Your Questions
Your Questions
Q: Dr. Eppley, I had a chin implant placed six months ago. The implant was fairly small (4mm) and didn’t seem to make much of a difference. I then had the implant replaced about a months ago for a larger one because I wanted to see an actual difference. Now my chin is huge! The surgeon who redid it didn’t show me my any pictures of what the result would look like or did he show me the size of implant that he would use. I was just told the measurements and didn’t see it. So needless to say I am not happy and am looking for a really good surgeon who would be able to go in and replace the implant for a more aesthetically pleasing one for a small petite female. I have a slender face but the new implant just makes it look longer and because of how large it now is, I can’t smile right, etc. Please let me know if this is something that could be considered. Thank you.
A: I can appreciate your dilemma. A 4mm implant is not really visible in just about anyone. But it is also easy to go too big and wide in a female. Too wide an implant in a female is a common problem that I see. Chin implants in women have to take into account different size and shape considerations. What you would use in a women can be different than that of a man. I would need to see some pictures of where you were when you started and what you look like now if that is possible. I am certain you can get a much better result than you have now just based on your description alone. I suspect it is the wings of the implant that are as much of a culprit as that of the actual horizontal projection.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, if eyebrow loss is due to disease process like alopecia and not to behavioral issues such as trichotillomania or over plucking, would it still be considered cosmetic or might insurance cover part of the procedure(s)? I realize cost may vary, but since I would be traveling a fair distance for a consultation, can you provide ballpark estimate of cost? Thank you.
A: Short of traumatic loss of part or all of the eyebrows due to trauma( burn, avulsions), insurance is not going to cover eyebrow hair transplants. Thin or thinning eyebrows are viewed by insurance as a cosmetic problem not a medical one. Generally speaking, most eyebrow hair transplants need about 150 to 200 hair on each side. (more may be needed) At $10 per each indivudal hair transplant that would bring the cost to about $ 4,000 for the procedure which is done in an office setting under local anesthesia.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have an horizontal scar split my eyebrow. from1mm in the middle of the eyebrow to 6 mm at the end of the eyebrow. I have 6 hairs growing in the scar and i wouldn’t like thm to be lost in a scar revision. I don’t want to lose even one eyebrow hair in a scar revision. It is possible?
A: The simple answer is I couldn’t tell you without seeing a picture of the scar. But by definition, a scar revision removes scarred skin and anything that lies within that scarred skin. When dealing with noticeable scars inside the eyebrow, what makes them visible is their lack of hair or very scant hair within them. This scar needs to be removed, and any free-standing hairs included, to bring the edges of the eyebrow skin that has good density of hair together to minimize the scar’s appearance. This concept of eyebrow scar revision is limited by the size of the scar and would not work well if the scar is very large. (greater than 1 cm.) In these cases to prevent eyebrow distortion, one would need to consider eyebrow hair transplants instead.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a better chin and jawline. I am a 28 year-old female and I have always thought my chin was too short. I am fairly tall (5’ 9”) and my short chin gives me somewhat of a short-faced look that becomes particularly apparent when I smile. I know chin augmentations in women are not that common but I think I really need it. I have attached some pictures for you to review and tell me what you think.
A: Thank you for sending your pictures. While the pictures you have sent show you smiling (which distorts the chin area somewhat), I can still see your concerns about a small chin. I have done imaging showing a 5 to 7mm horizontal advancement in side view and a central or button style chin implant in frontal view to give it more of a tapered look which is more aesthetically pleasing in a female’s chin. I think this size and style of chin implant gives your lower face better balance and shape.
Actually chin augmentation in women, while less common in numbers than in men, is not that rare in my experience. How chin augmentation in done in women, however, is different in the amounts and shape of the augmentations as what defines an attractive female chin is different than that of men. It is more than just a simple horizontal measurement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have underwent a lower jaw advancement plus a genioplasty few months ago. I think my chin could have been advanced a lot more and would appreciate feedback if such can be procedure can be performed once again. What would be a cost of such procedure given it would be a repeated genioplasty. Thank you.
