Your Questions

Q: Dr. Eppley, I am a 25 year old male. I’ve had a septorhinoplasty, a chin implant and orthodontic treatment previously. I feel that my previously under projected chin and jaw development are inter-related, however, given that I am fairly satisfied with my corrected bite and improved chin projection, I am interested in augmenting the jaw further (jaw angle implants perhaps) to achieve a more masculine look. There is a bit of asymmetry and the angle of the back of the jaw is more of a 45 degree as opposed to the more masculine 90 degree like angle. It seems that at this point, a sliding genioplasty may not be appropriate without removing the chin implant. I have considered fillers as a temporary ‘trial’ in the short term as a plastic surgeon locally is willing to provide Voluma for free to see if it fits his practice. Any thoughts or observations or anything else that may be beneficial given my facial structure is greatly appreciated.

A: Based on the current position of your chin and the rest of your facial structure, I would have reservations about any type of jaw angle implant augmentation. While you may not like your jaw angle shape now, any change in it would likely make it out of proportion to your chin, particularly if they were changed to a stronger 90 degree shape. That point could be proven, right or wrong, by having some computer imaging done to see how it looks to you. I think that of you do not add some further chin projection (vertical and horizontal) then the back of the jaw will look too ‘heavy’. I don’t think the chin needs to be moved much, maybe 5mm forward and 3mm down, but your chin is too short now to support much jaw angle augmentation.

It is not true that you need to remove a chin implant to do a sliding genioplasty. The osteotomy cut is done right across the top of the implant and the implant is moved forward with the bone as it comes forward and/or down. I have done that exact sliding genioplasty technique numerous times.

You certainly have nothing to lose by having injectable fillers done for jaw angle augmentation. But be aware that they do not produce the exact same effect as to what an implant does at the bone level. So it is not exactly a 1:1 comparative effect. There is probably as much to learn from computer imaging as there is from the filler treatment.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I underwent upper and lower jaw surgery over one year ago. The surgeon did a fairly good job advancing my lower and upper jaw, however, it has (if anything) accentuated the deficiency around my orbital area. I have very deepset eyes, which could pose a challenge with this sort of procedure. What are your initial thoughts – and do you have a lot of experience with infraorbital rim implants?

A: It would not be rare to develop an infraorbital rim deficiency after a lower maxillary/mandibular orthognathic surgery procedure. As the bones are moved below the orbital rim, how that area looks will be affected based on the lower facial skeletal movements. Infraorbital rim augmentation can certainly be done but the relevant question, as you have pointed out, is how will that affect the already appearance of deep set eyes. Will doing so be an aesthetic improvement or not? I have performed numerous orbital rim augmentations either alone or as part of custom malar-infraorbial rim implants. There are different styles/shapes between preformed off-the-shelf and custom infraorbital implants. Off the shelf infraorbital rim implants are designed to augment the front edge of the rim (sit in front of the orbital rim) and, in deep set eyes, such isolated horizontal augmentation may make the eyes look more deep set. In more custom designs, the infraorbital rim augmentation sits more on the top of the orbital rim with some slight overhang, causing a slightly different and more natural effect in my opinion and one that is less likely to cause an adverse effect on your eye appearance. These custom designs also flow into the cheek area with a smooth transition, providing as much augmentation effect in this area as the patient prefers. (or prefers not to have) As an initial thought on what make happen with infraorbital rim augmentation, I will do some computer imaging and get that back to you later today. At this point, I could not tell you whether this would be a favorable facial skeletal change or not.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am sending you some pictures for consideration for facial feminization surgery. (FFS) I am a 25 year-old transgender who wants to really make the change and be accepted for who I really am on the inside. What FFS procedures do you think I need and how successful will the change be in your opinion?

A: In assessing your pictures, I can see where the following procedures would be very help in achieving your goal of softening and feminizing your face and I would place them in the following order of importance:

1) Forehead Augmentation/Brow Reduction/Browlift  (the issue here is whether a hairline advancement can be done with any appreciable forehead reduction of vertical skin length from the hairline to the brows) But reducing the brow prominence, getting rid of the brow break and increasing the convexity of the forehead are key elements of your facial appearance change.

2) Jawline/Chin Reshaping/Tapering (reduce jaw angles and square chin in the frontal view) The horizontal chin projection as it is now is perfect for a female as you naturally have a convex facial profile due to your chin position)

Lip Advancements  (increase vermilion exposure and cupid’s bow enhancement) While injectable fillers or fat injections could also work on your lips, if you are undergoing surgery for other facial procedures then it makes sense to take this opportunity for a permanent lip enhancement change.

