Your Questions
Your Questions
Q: Dr. Eppley, I have terrible sagging elbows. It is not really the upepr arms like many people but just down and around the elbows. I have lost a fair amount of weight but the extra skin seems to have settled largely in the lower part of my arms. I am very interested in correcting this problem as when I lean on them they are painful and red. Is there a surgery for saggy elbows?
A: It is very common with a lot of weight loss for women to develop the saggy upper arms in the triceps area. (aka batwing) If extensive enough, the extra skin may extend the whole down across the elbow into the forearms. This is treated by an extended armlift.
But extra skin that is largely just around the elbows, and not involving the upper arm as well, is not common. Bur whether it is common or not, it can be treated by skin excision making it an elbow lift. Just like the armlift this does result in a longitudinal scar that crosses the elbow joint. The key to this elbow lift is to not put the scar on the back of the arm. This would make the scar come directly across the prominent angle of the elbow on bending one’s arm. That would likely cause healing problems in the short-term and scar pain in the long-term. The scar needs to be placed on the inner aspect of the elbow to both avoid the flexion of the elbow joint and to be least visible to others.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dear Dr. Eppley, what are the different techniques used in brow bone augmentation? What are the pre-operative and postoperative things to consider? Thank you so much.
A: When it comes to brow bone augmentation, the first consideration is what part of the brow does one want augmented? Most patients want the whole brow done and it must be approached through a scalpor coronal incision. There are some patients who just want the tail of the brow augmented and that can then be done through an upper eyelid incision. The next consideration is what material to use. There are four options including preformed implants and three mixtures which are applied and then harden which include acrylic (PMMA), hydroxyapatite (HA) and Kryptonite. (calcium carbonate) Because of moldability to the brow bones and that more volume can be obtained, I prefer the mixture materials. There are arguments to be made for any of them and they all will work. Considerations must be given to cost, long-term tissue acceptance and fracture resistance. From a cost standpoint, acrylic is best and is the most fracture resistant but there may be some tissue thinning over many decades of implantation. (emphasis on the word…maybe) HA and Kryptonite are very similar to bone so there will never be any problems with tissue acceptance but they are more easily fractured (theoretical concern, not one I have ever seen) and cost more. The choice of any of these materials for brow bone augmentation must be done on an individual patient basis.
Dr. Barry Eppley
Indianapolis Indiana
Q: Dear Dr. Eppley, I was looking at your web page description of ear lobe surgery and it made me feel hopeful. I recieved an infection/cut in my ear several years ago. Despite minor irritation, I continued to wear light earrings but the ear plug kept lowering and lowering until today. Today my earlobe has split entirely. I would like to have further information on whether and how this can be fixed. What should I do with in the interim to heap it heal?
A: Once the tissue begins to thin in the outer earlobhe skin from a piercing or a larger insert, eventually the skin will break down and a complete earlobe tear will occur. This is not uncommon and it is an easy problem to fix. It is a simple earlobe reconstruction done in the office under local anesthesia. The earlobe can be completely restored to normal size and shape, albeit with a fine line scar. The cost for this procedure is about $425. Once can re-pierce their ear 6 weeks after the procedure. (but gauging can never be done again)
In the interim you may apply antibiotic ointment until the skin edges heal in a few weeks. You may tape it together for appearance reasons during the daytime although this is not essential. Taping it together will help it heal a little faster.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am in need of getting jaw surgery and was told that I could get my nose and cheeks done at the same time. They want to do an open rhinoplasty and malar osteotomies as well to get an improved look to my face. My question is can these be done safely all during the same surgery?
A: There are several fundamental issues with this combined surgical plan. The first would be what type of orthognathic surgery? If it is just an isolated lower jaw (mandible osteotomy) procedure, then I see no problem with a combined rhinoplasty as one does not really affect the other. (other than the need to change position of the endotracheal tube for anesthesia) If it is an orthognathic surgery procedure that involves the maxilla (alone or in conjunction with the lower jaw), then more thought need to be put into it. The advisability of those two would depend on what type of nasal deformity one has and what needs to be done to the nose. A maxillary osteotomy changes the skeletal foundation on which the nose sits and detaches the facial muscles which affects the alar base or nostril width. This can make it hard to know with any certainty how the nose will change with rhinoplastic maneuvers. A rhinoplasty procedure, on its own, is fraught with certain variables that can adversely affect the outcome even in the most experienced hands. Adding the underlying changes of maxillary position only adds another variable that may affect the final shape of the nose after its manipulation.
Most of the time, the concept of combining rhinoplasty and orthognathic surgery is an issue of ‘surgical opportunity’. You just want to be sure that the benefit of the opportunity does not over ride the more important objective of a desired result with the least risk of complications.
