Your Questions
Your Questions
Q: Dr. Eppley, I was browsing through your website looking at facial implants and I realize that you are one of the experts in this field. I have a very small mandible and got my overbite fixed with 3 years of braces. However, afterward I still had a very small mandible. I got a silicone chin implant to fix my small chin. I am mostly satisfied with my chin. But I still have a very thin and weak jaw and I would like to get jaw implants to get width and angles on my mandible in the future. I look forward to hearing from you and discussing with you to determine the best possible process.
A: With a very small mandible, the jaw is usually deficient in more than just the chin area. It is really small from front to back throughout its entire length. The means the jaw angle area will be rotated upward, giving one high jaw angles that have little width. While the chin implant provides greater horizontal projection to the front of the mandible, angle implants are needed to improve balance at its back end. But the jaw angle implants must have a very specific style and dimensions to be effective. With high jaw angles, the implants must provide vertical lengthening as well as some width. Most current styles of jaw angle implants don’t provide these dimensions so you have to very careful to get the correct style to get the desired aesthetic result.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a bump on the top of my skull which appeasrs to have developed by injuring it years ago as a child. It would be difficult for me to send a picture of my bump since my hair covers it so perhaps I can describe it better. I am self conscious of the way it looks with shorter hair and effects the way I can keep my hair. It is like I said at the very top of my head and creates somewhat of a point. It is pretty swelled out and has more of an oval shape. It is similar to a ridge. I would love to somehow get rid of the bump so I can move on with my life. Personally it has had a profoundly negative consequence on my pyche throughout my youth. I am 24 now and am still reminded of its presence everyday. I have learned to deal with it mentally but the honest truth is that its a challenge to pretend it isn’t there. Thanks for listening and hope to gain more feedback from you.
A: Reduction of a prominent bump on the skull is a fairly straightforward procedure done through burring reduction using a small scalop incision. It is always helpful to see a plain skull x-ray from the front and side to see its thickness and how it compares to the surrounding normal skull. That tells me how much of it can be reduced and whether a completely normal skull contour can be obtained with this minor form of skull reshaping.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley. I am a 40 year old male with bilateral gynecomastia of undetermined origin dating back to puberty. I had surgery for it over 20 years ago which was not unsuccessful. By the surgeon’s baffled admission, it resulted in regrowth of breast tissue well beyond the original (pre-surgical), size. Since I had fully understood the procedure’s potential risks and could hardly blame the surgeon for the result, I dropped the issue altogether resigning myself to a lifetime of gynecomastia. However, having just come upon your site, particularly your discussion of the link between gynecomastia and temporal lobe epilepsy in King Tut's case, I cannot help wondering if a similar involvement has been a hidden factor in my own condition. Although I was never diagnosed with epilepsy, I had a fainting episode at 15 (coinciding with gynecomastia onset) followed by severe headaches, blind spells, and dysphoric moods. This was attributed by a neurologist to a “temporal lobe dysfunction due to damage to the sella turcica region of the brain,” possibly as a result of either meningitis or encephalitis. The antidepressants and anticonvulsants I have been prescribed to control what subsequently became recurrent major depression seem to implicate the condition further even as they themselves can either cause or aggravate gynecomastia as a side effect. I am wondering what your thoughts or suggestions might be in my perplexing case.
A: In regards to the cause of your gynecomastia, it is always an elusive question for most patients. Drugs are a common culprit although for most patients the exact reason is unclear. Whether there is any relationship between your neurological history and gynecomastia is speculative. I have never heard of regrowth of gynecomastia around a prior excision site and I would question that diagnosis anyway. I would wager it most likely represents inadequate resection that only become more evident after all the swelling went down months after the surgery. One of the hardest elements of open gynecomastia surgery through an areolar incision is getting adequate resection of the involved tissues well away from the areolar access area. A common aesthetic complication is to have adequate areolar resection but a surrounding donut of residual tissue that may not become evident until many months later when all the swelling has subsided and the skin has adequately contracted down, revealing the extent or lack thereof of the resection margins. This would suggest that further efforts at gynecomastia reduction may still be successful.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am wondering if I should be at my ideal weight before having breast augmentation?
A: In regards to getting breast implants and your ideal body weight, I think that answer depends on how much weight loss you are anticipating and what your breasts look like now. If you plan to lose a lot of weight (greater than 20 to 25 lbs) and you have some significant breast sagging, then you may be wise to wait until you achieve that weight loss. You do not want to put in implants that will later develop additional breast sagging as the weight loss may cause the breast tissue to slide off of the underlying implant support or ledge, maing the sagging look worse. Also additional weight loss may tip the balance between a marginal breast lift candidate with their implants versus someone who definitely needs a lift with their implants. If the breasts have little to no sagging and the desired weight loss is fairly minimal, then you could proceed with breast implants at any time.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, My question is about the appropriate age for my son’s skull surgery. I wasnt to get the flat back of his head fixed by an onlay cranioplasty procedure that you have described. He is now 18 months old. Should I wait until my son is older?