Cheek Augmentation (this is not on your list and may be surprising to you but I actually rate it as more important than the rhinoplasty) The flatness/gaunt appearance of your midface would benefit by some voluminization to create more of an ‘apple cheek’ effect. It not only would look more feminine but also creates a ore healthy appearance as well.

Rhinoplasty Very slight changes to your nose is all that is needed. Some tip narrowing and slight rotation upward would change your already thin nose to a more feminine one.

I think your face is a very good ‘canvas’ to work with to become very feminine and with a few of these changes can become so. Not every patient that undergoes even extensive facial feminization surgery can always become highly feminine in their facial appearance.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am suffering from an excessive buildup of scar tissue underneath the skin after my rhinoplasty. Multiple Kenolog shots did not help. my nose looks about 30% bigger and more bulbous then it was a few months right after the surgery. (my rhinoplasty was three years ago) I am convinced that 5-fu is the right approach for me now. I know that you are one of the best and most experienced surgeons known for using this post surgery corrective method. Can you please help me?

A: I would not think that 5-FU injections would be helpful for established scar tissue years after the original rhinoplasty surgery. The biology of 5-FU effects is to inhibit the creation or development of scar tissue, not causing it to break down. Steroids, specifically Kenalog, actually work through a dual effect of inhibition and  breakdown of scar tissue. In short, while 5-FU injections can certainly be done, I would not be optimistic that it would achieve the desired effect of nasal size reduction that you desire. It would be better, in my opinion, to have a revisional rhinoplasty for scar removal and then lay in on dissolveable collagen sponges (carrier) a mixture of steroids and 5-FU. This could then be followed by an early and aggressive use of 5-FU injection therapy.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am of African descent and I want to improve the shape of my nose and make my lips smaller. Sadly in my attempt to reduce the size of my upper lip and nose I ended up with a crooked nose and lips. The worst part being that my lips remained just about the same size. 

A: My assumption, based on your pictures, is that an implant was placed in your nose since that is about the only thing that can make the nose deviate like that after a rhinoplasty. When trying to improve a nose shape like yours (originally), the fundamental principle is one of a strong columellar strut to support the tip and a good dorsal augmentation. While an implant can be used for the dorsal augmentation, it should never be used for the tip-columellar support as it has a high propensity to deviate…just like yours has done. (not to mention placing the skin over the tip of the nose at jeopardy for vascular compromise) You need a good cartilage graft for support for your revision rhinoplasty and this almost always requires a piece of rib to do so. The implant may be able to be salvaged and used, but once you need a rib graft for the columella you might as well abandon the implant and go with a completely natural graft approach. There are other additive techniques that can be done, such as nostril narrowing, but the dorso-columellar buildup (augmentation) is the key.

From a lip reduction standpoint, if the tissue removal amount and location is not just right, a minimal result is seen and scar contracture can result in the lip. Since you already have a linear contracted lip scar, that would serve as the posterior (inner) incision location with a more aggressive excision done out on the anterior (outer) vermilion. It is the vermilion which needs to be reduced if any size reduction is to be obtained.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in possibly getting a testicle implant. I had an undescended testes removed at five years of age. I am 26 years old now and figured I would at least explore the option. I am interested in the details of the procedure, the risks and recovery period. I hear it is relatively minor procedure so I would like to know more. 

A: Testicle implants are made of either soft solid silicone material (soft spongy ball so to speak) or a saline-filled small bag. Either way, they are placed through a small scrotal incision in an outpatient procedure under anesthesia. One should expect some swelling for a week or so, awareness of the procedure having been done for three weeks and avoiding any sexual activity for up to a month after surgery. The risks of the procedure is that of infection which has a very small rate of occurrence. (1% to 3%)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, It has been determined that I suffer from brow ptosis by my general doctor, he had recommended orbital rim contouring and a browlift to alleviate the issue and prevent it from happening in the future. I have also checked with my insurance company and they have stated that both procedures would be covered if deemed medically needed by the surgeon of my choice. I would love to be able to submit pictures if needed to assist you in diagnosing brow tosis on your own and would love to hear feedback. I was hoping it would be possible to request that the brow bone can be shaven to a more feminine contour. Please let me know if you are interested in helping me pursue treatment and are able to accept insurance or if we need to make an exception!

