Your Questions
Your Questions
Q: I am 45 years old and have been frustrated with the appearance of my jowl area. I am interested in improving that part of my face. I want to learn more. What is the recovery/healing time? Can anything go wrong during procedure? Thanks
A: Sagging of the jowl area is a natural part of aging and is often the first area of the face to fall. Provided that the neck is not also sagging, and it often isn’t early on, a modified or limited type of facelifting procedure is used. Known by a variety of branded and marketed names, which imply rapid recoveries and minimal interruption in your lifestyle, it is a jowlift or a mini-facelift. Because it is a scaled down version of a facelift, it is a much shorter procedure to undergo and the recovery is likewise much quicker…like in the one week range. Recovery in this limited type of facelift is largely social in how one appears. (bruising, swelling) Other than the typical surgical risks of bleeding, infection and adverse scarring, there is nothing else that can go wrong of any significance. None of these risks have I ever seen in this jowl lift procedure.
The good thing about this jowl lift operation is that it is a solution that is well matched to the size of the problem. Jowling is a relatively minor facial aging issue and therefore it does not need a major operation for its improvement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hi Dr. Eppley, I would like to inquiry which scar removal procedure (besides laser treatment which I have tried – result is not so great) will you advise for the alar rim of the nose area? I had my alar size reduced through a surgery a few years back, the cutting was almost around the whole alar (sides). Unlike other scarring on other flat areas, the alar somehow retracts due to different expressions like laughing. Hope to hear from you, much appreciated thanks.
A: From your description you appear to have had alar rim narrowing, presumably as part of a rhinoplasty procedure. Usually that scar is intended to be placed in the ‘hidden’ skin groove between the attachment of the alar rim (nostril) and the skin of the upper lip. Most of the time this area heals very well although on close inspection in some patients the fine white line may be slightly perceptible. What you are describing as a scar problem does not sound exactly like a scar problem per se. Rather it sounds like it is a nostril retraction problem that becomes evident when smiling or other expressions that push the lip up against the nostril. I suspect that the problem is that the nostril shape has been changed (shortened in circumference) that now allows it to move unnaturally. The scar tissue from the prior procedure may also tether the nostril down creating the same problem. Whether it can be improved by any form of scar revision would depend on my assessment of pictures of the scar, both smiling and non-smiling.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am a 25 y.o male with a substantial overbite that has remained after a long orthondontic treatment at a too late of an age and a recessed chin, altogether creating that “neanderthal” ethnic look to my bottom face.
Rather than living with it or going through a massive jaw surgery, I was wondering since a significant part of the protrusion is actually caused by a fat philtrum – wether there is a procedure that can reduce the philtrum thickness (with an internal stitch in the upper mouth). From a short online enquiry I am starting to think it isn’t possible, and even if that is the case – would still like to know why – is it because it has muscles and not only fat?
I would also like to know why are lip reductions usually very subtle (only about 10%?), and whether there is a vertical reduction in the circumfrance of the lips (I have enough excess lips to go around two mouths…)?
Thanks for your time.
A: Philtral upper lip reductions are not possible because the lip is largely muscle and would cause a lot of lip dysfunction. PLus whatever little bit of thinning could be obtained is not enough to make a visible difference to compensate for maxillary protrusion.
I can explain to you why your perception of lip reduction results is only ‘about 10%’. That has not been my experience where it is more typically a 20% to 30% improvement in my lip reduction surgery efforts. Perhaps, some surgeons are understandably more conservative since you can always take more but you can”t put any back.
Dr. Barry Eppley
Indianapolis Indiana
Q: Hi, I wanted to ask you about lipolysis injection treatment in lipomas. I want to ask whether the method of lipolysis is effective over the lipoma. How many sessions are needed? Will I have the desired effect? I want your opinion on this matter… thank you.
A: There is no doubt that the excision of lipomas is standard treeatment because it is more effective and a one-time surgery for that specific lipoma. While there is a trade-off of a scar, it usually is less in size than that of the diameter of the lipoma. But for those who are opposed to excision, injection therapy can be done. But it will take multiple sessions whose number depends on how big the lipoma is. For each cm in lipoma size, there is usually 2 injection sessions. So measure yours and you can do the math to see how many injections sessions might be needed. There is also a higher risk of recurrence with injection therapy because not all of the lipoma, or its attached blood supply, may be completely eradicated.