A: There is no right or wrong answer to that timing of surgery question. Such 'cosmetic' skull surgery in a child is unique because they are not in a position to pass judgment about the value/benefits of the procedure. (and they won't be for a long time) Thus it requires the parents to determine the merits of the skull reshaping procedure as they look at the child's long lifespan and their psychosocial development. While that is not that helpful, you have to look at the magnitude of the skull deformity and determine if improving it early justifies surgery. It can be done at anytime as age is not a criteria (beyond 18 to 24 months old) for the surgery. You just want to be sure that the deformity has no chance to improve on its own with future skull growth.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have seen several doctors say they can use soft silicone implants to enhance the hips. I am also thinking the newer traditional butt implants can be shaped to be placed in the soft tissue “grove” of the hip found on most men, sometimes called “the boy dent”. Why would it not be possible to do? In my experience those who have gotten injectable silicone, most have never had a problem and they inject it below the facia on top of the muscle and a scar capsule is formed around the silicone. So why not place the implants either there or inside the muscle which are where some butt implants are placed now as seen on The Doctors.
A: I would not disagree with your contention for how hip implants can be used and placed. While there is no standard hip implants, ultrasoft buttock implants can be used as hip implants. You can not place them inside the muscle and the fascia overlying the hip musculature is very tight so the implant has to be placed on top of the fascia. But there is no reason why hip augmentation implant surgery can not be done
The problem with large volume silicone injections for body augmentation is that the material tends to migrate away from where you would want it to be. This would very likely happen in the hip area due to gravity. I would feel more confortable with actual implants rather than silicone injections for hip augmentation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I'm not actually interested in any plastic surgery, but I was compelled to write a thank you to you for not trying to make anyone think breast augmentation will give you perfect breasts. Your work looks good, and I'm sure they look even more amazing in person, but it's nice that you're up front. I fully support anyone who wants to change their look, or enhance it. I'm a beautician myself. I just felt I should say thanks for being real. Thank you for your time.
A: Thank you for your kind comments. While plastic surgery can make some very significant improvements, I have yet to see a perfect result. Every result has some flaws and no patient should expect an imperfect problem to turn into a perfect result with surgery. I am sure in your own field every person you do is much better as a result of your work, and some even amazing, but perfection is always elusive. I try to communicate that in all of my work and it is comforting to know that someone else does appreciate that insight.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I think I may have screws up my chuin surgery. I was washing my face and was pushing really hard on my chin but didn't know because it is numb and then something felt different…on the right the implant was in a different location. Then I protruded my mandible forward and it only felt tight on the left of my chin, not on both sides of it anymore. And then I palpated my implant and on the right the implant is completely on the outside of my mandible and on the left it is under it. It is bad. Now it is in a lot of pain. I tried putting it back in place but it is of no use. I will just injure myself. Now the incident is giving me a lot of pain: my whole chin and the new location of the implant. Before this happened I called about having you call in more pain medication to my pharmacy and I mentioned a painful tumor-like lump on the left side of my mandible. It is hard like bone, and round, and inferior to the bone as well as lateral to it. My pain includes pain in this area. However, the area felt different to the touch than other areas. Now, after what I have caused to happen with the implant, I cannot assess it. It is still painful to the touch, although the lump seems smaller and less obvious. It was causing my chin to look shifted to the left, because the right of my chin was flat and the left protruded where the lump was/is. Where the implant was feels like a dent in the bone of my mandible and somewhat looks like one. Now that the implant, out of place, adds width to the right side, my chin looks more centered than before, where it looked shifted to the left. I am also sending a picture of the area where the fat was inserted, just checking if everything looks normal. Both of the areas containing the transplanted fat feel to the touch like I am touching like hard rubbery rubber implants. Just want to know if everything's normal. Thanks.
A: Thank you for the follow-up and sending your pictures. Let me share with some basic concepts about the recovery process from your chin osteotomy/implant and fat injection surgery. It takes a minimum of at least 6 weeks and closer to 3 months to see the final result. It is very normal to have everything that you are feeling and showing at this point, which is very early at just 9 days after your procedure. Besides the swelling, numbness and bruising, every chin osteotomy patient at this point will have hard lumps at the end of the osteotomy cuts on the side of the jawline. That is what you are seeing on your left side and I would not consider that abnormal at this point. While it is possible that could be a malpositioned end of the implant overlying the osteotomy site on that side, it is just as likely that is swelling and a collection of blood from the surgery. I would be a lot more concerned about that issue if this was 4 or 6 weeks but not yet at 9 days out from surgery. I also doubt that you could have malpositioned the implant by rubbing on the outside. The bone and the implant are secured in placed by plates and screws so it would be very hard to displace it. The fat injections into the nasolabial folds will feel and look exactly how they do at this point and that is perfectly normal. It will take 4 to 6 weeks for them to smooth out, blend in and feel normal.
