Your Questions

Q: Dr. Eppley, I am considering getting liposuction on my stomach and waistline but am curious how do you know how much fat to remove. In fact, why don’t or can’t you take all the fat that is there? I don’t want to you can just take it all? I have been searching for answer to this question but have not been able to find it.

A: Your question is actually a common one and comes in different versions. Most liposuction patients usually say just before surgery…’take as much fat as you want’…or…’feel free to keep going until none is left’. The answer is while it is possible to take much of the fat from any given area, it is not possible to physically remove all of the fat by liposuction. The way the instruments work make this impossible. The reality is you would not want to remove all the fat even if you could. Fat plays an important role between the skin and the underlying tissues that does beyond its commonly perceived metabolic role. Without fat your skin would stick right down to muscle and bone and not move when you move. The skin would be tethered, contracted and very unattractive as well. Just ask any patient who has ever had skin grafting for burn injuries. While they have a healed wound, they suffer from a loss of normal skin elasticity and flexibility. It is also important in liposuction to leave an adequate amount of fat on the underside of the skin to prevent the cosmetic deformities of irregularities and indentations, in other words to get a smooth result. There is an old plastic surgery saying in liposuction which is just as true today as whenever it was originally said…’it is just as important what you leave behind as what you take in liposuction.’

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,I am really considering butt augmentation (but I’m nervous).  I am a 33 year old women, who was born with one leg longer than the other and mild scoliosis.  It was no problem in the begining because it was barely noticeable.  Now, however, my shorter leg is much bigger than the longer leg, and it has caused my butt cheeks to be very uneven.  My guess is they were probably uneven all along, but now it’s very noticeable.  I can’t buy jeans or pants because they are either too big on the small side or too tight on the big side, and it makes my butt that much more noticeable.  Anyway, my left butt cheek is bigger (meaning its more round and it hangs down longer) than my right butt cheek.  Before I get this fat transfer done, is there anything else I can do on my own (maybe exercise) that will even my butt out, or is surgery my only option?  And, if surgery is my only option, will that also change as years go by, because I will always have one leg longer than the other, that causes one to be more dominant? Thanks for your time.

A: There are no exercises or any other non-surgical methods that will change your buttock size.

When it comes to buttock asymmetry, there are two obvious approaches…make the smaller side bigger or the bigger side smaller. The bigger method usually involves fat injections to the buttocks and the smaller method involves a lower buttock tuck with or without liposuction. I do not have enough information to tell you which is the more reliable approach. It is also possible that a combination of the two may give you the overall best result. I would have to see photographs of your buttocks to better answer that question.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a long-time reader of your blog and it has been a terrific resource over the years, so thanks for all the great work that you do!

I have a concern about the jaw angle implants I had placed about seven weeks ago. I wanted and thought I was getting Medpor “Angle of the Mandible Implants” with 5mm lateral projection and 10mm inferior projection but ended up with “RZ Mandibular Angle Implants” due to a major misunderstanding with my surgeon. The implants currently in place have a whopping 11mm of lateral projection and negligible drop-down. As you can see from my “after” photo, these implants extend well past my zygomatic arch, resulting in an “hourglass” shape that I don’t care for. My question is, if I swap out the implants I have for the implants I originally wanted, do you think (based on my “before” picture) that I will experience a similar version of the same problem–just on a smaller scale? In other words, do my high arches and thin skin doom me to that hourglass shape no matter what? My aesthetic goals are to 1) make my jawline flush with my arches and 2) achieve the drop-down effect available only with the “Angle of the Mandible Implants.”
Thank you so much for your time and consideration!

A: The current problem with your indwelling implants, besides the fact that they have too much lateral projection, is that they are malpositioned high up on the bone rather than wrapping around the lower border of the mandible. This then gives you closer to 15mms lateral projection because the implant is actually rotated 15 to 20 degrees of how it was intended to be positioned on the bone.

I think you can reach your goal by one of two implant approaches. A Medpor RZ style jaw angle implant is fine if it was the small 3mm lateral projection size. Or the Angle of the Mandible Implant (aka Ramus with inferior ridge) with 5mms lateral projection would also work. Both would need to be trimmed to fit but you need a surprising small amount of lateral projection to stay within your zygomatic arch width.

However, the use of these new implants will still create the same problem if they are not in proper position on the bone. Placing jaw angle implants that drop the angle vertically downward are technically difficult. All of the soft tissue must be released from the inferior border, including the tendinous attachment to the jaw angle, to allow the implant to sit in its intended position. Also, when jaw angle implants are placed at this level they are inherently unstable because they is never a precise implant to bone fit. (the shape of your jaw angle I can guarantee is different than the skull model from which the implants are made) This is why screw fixation is almost always needed to ensure proper implant positioning as half of the implant is not on bone.

