It is not a question of whether it can be done but whether it should be done.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, So I don’t have a severe deformity, but the top of my head is basically flat. I have a big head but it’s very flat, it looks Cro-magnonish and it gives me a primitive look which I don’t like. Is there any option to add height to my skull? Just a few cms? Slightly reshaping it would really make a difference I think. My forehead is also very flat, so it looks really really bad. I would send pictures, but I don’t know how. Can this condition be treated somehow? Basically my goal is to add a little height to the top of my head so it won’t look flat. I await your answer.
A: What you need is a skull augmentation procedure using a custom skull implant. How much skull augmentation on the top of the head that can be achieved is limited by how much the scalp will stretch to accommodate the implant. But up to 1 cm to 1.5cm of additional skull height can be safely achieved. The shape of the implant would provide a rounder shape as the height is increased and that is part of the implant’s design.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a male and I’m interested in a lip lift procedure. I say this because I feel as if the distance between the base of my nose and my upper lip is too long for my face and throws my facial balance out or proportion. As you know, a lip lift is able to reduce that distance which is exactly what I need. What you also know is that the lip lift pouts the upper lip, which is something that I’m not aiming for with this procedure; mainly because pouty lips on a male can look overly feminine . I know that this effect is unavoidable, it’s a question of whether the benefits of reducing the upper lip distance outweighs the drawbacks of a slightly poutier upper lip. However I feel that I’m unable to make a decision without knowing precisely how the procedure will effect my upper lip. So my question is: is there any way in which I can visualize the likely result of this procedure on my own face? I’ve tried morphing my upper lip to be slightly more full but it doesn’t seem to give the same effect that I’ve generally seen with lip lift before/afters which tend to alter the upper lip size, but not in a straightforward way as the morphing app is only capable of doing.
That brings me onto my next question about patient results. From the many before and afters that I have seen, some seem to really change the lip proportions whilst others don’t really drastically affect the upper lip proportions at all. I have noticed that this is even the case where the upper lip distance reduced in these comparable results isn’t hugely different! Obviously I would prefer a result like those in which the upper lip hasn’t been changed all that much. But how am I to tell which sort of case I would fall under?
The last question I had was whether a portion of the underside of the upper lip could be removed in order to thin the upper lip from the underside. And then have the lip lift performed on the thinner upper lip? I say this because my upper lip has a very slight tubercle hanging downwards (I am not sure if I’m decsribing it rightly, what I mean is that a sort of triangle hangs down from the centre of the upper lip, it’s quite common). If this tubercle could be removed and the upper lip therefore thinned, could that mitigate the increased upper lip thickness that may result from the lip lift? If it can, that would be great because it means that I’ll have the same net upper vermillion size with a shorter upper lip length?
A: In answer to your upper lip lift questions:
- There is now way to accurately show before surgery what the real effects of a lip lift would be on your areas of lip shape concerns.
- The factors that affect how much change a lip lift does to the upper lip is the amount or percent of upper lip skin distance that is excised as well as the natural elasticity of the upper lip tissues. Thus that really makes it impossible to compare lip lift results between patients as these two variables are not the same in any two patients. The most important factor is how much of the philtral length is horizontally removed
- A smile line vermilion edge resection can be done at the same time as an upper lip lift.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a strange aesthetic problem that has to do with my eyes, more specifically with my eyeballs. I feel that they’re too deep set into my skull and that makes them look tiny. The problem, however, is that not only I don’t have “heavy” or protruding brow bones but my whole orbital rims (upper and lower) are recessed , I can tell that from my profile view because I have a visible bulge under my eyes and I also have dark circles. Unfortunately, I do not have a camera with me so you can see what my eyes look like. But supposing that all my assumptions are correct, is there any way to move my eyeballs forward ? I was thinking if orbital floor augmentation or craniofacial surgery to this area can be effective. Are any of these options to be seriously considered?
