Your Questions
Your Questions
Q: Dr. Eppley, I am inquiring about chin implant replacement. I had a Medpor chin implant placed six months ago. As time has gone by with healing,and my face has slimmed down a bit, the chin implant looks too boxy. Here are some questions I have:
1. Could removal of the medpor implant cause any damage, or unsightly scarring? That’s why we wanted to explore shaving it while still attached. It just sounded so much easier than ripping it out, and possibly causing problems with the underlying bone, etc.
2. The implant that was put in was much more square than my original chin and I was never happy with it but was encouraged to give it the “time” test. Time only made things worse. My worry now is upon removal is the stretching that has occurred in the skin and tissues. Would there possibly be sagging if we go to a smaller implant?
3.. If we sent you some pictures, is it possible to only come out there one time — for the surgery?
4. Finally, I should mention that I am a cleft lip and palate patient who went in for a rhinoplasty (which we’ve already had a revision), and the doctor suggested the chin augmentation. We agreed it needed to be done, but we got WAY too much of a good thing. Thanks so much for your expertise and advice.
A: Having removed numerous Medpor chin implants, I have found them not unduly difficult to remove or particularly destructive to the surrounding tissues. It is always helpful to know what style and size Medpor chin implant was removed beforehand to plan for its replacement and to choose a more smaller more feminine type of chin implant design.
I rarely would advise trying to modify a Medpor chin implant in place as that usually does not turn out well. The access and visibility is difficult and asymmetry of some kind is often the result. Most of the Medpor chin implants that I have removed and replaced have that exact history…initial placement and subsequent revision (with asymmetry) and now they want it removed and replaced.
As long as some type of chin implant replacement is done, soft tissue sagging is not usually a concern. It is the total removal and no replacement where that is more of a potential issue.
This is the type of procedure where you come the day before to meet, have surgery and return home the next day. There are no other visits needed beforehand or after. Any follow-up can be done by phone, e-mail or Skype.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I think I am interested in a direct neck lift. I am 68 years old, slim and sporty. I have had two face lifts, the second had to be redone completely five months later so this makes in reality three face lifts with the last one being done five years ago which still holds pretty well except for the neck. My surgeon suggested to have a direct neck lift, since I have no skin elsewhere to cut off. I saw that you are a specialist in direct neck lifts. I hesitate to have this vertical scar, although my scars fade away pretty well but in the middle of the neck would be awkward. I do dancing for my pleasure and my friends in the class would see the scar. There is little skin to be taken away. I have still a nice line around my face, but the profile is not nice looking, it makes a direct line from the chin to down to the neck. If I turn my head or lift it a little it is ok. Did you ever do a direct neck lift on a lady? How is the scar? Many thanks in advance.
A: I have done many direct neck lifts with the vast majority being in older men. I have done a few in older women as well but these were for considerable amounts if neck sagging and they were seeking an economic solution for their neck wattles. In a female I do not consider it as good a scar as in men. Based on your description of having only a little loose skin and being very sensitive about the scar in advance, I would be hard pressed to say this is a good procedure for you. While there is no questioning the simplicity and effectiveness of the procedure, it is simply an issue of the aesthetic trade-off. Is it better to have no scar and a loose neck or a sharp neck angle with a fine line scar? You simply have to choose which aesthetic problem would bother you less…and based on your description alone it sounds like a scarless but undesireable loose neck skin would be better than the scar trade-off.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have been waiting for my family physician to get me a referral to a plastic surgeon to consult me on a breast reduction. I have several health reasons for considering this type of procedure. I have a bulging disc along with deterioration of the tail bone and arthritis of the spine. I am about 50 pounds over weight, but have lost around 80 pounds in the last year or two. I have diabetes and kidney stone disease, so my losing weight was a must and I thought my pain would get better, but it has not, because I haven’t really lost any of my breasts. I would love to get a consultation with you, but I do not have the money to pay out of pocket and would like my insurance to pay for this procedure. That is why I wanted a referral so the insurance understands that it is not for cosmetics. What do you recommend for me to do in my situation. Thank you very much!
A: When using insurance you have to go through the proper channels (by the book) as this will ultimately effect the pre-determination process and decision for breast reduction surgery by your health insurance carrier. So you are going to have to get the referral from your family physician first before you can have a consultation. Most certainly they are never going to pay for a consultation without the referral.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in breast lift surgery. I have severe ptosis of my breasts. I had weight loss surgery in 2012 and my breasts turned into nothing but skin! I am let with extremely saggy breast.s I assume I need a reduction and then implants because my breast tissue is non existent at this point. I just know that I need new breasts. I want to know what my approximate cost would be to have the type of augmentation I need done. A breast lift with free nipple grafting may be the route to take. I just want nicer breasts. I don’t expect the nice set I once had but anything would be better than what I currently have! How can I achieve my goal?
I weigh 230lb, am 34 years old, and am a non smoker. I can be 180 to 200lbs in 30-45 days which is my target goal. I am ready to take the next step. I just need to know what procedure would work best to fix my horrible breast. Can I have decent looking breast with surgery? I want full breasts that aren’t saggy.