The problem you have is one I see when the surgeon may be used to placing silicone jaw angle implants, none of which have designs to drop the jaw angle down. This is a much more simpler procedure which involves just sliding the implant along the bone surface, dropping it into place if you will. (this is why your implants look the way they do now)Placing vertically lengthening jaw angle implants is much more difficult to do and is further complicated by the frictional resistance of the Medpor material, further adding to the difficulty of the procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 33 years old and  my cheeks are coming forward creating deep folds around mouth. I hate fillers as they don’t help, they make the cheeks look worse. I like the look of the cheeks slightly pulled back giving me a more youthful look. Is this something you could do on someone my age and how much would you charge to do this procedure. Thanks!

A: With aging, the soft tissues of the cheek do slide off of the bone and fall downward towards the mouth area. This is the source of the deepening nasolabial fold (lip-cheek groove), the cheeks tissues from above falling downward into the fixed tissues of the upper lip. The amount of falling tissue can be appreciated at the corners of the mouth where a roll of skin ends up hanging over the corner driving it downward creating a frowning effect. Some younger people have full cheek tissue that naturally sits lower but do not have a downturned corner of the mouth because the tissues are not really falling…yet. At the age of 33, I doubt if you have significant tissue falling or sagging and I will assume that this is really part of your natural facial anatomy.

A cheek or midface lift can lift these tissues and there are different versions of it. These include a traditional transcutaneous lower eyelid approach, a temporal endoscopic approach and a purely intraoral approach pinning the tissues up on the bone with a resorbable device. (endotine) The real question is how mobile your cheek tissues are and how much they can be lifted. At your young age, those cheek tissues may not be very mobile. That would be the determining factor in whether any form of a cheek lift would be aesthetically beneficial for you.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a mentalis muscle resuspension about 10 years ago. This was due to complications from a sliding genioplasty that made my chin huge, and a subsequent reduction a few years later. The suspension worked well but my lower gumline has slowly receded to the point where a few front teeth may be in jeopardy.Would dental implants affect the suspension in any way? It feels as if recently either my one tooth is infected or the suspension site has problems. Is it possible to redo the procedure if necessary? Also, would it be possible at this point to move the chin forward a bit due to some slack skin from the original procedures? Thank you for your time.

A: There are different types of mentalis muscle suspension procedures and I obviously don’t know which one you had done. Whether the suspension is the cause of your anterior mandibular gingival retraction I don’t know. But that issue aside, I see no reason that the teeth in jeopardy could not be removed and replaced by dental implants. The placement and soft tissue coverage around the implants would not negatively affect your prior suspension. It is always possible to redo your suspension at any time in the future. Moving the chin bone further forward (redoing your sliding genioplasty) would only help your soft tissue suspension effects as a whole new tightening of it would be done during that procedure.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley,  why is diced cartilage used in rhinoplasty? What is the risk of cartilage graft resorption in the nose? Does diced cartilage resorb less than regular cartilage? In using diced cartilage wrapped in surgicel, I keep coming upon studies showing that when compared to a patient’s fascia, it is much more often reabsorbed, at a much faster and greater rate. I would not like to use fascia just because I don’t feel it is 100% necessary in my case as well as avoiding another part of my body altered for this rhinoplasty. However, I am quite concerned about resorption of these diced cartilage grafts. What would you say would be your estimated percentage of resorption if it were to occur? Rib rhinoplasty is quite a major operation, I would not like to go through such a procedure with an additional scar on my body for an outcome that wasn’t dramatic or only to be reabsorbed down the line.

A: The concept of ‘dicing’ cartilage for rhinoplasty is to make it more malleable, eliminate warping (and the insertion of metal pins into solid grafts to try and avoid that problem) and to avoid excessive pressure on the overlying skin when solid graft is used. The cartilage graft is cut into small 1mm cubes and then placed into a collagen container. (sausage roll) This creates many tiny pores/channels into the graft that allow it to become very quickly revascularized and filled with collagen fibrous tissue which makes it become firm. Whether diced cartilage grafts or solid cartilage grafts have more or less resorption is a matter of debate and there is no clear science that demonstrates that one is necessarily better than the other when it comes to resorption resistance. In theory, the rapid revascularization and nourishing of the diced cartilage would lead to less resorption long-term. As the what causes a graft, of any source and tissue type, to resorb or not is how quickly it can re-establish nourishment. (blood supply) That being said, I have not seen significant resorption with either type of cartilage grafting in the nose.