A: Thank you for your inquiry and sending your pictures. Your chin certainly still appears short despite the recent combination of mandibular advancement and osseous genioplasty. Your chin needs to be brought forward at least 7mms if not more to bring your lower face into better balance. Whether that can or should be done by a repeat osteotomy or simply putting an implant in front of the osteotomy needs to be determined by a lateral cephalometric x-ray. That would show how far the chin as been brought forward by the first osteotomy and how thick the chin bone is to see how much further advancement can be done. It is not a problem technically to do the genioplasty again, you just want to know precisely how much advancement can be gained. It certainly appears that the original genioplasty was fairly conservative.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, The picture used on the December 28, 2008 article written by Dr. Eppley looks like my body. I have lost some weight but am still a large women. I am very curious about this procedure. Do I have to be at normal weight to have a pubic lift done? Does insurance ever cover this type of procedure. My Gyn says that she thinks I may have some sort of a “prolapse” and suggested I go see a plastic surgeon. I am so embarassed by how I look I haven’t done so. Your website gives me hope that I am not the only person who has this problem. I look forward to hearing from you. Thank you.
A: A large overhanging suprapubic mound is a common problem for men and women that either have a large abdominal pannus or who have lost a lot of weight. The difference between the two is in the amount of fat that either contains. Either way, this overhanging mound can interfere with urinary outflow, sexual function as well as pose hygiene issues. Its removal can be done through a procedure known as a suprapubic reduction/lift (mons reduction) which consists of liposuction debulking of its fat volume if needed and reduction and lifting of the excess skin that it contains. Based on the above or overlying abdominal anatomy, it may be necessary in some cases to remove any overhanging abdominal pannus or extra skin first before proceeding with a pubic lift procedure. (e.g., abdominal panniculectomy or extended tummy tuck) This is usually not a procedure that medical insurance will cover.
Dr. Barry Eppley
Indianapolis, Indiana
Stem cells have caught the imagination of medical specialists and researchers over the past decade. The idea that your body holds within it the ability to regenerate and heal itself through these wonder cells has an irresistible appeal. Stem cells show good promise for numerous d How Do You If Your Ex Boyfriend Wants You Back ifficult diseases for which modern medicine has few good answers. Clinical trials for some neurologic and degenerative disease therapies have been encouraging.
Because of the uncomitted nature of stem cells, it is no surprise that it has been touted for the most common of all human conditions…that of aging. As an anti-aging treatment, stem cells have become the magic pixie dust allegedly contained in numerous topical skin therapies and cosmetic surgeries. A topical potion that may contain stem cells is surely as close to the fountain of youth as we have ever been. Their use has spilled over into cosmetic surgeries which are now being advertised for such procedures as stem cell facelifts and stem-cell-enhanced fat injection breast augmentations. These are being promoted as not only cutting edge operations but promising results that are far better than traditional methods of plastic surgery used.
When you factor in that everyone has plenty of stem cells throughout their body, many of whom lie in great numbers in our fat, their benefits seem obvious. How could they not make any cosmetic surgery better?
While stem cells are a part of the future of some medical therapies, they currently represent a potential case of a ‘truism.’ Truisms are common beliefs in which something just seems to be so true that we assume that it is…only later on closer scrutiny to be proven to not be so. Currently stem cells, at least in anti-aging therapies and plastic surgery, has many of the makings of a truism.
Those that advertise and market them are making claims that are far ahead of proven science. There has yet to be a single piece of medical evidence or research that has shown that stem cells can make your skin younger or your facelift last longer or look better. While we would like it to be true, and it seems that it should be true, the reality is that stem cells and anti-aging effects are still courting but there is no signs yet that they are to be married.
Because fat is resplendid with stem cells and fat injections are a common part of many plastic surgery procedures today, it is tempting to call them ‘stem-cell enhanced’ or even a stem cell therapy. This is false advertising at the least and deceptive at the worst. While stem cells may be part of our fat, we don’t yet even know how to make them work or what they would do if they could be turned on.
If you drawn to some type of cosmetic stem cell treatment, whether it be a cream or surgery, remember that nothing sells better than hope.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have loose skin on elbows and I only want the elbows done, I have had a quote but unsure how and when I can drive, and I am not sure about visible scar will be which worries me. It’s just coming into summer and not sure if that would matter to have it done now or wait. Can you advise me Thanking you in advance.
A: The biggest issue with elbow lifts, very similar to armlifts, is that there will be a visible scar as the trade-off for the loose skin. Whether this is a good trade-off will differ for each patient. If you have a scar concern, then this may not be a good procedure for you. That aside, my patients can drive the very next day. This would not be a procedure that most people would want to do in the summertime due to early scar visibility due to short sleeves being worn.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hello Dr. Eppley, I have reviewed your website qned found that you have run across silicone oil pockets and were able to induce drainage during a lift surgery. I have had buttock injections done. I do not have any lumps and I wanted to know that if found by MRI is there a way for a large pocket of silicone in my buttock to be drained? I really want to know if you can help me by performing this procedure, since you have seen and had experience with silicone oil. I really need your care. Thank you for emailing me in advance.
