Your Questions
Your Questions
Q: Dr. Eppley, I have developed a neuroma after a facelift three years ago.I first noticed it when driving and my shirt collar rubbed against it and it felt as though there was something tickling my right ear. The surgeon treated the neuroma with a steroid shot. Although the numbness and sensitivity went down it was still there. The doctor treated the neuroma two more times without improvement. The numbness extends along my lower right jaw line, upper right neck, right cheek in front of the right ear and the right ear. My surgeon told me he never had a patient with a neuroma that was not treated successfully by injecting a steroid.
I visited another facial surgeon earlier this year. He told me if he did the facial surgery he would recommend treating the neuroma at that time as another facelift. He said he would cut the neuroma off/away from the nerve. He said it might not correct the problem completely and that I might have complete numbness in some of the areas where I now I have this strange feeling in my face.
I am reluctant to have either surgeon cut me since neither has treated a neuroma before. I would appreciate your recommendation concerning my neuroma at this time.
A: Thank you for the detailed descriptions of your after facelift issues. I can make the following comments.
1) While steroids is not an unreasonable approach to an initial treatment of a neuroma, when refractory, others more definitive approaches need to be considered.
2) I have not had a patient develop a neuroma of the greater auricular nerve after a facelift but I have treated several that have.
3) The traditional treatment of a neuroma would be excision and burying the ends of the nerve into the muscle. It is possible, although less likely, that the entrapped portion of the nerve could be identified, excised and the nerve repaired by putting the two ends back together. This would be dependent on being able to find the actual location of the neuroma amidst scar tissue which is usually possible because it is so superficial and its location can be identified externally before the surgery.
4) What will happen to the sensory innervation after any of these possible neuroma treatments is unpredictable…meaning it may get better worse or there be no change. Bring three years out of the procedure makes it a different situation than when done much earlier. Similarly the impact of the neuroma repair plus or minus facelift in your tinnitus is similarly a wild card. Getting it or its exacerbation from a facelift was not a predictable event so what happens with further surgery should not be assumed.
5) Whether you treat the neuroma independent on a facelift or at the same time is personal decision and depends on your motivation for a secondary facelift.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was wondering if you have performed this type of skull reduction surgery before. I have a very pronounced bump on the top of my head near the back as you can see. I would like to have the spot reduced down to make my head shape a little rounder. I am also wondering what kind of scarring I will have afterwards? I am bald so minimal scarring procedures would be the best option for me. If you could also give me a rough estimate of the cost that would be great.
A: Sagittal crest skull reduction is a procedure that I have done numerous times. Your situation is exactly the type of patient in which this type of skull reduction is done….male, shaved head, and a posterior raised end of the sagittal crest. This is done through a small curved 4.5 cm incision. From this limited incision as much bone is reduced as possible. I have always been impressed with how well this incision heals and how imperceptible it can be later. On average the total cost of the surgery is around $ 6,500. Most patients can achieve a near complete flattening of the raised area with sagittal crest skull reduction surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I read one of your posts about reversing cheek dimple surgery and I would like to set up a consultation with you. I had cheek dimple surgery on my left smile groove about 2 years ago. The day after the surgery I knew it was a mistake and asked the surgeon to undo the dimple. He loosened the suture but since then the dimple is still there. It was suggested that I do a subcision and I have had a total of 3 subcisions in the same area but now I have a donut-like shape to it whenever I smile. I also have a hard bump underneath the dimple that may be contributing to the donut-shape (I’m thinking this may be scar tissue from the subcision). I would like to fix the donut shape and to get my natural face back. Would this be something you would do in your office?
A: Most cheek simple surgery procedures have the problem of being unable to sustain their effect and the result is less than some patients want. Your problem is unusual in my experience in that a cheek dimple surgery undone the next day has resulted in a permanent indentation. Subcision early after the procedure was certainly a reasonable approach. But now at two years after the procedure, it is going to take more than that to create improvement in the cheek indentation. Your cheek dimple reversal surgery is going to require a fat graft either through injection or placement of a dermal-fat graft.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was wondering if you did the ‘chin wing osteotomy’ surgery which is different from a genioplasty where they move the jaw forward ? I saw your response to someone else asking the same question on Real Self and you said you’ve done it before and I was interested. Not a genioplasty or a chin implant which I can get done where I live. I’m not sure if there’s other names for it but that’s what it’s called on other surgeons websites who do it. I’m assuming it’s called a chin wing osteotomy.
