Your Questions
Your Questions
Q: Dr. Eppley, I am interesting in a skull reshaping procedure for a flat side to the back of my head. In my pictures you can see the difference between the two sides of the back of my head. I want to see if you could make the smaller side of my head (left side) look the same as the bigger side (right side). My ear on the flatter side also sticks out nore. Even though it would cause me to have a large looking skull I wish to find a sense of normalness.
A: Thank you for sending your pictures. You have a classic case of plagiocephaly with left occipital flattening and contralateral right frontal flattening. (cranioscoliosis) The skull reshaping treatment for it is an occipital augmentation on the flatter side. The protrusive ear can be set back in a more traditional setback otoplasty with conchs-mastoid sutures. I assume when you mean ‘make the smaller left side of my head look the same as the bigger right side’ you are referring to using a standard/semi-custom implant or bone cement to do so. I think I would use one of my preformed occipital implants that I use for plagiocephaly cases. It is not as perfect as a truly made custom implant from a 3D CT scan but it can make for a major improvement and lowers the cost of this skull reshaping surgery somewhat.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a frontal hairline advancement. I have no issues with hair loss. My hair hairline simply dips back into in the middle and that’s where I drew a line if that was eliminated on my picture. I have some breakage on the edges from hats and headbands, but nothing permanent. It grows back instantly. Is this possible?
A: Thank you for sending your picture. Where a hairline advancement works the best is exactly where your hairline issue is….in the center of the frontal hairline. This is because the best mobility of the scalp comes the center where the maximal its release is done down the middle all the way to the back of the head. This is due to the limits of the incision and resultant scar. In order to keep the scar from extending all the way down to the ears, most hairline advancements cut back no further than the high temporal region. As one gets closer to the end of the scar the amount of scalp advancement disappears.
Given where you have put the markings for the desired hairline end point I think is a very achievable goal. Scalp elasticity always determines how much the hairline can be moved but a 1 to 2 cm forward movement is possible in most people.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in rib removal surgery to get rid of my lower ribcage which sticks out. I do have a few questions about the surgery.
1. I know rib removal isn’t as common of a procedure as tummy tucks or breast augmentations, how many of them have been done?
2. What are the reasonable cosmetic expectations?
3. I’ve done some research and have read that in some patients it creates permanent pain. Is this sometimes the case?
4. Also, is there a chance of uncontrolled bleeding from the operation?
5. What are some common complications?
A: Rib removal surgery can be done to be used for grafts in various facial reconstuctions (usually rhinoplasty) or for cosmetic contouring of various ribcage protrusions. The fundamental difference between these two types of rib removal are the length of ribs removed and the number and location of them. In answer to your specific questions:
- Ribcage contouring by rib removal is a very uncommon cosmetic procedure but i do about 3 to 3 case of it per year. I do many more rib removals for rhinoplasty and jaw reconstructive procedures.
- The success of rib removal for improved ribcage shape depends on the exact ribcage anamoly. How many ribs and what areas can be removed vs. what is the source of the problem, and how well these match up, determines how successful the procedure can be.
- I have not seen a rib removal patient who has permanent pain and this most likely relates to rib removal for chest surgery which is done differently. (and at a higher rib level since they are interested in entering the chest cavity….a goal that is the exact opposite of aesthetic ribcage reshaping) This usually involves rib bone removal not rib cartilage removal in lower ribcage reshaping. In cosmetic rib removal or any rib graft harvest great effort is made to preserve the neurovascular bundle which runs along the bottom of each rib. Nerve injury or neuromas can be a source of chronic pain.The lack of permanent pain in aesthetic rib removal should not be confused, however, with the fact that there is some significant pain after the procedure. I attempt to limit this immediate postsurgical pain with the injection of Exparel long acting local anesthetic into the surrounding tissues as well as intecostal nerve blocks which usually lasts about 72 hours
- There is no chance of uncontrolled bleeding from this type of surgery.
- The complications from this type of surgery are essentially aesthetic….how does the scar look and how effectively has the ribcage protrusion been eliminated.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m interested in having brow bone augmentation to give it a deeper and more masculine appearance. I understand that there are various materials available, and I was wondering if you could kindly answer these few questions:
1) Which material would allow for the smallest scar?
2) I understand that custom silicone implants will provide the most dependable results, but will hydroxyapatite (HA) be able to provide a similar augmentation?
3) Which would also have the cheapest overall surgical cost – silicone, HA or PMMA?
