Your Questions
Your Questions
Q: Dr. Eppley, I am interested in implants for a frontonasal augmentation effect. Would it be possible to place a nose bridge implant so that it extends onto the forehead and fans out, so that it kind of gives the effects of a forehead augmentation as well? I am look to create the look of deeper set eyes. Also, how much for each of those procedures? Thanks.
A: I suspect you are referring to augmentation of the glabellar region of the forehead just above the nose. While both areas can be augmented concurrently (frontonasal augmentation), they can not be done using a single implant or through the same incisional approach. While such an implant can be custom designed, one has to consider the logistics of it surgical placement. Such a frontonasal implant would be too big to pass it into the forehead through an open rhinoplasty approach. Conversely an adequate nasal pocket could not be made from any type of superior or scalp incisional approach unless it was an complete corral scalp incision. These are general statements and I would have to know more about the exact forehead and nasal areas you want to augment to determine their applicability to your aesthetic facial needs.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a custom forehead implant. My goal is to widen my forehead and make it look a bit more square. I also want some more central fullness. How do you decide to make these measurements on the implant in the design?
A: Of all custom facial implant designs, I find none ‘trickier’ or more difficult from an aesthetic standpoint than the male custom forehead implant. The design and having a satisfactory aesthetic result is much easier in females. What makes the male custom facial implant, and the male forehead implant, so aesthetically difficult is several factors. Anatomically, most men want a bit wider forehead and not a convex one like a female. This means that the anterior temporal line must be crossed in the implant design. If not, widening in this lateral forehead area may create an abnormal frontal bossing effect. The anterior temporal line is the bony boundary of the forehead. Crossing it to widen the forehead spills the implant over into the temporalis muscle/fascia area. While it is necessary to do this there is the judgment of where should the implant should end, how thick should it be, what shape in this transition should it have and there is a need to have a fine feather edge at the implant to soft tissue transition area to avoid a visible edge on the outside. These are all considerations in the implant design that women don’t have. Psychologically the risk of revisional surgery in all male custom facial implants is 25% to 33% and in the forehead this probably increases to 50% in my experience. This is always due to aesthetic issues of how the result finally looks no matter how much thought and effort was put into the initial custom implant design. It is also complicated in some male who have little patience for the time that it takes swelling to subside to see the actual final forehead shape.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in rhinoplasty surgery.There are two main things I would like to change about my nose, that you will see from these photos. I have a small bump on the bridge as my nose, but I also really want to change the tip of my nose. My nose isn’t too wide or anything, but the tip and the bump are my two biggest concerns. The tip is the part I am most worried about and have been hesitant about rhinoplasty in general for fear that it won’t look natural after surgery.
A: Here is some imaging for your rhinoplasty. Your rhinoplasty is not quite as simple as ‘just take away the bump and lift the tip’. One of the reasons you have a bump on the bridge of your nose is because you have a very low radix or frontonasal junction. (the area above your bridge) This is part of your overall more recessed mid facial development. The bump is actually a pseudohump. It appears to be a hump because the bone above it is deficient. Just taking down the bump will make your nose look too low in this area. While some hump reduction is needed, the area above the hump must be augmented with carriage grafts as well. (radix augmentation) Your nose is also long with a hanging columella. The end of the nasal septum must be shortened to allow for any tip rotation upward as well as retraction of the hanging columella. With the hump reduction the tip absolutely must be shortened and rotated upward otherwise your nose will look even longer.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’ve been looking up videos and articles about your most well known rib removal surgery patient just for entertainment. It must get frustrating having to deal with so much misunderstanding and arrogance among people who couldn’t perform such a difficult procedure, and knowing there’s many doctors who do it privately. I just wanted to thank you again for making my life a little easier by not having to worry about corset training. I know I’m still in the recovery stage but I’m usually in a recovery stage these past few years. I have a general question, how often do you do rib removals a year?
A: There is no question that there remains a lot of ‘mystery’ and misconceptions about rib removal surgery, particularly amongst surgeons who often view it as dangerous and ill advised. (of course they have never actually done the operation or ever taken even a single rib for any purpose) Having done it many times over the years I have a unique perspective on it and its outcome and value to patients. In each and every case I have done, patients have had satisfactory outcomes and no complications. That is all the vindication that I need that the surgery is both safe and effective in the properly selected patient.
What used to be a procedure that was done once or twice a year is becoming a procedure that I now do about once a month. As the public becomes more aware of it and the procedure comes out of ‘hiding’, more patients are interested in having it done.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in facial reshaping surgery.I just wanted to make an enquiry about possibly having some cosmetic surgery with you in the coming months. I’ve been to a few plastic surgeons here in my country but I am having difficulty finding the right surgeon to operate on me. Having looked through your website I was very impressed with the before and after pictures of his patients and am now considering flying to America to have the surgery.