A: Many patients that have undergone extreme weight loss after bariatric surgery are left with saggy breasts and little internal breast tissue. While there are a number of types of breast lifts, these patients always require a combination of breast implants with a full breast lift, also known as the classic anchor pattern lift/scar pattern. The issue in very extreme cases of breast sagging like yours is whether the implants and the lift should be done together or whether it should be staged. (breast lift first followed by implants later) To avoid complications and the risk of loss of the nipple, you are one of the rare cases of breast sagging in which I would probably stage it. Besides risking loss of the nipple as a single combined procedure, you are at a very high risk (probably 100%) of needing a revision surgery anyway. It is just too hard to get teh amount of lift you need, put in implants for volume and have them be very symmetric all in one surgery.
Dr. Eppley
Q: Dr. Eppley, I am interested in skull reshaping surgery. My head shape is not normal. It is flat from the back side and inclined backward at the forehead making it smaller on the top as a whole. My face is not much wider as well resulting in a small head. I want to increase head size especially from my back side and forehead areas. Please tell me which procedure I need whether it is an implant or bone cement filling.
A: When it comes to skull reshaping and the aesthetics of your skull, you are talking about a sagittal (front to back) deficiency. Your forehead is slanted backward (retroclined) and the back of the head is flat. (or has a reverse retroclination compared to the front. This is treated by two different methods of dual forehead and occipital augmentation. It can be done with either a bone cement filling material (usually takes 150 grams) or custom forehead and occipital implants made from 3D CT scan. There are advantages and disadvantages of either approach but the end results of either one are the same with a potentially dramatic difference in the volume of your skull from front to back.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in chin cleft removal surgery. The deepest part of my cleft is at the very top. Ironically, the deepest part at the top goes down to the bone, which is not a valley but a peak at this part of the cleft. So the top is strictly due to the positioning of the attached muscle. The bone is grooved at the bottom of the chin with a 1/8th inch deep notch in the bone. This is basically the deepest possible cleft chin possible.
From what I’ve read, entering through the mouth to avoid scarring this is the best that can be done and will most likely not fully remove the cleft but dampen it. I would like to know how many cleft chin removals using subcutaneous fat as a filler with smoothing of the chin bone have you done?
A: When it comes to chin cleft removal (or more accurately for many patients a chin cleft reduction), it is important to classify the type/depth of chin cleft. I classify chin clefts into four types based on the clefting seen in the skin, fat, muscle and bone levels. By your description and the example you have shown which corollates to your chin cleft, that would be a type IV chin cleft. When the chin cleft is this deep and the skin edges are deeply inverted, placing a filler material in the cleft is really not the best treatment. The tissues are so deeply indented that it will resist any ‘soft’ push from any underlying augmentation in the soft tissue layer. Augmentation of the bone, although reasonable to do, has the less effect on Type III and IV chin clefts. The most effective treatment in Type IV chin clefts is external excision and multiple layer reapproximation to level out the clefted tissues all the way down to bone. While this is the best approach in very deep chin clefts, this creates an external scar which is rarely aesthetically acceptable. Thus one has to accept an internal intraoral approach with a much reduced result. If done intraorally, the bony cleft would be augmented, the skin released from the muscle and a dermal-fat graft placed underneath the released skin. I would expect maybe a 1/3 to 1/2 reduction in the Type IV chin cleft with this approach.
One simple test to determine how much a chin cleft can be reduced, a saline or synthetic injectable filler treatment can be done in the office. If reasonably successful that would indicate that soft tissue filling would be reasonable to do. One could then proceed with either fat injections or a longer lasting more robust filler like Juvederm Voluma for treatment. If unsuccessful, then one knows that a more invasive procedure as I have described above would be needed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in rhinoplasty and chin reduction surgeries. I am very unhappy with the profile of my face. I feel it looks very masculine. I do have a twisted nose and large tip. I feel my nose doesn’t fit in with my face and looks rather big when I start to turn my face from certain angles. When I use a plastic surgery simulator it makes a big difference when I make my chin and nose smaller. I would like to know what your opinion is and what would you think would help balance my face? I have been wanting surgery for a long time now and over the years wasn’t sure exactly what the problem was with my face but I believe it is do with the angle of my chin and nose.
A: The nose and the chin make up a major portion of one’s profile so it is no surprise that changing these two structures can make for a major facial change and not just in the profile view. I would agree completely with your assessment that your nose is too big in various dimensions and is a major culprit in your facial concerns. But as you have also pointed out, and astutely so, is that your chin is also a little too strong. That would become very apparent when the nose is reshaped and made smaller. Thus doing a concomitant chin reduction with a rhinoplasty would produce the greatest effect in make your face have an overall more feminine/less masculine appearance.
