Your Questions
Your Questions
Q: Dr. Eppley, I have a question about my breast augmentation procedure that I forgot to ask about during my consultation. My left breast is slightly bigger than my right breast and I was wanting to know if this would affect the overall look of my breasts after getting implants? It is only a slight difference in size, and is only noticeable from a side view. I am just afraid that it will affect the look of my breast post surgery.
A: Breast asymmetry is very common amongst many women undergoing breast augmentation and is a very important aesthetic issue to identify before surgery. As a general statement, all implants do is to take the breasts you have and make them bigger. They are nothing more than a mound enlarging device. Thus whatever breast shapes one has when they are small will become bigger. This means that for some women a small breast asymmetry may become more noticeable afterwards. (i.e., the breast asymmetry becomes bigger) In other cases, enlarging the mounds may make the slight breast asymmetry go away completely. The difference in what may make breast asymmetry more or less noticeable after augmentation is whether the asymmetry is due to mound size differences or whether it is due to a difference in the horizontal position of the nipples. Slight mound size differences will usually go away even with equally sized implants on both sides. (the key is the term ‘slight’ mound size differences) Conversely, horizontal nipple level differences will usually get worse with implant enlargement as the mounds enlarge. For this reason if I see such differences I point that out to patients during their consultation and usually recommend a small nipple lift at the time of breast augmentation to even out the horizontal nipple levels to avoid the so-called ‘cock-eyed’ breast look when nipples are at different levels on the breast mounds.
I don’t specifically remember any significant asymmetries in your breast mounds that would justify either a nipple lift on one side or the use of different implant volumes. But since you have noticed a slight asymmetry in your breasts and it is of concern to you, I would lastly mention an old breast augmentation adage…‘breasts are not twins but sisters’. This means that if they are slightly different before breast augmentation surgery, they will continue to be different after surgery. One should not expect perfect symmetry from surgery when the breasts are exactly perfectly similar before surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Is it possible to correct mild midface hypoplasia with fillers? Will it be a result that is approximate to what facial implants can do?
A: If you add enough volume of injectable fillers in the cheeks, orbital rim and paranasal regions, some midface hypoplasia correction (increased projection) could be achieved. But no filler is permanent and substantial filler volume would be needed. It is also important to remember that gel-like hyaluronic acid-based fillers (e.g., Juvederm Voluma) do not provide the same type of push on the soft tissues that implants do.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am 29 years old and I have 3 kids. They are all good size and I’m small build so therefore my skin has stretched out bad!!! Also as a result in having kids I have an umbilical hernia. Can that be taken care of as well at the same time as the tummy tuck?
A: It would be very common in tummy tucks and abdominal panniculectomies for a woman to have a concurrent umbilical hernia. The hernia can be repaired at the same time as the tummy tuck procedure and is an ideal time to do given the very open exposure. In some cases there is a risk of loss of the umbilical stalk with the hernia repair dependent on the size of the umbilical hernia.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Can oval shape buttock implants rotate? Is there an amount of time that goes by that rotation is no longer a concern because they are now in their permanent place? If so, how long until that happens? If they rotate can you push them back manually without another surgery?
A: Oval, sometimes called natural, shape buttocks implants can certainly rotate if they are placed in the subfascial location rather than the intramuscular position. That risk is greatest during the first several months after surgery but the risk is lifelong since they are not textured implants but have a smooth surface. You may be able to push them around back into the place but they can just as easily rotate again. But if the buttock implants are placed in an intramuscular pocket, the chances of inadvertent rotation are significantly reduced because of the more constricted pocket space.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had upper jaw surgery and a sliding genioplasty done four years ago when I was 18 years old. I have never been happy with the results on my chin and would like it reversed, is this possible? The surgery left indention’s on the sides of my chin and a upturned appearance to the chin.
A: A Sliding genioplasty can be reversed in the same fashion as it was done originally…the bone is cut and moved back to its original position. I suspect based on your description of the chin issues (notch deformities on the distal ends of the cuts and an upturned chin) that the angle of the genioplasty cuts was too steep. This moves the chin as much upward as it brings it forward and leaves a v-shaped notch on the lower edge of the jawline where the chin bone moved forward.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was searching for the information regarding facial sagging after cheek bone reduction surgery. I suffer from facial sagging after cheek reduction surgery that I had four months ago. Even though my bone is tightly fixed, sagging is quite severe and it keeps getting worse. I think it might be because of the loss of skeletal support. He didn’t reposition the unit of my cheek bone but removed part of my front cheekbone by dissecting it as an ‘L-shape’. The worst part is that only the right side of my face is sagging and I don’t know what to do. I’ve been searching for some doctors who are renowned for face lifting. They said that they need to release the zygomatic ligaments and lift the SMAS up as well as the skin. I can see that you are the one who understand the right reason and solution of this problem. So I will be truly thankful if you spare some time to give me some advice. Thank you so much.