Indianapolis Indiana
Q: I am thinking about getting numerous facial procedures and I have a few questions. I am wondering if getting a chin implant will stop hair growth on my chin? Whatever I have done I want a natural look, will too much facial surgery ruin this or make me look unnatural? Last question,what are some alternatives to cheek implants?
A: A chin implant will not stop beard growth on the chin. It is put in through an incision under the chin so it is very far away from the hair follicles of the chin skin.
Getting a natural result in facial surgery is based on doing whatever procedures are done in balance with the rest of the face and not overdoing any one procedure. Facial surgery, whether it is a rhinoplasty, chin implant or forehead recontouring, is making the structural change to look ike it belongs to the rest of the face.
The only alternative to cheek implants is fat injections. While I think cheek implants and their numerous styles and sizes offer more versatility for cheek changes, fat injections can definitely add volume to the cheek and submalar (below the cheek) areas. With today’s more concentrated methods of fat preparation, fat injections to the face also work better in terms of maintaining volume to the injected facial area.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am interested in getting either a new chin implant or modifying the one I have. I had a Medpor contoured two-piece chin implant with 7mm (medium) projection placed about one year ago. While I like how much projection it has given and its front shape, I feel it is not adequate as it goes around the side of my mouth below the corners. I would like it fuller in this area but I don’t want a square chin implant shape either. I still want it contoured. What do you recommend?
A:I have taken a careful look at your existing chin implant’s dimensions and your desire for more lateral fullness as the implant crosses a vertical line below the corner of the mouth. In most patients that is going to be about 30 to 35mms from the midpoint of the chin back along the jawline. Your current implant has a thickness of about 4.9 mms (.7 of total 50mm wing length x 7mm central thickness) in this area as it tapers posteriorly. Switching to a larger projecting implant (9mms) will only make about a 1mm difference (5.7mm) in this prejowl area. A different style chin implant of the same central projection will not produce any larger fullness in this area. (4.5mms) Therefore, it is my advice to not consider changing the implant as no current chin implants styles make for increased fullness in this area without adding more horizontal projection. One option to consider, which is actually easier, is to keep the existing chin implant and place ‘shims’ underneath the implant in these areas. Shims are wedges of cut material that are slid underneath the indwelling implant that can provide more fullness to the implant in this area than it otherwise has. Since you have a Medpor implant, I would use double-stacked 1.5mm shims to accomplish this implant modification.
Dr. Barry Eppley
Indianapolis Indiana
Q: I would like to know your opinion about mandibular implants for woman. I am 53 and I was told that an angle implant would improve my features, as I have a steep mandibular plane; it would also be better to do it prior to face lift. Thank you for your opinion and advice.
A: Jaw angle implants are not that common in women as a well defined and angular back of the jaw has not been an historic aesthetic feature for women. That has changed in more recent times as more celebrities and recognized women with fairly angular jaw structures are seen regularly. While too strong of a jaw is obviously not desireable for women, a weak jawline and shape does not age well either. More recently I have done jaw angle implants for women, either to get a stronger jaw angle in younger women or to enhance the appearance of an aging jawline in middle-aged women who have a weak jaw angle or steep mandibuar plane angle.
While I obviously can not answer whether jaw angle implants are a good choice for you without seeing pictures, it can be determined before surgery whether they would be advantageous with computer imaging. That can show you quite clearly whether they are of benefit. When done as part of a more complete hard and soft tissue facial rejuvenation, I would recommend having it done at the same time as a facelift. While there is an argument to be made for separating the procedures (swelling), there is the inconvenience of two separate procedures.
Dr. Barry Eppley
Indianapolis Indiana
Q: Dear Dr. Eppley, I am a 19 year old male. I am having a 5 mm lower jaw advancement (BSSO). I know that the human jaw and chin and other facial bones continue to grow until around age 25. I also know that after surgery, the doctors screw and bolt your jaw into a new position. Would this mean that since my jaw would be screwed and bolted in its new position that my jaw will not be able to grow anymore? Will I have my 19 year old jaw all my life? The reason I ask this is because I have a small jaw, and I want it to keep growing as much as it can, but I am afraid that this surgery I am having in a few months will stop the growth of my jaw.
