Your Questions
Your Questions
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
Q: Dr. Eppley, I have a flat head from behind. It has been that way since my childhood since I always slept on my back and never changed positions. I came across your procedure while looking for ‘flat head treatment’ on the Internet. I have a few questions.
- I wish to know how much improvement I can expect with the treatment. Can I get a completely round head?
- I also wish to know how exactly it feels after the implant is placed under the scalp. When I touch the back of my head would I feel like there’s something there or would it feel like bone?
- About the material, can it be carcinogenic or can it possibly cause any allergic reactions?
- Would the material completely adhere to my skull and not float around between the scalp and the skull?
- Can the procedure be done under local anesthesia?
Thank you in advance for your reply.
A: In answer to your questions about flat head correction using a custom implant:
- Only with a two-stage (first stage scalp expansion) can you get a fairly round head. one-stage occipital implant on the back of the head will produce about of that ideal result.
- The implant will feel like bone.
- A silicone implant os not carcinogenic nor will it cause any allergic reactions.
- The implant will not float around and will adhere to the underlying bone and the overlying scalp.
- The procedure can NOT be done be done under local anesthesia, it requires a general anesthetic.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m 19 and have a weak chin which I am beyond self conscious about. It is not extremely weak but it still makes my profile and resting face cringe worthy to me when people take photos of me. I do not feel comfortable getting a chin implant but also can’t afford to get chin fillers to fix the problem every six to twelve months for the rest of my life. I’ve considered fat transfer but would be devastated if the fat didn’t survive or became lumpy. I have come across Dr. Eppley on Real Self and am impressed with his knowledge about sliding genioplasty. I am a petite girl with a skinny face and well defined jawline (5’2 113 pounds). I am wanting a small amount of advancement forward and an even smaller amount if none at all of vertical advancement. However, given my skinny face, I am so incredibly afraid of having a “step off” or notch in my jawline. I am wondering if a 4 to 5mm advancement would create this irregularity in the jawline or if it is preventable. I am also afraid of nerve damage and want to know how common this is. Thank you so much.
A: There is no question that the smaller the amount of chin bone advancement by sliding genioplasty the less chance there would be for a notch or step off along the jawline. In my experience, I have not seen cases that I am aware of that has had permanent inferior alveolar nerve numbness. Just like the notch along the jawline, the smaller the chin advancement the less likely there is of a risk of nerve injury.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have questions about Brazilian Butt Lift surgery. What is the average percentage of the fat transfer that stays on the buttocks? After the surgery are the buttocks firm? I have not had children yet, when i have children if I would like to go forward with the procedure again if I lose the fat from mybuttocks afterwards will that be dangerous to go through another procedure?
I am very interested in this procedure and would like the best results. Do you have a way to show patients what the body will look like after surgery before the actual procedure?
A: On average the amount of fat that persists in most Brazilian Butt Lifts (BBL) is around 50% to 80% in my experience. But any fat transfer is not completely predictable and every patient will have varying degrees of fat retention. Initially the buttocks are firm from the immediate volume full but that softens quickly in the first month. Fat transfers do not create the firmness that comes with buttock implants. The buttocks will end up bigger but they will still feel soft. There is no harm or danger in the future to having another BBL procedure.
The key question is whether what one wants to achieve with BBL surgery can be done based on one’s goals and what they look like now. To determine whether BBL surgery has a reasonable chance to achieve your goals, I would need to see pictures of your buttocks/body now and what your buttock augmentation goals are.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in chin implant removal surgery. I had cosmetic surgery last year for cheek and chin implants. I was pleased with the experience and I am very happy with the cheek implants. However, I do not like the chin implant. The chin implant was very uncomfortable for the first few months and it took about 7 months for the swelling to completely go away. After the swelling had gone, I still did not like the look or feel of the implant. I decided to wait a few more months to see if the situation would change but it has not. I think it looks too bulbous and it still feels quite stiff.
The implant was put in from the chin. I would want to leave it out. Please find pictures attached how my chin looked before the implant (one year ago) and with the implant (now). Just to keep you in the picture, the reason for the chin implant was to help balance my face as I have quite a large overbite. After getting the implant, I don’t think that it really does balance my face and I have since been informed that this is because I would actually need a jaw surgery to improve the look of the overbite, not an implant. So, after the implant is removed, I will plan to get the jaw realignment surgery needed to correct the overbite.