A: I am very familiar with the chin wing osteotomy, having performed it numerous times. Quite frankly I think it is not a very good procedure for the problem that it is designed to treat. It is technically difficult to perform and is prone to a high rate of complications. Iy requires a long bony cut back from the chin to the jaw angles underneath the mental nerve foramen and the path of the inferior alveolar bone as it courses through the bone.
It is really an historic procedure for which there are more effective procedures today. It is far easier, has less complications and a better result is obtained using a custom made jawline implant when attempting to obtained total vertical jawline augmentation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like a more elongated lower 3rd of my face with less of a square look. I previously had liposuction done underneath my chin but it has never improved. Will the chin augmentation improve this area? Also, approximately how much length in mm is needed to achieve what I am looking for? Thank you!
A: You have a very distinct chin augmentation need. Your square jawline and distance between the base of the nose and the chin indicates that there is a vertical lower facial deficiency. I would not have expected liposuction under the chin to change what is a skeletal issue. There are twi fundamental approaches to managing a vertical lower third of the face deficiency. If it is just located anteriorly a vertical lengthening sliding genioplasty or a custom vertical lengthening chin implant can be used. If one feels the entire jawline is vertically short from front to back only a custom jawline implant that lengthens the entire jawline can be done. In looking at your face my feeling is that a vertical lengthening sliding genioplasty would probably be the best choice. In my experience at least a 7mm vertical increase is usually needed to make a noticeable vertical chin augmentation change. This is done by an open wedge bony genioplasty where the front edge if the bone rotate down while the back edge of the bony cut keeps the bone in the same position. The exact measurement of vertical chin lengthening needed can also be determined by two other methods. One can open their lower jaw to the vertical chin length that looks good to you and measure the created distance between the front teeth. One can also take measurements of their facial thirds and then see how short in millimeters the lower facial third is. I would do both methods to see how well they correlate so you can select the most effective vertical chin augmentation improvement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I spoke to you this last summer on Skype regarding forehead augmentation. I favor using bone cement as opposed to a silicone implant. Do you think burring of my supraorbital ridge will be necessary? If so, would the charge me extra? and is there a risk of damage to my sinus cavity?
A: When you have the severely sloped forehead that you have, it would be good to to do some modest burring of the supraorbital ridge. It would be complementary to the forehead augmentation in creating a better overall result. With burring the key is to stay out of the frontal sinus which requires experience in doing so. How much reduction can be obtained is a function of the thickness of your frontal sinus wall. If you need a frontal sinus setback that would be important to know up front because it will take some more surgical time to do and there will be some extra costs in doing so.
The choice of forehead augmentation material is a personal one. I have used both bone cements and custom implants successfully and each has their own advantages and disadvantages. I do not necessarily favor one over the other, I just try and educate the patient on the merits of each material.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a corner of mouth lift. I have had fillers and Dysport to lift the corners of my mouth. I don’t believe the doctor who did my filler placed it right. I have a puffy place then it goes flat and it didn’t raise the corners of my mouth at all. I spent a lot of money to get that done. I was wondering if you think a corner of the mouth lift would help and how much does it cost. I am 48 years old. Thank you.
A: While injectable fillers and neuromuscular modulators can have a positive effect on the corner of the mouth, it depends on what the original problem was (how severe is the corner of the mouth droop) and what type of change (corner of mouth lift) one was looking to achieve. Your result may be a function of an incorrect treatment for the problem (mouth corners to severely sagged) or the correct treatment that was not ideally done. I can not say which led to your post-treatment results. I would need to see pictures of your mouth area to determine what is the best approach now.
What I can say is that a corner of mouth lift is the single most effective method for changing the shape of the corners of the mouth that produces a more profound and sustained result.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in chin ptosis repair surgery. I am emailing you to see if you are able to correct my chin deformity from a previous surgery five years ago. I had a chin implant removed from twenty five years ago because it made my chin look very wide and bulky. The surgeon performed a sliding genioplasty for a 3mm advancement and a lipectomy which left me with a depression and a bulge. I now have redundant skin hanging and my chin is very flat and wide and misshapen. If there is anything you think you can do to correct this please let me know.