A: Jaw (mandible) growth in a male is known to not stop growing until at least age 21 or so. That is the reason any form of jaw surgery, mandibular advancement or mandibular setback, is not usually done until age 17 or 18. At this age, one is unlikely to outgrow their surgical result. This is much more of a potential concern when the jaw is set back than when it is moved forward. I have never seen a jaw advancement done where it becomes ‘too short‘ later in life. But I have seen jaw setbacks where the underbite recurs with ongoing jaw growth. This indicates that surgery of the ramus does not really affect jaw growth and I think this is not a concern that you should have.
Indianapolis Indiana
Q: I am writing because I have had migraine surgery for the occipital and temporal triggers last year. I am having a lot of migraines and tension headaches behind my eyes and above my eyebrows at this point. The frequency is about three per week. I can’t take it anymore. What do you see are my options at this point. The good news is I haven’t had any migraines on the back of my head. I am just discouraged because it seems the pain has migrated to another trigger site.
A: I think you do have some additional options at this point. The occipital area has had a good decompression which is why you have good results at this point. I always find occipital decompression works the best because it is the easiest and most direct to approach. The issue is the frontal/temporal region. There are two triggers in this area, one of which has not been treated at all (brow/supraorbital nerve) according to your description of your operation. It was not treated undoubtably because it was not a major contributor at the time. Treating one trigger can unmask other triggers. The temporal trigger (zygomaticotemporal) appears to have been treated from the temporal scalp approach which is not the best way. It has been learned that the main trunk of the nerve is in the midst of the temporal muscle and should be treated at this level which requires a different incisional approach. Both the supraorbital and the main trunk of the zygomaticotemporal nerve can be treated through an endoscopic browlift approach. Both nerves can be reached through two small scalp incisions and this additional migraine surgery should be helpful.
Dr. Barry Eppley
Indianapolis, Indiana
Q: My 17 year old son has pectus excavatum which is more pronounced on his left side. It is slight according to the pediatric surgeon we saw and he felt that any sterna reshaping surgery wasn’t justified. He was fitted for a chest brace which was ineffective. Is there anything that can be done that doesn’t involve cutting the bone like some type of implant?
A: Minor cases of pectus excavatum can be cosmetically treated by onlay implant augmentation. There are no specific sternal implants that are available off-the-shelf. In addition, it is desireable to limit the need or size of an incision to minimize scarring. A noticeable scar would make for a poor aesthetic trade-off despite the sternal contour improvement. Therefore, I have found that the use of Kryptonite bone cement currently offers the best treatment option. It can be injected through a small tube, making for a very small incision of just a few millilmeters. Once injected, it can be molded and contoured to smooth out the sterna depression. Another potential option is fat injections. With today’s improved fat concentration techniques, the survival and volume retention of fat is much improved. In small areas like the lower end of the sternum, I would expect fat volume survival to be good. The only negative is that it would be soft rather than firm like a normal underlying sterna bone. Whether this is significant is a matter of debate.
Indianapolis, Indiana
Q: Hello, my problem is that I have a lower anterior face height deficiency. Because of that my total face looks very small. First I didn’t know what the problem was. After examining my face very well I came to see that the lower anterior face height is very small. I have a very little chin and small jawline. I have read your article entitled ‘Case Study: Vertical Jawline Lengthening for a Short Lower Face’, and I think I have the same problem as this girl that is mentioned in the article but a bit worse than that. I have attached some pictures of my face so that you can take a closer look. When I look at the photos I think my lower anterior face height should be longer. Can I do this with a chin and a jaw implant or some kind of other implants? Because I’m not sure what kind of implants the girl in the article had. I think I have the same problem as her but more extreme. I would like to know your professional opinion. I went to a local plastic surgeon but they didn’t understand what I mean or maybe they just don’t have the techniques. They kept saying my chin had the right position. (apart from that my chin). Because my lower anterior height is small my forehead looks a bit big. But it is a normal size forehead, it’s just compared to the lower face it looks big. So I think my face needs to be lengthened vertically and a bit horizontal at the jaw (because when it is only vertically lengthened my face will look long, because I don’t have a wide face). I hope you see what I’m trying to say because I know something is not right.
