Your Questions
Your Questions
Q: Dr. Eppley, I am interested in facial feminization surgery but for different reasons that the typical facial feminization surgery patient. I am a 27 year-old female but my features have been destroyed by acromegaly making me unable to recognize myself. I want the frontal bossing removed and the overall size of my nose reduced. Have you ever worked on an acromegaly patient before? Do you think these two (generally speaking) procedures will improve my features or will I need a reduction in chin, etc? I had my pituitary tumor removed four years ago and my IGF-1 levels are controlled by medication. I have attached pictures of me both and before the acromegaly developed.
A: You are correct in that you desire/need for facial feminization surgery is rare. I have worked on a few acromegaly patients in my career and making significant changes can be challenging based on how much their face has become ‘overgrown’. You appear to have a favorable starting point where some changes (e.g., frontal bossing, chin and jawline reduction) can be visibly improved given that they result from excessive bony deposition and the bone is likely thicker than normal. There are limits in rhinoplasty because there is often as much skin thickening over the nose as there is bone and cartilage excess. As in any rhinoplasty patient the limits of what can be seen on the outside is partially controlled by how much the skin will shrink over a reduced osseocartilaginous framework. Based on just a frontal view alone, it is hard to assess his much nasal changes can occur. (as well as other areas of the face)
Since your pituitary tumor has been removed and your IGF-1 levels are being monitored/controlled, facial surgery would be reasonable to do as the risk of causing an excessive healing response to tissue manipulations (i.e., overgrowth) has been eliminated. It would be important to get an assessment of your facial skeletal features with a 3D CT scan so bone size/thicknesses can be assessed preoperatively. That can be ordered by me to any imaging facility that you choose where you live. Also please send some cur6rent picture from different angles (non-smiling) for my further assessment.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 32 year old female with flat cheekbones that
make my eyes look prominent. I have noticed that whenever I laugh the lower eyelid retraction vanishes and the eyes look quite normal. So I am thinking a fat transfer can considerably correct the problem. But I would like toknow if the maxillary hypoplasia is so severe as to make necessary the use of orbital/cheek implants. Or do you believe in using large volumes of fat transfer to treat such cases. And can fat grafts be used in the cheek eyelid junction too?
A: You have astutely discerned the two approaches to anterior midfacial/lower orbital hypoplasia. The bone can be built up with implants or fat can be added to the soft tissues that drape over the bones. Each has their own distinct advantages and disadvantages and the actual anatomy and severity of the tissue deficiency will play a major role in that treatment decision. It would be very helpful to see pictures of your face to provide a more specific answer to your exact facial concerns.
Having done a lot of both implants and fat grafting in this area, I am facile with both techniques and my treatment decision rests with what is best to anatomically correct the problem. Anatomic needs should dictate the treatment, not what ay surgeon is most familiar with doing. What I can tell about treating this area in general is that I often use a combination of both implants and fat grafting to get the best result. Implants can only go where the bone is, fat injection grafting can volumize soft tissues where implants can not. (e.g., lower eyelid above the infraorbital rim)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was just wondering how much the nipple reduction procedure costs. I have protruding nipples that seem “puffy”. I would love to have them lay flat so that I can quit wearing undershirts and join in on summer activities such as swimming. Please let me know.
A: Thank you for your inquiry. There is a difference between protruding nipples and a puffy areola. While sitting right next to each other, they can be very different and require different approaches to treating. One is a simple office procedure to reduce the length of the nipple. (protruding/raised/long nipple) When men use the term ‘puffy nipple’, they are usually referring to the whole nipple-areolar complex that sticks out which is really a very mild form of gynecomastia. That is treated quite differently by excision of the excessive gland tissue under the nipple through a small procedure done in the operating room. A protruding nipple reduction has no recovery at all while the areolar gynecomastia problem requires several weeks of avoiding strenuous activities such as exercise of swimming.
As you can see, I need a clear idea as to exactly what you are referring to. Sending a picture would be very helpful in making that important distinction between the two conditions.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in chin reshaping. I think my mid face and chin are long (I assume it’s easiest to fix just the chin). I’d like to reduce vertical height by at least a third and increase chin projection. I may also consider some work on my nose. (narrow bridge, hump removal, refine tip).
A: Thank you for sending your pictures. It is far easier to vertically shorten facial height by working on the chin. Midface vertical length can only be reduced by a maxillary impaction surgery which can only be done if one has true vertical maxillary excess. (too much tooth and gum show at rest)
Your chin appears long because of it is horizontally short and rotated backward. A sliding genioplasty can be done to bring it forward and to vertically shorten it at the same. To see how this would look, computer imaging needs to be done. To do this type of computer imaging analysis, I need non-smiling pictures from the front and profile views to get a non-distorted imaging. As beautiful as your smile is, it distorts the soft tissues of the chin and nose. This is the one time where smiling is not helpful!
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting a tummy tuck. My questions are:
1. Cost- do you know if insurance pays for the surgery or is it out of pocket?
2. Hospital stay – how long or outpatient procedure?
3. How long off of work?
4. Cost for an office consultation
A: Thank you for your tummy tuck inquiry. In answer to your questions:
1) Tummy tuck surgery is a cosmetic procedure and is not covered by insurance unless one has a large overlying abdominal pannus that has documented medical symptoms that have undergone unsuccessful non-surgical treatments. To be considered for insurance coverage a predetermination process is necessary.
