Your Questions
Your Questions
Q: Dr. Eppley, I am in need of jaw angle implant revision surgery, I had large, off the shelf, silicone jaw implants done two weeks ago. To me (at this stage) they look too big and are asymmetrical. As you can see from the photographs there is a distinct difference to both sides of my face, with one jaw side being lower than the other. i am also concerned that they bulge and “round out” my face from under the ears. also believe they made my face longer and squarer. I want badly to correct this and if this entails customized implants that achieve (or approach) symmetry, I hope you can help.
A: Let me start by first making a general comment about jaw angle implant surgery in men. Just about every patient in the first few weeks or month after surgery thinks that the implants are too big, asymmetrical or both. While they may very well be (I obviously don’t know what you looked like before and what your aesthetic goals were…and the beard adds another visual element which may or may not be helpful in interpretation of the results), what is important to know is that 50% of the final result is seen at 3 weeks, 75% of the result is seen by 6 weeks and it takes a full 3 months to see every detail of the final result in any form of facial skeletal augmentation surgery. So at just two weeks after surgery what you are currently seeing may or may not be a harbinger of the eventual outcome of the procedure.
I say this because I have seen numerous men jump too quickly into jaw angle implant revision surgery…long before the final result was apparent. There is an accomodation phase to the new look and that does not happen for most patients in the swelling phase of the recovery period.
The two most common complications from any facial implant surgery, in particular jaw angle implants, is what you are feeling now…over/undersizing and asymmetry. Given that you are still somewhat swollen it it hard for me to know what look you were trying to achieve and what makes the way it looks now not desired. Did you have computer imaging done before our surgery to get a feel for the look you could achieve in your face? Your description suggests that they are too big (wide) and are of a lateral design…which would account for the rounded lower face look. I suspect these are 11mm wide lateral angle implants. Such dimensions can also make the face look more square and longer (which is what many jaw angle patients want) but this style implant has very rounded edging.
Jaw angle implant asymmetry is a function of placement and how secure the implants are onto the bone. They were placed from inside the mouth but where they secured with screws?
I ask these questions because the solution to your jaw angle implant concerns may already lie within you (modification of existing implants and their positioning) While custom implants can always be made, I would first look at whether what you have can be salvaged to the right amount of jaw angle augmentation and symmetry…consisting of the simplest and most economic approach to jaw angle implant revision surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I need earlobe reconstruction. I’ve stretched my earlobes to two and a quarter inches. I’ve decided I want to get them fixed and I know you are the surgeon who is best at this. I was wondering how long will I need to let my earlobes shrink before getting the surgery?
A: I would allow them to shrink down for a minimum of 6 weeks, which will be about 75% to 90% percent of how much they will shrink. Usually three months is tehe time when 100% shrinkage has occurred. That is sort of a standard protocol since there is rarely is a need to fix them on an immediate basis. But having done several urgent cases where the earlobes have torn from overstretching and having fixed both sides at the same time, the outcome has been the same whether the earlobes were allowed to shrink down or not. This is not surprising since what is really expanded is the outer rim of earlobe skin which gets removed anyway. It is just smaller if the gauges are removed beforehand. The adjacent earlobe tissue around the gauged site (whcih is what is kept to reconstruct the earlobe) does not change that much.Thus I do not believe it matters greatly whether you allow the earlobes to maximally shrink or not. But if you have the time then I would do so.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a fat injection breast augmentation done one month ago. I took a vacation one week after surgery and I was fine. Well exactly two weeks after my procedure I noticed my left breast was bigger, swollen, tender, painful, and very warm. I thought nothing of it and my doctor said it was normal. When I questioned why my right breast didn’t feel that way he said each breast healed differently. Well the next day after my symptoms got worse and I felt dizzy and weak. I woke up soaked and noticed a yellowish pinkish discharge leaking from my left breasts incision. I ran to the ER and was admitted for 6 days. I had an abcess and required surgery for drainage. I was given a lot of antibiotics and I’m now having to clean and change dressing twice daily. This has been a total nightmare! How long will it take for my infection to go away and for pus to stop leaking? When will my incision close if I have no stitches? I’m afraid my breasts will now look deformed and different in size but im terrified to get another procedure done for correction. What caused my infection? Why only my left breast? Could too much sun exposure, drinking, and pool have caused my infection?
A: Sorry to hear of your very unfortunate complication. While using your own fat for breast augmentation is a natural material, that does not exclude it from the risk of infection. (although that risk is probably lower than with implants) Because the injected fat has no blood supply and must acquire it after being transplanted, there is a period of time after surgery when infection can develop. That is usually between 10 and 21 days after surgery, the time when you are off antibiotics and bacteria have had time to multiply and grow.
Almost all infections that occur close to surgery, regardless of the procedure, occur because some bacteria go into the wound during surgery. Why it occurred in one breast and not the other will never be known but fortunately it was just one breast.
Once you have developed an infection around injected fat, there will be fat loss or less take in that breast. Probably what you have coming out of your wound now is mostly liquified fat rather than pus which is injected fat that is breaking down due to the infection.It will probably two to three weeks until this clears up and heals.