There is largely one animal study that has created the spin-off of the negative use of Surgicel in diced cartilage grafts. Whether that translates to humans is speculation and has never been proven or shown. Certainly Surgicel is more convenient for the patient as it avoids a donor scalp scar. But when the patient will permit it and is accepting of a  temporal scalp scar, the use of one’s own fascia is always a more natural choice that will have less inflammatory response than that of an oxidized cellulose material. It would seem logical that less of an inflammatory response would lower the potential risk of some cartilage graft resorption.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a gummy smile procedure done about 3 years ago. I have attached a link so you can see what type of procedure the doctor did. Given that the soft tissue procedure did not work, I am thinking that I need the bone surgery instead. How long is the maxillary impaction osteotomy recovery time and would it require braces after?

A: In looking at the link, I would never have expected that type of ‘gummy smile’ procedure to have ever worked in your case. It was only a very limited anterior maxillary vestibuloplasty procedure. It may work for someone with a small gummy smile problem (maybe 1 or 2mms) but it is a fundamentally flawed procedure. There may have been some temporary restriction of upper lip movement but that would stretch out and relapse back into the full gummy smile in a matter of weeks or a month or two at best.

Maxillary impaction surgery requires orthodontic braces to be in place before (to be used during surgery to help make the bite fit) and then remain in place after surgery to do any adjustment and fitting in of the bite should it be off a little bit. Recovery from such surgery is defined largely by how long does the swelling last until you lok normal. The jaws are not wired together after this kind of surgery so isolated maxillary surgery is quicker to recover from than other types of jaw surgeries. I would say it would take about 3 weeks until you look pretty normal again, although the final bits of swelling takes several months to fully go away.

Give the very limited soft tissue procedure you had done and the more significant commitment of maxillary surgery, a more thorough soft tissue procedure for your gummy smile may be worth considering. One which includes superior labialis muscle release, aV-Y mucosal lip advancement and a more extensive vestibuloplasty procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hello, I am interested in non-surgical rhinoplasty as well as a small amount of Botox. What is the cost per unit of Botox and the approximate cost of non-surgical rhinoplasty for a dorsal hump. Thanks!

A: My assumption is that you are inquiring about 12 to 16 units of Botox for the glabellar area and about .3cc of Radiesse above a dorsal hump. (non-surgical rhinoplasty) You could expect to pay about $200 for the Botox and about $400 for the Radiesse injections. Expect that the Botox will last about four months and the Radiesse to last close to one year after injection.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve had silicone chin and jaw implants in for 3 months. However, I’m thinking of getting a bigger chin implant and a slightly smaller jaw implant. How difficult would the revision be and how much would such revision surgeries on cost on average (i.e. would they be much more expensive)?

A: With existing silicone chin and angle implants, revisional surgery would not be difficult…provided they are in an ideal position on the bone and there has to be minimal release/expansion of the capsules. If they look good and are just not sized to your aesthetic liking, then I can assume the implants are in good position. The more difficult facial implant to reposition/change are the jaw angles. But going smaller is easier than going bigger. From your standpoint, the very good news is that revisional implant surgery involves much less swelling and recovery than their original placement.

Generally revisional surgeries do not cost more than the original and, depending upon who is doing the revision, may actually cost less.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hello! I used to have my bellybutton pierced around a year ago. I loved it until it got severely infected and I was forced to take it out. However, now there is this medium sized swollen scar where my piercing used to be. Is there anyway that the doctor could remove this or make it look less noticeable. I am a little self conscious to where two-piece bathing suits now because it tends to look like I have two belly buttons!!

A: Unfortunately, piercings do occasionally get infected. Even though the piercing is removed to resolve the infection, the inflammatory process causes a reactive scar to form along the entire length of the old piercing tract. This results in a raised or hypertrophic scar on the outside. That scar you have from an infected belly button piercing is a common one that I see. There is actually a ‘tube’ of scar that extends from the outer scar inward towards the skin that lies the inside of the belly button. This is an easy problem to improve by scar revision by removing the entire scar along its tract and then closing it. This will leave a very small fine line scar on the outside that is flat where the raised scar now sits. This can be done in the office under local anesthesia. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a male 35 years old and I am interested in having facial implants. What’s the process to get them? What is the period of time to get healed after the surgery? And how much will it cost?

A: Your questions as posed are both vague and impossible to answer. Facial implants is a broad topic and there are implant possibilities for just about every region of the face.  The first place to start is to find what you are trying to achieve with your face and whether facial implants may be needed. I would write me back and tell what deficiences you feel you have in your face, what changes you would like to see, and also send me a few pictures of yourself. With that information, I can determine if facial implants, or other surgeries, may be helpful in you achieving your aesthetic facial goals.

I must first find out what you need before the secondary questions of healing, recovery and cost can be determined. For now, you have the cart in front of the horse so to speak.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,   I am a 25 old year guy and I am really not  satisfied with my looks. I am looking to improve upon my face for a more youthful look .I know it’s not wise to compare yourself to others as everyone’s face is unique but I think the most distracting feature of my face is a very big and wide lower face (mandible) that makes my face chubby and more old looking. The last time I inquired you about an outer cortex osteotomy for as such the same problem and you requested my pictures so I did attach them. Now I would be really grateful if you clarify me my following doubts:

1. Is it possible to reduce my lower jaw width and angle to make my face more slimmer and proportionate?

2. If yes, how much is it possible to reduce the bigonial distance and achieve a more ovoid looking face (Front view) in my case?