2) Unless it is a very large abdominal pannus and the patient has other medical issues, tummy tuck surgery is typically an outpatient procedure.
3) How much time one would need off work after a tummy tuck depends on what type of work one does. But as a general statement, two weeks for an office for sit down job and three weeks or more for a very physical occupation.
4) As a cosmetic tummy tuck there is no charge for am office consultation.
Dr. Barry Eppley
Indianapolis, India
Q: Dr. Eppley, What is the material used to widen my face at all areas. (especially the area at side from zygoma to lower jaw) Will silicone material be the best ? I have tried fat transfer but it was little volume and only had a temporary effect. I wish to widen my face with permanent and semisolid material. I have attached my photo. Thanks a lot.
A: The best way to permanently widen your face is by using a combined custom facial implants approach with jawline and zygomatic arch designs made from a solid silicone implant material. They will provide an immediate and lifetime change. With a custom design they can be made to match in their upper and lower facial width increases so one is not wider than the other.
Fat injections in you was never going to work. And even if the fat took it would look soft and ill-defined. But most importantly your face is too thin to ever have any fat graft take very well. Fat grafts always work better when there is some natural subcutaneous fat into which they are placed.
The only issue here is that there will be a concavity between the mid- and lower facial widths increases where there is no bone support. I assume this is one of the areas where the fat injections were placed that did not work.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in frontal bone reduction. (forehead reduction) What’s the average bone thickness of the frontal bones? How much can you usually take off that will a visible different?
A: Burring is the only effective method for forehead reduction or reduction of frontal bone bossing. Frontal bone thicknesses can range from 12 to 17mms in my experience. The bone can be reduced down into the diploid space. How thick the bone is down into that space (how much can the frontal bone be reduced) is best determined by a lateral skull film or CT scan by which the amount of bone reduction can be measured. In my experience that is anywhere from 5 to 8mms. That may not sound like a lot of frontal bone reduction but when done over the entire surface of the forehead it can create a much greater effect than the numbers alone would suggest.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 35 year old male-to-female transsexual. I feel that although I have a substantial amount of buttocks, when looking straight ahead my waist to hip ratio is like a square/box shape. And it doesn’t help that I have broad shoulders. I’ve used temporary solutions like Styrofoams to enhance my hips. I’ve thought about liquid silicone injections but I know that is illegal in the US and very risky/dangerous. I want something that is legal and a better approach to hip augmentation as much as possible. Is this something that you can help me with? Do you do fat transfer to hips only or do you do hip implants? Where are the scars made? Any and all information will help and would be greatly appreciated. Thank you in advance for your time.
A: Hip augmentation can be done by either fat injections or, occasionally, using actual implants. When possible, it is always best to perform hip augmentation with fat injections if one has adequate fat donor sites to harvest by liposuction. It usually takes about 150cc to 200cc of injected fat in each hip to make a visible difference. For both sides that would make a need for about 400cc of concentrated fat to inject. Given that the ratio of obtained concentrated fat to liposuction aspirate is 25% to 33% one has to have about 1500cc of fat to harvest to make the procedure worthwhile. These are average numbers which will vary up and down based on the body type and preoperative hip size.
Hip implants are made by modifying other types silicone body implants since no true hip implants are available as an off-the-shelf preformed implant. They are made of low durometer solid silicone so they are very soft and flexible. (actually feels squishy) They are placed over the desired hip augmentation area through a horizontal incision below the prominence of the iliac crest under the thigh fascia if possible. Because the hip area is a flexion region (e.g., sitting, bending) it is important to not get the implant too high and anterior in the hip region.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in breast augmentation by fat injections. I have no interest in implants whatsoever. I’ve attached a couple pictures for assessment. Do you think I would get a reasonable breast augmentation result (one to two cup sizes bigger) if the fat was taken by liposuction from just my abdomen and flanks. I just weighed myself this morning and my weight is around 170, but I’m typically 165. I’m approximately 5’7” tall.
A: Thank you for sending your pictures and your inquiry in fat injection breast augmentation. I think you have a low amount of fat to harvest to do the procedure given what your breasts are initially like and what your goals are. They have several unfavorable characteristics including a very narrow breast base with large areolae, breast mounds that are very widely separated and a very wide chest width. It would take more fat than you have to inject your breasts to increase the size of your breast mounds to the level that you are seeking. With the amount of fat needed and the assured loss of 50% of what is injected, your breast augmentation result is not going to meet your goals. If you can accept more modest goals such as a 1/2 cup to maybe one cup size bigger, then you become a better candidate for fat injection breast augmentation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am struggling with my confidence as a result of having a big head. I have read lots of articles on your webpage, and I would really like to do have something done with my head size. It is basically just big in every dimension. So I would like to do these surgeries:
1. Narrowing of head. (Partly removal of the temporal muscle and burring of bone)
2. Shorten the length of my head from my forehead to the back of my head.
3. I would like to reduce the height of my head. (For instance by burring down the sagittal ridge)
I have always had a quite big head, but I was involved in an accident recently, which provoked a bump on the back of my head. So my questions are, how much would it be possible to reduce the skull in the questioned areas?
