Your Questions
Your Questions
Q: Dr. Eppley, I am jnterested in rib removal surgery.I will like to slim my waist. I’m a bikini fitness competitor and my waist is very width. Off season (photo) I have 70 cm, in season I have 67 cm. I don’t know is there is another procedure that can help me slim my waist. I have been researching about ribs removal and I want to know how much time I could not exercise. And the most important question is how much could I slim my waist?
A: Given your picture I would agree that I don’t see anything else you could do on your own to narrow your waist any further. I suspect rib removal surgery could probably achieve a waistline reduction down to 62 to 64 cm in circumference . Time off from exercise would be totally dependent on how you feel but would most definitely be two to three weeks. There are no restrictions after surgery. You let your body tell you when to do any physical activities.
Rib removal surgery does leave a fine line scar as a residue from the procedure. So one has to be certain that aesthetic trade-off is a worthwhile one for the amount of waistline reduction seen.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in transgender buttock implants. I’m looking for assistance in achieving an hourglass figure, fat transfer and/or liposuction are not an option as I have always had minimal body fat. I know that some surgeons do not like to operate on transgender women. I am transgender, and have lived “full time” for more than 15 years. In this time I have worn padding to give the effect that i am looking for. The result is that I hate my naked, boyish hips and behind. I would like someday to be able to not have to wear padding and just have the body I have always desired. It doesn’t have to be perfect. I’m not expecting rainbows and unicorns, but I don’t think I am asking for the moon, either. Can you help me? thank you
A: With a thin straight body you are correct in that only implants can potentially make positive buttock and hip changes. Usually both buttock and hip implants are needed as buttock implants don’t extend to the hips and vice versa. I would be interested to see what amount of padding you use to create the optimal augmentation effects. Knowing what type of buttock enlargement change you are looking for will determine whether your buttock implants should be in the intramuscular or the subfascial location.
Most transgender buttock implants are often done in the intramuscular location since the amount of buttock enlargement desired is usually not extremely large.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 55 year old female who was on the oral bisphosphonate, Actonel, for about 5 years. I last took this medication about 5 years ago. I had a CTX test done in October (level was 215), because I was contemplating jaw surgery to correct a midline issue. Neither local oral surgeons who I consulted with felt comfortable doing the surgery for cosmetic purposes. I have since gotten into braces to correct the issue. My concern with genioplasty is whether the same risk level is present for osteonecrosis as exists with jaw surgery. Any thoughts would be appreciated.
A: Since the chin is part of the jaw, the same potential risks exists for it as any other part of the jaw for bisphosphonate patients in regards to developing jaw osteoradionecrosis from a surgical insult. Poor bone healing has been reported for genioplasty on bisphosphonate patients
However, the CTX (serum C-terminal telopeptide) blood test is used as a predictor of that risk which assesses how well the bone can remodel and heal. The risk stratification is seen as high risk at less than 100, moderate risk between 100 to 150 and minimal risk above 150. It is also known that the longer one is off the drug the CTX values will increase at a rate 1/month. This explains your favorable CTX value five or more years off the drug.
While no one can say that your jaw osteoradionecrosis risk is zero, it would be considered minimal at this point.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in cheek implant replacements. I had cheek implants placed two years ago. As a result, my cheeks are uneven and prominent in the wrong place. I want high cheekbones and also the uneveness of the current submalars makes one cheek look higher and more prominent and throws my jawline off making it look wider on one side. I want to correct this and obtain higher cheekbones instead of the cartoon character look. That’s why I want to swap them out for other cheek implants, either malars only or combo implants. Can you look at my pictures and give your recommendation?
A: Thank you for sending your pictures and questions about cheek implant replacements. It is very clear that the large submalar cheek implants is really not the right cheek implant style for you. It creates too much fullneess below the cheek bone which does not work well in your face. I would recommend the following:
1) Remove existing submalar cheek implants.
2) Your new cheek implant style would be any form of a combo or one that has no submalar component at all.
3) You need ‘high’ malar augmentation style implants that also go back further onto the zygomatic arch. No such standard malar cheek implants exists, even amongst the standard malar options. Ideally a custom cheek implant style is made that would fit your face precisely and create the augmentation exactly where it is needed. Because your current implants have created loose cheek tissues, the new cheek implants really need to help lift up this tissue.
4) If I was ‘forced’ to use a standard cheek implant I would use the malar shell style and modify it during surgery.