A: Thank you for sending your pictures. What you have is chin ptosis and a residual wide chin. (since I do not know what you looked like before I can only go by your current picture) The best approach for your chin ptosis repair is a submental chin reshaping procedure to taper your bony chin and get rid of the overhanging tissue. This is the most assured way to get a better chin contour by dealing with both the bony and soft tissue components of the problem from the underside of the chin. As your chin problem is primarily that of loose skin this is particularly the best chin ptosis repair approach for you.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a full tummy tuck. I believe I would accept the trade off of the scar for the results of the tummy tuck. My loose skin bothers me so much I do not take my shirt off in front of anyone and I will not wear a bathing suit. I find myself covering my stomach with my arm even when I am alone. It would ultimately depend on how high the incision would be and how inconspicuous it would be over time. I have researched hundreds of before and after photos on real self and women with similar “before” photos like my stomach and was very impressed with the results. With my C-section incision, my appendectomy incisions and all the stretch marks from pregnancy I think the incision would be a fair trade. Again, I would want to know where the incision would be and I know that could only be accomplished through an in-person consultation.
I am slightly concerned about the nipple lift for my breast augmentation. I am not sure what that entails, but it makes me more nervous than the tummy tuck incision. I am most concerned of lost sensation and additional scarring as a result.
A: You have made a key point in understanding the aesthetic trade-offs of many cosmetic procedures, particularly that of a tummy tuck. Each option (keeping your loose abdominal skin vs a tummy tuck) is not perfect and you choose which ‘problem’ you can live with the best. The tummy tuck scar will not end up as low as your c-section scar and will probably end up 1 to 2 inches higher. Also it would be likely that our full tummy tuck scar will end up with a small midline vertical component running just above the horizontal part of the incision. This is sometimes necessary when doing a full tummy tuck to keep the central aspect of the scar low rather than being pulled up in the middle. While many tummy tuck scars do heal well, I don’t think I would ever call them inconspicuous but that is a matter of personal perspective.
The small nipple lift scars are really irrelevant and are not a concern for visibility or nipple sensation. The choice you will have to make is that your nipples may not be centered on your breast mound without them given your existing breast sagging. It is important to understand that implants do not create a lifting effect on the breasts. They merely make breasts bigger and can magnify any existing breast asymmetry or breast sagging.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in some type of shoulder implants. I want to correct my body shape. All of the doctors I have seen suggest liposuction from belly and then inject that fat to shoulder areas but I think this is temporary solution. I dream something like silicone implants which are created custom for me. Please check my before and after photos I made it on an app.
A: What you seek for shoulder implants does exist and they are known as deltoid implants. Shoulder widening surgery can be done using preformed body implants or they can be custom made from a low durometer (very soft) solid silicone material. They are inserted from an incision at the back end of the armpit skin crease. Since there are no performed or standard deltoid implants, preformed calf implants are often used for the deltoid area as they have a long cylindrical shape to cover the central deltoid muscle. Custom shoulder implants can also be made from measurements on the patient baed on their length and width of the central deltoid muscle. Shoulder implant surgery is a procedure that takes about 90 minutes to perform under general anesthesia.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in vermilion border advancement (lip advancement) in the sides/ corners of my upper and lower lips. I would also like to pair this with large permalip implants. I have several questions. Can these two procedures be done at the same time? What would the down time be? What is the cost? Finally, I am not looking for a “natural look”. I have had my lips quite full using injections for several years and like this look but do not enjoy the costly upkeep since they wear off in two to three months in my lips. I can pictures of my lips without injections and a photo of what I want to achieve to see if you think it is achievable using the Permalip implants and vermilion border advancement in the sides/ corners. Thanks!
A: Your description of the lip procedures you would need to achieve your goals is correct. It would be necessary to do an upper lip[ advancement but spare the central cupid’s bow area. Permalip implants could be placed at the same time as the lip advancements. As you might image there will be some considerable lip swelling that will take several weeks to subside but that is more of a social issue not a physical limiting one from a recovery standpoint.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a sliding genioplasty revision. I am a young male who underwent a sliding genioplasty six months ago to fix some minor facial asymmetry. The idea was to move the chin 1to 2 mms upward and 3 to 4 mms forward. Unfortunately, this didn’t happen. Instead, the right side was moved according to plan, but the left side wasn’t causing it to be rotated outwards and downwards. My chin is now crooked with the left side being considerably fuller both laterally and anteriorly, but also vertically longer (aproximately 5 mm height difference).