3. Would chin augmentation be helpful to achieve the same?

4. I also want to have a tip rhinoplasty that would give my nose tip more definition and sharpness. Again, how much is it possible to achieve a nose like the one in the model pictures I have attached?

5. Please suggest any additional improvements in case you notice that would be required for a more youthful appeareance such as brows,cheeks or any other.

A: In answer to your questions:

1) There is not a really good procedure to make your entire lower face more narrow. Even if one could do a lateral corticotomy (remove the outer layer of the lower jaw bone) that would just not make enough of a difference in your face.

2) Certainly the jaw angles can be removed but whether that would make a very visible difference is uncertain. Some of your facial width is soft tissue and can not be reduced. The best way to answer whether this procedyure would be worth it is frontal cephalometric x-ray or facial film to look at how much flare the angles have. If it is significant then it may be worthwhile.

3) Vertical chin lengthening is, by far, a more practical approach to facial lengthening (and narrowing) for you given the more square facial shape that you have.

4) A tip rhinoplasty will definitely help narrow your nose but trying to achieve the very slim noses in the pictures you have sent is unrealistic. You will likely end up halfway between where you are now and those type of results.

5) Some soft tissue (fat reduction) would also be helpful, removing part of the buccal fart pad and thinning out the fat outside of the corners of the mouth.

I would think that a vertical lengthening chin osteotomy, tip rhinoplasty and buccal lipectomy with perioral liposuction would be the three procedures that I would recommend that could make the greatest difference in your facial shape/appearance.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I write to you to inquire if Lefort 1 osteotomy can be done for cosmetic purposes ( for instance: if a person considers herself to have a long mid face). I know my question is vain and somewhat selfish, but it is something that really bothers me about my appearance. Thank you for your time.

A: While a low level maxillary osteotomy (LeFort I) is usually done for some functional benefits (improved occlusion), it can also be performed for a pure cosmetic benefit. The usual reason that is done is in the patient with a long midface and a gummy smile. This is known as LeFort I impaction or vertical maxillary shortening. This is almost the only incidence where a LeFort osteotomy can be performed without having to cut (move) the lower jaw as well. Depending upon how much vertical movement is being done, the lower jaw (mandible) may autorotate enough so that orthodontic tooth movement/alignment before and/or after surgery may not be needed. Because of this potential issue, it is imperative to have an orthodontic consultation prior to considering this surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would love to show less gum when I smile. I have tried Botox and it has slightly improved the amount of gum shown, however I would like a more permanent solution. I have had repositioning which involved sewing the lip down, and although it looked nice for a while, it appeared to stretch out and go back to normal. I am terribly afraid of the procedure which involves cutting the bone, so I’m hoping that a soft tissue correction will fix my smile.

A: Based on your pictures and the magnitude of your gummy smile, I would not be optimistic about any soft tissue procedure significantly improving your gummy smile. As you know, the best procedure for you is a maxillary impaction osteotomy. (vertical upper jaw shortening) Since I do not know exactly what soft tissue procedure you had done, I can not tell whether my soft tissue approach to the gummy smile will provide benefit to you. I am not sure what was exactly done in the ‘sewing the lip down’ procedure and whether it involved labii superioris muscle release and a mucosal v-y lip advancement. I would need to read the operative note from the procedure you had done to tell if a different soft tissue approach to your gummy smile would be more effective.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to ask about the inconsistency that I see and you have talked about in jaw angle implant outcomes. For some reason, results seem to be very inconsistent with this procedure even with the same  plastic surgeon. Could you explain why this happens?

A: Jaw angle implants are a very tough procedure to do and ideal symmetry is often a problem. Even in the best and most experienced hands, asymmetry of identically shaped implants is not rare. While the implants may have an identical shape, the patient’s bone often does not and you are trying to precisely fit a preformed shaped implant that does not have an identical match to the bone on which it sits. In short, it is an imprecise science. The only really good symmetrical results that I see consistently is in the use of custom implants done off of a patient’s 3-D model. And this is for good reason, perfectly adapted implants that have been made to fit the patient’s jaw anatomy.