A: While there is no question that brow contouring can be done to create a more feminine appearance with or without a browlift, the issue of potential insurance coverage for it is almost certainly not. It is important to understand that when a patient calls up their insurance company, the standard unqualified answer is always ‘if your doctor says there is a medical reason for it, it will be covered’. Unfortunately that person and the section of the insurance company that they work for has nothing to with the department that actually approves the surgery and issues payment for it. That is the Predetermination section and they are tasked with determining whether there is any medical reason for the surgery. The only medical reason for a browlift is upper visual field obstruction and this must be substantiated with a visual field test. This must accompany a predetermination letter on which they will pass judgment about medical coverage. If they deem it is medically necessary based on the evidence, a browlift may be approved as a medical procedure. Any orbital rim/brow bone reduction/shaving never has a medical reason for it being done and is always deemed a cosmetic procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a full tummy tuck three months ago. I opted liposuction with my tummy tuck. I am very pleased with the way the bottom of my abdomen looks, however, I have quite a bit of fat on my upper abdominal. I was under the impression that you would do liposuction on the upper abdominal area during the procedure, however, it wasn’t. Can you advise why? I did pay for the tummy tuck and liposuction. I have researched it quite a bit to make sure I didn’t misunderstand, and it looks like that would be the “norm” if you had a tummy tuck and lipo that it would be done on the upper abdominal area, however, it wasn’t in my case. I look forward to hearing from you.

A: This particular tummy yuck question is not uncommon and there is a very straightforward answer. The concern about fullness in the upper abdominal area is one of the most prevalent after surgery issues after one has had a tummy tuck. One does not have to look too hard on any plastic surgery forums on the internet to see how common this tummy tuck question is.

This question is so common that in every tummy tuck consult I emphasize to patients about this issue and, while liposuction may be done in the flanks and lateral abdominal wall, I do not perform it in the upper abdominal region. Thus, one may be left with an upper abdominal region that may be more protrusive than in the lower area where all of the tissues were cut out if they have any fat thickness in their upper abdomen originally.

It is not the norm in a full tummy tuck to perform full abdominal liposuction on the upper abdominal skin flap. This is avoided by most plastic surgeons because of its devascularizing effect on the skin flap and the risk of causing poor wound healing, central    wound dehiscence and even overt tissue necrosis between the new belly button and the incision line. One also does not have to look to hard online to see some disastrous results when upper abdominal liposuction is done with a full tummy tuck. While it may not occur in every such case, one devastating tissue necrosis event can take months to heal and create a permanent abdominal wall deformity.

This makes going for the very flattest total abdominal result possible by widespread use of liposuction at the time of a full tummy tuck a risky manuever. This is one that I will not do out of concern for patient safety and to avoid risks of a postoperative complication. This is why I point this issue out during the initial consultation and emphasize that secondary liposuction may be needed for flattening the upper abdomen six months or more after the procedure when it is safe to do so.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m 56 yrs. old and have developed 2 vertical lines between my brows. They make me look mad or mean. My face has also started to sag. I have the saggy vertical lines from sides of mouth to chin and the sides of my mouth are starting to turn down. I use to have beautiful lips and they are looking thinner and I have vertical lines from smoking. I have always had a high forehead plus I had 40 stitches in my head from a car wreck years ago and my hair never grew back over the scar. I nose is slightly crooked and is showing more now. My face needs refreshed.

A: Many of your facial concerns are very common and there are a variety of surgical options for substantial improvement. I could give you a more detailed description of what they would be if I could see a few pictures of you. Just by description I am envisioning the needs to be a lower facelift (of some type), possible upper and lower lip advancements/lift with corner of the mouth lifts, possible hairline lowering with glabellar muscle excision for the vertical lines, scale scar revision and possible rhinoplasty. As you can see there are a lot of good options here and the issue is just how to put a surgical plan together that will optimize your face and give the most refreshed facial result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was born pre mature and have a bad tracheostomy scar that I really want improved. After reading your website I can see that you are a extremely talented surgeon with lost of practice in this area. I have attached two pictures, one where the neck is stretched and one where Im looking straight forward. Can you please tell me what is possible to do here, and what results I can expect?

A: What you have is a vertically oriented tracheostomy scar with a central depression. The best way to treat that type of trach scar would be total excision and contracture release, interpositional dermal-fat graft and linear or partial broken line skin closure. You most certainly should be able to substantially narrow the scar line and even out its contour with the surrounding unscarred skin. In short, there is a lot of room for improvement in your tracheostomy scar. The one negative to your trach scar is that it is vertically oriented, completely perpendicular to the natural horizontal relaxed skin tension lines of the neck. This natural anatomic violation will make any neck scar revision more prone to secondary widening than if the initial scar was horizontal in orientation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a tummy tuck eight months ago and, although I am happy with most of the results, my belly button afterward has always looked a little funny to me. It looks bloated for lack of a better medical description and bigger than it did before the tummy tuck. It was not a great looking belly button before the surgery but it looks no better now and even looks a little deformed. Can you tell me what is going on and how I can fix it?

A: A ‘bloated’ belly button after a tummy tuck suggests that too much of the umbilical skin is seen on the outside. This usually results from an umbilical stalk that is too long for the thickness of the tissue between the skin and the abdominal wall, pooching outward creating a mushroom or bloated appearance. An umbilicoplasty procedure can be done to shorten the stalk and pull the belly button back inward for an unbloated or more of a funnel effect to create a more natural belly button appearance.