A: Thank you for sending your pictures and providing the details of your surgical experience. From the submental incision the Medpor chin implant and any screws used to secure can be removed. Be aware that there may be some adverse aesthetic sequelae from its removal. Not that the chin tissues have been stretched out with the implant (which I would bet is not a small one), they will not retract back down completely. Thus you will likely develop some soft tissue chin sagging. (ptosis) To avoid this after chin implant removal problem, the soft tissues of the chin will need to be tightened back down to the bone at the time of the implant removal. (chin ptosis repair) This is not a problem that will be solved later by jaw advancement surgery since that affects the teeth position by the whole mandible coming forward. Such a bone movement will have no impact on the chin bone-soft tissue relationship even though the chin comes forward as the whole jaw moves forward.
I will have my assistant Camille pass along the cost of the surgery to you by tomorrow.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am looking for an otoplasty reversal surgeon who can offer the best possible result for an undesirable otoplasty result in my left ear so. I have attached a picture showing my ear before the otoplasty and a second picture where i had undergone a revision where the sutures and scar tissue was removed in the hope the ear would look how it was before. It shows the antihelix being thick and overfolded in the lower part and the upper part has lost roundness. I appreciate my ear will never look the same as before I had the original procedure but what are your experiences in an antihelix deformity such as this and do you feel you could make a significant difference using any type of revision (cartilage/skin graft, scar release etc).
Thank you for taking the time to read this and I look forward to your response.
A: Thank you for sending your pictures which are very helpful in showing the otoplasty problem. This appears to be an overfolding of the helix, causing a deformity of the antihelix which lies in front of it. The correction would obviously lie in reversing how the otoplasty was done…getting the helical rim to unfold back out. This will not be achieved by releasing any tissues alone as the cartilage is now ‘deformed‘ and has a new shape. The release must be supported by an interpositional graft of which I have used cadaveric rib/bone and the patient’s own small rib graft to achieve a stable otoplasty reversal result. In my experience, this graft technique is essential for the procedure’s success as you have learned that releasing the scar/sutures alone is unsuccessful. (unless it is done within a few weeks/months after the procedure)
Dr. Barry Eppley
Indianapolis, Indiana
Q:Dr. Eppley, I believe that many of the surgeries you perform are far more effective and life changing than traditional plastic surgery procedures.
I’m looking into having forehead, temporal/skull, and chin augmentation, and have found there are very few plastic surgeons are experienced in craniofacial surgery for cosmetic purposes.
I know that plastic surgery in Korea focuses very much on altering the bony structures of the face to achieve a prettier and more youthful appearance and for this reason I have been enquiring with some plastic surgeons in South Korea. Ideally I would prefer to travel to the US and have the above procedures performed by you.
I am interested in having forehead augmentation- preferably using bone cement as I understand that implant placement can be difficult, particularly when placed lower on the skull; I feel that my brows/superior orbital rim are quite flat and contribute to some minor eyelid sagging so would like the forehead augmentation to extend to this area, as well as smoothing out the temporal bone area, and reducing the backward slope towards my hairline.
I’d like head widening implants possibly extending to the temporal region to balance my lower face.
Lastly I’d like to get an “anatomical” or “extended” type chin implant which extends into the pre-jowl area which is quite hollow and shadow-y, and makes my lower cheeks look a little droopy.
A: My understanding of your email is that you seek the following procedures which are primarily Forehead Augmentation and Chin Augmentation. Let me provide some initial clarification on forehead augmentation because your assertion that implants are harder to get lower on the brow bone than bone cement is not accurate. Actually it is the exact opposite. Because foreheads/brow bone implants have a preformed shape they can more effectively positioned on the brow bone area through a smaller incision. Bone cements can achieve the same result but they take a full coronal scalp incision to really place as low as possible.
The biggest dilemma in forehead augmentation is management, if need be, of adding the temporal area in the overall augmentation. Bone cements can not be placed past the anterior temporal line onto the adding temporalis fascia as that often creates the potential for edge visibility and/or pain. Some slight blending of the upper temporal region can be done but it can not extend down too far.
The only really effective method for anterior temporal and posterior temporal head widening is with the use of subfascial implant placements which have to be semi-custom made and are designs of which I only have.