I’ve met with a new surgeon in order to try to get this corrected. He suggested an intra-oral burring of the bigger side (left) in order to spare me a scar. He said he would be able to reduce the height too. I did some research and it seems to be quite tricky to do an intra-oral burring for vertical reduction? I know you prefer the submental approach, but I’d like to hear your views on doing this intra-orally. Can the inferior border really be reached? How many millimeters can usually be removed vertically using the intraoral approach? And what are the chances of tissue sagging?
A:You are correct in assuming that it can be both difficult and unpredictable attempting to make these modifications through an intraoral approach. It would be simpler, more predictable and have lower risks of tissue sagging if it was done from a small submental incision. Seems like a difficult approach that has limitations when you are trying to fine tune the chin bone shape. You have already learned the lesson that when doing minor aesthetic corrections it is easy to miss the mark and still have residual issues. Any further revisions should be done with the technique that would be most likely to reach your goal with a low risk of further aesthetic issues.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in revision of an otoplasty reversal procedure that I had just a few weeks ago. I had an otoplasty twenty years ago where the ears were over corrected and pulled back too far. I had an otoplasty reversal done two weeks ago to project the ears further out from my head. When i left the doctors office they looked great but with in five days the results were back to the same as before surgery and is still changing. Is there anything i can do to correct and regain the result of a few weeks ago. What my options? Thank you.
A: In otoplasty reversal surgery for the classic telephone ear deformity that you have, the key surgical maneuver is to place an interpositional spacer or graft once the overfolded ear cartilage is released. If this is not done the procedure will not work. It may look good for a few days because of swelling and the local anesthetic injected into it but cartilage release alone will return quite quickly back to where you started. That will only work if the otoplasty is new and within a few months after the initial surgery. Once the cartilage is released something must hold it out to occupy the open space between the ear folds to not only overcome the ear cartilage memory but to prevent scar contracture pulling the ear right back into the overfolded position. I have used a lot of different material for the procedures but my current favorite is irradiated homologous rib graft. It is very sturdy and avoids any rib graft harvest from the patient.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in facial asymmetry correction. My son was born with torticollis. He had physical therapy for a few years but he still is self conscious about his eyes and the fact that his nose and chin don’t align. Is this something that you could improve?
A: It can be seen that he has right sided facial shortening type facial asymmetry. The vertical length of his right face from eyebrow to chin is shorter than the left side. As a result there is a deviation of twisting of the face to his right. Because of his congenital torticollis he may or may not have a chronic head tilt to the left side. My comments will be based on that he does not.
The top and bottom of the vertical facial axis is the key. A right endoscopic browlift with upper blepharoplasty (to create a visible supratarsal fold like the left side) is what is needed superiorly. Inferiorly the chin need to be rotated over to the left with a vertical opening wedge on the right to straighten and lengthen it. I think these would be the two key areas to improve for his facial asymmetry surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I want to get orbital rim implants to correct my negative vector (it bothers me a lot), and being that it’s an obscure procedure (I’ve only found you and one other doctor that performs it), my biggest concern is the implants’ safety, considering their proximity to the eyeball, and chance of migration. I also wanted to correct a nasal tip deformity that happened as a result of an initial rhinoplasty five years ago. Thank you, Doctor.
A: Orbital rim implants are one of the most uncommon facial implants as there are no preformed implants for this facial skeletal area. The best way to create orbital rim implants is to have them made in a custom fashion for each patient off of a 3D CT scan. That way they will fit the bone precisely which, when combined with microscrew fixation, assures their long-term stability. These implants are very safe and pose no threat to the eye when out in by a surgeon skilled in working in this area. Orbital rim implants are very effective at achieving exactly your concern…eliminating tear troughs and a negative orbital vector.
As for your nose, what I see is an entire deviated nasal axis to the right and tip cartilages that deviate to the left. The deviation appears to not be just restricted to the tip of the nose.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have an ethnic rhinoplasty question. Is there a medical term for putting a building block or supporting structure under the nose tip if you don’t have much under there? (i.e such as that in Asian and African American noses) I thought it was a nasal strut but I don’t think that is it because that is only used when someone’s nose tip is drooping. Would a nasal strut make someone’s nose more turned up than it already is? Mine is already turned up. I am just asking because I am trying to figure out exactly what I need before I do anything. Thanks.