I have done some imaging of the one picture you sent to illustrate those potential changes with a rhinoplasty and chin reduction.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, What is the recovery time for liposuction? I was looking to have liposuction done on my stomach, upper back, thigh and bottom area. I am not sure what type of liposuction would be right for me. I am 38 years old, eat healthy and exercise, but I can’t seem to tone those areas after having two children. I look good in clothes but do not like what I see in swimsuits.
A: The areas you are considering having treated by liposuction would be many of the typical areas of the truck. I would not get too focused on what type of liposuction, all have the exact same amount of recovery and final results. In terms of recovery, it all depends on how you choose to define it as to how to answer it. If you judge it by when are you up and around…that would be the next day. If you judge it by when will you be doing all normal activities including exercise…three to four weeks. If you judge it by when all areas will feel perfectly normal and are looking at the final results…6 to 8 weeks.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was wondering if you could take a look at the attached photos and see if I am a good candidate for umbilicoplasty to achieve a typical “innie”. I have been told by my general practitioner and another cosmetic surgeon I do not have a hernia (they made me cough and felt around my abdomen) but I can insert more than half my finger into the tunnel of my bellybutton which made me question this? It just feels like it is a VERY long stalk and with excess skin. I do have a little fat around my midriff but when I was younger and very skinny my belly button protruded a lot. I am working on losing the weight but do not want it to protrude again. Please have a look and tell me what you think.
A: When it comes umbilicoplasty surgery, it is important to consider what makes the outie belly button look the way it does. Outie belly buttons can occur by two anatomic mechanisms. The most recognized one is an actual umbilical hernia (Type 1) that causes the entire stalk of the belly button to protrude outward either staying within the umbilical stalk or even protruding beyond the outer skin ring. This type of outie belly button feels very soft and can be pushed all the way beyond the abdominal wall fascia. A ring defect through the fascia can be felt by deep palpation. The other type of outie belly button is not associated with a true hernia (Type 2) and is either due to a long umbilical stalk (probably due to where it was cut at birth) relative to the thickness of the abdominal wall or from a weak or absent attachment of the stalk to the fascia. This type of outie belly button will feel more firm, less distensible and can not be pushed inward beyond the underlying abdominal wall fascia.
Either way the outie belly button can be converted to an innie through an umbilicoplasty procedure. The Type 2 outie belly button is somewhat easier and more reliable to fix since there is not a concomitant fascial defect/hernia to deal with at the same time and thus has a more stable base onto which to attach the inwardly reshaped umbilicus.
Dr. Barry Eplpey
Indianapolis, Indiana
Q: Dr. Eppley, I’m looking to get buttock implants. I am very small framed (5’0” and 105 lbs) and wanted to know what should I get for my size?
A: When you get buttock implants, they should almost always be placed in the intramuscular space to lower the risk of long term problems. While above the muscle (subfascial) is also popular, there are higher risks of seroma formation, implant show and mobility, and infection. The recovery may be quicker but that short term benefit may not be worth the long term consequences.
In the intramuscular space there is a size limitation as to how big the implant can be. You do not have the choice of just any size, the anatomy of the space limits the size anyone can get. Everyone gets the biggest implant size that the space can take because there is no risk of being too big in this buttock implant location.. Generally that is going to be anywhere from 270cc to 330cc. With a small person, it is probably going to be closer to 300cc or less. Fat injections can be added around them to help with some additional size increase if you have some fat available to be used.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting chin and jaw angle implants.I want to be an actor, and I have always been considered attractive however I feel that I need to have a wider jawline like Brad Pitt or Stephen Amell as well as a chin implant in order to balance out a bit of a weak chin and achieve the male model look. I was wondering, is this something that can be achieved for me and be considered extremely physically attractive? Also, when it comes to recovery, what can I expect? Will I be able to have the same smile and live my life the same way after everything is healed? Is it possible to participate in sports or boxing after a procedure such as this? Have many actors and male models had procedures such as these done to help them get to where they are today?
A: First and foremost, the most important thing to realize is what jawline augmentation (chin implant and jaw angle implants) can physically do for you. You can never look like someone else and you can never have their jawline or other facial features. All you can do is make the most of what you have. I have done some imaging of chin and jaw angle implant augmentation to help you see what that potential change would be on you. Expect three weeks of complete physical recovery and three months to finally see the healed and settled look as well as enough time to psychologically adapt to the facial changes. Chin and jaw angle implants will not affect your smile, facial movement or any other physical activity once fully healed. There is no problem participating in sports afterwards. Whether this type of surgery will make you more attractive or successful in whatever endeavors you do in life is more of an internal issue rather than what is seen exclusively on the outside.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was interested in a chin reduction surgery, perhaps rhinoplasty (although I really don’t mind my nose). I am very comfortable with my appearance, and don’t mind it much although I find my chin to be too large! I think I would be much more attractive and feminine if I had a smaller, less gaunt/obvious chin. I was wondering if you could possible let me know if I would be a good candidate? I know most doctors suggest a traditional ‘almond’ shape, but I don’t mind my jaw square-ness, I just wish my face were shorter. Thank you, I can’t wait to hear your reply!