A: I can see perfectly what your facial concerns are and you have stated them quite accurately. Your lower facial height is proportionately short compared to the upper two-thirds of your face. Your chin needs to be vertically lengthened by 7mms and horizontally advanced 5mms. That can not be done with an implant but requires an osteotomy. There is where the chin bone (not the main jaw bone) is cut and moved down and forward. It is held into its new position by a small plate and screws as it heals. This is done from inside your mouth through a small incision in the vestibule below your front teeth. This is a common chin surgery that I regularly perform which is highly successful at improving your lower facial lengthening.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hello! I’d love to schedule an initial consultation with Dr. Eppley. I’m also interested in the program Dr. Eppley offers for military families as my husband is an active duty soldier who’s been in the Army for over 10 years. After two deployments and a new baby, we are ready to try and normalize our lives again. For me, feeling normal and happy is critical and in order to achieve my dreams, I must address my post-baby body! Although I’m nervous about heading down this road; I’m ready and I look forward to hearing from you. Thank you very much.
A: When you consider the post-partum body changes and being in the military, what you need is the Military Mommy Makeover! (M cubed so to speak) All mommy makeovers involve contour changes on the abdomen and breasts. While there are many variations and combinations of these procedures, it could be as simple as abdominal and waistline liposuction and breast augmentation to a full tummy tuck with flank liposuction and breast implants with a lift. More times than not, it is the latter as pregnancies usually leave extra skin on the stomach and sagging skin on the breasts partticularly if one has had more than one child. My Patriot Plastic Surgery program offers military members and their direct family a discount for surgical procedures. This will hopefully enable them to have some desired physical changes done, and as you have described, normalize your life again.
Dr. Barry Eppley
Indianapolis Indiana
Q: I need to have my brow bones/forehead contoured by you. I must let you know that I have had my brow bone shaved down 3 years ago and I have been having problems with air leakage into my forehead. I am thinking that maybe the dr. shaved down the bone a little too much. My forehead has a “flat” surface above my nose. I would like to have my forehead rounded out and possible have my eyebrow bone made a little bigger? Do you think that would fix or help the air leakage problem?
A: Brow bone reduction is about taking down the outer table of the frontal sinus. That bone is actually very thin and is not a solid block of bone as many people think. The brow bone can be reduced by burring or actually an osteotomy with plate fixation. It sounds like you had the brow bones reduced and have an area where the bone is too thin. This can happen in burring reduction by removing too much bone or in an osteotomy with plate fixation where there is an uncovered hole area. Either way, it is clear that you have a frontal sinus fistula as a result of a hole acting as a source for an air leak. This air leak should be pushing outward into the forehead tissues as it escapes from the frontal sinus which connects to the air cavities of the nose. You would do well with an hydroxyapatite cement brow bone augmentation which would build your brow out and close off the air leak as well.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I want to make numerous changes to my chin as I think it will make my face look better. I am looking to decrease the horizontal dimension of my chin as well as increase the vertical dimension. I think this will create a more angular jawline as my lower face is very rounded. My chin feels like it pushing my bottom lip upwards so I wanted the lower lip to be brought down slightly, would this be at all a possible? I would also be wanting a rhinoplasty, however at the moment, I will be focusing on the chin. Would these chin changes be best done with an implant or an osteotomy? I really hope you can help Dr. Eppley. Thank you for time.
A: That type of chin change can only be done by an osteotomy. With the chin pushing up on the lower lip, this suggests that it is too vertically short. A chin osteotomy can easily increase its vertical length by making an opening wedge that is held apart by a special chin plate and four screws. Lengthening the bony chin will always make it look thinner, but its bony width can also be narrowed by a midline ostectomy of the downfractured segment at the same time.
As the chin is lengthened, it can create a slight lower lip lowering effect as the mentalis muscle is also lengthened. As the upper attachment of the mentalis muscle does extend to just below the lower lip, its lengthening as it is carried down with the bone should make the lower lip less pushed up.
Dr. Barry Eppley
Indianapolis, Indiana
Q: It has been 2 months since my rhinoplasty. Everything is going down very nicely. I had my bump removed and narrowed and my tip raised a little. I had a droopy profile. Sometimes when I look at my profile I see a slight hump still when I smile. That is driving me crazy, not so much on my right side but my left side. When it gets down to the tip, it goes in slightly and goes up the tip very little. My question is I was very swollen when cast was taken off. My nose was taped right away and the tip of my nose is still swollen. Could it be that this slight hump is still swollen and when the swelling comes down so will the hump and the swelling in the tip the swelling on both sides of my nose went down dramatically but I’m just concerned about the profile. Thank you.