Lastly, I am unclear as to the need for malar osteotomies vs implants for cheek augmentation. Malar osteotomies tend to be more difficult bony movements that often do not produce as good as a cheek result as the more simple placement of implants. I have put in many a cheek implant with a LeFort 1 osteotomy and have never seen an infection.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hello! I had gastric bypass surgery in August 2008. Since that procedure, I have lost over 135 pounds. Here is the my problem. I have worked much of my life trying to gain control of my weight and now that I have done that I have excess and sagging skin that is a constant reminder of the overweight, unhealthy person I used to be. Furthermore, I am at a dead end financially as I had to pay out of pocket the expenses for by bypass surgery which was almost $50K. I am exhausted financially between the surgery and my four kids. Are you aware of any programs, grants or clinics that are available to assist bariatric patients with the skin removal they need after their weight loss?
A: Congratulations on your weight loss success. That is a big accomplishment. While such extreme amount of weight loss is a big first step, most patients with this much weight loss will have large amounts of deflated skin that just hangs. This is managed by a range of procedures known as bariatric plastic surgery. With the exception of an abdominal panniculectomy, these procedures are cosmetic from a financial perspective. I know of no doctors or clinics that perform these extensive procedures at low to no cost. They require a large amount of surgical effort and operating room expense which is why there are no limited cost facilities or programs that perform them.
I wish you continued success in maintaining your current weight and one day being able to complete phase 2 of your body metamorphosis.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hello, I am a 27 year-old athletic male who is bothered both my puffy nipples. Some days they don’t seem that bad. But other days they really stick out. I don’t know why they are so different on different days. I am not sure whether I need my nipple cut down or the tissue under the nipple removed. Whatever it takes to do it I don’t care as I just want it gone. What do you recommend and what is the surgery like and how quick will I recover?
A: Puffy nipples are different than pointy nipples as patients often describe these two male chest problems. A pointy nipple is when the centrally located nipple within the areola sticks out like a small sharp point. It is small protrusion and is managed by a simple nipple reduction which is an office procedure done under local anesthesia. There is no real recovery as small dissolveable sutures at placed and one goes about their activities as normal immediately afterward. A puffy nipple refers to the development of a small mass of breast tissue underneath the nipple-areolar complex that makes it stick out or be puffy. This is known as areolar gynecomastia and is a limited gynecomastic reduction. It is treated by an outpatient procedure in which the enlarged breast tissue is removed from under the nipple by a small lower areolar incision. Patients wear a chest wrap for a week or so and show refrain from exercise or strenuous exercise for a few weeks to avoid a fluid collection or excessive scar tissue formation which will wipe out the benefits of having the puffy breast tissue removed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I need to have my chin brought forward as it is very weak. I know that the bone hs to be moved given how short it is. I want to have this surgery but I have a lot of questions. I am hoping you can answer them for me. Will I need to put braces or get some teeth removed to do this? How long will I have to stay in the hospital and how long will it take me to recover completely? In case I meet with an accident in the future and hit the chin, what would be the consequences? In case I meet with an accident in just a few weeks/months after the surgery and hit the chin, what would be the consequences? What are the risks of this surgery? In case the results are not what I desire, what kind of measures do you use to fix it? Any long term side effects? How painful will it be, and for how long can the pain last. Are there any breathing problems? How different is this from a complete jaw surgery? Are there any visible scars after the surgery? If yes, where exactly on the face? Thank you in advance for taking your time to answer my many questions.
A: If one is having the whole jaw advanced, braces are needed. I have not seen your bite nor do I know if you have any interest in changing it. If so, then presurgical orthodontics are needed. However, I am assuming that this is a chin osteotomy advancement and not the whole jaw so the answer would be that no braces are needed. All the remaining answers are based on a chin osteotomy procedure. This is an outpatient procedure and is done in a surgery center not a hospital. The chin bone will heal normally and will be no different than your normal chin bone is now once full healed. The chin would not move after the surgery since plates and screws are holding it together as it heals. The biggest risk of surgery is some temporary numbness of the lip and chin. If the look is not adequate or the chin not advanced far enough, the bone can always be readjusted or an implant placed to augment it further. I have never seen this so it is unlikely. There is no risk of breathing problems from chin surgery. Most patients report that the chin area is sore and mildly uncomforatble but not severe pain. In a chin osteotomy, only the deficient chin bone is moved and does not involve movement of the rest of the jaw and the teeth. Everything is done inside the mouth. There are no external scars.
Dr. Barry Eppley
Indianapolis Indiana
Q: I have a weak jawline and would like to do something about it. I have previously had a chin implant but it did not appear to have made much of a difference. The implant didn’t address my weak jawline. I would like to find out more about the wrap around jaw implant. How many days do I have to wait between 3D CT scan and the actual surgery? I have attached a side view picture of myswlf for you to see what I mean.
A: Thank you for sending your picture. Based on this one view, I am seeing the need for chin augmentation and possible jaw angle imlants. But it is not clear to me why a custom-made implant would be necessary. Such wrap around implants are most beneficial when the entire jawline needs to be augmented from one angle to the other It is especially useful when the entire jawline is vertically deficient for which there is no off-the-shelf implants available. Horizontal or minor vertical jaw angle deficiences can be managed by non-custom made implants. I would be curious to know why has interested you in the custom wrap-around jaw implant. Perhaps it is because you have had no success with a chin implant already. But that may be because the size and style of implant chosen was too small. I would need to know what type and size of chin implant was used to determine whether to go with a stock or custom implant for better correction.