A: I am sorry to hear of your unfortunate unilateral outcome from your cheek bone reduction surgery. The obvious origin of the problem is the loss of ligamentous attachments of the overlying soft tissues to the cheek bone as well as the loss of skeletal support for them. It is interesting, assuming that the same bone reduction techniques were done on both sides, that only one side of your face has this tissue sagging problem. This shows how precarious the soft tissue attachments are to the bone and how slight differences in dissection techniques can make a big difference in their outcomes. As has been pointed out to you, the key to improvement is not just the skin shifting but the need for deeper soft tissue repositioning. The only tissues that possible to relocate are the SMAS layer. But moving the SMAS layer without giving it skeletal support will not provide a significant improvement. The first place to start is to have a good idea of what the underlying bone support looks like between the two sides. I would recommend that you get a 3D CT scan to visualize your cheek bone anatomy as it is now. Then with that information a more complete surgical plan can be devised as to how to manage the bone and the soft tissues.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in jaw angle reduction surgery. My problem is that my jaw line is low which gives me a rectangular/long face look. But honestly I don’t really mind that… I prefer having a softer angle. Mine is really low. If it was higher it would be good. But I’m wondering if you can actually do this surgery in several appointments? Like each time cut/thin off a tiny bit of the bone, so that it’s safer and faster… Honestly I’m scared that the results will be too drastic.
A: On a practical basis, you would really on go through a single jaw angle reduction procedure….and be certain that it is not too radically done. It is possible to do it in stages, and there is nothing wrong with that approach (and might end up that way anyway with a conservative reduction and if you like the improvement and want more), but most patients would only want one surgery. But doing smaller amounts does not result in a faster recovery…as the same dissection is needed to reach the jaw angles. The amount of jaw angle bone removal has nothing to do with the length of the recovery period.
The key to a successful jaw angle reduction in is too simply not over do it. (remove too much bone at too steep of an angle) It is somewhat easier to do more than to add back jaw angle height that has been removed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, My desire for rhinoplasty surgery is purely a cosmetic one. I am a healthy and active 25 year old who has never had any complication or surgeries before. That being said I’ve also wanted this procedure done for some time now but never had the opportunity to speak to a physician about it. I have a very typical Arab/Roman nose with a bump on a wide bridge and somewhat bulbous drooping tip. Which with my slender face it looks disproportionate I believe. Furthermore I have a deviated septum which is not noticeable but make the tip look bigger and the hook worse from the right than from the left. I will attach pictures of my nose which will show that from one side nose looks more straight than the other. All in all I would like my nose to be a tad smaller yet still maintain a natural look to my ethnicity (I believe it’s called a ethnic rhinoplasty?). What do you think can be achieved with my nose? Thank you for your time I hope to hear from you soon!
A: When one uses the term ‘ethnic rhinoplasty’ that could mean one of two things. An ethnic rhinoplasty could be any non-Caucasian patient that has nasal features typical for their race and they want a more ‘westernized’ nose change or a radically different nose look.. Or an ethnic rhinoplasty could mean a non-Caucasian patient that wants to undergo rhinoplasty but with changes that still fit their face and to not lose most of their natural ethnic look. I believe you are referring to the latter with the term ethnic rhinoplasty and that is how I usually interpret it and attempt to achieve for my non-Caucasian patients. Whaty this translates in your nose is that some of the bump would be reduced and the nasal narrowed and the tip would be straightened and lifted somewhat so that the nasolabial us closer to 90 degrees rather than the 75 degree angulation you now have. It is very important in a male to keep the dorsal line straight (or even maintain a avery small bump) and that the tip is not overlhy rotated upward.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in ethnic rhinoplasty. I have a very flat noseand would like to narrow bridge significantly to enhance my facial features as well as narrow the tip. My ideal nose features are those of Halle Berry, Beyonce and Vanessa Williams. Can you achieve this finish by reshaping my nose?
A: The first issue about ethnic rhinoplasty, and any rhinoplasty for that matter, is that trying to have the nose of someone can never be achieved. It is good to have a desired rhinoplasty goal. But in the end, no matter how well executed a rhinoplasty is done, factors such as the thickness of the overlying nasal skin will have a major influence on the final nose shape result.