5) I would consider doing subtotal buccal lipectomies and perioral mound liposuction to contour in the area below the new higher malar augmentation to maximize the effect.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 28 female with bad dark circles. I would like to have hyaluraunic acid injectable filler to improve the look of my under eyes. I have attached some pictures without makeup for your consideration. I have never had any procedure performed before. Am I a good candidate for the under eye filler? Also, could you please let me know the cost of the procedure. Many thanks.
A: Thank you for your inquiry. A hyaluronic-based injectable filler is a good place to start for your dark circles under eye issues even though it is not the best treatment for it. It is important that you understand that any filling of the under eye hollows is not going to solve your hyperpigmentation problem. It will improve the hollows but that alone will not make the dark color go away. Ideally you would treat them with fat injections combined with a peel of the skin with pre- and post treatment topical hydroquinone. But starting with a temporary filler will determine for you whether the correction of the hollows alone can be done by injection of any material and is a ‘pre-test’ for future fat injections which are superior in terms of both volume retention and potentially aiding in the hyperpigmentation issue.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I understand that you are the inventor of the Brink Peri-Pyriform implant. I am writing you to inform you that this implant improved my speech and my life. I am American-born Chinese, and English is my native language. However, until I had the Peri-Pyriform implant put in, I always had a significant amount of difficulty speaking fluently and clearly.
All of my life, people have often told me that they could not hear, or make out, what I was saying, or that it seemed like I spoke with an “Asian American accent.” Several years ago, I noticed that words containing “ch”, “sh”, “j”, “zh”, “n”, and “r” sounds were especially difficult for me to articulate. I also began to notice that many other Asian people, both native and non-native English speakers, also exhibited these speech characteristics to varying degrees. Furthermore, as I am sure you already know, Asians typically have shorter head lengths than do people of other races.
This led me to a theory: In Asians whose head lengths are particularly short, separation between the upper lip and the premaxilla impairs articulation of the speech sounds “ch”, “sh”, “j”, “zh”, “n”, and “r”, and this, in turn, impairs significantly the articulation of words and sentences containing these sounds in English and French, and possibly in other phonetically similar languages.
Shortly after coming up with this theory, I had premaxillary augmentation surgery using the Peri-Pyriform implant. Immediately after the surgery, my articulation of those sounds was improved, as well as my clarity in speaking.I had always been very quiet. Now that I can speak more fluently and clearly, I am less shy about speaking, and I have a much happier disposition. Hopefully, others like me will also be able to benefit from the Peri-Pyriform implant.
A: Thank you for your relaying your experience with implant augmentation of the pyriform aperture region. I have to confess that I did not do the original design of the implant, that credit goes to Dr. Brink as indicated in the implant product’s name/description. I do have a lot of experience with this facial implant, however, and most of that is in Asian patients for the facial shape reasons you have described.
Of all the potential benefits of a Peri-Pyriform implant, speech improvement is not one I have ever heard of or could envision occurring. Your anatomic explanation/theory sounds perfectly plausible however as it can cause greater upper lip projection, particularly at the nasolabial area. That may improve upper lip contact with the lower lip which may help in articulation with certain sounds.
Regardless of how it may have helped, you are living proof that it indeed has. I could not be more happier for you that such a simple facial procedure could have been so helpful.
Thanks again for taking the time to share your most fascinating facial implant experience,
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a breast implant exchange. I want to change from Mentor moderate plus silicone breast implants to moderate classic profile silicone implants with the same submuscular placement.(dual plane) I want only Mentor smooth round moderate classic profiles in size 385cc or 405cc. I want the most natural natural results with no upper pole fullness. I currently have Mentor 325cc and It is still not natural enough for me. I don’t want to look like I have breast implants.
A: From a breast implant exchange standpoint, changing the profile from moderate plus to a moderate profile will help a little bit bit I suspect not as much as you would like. The best way to maximally decrease upper pole fullness would be an anatomic or shaped breast implant since the shell is designed to distribute 2/3s of the implant’s volume in the lower pole. But smooth silicone implants offers a slightly lower expense to this aesthetic concern so this is an economic choice. But certainly the breast implant exchange as you have proposed can be done.
The interesting question, regardless of the breast implant profile, is how going up in size may work against the very goal you are trying to achieve…a natural look. i suspect that lowering the implant profile while simultaneously increasing implant size have you ending up right where you started… too much upper pole fullness.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m concerned about my right buttock implant. I had large buttock implants (625ccs) placed above the muscle about one year ago. My right buttock implant seems to be lower than my left and it seems to continue dropping. As shown in the attached pictures the left is the perfect buttock while the right is not so perfect. What are my options to correct this without another surgery or spending thousands of dollars?
