Your Questions
Your Questions
Q: Is a cheek implant that is placed high (near the orbital rim) and lateral, that extends to the orbital rim and that provides a significant augmentation (5 mm or more), able to lift the portion between the iris and the lateral canthus (not the lateral canthus itself) of the lower eyelid a little bit? I noticed this feature of the lower eyelids in people who have naturally very high and prominent cheek bones.
A: The simple answer is that it is unlikely. While it seems logical that the lower eyelid can be pushed upwards, and it is easy to do with one’s finger, try it by pushing up on the cheek tissue. You will notice the lower eyelid does not really move upward but just creates bunching of tissue right beneath the lid line. This is because the lateral lid line is fixed by the lateral canthal tendon. The only way to change the lateral lid line is by repositioning or tightening the lateral canthus. I suspect that putting in a cheek implant as you have described may seem to work during surgery, only to be disappointed later when no change is seen.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have a very high jaw angle. My goal is to have a jaw implant that will lower my jaw angle as much as possible. The problem is that the biggest implant I have seen only has 35mms of vertical length and the inferior ridge is just under 10mms. Does a bigger jaw angle implant exist and I have just not seen it? If not, how can a bigger one be made if possible?
A: Your are correct in your assessment that no off-the-shelf jaw angle implant can drop one’s angle down anymore than 10mms at most. Anymore more than that requires a custom implant to be made which can bring it down closer to 20mms. Such exceptional jaw angle extensions are uncommonly requested or needed which is why no stock implant exists with that degree of accentuation. I have made custom jaw angle implants that do achieve what you are after. They require a jaw model to first be made which is done from a 3-D CT scan of the patient. The jaw model made is then the exact anatomy of the patient from which the design and model are created.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am interested, I think, in some fillers, Botox and perhaps a partial facelift. What I would like to achieve is a firmer jawline, reduce my crow;t feet and just have a refreshed look. I am attaching some pictures for you to review and give me your recommendations. Thanks!
A: Thank you for sending your pictures. I have done some imaging looking at firming up your jawline. You hve the typical jowling the comnes with aging and this also creates a prejowl indentation as the jowl sags. That is best corrected by a lower facelift (neck-jowl lift) and adding in a small chin-prejowl implant to bring the chin out slightly (yours is a little short) and filling in the prejowl deficiency. The combination of these two makes for a smooth jawline. At the same time, I would place some fat injections in the nasolabial folds (lip-cheek grooves, parentheses) as this is the best ‘filler’ to use when you have are doing a facelift as it is the only filler that potentially can be more permanent. Botox for the crow’s feet can be done either during a facelift or anytime in the office. Just for the sake of one additional suggestion, I have also imaged a rhinoplasty by doing some nose narrowing and lifting the tip a little as this can also have a rejuvenating effect as one gets older.
These computer images will help you think more about what can be done for a refreshed look.
Dr. Barry Eppley
Indianapolis Indiana
Q: Six years ago I had a mandibular implant placed as well as malar implants. I am unhappy with the end result and do not feel the result was what I requested. I think, as I did then, that a geniomandibular groove implant with extended malar implants would provide my desired results.
A: I am assuming when you say mandibular implant you are referring to a chin implant. Since you feel that a geniomandibular groove implant is better, it appears that you feel that the transition between the chin and jowl area is not a smooth or confluent one or that the jowl area needs to be more enhanced as well. Do you know what type of chin implant you have in now?
From a cheek standpoint, the desire for further malar extension suggests that either you desire more fullness out across the zygoma to the zygomatioc arch or that your desire more fullness in the submalar area suggesting more of a malar shell design. Do you know what type of malar implants you have in now?
Please send me some photographs of your face and let me know, if you can, what type of implants you have in place. A copy of your original operative note can also be very helpful as often the type of implants used are described there. Once I have this information, I can offer a more qualified response as to the best replacement facial implants for you.
Dr. Barry Eppley
Indianapolis Indiana
Q: I’m planning on having a tummy tuck and have read that they can be done without using any drains. I don’t want a drain because it creeps me out thinking about a tube coming out of my body. I have also read that some plastic surgeons still use drains because they think it is better. What are your thoughts as to which way is best?
A: I have done tummy tucks both with and without drains. There are pluses and minuses each way which is why drain use is controversial and variable amongst different plastic surgeons. The purpose of a drain is to remove fluid that the body produces in the healing space of the tummy tuck area. When doing a tummy tuck without a drain, this open space is closed down with extra sutures which takes time and does add to the cost of the operation. Even though a drain might not be used, there is a small chance that fluid can still accumulate and have to be tapped later. When doing a tummy tuck with a drain, it will stay in for 7 to 10 days. There is about a 1/3 chance later that some fluid will still accumulate and have to be tapped.
