Your Questions
Your Questions
Q: Dr. Eppley, I already had orthognathic surgery several years ago which involved moving my two jaws forward. Now I’m considering that augmentation was too much and I would like to revert the procedure and move my two jaws inward and upward. I’ve already had braces for years and they are not an option anymore, in part because I already have veneers in my teeth. I hear some doctors perform this surgery without braces in cases where the bite is already correct. Would this be an option? Thanks.
A: Doing double jaw orthogathic surgery without braces is known as non-orthodontic orthognathic surgery. You are correct in that it is rarely performed and many maxillofacial surgeons will not do it. If your teeth have a good interdigitation (occlusion), and they should from prior orthodontic work, then you can have orthognathic surgery a second time without them. The key is that both jaws have to be moved together with the teeth fixed into occlusion during the operation. (using preoperatively fabricated splints or the Omnimax inter maxillary fixation system) Provided that the jaws can be moved in the desired direction (moving the maxilla back is the harder one), then the surgery can be done without the preoperative application of orthodontic brackets.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in skull reshaping surgery. As you are probably aware, healthcare over in the UK is pretty much free. Cosmetic surgery is not given for free due to the fact its simply cosmetic, something you don’t like the look of on your body. If it is present from birth or is causing psychological effects, it can be done for free. I have had a very flathead from birth and it is causing me all sorts of stress and depression. Do you think the NHS (National Health Service) in the UK can provide me with help? Have you heard of anyone getting this type of surgery in the UK through the NHS? Also whom would you recommend that I go to for skull rehaping surgery in the UK?
A: I have had this question from patients from the UK many times. The simple answer is that there is no surgeon in the UK or Europe that performs these types of skull rehaping surgeries. And even if there were, NHS would consider this a cosmetic surgery just like all insurers do in the U.S.. Reconstructive skull surgery is for the restoration of skull contours for partial or full thickness bone defects. Aesthetic skull reshaping are a collection of cosmetic procedures whose purpose is to change the shape or contours of a skull that have adequate bone thickness.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting a Brazilian Butt Lift. I am a 24 year old female who is not comfortable and is ashamed of her body. I have been doing research on Drs where I currently live and I haven’t found a Doctor who meets my expectations. And I have seen your woek and I like what you do.I think I am a perfect candidate for a Brazilian Butt Lift since I have some extra fat over my entire body gained after I had my son via c-section three years ago. I really really want a better body with an “S” shape on the sides. I want my butt and my hips enlarged and I am really hoping you are the one who can make my dream come true.
A: As you know the Brazilian Butt Lift or BBL procedure is a dual benefit operation where multiple body areas are contoured through the redistribution of fat approach. The liposuction harvest areas create reduction while the fat transfer to the buttocks causes an augmentation. While the Brazilian Butt Lift is a very common operation today, and I have done many of them, the keys to a successful and satisfying outcome are based on realistic patient expectations and an understanding of the natural biology of fat transplantation. Let me highlights these key points:
1) The liposuction harvest is not an overall body liposuction procedure. The goal is to obtain as much fat as possible for the buttock injections for which the vast majority comes from the abdomen, flanks and back areas. The reduction of the waistline above the buttocks plays a major role in helping the buttocks appear bigger.
2) There may be undesired aesthetics from the liposuction harvest in the abdominal region, particularly in women that have had chldren. (loose skin) Ay such loose or irregular skin may require a secondary tummy tuck to create the best abdominal contouring effect.
3) The size limitations of the buttock augmentation increase in BBL surgery is a direct result of how much fat one has to harvest. Thus some buttock enlargement goals are not possible for some women because there is a mismatch between what they want and what they have to give to try and achieve it.
3) The amount of fat that is available to be injected into the buttocks is but a portion of what is harvested. Since the best type of fat to inject is a concentrate of the total liposuction aspirate, not all fat volume that is extracted ends up being injected. It must be concentrated which in women usually means about 40% of what is harvested is useable for injection. (e.g., 1,000 of fat harvested = only 400cc to be injected)
4) The survival of injected fat is not predictable and is never 100%. Thus some of the injected fat will die and some of the initial volume increase will be lost over the first six weeks after surgery. This fat transplantation biology fact seems to confuse many patients as they wonder why their results are ‘disappearing’ over the first month or so after surgery.
5) The final outcome of any BBL surgery takes 6 to 12 weeks after surgery to stabilize and see the final result. But it will not end up as full as one what sees in the first weeks after surgery.
These are the important concepts to understand so that one can have a realistic expectations about what to expect from their BBL surgery results.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in male brow bone reduction. But because of my hairline I can not have a coronal incision to do the procedure. I know that the alternative for some men is a mid-forehead incision. But that would only be for brow burring correct? Which wouldn’t have a very big overall impact as my bone is thin. It seems the only real option is to have coronal incision which just seems very excessive. Surely there is a better way to do it.