A: You have highlighted the five site specific skull reduction locations (front, top, back and sides) where reduction procedures are possible that can have an effect on overall head size. It is hard to put an exact number or percent as to how much head size reduction would result from these collective efforts Since every patient is different with varying amounts of head size protrusions and bone thicknesses, each case has to be evaluated on an individual basis. The question is not whether one can perform all these skull procedures but whether the end result justifies the effort. I would need to see pictures of your head from different angles to provide an answer in your case. Ultimately a CT scan is needed to assess the thicknesses of the bone and muscle which also helps in making that determination.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a nasal implant question. I would like to have the very tip of my nose lengthened but have been told that my existing implant must be removed due to the fact that it causes the skin of the tip to harden and in future years the implant will cause problems anyway? During my first rhinoplasty a little cartilage was added to the tip. I didn’t feel that it was nearly enough. I have a blue silicone implant in the bridge, “Flowers” is the brand.
A: If you want to lengthen your nasal tip, placing cartilages on top of the nasal implant in the tip area can be done. (if the implant even goes down over the tip) There is no reason to remove the nasal implant to do so.
By the way, if you have a blue colored implant on your nasal bridge, that is not an actual implant. That is the nasal implant sizer used to try in before placing the real implant. Some surgeons unethically place sizers instead of the real implants because they cost only 10% as much as the real implant. That is why the company colors them blue, to try and prevent surgeons from using the sizers as the actual nasal implant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am inquiring about the possibilities regarding slimming down my face. It is just long and wide and does not look proportional to my body at all. What could be done to reduce the size of my face? I obviously see that there are limits of what can be done. Whereas I for instance could have jaw reduction and/or cheek cutting. But what sort of experience do you have here?
A: In facial reshaping surgery, slimming the face can be done by three different approaches depending on the dimensions involved. Normally the face could be vertically lengthened to make it look less wide. The face could also be made less wide (width reduction) without changing the vertical length. Lastly, a combination of vertical lengthening and width reduction can be done which often is the most effective.
Your facial dimensions and concerns (‘long and wide’) leave you with only facial width reduction options as you have noted. Cheekbone narrowing and jaw reduction would be the logical procedures of cboice. Whether this would include vertical chin reduction to help with the long face can be debated since vertical facial shortening works against facial width efforts.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a chin augmentation and rhinoplasty after our consultation? What are the logistics of the actual procedure…i.e, time needed to recover, possible adverse short and long term effects, are the results permanent or will it need to be altered down the road to maintain its new shape, and are allergic reactions to the implant material common?
Another concern of mine is that I train in jiu jitsu (it’s like wrestling pretty much) so would the implant possibly be jostled loose if I were to get knocked in the chin? If so, would the sliding genioplasty yield similar results or no? I do like the chin implant.. just worried that it could be a potential problem.
A: The combination of rhinoplasty and chin augmentation is a very common facial reshaping surgery because of its dual benefits in changing two important areas of facial prominences. These are outpatient procedures done under general anesthesia. The most significant recovery is the first week when the nose will have a tape and splint dressing and the chin will be the most swollen. After the first week the nasal splint comes off so it is easier to be seen out in public without having had obvious surgery. Most of the swelling is gone by about three weeks after the procedure although it really takes a full three months before one should critique the results.
Both the rhinoplasty and chin augmentation create permanent effects through bone and cartilage modifications (nose) and the placement of a non-degradable implant. (chin) There is no such thing as an allergic reaction to a silicone implant although there is the rare occurrence of the risk of infection (1% or less) The chin implant will be secured in placed by small screws so between screw fixation and the enveloping scar that occurs around any implant, it will never move regardless of almost any degree of physical contact. You would have to break the bone to move the implant.
The biggest risks or need for revisional procedures for either a rhinoplasty or chin implant are aesthetic in nature…how does it eventually look and is the patient satisfied. The overwhelming reason for revision of any facial aesthetic procedure is the patient desire for additional changes/improvement in the shape of the nose or chin.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was seeking a natural tummy tuck result. But after looking at the picture you provided to me, I now realize that removing the excess skin/tissue across my abdomen is not going to give me the “natural” look I was hoping for. So my questions are:
- What other procedures do I need which will help to reduce the flank areas and outer thigh areas (lipo, lifts, different abdominal procedure?). I am not interested in the inner thigh at this point, but I would like surgery results closer to the “after” picture than what the one procedure appears to be able to provide.
- By adding these procedures how much additional time or what will the total surgery time be? Given my age, do you consider this extended time to be a concern?
- By adding these procedures what amount of recovery time do I need to plan for. (My daughter is getting married in late June and activities are already planned for mid-June.) Will a mid-April surgery date, if available, give me the necessary recovery time to fully enjoy the wedding activites, anticipating no surgery complications?
- Will I need to plan more time off than just the day of and day after surgery?
A: The concept of a ‘natural’ look after a tummy tuck is open to wide intrepretation and is subject to one’s own perception. But in answer to your specific questions:
- It is important to realize that you are not able to achieve the after picture that you saw. Your body is completely different in many dimensions and no amount of additional liposuction will make those type of changes.