A: Your question appears to relate specifically to ethnic rhinoplasty. What you refer to as a nasal strut is more specifically called a columellar strut. This is a vertical strut of cartilage placed between the base of the nose up to the tip between the medial footplates of the lower alar cartilages. This is a very versatile support graft that can be used for a variety of nasal reshaping. purposes such as long-term support to prevent tip collapse/rounding to being long enough to increase actual nasal tip projection.
The use of a columellar strut is of critical importance in just about every Asian and African-American ethic rhinoplasty to change the rounded tip of the nose to a more narrow one with better definition. It is not the only rhinoplasty maneuver done to create that effect but it would be considered the ‘building block’ of the tip of the nose. A columellar strut, in and of itself, will not necessarily increase nasal tip projection. When combined with a variety of other cartilage grafts (e.g., septal extension graft) it may even be used to decrease tip projection while also making the nasal tip less wide and more defined.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, This is a strange question but is it possible to get donor grafts from the part of the head that isn’t considered a donor area? I know your average person has around 8K hair grafts available from the DONOR area, but if someone wanted to access the grafts from the other areas, would this be technically possible?
Say there was a person that wanted a significant beard transplant and this person was much taller than the vast majority of people. They would prefer to take grafts from the non donor areas of their head because they are much taller than everyone around them, they would like to be able to conceal their scar or FUE procedure more effectively since very few people would see the top of their heads. They understand that FUT and FUE procedures nowadays can go undetected with good scar rejuvenation but still they would rather have the scars placed in a more undetectable area. They completely understand that non donor areas are labeled such because there is the risk that they will dissipate with progressive male hair pattern baldness and they are completely aware of this risk because they are already on balding medications such as finasteride and have no significant history of baldness in the family.
Would a situation like this be reason enough to oblige to their request of taking hairs from where they want:non donor area on top of head? or is there some physical reason why something like this may not be possible.
A: The simple answer to your question is that there is not a technical reason that the harvest site for hair transplants can not be taken from anywhere on the head. The reason the back of the head is used is two-fold; that is where most of the available hair is and it is hair that is theoretically programmed to last a lifetime for many men.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in revision rhinoplasty. I had a rib graft placed last year and now it is quite deviated. I want to straighten my nose and it should be a bit higher. What I don’t understand is why the rib graft was ok in the beginning and now it has deviated so much. Can you morselize the deviated part and put it back in. Will the morselized parts be healed like bone does? Will the nose be deviated again? If I go with a nasal implant instead of the rib graft, will it have any chance to deviate again? And will you have to harvest ear cartilage for the nose tip or you can utilize the cartilage that they used in the previous surgery?
A: It is not rare that a rib graft to the nose will eventually develop some deviation. This is a function of its natural curved shape and the memory of its cartilage shape. No matter how the rib graft is harvested it is rare to ever get a perfectly straight piece. As a result it must be carved to be straight. Depending upon how it is carved and where it was harvested along the subcostal margin, deviation can develop. Usually it appears quite soon after placement (a few months) but can be delayed in its appearance much later.
If the goal is a straight nose that is higher, then the rib graft should be replaced with a nasal implant in your revision rhinoplasty. A nasal implant will have more assured straightness since it is made straight. The tip of the nose and the columella, however, should remain cartilaginous, most likely using the rib graft which was removed.
If the goal is simply a straight nose with the same height then the rib graft should be configured into a diced cartilage graft for your revision rhinoplasty. This will eliminate ant risk of subsequent graft warping.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a nasal hump reduction rhinoplasty. I have been looking into various options to achieve a straight nose in profile. As you’ll note from my photos this really is VERY minor – I’m under no illusion that this is not the case. Despite that I’m still very apprehensive about any work on the nose due to the complexity of it all and high revision rate. In particular I’m most concerned about affecting the nasofrontal angle negatively, and building up the bridge and radix too high whereby the eyes look closer together. The latter in particular is concerning as I’ll be having a midfacial operation that will widen the area even more. As such even a slight narrowing effect on the eyes could be exasperated later on with this next operation (infraorbital rim advancement).
As such, what would you recommend? As far as I can tell the position of my radix and nasofrontal angles are all relatively ideal. Would it be best then to shave down the dorsal hump? Or would building up the radix be ok given how minor it would be?
I look forward to your response.
