Your Questions
Your Questions
Q: I have suffered from severe disabling migraines for years. I have seen two different neurologists and none of the medications seem to work or are causing severe side effects. I’ve been doing research and came across the migraine surgery. I am willing to try anything to do away with or at least ease my migraines. As I am a single mother of three small children and it is crippling my income because I miss so much work due to these awful migraines.
A: Certain types of migraines can be cured or significantly improved by migraine surgery. Such surgery is based on release or decompression of sensory cranial nerves as they pass through muscles as they emerge from the bone. This has been shown to be effective for migraines that originate from the occipital, temporal, or supraorbital (brow bone) areas. A physical examination and the history of the migraine headache pattern can determine if one is a potential candidate. The definitive presurgical test is a Botox injection treatment into the identified nerve area. If significant relief occurs with the Botox injection, then this is a very good indicator that surgical decompression will be effective. I have yet to see a positive Botox test in which the patient did not get significant and sustained relief from the surgery.
Long-term studies out to five years has shown that about one-third of patients who undergo migraine surgery are cured. The majority of migraine surgery patients (about half) are not cured but have reduction in the number and severity of their headaches. A small number of patients (about 10%) failed to get benefit from the surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Will a LeFort osteotomy for short face syndrome tend to increase upper lip length (vertical height of upper lip)? If not is there a surgery to increase upper lip height (distance between columella and mouth)?
A: A LeFort I (maxillary) osteotomy for a short face is either being horizontally brought forward or being vertically lengthened. Either way, that facial bony movement will not make the upper lip longer. In fact, it is more likely to make it shorter due to the new bone position and the facial muscles which have been detached from the vestibular incisional access. During incisional closure of a LeFort I osteotomy, it is important to do an alar cinch suture and a v-y mucosal closure to prevent the nostrils from widening and the upper lip becoming shorter and more thin.
While there are multiple plastic surgery procedures for shortening the long upper lip, there are no operations that can truly lengthen the outside skin of the upper lip. Injectable fillers to the vermilion of the upper lip and internal V-Y mucosal advancements can provide the illusion of longer length or maybe even add a millimeter or two. But significant upper lip lengthening is not surgically possible.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have scleroderma which over time has caused atrophy and asymmetry to my face. I’m interested in plastic surgery to help fill my face out and not make it look so narrow. So if you could please just send me some more information about this that would be great. Thank you.
A: Scleroderma that affects just one side of the face (most commonly) is known as linear scleroderma or Romberg’s disease. It is a rare facial condition that often does not start until late childhood or early adolescence and then burns itself out by early adulthood. It is not known what causes it or why it stops. It is currently thought there is a neurogenic basis for it. It results in soft tissue atrophy, with loss of subcutaneous fat, thinning of the overlying skin, and occasionally loss of some of the underlying bone. (most notably the mandible with loss of the jaw angle and shortening of the jaw line) This creates one-half of the face that is thinned and asymmetric. The forehead may have just a vertical line atrophy. Romberg’s disease comes in all variations from just a single area of atrophy to an entire facial half that is severely withered.
The key to reconstruction in Linear Scleroderma is soft tissue replacement or augmentation. I have done numerous Romberg patients and have used allogeneic dermal grafts, dermal-fat grafts, fat injections and even vascularized free flaps. Since the problem is largely soft tissue loss, the focus on reconstruction should be soft tissue-based. Occasionally, I have used a synthetic implant in the jaw angle but one should generally avoid placing implants is areas of thin soft tissue coverage. Which one of these soft tissue replacements is best on based on the location and degree of the facial atrophy. Each of their own advantages and disadvantages and combinations of two or more of them are usually needed.
Indianapolis, Indiana
Q: Hello Dr. Eppley, I have many problems related to my face. Firstly, my jaw is asymmetrical. Right side of my face/jaw is smaller than the left side. Therefore, my jaw is slanted to the left. My nose is deviated. Secondly, I have prominent zygomatic arch but my cheeks are hollow. My eyes are also deep probably due to my prominent brow bone. Beside my jaw, my left and right profiles are different. Back of my head on right side is flatter and hairline in the temporal area is different. How can these problems be solved? I want a more balanced face, in fact a more balanced skull, a flatter forehead, stronger and symmetrical jaw. I also want to have strong cheekbones but maybe a narrower midface. In addition to my photos, I also added photos of the face type that I want to have. Of course it is impossible to have the exact same face but similar facial features and proportions are what I think of. To what extent it is possible?