I have done some imaging work on your pictures. The picture quality is not great but they are useable. Your nose is interesting because it looks the way it does because the nose has little cartilage support from the underlying septum which is why the tip is flat, the bridge is low and the nostrils are flared/wide. This is not unusual in African-American noses who often has weak septal support and widely splayed nasal cartilages with short nasal bones.
To make any significant changes to your nose, you would need an L-shape cartilage graft to both build up the tip and the bridge. Much like making a roof on a house, underlying support is need to build up your nose to give it more projection which is what will make it look more narrow and refined. This amount of support can only come from a shaped rib cartilage graft. Your nostrils would also need to be reduced/narrowed at the same time. The imaging predictions show some of the changes but be aware the frontal view image does not do justice to what would really happen when the entire bridge and nose comes forward as the computer software can not really show what happens as the nose is pulled forward. In short, the real result would look much better from the front that the imaging shows. I don’t know if your nose would look exactly like Vanessa Williams but it would be a lot closer than it is now.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in combining a chin implant and facial liposuction for making a round face thinner. I want to have normal shaped face, but also would like a skinnier face overall if possible? And are results permanent because I can get puffy just by taking a shower, so I am worried that my face is not stable and will that interfere with my surgery results. Thanks for any advice 🙂
A: Your desire for a slimmer face is actually based on a deficiency in your lower face not too much fat. You have little little fat throughout your face as you can see your cheek area is fairly thin and flat. The facial shape problem is that your chin is both horizontally and VERTICALLY short. As you can see in the attached imaging , when the chin is brought forward and lengthened, your face overall looks thinner. Thus making you have a thinner face is not based on liposuction fat removal but a very elongation of the lower face done through either a chin implant (vertical lengthening chin style) or a sliding genioplasty. (opening wedge type)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley,I was considering getting an injectable filler for my cheeks like Voluma that supposedly last for wo years. Would I be able to get rhinoplasty a couple of months after having the Voluma or should I just wait until I have rhinoplasty?
A: Your question about the use of Voluma Injectable filler is a frequent one that is posed by patient prior to some form of facial plastic surgery. If one knows they are going to eventually undergo surgery (rhinoplasty for example) then doing more permanent for the cheeks (fat grafts or implants) should be considered since one is in the operating room anyway. However, if one is uncertain that cheek augmentation is beneficial then an injectable filler can be done as a ‘trial’ method to judge the results and see if it what you like. But in that case you would use a short acting injectable filler so it goes away by the time of surgery. In short, if you were having rhinoplasty, for example three months from now, then you would use a quickly absorbing filler so in the event that the result is very positive you can then have a more permanent approach done with your rhinoplasty. But if your rhinoplasty was going to be done next year , or never, then you would use an injectable filler like Voluma due to its longer lastng effects
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had brow bone augmentation by fat grafting done yesterday, and I think my surgeon placed 8cc per side. I told my surgeon not to be aggressive, but I’m worried that he might have overdone it. It currently looks like an excessive amount of augmentation. Do you think this is what the final look will be, or will the amount of augmentation decrease to a reasonable amount with time?
A: Fat grafting to the face, by injection, is unfortunately not uniform in its outcomes or how well they survive. While there are a lot of variables in what makes an injected fat graft survive, and one can not assume that every surgeon does every step of fat grafting the same, the face has variable rates of fat graft take by region. The brow area has only a moderate fat graft take between 20% to 30%. Thus overinjection is commonly done knowing that much of the injected fat will take. That is why your surgeon uses 8ccs per side with the outcome likely to be only 1cc to 2ccs of fat that will actually take. So what you are seeing today will change and will go down substantially over the first month after brow fat grafting surgery. Ironically the concern you have today (too much) may turn into the opposite concern (too little) six weeks from now.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, My question is what should type of chin procedure do I need to get the best possible aesthetic result. I had double jaw surgery six weeks ago, and also a medium size silicone implant placed intraorally and fixed with 2 screws. I think most of the swelling is gone now. I’m noticing that my mentalis muscle is acting up again, especially at the bottom of my chin. I thought the implant as well as reduction of my vertical maxillary excess and lower jaw advancement would have resolved the mentalis strain completely. The bumpy appearance is much better than before I had the implant, but I’m unhappy with any dimpling, and am worried that it will return in full force eventually. I also think my chin implant projects too far forward (for a female) and it looks too high. I would ideally like my chin to taper to a slight V in the frontal view rather than the flat U I have now. I also noticed my lower lip looks really asymmetric post-surgery, wondering if it has to do with the implant? What would be the best course of action? Reposition or replace the implant? Fillers? Botox the mentalis? Sliding genioplasty? Thank you for your time and consideration.