Having done tummy tucks both ways, I have seen numerous cases where fluid still had to be tapped later whether a drain was placed or not. Unless a patient is possessed about not having a drain, I will use a drain most of the time. When a patien is opposed to a drain, I will use extensive plication sutures and extra OR time to perform it. That will add about a one-half hour to the cost of the operation.
Dr. Barry Eppley
Indianapolis Indiana
Q: I have a 3 years old with mild plagiocephaly. I’m very interested in kyptonite injection to correct that problem in the future. Here’s my question about that technique: what is the method you are using to determine where (on the head) and how many (what quantity) kyptonite you will inject? Can we see a proposed “corrected headshape” before the procedure?
A: The determination of where to place the injectable cranioplasty material is determined before surgery by what everyone feels is the flattest area on the back of the head. That area is marked out prior to surgery. The location and size of the area to be filled in is a joint decision between the parents and myself. The amount of Kryptonite material needed is the greatest variable and the real guesswork in doing the procedure. What I know from experience is that 5 grams is inadequate and 20 grams would likely be too much. Usually 10 to 15 grams of material is needed. But the diameter of the defect is measured and then a benchtop test is done to determine whether 10 or 15 grams is best prior to surgery. Computer imaging is also done based on a superior view of the back of the head to get a prediction as to what may be obtained. It is important to realize that computer imaging is a prediction and not a guarantee of the exact outcome.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hi Dr. Eppley, I emailed you about a month ago about getting 5-FU injections for lumpy scar tissue underneath my nipple for a revision gynecomastia surgery I had about 4 1/2 months ago. I have been really busy at work and unable to get time off to make an appt. Last time you emailed me about a month ago you said I could schedule an appt. and possibly get a 5-FU or kenalog injection. I would really like to do this but an injection of kenalog makes me nervous due to the possibility of skin atrophy and other side effects I have heard about. I have heard that 5-FU mixed with a small amount of kenalog does not really carry these side effects and can work quite effectively. I have to travel about two hours or so to get there so I just want to make sure that 5-FU injections are a possibility before I make the trip. Also I have an issue about the scar I have from the surgery I had and I saw on your website that you deal with scar management. I know that the scar I have is only 4 1/2 months old but it does not seem to be getting any better and I was wondering if there are any non-surgical procedures or techniques, such as laser therapy, that you specialize in that could help to minimize this scar? Thank you for any help you may be able to give me.
A: We can certainly do 5-FU injections for scar therapy as that is an item I keep stocked her for injection treatments. While it is uncertain whether 5-FU is really better than Kenalog, it does have a higher safety profile. Kenalog done judiciously (low dose), however, can be done without significant side effects as well. As for scar management, there are numerous options regarding non-surgical approaches depending upon the scar issue such as hypertrophy or redness. Most commonly we do pulsed light therapy (Broad Band Light, BBL) or laser treatments. That decision would have to be made at the time of examination.
Dr. Barry Eppley
Indianapolis Indiana
Q: Dr. Eppley, I had a rhinoplasty six months ago. My main goal was to make my nose larger in the middle. I have breathing problems and when I use nasal strips it makes me breathe better. I didn’t want to change my nose very much but just add support and width to the middle part. My rhinoplasty surgeon said he would put in spreader grafts and a columellar strut. After surgery when the splint was removed, he said he had also put in an onlay dorsal graft to make my nose look more balanced and masculine. My problem is that I didn’t want the dorsal graft. Now that I have more support in the middle vault, the dorsal graft makes my nose higher which I do not like. Can this dorsal graft be removed?
A: Dorsal grafts are onlay materials, usually cartilage, that is simply put on top of the bridge of the nose. How long it is and its size is largely irrelevant when it comes to removing it. The graft should be fairly easy to remove through a closed endonasal rhinoplasty approach. Unlike a bone graft, a cartilage graft never really becomes part of or truly incorporated into the underlying cartilage and bone but simply sits there with a surrounding capsule. This makes its secondary removal fairly easy. Since you are six months out, it is fair to say that you have a good idea of what your nose looks like and are certain that the dorsal graft does not fit into the desired aesthetic shape of your nose.
Dr. Barry Eppley
Indianapolis Indiana
Q: Dear Dr. Eppley, I am interested in both malar and paranasal implants and I have learned a lot about facial implants on your homepage! In one article you stated that some areas in the face are more sensitive to implant size than others. For example, the orbital rim is one of these areas where the size of implants have to be chosen very carefully because 1 mm can make a huge difference. I guess it is the opposite with paranasal implants because (although they can be tailored) they are only available in such big sizes like 4.5 mm and 7 mm. I am not sure if I should choose the 4.5 mm or the 7 mm implant, but I am sure that I want rather a more dramatic look than a very subtle outcome. Do you think 2 mm difference in the paranasal area can make such a huge difference? Is the paranasal area more tolerant towards a slight overcorrection? Is my assumption, that paranasal implants are less sensitive to size, right? The worst thing that could happen to me after the implantation of the paranasal implants would be an increase of my nose tip projection, an increase of my nasolabial angle and a lengthening of my upper lip. Of course I know that paranasal implants usually don´t do this, but I am a little bit afraid that this could be different with the large 7 mm implants. Have you ever implanted the 7 mm paranasal implants and what are your experience with patient´s satisfaction? Did they rather wish to have more or less projection after they saw their final paranasal implant result?