A: Like all implant asymmetry issues anywhere on the body or face, there are never any non-surgical solutions to their repositioning or adjustment. But to provide a more wholesome perspective, let’s review why you have what you have and what you would do if the concept of another surgery or economics were not an impediment to the desire for improvement.
Buttocks implants in the subfascial plane (above the muscle) have a known propensity to potentially drop as they heal and settle. This is quite unlike intramuscular buttock implants which stay locked in a high pocket because of their tight muscular confinement. At 625cc implant size, this was never an option for you since the largest implant in the intramuscular pocket at your height would be about 350cc to 400c maximum. In the subfascial plane, all the surgeon can do is place them in what appears to be a high pocket knowing that they will settle. Why one implant eventually settles lower than the other one, like in your case, is unknown and unpredictable. Why it may do so even at a late period after surgery is also unknown. The size of the implants may have something to do with it but then the one buttock implant is fine….so clearly size alone is not the sole driving factor. Whether any further dropping may occur is also not known but there is a limit as to how how low it can go and I suspect you have likely reached it.
Correction of buttock implant asymmetry, unlike that of breast implants, is neither easy or assured. Repositioning of a low breast implant, for example, is comparatively easier since the access point (the incision) is at a convenient position on the underside of the breast and the pocket can be sutured upward. Such is not the case with buttock implants where the access point is from above. The implant would have to be removed and the pocket attempted to be sutured from far away through a small incision and the implant re-inserted. This is a very difficult surgery and the retention of the pocket elevation very unlikely given that one has to sit on it at some point after surgery. While it can be done, success with upward buttock implant respositioning is usually very low.
While buttock implant asymmetry is not a desired aesthetic outcome, the risks of revisional surgery may outweigh any effort in that regard. Besides the low probability of success, entering a healed implant pocket always induces the potential risk of infection. Should infection occur, which is always more likely in subfascial vs. intramuscular pockets, the aesthetic outcome would be disastrous with loss of the implant.
Putting all of this in perspective, living with some buttock implant asymmetry may be the only economic choice, it may also be the best medical decision also.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have some questions about custom facial implants.
1. How long is the standard recovery process after chin/jaw surgery? Is one week reasonable to plan? Please note, I´m not looking for an exact number of days, only an estimation.
2. The webpages you provided, while helpful in delineating different procedures, do not offer much insight into Dr. Eppley´s expertise vis-a-vis chin/jaw custom facial implants. Hence: how many of these surgeries does he perform per year?
3. What is success rate of these procedures, purely in terms of patient satisfaction?
4. How high/serious is the risk of infection or asymmetry?
5. In the event of infection, does implant have to be removed? If so, will my stay have to be prolonged? Should the new surgery be required – who covers the new expenses?
A: In answer to your questions in regards about custom facial implants:
1. It depends on how one defines recovery. Full recovery with all swelling gone will take a full six weeks. 50% of the swelling is gone by 10 days so a one week recovery would not be realistic in terms of appearance.
2. I perform over 100 semi-custom and custom facial implants per year, more than most any other surgeon in the world.
3. All of these procedures are successful. The better question is how many revisions are performed due to aesthetic concerns. (10% to 20%)
4. I have never seen an infection. Custom facial implants minimize the risk of asymmetry significantly..
5. The expenses of revisional surgery of custom facial implants, for whatever reason, are the responsibility of the patient.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I stumbled upon your case study for vertical orbital dystopia when researching potential corrective procedures for just that. I’m a 27 year old male who has orbital dystopia with about the same severity as the guy in your study and I’m curious what the ballpark price would be for such a procedure. I’ll gladly send you a picture, or provide you with any other information you might need.
A: Thank you sending your pictures. It appears you have about a 5mm horizontal discrepancy as based on the position of the pupils. The is probably just within the range of what can be improved by an orbital floor/orbital rim augmentation procedure. This can be accomplished by either using hydroxyapatite cement for the buildup or using a 3D CT scan to make a custom implant.
The bony augmentation aside, the real key to a successful aesthetic outcome in vertical orbital dystopia is how the lower eyelid is managed. For the lower eyelid must be elevated with the globe or an increased amount of scleral show will result. At the least this requires a lateral canthoplasty, which may or may not, require a mucosal spacer graft.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I notice you also do a surgery that can increase the width of your mouth. (mouth widening surgery) Can this be combined with a corner lip lift? Also does the procedure that increases the size of the mouth help the smile out? I notice when I smile I only have about 4 teeth showing on each side not because of the way my teeth are but because of how narrow my smile is. It just doesn’t stretch nearly as far as I would want it to. Would a wide mouth surgery give me more of a cheshire cat grin where I would be able to expose more teeth on the sides?