A chin implant that extends back more posteriorly would be the anatomical design which has long tapering wings back to the pre jowl area. That is a fairly standard facial implant request.
In conclusion, the most economic approach would be PMMA bone cement forehead and chin implant augmentation. The cost of the temporal implants would, by your own description, be prohibitive.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in temporal artery ligation. My right temporal artery is considerably larger than the one on my left. Although both are unsightly and bothersome. I have become very self conscious of them. And the are affecting my daily life. At normal rest they are slightly visible. They become increasingly larger and more noticeable when I exercise, when its warm, and when I consume alcohol. And not much alcohol either ! Just a few sips of beer or wine. They even enlarge when I’m talking a lot.
A: Your description of prominent temporal arteries is classic. Prominent temporal arteries can be successfully reduced, and some times completely eliminated, by temporal artery ligation. The secret is to locate the pattern of flow into the visible artery and do ligations both anterograde and retrograde. This is a bit of an art form and, while every temporal artery ligation procedure shows immediate improvement, the real test of the effectiveness of the procedure is what it is like 3 to 6 months afterward.
Temporal artery ligation is a procedure done under local anesthesia in an office setting. Each small access incision for ligation is about 5 to 7mms in length. There is no bruising afterwards with minimal swelling.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, i have an occipital fold that I would like removed. I am a 62 year old (hx Type II, obesity) I have a large protruding skin fold at the occipital part of my scalp. I find it extremely bothersome. I’m not sure there is a bone protrusion or just a fold of skin cause I can grab the darn thing between two fingers. I want to get rid of it. I have photos that I can email separately (took them myself and aren’t great quality, but you’ll get the idea).
A: Thank you for sending your excellent quality pictures of the scalp roll on the back of your head. This is a common location for such a scalp skin roll. It can certainly be excised with the aesthetic tradeoff of a fine line scar as its replacement. (occipital skin fold excision) This can be performed as an outpatient procedure with minimal recovery. In the properly’ motivated’ patient it could even be performed under local anesthesia. (although it does not have to be)
Occipital skin fold excision is done by cutting out the redundant skin fold and putting the scalp back together in a more flattened contour. When performed well it can be done with a fairly minimal scar.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a flatness in the occipital area of my head which is very pronounced, especially with short or wet hair. I have x-rays with a little outline of the augmentation I wish to accomplish. If I were to proceed with an augmentation procedure I would prefer a custom occipital implant. With today’s technology, how big of an incision should I look forward to, and where would this incision be made? Can a custom occipita implant be fabricated using the x-rays I have or is there another form of imaging technology that needs to be used? There is also a slight bump on the top left side of my head. If I wanted to try an shave that down a bit, how much would the incision size change, and can that same incision be used to insert a custom implant for the occipital portion?
A: A custom occipital implant is made from a 3D CT scan, no other form of x-ray will suffice due to inadequate imaging data. A custom occipital implant is usually placed through a low horizontal scalp incision on the back of the head. Unless the skull bump is very near the location of this incision, it would not be able to be reduced through it and another scalp incision closer to it would be needed. There is also the alternative of making a higher scalp incision where the custom occipital implant could be placed and the skull bump could be reduced through the same incisional access.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a tear trough implant. I had a four lid blepharoplasty performed ten years ago followed by an inappropriate injection of Radiesse to both lower lids. Granulomas subsequently developed and were excised a year later but this left me with a depression and mild ptosis of the right lower eyelid. I have had this lower eyelid depression treated with hyaluronic acid fillers for years by a dermatologist, but the depression needs more stable support, especially as I age. I am Interested in consulting with you due to your extensive experience with facial implants. I have attached pictures of my lower eyelids for your review.
A: Thank you for your inquiry and sending your pictures. I can clearly see the depression along the medial half of the right infraorbital rim. As you probably know there are a variety of materials to build up the infraorbital rim. Since the deficiency is really caused by a soft tissue problem (due to the excision of tissues) one could argue that either fat injections or the actual placement of a dermal-fat graft would be the most appropriate technique give the source of the problem. With your history, injections would understandably not be appealing. This leaves the choice then between he dermal-fat graft and a tear trough implant. Each one has their own advantages and disadvantages. But certainly the main advantage of a tear trough implant is its volume stability moving forward.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I think I need a chin implant. I have a recessed/weak chin and jaw I am looking to get corrected. I had braces as a kid and my teeth fit together fine. I was hoping a chin implant would help alone but my nose might be too large as well.