A: Your assumption about the limitations of the mid-forehead incision for male brow bone reduction are incorrect. Total brow bone reshaping by osteotomy and bone replacement can be done through this small mid-forehead incision….not just bone burring. (there are very male patients who would get any benefit from simple bone burring of the brow bones) I have done it many times and for smoke men it is the only way to do it because of their hairline location or density. One could also use the old open sky incision at the top of the eyebrows and across the nose but this risks permanent injury to the sensory nerves of the forehead.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am in need of a tip rhinoplasty repair. The tip of my nose went bright pink about two years ago. I have consulted with dermatologists and ear nose and throat surgeons. Until today nobody could name what is to me a problem. I came across your website and I feel so relieved as I saw a picture of someone with my same problem. The tip of the nose has split. The cartilage is in two pieces and what used to be a nice nose, to me now looks wonky. I would like to come and see you and get it fixed. I look forward very much to hearing from you.
A: Thank you for your inquiry and providing your history and picture. Your history is a bit unusual for the classic bifid nasal tip deformity as the separation of the lower alar cartilages is almost always of congenital origin. The typical bifid nasal tip patient has had it all their life because that is just the way their nose developed. To develop a nasal tip crease later in life and after the tip of the nose developed a bright pinkness suggests not a tip cartilage issue but a crease that has developed in the skin itself. (perhaps from an automimmune disorder) Regardless of the specific cause (split of cartilage or dermal skin crease), it can be successfully treated by a limited open tip rhinoplasty. It may involve tip cartilage reapproximation, overlay septal cartilage grafting or a crushed cartilage graft. That would have to be determined intraoperatively when viewing what is on the inside.
DR. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in migraine surgery. My migraine history is long. I started having migraines over twenty years ago. I take multiple prophylactic and rescue medications with mixed results. My headaches usually last two to three days and have lasted up to several weeks. The post-dromal lasts up to a week longer than that. I have had as little as a migraine every week or as many as a dozen migraines a month. I have been getting Botox for more than a year. Under normal circumstances I get a migraine a week, usually a 5-7/10 severity, taking the current medications. After the first day or two of rescue medications I stop taking them, I don’t think they do anything if they haven’t worked on the first day or so. I get Botox shots injections every three months.
A: Thank you for providing your detailed history and medication profile for your migraines. While migraines are complex, qualifying those patients that may have a successful outcome from migraine surgery is much simpler. The surgical treatment of migraines is based on identifying those migraine patients that have focal trigger points where the sensory nerves exit from the skull and pass through muscle where they can be entrapped. The three classic areas are the supraorbital, temporal, and greater occipital regions. Good surgical candidates have very specific trigger areas that they can pinpoint precisely, have repeatable symptoms from the same focal areas and usually have positive relief from Botox injections. Since you have had repeatable positive responses to Botox, it would be helpful to know more specifics about those injections. (location and dose)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in jawline surgery. The kind of strong jaw and face I’d like to have is like his model picture that I have attached which shows how her jawline drops and she has very pronounced and positive cheeks which I really like. I want something extremely dramatic, my jawline isn’t anything like the model I showed above. I’m cute, but my face is just so narrow that it takes away from the potential attractiveness that I could have. The debate for me is either a sliding genioplasty and two hardcore flared jaw angle implants OR a custom implant for everything. I hate the side profile view right now, as my nose and philtrum are overprojected and everything else is just weirdly shaped due to my terrible genetic inheritance.
A: Thank you for sending your pictures and providing a detailed description of your jawline surgery goals. While the debate is between a total custom jawline implant or a combined sliding genioplasty with two separate jaw angle implants, for a female and your goals I would choose the latter. The reason is that a total custom jawline implant will make the whole jawline wider from front to back, regardless of the dimensional changes in the profile view of the chin and jaw angles. I don’t think that works well for many female faces. What you want to achieve in the front view is a chin that ends up somewhat more narrow, or at least no wider, as it comes forward, a central jawline that dips in on the way back to the jaw angles and posterior jaw angles that flare out. A sliding genioplasty as it comes forward does make the chin a bit more narrow and it also allows the central jawline to remain narrow. (rather than bow out like a custom jawline implant may create) Your jaw angle dimensional needs is a combination of vertical lengthening and horizontal width for which I already have a variety of jaw angle implant styles to meet those needs.
In the side view you probably needs an 8 to 10mm chin advancement. the jaw angles need a 7mm vertical drop down and a 5 to 7mm width increase.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in custom paranasal implants. I would like custom designs because I do not think that the standard implants will provide enough forward projection. I think I need about 7 to 8mms forward projection while the standard paranasal implants only provide about 5mms of projection at the anterior nasal spine level.