A: A mouth widening procedure can be combined with a corner of the mouth lift. It is just how the angle of the mouth widening is positioned to create that effect. A mouth widening procedure has a static effect, not a dynamic one. It is the pull of the zygomaticus and upper lip muscles that drives the corner of the mouth and the upper lip upward and outward to expose the teeth. It is not how wide the distance between the mouth corners are that has the biggest effect. Thus, I would not expect much improvement in tooth show just with a mouth widening procedure. But it certainly will not hurt and may have some small improvement in tooth show.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in occipital knob reduction surgery. I have an occipital knob I would like removed on the back of my head. My initial questions are:
1) would I need to arrange a scan or something similar over here to send to you or would you be able to see enough from pictures I can provide to determine whether I am a suitable candidate for this surgery?
2) is this surgery only performed under general anaesthesia, could it be performed under twilight or local even?
3) what are the potential risks of the surgery?
A: No x-ray or preoperative visit is needed for the occipital knob reduction procedure. Pictures alone are all the preoperative information that I need which you can send to me at any time. The surgery is done in the prone position (face down) and the occipital region is virtually impossible to adequately make numb by local anesthetic to adequately perform the procedure. IV sedation can not be performed in the prone position due to inadequate protection of the airway. Thus general anesthesia must be used for the occipital knob reduction procedure. The only minor risk, and an expected one, is the small horizontal scalp incision/scar used to perform the procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in chin ptosis correction by reduction of bone through burring or shaving (to reduce blunt and long chin) and chin resection for removal of excess soft tissue to correct my chin ptosis. I had a sliding genioplasty and ever since I have always had a problem when I talk or smile. My chin pad or mentalis muscle drops below my chin bone. It’s a problem that I hate so much! I though the sliding genioplasty would ix the problem but it didn’t. It also made my chin look loner not shorter.
As part of the chin reduction, I would want a prejowl chin implant, medium size by Implantech, secured with screws for forward chin projection.
A: A: In regards to your chin ptosis correction, I think you are spot on for what will solve your chin concerns. Only a submental resection of the overhanging chin pad will get rid of the ptosis that you have. Adding a chin implant will have a complementary effect in that regard as well as provide some forward chin projection. Horizontal chin augmentation is another method that can pick up or fill out a loose chin pad.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in temporal implants. I wanted to know if you have picture of the scar like one year after surgery? Or just a picture of the scar, to know what it will look like. I like to keep my hair shorts, and I wonder what it will look like? As a second question, would therapy to heal scar would help making it less visible?Also, as a third question, what would be the shortest I can keep my hair on the side to hide the scar? 0.5 cm or more? Thanks.
A: I do not have a picture of a temporal scar after implant surgery. I have seen several of them long-term and many of them are virtually undetectable even on very close inspection. I can also say I have never been asked to do a scar revision on the scars after temporal implants. If one has hair there would be no need to do any form of topical scar therapy on the incisions. This is impractical and unnecessary for scalp scars. If the temporal hairline scar heals very well (and it should) you should he able to wear your hair as short as you would like without concerns about visible scars.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, We had previously discussed that a button chin implant would be an option for me if I wanted to make the bottom of my chin appear less squared off. I tried the filler as you suggested and actually really liked the rounder/pointier shape… but since I feel like my face is already long, adding that vertical height to create the pointer shape wouldn’t be my first choice..
1) Would it be possible to do something similar with a chin reduction technique so that the chin becomes somewhat narrower/rounder/more feminine and maybe slightly reduced vertically (vs an implant or filler that would require augmentation to add that shape onto my chin)?
2) Would it be possible to do this from an intraoral incision? I saw examples on your blog using an intraoral approach as well as submental and wasn’t really sure what category I’d fall into…
3) If an intraoral approach is possible, what are common complications/complaints you see or hear the most from your patients? Are any of these permanent?
A: In answer to your chin reduction questions:
- A chin reduction can reshape the chin, making it less square and reducing the vertical height.
- To do it intraorally, it would have to be an osteotomy technique where a wedge of bone is removed from the middle of the chin. This keeps the bottom of the soft tissues attached to the bone so there is not ptosis or sagging afterwards.The submental approach is simpler but does involve the scar on the underside of the chin.
- The intraoral approach will involve a slightly longer recovery and will create some temporary numbness to the chin and lip. Such numbness if not usually permanent in my experience.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have some lateral brow questions.