A: The paranasal area is less sensitive to implant size for a variety of reasons. The first is that the skin around the base of the nose is thick so implant thicknesses are easily masked. A paranasal implant also has to push the base of the nose (nostrils) outward so it takes a bigger implant to do that. Lastly the surface into which the implant is placed is curved inward and not outward, further decreasing its influence. In general, small paranasal implants placed at the bone level has little effect so thinking bigger (7mms or more) will have a more visible effect. I don’t recall using a paranasal implant that was ever smaller than 7mms at its thickest portion.
A paranasal implant has no influence on the projection of the nasal tip, regardless of size. Only when a premaxillary implant is placed across the anterior nasal spine will it change the nasolabial angle with a small influence on the nasal tip.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am interested in a corner of the mouth lift. I have checked in my area but have been unable to find anyone as of yet. How would it work if I was to choose to see you? How many trips would I need to make? Have you done many of the corner mouth lift procedures? I am 48 and do not feel I need, nor do I want at this point, a face lift as it is really only the beginning of slight mouth droop/marionette lines that really bothers me.
A: In answer to your questions, We have many patients how come from afar so we are very familiar with working with out-of-town patients. Ultimately, a corner of the mouth lift is done as an isolated procedure in the office done under local anesthesia. One only needs to come once, for the procedure only. An initial consult can be done by phone or Skype with photos of the mouth area sent in advance. Everything that needs to be discussed and determined can be done from afar. Once the procedure is done, there are no sutures to remove as they are just tiny dissolveable ones on the skin. There are no restrictions after surgery. Any follow-ups can be done like the initial consultation by phone or Skype with photos. A corner of the mouth lift is really a simpl;e proedure with the minor trade-off of a small scar. I have performed many of them either as a sstand alone procedure or often in conjunction with facelift surgery.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am a 24 year old male who was born with a right cleft lip and palate and have been through five surgeries so far in my life. Besides my inital cleft lip and palate repairs, I underwent iliac crest bone grafting at age 11 and a Lefort 1 osteotomy combined with alveolar cleft bone grafting again at age 21. I have a fixed bridge across the alveolar cleft site. My current complaint is that I feels my upper jaw is collapsing again causing poor fitting of the bridge and thus pain. A CT shows a very small, but present, bridge of bone across the alveolar cleft. Also, the Lefort 1 plates appear in good position. I have no visible fistula but I can force air into my nose from the upper buccal sulcus. What, if anything would you recommend to try and solve my current orofacial problems? Thank you sincerely for your help.
A: It sounds to me like you still have a small oro-nasal fistula through the original alveolar cleft site with inadequate bone stock. I would look at repeating your alveolar cleft site grafting using a combination of some marrow and a cortical onlay graft screwed into place across the cleft site. It is very common to have resudal alveolar fistulae even though the site has been grafted more than once. If you can force air through it then there is a fistula. Plus if you have been grafted twice and it was done well, you should have more than just a small bridge of bone across the alveolus. I would wager you have a fistula going behind that bridge of alveolar bone. While alveolar cleft grafting seems simple, it actually is technically difficult and results can be less than ideal in many cases.
Indianapolis Indiana
Q: I am an 18 year old looking to correct “witch’s chin” deformity or chin ptosis. I do not know of any doctors in my area who have experience with this procedure, so I am seeking your advice and hopefully you can educate me a bit more about my case. The problem is that I have a lot of extra soft tissue in my chin that folds under and looks very awkward when I smile. I had a consultation with a plastic surgeon who said he would scrape out some of the fat and pull the skin back. He also said that he would cut the muscle. I know he has not seen this case before and that is why I have not confirmed the surgery with him. How exactly is this surgery performed and what are the different ways to go about it? How complicated is the procedure? What are the risks of going to somebody who has not done it before and how high is the risk of causing a deformity? I have attached some photo of me smiling and not smiling from both a front and side views. Your insight is very much appreciated! Thank you.