A: Your chin reduction request is a bit uncommon as what you have is a horizontally short chin that is vertically long because of its retrusive position. This type of chin reduction would actually be performed by a sliding genioplasty technique where the vertically long but horizontally short chin bone is cut at an angle and moved forward. (with a wedge of chin bone removed in the process) I have attached some imaging to illustrate that type of change. What actually happens is that as the chin bone comes forward it is vertically shortened as it is horizontally advanced.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a facial scar revision. My facial scar is three years old and is the result of a sharp tool attack. It was thinner after the attack but has grown considerably larger with time. It also appears more indented now. What are my scar revision options to make it less noticeable? I have attached several pictures which shows the scar as it cross the cheek and goes below my eye.
A: You have a very classic scar pattern that occurs when a long scar horizontally crosses the cheek area. Since it runs perpendicular to the relaxed skin tension lines (RSTL) of the face in that area, it is very prone to widening over time no matter how well closed it was initially. This creates scar widening and an indentation along its course as the weight of the facial tissue pulls down on it over time. Your long facial scar can be improved but its appearance can not be completely eliminated. It needs to be excised along its length and then put back together in a broken line closure pattern. Such interdigitations prevent the recurrent scar widening that you now have. While in some cases of facial scar revision it would be followed months later by light laser resurfacing or dermabrasion, your darker skin pigmentation would preclude that final touch-up after your scar revision.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a tummy tuck which is needed after my bariatric surgery. After my bariatric surgery I’ve had this horrible itching and burning under my skin flap over my c-section scars. Do you thing my insurance would help pay for me to get a tummy tuck? I am too embarrassed by my body to swim or dress in front of anybody. It really is horrific on my life.
A: For the sake of clarification, you are specifically asking about an abdominal panniculectomy not a tummy tuck. An abdominal panniculectomy is a potentially medically indicated procedure to treat a flap of overhanging skin that causes dermatologic problems underneath it due to chronic moisture. A tummy tuck is a purely cosmetic procedure that removes loose abdominal skin and fat that may or may not have some waistline overhang.
Only your health insurance company can truly answer the question of whether an abdominal panniculectomy would be a covered procedure. That needs to be obtained through what is known as a predetermination process. This involves a consultation from a plastic surgeon from which a predetermination letter with picture and medical documentation would be submitted. From this information, your health insurance company will then determine whether they authorize coverage.
While only the insurance company can make that decision, there are very specific criteria that they look for in determining that eligibility. Without all of them, it will most assuredly be denied. They include photographic documentation of an abdominal pannus that hangs over the groin crease onto the upper thighs, photographic documentation of redness/skin irritation under the abdominal pannus, and medical records that demonstrate there has been a history of skin infections that have been treated by topical methods that have recurred despite these treatments.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting some information on scar revision. My daughter has a lip scar from an injury 5 months ago. Is there anything that can be done to fix the misalignment of the vermilion border and to minimize the white scars on the red part of the lip? Attached are some pictures of her upper lip scar.
A: Your daughter’s residual lip scar is classic for what happens in many lip lacerations that cross the vermilion-cutaneous junction. There remains a residual misalignment of the vermilion edge, white scars on the vermilion and thickening of the involved lip area with a knotty feel to it. This can be improved by a lip scar revision in which the scar tissue is removed by vertical excision and the lip elements then anatomically realigned. The question about the timing of a lip scar revision is determined by when after the injury one is certain that a revision is needed. That is most evident now so it can be done anytime moving forward.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like to have a forehead augmentation. I am a female and have a small feminine-type forehead and would like a bigger more masculine forehead, one that is much more convex in shape. It is very clear to me now that the women I find the most beautiful almost all have a large forehead. Prior to the operation I will get permanent hair removal on the hairline. I think this hairline makes me look like an angry man from the sides. Thank you very much.
A: Forehead augmentation can be done to create a variety of aesthetic forehead changes. For many women that seek forehead augmentation, they are interested in a rounder or more convex forehead shape. This is one where there is no distinct brow break and a forehead shape that extends upward from the brow area in varying amounts of projection before heading back into the hairline. The degree of convexity, so to speak, is a matter of patient preference. The only issue in larger amounts of forehead augmentation is to make sure that it tapers gradually into the temporal line area on each side. Lack of a more gradual side transition can create a boxy forehead shape when the central augmentation amounts start to exceed more than 10 to 15mms.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m interested in abdominal scar revision. I’m a 35 year old female who has a very big scar on my abdomen from an open surgery on my pancreas (Whipple procedure) done six months ago due to chronic pancreatitis and necrotizing pancreatitis. You can see where the staples were on the scar as well. I also have two small scars on both sides of my belly button from the same surgery where they attempted laparoscopic surgery. I’m most insecure about the huge scar from the open incision. Is it possible to remove this scar? What options are available to remove or reduce this scar? What cosmetic procedure is recommended? Can you tell me about these procedures? As it has only been 6 months since my surgery, how long would I have to wait before having a cosmetic procedure? As you can see I have a few other scars from a laparoscopic surgery to remove my gallbladder years before These scars are inside/right outside my belly button, two on the far right side of my upper abdomen, and one in the center of my upper abdomen right near my new scar. These scars are small and blend in well with my skin now. Will my other smaller scars from this past surgery blend in like these eventually or would it be possible to remove or revise all the scars? Would my current health be a factor in determining if I’m a candidate for cosmetic surgery? Please advise me as best as possible. I would really appreciate your help. Thank you!