A: While custom paranasal implants can be made, I would opt for what I call semi-custom paranasal implants. These are actually custom paranasal implants made for other patients. But when used for someone else we call them ‘semi-custom’. I have found that the size and fit of most of the custom paranasal implants will fit just about anybody. (and coincidentally they all have been made for Asian patients who are seeking the same aesthetic changes you are) Semi-custom facial implants cost less than custom facial implants. Well-fitting paranasal implants can’t really or become displaced…but I still put a very small screw into each side just to be sure.
A custom paranasal implant can produce a facial effect that is very similar to that of a LeFort I osteotomy. While it does not move the teeth forward like a maxillary osteotomy can, its effect on the nasal base is very similar.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am jnterested in lip reduction surgery. I was having problems snoring, went to sleep doctor, dx’d with sleep apnea. He offered CPAP but said corrective jaw surgery would also fix my problem. I went to oral surgeon and will be later this year having both jaws moved forward about 7mm to fix my sleep apnea.
I am interested in an upper lip reduction (we can discuss at the appointment, no problem). My only question is do you recommend I wait until after the jaws are moved forward or can it be done before the jaw surgery? Thanks a lot.
A: Because orthognathic surgery, particularly two jaw advancements will have some lip thinning effect, any consideration of lip reduction should be 3 to 6 months after the procedure. It may well be possible that after orthognathic surgery with the jaws advanced you may no longer see the need to have the lips made smaller. Between the thinning effect on the lips from the jaw advancements and the scar tissue created, it is likely that there will be less vermilion show particularly of the upper lip. As the jaw moves forward it does push the lip forward causing some potential rolling in effect of the lip vermilion.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a forehead implant placed three weeks ago, but it seems a little too big. At this point, roughly how much swelling is left from the procedure? I’m just a little concerned as it has been quite a while after the surgery.Thank you for taking the time to read this and it is much appreciated.
A: I am afraid you have my at an informational disadvantage. I did not do your forehead implant surgery, I have no knowledge of what you looked like before your surgery, nor any idea as to the size and dimensions of your forehead implant. This is really a question for your surgeon who implanted it. You had the confidence for him/her to do the surgery, you should have the confidence in what they are telling you now about your postoperative concerns.
But as a general rule, 50% of the swelling is gone by 10 days after surgery, 75% by three weeks after surgery and 95% by six weeks after surgery. This it is still a bit too early to know what the final outcome will be. There is certainly still some swelling that remains so your recovery is still not yet complete.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in chin and jaw enhancement. I am reaching out to you after doing thorough research in hopes that you could bring some clarity to my concerns and harmony to my face. I am attaching pictures of me in different angles as well as pictures that I have edited with photoshop which reflect a look I would like to achieve. Whether that is possible or not, that is something I trust you with.
I am a female model currently living in Los Angeles. In this industry strong, defined bone structure such as jaw line and cheek bones are critical to a models success and highly sought after. As it stands I have a receding chin that I would like to correct and perhaps dramatize the look of my jaw. In your opinion, what does my face need in order to achieve a more defined look, like presented in the pictures? What are my options? As an out of town patient, planning a surgery requires more resources and time. I am looking forward to hearing your thoughts on improving my face as well as to get a general idea of the cost break down per procedure. Thank you in advance for taking the time to read my email, I greatly appreciate it.
A: Thank you for your inquiry regarding jaw enhancement and sending your pictures. What separates your face from that of the model pictures you have shown are three facial features. The jawline (chin and jaw angles) and nose are the most strikingly different. Besides the shorter chin you have mentioned, your jaw angles are more rounded and indistinct. (unlike the models which are more square and defined) Such a more deficient jawline looks more so because of the size of your nose. (and vice versa)This can be treated by separate chin and jaw angles implants or a sliding genioplasty and jaw angle implants. Coming jawline augmentation with a rhinoplasty would make the most dramatic facial change that would enhance its overall features and bring them into better balance.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in forehead augmentation and have enclosed photographs for your review. I am interested in augmentation of my forehead and brow area. As you may be able to see, my right side is much flatter than my left side and I have a very narrow forehead. I have chin and jaw implants and I feel that my recessed forehead caused my face to be out of balance. I am looking for augmentation to allow for an overall balanced and more aesthetically pleasing look.
Do you believe I need augmentation to the front part of the forehead or just the lateral forehead? Based on your recommendation, how much would such an augmentation cost for PMMA? What are your thoughts about using fat to augment the necessary areas?
A: For your forehead augmentation, you need both central and some lateral fullness. If only the central area is augmented the sides will even more narrow. Such forehead augmentation should not be done with PMMA bone cement since you can’t place a bone cement material past the temporal lines on the side of the forehead where there is not bone. Also PMMA bone cement does a poor job of creating any brow bone augmentation. The type of forehead augymentation you need is best done by using a custom silicone implant designed from a 3D CT scan.
