Your Questions
Your Questions
Q: Dear Dr. Eppley, my breasts are slightly droopy and I want them to be more perky. I thought I needed a lift but one doctor that I consulted with said that I needed more volume in my breast instead of a lift. He said this could be done with an implant or fat injections. The length between my nipple to sternal notch is 22.5 cm. Should I have breast lift or breast augmentation? If augmentation is best, which treatment is better an implant or fat injections?
A: The key to knowing whether a lift or the addition of volume can make the breast look better depends on the position of the nipples. If it sits above the lower breast fold, then volume is the answer. While I do not know exactly what your breasts look like, knowing that the distance from your nipples to the sternal notch is only 22 cms tells me that your nipples are definitely above the inframamammary folds. That is essentially a completely normal or ideal nipple position. (the normal range is 18 to 22 cms depending in the length of one’s torso)
Since more breast volume is the answer, the question of whether it can be done with an implant or fat injections becomes very relevant. The use of fat injections for augmentation of a variety of body areas has become very popular in plastic surgery recently. While it is widely accepted for volume augmentation of the face and buttocks, its use in the breast is currently controversial. This is because there already exists an augmentation method that works well and is very reliable, an implant. For overall breast augmentation, an implant works better, is a one-step procedure, and will cost less. If there is just one area of the breast that needs filled in, then fat injections becomes the preferred treatment.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dear Dr. Eppley, what is the difference between craniofacial and maxillofacial surgery? I am thinking that they use the same surgical procedures and the same materials like bone cement? I am interested in getting my forehead reconstructed from a dent in it due to an injury but don’t know which type of surgeon to go to. And are you practicing both craniofacial and maxillofacial surgery?
A: Maxillofacial surgeons are usually dentists (with or without a medical degree) that have trained in facial bone surgery below the forehead, mainly of the jaws. Craniofacial surgeons are plastic surgeons that have done extra training in craniofacial deformities and have much greater experience in bone surgery above the jaws. Most maxillofacial surgeons will have very limited experience if any in forehead surgery and cranioplasty.
While there are exceptions to either of these types of surgeons and training and experience can vary by country and geographic region, these are general guidelines. I can speak to their differences quite clearly as I have trained and am board-certified in both specialities. You should seek out a plastic surgeon who has considerable experience in cranioplasty and the various materials used to do this type of forehead surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dear Dr. Eppley, I want a rhinoplasty and as part of it I’d like a wedge excision procedure to reduce the alar flare without reducing nostril size. However, there seems to be a lot of concerns with the wedge procedure as it leads to some external scarring. I wouldn’t mind this if the scar itself was camouflaged within the alar crease. My main concern is that there might be an obliteration of the facial alar groove with this procedure. Is this a real concern? What is the best way to go about this without obstructing the alar crease?
A: There are two basic skin excisional approaches in rhinoplasty to change the bottom shape of the nostrils. The first technique is the removal of a vertical wedge of skin inside the nostril just next to the lateral nostril wall. This will reduced the flare of the ala with minimal narrowing of the nostril width. This leaves no visible external scar and will not alter the alar-facial groove. This appears to be what you may need. The other technique is where this inside the nostril excision is extended out along the ala-facial groove. This results in significant nostril narrowing as well as flare reduction. This does place a scar in the alar-facial groove which, if well placed, is not a visible scar concern. It does not result in any chance of effacement of the alar-facial groove.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had an accident when I was 16 that resulted to a dent between my eyebrows. I had a surgery to elevate that dent 10 months ago and it was done by my neurosurgeon because my frontal sinuses were also indented. My forehead now is improved but I can still see a slight dent which is very acceptable. My question is if the bone cement on my forehead will deplete overtime resulting to a more indented forehead again?
A: What you had sounds like an outer table fracture of the frontal sinuses, also known as brow bone fractures. Because this portion of the forehead has only a thin layer of bone in front of the underlying air-filled frontal sinuses, it can be pushed inward with a significant traumatic force. This buckling inward creates the outward appearance of an indentation of the forehead just above the eyes. When a delayed repair is done, it is much easier to build up the contours of the brow bones that it is by repositioning the displaced bone. This is done using any of the available cranioplasty materials. While I don’t know what type of cranioplasty was used for your brow bone augmentation reconstruction, none of them are resorbable. They all are stable biomaterials that do not degrade over time. So your current result will stay stable throughout your lifetime.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I’m very interested in chin and jawline enhancement, particularly the solid one piece custom made framework. I have very little time off these days due to the economy so time off and downtime is of great concern for me. I loved the before and after pictures and would be ecstatic to get rid of my beard which I have worn since I was 19. I have had several other surgeries with great success and am very pleased with their outcome. I look forward to hearing from you.