That breast should be allowed to heal for a year, get soft to the feel, and see what the final amount of fat take will be. I suspect there will be some breast asymmetry due to different amounts of fat take per breast. Correction of that breast asymmetry, if it occurs, will be by additional fat injections. Just because you have had this complication does not expose you a subsequent or higher risk if you have the procedure done again.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in some type of forehead reduction. I am a young woman and I’m not happy about my face at all. The biggest problems I have are with my jawline and my frontal bone. I also have really deep insetted eyes. I’m kinda chubby but I used to be skinny and I had to exact same problem. I have big cheeks , something like squirrel cheeks and jowls on the side of my face. I really want a nice tight jawline. When I tighten the skin together and pull it through my ears I see it the way I would want it to be. I was wondering if that is possible for me without having a jawline surgery.
I have a very big frontal bone and I would love to have a nice flat forehead like most women have. I was wondering if that is possible for me to get it flattened. Maybe there is also someting you could do for my deep insetted eyes. I want to send you some picture’s and I’m wondering if you could look at them yourself and if you have any tips for me to make me as beautiful as possible.
A: Thank you for your inquiry and sending your pictures. The most effective procedure that you could do for your face would be a combined orbital/forehead reduction and hairline scalp advancement. This would reduce the depth of your eyes, lessen the brow ridge prominence, and make the forehead look smaller.
Only a jowl lift can create the desired look you are after along the jawline and you are too young for that procedure. There are no non-surgical methods that can create the same effect.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in scar revision surgery. I have a transverse abdominal scar from surgery I had as an infant. It is “socked in” . My skin is adhered to my muscle and there is an overhanging lip above the scar. I am 27 years old. I also have a vertical 4.5 inch scar below the belly button I would like to have lightened. It is two years old.
A: It is very common to see scars from abdominal surgery done as an infant to be completely adhered to the muscles. This is because at such a young age there is little to no subcutaneous fat between the skin and the muscle. The incision line scars down to the muscle (as there is little to no fat interface) and appears as an indented fixed line as fat tissue develops between the skin and muscle around it as the patient gets older. This can be dramatically improved by scar revision surgery by cutting out the scar, releasing the surrounding tissues from the muscle and advancing and closing the skin edges together. While a scar line will still be present, it will be leveled and a much narrower scar. Such scar revisions can often make for a dramatic change in the appearance of such scars.
When it comes to scar lightening that is a different matter. There are not many effective therapies for scar discolorations other than to cut (excise) out the scar.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have two issues: 1) a birthmark the full length of my cheek which I’ve had my whole life and 2) the facial hair covering the birthmark is substantially thicker than that covering my other cheek. Can you help with either of my two issues? Photos attached.
A: What you have is a congenital nevus of the face. Its characteristics are well known and include being born with it, the involved skin is thicker and more pigmented and the hair that grows from it is often darker and thicker. The key concept to understand about congenital nevi is that involve the full thickness of the skin. Thus they can not be removed or reduced by laser resurfacing or treatment method. The entire full-thickness of the skin needs to be cut out (excised) either through serial reductions or as a single surgery and then covered with a skin graft. While this would cure the nevus, it would result in a worsening of the aesthetic appearance of the face and I do not believe you would consider it an improvement. This is a long way to say you are better off to leave it alone as the treatment of it is worse than the problem.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have breast asymmetry and am interested in breast augmentation/lift surgery. I am 18 years old and have had two children. My breasts are significantly different by at least two cup sizes and have been so for six years. I have Tricare insurance. I am wondering if my being 18 years old is ok for breast surgery because I have already had two children so my body is done growing. I’ve spoken with my family doctor about wanting to have this done because its already done a lot of physiological damage to me.
A: Significant breast asymmetry is always a challenge in any form of cosmetic or reconstructive breast surgery. Having had two children and being two cup sizes different almost certainly speaks to the potential of needing some form of a breast lift on at least one the breasts (usually the larger one) and perhaps implants for both. Until I can see some pictures of your breasts I can not be any more helpful in recommending a specific plastic surgery treatment plan as there is great variability in many cases of breast asymmetry.
What is known now, however, is that insurance is not going to cover this type of breast surgery. Unless it is a case of reconstruction after breast cancer, breast reshaping surgery will be considered as a cosmetic procedure by any insurance provider today. The fact that you may have developed this through no fault of your own and it has a significant negative impact on your self-esteem is something that I have learned carries little weight with insurance companies.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am looking for extreme jaw angle augmentation. I recently came across a paper that described a technique for mandibular angle augmentation, where segmental distraction osteogenesis and rib cartilage transplants were used to achieve the desired effect. What I found notable was that the degree of vertical augmentation and the extent to which the jaw became “square” was extreme, beyond what I have traditionally seen achieved with implants. For reference, I have included the before/after pictures from the paper below.
My questions are:
1. Do you (or would you) ever perform distraction osteogenesis to vertically lengthen the jaw, without affecting the bite?