While the creation of the ‘new’ belly button in a tummy tuck is the most minor part of a tummy tuck, it along with the scar line is the most heavily seen feature of the result. Shortening the umbilical stalk, keeping the new opening in the skin small, and removing a funnel of fat between the skin and the abdominal wall all help to create an inward shape or pull to the recreated belly button and allows the scar line to be situated in a more obscure location.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a tummy tuck six months ago but am not happy with the result. My lower stomach area around the incision is flat but my upper stomach below my breasts bulges out. Is this swelling, fat or something else? Why isn’t it flat like my lower stomach?

A: It is not rare after a tummy tuck to have the upper stomach area above the belly button remain than the shape of the stomach below the belly button. This can occur in those patients who have thick fat layer to their stomach initially. Because most plastic surgeons avoid debulking the upper stomach area during a full tummy tuck by extensive lipsouction, and repositioning of the upper abdominal flap downward over the excised area is done to ls close the wound, can create a mismatch in fullness of the tissues above and below the belly button. What you have is not swollen or bloated but the natural thickness of the upper abdominal fat layer which has largely been undisturbed. This is why liposuction of the upper abdominal area six months or more after a tummy tuck can reduce this fullness and put the finishing touches on a tummy tuck effort.

I always make it a point of emphasis in presurgical discussions to point out this exact issue in patients that have naturally convex abdominal shapes and thick fat layers on their abdomen. There are many tummy tucks who can not achieve a completely flat abdomen and this is important to point out beforehand.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have quite significant nasal deviation and also maxillary retrusion from unilateral cleft lip and palate. To create fullness in that area I have inquired about orthognathic surgery and was told that the removal of teeth when I was younger makes that almost impossible. I was wondering if theoretically it is possible to put premaxillary implants in with a deviated septum that needs correcting. Does the premaxillary implants stabilize the septum?

A: When a Lefort I or maxillary advancement is not possible, onlay facial implants can provide a similar aesthetic effect. (with the exception of the effect on the upper lip by the anterior tooth movement) Midface augmentation could include premaxillary, paranasal, maxillary and/or cheek augmentation. These are all different types of facial implants to augment various areas of the midface. An entire custom midface implant can also be made from a 3D CT scan. Placing any of these implants is not influenced by any form of septal correction. Septal straightening is needed in every cleft patients and how it is straigthened and its stability is not changed or influenced if a premaxillary implant is done at the same time.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, What is the most natural lip augmentation filler that you offer?

A: When someone speaks of a ‘natural’ lip augmentation result or procedure, they could mean two distinctly different things…that the material that is implanted is natural or that they want a natural-looking result. For lip injections, the most natural filler is fat. (although by far the most common lip filler materials used are hyaluron-based like Juvederm for example) Fat may be the most natural injectable filler for the lips but it has a poor track record of graft take and requires more of a surgical procedure to do it. (liposuction harvest)

A natural result in lip augmentation is generally one that is not overdone or has had too much filler placed. It is unnatural when the upper lip becomes bigger than the lower lip. Most of the time patients want an upper lip augmentation whose size (vertical vermilion height) matches that of the larger lower lip. That is influenced as much by the technique and volume of injectable filler material added than it is by any specific injectable filler material.

Most likely you are referring to the latter where the result does not appear as if ‘something had be done’ or the dreaded ‘duck lip’ result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am one month post-op from a v-line jaw reduction and sliding genioplasty. Although I am well aware that I am not at my final result due to swelling, observing through my x-rays I can confirm that my chin has actually increased in vertical length when I desperately wanted the opposite. My surgeon is unfortunately non-responsive. My question is, is there any way I could undergo a revision sometime in the next month since the detached part of my chin that is secured with screws is entirely the length of bone that I would like to have removed? I have linked my post-op x-ray with a photoshopped x-ray of what my desired results are to clarify what I am trying to express. Thank you so much for your time!

A: It appears that you have had a set back sliding genioplasty from your x-ray. The severe angle of the bone cut makes vertical lengthening occur when the downfractured bone segment is slide backward. To effect that degree of vertical shortening that you want, you would take out a wedge of bone from above the cut and bring the lower segment up to it. You can not just remove the bottom segment because the muscular and soft tissue attachments to the chin bone would be lost resulting in significant chin and neck soft tissue sag. Given that you have not had any bony healing from your prior sliding genioplasty, you should have such a revision in the next few weeks or month.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have done some research on an occipital augmentation cranioplasty for a flat back of the head. I am still about 18 months away from having the money to receive such an operation but in the meantime I have two questions. 