A: Based on your photos, you are correct in that you do indeed have a witch’s chin deformity. The smiling view magnifies the redundancy of muscle and skin and pulls it down abnormally over a pointy bony chin. In the truest definition of a witch’s chin, it is a deformity that occurs after some form of bone chin manipulation. Your case is different in that this is a developmental/congenital problem and not an iatrogenic or surgically-caused one. In these non-surgical cases, the bony chin is also protrusive and that can be seen at rest in your profile view. So the actual anatomic proboem is one of ‘too much chin’ from all tissues involved.
Surgical correction is done from an incision underneath the chin, what is known as a submental approach and the overall procedure can be called a submental chin reduction. From below the chin bone is shaved down and excess muscle, fat and skin is removed. The chin is then reshaped by adapting the shortened soft tissues over the reduced bone. This is not a complex procedure but must be done carefully and all chin tissues musts be reduced and tightened. The trade-off is a scar under the chin. I have attached a patient example of the procedure for you to see the results and the scar.
Dr. Barry Eppley
Indianapolis Indiana
Q: My 14 year-old son has developed breast enlargement that is quite troubling to him. Do you know if insurance will cover gynecomastia surgery?
A: There is no way to predict whether any insurance company will or will not cover an adolecent’s gynecomastia surgery. I have seen numerous cases over the years that has been covered (most before 2000) and many (since 2000) that has not. Regardless of what an insurance company may say in its declaration of coverages or what may be spoken on the phone by their representatives, nothing is certain unless it appears in writing. Therefore, pursuit of insurance coverage must be qualified with a predetermination process. This is essentially a letter from a plastic surgeon stating the diagnosis and intended surgery, complete with photographs of the patient’s chest. In addition for gynecomastia determination, it is important to have an endocrinologic work-up which demonstrates that there is not an hormonal basis for the gynecomastia which could be treated and reversed by medical treatments and thus not needing surgery. Even with this approach, there is at best a 50:50 chance. If the photographs do not show a significant breast mound (like a woman’s breast) those chances drop significantly. Only the most severe gynecomastias would be likely to be covered, anything less will be judged to be just a cosmetic gynecomastia surgery problem.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am studying to become a radiology technologist at a local community college and I am preparing a powerpoint presentation on the skull. I’d like to play Dr. Eppley’s HTR/PMI Cranial Implant Reconstruction video as seen on YouTube during my classroom presentation to demonstrate current medical procedures to repair and reconstruct features of the skull. Can I please have Dr. Eppley’s permission to show his video to my class? Also, I’d like to inform my audience to what extent x-ray and fluoroscopy C-Arms are used in HTR/PMI cranial implant reconstruction cases since these are the devices we are learning to use. Does Dr. Eppley use fluoroscopy C-Arms during these surgical procedures to assess placement of the implant? Thank you for your consideration.
A: You may certainly feel free to use my HTR/PMI video for your classroom presentation. Hopefully it will add to the value of your presentation. This method of reconstruction of large cranial defects uses a custom implant (PMI = patient matched implant) fabricated from a polymeric bone substitute known as HTR. (Hard Tissue Replacement) The implant is fabricated from a 3-D model from a CT scan taken from the patient so it is an exact fit to the skull defect. The operation for implant placement is done in an open fashion, meaning the scalp is reflected and peel back for wide exposure. Since the implant is placed under direct vision, there is no need to use any radiographic method such as a C-arm to ensure a precision fit.
Indianapolis, Indiana
Q: I want to thin out my face and am thinking of having a facelift to initially tighten my skin and then my cheekbones (zygomas) cut and narrowed. The reason I am considering zygomatic reduction and face lift is to first “trim” excess skin for maximum tightening of the jowls, nasolabial region, cheeks and neck. Then narrow my face with zygomatic reduction, perhaps including the arch and the zygomatic body itself. I was hoping to improve skin definition below zygomatic arch and angularity of the jaw first, than schedule second surgery afterwards. Do you think it is a good plan for my case? Thank you kindly.
A: While I don’t have the advantage of looking at your facial pictures, I think your plan is fundamentally fine but it is planned in reverse. You want to do any skeletal or underlying foundational surgery first. The reason being is that such surgery causes a fair amount of external swelling which will stretch any tightened skin, potentially reversing some of the effects of any skin tightening procedure. Maximum tightening of the jowls cheeks and neck (facelift) should, therefore, be done after the bone foundation has been treated.
When considering zygomatic reduction, it is important to know if it will produce much of effect. This can be assessed by locally at plain film x-rays, particularly a submental and/or a water’s view. These simple films give a visual assessment of how significant the curve is on the zygomatic arches. That will have to be ordered through a hospital or any free-standing x-ray facility where the appropriate equipment exists.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am interested in changing the shape of my neck. I want a visible Adams apple as my neck is too flat and feminine. Can it be done? How would it be done? Imperative to get an answer please!