A: Thank you for your inquiry. There are numerous types of preformed and custom jawline implants, depending upon one’s lower jaw and neck anatomy. Most are three-piece assembled units (extended chin and jaw angles) as opposed to a single-piece unit. The only one-piece unit is when only vertical elongation of the mandible/chin is being done which is the least common.
Whether one can be augmented with available preformed implants or requires a custom approach depends on what one wants to achieve as it relates to the jawline. I would need to see some pictures of you and do some computer imaging of the options to see the differences between a preformed vs a custom approach. The basic difference is that custom jaw implants offer increased augmentation sizes and can create a smooth straightline jawline from the chin back to the jaw angle. There has to be a compelling reason to use the custom approach as it requires a CT scan from which a model and the implants are made and thus costs more.
Whether preformed or custom jaw implants are used, the recovery is no different. While there are few physical limitations afterwards (other than some temporary restricted oral opening), there is considerable facial swelling which takes up to three weeks until it largely passes.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a sliding genioplasty four years ago. Everything went well and I like the result. My surgeon told me that he could remove the titanium plates and the screws but it wouldn’t be a problem if they stay inside me for the rest of my life. So I decided to let them stay inside of my chin. Last week I meet another surgeon who said that titanium plates and screws should be removed in younger patients. On ‘House MD’ it has been shown that titanium plates can severely burn soft tissue and skin when an MRI is needed. Is this true? Should my titanium plates be removed because they can lead to bone resorption or other problems in the future?
A: The simple answer to your question is that none of what you have heard or been told is true. Titanium is the most biocompatible metal in the body which is why it is so commonly used. In facial plates and screws it is a nearly pure metal to which bone will bond directly (and often grow over) and it is non-ferromagnetic so it is not affected by the powerful magnetic influence of an MRI. There is no reason whatsoever, therefore, to remove your chin osteotomy plates and screws. Of all the places on the face where rigid fixation is used, the chin is the one area where I have never seen any long-problems such as loosening, irritation, or interference with function. Removing them may be a good exercise for the surgeon but is of no benefit to you at all.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, My son required a decompressive craniotomy after being injured in a sporting event. His replaced bone flap subsequently got infected and had to be removed. He is now awaiting a second cranioplasty for replacement of his bone flap. Could you provide any insight to titanium versus PMMA and/ or PEEK custom manufactured implants? Any added information would be most appreciated.
A: There are many materials that are available for reconstruction of cranial defects, particularly those in replacement of a lost cranial bone flap. The three you have mentioned are all synthetic materials and will all work when well handled. No one can tell you that one is superior to the other and surgeons will have their own opinions and preferences. All of these materials can be custom fabricated from the patient’s 3-D CT scan to create a near precision fit implant. The one material that has the longest history in cranial reconstruction is a modified form of PMMA known as HTR-PMI. This is a porous material of sintered HTR granules (PMMA-Poly-HEMA) that creates a solid material that is both porous and hydrophilic. These properties allow the material to become ingrown with blood vessels and connective tissue, which always bodes well long-term for any implanted material in the body. There have been over 10,000 cases of HTR-PMI cranial implants placed since 1990 with an impressive history of success and resistance to infection. (in non-irradiated wounds) This would be my choice if I had to have a cranial flap replacement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I know that there are silicone and Medpor facial implants for the tear trough areas. But I have also read about the use of Gore-tex material as well. I don’t know if there are specific tear trough implants for Gore-tex though. My question is how easy are they to remove if the need arises sometime later in the future? Is it like Medpor in that it can be difficult to remove later in life? Thank you
A: Gore-tex is one of the available facial implant materials although it does not have many preformed shapes available. There are no specific Gore-tex tear trough implants. It is a material that largely comes in sheets and blocks that can be cut and carved into almost any shape. It is also a softer and more spongy material. While these material properties are disadvantages for many typical facial implant locations, I do not consider it so for the tear trough area. In fact, it is my preferred material for this area and the orbital rim and floor…exactly because it can be custom carved and adapted along the infraorbital rim and is soft. It is a smooth slippery surface material so it must be screed into place to keep it from being displaced. Because it offers a smooth surface, it is also as easy to remove as silicone and quite unlike Medpor in that regard.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley My problem is that I look pregnant even though I am not. I was very athletic until I went through three pregnancies and never had time to get back to exercise between them. My underlying stomach muscles feel tight and I can suck in my stomach but there still remains a pouch. If I wear tight clothes it hides it but otherwise it just sticks right out. I’ve had a c-section but I do not want a tummy tuck because of the scar. Would liposuction help reduce the size of this pouch? Thank you in advance as I would value your opinion.