I noticed he seems to offer a lot of different types of facial implants which I am most interested in. I’m just wondering is there a limit on the amount of procedures that can be carried out at one time? I would be looking to enhance and refine several features on my face and finding a surgeon that can perform a lot of the procedures I’m interested in in Europe is very difficult.
I was hoping that you review some photographs i’ve edited myself and let me know if he thinks the result I’m looking for is possible. My goal is to install more classical features onto my face and to create a more chiseled, symmetrical bone structure with the most natural result possible so as to avoid a ‘surgery look’.
A: Thank you for your inquiry. One can have done any number of facial procedures at one time, albeit bony change or soft tissue. Even with doing a large number of procedures simultaneously, the concern is not usually looking overdone but whether enough change has occurred to satisfy the patient’s aesthetic goals. The concern about being overdone is largely relegated to anti-aging facial surgery not the type of facial reshaping surgery that younger people undergo such as you are considering. In the spirit of expectations, let me go over your morphed facial images to review what is and is not possible. You have illustrated the following changes on your face:
1) Hairline Advancement – what you have shown is reasonable although be aware that the greatest forward movement in the hairline is in the center and not in the temporal areas. Once can expect about a 1cm forward movement in males which is about what you are showing.
2) Rhinoplasty – dropping the dorsal line and shortening and rotating the tip is an achievable goal as you have shown.
3) Submalar Hollowing – removing the buccal fat pads with perioral liposuction will help but it needs to be combined with a zygomatic arch augmentation to have an effect that goes further back on your face.
4) Upper Lip Advancement – this procedure can set the vermilion-cutaneous border where you want it so that outcome can be obtained.
5) Jawline – In trying to achieve a more defined jawline (stronger chin and prominent jaw angles) you are showing the type of change that is not possible. What you have done is to vertically shorten the entire jawline and create a degree of jawline sharpness that can not be done. You just can’t vertically shorten the middle portion of the jawline like you have shown. While the squareness and greater projection of the chin is possible and well as the vertical elongation of the jaw angles, the vertical height of the middle portion of the jawline can not be changed. Either a custom three piece jawline implant (chin and two jaw angles) or a custom one-piece jawline implant (with a thin connection between the chin and jaw angles) would create a much improved definition of the jawline albeit not as vertically short or quite as sharp as you have morphed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 21 year old girl, but I have a masculine forehead. I am interested in forehead augmentation and brow bone augmentation with bone cement. Could you tellI am a little girl, 5 feet tall, and I have a pretty small forehead. Also I was wondering, after the procedure will there be permanent metal or titanium in my forehead? Lastly, what is the general recovery time like? Thank you for your time!
A: Such forehead augmentation can be done using bone cement materials which are like putty and are shaped and allowed to harden during surgery. There are no metal materials that are used. The recovery from this type of surgery is largely just about the swelling that temporarily occurs around the eyes and forehead area. (the eyes do not swell shut) Most patients come in the day before the surgery, have surgery the next day and stay over night in a hotel the night and first day after. One can go home fairly quickly in a day our two after the surgery. It is not a procedure that is usually associated with much discomfort. In fact the forehead will be numb for awhile rather than painful.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Hello! I’m 46 but I feel like I look 76 years old. I don’t know if a filler or mini facelift would be the answer. I just want to smile without all the wrinkles. I have tried lasers, dermapen and ultherapy. I’ve tried fillers but am not happy with the results. Thank you for your time.
A: You certainly don’t look 76 but I can see your concerns. What you havhe done is prove that nothing short of a surgical procedure would be of benefit. Non-surgical treatments like injectable fillers, energy-devices for skin tightening many other options have their place in facial rejuvenation. But there does come a time when what they can do is beyond their capabilities. Your own experience with them has proven their limitations in anything but the most early signs of aging.
You have reached the point where, if you are going to do anything, it must be surgical which involves skin removal and tissue tightening. And you don’t really want to waste time and money on limited procedures such as many of the so called ‘mini facelifts’. They also have their role in facial rejuvenation but the results they provide will be ‘mini’ and short lived also. What you need is a lower facelift to completely tighten the neck and get rid of the jowls. Ideally this should be combined with laser resurfacing over all other facial areas that are not undermined from the facelift procedure. Anything less will end up with disappointing results.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m looking to get augmentation to the base of the nose (the area directly below the bridge/nostrils) to ‘rotate/push’ it forward as seen in the picture. (per maxillary augmentation) I’ve seen pictures of paranasal and peri-pyriform implants, but those involve augmentation of the sides of the nose, and that’s not something I do not want.