A: In answer to your abdominal scar revision questions:
- I believe all of your scar appearances from this past extensive surgery are stable, will not improve, and can be revised at any time.
- As long as your healthy enough to go through surgery and heal uneventfully, then you would have no problem with extensive abdominal scar revisions. I would need to know more general health information and any medications that you may be on to answer this question better.
- Your scar revisions would be complete scar excision with abdominal skin flap raised to close the extensive subcostal excision area. (like a reverse tummy tuck skin flap)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have stretch marks covering most of the center of my abdomen. They are about two years old. I am curious about the pricing of your fractional CO2 laser resurfacing as well as recommendations for the best type of treatment or any other suggestions.
A: When it comes to treating stretch marks, there are no completely effective strategies. They may be able to be reduced but can never be completed eliminated. Fractional CO2 laser resurfacing, while effective for facial skin wrinkle reduction and skin rejuvenation, has not shown a similar profound effect on stretch marks. The best way to determine if it would have any beneficial effect would be to do treat a small area first (test patch) before embarking on treating the whole area.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a lot of facelift questions for you. Which ‘full facelift’ technique do you offer? Do you offer the deep plane composite facelift technique with a 80% vertical pull and 20% lateral pull? I see on your website that most of your pulling is towards the ear. Doesn’t this result in a ‘wind pull’ ‘done’ appearance? The vertical pull seems to be more natural. And using the deep plane technique to offer a longer lasting result by accessing the the premasseter space, to lessen the jowl, and the labiomandibular fold?
A: Facelift surgery comprises a large number of techniques that can principally be broken down into incisional locations, skin flap undermining, SMAS management, platysmal muscle manipulation, method of fat removal and/or fat volume replacement. Any facelift procedure and its results and longevity is really a symphony of how these parts are put together that can really be different for each patient. Rarely do two facelifts have exactly the same anatomic components. I would submit that each and everyone of these parts have a role to play in the outcome and no one component alone is responsible for how a facelift result will look or how long it will last. There is also the other important variable which is the patient themselves…how extensive a procedure do they want, how much recovery and swelling can they tolerate and what is their budget.
But since you have ask about the SMAS component of a facelift I will address that issue in detail only as it relates to results and longevity. Manipulation of the SMAS layer in a facelift can be done by numerous methods including suture plication with no undermining to extensive undermining with a SMASectomy and plication. (what you are partially referring to with the term deep plane) While some manipulation of the SMAS has proven benefits over none at all (a simple subcutaneous facelift) it is has never been conclusively proven that deeper methods of SMAS undermining produce a more natural result or last longer than lesser degrees of SMAS undermining. It would theoretically seem like it would, and it may well be, but proving it (other than some surgeon’s touting it as so) is another matter. Its proof would be difficult as it would require one type of facelift being done on one side of the face and another on the other side in a series of patients.
It is also important to understand the movement of the SMAS layer and the overlying skin may and often are different. Since the skin and SMAS are commonly separated, their tissue movements are usually in slightly different vectors. The SMAS layer can be done in a completely vertical direction (when it is plicated) or in a more superolateral direction when it is undermined and repositioned. Likewise the skin layer can be similarly moved in these directions. Both the SMAS and skin layers are moved in varying degrees of superolateral movements. There is no such true lateral repositioning in either the SMAS or the skin layers. This is probably where you have gotten the phrase ’80% vertical and 20% lateral’, demonstrating that tissue relocation in a facelift is a combined superolateral translocation of tissue that is directed primarily towards the ear and the lower temporal region.
When it comes to what makes a facelift look natural, it is not an issue that is caused by one facelift technique being better in that regard than another. All facelift techniques, big or small, can make for an unnatural result. It is most significantly influenced by the ‘artistry’ of the plastic surgeon…not overlifting or overpulling any tissue layer and in how the incisions and hairline are managed around the ears and the temporal hair-bearing region. (e.g., more vertical directions of skin movement will move the hairline up higher unless that is factored into the incision design.
The deep plane composite facelift is unique amongst facial rejuvenation techniques because it basically does not separate the skin and the SMAS layer once beyond the anterior border of the parotid gland. Once the tissue plane is elevated, the entire composite of tissues is then lifted and secured. This composite tissue unit will always have a more vertical direction of relation, because if it does not, the amount of change would be minimized because the skin is attached to the SMAS layer throughout the flap. The deep composite facelift takes the longest to perform, has the greatest risk to injury of the buccal facial nerve branches, and will have a longer recovery due to prolonged swelling. Its best benefit, in my experience, is that it is the ‘safest’ facelift technique in smokers and others that may have compromised healing as the blood supply to the overlying skin is not disrupted by making a completely separate tissue layer from the SMAS.