Hang in there as it is still very early in your recovery process.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was wondering if it were possible for a bump caused by hitting the very top of my head when younger could be removed. It creates a rounded point at the peak of my skull. I know it was caused by the impact and always thought it would just reduce on its own, but never did. I believe it hardened when the bone healed from the injury. It is something that I often think about and am trying to research to see if it could ever be realistically and safely renewed to its original shape.
A: You are correct in deducing that the bony bump that you have acquired is due to scalp trauma, particularly when it occurs at a young age. Any small amount of bleeding from perforating vessels from the bone causes an accumulation underneath the periosteum of the bone. The blood will cause the periosteum to turn it into bone, thus making the round bump that you have. That could be reduced by a simple skull reshaping procedure using a small incision to burr the bone down to the level of the surrounding bone.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, A friend of mine from another country who is in his mid twenties had a temporal lift.He didn´t had any excess skin and for this reason no skin was removed. He only wanted to have a slightly exotic look of his lateral corner of his eyes and his lateral eyebrows…. now he has this sexy Keanu Reeves look. He had this surgery three years ago and it still looks fantastic – no relapse at all! I would like to have the same surgery. Unfortunately he doesn´t remember how it exactly was performed by his surgeon. He has a 6 cm long scar behind his temporal hairline and he remembers that his surgeon told him that it is important that there is no pull on the skin and only the deeper tissue has to be lifted. Otherwise the result wouldn´t be permanent and the corner of the eyes and the eyebrows would pull back to their original position again after a few months.
Do you have experience with this kind of surgery? Could you please describe to me how this surgery is done properly, what tissue is actually lifted and what has to be done that the results are long lasting? What is the cost and recovery from this surgery?
A: Temporal lifts have a long history of being done and the techniques range from skin only excision to deeper tissue release and fixation. Old style temporal lifts removed only skin and that may still work well in older patients who have significant brow ptosis and loose forehead and temporal skin. But in younger patients with minimal to no loose skin or brow ptosis, skin excision only will relapse quickly and end up only leaving a wide scar due to elastic recoil of the younger skin. Contemporary temporal lifts usually use minimal to no skin excision and rely on superficial temporalis fascia mobilization and posterior fixation. The periosteum around the lateral orbital wall and the lateral brow area is the key to mobilization and must be released for the entire tissue unit to move up and back…and stay there on a long-term basis. This is a technique somewhat similar to an endoscopic browlift and a SMAS facelift, both of which rely on tissues deeper to the skin to create their effect.
The recovery from this type of temporal brow lift is all about how much swelling and bruising one gets around the eye area…and there will be some due to the periorbital tissue release. Expect it to take two to three weeks for all such swelling and bruising to clear.
Dr. Barry Eppley
Q: Dr. Eppley, I bite down on my cheeks sometime when chewing my food which makes it uncomfortable and sore. Sometimes I can barely eat they are so sore. My cheeks are also sunken in. What are your recommendations for submalar surgery to correct this problem and get it covered by insurance.
A: Biting down on one’s intraoral cheek mucosa is not rare but occurs more frequently in some people. This can occur because of the cant of the occlusion, broken teeth, a swollen cheek lining and particularly if one is wearing hardware on their teeth such as braces. Once the cheek lining gets swollen, it is bigger and creates a protruding ridge which is a viscous cycle for recurrent biting on it.
Having a sunken cheek, however, is not an anatomic reason why one would bite their cheeks. This make seem like a logical explanation but the fat atrophy of the buccal fat pad occurs on the outside of the buccinator muscle and does not effect the shape of the inside of the cheek lining. The buccinators muscle is like a stretched trampoline and what occurs on the outside (visible submalar area) does not effect what lies on its opposite side inside of the mouth. (buccal mucosa) Thus performing submalar augmentation by injecting fat or placing an implant will not improve the shape of the lining inside the mouth…or improve the cheek biting problem.
Submalar augmentation can be performed to improve the aesthetics of the face and would not be covered by insurance under any circumstances. If a palpable ridge of mucosa exists along the occlusal level inside the mouth, its excision may remove the cheek mucosa that is getting in the way of the upper and lower teeth biting together.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have been considering getting cheek implants for a while now. I understand that one of the risks associated with them is asymmetry and I was wondering, what is your stance on revision surgery should it be required? I understand that the OR and anesthesiologist's fees will still be payable by me, but do you still charge your surgical fee or will it be waived/subsidized for your patients? I ask this because my financial resources are limited, and I would just like to be prepared for any financial contingencies should it be required.
A: Your question is a vey thoughtful and forward thinking one that every patient should get clarified before they have surgery. You are correct in asssuming that in most cases my professional fee for revisional surgery is waived or dramatically reduced but the OR and anesthesia costs are still borne by the patient. It is important to clarify what constitutes a revisional procedure also. If there is a problem induced by the execution of the surgery, such as infection, asymmetry, malposition or other implant placement issues, then that would constitute such professional fee reductions/eliminations. If a patient desires additional improvement/enhancement on an already acceptable result (particularly months to years later), then that may modify this revisional fee consideration.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had breast implants placed three years ago which were 375ccs. I want to go bigger but am not sure what size implant to go to. Do you think 450ccs would be enough?