1) What are the most common complications or patient complaints associated with a lateral brow lift in your practice? Are these permanent?
2) Will the temples/forehead be numb after a lateral brow lift?
3) Approximately how many millimeters of lift can I expect?
4) Will my hairline be lifted? If so, how much?
5. I just wanted to confirm that the tail and some portion of the arch/point of the brow are adjusted – meaning the brows aren’t just lifted at the bottom of the tail causing the brows to become straight/flat… It seems from looking at online pictures the results vary greatly from surgeon to surgeon so I am guessing there is room for some tailoring to the patient in the operating room.
A: In answer to your brow lift questions:
- The most common issues after a lateral or temporal browlift procedure are adequacy of the lift (how much lift was achieved) and the potential for widening of the scar in the temporal hairline.
- I would imagine that there is some temporary numbness of the skin in the direction of the temporal browlift but that is not an issue that I hear patients mention.
- The amount of lift obtained from a temporal browlift is variable, anywhere from 2to 3 mms to 5 to 7mms.
- While the hairline should be lifted as much as tail of the brow, the distance between the hairline and tail of the brow stays the same…thus it is not really noticed.
- Temporal browlift results are indeed highly variable and it is not an exact science. The fundamental problem with this technique is that the best and most predictable way to do it (making the incision along the front edge of the temporal hairline and excising skin doing the lift there) is rarely where the patient can accept the scar line. Thus putting the incision back in the temporal hairline is usually necessary and this is where the lift becomes less effective. To make it effective the incision and skin removal has to be bigger because the point of lift is further away from the brow.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m about 6 weeks after placement of a custom jawline implant. To be honest, I’m not too thrilled about the results and would like to possibly schedule a revision surgery with yourself. First off I’d like to tell you the situation with my custom jawline implant. On the positive side, in terms of the added bulk along the jawline, I think it’s perfect. There are two main issues I have which I would love your feedback on how to improve. The first is that I feel the lateral projection/width of the angles is not big enough. At about the 3rd week after surgery, I think it was at the perfect level. But after a few more weeks passed, I lost that added width and and angularity and now the angles blend in with the jaw, giving my face a big U look, rather than adding any angularity or sharpness. The second is that because I lost the added width at the angles, the newly added vertical length of the chin has my face now with a stretched out/elongated look. While the projection of the chin is fine, I feel the length really needs to be shorten about 1.5mms or so.
Can I ask your feedback on what you would recommend on terms of design to rectify these issues? To get better sharpness at the angle, should we increase just the lateral projection or also increase the thickness? How do you think would best to handle the chin? Again, the jawline itself looks much better and defined but I would really like to fix the angle and chin issues.
A: The first thing I would tell any custom jawline implant patient is to wait a full three months before contemplating any revision. It takes time for all of the swelling to subside and the tissues to contract back down around the implant. There is also the accommodation phase of adjusting to a new look. Between all of these factors how one feels at just 5 weeks after surgery may change…I have seen it happen.
That being said, what you have learned is that while computer designing is a great and only way to make a total wrap around jawline augmentation, there is no accurate way of predicting what the final aesthetic result would be. The computer has no innate knowledge of how to make those dimensional changes and that input must come from the surgeon based on his/her experience.
What you do know now is what effect the current design has created. Those dimensions are critically important when contemplating a revision/replacement implant. What would be important to see, and it is of critical importance, is where you started and what you look like now. That information helps gauge how the dimensions of the chin and jaw angles have had an initial impact and will play a critical role in knowing how to change the current implant design.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’ve been diagnosed with lupus and ITP. However, my platelet count was always low (lowest was 12) back in 2013 when I went for my blood work to have a rhinoplasty. I was prescribed steroids to take to increase the count and undergo surgery. So I think I had lupus back then and it affected my platelet count. Every time I wanted to have surgery, I would just take the steroids for about a week prior to surgery. I’ve had 2 rhinoplasty, breast augmentation, upper and lower eyelid surgery, and mid-face lift. But now I am now taking plaquenil and prednisone (50mg) for the past 6 months. I am interested in revision rhinoplasty, zygoma reduction, and jawbone reduction. I am little afraid since this time I am taking medications for my lupus. If my platelet count is above 100. Is it safe for me to have those surgeries?
A: I think you have to recognize that at least two of these surgeries (zygoma and jawbone reduction) are major bone surgeries that can cause a lot of bleeding and require better healing potential that any of your prior aesthetic procedures. Since they are elective I would be very cautious about undergoing them. Plaquenil and prednisone are major anti-inflammatory drugs that can have negative impacts on healing, particularly at the doses you are taking.