A: If any form of a tummy tuck is not acceptable, the question then becomes how much of a difference liposuction can make. No plastic surgeon can say for sure without at least seeing some pictures of you. But knowing that you have had three pregnancies spaced fairly close together suggests that the quality of your skin may not be good. (poor elasticity) This is relevant in that as the fat is removed what will happen to your abdominal skin. If your pouch is less but your skin sags and hangs worse, you may not consider that a good aesthetic trade-off. Liposuction is always an option as an alternative to a tummy tuck, the question is whether it is a good one. Not all fat reductions necessarily make the body part better looking even though it may be smaller.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr Eppley, I would like the fat tip of my nose made slimmer and the size of my nostrils reduced. While I like the shape of the upper part of my nose, the lower part is too big and disproportionate to how small the rest of my face is. Is this something that rhinoplasty can do, just change one part of the nose without affecting anything else? I do not want to change the shape or height of my bridge. I don’t know how difficult it is to just change the shape of the tip. I also fear that the tip could become too small and give me a reverse problem than what I have now. I do not want a petite nose with a pinched tip, just one still looks like me only in better balance. Thanks
A: Tip rhinoplasty is a very common nose procedure and only changes the shape and size of the lower third of the nose. Whether that will look more balanced without the need to alter any other part of the nose is best determined before surgery through computer imaging. You may very well be right but it can be surprising sometimes other areas look when one part of the nose is changed. Just be certain beforehand by some computer imaging work. It would be rare to take a big tip of the nose and make it too thin. (discounting Michael Jackson who had many nose procedures and is a result that should not be seen as the norm) Usually the question is whether as much tip refinement can be achieved as the patient hopes, particularly if the nasal skin is thick.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am 29 years old and have always had heavy legs. For whatever reason, I got stretchmarks on my inner thighs during my teen years and they have never gone away. I want to get liposuction and was wondering if my stretchmarks would affect the result in any way. Will it not look as good afterwards if the skin is stretched out to begin with. If so, is there an alternative to liposuction that would be better? Thanks!
A: You have brought up a very good question, particularly when one is contemplating liposuction of the inner thighs. The inner thighs is a common area for patient dissatisfaction after liposuction. This is because the skin of the inner thighs does not have as much elasticity as other body areas so it is prone to not adapt well (shrink down) after fat reduction. This can lead to an inner thigh with irregularities and more loose skin after liposuction. This is why liposuction of the inner thighs must always be done more conservatively than in many other body areas and patient should expect modest improvements only. This would be particularly true when it it recognized before surgery that the skin is of questionable elasticity. Having stretch marks put you into the questionable skin quality category. One must think carefully about liposuction in this area under these circumstances and, without examining you, I can not tell you whether you would be wise to have liposuction or not. There are some emerging non-surgical technologies that are good alternative choices. Radiofrequency devices, like Exilis, can be very beneficial for skin tightening and some fat reduction. Whether you should have this alone or done after your liposuction surgery is a good question that can only be answered by an examination.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, five years ago I got Medpor malar implants. I am very happy with my cheek implants that provide me with very high and prominent cheek bones – a look that I have always wanted. I also like the fact that they integrate with my own tissue. But recently I have read this on the internet:
“Explantation of nonsilicone facial implants that have integrated into the surrounding tissues can be very difficult to remove, and in some cases it can contribute to nerve injuries. Any implant, regardless of material, can produce nerve injuries if a portion of the implant is in direct contact with a main branch of the sensory nerve.”