Fat is almost always a terrible idea for forehead augmentation because it survives poorly, has an irregular take and any such irregularities will be impossible to remove secondarily. Fat also produces a soft doughy appearance and not a well defined shape like augmentation of the bone does. A good forehead and brow bone augmentation in a male requires the hard push coming from placing a firm material on the bone.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I know you warned me that the jaw angle implant recovery would involve substantial swelling for a while. I am at the 2 week mark. I can tell I should not have gone with any ‘drop down’ with the implant. This change is a bit more than what I was looking for. I should have stuck with just 3 mm width, no vertical lengthening. I am wondering what is the next step to getting this fixed. Would I be able to get them replaced with smaller ones (or completely removed)? And, could this happen soon? I am sort of desperate at the moment, I am really sorry. I do need your help on this.
A: I am going to give you some advice on jaw angle implant recovery based on an enormous experience with them in young male patients. You may choose to take it or not and I will do whatever your decision may be.
- I have heard your concerns from innumerable young men who have had jaw angle implant surgery and it is always about the same time period…about two weeks out from surgery. At this point you are far from seeing the final result, both physically and psychologically. On average 50% of the swelling is gone in10 days, 75% in 3 weeks and 95% by 6 weeks after surgery. So while you may think you know what the final outcome will be, you do not. No one can say for sure at this point in the incomplete recovery process. There is also the ‘getting used to’ the new look which takes much longer. So any decision made today is a premature one that could result in an unnecessary surgery.
- The economically prudent and medically advised recommendation is to give the recovery process a minimum of 6 weeks and ideally one should not have revisional surgery for three months after any form of facial skeletal surgery. (temporal implants are NOT like facial skeletal surgery) Any surgery before that time period is really chasing a moving target from an aesthetic standpoint.
- Any surgery before this time period has elapsed is really an emotional one that is not based on logical thinking. I will do it but I need to make clear I do not think it is a wise choice. After three months you may still come to the same conclusion (or not) but at least you will know an undisputable clear idea of the result and how you really feel about it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 28 year old Asian male interested in head width reduction. I have received a consultation in the past, where I was told the surgery I needed would be very dangerous and expensive potentially even lethal. Is your procedure different? I believe my face is otherwise fine except I have a very wide head above my ears. I have a smaller chin so my head appears unbalanced. Would I benefit from surgery? I noticed you also use Botox to good effect. Could I try the Botox first to see how it looks and then go with the surgery if the result is good? Looking forward to your advice.
A: The statements that you have been told about posterior temporal reduction (head width reductio above the ears) are completely untrue. There were obviously made by surgeons who have no experience in this type of surgery nor understand the anatomy of the area. The majority of the width of the size of the head is made up of muscle not bone. The posterior temporal muscle width is as much as 9mm in thickness. When this is reduced through a very straightforward and effective procedure with no side effects and very minimal recovery, the change in the width at the side of the head can be dramatically different. If you do the math, up to almost a 2cm width reduction in head width can be achieved. This is particularly true in Asians males where the thickness of the temporal muscle is quite significant. There are no adverse functional effects on jaw opening by removing this portion of the muscle.
While you can certainly do Botox first, it will not create the same head width reduction effect as this type of surgery. But there is never any harm in doing so.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have some questions about facial feminization surgery. I was wondering the prices of the surgery and whether insurance many cover some of them. I am a 32 year transgender male to female.
A: As you know Facial Feminization Surgery is a compilation of a variety of facial procedures which differs amongst each patient. The first step is to determine which facial features would benefit most by changes and establish a priority list of what the are from most important to least important. This requires considerable input by the patient themselves. You probably have a good feel for the facial areas that you think would make the biggest difference in a more feminine facial appearance. I would ask that you listen for me the top three in your assessment. Once we have a list of procedures then you can be provided pricing.
As for insurance coverage for facial feminization surgery, that is very rare…but I have seen it occur. The way to determine if insurance would potentially cover any of these procedures is to file a predetermination letter. It is up to the insurance company, not the surgeon, to make that decision. All I do is provide them with the information needed. That required information would be the following; a set of facial photographs, documentation from a physician/ therapist that states that these procedures are medically necessary and the patient is a good psychological candidate to do so and a list with procedure codes of the facial operations needed. The latter is my my responsibility as well as the composition of the letter, the fist two are your responsibility to get to me.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am an Asian male interested in custom cheek implants. Is it possible through custom implants to add lateral projection to the zygomas? What would be the maximum lateral projection the implants could give? (Iam hoping for at least 1.5cm to each zygomatic, but 2cm each would be ideal). I am after a look of very prominent cheeks to go with a very prominent jawline (also through implants) similar to the guy in this picture (note his flanged and very prominent cheekbones) Thank you for your assistance.