A: When it comes to tracheal or thyroid cartilage (Adam’s apple) surgery, the standard operation is that of reduction. Known as Adam’s apple reduction (technically reduction chondrothyroplasty) it is done by shaving down the upper v-shaped edges of the thyroid cartilage through a small horizontal incision directly over the thyroid prominence.
Thyroid augmentation is a very rare request but can be just as easily done. Through the same type of horizontal incision, the upper edges of the thyroid cartilages are exposed and built up with a variety of potential materials. Then the strap muscles are closed over the augmentation and the skin closed. Essentially, the reverse of a thyroid cartilage reduction is done. This is a one hour operation done under general anesthesia as an outpatient. There is minimal discomfort and swelling afterwards. There are no restrictions after surgery.
The key element of thyroid augmentation is what type of material to use. Ideally, cartilage is best and the loosely attached ninth rib at the subcostal margin has the right shape and size to be fashioned into a v-shape. But patients are unlikely to want the discomfort of its harvest and the small scar. This leaves a variety of synthetic material choices. Either a Gore-Tex or porous polyethylene (Medpor) block can be carved and secured by sutures to the existing thyroid cartilage framework.
Q: I have a 14 year old boy with gynecomastia. It is hereditary. He is a thin boy but his chest is overdeveloped. If he has a liposuction done now, what are the chances he may need to do it again in the future?
A: The classic teaching in plastic surgery is to do gynecomastia surgery when growth is more complete. This is done with the concept in mind that there will be less chance of gynecomastia recurrence and the need for secondary surgery. While this does make sense from the perspective of decreasing the risk of further surgery, it does not take into account something that I think is more important…the psychosocial development of the young teenage male. Waiting until age 17 or 18 for gynecomastia surgery exposes the adolescent male to vital years of self-image development. For this reason, one should consider gynecomastia surgery when the problem clearly affects teenage behavior and a medical reason for the gynecomastia has been ruled out.
When undergoing early gynecomastia surgery, one accepts the trade-off that recurrence is more likely than when done at an older age. In my experience of doing gynecomastia surgery at age 14 or 15, however, I have not seen patients that have returned with recurrences. (although just because they have not returned does not mean that some have not had recurrences)
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have very dark circles under my eyes that bothers me a great deal. I have tried all sorts of creams and lotions without any improvement. Are there any more result-oriented surgical approaches that will work?
A:Some of the best results for dark circles improvement is based on volume addition, either using injectable fillers or surgically done with orbital rim implants. (synthetic implants or dermal grafts) The cause for the appearance of dark circles in some patients is that the orbital rims (lower eyelid socket) is weak or underdeveloped. This causes the lower eyelid tissues to lack support so they fall inward, creating both a trough or depression whcih is also prone to looking darker due to shadowing. It is easy to see whom may have orbital rim hypoplasia by a side view. If the front part of the eye (cornea) sticks out further than the lower orbital rims one has lower eye socket hypoplasia.
The success of orbital rim implants can be predicted by initially using injectable fillers. Injectable fillers are both a diagnostic test and a treatment. Unlike the lips or nasolabial folds, which are exposed to a lot of muscle movement, the tear trough and lower eyelid area is not so injectable fillers can last a much longer time in this area.
Since any form of orbital rim implant must be put in through a lower eyelid incision, this also gives the opportunity to do a little skkin removal and tightening which can also help improve the dark circle appearance.
I would have to see pictures of one’s anatomy to determine if orbital rim hypoplasia is making a major contribution to one’s dark circle appearance.
Dr. Barry Eppley
Indianapolis Indiana
Q: I hate my deepening nasolabial folds that are developing. I was looking for something more long-lasting to treat them. I have read about the wire release method. At what age can you perform the new wire-release method for nasolabial folds?
A: Deepening nasolabial folds is a result of the cheek tissue above the lip falling down over the more fixed lip tissues. It is actually not a fold that is deepening in terms of indenting into the tissues but a rolling overhang of tissues. Injectable fillers are most commonly used to plump up the fold in an effort to get the top edge of the upper lip more even with the falling cheek tissues.
The concept of doing a release of the dermal attachments of the upper lip so that it ‘springs’ upward to be more even with the lower cheek tissues is not new. The wire release method is just a different way to do this older concept. It is clever but not original. Age is no determinant as to when it can be done. The timing of it is when the nasolabial folds are deep enough to justify more of a surgical approach or when one has tried injectable fillers and found them wanting in terms of a long-term result.
While the wire release method is clever, the nasolabial fold can be released just as easily with more simple pickle-fork instruments and large beveled needles. What we have learned with any method of doing nasolabial fold releases is that they require some interpositional material placed after the release to prevent the fold from re-forming over time. This can be done with with fat injections or allogeneic dermal grafts.