A: One of the hardest things in undergoing rhinoplasty is to have patience. The shape and appearance of the nose can take months to fully appear after surgery. Final results in most cases can not be fully judged for up to one year after surgery. I believe you have answered your own question already. While some swelling has gone down, it is far from being completely resolved. Whether your dorsum and the pre-existing hump will be completely gone is not yet known. If you feel that there is still some tip swelling (which there undoubtably is), then there is still some dorsal swelling which may account for a pseudohump appearance. Don’t get out the critical eye until 6 months after surgery. If the hump is still there, then it is no longer just swelling and revisional rhinoplasty may be considered.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I fell and now have a depressed scar on my forehead that I think (but what do I know) should probably be cut open and resutured so it results in just a fine line. It’s about 2″ long. I have attached a picture of it for you to see what it looks like. What do you think?
A: Scar revision is ideal for those scars that have healed with a contour depression or indentation. No other method, such as injectable fillers or lasr resurfacing, can change the level of the line of original injury as well as excision and reclosure. By cutting out the scar edges and recruiting normal unscarred skin and subcutaneous tissues, the lack of volume which represents the original scar indentation is replaced. You are correct in assuming that you are trading off an indentation for a smoother fine line scar. Your scar is small enough that it can be done in the office under local anesthesia, saving the expense of the operating room and other supplies. The new scar will be finer and mor even with the surrounding skin. It will take months for its redness to go away but, in the end, its appearance will be much improved.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am interested in rhinoplasty and jawline enhancement. My nose is too big and my jaw is weak in my opinion. I am hoping to achieve a more masculine and symmetrical appearence to my face. I would greatly appreciate any suggestions as to how to best go about achieving my goals. I have considered possibly just opting for rhinoplasty and not having any jawline augmentation at all. I have pulled my hair back in the photos to give you a better idea of the overall shape of my face. P.S sorry if the photos are not crystal clear, but this is the best camera I have. Thank you for your time.
A: Thank you for sending your pictures. I have done some imaging using a combination of rhinoplasty and chin augmentation. When you have a larger nose, even when the chin is not overly weak, a chin augmentation provides better facial balance by counteracting the appearance of the nose. This is particularly true in a man where a stronger chin can be better facially tolerated. No rhinoplasty can truly make a large nose small but it can reshape it so that its size is better balanced. The chin augmentation really enhances the facial effect of the rhinoplasty and is really the only jaw enhancement procedure that you need in my opinion. For the best effect, both rhinoplasty and chin augmentation should be done at the same time.
Dr. Barry Eppley
Indianapolis Indiana
Q: Hello, I know I’ve contacted you before I would just like to go a little more in depth. I searched the web and you seem to be the most qualified surgeon in terms of facial/skull surgery. I had contacted you about taking hgh pills at 16 (now 18) and seeing an increase in head size. My head is not extremely big but I don’t feel comfortable with it from how my head size should be and also I have concerns of possible frontal bossing in the forehead area. I understand costs can be high for this kind of extensive work but I’m very interested in finding out how you could help me. I have attached some photos of me and I also am planning to have the necessary x-rays done in order to understand how much between the skull and actual brain.Thank you.
A: Thank you for sending your pictures. I am seeing some mild frontal bossing (brow reduction), a smaller chin (chin augmentation) and a larger nose (rhinoplasty), all of which could be surgically modified. But I am not seeing reason for any other skull modification or skull problems. The x-ray would be helpful to know how thick the frontal bone is over the frontal sinus which helps choosing the surgical technique for brow reduction should that be a desired change.
Dr. Barry Eppley
Indianapolis Indiana
Q: Dr. Eppley, I have a scar in the middle of my eyebrows that has bad indents from stitches that look like a train track. Can scar revision fix these indents?
A: When referring to indents, it appears you are talking about the stitch marks which are often called ‘train tracks’ or ‘train-tracking’. These are the result of using sutures that are too big for the face, leaving sutures in too long, or a combination of both. What they are is the healed indentations from where the sutures went into the skin and the skin healed around them. While all sutures have the potential to develop these dots or indentations, large sutures leave little round white holes and sutures that have been left in way too long can have these hole which are indented.
These train track scar marks can be difficult to remove since they lie outide of the existing scar, making wide scar revision often not possible. This leaves the option of removing the track marks iindividually through small punch excisions. This may make it possible to improve the indented nature of theae marks but there will always be a small white scar from the original or new hole. I wowuld have to see a picture of how bad these marks to determine of there is any worthwhile treatment option.