A: In trying to achieve improved facial balance it is important to focus on those features that can be changed without causing a lot, if any, surgical scars to do. This makes the improvement of jaw and cheek asymmetries capable of being improved with jaw angle and cheek implants that can be placed through the mouth. Similarly, cheekbone reduction can be done through combined incisions inside the mouth and from the temporal hairline. A rhinoplasty, open or closed, can be reliably done for better midline nose alignment and shape changes. Brow bone reduction, while commonly requested by men, is a more difficult choice because there is no ‘scar-free’ way to do it ( a scalp incision is needed) even though the procedure is very reliable at lessening the prominence of the brows. Skull augmentations may be able to be done through an injectable cranioplasty technique depending upon the degree of skull flattening.
When it comes to the potential of face changing surgery, it is best to think of altering and improving the foundation of what you have…not facial transformation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr.Eppley, my fiance was hit in his face with a softball. We went to the doctor and the doctor told us that a part of it had shattered and recommended us to see a specialist. Approximately how much will his cheekbone surgery be? He doesn’t have a job, or any insurance. It is only I with an income and I’m supporting a family of five will that take part in paying for it?
A: It would be impossible for me to say exactly what needs to be done with your fiance’s facial bone fracture. I am assuming, having seen a lot of ball injuries to the face, that it is a cheekbone fracture that may or may not involve the orbital floor. Some types of cheek bone fractures can be repaired simply through a single intraoral incision. If the orbital floor is significantly displaced, the fracture is more complex and would require a combined intraoral and a lower eyelid incision. Because of these differences, it is difficult to provide an accurate cost estimate. I would need to see some x-rays of his facial fracture to provide a good estimate.
Indianapolis, Indiana
Q: I don’t like the appearance of my nose and want to get a rhinoplasty to fix it. The problem is that the upper part of my nose is not straight or symmetric. There is also a small bump that I want to get rid of as well. Is there any way to really just straighten out the top bone of my nose? The upper part of my nose is diagonal. That is what I believe makes the one side look bigger. Is there any way to shave just a bit off the tip of the nose as well without tampering with the nostrils or performing open surgery? What happens if the surgery does not heal correctly? Will I need to pay to fix it again? By that I mean deformed nostrils of something of that nature. Thank you so much! Sorry for my abundance of questions.
A: You are talking about a closed rhinoplasty versus doing an open rhinoplasty. Through a closed rhinoplasty approach, the hump can be taken down, the nasal bones straightened by osteotomies and the tip narrowed by plication with sutures . With a closed rhinoplasty, there would be limited risk of nostril asymmetry. The more major issue and the real concern is how straight and symmetric the nasal bone area (pyramid) can be made. It is also important to realize that the tip changes through a closed approach would be less significant than that of using an open approach.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hi Dr. Eppley. I am considering going to you for facial surgery, but I am unsure about exactly what procedure is necessary. All I know is this: I am a male with a long, narrow face. Can jaw angle implants make my face look more wide and more square-shaped? I am interested in making my face seem less long and vertical.
A: Thank you for your inquiry. Jaw angle implants do make the lower jaw more wide and square-shaped which may, or may not, be beneficial in helping you improve your long and narrow face appearance. That question can be answered by computer imaging. By simulating the results of the surgery on your own images, you can visually get the answer to these questions. If you send me some photos (front and side of your face on a clean background such as a wall or door), I will do the computer imaging so we can see if jaw angle implants are beneficial for you. Once we see the results, we will know if jaw angle implants or other facial implant procedures may be beneficial.
It is true that one way to change the illusion of how a face appears is to change the alternative or perpendicular dimensions. Therefore, vertical facial length may be counterbalanced by increasing facial width or forward facial projection.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am wanting to get my forehead fixed. It just never grew in right and I have been made fun of since I was a kid. Photos may not look bad but I have been called horn head, hell boy, and square head all my life and I just want it to look a little better. I have two prominent ‘horns’ for lack of a better word on my forehead. I don’t know if these are just bone growths or my brain sticking out. They feel hard though. I have attached a picture so you can see them. Can these be burred down or something to make them look better?
A: Based on the one picture that I could see, it looks like you have two bulges on the sides of your forehead creating that look. These are very much like larger osteomas. The skull is thicker in these bulging areas. Reducing the bony bulges is actually fairly easy by burring them down to make the forehead less square and more round. The trick to it, however, is getting there to do it. The best approach would be a coronal (scalp) incision across the top of the scalp but that resultant scar (fine as it is) may not be a good choice for a male.The other approach is an endoscopic one where much smaller incisions are used. The access is not quite as good but I should still be able to burr down the prominent areas.
Indianapolis Indiana
Q: I had a rhinoplasty last year of which I am not too happy about. The bridge was shaved too low and I do not like the tip. It looks fat and pinched to me. I have attached a front and side view of your nose so you can see the problems. I would love to see what kind of improvements you think should be made! Thank You.