A: In short, you can not move your eyeballs forward. They are on a tether known as the optic nerve. It is not a good idea to stretch the optic nerve as this could very well led to visual disturbances or blindness. Orbital floor augmentation can potentially move the eyeball up. Craniofacial surgery moves the orbital rims around the eyes. Neither of these are to be seriously considered, even if they would be effective, for an aesthetic eye concern.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Several years ago, I developed bulging temple veins and I had the superficial temporal artery ligation in my right temple with a single point ligation.I’ve had some potential complications and I’m looking for a second opinion.
For the most part, the surgery was a success. The bulging vessel is gone and any scarring was very minimal. A couple years after the surgery, I developed a very rare condition called Partial Third Nerve Palsy, most likely caused by lack of blood flow to my ocular motor nerve. As with most partial ocular nerve palsies, my condition improved within weeks.
Fast forward a couple years and it happened again. And just like the first time, I recovered completely. I had the top ophthalmologic docs stumped. I told them about my superficial temporal artery ligation and they brushed it off as insignificant. I’m relatively young and healthy and have no other conditions that typically would cause an ocular nerve palsy.
I was recently reading Men’s Health and there was an article about giant cell temporal arteritis and how it can cause double vision or blindness. So that tells me that there IS a possible connection between the superficial temporal artery ligation and vision, right?
But everything I read online said the procedure is safe and perhaps my recurring ocular nerve palsy is just a totally unrelated coincidence. As you seem like an expert in this field, I thought I would reach out to you and hope you can put my mind at ease.
Q: In short, I know of no connection between superficial temporal artery ligation and oculomotor nerve palsy. The superficial temporal artery is a terminal branch of the external carotid artery that supplies the forehead and anterior scalp. Conversely the oculomotor nerve receives its blood supply from the internal carotid artery through an intracranial course. Thus there is no apparent anatomic connection on the basis of arterial blood supply.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Wouldn’t a jaw implant have the same issues as chin implants where eventually the bone starts to become reabsorbed?
A: The belief that chin implants cause ‘bone erosion’ is both inaccurate and biologically misinterpreted. Some, but not all, chin implants develop passive settling into the bone as a biologic response to the tissue displacement pressures of the implanted device. This is a passive and natural process that occurs in many augmentation implants throughout the body that is self-limiting as a method of pressure relief. This should not be confused with an inflammatory process like bone erosion which develops as an adverse reaction to either a material’s composition or an infection from the implant material.
Such passive tissue remodeling responses to a facial implant is most commonly see in chin implants. It is probably because of the tight tissues of the projecting soft tissues of the chin stretched out over a projecting underlying bone. This puts a lot of pressure over a single bone point. (chin) This is not seen in larger jaw implants because the displacement forces are spread out over a much larger bone surface area and there is no one single pressure point or area.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, My primary cosmetic concern is actually very dark skin in the upper and lower lids as well as the sides of the nose. Unfortunately, without make-up this feature dominates my face. However, I am also aware of some structural issues that make this darkness look worse. My prominent brow bone casts a shadow over my deep-set eyes and that the radix of my nose is very narrow. Would you agree that these are contributing factors? (Photos, with make-up, are attached.) Would brow bone reduction and nasal augmentation help?
I had some fat transfer to the lower lids ten years ago with some lasting success. I would now like to correct the darkness in my upper lids and medial canthus and I’m researching two options. One option is fat transfer. The other is to address the structural issues through reduction of the brow bones and lateral augmentation of the radix of my nose. Ideally, I would pursue all of these (along with hairline lowering) but am hesitating to have such invasive procedures.
Can you advise me which of these procedures will make the most difference to the darkness in my eye area and my overall appearance? Also, what is the likelihood of a good result? Any advice you can offer is greatly appreciated.
A: Thank you for your inquiry and sending your pictures. While your structural issues may make a contribution to your periorbital dark skin appearance, you would never do structural surgery such as brow bone reduction or nasal augmentation in an effort for skin coloration improvement of the adjoining areas. The risks are simply too high. You do those surgeries for what they primary purpose is…creating a structural change not a potential secondary benefit.