1.) What are the long term effects of such a operation?

2) How long is the scalp incision to do the surgery?

3) If I sent in a picture, is there any way to get a good estimate of the size of the needed incision? And is there a way to see what possible results would look like on myself?

Thank you for your time!

A:  In answer to your questions:

1) Based on my extensive occipital augmentation experience, I have yet to seen any long-term untoward consequences such as implant problems (infection), skull or scalp issues. There can be some aesthetic issues such as smoothness and edge transition blending into the bone.

2) The size of the incision is going to be based on what implant method is used, preformed implant (6 to 7 cms) or PMMA bone cement. (9 to 10cm) That is predictable up front.

3) Side view pictures can be used to show potential result predictions using computer imaging techniques.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was reading an article by a male to female transgender woman who mentioned having a procedure in Mexico where the doctor broke her lower ribs and wrapped them tightly so that they would fuse together in a more narrow position. I am a slim young woman who would like a more narrow rib cage to give me a longer more narrow waist, but would like to keep my ribs if at all possible. I assume this would be called “rib manipulation” since it is the controlled breaking of the lower ribs. Have you heard of this being done for cosmetic purposes and can you give me information on the pros and cons of this procedure?

A: What you are referring to would be known as rib reshaping by osteotomies as opposed to the more traditional rib removal procedure to make a more narrow rib cage. The rib as it extends from the spine and around the side of the body is composed of bone (from the spine out to about halfway around the side of the body) and then becomes softer cartilage as it extends to join the sternum. (ribs 10 through 12, also known as the ‘free floaters’ do not extend to the sternum…which turns out to be a very important point in this discussion) If the rib is osteotomized (cut) at the bone-cartilage junction, the cartilaginous end would be more bendable and theoretically could be molded inward as it heals for a more narrow waistline with after surgery binding. This would only apply to the free floating ribs which do not have an attached end. It would not work for any higher ribs because they have a complete arc around the body with a fixed point to the sternum.

The advantages to rib reshaping is that it would be less invasive since the ribs are not being removed, would have an easier recovery, may be able to be be done with a smaller incision on each side and would preserve the ribs. The disadvantages is that it is not really clear if it would really work and could be a source of chronic pain if the separated rib area do not heal. (osteochondritis)

Dr. Barry Eppley

Indianapolis, Indiana

Q:Dr. Eppley, I came across your website and your blog. From what I gather, you have extensive experience dealing with complex chin augmentation cases. I have had three chin implants placed in the past (the first was mersilene mesh, replaced with silicone, and then replaced with Medpor), all giving less than ideal augmentation. The silicone one was replaced by Medpor because my chin felt really sensitive and uncomfortable. My doctor said it was due to bone erosion and that Medpor would be better. However, the area still feels sensitive. Currently, I have the RZ Large Medpor Square Chin implant in and it’s smaller than the previous XL silicone chin implant I had, so the chin contour is very strange now as a result of putting in a smaller implant. I saw one p[lastic surgeon who told me that due to all the erosion as a result of the implants, I may not have much bone to augment. I believe that without the implants, my horizontal chin deficiency is around 13mms. My chin could also use a bit of height. Given all this, I have seen one of your cases where you combined sliding genioplasty with an implant. Do you believe this is viable in my situation?

A: Certainly chin augmentation history is complex but you now learned several important issues. First, no preformed off the shelf implant alone can create the chin augmentation effect that you desire. Secondly, the chin sensitivity has nothing to do with the often misused term, ‘bone erosion’ or the implant material. This is more of a soft tissue stretch issue as the implants have gotten larger over your first and original much smaller chin implant.

At this point, you have only two viable options for chin shape improvement. Either get a custom chin implant made from a 3D CT scan that can meet the dimensional needs that you want and now know better or use a sliding genioplasty combined with a chin implant to create a dual autogenous/alloplastic change. How viable the latter approach would be be based on knowing what the bone looks like now. The best way to get that information, which is critical at this juncture so that you have the best chance of having a fourth and final chin augmentation procedure, is a 3D CT scan. This will show the amount and shape of the chin bone as well as the implant that sits on top of it, all of which can be measured to the millimeter to know how likely a sliding genioplasty will ‘work’ and what size implant would need to be used in conjunction to get the chin dimensions that you need.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a minor amount of loose skin under my chin and between my Adam’s Apple that I want flattened. The neck skin has very little, if any, fat. I’m 51 years old and my skin heals from cuts and abrasions very well. The procedure with the lowest trauma and shortest recovery time along with the lowest cost is preferred. Please let me know what procedure you recommend, along with the its recovery time to where I can be out without the procedure being noticeable. Thank you.