A: I have looked at your nose and my thoughts are that you have a fundamentally over-resected nose that was done too aggressively. While it may have looked good initially, the nose is now collapsed and contracted inward at the bridge and upward at the tip. In short, you have excessive hump reduction, an inverted v deformity due to nasal bone collapse, an over-rotated and pinched tip and excessive nostril show. In days of old, this type of problem was more commonly seen. Today it is more uncommon as the emphasis on rhinoplasty has been on conservation of structures and not simply removal.
To improve this nasal deformity, the nose needs to be done through an open approach with the nasal tip de-rotated, the bridge and middle vault built back up and the nostril rims grafted. This requires cartilage grafts which, most likely, can come from the septum and ear but may require rib cartilage to get the best amount of graft material. I have attached some computer predictions which demonstrates the objectives. This is a difficult recondary rhinoplasty problem but good improvement can almost always be obtained.
Dr. Barry Eppley
Indianapolis, Indiana
Q: My 19 year old son has very large guaged ear lobes. I am told they are the largest people say they have ever seen. He has been living in Los Angeles and now realizes that he has made a mistake. He will be moving back home where I am living in the rural Midwest.. He is hoping to attend college and make a new start here. We are looking for a plastic surgeon here and some information on what the cost may be. Thank you for the information provided here and any further info you could provide to us. I really appreciate it!
A: Thank you for your inquiry. I have seen all types of gauged earlobes, so they may be big, but that doesn’t change the ability to fix them. All he has done is make more earlobe tissue to work with. More earlobe tissue is always better than less. While putting the earlobes back together is a delicate and complex task, it is a lot easier when there is adequate tissue to manipulate. Thus, while gauged earlobes look bad they almost always havge an ample supply of skin. Please have him send some pictures to me of his earlobes for my assessment. As a general cost quote, reconstruction of gauged earlobes (both sides) done as an outpatient procedure, either under straight local or IV sedation, is around $3500.
Dr. Barry Eppley
Indianapolis Indiana
Q: I self harmed for many years as a young person, I haven’t done so in almost a decade and I am a different person to the one I was back then. I find it almost unbearable to see the constant reminders on my arms and stomach. They are quite bad. I never go out in short sleeves and this has lead me to detest the summer as I am always covered up, miserable and uncomfortable. I wish I was like everybody else. Is surgery a good option for me to think about? I’m desperate to live a ‘normal’ life.
A: Self-mutilation leads to many linear and cross-hatched scars, often on the patient’s arms. They usually appear as fine white lines. They are white because of the unpigmented scar that is created from the often superficial lacerations. In general, the concept of simply wiping them away by laser resurfacing is not possible because the scar depth is too deep. At best, all one can do is trade-off a different type of scar for the self-mutilation scars. I have done deeper laser resurfacing to create a burned appearance as well as have even skin-grafted arm areas. The intent of this scar trade-off is that it can be more easily explained as part of a more socially accepted injury (e.g., burn) and not look like it was from self-mutilation or from someone who is a ‘cutter’. If one can accept this scar trade-off, such a scar revision approach may be reasonable.
Dr. Barry Eppley
Indianapolis Indiana
Q: I would like to know if Dr. Eppley has any experience in removing free silicone oil from the butt? I had silicone injections in my butt and would like it removed and replaced with my own fat.
A: Once silicone oil is injected into any tissue it can not be removed, from a practical standpoint, from the recipient site. The oil is dispersed throughout the tissues in many islands or droplets (really pools of oil) so it is not just one large collection which can be evacuated. It is not like an implant where it is in just one location as a congealed or formed mass. During buttock lifts I have run across injected silicone oil several times and it just runs out as you hit every subcutaneous pocket that it is in. The only way the silicone oil can be removed would be to completely cut off one’s entire buttocks. Therefore, it is best left alone.
The good news is that the silicone oil is not in the deep muscle but in the fat or subcutaneous tissues under the skin. Buttock fat injections can still be placed with the silicone oil in place as they are placed deeper into the gluteal muscle and deeper fat. I am not aware that the presence of silicone oil causes any problems with doing fat injections to the buttocks or necessarily causes greater problems because it is there.
Dr. Barry Eppley
Indianapolis Indiana
Q: I recently had small cheek implants but they don’t seem to have made much of a difference. No one has really noticed. In addition, I have pain on my left side, it is more swollen, and my teeth and upper lip are numb. I think they should just be removed. Do you think implants should be removed sooner rather than later? What sort of time frame would you suggest -one week, two weeks etc? At this point I am taking Oxycodone just to get through work due to the pain. My plastic surgeon does not seem overly helpful at this point. I cannot get in to see him until the end of this month. The pain was so great over the weekend I was thinking of going to the ER but I did not think an ER doc could do a whole lot to help. Also, if the implants are removed will there be any permanent structural change to my cheeks, from the pockets that were created for the implants?