This leaves you with the only treatment option of which you have had prior experience…fat grafting. Whether this would be effective to improve your periorbital skin discoloration is not precisely known.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’ve underwent a male breast reduction surgery five years ago. Everything went well. Months after my surgery,I had slight scar tissue build-up in my chest—nothing too concerning, absolutely livable. I massaged when I could but it was always so sore and I was too scared of messing up my results. I noticed the scar tissue in my left pec fluctuated slightly in size slightly over time. Massaging wasn’t helping, so at one year post op I went in for Kenalog shots to break up some of the tissue. It seemed to work but it also left a slight dent when I flex. Now, four years post op, the tissue seems to have grown again out of nowhere. I began massaging vigorously again. At first, the scar tissue seemed like it was breaking up and getting smaller. I was massaging just about everyday and then it started to harden. I even got some bruising around my left nipple. I tried to keep massaging, but I’m not seeing any progress. It only seems to be getting bigger, harder, and more noticeable—is that good or bad?
A: At this point the only effective option is going to be further gynecomastia reduction surgery. Whether it is scar tissue or actual breast tissue regrowth, further improvement is not going to come from massage or steroid injections. Secondary or revisional gynecomastia reduction surgery is not rare due to either the development of scar tissue or some breast tissue regrowth.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have had a Medpor chin implant placed last year. I am ok with the look although it is a bit big for my feminine small face and my chin looks a bit big and asymmetric when I smile. However my big problem is when I woke up after surgery with excrutinating pain on the right side, probably along the branch of the mental nerve that goes to the lip. And it still hurts a lot, focused on that groove between chin and lip on that side. It improves when lying down after a while and worse when I move my mouth, speak etc. What should I do?
The surgeons are very experienced but have never experienced this kind of problem before, and have never removed or performed a chin implant revision. I also have numbness in the same side of the lip and a bit problem with articulation.There is also pain in the lip when I stretch the lip. When I wake up in the morning the pain is almost gone and comes when I start moving around. I consulted a neurosurgeon who said there is nerve damage, not a cut nerve. The surgeons are willing to take out the whole thing but I think that is very drastic. What would be your advice, and where to find the best expertise for my problem, and how to fix it – the situation is kind of desperate as i do not function so well wit all that pain. Hope to hear from you soon.
A: Either the chin implant is impinging on the nerve (mental neuropraxia) or the nerves has beens stretched/injured during the making of the pocket to place the implant. Given the overall larger sizes of Medpor chin implants and their stiffness, it is likely that it is the former. I think the only way you can make improvement is to do a Medpor chin implant revision where the implant is removed, the right mental nerve checked/repaired/fat grafted and the implant modified in size and reinserted. It is unfortunate that this was not done a long time ago when an injury to the nerve had a much better chance of having a full recovery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in masseter muscle reduction via electrocautery for a permanent solution. I would also like to know if this method can be used for the upper trapezius muscle as well? Mine is way over developeddue to genetics as well as being top heavy…thank you.
A: Masseter muscle reduction is surgically done using electocautery to treat the entire internal surface of the muscle from where it is lifted off the jaw bone. By so doing it causes some muscle cell atrophy, reducing the size of the overall muscle. Treating a much larger muscle like the trapezium is more analogous to that of the calf muscle. In calf muscle reduction a portion of the fibers of the muscle are released from its origin by electrocautery resulting in a different mechanism for muscle atrophy. This would how the trapezius muscle would similarly treated. What bothers you about the trapezius muscle would most likely be the upper third where it is seen gong from the back of the head down across to the shoulder. Such a trapezium release of the upper third of the muscle would have to be done where it attaches to the occipital skull bone.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have some questions about custom facial implants. I have attached a frontal shot of my face in harsh bright lighting. I have also attached a side profile shot along with an adjusted “goal” image of what I would like my profile to resemble. I have also attached a picture of a famous actor who has an incredibly angular and well defined jaw. It would be my dream to have a jaw like his. Is it achievable? My budget is considerable. My primary aim is to get rid of my round face front on and have something square and angular both in the chin and jaw angle regions.