A: Thank you for sending the pictures and describing your objectives. The small midline neck wattle poses a bit of a quandary in terms of an ideal procedure. It is not big enough to justify any more major surgery (formal neck lift)  but it is significant enough that is it not going too respond to smaller minimally invasive procedures. (e.g., external skin tightening, liposuction etc) Thus in these situations one is ‘forced’ to choose a procedure that is not perfect. (can not create the ideal result or has some trade-offs) This translates into either a submentoplasty with liposuction (otherwise known as a submental tuck up or a direct small neck lift. (most effective since the skin excess is vertical but the scar may not be acceptable in a younger patient)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have questions about jaw angle reduction and temporal implants. Here’s a list of my questions I want to ask:

1. My jaw is still growing and i have braces, will this affect anything? What possible complications can there be? I’m willing to take all the risks and complications. ( i am getting the braces removed soon)

2. If my jaw angle is vertically reduced to make its location higher, will this make it higher from the front view too? Can this be an possible result? By higher i mean close to the ear.

3. Is there any implant to make my head larger or my forehead larger? Since my face is long, i want to make it more proportionate. I have been reading about the temporalis muscle, any implant/augmentation surgery for that 

4.what is the difference between having the jaw shaved with a ear incision, and inside mouth incision? Recovery time? Results? Damage? Risks?

5. Here comes the important part… How long is the recovery time? For the ear incision & inside mouth incision? Is there any massage or laser treaments i can take to dramatically reduce the swelling so i can look ‘normal’ after a week of recovery?( i’m willing to pay a lot for any treatments that’ll help ) please include the implant part as well! 

6. is it possible to do implant and jaw reduction surgery together? If so how much time will it take and what risks are there?

A: In answer to your questions:

1) Having braces and undergoing orthodontic treatment has no impact on any type of jaw angle surgery.

2) The traditional method of jaw angle reduction surgery does exactly what you are describing. It removes the jaw angle so that the most posterior part of the jaw angle is at the same level as the earlobe. It is important to understand that is so doing the jaw angle will no longer have a square form but a more rounded or sloped angulation.

3) Forehead and mid-temporal augmentation can be done to achieve a larger more pronounced forehead and increase the bitemporal distance for a wider head as judged by its width above the ears.

4) The jaw angle can be reduced by two different surgical approaches. (incisions) The intraoral method is the historic and most common method still used but it does pose challenges for angling the bone cut in an ideal and symmetric manner. The external approach uses an incision behind the ear or just below the ear and provides a much better angle for the bone cut and a quicker recovery (by staying out of the mouth) but runs the risk of causing temporary or permanent facial nerve injury. (that risk is low but is not zero)

5) There is nothing a patient can do to expedite the recovery process which is largely about who long it takes the swelling to go away before one looks human (7 to 10 days) and for its complete resolution. (4 to 6 weeks)

6) It would be common to combine any number of aesthetic craniofacial procedures such as jaw angle reduction and temporal augmentation. The risks of such surgeries, besides infection, are largely aesthetic…symmetry, over/under correction of the desired goals.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I read somewhere about temporal implants for head augmentation which I assume is of the muscle. If you add an implant there, wouldn’t it widen my head? And if so, how is it done with what type of implant and location?

A: It depends on what part of the temporal region in which the implant is placed and what type of implant is used. A preformed anterior temporal implant is now available that augments the temporal hollow. (the region between between the anterior temporal hairline and the eyebrows/side of the eye) which often occurs from aging, genetics, drug therapy or neurosurgical approaches. A larger preformed or custom mid-temporal implant is also now available that when placed below the muscle on the side of the head above the ears will increase the bitemporal dimension or width of the head. This as you can see, it is important to know what temporal region of augmentation one desires to select the right temporal implant style and location of augmentation.

Using implants for temporal augmentation is one of the newest areas of craniofacial implant development that has extended the use of implants in the face upward to that of the skull.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like information about brow bone augmentation with calcium hydroxyapatite and customized implants from 3D CT scans. I had a rhinoplasty where the surgeon used transverse and medial osteotomies of the nasal pyramid, and nasal dorsum. I realized that the eyebrows lost support after surgery. The augmentation surgery in the region of the supra-orbital rim or brow ridges with customized implants are made of what material?