A: You have at least a 10mm chin deficiency. The choice between a chin implant or a sliding genioplasty is how you would view it from the front view. A sliding genioplasty will keep the chin at its existing narrow width. (unless an overlat implants put in front of it. Conversely a chin implant can make your chin wider/more squatter from the front view. That is what should principally make the aesthetic decision between the two chin augmentation approaches. Regardless of the method used, your labiomental fold will get deeper, unlike what you are showing by pushing your jaw forward to simulate the chin augmentation effect. (this is because the teeth come forward and help augment the labiomental fold)
A chin implant can also help reduce the appearance of a large nose by making the lower face more prominent. It may not eliminate the need for a rhinoplasty is a very large nose but it can delay or even change how the rhinoplasty surgery is done.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was in your office a few weeks ago originally for a consultation about liposuction. However after speaking with you, you informed my that the best procedure for my goals would be the extended male tummy tuck. I’m still considering this procedure however, I’m getting a bit nervous as while I have had surgical procedures before, this would be the very first one that is considered “elective”. While I have a few more questions about this procedure and your practice.
I’m not sure if I should email you these questions or if I should schedule an appointment to meet with you. Therefore, I figured I would try email first and if you recommend me coming in, I’m willing to do that as well. Please see the below:
1. I was looking through your website and while I see some of the procedures you have done with respects to this procedure with women, I didn’t see any regarding men. Are there significant differences between performing this procedure on men then women? Also, if I can ask, how many of these procedures have you performed on men?
2. What would be my realistic outcome should I have this procedure done? I realize that you would have to remember speaking with me regarding this question. However, in the event you do I figured I would ask in this email. I have looked online and have seen many success stories regarding this procedure. However, I have also seen many not so successful stories where the outcome had’t met the patients expectations.
A: In answer to your questions:
1) About one-third of extended tummy tucks that are done (usually due to weight loss) are in men. I have done many. What prospective patients fail to appreciate about any plastic surgery website is that any photos shown are just a small fraction of what has been done and are only there to provide a general idea of the procedure. Also plastic surgeons can only post pictures that patients will allow to be posted and that is often a very low percentage of patients…men are the most restrictive in this regard.
2) There is nothing in men that make any form of a tummy tuck harder than in women.
3) Every tummy tuck patient, men or women, achieves great improvement. I don’t ever recall any patient that has ever said it was not worth it or did not have significant improvement. This is particularly true in weight loss patients who have no other mechanism to get rid of their resultant loose skin or tissues. That being said, that does not mean that in some cases a secondary revision may be done to help some solve residual issues (e.g., dog ears, scars, contour asymmetry) No plastic surgery procedure, particularly one that covers such a large surface area, ever produces a perfect result. Whether any remaining or more minor aesthetic issues are bothersome enough for the patient to undergo a touch up or revision procedure will vary for each patient.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have an active depressor septi muscle in a way my upper lip is very shortened during smiling. this muscle has been partially cut during a nose job and it was perfect, but after a few months it has reattached.
Therefore, i would like a permanent outcome… a complete cutting of the muscle. Can you do the incision from inside the mouth? Can you explain to me please the process of the surgery?
A: Since the depressor septi muscle can not grow back or reattach itself after surgery, the temporary improvement you saw was due to swelling and temporary muscle inactivity from the rhinoplasty surgery. Once the muscle recovered from the surrounding surgery, it recovered to full motion like that prior to the nasal procedure.
The depressor septi muscle can be cut from inside the nose or from inside the mouth. I find the intraoral approach to be the most assured at getting a complete release of the muscle. This also allows the best view of the muscle from its origin at the incisive fossa of the maxilla to its insertion on the nasal septum. By electrocautery the muscle can be visualized and released in a controlled fashion.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a custom skull implant.I have a flat back of the head, that I hide every day as much as I can with my hair (no hair loss). I am interested in the skull reshaping procedures using custom implants described in the page: http://eppleyplasticsurgery.com//skull-reshaping/. I am particularly interested by the computer designed flexible implants, and the example photographies of a skull with/without implant in the middle of the section ‘custom skull implant’ matches quite closely my situation. I believe that an additional 50cm3 volume would be largely sufficient to get the desire ’rounding’ effect, after testing with plasticine, however I do not know if this volume would fit under my scalp.