Facelifting in men offers several unique considerations. The vector of tissue lifting in men has to be as vertical as possible since any significant lateral movement will result in having to workout tissue excesses behind the ear, risking a longer and more visible scar into the occipital hairline. Moving the sideburn higher is overcome by merely growing out the beard skin to drop the hair level back down. (which is why it is advised that men grow longer sideburns before the procedure) Too much of a lateral movement will also risk placing the beard skin closer to or on the tragus of the ear which is obviously undesirable. (although this can be prevented regardless of tissue movement by the location of the incision) Men are also unique facelift patients as their tolerance for a lot of swelling and prolonged recovery is not typically very high.
As you can see, facelift surgery is a myriad of assembled parts. While it is understandably convenient to label them as certain types, each facelift technique has varying influences on the outcomes, recovery and risk of complications. One facelift type is neither completely superior nor applicable to every patients’s facial aging needs and concerns.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a question concerning using injectable fillers in the jawline. I’m considering doing a jaw implant, not so much to widen the jaw but to lengthen the jawline down in the vertical direction. I know that injectable fillers (such as Juvederm Voluma) is a great option when it comes to widening the jaw and this is commonly done. But my question is if it´s possible to also lengthen the jawline in the vertical direction with fillers. Is it a good use of an injectable filler? I don´t want it to float about when your laugh for instance but I guess it could be a good strategy to start with fillers before possibly doing an implant. I also would like to know how much approximately you can lengthen it with fillers, maybe 4mm to 5 mms?
A: Injectable fillers can be a good starting point when considering any type of facial skeletal augmentation including the jawline. It will work equally well for vertical jawline lengthening as well as jawline widening/accentuation. It will not move around anymore on the lower edge of the jawline than it will when it is placed on the side.
Dr. Barry Eppley
Indianapolis, Indianapolis
Q: Dr. Eppley, Could you tell me when diced cartilage injections are recommended in rhinoplasty? Five years ago I received a septal cartilage graft on my nasal dorsum but there remains a little gap on the side of the dorsum between the eyes. Could a diced cartilage injection resolves my problem? Does it need a lot of spetal cartilage which was used initially for my dorsal cartilage graft?
A: Small cartilage deficient areas of the nose are fairly ideal for an injectable diced cartilage rhinoplasty. What you are ‘missing’ is that the dorsal augmentation has created a relative deficiency along your nasal sidewalls. That could be filled in with diced cartilage injected from an intranasal approach. A small septal or ear cartilage should suffice as the cartilage donor source.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’ve been looking into cranial augmentation and it has led me to here. You seem to have a lot of experience in the matter so I have a few questions. I have flatness in the back of my head and also a hump on the top of my head. If you look at my pictures, the flatness starts at point A up to the top of my head. The hump starts at point B and continues to point C. I have also outlined a drawing of how I would like the final result to shape into. My questions are:
1. Can both of these issues be corrected in the same procedure and through the same incision point?
2. Could a single vertical incision,essentially from point A to point C give better access to address both issues, or is a coronal incision still the method of choice?
3. I would be an out of town patient. If I were to go through with the procedure, how many days would I have to stay in the Indianapolis area for?
A: When it comes to skull reshaping, it is very common to simultaneously perform areas of reduction and augmentation. In answer to your specific questions:
- Both the sagittal ridge reduction and the occipital augmentation can be done through the same incision at the same time.
- The transverse coronal incision would be the standard approach. While there is nothing wrong per se with a sagittal or vertical incision, as equal access to do the procedure can be obtained as the coronal incision, there would be greater scar widening with that scalp incision orientation.
- You would be able to leave for home by 48 hours after surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley,I am interested in a testicular implant. I’ am 24 years old and I have monorchism. When I was in grade school my older brothers thought it was funny to tell every one and this humiliation as stuck with me my whole life. They called me “Half a Man” or “UniBall”. It was a traumatic experience to say the least. Now that I am older I would like to have an implant put in. I just want to feel normal. I’ve read enough about testicular implants over the years to know the surgery is considered an aesthetic procedure but there’s so much more to it than that. Is there any way an insurance provider would consider covering such a surgery?
A: Whether insurance would cover a procedure like a testicular implant is one they have to answer. I can not predict with any accuracy what any insurance may or may not do. My experience would suggest, however, that they are likely to call it a cosmetic procedure as it serves no medical benefit. (unfortunately they do not consider the psychological aspects of any missing or deformed body part as being medically significant) However this is a question that you would have to ask your insurance carrier.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a rhinoplasty combined with orbital and maxillary osteotomies on me. I am wondering if it is possible to completely or partially reverse the osteotomies specially the orbital ones. In my picture you see how there is a bone that sort of curves from the eyebrow to the eye corner and then from the eye corner to under the eye and then becomes the nasal sidewall? This bone is missing now. The entire nose is thinner at the dorsum and base of the pyramid and the bone between my eyes is thinner too. The operative report says he performed medial and lateral osteotomies. I don’t like how my sidewalks are gone… Is there a way to make my bones back to how they used to be? My nose is flat on the sides and has a very thin dorsum I had to add filler to make normal-looking. I liked my wide sidewalls before the surgery. The best way I can explain this is that the ascending process of the maxilla used to be very far apart from each other and now it’s all closer to the midline.