Dr. Barry Eppley
Indianapolis Indiana
Q: Dr. Eppley ! My question to you is that I have a very short face. My midface is short and my ramus and lower jaw is also short which makes my face long horizontol and very short vertically. Also, my teeth of my upper jaw is way forward which is making my life miserable of having low self esteem. What type of surgery can correct this?
A: When there are jaw and teeth disharmony, one should look at the overall maxillomandibular and occlusal relatiopnships. Many times these require orthodontic and ultimately orthognathic surgical solutions. This is a path thaty should be pursued if one is young and this amount of effort can really be worth it over the long span of one’s life.
Short of major orthognathic surgery, there can be ‘camouflage’ solutions that can improve the facial skeletal balance. These are done using facial implants, usually off-the-shelf implants will work but sometimes it requires custom-designed implants. This is particularly useful in the vertically short face where the lower border of the lower jaw needs to be lengthened for which there is no way to do this without a custom implant design which is done off of a skull model made from the patient’s 3-D CT scan.
For the upper teeth protrusion, I would look into selective orthodontics. Even if you just pulled back the upper teeth only, that would make a cosmetic improvement for you and reduce the upper lip flaring.
Dr. Barry Eppley
Indianapolis Indiana
Q: I desire to have cosmetic surgery next year with the wishes of making my forehead larger both in length and width. Can you inform me with what this procedure is called and also with all the information there is to know on this surgery (including risks, the type of implants used, how long it takes for the healing process, the cost of the surgery, how you go about customizing the implant and etc). Please respond as soon as you can with a detailed response. Thanks so much.
A: You are specifically asking about forehead augmentation. This is a procedure done through a scalp incision approach Augmentation of the forehead contour can be done using any of the cranioplasty materials, which include PMMA (acrylic), HA (hydroxyapatite cement) and calcium carbonate. (Kryptonite) Each of these materials has its own advantages and disadvantages. Large forehead augmentations (which you are referring to) is best done with PMMA due to cost considerations. These materials allow wide variability in adding to the brow ridges if desired and increasing the amount of frontal bone convexity, width and smoothness. These are liquid and powder mixtures that are put together and applied to the forehead in a putty form and then shaped by hand to the desired new forehead shape and allowed to harden. The operation takes about 2 hours and is done under general anesthesia as an outpatient procedure.
This is a highly successful procedure whose trade-off is a fine line scar in one’s scalp. The typical cost range for the procedure is $8500 – $9500. Healing is quite rapid and one can look fairly normal in about 10 days after the operation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: My 13 year-old daughter was bitten by a bull mastiff just 4 days. She has a lot of jagged lacerations across the nose and just under the left eye. There were no lacerations on her left eyelid or any eyeball trauma. She was repaired in our hospital’s emergency room with a lot of stitches. It was not a fun experience for her to have it done that way with just local anesthesia. It will be time to get her stitches out shortly and I want to be on top of anything that can be done to minimize her scarring.
A: Like any patient that has gotten their face cut, but particularly for the parent of a child, there is always great concern about the eventual scarring that will occur. In the short-term, getting the stitches out and letting the initial healing take place for a few months is all one can do. There are no magical potions or lasers that can alter or make better the early phases of wound healing. Once the wounds have healed and scar tissue has formed (which is inevitable and absolutely necessary for healing) there are highly touted methods of scar treatment. These can include topical agents, such as silicone patches/tapes and paint-on products, as well as light and laser therapies. It is controversial as to how helpful these are as to the final scar appearance but they are not harmful and may have some benefit. Therefore, I would recommend any of them, or a combination, beginning several months after the injury up to six months after. Which one(s) to use will vary based on the opinion and expertise of your plastic surgeon as well as the scar’s appearance and location. After 6 months, actual surgical scar revision becomes more of a useful technique.
Dr. Barry Eppley
Indianapolis Indiana
Q: Hello Dr. Eppley, I was considering zygomatic reduction surgery to narrow the sides of my face. I am also considering SMAS facelift or modified SMAS like MACS-Face Lift to be done later this year. Could facelift interfere with zygomatic arch reduction surgery? Could you give me a second opinion if either or both procedures will take care of heaviness and fullness of my face? Would I esthetically benefit from these procedures and achieve better symmetry and balance to my facial features??? I have attached some photographs for you to see what I am talking about. Thank you.
A: In reviewing your two frontal photographs, I can see that you have a broad facial width across the cheeks and jaw angles. This skeletal base helps create more of a square face configuration which makes a significant contribution to your ‘heavy-looking’ face. Part of that appearance also has to do with your thicker soft tissues such as your skin, fat layers and muscles.
In considering how to make your face appear slimmer, I can clearly say that no form of a facelift will help in that regard. You are too young to have any significant sagging of your facial tissues (your pictures show none) and what any type of facelift accomplishes is cleaning up the jawline and neck of sagging tissues. In someone with your facial anatomy you are likely to end up making your face look a little wider by some type of a facelift, not thinner. You can’t make your tissues look thinner by lifting or tightening them. In making that statement, I am at a disadvantage since I can not examine you and am looking at only one view of your face.