A: The traditional method by which silicone oil injections are done is supposed to be a small or ‘microdroplet’ approach for soft tissue augmentation. This is taught this way to avoid a large collection of isolated oil which can cause tissue reactions and fibrosis. While this may be the way it is done in the face, I suspect that most buttock augmentations with silicone oil involves much larger deposits than small drops. Since you have no lumps in your buttocks, you may not have any large oil collections that are capable of being drained. Certainly an MRI would reveal if such collections exist. If they do, drainage may certainly be possible. The one question I would ask then is, if you are having no problems, why do you want it removed? This is particularly relevant given that a surgery and an incision may be needed to do so.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a flat spot on the back of my head that I would like corrected. It is at the back of the crown of my head and it gives me a funny looking head. I have attached pictures and have drawn on them the shape that I would like to have. Can you tell me I how this can be corrected? What material and how would it be placed? What is the recovery after this type of operation?
A: Having done quite a few occipital cranioplasty procedures for skull flattening that looks just like yours, I would recommend PMMA. This is because it will take about 40 to 60 grams of material to create the desired effect. PMMA offers the most cost effective material when it comes to this amount of cranioplasty augmentation. Other material options include HA (hydroxyapatite) and Kryptonite but they will cost anywhere from 3x to 5X more in terms of material cost, that can add thousands of dollars to operative costs. The procedure would be done through an open approach through a low horizontal incision on the back of the head, where hair loss is not likely to ever occur. This is done as an outpatient procedure done under general anesthesia with an operating time of approximately 90 minutes. There is actually very minimal recovery afterwards other than some non-visible swelling on the back of the head. Occipital cranioplasty is a much simpler procedure to go through than most people envision.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, what can you tell me about this new procedure of making cheek dimples?
A: There have been media reports recently that talk about a ‘new’ plastic surgery procedure known as dimpleplasty. While this has been touted as being new, it really is not. The actual procedure of making dimples dates back several decades.
Cheek dimples are actually anatomic defects in the zygomatic muscles which run between the lips and the cheeks. This is an important muscle for smiling as it helps lift up and out the upper lip. In someone with cheek dimples, this muscle has a split in it. When someone smiles and the zygomatic muscle contracts, the split in the muscle separates which allows the skin overlying the split to be pulled inward. Thus a cheek dimple is really a hernia in the muscle. How big and where it is located determines the location and the size of the dimple.
In cheek dimpleplasty, a small incision is made inside the cheek where a split in the muscle is created. This allows the underside of the cheek skin at the desired dimple location to be sewn or attached to the inside of the cheek lining. This creates a scar or attachment that will lead to dimples when one smiles. This is a simple outpatient procedure done under local anesthesia so the dynamics of smiling and the dimple effect can be seen. There really is not recovery other than some mild cheek swelling. The biggest risk of the surgery is that the cheek dimples may be less or even more noticeable than desired. (depth of the dimple)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in using PRP for lip augmentation. I am looking for something more natural and longer-lasting other than the typical injectable fillers. Can PRP be put into the lips and how well does it work?
A: PRP can be injected into the lips just like anywhere else. It is not a question as to whether it can be done but whether it should be done. Will it create a lasting augmentative effect beyond that of a short-term fluid distention is the question. There is no medical evidence that it would nor would I biologically understand why it would. PRP is not a filler material per se but rather an adjunctive healing agent. It has no primary effect on its own such as creating more collagen than would normally exist in an otherwise healthy tissue site. The PRP I have put into the lips has been combined with fat to offer a higher probability of a sustained effect. It is the fat that is the filler and the PRP is added for its theoretical benefit on helping fat cells to survive or in helping stem cells to convert to fat cells. This is the most natural lip augmentation injection treatment but it is unproven as to how sustained or permanent the lip enhancement effect is.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like to start by saying your website and blog have been so helpful as both a research tool and making me feel so much more comfortable in approaching this issue. It is one of the few sources I have found that really takes the time to properly explain things, that most people in plastic surgery don’t understand. I would like to have more balanced facial features and to improve my asymmetries to improve my facial appearance. I feel that I have a long lower face and chin compared to my forehead, which is very low and slopping. I can’t wear hats and have to spike up my hair all the time so I don’t get teased. I recently lost a lot of weight and with it my cheeks, with used to be very full. But I guess what bothers me the most is my nose – I have a deviated septum which makes me look crooked and my nose is very romanesque in appearance. I think that a rhinoplasty and cheek augmentation would help me best but I’m open to suggestions. I just want to be the most attractive me I can be. From my photos can cosmetic surgery help me?