Dr. Barry Eppley
Indianapolis Indiana
Q:I have a light brown birthmark on my left hand. It is the shape of a thumb print. I am very self concious about this, and I would like it removed. Is this possible? If so, could I please receive information about the consultation & cost.
A: Thank you for your inquiry. Whether the brown mark on your hand can be removed is a function of whether it is an acquired skin discoloration or whether it is a congenital or birthmark skin lesion. That difference is significant as it indicates at what the level the excessive brown pigment exists in the skin. An acquired brown lesion develops because of chronic sun exposure and the excessive pigment is in the superficial layer of the skin. (epithelium and upper dermis) That can be treated quite successfully by pulsed light therapy such as BBL (broad band light) or IPL. (intense pulsed light) Brown birthmarks, however, usually have pigment that goes all the way through the thickness of the skin and involves the deeper dermis. These do not respond to any type of light or laser treatments because the discoloration is too deep to reach without burning the skin. In some cases, removal by excision can be done by that leaves the trade-off of a scar which is often not a better cosmetic result.
I would need to see a picture of your hand ‘birthmark’ before I could comment on whether any removal treatment is possible.
Dr. Barry Eppley
Indianapolis Indiana
Q: Hello, my name is Mary. I am currently a 36DD and hate them. I have back pain and my ribs hurt. I have trouble finding comfortable bras, and I would much rather be a large B cup or small C cup. I had a baby 6 months ago and wanted to know how soon I could have a breast reduction. Thanks.
A: It is clear from your writing that a breast reduction would be beneficial. The timing of any breast reshaping surgery after pregnancy depends on several factors. First consideration is that one has to have stopped breastfeeding. Second and most importantly, one’s breast size and shape should be stable. The breasts should have maximally involuted (shrunk) and sagged from the effects of pregnancy. This makes the breast tissue removal (reduction) and the accompanying lift to be best done without having the uncontrolled effects of these ongoing breast changes. Lastly and ideally, one should be certain that they are done with having children as this will have a negative effect on the long-term breast size and shape.
Breast reduction provides a consistent improvement in the back, shoulder, and neck pain that frequently accompanies large breasts. Its improvement is a function of the weight reduction but can also be attributed to the repositioning of the breast tissue back and higher on the chest wall.
Dr. Barry Eppley
Indianapolis, Indiana
Q: My 5 year old daughter fell on a metal fireplace about 3 months ago and has been left with an oblong dimple across her right cheek that turns in significantly when she smiles. We have seen a plastic surgeon who thinks we are best to do nothing for say ten years. I am assuming this is because as she grows her face will change and also by the time she is 15 she will be able to make her own mind up about surgery. What would be your opnion on operating on young children and are there benefits to waiting?
A: Given that injury is only a few months old and she is five years of age, there is still a chance that time and healing will make the cheek dimple better or it may go away completely. That is still to be determined and you will know how permanent the dimple is by one year after the injury. If there has been no change or significant improvement by then, then one can consider corrective plastic surgery. My philosophy on the timing of ‘cosmetic’ plastic surgery procedures in children is that it is a parental decision until the child is a teenager. Once puberty hits, it then becomes a patient-driven decision. Either way the treatment would be concentrated fat injections into the depressed cheek area. The only advantage to waiting is in the first year after the injury to see how much improvement is obtained naturally so surgery might be avoided.
Indianapolis, Indiana
Q: I am interested in getting my nose fixed and have my upper lip shortened at the same time. I have been some research on lip lifts and it seems wonderful and the results are exactly what I want. But you have written that a rhinoplasty can not be done at the same time. That bothers me because I did not want to recover twice. But I have been doing some searching and som,e doctors do both at the same time but some don’t. Is there a possible reason/ I really want to have my surgery with you because you have the best before and after pictures I’ve ever seen for noses that are similar to mine.
A: The reason that I don’t combine an open rhinoplasty and a subnasal lip lift is because of the potential risk of skin necrosis. When done together, there will remain a small area of columellar skin between the two incisions, that of the open rhinoplasty and about 6 to 8mms below that of the subnasal lip lift. The survival of that skin depends on having an adequate blood supply coming into it. Part, and may be most, of the blood supply to that skin is cut off by making those two incisions at the same time. While it is likely that it would be fine with some blood supply coming from the septal mucosa, there is some risk that it might not be and that skin would then die. That would be a cosmetic disaster and my concern is more then theroetical…I have taken care of a patient who had that exactly happen when those two procedures were done together by another surgeon. Given that the lip lift can be done as a simple office procedure later under local anesthesia with very little recovery, I don’t think the risk is worth it for an elective cosmetic operation.