A: When it comes to designing custom cheek implants, any size or dimensions of the implant can be done. In making these designs and in looking for an ‘extreme’ facial look, one only has to be vigilant of two issues. First, one must make sure that the size of the implant does not preclude a good and competent intramural soft tissue closure over them. The stretch on the cheek tissues in very large implants can theoretically cause such an issue which would be disastrous if wound breakdown occurs postoperatively. Fortunately the cheek soft tissues are fairly elastic and have a lot of give to them. Secondly, one must avoid making an implant that is too big and thus creating the need for revisional surgery. The actual site and thickness of a cheek implant to create the look you are desiring is probably less than what you think. I have placed cheek implants up to 1 cm in thickness on each side and it can be impressive as to how much change that creates. I would doubt that you need 1.5 cm to 2cms of width on each side to achieve that cheek augmentation look. Dimensions such as those does run the risk of oversizing and the potential need for a revisional surgery to downsize the implants.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was previously going to have a chin implant with screw fixation. At the time, I was planning to get one and was planning to consult with you. I’ve done a lot of research since that time and have come to the realization that I’d like to address my issues with bimaxillary advancement as my entire jaw region isn’t adequately projected and I have a “fleshy neck” appearance in photos and on video. My airway is also smaller than it should be and obstructive sleep apnea is an issue.To the point – I’m debating getting a sliding genioplasty in conjunction with my bimaxillary advancement to advance the chin horizontally. I want my chin to be closer in line with my lips and I did not know if bimaxillary surgery alone would address this or not. Would a sliding genioplasty be a bad idea (too deep labiomental fold afterward)? Thank you
A: Having done lots of orthognathic surgery, including bimaxillary advancements, the only reason to pursue that course is for the purposes of improving sleep apnea. From an aesthetic standpojnt, bimaxillary osteotomies along would not cure the weaker chin and fleshy neck appearance that is of concern to you. That anterior movement of the mandible, in the range of 6 to 8mms, would help your chin projection but since the upper jaw is coming forward it would not provide the ideal correction. Cephalometric tracings would verify the accuracy of that statement. A sliding genioplasty would still be needed to provide the aesthetic goal of making the chin be closer in line with the lips. The bimaxillary advancement would make the amount of amount of the sliding genioplasty less however. All forms of chin augmentation, including a sliding genioplasty, will make the labiodental sulcus deeper. That is unavoidable but a 4 to 5mm sliding genioplasty advancement would not make it that much deeper or would make for a minimal adverse change in its depth.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in nerve repair. I had eyebrow hair transplants three times. The last time I had done was over one year ago. Since then I have had electric, shock like, tingling, numbness pain and crawling sensations that are felt along the eyebrows and down sides of nose. Smoking and stress worsen nerve pain and nothing relieves it. It lasts all throughout the day. I feel I have had a nerve cut in that area and wondered if I would be a candidate for surgical repair to this area? It causes much distress in my life. I would be happy to hear any input from you
A: With eyebrow hair transplants I can theoretically see that injury to the nerves under the eyebrows could account for either pain or sensory loss by either the injection of a local anesthetic into the eyebrows or from the creation of a needle tract for the placement of the transplanted hair follicle. The distribution of the pain should help determine if this could be the source.
The only nerves that are under the eyebrows are the supratrochlear and supraorbital nerves. In detailing the anatomy of the supratrochlear nerve, it is a branch of the frontal nerve (1st division of the opthalmic division of the fifth cranial nerve. It comes out right below the inside the brow bone and comes up onto the forehead in the glabellar muscle region. It supplies feeling to the skin of the upper eyelid and the glabellar region of the forehead. The larger supraorbital nerve, also a branch of the frontal nerve, comes out either right under or on the brow bone right below the inner half the eyebrows and supplies feeling to the frontal sinus and skin of the forehead all the way up into the scalp. As you can see from this anatomical description, injury to either of these nerves does not account for the distribution of the pain down along the sides of the nose. That is the vexing part of your pain symptoms
But using the analogy where there is smoke, search for a fire. It is fair to say that it must be some type of injury to these nerves. At this late date, actual repair of a cut nerve if it existed would not be possible. All that can be done at this point is an endoscopic approach to decompress and release the supraorbital and supratrochlear nerves, possibly wrapped in fat graft to prevent secondary scar tissue formation around them. This is exactly what is done in migraine surgery. Whether this would work for you is unknown. One test you could do is to inject Marcaine local anesthetic around these nerves to determine of that provides temporary symptom relief. If it did that would provide you with great confidence that is the source of the problem and an endoscopic release may provide some symptom improvement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, it is hard to find a good scar revision specialist who can answer some basic questions without a formal consultation. As you have already answered my initial questions in regards to my scar, I would like to ask you my most important last question that is still on my mind.I still have not decided what to do about my scar. The best treatment would be excision as most of the doctors have recommended. But the reason why i still have not gone for excision is that I do not like the fact that my scar will be much longer. My chin scar is 0.3 cm wide and 0.5 cm long now. I had a prior consultation with scar revision specialist and he said that scar will be about 1.2 cm long after the revision which I do not like. He would place it in a curved or oblique line that parallels the curve of my chin pad – this is called a resting skin tension line (RSTL). I saw many scars after excision so why some of them are not so long even though they are as wide as mine. I would appreciate your answer.