A: My advice for you is not to have rhinoplasty surgery. The revision rate in rhinoplasty where patients have relatively major nasal shape issues is around 15%. When it comes to minor deformities the revision rate is higher…much higher. Contrary to popular perception, the smaller the nasal problem in many cases the harder it is to get it right. (perfect) The margin of error in minor aesthetic nose concerns is zero. It is just as easy to overcorrect in minor nasal shape issues as it is to get it perfect. By your own admission the position of the radix and nasofrontal angles is ideal and the hump is very minor. Be aware you will be scrutinizing the after surgery result just as carefully (if not more so) as the preoperative deformity. The chances of a successful outcome is no greater than an unsatisfactory one. Unfortunately rhinoplasty surgery is not a precise science and can not be controlled down to the level of a millimeter or two of structural changes.
In addition if you are going to being having infraorbital augmentation in the future, that facial change can potentially impact how you see other facial structures. Since that will be having a more major impact on your face I would defer any consideration of rhinoplasty until after that procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in revision rhinoplasty. I have a problem with my deviated nose. This is the result of the rib cartilage placed in my nose which has become deviated. I had a nose job done in 2011 in Korea. It was fine at that time but now the deviation of the nose is very visible. My nose was originally not deviated like it is now
1. My question is whether it is possible to also have a nose surgery to remove that rib cartilage and replace with a good and straight implant. I just want a straight nose, the nose tip and wings are ok.
2. How much of the cartilage can you reuse and how much ear cartilage you need to harvest for the tip?
A: Unfortunately rib cartilage does have a tendency to warp in some patients creating a subsequent deviated nose. You have several revision rhinoplasty options considering that it is just the bridge part of the rib graft that is the issue. (and not the tip) These include the following:
- Remove the dorsal part of the rib graft only and replace with an implant
- Remove the deviated part of the rib graft, morselize it into small pieces and replace it as a diced cartilage graft without using an implant.
The decision between these two revision rhinoplasty choices depends on whether you just want to straighten the nose only or straighten it with further augmentation along the line of the bridge.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am seeking your professional opinion on how to treat my facial asymmetry. What do you think can be done? When I was 17 I underwent double jaw surgery to correct sleep apnea. I believe the right side of my face is lower than my left, my smile moves predominantly to the right, and my left eye is higher than the right. I do not know exactly what has caused this. I would like to know what is your diagnosis and what is a possible treatment. Thank you so much.
A: What you have is facial asymmetry with your right facial side being overall lower than that of the left side of you face. This is evident from the eyebrow down through the jawline. Given the fact that your facial asymmetry is not severe (I know it is to you but in the big picture it is not) any corrective procedure options should be considered from the perspective of what can be done with the lowest risk of aesthetic complications. (trading off one problem for another)
The most visible part of your facial asymmetry, as it is in a lot of facial asymmetry patients, is around the eye area. An endoscopic browlift on the right side with orbital floor augmentation (to raise up the eye) and lateral canthoplasty (change the location of the corner of the eye to a higher position) would make the greatest improvement in your facial asymmetry. Possibly a small cheek implant as well, I would leave your jawline along and there is no surgery that can be done to improve your smile asymmetry.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a custom skull implant for my occipital augmentation revision. I came across this company in my research, Xilloc, which uses 3D printing technology along with CT scan image to manufacture patient specific implants using various materials.
They are on the verge of licensing and releasing a new technology for bone implants called CT-Bone. The patient’s implant is made by printing the material from calcium phosphate. Since calcium phosp is the primary constituent of natural bone, the implant fuses with the existing bone and the body integrates with it just as natural bone bone. The material can also be controlled to exhibit the same porosity as natural bone which may aid in vascularization. The future of cosmetic surgery looks so exciting with this technology. Scientists have also printed human organs like skin, liver and heart with 3d printers using human tissues. Hopefully it will be available in the US market as well.
I really like to have my surgery redone but i have many concerns and expectations that hopefully can be solved with newer and better options.
-100% biocompatible material
-custom fit
-no use of metal, including titanium screws
-desired cosmetic correction, smoothness and symmetry
Will you please look into this, Dr. Eppley.
With your expertise and skill and open-mindness I think anything is possible.
Thank you.