A: When one desires to have bigger breasts with indwelling implants, the question of how much bigger is obviously very subjective. But most women are not going to go through the effort and expense of surgery if they did no want to see an appreciable difference, at least being a 1/2 cup to a full cup bigger. One of the common mistakes with breast implant replacements for a size change is to not go big enough. While numbers like 500cc or 550cc can seem daunting, the reality is that represents only a 33% to 45% increase in your current breast size. As a general rule, you have to have at least a 25% to 33% change in volume to ever see much of a difference. Another commonly stated number is that it takes 150cc to make a cup size change, although this would be highly influenced by the size of the woman’s chest and her body frame. So you can see that changing from 375cc to 450cc is not going to make much of a difference when it comes to a breast size change. That will make your current a little fuller but that is about it. For those woman that want just a little change or more perky, a 75cc volume implant change may be adequate. But for most women seeking a breast size change through an implant exchange, it will not have been worth the money to do so.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a fat transfer to remedy malar crest. Now there is still a prominent dent across the upper line. What do I do now?
A: I would have to see some pictures of your concern, which I assume is a residual malar crease that was unlikely to be improved by fat grafting alone. Malar crescents are rarely completely eliminated by fat grafting alone because there is a tissue sag component to it. It is not just a volume depletion issue alone.. Ballooning the crescent up with fat may be helpful in some cases but often can lead to a fuller crescent but one that still has a visible crease or dent. If you are more than 3 months after your fat grafting procedure, you may need to consider a cheek lift which can be done multiple ways depending on the aging condition of the lower eyelid. Cheek lifts are most effective in middle-aged to older patients who have a more significant aging component to their midface. A combined lower blepharoplasty with cheek suspension can work well in these patients. Cheek lifts in younger patients are more problematic because the lower eyelid is tighter and less aged. This leaves little eyelid skin to be removed with the cheek lift.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I already had several consultations with other surgeons, but nobody seems to understand my “problem”. I would like to have cheekbone augmentation, but I already have high and prominent cheekbones.But in my opinion there is a difference between the body of the zygomatic bone (where the cheekbone goes around the corner and what is usually called “the cheekbone”) and the arch of the zygomatic bone (the very lateral part of the cheekbone that extends to the ear and looks like a rather thin bow). My surgeons always acted like I was crazy after I explained that difference to them and that I only would like to have an augmentation of the arch of he zygomatic bone. They told me they have never heard of this kind of augmentation and there are even no implants out there that could address this problem. Then I found out, that there is a very popular kind of surgery around South Koreans.Many South Koreans have very wide zygomatic archs that stick out of the sides of their face although they often have a rather flat body of the zygomatic bone. For some reason (I think because they prefere a more western look) many Koreans don´t like this wide zygomatic arch and get zygomatic arch reduction surgery. It is a reduction osteotomy of this bone, that is done through an incision just in front of the ear. (like a face lift incision). I thought if it is possible to reduce the zygomatic arch, it should be also possible to augment this area. After I told this another surgeon, he said that this is called a preauricular incision that is only done in superficial layers, for example to do a face lift, but it is not possible to have a safe access to the bone via this incision, because the facialis nerve lies there. But I don´t belief him, because I have seen many pics on the Internet of this kind of incision that goes right down to the bone. It is used for correction of a fractured zygomatic arch or for operations on the temporomandibular joint. Does this sound crazy to you, Dr. Eppley?
Is there a way to augment only the arch of my zygomatic bone? Is it possible to carve impants for this area? I know that midface implants are usually placed through the mouth, but it seems logical to me that it would be easier to put a “zygomatic arch implant” through a praearuicular incision. Is it possible to have save access to the bone through this incision?
A: I think you have a very good grasp on what you are trying to achieve. Can you just augment the zygomatic arch with an implant…absolutely yes. While wide zygomatic arches are reduced by osteotomies, expanding or augmenting the arch requires an implant not an osteotomy. Since they are no specifically designed zygomatic arch implants, they would have to be fabricated by either modifying an existing stock implant (such as by using the wings or flanges from an anatomic chin implant) or hand-making custom ones. Which implant technique would be better depends on how much augmentation you are desired the exact location on the arch. When it comes to placement, zygomatic arch implants could be put in either through the mouth (anterior access) or from a preauricular incision. (posterior approach) Which method of access would depend on the shape and thickness of the implant, although I would likely prefer the posterior approach because the implant could be secured to the bone much easier this way.