A: What you had done was a LeFort II osteotomy. Bringing the nasomaxillary complex forward, it could be predicted that the nasal sidewalls would get more narrow. This is due to not only the bony area moving forward (telescoping effect) but the probable collapse of this thin bone area from the destabilizating effect of the osteotomies.
To rebuilt this area, there are multiple options depending upon the type of graft to be used and the surgical approach. The simplest approach would be using injectable fat with the disadvantage of the high unpredictability of its survival. I would only do this if one was seeking a ‘non-surgical approach. Another semi-injectable approach would be the placement of hydroxyapatite cement placed through intranasal incisions. (similar to how nasal osteotomies are done) More traditionally, the bone grafts can be inserted through either an intranasal, eyelid or coronal approach. I assume that your LeFort II procedure was done through a combined intraoral and coronal incisions.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in pubic liposuction. I have an enlarged mons pubis and always have. It sticks out, is soft and doughy and protrudes further than my stomach. I wonder if my pelvic bones are at the wrong angle. My mound has really no sensation which I assume is because it is just a mound of fat. This is very embarrassing as I am small and thin with a weight of 104 lbs at 5’ 2” tall. While my weight fluctuates a little, there is no change in the size of the pubic mound. I am assuming that some form of liposuction is the best method to reduce this mound to a flatter profile.
A: A protrusive pubic mound is a not uncommon problem for many women. It is most frequently seen after a tummy tuck where the waistline is the most narrow circumferential area and a residual pubic mound (not recognized before surgery) now sticks out further than most of the stomach. It can also be seen in very thin women who naturally have a thicker fibrofatty layer on their pubic mound. This type of fat is not responsive to weight changes as it has a protective padding purpose and not a metabolic fat depot role.
You are correct in assuming that pubic mound liposuction is the definitive treatment. While much is made of the type of liposuction used, the reality is that ‘simple’ non-energy based liposuction will work just as well. The key is that it must be of the small cannula variety since the area is so small. This discrete type of small fat removal does fall into the moniker of ‘liposculpture’.
Pubic mound liposuction can be done under local or IV sedation, takes less than one hour to do, and involves very little recovery. One needs to be aware that there will be some bruising and swelling of the mound and labia and that it will take several months until the pubic area feels soft and normal again.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in skull augmentation I was wondering if you ever use an inflatable under the crown of skull to inflate skin so you can have more room to shape head? My niece needed an inflatable on her leg when she was young, which they used when they removed cancerous skin. I believe they can do this if area on skull needs extra skin to cover cement. If you do this, maybe you can tell he how much and my procedure can be a two step procedure. If I can pay for this and come back when time for procedure to correct and reshape flat areas. Please let me know. Not sure what the procedures are called but I may need more serious fix and may need more room for reshaping.
A: When it comes to skull reshaping or skull augmentation, you are referring to a two-stage approach initially using a tissue expander. For larger amounts of skull augmentation, particularly for a flat back of the head, more scalp is needed. A small scalp tissue expander, slowly inflated over six weeks, creates more than enough extra scalp tissue to cover any degree of augmentation desired.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I need help in figuring out the best way to enhance facial volume. I have hollowing under my eyes and would like a stronger jawline. I had cheek implants placed two years which have done great so am looking for similar impact on my other facial areas. But I’m not sure what the best way to accomplish this is using either facial implants, fat injections or injectable fillers.
A: When it comes to facial volume enhancement the surgical debate is always whether it should be done by fat injections or facial mplants. This is no different that the debate would have been about your previous cheek augmentation. There are advantages and disadvantages for either approach but that debate must be assessed more specifically for the facial area that one wants to enhance and whether it is composed of underlying bone, soft tissue or both.
The jawline is primarily supported by bone so any effective augmentation is almost always done by some form of implant placement. You would have to further define what jawline area to which you want changed to better answer what type of implant may best address it. This is identical to your cheeks which are usually most effectively done by implant because they are a bony supported area.
The under eye area is different than the jawline because it is a combined bone and soft tissue area. The lower end of the under eye area is the inferior orbital rim while most of the lower eyelid is soft tissue supported. This usually means that fat injections are needed as an implant only covers the very lower end of the under eye area and placing it requires a lower eyelid incision to do so. So fat injections, even though they are unpredictable, usually win out over any implant augmentation. Their ‘softness’ is kore appropriate for the under eye area than the jawline.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am inquiring about skull reduction surgery. I have read online said that you can reduce the head. I have always been very conscious about how wide my head Is. It’s wide and big. What can you do exactly? May I send you some pics so you see what I am talking about? I also am losing hair and I read on your website that you don’t recommend the procedure for hair loss. But I am not entirely sure how you narrow the head, mine is very broad. I often wear hats because I am self conscious about my wide head and hair loss.
