Your Questions
Your Questions
Q: Dr. Eppley, I’m interested in a reverse tummy tuck, I’m at my goal weight and I’m 48 years old. I’ve had previous liposuction to tummy, buttocks, and thighs. I’m interested in just tightening the skin in my upper abs. I do not want any liposuction as this has already caused uneven skin and a permanent wrinkle in my tummy. I don’t need my muscles to be tightened as they are already pretty tight. I just want to tighten the skin. When I pull the skin up under my breasts, it does miracles. I am not looking for perfection. Even if it protrudes a bit, I’m fine with it. I just want to fix the uneven skin and the permanent wrinkle that is there.
Can this be done with local anesthesia and twilight or IV sedation? I have a real hard time with general anesthesia. Also, where do you tether the incision? The rib or the muscle? To keep the scar from stretching or moving downward? Does the scar have to go across the breast bone? Can it be just under the breasts? I do have large breasts so they may hide the incisions which would be a bonus. Again, I am not looking for total flatness. Just get rid of the bumps or unevenness.
I’m also interested in skin removal from my buttocks and outer thighs. I don’t want a Brazilian butt lift. I don’t care if my butt is flat. I have lost weight in my lifetime and gained and lost again. This has left me with saggy skin and some dimples, maybe due to liposuction as well. I don’t want liposuction in this area. If you think it has to be done then that’s fine. I just want some even skin with no dimples. Can you suggest something for this area that I have not been able to find? The only thing I can think of that would help is a skin removal/tightening. If it can help my outer thighs then great. Please see my photos. I would also like this to be done without general anesthesia. Is this possible? Can this be done the same time as the reverse tummy tuck.
A: Thank you for your inquiry and sending your pictures. As reverse tummy tucks go, you are about as perfect a candidate for it as I have seen. They are for women that have either had liposuction, a tummy tuck or weight loss where the tissues below the belly button are taut. But the skin above the belly button is loose and has some overhang exists onto the umbilicus. By simply pulling up on the abdominal skin a good improvement is seen. By definition a reverse tummy tuck is a more simpler form of a tummy tuck, does not involve muscle plication and is a skin excision only procedure.
The key in a reverse tiummy tuck is the incision location. I have done it either keeping the incisions limited to the inframammary folds or crossing the lower end of the sternum. When it crosses the sternum it produces a better skin lift/tightening (due to the central pull) but does have visible scar location in the very center. When the ellipitical skin excisions are limited to the inframammary folds, the effect is not quite as good but still apparent. One has to decide whether more upper abdominal skin tightening is worth the scar trade-off. The upper abdominal tissues are plicated to the fascia over the ribs at the inframammary fold level.
In regards to your buttocks and outer thighs, a partial solution exists. A lower buttock lift can tuck and tighten the lower buttocks through an elliptical excision along the infragluteal crease. It does flatten the lower buttocks a bit but this is not an issue for you as you have stated. The outer thighs is a more problematic area because any effective skin tightening/lift will create a visible scar that would only be an acceptable trade-off in the extreme weight loss patient.
As uncommon as reverse tummy tucks and lower buttock lifts are, they are not in my practice. I have performed them many times although their frequency is in the range of 3 to 4 per year for reverse tummy tucks and 10 to 12 times per year for lower buttock lifts. Both can be performed under IV sedation although, because of the prone position and airway security, the lower buttock lift should be done under local anesthesia if one is not having general anesthesia.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am looking for a doctor that has done brow bone augmentation. I came across Dr. Eppley and am considering both rhinoplasty and brow bone augmentation to improve my profile view. I want my forehead to come out further, as of right now my eyes are flush with my forehead and it’s very flat. I want more dimension in my face. I wanted to know what you would recommend and how confident yo are with Asian rhinoplasty. Thanks!
A: Thank you for your inquiry and sending your pictures. I have done many Asian forehead and brow augmentation and rhinoplasty procedures. The key question for both procedures are the materials to do them. In the forehead you have the option of either bone cement application through a near complete coronal incision or a custom forehead/brow bone implant placed through a smaller scalp incision. For the rhinoplasty, one of its key elements is the augmentation of the nasal bridge. This can be done using either a cartilage rib graft or a silicone nasal implant.
The use of these various materials for both forehead and brow bone augmentation and rhinoplasty affects numerous aspects of the procedures including cost and recovery. I would need further input from you on these choices.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am inquiring about a genioplasty revision.I originally had double jaw surgery and a genioplasty performed. The results of the jaw surgery were great and the genioplasty was not bad either however there was some asymmetry and the chin projected just a tad more then I preferred, so I had a revision on the chin to move it back very slightly, a total of 1.5mm back from the original 4mm that it was moved forward as well as correct the asymmetry.
The results of the revision were not satisfactory, I developed chin ptosis and loose skin. 8 months later I decided to have another revision surgery to move the chin forward by 1mm, nearly back to it’s original position of 4mm and the mentalis muscle resuspended. After recovering from this surgery I have realized that the chin was not moved forward enough to support the mentalis muscle and the loose skin. There has been some improvement, I have a slightly droopy smile and I still have loose skin. I believe that the surgeon used a different type of plate and therefore the measurements were not as accurate as expected.