To answer your other question, the usual turn around time from the patient getting a 3-D CT scan and then the jawline implant being ready for surgery is about 6 weeks.
Dr. Barry Eppley
Indianapolis Indiana
Q: Dr. Eppley, several weeks ago I had surgery to repair a cheekbone fracture. However, I am not satisfied with the results. The cheek bone fracture was repaired through an incision in my temple hair. I was told by the surgeon the fracture couldn’t be accurately aligned and fixed together without significant scarring so this was the best way to do it. Is this possible for you to do? Is it too late? I have attached a picture of how I look now so you can see that my cheek is flat but the side of my face is wider than before.
A: Your history and picture are very helpful in understanding what type of zygomatic fracture that you have.It appears you have a classic ZMC fracture with inward rotation of the cheekbone complex into the maxillary sinus. This is the classic direction that it rotates when displaced, down and in. That explains the orbital rim-zygomatic flattening with the lateral facial widening (bowing out of the zygomatic arch) that you have.
I wonder why a Gilles approach as used for your repair that as that would never work. The Gilles approach is for an isolated zygoimatic ARCH fracture not a body fracture. Your cheekbone fracture repair could be fixed by either an intraoral incision alone or combined with a lower eyelid approach. The bones could be realigned and then secured by plate and screw fixation. That would not result in any significant scarring. That is the classic and best approach with hat appears to be your zygomatic fracture.
Dr. Barry Eppley
Indianapolis Indiana
Q: Dr. Eppley, I am curious about nipple reduction. I am an athlete with only about 10-12% body fat but I have nipples that stick out. I have always been self-conscious about the kind of shirts I wear or even taking my shirt off. I would like more information on what is best for my situation.
A: When one is concerned about nipples that stick out, it is very important to differentiate between true nipple protrusion and areolar gynecomastia. Both can cause protrusion from the nipple area but they appear quite differently on close inspection anad are treated with different techniques.
The commonly called nipple is really better understood as the nipple-areolar complex. There is a central protruding nipple surrounded by a flat pigmented areola. In men, the nipples are smaller because the size (diameter) of the areola is very small. In nipple protrusion or hypertrophy, the small central nipple sticks out while the surrounding areola is flat. This makes for a small point that sticks out in shirts. It is treated by a simple nipple reduction done under local anesthesia in the office. Most of the nipple is removed so it lays flat and will never protrude again. In areolar gynecomastia, there is a mass of breast tissue that pushes out the whole nipple-areolar complex. This is better called a ‘puffy nipple’. It is treated by removing this mass of breast tissue through a small areolar incision. This is done as an outpatient procedure under IV sedation or general anesthesia.
Dr. Barry Eppley
Indianapolis Indiana
Q: Hello, I’m writing because I am in need of a tummy tuck. I have had four c-sections and I would like to know if I will be able to get a tummy tuck. I have a very large stomach pouch that I dislike and would like for it to be removed before I get too old. If not, it will be sitting in my lap. Will having these c-section scars interfere with having a tummy tuck? Can the entire stomach pouch be removed or can only some of it come off? Thanks for answering my questions!
A: The large stomach pouch to which you refer is a pannus, otherwise known as an apron of skin. (and fat) Between multiple children, c-sections and weight gain, the excessive abdominal skin and fat falls over the waistline. The scarred and indented c-section location accentuates this pannus by pulling in tightly underneath it. The solution to this pannus problem is a modification of a traditional tummy tuck known as an abdominal panniculectomy. It differs from the tummy tuck because the amount of tissue that is removed is larger. This makes for a longer low horizontal incision, often extending into the back area. The final result is often not as refined as that of a tummy tuck given the type of body on which it is performed. In its simplest form, an abdominal panniculectomy is an amputation of the pannus from along the waistline.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have previously had a tummy tuck and liposuction of my waistline and thighs last year. That went well and the results are really good. My remaining body issue is my lower legs. They are still so thick and they have no shape. I guess they are called ‘cankles’. I am embarrassed by them so I always wear pants. I wold love to be able to wear shorts and even a low hanging skirt. I have read that liposuction can be done for the lower legs. Do you think it will make enough of a difference? Will I be as satisfied with it as my tummy tuck and other liposuction?
A: Calf and ankle liposuction can be very gratifying and make a big difference in the shape (not the size) of the lower leg between the knees and the ankles. By selecting removing small fatty areas and making curves in the favorable silhouette areas of the inner knee, upper and lower calfs and ankles, the shape of the lower legs from the front can be made more pleasing. This is done with small cannulas and is really a form of liposculpture rather than volume reduction liposuction. The biggest issue with lower leg liposuction (cankle liposuction) is that there will be prolonged swelling in the lower leg. The changes may not even be apparent in the first few weeks after surgery adn your lower legs may even look fatter initially. It will take several months to really appreciate the final result. It always appears but it does take time. In my experience, patients have been happy with the results even though they do not end up with skinny legs, just more shapely thicker ones.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am interested in getting a complete mandibular implant and would like to know an approximate cost.