2. Assuming you do not perform this type of surgery, would custom implants be able to achieve the same effect to the same degree?
A: That is an extreme approach to jaw angle implant augmentation for which there is a much simpler technique to get to the same place, custom jaw angle implants. I have done numerous jaw angle implants that drop the angles down as much a 25 to 30mms. I see no reason to ever do a distraction technique to achieve that kind of jaw angle result. What that paper is not showing you is the long-term result of that technique of which I will wager that much of the jaw angle lengthening either relapses or resorbs….not to mention the notching that undoubtable develops between the anterior edge of the distracted bone segment to the normal mandible in front of it. The x-ray shown does not show bony consolidation across the distraction site…probably because it does not occur in an adult. Such a result demonstrates that it can be technically done but that does not always mean it is a good thing to do.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in facelift surgery. I am 55 yrs old and have been single for twenty years. I want to finally get to the place were I feel wonderful about me. I do not want to look like a different person with a drastic change. Is it really possible to have the face procedures to look younger/fresher and still be me? Seriously, I hate what I see on TV from even Hollywood stars who have all the financial resources I could not even imagine.
A: Despite what you see from Hollywood celebrities, that is not the way the vast majority of facelift procedures turnout. Unlimited financial resources do not necessarily allow one to make better choices, often the reverse is true. Being able to do anything doesn’t always mean you should. It is also important to understand that those who are in the spotlight on a continual basis face a whole different set of pressures from an appearance standpoint than you and I do. Lastly the face and body standards in Beverly Hills and Hollywood where most of what you see comes from is much different than here in the Midwest. Just walk around those areas and you will see what I mean.
The reality about facelifts and other facial rejuvenation procedures is the opposite of what you think. It is almost never an issue of ‘doing too much’ but can enough results be achieved to make the patient happy. When it comes to facelift procedures, no one ends up looking like a different person. The key is to do the right combination of facial rejuvenation procedures in a judicious manner that makes one look better and younger and not ‘overdone’.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in brow bone reduction surgery. In the past few months my brows have started to be protrude. Is there anything that I can do to stop it or how much would it cost to have it remove or is their payment options? Its really affecting my way of life.
A: Brow bone reduction surgery is always an option for brow ridges that have excessively overgrown. Your brow protrusion, as long as it is symmetric (and it appears so in your pictures) is the result of a pneumatization process. (development and expansion of an underlying air cavity) While not present at birth, the frontal sinuses have a fair degree of development by 7 or 8 years of age but continue to grow (expand) until well after puberty. Why some people develop bigger frontal sinuses than others is not clear other than due to hormonal influences. (men develop bigger frontal sinuses than women hence the development of the stronger male brow ridge) Spontaneous frontal sinus growth after puberty could be the result of a late pubertal spurt, medications such as steroids or a more conscious awareness of its size.
While brow bone reduction surgery can be done (usually an osteoplastic flap setback is the most effective technique), this requires a scalp or coronal incision way back in the hairline. While this can certainly be done, men always have to think very carefully about this scar trade-off. Given that you shave your head this consideration is of high significance. Initially this is a far more important hurdle to cross than that of the cost of surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in fat injection breast augmentation. I have a consultation coming up with you next week and was wondering if you use the Brava before fat transfer for breast expansion? I was wanting to get into surgery ASAP as I am going on vacation next month and want the surgery prior to the trip. If I have to wear the Brava, I won’t be able to get the surgery done before the trip and be healed enough to wear a bathing suit. Also, I would prefer conscious sedation to a general if you do that.
A: If your goal is to have a completed fat injection breast augmentation within the next thirty days, that is not an achievable goal. Breast augmentation by fat injections, if you are a good candidate (and most people aren’t) requires 3 to 4 weeks of presurgical breast stimulation by the Brava device followed by a similar time period after surgery of use of the device. This is an optimal device, even though it is inconvenient, as it provides stimulation to the breast tissue and the injected fat so that its survival is optimized. Thus you can quickly see that is not going to work by your desired schedule. The only way that time period works to enjoy the benefits of breast augmentation by your vacation is the placement of breast implants. In either case, however, both are best done under general anesthesia. Successful breast augmentation, by any method, is not something to be done under local or sedation anesthesia without suffering a suboptimal result.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a few questions regarding the chin and jaw angle implant procedure. I know you are very busy as a surgeon but if you had a few minutes of free time, I would appreciate it if you could answer some questions before our consultation. It would probably save time for both of us as well. Regarding the Mandible Jaw Implants, I’ve been researching online that this procedure is riskier than chin implants and that they tend to have a higher rejection rate. I’ve also read that they require a very skilled surgeon who has a lot of experience with this procedure. I’m sure you can understand my concerns, so here are my questions:
1) How many mandible/jaw implants (NOT just chin implants) have you done in the past?
2) How often does infection occur with jaw implants and how often do patients request to have them removed (either from infection or dissatisfaction)?