A: Facial symmetry and proportion are the two most important components of facial attractiveness. In looking at your photos, I would agree that the deviated and dorsal convexity of the nose combined with flat cheeks are the two main areas to try and improve. I would propose a rhinoplasty whose objectives are to straighten the nose in the frontal view and bring down the dorsal line to one that is straight between the frontal-nasal junction and the nasal tip. The tip could also tolerate a bit of thinning as well. For your cheeks, anatomical style cheek implants secured high up along the flat malar prominence will bring some highlights to your midface and more angularity to your face.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a son whose ears stick out. When he was little, he was sometimes called dumbo which was cute at the time. Now that he is in school, he is called dumbo and it is no longer funny. I can tell that it bothers him considerably and he is very self-conscious about his big ears. I want to get him an ear pinning procedure, which I know is the right thing to do, but I need some more information about the operation. Please give me an overview of some of the specifics about this type of ear plastic surgery.
A: Ear deformities can be emotionally traumatic to anyone but it is particularly bothersome to young school-aged children and teenagers during their very important formative years of their self-image. The good news is that an ear pinning, known as otoplasty, is a relatively easy and highly successful procedure. As the ear is about 90% complete in its growth by age 5 or 6, an otpoplasty can be done before a child enters school.
Otoplasty is done under general anesthesia in children. The incision and resultant scar is placed on the back of the ear and will heal so that it is never seen. The ears are reshaped by giving the ear cartilages a new shape through the use of permanent sutures which folds the ears back. The operation takes about one hour. Dissolveable sutures are used to close the incision and a head dressing is applied for few days. There is some slight discomfort but it is not a painful experience afterwards. Once the dressing is removed, the results are immediately seen. While there is some slight ear swelling, there is usually no bruising.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am curious about the use of hydroxyapatite or kryptonite bone cement for the use of building up areas of the cranium that are asymmetrical. Is hair loss something that occurs over the area where either of those two materials would be applied or is hair growth unaffected by having those materials placed onto the cranium?
A: Hair loss is not a potential complication of any cranioplasty procedure. I have been asked this question many times and it is an understandable concern.The blood supply to the scalp is extensive as the scalp is one of, if not the most, vascularized skin structures on the body. More pertinently, the scalp is tremendously thick often being 1.5 to 2 cms in tissue thickness. The hair follicles reside just under the skin in the top layer of the scalp, being in the upper 10% to 20% of its thickness. When raising a scalp flap for any cranioplasty procedure, the entire thickness of the scalp is raised off of the bone. Thus the plane of dissection and flap elevation is far away from where the hair follicles may be injuried. The only risk to hair follicles is in the making of the scalp incision not in the raising of the scalp flap or from the cranioplasty material underneath it. Such limited damage can be avoided by careful angulation of the incision, not using cautery in the upper level of the scalp and in careful scalp incision closure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had implants for submalar augmentation placed through mouth on September 2nd and then had them removed one month later. I also had a small premaxillary implant put in through the nose. I removed them because they were too big and the premaxillary implant changed the way my nose looked. The implants have been out for one week. I know that some of the undesirable effects were swelling and that I didn’t give them a real chance. But the anxiety they were causing me on a daily basis was too much. I can’t find any information as to why my nose looks different still after removal, it is wider and the nostrils look rounder and slightly more upturned. Is it possible it won’t go back to pre op look? Could scar tissue have formed that quickly or is it just swelling and if so when should I expect it to truly resolve. The cheeks and lower face are still very swollen also, will this eventually return to pre op look also given that they were in and out so quickly? When can I expect to look like me again? My muscles are a bit tight but overall seem to be functioning without any issues to the nerves and I can smile. Thanks and I look forward to your response.
A: Certainly one week after implant removal, there will be residual swelling and facial distortions. By your own admission you know this and it will take several months before you can judge the final outcome. I would have no doubt that the cheeks area will return completely to normal. Whether the nasal base will is unknown. In placing premaxillary implants the attachments to the nose around the pyriform aperture and the anterior nasals spine are disrupted. This may cause the nostrils to end up slightly wide than before but this is a possibility not a certainty.You must wait three months after facial implant surgery, either after their placement or removal, before seeing the final results.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am in need of some breast help! I have had three children, all whom I have nursed. I have also lost 45 lbs over the past year through diet and exercise. This has left my breasts saggy. I know that I need a breast, that is without question. The only question I really have is whether I can get by with out breast implants.Do you think that’s possible with how my breasts look? I’m happy with the size of my breasts when I wear a good bra (currently 40D) but unhappy with how deflated and saggy they are without a bra.