A: When people use the term, complete mandibular implant, their objective is to enhance along their jawline from the angles to the chin. To achieve that look, there are two different approaches. These different methods affect how the procedure is done and the cost. The first approach, and the most common, is to use three separate implants. This includes off-the-shelf chin and jaw angle implants placed through a submental and intraoral incisions. That total cost averages around $8500 to $9500. The other approach is a custom one-piece implant that is made off of a 3-D CT scan taken from the patient. It may or may not be put in as a one-piece implant but it is completely customized to the patient’s jaw anatomy and aesthetic desires. That total cost is in the range of about $15,000.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am interested in getting cheek implants as I think they would help my facial appearance. But I don’t really know if that is true. If it is, what type of cheek implant would be best? I know there are different types, like malar, submalar and shell styles, so which would be best for me? I have attached some pictures of my face for your opinion. Thanks and looking forward to your recommendations.
A: When looking at cheek augmentation, you must first determine whether and where any cheek bone (zygomatic or malar) deficiency exists. This requires looking for obvious bony deficiences of the midface, the relationship of the eye to the brow and cheek bones and the thickness of the overlying soft tissues. This must all be taken in context of the overall facial shape as well.
In looking at your face, you have a longer face that is fairly skeletonized. Your eyes do not have a lot of fat around them which makes them more deep-set. This is magnified by prominent brow bones and heavy eyebrow hair density. Your malar area shows good width but there is anterior malar and infraorbital rim deficiency. This is why your cheeks appear flat to you in a side or three-quarter view. When considering cheek implants, therefore, it is important that you avoid submalar and any malar implant that adds much zygomatic arch width. Augmenting these areas are not helpful to your face. Malar implants that add some anterior fullness along the suborbital groove and front end of the cheek is where your augmentation needs to be. This cold be done with either a modified malar shell implant or an extended tear trough style. Either way the volume should not be much greater than about 5mms. Too big of a cheek implant size will make the eyes even more deep-set or hollow in appearance.
Dr. Barry Eppley
Indianapolis Indiana
Q: Dr. Eppley, I had a rhinoplasty done three years of which I am very unhappy from the results. I am of Middle eastern ethnicity and initially had a big hump on my nose that I wanted to get rid of. I just wanted my nose to look more proportionate and not be so big. Right after ther surgery it did look better but as the swelling went down after a few months it didn’t look as good. While the hump is gone, my nose is now twisted and somewhat deformed. My breathing got worse after surgery too. It seem like it is getting worse with each passing year, is that possible? i have attached some pictures so you can see what I mean. I know I need a redo rhinoplasty but what do you recommend to make it better?
A: Your nose has some of the classic problems from an over-resected or radical reductive rhinoplasty. I suspect this was done through a closed technique and you may have initially had a large dorsal hump. Your nose shows middle vault collapse, indentations at the osseo-cartilaginous junctions, a pollybeak tip deformity and alar rim retraction. The upper nose deformity can happen when a large dorsal hump is taken down and the resultant open roof is closed with osteotomies that get infractured too far. This causes disruption of the upper lateral cartilages from the nasal bones creating an ‘hourglass’ deformity where the hump used to be. The middle vault constriction (pinched middle third of the nose) is the result of too much of the height of the upper lateral cartilages being removed causing collapse and possible breathing difficulties from pinching of the internal nasal valves. The tip deformity is marked by a hump in the supratip area and alar rim retraction with excessive nostril show. This occurs when too much cartilage is taken away and the tip is no longer supported. It then collapses and retracts so that the upper end of caudal end of the septum (septal angle) is now more prominent than the tip.
Your revisional rhinoplasty would be done through an open technique using spreader grafts for the middle vault, rasping of the dorsum, lowering of the lower end of the septal height, and columellar and alar rim grafts to the tip. In essence, cartilage support need to be put back into your nose to improve its appearance as well as your breathing.
Dr. Barry Eppley
Indianapolis Indiana
If you ever consider having plastic surgery, qualifying the doctor is an important first step. Are they the right doctor for you and what you need? Many magazine articles and other sources will give you a list of good questions to ask when you have an in-office consultation such as (1) are they board-certified, (2) how many years have them been in practice, and (3) how many procedures of your interest have they done?
While these are certainly good questions and the answers are extremely relevant, such questions today can be answered long before you ever pull into the parking lot of the doctor’s office. If you walk in with these types of questions for your consultation, you must not have a computer in your house or have never done a Google search. It is hard to imagine that such a person exists today, except maybe my 95 year-old grandmother.
While these were once good questions for prospective patients to ask during an office visit, they have gone the way of the bag phone. Such answers are relatively easy to find at the click of a mouse from home. Whether we as plastic surgeon’s like it or not, our websites and the information that they provide is a lot more relevant to patients than any number of diplomas hanging on the wall. If a plastic surgeon doesn’t have an up-to-date website that easily provides this basic information, patients will quickly move on to another surgeon that does. Today’s internet-based society makes it essential that these once basic qualifying questions are easily answered with minimal research effort.