A: I am familiar with many custom skull implant technologies but there are multiple limiting factors. First many such porous hydroxyapatite or calcium phosphate materials tend to be form and less malleable. This creates challenges in surgical placement particularly for the aesthetic skull augmentation patient. A stiffer skull implant material requires a long incision to insert from ear to ear and a complete turn down of the scalp flap. Second, calcium phosphate materials can be more difficult to be made down to a smooth feathered edges. Thus there will be very palpable step offs at the edges of the implant when used as an onlay. This is not an issue for an inlay skull implant but is a huge aesthetic concern in an only skull implant down for aesthetic purposes. Third, the average cost of just the implant alone can be considerable. I don’t the know the exact cost of what this skull implant would be from this company but I would expect it to be more than new thousand dollars.
What you have to appreciate about this technology is that it is understandbly made for inlay bone defects and not primarily for onlay bone augmentations. It is geared for patients who had have skull defects from trauma and neurosurgery and are likely covered by insurance who can absorb the high cost of the implant.. For all of these reasons this may not be a custom skull implant technology for the aesthetic skull augmentation patient. This is a great example of while the technology is great the material chosen for it may limits its application in outer skull contouring/augmentation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Thank you for your rhinoplasty consultation and doing some computer imaging for me. Now that I am moving forward with actual rhinoplasty surgery can you send me the exact prediction images of my nose results? That will help me understand what I can expect after surgery.
A: There is no such thing as ‘exact prediction images’ in rhinoplasty or any other facial surgery. Prediction imaging is done as a communication method between the surgeon and the patient to determine what changes the patient desires and to make sure what may be possible is in line with the location and extent of changes the patient wants. They should not be interpreted as exact replicas that surgery may achieve nor are they guarantees of the result that would be obtained. They are estimates as to what the surgeon believes may happen but can not take into account the exact anatomic changes they would be done nor the effects of healing on these surgical changes. Therefore one should appreciate the term ‘prediction images’ when it comes to this important presurgical step. Fortunately it is usually more accurate than predicting the weather but the accuracy of rhinoplasty prediction imaging depends on the surgeon doing it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in blepharoplasty surgery. My upper eyelids are very heavy and my lower eyelids have large bags under them. They make me look very tired and old. Attached are some eye pictures for your review and recommendations.
A: Thank you sending your pictures. Both your upper and lower eyelids show considerable tissue redundancies. The upper eyelids have a lot of extra skin and hooding (skin pushing down on the lashes) and the lower eyelids show tremendous herniation of the orbital fat pads. They are so pronounced that you can actually see all three fat pads under eye distinctly. (medial, central and lateral fat pads) You would benefit tremendously by both upper and lower blepharoplasties. What is unique about your lower eyelids is that your infraorbital bones are deficient so when the fat is taken away the bags will be gone but the eyes will look very shallow. For this reason that fat that would be removed actually needs to be repositioned so it is draped over the infraorbital bones to correct the tear troughs and infraorbital rim deficiency. So your lower eyelids fat pockets don’t need to be removed per se but they needs to be repositioned to get rid of the prominence and simultaneously correct the bone deficiencies.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in jawline reconstruction.I had upper and lower jaw surgery in 2012 where I was referred by my orthodontist and convinced that I needed it. However, they ruined my face and my bite has subsequently shifted. I would like a sharp jawline. Is it possible to get implants? Now, I cannot close my mouth properly and I have a weak chin.
A: While I do not know what you looked like previously, I can see now that you have a very steep mandibular plane (high jaw angles) and a recessed chin. From a jaw angle standpoint, vertical lengthening jaw angle implants are needed to drop the angle down and provide a more square angle shape. (not really square but closer to 110 degrees) Given that you have had prior jaw surgery (and I assume a sagittal split mandibular osteotomy, SSRO), your jaw angles are likely asymmetric and scarred. Custom jaw angle implants would be the ideal method for these unique jaw angle shapes.
For the chin the options would be either a sliding genioplasty or an implant as part of a total jawline implant which includes the jaw angles. Initially I would favor a sliding genioplasty because the vertical height of your chin needs to be reduced. But a custom implant may be designed this way also.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in jawline enhancement surgery doing a sliding genioplasty and jaw angle implants. Can the chin surgery be done at the same time as adding jaw angle implants? Would these custom implants be of a material that would be able to last a lifetime? I’m only 25 years old and have already gone through so much with my jaw and teeth that I wouldn’t want to go through with another surgery, but I am very unhappy with the way my face looks currently. I think that a sliding genioplasty with the jaw angle implants would be ideal because I agree that my chin looks rather long and I would rather adjust/fix it than add a chin implant. I know that this isn’t a consultation but what would be approximate cost be for these operations…10-12k or over 15k? I am currently covered under Tri-care but I know that these would be considered cosmetic and probably nothing would be covered with insurance.