My question to you is, what are my best options to correct this, I am okay with having a bigger chin at this point, so I am considering having a 4th genioplasty and utilizing my CBCT scans, images, etc to have it moved to exactly into the same position that it was in after the first surgery, but do you think that undergoing a 4th genioplasty would be okay to do? Also, if the chin is moved to the same position that it was prior to any revision and the mentalis muscle is suspended correctly, what do you think my chances are of achieving similar results of what I had prior to the revisions?
I understand that some of these questions can’t be truly answered with out a full examination but if you can answer them based on experience that would be helpful,
A: The short answer to your question is that approach would be the only viable option. Bony support has to be re-estabished to the soft tissue chin pad. Whether returning to its original advanced position is enough is unknown but it can only help. There certainly is no harm in doing a 4th genioplasty as the vascular quality of the tissues would not be impaired and the amount of scar tissue at this point is irrelevant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am considering a series of separate body feminizing procedures (transgender body contouring) in this sequence:
1. Butt Implants with body lipo/fat grafting to complete hip/butt shape.
2. Then take 3-6mo to regrow some fat for Breast Implants with body lipo/fat grafting for cleavage and more natural finished shape.
3. Ribs removal. Front and back. Im not sure of the exact rib #s, but Im referring to both protruding ribs in front, and lower floating ribs. Would you kindly advise what exactly is possible, safe, and effective?
4. Tummy tuck with plication and for “internal corset” effect.
My thinking is that doing rib removal as a separate procedure before tummy tuck, allows for removal of more ribs than if removing ribs at the same time as tummy tuck, and will create more potential for the tummy tuck to draw in/around the trunk, for an overall slimmer torso and waist.
Would you kindly let me know your thoughts?
Thank-you Dr!:)
A: Thanks for detailing your transgender body contouring sequence, I would make the following comments to them .
1) Buttock implants with overlay fat grafting is a good approach to these needs. Fat grafting can only be done if the buttock implants are placed in an intramuscular position and not in a subfascial location. This would really be based on implant size. Any buttock implant bigger than 330cc would have to be placed in a subfascial location. In thus case, fat grafting is done first followed by implants secondarily.
2) I doubt once you harvest fat the first time there would be enough for the second time. The concept of growing fat is not usually a good idea for fat grafting since any weight loss will simply make what has been transferred to go away. It is important to remember that grafted fat acts like where it comes from, it retains its donor sit characteristics. It would make the most sense to rely on implants to do the complete breast augmentation/reshaping.
3) For waistline narrowing, ribs #10, 11 and 12 are commonly removed with small incisions from the back. For anterior protruding ribs (ribs 8,and 9) that is done through either a low subcostal incision or through tummy tuck incision.
4) If one is having a tummy tuck then that would be the ideal time to remove the subcostal ribs #8 and 9.
With this information, I would make the following recommendations based on how to best put the body contouring program together in two stages.
#1 Rib removal #10, 11 and 12, intramuscular buttock implants (300cc) and waistline/abdominal liposuction with fat grafting to the hips and around the buttock implants.
#2 Six months later….breast augmentation with implants, tummy tuck with rib removals 8 and 9.
This, in my opinion, would be the best way to put in all together and is actually how it is commonly done.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have what to me is extreme facial asymmetry, and have wondered all of my life if anyone could correct my face. I destroy all pictures of myself I am so ashamed of what I look like. Is there anything you can do for me? If I take a reverse picture using a mirror, I look pretty normal ( pictures attached). Is there a way I can look like that without using a mirror to reverse my image? Thank you very much.
A: Thank you for your inquiry and sending your pictures for assessment of your facial asymmetry. In critically looking at your pictures, I see four very specific difference between the two sides of your face. They include the following and are based the way I am seeing the picture (which may well be reversed in real life based on how the picture was taken)
1) Cupid’s bow asymmetry of the upper lip. The right of the cupid’s bow is lower than the left. (correction – cupid’s bow vermilion advancement)
2 Nostril asymmetry. The left nasal base is wider and more elevated than that of the right side. (correction – left alar base lowering and inward relocation)
3) Left eye asymmetry. You have a significant left lower eyelid ectropion/sagging) This is probably the one facial feature that is the oat obvious. (correction – lateral canthoplasty and lower eyelid repositioning)
4) Left eyebrow asymmetry. The left eyebrow is lower than the right. (correction – left endoscopic browlift)
When these four facial asymmetries are out together it can create a rather significant facial asymmetry.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in brow bone augmentation as well as orbital floor augmentation. But I don’t want to use any synthetic implant materials to do so. Can Bio-oss (bovine hydroxyapatite) be used for orbital augmentation and brow bone augmentation?