A: Breast lifts do an excellent job of lifting and tightening the shape of the breast mound. By keeping the same amount of breast tissue and lifting and tightening the ‘bag’ which contains them, this does create a less saggy and more round breast. This is particularly true in the bottom pole of the breast and less so in the upper pole of the breast. In the beginning right after breast lift surgery, the upper pole of the breast is quite round and full. But as the tissues relax and settle, much of the upper pole fullness will be lost. If one doesn’t ming some rebound flattening of the upper breast pole, then I think you would be fine with a breast lift alone. However, if your goal is to have a rounder and more full upper breast pole long-term, then a small implant will be needed to accomplish that breast shape goal.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had Botox for the first time a year and a half ago for free. A local doctor was training a woman on it and he did one side and instructed her on the other side. It was just okay, one side felt heavier than the other and one eye brow was higher than the other.
Then an anesthesiologist friend offered to give me Botox injections as she does a small group of women from time to time and I wanted to try again. This was like eight months after my first try. Long story short, I had a furrowed left brow for a while which was not cool. Plus she diluted it big time which in hindsight was a blessing because of the furrowed brow. I was starting to think that there is definitely an “art” to this injection thing.
Then I was out of town visiting friends and a local doctor introduced me to Dysport. At the time I was totally feeling ugly and wanting to try anything to reduce the fine wrinkles in my forehead, just look fresh. Well he did a first rate job so I loved it! No heavy feeling in the forehead and it took almost immediately and looked great! I’m sold on Dysport for no other reason than it was my best experience to date. You will have to educate me on the cost vs Botox as I have no idea.
So here I am today, looking online for a reputable guy to help me out…I’m due for something, but will not go the route of using anybody but a professional ever again!
A: The apparent simplicity of facial injections does belie that there is actually some art to it. There is also an obvious benefit to knowing the underlying facial muscles and how their movement contributes to facial expression. It is slightly more sophisticated that just throwing darts at the side of the wall so to speak.
The actual differences between Botox and Dysport are very slight and there is no real evidence that one is more effective than another. Dysport may ‘kick in’ a day or two earlier than Botox but otherwise lasts and costs about the same as Botox. The differences you have had with two negative experiences with Botox and the favorable one with Dysport undoubtably reflects technique (injection location) and doses used. I have not seen any differences in my experience with either one. There is some evidence that Dysport may be slightly more effective than Dysport (because it spreads out better) but in the forehead there is no appreciable difference in effect.
All of that being said, you should continue with Dysport because you have had a good experience and there is no change what isn’t broken.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 36 year-old and I have a very thick and prominent brow ridge bone. A few years ago I suddenly lost my hair because of alopecia and now my forehead looks very unpleasant. I was wondering if you can offer bone reduction and reshaping solution for me. I have taken some photos of my facial profile which would be available if you required. I am serious to perform the procedure and at the same time have some concerns regarding the techniques to approach this procedure .
A: Brow bone reduction in a male, who is the most common type of patient who develops prominent brow bones, must always take into account the surgical approach. The only way to do brow bone reduction in any patient, male or female, is through a scalp incision. There is simply no other incisional method, even an endoscopic technique, that can provide the exposure for the instrumentation to do the procedure. In the male patient with no hair or a very sparse hair pattern the trade-off of a scalp scar must be considered very carefully. Essentially one is trading off one problem (prominent brow bones) for another. (scalp scar) This may be a reasonable trade-off but the magnitude of the brow bone protrusion has to be fairly significant and really deform the shape of the forehead to justify brow bone reduction in men.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, one year ago I underwent surgery for a medium chin implant and neck liposuction. Though I was initially pleased with the result due to the way the swelling made my chin look, after the swelling had subsided I was very disappointed with the outcome. I feel that my chin and jaw line are vertically short and that my chin is still a little bit horizontally short. Additionally, my jaw line lacks solidity and I think that my chin could stand to be a little wider/fuller. I have attached two photos of what my face currently looks like.
I would like to add roughly a 1/2 inch to my chin/jaw line vertically, as well as 3-5 mm horizontally (from where the current implant ends). I would like my jaw to angle down to my chin, so that the chin is lower than the rest of the jaw. As I previously mentioned, I would also like my chin to be a little bit wider and to add solidity to my jaw line as it gains fat easily.
In order to obtain the results that I desire and keep them long-term, what would be the best procedure for me? The three that I have been looking at are a sliding genioplasty, a geniomandibular implant with Gore-Tex strips or a custom jaw implant. Money is a little bit tight for me, so I’m hoping to avoid the custom jaw implant.