A: While an implant offers the simplest approach to chin augmentation, it is usually not ideal in the face of a functional mentalis strain and can produce an aesthetically undesireable widening in a female. From your profile picture, I would agree that it seems too highly positioned which can also place a strain on the mentalis muscle.
For substantative improvement, it now appears that the implant should be replaced by a sliding genioplasty whose dimensional movements I can not say just based in these pictures. That would not only improve the mentalis muscle position but the chin could be narrowed in the frontal view with a v-line reduction technique as well.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I read literature online that (if I comprehended it appropriately) that a sliding genioplasty can relapse. Meaning, the chin advancement goes back to the original placement over time. Is this really true? Also, can bone resorption and/or bone remodeling in the long run take away from the aesthetic appearance achieved from the initial sliding genioplasty procedure? I thought the results of this procedure were supposed to be permanent. Let me know what your thoughts are.
A: If a sliding genioplasty is rigidly plated into position, theres is zero chance of relapse. You are referencing old chin fixation techniques that only used wire fixation which are far less stable. While I doubt they could even then relapse back to the their original position, they were less secure the further the chin was advanced.
In extreme or large amounts of chin advancement (10mms or greater), bony remodeling may account for a negligible amount of reshaping over the pogonion area of about 1mm. This is not aesthetically noticeable.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, over a decade ago I approached a surgeon as my upper lip did not raise well when smiling and my appearance was edentulous and a little tight when I smiled. Rather than the more typical bull horn type sub nasal lip lift procedure, the surgeon performed an operation that he designed to raise the complete base of my nose and debulk the premaxillary area. He did this by taking a full thickness crescent of skin from the floor inside the nasal vestibule of each nostril as well as segment of the nasal spine lifting the nasal base and sill into the deficit on closure which also closed the naso labial angle. By lifting the nasal base the columella was slightly rotated inward. This left me with a flatter lip which gives the impression of being overly long rather than shortened. I understand that the current wisdom is that this is not surprising. For some reason it also left me with difficulties in balancing the facial expressions involving the central elevator muscles which seem unrestrained or supported seemingly due to the missing bulk of the premaxillary soft tissue. The result has been a hyperactivity of the depressor alae or alae nasalis pulling my nasal base and lip downwards (see attached pic) and my impression is that this is in compensatory opposing the levator labii muscle or alaequa nasi. I had Restylane injected into the premaxillary area some time ago which very temporarily helped moved the central lip forward rather than downwards looking noticeably odd. I believe that the original incision needs releasing to allow the nasal labial angle to fall back into place for the best function and cosmetically (ie a de-rotation). I am unsure how to proceed or better describe the subjective problems I have and any advice or help would be welcome. If I were to describe this in more approachable terms I am trying to lower the base of my nose to its previous position by nasal spine augmentation and soft tissue repositioning / release.
I have attached some pictures pre- and post- op which demonstrate the difficulty I have in expression and smiling. I am hoping that you might be able to offer operative help or advice.
A: Certainly the operation you had done was unusual and predictably problematic. The question now, however, is how to reverse its effects. The fundamental problem appears to be a scar contracture/tissue loss at the nasal base/spine area. I would agree that the original incision and underneath it need releasing but that alone would not be adequate as it would just scar back done. It would need to be filled/augmented (premaxillary augmentation) and that is probably best done by a dermal-fat graft not an implant. You need biologic tissue that can fill the released space and not just turn into hard scar. You could do the same thing with injectable fat grafting but it would take several injection sessions to achieve a good release and tissue fill. This is better done by an open approach and en bloc tissue grafting
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m having my cheek implants removed later in the week due to an infection. Just wondering, will there be an excessive amount of swelling like when I had them placed in or will the amount of swelling be more limited this time round? Also, I’ve had them in for a year and will be replacing them in 6 months. In the meantime though, should I expect any damage or deformity from their removal? Lastly, I will be having some fat grafting done to my brow ridge. Will there be a lot of swelling associated with fat grafts to that region? Thanks for taking the time to answer my queries and it is much appreciated!
A: Removal of cheek implants is associated with far less swelling than their initial placement. Letting the tissues settle down and replacing the implants months later is not associated with any damage or deformity issues. Fat injections to anywhere on the face do not cause much tissue swelling.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am 42 years of age and have suffered all my life with what people around me have described as a square head. The head isn’t misshaped at the side or the back but is flat on top with a bit of a bump in the centre of the top. This has made all hair styles very difficult throughout my life and has affected me severely.
I wanted to know the following:
1) Is there any surgery available for this type of head shape?
2) How long would such surgery take and what kind of recovery is involved?
3) What are the results of such surgery?
4) What are the risks of this skull reshaping surgery?