I have listed below my questions (I have a lot, but I am considering very seriously this surgery), I hope you can answer them either by mail or a scheduled interview, as you see fit (however I’m more comfortable writing english than speaking it):
1) what is the volume range of the implants that can be inserted?
2) what is the material used to 3d-print the implant? How long is it supposed to last?
3) what would be the size and position of the scar necessary to insert the implant?
4) can you give me the necessary details of the 3D imagery you need, so that I can already schedule the skull scanner in a nearby laboratory?
5) what would be the cost of such an intervention?
6) If the implant has to be removed, even a few years later. Iis the removal a simple process? Can the screws be removed?
Thank you for your time.
A: In answer to your questions about a custom occipital implant:
- I do think of skull implants in terms of volume. Rather I think about their maximal thickness and how the scalp can stretch to accomodate it. In general, a custom occipital implant of 10 to 12 mms thickness can be tolerated by most patients regardless of the surface area that it covers.
- The implants are made of solid silicone and will last forever.
- The implant is inserted through a low horizontal scalp incision on the back of the head.
- A high resolution (.1mm thocknes slices) skull 3D CT scan is needed.
- My assistant will pass along the cost of the surgery to you tomorrow.
- The implant can be easily removed later. I no longer use screws for implant fixation as they are not needed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a sliding genioplasty to correct my weak chin and create a longer jawline. I have fullness at my lower half of the jaw which is actually bone even though it looks like jowls. I have a bone notch half way down my jaw where the bone comes out so the jaw looks fuller and looks too masculine for my liking from the front. I’m not sure where the cut from a sliding genioplasty is but if it is quite far forward so this part of the jaw can be shaved down a bit in addition to moving my chin?
A: Your question is a good one as it relates to the width of the jaw behind the chin where the location of the sliding genioplasty is performed. The bone notch to which you refer is actually normal and is known as the antegonial notch. As the jaw bone descends from that area it can sometimes get a little wider. Whether it can be safely reduced depends on the exact location of the width and its relationship to the mental nerve from the bone which exits somewhere close to that area. While to may be aesthetically desired to reduce it you also don’t what to potentially cause permanent numbness to your lower lip and chin either. The bone cut from a sliding genioplasty is a horizontal one and usually goes back behind the location of the nerve. This bone segment moving usually creates a more narrowing effect to the jawline as it becomes longer. In some cases it may be possible to reduce some of the bone behind it but if I think that the mental nerve is at risk for injury I won’t do it. It all depends on where your mental nerve comes out of the bone in relationship to this area of bone width.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a chin implant revision or removal. I had my initial chin implant placed about one year ago. Immediately I know it was too big. The doctor talked me into a revision and now it’s pointy and not the shape of areal chin. I Only wanted subtle chin projection. Now I wish I never had it done at all. I am worried about chin ptosis if it is removed especially after reading your info online and I don’t know what to do.
A: I think you have two chin implant revision or removal options:
1) Downsize the chin implant to a much smaller one with intraoral suspension. This still leaves some soft tissue support and has the lowest risk of chin ptosis, or
2) Remove the chin implant entirely and do an intraoral suspension and hope for the best. There is still a chance you may be able to avoid the chin ptosis problem. It is not always a 100% guarantee that it will always happen when a chin implant is removed. The risk is high but it is not 100%. There are successful ways to manage chin ptosis even it occurs.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, My knowledge about Smartlipo is limited. I have watched many tutorial videos and read information that has been posted on doctors websites. I understand that it is a procedure that uses a laser to help extract the fat. It seems to have less bruising, less downtime and less time one has to wear the compression garment than traditional liposuction.
Maybe Smart lipo is not the best procedure for the unwanted fat on my abdomen, flanks, back bra area, thighs and let’s throw in the chin area for good measure. But that is the reason for the consultation….for you to advise me on options that will best fit my needs.