- If there is truly a ‘dangerous’ part of abdominal contouring, it is large volume liposuction that may accompany the procedure. It is one thing to do a little flank liposuction as part of a tummy tuck, but major liposuction places certain patients like yourself at increased risks and exposes yourself to some of the greater risks and problems that you have heard with other people. I would not recommend it for you other than some small contouring liposuction at the back end of the tummy tuck incisions.
- When you think of any significant event that someone wants to attend and be truly 100% fully recovered, the minimum time for the surgery before the event would be 8 weeks.
- I would definitely plan for more than just one day after the surgery to return to work. For computer work at least a few days would be in order.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had combination malar submalar implants placed a year ago, but they were too big and I had them removed. I later decided to go with malar implants only, but they got infected and I had to remove them too. I guess you can say that I haven’t had the best of luck with these implants.
Anyway, what I’ve noticed is that there seems to be some sagging in the mid-face from the cheek implant removal, and I seem to have deeper nasolabial folds and some droopiness at the corners of my eyes too. I’m not too happy with this, and would like it fixed.
Would it be possible to explain to me what my options are? Are there any minimally invasive lifting procedures that can be done? I’m still young (mid-20s), so I would preferably like to avoid anything too extensive or invasive.
A: With cheeks implant removal of any style and size, tissue sag is inevitable due to loss of anchoring attachments of the overlying cheek tissues to the zygomatic bone. The only potentially effective treatment would be cheek soft tissue resuspension. There are multiple ways that cheek resuspension can be done from using intraoral, lower eyelid and temporal suspension points of anchorage. One can debate whether any of these techniques are less invasive or extensive than the other, but I would not make much of a distinction between them. It can also be debated as to which of these cheek resuspension techniques is more effective than the other. But that is probably more surgeon dependent than technique dependent per se. Lastly whether they can create the more complete improvement that you seek (midface sagging, nasolabial fold reduction and corner of eye droopiness correction) is asking a lot of them.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 29 year old female and I am interested in a midface lift in hopes of achieving a cat eye look. I love how my hair looks when pulled back into a tight high pony tail. It gives me Asian eyes and lifts my cheeks.
I notice celebrities are having this look, people refer as the PILLOW… I read they have a lot of fillers and botox but i want something that will last longer.
I once had a temple lift with Endotine and done by endoscopic. I loved the results. It gave me exactly what I wanted…slanted eyes and my cheeks raised. But unfortunately it lasted no more than a month. My skin, just went back to it’s pre-surgery state.
So will a midface lift help achieve this for me? I see other questions you answered involving lateral canthoplasty, would that help as well? Which is preferred? Thank you so much for your time Dr. Eppley!
A: What you have learned from your midface lifting experience is that simply pulling on the skin up and back, like a tight ponytail, is not going to create a sustained result. It simply is not that easy. Such endoscopic temporal lifts alone always fail because skin pulling/shifting alone is not the answer for raising the corner of the eye and keeping the cheek tissue lifted. A direct approach to the corner of the eye (lateral canthopexy vs canthoplasty) is needed in conjunction with a high placed cheek implant and and an excisional temporal lift. Like a strair step approach, lifting and support needs to be added at three levels to get a better and more sustained result.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m not able to find any image for a “custom made vertical” chin implant. I’m trying to figure out what a vertical chin implant might look like,where it will sit on the chin bone or where the screws will be fixed.
1. Please can you show an image for a custom made vertical chin implant and where it will sit on the chin bone. Hopefully this type of implant will be able to augment 4 millimeters vertically.I read that extended anatomical gives a more natural fit?)
2. If a patient already has a CT scan (including DICOM) of their current jaw/chin bone in order to design a custom made implant; how many weeks will they have to be in Indianapolis to have the jaw angle/chin implants made plus have the surgery done and be safe before they fly out of indiana back to their country? (4wks,6wks?)
(Just in case the implants may result in any infection, how many weeks should one really stay in Indianapolis and wait until it’s safe to know everything is OK before leaving Indiana/the US? Thank you
A: A custom chin implant can be made any way one wants or needs it to be shaped. It can provide the required vertical increase (4mms in your case) and has a lip or edge that goes up over the lower end of the chin bone so it can be secured into place by screw fixation. No standard or preformed chin implant today (other than my small vertical lengthening chin implant can create this type of chin change)
If one has an existing 3D CT scan that reflects the current jaw shape, it can certainly be used. The CT scan is simply sent to me and the implant design is done from here. There is no need for the patient to be here to have it done. The patient only comes in for the surgery and can return home in a few days. There is no need to stay here any longer. And staying here any longer has notbenefit from an infection standpoint. The infection risk is so low (less than 1%) with facial implants and its occurrence could be weeks or months later if it does occur.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am having breast implant replacements surgery one week from tomorrow. I am going to send some photos of myself again and the final pic of what I would like to get close to ( yes I know I’ll never be them or anyone else) just looking to getting close to that result. I also realize you told me I’d have to give up silicone and go with saline overfilled. You had me at 655cc Sientra high profile silicone, but if I need to stay with saline to even go in that direction of a result I understand. Also, I understand you won’t be able to use my previous under the breast incision, but the aerola one. The picture I am sending is close to my stats, although I don’t know exact size I know I was an A before I ever got implants too and I don’t know her bwd measurement. Looks like she has 700 silicone ultra high profile, but then again I have the sag that filters in too. Thank you again for your patience! You don’t know how much it is appreciated.