I know that one wing of the malar implants is directly below the foramen infraorbitale, where the infraorbitalis nerve comes out of the bone. Now I am worried that I could get serious nerve damage if the implant should have to be removed for a medical indication in future. What is your experience with explantation of Medpor malar implants and the risk of permanent nerve damage? Does this nerve stick to the Medpor implants?
A: While your concerns are understandable, you are worrying about a problem that you do not have and are very unlikely to ever get. Unless you now have infraorbital nerve symptoms (pain and/or numbness), your implants are not impinging on the infraorbital nerves and are not even that close to them. Thus, if you ever should need the implants removed, they should be able to be explanted without nerve injury. While Medpor facial implants are frequently stated to be very difficult and destructive to remove, that has not been my experience.
Dr. Barry Eppley
Indianapolis, Indiana
Q:Hi Dr. Eppley. I will be 17 years old next summer. I’m looking to get some implants as I get a little older. Is there any way of creating a custom jaw/chin implant? If so, would this cost extra? If so, how much? Much appreciated. Also, what is the minimum age requirement if one wanted to get some facial implants? I’d like as much information as possible please. Much appreciated.
A: The timing of chin and jaw implants is based on two factors; the degree of jaw deficiency, one’s bite or occlusion and the near completion of jaw growth. At this age you want to be sure that you do not have a correctable malocclusion by a combined orthodontic and orthognathic surgery approach. If not, then chin and/or jaw angle implants may be appropriate. I certainly would not perform that surgery before the age 18 when jaw growth is closer to being complete in a male. Custom chin and jaw implants can be done and I do them on a regular basis. But whether they are really needed and offer any advantage over stock preformed implants must be determined on a regular basis. It is hard to give any reasonably accurate pricing when I don’t know whether one needs just a chin implant or whether one needs a combined chin and jaw angle implants for total jawline enhancement. In either case, custom implants will double the price of the surgery due to the need for special design and fabrication. For this reason, one has to have a very compelling anatomic need to justify the expense of a custom facial implant process.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have questions about using rib grafts for rhinoplasty. How would the surgeon even determine if the rib graft he is going to take would be straight ‘enough’ for it to be placed directly to augment the bridge? What if the carving of the graft isn’t successful? Would you diced it instead and continue the surgery when the patient requested not to have the diced method done? After reading what you have written, a diced cartilage method is obviously better than a ‘single rib’ method right? But one question is that why many patients and surgeons are choosing the ‘single rib’ method instead of the diced method? Can I also know how much does a rib graft rhinoplasty cost? Does it include tiplasty and alarplasty too? Thanks Dr!
A: The quality and straightness of the rib graft is determined by the skill and experience of the surgeon taking it. There are a lot of rib choices on the lower end of the costal margin from the free floating #9 to the fixed ribs #s 6, 7 and 8. Usually a straight piece can be obtained as the longest rib graft that is needed does not usually exceed 4 cms.
If the patient does not want a diced graft method and does not consent to that option, then only the single piece method would be used.
The question of whether a diced vs a solid rib graft is better is a controversial one and every surgeon will have their own opinion on that matter. The answer would also depend on what the nose anatomy is and what one is trying to achieve. It is never that one method is always better than the other, it must be taken on an individual case basis.
A rib graft rhinoplasty can or cannot include tip and other work depending upon what needs to be done. I would view it as a comprehensive rhinoplasty with one fixed cost, no matter what needs to be done.
As a ball park figure, all costs included, the cost is in the range of $8,500 to $9,500.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have some questions about skull reshaping. I have a decent head shape, it’s just that when I cut my hair really short or shave off all of my hair my head shape looks distorted. I’ve been realizing lately that the two sides of my head tend to be larger than the rest of my face and my skull is too large above my ears. It makes me have a very awkward face structure almost like a balloon and was wondering if you had any ways to reduce the size. It isn’t a big reducement, just maybe 1/4 of an inch to make it symmetrical. But would there be any scars left after surgery that would be permanent? Thank you.