4) As I’m leaning towards HA, could you also provide the cost of getting this procedure?
Thank you!
A: When it comes to your questions on brow bone augmentation the answers are as follows:
- A silicone brow bone implant can be placed with the smallest scar. Because of its preformed shape it can be inserted and positioned with a limited incision or endoscopic technique. All other forms of brow bone augmentation (except fat injections) require a wide open scalp incision technique with a long scalp scar.
- Hydroxyapatite can provide a good brow bone augmentation if one can tolerate the coronal incision to have it placed. This is a liquid and powder mixture that must be carefully applied and shaped. To do so requires wide open visibility.
- A preformed silicone implant would provide the most economical approach since it has the shortest operative time to complete.
- I will have my assistant pass along the cost of the different brow bone augmentation procedures to you on Monday.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am seeking a sliding genioplasty or chin reduction revision. After a sliding genioplasty 18 months ago and two bone burring operations to reverse it (6 and 12 months after the original surgery) there are still areas of bone, on either side of my chin, that were not shaved back to create my original narrow shape. I am left with a wide bulky chin, the excess skin and tissue have sagged from over the past year. Now, after my most recent operation, I have even more tissue. I am always advised to go back to the trio of surgeons who did it but after this I really do not want to. There is a huge miscommunication and when they discuss things in Spanish, in front of me, I no longer trust them. I just want to have my normal looking chin back. Do you perform this type of revision and reconstruction surgery? How often?
A: While you did not state exactly the method by which your two chin revisional procedures were done, I suspect they were by an intraoral bone burring method. While you should have had the sliding genioplasty reversed by redoing the osteotomy and setting back where it once was, intraoral bone burring was destined to create exactly what you have now…a broader flat chin with soft tissue excess. The proper solution now is a submental chin reduction technique where the chin bone can be narrowed and the excessive chin soft tissue removed.
This is a sliding genioplasty and chin reduction problem that I see and treat regularly. It would be helpful to see some picture of your chin and to know the exact details of all three of your prior surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in rib removal surgery to reduce my protruding ribcage. How risky is this procedure? What are the complications/healing time? What would the results look like? How much, on average, would this cost? What other medical issues would be affected by the surgery? Sorry so many questions! Also, I live in Idaho how do you work with out-of-state patients?
A: Rib removal is not a dangerous surgery but, like any surgery that involves rib manipulation, it does cause some considerable discomfort. This is magnified when both sides of the ribcage are operated on at the same time. The best method of postoperative pain management I have found is the use of Exparel injections as intercostal nerve blocks done during the surgery. This is a local anesthetic that lasts for 72 hours after its placement. One could expect that it would take up to month after surgery until one has fully recovered. There will be a scar for the incision needed on both sides which would be about 6 to 7 cms long. The goal of the surgery is to remove ribs number 8 and 9 to reduce the subcostal protrusion.
My practice has many patients from all over the world for various types of plastic surgery. Patients usually come in the day before the surgery to have a face to face consultation and have surgery the next day. Whether you would stay overnite in the facility depends on whether you are traveling alone or with someone. I would anticipate your stay here to be no more than 2 or 3 days after rib removal surgery before returning home.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting breast implants. However I’m terrified of losing sensation in my boobs and not be able to breast feed. What are the chances I will lose sensation? Also I’m worried my implants won’t look symmetrical, what are the chances this will occur. Because of these concerns that’s why I’m trying to find a doctor that I know cares about my results and does the best job that they possibly can!
A: Breast implants are placed in a partial submuscular position which means there is no chance of any interference with the ability to breastfeed. Loss of nipple sensation, while a risk of breast augmentation surgery, is very uncommon in my experience and only patient in the past twenty years has reported it to me. The biggest reason for revision in breast augmentation surgery in my experience is implant asymmetry. That risk is about 5% to 7% and is highly influenced by how much breast asymmetry one has initially and whether there is any existing breast ptosis. (sagging)
An important consideration in having breast implant surgery is that there are risks like any surgery and one should have a full understanding of them before undergoing the procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have had a Mentor saline-filled testicular implant for approximately three years. While the implant has been relatively trouble-free, I do have some issues with it. I tend to get some occasional soreness due to the hardness of the implant. Also, as you might imagine, it is somewhat akin to having a nerd ball on one side and a superball on the other. Additionally, the implant, even though it was the largest size available, is perhaps one-third to one-half the size of my natural one. In other words, it’s far from a matched set. What options are available to me? Thank you very much for your help.