Can I check if my aesthetic goals are possible, and if so, what options are available for doing so? I understand that you do custom designed implants, but are there any off the shelf alternatives to those?
Additionally, could fillers be used in the interim to simulate what an implant would do? This is something I would like to consider to see if I would like the augmentation before proceeding with a more permanent implant.
Thank you!
A: First, what you are trying to augment is the nasolabial angle or the nasocolumellar-upper lip junction. This is more commonly referred to as the central premaxillary region or the anterior nasal spine specifically. This has been done fro decades using a wide range of materials from autogenous materials like cartilage and bone to allogeneic materials like irradiated cartilage to a wide range of synthetic msterials. (e.g., Gore-tex, mersilene mesh, silicone implants) They all can work in such a small area. There would certainly be no reason to make a custom implant for this small areas. Whatever the implant material would be it would be ‘custom made’ or hand fashioned at the time of surgery out of any of these materials.
You can certainly test the benefits of premaxillary augmentation by using any of the injectable fillers. They may not create exactly the effects of any implant material which would have more of a push on the overlying soft tissues than softer injectable filler materials.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a sliding genioplasty and jaw augmentation using hydroxyapatite several years ago. The jaw is asymmetric and bumpy, and the chin was moved up instead of just forward. I wanted to have the HA paste along the jaw re-contoured if possible, and the genioplasty revised to give me some more vertical height and more projection too if possible. I also have loose skin on my neck from the massive amount of swelling that I had after the procedure. If you could give me a breakdown of the procedures id be so grateful. (Jaw HA paste contouring/ revision Sliding genio / neck lift/tightening) thanks!
A: The angle of the bone cut on the sliding genioplasty obviously created a vertical shortening effect as the bone was brought forward. Moving the chin back down and out further can be done by a repeat of the sliding genioplasty. The HA granules appear to have been used to try and create a posterior jaw angle augmentation effect. HA onlay application to the bone very often creates an irregular surface contour as it heals and bone grows into it. The HA granules can not be removed per se but they can be contoured (burred) down to create a smoother contour. As for the neck, it is impossible for me to say what may be beneficial since I don’t know what your neck looks like. Real neck tightening comes only from a lower neck/jowl tuck-up. I would assume you are young so this procedure seems a bit aggressive for your age but the problem may warrant it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr, Eppley, I am interested in a cranioplasty procedure.I have a depression on both sides of my skull and the back goes in little also. I have thick hair which covers it up. but, it really bothers me. I’m not sure how my skull go the way it did. but I would like to know if its can be fixed and is it safe. I was also reading about Osteobond from another plastic surgeon. what do you know about that…. thanks.
A: There are two cranioplasty materials to fix skull depressions/contour issues, bone cements (like Osteobond) or a custom silicone skull implant. Having done hundreds of skull augmentations, I have largely moved away from bone cements for many aesthetic skull augmentations due to access and contour issues with them. To properly place bone cement materials, a long scalp incision is needed. This is the only way to place and properly smooth out the intraoperatively applied and shaped bone cements. Putting such bone cements in through small limited incisions is prone to a near 100% irregular contour occurrence. The large the skull augmentation the bigger this contour problem becomes. Custom made skull implants solve these problems by being perfectly smooth (because they are computer designed) and can be placed through smaller incisions than bone cements. While both cranioplasty materials can be successfully used for your described skull shape issues, it is important to understand how and why they are different.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, My daughter has Plagiocephaly that we were told would round out on its own and were refused helmet therapy. I saw your information about skull implants. I am very interested to know if this can be used on children, my daughter is 21 months. She has 10 mm asymmetry with flattening on her back right side and left forehead.
A: While skull implants can be made for plagiocephaly patients at any age, in young children with a lot of craniofacial growth yet to occur, augmentation of skull contour defects is best done by the application of intraoperatively shaped hydroxyapatite bone cements. These materials are more biocompatible with growing bone and will integrate into the bone as the process of appositional skull growth continues. I have seen case where bone has completely grown into and/or over such applied bone cements in children.
As a general rule I do not use synthetic preformed skull implants in patients who have not yet reached near complete craniofacial growth. While they are tremendously effective and make the surgery very predictable and allow for a quicker recovery, what happens to the bone around such an implant when applied at at early age is unknown.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in temporal reduction surgery. I have too much width of my head. So I wanna reduce width and do your surgery that removes temporal muscle and/or reduces the underlying skull bone .I think the back of my skull needs more volume as well but I want to take surgery that reduce skull width first. I am sure I need surgery seriously as soon as possible.I think I need upper side bone reduction and lower side bone or bite muscle reduction. I am 30year old male living in Japan. I also wonder whether Botox injections that reduce bite muscle is safe and effective or not. Thanks for taking your time to read this.