A: In a normal shaped head, the sides in the front view stay well within a vertical line that extends upward from the helical attachment of the ears. Any bowing out from this line can make it look disproportionate. The temporo-occipital region of the skull (sides of the head) are composed of a thick layer of temporalis muscle as well as bone. It can be reduced about a 1/4 inch per side. Skull reduction in this area is a combination of muscle and bone reduction. It is done through a small vertical incision on each side so there would be a small residual fine line vertical scar on each side.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am Asian and am interested in getting my jaw angles reduced. They make my lower face look too wide. How risky is the surgical reduction? And how long is the down time? Is it possible for me to undergo the procedure during spring break (2-3 weeks)?
A: This is not a procedure that I would consider risky. It is a cosmetic procedure that is about reducing the width and shape of the jaw angle. That being said, it does require the masseter muscle to be lifted off of the bone to do the procedure so there will be some significant swelling afterwards. The procedure is done by either burring down the width of the jaw angle (outer table reduction) or actually removing the jaw angle by an osteotomy. It takes about 3 weeks for most of the swelling to go down after this kind of facial bone surgery and about another month or so to see the lower facial width reduction benefits of having the operation. I tell patients that it takes 3 months to see the final results after jaw angle reduction surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, A friend of mine just had her upper and lower eyelids done. She said that on her lower eyelid, besides removing fat and pinching some skin out, that she also had her cheek muscles repositioned. Is it true that cheek muscle can be lifted with a lower eyelid procedure? If so, what is the cosmetic benefit for doing so?
A: What you are referring to is known as lifting the sagging cheek at the same time as a lower blepharoplasty. Some call this a midface lift or malar resuspension. It is not a true muscle lifting procedure but rather that of sagging cheek fat and skin. As the midface ages, the cheek tissues will slide off the cheek bone particularly if the cheek bone is naturally flat or not that prominent. This creates malar pads that can be seen as an additional fold of tissue below the lower eyelids. This sagging cheek tissue can be lifted through a standard open lower eyelid incision for a full lower blepharoplasty. This is convenient since both the lower eyelid and cheek issue can be addressed through the same incision. The operation you describing that your friend had was a more limited blepharoplasty known as a pinch lower blepharoplasty. Through this limited approach it would not be possible to do a true midface lift or malar resuspension.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have had several children and am wanting to get my stomach back in shape. I am only 26 years old and I don’t want to live the rest of my life with this stomach. I am too young for that! My question is what will happen to my pubic area after a tummy tuck. I noticed that it got bigger after having children and I would like to see that area flatter as well. Will it be taken care of if I get a tummy tuck? Also I have love handles that I would like to get rid of as well. Will a tummy tuck get rid of those as well?
A: A tummy tuck will only solve the problems that lie within its zone of tissue excision. When looking at the markings of a tummy tuck, you will see that the love handles and the pubic area lies outside the excision zone. However, the addition of flank liposuction is a part of most tummy tucks with the recognition that the goal is an extended waistline reshaping that wraps around to the back. Pubic or mons reduction, if needed, can be incorporated as part of the tummy tuck procedure whether it is reduced with liposuction or it is lifted as part of the tummy tuck design. You can see in planning a tummy tuck that the entire area must be taken into consideration to get the best overall result.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had breast augmentation eight months ago. They were Mentor 375cc moderate profile silicone gel implants. My problem is that the implants are too widely spaced apart. My plastic surgeon told me he could fix them by removing the implants, putting in stitches into the sides of the pockets to move them closer together and then put the implants back in. I would like to have more cleavage but don’t know if this procedure is worth it. Should I have this done and how long does it take to heal?
A: While repositioning implants through suturing of the surrounding capsule (capsulorraphy) can be done to push implants in any direction, the question is how effective would it be. This is particularly relevant when trying to make implant move closer to the sternum. If these are submuscular implants, and I have to assume that they area, you must know the edges of the pectoralis muscle will block the implants from moving very close to the sternum. The reason in my opinion to undergo the procedure is to move implants inward that you feel are too far to the side…not because you think will get more cleavage. Laterally displaced implants can be reliably moved back onto a better position on the chest wall. Moving breast implants with the primary intent of creating more cleavage is less certain to be able to achieve that goal. Either way, recovering from an implant repositioning procedure is much less than the original breast augmentation surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dear Dr. Eppley, Do you mind sharing some advises of yours regarding to diced cartilage for nose jobs? What is the main difference between a piece of rib cartilage being place directly to augment the bridge and injecting fine diced rib cartilage into the bridge as well? Are the side effects of using this ‘diced cartilage’ technique be higher too? Lastly, are there any limitations pertaining to nasal bone narrowing procedures and tiplasty?