With today’s electronic informational access, photo and video acquisition, and numerous locations for postings, contemporary plastic surgery qualifiers are different and more meaningful. Today, the more relevant checklist in finding the right plastic surgeon for your needs is procedure education, photographic examples and patient testimonials.
Traditional office print pieces, such as brochures and flyers, are historic methods of education in every plastic surgery practice. While they are still useful, so many are tempate-derived that they provide generic and virtually useless information…other than to say this service is provided. You want to know what this specific plastic surgeon does, not what most plastic surgeons do. This has spilled over now into websites as well. They all look pretty but what about their content? Is it meaningly and relevant to your needs? Look for brochure and website information that provides current and updated procedure information. This also suggests an interest in ongoing patient education which is most manifest in some type of website blog.
We have image overload everyday. Whether it is on Facebook or on your cell phone, we are surrounded by pictures. Plastic surgeons are without question the most advanced and proficient of all medical specialities in taking pictures. Therefore, patients should expect a good demonstration of a plastic surgeon’s most valued asset, their before and after patient photographs. While it is true that the best results will be posted, at the least you need to see a handful of actual patient before and after photographs. The more, the better.
Patient testimonials carry a lot of weight. Who doesn’t want to hear about a happy patient when you are considering going to that plastic surgery practice. But don’t just rely on what is posted, ask to talk to at least one patient who has had your similar procedure. But a patient who had surgery a long time ago is not as useful as one who has had surgery in the past weeks to months. Fresh experiences are what you need as these patients have the best recall of what it was like right after surgery.. Having a recent patient also suggests that the procedure is performed more than just a few times a year.
Dr. Barry Eppley
Indianapolis, Indiana
Liposuction is a very popular body contouring surgery largely because it works. It is an immediate method to remove certain areas of unwanted fat that you just haven’t been able to budge by your best efforts. With this fat removal method, may people expect to lose weight as well. It is no wonder many people think this when you see such advertisements such as ‘Lose 10 lbs In A Few Hours’ or ‘Get The Body You Always Wanted’. I have seen many such liposuction promotions in magazines and on the internet and it begs the question of aggressive advertising vs . medical fact.
Can you lose weight by liposuction? The simple answer is yes…in the short term. When advertisements promote how much weight is removed with liposuction, they are referring to what is suctioned out at the time of surgery. This is known as the fat aspirate and and is collected in a canister. It can be both measured in cubic centimeters or millimeters (always is) and weighed. (sometimes is) The weight of the aspirate can be closely approximated by its measured volume. Since a gallon of water weights 8 lbs and a gallon contains 2.2 liters (2200cc), then a liter (1000cc) of fat will approximately weigh 3 1/2lbs. Therefore if you have had liposuction surgery and had 2000ccs removed, for example, then you would have had a surgical weight loss of about 7lbs.
While this seems impressive, and one did have this 7lb weight loss in a hour or two, it is actually a bit misleading. The reason is that prior to the actual liposuction being done, a large amount of fluid is first put into the fat known as tumescent fluid. This is essential to liposuction to not only lessen the pain after surgery but, of equal importance, to reduce any bleeding that the procedure will cause. This fluid has both volume and weight and the actual fat aspirate will contain up to 1/3 of this by content. So the actual amount of fat removed and weight that has come off has to be toned down a bit. When you see large weight loss claims from liposuction, it is because large amounts of tumescent fluid have been initially placed….and then removed as well.
While liposuction may cause some weight loss immediately (surgical weight loss), a more significant drop may actually occur afterwards. In the healing phase for several weeks after surgery, most people are not motivated to eat normally. When combined with the increased caloric demands of healing, a metabolic weight loss often happens. This will usually equal the surgical weight loss by four to six weeks after surgery. So if 5lbs of fat aspirate has been removed during surgery, one can usually expect to be down 10lbs in another month or so. Whether one sustain this weight loss over time is affected by many factors, not the least of which is one’s lifestyle habits.
While liposuction and weight loss will be forever linked, one should view the association as incidental and a side benefit. Weight loss is not the reason to have liposuction…spot body contouring is. Some weight loss will happen for almost all patients. The amount varies on one’s body and how much fat was removed. Some view liposuction as a jump start method for their weight loss approach and, in the short term, that is what will happen.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was involved in a car accident in 2009 and sustained what is called a subcondylar jaw fracture. I was told by the doctors that it was not bad enough to fix so they let it heal without surgery. After a few months when I could open my jaw better, I noticed an obvious difference between the two sides of my jaw. My left jaw angle appears to have disappeared. It now makes my face appear crooked. I was wondering if some type of implant may help cover up this lost part of my jaw. What do you suggest?
A: When the neck of the jaw is broken, the thin connecting bone between the condylar head and the big ramus of the back part of the jaw, the vertical length or height of the jaw can shorten. A subcondylar fracture, if unrepaired, can make for a shorter posterior jaw height and apparent ‘loss’ of the distinctive jaw angle. This is because the jaw angle moves upward as the jaw height shortens. Provided that you have good jaw function and the only issue is a cosmetic one of the jaw angle, that could be camouflaged and made more symmetric by a jaw angle implant. It would be important that the right jaw angle implant be used. It needs to be one that doesn’t just widen the jaw angle (lateral augmentation) but rather provides a lengthening to the jaw angle. (inferolateral augmentation). These type of jaw angle implant can provide up to a centimeter of vertical length increase.