If your platelet count is acceptable, I would only undergo a revision rhinoplasty first to see how the surgery goes. That would he a good test before ever proceeding with the more major facial bone surgeries.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am researching jaw angle implants and am seriously getting ready to choose a doctor. I consider you to be one of the top few in the nation, and have read your blog on how you’ve never experienced a tear with the masseter sling with jaw angle implants. However, is there still some roll up?
Another well respected doctor has told to me that no matter what there will be a bit of roll up, but did not clarify whether or not that implied no tearing.
A: To clarify the issue of the masseter muscle sling and its potential disruption, you first have to differentiate whether you are talking about width only jaw angle implants or vertical lengthening jaw angle implants. With width only jaw angle implants, it is not necessary to strip the tissues off of the lower border of the mandible. Thus there is little to no risk of any masseteric muscle sling disruption/roll up/retraction issues. With vertical lengthening jaw angle implants or total custom jaw angle implants, that is a completely different issue. By definition it is necessary to elevate the sling attachments off of the border of the mandible and the massteric pterygoid sling is disrupted. This is unavoidable. Whether there will be some muscle rollup depends on how much vertical jaw angle lengthening is created by the implant. If it is 5 to 7mms, for example, then the rollup will really be minimal. But if the vertical lengthening is 15 to 20mms, then it will be more significant. (more visibly noticeable) It is important to remember that the masseter muscle can not lengthen, that is a physical impossibility. So the longer the jaw angle is lengthened, the more the original position or even roll up of the muscle may be seen when biting down.
A complete tear or retraction of the masster muscle is a slightly different situation. For this to occur the entire attachments of the masseter muscle must be detached from the angle point forward to the mid-body of the mandible as well as high up onto the lateral ramus. The angle point attachments are quite significant and not easily dissected off of the bone. With aggressive degloving of the posterior and inferior mandibular borders (and I might add this is almost always done in sagittal split ramus osteotomies in orthognathic surgery) the risk of a more substantial masseter muscle retraction may be seen where the lower end of the muscle is seen up almost at the level of the earlobe when biting down.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Can a corner lip lift combined with a subnasal lip lift bring about the same results as a gullwing lip lift if you want to try to do avoid as large of a scar at the vermillion border as possible?
How much can alar retraction be corrected in millimeters? If oyu have an exceptioally severe case is it possible to do two operations the same way if someone wants exceptionally large breast implants they can get implants the first go around and then have the skin stretch, then replace implants later with larger ones? In the case of the nostrils, is it possible that the first time will not fit a large enough graft but this can be replaced later on down the road after the nostrils have adjusted?
Is there a procedure that can correct masculine and broad shoulders for a female that wants a more petite upper body? Something like clavicle reduction?
A: A subnasal liplift combined with an extended corner of the mouth lift is a way to create a similar effect as that of the lip advancement procedure. (gullwing lip lift) The subnasal lip lift substitutes for placing the excision of skin across the cupid’s bow area. Lateral vermilion advancements brought inward from the mouth corners is still needed but they do not encroach onto the more visible and delicate cupid’s bow area of the upper lip.
Alar retraction is treated by the placement of alar rim cartilage grafts. They will create a several millimeters of correction. More significant alar retaction may need to be treated by the placement of composite skin and cartilage grafts to roll out the inner lining. (which is where the skin portion goes. This it is not like your breast implant analogy at all.
There is no operation to reduce wide shoulders. A bony reduction is not possible because that impinges on the moveable shoulder joints.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting breast implants but am uncertain if I need a breast lift also. I saw a breast augmentation patient you had done who looked somewhat similar to me and she was able to have a good result with large implants alone. I was wondering if I might obtain a similar result. I have attached some pictures of my breasts for your opinion on this matter.
A: Thank you for sending your pictures. I think you just have too much ptosis (sagging) to avoid a breast lift with your implants. The key is the level of the nipple to the inframammary fold. If the nipple is at or just a hair below the fold level, implants can create a bit of a lift or at least not create the appearance of breast tissue sagging off the front of the implant. But when the nipple is really below the inframammary fold (and in your vase it is by several centimeters), the implant will merely drive the already hanging breast tissue off the front if it…making a not so good breast appearance even worse. While I do many breast lifts, I really don’t like them for women due to the scars and try to avoid them when there is a good chance that a women may get by without it. But unfortunately I just don’t see that being a good option for you. (implants with no breast lift)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in facial plate removal as part of other cosmetic facial work being done. But I have four titanium plates in the left side of my face from a previous facial trauma. Can I have those facial plates removed at the same time as the cosmetic work as well.