A: The best treatment for your scar is a two-stage excision scar revision approach that does not make the scar any longer. The problem with your scar is that it is wide over a tight chin area. While it can be removed as a single stage procedure, the scar length would nearly double in size. Because of its width it is best served by doing a subtotal excision, let it heal for three months, and then doing a second stage completion scar revision. This is the only way to improve your scar without making it any longer.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I understand if this is an upper blepharopasty question you cannot answer online, but I was wondering if I could get your honest opinion regarding my eyelids. Although I’m young, I’ve always felt they are unusually droopy and asymmetric. In particular, I do not like the excess skin of my left eyelid. I understand that my case is a little weird and subtle, so I would appreciate your honest opinion whether surgery would actually benefit me or not. Thank you very much for any information!
A: In looking at your pictures, you do have an extra skin roll on both upper eyelids of which the left side has the greatest amount. A limited upper blepharoplasty of either just the left upper eyelid or both eyelids would be beneficial and a very straightforward procedure to go through with a very short recovery. One’s age really does not matter, what counts is what is the anatomic problem and is it correctable. This is your natural eyelid anatomy and if it bothers you this is a very minimal to no risk procedure to undergo. Upper blepharoplasty scars are very minute and usually not visible even with the eyelids closed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a chin implant revision. I had the chin implant placed three years ago. It’s not a huge issue for me, but I think it should stick out a little more to be more proportionate with my lips and nose. Also, from the front I feel like it looks kind of square. Ideally, a little more narrow in the front if that’s possible? As far as the jaw implants, I just want to have definition. I definitely don’t want to look masculine. I just want my face not to melt into my next like it does now.
A: Thank you for sending your pictures. Your existing chin implant is still abut horizontally short, sits vertically high on the chin and is most definitely very square. Your chin implant revision should provide more horizontal projection (about 3 to 4mm), be positioned a little lower and be of a style that provides a more tapered chin look from the front view. It appears that your initial chin implant was placed using an intraoral approach. Your chin implant revision can be done in a similar fashion.
Your jaw angles are high and some vertical lengthening of the jaw angles with just a bit more width would complete your jawline makeover.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley,I am looking to get a breast lift revision. I had breast implants and a periareolar breast lift performed over one year ago . Since then I’ve had three nipple revisions due to inconsistent shape and size. I am unsatisfied with the result and I am in need of new approach to hopefully fix what I have left. To deal further, I had the initial procedure done 18 months ago. I’ve had two revisions on my nipples since then. My left nipple continued to be more oval and larger then my right. My right I was very pleased with. The most recent revision was done to correct my left nipple as well as lift the breasts, as my original inframammary fold was showing upon any flexion. Both nipples were revised and I developed on infection on my right side. A tip of nylon suture had migrated to the skin surface and caused the infection. There is also a dark spot on my left nipple were I can only assume is nylon as well. Please see if there can be a revision done to restore my feelings of happiness in having this done. I feel very much like Frankenstein and embarrassed with my bra off. Although if more time is needed to pass and I just need patience for them to heal? I don’t have a good feeling that they will. I’ve attached photos of my recent outcome. Thank you so much.
A: Thank you for sending your pictures and detailing your history. It appears that you have had an original periareolar mastopexy (donut lift) with your implants and have been battling areolar asymmetry and hypertrophic scars since. I am not a fan of the periareolar mastopexy as I have seen too many patients go down the road you are traveling. But despite the revisions maybe it is still worth it to avoid the scars from a vertical breast lift. (although they have a much lower risk of these problems than the periareolar mastopexy) The reason is that all the tension of the lift and the implants is placed on the areolar closure. Inevitably they widen and have hypertrophic problems frequently.