A: Any hydroxyapatite granular material can be used to augment a confined space like the orbital floor or a more open surface like that of the brow bones. Whether a bovine hydroxyapatite will persist or develop any significant bone ingrowth as an onlay material is a matter of debate. (it works best as an inlay bone substitute material) But from a handling standpoint, it can be used for either craniofacial application. Applying the material to the orbital floor is very straightforward. Applying to the brow bones, however, is a bit challenging because access to the brow bones is more restrictive. The ideal way to use it in brow bone augmentation would be an injection technique that uses a brow incision to do so.
While the concept of hydroxyapatite granules is understandably appealing, there are prone to irregularities and asymmetry when applied as an onlay graft. This would be particularly evident when introduced as an injection as the material does not have a smooth linear flow when injected out of a syringe.
Dr. Barry Eppley
Q: Dr. Eppley, I am interested in multiple facial reshaping procedures. I have a long face with a vertically long chin. The last time you said you would take it back and wouldn’t shorten it. I disagree.I f I set it back I have not enough forward projection, I need to shorten it. My jaw is too long too. I need to change the mandibular angle to make it look rounder it is not soft looking. Next thing is my forehead goes backwards a little, I want it rounder and filled with nothing permanent.
A: Good to hear from you again. I must confess that I do not remember our prior emails. about your desired facial reshaping goals. The projection of one’s chin is open to personal opinion so if you prefer the anterior projection you have then vertical chin reduction should only be done. The jaw angles can be made more round by removing at a 45 degree angle their back end. The only non-permanent method of forehead augmentation would be either synthetic fillers. It can be argued that fat injections may not be permanent but they are best thought of as having some amount of permanent retention. The problem with synthetic injectable fillers is the volume that would be needed to augment a large area like the forehead.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, you performed a 12mm sliding genioplasty advancement (with a Gore-tex implant in the step-off, jaw angle implants, and infraorbital-cheek implants two days ago. My face is very swollen and appears lopsided. I am concerned that something is wrong. Please tell me that the facial swelling will go down very soon.
A: I will repeat what I extensively reviewed before surgery which are my six principles of facial implant surgery recovery:
1) The swelling from theses types of facial reshaping surgeries will be horrendous and very distorting…and psychologically troubling. You will not recognize yourself and will wonder if something is wrong or whether you should have done the surgery at all.
2) The resolution of swelling will go down in a very typical progression…50% by 10 days, 75% by 3 weeks and 90% by 6 weeks. It will take a full 3 months before the final result will be seen.
3) With the swelling there will be typical differences between facial sides which is very common as no two sides of the face will swell the same.
4) I do not critique/judge the result myself for a full three months…nor should you.
5) I never consider any changes or revisions to the surgical outcome until a full resolution of all facial swelling has resolved and the tissues have shrunken/adapted back down the changed skeletal framework.
6) When asked at any time period doing this full recovery period about the result or any concerns, I will repeat the aforementioned five principles.
Wbile it is hard, patience is paramount. You are only at day 2 which is the peak of the facial swelling. (it takes two days for facial swelling to maximize)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m looking to have an angle jaw implant procedure done this summer. I However am not interested in adding too much width nor am I looking to add any length (Nothing vertical length). My goal is to gain some width but mainly I’d like to get a sharp (not round angle like) from the front as well as profile, Brat Pitts Jaw sort of thing but less wider and more natural looking. I was thinking about the lateral angle jaw angel implant until I came across this new implant on implanttech the other day that looks very promising in terms of what I’m looking for which is adding some width as well as a sharp/chiseled angle. It’s called Conform™ Mandibular Angle implant, On the description it states that it’s Evolved from years of feedback by leaders in the field and creates the magazine-model jaw angle desired by many patients. Its patented grid backing readily adapts to the gonial angle, while its extended design easily enables optional screw fixation. Fine anterior edges ensure a smooth implant transition.
I’d really like to hear your opinion about this since you are an expert in this particular procedure. Have you used this implant on any of your patients, and if so do you have any before and after picture available?! In your professional opinion does this new Conform™ Mandibular Angle implant deliver a chiseled angular projection to the jaw (Brad pitt alike, both from the front and side) rather than a round look?
Looking forward to hearing back from you very soon.
A: Thank you for your inquiry. I have intimate knowledge of every jaw angle implant that exist or will exist in the near future. The new Conform Mandibular Angle Implant is exactly the style of jaw angle implant that I wouldn’t use. It has a very rounded jaw angle shape that is situated about the mandibular angle point by a considerable amount. This will create a rounder/fatter looking jaw angle not the sharper more well defined jaw angle shape that your desire. It does not in my experience create the ‘magazine model jaw angel shape’. The newer widening jaw angle implant is better in that regard because it has a more defined angle shape and its point of maximum projection is directly at the lowest angle point. This jaw angle implant style has a much better chance of succeeding with that desired outcome.