A: Soft silicone testicle implants feel a lot more natural than saline implants for sure. As for size I obviously do not know exactly what size your existing saline implant is by dimensional measurements. (saline is done by volume instillation) But the largest silicone testicle implants is 4.5 x 3.5 cms which would seem to be more than adequately large. It would be hard to imagine you would need a testicle implant bigger than that. (although custom ones can be made of any dimension) The pocket for the silicone implant replacement will need to be bigger than your current pocket but it should be no problem expanding the existing scrotal capsule.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a necklift to get rid of my turkey waddle. What would be the best surgical option to do so? I have attached a side view picture of my neck so you can assess the waddle. What type of recovery would be needed?
A: Thank you for sending your picture. Your turkey neck poses a bit of a challenge given your hairstyle. Normally a more traditional lower facelift (neck-jowl lift) would be the preferred treatment. But with no hair cover around your ears, this makes it challenging for incision placement to get the optimal neck contouring which is needed most in the center of the neck. This leaves us with the alternative option of a direct necklift with a fine line neck scar down the center of the neck between the underside of the chin and the adam’s apple. You situation is actually common in today’s world as so many men now just shave their heads.
A direct necklift has a much simpler recovery than a more traditional lower facelift as the loose neck skin is excised directly rather than being loosened and being shifted to another location (ears) for removal. One can look pretty good in a week after surgery other than a healing neck scar.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a facial scar is approximately three years old completely severing lip and chin tissues. An excellent alignment repair was done at the time. But over time the chin repair changed from a raised scar to an indention. What type of scar revision procedure would be used to correct it? Will this be a permanent correction?
A: Many facial laceration repairs look great early, become raised secondarily and then eventually become wider depressed type scars over time. This is due to the different phases of healing that occur from early inflammation, intermediate collagen deposition to late effects of scar contracture and collagen/fat resorption.
Given its facial location in which it completely violates the relaxed skin tension lines of the skin, a geometric type scar revision is needed. It would be either a running W-plasty or another form of broken like type scar revision. When the scar limbs interdigitate there is less chance of recurrent widening or depression of the scar. Most facial scar revisions do end up better in the long run but it is a process that will also go through the similar phases of healing that the original injury did.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am contemplating seeing you for sagittal ridge reduction surgery. My understanding is that the resultant scar will be 5 to 7cm in length, from left to right, at the crown of my skull. I am Caucasian with “medium” toned skin. While the prominence of the sagittal ridge bothers me tremendously, I’d like to get an idea of how well the scar will heal in order to determine whether surgery will be worth it. I’ve done an Internet image search for “scalp scars” and the search returns pictures from hair transplantation surgeries, brain surgeries, etc… A lot of these scars are quite prominent, and it’s difficult for me to figure out what a “fine line” scar actually means in my case. So my questions for you are:
1) How well do sagittal ridge surgical scars heal compared to other cosmetic surgical scalp scars? Since the surrounding skin is tight at the crown region of the skull, I’d expect there to be tension on the scar, which would make it wider. Is that true?
2) What can be done, if anything, to improve the scar once healing has occurred. Is Fraxel effective? What about other dermatological techniques? Are there concealer creams that can be used on a daily basis to hide the scar?
3) Do you have more before/after pictures of scars that you can post?
A: Your questions and concerns about the scalp scar from skull reshaping surgery is understandable and appropriate given the elective aesthetic nature of the surgery. Searching the internet will not be helpful since just about every surgical scalp scar you see is not what scars from this type of surgery will turn out. There is no comparable other skull/scalp surgery to which this applies. In answer to your questions:
These type of scalp incision usually heal remarkably well and ion many patients can be very hard to detect. These are not scars in which there is any tension since this is a reductive operation not an augmentative one.
There will be no scar treatments that are needed. I have yet to do a scalp scar revision from one of these surgeries as they heal so well. I do many skull recalling surgeries on bald/shaved men and the scar is usually very slight at worst.
Attached see an example of a scalp scar in a shaved head male who had sagittal ridge skull reduction.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in breast implant removal. If I have complete removal do you take out the capsule? Do you check for fungal or bacterial infection? With breast lift create risks of deformities? How many removals have you done? If the implants are not removed is there a concern of future surgery at my age. My primary care Dr will contact you for a consultation. Thank you.
A: In answer to your questions:
1) There is no compelling medical reason to remove the capsules. They will shrink away on their own with time. It can be done if the patient wants.