A: The reason I ask about your perspective on Smartlipo is that it is highly misunderstood…which is not the patient’s fault. Many doctor’s marketing of it is false…or at the least a but understated. Smartlipo is not different in terms of invasiveness, amount of bruising, recovery or downtime than any other form of liposuction. It is just a different way to loosen up the fat to remove it but it is still a very invasive procedure just like every other form of liposuction.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting a skull implant. I have attached photos of my mutant head. As you can see I got this stupid bald ugly head, it is not very visible from behind but looks very bad from left or right side. It is not very much dented but it is enough and bothers me very much. So many people ask me what happened to my head or they just staring at my head like I came from another planet. Is there any way to fix it? This skin on my crazy head is kinda flexible and I thought it would be enough to pull that skin in a direction to make it less visible or apply some kind of implant under the skin to make my head more round on that flat area and cover that bump/dent. Any suggestions? How long does it take for such a surgery or some other kind of fixing it?
A: Thank you for your inquiry and sending all of your pictures. There is no question that the best and only way to get the back of head built out and smooth is with a custom made skull implant. This can be designed on the computer using a 3D CT scan of you and then inserted through a small low scalp incision to fit over the bone. I have done such skull augmentations many times. I have attached a recent back of the head case that shows how this technology works and how effective it can be.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a large congenital nevus on my left cheek. It has been bothering me all my life and at this point I just want it gone. Please see below for pictures. Would skin graft treatment be an option for me and would it have a lesser chance of scarring?
A: Thank you for sending your cheek nevus pictures. The best way to treat your congenital cheek nevus is through a process known as serial excisions. You can’t just cut the whole nevus out or skin graft it as that would end up making it look worse. To end up with the best final scar, one does subtotal removal of the nevus inside its existing margins for two stages spaced three months apart. This does not overstretch the surrounding skin (thus keeping the scar narrow) and keeps making the nevus smaller. After two stages only a thin one of nevus if any will be left for the third and final excision/scar revision. All of these procedures can be done in the office under local anesthesia. There will be a scar but the goal is to have it end up as small as possible without distorting the surrounding cheek tissues.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in eye asymmetry surgery. A few months ago I fainted and fell against a sink. The result was a left eye broken orbit (only the rim below, not a blow out fracture, no displacement). After a few weeks when the swelling was gone, I saw that the position of my left eye was different from the right side. Doctors measured a different of the position of the globe of 1.5 mm. Although it might not be much, in my case it is obvious. Doctors told me that it could be from fat atrophy. Do you think that an implant or so can help me to get my eyes more symmetric again? Many thanks for your response!
A: If an eye asymmetry has indeed developed after some type of orbital fracture, particularly if occurring within the first month after the injury, I would have it assume that this is due to a skeletal issue not fat atrophy. (as that would take many months or even years to be seen) But regardless of its cause a horizontal globe asymmetry can be treated by one of two methods, an implant or fat grafting. A small implant can be used to build up the orbital floor or a dermal-fat graft can also be so placed. (if you happen to have a c-section from your children) This is a simple surgery in which either material can be placed through a limited subciliary or transconjuncitival incision. The hard part is just deciding if such surgery is absolutely necessary and what material to use in doing it should it be so. Please send me a picture of your eyes showing their current state.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have an Inquiry regarding breast augmentation, I am wondering if my wife would be a candidate or should even consider a consultation. She had ovarian cancer in 2005 and then in 2014 was diagnosed with Stage 4 head and throat cancer. She is currently in remission. She has always wanted breast augmentation surgery but I wonder now if it would be too late.
A: Just because one has cancer, or even a lifespan that looks limited, does not preclude one from undergoing breast augmentation surgery. I did a lady some time ago who a stage 4 liver cancer. She had always waned to have breast implants and finally fulfilled her wish. She lived for two years after the procedure. It is all about making patients happy. Some people in having a cancer diagnosis may take that trip around the world or climb up Machu Picchu…others may want to have breast implants. There is no medical reason to not do so if her cancer doctors approve and she is not on any active chemotherapy or immunosuppression drugs. Breast augmentation surgery would be comparatively ‘easy’ to go through compared to any of her other cancer surgeries.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in paranasal implants…again. I had jaw surgery five years ago which successfully corrected my under bite, but I still have mid-face concavity. I originally sent you pictures a couple of years ago and you said I was a good candidate for this procedure. A little over year ago I had the paranasal implant surgery done locally, but there were about 3 small tears that opened opened up along the incision line, which lead to infection less than 2 weeks after the surgery. The surgeon offered to redo the procedure after 6 months of healing at a discount, but I didn’t have much faith in him after that.