A: I would only suggest getting them removed sooner rather than later given your pain issues. If they weren’t painful, then there would be as much urgency to it. Such pain after cheek implants is uncommon…plus if the implant on the numb side is sitting up against the nerve (don’t know whether it is or isn’t but the numbness on just one side is a concern) the sooner it is removed the better for nerve recovery. With such small implants, there should not be any residual effects from having them in there. The pockets will just shrink down and go away and will leave no residual structural or scar issues.
Dr. Barry Eppley
Indianapolis Indiana
Q: I’m considering a breast reduction with the hope of going from a 36DD to a C cup. The surgeon is anticipating approx 300 cc reduction on each breast. Will that leave me with a C cup or less?
A: I would have to say that this is a question that your surgeon should answer for you since he/she has actually seen you and is in a better position to answer.
That being said, a 300cc reduction in breast volume for most women will not take a DD cup down to C, let alone less than a C cup. A 300cc reduction is quite small and would not qualify for an insurance-covered breast reduction because of the small amount of breast tissue being removed. Unless you are quite a small person, this will not cause a significant reduction in your breast size. I would go back and revisit this issue with your surgeon as there appears to be different levels of expectations in the end result. Breast reduction is a significant operation that is changing breast size at the expense of permanent scars. You want to make sure that in accepting this trade-off you are getting the breast size reduction that you desire.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I had a rhinoplasty several years ago. One of my reasons for having the operation was to get a large hump on my nose removed. Since the surgery I have had trouble breathing through my nose. What can be done to correct the breathing problem resulting after hump removal? Is the cause of these breathing difficulties the enlarged inferior turbinates?
A: In removing a large nasal hump, several structures are taken down. While most people think a hump is made up of bone, it is really as much cartilage as it is bone. This cartilage includes the upper half of the septum and portions of the upper lateral cartilages. The merging of the upper lateral cartilages and the septum make up what is known as the internal nasal valve. This internal nasal valve is an important area that has great influence on how easily air moves through the nose. With larger hump reductions, the internal nasal valve may become compromised, causing postoperative breathing problems. While the size of the inferior turbinates may have an effect on your breathing, the most likely cause is internal nasal valve collapse.
Reconstruction of a collapsed middle vault (compromised internal nasal valve) is done primarily through cartilage grafts, a procedure known specifically as spreader grafting. This is done through an open rhinoplasty approach. Reduction of the inferior turbinates can be done at the same time to eliminate any other airway obstructive factor.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am asking about what to do with my under eye area. I had a lower blepharoplasty 15 years ago. My undereye area is very sunken looking and there is a little darkness in the skin but that may be due to some shadowing as well. I am wondering if I need a redo with a canthoplasty/canthopexy and some orbital rim/tear duct/cheek implants. I have attached some photos of my eyes from different angles. I assume you can tell from photos I also had a cheek lift and other work.
A: Based on your photos, you have a significant volume loss of fat/tissue of the lower eyelids and over the lower orbital rims onto the cheeks. Whether that is due to your prior lower blepharoplasty with fat removal is speculative and irrelevant at this point. Because of the loss of lower eyelid/cheek volume and support, you also have increased scleral show. (pseudoectropion)
What you need is volume replacement of the lower eyelid and cheek. There are several different options to consider for this replacement. It fundamentally comes down to synthetic vs. autogenous graft materials. The synthetic approach is one you have already mentioned, that of an orbital rim/cheek implant either as a single piece or in two different segments. There are several different styles for this area. These have the advantage of an immediate augmentation that will be permanent. They are placed through your old blepharoplasty incision and a canthopexy would be done at the same time. The other option is that of fat injections to add volume or the placement of allogeneic dermal grafts. This approach has the advantage of not using an implant but the survival of fat is not assured and it may require more than one treatment session to get the best result.
There are advocates for either approach and it is not a proven matter than one method is better than the other. The use of implants has a more proven track history of use.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hola por favor diganme si colocarse silicona solida en la parte de atras d la cabeza es bueno o malo? si mas adelnate de dañara cual es el costo y en donde puedo hacermelo,xfavor diganmee!! tengo la cabeza plana y tengo 20 años esto me ha molestado toda mi vida!! ayudaaaa xfavorrrrrr
A: A solid silicone implant is not a good idea for the back of the head for correction of flatness or asymmetry. However, an acrylic or PMMA cranioplasty is a better idea and is commonly used. This is placed through a scalp incision where the acrulic mixture is placed, shaped, and allowed to set before closure. One could anticipate a total surgical cost of around $7500 when done as an outpatient procedure.