3) I’m looking for that “Chiseled Look”, or angular looking jawline which you see on many famous actors or male models – not necessarily a massive or fat looking jaw – but a defined/contoured jawline. Assuming one has a low body fat percentage, is this look possible with a jaw and chin implant? Also, will the jaw/chin implants look natural in that they look contoured to the face rather than just a large mass hanging from your lower face?
4) How long does recovery take for both a Chin and Mandible Jaw Implant procedure? I’m starting a new job soon so I’m probably going to give myself 2 weeks in between leaving from my current position and the start date for the new job. Would 2 weeks be enough time? It wouldn’t make the best first impression to walk into my new job on the first day and have a swollen jaw, haha.
5) Are the Mandible Jaw Implants customized for different size faces or are they “One-Size-Fits-All” ? I noticed some doctors use customized ones and some use standard implants. Is there a major difference in looks between the two types?
6) Finally, I noticed there are not a lot of Before and After pictures of jaw implants on the internet. Is this because the results don’t turn out good or it because its just not a common procedure? Would it be possible to see some of your jaw implant work during our consultation?
A: In answer to your questions:
- I have performed over 100 standard or custom jaw angle and jawline implants. (and many more chin implants) You are correct in that it is a harder facial implant procedure to do and is not a mainstream facial implant procedure done by a large number of surgeons.
- The infection risk with jaw angle implants is not higher than any other facial implant although the material of which they are made can affect that risk. (Medpor has higehr risk than silicone) Expect a 10% to 15% risk of revision which is usually for asymmetry or unhappiness with the size. (too big or too small)
- The only male patients that can achieve a ‘chiseled’ look or a male model look are those men that have a lean face where changes in the skeletal contours are most easily seen. With today’s implant shapes and designs there is no such result as the implant looking like it is ‘hanging from the bone’.
- Two weeks is really not enough time to recover from a facial appearance standpoint. Three weeks is more realistic.
- Both standard off-the-shelf implants as well as the option to customize them are available. Which approach a patient takes depends on their aesthetic needs and their budget.
- Since few plastic surgeons do this kind of facial work, it is hard to find many examples of results. My work is fully reviewable on my website at http://eppleyplasticsurgery.com//jaw/ under the patient photo section.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I want to know about facial fat injections. I know a 24 year old who is unsatisfied with her facial appearance. She weighs 118 lbs, and is 5’6”. She does have a lot of facial fat especially in her lower cheek and the areas around the mouth. Ironically, this makes her mouth look fat. She has had braces, but is still unsatisfied because she says that the most noticeable part of her face is still her mouth. She is pretty, but she does not smile because the “excess skin makes creases” at the sides of her mouth. I did a little research and deduced that she has noticeable perioral mounds due to a lack in facial volume. Do you offer fillers such as sculptra and radiesse, or would fat transfers to the cheeks be possible and could this possibly improve her appearance to a noticeable extent? She is doing all she can to avoid getting cheek implants. She is so young to be unhappy about her face.
A: Some of what you ate saying is a it contradictory. Perioral mounds are excessive collection of fat just to the sides of the mouth. They do not occur ‘due to a lack of volume’ as you have described. You may have mispoken in that regard. Thus I am not sure your friend had too much fullness at the perioral mounds or a lack of it.
Injectable fillers are always a good first step to try if one is uncertain whether the addition of volume is the correct facial approach. If one is certain that the addition of volume is needed, facial fat injections would be a better approach as it has the potential to offer some permanency while synthetic fillers do not.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Can I benefit from cheek implants? I have a long thin face that has always bothered me. I don’t know what if anything can be done to add fullness or reduce length? I always look like I am scowling and as I age…it gets worse. The first picture attached us awful I know but it at least gives you an idea of my situation. The second pic is simply one I have played with to widen my features and wish were possible. Thanks for your time.
A: There are improvements that can be made to a long thin face in terms of both length and width. Facial height reduction options are more limited than those of width and are often relegated to the considerations of vertical chin reduction, upper lip lift (shortening) and in some cases rhinoplasty. Numerous facial width increase options include jawline and jaw angle widening, cheek implants and fat injections between these two skeletal area. (the trampoline facial zone) Which one(s) of these might be most beneficial to your face depends on a computer imaging analysis. Unfortunately your one picture is not adequate to much of anything with due to the poor picture quality. If you could send me a front, quarter and profile views of your face (non-smiling) I would be happy to do that assessment for you. Based on this one picture it does seem that cheek implants may be helpful for more facial width and that could be combined with fat injections for a more blended transition from the implants into the thinner and non-bony supported areas outside of the cheek zone.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like to have a chin dimple made to look like Adele’s chin. Can you do that and how is it done?
A: What you are asking about is chin cleft creation surgery not the creation of a chin dimple. In looking at the chin of the singer Adele, careful assessment will show that what she actually has is a chin cleft and not a chin dimple. This chin feature distinction is not really semantics but two distinct anatomic entities. A true chin dimple appears on the center of the chin pad above the lower border of the bone and is a circular indentation. It occurs as a result of an underlying soft tissue (fat) deficiency without a mentalis muscle defect. Conversely a chin cleft appears on the lower end of the chin pad and is a vertical groove that crosses the lower border. It can have a wide range of depths from just a very shallow hint of a line to a very deep groove. Chin clefts are the result of an actual mentalis muscle defect (midline separation) and may actually involve a groove in the underlying chin bone as well.