I appreciate your help and eagerly await your response,
A: I have taken a careful look at your photos and your desired aesthetic chin changes. While a custom implant is one method to achieve those changes, it is not the only way as you have pointed out and the cost of it eliminates it from consideration by your own admission.
Between a chin osteotomy and geniomandibular implants, each has its own advantages and disadvantages. A chin osteotomy (keeping the chin implant in front of it) would easily create 10mms of vertical lengthening, about 5mms of additional horizontal advancement and could be sectioned to create 5mms of horizontal expansion as well. It is done from the inside of the mouth and would actually be my preference in your case even over a custom chin implant. Geniomandibular groove implants could also provide up to 10mms of vertical lengthening and 5 to 7mms of horizontal widening as the implants can be placed with separation between the two sides. The problem with these implants is that you would only get about 2 to 3mms of additional horizontal advancement and your existing chin implant would have to be placed on top and in front of it to keep and enhance the horizontal projection that you already have. That is not a big problem, just that you have two implants stacked together. This procedure would need to be done from a submental skin incision from below the chin with a resultant scar.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Hi. I have a few queries about possible procedures which may enhance my smile and lip shape. First of all, I have quite a small mouth, as in the horizontal distance from corner to corner of my lips is quite short, and therefore my mouth at rest is small and my smile does not show many teeth. Is there any procedure, such as lip lengthening, which can make my mouth opening wider- hence make the horizontal distance of my mouth at rest longer, and to make my smile wider? My next issue- which I think is related, is that my top lip covers quite alot of my top teeth when smiling, and also I would like my top lip to be more outturned or ‘pouty’. Is there a surgery which can reduce the distance between the nose and the lip to reveal more vertical distance of the teeth when smiling, and to achieve a more “pouty” shape? I’m not sure if it would help to send photos, but I can if that is needed. Thank you in advance!
A: What you are seeking is a horizontal widening of the corners of the mouth and a vertical shortening of the upper lip. There are surgical procedures for each of those changes. The upper lip can be vertically shortened, the upper lip become more pouty and more upper teeth can be shown through either a subnasal lip lift or an upper lip vermilion advancement. Which one is better for you would depend on seeing a picture of your lower face for my assessment and what location of scar would be preferable. (under the nose or along the vermilion-cutaneous border) The corners of the mouth can be widened through a commissuroplasty procedure where a v-shaped segment of skin is removed (about 5 to 7mms per side) and the corner vermilion advanced outward on each side. Whether that fine line scar around the corners of the mouth is acceptable would be the concern.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 46 year-old female. I would like to get an upper and lower blepharoplasty. However, I have problems with my nose due to a sinusitis and a collapsed septum. I got an x ray last week and the doctor said I have a deviated septum as well as thickening of turbines. I have been on antibiotics for five days. This problem wears me out a lot. I am often tired with headaches and my face always looks puffy due to continous allergy symptoms. My question Dr Eppley is what do you suggest for me to have first or not to have- a Rhinoplasty/Septoplasty to correct the nose issue and then a blepharoplasty? Please doctor I would appreciate your advise. I found your website very helpful, thank you again.
A: There is no question that septorhinoplasty and blepharoplasty can be performed together. This is not a technical nor a safety issue. It is an issue exclusively of how much recovery do you want and how long can you tolerate (socially and workwise) the way you will look during this recovery. When combining rhinoplasty and blepharoplasty the swelling and bruising around the lower eyes can be quite severe, particularly when nasal osteotomies are performed. Otherwise, there is no reason why the two facial procedures can not be performed together. There may also be other advantages beyond one single recovery period for combining them, such as cost.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a primary rhinoplasty over a year ago where my doctor used diced costal cartilage in fascia but I do not feel we had the same aesthetic vision. My nose is still larger and higher than I would like it to be (more masculine than feminine). I would like it to be smaller and more feminine. I am wondering were I to pursue revision rhinoplasty, would the diced cartilage with the fascia be shaved? If so, would new fascia (requiring a second operation site) need to be applied over the shaved sections? I am trying to assess the risks associated with revising a rhinoplasty that was done using diced cartilage and the likelihood that it can be reshaped. I can live with my nose today but don’t like it.
A: When undergoing a rhinoplasty, because it is a facial structural change, it is important to see what the result may be like through computer imaging before surgery. This is an operation that is about changing how you look so there is significant psychological overtones to how the result will impact a person afterwards. While computer imaging is a prediction and not a guarantee of a rhinoplasty outcome, it does shake out whether what the plastic surgeon envisions and what the patient hopes to achieve are closely matched.