In conclusion, your request for zygomatic arch augmentation is very uncommon but most certainly not crazy. One should not confuse unfamiliarity with impossible.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, my son had gynecomastia surgery last year and has developed severe scarring from this surgery. We have tried creams, silicone sheets, several rounds of shots and laser treatments as well. Nothing has helped for his scarring. It is so sad that a 17 year old young man is unable to remove his shirt in front of anyone, due to the embarrassment from these scars. He often has sharp pains from the scarring that requires him to rub out the pain. As you can tell from the attached pictures, the scarring on his right side is much worse than the left. This is due to the fact that he formed a hematoma under his right nipple after surgery and required a second surgery on the right side to remove the hematoma. I would appreciate your opinion to see if a scar revision and possibly radiation to prevent new keloids from forming is a possibility.
A: Thank you for sending your son’s pictures. I can clearly see that he had an initial periareolar approach to his gynecomastia reduction surgery. Due to the maturity of his scars, it appears that surgery was done at least a year ago. While I have no idea as to the magnitude of his original gynecomastia problem, I see the following current problems; wide hypertrophic periareolar scarring, a residual mega-areola deformity and some persistent gynecomastia fullness. His periareolar scarring does not represent keloids but rather is hypertrophic scarring, a not uncommon reaction to periareolar mastopexies in general. This is normal scarring that develops from tension and/or suture reactions from this type of procedure. It is not pathologic scarring nor would ever merit being treated by radiation after revision. While I can appreciate all of the scar treatment strategies done after his surgery to try and improve his scarring, re-excision was only ever going to be a strategy that has a chance to work. No scar treatment other than excision will ever make wide scarring more narrow. The main benefit to all these other scar treatments was that they have allowed time to pass for the scar tissue to settle down as well as being proactive along the way.
He clearly would benefit from periareolar scar revision combined with further areolar reduction and maybe some additional gynecomastia tissue reduction. The burning question is will this scarring problem recur and what can be done to prevent it. While I have my own techniques for how I do this surgery, it is always helpful to know what was done in the past. As the old motto goes ‘past history predicts future behavior’. From that perspective, I would need to see his previous operative note to understand what closure techniques were done so what didn’t work well would not be repeated.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I hate my fat knees and my ankles just don’t exist. I know that liposuction can be performed just about anywhere on the body. How effective is it in these areas and will I be back to working out and be physically unrestricted in two weeks after the procedure? (I’ll be leaving for a European vacation)
A: Liposuction of the inner knees can get rid the bulge that interrupts a desired straight line from the thigh down to the calf. Small cannula liposuction can also help one reduce one’s ‘cankles’ by creating a noticeable difference between the calves and the ankles. While these are some of smaller areas on the body to treat by liposuction, they can be tremendously effective. Despite their small size, however, I would not call recovery quick particularly if the criteria you are using is a high level of physical activity in a foreign country. The knee and ankle are unique because they are the only areas of the body in which liposuction is done across a moveable joint. This means that the knees and ankles will be stiff for a while (4 to 6 weeks) and the swelling in the lower extremities will take a long time to go away. (months) This does not mean that one can not perform all normal activities of daily living but placing a lot of physical stress on the knees and ankles (like occurs in traveling) is not something that is going to be fun just two weeks after surgery. I would highly advise that you defer knee and ankle liposuction until after your European vacation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had an otoplasty about 15 years ago that I was never completely happy with. While it did pull my ears that stuck out back, I always felt that it was pulled too far back in the middle making the shape of my ears look funny. I lived with it all the years thinking that I would just get used to it but I never have. In doing some research I got the impression from reading several doctor’s comments that nothing could be done, that it was unfixeable. I know that you a very creative and innovative plastic surgeon, so have you ever tried to reverse an otoplasty with any success.
A: When an otoplasty is overdone, the outer rim of the ear (helix) drops out of view behind the antihelical prominence. This is most manifest in the middle of the ear as you have described as this is the center of the arch so to speak. While sutures used to create the bend in the cartilage, what really holds the ear back long-term is the growth of scar tissue between the two sides of the cartilages. Some amount of otoplasty reversal is possible in my experience. But simply releasing the scar tissue between the two sides of the cartilage will not make it magically spring out again. This might be effective in the first several months after surgery but not after so many years. The scar tissue must be released//removed but that is not enough. The cartilages must be scored and then a small cartilage graft placed between the sides of the released ear cartilage like a spring. This will help hold in out as it heals and prevent total recurrence of ear shape. One can usually get 3 to 5mms of outward helical rotation/show. The cartilage graft can conveniently be harvested from the concha which is right next to the release site.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, is it true that it is hard to have a bloc rib cartilage inserted into the nose since I've got so many diced rib cartilage pieces in the nose? Will the surgery be somewhat messy and exhibit unpredictable outcome? A surgeon I consulted said he may need to remove all those diced pieces and that he doesn’t believe I will have enough rib cartilage to be harvested and carved into a bloc graft. I was somewhat speechless, because I thought rib cartilage is abundant. Then he pointed out that since I'm already 26 years old most of the rib cartilage has ossified. I'm really confused. Please help, thanks very much Dr Eppley.