In the surgical creation of chin dimples and clefts, this distinction is critical as the technique to do them is different. As a general rule, successful creation of a chin cleft is more reliably done than that of a chin dimple. Chin cleft surgery is best done from a small incision on the underside of the chin, a groove is made in the bone, a strip of soft tissue including muscle is removed above it and the underside of the skin sewn down to the groove made in the bone. It can also be done intraorally but it is technically more difficult and I have found it to be not quote as reliable in terms of getting a good result. This is a small outpatient procedure that can be done under local anesthesia or IV sedation. Other than some mild chin swelling there is no real recovery afterwards. Expect that to see the full depth of the chin cleft result to take about six weeks.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had an intraoral large silicone chin implant placed about nine years ago and have had a lot of chin implant complications. am 31 years old now and since the beginning I got into a cycle of pain from chin swelling followed by tightness, numbness and itching sensations. Rare were the moments where my chin wasn´t swollen and pain free. The itching is basically in my right cheek. Four years ago I had a fibrosis inside this right part of my face and the doctor thought it was due to the tip of the implant so he had cut the cheek from the outside and cut the tip of the implant filling the hole left from the fibrosis with body fat. The appearance from the right cheek didn´t improve much and from then on I had to carry a scar from the procedure. About a year ago I had a fistula in the right gum that bleeds weekly. I´m terrified about the implant removal procedure been performed by the same doctor, the pain not going away due to eventual permanent nerve damage and bad looking chin appearance after removal. Do you know how to solve this by eliminating the pain and also leaving me with a good looking chin?
A: Chin implant complications of this magnitude are rare. I am not sure why you have such symptoms of itching and chronic pain but this long sequence of events suggests that the implant should be removed and your chin augmentation done with a sliding genioplasty. Moving the chin bone would eliminate any potential concerns about a foreign body in your chin and all the issues that have accompanied it. I would need to see some pictures of your chin for your further assessment but this does not sound like an implant salvageable situation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, is there a mouth widening surgery? can a mouth actually be enlarged? My mouth is so small dentists literally have difficulty working inside. One told me it was the smallest mouth he’s ever encountered (I’m not making this up). A 1/4 inch more would make me and my dentist infinitely grateful. But is that possible?
A: Yes a mouth can really be enlarged or made wider (longer) from a horizontal standpoint. Known as a lateral commisuroplasty, the corners of the mouth are opened up and the horizontal width (length) of the corners are expanded. This is done by making a 1/4 inch (6mms) incision in the skin from the vermilion-cutaneous junction horizontally outward. Then the vermilion lining (pink part of the lip) is advanced from the inside out to make a new lining and corner point. While an incision is necessary, all scars line remain along the vermilion-cutaneous junction (skin-lining edge) and not beyond the corners of the mouth. When done on both sides this amounts to a 1/2 inch mouth widening. When you factor in scar contracture of about 25% to 33%, that still leaves one with a 1/4 inch or more increased mouth width.This is a very simple procedure that can be done under local anesthesia.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I found a comment from you on the internet regarding burn scar revision. The reply seemed very honest regarding how to treat burn scars….meaning it is very difficult to treat and a 100 % elimination of it is not possible. My daughter is 14 years old and when she was 4 she was involved in a terrible accident, which left her with a 3rd degree burn scar on her forehead. Now the teenage years has begun and that is very difficult for her, as the focus from other teenagers constantly is her scar. We have tried laser surgery with limited success. The main challenge is the dark colour surrounded by a white scar colour and then the normal skin. What kind of solutions do you see, if any. Please let me know or perhaps I can sent you some photos. Thanks a million in advance for your reply from a very desperate father.
A: While I would need to see some pictures of the forehead scar to give a more definitive answer for your daughter’s case, I can make some general statements about burn scar revision. Burn scars are the most difficult of all scars to treat because they are broad-based and the involved skin, and sometimes the surrounding skin, is not normal. Pigment has been lost and the healed burned skin is not normal. There is just no way to ever make burned scar acquire pigment (the melanocytes in the skin layer has been lost) or achieve normal elasticity. Some texture changes in the skin may be possible by fractional laser resurfacing but you can not stimulate abnormal skin to become normal skin. The surrounding hyperpigmentation of the unburned skin can also be very difficult to eradicate. While some mild improvements may be possible with fractional laser resurfacing and pulsed light treatments, significant changes are not usually seen and the results will always be less than what any patient desires. In some cases, the burn scar is more linear and it may be able to be excised back to normal skin. There will always be a scar but this type of burn scar revision makes for more significant improvement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like to know if you actually do silicone drop down jaw angle implants. Where I am from not many people do it here. I am not a big fan of Medpor. Roughly how much would you charge for this procedure as I am saving up. Let’s say if you do have a drop down silicone implant can one get a few mm width as well? Iwould like a bit of a square look from front but not too extreme as I have a skinny skeletonized face? On the picture I have uploaded my right side jaw as without the beard I do not like the shape of it. I would like the jaw angle to go back towards my ear and possibly a small drop down so my face does not look too long. Personally I think my chin is fine and my jaw isn’t too bad as some peoples but I’d like it to be more square from the front and from the side. I have also took a picture of my front face and as you can see it is a bit more chiseled. I am hoping I can achieve this look like in my after picture since my face is skinny. I’d preferably like silicone.