A: Brow bone augmentation can be done by different materials which can also control the surgical approach to place them. (incisional access) The traditional and still most commonly performed technique for brow bone augmentation is through an open scalp incision using either PMMA or hydroxyapatite bone cements. When just the brow bone is being done, hydroxyapatite cement is the material of choice. But when the brow bone is being combined with total forehead augmentation, PMMA bone cement is used due to being a more lower cost material per amount of volume. Performed or custom implants can also obviously be placed through such a wide open exposure. Custom brow bone implants made from a 3D CT scan are always made of a silicone material, primarily due to ease of adaptation to the underlying brow bone and cost. Newer techniques of placing custom or preformed silicone brow bone implants are being developed to avoid the larger scalp incision. (endoscopic frontal and upper eyelid incision)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Dr. Eppley, I am 20 years old but have had prominent “tear troughs” all of my life, my left tear trough being more prominent than my right. I am very interested in getting injectable fillers for that area. I was wondering if you would be able answer a few questions for me. Would you recommend fillers for my tear troughs? If so, what kind and how much filler would you most likely use? How much would it cost? Is this something that you perform often? Thank you for your time.

A: Based on just the one side view picture you have shown, you do not have a true tear trough deformity. Rather you have pseudo or seemingly tear troughs when in fact it is caused by something else. What it appears you have is congenital herniated lower eyelid fat pads. This causes a fullness/bulging/bags of the lower eyelids which subsequently creates a tear trough appearance due to the bulge above an otherwise normal tissue area along the infraorbital rim. (lower eyelid socket) Injectable fillers would be contraindicated in this type of lower eyelid anatomy. Conversely you need removal and/or translocation of the lower eyelid fat pads. Some would be removed while a portion would be moved to drape over the infraorbital rim, thus eliminating both the lower eye bulge and the tear trough at the same time. This operation is known as transconjunctival lower blepharoplasty with fat transposition.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in fat injections (Lipodissolve) for my lower abdomen. I am done having children and have gained an excessive amount of weight during my pregnancies. I have lost the weight, but the aftermath is stretch marks, loose skin and a “pudge.” My upper abdomen has no stretch marks and is ok. I am trying to find an affordable procedure, that I can handle with minimal downtime, as I have 2 small children.

A: What you need, without even seeing a picture of you and based purely on your rather classic description, is not going to be achieved by an injectable fat reduction technique. Lipodissolve is intended for very small fat collections (like the neck) in which the overlying skin is of good quality. It is completely ineffective for the post pregnancy belly that you are describing. What you need is some form of a tummy tuck which can more effectively deal with the excess/loose skin and fat. With this type of abdominal problem, you either hold out for a tummy tuck one day or do nothing…as nothing will offer any acceptable level of improvement.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in occipital augmentation. I have a flattened head at the back which is also assymetrical. It has been a major problem for me for many years. Isolation and depression are the main effects. I have a local surgeon who is tells me a PEEK onlay is the best option. Would you consider this to be better than a filler material. He tells me I will have a transcranial scar and will have to have my hair cut short, preferably shaved. The argument for the onlay is it is difficult to achieve a smooth transition with filler material. I should add he has never done this operation before. Could you give me any advice. I am a little nervous about head shave and a huge incision.

A: After having performed over 100 occipital augmentations with every known material (except PEEK) and method, I can tell you for certain I would never use a hard preformed material like PEEK. (or preformed HTR or preformed acrylic for that matter) The material on insertion is too hard and this requires a maximal incision to get it into place. That may be fine but I don’t know of too many patients that want a full coronal incision for their occipital augmentation.

The two most commonly used and preferred cranioplasty materials in my practice are either intraoperatively fashioned PMMA bone cement or a preformed silicone implant. Either of these materials can be placed with much smaller incisions and work well. I have not seen an infection with either cranial augmentation material to date. This does not mean these methods are perfect (PMMA can have some edge transition issues because of its intraoperative fashioning) but these issues are aesthetic and not of any major medical significance.

FYI, I do not have my patients shave any hair for their skull augmentation regardless of the material or approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, What is the difference between the composite facelift using the subSMAS spaces and your technique? Do you make those incisions inside the ear cartilage behind the tragus? Can you please explain the differences between the Deep Plane facelifts? I am basically looking for the most invasive change/longest lasting facial rejuvenation change.

A: Let me provide you with some further comments and my experience with composite acelifting since this is a topic about which you have inquired.

I do not claim to have originality or unique experiences with extended SMAS or sub-SMAS facelifting  or composite facelift procedures. The principal motivation of a composite facelift is to bring a rejuvenative effort to more of the midface rather than just the neck and jowl areas. In other words, extending the lifting efforts to more of the central face area. A true composite facelift, in the purest sense of the term, works below the SMAS layer around the cheek, buccal fat pad and deep to the nasolabial fold area. The theory behind such a central dissection is that there is volume descent of the midfacial fat pads which has certainly been shown to be true by anatomic studies. This is not an area that any of the more traditional forms of facelifting strive to reach and treat. By dissecting the fat pad out and lifting and securing it vertically, midfacial descent of tissues is improved.