Will zygomatic arch reduction help your face look somewhat slimmer? Quite possibly, it is just a question of how much. One helpful piece of information would be a simple submental view x-ray which could show how significant the arc is in your zygomatic arches. The more arched it is the more likely it will make a visible difference. The combination of zygomatic arch reduction and buccal lipectomies could likely be helpful.
Dr. Barry Eppley
Indianapolis, Indiana
Q: My chin is too big and I need it reduced. What is the cost of chin shaving surgery?
A: Thank you for your inquiry. When one mentions ‘chin shaving’, they may really need a submentoplasty with chin burring reduction or they may really need a chin reduction via an osteotomy. It depends on their chin problem as the approach for chin reduction can differ based on the size and shape of their chin bone and the surrounding chin and submental soft tissues. Each method of chin reduction also differs in cost. Therefore, before providing a surgical fee quote please forward to me some photographs of your chin and what specific dimensional changes you want to see.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hello Dr. Eppley, is it possible since you’ve had experience with silicone injections running out before during your surgeries for you to do a surgery and just let as much of the oil as possible run out?? I had the same injections but I don’t know if they were done in my tissue of my gluteus muscle. What happens to the gluteus muscle if it is injected?? Does the muscle absorb the silicone oil??
A: The injection of silicone oil for buttock augmentation is almost always done in the subcutaneous fat and not the gluteal muscle. It is taught to be placed as a ‘microdroplet’ approach, meaning to try and disperse the silicone oil into many small pockets and not just one big one. In the buttock, it is not really a microdroplet approach but more like smaller island or pockets of silicone oil placewd through the buttock. Silicone oil is not absorbed no matter whether it is injected into fat or muscle. It is an inert material thaty can not be metabolized by the human body.
Because it is dispersed out through the fat, it is nit really possible to perform a surgery to ‘drain it out’. This would only be possible if there was one large pocket of silicone oil confirmed by an MRI or if there were some problematic areas or pockets that would bebnefit by some drainage. But because multiple incisions would be needed to drain small pockets, this would end up causing significant buttock deformation. Unless certains areas are causing problems such as swelling and pain, it is best to leave them alone.
I have run across silicone oil pockets inadvertently during buttock lifts and any drainage that was achieved was coincidental not intentional.
Dr. Barry Eppley
Indianapolis Indiana
Q: I underwent suprapubic liposuction one week ago. I was surprised and concerned about how much swelling and bruising I have on my penis, scrotum and inner thighs. There is also a lump at the base of my penis which makes it look shorter than before the surgery. Will this go away and will my penis now be deformed? Will look a long when the swelling and bruising goes away as it did before? Is what I am seeing normal or am I understandably freaking out about what I am seeing? How long will it be before it looks normal again? Will I still be able to get an erection?
A: What you are experiencing is absolutely normal after suprapubic liposuction. Either you have forgotten all therse details of how things will look after for a period of time or you were never properly educated before the procedure. What I tell all males that receive liposuction in the pubic area is that they will have a tremendous amount of bruising and swelling of the penile shaft and scrotum afterwards…usually shockingly so. This will be striking to the man that has not seen it before but normal from my standpoint. When you see your scotum twice as large than normal and bruising at the base of your penis, you will freak out…unless you know that this is completyely normal. Gravity and the scotal pouch drives most bruising and swelling south. It may get so swollen that the penis may become almost completely buried.This will take about 3 weeks to completely go away. From an erection standpoint, it will work just fine as liposuction does not damage (nor is close to) any of the nerves that are responsible for this important function.
Dr. Barry Eppley
Indianapolis Indiana
Q: I have a major issue with my face that has effected me my entire life. I was born with a skeletal deformity which caused my entire right side of my face to be noticeably bigger then my left side. My bite pattern is off due to this problem which in turn has prevented me from getting any adult teeth on my left side because of the lack of bone to support the teeth. I was also born with glaucoma which has been said to be the result of a tiny unseen eye ball in my left socket which caused the orbit to grow different then my right side. I have attached some pictures. As you may notice, I need some serious help. I have dealt with it all my life but I dream of the day I can look in the mirror and see the same person on both sides. If you can help me in my time of need it would be greatly appreciated. God bless.