A: Your breast implant replacements choice is a tough one because there is no ideal solution. Each implant size type choice has its own aesthetic tradeoffs. To get a really round look, it is going to take significant volume. Given that you have roughly 350cc implants in place now, you would have to triple that volume to create a very full round look. Only saline implants will allow that volume by taking 700cc/800cc implant and overfilling them to 900cc to 1000cc volumes. (e.g., Allergan high profile round saline 750cc implants) That will pick up all the loose skin and fill it out but to do so will likely make you bigger than the pictures you have shown. Your natural breasts have a bigger base and a lot more loose skin than any of the ideal pictures you are showing. In addition, it is important for you to realize that even at these volumes your breasts are not going to be lifted per se. They are going to stay where they are and just bigger in that position. In conclusion with overfilled saline implants, it is important that you will have to accept a very large round size that sit slower in your chest wall than you desire. The only way to get around the sagging issues is to have a breast lift first and then six months have new implants placed. But because of the scars this is not on the table for consideration.
If we go with silicone breast implant replacements, it would have to be an ultra high profile implant at 700cc or 800cc volume with base widths of 13.5 or 14.2 cms respectively. (Allergan) In so doing you will get the most breast volume that can be achieved with silicone implants. But whether it will give that very round full look that you desire can not really be known until during actual surgery. It is just hard to predict what the skin will do with the volume. I suspect it will take the 800cc to get the best effect possible with this approach. Again, however, this will not lift up the breasts higher in the chest wall.
Regardless of the implant style and volume chosen, the safest approach in very large breast augmentations is with the areolar incision. This deuces the risk of bottoming out of the implants after surgery because it does not place a ‘weak point’ on the underside of the breast where a lower breast fold incision is placed. It is important to realize the stress of the supporting breast tissues that large implants place.
This should give you enough information to pick which implant type (saline or silicone) and their tradeoffs is most important to you.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I recently learned that I have two ruptured disc in my back and pressure on a nerve. I am wanting to know if I was to get a tummy tuck, liposuction, etc would it help with my back pain?
A: Whether a tummy tuck would provide any relief of our back pain would largely depend on the size of the abdominal overhang. Some tummy tuck/abdominal panniculectomy patients do report that they do have improvements in back pain after the procedure due to the loss of an overhanging abdominal pannus or even lesser amounts of skin and fat excess. But whether a tummy tuck would help you can not be predicted and is certainly not a common improvement that occurs after any abdominal reshaping procedure. Unlike breast reduction surgery which causes musculoskeletal symptom improvement in every patient, back pain improvement from a tummy tuck is far less assured. This is evidenced by the fact that no insurance company will approve tummy tuck surgery on the basis as a treatment for chronic back pain with or without ruptured discs and/or sciatic nerve pain.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in forehead and brow bone implants augmentation. I’m an Asian male, living in Korea, whose appearance is just like any other Asian’s. My eyes are very big for an Asian’s, but they are pretty much bulging. Besides, the prominence of my forehead and brow bone (I have heard that it’s called ‘supraorbital ridge’ or ‘supraorbital torus’) is very slight. It makes my eyes looked more bulging. And it also makes the distance between my eye and eyebrow look too far. All these all things make me look feminine. It’s really awful. Many people tell me that my eyes looked ‘faggy’.
So I’m considering the forehead and brow bone augmentation with intraoperatively applied bone cement. As you know, preformed custom implants easily makes
empty space between itself and forehead bone, and it can cause fatal side effects like dropsy. So I think bone cement will be better, but I want to know what
you think. I have wondered about this. For years, I have searched for a hospital who does forehead “including brow bone” augmentation surgery, but all hospitals in Korea told me it’s dangerous to use any implants on the brow bone, because there are much important nerve on brow bone region. So I had almost given up, and just at that time, I found your
website in google. So I wonder whether this surgery is really dangerous or not.
Finally, I wonder how much my forehead can be protrude by surgery. You know I am Asian, and I want to make my forehead and brow bone protrude as much as a Caucasian, if it’s possible. I really want to know whether it’s possible or not.
A: I have done forehead and brow bone augmentation over my career by every conceivable method including PMMA and hydroxyapatite bone cements, prefrormed Medpor implants and, more recently, custom forehead and brow bone implants.
Each of these methods have their own distinct advantages and disadvantages…neither one is perfect. Bone cements are very good to use but they require a lot of intraoperative shaping, can be very expensive (HA cements) and can lead to frontal bossing/protrusions if the forehead and brow bones is brought too far forward. (as bone cements should not extend beyond the anterior temporal lines onto the tenporalis muscle fascia where they will not adhere and can lead to visible edging). To place them well, they require a long coronal incision to get adequate exposure way down to the suprarbital ridge. They are also associated with modestly high revision rates particularly when the amount of augmentation needed/desired is significant.