A: In answer to your jawline enhancement surgery questions,
1) A sliding genioplasty and jaw angle implants can and should be done at the same time.
2) All facial implants are made of non-biodegradable silicone material which will last much longer than you and I will.
3) I thin the best approach in you would be a sliding genioplasty and vertical lengthening jaw angle implants. The most ideal approach for the implants is to have them custom made because you probably have some degree of asymmetry between your jaw angles given your prior surgery. But in the interest of cost, semi-custom vertical lengthening jaw angle implants can be used.
4) I will have my assistant pass along the exact cost of the surgery to you tomorrow.
5) Unfortunately your assumption is correct in that this would not be considered a medically necessity and would be viewed by TriCare as an elective cosmetic procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a revision rhinoplasty. My ENT performed a septoplasty in March of this year. He added cartilage from my septum to make my nose shorter and wider for breathing purposes. While my breathing has never been better, my appearance has changed, and I’m not a big fan of how my nose looks now. I would love to see if this is something that could be corrected.
A: By your description, you likely had spreader grafts placed in the middle vault and perhaps even alar batten grafts. These do successfully open up the internal valves and improve nasal breathing but can make the nose in some patients potentially wider.
The question is now how make your nose look better without recreating your breathing issues. This is most likely an augmentation approach for your revision rhinoplasty but I would need to see some pictures of your nose now to see what potentially could be done if anything. Given your improvement in breathing I would not recommend removing your spreading or batten grafts. Rather I would look at building up the bridge and tip of the nose somewhat to overcome the shorter and wider nose.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a custom occipital implant. My head is obviously flat. I have been insecure about it since my teenage years. I am know in my late 20’s. I am interested in a custom occipital implant to make the back of my flat flat head perkier and rounder. I was wondering what the estimation of this procedure would be? I was also wondering, since you cut the hair/skin part of the back head, is the scar obvious (aside from hair covering it)? For example, if I were to show that area would the scar be obvious? Thank you. I look forward to your reply.
A: For augmentation of a flat back of the head, a custom occipital implant is the best method. It does require a scalp incision somewhere and that would depend on its size and location on the occiput. The scalp scar usually turns out very well particularly in women. If you shave your head the scar would be somewhat obvious but that is the situation you probably are not going to find yourself in. Great care is taken in aesthetic skull reshaping surgery to preserve hair follicles along and around the scalp incision.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m interested in a rhinoplasty procedure where the nostrils would be thinned out. Not brought closer to the center but actually having each nostril thinned out. However I can’t find any literature or examples on the Internet (I remember reading about it years ago though). Is this a thing and can it be done?
A: You may have trouble finding such a rhinoplasty procedure (nostril thinning) because it is very rarely done. That does not mean it can not be done just that one has to consider the aesthetic tradeoffs very carefully. True nostril thinning (not nostril narrowing or base width reduction) is done by excising skin right along the nostril rims. While this can thin the nostrils it will leave a fine line scar and may also create some increased columellar show in the side view. (alar rim retraction) This used to not be an uncommon procedure in cleft rhinoplasty. Thus a patient has to be selected very carefully for it so one does not simply trade off one nostril problem for a new set of nostril problems that may be worse than what one had initially. Scars along the edge of the nostril rim do not heal as favorably as other nasal locations.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in chin implant revision surgery. I had a chin implant placed a little over 4 years ago (I am 26 years old) because of a severe receding chin. I feel that it has always been placed in the wrong positions. Wing placed too high and Apex too low leading to too long of a face and still do not have a chin that looks normal from side view. I was wondering if I could get some information on possible consult such as fee and how much a chin implant revision surgery would be?
A: If the chin implant is positioned too low on the apex of the chin that will create a tilt of the wings upward. That will also make the vertical length of the chin longer by definition. It sounds like chin implant revision by repositioning of the chin implant back up on the bone will bring the wings back down as long as you are happy with the amount of horizontal chin projection that you now have. This would not require the use of a new chin implant unless there were other changes to your chin augmentation result that you desire.
Dr. Barry Eppley
Indianapolis, Indiana