While this dissection can be done, and a few surgeons certainly tout it, more widespread experiences have been that the risk of injury to the buccal branches of the facial nerve, prolonged operative times, substantial and sustained edema and recovery and the sustainability of the midfacial results do not justify this type of effort in most patients. Other than a very few surgeons, the documented and proven long-term results simply do not justify that effort. The risk of buccal nerve injury, even if temporary, is very real and unsavory for any patient who sustains it.

If it is midface rejuvenation that one is striving for from a deep plane approach, there are more effective and less risky methods that can be combined with a good SMAS dissection. (e.g., subperiosteal midface lift through  an eyelid approach)

Thus one should not confuse longevity of a facelift necessarily with the deepest plane approach. There is only so much one can do with the SMAS layer and the intent of a deep plane technique is not necessarily one that ensures a more sustained result because of its  extensive SMAS manipulation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had the silicone micro-droplet injections initially done two years ago with no problems.  Then I had a second silicone injection into my upper lip six months from which my lip has turned hard and tight. What can I do now to get my lip back to being soft again?

A: Silicone injections may have their role in facial soft tissue augmentation but the lips is the most precarious place to put such a material. When it works it is great but the risk of significant scar reaction/nodules in the lip poses a difficult problem. Whether it is possible to get your lip soft and supple again is hard to predict. Since it is virtually  impossible to ever get the silicone material out of the lips, unless there are some distinct hard nodules, all that can be done are fat injections. The objective would be to break up some of the fibrotic scar tissue and layer in some healthy fat grafts that hopefully survive and act as a more supple interface amidst the silicone material which is encased in scar tissue.. This adds new healthy fat cells in and around the scar that would hopefully soften up the lips through the addition of new tissue.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am wondering if I am a candidate for an abdominal panniculectomy procedure. What I mean by being a good candidate is whether insurance will pay for the procedure. removal. I am not sure if I am a grade 2 or 3 pannus.

A:  Only your insurance company can truly answer the question of whether an abdominal panniculectomy would be covered but the basic criteria are:

1) an abdominal pannus that covers the groin crease and hangs onto the thighs,

2) an abdominal pannus that is associated with recurrent groin crease skin infections that has a documented three month history of topical skin treatments (non-surgical therapy) that has failed,

3) a BMI of less than 30 or a body weight that in within 20% of their ideal body weight based on standard height and weight measurements.

If one does not fulfill all three criteria, my experience has been that approval for abdominal panniculectomy surgery will be denied. And in some cases, even if all three criteria are met, a denial will still be given. It is also important to check whether your insurance company has a policy exclusion for panniculectomy surgery, as many companies now do, so this may not be a surgical procedure that is even eligible for coverage.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I developed a depression/dent on the middle of my forehead that is circular after the birth of my second son. Whenever I bend over or pressure is applied to my abdominal area, the depression on my forehead fills up with fluid and a huge bump is visible. I have had a CT scan done and the results showed that it was not a dent on the skull surface, however it did not explain the cause. Why do I have it and will it ever go away?

A: The simple answer is I don’t know why you have it nor can I predict with any certainty if it will go away…but if I had to guess I would not think it is going to go away. Since the dent does to have a bone-basis for its presence, one can assume this is a soft tissue deficiency. That is predictable since if the dents as due to a bone issue, it would have been present essentially since birth. (short of some traumatic event) I have no doubt that the dent fill sour when you bend over but that is not because it fills with ‘fluid’ per se. That is probably due to blood vessel engorgement from the pressure which would be more obvious when the tissues are thinner.

What I would initially is to some temporary filler injections to make it more level and probably resistant to that bulging engorgement effect. If that us successful the you can eventually move on to a fat graft or fat injections for a more permanent result once you are assured that a soft tissue fill solves both problems.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had an endoscopic mid face lift two months ago. Actually I had minimal problem but I decided to go through this surgery. Actually it did not help me that much. I did not have any complication but it just was not very helpful for me. As my swelling went down I do not see any noticeable changes at all. Now the problem is that my upper lip is very stiff and it is hard for me to move it. I am at 2 months post surgery and it has only improved by about 30%. The approach was through my mouth. Is this caused by the Endotine device or because the dissection was through my mouth and temple. Is it normal to have a stiff upper lip after midface lift? Your answer will be very highly appreciated.

A: Most effective midface (cheek) lifts do involve a combined temple/scalp and mouth approach. While this does create some temporary mouth soreness and upper lip stiffness, it has not been my experience that the upper lip stiffness is prolonged out to months after surgery. The Endotine device is positioned up on the zygomatic bone so that device is not the source of prolonged upper lip stiffness…or should not be. It is the path of dissection and how much tissue was released in doing so that is the cause. This is an issue for which only time and further healing can provide a resolution.

Dr. Barry Eppley

Indianapolis, Indiana