2) Without evidence of an active or chronic infection, there is no reason to do bacterial or fungal cultures.
3) Concurrent breast lifts will create their own aesthetic deformities known as scars. How extensive they would be depends on the type of breast lift needed.
4) While breast implant removals without replacement are fairly rare, I have done dozens of them over the years. About half the time a breast lift is needed with their removal.
5) If you replace the implant with silicone devices that would be the most assured approach to keeping implants and have the lowest risk of of any future implant-related problems.
It is not necessary to have your primary care doctor arrange for a consultation. These are not procedures that would be covered by insurance unless there original placement was for breast reconstruction due to cancer. Otherwise this is a cosmetic procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in cheekbone reduction. I have been very insecure about my face structure. I feel like if I get cheek bone reduction it would really change my life because I am tired of thinking about it all over again everyday, it really frustrates me and depresses me. So for my cheek bone reduction would I have any visible scar? And how stable would the cheek be? Would it be stable as before? Would it be able to take a punch? Because I’m really worried. I have attached pictures so you can see how prominent my cheek bones are.
A: Thanks for sending all the pictures. Cheekbone reduction surgery is done mainly from inside the mouth. There is a very small external skin incision on the backside of the sideburn area to get to the posterior tail of the zygomatic arch but it is very small and heals well. The bones are put together with small plates and screws for stabilization afterwards. Once the bones are healed, like any facial fracture, they can resist trauma such as taking a punch in the face. You also have to remember that the cheekbones will already be broken (moved inward) so their ability it get fractured is less anyway.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m looking to have liposuction. My main concern is being put to sleep. Ive watched a few YouTube videos and noticed that the Smartlipo procedure was done without general anesthesia, all while awake.
A: If the principle concern about liposuction surgery is being put to sleep (local anesthesia liposuction), then I am not the surgeon for you. My experience with any form of liposuction done under local anesthesia (unless it is a very small area) is not very good with suboptimal results, patient discomfort during the procedure and an experience that the patient and I would usually not like to repeat in most cases. In my experience when a patient chooses local anesthesia for an invasive liposuction procedure, they have to be willing to accept a limited result and that they may need multiple treatment sessions to ultimately get the best result. Such an approach will also cost more than if done one time under general anesthesia. Regardless of what you see on the internet and how it is promoted, liposuction is a very invasive procedure that covers large body surface areas and is a completely effort dependent process. When this surgical effort becomes compromised by an anesthetic choice that limits these efforts, the surgeon’s hands becomes ’tied’ and the result and experience ultimately suffers. At least this has been my liposuction under local anesthesia experience.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a healthy 50 year old male. I have had liposuction and fat transfer to my buttocks two years ago along with fat removal from my chest area. I am happy with the results of these body contouring procedures. I have however put on more weight and I am wanting to have fat transfer now to my shoulders along with sculpting of the waist, lower back and flanks. My question is will this give me a more athletic look. And is fat transfer to shoulders a successful procedure. How much fat will be saved in the shoulders as the shoulders are my first priority. If I have fat left I want my buttocks still a little more fuller. So in a nut shell I am trying to get a V shape look. Is this possible?
A: Fat transfer to the shoulders (fat injection shoulder augmentation) is just as successful as most other area of fat grafting such as the buttocks. The argument can be made that it may be a more favorable area for fat injections since the recipient site is largely muscle, always the most preferred site for optimal fat take. I almost always mix the harvested fat with platelet rich plasma (PRP) to optimize fat graft take. The real rate-limiting step in any fat grafting procedure is the amount of donor material one has to harvest and process for injection. All one can do in any patient, particularly a male, is to harvest as much fat as possible from the abdomen and flanks for injection. This should certainly help in obtaining more of a V body shape.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a sliding genioplasty three months ago and now my left lower lip is paralyzed. It affects my smile and when I open my mouth. What surgical procedure can I do to make it better. What type of nerve repair is needed and how is it done?
A:The most common nerve injury from a sliding genioplasty is that of the mental nerve, a sensory nerve that controls the feeling of the lip and chin. Injury to a branch of the facial nerve is different as this is a motor nerve that controls the depressor anguli oris (DAO) muscle which provides a depressor or pull down of the lower lip when smiling.