A: With a prior diced cartilage graft nasal augmentation, it does make it more difficult to replace it with a new solid cartilage graft. But just because it is a little more difficult does not make it impossible. Many times diced cartilage grafts can be removed without a lot of difficulty because they have fused into a near solid mass that is held together by scar/fibrous tissue. I do not see the inswelling diced cartilage being a big obstacle to a second effort at a rhinoplasty for more dorsal augmentation. It is not true that at age 26 most of your ribs are ossified. I can assure you that your ribs # 6,7,8, and 9 are still very cartilaginous and abundant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Can a combination premaxillary implant and paranasal implant be done?
A: A premaxillary implant is different that a paranasal implant as your question implies. A premaxillary implant goes under the base of the nose in front of the anterior nasal spine. It opens up the nasolabial angle and provides some augmentation of the upper lip. Paranasal implants are different in that they go along the side of the nose to add volume to the flatter or more deficient midface or maxilla. This is above the alveolar level and to the side of the nose. Both implants are used for similar overall facial profile indications…for the patient with a flatter or retrusive midface. These implants actually exist most commonly in silicone are are done as a combined premaxillary and paranasal implant known as the peri-pyriform implant. It can be used to wrap around the entire nasal based or can be cut to be used as separate premaxillary and paranasal implants.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, my question is actually regarding lip reduction. Two years ago I had silicone injected into my top and bottom lips. One year ago I had a lip reduction procedure performed. Since last march I have been receiving steroid and 5-FU injections into my lips to help calm the swelling. Now my doctor is telling me I need another lip reduction. My problem is that the first surgery was botched. After reading your website about where lip reduction incisions should be placed (inside vermilion cutaneous border) I realized that my surgery placed my incisions about 1/4 inch away from this location. My incisions were made in the mucosa region roughly halfway between the nose and the vermilion ridge on the top lip and just above the labiomental groove on my bottom lip. Now the entire cutaneous region surrounding the pink part of my lips protrudes and is swollen from these ill placed incisions. My surgeon believes the the swelling is due to residual silicone left in my lips from the first surgery. I know there is silicone left in there because I can feel it. However, I don’t believe that is what is causing the distortion. My question to you is what do I do now?
A: While this is water over the dam now so to speak, your situation illustrates the problem with permanent injectable materials particularly in the lips. Once in there there is virtually no way to get it out in any completely satisfactory manner. Lip reduction will remove part of it through direct excision but a fair quantity will still remain in lip areas not amenable to the excision. While your lip reduction incisions may have been placed a little too far inward on the musosal surface, I would not consider this botched surgery. That is just not the most effective position to place them for maximal lip reduction. As to what to do now? I would give yourself a good year from the lip reduction and see how things are then. This will give the maximum amount of time for swelling to go down and the scars to soften. Whether another attempt at lip reduction is worthy will be more apparent then.
Q: Dr. Eppley, I have had three c-sections, gained and lost over 100 lbs at least three times. ( after each pregnancy) I want to know if I need a tummy tuck or some type of pannus removal.
A: The difference between a tummy tuck and an abdominal panniculectomy is really one of magnitude. They are in many ways the same procedure with some different variations to them. A panniculectomy is nothing more than a ‘big’ tummy tuck. It involves a larger amount of abdominal skin and fat removal as a pannus means an apron or overhang of abdominal tissues across the waistline often onto the pubic areas or upper thighs. This means the horizontal incision and resultant scar may be longer and even extend into the back area from that of its smaller cousin, the more traditional tummy tuck. Given your description of recurrent weight loss of that magnitude and pregnancies, I would have no doubt that you have a pannus and your surgery would be a panniculectomy, often called an extended tummy tuck. The recovery from a tummy tuck or an abdominal panniculectomy would be the same. Longer incisions do not really mean a longer or more significant recovery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting a tummy tuck but have been told that I can’t due to my gall bladder scar. I have attached pictures and have highlighted my scars with a marker so that you can see them better. I am told that my appendix removal scar (30 yrs old) and c- section scar (9 years old) are no issue since they are below the belly button and would be removed. My gall bladder removal scar is 11 years old. I was told by one doctor that the skin below the scar would not survive if a tummy tuck was done. What technique for my tummy tuck would you recommend?
A: A long traditional gall bladder removal scar does place at risk for survival the triangle of skin that will ultimately result between the lower edge of the old gallbladder scar and the new horizontal tummy tuck scar. If done with care and looking out for several factors in the execution of the tummy tuck it can be done safely and without problems. The key factors are not to place the tummy tuck closure under too much tension (not too large of a horizontal excision), a limited central tunnel dissection of the upper abdominal skin flap and avoidance of any lateral abdominal wall liposuction. This will preserve the maximal amount of blood supply to the skin both above and particularly below the old gallbladder scar. This will allow the tummy tuck to heal uneventfully.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, Let me say right off the bat that I've had rhinoplasty 3 times. The first one, done in 1999, was kind of silly because the change was so minute that I felt I wasted my time and money. My complaint was that I wanted my bridge to be higher. The doctor took a bone off my hip, and placed it on top my nose. Basically it looked the same. Yet, I dealt with it and moved on but the feeling that the surgery was a failure never went away. I did a second rhinoplasty in 2005. The doctor placed Gortex on top my nose towards the bridge, which made my nose look a little dented in at the middle part of the nose. For a few years, I tried to convince myself of a positive change, but to no avail. Lastly, the third surgery was done in 2009 to address the dent. The surgery was successful in removing the slight dent but it didn't remove how I felt about my profile. All the doctors made conservative changes to my nose which I am fine with since my intention was not to change the racial characteristics of my nose. Again, I did it with the hope that it would improve my facial profile.