While jaw angle implants can make a significant aesthetic facial difference, one who undergoes the surgery needs to be willing to accept jaw angle asymmetry is a risk as well as it is impossible to guarantee any particular look that will result from the surgery. For the patient who is seeking a perfect result and will only be satisfied with such, jaw angle implants may not be a satisfying procedure for them. That does not mean that a very good result can not be obtained, but perfect asymmetry in any bilateral surgery (jaw angle implants not withstanding) is difficult to achieve.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I definitely have come to the conclusion Silicone/Goretex, and a  foreign implant of any sortfor my rhinoplasty  is not the route I want to go. Not only am I worried about the complications as far as infections, extrusions, and any deformity it might bring to the skin if it ever decides to reject these implants, but I don’t think it would be the ideal material to use for my desired augmentation of the nose.

 At this point, I am pretty much set with using rib grafts for my rhinoplasty. Following are some questions I have for you regarding rib graft rhinoplasty:

• How big is the scar for the rib harvest?
• Which rib do you  harvest? Are you familiar with the method of making the incision right on the breast crease and then using an endoscope to find the 7th rib? thoughts?
• Will that area on my rib ever look ”odd,” ”off,” or worse, deformed?
• The collagen that diced cartilage grafts are wrapped in, is it either Alloderm or Surgicel? One of my main concerns with wrapped diced cartilage is reabsorption. I have read that the reabsorption rate can be anywhere from 0.5% to full absorption. Though this is quite concerning, I am aware there is a chance of reabsorption in any case using cartilage of any kind.
• I have read that you can ”mold the nose” externally even after the surgical procedure with diced cartilage.How exactly is this done and what kind of changes can one make at that point?

A:  I think you are wise, in the long run, to avoid a snythetic implant for dorso-columellar augmentation rhinoplasty. A lot of stress on the skin over time with an avascular rigid implant could cause problems.

Here is some general information on rib grafts and their use and harvesting. Rib grafts can be all cartilage, all bone or a combination of both. The choice of the donor site controls what the graft will be composed of. Rib grafts harvested through the lower breast crease gain access to the costochondral junction (rib-bone interface) and have a much greater risk of pneumothorax. (collapsed lung) The only time I go there for a rib graft is for a costochondral graft for TMJ mandibular reconstruction. The ribs are a lot of bone at this level and are right over the lung. This is not my choice for a rhinoplasty rib graft harvest. The lower 4 ribs (6,7,8 and 9), also known as the subcostal location, are all cartilage with a large volume of material. There is no risk of pneumothorax as the apices of the lung is just at the upper edge of rib #6. This necessitates a subcostal incision along the bottom part of the rib cage. The incision can be as small as 3.5 to 4 cms because the skin slides freely over the rib cage, thus being able to work over a wide area of the rib cage through a small incision. I have no knowledge or experience in trying to do this harvest through an endoscope from the lower breast crease. These ribs are long and slightly curved but have not shortage of donor material. The amount that is harvested for a rhinoplasty will not cause an external chest deformity. (this is an issue in ear reconstruction where much larger volumes are harvested.

A pure cartilage rib graft can be either solid (enbloc) ot diced. When talking about the use of such rib grafts in rhinoplasty, it is important to separate where on the nose it would be used and what its construct should be. For the columellar strut, the only choice is a solid graft as this must act like a tent pole. The only question about columellar struts is how long they need to be. They act essentially by being a pole onto which the lower alar cartilages are attached to raise the tip height and to some degree its angle. The dorsum, however, can be augmented with either solid or diced cartilage. I have gone away from solid cartilage grafts because they definitely have risks of warping and shifting position. Also the amount of dorsal height they can create is limited by how thick the rib graft is. (in most cases this is not an issue but it is a limited factor) Diced cartilage created into a rolled construct (sausage if you will) generally avoids warping and ‘edge’ show. It is placed into the nose and molded after insertion both at the time of surgery but also critically by the shape of the splint applied over it and the patient wears for a week afterwards. It usually sets up pretty firm in a very short time but can even be further shaped after the splint is removed by pinching it further together if needed. It may be placed like a sausage roll it is pinched and squeezed into the desired shape once it is placed into the nasal pocket. Once can even do a combo, having a solid inner core onto which diced cartilage is placed around and on top of it. Diced cartilage requires an ‘envelope’ to make it into an insertable graft and there are numerous options from surgical, alloderm to the patient’s fascia. It is not presently clear if one of these has an advanatage over the other. Surgicel is the most convenient technique for making a diced cartilage dorsal graft.

Like all cartilage grafts, there is always the risk of some resorption but my experience in this larger diced graft is that it seems to be very low.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, my three year-old son has an 8 x 10 cm parieto-occipital defect after a craniectomy. I know there are numerous methods of skull reconstruction such as bone cements, bone grafts and computer-generated implants. Is the computer-generated implant the best method?

I also have few more queries:

How safe is bone cement in the long run? What are the recovery rate and chances of infection post operation and also down the line, does the patient has to face any risks or infections? Since he is a growing child, his skull would grow, how would that be addressed? 