The other way to be most assured of the optimal jaw angle shape is to have them custom made in exactly the shape you desire.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a sliding genioplasty after I had braces for 2 years to fix my bite. I thought my chin was large and I wanted it reduced. I did not like the results. I felt like my face looked fatter and as though there is extra tissue/bone under my chin. My oral maxillofacial surgeon told me that if he removed the screws and plate from the previous surgery it would not make my chin look as big and I thought he was going to shave off the bottom part of my chin that appears to stick out but the only thing he did was remove the one screw as he said he couldn’t remove the other one. My chin looks very asymmetric to me and there are indentations and lines that I do not like. I was wondering what your opinion is and if there are any options to improve my appearance. I have more pictures I could send if it would be helpful. Thanks!
A: Thank you for your inquiry. I suspect you originally had a reverse sliding genioplasty to fix a protruding or big chin. This operation is always never a good idea because even though the horizontal projection of the chin may be less, the chin will look wider in the front view and a bulge or increased fullness will occur under the chin. These are the exact symptoms that you developed after your sliding genioplasty. While your surgeon meant well, removing the fixation hardware would not have made any difference in how it looks even if all the plates and screws could be removed.
While I would need to see your after surgery x-rays, the correct treatment now is a submental chin reduction approach to vertically shorten and narrow its width. At the same time, liposuction and a submental tuck needs to be done to smooth out the contour under the chin.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in female skull augmentation. I have hated my small head for as long as I can remember. I am finally looking into this and didn’t know there was really any options. I have a flat, small head and small, flat occipital area. Would like to know what may be the best option for me and what price range I’d be into. I feel like an implant type thing would be best (to cover a couple of problem areas) but not sure. I can send a photo but would like to hear back first.
A: All cases of women who want a bigger head involve augmentation of multiple skull areas. (female skull augmentation) That is almost always in the back over the crown and around the sides. Because of most women’s goals in this type of skull augmentation procedure, the scalp has to be expanded as a first stage procedure to get in the bigger skull implant that is needed to try and get this effect. Having done many of such skull augmentation cases my experience has been that usually only about 75% to 80% of the ideal skull enlargement goal is achieved even with scalp expansion. The limiting factor is how much of the scalp can be stretched safely to cover a larger skull implant…with emphasis on safety first and the amount of skull augmentation second.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Does a breast reduction include them being lifted? Is there a way to make my areola smaller? Will my stretch marks go away if they are lifted? Is a reduction what you suggest or just a lift? I am only 19 and I feel like my breast look like Im 40 and have had kids already.
A: Thank you for your inquiry. I would agree that for a young women that is too much breast tissue with a lot of sag for you to carry around as well as from an aesthetic standpoint. You are an dial candidate for a breast reduction and your questions about such surgery are common. Let me clarify some basic concepts about breast reduction. Every breast reduction includes a full breast lift. While a breast lift can be done with a reduction, a breast reduction can not be done without doing a lift. In almost every breast reduction the diameter of the areola is reduced significantly, usually done to 40mm to 44mm diameter. Stretch marks that lie within the excised skin of the breast lift are removed. Any stretch marks that lie outside of that zone remain but often look better because of the lifting effect.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley I am interested in more information regarding the extended zygomatic cheek implants you describe here:
http://exploreplasticsurgery.com/extended-cheek-implants-high-cheekbone-look/
1) Can you share any before-after pictures of people who have had this done (specifically with zygomatic arch extension)?
2) Where would the scars be and what size?
3) Do you anchor these to the bone in any way to prevent shifting?
4) What percent risk is there of damage to the infraorbital nerve during placement and what would be the usual result (ie. numbness, sagging, pain) if such damage occurred?
Thanks
A: Thank you for your inquiry in regards to extended cheek implants. In answer to your questions about them:
- Due to patient confidentiality, I can not release patients across the internet without their explicit permission. No such extended cheek implants patient has ever agreed to do so.
- The implants are placed from inside the mouth so there are no external scars.
- I always secure every type of cheek implant with a single small titanium microscrew.
- There is no greater to the infraorbital nerve from extended cheek implants as opposed to standard styles of cheek implants. The implants are placed to the side of the nerve so it is not in the path of dissection for their placement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in facial reshaping surgery. I am a female and am 25 years old. I really don’t like my face but I don’t know whats wrong with it. My forehead is too small, my cheeks are huge and my jawline doesn’t exist or maybe its my chin. Its like too long and wide and my nose is fat. I just want to know if it is possible to change the shape of my face.
A: Thank you for your inquiry and sending your pictures. Much can be done with your face in terms of overall facial reshaping. Your forehead is small because of the low hairline and it lacks projection and convexity. A forehead augmentation can be done to build out the forehead which will also have some effect on increasing the distance between the eyebrows and the hairline. Cheek reduction can be done by osteotomies to narrow their width and projection. Your chin can be vertically shortened and narrowed. Your nose can also be made thinner/more narrow.