If you have developed marginal mandibular nerve weakness from a sliding genioplasty (or any other chin surgery), which is a very rare complication from this type of surgery, the only potential resolution is time. This is a monofascicular branch of the facial nerve that has no interconnections with other facial nerve branches so its recovery will be slow. It is not likely that it is cut or torn but stretched. Even if it was inadvertently cut it is too small to find and repair. This is why time is all that can be done with marginal mandibular facial nerve injuries. Many do resolve satusfactorily with time.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in calf implants. I have thought about it for years. I am tired of being self-conscious in shorts. I’m almost 40 years of age and want to do something about it now. Here are some photos. In my opinion my calves do not match my body frame. Despite working them out daily, they refuse to grow.
A: Thank you for sending your pictures. Calf muscles are the hardest of all body muscles to increase in size due to their dense compact type of muscle fibers. Calf implants are the immediate cure for that problem. Placed through a small incision in the popliteal crease behind the knee, they are placed underneath the fascia on top of the calf muscles providing an instant augmentation. In looking at your calf pictures I would recommend medium size calf implants for the medial calf muscle and small calf implants for the lateral calf muscle for a total of four calf implants.
While calf implants are instantly effective (just like breast implants) there is a substantial recovery from them. The calf muscles will be tight and sore and walking can be initially difficult for the first few days after surgery. It takes about three weeks to have a near full recovery from calf implant surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am having facial feminization surgery by you in a few months. Is it possible for me to have breast augmentation at the time of my facial feminization surgery? Or will it need to be on a different day? How long after FFS would you recommend I wait to have it done?
A: The first thing to appreciate is That is too much surgery at one time. I don’t think you realize (understandably so) what is going to happen to your face and the recovery that is needed for that collection of facial procedures. Eight to ten hours of surgery is an extreme stress on both your face and body already. Adding breast augmentation to a facial feminization surgery can be done but let me give you several thoughts as to why that is not the best idea and how to think about staging it.
While a young person like yourself can undergo an extreme amount of stress (extensive surgery), there are numerous other issues that can develop from extensive surgeries that go well beyond 8 hours. Such potential medical issues such as blood clots (deep vein thrombosis) and the risk of infection increase significantly. With extensive facial surgeries that involve the nasal and oral cavities there is a bacteria load that is released into the blood stream from them. Placing a large synthetic implant at the same time becomes a great point of attachment for such bacteria floaring in the bloodstream and thus a potential source of implant infection.
When staging facial feminization surgery and breast augmentation there are numerous ways to do it. But the most practical one is to consider the risk of revisional surgery from the initial facial feminization surgery. While each procedure in a facial feminization surgery has its own inherent risks (mainly aesthetic outcomes) when all the procedures are put together that risk becomes additive or cumulative. So let’s say for example that each facial procedure has a 10% risk of revisional surgery, a combined ten procedures would then ensure a revisional surgery for at least one of them. Thus it is better to wait a few months to see the complete outcome of the facial feminization surgery and then combine breast augmentation with any revisional facial procedure if needed. This would be the prudent approach to lower the number of potential surgeries needed/desired.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in skull augmentation or skull reshaping, I don’t know which is the right term. I feel it’s from the back of my head circumferentially around the sides. When I push fthe ront of my hair up (to increase volume) I feel my face looks normally. But when I take my hair tightly I feel my head is smaller than my face.
I am really sad and frustrated. I feel there is no way that I can feel normal I even went to a good plastic surgeon for a consultation but after 5 minutes he said it’s genetics and not worth it to be corrected.The only doctor that I found is really supportive is you.
I think my problem is more than just cosmetic, I I don’t look normal and I cannot do normal activities like swimming. I always have to use many clips to push my hair up.
I really appreciate your kind support.
A: Your description of your skull/head shape problem is one that I have heard from female patients many times. The skull size descriptions and their aesthetic concerns and psychological effects are identical. Their is a solution to these skull size concerns and it involves a custom skull implant that adds volume to the head in exactly the areas you feel are most deficient. But there are two ways to use such a custom implant and they will create different results.
Having had patients just like you I have a good feel for the amount of additional skull volume you need. Thus the ideal approach is a two-stage one. The first stage is the placement of a tissue expander for 4 to 6 weeks to create the scalp stretch that is needed for the size of skull implant that will create the ideal result. The second approach is one-stage with the placement of a smaller skull implant without doing scalp expansion first. The way to think about choosing is what type of result are you willing to accept for the effort invested? If you can live with improvement and 50% to 75% of the ideal result then place a custom skull implant without scalp expansion. If only the ideal skull height/shape increase will do the do the two-stage approach. Be aware that once you have an implant placed you can do not do scalp expansion later. (should one decide afterwards that they want more volume. Obviously the one-stage approach is quicker and costs less…but you have to be prepared to accept improvement in skull size but not perfection.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Is it possible to do forehead lift to rid of horizontal wrinkle lines and raise the forehead but not move eyebrow position? Because I have many forehead wrinkles. I have tried Botox but I want a permanent result. I don’t want any movement position in eyebrows. How is it done?