Custom forehead and brow bone implants have numerous advantages over bone cements. Computer designing the implants allows much greater precision and control over the amount and symmetry of augmentation. They can be designed with forehead widening in mind in large augmentations as the material can sit without complications on top of the temporalis fascia beyond the anterior temporal lines. The potential open space under the implant (which I have never seen to be a true problem) can be circumvenyed by screw fixation and the placement of numerous perforation holes in the implant to allows for tissue ingrowth through the implant and down to the bone. A custom implant also allows for a smaller scalp incision to be used to place it since it already has the desired size and shape through preoperative designing.
There is no truth at all that forehead and brow implants are dangerous. They are no more ‘dangerous’ than bone cements. They do not cause ‘dropsy’. They do not have a greater incident or risk to the supraorbital nerves than bone cments.They require the same amount of tissue dissection down onto the brow bones that bone cements do. Forehead and brow bone implants are just as safe as bone cements, they just are another implant option to consider for aesthetic augmentation in this area that has its own unique advantages.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a few questions about facial implants. Do tear trough, cheek implants, and orbital rim implants become visible as the skin ages? If I need to get them removed will it leave obvious scars? If I get the facial implants but later decide to get a cheekbone reduction would it affect the implants? Thank you!
A: This is a good question about facial implants and is not the first time I have heard it. I have not seen increased visibility of midface implants with aging but that does not mean it does not exist. It would depend on the patient’s face and whether they suffer significant fat loss in the face as they age. It would also depend on how much fat one has in their face and the number and size of midface implants placed.
The removal of implants does not usually any more scars than those that were used to place them. If you get cheek implants and then elect later to have cheekbone reduction, the implants may or may be in the way based on how far back the tail of the cheek implant goes. Usually the implant would be in the way but it could easily be displaced so that the cheekbone osteotomies could be done.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have had a silicone implant in my nose for 6 years. No major problems yet. Just pressure in the bridge area. Will the bone under the nasal implant resorb?? Was thinking about removing the implant because I don’t want to lose what bone I have in the bridge area. I am half Korean and half Caucasian with a relatively flat bridge without the implant. Thanks.
A: Bone resorption under a silicone nasal implant is very rare…to the point that I have never seen it or have seen it documented in the medical literature. (but that may be because x-rays are rarely taken of the nose to look for it) The likely reason is that of the three elements involved in this equation, an unresorbable silicone implant, hard bone and a thin overlying soft tissue cover, the weakest link is what lies above the implant. Rather than the bone resorbing underneath the implant, the overlying soft tissue thins in response to any pressure caused by the implant. Whether this will actually happens depends significantly on the size/thickness of the nasal implant and its durometer. (measure of its hardness) In conclusion I would not remove the nasal implant because of any fear of bone resorption. Be aware also that your nose will look flatter than before having the nasal implant because the overlying skin has gotten stretched and is now thinner as well.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting a rhinoplasty to straighten and reduce the hump on my nose. My questions concerns that I do not wish to go under general anesthesia and wish to be sedated and under local anesthesia instead. Please also let me know what you think in regards to whether I should also consider reducing the size of the nose overall or nostrils.
A: Thank you for your inquiry. When it comes to anesthesia options for rhinoplasty surgery, that is highly influenced by the type of rhinoplasty being performed. If nasal osteotomies with hump reduction and/or internal nasal surgery is being done (septoplasty, turbinate reduction), local anesthesia with sedation is a poor and unsafe choice. These types of rhinoplasty induce bleeding down the nose and into the throat and risk aspiration and laryngospasm, two potentially deadly problems. A general anesthetic with an endotracheal tube is the only prudent way to have such a rhinoplasty. If no bone work is being done and no cartilages grafts are needed such as in a tip only rhinoplasty, then local anesthesia with sedation would be safe and tolerable.
I would need to see pictures of your nose (front and side views, non-smiling) to see what type of changes you desire/need by doing some computer imaging.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in rhinoplasty surgery. I hate my nasofrontal angle, it is very deep. I am not sure if I need to build up the bridge, reduce the projection of the tip, or both… I would value very much your learned opinion and recommendations.
A: A deep nasofrontal angle is often cased by a combination of factors including a low nasal bone height, an overprojecting nasal tip and low dorsum and, of equal importance, brow bone bossing/protrusion. In doing some computer imaging (which is attached) you can see that the effects of a rhinoplasty (radix/dorsal augmentation and tip deprojection/rotation) lessen the depth of your deep nasofrontal angle by about half. When you add in a brow bone reduction with the rhinoplasty (see attached imaging) the deep nasofrontal angle problem is completely solved. So you see in your case, which is not rare, that it is really a combination of low nasal bones (45% of the problem), brow bone bossing (45% of the problem) and very minimally impacted by nasal tip changes (10% of the problem). For a female you have fairly prominent brow bones and that is most certainly a big part of the problem. There is nothing wrong with a rhinoplasty alone you just have to realize its limitations…it will make it better but is not the complete cure for it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I reviewed the jaw angle implants imaging you provided and have some questions about it. The left side seems slightly asymmetric to the left and the two sides of my face are not perfectly even. Is this the way the surgery will turn out?