Secondary revision of a prior dorsal augmentation with diced cartilage can be done. The augmented cartilage can be shaved down or completely removed depending upon what creates the best aesthetic result. It almost sounds like in your case that the need for an augmented dorsum may not have been desired at all since you now realize that a smaller and lower dorsum is desired. You have correctly pointed out, however, that dependent on how smooth the diced cartilage reduction is done that some graft coverage may be needed. If there are some irregularities that are best covered by a graft, I would choose an allogeneic dermal graft (less than .5mms or less) rather than another fascial harvest.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, four years ago I had a hair transplant procedure done. The procedure left me with a wide, deep and very visible scar in the back of my head. I want to do anything that is possible to reduce the scar. Can you please help?
A: The traditional method of hair transplantation uses the strip method from the back of the head for the donor hairs. One of the problems with this donor site is that it can leave a large scar due to its horizontal orientation, which exposes it to the downward pulling forces of the lower scalp and neck skin. This can result in a wide scalp scar if not closed properly or if this donor site is used more than once, which is frequent. If a man at some point decides to give up on hair coverage on top and wants to shave his head or have a close-cropped haircut, this scar can become an aesthetic liability. This is why the contemporary approach of FUE, follicular unit extraction (Neograft), is better because it does not leave a single long scar for the posterior scalp harvest.
When it comes to improving the wide horizontal scalp scar from a hair transplant, there are two approaches. A traditional scalp scar revision can be performed which means that the entire scar is removed and re-closed, making it a much finer and more narrow scar. The other approach is to use an FUE technique. The scar is contracted by the punch excision of scar tissue and hair transplants are inserted. Both have their merits and I would need to see pictures of the scar to determine which may be best. If there is significant scalp laxity, then scar revision is a good choice. If the posterior scalp is very tight, then the FUE approach may be better.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am writing to you because I am interested in getting a custom implant made for my jaw/chin to improve my profile. I currently have a chin implant that I am not satisfied with because it only advances my chin horizontally. I am interested in vertically lengthening my chin. I saw on your website the case study of vertically lengthening using a custom implant and I wanted to see if this could help me to achieve the results I desire. Specifically, I want to know if a custom implant can both vertically and horizontally lengthen my chin and front of my jaw. I have attached some pictures of what my face looks like before and after the original chin implant surgery.
A: In looking at your desired chin change, there is no question that a significant vertical lengthening as well as some further horizontal advancement is needed. There is two ways to get there.
1) Custom Chin Implant – There is no off-the-shelf implant that can remotely make this amount of chin change. Based on a mandibular model from a 3-D CT scan, I can custom make an implant to the exact specifications that will work. Your existing chin implant would then be replaced by this new one. This is the ideal implant approach and adds additional costs to the base surgery to make the actual implant and have it ready for surgery. (the CT scan cost would be in addition and is based on the facility fee charge)
2) Chin Osteotomy – Keeping your current chin implant in place, a chin osteotomy is performed above it and the entire chin with implant is brought forward and vertically lengthened with an interpositional hydroxyapatite block used as a graft. This is what I call the extreme chin augmentation approach, combining an implant with an osteotomy.
In looking at your pictures, I think #2 is a viable option but I would need to confirm that by looking at a lateral cephalometric x-ray. (standard orthodontic/oral surgery film.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have saline breast implants in now that are 375cc in size. While my surgeon said they would be perfect, I knew from the beginning they were too normal. (maybe perfect for him but not for me) They are under the muscle and are smooth Mentor saline implants. They were placed through an incision under my armpit as I did not want any breast scars. After having had them for six months, I am more convinced than ever that I want to go bigger. I want to go at least 500cc and maybe 550cc. Can my current implants be removed and replaced by going through the armpit again? I still do not want any scars on my nipples or under my breasts. Should I use saline again or go with silicone implants this time?
A: In terms of a size change, you want to make sure that you are having a breast implant volume change of at least 30%, as that usually the minimum it takes to see a real cup size difference on the outside. That is why a change to 500cc (33% is the least you should go) and 550cc (46%) would be more ideal. You do not want to go through a second surgery and still fall short of your size goal.