If one was doing a closed rhinoplasty, in which a columellar incision is not used, then a subnasal lip lift could be done at the same time. It is likely that is the type of rhinoplasty the doctors who say they do it at the same time are performing.
Dr. Barry Eppley
Indianapolis Indiana
Q: Dear Dr. Eppley, I am having a bilateral sagittal split mandibular osteotomy with upward rotation as well as a sliding genioplasty done by a maxillofacial surgeon in a few months. I still want to get jaw implants. Is it still possible to get jaw implants even after all these surgeries I am getting? Wouldn’t all the screws and metal plates they are putting into me cancel out the ability to get jaw implants? Thank you.
A: The simple answer is no. Most of the titanium plates and screws that are used in orthognathic surgery ends up inside the bone. The outer screwheads and plate profiles are very thin, generally only sitting up 1 to 2 mms above the bone. Furthermore the location of the metal fixation devices lies in front of where jaw angle implants are placed or behind where a chin implant would be positioned. While there would be some scar from the prior surgery, it only makes the path of dissection a little more difficult than normal. This in so way precludes the placement of any type of jaw augmentation implant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hello! I’m a young girl who has very puffy and big cheeks. From my cheekbones down to my jawline it is very full. I really love my face otherwise, but it’s too much fat there. I am a very thin girl and no one in my family has these big cheeks. Is there any way to reduce the chubbiness of my face? Do you think liposuction would make it thinner? Or is there something else to make my face thinner? I’m willing to do anything for this, because I’m depressed and desperate. Thanks.
A: Chubby cheeks are part of many person’s facial makeup, particularly when they are young. You did not provide your age other than to say you are young. But if you are under the age of 16, your chubby cheeks may become less so as you mature further. If you are over the age of 18 and at a good body weight then the fullness of your cheeks is built into your genetic code so to speak. Some reduction in the fullness of one’s cheeks can be done by buccal lipectomies and small cannula liposuction of selective facial areas. Potential liposuction areas include the perioral mounds (below the cheeks) and lateral facial areas around and in front of the parotid glands. These facial fat reduction methods will not make a chubby face thin but they will help provide some more shape and contours to an otherwise amorphous round face.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 30 year old male and I have a flattened skull at back, which I understand to be plagiocephaly. This has until now been fairly well-covered with hair, but I am beginning to recede at the temples, and so I am becoming increasingly concerned about it, should I go bald. I am therefore interested in exploring possible treatments- I hear you offer a cranioplasty procedure involving injectable kryptonite? I would be very interested in hearing more about this- in terms of how successful/established the procedure is, likely cost and potential risks. Any information you could provide would be really useful. I appreciate it may be difficult to provide a concrete answer without a full consultation, but any general information would be really useful.
A: I would seek out any postings that I have written using Kryptonite cement for skull reshaping which would appear on a Google search. I have written extensively about it and all of your questions would probably be answered there. In summary, it is a developing technique that is far from perfected with the biggest complication being irregularities and the potential need for a smoothing revision. But it is a simple one hour procedure that involves minimal recovery using only a one inch incision. The cost of this cranioplasty procedure is largely driven by the volume of the material that is used. The cost of the material will easily make up more than half of the cost of the surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am interested in getting a six-pack look to my stomach. I work out all the time and do a lot of abdominal crunches but it is just not appearing. I am a man who is fairly lean and have only 9% body fat at 34 years of age. I have read about a liposuction method called ‘etching’ which can make the six-pack look in one surgery. Can you tell me how it is done and what makes it work? Are there any long-term problems with having it done?
A: The abdominal etching surgery to which you refer is a modified liposuction method for producing abdominal highlights. Using fine liposuction cannulas, fat is removed along predetermined highlight lines in a linear array of a central vertical line and multiple (usually three) horizontal lines. By removing linear lines of fat lines, this causes the stomach skin to selectively indent inward which then appears like the underlying abdominal muscles lines, creating the ‘six-pack’ look. Interestingly, abdominal etching is done in exactly the opposite way that traditional liposuction is done. Rather than trying to remove an even amount of fat over a broad surface area of the abdomen to avoid any irregularities, etching deliberately aims to create indentations through an uneven (but precise) amount of fat removal. Abdominal etching is really best done on someone who already has a near flat abdomen and wishes for a more liposculpture approach rather than a large amount of fat removal. It is not a good idea for someone who has a large protuberant abdomen or is significantly overweight. The only long-term issue is what would happen if you gain abdominal weight. The etch lines may look peculiar on a bigger belly.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, does zerona help with belly fat and gynecomastia. Not sure why it wouldn’t help gynecomastia if it’s all adipose tissue.