A:You are way over reading the jaw angle implants prediction images. I have stated in the past these are approximates so see what direction/dimensional changes someone is looking for. They are not meant to be nor should you interpret fine details in them such as some asymmetries or slight differences in these dimensional changes. These are the variabilities of computer imaging and I also doubt that you are perfectly symmetric either. I should also point out that there are going to be postoperative amounts of jaw angle asymmetry. You will not have a perfectly symmetric result, nobody does. If a patient finds that these fine details are unsettling or is going to critique their postoperative results in the smallest detail, then they are going to be unhappy and have a very high risk of revisional surgery. I make these comments not to be unkind or unfeeling, it is based on a vast experience with male patients and facial surgery. And the goal is not do end up having revisional surgery on any patient.
The reality is that surgery is not an exact science no matter how much thought goes into its preparation and execution. It is an imperfect art practiced on asymmetric features that do not have completely predictable patterns of healing. Therein lies my caution to you. To have a satisfying jaw angle implant augmentation result, one must be prepared to accept some imperfections and realize that a close approximation of one’s goal needs to be good enough.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a lip corner uplift. The ends of my mouth are drooping and I wish to enhance the corners of my mouth so I don’t look depressed, when I am not! I have attached a picture of my droopy mouth for you to see what I mean. Thanks
A: A corner of mouth lift is the only surgical procedure that can change the inverted U-shape lip line into a straighter one. Injectable fillers can help provide some corner of the mouth lift but its effects are limited and only temporary.
While there is no question you would benefit from a corner of mouth lift, I do have some concerns about the small scars that result given your skin pigmentation. The most effective corner of the mouth lifts (traditional triangular excision) do leave some small linear scars that radiate outward from the corners of about 7mms. The other corner of the mouth lift technique is the ‘pennant method’ where all scars remain at the vermilion-skin border but it does not lift the mouth corners as much.
Given your Hispanic ethnicity I would tend to choose the pennant corner of mouth lift method so as to keep the scars at the vermilion-cutaneous location. I would accept the trade-off of a less result to reduce potential scar issues.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I want to know the cost of fat transfer breast augmentation procedure. (fat injection breast augmentation) What is the time needed for prepping before surgery with the Brava bra? How long does the procedure take? Will there be any scarring?
A: Thank you for your inquiry. The first place to start in this type of breast augmentation is to determine whether you are a good candidate or not. There are many more variables in fat injection breast augmentation than in breast implant augmentation in determining a successful outcome. When using a breast implant, the final volume is assured regardless of the overlying breast soft tissues as the implant is firmer than they are and it provides a good push outward. Also whatever implant volume is placed will remain no matter the healing process and how the body responds to it. Picking a target volume is also assured although what implant creates the desired breast look is still as much art as it is science.
Fat injection breast augmentation is a completely different animal in which achieving even a modest permanent breast size change depends on numerous factors. The key ones are how much fat you have to harvest, how much natural breast tissue you have, the tightness/looseness of the overlying breast mound, and what your breast size expectations are. There is also the unknown variables of how well the fat will survive, does one need multiple fat grafting sessions and is the use of the Brava device absolutely necessary. Lastly there is the expectation level of the patient and are they prepared to accept these unknown and costs that will substantially exceed what breast implant surgery costs.
To help you make this determination I will need to evaluate you. This can be done by sending pictures and height and weight numbers or come into the office for a more thorough one on one discussion.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I reached out to you last year regarding a consult for reconstructive facial surgery following an ATV accident several years ago. Since I have had several reconstructions and am now looking to improve my overall appearance and have reached out to you because of your experience in both aesthetic and reconstructive plastic surgery. Your name was also mentioned in a report by Advance Medical as an expert in this area.
At the time, you had requested a CT scan of the face, which I did not have–but now have one. I have attached photos, 3D reconstructed CT scan, and a brief medical history for your review. The goals of surgery are:
– Improve symmetry of the face, especially involving the eye. This includes the buldging of the eye ball itself, and position of the lid. I fully realize that a full restoration of symmetry is not possible and that surgery on the opposite eye may be necessary to get the most aesthetically pleasing result.
– Reduce the appearance of the port wine stain on the left side of face, near the eye
– Reduce the appearance of the scar on left cheek
– Improve overall appearance, ie. what procedures could be done in combination to ENHANCE overall appearance. Would a strong chin/jaw divert attention from eyes? Would other facial implants help? Would removing the nose bump? (This is why I value your experience in aesthetic plastic surgery)
I know you are very busy and I appreciate you taking a preliminary look at this case for consult.
A: Thank you for sending your pictures and 3D CT scans. What they show is that despite an excellent anatomic reduction of the fractured zygomatico-orbital bones (and an infraorbital-malar implant) your face is not normalied. The problem now, and is a quite common one after facial trauma and multiple reconstructive surgeries, is that the original injured tissues have become ‘skeletonized’. There has been loss of subcutaneous fat with scar tissue that has caused lower eyelid scar contraction as well as the lower facial scar prominence. I think that the left eye does not really bulge but that the lower eyelid is vertically short and contracted, exposing more sclera in that eye.