You may feel free to send me some photos of your head for my assessment to see if this is a good procedure for you.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dear Dr Eppley, I am an Asian female. I have had an advancement chin osteotomy, 4mm forward and 2mm downward. But the result makes me have a long flat face with wider chin. As it’s not just the tip of the chin move forward but also the wide chin so it’s not good. I am guessing that the chin bone should be trimmed and I was wondering if it can be done in 2 to 3 weeks after the chin osteotomy has been done? It seems the swallow is not yet gone, is it good for immediate surgery again? Also I will do a facelift with fat transfer with other surgeon. I was wondering if I should wait and to have the chin bone trimming and facelift done at the same time, rather than do the bone trimming now? If I can’t do them together, how long should I wait before each of the steps? I look forward to hearing from you very soon.
A: Based on your description, it sounds like your chin osteotomy was just done. Your chin bone movement was very small and I doubt that amount of bone movement would make your chin ultimately look wider. I think what you are seeing is swelling, particularly if it has just been done in the past few weeks. You can not really judge the dimensional changes after a chin osteotomy, particularly width, for several months. I would advise waiting 3 months and then see what you think. There is no reason you can not do some chin reshaping if needed with a facelift and fat transfer later.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am a bit disappointed with the way that I look and I would like to fix some things. I believe a forehead augmentation would help me look a lot better. One of the changes I would like my forehead to undergo is to put the hairline at a higehr height, so my foehead would become a bit higher. That means building up the upper forehead area about 1 to 2 cms. I don’t think it is necessary to build up any area of the parietal bone. These are the changes I desire in the hairy part of my forehead. The second change I desire is in the brow bone. I have the feeling that from the side, it doesn’t look masculine enough because the brow bone doesn’t stick out as it should in a male. I think an augmentation of a few millimeters and a reshaping with nice corners would improve the way my brow bone looks. The second change I would like to do is the slope of my forehead. The slope of my forehead is very good but somewhere between the hairline and the brow bone the frontal bone has a small ‘puddle’ and I think it should be built up too. Those are the changes I want to do for my forehead and I hope that an endoscopic bone augmenttaion would help. How many grams of cranioplasty material woould be used for this? I have attached a side view of my forehead for you to see its shape.
A: Thank you for sending your pictures. Despite the relative poor image quality, it is clear as to your forehead concerns. I think there is no doubt you would benefit by forehead augmentation (frontal cranioplasty) but I need to clarify what is and is not possible. To achieve a good result, your forehead augmentation can not be done closed or endoscopically.There is no way to ensure a smooth and confluent result by any type of injectable approach. Your forehead reshaping is too complex for that it would have to be done through an open approach requiring a scalp incision. Secondly, the volume of augmentation material that you require makes the use of Kryptonite too expensive. You likely require about 40 grams of material. Your most economic approach would be acrylic (PMMA) where such a volume of material is economically feasible. Thirdly, it is not possible to buildup your forehead as much as 2 cms, the scalp incision could not be closed afterward.
One cm. at most is what is possible. Lastly, your frontal hairline may come up a bit with the augmentation but not substantially so. It is not possible to buildup your forehead an surgically move your hairline back at the same time.
These are some practical considerations for you to consider.
Dr. Barry Eppley
Indianapolis Indiana
Q: I had a Le Fort I osteotomy to correct my bite, which it did. Despite the upper jaw movement my midface still appears flat. I was told to look toward having cheek and paranasal implants to correct my profile.
A: A LeFort osteotomy only affects the face at the upper jaw/upper tooth level, otherwise known as the maxilla. If the maxilla is brought forward (LeFort advancement) it can change the anterior nasal spine and the base of the nose, opening up the nasolabial angle and providing some paranasal augmentation. But it takes a significant movement forward to make those changes. But it will never provide any cheek or zygomatic enhancement as the level of the bone movement is way below these bone structures.
Secondary midface augmentation will require cheek and paranasal implants to achieve increased midface fullness/projection. When the degree of midfacial fullness is recognized before the LeFort procedure, the implants can be placed at the same time. But they can also be done afterwards as a secondary procedure. This would also provide an opportunity to remove the metal plates and screws that were initially placed to hold and heal the LeFort osteotomy. Four implants are used to create both lower (paranasal) and upper (cheek) midfacial augmentation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am an Asian male and I have a retracted columella and a slightly acute nasolabial angle (I’d estimate it to be roughly 85 degrees). I have read that it is possible to use cartilage (either from the septum or the ear) and fill in the area of the columella to increase the nasolabial angle. I have also done research and found that a subnasal lip lift can correct the nasolabial angle as well. I don’t want anything else done but to have the base of the columella fixed. How do you recommend it to be done?