When you put the forehead, nose, cheeks and chin changes all together at once then a facial reshaping change will be seen.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had two sessions of Sculptra and one session of Radisse fillers earlier this year in January. In early April of this year, I had a chin implant with an incision in the mouth. After the chin implant, my chin and sides swelled up and hardened. It’s been over a week and can’t seem to bring the swelling down. Could this be due to the Sculptra and Radisse fillers that I had earlier this year? If so, what can I do to bring it down.
A: If I interpret your inquiry properly you had a chin implant placed just one week ago. It is perfectly normal to have considerable swelling after such a chin augmentation procedure that will take up to six weeks after surgery to completely go away. As a general rule, 50% of the swelling goes down by 10 days, 75% by three weeks, 90% by 6 weeks and 100% by three months after surgery. The fact that you have had prior fillers in your face has nothing to do with the swelling that you are experiencing now. There is also nothing you can do to hasten this natural healing process. I would have assumed that your surgeon reviewed the typical swelling and tissue firmness that occurs after any facial implant and the protracted time that it takes to resolve.
Dr. Barry Eppley
Indianapois, Indiana
Q: Dr. Eppley, I am interested in custom jaw implants. I had a chin wing osteotomy done three months ago and I am happy so far with the result, but not with the width of my jaw and the asymmetry. Is it possible to get this procedure done after a chin wing osteotomy? When could I get the surgery this year? How much will it cost? How long do I have to stay?
A: It is possible to do a custom jaw implant after a chin wing osteotomy. I have done numerous such cases. The chin wing osteotomy provides no facial width, no posterior jaw angle vertical lengthening and often ends up asymmetric/irregular. I would wait until six months after the chin wing procedure to be certain you known exactly the dimensional jaw changes you want to achieve. A custom jaw implant will require a 3D CT scan for implant design. You have a very good knowledge of the recovery based on your chin wing osteotomy experience. It would be similar to that although the amount of swelling may or may not be less.
The cost of a custom jaw implant will be greater than that of the chin wing due to the design and fabrication of the implant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’ve tried doing research about chubby cheeks and cheeks sticking out of the face when smiling, and I can’t seem to find anything about it. I don’t think it’s something common that people have. I’ve seen pictures of people generally having chubby cheeks but not the way mine are. My cheeks stick outward of my face when smiling. I have a whole bunch of extra fat on the side. My hair is always worn down to cover that extra patch. I get very self conscious to wear my hair up and reveal my cheeks. I’ve noticed that whenever people smile, their cheeks align with their forehead and my cheeks do not do that. The shape of my face is very chipmunk-like when I smile. My cheeks expand further than the rest of my face/forehead. I really want to get rid of that extra fat and not having to be self conscious about my chipmunk cheeks when smiling. Have you ever seen anything like this before? What do you suggest.
A: This is not the first time a patient has expressed your same concerns/desires to me about the chubby cheeks that appears when they smile. In reality, this is not an adviseable problem to treat for the following reasons. First, plastic surgery on the face is almost never performed because of an animation/smiling concern. Facial structures/tissues are changed/modified because of how they look in a static or non-animated because that is how surgery is usually performed…with the face still and not moving. Secondly, changing facial structures for how it looks when one is smiling will almost inevitably cause an undesirable effect when one is not smiling. (face now too thin or droopy because of loss of support) Lastly, what is making your chubby cheeks look like that has do with the skin and subcutaneous fat that lies over the cheekbones. These are not tissues that are amenable to surgical reduction due to the facial nerves that cross in them. Your chubby cheeks are not caused by too much buccal fat or other fatty areas that can be safely surgically reduced. This cheek bunching effect is the result of normal tissues being pulled up and over the cheekbones.
The conclusion is that chubby cheeks is an unsolveable cheek problem and any effort to try and treat it will likely cause other problems…that may be more undesireable that what you have now.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a question regarding chin implant fixation. I’m still having trouble deciding whether to travel to get my implant done by a surgeon who will use screw fixation, as it would obviously increase the costs. Do implants secured with screw fixation cause additional issues over unsecured implants if infection occurs? For example, would screw-fixated silicone implants be more difficult to remove than non-fixated? Would they require special attention since infections could spread into the bone tissue via the holes used for the screws or anything like that?
A: Your concerns about screws in chin implant fixation are unfounded. Chin implants secured by screws are no more difficult to remove than those that are not. A screw is not a source of infection into the bone should the rare incidence of infection occur after chin implant placement. Some of your thoughts about screws are probably based on the misconception of their size. Screws used for skull and facial implants are 1.5mm in diameter, roughly the same size as screws used in a pair of eye or sunglasses. When the screw is placed on a penny, it is only as big as Lincoln’s jaw.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Have a saggy butt and slightly saggy inner thighs also. Would a buttock lift incision in the infragluteal fold(under buttock)while pulling up the inner thigh slightly be realistic. I donr think a radical upper buttock lift would be necessary as it is more radical and the inner thighs would have to be done separately. Also could my extra tissue cut off be used as an implant to improve the form of the buttocks.What concerns me is the scar in this operation. Is it eventually not too conspicuous as when wearing a bathing suit esp. when bending over. There is a surgeon close to where I live who would do it that way, as he feels a higher buttock lift would flatten my buttock as it is just slightly saggy with a banana roll. Please give me your opinion.