None of these surgeries addressed my main concern which is to make my profile at the midface less pushed in looking when I am expressive with my face. When I do this my profile looks ape-like, so I try not to make expressive facial profile which is really hard to do. It is not easy to walk around stoned face. I also had Invisilign work done last year. This was not done to correct crooked or misaligned teeth, as I have relatively straight teeth. It was to hopefully undo the imperfection I see in my profile while at the same time maintaining my facial identity. My teeth still flares out. The results were not a major difference from what I started with. So basically my teeth is the same way. The orthodontic treatment was done by filing in between the teeth to create space for the teeth to move back. I did this because I absolutely didn't want to loose four teeth to create space. I didn't see any noticeable change.
All the above doctors I visited were never aware of my underlining concern which is that I am not please with my profile because it make me look ape-like, due to how the mid part of my face is position with respect to the lower part, especially when I make facial expressions. This is not an easy issue for me to talk about so I kept it to myself instead of disclosing my feelings to the doctors. The orthodontist I visited last year told me that I have a large lower jaw and a smaller upper jaw which is the reason he was having trouble getting my teeth in the position he wanted, which was more vertical. Hence, the teeth moved backed, but not much. The change was so imperceptible (honestly I don't think It made any difference what so ever to my face) that no one ever commented to me of any change.
That is pretty much my situation in a nutshell. I am not happy with my profile, and as you would expect it is hurting my ability to live a happy, social life because of the way I feel about myself. I've attached pictures for you to look at. Pictures are of me after all procedures.
A: Thank you for sharing your surgical history, concerns and pictures. Your fundamental underlying problem is maxillary alveolar prognathism, which is common with your ethnicity. I am not surprised that orthodontics alone, of any form, did not improve that problem., It never had a chance to, its movements are too small for your problem. Ultimately you would have to have upper teeth extracted and the entire cant of the maxillary incisors brought back in to make a visible difference. Your rhinoplasty using a bone graft was a poor choice because that type of nasal augmentation will end up just resorbing, even if you get enough dorsal augmentation. A cartilage rib graft would have been much better. You had had three inadequate dorsal augmentation approaches because the materials and their volumes used were insufficient. You need a combined dorsal onlay with a columellar strut approach to get a much higher dorsal profile.
There are other midfacial procedures that can be used to help change your profile at rest or in expression but their effectiveness is uncertain. These include augmentations of the paranasal and cheek bones. And perhaps a good nasal augmentation with paranasal implant enhancement may be beneficial. I have attached a computer imaging prediction of that potential outcome.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I had a facelift which left my pixie earlobes. I had three procedures to fix my pixy ear but it stretches back toward my jaw due to not enough skin or too tight skin. Is there any other technique for my case which you think would work better? The last two ear procedures where done three and one month ago by two different doctors. One doctor cut the skin around the earlobe and the other doctor chose only to cut behind the lobe in order not to push the cheek skin. In both cases I was not satisfied. I have attached two pictures, one before the scar and one the way I am now.. I used to have a small high based ear with square jawline that now I can't see due to bad ear position.
A: The pixie ear deformity is marked by a lack of a definitive separation of the earlobe from the face and an earlobe that is ether elongated or abnormal in shape. In essence the earlobe is pulled down. Usually small local procedures of releasing and tucking the ckin around the earlobe, while tempting and worth a try, do not usually produce a very satisfying improvement. This is because they do not recruit/move skin to make a separation between the earlobe and the face that stays and the problem quickly becomes a recurrent one. The options are either an earlobe release and reshaping with a resultant vertical scar below the earlobe in its wake or a secondary mini-facelift to move more skin underneath the earlobe for a definitive separation. These approaches will likely be more successful than your previous procedures.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I would like to have an upper lip reduction, along with a reshaping of my upper lip. Are you able to perform this surgery? If so, do you use laser surgery for the procedure?
A: I am a bit confused by the combination of an upper lip reduction and reshaping of the upper lip. What do you mean by reshaping and what are you trying to achieve? An upper lip reduction is performed on the inside of the lip at the wet-dry mucosal junction. A horizontal strip of dry vermilion is removed and the remaining dry vermilion is rolled inward, thus reducing the visible vermilion or size of the lip. While this reduces the size of the lip, I am not so sure that I would call it a reshaping. Lasers are never used for skin or mucosal surgery. While they have theoretical appeal because they seem like a better way to do surgery, they actually have worse outcomes, delayed healing and usually bad scars. Lasers essentially burn the tissues that they cut through which causes all the aforementioned problems. They are also associated with wound complications such as edge separation in the healing period because of the tissue burn at the wound edges. They actually cause a more longer healing period and are not used for any plastic surgery operation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I want to create dimension to my face by making bony features more prominent. I would like to correct my flat midface, drooped nasal tip, recessed chin, flat cheeks and forehead, and create a more prominent bridge to my nose. What procedures would you use and how would you make these changes?