Dr. Barry Eppley
Indianapolis Indiana
Q: Hello Dr. Eppley, I am an Asian male and want to know if alar plasty can reduce the size my nostrils and reshape my nose? It kind of looks like Eddie Murphy as it is really flared. I want my nose to look like Justin Biebers nose , straight and pointed and not very flared. Can rhinoplasty make this happen?
A: When I hear these type of goals from a rhinoplasty, it brings me to a discussion of expectations and reality of what can be achieved from surgery. The simple answer to the question of whether you can have a nose like Justin Biebers is no. That is not surgically possible. Justin Biebers is Caucasian, you are Asian. The underlying anatomy of the nose stucture is different and, of equal importance, the overlying skin thickness and texture is not the same. This makes it impossible to achieve what is essentially transracial changes. Even if you were Caucasian, you still could not have his nose. Rhinoplasty can not make you look like someone else or give you someone else’s nose. Pictures of famous or other people faces are helpful, as they help to convey what one’s nose shape goals are, but they can not be surgically duplicated. One of the most challenging aspects of rhinoplasty surgery is to meet a patient’s expectations. When patients bring out celebrity or model photos to say what they want, it is always is a concern that their expectations may not be able to be realized.
Dr. Barry Eppley
Indianapolis Indiana
Q: I have a steep angle from the back of my jaw straight to the chin. It looks very odd to me although no one else seems to notice strangely enough. I know it is not very common in women but I think a jaw angle implant would work well to make this look better and give my face more balance in profile.
I also have issues with a very bad rhinoplasty as you will see in the attached pictures. If you could simulate a nice straight nose with a nice narrow tip and not so ‘turned up’ I would very much appreciate it Out of interest, is it possible to make the sides of the nostils narrower to give the appearance of a narrow nose or is that not really worth it?
Attached are a couple of pictures they are not great but I don’ t have any digital pics. Thanks for giving me an opinion.
A: As you surmised, on reviewing your pictures, you do have a high jaw angle and a steep mandibular plane. I have done some imaging which demonstrates the effect of a vertical lengthening jaw angle implant.
From a rhinoplasty standpoint, your nose shows a bulbous tip, a pinched middle vault and a still wide nasal bone area. The side view shows too much upturning of the nose and some nostril rim retraction. I have done some imaging with a rhinoplasty that includes nasal bone narrowing, middle vault spreader grafts, tip narrowing, tip derotation, alar rim grafting and nostril narrowing. This will give you a more balanced and narrow-appearing nose.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I would like to get a tummy tuck, but I scar really bad. Will the scar be just a bad as and noticeable? All the scars I have are big and bold and dark. I am Puerto Rican.
A: The issue of scar appearance after surgery due to hyperpigmentation (darkening of the scar) is always a potential issue in patients who have intermediate pigmentation. This captures those ethnic groups of Hispanic, Asian, and Middle Eastern descent. African-American patients, even though they have more pigment ironically do not pose the same level of scar hyperpigmentation risk. Not knowing what your other scars look like makes it impossible to compare how a tummy tuck scar may turn out to them. Scars can look ‘bad’ for numerous reasons such as how they were caused and whether they were surgically managed. At least in tummy tuck surgery, the scar that is created is caused by a gentle cutting and closure technique which is the ultimate form of controlled trauma. I had done many Hispanic tummy tucks and have not seen what I would consider a really bad scar. Nor have I heard of patient complaints about the scar. It may re slightly more noticeable than the tummy tuck scar in a Caucasian patient but I would not classify them as ‘bad’.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am interested in RZ Mandibular Angle Implants for cosmetic purposes – the smallest size. Approximately how much do they cost? Also, could Dr. Eppley do a consult via photographs or Skype?
A: The smallest size of the RZ Mandibular Angle implants adds 3mms in width (this can be shaved down even further during surgery) and about 10mms in vertical length. That is a good implant if one is interested in both vertical lengthening and an increase in jaw angle width. If not then one needs to go with a lateral augmentation jaw angle implant only. These are the two basic styles of this type of facial implant. Regardless of the jaw angle implant type, the general cost quote for all expenses is around $6500. I regularly perform Skype or phone consults and that can be arranged anytime. Please send some pictures for my assessment in advance of either a phone or Skype plastic surgery consult. Dr. Barry Eppley Indianapolis, Indiana
Q: Hi there. I tried to send a photo over for the 3d imaging but it didnt send unfortunately – said I hadn’t filled in all fields but they were all complete.Was after some advice really. I have had maxillofacial surgery because I had an under developed bottom jaw. This included a genioplasty too. However, since having the genioplasty my chin looks really long to me when I smile, especially from the side. My jaw bone is only a cm under my ear. Would jaw implants in this area improve the look of the length of chin do you think and widen the lower face a little?