A: Thank you for sending your pictures and expressing your concerns. There are procedures that can very effectively reduce the size of your head including temporal muscle reduction and bone burring. (skull reduction) There is no doubt in my experience that they could change the way you see your head. However, to do these procedures one needs a scalp incision to do it and with your hair loss I would have grave concerns about the remaining fine line scar from the surgery. Thus in your case I would seriously question that aesthetic trade-off. You don’t want to trade one problem for another. While there are trade-offs in every aesthetic procedure, what one trades into should be perceived as being better than what they currently have.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in skull reshaping surgery. I am a 35 year old female who is concerned about head size and shape. My head is wide and big overall. Especially, the top and the sides of parietal bone are bulged so that it is really difficult to find hats to wear. I hope to reduce the top and side portions of my skull as much as possible. Having the surgery done is only way to get to rid of my life long distress. Is it possible for a patient who lives outside of the US to get this surgery done? The hardest part for me is to take a long absent from work so the time is my big concern. How many visits are required before and after the surgery? If I am sure to have the surgery, is it possible for me to visit you first time and get the surgery done in a week or so? I could possible use the weekend for before and after consultations. Another concern is that I need to visit and get through it by myself. Would that be okay?
I am sending you some pictures. Because of my thick hair, it might be hard to understand my head shape. But my hair is wet and pushed to my skull. I would not say my head is deformed. The head shape is like an apple. Both back sides of my head are sticking out. I also wish to reduce the top portion of my head as well to make my head smaller overall. Especially, the back side of the parietal region.
Here are some specific questions…I am sure you get these questions all the time.
1) What are the risks of the head reshaping surgery?
2) How much swelling will be expected? Does my head get bigger than before until the swelling goes down?
3) What will happen to the excess skin? Is it possible to cut it off? Is there any sagging skin issue after?
4) For the top and the side skull reduction how long the incision will be?
I don’t know how much physical difference you can make. But even 5 to 7mm, I will be
happy.
Sorry to bother you with many questions. Looking forward to hearing from you.
A: It is very common in my practice to have patients come from all over the world so we are very familiar with this scenario. Far away patients usually come in a day or two before surgery, have the surgery, and return home in 3 to 4 days after this type of surgery. Most do come but themselves which is why they stay overnite in the facility after surgery. Any after surgery followup is done online by email so there is no reason to return for a specific follow-up appointment. It is usually just a one time visit for the combined consultation and surgery.
In regards to skull reshaping, specifically skull reduction, the answer to your question is as follows:
1) The only risk is that there will be an incision (scar) to do the surgery and the question of how much can be reduced. (i.e., can enough be done to make the surgery worthwhile) In that regard you have made a key statement in that if even 5 to 7mms was taken down that would be viewed as an improvement. By that measurement of success, then it would be worthwhile as that is what can be maximally taken down in most areas.
2) There would be some swelling and your head would initially be slightly bigger than when you started. But the swelling is not so significantly different that it makes your head look overly big.
3) There would be no sagging skin afterwards. The scalp skin will shrink down quickly to adapt to the smaller size.
4) To get the maximal reduction of all involved areas, an incision would be needed in the more traditional coronal style, meaning a longer incision from the top of the ear from wide to side. This gives maximal exposure to do the work for the best reduction possible. It is an incision that heals well with a very fine line scar in most cases.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, two years ago I had jaw advancement and sliding genioplasty surgery. Although my face symmetry has improved dramatically, this surgery has left me with lower lip incompetence. There is a 5mm to7mm gap between my top and lower lip when my lips are in resting phase, and although I have no evident mentalis strain when I force my lips to close, I would like to know if anything can be done to correct this lip incompetence. I have read that mentalis resuspension can work but I am not sure if this applies to me as I do not know the source of my lip incompetence (though I suspect it has to do with the mentalis muscle). Please see a before and after picture demonstrating the change in my lower face shape/size as well as my lower lip incompetence.
A: Any lower lip repositioning downward after any intraoral procedure that involves an incision inside the mouth at the chin area disrupts the mentalis muscle. Whether the muscle was adequately resuspended or not I would have no idea. But when the lower jaw is advanced combined with a sliding genioplasty, the amount of soft tissue to cover over the chin may simply have become ‘inadequate’ or stretched. This is reflected in the lower lip position which is affected by being pulled downward. Whether you can overcome the lower lip position by mentalis resuspension alone is suspect. That alone is unlikely to hold the lower lip upward and reduce the incompetence. This is a problem of tissue deficiency not just one of tissue malposition. The mentalis resuspension would have to be combined with other maneuvers to have chance of success. The addition of dermal-fat graft on top of the muscle suspension and a V-Y mucosal closure would be needed to end up seeing any improvement in your lip incompetence.
Dr. Barry Eppley
Indianapolis, Indiana