A: Posterior temporal reduction (mainly muscle with some bone) can be an effective head width reduction procedure. (it is also the only one that can be done) While Botox injections may have some mild effect on muscle reduction, the amount of Botox that would be needed would eventually be greater than the cost of the surgery, would need to be repeated and at best would only create about 1/3 to 1/2 the effect of surgical reduction. But Botox injections are certainly safe and effective, it is just a question of their cost over time in such large muscle masses.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in numerous facial reshaping procedures including cheek augmentation. I think my chin is too big, my cheeks are flat and my nose could have a better shape. I have attached some pictures for your review. What do you think about these three facial areas in me?
A: Thank you for sending your pictures. From a chin reduction standpoint, it appears you have too much horizontal projection. Your chin can be reshaped by a submental approach where it is horizontally reduced and the sides tapered in so it does not end up looking wider. The cheek look you seek is a classic ‘apple cheek’ look that many females want. You have a very visible submalar concavity, probably due to buccal fat atrophy/deficiency, which gives yours cheeks an hourglass appearance as opposed to a fuller more convex anterior shape. You need a combined malar-submalar shell type cheek implant for your cheek augmentation which places the implants anteriorly to help achieve that type of cheek augmentation look. As to your nose, I would need more information as to what changes you seek as I see no obvious or glaring nasal shape deficiencies.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr.. Eppley, Why are there so few surgeons who perform skull reshaping surgery? Is skull reshaping surgery safe like other types of cosmetic surgery? What makes it so different from other types of cosmetic surgery like a facelift or breast implants?
A: You have to have specialized training in craniofacial surgery, which is a subspecialty of plastic surgery. Then you have to know how to apply craniofacial surgery techniques to aesthetic skull shape concerns and to do in a manner that does not leave undesired effects like adverse scarring. Third, you have to have a worldwide internet presence to draw enough patients to gather the experience to get skilled and proficient at it. Lastly, you have to have an interest in aesthetic skull surgery to develop this very niche area of plastic surgery. When you add up these four factors that makes for a very limited number of plastic surgeons who would ever do it.
In fact, most plastic surgeons today are completely unaware that such aesthetic changes to the head shape are even possible. Most surgeons and patients alike equate skull reshaping surgery to taking the skull bones off, reshaping them and putting them back. That is what occurs in infant craniofacial surgery but not aesthetic skull reshaping surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I read your case studies on custom jawline implants and wonders if the same could be performed to avoid jaw realignment surgery? Because the studies featured all men wanting masculine jaws what about Asian women who desires a V-shaped jaw? I had a sliding genioplasty and braces five years ago but I still needs to protract my jaw forward.When I protract my jaw I’m satisfied with my looks but I have a cross bite. If I revert to the proper bite the braces gave me then I look almost jawless/chinless. All surgeons I approached told me I have to go back to braces for several years and redo the jaw alignment. I also have a cobblestone chin appearance which I suspect to be caused by the scar tissue from the sliding genioplasty.
A: While many custom jawline implants are doing in men, there are some women that get them. And they usually do get them to create more of a v-line jawline effect. Please send me some pictures of your jaw at rest and then the look you are trying to achieve with your jaw protracted. I have not doubt that a custom jawline implant can achieve that look from the voluntary jaw protrusion.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a custom jawline implant. I have had Radiesse injected in my jawline about six months ago. I am looking into getting a custom jaw implant as I feel the Radiesse has made my face too rounded looking. How long would I need to wait for the Radiesse to go away before getting the implants? I also have a chin implant already, would this present an issue with the jaw implants?
A: It would be best to have most of the Rardiesse dissipate before placing custom jaw angle implants. This would allow a better assessment of your aesthetic jawline needs. When you say a custom jawline implant, I am assuming that you mean a wrap around jawline implant from jaw angle to jaw angle that crosses and includes the chin. Having a chin implant in place is not a problem as the design of the implant will digitally remove the chin implant from the scan so the jawline implant can be designed. In surgery the chin implant is simply removed to make way for the new custom jawline implant.
In theory an injectable filler is a god trial for what a facial implant can do in some cases. But it does replicate the exact effects of what a more firm facial implant on the bone can achieve.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a lower buttock lift. I do not want a bigger buttocks or anything put in it, I just want the bottom of it to not sag. I don’t care if the buttocks is a little flatter I just don’t want it to hang down anymore. Since I have lost a lot of weight not only has my buttocks dropped but my outer thighs have dropped as well. My thighs are not heavy but they have some loose skin. When I pull them up they look just fine so I am wondering if some type of thigh lift could be done as well.