A: The first thing to realize about fat is that it is not all the same throughout the body. It is both structurally and biochemically different as it actually serves different physiologic roles depending upon its anatomic location. It is present in our bodies for very functional purposes other than being a source of annoying collections of unwanted bulges. It also has some differences between males and females as well. This is illustrated in your question about male gynecomastia and belly fat. Male breast enlargement is composed of fibrofatty tissue. Some of this is fat but it also has a significant component of gritty fibrous tissue. This makes it unresponsive to an external treatment like Zerona. Gynecomastia can only really be effectively treated by liposuction, particularly Smartlipo, or open excision. Belly fat is distributed differently in men than women. Most of belly fat in women is external to the abdominal muscles (subcutaneous) and can be reached by Zerona (up to 5 cms. penetration) or liposuction. Male belly fat has a greater percent hat lies underneath the abdominal muscles (intraperitoneal) and does not respond as well to such fat treatments.
That being said, Zerona is not a good treatment for Gynecomastia and tends to be less effective for some men than women for the reduction of belly fat.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am interested in forehead augmentation to make the slope of my forehead less so and longer. I was hoping to retain my brow ridge prominence somewhat as that is a family trait…and in fact I’d like to keep the forehead looking sloped and straight as opposed to rounded and convex….keep it similar to how it is now, except for perhaps slightly raising the hair-line and moving it out a bit, while making the slope of the forehead greater, but certainly no where near convex. In other words, just as the brow ridges end moving toward the hair line, all of that forehead area I was hoping to making steeper, but still straight and non convex, and at the very top where the hair line is i was hoping to making higher and more in line with the rest of the forehead. Is that not possible? I don’t know how these surgeries work… in other words, I don’t know what the limitations are for the shape of the molds and their complexity…but I certainly didn’t want a drastic change in the forehead. How “complex” can the moulds be made that fit into the forehead region? What is the potential for tweaking certain aspects?
A: Forehead augmentation is not done by a preformed implant or a mold. It is done by cranioplasty onlay materials. These are mixed together at the time of surgery and applied like plaster of paris. It is then shaped by hand until the desired form is obtained and then allowed to set or cure. The average working time is about 10 minutes for this process. It is a very artistic technique which is why one has to have a very good idea what type of forehead shape the patient wants. You have been quite explicit as to your forehead shape desires which is good. Given the volume of material needed (at least 40 grams), PMMA (acrylic) is best for you because of the cost issue with that volume of material.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Would Acell Matrsitem be helpful in forehead reshaping to minimize the scalp scar in the hairline? I have a crooked forehead as a result of the way I slept as a child and I know surgeons are generally reluctant to perform this procedure in maklkes due to the scalp scar in the hairline showing as it recedes.
Also, I was wondering of you have ever heard of or used Resobone (custom fit degradable implants to correct bone defects and what are your thoughts on this technology?
A: I think when it comes to optimizing a scalp scar in any patient, but particularly a male, anything that may help would be useful. In that regard, Acell Matristem may provide some healing advantage and it is certainly easy to apply into the wound during closure. While it is not magical and can not make it heal without any scar, anything benefit it can provide to making the scar as narrow and inconspicuous as possible is a bonus.
Resobone is a mixture of two resorbable materials, poly-lactic acid polymers and tricalcium phosphatre. Its intent is to act as a matrix to encourage bone to heal a defect. For bone reconstruction of bone defects, it is an option although I do not see a big advantage over many of the hydroxyapatite cements that exist today or even a computer-generated custom HTR-PMI implant. It does have one disadvantage and that is it is resorbable, so if bone doesn’t replace it the reconstruction will be gone. It should not be used, however, as an onlay or building up material. Since bone will never grow into and replace that of an onlayed resorbable scaffold no matter what its composition. If your thoughts are to use Resobone as a forehead cranioplasty implant it will eventually resorb away and be left with very little if any augmented result.
Dr. Barry Eppley
Indianapolis Indiana