But that is water over the dam so to speak now. The question is whether a third areolar revision (breast lift revision) would be beneficial. Despite having two ‘failures’ at them I would still remain an optimist. But you would ned to wait at least 4 to 6 months if not longer to let the scars mature first. Redoing the areolar scars too soon is just a set up for recurrent hypertrophic scar formation as the scar tissue is still inflamed and highly reactive.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a question regarding surgery on lower lip sag. I show a lot of teeth (all my lower teeth) when I smile or talk. I have had a few genioplasties which I worry may have caused it to be like this. Also had braces before which may have more my teeth up. Is there any way to fix this? Like a lower lip suspension? I don’t know if it is scar tissue or what it is. I already have full lips so filler would not be very beneficial. Also I am a guy so I don’t want filler to thicken my lower lip. I don’t know what to do but I am so self conscious about this. Do you think the previous scar tissue needs to be removed from the chin area and resutured with more skin lax above the suture so the lips can spring back up ? Is that even possible? I have heard Botox doesn’t really do much to the lower lip and only moves upper lip down which I don’t want to do as I don’t want a long upper lip. Hope you can help.
A: Correction of a lower lip sag is a very difficult problem and often unrewarding surgical effort. The traditional approach to treating it would be a resuspension of the mentalis muscle through an intraoral approach. Althugh having done this many times, it is unsuccessful more than it is successful. It works best when it is combined with chin augmentation or a sliding genioplasty since it adds to the upward soft tissue support.
In reality the lower lip sag is more of a soft tissue defect than one of malposition when it comes to surgical correction. From that perspective, grafting the vestibule with a dermal-fat graft along with the muscle suspension makes the more sense.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting a tummy tuck but don’t know too much about it. What type of tummy tuck do I need? Should I try and lose more weight before? Although with my back injury and being on disability I don’t see any significant weight loss happening. I have attached some pictures of my overhanging stomach for your review.
A: Thank you for sending your pictures. What you have is a large abdominal pannus and thick abdominal tissues. What you would ultimately need is really an abdominal panniculectomy rather than a classic tummy yuck. Your abdominal tissues are too thick an your weight is too high to do accomplish anything more than an extended abdominal panniculectomy. While such a procedure would clearly have great benefit, ideally you should lose a lot more weight to have the better abdominal reshaping procedure. But for many patients weight loss is difficult and an abdominal panniculectomy now is better than nothing at all. That would have to be a decision that only you can make and I think with your back injury that decision has already been made.
You should clearly understand that an abdominal panniculectomy is not the same as a tummy tuck. It is a less refined although larger amount of abdominal tissue removal whose main objective is to eliminate the overhanging abdominal tissues.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have some questions/concerns about a forehead implant on what can be done over it after it is in place. Would I be able to have Botox injections in my forehead after getting the implant placed by you? Or would this inhibit the ability to do Botox injections there? I also will need a thickening hair transplant in the very corners (temples) which I will do after we do the forehead implant but I want to be sure the transplant can still take to the forehead even if the implant is directly underneath it because I want the forehead implant to raise high up.
A:You should have no problems with getting Botox injections after having a forehead implant placed…as long as the injectors knows not to inject down to the ‘bone’. (that would be a waste of Botox and risks implant infection) Botox injections are placed right under the skin into the muscle not deeper. Also doing further hair transplants after getting a forehead implant is no problem since the implant sits well below the skin level down at the subperiosteal plane. Everything aesthetically you want to do after this type of facial implant is placed is more superficial to it and is perfectly safe.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am very happy with the buccal fat removal and perioral liposuction you did on me a few years ago. I still feel that my face lacks definition though and have been researching lower jaw surgery/sliding genioplasty and vertical lengthening chin implants and wondering if one of those procedures would be beneficial for me to get that angular, taut lower and mid facial structure that a lot of models have. A jaw/chin that has extra projection seems to produce a concavity in the para nasal area that think is really pretty…I know I have an overbite but it’s not severe and I am hoping to avoid having to go through orthodontics and jaw advancement IF a sliding genioplasty and/or a custom chin implant would yield the same results. I have attached some photos of the look I am aiming for (as well as one of myself for reference) and would like to know if you think I could get close to my “ideal” with a genioplasty/implant or if lower jaw advancement is really the best treatment (for aesthetic purposes only). I always feel myself involuntarily jutting my lower jaw forward (it feels more comfortable that way and it also makes my face look better). My face just looks better from ALL angles when I’m projecting my jaw forward. Since I’m already 31 I would like to get started right away, especially if the best choice is jaw advancement since I would have to have braces before and after that.