A: The concept of vertical lengthening jaw angle implants made of silicone is one of which I am quite familiar. Historically silicone jaw angle implants could only add width and not vertical length, a flaw in their basic design. Snce most patients that want jaw angle augmentation have a high jaw angle position, vertical lengthening is one of their most important dimenions. I am working with a major silicone facial implant manufacturer on these new jaw angle implant designs which will have various length and width dimensions to them. With a silicone material these implants will be easier to insert as well as revise/remove should that be necessary.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am very sorry to disturb you, I live in a remote area of Russia, and my grandson was born with craniofacial distortions of his face and skull. My friend found your contact details in the Internet. I have a few questions to you:
1) Is it possible to enhance at the same time (by one surgery) my grandson’s forehead and back of his head? They are both too flat and the maximum distance between his eyebrow line and the back of the head is 14.7 cm only. By how much is it possible to make this length longer?
2) What should it be done with his medium face? Will it be the treatment by implants, or it is possible to put there human grease/fat?
3) What else could you recommend on him ? We know that he also needs the surgeries on his jaws.
4) How much will it cost us to get the above mentioned treatments ( 1) and 2) points) at your clinic in the USA?
Thank you so much for your reply.
A: Thank you for your inquiry. In looking at your grandson’s pictures, it is clear that he was born with some form of craniofacial deformity, most likely one of the craniosynostoses. (Crouzon’s etc) It also appears based on the scars on his forehead that he may have had some initial efforts at craniofacial surgery when he was younger.
While you did not state his age, he appears to be a mid-teenager at least. I will separate his craniofacial concerns for this discussion into cranial (skull/forehead) and face.
From a skull standpoint he has a short front to back distance typical of many congenital craniosynostoses. He is shorter in the back than in the front in my assessment. The back (occiput) can be augmented significantly (up to 2 cms.) and the forehead smoothed out for a better contour. The most relevant issue here is where is his previous coronal (scalp) incision as that will determine how to approach is skull augmentation reshaping.
From a face standpoint there are two directions to go. Ideally he needs pre- and postsurgical orthodontics and a LeFort I midface advancement with a sliding chin genioplasty. The key there is orthodontic preparation. If this is not possible, the second approach is to camouflage the bony deformities by a combination of orbital, cheek and paranasal implants combined with a sliding genioplasty. (see attached imaging) That could be done at the same time as skull augmentation.
The key in any complex craniofacial problem in a mid- to late adolescent is to identify those craniofacial surgery procedures that are most practical to do that provide the greatest physical and psychological change for the patient.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am working on a story and wanted to get a quote from you in regards to mouth lift surgery. What are your thoughts on people who are having it at a young age – are there pros and cons? How serious is the operation? What is the average age for this procedure? Does it make a difference on Asian patients?
A: Corner of the mouth lift surgery has been around for a very long time. It was introduced over fifty years ago, long before facelift surgery was widely done. It was developed to treat the downturned corners of the mouth that develop from aging as the facial tissues sag. This facial droop pushes down on the mouth corners changing a horizontal smile line to an inverted smile line (at rest) in some people. The corner of the mouth lift was done to directly remove the overhanging skin and lift up the commissures. (corners of the mouth) It is a very effective small procedure that has not really changed over the years. Despite its history, it is not well known and many think it is a new surgery.
A corner of the mouth lift is a very simple procedure done in the office under local anesthesia. There is virtually no recovery other than having a few small sutures for a week. While it is incredibly simple to do from a plastic surgery standpoint, it is a very technique sensitive and delicate procedure in which the design of the cutout must be very carefully done to achieve a good result and not have any adverse scarring.
As you could surmise by its history, the corner of the mouth lift is traditionally done for patients who have general facial aging concerns. (usually greater than 45 to 50 years of age) But I have done the procedure on much younger patients (as young as age 16) who naturally have downturned corners of the mouth or corner of the mouth asymmetry. (one corner turned down, the other one normal)
As you have mentioned Asian patients, you may be referring to the recent internet story on the ‘Smile Lipt’ procedure out of Asia. This is just the traditional corner of the mouth lift done to give patients a permanent smile or mouth curls, often it appears on younger patients. By American standards, the Asian mouth curl result would be considered unnatural and exactly the ‘complication‘ from a corner of the mouth lift that we would want to avoid. But this is just the fashion and beauty differences between countries with very different cultures. You may read more about this in my recent blog story entitled ‘The Global Differences in Corner of the Mouth Lifts’.