A: Correction of the too acute nasolabial angle can be done by directly addressing the source of the problem. The nasolabial angle is effected by numerous anatomic factors but the angulation of the causal end of the septum and the anterior nasal spine most directly influence it. I am not aware that a subnasal lip lift can change the nasolabial angle to any great degree and that would not be an option unless one had a long upper lip concern also. Correction should be directed towards modifying the underlying osteocartilaginous foundation. Cartilage grafts can be used to buildup the base of the caudal septum. But attaching grafts in an end-to-end manner to the end of the septum has them being unstable and to wiggle back and forth. To be stable they have to be placed as a bilayer with the septum in the middle of the ‘sandwich’. A more stable method is to augment the anterior nasal spine, also known as premaxillary augmentation. Cartilage grafts and synthetic implants can be used but I find that a dermal graft is the best graft in the long-term for this area. That can be placed through an intraoral incision under the upper lip above the frenum.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr.Eppley, will you look at patients that had cheek implants performed by another surgeon? The surgery was performed a month ago and they are asymmetrical and one side is more swollen then the other. They don’t look right. I would like them revised or removed.
A: Thank you for your inquiry. The first thing to realize about cheek implants is that the swelling between the two sides is never exactly symmetrical. Even though you do exactly the same thing to both sides, they will have differential amounts of swelling. Secondly, it really takes almost three months to see the final results from the procedure. It takes this long to have almost all of the swelling gone and to see if true cheek implant asymmetry exists. Since you are only one month from surgery (which does seem like forever when you are the patient), it is too early in my opinion to yet assume that the cheek implant placements have been asymmetrical. That being said, I would be happy to assist you. Please send me some pictures and any information about your surgery (when, type of implants if you know etc) that you know. Let us assume that after three months, this cheek asymmetry persists. Since there is asymmetry, I am assuming that there is one good side and one unhappy asymmetric side. That raises the question about whether the off side should be adjusted to better symmetry, changing the styles and position of the implants on the cheeks (there was a good reason you have it done to begin with) or simply having them removed altogether. At that point, we can delve into what your original objectives were for getting the cheek implants and see if that effort can be salvaged.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr Eppley I am currently in Iraq and my wife and I have been researching breast augmentation for her upon my return. She has had two children over 4 years and, as a result, has since lost much of her perkiness. She is currently 32 yrs old and is 5′ 3″ and weighs 124lbs and is a 34C. She wanting to go to a 34DD. We are currently stationed in Texas. We do not mind traveling if the price is right. If you could let me know the prices and also how long we would have to stay. We want the procedure to be done this summer but we could also wait until fall when I am on leave.
A: Thank you for your inquiry. I will have my assistant pass along the costs for breast augmentation through our Patriot Plastic Surgery program. In general, the cost is about 20% less that that of the average cost of the procedure. Several important questions to know is whether she prefers saline vs silicone implants as that has a major influence on costs of the procedure. (up to 20% in cost differential) Also with C cup breasts, having two children and having lost her perkiness, does she have any significant ptosis? (breast sagging) If she does, implants alone will not lift a breast up or move the nipples upward. Implants add volume and will only make the way her breasts look now bigger.regards. So the potential issue of a some form of breast lift may be needed although it is impossible for me to say without at least seeing some pictures of her.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Having recently had a mini-facelift7 and eyelift, I found your sit7e very useful and explicit. I had my surgery 5 weeks ago and the scars around the ears are more pronounced that say 2 weeks ago. I was quite alarmed and decided to search the internet for answers. I came across your site and have to say it was the only one that gave me the specific answers I needed for peace of mind. Thank you so much.
A: Undoubtably you are referring to the inevitable change in the appearance of most incisions that occur several weeks after surgery. This is the typical change from what appeared as an initially great looking incision to now a more red scar. Many patients understandbly think that something is wrong or that they have an infecion. In reality this is a normal biologic process and is part of the typical cascade of events that lead to wound healing.