A: Thank you for your inquiry. I would need to see some pictures of your buttocks to best answer your questions. But I do know the following without seeing any pictures.
1) A direct approach to the lower buttocks and thighs is needed. No far away or upper buttock procedures will work.
2) Buttock lift and inner thigh scars I never consider great in many patients. One just has to choose which aesthetic liability they would like better. (scars vs tissue sag)
3) Any buttock or thigh tissue removed is not going to be enough volume to be successfully used as an implant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a sliding genioplasty revision.I had a sliding genioplasty in Feb 2014 moving my chin forward around 8.5mm. From the start it looked like the result was asymmetrical. 2 years later this is definitely the case. From my attached photos you can see that the left side is sticking out of the face slightly when viewed from the front and there is also a step off when viewing from the side. I’d like to know what my options are.
A: Most asymmetries after a sliding genioplasty comes from differences in the angle and length of the bone cuts on the two sides. Even subtle differences become really apparent when the horizontal movement become bigger. This creates asymmetry from the appearance that the chin is rotated (which it may well be) but often it is just two different lengths of the bone cuts.
In correction of your chin asymmetry, the first piece of information that would be very helpful is to know exactly what the bone looks like. This is where a 3D CT scan can be enormously helpful in understanding your existing chin shape as well as planning what to do about. Fundamentally it comes down to either reduction of prominent bone wings or augmentation of bone wing deficiencies…or some combination there of. You appear to need this exact combination by both your picture and your description of the chin asymmetry.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have questions about a custom skull implant My son wants to be a few cm taller. He said doing skull augmentation will let his total height longer by measurement by a few cm. He is about 5 ft 5 inches tall. Is it safe to do skull augmentation? Is the material used safe? Can the material or implant be removed if complications arise later? Will it affect hair growth after the implant or filler inserted? Please explain the steps and procedures a bit. Also the risks, if any. Please suggest and reply as I don’t know what to do. Thank you.
A: I do not see that a custom skull implant is an approach to be used for ‘heightening’. It is ideally used to correct a flat top of the head. It is a perfectly safe procedure which is done using a custom silicone skull implant made to fit the patient from their own 3D CT scan. As single stage procedure the most height that could be obtained would be 12 to 15mm due too the limits of how much the scalp can stretch. As a two stage procedure with first stage scalp expansion, the amount of skull augmentation could be close to 25mms. Placing an implant on the bone will not affect hair growth. The implant is relatively easily inserted and removed secondarily if necessary. In my vast experience with this type of aesthetic skull surgery, I have not experienced any major problems. But the key is to stay within the limits of what the overlying scalp can accommodate.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in custom jaw implants. I had a chin wing done 3 months ago and I am happy so far with the result, but not with the width of my jaw and the asymmetric. Is it possible to get this procedure done after a chin wing osteotomy? When could I get the surgery this year? How long do I have to stay after surgery?
A: It is possible to do a custom jaw implant after a chin wing osteotomy. I have done numerous such cases. The chin wing osteotomy provides no facial width, no posterior jaw angle vertical lengthening and often ends up asymmetric/irregular. I would wait until six months after the chin wing procedure to be certain you known exactly the dimensional jaw changes you want to achieve. A custom jaw implant will require a 3D CT scan for implant design. You have a very good knowledge of the recovery based on your chin wing experience. It would be similar to that although the amount of swelling may or may not be less.
I will have my assistant Camille pass along the cost of a custom jawline implant to you tomorrow.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a custom jaw implant. I have always felt my mandible is very under developed and I am starting to think my neck and jowls are slowly swallowing the thing. I just turned 35 and I look like I’m about 21 years old. I feel this is mostly because my mandible hasn’t grown much since I was a teenager. As a male, I feel like I project slight weakness because of my insecurity. I thought for a long time I would outgrow my dissatisfaction but unfortunately that has not been the case. I have also been hopeful that my face would eventually full out, but that too has not occurred.
I read countless reports about chin implants and jawbone expansion techniques, etc. your website had the most comprehensive descriptions of what I feel is “wrong” with my ever slimming face. I like your description of how the jawline can be lowered as well as widened with specific implants. I want to keep my “shape”, but I want it to be lowered and widened. Does that make sense?
A: Thank you for sending your pictures. What I see is an entire lower jaw that is both vertically and horizontally short. This makes it disproportionate to the upper two-thirds of your facial structures. This is the ideal anatomic deficiency for which a custom jaw implant works so well to correct and put the face in balance.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have heard about temporal reduction and I know you are an expert at it. I was wondering if its possible to reduce the size of a WIDE head from the front view. I realized also when I fully open my mouth my head looks smaller compared to when my mouth is closed. I hate my head and was wondering how long is the down time for this surgery?