One of the neurosurgeons here suggested a autogenous bone graft using the bone from adjacent skull and slicing it laterally and then placing back the resultant two bone grafts each on the donor site and on the defect. How would that fare actually? I am worried regarding this process .

Another suggestion is to use rib grafts. The doctor here said its quite painful. What is your thought on this?

One more suggestion was something called “Osteosynth”….to place a scaffold over the defect and then place the patients bone on that, compelling the nearby bone cells to reach out for each other and then grow. Do you have any inputs on this?

A: In answer to your questions:

1) Computer-generated implants for cranial reconstruction is the best method when one’s bone is not available.

2) Bone cement is very safe and will work well, if it is placed properly into the defect and does not get displaced. As I mentioned in my last e-mail, you can not just put bone cement by itself in the cranial defect…that will not work. Any type or reconstruction will grow as the skull develops and is not a problem.

3) Your son is too young to try and split his cranial bone flap. It is too thin. That will not work. It is usually not possible to split cranial bone into two complete pieces until one is 10 or 12 years of age.

4) While you can harvest rib grafts, it will take at least 3 or 4 ribs to reconstruct the defect. That is too many ribs to take in a young child.

5) Osteosynth is just one of many resorbable bone substitute materials. Like the bone cements, it must be stabilized into the defect with little guarantee that it will regenerate real bone. If it does not, and it likely will not, then the defect will return. For smaller bone defects this may be an option, but not for one of your son’s size.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have some questions about custom jaw implants. First, can they not be made of Medpor material as opposed to silicone? Secondly, what is the limit of vertical lengthening of the chin. I have read that if you lengthen it very much you will disrupt the mentalis muscle sling. How do you determine the maximal limit?

A: In answer to your questions: 

1) Medpor is a machine milled product, silicone is a poured product. Since custom implants are made out of molds from hand-carved clay designs, the implant material must be poured into a mold to be made. In addition, ,many custom facial implants designed are large with complex shapes, the use of silicone material which is very flexible makes it possible for them to be inserted through many traditional small incisions, particularly from inside the mouth. Medpor is a rigid material which would make it impossible to place many custom implants. It is hard enough to place many standard Medpor implants, the need for a two-piece design of the chin implant is an example of that material problem.

2) In my experience, the limit of vertical elongation of the chin area is a function of the skin stretch more than ‘disrupting the mentalis muscle sling’. I have rarely found the need to go beyond 10mm to 15mm and have no found it to be a problem. The key to inserting such an elongating implant in the chin area is the location of the submental incision. If you use the traditional incision location, its position will be displaced outward up on the edge of the rather than under it. Therefore, the submental incision must be moved back from the traditional location when using a custom chin implant that creates substantial vertical lengthening.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I am 24 years old and am needing a breast lift with implants. I am looking for the least amount of breast scarring as possible but also the best results. What type of breast lift do you think is best for me? I have seen scars from the periareolar breast lifts and they look good but will they lift my breasts enough? What should I do? I am very unhappy with my breasts but I do not want to have horrible scars. I don’t want my breasts to look like they have been in an accident.

A: In looking at your pictures, you are in a classic situation that many women are in. They really need some form of a breast lift but understandably don’t want a lot of scars as a trade-off, for they have their own aesthetic liability. What one would consider ‘horrible’ scars is open to interpretation but suffice it to say that breast lift scars will look nothing like ones that occur from being in an accident. Ultimately the breast lift decision comes down to less of a lift with the perirareolar approach (with less scar) vs much more of a lift with the lollipop approach (vertical breast scar) but with more scar. Which choice is the right one for you requires some more research on your part. Spend some time looking at these two different breast scar patterns and results on the internet. I suspect it will not take long before those visual scar images will guide you to the best breast lift choice for you.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a cranioplasty on August 2012 after having a craniotomy in June.  A of now I have temporal wasting of the muscle on my right side and a serious indention where the muscle should be. My neurosurgeon says thats because the temporal muscle has fallen down and is being clinched in a spot right above my ear.  Is there anything we can do for the muscle, to try and get it back to where it was preinjury?

A: What you now have is a combination of temporal muscle atrophy and shrinking as a result of the muscle losing its superior attachments. At this point the muscle is one shrunken scarred mass and there is no stretching it back out and resuspending it. The muscle is now forever shortened and scarred. So trying to move the muscle back up will never work. The correction of the temporal defect will now require the use of a temporal implant to fill the defect.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am considering having jaw surgery.  We have email conversed before and I am impressed with your perception and knowledge.  I hope you will help me in my search for answers. I have attached photos for you to review if you so choose. I wore braces in the past and had no teeth extracted.  My orthodontist says I have a Class I occlusion.  As you can see, I show 1-2 mm of upper teeth at rest.  When I smile, I show all of my upper teeth.  When I laugh, I show 2-3 mm of gum.  When my teeth come together, my lips don’t, so I have have to strain to close them.  This seems to have resulted in my chin having a dimpled look almost as though there is a “fullness” of something. What bothers me is the protrusion of my mouth above and below the lip area, the crease under my lower lip, and the straining of and dippled look of my chin.  I like the position of my chin and don’t want it pushed back if my jaws are moved back.  I’m not sure if I would aesthetically look better if my jaw were moved back 2-3 mm.  I don’t desire that my lips look a lot smaller. Do you have any thoughts???