While incisions make look fantastic during the first week after surgry, that is largely because little to no wound healing has actually occurred. The wound is only being held together by the stitches and the fibrin glue that the body naturally makes between the skin edges. It requires before the blood vessels grow into the tissues to supply the necessary elements that cause complete wound healing. It is the ingrowth of blood vessels into the scar that makes it turn red. Think of it as soldiers being amassed before an attack can occur. Once the wound is more fully healed, there is no purpose for the extra blood vessels and they go away…leading to the fading of the redness of the scar. This scar maturation process takes many months and can last up to a year after surgery. Although in the face it occurs much faster due to the already good supply which exists in the tissues. This is also why scar revision are often not recommended to be performed until all of the redness of the scar has subsided.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am Vietnamese and want a rhinoplasty. The rhinoplasty I would like to have done is a higher nose base (i think its call dorsal augmentation), have the tip more pointy (is that call narrowing?), as well as nostril reduction. I was also wondering if I need “nasal bone osteotomies”? And for a dorsal augmentation, please can you let me know what is the difference between a cartillage and a synthetic implant. And please if you could let me know the average cost of a rhinoplasty so I could have a better idea. I have attached a fromt picture of me for you to see what my nose looks like. Thanks so much!
A: Thanks for sending the picture. While its clarity is satisfactory, it is not a good image to judge the effects of a rhinoplasty. At the minimum, two facial views are needed…a front and a side view. A non-smiling front view is needed as smiling distorts the nostrils and makes them even wider. The effects of dorsal augmentation can not be seen at all in a front view and requires a side view to see that part of the result.
There is no question that what you are looking for in your rhinoplasty is dorsal augmentation, tip narrowing amd nostril reduction. These are very typical changes that are requested in rhinoplasties of your ethnicity.
The biggest decisiion to make in your rhinoplasty is that of the augmentation material for the dorsum. This is a classic debate between a synthetic implant and your own cartilage. Cartilage for your dorsal augmentation, due to the volume needed, would have to come from the rib. Your septum is inadequate for your dorsal augmentation needs. While there is no question that a small piece of rib cartilage is much better for you over your lifetime and will not give you any healing, infection or rejection problems, it is not appealing in a primary rhinoplasty to harvest it. This is why many such Asian rhinoplasty patients choose a synthetic implant even though there are higher rates of long-term problems with them.
Nasal osteotomies means cutting the base of the nasal bones to try and narrow the broad width of the upper part of the nose. With an adequate dorsal augmentation, this would not be necessary as when the dorsum is built up it makes the base of the nasal bones look more narrow.
The average cost of a full or more complete rhinoplasty, all fees included, is in the range of $ 6500 to $ 8500.
Dr. Barry Eppley
Indianapolis Indiana
Q: I have a deficient jawbone on my right jaw. I had braces in my teens, but I never had the underlying jaw issue corrected (there is lack of bone on the entire side). My teeth are somewhat slanted to compensate for this (deficient ramus included), and I have a bit shorter jaw on one side. I saw your comment on the custom jaw implant. I have a CT scan and am curious as to the cost of the custom implant. This of course is a cosmetic procedure, and I don’t think I want to suffer another 2 years in braces and jaw surgery when potentially an implant will work out for what I want (especially since my teeth fit very well right now). It does not bother me much, but I could definitely benefit from having more structure to one side of my face, as my chin gives a pointy appearance due to the lack of jawline. What is the estimated cost of a full length jaw implant underneath the bone? I take it this is screwed in? If something goes wrong, can it be removed without damage to the nerves/muscles? Any risks 20 years down the line? Thanks.
A: What is have sounds very similar to a variation of hemifacial microsomia where the one side of the face is shorter than the other, particularly the lower jaw. This cases the bite (occlusion) to be canted upward, the chin deviates to the shorter side and the jawline/jaw angle is less full on that side. The first important question is whether a custom implant is really needed at all for improvement of the right jaw. A common approach is a chin osteotomy to move the chin point to the midline and an extended off-the-shelf jaw angle implant. This may well work fine for you and would obviate the added expense ($7500) for custom implant fabrication. Custom implants are invaluable when nothing else will work well, but more standard techniques with your jaw asymmetry problem may offer similar results.
Dr. Barry Eppley
Indianapolis Indiana
Q:I would like to ask you some advise. I have a high natural hairline that makes my forehead look bigger. I don’t have problem of losing hair. I would like to have a hairline lowering, but I don’t know how to choose between a forehead reduction and a hair transplant. With the forehead reduction I will have a quick result and after seeing some pictures on internet the result looks great. The bad point is the scar and I would like to know if this procedure can have a bad consequence for the future. For the hair transplant I would like to know if the result can be natural, I have long and dense hair. I have attached some pictures for you to see.