I am also interested in what parts of my face are lacking and how I can improve it aesthetically. What are your thoughts, I’m open to suggestions. I seem to have quite a round face despite being low in body fat (my abs are visible and I have a “four pack”). I’m puzzled by what I need to enhance to get the look I desire. Is my lack of facial bone structure causing poor tissue distribution or is my poor tissue distribution hiding my bone structure. Interested in your thoughts and potential solutions, I like your intelligent approach that I’ve been reading in your blog.
A: Thank you for sending your pictures and describing your aesthetic goals. In reality you do not really have a round face. It may appear that way to you and is not to your liking but it is certainly not round. Your face is thin and you have decent facial bone structure. What you lack is the bone structure to get the ‘supernormal’ look you desire. With the right cheek and jawline implant designs such facial changes that you seek are possible. That type of facial change can really only be achieved in someone with a thinner face where the enhanced skeletal projections created by custom facial implants become more evident externally.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, With my custom midface implant I hope to be able to meet with the engineers to tell them how I want my implant designed in detail. I also wonder if I can have a midface lift at the same time as the placement of the custom midface implant.
A: In terms of custom midface implant design process, patients can not have a direct participation in the actual designing of the implants with the engineers. Since the patient is not a surgeon, direct manufacture and patient contact is prohibited by the FDA. The implant design process is done between myself and the engineers independent of the patient. Patients to get to see the implant designs and make comments and suggestions from the PDF file designs provided to them after each design session. Only three implant design sessions are done from which the final design must be completed. Final implant designs must be submitted a minimum of two weeks before the actual surgery date.
With the placement of any midface implant a midface lift can not be performed at the same time. A midface lift in a young person is also an unnecessary and ineffective procedure. This is an operation for older patients who actually have lose midface misses from aging and bone loss.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, So I don’t have a severe deformity, but the top of my head is basically flat. I have a big head but it’s very flat, it looks Cro-magnonish and it gives me a primitive look which I don’t like. Is there any option to add height to my skull? Just a few cms? Slightly reshaping it would really make a difference I think. My forehead is also very flat, so it looks really really bad. I would send pictures, but I don’t know how. Can this condition be treated somehow? Basically my goal is to add a little height to the top of my head so it won’t look flat. I await your answer.
A: What you need is a skull augmentation procedure using a custom skull implant. How much skull augmentation on the top of the head that can be achieved is limited by how much the scalp will stretch to accommodate the implant. But up to 1 cm to 1.5 cms of additional skull height can be safely achieved in most patients. The shape of the implant would provide a rounder shape as well as the skull height is increased. This is known as a skull cap implant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Recently had a mini facelift. I’m 3 weeks post op and I’m concerned about the areas of what appears to be fat next to my mouth. It gives me a bit of a “joke smile” look quite frankly. I spoke to my doc about it and he said photos were in bad light and area might calm down but I’m looking for a second opinion and wondering if these fat line areas can be removed with micro liposuction or should I use fillers to make less noticeable. I wonder if these areas are the fat that was previously along my jawline, or is it swelling still I cant seem to get a clear answer so I’m looking elsewhere.
A: It is important to note that you are just three weeks after your mini facelift surgery. The tightening along the jawline makes the perioral region look puffy or at least has exacerbated what it was before surgery. This is the effect of a mini facelift where minimal skin undermining is done. It may be that with more healing time and the jawline skin relaxes a bit that its appearance may decrease. I would give it at least 6 weeks after surgery to see how it looks then. If it has not improved substantially by then small cannula liposuction should be used to reduce the perioral mounds which has become unmasked. Trying to place injectable fillers around it is likely to make look worse.
Dr. Barry Eppley
Indianapolis, Indiana