A: Rib grafting of the nose is most commonly done for significant dorsal augmentation. Rib grafts offer the most volume to do the procedure and can be done either as an en bloc or a diced technique. There are advantages and disadvantages to either approach. If one can get a nice straight piece of rib cartilage, in which carving and shaping it will not induce warping, then a single en bloc graft method should be done. The problem is that often a good perfectly straight rib graft can be hard to obtain or carving it straight may not make it stay that way. Also, the tunnel or tissue pathway into which the graft is placed must be very tight so the solid one-piece graft does not slip from a straight midline position When the rib graft is not straight and/or there are concerns about midline graft security/fixation, then a diced cartilage approach is the solution. While this takes intraoperative time to do, the risks of graft warping, graft malposition and a crooked nose are virtually eliminated. A diced cartilage approach can also be used when one has multiple small pieces of cartilage, none of which are long and straight enough for a good dorsal augmentation.
The vast majority of diced cartilages grafts in rhinoplasty are placed through an open approach. The cartilage is diced and placed in a fascia or surgical wrap and inserted like a one-piece rib graft. The injectable cartilage approach is only used for very small defects of the nasal dorsum.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am pursing getting a rhinoplasty to make my nose look better. In fiddling with my own version of computer imaging, I have made some changes to my nose that I would like to get done. Are these type of nose changes possible? If so, Acne X Factor what type of rhinoplasty do I need? I know there are two types of nosejobs, a tip rhinoplasty and a full rhinoplasty. Which do you think is best for me?
A: I would not as a patient get concerned about the different types of rhinoplasties. The differences between a tip and a full rhinoplasty is somewhat artificial. The basic difference that separates the two rhinoplasties is that a more complete technique involves osteotomies or the narrowing of the nasal bones due to hump reduction or bridge modification. A tip rhinoplasty by classic description does not go past the lower tip cartilages. Regardless, many rhinoplasties incorporate techniques that borrow from each basic type of rhinoplasty making the surgical changes that each patient’s nose needs unique. Your attempt at rhinoplasty imaging is pretty good and I think that it is a fairly achieveable outcome. Hump reduction and tip narrowing and elevation are fairly standard changes that can make many noses look better. Your lack of thick nasal skin makes it also realistic that the alterations to the underlying cartilage and bone will be seen on the outside when the swelling goes down. You may call the type of rhinoplasty that you need a more complete one.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a gullwing upper lip lift two years ago. I am very unhappy with the resulting scar. The surgeon who did the procedure said that the scar would end up invisible…it did not. The scar sits 2mm above my vermilion line and is very indented so even if I try to cover the scar with lip liner and concealer it still shows. The surgeon cut very deep and used only eight sutures on the whole of the top lip. Please give me your honest thoughts and whether it can be improved by scar revision. I have attached a picture of my upper lip so you can see how bad the scar is.
A: Thank you for sending your pictures. I think without a doubt that the scar and the upper lip shape can be improved. The indentation is so visible because the natural shape of the white roll (where the skin of the upper lip and the vermilion meet) is everted not inverted. While the eversion of the white roll is lost in every lip advancement, it should be flat and not inverted. I suspect that deeper sutures were not used in the closure so that inversion resulted. In addition, I see no definition of the cupid’s bow of the upper lip, which is one of the main benefits that a lip advancement can achieve. In looking at your before pictures, I think you had the wrong lip enhancement procedure from the beginning. You would have been better served with a subnasal or bullhorn lip lift not a vermilion or gullwing lip advancement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a belt lipectomy six months ago. The tummy tuck portion in the front did lift my pubic area a bit but it is still puffs out below the scar line compared to the tight abdomen above it. When I lay on my side, my abdomen is tight but the pubic area is puffy and sags like old wrinkled skin. While standing it just looks a bit puffy but no wrinkles. What pubic reduction method would work the best and can it be done under local anesthesia?