A: Indwelling metal facial plates can be removed during any upcoming facial procedure. The only question is where these plates are located, what access would be needed for their removal and would the trauma of trying to remove them be worse than just leaving them alone. One never knows if the plates have bony overgrowth on them and whether the screw heads that have been used to place them have been stripped. (making them difficult for a screwdriver to get a good purchase on them) With four plates I can going to assume that the metal hardware is likely around the cheek and orbital area.
In most cases in which patients have no symptoms from their indwelling facial plates, facial plate removal is more for self-relief or are being removed because of surgical convenience. For these reasons I needs to think carefully as to whether the trauma induced by facial plate removal makes it worthwhile.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in occipital and forehead augmentation. I am aware of custom forehead and occipital implants but I have several questions for which iIhope to get answers.
1. I do know through research that there are alternative material called PMMA, how does this compare with pre fabricated silicone ?
2. Which one is cost effective?
3. Which one get less side effect and after-problems?
4. If I included my forehead, are we using the same materials?
A: In answer to your additional questions:
1) You are referring to PMMA, a born cement material which is applied like a putty, shaped and than allowed to harden. This is what I used a lot before custom skull implants of which has largely replaced PMMA bone cement in my practice.. A custom skull implant is always better because its shape and exact dimensions are made before surgery. Because it has a preformed shape it is also put in with a smaller incision and less operative time and with a much lower risk of revision due to irregularities or edge transitions.
2) A custom skull implant costs more but PMMA will exceed that cost of a revision surgery is needed due to irregularities or edge transitions.
3) A custom skull implant has much lower revisional surgery risks than PMMA bone cements. It is also much easier ti remove and revise if that need should arise.
4) The issues are the same in the forehead where a custom implant works better than PMMA bone cement.
But the differences between using a custom implant vs. PMMA bone cement may be greater or more similar depending upon the size of the front and back of the head augmentations desired and how much scar length one is willing to tolerate. I would really need to see pictures and do computer imaging of you to get a better idea as to these very important issues.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I just got buttock implants done (425cc), but they are no where near the size I want. I was wondering is there anyway for you to add to my hip/ butt area maybe with more implants? I can’t do a fat transfer as I am too thin.
A: Thank you for sending your pictures of your buttock implants result. While I do not know where you started, you have a very good result. It is not possible nor medially wise to seek that degree of buttock size change by larger buttock implants or adding other implants. Such implants in a thin frame like yours is asking for complications and risks losing what you have now. Surgery with implants anywhere in the body is like a roulette wheel. You have spun the wheel once with fairly large buttock implants for your frame and you have achieved good improvement without complications…at least up to this point early after surgery. Pushing all your chips for another spin at the roulette wheel (further implant surgery) risks losing everything with complications like infection, implant capsular contracture and lifelong buttock deformation. While you may have not achieved your ideal buttock enlargement goal, which was never a realistic goal with your body frame, you have reached what I would consider to be medically safe and the probably limits of what your body can tolerate.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am seeking vertical facial lengthening. I am told and agree, that my face is short and looks clamped. My dad has a bite issue and his face also is short but not as short as mine. I was told by an orthodontist that it was a borderline deformity. I have noticed strange looks from others and have caught some laughing at me. This is affecting my quality of life. I have heard of procedures to lengthen the jaw and was wandering if this falls under facial asymmetry or if it doesn’t if you could correct this?
A: Thank you for your inquiry and sending your pictures. What you have is most certainly a short lower third of the face due to the vertical height of the lower jaw. (and some jawline asymmetry) Many people that have this vertical jawline deficiency have a near 100% overbite and are over closed, thus creating that look. Since you have been clearly seen and evaluated by an orthodontist this is not the primary cause in your case.
Your vertically short lower jawline (lower facial height) can be best and only treated by a vertical facial lengthening surgery using a custom jawline implant that will lengthen the entire jawline from front to back. This is made from a 3D CT scan and is custom designed for each patient. This is aided by the use of computer imaging of pictures and computer design software, meshing the two together to create a much improved but not over corrected result. The custom jawline implant is inserted through incisions inside the mouth.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a sliding genioplasty done two months ago and I think that it has shifted. I am not sure if there is a gap on part of it because of the shift. I would like your opinion and evaluation.