A: What you are asking can not be done exactly the way you want it. You can not permanently paralyze the entire forehead even with extensive muscle stripping. And if you remove all the muscle between the eyebrows to try and achieve it you will need up with a dent or depression between the eyebrows. You definitely can weaken it considerably by muscle resection (glabellar area) but it should be combined with the placement of a dermal-fat graft in the resected area so that a depression is not created and it will inhibit any muscular reattachments as well.
In reality a forehead lift and a browllift are one and the same. A forehead lift can not be done without some browlifting effect. That effect can be made minimal but no change can be done in the forehead without some potential change occurring in the brow area riught below it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 28 year old male. I was always bothered by a flat spot on the back of my head. It has a profound effect on my confidence and makes me feel very self-conscious about myself. Even though it is not terribly bad, I would still like to get it corrected. Going through similar cases on your website, I would like to know if I will be a good candidate for the minimally invasive closed cranioplasty approach. What is the success rate of such a procedure? Are there any side effects? How long does it take for the scar to heal and will it be visible? How large of an incision will be needed? I have attached a photo of back of my head. Also, my hair is currently thinning on my crown area. I would like to get an FUE hair transplant. Is it recommended to do the hair transplant first prior to the cranioplasty or vice versa? Will cranioplasty have any effect on hair growth in general?
A: The best and only way I will do occipital augmentation today is using semi-custom or custom occipital implant placed through a low occipital incision. (general 9cms in length) This has a high rate of success (as long as one is not asking to achieve more than 10 to 15mms of augmentation) and a low rate of revision. A closed cranioplasty procedure has a high incidence of irregularities and asymmetry…which can only be revised then by an open cranioplasty approach.
Occipital implants do not cause hair loss. When it comes to hair transplantation, the impact of occipital augmentation depends on what method of FUE harvest is going to be done. If one is going to have a traditional linear strip harvest then one should have an occipital implant as least one year before the procedure to allow the scalp to relax. But one would be unlikely to get more than one harvest so ideally this FUR harvest method should not be used. If more contemporary methods of harvest are going to be used (Neograft, Artess) then the hair transplant procedure can be done six months after the occipital implant is placed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, why does plastic surgery get its name? Can I assume that most plastic surgery operations work by putting in some form of plastic or synthetic material?
A: While there are certainly some plastic surgery procedures that do employ the use of synthetic materials to create their effects, most commonly that of breast augmentation for example, the vast majority of plastic surgery procedures use the patient’s own natural tissues for either cosmetic and reconstructive efforts. The timeline of plastic surgery history will show that the surgical specialty name and that of synthetic material development are quite different.
By modern day perceptions of plastic surgery, most people would be surprised how old the field of plastic surgery really is. The term plastic surgery can be traced way back to the early 1800s in German surgical texts. This predates the development of synthetic plastic materials by more than one hundred years. India placed a major historic role in developing reconstructive plastic surgery techniques due to the need to rebuild lost noses and lips that had been cut off by local warlords to mark the people that had violated local customs and rules. But it was World War I that catapaulted plastic surgery into an organized and recognized surgical specialty due to trench warfare and the devastating facial and burn injuries that it created. This subsequently lead to the creation of the American Society of Plastic Surgeons in the late 1930s…which still predated the developement and commercial use of plastic materials.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am an Australian looking for someone who does head widening implants in Australia. I have been researching for some time but you are the only surgeon I can find who performs this surgery! Unfortunately, as a student, I don’t see myself being able to afford a trip to the US any time soon so I was really hoping that you may have an idea/possibly know a college here in Australia who may be able to perform this surgery. I would really appreciate any advice or recommendations you could give me.