A: When an osteoplastic or sliding genioplasty is done, the vertical dimension of the chin almost always increases. That is because as the chin is brought forward there is a natural tendency to open the ‘wedge’ of the osteotomy or it may be deliberately done to actually lengthen the chin as well. That is part of the presurgical planning. If a genioplasty is done with a mandibular advancement osteotomy (jaw brought forward) that may leave the posterior height and width of the mandible deficient. This would be evident by a steep mandibular plane angle between the bottom of the jaw angles and the bottom of the chin. In these cases, I have done jaw angle implants whose primary goal is to increase the vertical dimension of the jaw angles more so than adding width. Much jaw angle width is rarely needed in most females.
Dr. Barry Eppley
Indianapolis Indiana
Q: I have a keloid on both sides of my right earlobe and it was at the back before I’ve tried operation back in 2008. Last year I went back to the hospital and they told me they would have to cut my whole earlobe off and that’s when I asked them to discharge me. I now want to know if it could be fixed?
A: Keloids of the earlobe are common problems for certain ethnic groups as a reaction or problem from ear ring wear. I have seen it in both men and women and they come in all sizes. They usually do involve both sides of the earlobe eventually since they are the result of a piercing. When ear keloids become very large, it does appear that the earlobe would need to be completely amputated to get rid of it. In actuality this is not true. A keloid acts very much like a gauged earlobe. There is a central keloid expansion, as opposed to a metal gauge, and the earlobe around it expands and thins. This means there is always earlobe tissue to use that can reconstruct a new earlobe. It may be smaller than one’s original earlobe but an earlobe can always be made. The best approach is a modified wedge excision, tapering the outer aspect of the wedge down to preserve as much earlobe tissue as possible. This usually leaves more than enought tissue for earlobe reconstruction. It is also important to not leave behind any keloid tissue in the resection and to do some type recurrence prevention therapy with the surgery, whether it be serial steroid injections or immediate low dose radiation.
Dr. Barry Eppley
Indianapolis Indiana
Q: I have a quick question…I got liposuction last year and I recently had to have it touched up in March. I noticed these “indentions” on the side of my back so I googled to see if it is normal and I ran across your post on Explore Plastic Surgery. I was just wondering if you could tell me if my back looks normal or if it is something that I should be concerned about? I never noticed this before I had the surgery and it is driving me crazy now because I am not sure if it looks right. I really appreciate your time. Thank you!
A: What you have is linear indentations from the liposuction cannulas. That has created a groove or inward depression in this portion of your back. This is due to the amount of fat that has been removed in that one area compared to the surrounding back areas. This gives your upper back that V-shape look. It is not an issue of medical concern only one of aesthetic judgment. Whether this tapered look is considered aesthetically pleasing or not is a personal one. Some would consider that this aggressive liposuction has created an improved back contour. Others may feel that these indentations have created an undesired back contour.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am interested in getting bigger fuller breasts with cleavage. I have attached a front picture of my breasts for you to see what shape they are in. Do you think this is possible to achieve?
A: Thank you for sending your picture. There is no question that your breasts can be made bigger by implants. But certain features of your breasts and chest may temper some of your desired breast goals. In looking at your breasts, they have obvious deflated volume and a sagging condition known as pseudoptosis. This means that the skin on the underside of your breasts hangs over your lower breast crease but your nipple remains at or slightly above the breast fold. This condition creates a problem in using implants alone to get bigger breasts. Some form of a breast lift is needed so that you do not end up afterwards with breast tissue and a nipple that hangs off of the edge of the implant. Whether a nipple lift (superior crescent mastopexy) or a periareolar (donut) lift would be best can not be predicted based on the one picture that you have sent. The other issue is that you have very widely spaced breasts with a large gap between them. Breast implants can not be placed so that they will create cleavage on their own. You will always have a gap between any type of breast augmentation/lift and this can not be prevented. Bras make cleavage in augmented breast cases like yours.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had silicone chin, cheek and jaw implants placed.Within a month, the jaw implants and the chin implant had shifted. The right jaw angle implant actually shifted through the incision into my mouth.The doctor repositioned both implants in a revision surgery. I asked him about fixating the implants with screws, but he insisted that a stay suture would hold them. Despite the stay suture, this time the left implant shifted — through the incision and into my mouth. The right implant seemed to be fine. In a third surgery, the doctor repositioned the left implant, with a stay suture again. Lo and behold, I discovered this afternoon that the right jaw angle implant has again shifted through the incision. A tiny sliver of it is poking through sutures which I thought would have dissolved by now, but which have not. I would like to have both implants repositioned and fixed with a screw. Can you do this type of revision?
A: Thank you for sharing your story. I am very familiar with why you have had recurring problems and it is not a mystery as you undoubtably know. Smooth silicone jaw angle implants are easy to put in which is why many surgeons use them. But unless they are positioned properly down at the inferior border of the mandible and secured there by a screw, there is always the risk of extrusion. While many such placed silicone jaw angle implants do not migrate and extrude, it is not rare when it happens. I have seen numerous patients just in the past few years who have had an identical problem. I experienced it myself when I placed my first set of silicone jaw angle implants over ten years ago…and vowed never to go through the endless revisions again which always ended up with recurrent extrusion. There is nothing wrong with silicone jaw angle implants, and placing a screw in them is not easy, but the avoidance of an extrusion risk is well worth it.