A: In regards to your buttocks and outer thighs, a partial solution exists. A lower buttock lift can tuck and tighten the lower buttocks through an elliptical excision along the infragluteal crease. It does flatten the lower buttocks a bit but this is not an issue for you as you have stated. The outer thighs is a more problematic area because any effective skin tightening/lift will create a visible scar that would only be an acceptable trade-off in the extreme weight loss patient who suffers a lot of thigh skin sagging. Whether such a scar would be acceptable to you remains to be determined.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m currently looking for a surgeon to do my transgender breast augmentation, I’ve done my research for a few years and now. Looking for a surgeon, a little about my profile: I’m a transgender girl with a small rib cage and an overall very small frame and build. I’ve been on hormones for about two years now and believe I’ve achieved all I can naturally. I definitely know that I want to do cohesive gel ( “gummy bear”) implants, if you offer them (I think I read that you do). And would love to hear back from you!
I also would like to ask about removing ribs 11 12 and maybe 10, I know you’ve recently removed them from two women before and I’ve read your feedback on RealSelf.com about the procedure. I’d love to hear back from you on what you recommend! Much appreciated!
A: All silicone breast implants today are of the highly cohesive gel variety known as the urban term, gummy bear breast implants. All three existing breast implant manufacturers use the same silicone gel today. What implant size, shape and profile remain to be determined. (volume in ccs, round versus tear drop shaped and medium vs. high profiles) Such selections are based on what your breast augmentation goals are.
The role of lower rib removal is for narrowing of the anatomic waist. This is for patients who are unable to achieve a more hourglass shape or any inward indentation at the level of the waistline at the umbilical level. This is often a particular body contouring issue in male to female transgender patients whose ribcages are phenotypcally wider with greater outward rib flare.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a breast augmentation revision. I currently have high profile 800cc silicone gel implants under the muscle. They are too big so I want smaller implants and a moderate profile. I have terrible scarring from an attempted perirareolar lift. My areolas are larger than my hands when I place them over it. I really want to resolve this issue after having this insecurity about my breasts for several years since the surgery.
A: Thank you for sending your pictures. I am assuming based on these pictures that these large implants and the periareolar lift were done in attempt to correct some breast sagging and thus avoid the scarring from either a vertical or full breast lifts. Given your present breast situation you have two breast augmentation revision options which would be highly influenced by how much implant size reduction you want. The options would be:
1) Downsize implants slightly (100 to 150cc) and do a large periareolar reduction. This will still leave your breasts with some sag and downward projection but would avoid any further extent of scarring.
2) Downsize your implant more significantly and do a vertical or a more complete vertical-horizontal type breast lift. This will create a more uplifted and smaller breast shape but with scars on the lower breast mound/ (but also with much smaller areolas as well)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m curious about surgery for orbital dystopia. I’m in a similar situation to the one described on one of your site’s articles. I have vertical dystopia that doesn’t cause issues with my vision, but makes me uncomfortable about my appearance. I was wondering if this has been done on other patients before, and what the success rate has been.
A: Thank you for sending your pictures. Your case of orbital dystopia is rather classic. The horizontal difference in the level of the pupils is between 3 to 5mms. While the level of the globe (eyeball) can be raised by orbital floor augmentation, it is important to appreciate that as the eye comes up, the attached position of the eyelids will change. This means that the lower eyelid will need to be resuspended through a lateral canthoplasty and the upper eyelid will need to be raised like a ptosis repair. Thus as the eye moves up it will get further ‘buried’ under the upper eyelid and the lower eyelid will be further ‘retracted’ downward. While the lower eyelid can be adjusted at the time of orbital floor/infraorbital rim augmentation. The upper eyelid ptosis repair, however, can not be done at the same time and its repair, if needed, must be done secondarily.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a reverse tummy tuck. All my loose skin is above my belly button. When I pull up on my upper abdominal skin it looks great. I have attached pictures for your review.
A: Thank you for your inquiry and sending your pictures. As reverse tummy tucks go, you are about as perfect a candidate for it as I have seen. They are for women that have either had liposuction, a tummy tuck or weight loss where the tissues below the belly button are taut. But the skin above the belly button is loose and has some overhang exists onto the umbilicus. By simply pulling up on the abdominal skin a good improvement is seen. By definition a reverse tummy tuck is a more simpler form of a tummy tuck, does not involve muscle plication and is a skin excision only procedure.