A: The surgical concept and the implants used for head widening implants are those that I have developed. This is a new cosmetic temporal surgery that would be unknown to almost all surgeons in the world. Thus I am certain there is no one in Australia or anywhere else in the world at this time that performs this surgery. It uses as dual combination of anterior and posterior temporal implants placed in a subfascial location to create a widening effect from the lateral orbit and forehead all the way back to the anterior occipital region. Since the side of the head is largely made up of temporal muscle it makes sense to augment this large muscular surface area to create greater convexity to the side of the head.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am really feeling confident with what you have advised for other procedures and was wondering if after having everything we discussed whether I could possibly have marionette fold excision. I can’t stress enough how much I detest these lines. They are extremely prominent and appear to take over my face. I have researched my options and I’m not really sold on the filler injection as I would much prefer a permanent solution. And having typed in marionette fold excision your name came up. I have my fingers crossed this may be possible.
A: Marionette fold excision can be done and is a permanent solution. But it is almost always reserved for older patients with really deep (inverted) marionette lines/folds who are more than willing to trade off a scar for the fold. That can be an easy tradeoff in much older people, usually 65 years or older since they already have many lines and wrinkles. That tradeoff may be more suspect in someone younger…or at least one should give very careful consideration of it. In addition an older person’s facial skin stretches more due to being thinner with less elastic fibers. Thus they scar much better. This is why skin cancer excision and reconstruction has such good results on older people.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m interested in masseter muscle reduction and am aware you offer electrocautery as a treatment. I have a few questions regarding this procedure :
1) Is it permanent? I understand Botox is used for this as well but it is temporary and radio frequency has also been used but lasts only for a couple years. I am looking for a permanent solution.
2) Are the effects significant? I have seen the effects of Botox for masseter reduction and I really liked it but as I previously mentioned the effects wear off. Will electrocautery provide the same effects or is it more subtle? If I find the result too subtle could I possibly come in for a second treatment?
3) Will there be any complications such as nerve damage, eating/movement limitations, premature sagging skin, or asymmetry?
4) Also, I have a dental Herbst appliance. Would that be an issue?
I look forward to your response. I apologize for the many questions.
A: Electrocautery is a form of surgical masseter muscle reduction. Somewhat similar to radiofrequency, it is a method of causing direct thermal injury to the muscle resulting in permanent loss of some muscle fibers. Unlike radiofrequency it it done through an open approach intraorally where the undersurface of the masseter muscle is treated. Through a combination of subperiosteal muscle release and direct electrocautery the size of the muscle mass is decreased as it heals. To answer your specific questions:
- Those muscle fibers that are directly thermally injured does result in their permanent loss. However, like liposuction which permanently removes some fat cells but weight gain can return by those fat cells that remain undergoing hypertrophy, the same can be said for muscle tissue. If the cause of the masseter muscle hypertrophy persists the remaining muscle fibers can become hypertrophic and muscle volume returns.
- Generally the effect masseter muscle reduction by electrocautery are similar to the effects of Botox injections. Further reductive treatments can be done.
- Other than some temporary muscle stiffness (trismus) there are no other adverse effects. It is just an aesthetic question of what degree does the overall muscle mass shrink.
- An indwelling oral appliance is not a preventative factor for having the procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have an odd question about testicle implants that I hope you will not think is too weird. I have had great loss of testicular size due to testosterone therapy. Is it possible to get two testicle implants and not disturb the small testicles that I have?
A: I think your question is whether you can add two testicle implants while keeping your existing small testicles. Provided there is adequate scrotal sac space, and there most likely is, the answer would be that you could. You would just have to be sure that you can get a testicle implant in the sac that is appreciably bigger than the existing smaller testicle. That way you could have two ‘dominant’ testicles and not just four smaller ones. (aka sac of marbles) The obvious assumption is that you are trying to have a more normal testicle size while keeping the simultaneous function of the existing testicles, small as they may be.
Testicle implants are placed through high scrotal incisions near the groin crease so the final resting place of the implant is not directly against the incisions. This is a procedure that is performed as an outpatient under general anesthesia.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I made a terrible mistake with my son’s otoplasty. I went with the less invasive procedure for his ears. I had a doctor perform an incisionless otoplasty six days ago. The bandages were removed this weekend and I am extremely unhappy with the results. There is virtually no change at all and it looks terrible. I am embarrassed that I made this choice and I now realize I should have gone with your approach at our initial consultation. Is there anything that you can do to help revise this now or should we wait a few months?
A: At just six days after an incisionless otoplasty it is possible that the ears are so distorted with swelling that you may not be really looking at any approximation of the final ear reshaping result. The incisionless otoplasty works on the principle of a closed cross hatching of the cartilage with a needle (to weaken it) and then passing multiple sutures under the skin using the same entrance points. This technique does cause a lot of trauma to ear so I would not rule out what you are seeing as temporary ear distortions due to swelling and bruising.