Given that you may not have the opportunity to revise your jaw angle implants for months, I would strongly advise getting them out so the open wounds can heal. These openings cause the posterior mandibular vestibule to deepen and make less tissue available for a competent closure over any new implants that are placed which increases the infection risk in replacement surgery. This also allows the incision edges to heal and hold sutures better down the road.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am interested in getting chin and jaw angle implants. I would like the chin implant to be lengthened (to the most extent) and squared (to the most extent) being in the category of the latest style available on the market. The jawline height should be lengthened and widened to its proportionate maximum possibly by having a “wrap around” implant and/or separated combination of implants. Do the latest style chin implants stating the above written factors of width and length fit the “wrap around” implant or separate implants more accordantly? Thank You.
A: In answer to your questions about chin and jaw angle implants, here is the following dimensions:
Square Chin implant (Style 2 Terino), Implantech = 6.5mm anterior projection in the middle, 10mm projection on the square portion (transition corner) of the implant, 9cms long (4.5 cms back from the middle on each side)
or
RZ Extended Square Chin, Medpor = 7mm in anterior projection, 11mm projection on the square portion of the implant. Because of the central connector, the implant can be expanded and made more square which also allows for the creation of central cleft
RZ Mandibular Angle Implants, Medpor = 11mm width expansion, 10 mm vertical elongation
These three implants must be put together to create a ‘wraparound effect’ but there will be a depression between the two along the jawline because their edges are feathered where they come together. They were never made to be used to create a completely smooth wrap around jawline effect. What you may really be searching for is a custom one piece wrap-around jawline implant that can be made to almost any shape and dimension.
Dr. Barry Eppley
Indianapolis Indiana
Q: Dear Dr. Eppley, I wanted to send you my pictures to review. I had a childhood scar which I had revised in 1995 and the result was this elongated revision which I have not been too happy with. It has been about 16 years since then and I was hoping to find out if can have anything done to make it less visible. I am currently 30 years old and of Asian decent. If you have few minutes, I would appreciate your input on a few of the questions as it will help me be more knowledgeable.
1. I realize that the scar revision is replacing one scar with a less visible one. Would you consider the revision for this vertical midline scar to be GBLC, serial W-plasty or a simple vertical excision?
2. I know there may be a bandage or silicone gel sheet after the procedure. Any idea of how long I need to wear one and the down time in general?
3. Following the revision, would there be any additional resurfacing required? If so, would you recommend dermabrasion? And any idea of total number of follow-ups required?
A: Thank you for sending your pictures and reviwing your scar history. Your forehead is a relatively flat wide scar that runs vertically right down the middle of your forehead. In answer to your questions:
- As this scar runs completely perpendicular to the relaxed skin tension lines of the forehead, which run horizontal, any successful scar revision should nto be a straight line. Some form of irregular pattern needs to be used. Given that the scar is absolutely vertical, I would use a running or serial w-plasty type of scar revision.
- I would apply just some glued brown tapes for a week after the procedure over the sutures. Thereafter, one would apply a light antibiotic ointmnent for an additional week and then change to a topical scar gel. Scarguard is my preference.
- I suspect that some light laser resurfacing may be beneficial done once about 6 to 8 weeks after the procedure. That would depend on how the scar appears. Definitely not dermabrasion as that is too deep. With your Asian skin I would be very conservative with any type of scar treatments that use heat due to the risk of pigmentation changes.
Dr. Barry Eppley
Indianapolis Indiana
Q: Hi Dr. Eppley, I don’t like the look of my mouth. Can you help me to look like every other normal people and to make my mouth so that it isn;t so big. Because now I look like a monkey. I really don’t like my look and nobody else likes it either. Please send me a picture if you can do something about me. Big thanks!
A: Thank you for sending your pictures and stating your concerns. What you are referring to is known as macrostomia. This is where the horizontal length of the mouth, from one corner to the other, is too long or wide. Technically, the upper and lower lips are too long but it is where they join (called the commissures) where the mouth width is judged. By standard anthropometric measurements (created largely from Caucasian study populations), the width of the mouth should not exceed a vertical line drawn down from the pupil of the eyes. While this is a measurement it has to be taken in perspective of the patients overall facial aesthetics to determine if it is really abnormal or bothersome. It can seen in your one frontal photograph that your mouth corners extend beyond this area.
An excessively wide mouth can be horizontally shortened through a procedure known as a commissuroplasty or corner of mouth tuck. While this is more commonly used in the treatment of the reverse mouth problem, microstomia (too small a mouth), it can be used to make a wide mouth more narrow. While this could easily reduce your mouth width by 5 or 6mms a side (reducing total mouth width by a cm.), there is a trade-off of a fine line scar that goes a short distance in the skin outward from the corner of the mouth. One has to consider this scar trade-off carefully.
Dr. Barry Eppley
Indianapolis Indiana