A: It is not uncommon that pubic or mons fullness becomes evident after a tummy tuck or curcumferential lower body lift. While this fullness was always there, it becomes apparent when the tightness of the scar above it is more narrow than the original projection of the pubic tissue. Every tummy tuck does create some degree of a pubic lift but it may not be enough to obscure the larger pubic mounds that exist in those that need a circumferential body lift. If this is diagnosed in advance, it can be incorporated into the frontal tummy tuck design or undergo liposuction for reduction. On a secondary basis, pubic reduction can be done liposuction alone or combined with a pubic lift skin excision pattern. Since it appears by your description that you need more than just liposuction, I would recommend a general anesthesia approach.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting an otoplasty but am concerned about how will the scars on the back of my ear look after surgery. I almost always wear my hair pulled behind my ears. I worry that my friends and others will be able to notice the scars from having my ears pinned back. How often do otoplasty scars need scar revision. Will laser resurfacing of the scars help if they look bad and how long after surgery can I have it done?
A: While I understand your concern about the scars on the back of the ears, it is not an issue that I have ever heard a patient who has had otoplasty have. Besides the fact that the scars on the back of ear heal really well, there are also essentially invisible because the ear is folded back obscuring the back of the ear skin completely. If you look at back of the head views of otoplasty patients, you will see that the outer helix of the ear hides most of the skin on the postauricular surface. I think your concern about poor or visible otoplasty scars should not be a significant one. Of all the otoplasties that I have ever performed, I have never done a scar revision on them.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I got jaw angle implant one year ago and want to get new ones. I have two problems with the ones I have. The first thing is that they did not give me the look that I wanted. They added very little width and did not make the jaw angle any more prominent. The second thing is that one of them has slipped and is starting to come through the incision as it is sore and I can see an edge of it inside my mouth. What do you recommend? I have a picture of me so you can see where I am now.
A: Based on this one picture, I believe your jaw angle goal can be achieved with an off-the-shelf implant as it appears that what you need is more width and jaw angle prominence. That can be done with either a silicone lateral augmentation style or a medpor inferolateral augmentation style (modified) based on your width desires. I know that you said you have jaw angle implants now but I don’t know how much they are adding to where you are at present. Besides one of them slipping (they should always be screwed in) they may not be big enough or placed low enough on the mandibular ramus to have the proper effect. This is both a sizing and placement issue. If you desire a much more prominent jaw angle, I would consider using a medpor RZ angle implant of the 11mm size. That will give you the most prominent jaw angle possible with a preformed jaw angle implant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a chin implant revision. I had a chin implant about six months ago and the doctor said it would look just like I wanted. Well it hasn’t and he appears to have chosen the wrong implant. What I wanted was a much wider and more square chin look and it doesn’t look that way at all. I have done some imaging on my picture to show you what chin look I am after. What is the best type of chin implant to achieve my desired look?
A: The imaged change that you desire in the width of your chin can not be made by almost any off-the-shelf preformed chin implant. Even square chin implants do not add that much width. If you look carefully, the widest part of the chin goes past a vertical line dropped down from the corners of the mouth. That is beyond the widths of most existing chin implants.
There is however a way to do it with one and only one preformed implant, the Medpor RZ extended square chin implant. It is possible to exceed its natural width because of its central connector. It is actually inserted in two separate pieces and then attached once in place. You can increase the width of the chin by a full centimeter by not snapping it together but by leaving the two pieces spaced apart and made ‘one-piece’ by only the thin bridge of the connector.
The other option is to make a one-piece design out of silicone that contains all the desired dimensions and is placed as a single piece implant. (aka custom chin implant)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a revision rhinoplasty about ten years ago. I had a Medpor nasal shell put in. It was a thicker shell which augmented my nose too much in width, but I’ve always liked the right side and the profile is good. However, the left side is too bulbous and makes my nose look too big. I have talked to two rhinoplasty surgeons who have given different opinions although both are very confident about working with Medpor. One suggests removing the shell and replacing it with a smaller implant or a rib graft. The other said to leave the implant in and just carve into it on the left side and make it smaller. What’s your opinion? What do you think will yield the best results, but also be the safest in preventing infection and is less intrusive?