But it would be important at this early point after surgery to allow the swelling and bruising to subside and let healing take place for the next three months. At that point the ears will have their final shape and you will be in a better position to assess the result. The ears would also be healed enough at that point that I would consider converting to an open otoplasty to get a better result if that is needed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, What can be the most likely solution to my bulging eyes? You can see in my pictures that my eyes stick out. They have been this way since I was little girl.
A: Thank you for sending your pictures. The first question to answer is whether this is exophthalmos due to a medical condition such as hyperthyroidism. But since your eyes have always been ‘buggy’ it would be reasonable to assume that this is their natural appearance. It looks like you have what is known as pseudoproptosis. (appears like eye bulging when in fact it is not) This is due to a lack of bony rim/fullness around the eye particularly in the superior and lateral orbital rim areas. When the bony rims are recessed or not adequately projected the eyeball will look like it is sticking out when in fact its position is normal within the orbital box. The fact that they have been this way your whole life would support that this is just the way your face developed. Placing custom made superior and lateral orbital rim implants through an eyelid incision or doing it from above through a scalp incision would be the only way to improve this bulging eye appearance.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, . I have seen you have had experience with temporal artery ligation and success dealing with this procedure in the past which is why I am contacting you. Attached is a picture of my problem. The artery gets larger if my heart rate is up or its hot outside. I have another one that is not as bad on my left side as well that I would like to deal with at some point if the initial procedure works. Is the success rate of this procedure pretty high, in terms of greatly minimizing the size of the entire artery? I am very interested in having this procedure done.
A: The success rate of temporal artery ligation in my experience is always 100% or very close. That would be expected when you shut down both ends of the pipe so to speak. That is actually not the question that is the most relevant. The more relevant question is…does collateralization or shunting of flow occur? This means if you shut down one section of the pipe way will other previously invisible sections of the pipeline appear later. It is important to remember that all the arteries in the scalp and forehead are very extensive and interconnected. So in theory the blood flow that went to the vessel that was shut down could be shunted and cause vessel dilation elsewhere. I only mention this point in cases of men that shave their head where the entire scalp can be seen. I have had a few patients contact me over the years who had their temporal arteries ligated elsewhere and they developed visible dilated vessels elsewhere in the scalp weeks to months later which they felt was a worse aesthetic problem than the one they had treated. This shunting is not a problem that I have seen with temporal arerty ligation but it is one of which to be aware and a potential risk of the surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Dr. Eppley, I have just learned of fat injections to help narrow small shoulders. Could you help me learn more about it? I have a lot of fat around my abdomen and obliques. Could that fat be used to make my shoulders bigger (broader and thicker)? If I were to diet, does that mean I would lose fat in the shoulders and they would shrink and I would have to repeat the fat transfer procedure? A lot of stomach fat has been something I always had. Even at 125 lbs. even when I do lose weight, I still have a big stomach. Would that fat be as difficult to lose in my shoulders as it is my stomach? How much broader could I make my shoulders with the fat transfer procedure (half inch, full inch)? Sorry to bombard you with questions.
A: Deltoid augmentation by fat injections can be a successful method for shoulder enhancement. The key is whether one really has enough fat to do the procedure or, more relevantly, to make it worthwhile. While you may think that you have enough fat, and you may very well do, that is somewhat hard to imagine at a 125lb weight. Whatever stomach fat you think you may have by appearance, that protrusion may be from an intraperitoneal basis (behind the abdominal muscles) rather than in front of it. (intraperitoneal fat is inaccessible from liposuction) This is obviously an issue that requires further assessment/examination even if only by pictures.
But for the sake of discussion let us assume you could have the procedure. Abdominal fat transfer to the shoulders (or anywhere else) is going to behave like the donor site and not the recipient site. Meaning if you lose weight the fat cells will get smaller as well as the reverse. These transferred abdominal fat cells have depot behavior with higher metabolic activity. Thus they are more sensitive to weight changes that normal shoulder subcutaneous fat would be. How much increased shoulder definition you could get would completely depend on how much fat is capable of being transferred…and how much survives the transfer process. Thus it could be anywhere from a very modest change to a more robust 1/2 inch or so.
Dr. Barry Eppley
Indianapolis, Indiana