A: My overall thought is you are not a candidate for major orthognathic surgery. You have a Class 1 occlusion and the aesthetic skeletal maxillary and mandibular problems that it is causing does not justify bimaxillary (maxillary and mandibular setback) surgery. While it can be done it is, so to speak, a long slide for a short gain…and not without some significant risks of morbidty. The magnitude of the problem and its potential benefits does not justify the effort for what is to be achieved. In short, the balance of benefits vs risk is not favorable.

I think there are some other alternatives, however, that are more appropriate for your facial problems. You have a horizontally short chin and mentalis muscle strain. That would be better treated by a sliding genioplasty to move the chin bone forward and give you lower lip conpetence. That would also improve the mentalis muscle strain and perhaps some of the dimpling. As for the upper lip, I question whether anything should be done for just a few millimeters of a gummy smile at maximal smile excursion. I might consider a simple levator superioris muscle release and vestibuloplasty only to blunt the upper lip excursion seen on maximal smile.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 26 years old and I have lived with a webbed neck birth defect all my life. I would like to have a normal length neck for looks as well as for pain. The last doctor I saw said I had short tight trapezious muscles and they actually hurt I have limited rotation with my neck so when turning it pulls a great amount and does not feel good. I saw your website and seen a picture of a woman who had a neck lift and her neck looked slighty webbed and looked ALOT better in the after picture, I’m not sure if the neck lift will completely help my case but I’m hoping you can lead me in the right direction to get what I need done.

A: I have taken a look at your pictures and see your neck concerns. While you do not have the classic web neck deformity that appears in Turner’s syndrome, I do see your concerns about the shorter and wider neck. What is different about your webbed neck from that of Turner’s syndrome is that in Turner’s the webbed neck is largely skin folds. Yours is largely a combined skin fold and trapezius muscle. That means your webbed neck would be much harder to move because of the muscle composition. It would be necessary to release some of the trapezius muscle to be able to narrow your neck and move/lift the skin backwards to get a visible correction. It is certainly doable but the muscle release would certainly cause some discomfort after surgery.

Whether this procedure would really be worthwhile would require an actual examination for me to feel the neck tissues and see how much I think they can be moved.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a question or two. I’m 18 years old and have an really messed up forehead. Its bulgy, has horns and the brow bones sticks out and I also have a high hairline but small forehead. Is 18 to young to be fixing this? What age should I wait till. This is my biggest insecurity. And also how is the pain process?  Thank you for taking your time to read this and I hope you respond soon! I have attached pictures so you can see how ugly it is!

A: It looking at your pictures, I see an uneven forehead, small upper prominences (what you can horns) and some brow prominence. You also have a mildly high frontal hairline or long forehead. That all could be treated in a single procedure, going through a hairline or pretrichial incisioon, burring down the forehead from brow bones up to the horns and then bringing the hairline forward to close. (removing so upper forehead skin to make your forehead vertically shorter. Surprisingly, that is not a painful procedure afterwards (patients report more like a headache) as it is really just a reverse form of a cosmetic browlift procedure with some bone reduction. At your age, your forehead bone is fully grown so it is perfectly appropriate to be doing these permanent modifications. The question to consider is not your age for the procedure (physical maturity) but whether this is enough of a concern for you to justify a surgical change. (emotional maturity)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, my son is 5 years old and has undergone a craniectomy of the right parietal skull bone which is quite large when he was 4 years old. We want to know which cranioplasty procedure would be best for him, bone cement or autologous bone transplant from the adjacent side of the skull? He is otherwise neurologically fine with no functional or developmental deficits.

A: To give a very specific answer as it relates to your son, I would need to know some more information about his defect including reviewing a CT scan and see pictures of him. But I can make some general comments about skull reconstruction in children. When you have large skull defects in young children, the reconstuction options are somewhat more limited because you really don’t have the ability to use a cranial bone graft. While a cranial bone graft, what you call an autologous bone transplant, can be done you essentially would be ‘robbing Peter to pay Paul’ do to speak. In children the skull is not think enough to harvest a split-thickness cranial graft. This using a cranial bone graft just creates the same problem you are trying to solve somewhere else. Thus one is forced to use a variety of synthetic methods for the skull reconstruction. These could include bone cements (resorbable and non-resorbable), metal meshes (one I wouldn’t do), and a assortment of synthetic implant material that are either preformed or custom-made from a CT scan. (e.g., HTR-PMI) There are advantages and disadvantages to all of these synthetic approaches and that needs to be discussed on an individual case basis.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, my question is in regards to my face shape. I am twenty years old and I feel my face is too wide. I am in very good shape but I feel as if my face doesn’t have the chiseled look I want. The problem is I believe my cheekbones are too wide and my jaw is too wide also. So I am asking can I somehow do a cheekbone reduction with a jaw reduction and a genioplasty to lengthen my face as a whole. Being only twenty I am strongly considering doing these procedures. I feel I am a relatively good looking guy as I have received many compliments over the years but its a choice I want to make for myself not others. Basically I want to have a male model look. I want something like that to make my face narrower and longer.