From a reconstructive standpoint focusing on the original injured tissues, I would recommend the following:
- Lower Eyelid Reconstruction with Dermal-fat Graft and Lateral Canthoplasty (your prior canthopexy was insufficient)
- Left Geometric Facial Scar Revision (your prior laser resurfacing probably made little difference)
- Injection Fat Grafting to Left Cheek and Infraorbital areas (the tissues don’t need suspending, they need more volume.
From an aesthetic standpoint, I would need more pictures for better assessment for both rhinoplasty and jawline enhancement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m really pleased to know a chin implant can be a solution after my chin and jaw angle reduction surgery which has left my face deformed. I’ve sent pics to show how my chin dips in side profile and how the chin area directly below my lower lip protrudes when I smile. I think this is related to mentalis suspension? Really want to get rid of this protrusion, not normal looking.
- Can vertical chin implant get rid of this protrusion under my lower lip?
- Does a “mentalis resuspension” mean, cut along the gum line and stitch it again with a new stiching line in a different place? What does mentalis resuspension mean?
- What is the risk involved in mentalis resuspension? ( Or could it result in a worse bulge/protrusion or some other complications?) Or should I best leave it, if it’s going to risk resulting in a worse protrusion or some other complications.
- The center that did my CT scans seem to think that my jaw angles have been over cut (surgeon took too much bone off?), it was not cut straight and I have indented jaw angles? Does it look as if my jaw angles have been over cut? ( CT scan attached)
- Is it best I get a chin implant and 2 jaw angle implants? Or is it best to get a one piece implant that goes from one side of jaw angle ,across the chin, to the other side of jaw angle?
- Are there any down sides to having screws in your face bones? How many screws will it take to hold the implant(s)in place?
- I read online that a silicone jawline implant does not give good defined bone shape/anatomy, but acrylic PMMA is able to give that defined bone structure, is there truth in this ?
Thank you so much.
A: Thank you for sending your pictures of you and your 3D CT scan after your jawline narrowing or V line jaw reshaping surgery. In answer to your questions:
1) Vertical augmentation of your chin will help with the protrusion as the origin of the problem is the loss of volume from the previous chin reduction.
2) Mentalis resuspension is an intraoral technique where the mentalis muscle is repositioned higher on the bone.
3) The only downside with mentalis muscle resuspension is in how well it works. It has no other downsides and will not make what you have now worse. I do not think, however, that mentalis resuspension is needed for tour chin problem and implant augmentation alone is a better approach.
4) Your jaw angles do look over cut with a severe 45 degree angle to them. That matches with how you loo on the outside of your face. (the indentations over the angles)
5) Unless you want the side of the jawline augmented (which I do not think you do as there is a reason you had the original surgery…a narrower jawline), I would go with a three piece chin and jaw angle implant approach. They need to be custom made and I would design them as a single attached jawline implant (because it will cost you less to do so) but in surgery I will convert it to three pieces.
6) There are no downsides to have small 1.5mm screws in your jawline for fixation of the implants. They are roughly the size of the screws used in eye glasses.
7) A custom jawline implant, made of silicone, creates the best jawline definition and shape over any other material. PMMA would be the worst material to use since you have to shape it during surgery and achieve any symmetry and good shape between the two sides of the jawline would and be virtually impossible. Anyone who would say so otherwise is inexperienced and ill informed and does not have a contemporary understanding of facial implant materials and how to design and place them.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in facial fat removal after fat grafting. Two months ago I had fat injected to my bottom cheeks (30 ccs of fat) and the result was horrible! Is there a way to remove this fat? Would be difficult to remove it all? Won’t be there any side effect resulting from the liposuction? And what about Lipodissolve (phosphatidylcholine), does it help melting out the fat? Would Lipodissolve eventually at the end of the required sessions would melt the unwanted fat? Unlikely liposuction, lipodissolve can be injected to muscles, right? Actually I am desparate and am going through a very difficult time because of my face and want to remove/melt as much of the injected fat as possible. How many sessions of Lipodissolve do you think I might need? And how long should I wait to get my old look back?
A: Thank you for your inquiry and sending your picture. Most likely some of the fat can be removed by small cannula liposuction. (microliposuction) It is important to realize that all of the fat may not be removeable. If some of the fat is on the muscle then that portion can not be removed. One must also be careful to refrain from too aggressive liposuction is this area to avoid injury to the buccal branches of the facial nerve.
The use of fat melting solution like phophatidylcholine (aka Liposdissolve injections) is that their effects are unpredictable and will require mutiple injections sessions to do so. For one week after each injection session the treated area will be swollen and double in size. There is no assurance that any chemical method can get rid of all of the fat. It is unpredictable. You never inject Lipodissolve solutions into muscle unless you want to potentially damage facial muscles as well.
It is also important to realize that the Lipodissolve solutions used in the past were made by compounding pharmacies and were not FDA-approved. The only true Lipodissolve solution that exists today is known as ATX-101 and is under clinical trials by the FDA and is not currently available for patients outside of the clinical trials. (it is only being tested for the reduction of submental neck fat) It will likely be fully approved for general patient use in later 2015 or early 2016. Thus there is little reason to continue the pursuit of Lipodissolve injectiojns as it is not available currently. (unless one wants to use unapproved solutions from compounding pharmacies)
Dr. Barry Eppley
Indianapolis, Indiana