A: To best answer your question about chin lengthening, I have done imaging based on some old pictures that I have of you of a combination chin lengthening and small jaw angle implants for the more complete jawline effect. You definitely do not need to move the whole lower jaw with orthodontics. That would not produce the same result. The choice is really between a sliding genioplasty vs a custom V-shaped chin implant. Both theoretically could achieve the same longer chin, they are just two different ways to get there. You already have a pretty V-shaped chin and you are young so I am leaning towards the sliding genioplasty because it is more ‘natural’ and would even accentuate the V-shape of your chin. I simply put in the small jaw angles just to give you a little more width and squareness to the back of the jaw…which is what all those models also have.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting a tummy tuck later this year. I work out five days a week lifting weights and and eat a high protein based diet. I am 220 pounds and 6’ 2” feet tall.mI am trying to get down to 10 percent body fat and stabilize at 190 pounds. My trainer predicts that we can achieve that in 6 months and that is when I would like to have the tummy tuck surgery. My lower body is all muscle but I have a very fatty upper body. I have significant visceral fat and of course subcutaneous fat below the skin which will be removed during the tummy tuck. My weight has fluctuated a lot in the past which has resulted in a very lax bulging abdominal wall and stretch marks on the skin. I was recommended to have a full tummy tuck with flank liposuction and central abdominal liposuction as well. But I don’t want central abdominal liposuction, I don’t want to risk any healing and circulation complictitons. It can be done later after the tummy tuck. I have attached pictures of my stomach for your review.
A: Thank you for sending your pictures. I would certainly agree that your tummy tuck should wait until you have maximized your weight loss. That is the only way to reduce your visceral fat component of your abdominal protrusion. This will also allow for the most extra skin to be taken during the tummy tuck as well. I would also agree that any abdominal liposuction or etching can be done as a second stage procedure. That is both safer and more effective when done that way.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am 28 years old and would like to discuss a lower blepharoplasty with fat repositioning. I should say that I have researched this quite a bit and understand the different options. I am only unsure of whether I need the transconjunctival lower blepharoplasty with fat repositioning into the tear trough at all versus whether I would perhaps only need lower eyelid fat injections without a blepharoplasty. I don’t want synthetic injectable fillers.I am attaching some photos for your review. I don’t have excess skin that would require the subciliary incision. Unfortunately, the photos don’t do justice to show that you can actually see several of my veins through my lower eyelid skin. The photos seem to always filter that out but in person, the circles are quite dark and the skin quite thin. I do not have pigmentation of the skin, however- it’s definitely due to the underlying structures. Thank you so much!
A: Thank you for your description and the comprehensive set of pictures sent. They all lead to the following:
1) Your young age and lack of any excessive skin eliminates any open lower blepharoplasty needed.
2) You do not have any herniated lower eyelid fat so fat transposition is not an option.
3) As you may have already concluded, fat injections would be the appropriate and only treatment option. (given that you have excluded synthetic fillers)
Fat injections to the lower eyelids is an exquisitely technique sensitive procedure in the very thin cover of lower eyelid skin. Over correction and lumpiness is not rare as the flow of concentrated fat is not linear due to its more irregular shaped globs of fat that are harvested and concentrated. I have learned to process the fat into an emulsified form to create a more even flow of the material as it is delivered through a microcannula for placement. I also like to add in PRP (platelet-rich plasma) with the fat to get the potential benefits of its growth factors on the cells. In a low volume injectate like that of the lower eyelids the ratio of fat:PRP would be quite favorable
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting a chin reduction in the near future. However, I have been considering having lip implants (Permalip) before surgery on my chin. I was wondering if the implants would in any way hinder a chin reduction surgery? Would it also depend on whether an intraoral method was used? Thank you.
A: You are correct in making the connection between lip implants and intraoral chin reduction surgery. If you were having a submental type of chin reduction (an incision done on the underside of the chin) then having lip implants done at the same time would not matter. But if you were going to have the chin reduction done intraorally it would be advised to either do the implants at the time of the chin reduction ( chin reduction first and the lip implants as the second part of the procedure) or afterwards… but not before.
Permalip lip implants can be an effective and permanent method of lip augmentation. But they require careful placement in the lip tissues and should not be disturbed by traumatic stretching after their implantation until well healed. Thus it is best that they be surgically placed after other oral or facial procedures have been performed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am wondering if sagittal ridge skull reduction plus/minus skull augmentation is an option for me. I went to my doctor with this and had an x-ray, head CT, and bone scan done. A surgeon then biopsed this ridge about two months ago. The biopsy showed benign fibroadipose tissue which he tried to take as much of that tissue off as he could. The surgeon also told me the rest of the ridge is bone. I would like to have this extra bone removed so I can achieve a more natural head shape. The ridge measures approximately 7 cm long x 2.5 cm wide x 0.5 cm high. Of note, I have a healing scar from the biopsy that is about 5 cm long that is midline and runs anterior to posterior over the ridge.
A: Your pictures show what appears to be a classic sagittal ridge skull deformity. I have not seen the x-rays but that entire ridge would be expected to be solid bone. I do not know why a ‘biopsy’ was done nor why there would be a sagittal incision of that length for it….but that is past history now. Using that same incision sagittal ridge skull reduction could be down by a bone burring technique. It would be help to see the thickness of the sagittal ridge on the CT scan.
Dr. Barry Eppley
Indianapolis, Indiana