For the implants, we had selected the larger 7mm porous implants, and it completely eliminated the concavity, and it looked good despite the little bit of swelling that remained.
A:Thanks for providing your paranasal implants history. You obviously had Medpor paranasal implants which I don’t like since they have a higher rate of infection due to their porosity. Paranasal implants are unique amongst facial implants because they have the thinnest soft tissue cover over them being right under the lip. Unless one gets a two layer closure over the implants, which includes a good muscle layer, wound breakdown will occur. It sounds like you probably had a combination of both that lead to an early exit of the implants. Whether the 7mm thickness of the paranasal implants is really adequate is unknown because it really takes up to 6 weeks for all the swelling to be gone. But with your history of prior surgery and now scarred tissues, I would not push it beyond that thickness anyway.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, A while back I had some excess skin removed from under my chin along with some liposuction on the left side. This was done with a t-scar with decent results. (direct necklift) The skin on some of the upper neck is still a bit looses especially where the lipo was. It also pulls some when I look to the right. I would like to come in and have the t-scar extended a small amount in order to clean up more of the loose skin and get rid of the pull. Also, I would like to improve on the scar as it is a little wide where the lateral and horizontal incision meet. I’m not looking for any miracles but I am looking for a decent amount of improvement without extending the scar down to my Adams apple. I would like to be able to hide the scar behind a beard for a year or two and allow it to heal to an acceptable appearance. In April, I have a two to three week block of time in order to get this done. What are your thoughts?
A: In my experience with the direct necklift, the vertical scars can do well in older male patients. Such scars do not do very well in younger males that do not have a lot of loose neck skin. The lower that vertical scar becomes the more potential problematic it can be. (postoperative widening) ‘Significant’ results usually mean more skin excision, more tension on the scar line and some degree of lengthening of the vertical component of the T scar.
While such a procedure is easy to do in the office under local, I remain cautious about these vertical necklift scars in younger patients. (under age 60 to 65) Whether you can get significant improvement without substantially increasing your scar morbidity is not something I can comment on without seeing pictures or examining you in person.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in abdominal panniculectomy surgery although I am not exactly sure what it is but it sounds like what I need. I’m 45 and am about 510 lbs at 5’10.
I need help asap. I have a real bad overhanging belly and a scar from my belly button to waist that’s feel likes it’s ripping. I also have bad hernia that’s randomly pokes out and creates extreme pain.
A: While there is no question that some form of an abdominal panniculectomy could be incredibly helpful, at your level of weight it is also a surgical procedure that has a very high risk and will undoubtably have a 100% complication rate. This most certainly will be from a wound healing standpoint and potentially from medical risks as well. This is also a procedure that would have to be performed in a hospital that would likely need 5 to 7 days of hospitalization…and that is providing that no significant medical complications occur. You are going to have to get a medical reference from your physician who has been following you and has you in the best health as possible for this weight. He/she must also feel that the procedure is medically indicated and that your are cleared to have the procedure.
In short, while an abdominal panniculectomy would provide numerous medical benefits, it is not a procedure that should be approached lightly and with great preoperative consideration. I would assume you know that losing weight by bariatric surgery would be far preferred before undergoing such a procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in facial reshaping. I absolutely hate my face and how it looks different on both sides. What would I need done to make myself look more symmetrical. I only like the left side. I hate people even looking at my right side and I wont ever take face forward shots. I attached a picture to show you. I just really hate it and very insecure. I feel like everyone can notice that one side of my entire face is higher than the other and that one eye is bigger than the other.
A: Thank you for sending your picture and expressing concerns. I can clearly see the differences between the two sides of your face and most, if not all, of the asymmetry is in the periorbital region. (around the eye) Because the picture you sent may be inverted (mirror image) I am not sure which is the right or the left. But there is one side where the eye is bigger and the brow bone and cheek bone on that side are more developed. While the opposite side has a smaller eye and a slightly lower brow bone edge and smaller cheek.
When it comes to facial asymmetry and facial reshaping surgery that involves the eye, the bigger eye or higher side can not be lowered. Only the smaller side can be made more open or raised. Thus on the smaller side the brow bone can be shaved to raise it, the cheek augmented to make it fuller, the eyeball raised to make the pupil more even with the other side and the upper and lower eyelids raised to expose more of the white of the eye.
Dr. Barry Eppley
Indianapolis, Indiana