The key in a reverse tiummy tuck is the incision location. I have done it either keeping the incisions limited to the inframammary folds or crossing the lower end of the sternum. When it crosses the sternum it produces a better skin lift/tightening (due to the central pull) but does have visible scar location in the very center. When the ellipitical skin excisions are limited to the inframammary folds, the effect is not quite as good but still apparent. One has to decide whether more upper abdominal skin tightening is worth the scar trade-off. The upper abdominal tissues are plicated to the fascia over the ribs at the inframammary fold level.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a mild to moderate case of cvg (cutis verticis gyrata) that has started in the past 6 months. I have 4 very long vertical creases in my skin. Two are very long going from mid forehead to top of skull. What is strange is it doesn’t look or feel like I have extra skin on my head. They just look and feel like long large scars. In the morning apon waking they look like fresh deep scars. And at night they don’t look too bad at all. I saw your article where you discussed an alternative to normal scalp tightening surgery so I wanted to find out more about that.
A: When it comes to cutis verticis gyrata, no one knows why it occurs or how to effectively treat it. There is not standard proven therapy for it. Cutting them out has been the only treatment that has been proposed in the past and up to the present time. But the scar tradeoff does not seem worth it in most casesand its effectiveness is poor. I have proposed doing fat injections instead to treat what cutis vertices gyrate really is…linear strips of scarred scalp tissue. The goal is to introduce healthier cells, including stem cells, into the very fibrotic scalp tissue.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was wondering if you perform masseter muscle removal? And if it is a high risk surgery? Thank you!
A: The proper term for what you seek is…masseter muscle reduction. Complete removal of the masseter muscle is both impossible as well as would create severe masticatory and jaw movement dysfunction. Masseter muscle reduction can be done by either chemodenervation injections (Botox) or surgical electrocautery. Botox injections can be vert effective but usually have to be repeated for a sustained reductive effect. Electrocautery is a surgical procedure done from an incision inside the mouth. The muscle is raised up off the jawbone and the inner surface of the muscle is treated by electrocautery to create a muscle injury and subsequent atrophy for a more permanent effect. The use of electrocautery for masseter muscle reduction is relatively new but employs an old concept for tissue destruction by using electrical currents.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Would a zygomatic osteotomy work on an individual with cheek asymmetry due to hemifacial microsomia? I am considering orthognathic surgery to fix my jaw and masseter muscle. I am also considering a procedure to enhance my cheek symmetry. I have heard implants can be unnatural when placed unilaterally even when custom made. I thought a zygomatic wedge osteotomy may be better. Because the eye and cheek are interrelated it could make eye look smaller?
A: What is best for your cheek symmetry would really require evaluation by pictures of your face and review of a 3D CT scan. But as a general statement, a zygomatic expansion osteotomy (which is what you mean by ‘zygomatic wedge”) only affects one dimension and that is cheek width. It can not change any other cheek dimension. In my experience in the hemifacial microsomia patients, the dimensional changes need to the cheek area are more than just that of width. Plus the bony edges of a zygomatic osteotomy and the plates and screws to hold it would ultimately be able to be felt and many be able to even be seen through the skin. It is not true that a custom implant would look unnatural and, because it is custom made and fits the bone in a smooth transition manner, would probably look more natural than any osteotomy/bone grafting procedure.
Any cheek augmentation procedure, by definition, may make the eye look smaller no matter what technique is used. Although that degree of orbital change may be aesthetically negligible.
These are general statements which are made with no specific knowledge about your case.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a problem with my lower floating ribs. They touch my pelvis bone and cause a lot of pain and discomfort. Typically they render me inactive for weeks, sometimes months at a time. I’ve been to countless physiotherapy sessions, and I have looked and looked for a doctor who would consider rib removals.. I just discovered you on YouTube, and I am wondering if you would consider this for me. Thank you for your time.
A: Thank you for your inquiry. It is very rare that the lower floating ribs actually touch the iliac crest of the hip with certain body movement…but I have had previous patients tell me this before. And it can be anatomically explained as ribs #11 and 12 actually point downward as opposed to the ribs above it which point more to the side. Also they are partial ribs and not complete ones so they do have a blunt end to them. The good news is that rib removals of them should be a cure for this type of anatomic impingement problem.
Rib removals of ribs #11 and 12 are done through small incisions on the back that parallel the direction of the ribs.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m interested in a reverse tummy tuck, I’m at my goal weight and I’m 48 years old. I’ve had previous liposuction to tummy, buttocks, and thighs. I’m interested in just tightening the skin in my upper abs. I do not want any liposuction as this has already caused uneven skin and a permanent wrinkle in my tummy. I don’t need my muscles to be tightened as they are already pretty tight. I just want to tighten the skin. When I pull the skin up under my breasts, it does miracles. I am not looking for perfection. Even if it protrudes a bit, I’m fine with it. I just want to fix the uneven skin and the permanent wrinkle that is there.