A: Thank you for your inquiry. I understand that you think your sliding genioplasty has shifted. Did you have any x-rays after surgery or any now that would help understand if that is what has happened? It is also possible that as all swelling has finally subsided any asymmetries can become more apparent which are masked for the first 4 to 6 weeks after surgery due to the swelling. Please send me some pictures or anything that shows where you see the chin/jawline asymmetry. It is also more likely than not that the gap you see is the step-off at the tail end of the sliding genioplasty along the jawline behind the chin.
An under appreciated aspect of any sliding genioplasty is that it causes a disruption of the inferior border of the jawline. Depending upon the angle of the bone cut and the amount of forward advancement of the chin, the inferior border disruption may be minimal or significant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am seeking a skull implant. The crown of my head is flattened out in the back and I would like to have the back of my head have a more rounded shape to it. I’m bald and wear a hair system that’s adhered to my scalp right now. But I am considering having scalp micropigmentation to give me a buzzed haircut look and the appearance of the back of my head is the only thing that’s stopping me right now from doing this. the scar which would be created can be hidden somewhat with the micropigmentation. On your website, you have a pic of what the back of my head somewhat looks like but maybe not as extreme so I have attached it so you can see what it looks like. If you need a more detailed pic, I would have to remove my hair system which would take time to remove it but if its needed, please let me know. I am hoping to get an approximate cost for the procedure if its something that can be realistically done. I don’t have enough donor hair to consider having a hair transplant and this to me is the next best option as I’ve always wanted as I’ve always loved the buzzed cut hair look. I hope to hear from you soon, thank you for your time.
A: It is extremely common in men that they seek skull implant augmentation when they are either going bald, want to shave their head or permanently eliminate the need for a hair prosthesis. The fear of what their head shape looks like may drive them to seek skull shape correction. In short, I have heard your story and motivation for skull reshaping surgery numerous times.
The best approach for increasing the convexity of a flattened back of the head is a custom skull implant. This is made from a 3D CT scan. My assistant will pass along the cost of the surgery on Monday.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I need advice for facial reconstruction. I had surgery consisting of a left partial maxillectomy to remove a muco-epidermoid carcinoma. (intermediate grade).
Since then, my face have partially distorted as per current picture. Could you please suggest what type of procedure is good for me , to have a better natural handsome look. Could you please recommend the best option and how the procedures are carry out.
A: Thank your for your inquiry regarding facial reconstruction and sending your pictures. The key question is whether you have undergone any radiation treatments to your face after your cancer resection??
Your face is collapsed inward on that side due to lack of underlying bone support from the maxillectomy. Replacing that bone and rebuilding that side of your face would require a complex form of reconstruction known as a free flap as there is inadequate soft tissue to cover any bony reconstruction. This would be particularly necessary if you have had radiation treatments.
A simpler and less complex form of reconstruction would be to focus on building up the soft tissues through fat injections. This can be done whether you have had radiation treatments or not.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a breast reduction but my situation is a bit unusual. I currently have breast implants but gained weight after surgery with my third child. That was over ten years ago. I would like a breast reduction with my implants removed. I do not want to be bigger than B cup… I am currently a D/DD cup.
A: With breast implant removal and some significant breast tissue on top of them, a full breast lift may be likely needed. Due to concerns about blood supply to the nipples, the amount of breast reduction/lift that can be done may be more limited than going all the way down to a B cup may permit. Conversely, based on the size of your existing indwelling implants and their location (submuscular vs. subglandular), such a breast size reduction may be very possible. Larger breast implants that are in a submuscular position will safely permit more of a breast reduction/lift. I would need to see pictures of your breasts to help make that determination.
Removal of breast implants by itself causes an obvious breast reduction effect. But the now excess and potentially sagging overlying breast tissue must be managed to create a smaller and tighter breast mound.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in forehead recontouring but all of your case studies of the procedure show people with hair. I can see how an incision made for forehead recontouring along the hairline is great if you have hair and can hide the incision. But what if you don’t have hair, how would you handle that?
A: There is a reason you do not see pictures of almost any kind of forehead recontouring procedures in men who either do not have hair or have a shaved head…they do not do the surgery. The scar would not be a good tradeoff in the vast majority of men unless the forehead deformity is very noticeable or extreme. Having said that, I have done a handful of men who have no hair for forehead recontouring but they are extremely motivated and are willing to make the aesthetic tradeoff of a scalp scar.
In some cases of forehead recontouring a forehead incision through a prominent wrinkle line can be considered as an alternative to a scalp incision. This can be a more ‘natural’ and direct approach based on the age of the patient and the extent and depth of the forehead wrinkles.
Dr. Barry Eppley
Indianapolis, Indiana