Dr. Barry Eppley
Q: Dr. Eppley, I am interested in breast augmentation and possibly breast lift. I live in Minnesota but my best friend lives in Indianapolis and she suggested you. I am wondering is I were to come to Indiana for the surgery if I could have a consultation with surgery the following day. Also, being from out of town, how often would I need to be rechecked?
A: There would be no problem with scheduling surgery and just having a consultation the day before. That is a common occurrence in my practice as we see patients from all over the world every week. To make that happen effectively there are certain breast augmentation questions that should be answered in advance. They include the following:
1) Are you interested in saline or silicone breast implants?
2) Are you interested in round or shaped (anatomic) implants if you prefer silicone?
3) Do you have an incisional preference for placing the implants of lower breast fold (inframammary) or axillary (armpit)?
4) What size result do you want? (pictures are helpful here of breast augmentation results you like)
5) What is your height, weight and current bra size?
6) Do you have any breast sagging? (this is a very important as if so a breast lift may be needed with the implants)
If you have the ‘perfect’ breast for augmentation (no sagging, nipples locate well above the lower breast fold) then presurgical photos may not be necessary. But if your breasts may be less than perfect or have known sagging, please send me some pictures of them so I can know in advance as to what you exactly need.
As for follow-ups, I like to do phone, Skype or Facetime conversations to accomplish that for my far away patients. Between pictures and e-mail communications, all the follow-up that is ever needed can be done at a distance. From these we can make the determination if you ever need to come back and be seen by me in person.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was in a bad car accident over 15 years ago. I had a tracheostomy to enable me to breathe. But it has left a terrible scar. Growing up through high school, college, and even some times today; people tease me about having a “hickey.” Also even children who I do not even know will point to me to their mothers after they see me because they notice the scar on my neck. I am tired of being teased by people I know and even young children who do not even know me at all. Would I be able to have tracheostomy scar revision to remove the scar. (The doctor “fashioned” the scar to look like a cross but since it’s over 10 years old, the scar does not resemble a scar.
A: I think there is no doubt that your tracheostomy scar had a lot of room for improvement. I would not use the term tracheostomy scar ‘removal’ as that would be impossible to never have any scar on your neck. But minimizing it is the realistic goal so the proper term would be tracheostomy scar revision or tracheostomy scar reduction. This would require complete horizontal scar excision, surrounding skin underming, possible dermal-graft placed underneath and then a linear layered closure done. While initially his would be just a fine line scar, it would take a few months to see if any scar widening developed. (although never to the degree that you have now) One should even think about a second stage revision or laser resurfacing for optimal improvement should the scar become a little wide although I would hope this would be unnecessary. This is a procedure that could be done general or IV sedation an an outpatient procedure. There essentially is no recovery from it other than scar healing.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Is it possible to thin out my large African-American nose, add a defined bridge and still look “natural”? How long does surgery take and how long is recovery?
A: Thank you for your inquiry and sending your pictures. The African-American rhinoplasty is unique because of the very thick overlying skin and lack of a strong bone or cartilage framework underneath it. You are correct in your description of how to approach the broader and flatter nasal structure by dorsal augmentation (usually with an implant), increasing tip projection with definition with columellar strut and tip cartilage grafts and nostril narrowing. I have done some computer imaging to show some of the potential outcomes with are highly controlled by the thickness of the overlying skin and how well it can contract down over a new supporting framework. The first imaging prediction is based on the least amount of change (thinning) that can occur while the second imaging prediction is based on what I believe to be the maximum change that can occur in a single rhinoplasty procedure. You did not provide a side view image so how that would be affected will require a profile picture. I will let the images speak to your assessment of whether such a result would be natural in appearance.
This typical African-American rhinoplasty usually takes about 2 1/2 hours to perform under general anesthesia as an outpatient procedure. Since internal breathing work does not need to be done (I am assuming) nor do nasal osteotomies or a rib graft harvest (since an implant would be used), there should be minimal pain afterward and no bruising. Recovery is more about how you look having to wear external nasal tapes and a splint for a week after surgery. Once that comes off there are no physical restrictions and one’s appearance should be socially acceptable. While the final results of a rhinoplasty can take six months to fully appreciate (maximal skin contraction and thinning), one should be reasonably comfortable returning to work and socializing again in 10 to 14 days.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I will be turning 20 later this year and I was wanting a more thicker appearance at the top of my breasts. I’m fine with my chest area I really wanted to get a fat transfer I really don’t want the implants but if I would need to I could.Thank you.
A: Whether you are a good candidate for fat injection breast augmentation depends on the size and shape of your breasts and what your breast augmentation goals are. You describe the goal of ‘thicker appearance at the top’ which I interpret as just wanting more upper pole breast fullness. Given your young age and this smaller type of augmentation, fat injection breast augmentation may be a reasonable option instead of implants for your needs. However, whether you have enough fat to harvest, how much fat graft volume is needed and whether this would require more than one injection session are issues to be evaluated before determining if fat injections can achieve your aesthetic breast goals. We know that a small breast implant can achieve that goal successfully and in an efficient manner, the question is whether fat can do the same.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have been told by another physician that infraorbital rim implants would benefit me. I have dark circles that have really been developing a lot under my eyes and have had Restylane with little effect (just one treatment). I am hoping for a more permanent solution. Do you agree it could benefit me? Can this procedure be done under local anesthesia? What is the approximate cost of this procedure? I have attached my photos.