A: Thank you for sending your pictures and sharng your story, You were born with microphthalmia which has caused the left side of your face (orbit and maxilla in particular) to develop differently than the right. (the growing eyeball has a major influence on the surriounding maxillofacial bones). This means the the left side of your face is vertically shorter than that of your right, known as facial hypoplasia on the side with only an eyeball remnant. There is much that can be done but a good place to start would be with a 3-D craniofacial CT scan to clearly show the extent of the anatomic deformity. Treatment planning could then be done and could go in two different directions, major bone repositioning through osteotomies and/or bone grafts or a camouflage approach using facial implants. It would also be extremely helpful to have a good view of your existing teeth, even starting with a simple panorex x-ray and a view of your current bite relationship.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am developing deep folds on the sides of my mouth and my eyelids have extra skin that make me look tired. I have attached a picture so you can see my concerns. What type of plastic surgery will get rid of these problems?
A: Thank you for your inquiry and picture. There are two comments that I can make based on your pictures. First, you have a thin and lean type of fat. As a Caucasian, this makes your skin thin and extremely prone to wrinkles particularly around the mouth area. Such wrinkles around the mouth, known as smile lines outside the corners of the mouth, are virtually resistant to any treatment other than temporary injectable fillers. There is no surgery that can provide a cure or any long-lasting treatment for that resistant wrinkle problem. It is resistant because the one thing that would help in not making them continue to develop is to stop smiling or moving your mouth…not only an impossible but not a good social habit to develop.
From an eyelid standpoint, you have deep set eyes (again due loss of fat around the eyeball area or, in your case, you may have never had it to start with) with some moderate skin redundancy of both upper and lower eyelid skin. The real issue is whether the skin on your upper eyelids needs to be removed (eyelid tuck or blepharoplasty) or whether lifting of the eyebrows is better. You can determine that by doing a simple lift test on your eyebrows and see what it does to the skin on your upper eyelids and the new brow position.
For all of these reasons, I don’t think computer imaging is helpful in making these facial aging treatment decisions. It would be better to come in and sit down and go over the options that are available…and see what they can and cannot do.
Dr. Barry Eppley
Indianapolis Indiana
Q: I have had 3 c-sections, hysterectomy, and my gall bladder removed that left a large scar. I have a lot of scar tissue that causes me sever pain in my stomach plus I know the muscles in my stomach have separated because you can feel it by feeling my stomach. The scar tissue is attached to my bladder which causes me problems in urination. I also have a large cyst on my left ovary that has added to the pain for the last year. I have a severe amount of skin that hangs from my lower stomach also. My question is since the scar tissue is causing my so much pain in my lower stomach, would it be possible that it would be a surgery that might be covered by my insurance and have the skin removed also.
A: Unfortunately, the simple answer to your question of insurance coverage for a tummy tuck is no. Insurance may cover adhesion release from your bladder and ovarian cyst removal which need to be evaluated and predetermined by your Gynecologist and/or a Urogynecologist. But the skin overhang and its skin removal (tummy tuck or abdominoplasty) will be deemed cosmetic by your insurance company. Similarly, the separation of the muscles (known as rectus diastasis) and bringing them surgically back together is not a medically necessary issue as would be determined by any insurance company that I have ever worked with. This is not to be confusd with a hernia which is a defect in the abdominal wall where bowel may be protruding through, which is a covered procedure.
This may all sound very unfair to you but that is the stark reality of insurance coverages today. There was a day long ago when insurance coverage was more broad and less discriminating but those days have gone the way of the Walkman and the eight track tape. You may even contact your insurance company and they may even say they will provide coverage if the doctor gives a medical reason. (they say anything on the phone but don’t confuse that with what they will really do later…since the person you are talking to will not even be in the section of the insurance company that actually makes the coverage decisions) The only way to know for sure is to send in an actual pre-determination letter which has to be done by the examining plastic surgeon.
Dr. Barry Eppley
Indianapolis Indiana
Q: I would like to know more about the transconjunctival approach referring to orbital rim augmentation with medpor implants and subperiostal midface lifts. Because you are both a plastic surgeon and an oral an maxillofacial surgeon I´am sure you are very familiar with this kind of approach. Once I have read that the infection rate of medpor implants placed through an intraoral approach is a little bit higher, because the mouth can´t be completely disinfected. Is it the same with the transconjunctival approach or is the mucosa in the lower eyelid an area in the face that is usually very clean due to its special purpose? What are the common risks of a tranconjunctival approach? Is there any chance of getting blind after such an operation? If performed right, has the transconjunctival approach any risk of ectropion or entropion or an increase of scleral show? Thank you in advance for your reply.
A: Unfortunately, you have been misinformed about placing any type of orbital rim implant through a transconjunctival approach, regardless of the material type. That is simply not physically possible given the size of the implant and the very size of this inner eyelid incision. All orbital rim implants have to be done through an external or subciliary lowere eyelid incision. This is the only way to insert them and have them properly secured into place.
You are correct about the higher rate of infections with porous implants like Medpor when placed through an inside the mouth or mucosal incision. That has been my experience as well.
Dr. Barry Eppley
Indianapolis Indiana