A: Temporal reduction is an interesting aesthetic skull procedure that few patients or surgeons have ever heard of. Your description of seeing head width improvement when opening your mouth is due to the thinning of your temporal muscles on the side of your head. They lengthen and narrow when opening one’s mouth widely. Thus you would need reduction of both the anterior and posterior bellies of the temporal muscles. The posterior temporal muscles can be surgically reduced from an incision behind the ear in the postauricular sulcus. Th larger anterior temporal muscles can not be surgically reduced but often respond well to Botox injections. Complete head widening by total temporal reduction is done by a combined procedure of surgical posterior temporal reduction and anterior temporal muscle Botox injections. This procedure surprisingly has very little if any downtime.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am after a very large chin implant (actually, probably a custom wraparound implant, but my question is in relation to the chin). I would like a vertical lengthening of 2cm to achieve a huge looking chin that i desire. I would likely get a vertical lengthening genioplasty at an earlier stage but I will still need the implant to get the rest. In addition to the large length increase, i’d like it to be very wide and square. But I’m aware the skin cannot stretch this much in the chin. Is it possible to use a tissue expander in the chin before the implant, much like you use in the scalp for large skull implants?
A: In relation to achieving such a large vertical increase for a large chin implant, you would need to take a three step approach. First, A vertical lengthening genioplasty needs to be done of about 8mms. Three to six months later, a vertical lengthening chin implant needs to be placed from a submental approach. These two together will approach a vertical chin increase and chin pad soft tissue expansion of 13 to 15mms. Then a custom wrap around jawline implant could be used to complete the maximal vertical chin increase.
While a tissue expander could be placed in the chin, there are multiple problems with its use in this anatomic location. The incision for its placement would be right over the expander and that is a recipe for wound breakdown and exposure of the implant during the expansion process. There is also the problem of where to place the remote port to inject fluid to expand it as it is not practical to have it handing down from the chin or sticking out into the mouth.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, What if anything can be done for my orbital and overall facial asymmetry? Its clearly affected the entire side of my face not just my eye. I have to tilt my face for pictures and even then its way off. Thoughts? The second pic is with my head tilted…I am tired of having to do so and has really hindered my confidence my entire life.
A: Thank you for your inquiry and sending your picture. Eye asymmetry (orbital dystopia) rarely occurs in isolation and is often part of an overall facial asymmetry. The brow bone, cheek, nose and even the jawline may be lower or deficient on the ‘lower eye’ side. Tilting the head helps ‘lift’ the deficient side to make it more even. The key is this type of facial asymmetry is to pick the procedures that would make the greatest difference. The hardest choice is deciding what to do with the eye as this is the most important part of the facial asymmetry correction. The eye must come up as well as the outer corner of the lower eyelid. One caution here is to keep an ‘eye’ on the position of the upper eyelid so the raised eye does not get buried under the upper eyelid creating a pseudoptosis appearance.
Vertical brow bone reduction, cheek augmentation and jawline reduction/widening and a straightening rhinoplasty are all other options to consider in facial asymmetry correction.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Thank you very much for responding about lower buttock lifts. Very rare doctors take that much interest. I do have a few more questions though, if you could again answer. 1) Is there anyway the scar in the lower buttock crease (infragluteal) can be made less conspicuous? (less wide or by tattooing after) 2) If a surgeon uses the buttock tissue removed to implant as a graft will it cause problems? (e.g., infection , circulation) Will it not add a bit more volume to my buttocks? 3)When you do the incision in the infragluteal fold do you tuck the extra tissue inside/under or cut it off? 4) Are there different ways of doing this operation. 5) Is there not a risk that there is no crease /projection left—in other words—does it create a flat butt? 6) It seems like an operation lasting more than 3 hrs. Do most patients do well–as I am a little scared–I prefer twilight sedation–seems like it is not the method used for this surgery. 7) If the saggy inner thigh skin is pulled up at the same time, will the scar descend with time to become visible within the groin area?
A: 1) Tattooing is not an effective form of scar camouflage anywhere on the body.
2) The thin strips of skin and fat are worthless as grafts because of their very low volume. And placing such a graft always runs the risk of causing an infection. This is not a good benefits vs risk proposition.
3) In a lower buttock lift in my hands, it is a combination of tissue removal AND the recreation of an infragluteal fold. (aka tuck)
4) The number of ways to do a buttock lift seem rather limited…but I can not speak for what other surgeons may or mat not do with this uncommon body contouring procedure.
5) If an attempt is not made to recreate an infragluteal fold and too much tissue is taken, the result cold very well be a flat lower buttocks contour.
6) How long it takes a surgeon to do any procedure is highly variable. Whether your buttock issues makes this 3 hour time long or appropriate I can not say since I don’t know what your buttocks look like. Because a lower buttock lift is done in the prone position, the only acceptable anesthetic is most cases would be a general with a controlled airway.