A: I would agree that you are a good candidate for combined infraorbital rim-malar implants given your anatomy and the lack of success with injectable fillers. Both your cheeks and your lower orbital rims are retrusive in position. From the side view you have a negative vector, meaning the cornea of your eye sticks out further than the cheek-lower eye socket bone. This is an anatomic sign that bony augmentation may be aesthetically beneficial. The placement of orbital rim implants can be done in two ways, either through a lower eyelid incision (preferred) or from an intraoral approach. Better implant placement and less risk of injury to the infraorbital nerve is ore assured with a lower eyelid approach. Either way the procedure can NOT be done under local anesthesia under any circumstances. The approximate total cost of the procedure is around $6500.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m doing fine after my facelift surgery except for one big problem. I have a serious issue with bladder control. I’m constantly feeling the urge to urinate and can expel just small amounts to less than a dibble. It’s been uncomfortable. Any ideas on how to re-regulate this?
A: I am not a Urologist but your after surgery issue is not the first time I have seen it. Urinary retention after surgery in older men is not uncommon, particularly if they have a known or unknown enlarged prostate gland. Usually the problem is treated by the use of a catheter which is passed into the bladder to allow the urine to empty. Initially a one-time (in and out) catheterization is done. But if the bladder fails to continue to empty properly, a catheter may need to be replaced and left in a for a few days. There are no medications that have been proven to be helpful for urinary retention although drugs such as cholinergics and sedatives have been tried with variable results.
You do not want to go for an extended period of time with bladder over distention. Based on your comfort level and how much (or little) urine you are getting out, a visit to the local emergency room may be in order.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in liposuction surgery. I have never been terribly overweight, however, I can’t lose the belly fat. I would also like to take a few years off my face. Most people tell me I look to be about 45, I’m actually 56. My looks probably matter more to me than most people as I currently work in a very visible public position so I feel I need to look my best so I can stay in this business until I retire. I would like to know what I can get done and not have to be off work any long periods of time. I am very interested in liposuction of my stomach/butt/thighs/ and arms, possible facial work later.
A: Since body contouring (liposuction) in your primary focus for now, I will keep my comments to that area. The most important question based on your inquiry is what is the best treatment for your body fat concerns. The abdominal area is always the one body area where the debate is between liposuction and a tummy tuck. It has been my experience that most people assume that liposuction can do too much, that it can magically remove a lot of fat and tighten up a lot of loose skin. While liposuction is a very good fat reducer, it can do little for excess skin. Thus whether it is an appropriate surgical method for your abdomen, arm, thighs and buttock issues will require a physical examination to answer. My concern for you is that the desire for great body contour changes and little time of work often do not go together very well.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Is there a way I can find out more about the rib cage narrowing you have posted on your website? I am interested in this procedure and would like to know more about how it is done, costs involved, and recovery time. Thank you.
A: Ribcage narrowing, also called waistline narrowing surgery, is done by removing the 9th and 10th cartilaginous ribs (and occasionally the 8th) to make the waistline vertically longer and narrower from the sides by removing the bulges of the ribs. It is a procedure that may be effective for some patients based on their anatomy and if they are already fairly thin. It is done through a 4 to 5cm incision directly under the rib cage on each side. One has to carefully balance whether the thin scars are a good trade-off for the result. Recovery is solely based on the level of discomfort and is, of course, quite similar to traditional rib graft harvesting for rhinoplasty or mandibular reconstruction with the exception that it is done on both sides. Immediate pain management is aided by the use of rib nerve blocks and infiltration of long-acting local anesthetics into the rib and abdominal musculature. It is done under general anesthesia as an outpatient. The total cost of the procedure is around $6500 – $7500.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Dr. Eppley, why is my abdomen and waist so hard after two weeks, sore I can understand. How long before it gets back soft. Further when can I stop wearing the garments they are so uncomfortable. Can I take an over the counter drug to help the with swelling or what can I do to help the hardness HELP PLEASE
A: Liposuction is a very traumatic procedure to the tissues that results in swelling, induration and a scar-type reaction. Every liposuction patient, regardless of the technique used, will have to endure a period of swelling and tissue firmness. This is normal and to be expected. The two go hand in hand and both resolve slowly. It is a natural process that takes time as lymphatic drainage is restored. Tissues will return to a normal feel as the soreness and numbness passes. While it will get better as each week goes by, expect a return to complete normalcy of up to a minimum of 6 weeks and possibly as long as three months. There is nothing you can do to hasten that process along such as any OTC medications.
Dr. Barry Eppley
Indianapolis, Indiana