A: Thank you for sending your pictures. I don’t know if that is the standard way you wear your hair or whether you were doing that just for the pictures. (I’ll assume you were doing that just for the pictures) You have a very good hair density and a relatively full hairline pattern. I really think you could go either way with a hairline advancement or hair transplants. each has their own advantages and disadvantages for you. Hair transplants will have no hairline scar but I doubt you can get the density of your natural hair down to 2 cms from your existing hairline. You certainly won’t be able to do it in one session. If for whatever reason you don’t like the transplants then that effort will be wasted by doing a hairline advancement after. With the hairline advancement, you will get a well matched hairline density and pattern but at the expense of a very fine line scar.
My thoughts are that the hairline advancement is the best initial approach. Because…if the scar is too prominent it can be easily covered up with some hair transplants later. The reverse is definitely not true.
Dr. Barry Eppley
Indianapolis Indiana
Q: I’ve been considering a couple of procedures for several years. While googling plastic surgery procedures I saw several patient results that I liked and I noticed you had performed the surgeries.You really made an impression on me with what I seen in the before and after results. This year might be a good possibility for me to follow through with my hopes of doing some plastic surgery. I look forward to hearing from your assistant or even more so – would like a pamphlet mailed out to me so I can have some literature to review. Thanks!
A: Before and after photographs of a plastic surgeon’s work is one of several methods to determine whom a patient may visit for a consultation. While any single set of before and after photographs of a procedure does not mean that the same result will happen for you, it is one piece of the puzzle in the plastic surgeon evaluation process.
In today’s internet world, there is no longer a need for generic pamphlets. Pamphlets provide just a cursory overview and often are more sales or promotional than they are educational. In my Indianapolis plastic surgery practice, I have replaced pamphlets with an educational blog. My blog, http://www.exploreplasticsurgery.com/, has nearly 2,000 articles about every conceivable cosmetic plastic surgery procedure. Written from my own personal experience and with the intent of explaining how things work and what it is really like to go through, there is an infinite greater amount of useful information there. All you have to do is go to the site and use the search to pull up articles for your procedures of interest.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I had a chin implant done on 2/1/2011. It was a 7mm projection Mettleman style. The right side looks wonderful and I cannot feel the implant really at all. On the left side, however, the implant traces nicely along the edge of the jawbone until aproximately the last 8mm of the wing. At that point it swings upward at about a 40 degree angle. The wing can be felt intraorally with my finger near the bottom of my mouth on that side. Aesthetically, on that same side, there is a jowling effect. I do not know if this is due to the free floating wing or if the wing has pushed other tissue upward and created a lump or ball. My surgeon has suggested that we wait 6 weeks and then go in intraorally and either “tuck” the wing back under the periosteum or simply snip it off IF it is beyond the point of the pre-jowl sulcus, thus accomplishing the pre-op goal of filling in that area. He described it by saying that that what is now the “floor” of the pocket where the wing is malpositioned will be the “ceiling” if we tuck it back under the periostium. I believe he would suture the ceiling so as to ensure the wing doesn’t communicate with the previous pocket and again migrate north. Does this sound like a reasonable plan to you?
A: With today’s extended chin implants, exclusively those made out of silicone, the most common complication is wing malposition. The ends of the silicone implant wings are very thin and easily bent or folded onto themselves if the pocket made during surgery is not fully developed and extended enough to accommodate the full length of the implant. Because you can feel the end of the implant in the vestibule at the side of your mouth,it is bent up in that direction which also causes an implant to create a bulge in the jowl area. There are several approaches to fixing the malpositioned implant wing. The intraoral approach is one and is the easiest. The implant can also be removed, the pocket extended and replaced but involves ‘more surgery’.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hi, I live in the UK and am interested in a gull wing lip lift. I have a few questions. How bad can the scar be? Do you have any photos of ‘worst case scenario’ ? Also can there be tightness or loss of feeling afterwards? Why do so few plastic surgeons do this operation? If I have a lower lip increase as well as upper would I have increase bottom tooth show? (which I don’t want). Lastly, how soon after can I fly back to the UK? I could get a surgeon here to remove stitches if necessary.
A: Thank you for your inquiry. Having done a lot of subnasal lip lifts, I have never seen a bad scar and not a single patient has ever complained about any scar issue. While there may be some temporary upper lip tightness, it passes quickly and no patient has ever told me that it is a long-term problem. Patients do say that they have some upper lip numbness for a period of time which has always surprised me but it is a consistent finding. No sutures are placed that need to be removed as they are all dissolveable. One can return home the very next day. There are no restrictions after surgery.
While you will have some increase upper tooth show (1 to 3 mms), which is desired, there is no increase in lower tooth show. That is controlled by the lower lip position not the upper lip.
I don’t know why so few plastic surgeons do lip lift or advancement procedures. In the right patient they are extremely successful with no significant problems.
Dr. Barry Eppley
Indianapolis, Indiana