Can this be done with local anesthesia and twilight or IV sedation? I have a real hard time with general anesthesia. Also, where do you tether the incision? The rib or the muscle? To keep the scar from stretching or moving downward? Does the scar have to go across the breast bone? Can it be just under the breasts? I do have large breasts so they may hide the incisions which would be a bonus. Again, I am not looking for total flatness. Just get rid of the bumps or unevenness.
I’m also interested in skin removal from my buttocks and outer thighs. I don’t want a Brazilian butt lift. I don’t care if my butt is flat. I have lost weight in my lifetime and gained and lost again. This has left me with saggy skin and some dimples, maybe due to liposuction as well. I don’t want liposuction in this area. If you think it has to be done then that’s fine. I just want some even skin with no dimples. Can you suggest something for this area that I have not been able to find? The only thing I can think of that would help is a skin removal/tightening. If it can help my outer thighs then great. Please see my photos. I would also like this to be done without general anesthesia. Is this possible? Can this be done the same time as the reverse tummy tuck.
A: Thank you for your inquiry and sending your pictures. As reverse tummy tucks go, you are about as perfect a candidate for it as I have seen. They are for women that have either had liposuction, a tummy tuck or weight loss where the tissues below the belly button are taut. But the skin above the belly button is loose and has some overhang exists onto the umbilicus. By simply pulling up on the abdominal skin a good improvement is seen. By definition a reverse tummy tuck is a more simpler form of a tummy tuck, does not involve muscle plication and is a skin excision only procedure.
The key in a reverse tiummy tuck is the incision location. I have done it either keeping the incisions limited to the inframammary folds or crossing the lower end of the sternum. When it crosses the sternum it produces a better skin lift/tightening (due to the central pull) but does have visible scar location in the very center. When the ellipitical skin excisions are limited to the inframammary folds, the effect is not quite as good but still apparent. One has to decide whether more upper abdominal skin tightening is worth the scar trade-off. The upper abdominal tissues are plicated to the fascia over the ribs at the inframammary fold level.
In regards to your buttocks and outer thighs, a partial solution exists. A lower buttock lift can tuck and tighten the lower buttocks through an elliptical excision along the infragluteal crease. It does flatten the lower buttocks a bit but this is not an issue for you as you have stated. The outer thighs is a more problematic area because any effective skin tightening/lift will create a visible scar that would only be an acceptable trade-off in the extreme weight loss patient.
As uncommon as reverse tummy tucks and lower buttock lifts are, they are not in my practice. I have performed them many times although their frequency is in the range of 3 to 4 per year for reverse tummy tucks and 10 to 12 times per year for lower buttock lifts. Both can be performed under IV sedation although, because of the prone position and airway security, the lower buttock lift should be done under local anesthesia if one is not having general anesthesia.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am looking for a doctor that has done brow bone augmentation. I came across Dr. Eppley and am considering both rhinoplasty and brow bone augmentation to improve my profile view. I want my forehead to come out further, as of right now my eyes are flush with my forehead and it’s very flat. I want more dimension in my face. I wanted to know what you would recommend and how confident yo are with Asian rhinoplasty. Thanks!
A: Thank you for your inquiry and sending your pictures. I have done many Asian forehead and brow augmentation and rhinoplasty procedures. The key question for both procedures are the materials to do them. In the forehead you have the option of either bone cement application through a near complete coronal incision or a custom forehead/brow bone implant placed through a smaller scalp incision. For the rhinoplasty, one of its key elements is the augmentation of the nasal bridge. This can be done using either a cartilage rib graft or a silicone nasal implant.
The use of these various materials for both forehead and brow bone augmentation and rhinoplasty affects numerous aspects of the procedures including cost and recovery. I would need further input from you on these choices.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am inquiring about a genioplasty revision.I originally had double jaw surgery and a genioplasty performed. The results of the jaw surgery were great and the genioplasty was not bad either however there was some asymmetry and the chin projected just a tad more then I preferred, so I had a revision on the chin to move it back very slightly, a total of 1.5mm back from the original 4mm that it was moved forward as well as correct the asymmetry.
The results of the revision were not satisfactory, I developed chin ptosis and loose skin. 8 months later I decided to have another revision surgery to move the chin forward by 1mm, nearly back to it’s original position of 4mm and the mentalis muscle resuspended. After recovering from this surgery I have realized that the chin was not moved forward enough to support the mentalis muscle and the loose skin. There has been some improvement, I have a slightly droopy smile and I still have loose skin. I believe that the surgeon used a different type of plate and therefore the measurements were not as accurate as expected.