A: The concept of narrowing your existing implant rather than replacing it with a new implant or a rib graft is a sound one to me. If you like most of what you have in place and just need a little tweaking of it, then you should just modify the existing implant. Doing so also has the advantage that it is really what I call an ‘autoimplant’ at this point. It is part implant and part autogenous since you have tissue ingrowth into it. I would also contend that using the existing implant has less of an infection risk than placing a new one, since the ability to get it inoculated with bacteria into its porous structure is less due to the existing tissue ingrowth.
Whether you carve it in place or take it out to reshape the existing implant is matter of nuances. Either way you have to do a complete dissection over the top and both sides of the implant. Even for in situ carving, you need the space to work. The only difference is that in removal you have to release it underneath from the cartilage-bony framework. Based on my experience, I could not tell you until I was in there which way I would do it. If I had good access with it in place, I would carve it down without removing it. If I could not get a space to work and was concerned about the overlying skin, then I would remove it, carve it down and re-insert. I don’t think any surgeon can tell you which exact method is best until they are in there. What matters is which way will give the best rhinoplasty revision result and not injure the overlying skin cover.
I have never found Medpor implants hard to remove. Surgeons say it is hard because they have never done it or are comparing it to silicone implants which slide out quite easily. Medpor implants require more care and finesse in their removal to not injure surrounding tissues but they can be removed even though they are more adherent to the tissues.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I need a sinus setback procedure. I think it is called the brow bone. but my brow bone is a bit asymmetric. Will a browlift be needed after this surgery? Is in the quoted price also the hospital care and everything? How many days should I stay in your town all together? Also is it possible to make some sort of insurance arrangement in case something goes wrong so that I am fully covered in this case? Finally have you not seen or have you also not heard of anybone resorption with this procedure? Long term consequences really scare the XXX out of me.
A: In answer to your questions:
1) Generally, a browlift is not needed after a brow bone reduction. It does not usually cause the brow bone to fall.
2) Any price estimates given to you is all-inclusive of the surgeon’s fee, OR and anesthesia costs. A formal price quote can be given based on reviewing pictures of the patient. Most patients return home 48 to 72 hours after the procedure.
3) I can not think of anything that could go wrong with this type of surgery that would require hospitalizations. But most insurances will cover medical problems, regardless of the origin of the problem.
4) I have not seen or heard of any bone resorption afterwards with this operation.When properly done with good surgical technique, brow bone reduction should not result in any long-term bone resorption problems.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dear Dr. Eppley, i have really hollowed temporal areas and I have heard that there are temporal implants which can correct this. So can an implant be placed under the skin of the temporal regions? Also, can the implant be misplaced or is it screwed in place to stay there? Thanks a lot doctor 🙂
A: There are very specific temporal implants for the correction of different degrees of hollowing. These temporal implants can be used in the various sizes or can be custom carved to fit any shape or size of the hollowing. They are placed through a small vertical hairline incision and their flexibility (silicone rubber) makes them capable of being inserted through a much smaller incision than one would think possible based on the size of the implant. They are not bone-based implants so they can not be screwed in to any of the surrounding bone. Rather, they are placed right underneath the temporalis fascia in a tight pocket so there is no chance that they can migrate or move from this position. It is a procedure that is associated with virtually no pain afterwards and very little swelling.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley I have a question. I did open rhinoplasty and now I’m 3 months post op. I have stopped taping my nose but now I feel like my tip is more bulbous than it used to be. When I was taping it was more rounded and big. Now it feels firm with slight pain if I try to move it. Is that swelling? Will this shape change with time? I’m so confuced and I don’t want to undergo a revision.
A: Your questions are the most common concerns that most patients have after rhinoplasty. While I obviously don’t know anything about before surgery nose or what exact rhinoplasty maneuver were done, I can make some general comments. If you have read my four phases of rhinoplasty recovery blog, you will see that you are currently entering phase 3. Tip swelling is very common in this phase and often the tip may even appear bigger than before. The fact that it is firm and slightly painful indicates that you still have significant tip swelling. What you can know for sure is that the tip is going to get smaller. How much smaller and whether it will end up better than before surgery remains to be seen. You will know that all the tip swelling is gone when it feels soft again and can be freely moved without discomfort. The consideration of a potential rhinoplasty revision is a long way off and you must wait a year after surgery to be certain you are really looking at the final result.
Dr. Barry Eppley
Indianapolis, Indiana