Since the incision is an important concern for you, the armpit approach can be re-used and your saline implants exchanged for larger ones. While silicone implants can be placed through an armpit incision, there are some limitations of size. The size you have in now is about the limit for inserting silicone implants using a funnel technique through the armpit. There is no limit of size when it comes to saline breast implants through the armpit.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have lost a lot of the fat in my face particularly in the cheeks which has left them very hollow and sunken in. The area below my cheeks looks too full because it is indented above it. I havhe been told that fat injections would be the way to go even though fat transfer may not always stay. I know that cheek implants are permanent becuase they can not be absorbed. But I didn’t know of they come big enough to fill out the entire depressed cheek area. What sizes do they come in and do you think they are big enough to fill out the whole cheek area?
A:Your concept of considering cheek implants for helping restore facial volume loss is only partially correct. Cheek implants are not a substitute for fat injections when it comes to facial fat volume loss. The submalar style of cheek implant can help fill out the buccal area of the cheek (right below the cheekbone) but this represents only part of a larger surface area of the cheek and surrounding tissues which makeup the gaunt or skeletal facial look. Therefore, the use of this type of cheek implant may be a companion strategy with fat injections but is not a stand alone treatment for refilling out the deflated or fat-depleted face. Fat injections are more versatile because they can be placed anywhere. Cheek implants, even the submalar style, can not go very far from the edges of the bone and are more limited as to the facial area that they can cover.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, after enduring over twenty years of having an indented tracheostomy scar, I am finally getting it revised. I understand that up to 50% of the fat tissue that is used as a filler gets dissolved by the body while it is healing. Is it possible that one would need multiple visits over the years to keep adding filler injections or something of that nature? Also, if one were to avoid that route in favor of something “off the counter” which product would you recommend? Thanks in advance.
A:Most tracheostomy scars can be revised and the neck skin leveled by simply closing the deeper layers of the excised scar as it is closed. This brings in tissue from the side and fills the defect or area of missing tissue underneath the skin. Larger or more indented tracheostomy scars, however, do have a real subcutaneous tissue deficiency as a result of fat loss due to pressure atrophy caused by the indwelling tratcheostomy tube. When these are merely excised and closed, they will revert to some degree of inversion as the skin is essentially closed over an ‘open space’. This is why the placement of fat grafts can be so helpful in tracheostomy scar revisions. However, the choice of fat grafts is critical and should be a dermal-fat graft and not fat injections. These are small composite grafts that can be taken from many locations with a small resultant scar. There are no ‘off the shelf’ products, such as allogeneic dermal grafts, that are a good substitute for a supple dermal-fat graft.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have this weird-shaped head in the back sticks out. I have been teased about this since I was a child. As an adult, it has not gotten any better. They call me all sorts of names like football or peanut head. I have very low self esteem from this my whole life and I feel like people are always looking at it. I was just wondering if there is a way to flatten the back of my head or make it not stick out in the back as much. Please help me. This would change my life and give me great confidence.
A: While I can not provide any exact recommendations without seeing pictures of your head first from different angles, I can make the following general comments. When it comes to head or skull reshaping, the question is whether the bone needs to be reduced, built up or some combination to get a smoother and better-shaped skull area. Given that there are limits as to how much the skull bone can actually be reduced and that the amount of build-up is always much greater than what reduction can be achieved, the focus should be on whether an augmentative cranioplasty will help. The second general comment is that most cranioplasties, other than for very small areas, has to be done using an open approach. From a scar standpoint, this makes skull reshaping a more common procedure in women than men due to differences in hair densities.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 50 year old woman and am fairly thin being 5’3″ and weigh 117lbs. I have had what I think is fat on the back of my neck for as long as I can remember. It looks like a buffalo hump and it runs in my family. I have exercised all my life and continue to this very day. I have always been concerned about my posture so this buffalo hump is quite disturbing. I HATE IT! I have had liposuction on my stomach and thighs but no doctor seems to want to address my neck problem. I have had xrays and I do have a greater curve in my upper back than most people. Looking at me from the front my posture is impressive, but when I turn to the side it looks thick like there is a flap of thick fibrous fat. I can grab and feel it. I am self-conscious about wearing my hair up. Now blouses do not fit properly and often I have to alter clothes for them to fit. Please, I hope that you can help me.
A: Buffalo humps on the back of neck are almost always collections of fat. Why you have it there in an otherwise thin person who is very active is unknown. Seeing that your relatives have it indicates that it is genetic in origin and not from one’s lifestyle. An attempt at liposuction would certainly seem to be worthwhile. The fat in the buffalo hump is different than that in other body areas being more fibrous and not pure fat. This is why an open excision is the most effective approach but the midline scar may not be worth it. I would recommend laser liposuction (Smartlipo) as a better liposuction technique in fibrofatty areas.
Dr. Barry Eppley
Indianapolis, Indiana