My question to you is, what are my best options to correct this, I am okay with having a bigger chin at this point, so I am considering having a 4th genioplasty and utilizing my CBCT scans, images, etc to have it moved to exactly into the same position that it was in after the first surgery, but do you think that undergoing a 4th genioplasty would be okay to do? Also, if the chin is moved to the same position that it was prior to any revision and the mentalis muscle is suspended correctly, what do you think my chances are of achieving similar results of what I had prior to the revisions?
I understand that some of these questions can’t be truly answered with out a full examination but if you can answer them based on experience that would be helpful,
A: The short answer to your question is that approach would be the only viable option. Bony support has to be re-estabished to the soft tissue chin pad. Whether returning to its original advanced position is enough is unknown but it can only help. There certainly is no harm in doing a 4th genioplasty as the vascular quality of the tissues would not be impaired and the amount of scar tissue at this point is irrelevant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am considering a series of separate body feminizing procedures (transgender body contouring) in this sequence:
1. Butt Implants with body lipo/fat grafting to complete hip/butt shape.
2. Then take 3-6mo to regrow some fat for Breast Implants with body lipo/fat grafting for cleavage and more natural finished shape.
3. Ribs removal. Front and back. Im not sure of the exact rib #s, but Im referring to both protruding ribs in front, and lower floating ribs. Would you kindly advise what exactly is possible, safe, and effective?
4. Tummy tuck with plication and for “internal corset” effect.
My thinking is that doing rib removal as a separate procedure before tummy tuck, allows for removal of more ribs than if removing ribs at the same time as tummy tuck, and will create more potential for the tummy tuck to draw in/around the trunk, for an overall slimmer torso and waist.
Would you kindly let me know your thoughts?
Thank-you Dr!:)
A: Thanks for detailing your transgender body contouring sequence, I would make the following comments to them .
1) Buttock implants with overlay fat grafting is a good approach to these needs. Fat grafting can only be done if the buttock implants are placed in an intramuscular position and not in a subfascial location. This would really be based on implant size. Any buttock implant bigger than 330cc would have to be placed in a subfascial location. In thus case, fat grafting is done first followed by implants secondarily.
2) I doubt once you harvest fat the first time there would be enough for the second time. The concept of growing fat is not usually a good idea for fat grafting since any weight loss will simply make what has been transferred to go away. It is important to remember that grafted fat acts like where it comes from, it retains its donor sit characteristics. It would make the most sense to rely on implants to do the complete breast augmentation/reshaping.
3) For waistline narrowing, ribs #10, 11 and 12 are commonly removed with small incisions from the back. For anterior protruding ribs (ribs 8,and 9) that is done through either a low subcostal incision or through tummy tuck incision.
4) If one is having a tummy tuck then that would be the ideal time to remove the subcostal ribs #8 and 9.
With this information, I would make the following recommendations based on how to best put the body contouring program together in two stages.
#1 Rib removal #10, 11 and 12, intramuscular buttock implants (300cc) and waistline/abdominal liposuction with fat grafting to the hips and around the buttock implants.
#2 Six months later….breast augmentation with implants, tummy tuck with rib removals 8 and 9.
This, in my opinion, would be the best way to put in all together and is actually how it is commonly done.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have what to me is extreme facial asymmetry, and have wondered all of my life if anyone could correct my face. I destroy all pictures of myself I am so ashamed of what I look like. Is there anything you can do for me? If I take a reverse picture using a mirror, I look pretty normal ( pictures attached). Is there a way I can look like that without using a mirror to reverse my image? Thank you very much.
A: Thank you for your inquiry and sending your pictures for assessment of your facial asymmetry. In critically looking at your pictures, I see four very specific difference between the two sides of your face. They include the following and are based the way I am seeing the picture (which may well be reversed in real life based on how the picture was taken)
1) Cupid’s bow asymmetry of the upper lip. The right of the cupid’s bow is lower than the left. (correction – cupid’s bow vermilion advancement)
2 Nostril asymmetry. The left nasal base is wider and more elevated than that of the right side. (correction – left alar base lowering and inward relocation)
3) Left eye asymmetry. You have a significant left lower eyelid ectropion/sagging) This is probably the one facial feature that is the oat obvious. (correction – lateral canthoplasty and lower eyelid repositioning)
4) Left eyebrow asymmetry. The left eyebrow is lower than the right. (correction – left endoscopic browlift)
When these four facial asymmetries are out together it can create a rather significant facial asymmetry.
Dr. Barry Eppley
Indianapolis, Indiana