A: To make those facial changes, I would perform forehead augmentation with PMMA, a rhinoplasty using either a synthetic implant or rib cartilage grafts, and cheek and chin implants. I have done a side imaging photo to illustrate what I believe you are after with this compilation of procedures, to pull your face out and provide projection to a face that is naturally flatter and more wide. The only thing that I couldn't properly illustrate in the imaging is the bridge of the projection that would be achieved. Your natural bridge is hidden behind the eye so its profile can not be pulled based on this one photo. Always remember that computer imaging is just a visual way to start the discussion about what changes one wants and how much they want those changes to be. All of these facial changes can be done in varying degrees. Finding the correct amounts when multiple facial areas is being done is the key to a successful result.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I want to get the size of my chin reduced but am afraid of pain. Is there any painless way to reduce the size of my chin?
A: What you are asking is not possible. The surgery to do reduce the chin may be painless during the procedure because you are asleep. But after surgery there would be some pain and swelling. Most chin reductions involve bone removal, which by definition, will cause some after surgery discomfort. For the most part, anything painless in plastic surgery also correlates with things that don't work.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 27 year-old male. I have my nipples removed 8 months ago because it was too sensitive. I know the male nipple can be highly sensitive sexually and most of the men enjoy it but in my case I am unhappy with this sensation from childhood because it is intolerable and disgusting. And you know more than 30% male do not like that. I am among those men. So if someone tell that it is one kind of mental disorder, I do not believe it since I have taken mental and skin treatments since 2007 but there was no progress and I do not want to spend anymore money for medication. However, after the reduction of nipple there is little sensation on the center of the areola until now. When this place is pressed, it make me feel of the same sensation that I felt before. Finally, I have decided to remove the areola totally and want to make this place permanently numb. So what I want to achieve is the following:
1. Permanent numbness on areola by removing them.
2. Removing breast gland. (Actually, I have removed breast gland before but just need to check whether any gland tissue left. If it is then need to remove it.)
3. Removing whole areola. (It is not just the upper surface but also inner part. I mean after removing areola it will looks like a hole on skin.Probably, numbness surgery and whole areola removing may be at the same time.)
#2 and #3 is not mandatory but #1 is mandatory for me. #2 is optional.
*** It is notable that My problem is not gynecomastia. This surgery will be just for numbness on areola place to live rest of life with happiness. I think it can be done by local anesthesia.
A: The most likely reason you only lost partial nipple sensation is that only the tops of the nipples were removed. The nipple and its ducts extend deeper which is where it receives its nerve supply and sensation. While initially after surgery the nipples were completely numb, some feeling has returned because these deeper tissues remain. While the entire areola can be removed, it should not be necessary to do that to eliminate all sensation permanently. A lower areolar incision can be made and all tissues removed right up to the underside of the dermis of the areola. When this is done, the remaining areola is just a cosmetic feature on the outer side of the chest skin. As you have mentioned, removal of the areola will result in a purse-string type scar on the chest wall which may be indented. I am not sure that is a good trade-off but only you can make that decision. I would agree that either approach could be done under local anesthesia.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, One week ago I had a syringe of Juvederm injected injected under my eyes. So far, the results are not fantastic but at least It did not create bags, as I often read in “horror stories”. Maybe I look less tired. I know I won’t go for a touch up, I had a bruise which freaked me out and “perfection is the enemy of good”. But I m wondering… Does this HA create any long term side effect such as lumpiness or swelling months after the injection? Also based on your experience, how long does it really last? Because my injector said it could last for 3 to 5 years because there is no hyaluronidase in this part of the face (!!). And if people get treated again, it is because they have aged, the filler won't disappear. What do you think? Does HA under the eyes ever get broken down by the body? Thank you very much.
A: The information you have received about the longevity of Juvederm or any HA (hyaluronic-acid based) injectable filler is erroneous. No form of HA is permanent and they all eventually go away by the absorption of water which breaks down the filler. How long they last depends on the concentration of the HA in the filler and how it is cross-linked. It is true that they do seem to last longer in the lower eyelid/periorbital region, perhaps up to 12 to 18 months but definitely not three to five years. One of the real advantages of an HA filler is that it is a natural material as the body is composed of lots of HA material in its tissues. Thus there are no known untoward effects of repeated HA filler injections such as accelerated aging or tissued damage. Age also does not seem to play a role in how quickly or slowly any particular HA material persists.
Dr. Barry Eppley
Indianapolis, Indiana