7) Many thigh lift scars can descend downward. Whether that occurs or not is both a function of how much tissue is removed and how the procedure is performed. (e.g., incision location, use of fascial fixation)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I came in about a week ago to discuss breast augmentation. I am confused about breast implant profiles. I’m about five one and 100lbs. Right away I knew I wanted silicone due to them having a softer feel and I also was leaning towards moderate Plus due to the pictures that I have liked. They seem to look more natural well as natural as you can get with implants. Though right away you said high profile I’m sure it’s due to my small frame. My question is this afterwards will the high profile give me that two very round balls on my chest? Or will they hang a lil and have some side boob like real ones do? I just don’t want to look like I have balls on my chest though with my small frame will the high profile give me the boob look I’m looking for the noticeable though somewhat natural look. That the moderate Plus would give if I was a little wider? Could you help explain a little more the difference and looks please. I’m very interested I just want to be 100% with my decision. I understand with my small frame my options are limited. I believe I decided with 400cc round high profile silicone.. Thank you.
A: Your primary question about breast augmentation is in understanding the difference between high profile and moderate plus profile implants. To some degree, the size of 400cc in your body size is never going to look ‘natural’. Larger breast implants placed in smaller tight chested skin can not really avoid having a rounder/fuller look. That is more a function of the patient’s anatomy that it is being placed in and much less to do with the implant’s profile. There is also the very relevant issue of what happens with time (e.g., 6 months after surgery) as the tissues relax and settle after being so dramatically expanded in such a short time. Meaning implanted breasts that look high and round will always settle into a more natural shape over time. But the key issue is time and one has to be patient.
To better understand breast implant profiles, a high profile implant is less wide than the moderate plus. (even though they have similar 400cc volumes) This type of implant profile is often used in smaller women who are getting ‘bigger’ implants so the implant does end up too wide or too far to the side of the chest. (in the way of the swing of the arms) The tradeoff for that choice may be that they will slightly more round in the upper part of the breast. A moderate plus profile implant is more wide and slightly less high. It will have slightly less upper pole fullness but at the expense of more implant to the side. At the end of the day one has to choose which aesthetic tradeoff they prefer….a slightly rounder looking breast (high profile) or one that is a bit too far too the side. (moderate plus)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a custom jawline implant. One year ago I had jaw surgery and a sliding genioplasty. I had a receding chin and an overbite so it was recommended o have my jaw brought forward and have a sliding geniplasty instead of a chin implant. The surgery was certainly not fun and I was very swollen for many months. Six months after the surgery I was happy with how my face looked but as the swelling further reduced my face became more narrow and asymmetrical. I ended up with a very narrow asymmetric face and a very pointy chin. This was devastating for me as this was not how I envisioned I would look. I thought I would get a stronger more chiseled jaw and mandible as this is what the surgeon told me! But I ended up with a very long and narrow looking face.
I consulted another surgeon to ask about getting implant/implants to fix the asymmetry but he didn’t recommend it. He recommend fillers or a fat transfer. I ended up getting fillers but the asymmetry was so much (and the volume loss on the right side) that I had to have six treatments. It was expensive and I still wasn’t happy with it. I’m looking for a permanent solution.
A: Thank you for your inquiry and detailing out your surgical history and current concerns . While moving the chin and mandible forward does enhance anterior skeletal projection, it almost always does so at the expense of width. (A U-shaped structure that comes forward in two places will be more narrow….this is magnified when the surgical trauma and swelling causes soft tissue atrophy) While an effort at injectable treatment was worthy of the effort, to prove to yourself what the results would be, it never was a long-term solution. In addition, no form of fillers or fat can create skeletal highlights or angularity, all they can do it makes things puffy and round which is why they rarely are effective for jawline augmentation.
It would seem by your concerns and pictures that custom jaw implant would create the missing chin and jaw line dimensions. This is done using a current 3D CT scan. This is also an excellent method for improving any bony asymmetries since the computer design process can make those adjustments done to the 1mm level.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have asymmetric eyes, the left eye is 3 millimeter lower than the right. I do not have double vision. Can I have the surgery to move my left eye up and into a more correct horizontal position? I really thank you for answering my question. I have attached a picture which shows the difference between my two eyes.
A: Thank you for sending your picture. Your entire orbital ‘box’ on the left side is shifted downward, otherwise known as orbital dystopia. This is a more challenging problem to fix that it initially seems because of the existing ptosis (sagging) of the upper eyelid. The brow bone above will need to be vertically shaved (raised)and the orbital floor augmented. The problem is that this will raise the eye upward but it will become more ‘buried’ under the upper eyelid than it is now. This will require either a simultaneous upper eyelid ptosis repair or have the ptosis repair done as as second stage procedure 3 to 6 months later. The problems with ptosis repair at the time of other orbital procedures is that the eyelid adjustment is being done when everything else is being changed. It would be highly unlikely that the upper eyelid position would be correct or ideally located on the newly elevated eyeball.
Thus while there can be major improvement in your left orbital dystopia, I would not think of it as only a one-stage operation.
Dr. Barry Eppley
Indianapolis, Indiana