A: On a realistic basis you should look at lengthening your face. It is not really possible to have jaw narrowing although it is possible to have some cheek narrowing. A chin osteotomy (sliding genioplasty) can be done to vertically lengthen the face. I would do some computer imaging first to see how that changes the appearance of your face. That will likely create a slightly more narrow face effect. You may find that the need for cheekbone reduction may not be necessary. But let the computer imaging help you through this decision process.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a gummy smile and spacing. Is it possible for the maxilla to be shaven flatter with the muscle lip lengthening?

A: I am afraid I do not know what you mean by having the ‘maxilla shaven flatter’. There is no such bony operation per se. In gummy smile surgery, there are two basic approaches, either bone-based or soft tissue reconstruction. The bony procedure is a maxillary or LeFort 1 osteotomy. This is where you cut the whole upper above the roots, remove bone above it and then reattach the maxilla up higher. This is known as vertical maxillary shortening or a maxillary impactionk operation. As the maxilla moves up higher, the teeth follow it, moving the excess gum show up under the lip.

You either do the bone operation or all three of the soft tissue procedures. It is all or none one way or the other. You can not intermingle the bone and soft tissue procedures in gummy smile correction.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I want a slimmer less round lower face, so a slight ogee curve is visible. How is that best done? Or can it even be done?

A: When it comes to  contouring the area between the cheek and the jawline, it is important to remember that this is an area not supported by bone. So any fullness is due to the thickness of the soft tissues. (skin, fat and muscle) To get any change in this area (a midfacial slimming effect), a combined buccal lipectomy with perioral liposuction (affects lower cheek area, buccal lipectomy does not) is needed to achieve the best facial contouring. The question for this procedure combination is how much of a change can it make. In my experience, most patients will experience a visible contouring effect but it may take up to six weeks after surgery to see the full result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: D. Eppley, I am a 30 year old and have had prominent eyes that are congenital but not hereditary. I have no medical problems and the thyroid readings are normal. My eyesight is very good. I have a negative vector and shallow orbits . Will I need both cheek and orbital implants? Could you please give me an idea of the nature of the implants before I come down to your clinic. Thanks

A: When one has pseudoproptosis (eyes that appear to bulge out but actually are normal in position but the bone around them is deficient), the consideration of orbital rim augmentation with implants is a reasonable one. Whether the orbital rim or the rim and the cheek needs to be built up is a matter of one’s anatomy. In most cases, significant orbital; rim hypoplasia is accompanied with an underdeveloped cheek as well. This is where the use of a combined orbito-malar implant can be most beneficial.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, do you think temporal implants is gonna have a positive change to my face? I want my upper face be wider than the lower part but I don’t want it to look fake or obvious. Lastly, can the temporal implants be fixed permanently so there is no risk of displacement?

A: I would have no concerns with temporal implants about looking fake or being too big. Conversely the issue is actually whether they do enough and satisfy your aesthetic desires. The implants are placed in pockets beneath the temporalis fascia so there is no need for fixation to prevent displacement as there is nowhere for them to go. They can not get outside of the pockets that are made to receive them.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am considering a facelift and have consulted with three different plastic surgeons. From these consults, I got two different basic opinions. One option was a more traditional facelift with incisions in front of and behind the ear. The other approach presented was a mini facelift with an incision mainly on the front part of the ear. I am leaning towards the mini facelift but am just not sure which way to go.

A: The decision between a mini- or a full facelift can be a difficult one for some patients. Understandably, the concept of a mini facelift is more appealing in the hopes that ‘less is really the same’. But the reality is less is…less in most cases. Therefore do not get catch up in the benefits of smaller incisions and less recovery because the differences between these two types of facelifts are not as great as patients are lead to believe. Two or three weeks after surgery the incision and recovery issues will have no significance and all you will care about then is the result. The important question is what do you hope to be achieved. If jowling is your major aging concern then any of the smaller facelift versions will likely be satisfactory. If your neck is the biggest concern then a fuller version of a facelift will be more satisfactory.

Dr. Barry Eppley

Indianapolis, Indiana