5) Can you show images of what the likely results will look like before surgery?
A: Based on your description, it sounds like you need a convex augmentation across the top of your head for skull reshaping. In answer to your specific questions:
- Skull reshaping by onlay augmentation is a common surgery to buld up
- It is a 2 hour surgery under general anesthesia with about a week recovery at longest.
- The results of such surgeries are always successful in terms of improvement.
- Besides a fine line scalp incision needed to perform the surgery, the risks are generally aesthetic…shape and smoothness of the augmentation.
- I would need to see a front and side view pictures of your head to do predictive computer imaging.
Dr. Barry Eppley
Q: Dr. Eppley, I need your assistance with helping my doctor “get it right” when it comes to my jaw implants. Last year I had jaw angle implants placed which were lateral ones and they were the largest ones by Implantech. I then developed an infection on the right side and then I got one side taken out and then I was booked into have it reinserted two weeks later. However I found that although I loved the size of the implants it was the swelling that I enjoyed. So I asked my doctor when he put back the implant that I would like bigger implants. However he told me there were no larger sizes so what he did was simply place silicone block between the jaw bone and the current implant to push the jaw out more. Months passed and then I had another operation because what happened was that the silicone block was pushing out the contours on my cheeks and simply producing a very fat, large, round looking face. So the next operation involved cutting a portion of the implant between the jaw and cheekbone (near the ear) so that my face would ” dip in a bit”. I let that heal and now I’m still not happy with my jaw. Although it is okay I find that I never have reclaimed that lovely square contoured look I wanted when it was swollen from the first time I had it done.
So what my doctor has decided is to place Medpor instead of silicone during my next operation. He says that Medpor looks and feels more like bone and will produce a more better shape especially since i have thick soft tissues. He showed me the catalogue and i think the biggest one was 11mm. However I’m not sure if this time round it will work. I think my current implant combined with the silicone block is a lot bigger in width compared to the Medpor. Is Medpor better in my case? Will it give me more of a chiseled look? I’m concerned that my doctor isn’t looking into vertical augmentation as well.
A: When standard sized jaw angle implants are not sufficient because of their size or shape, trying to modify them or adding to them is usually not a satisfactory solution unless the changes needed are relatively minor. This is where the role of custom jaw angle or jawline implants have a very valuable role. Made from a patient’s 3D CT scan, implant dimensions can be made that best suits the patient rather than standard sizes that are made for ‘average’ amounts of facial augmentation.
Medpor does not look or feel more like bone than silicone. That is a completely false statement. More relevantly, any implant dimensions offered by Medpor are not really much different then silicone particularly in width.
Once you have been through two jaw angle implant surgeries with still unhappy results, you have to choose a different approach. Without taking a custom implant design approach, you would be best to leave what you have alone as continuing to use standard jaw angle implant sizes and shapes will still ‘not get it right’.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a nonsurgical injectable rhinoplasty last year but I believe the effect might be over. My question is do you think I should consider rhinoplasty because of the projection of my tip when I laugh and my bump on nose. Or should i just get another nonsurgical rhinoplasty because the tip is bothering me. The problem is my nasal profile from side could be adjusted with injection of the but it doesn’t do anything to the tip and it droops or falls down when I laugh. Please let me know thanks
A: I believe you have really answered your own question about the decision for a second injectable rhinoplasty vs. open surgical rhinoplasty. One of the benefits of any type of non-surgical aesthetic treatment is to determine if its effects can produce an equivalent result as that of surgery. While an injectable rhinoplasty can provide augmentation to a low radix or bridge of the upper nose, it will have no effect on any other areas of the nose other than that of an illusory effect on the overall nose shape. It will certainly not have an effect on an overly dynamic nasal tip that pulls down with smiling or laughing. Thus, some form of surgical rhinoplasty is the only treatment that can treat both both the bridge and tip problems.
A surgical rhinoplasty for you would augment the bridge with either an implant or cartilage graft and resection of the depressor septi muscle if the only tip issue is its downward pulling.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, my clavicles on both sides stick up. Have you dealt with this surgery before – do you recommend anything (would deltoid implants resolve this)? I don’t want huge shoulders, just bones not so prevalent and I don’t want scars. Appreciate any feedback.
A: I have seen and treated prominent clavicles before and they are not rare. From an anatomical standpoint, the clavicle or collarbone is the only long bone in the body that lies horizontally as it connects the medial sternum to the lateral scapula. The knob at the acromial end of the bone can be felt in anyone but in some people this bony bump is very prominent as a bulge underneath the skin on top of the shoulder. This occurs due to either more bone in some people or less surrounding fat in others.
Cosmetic camouflage can be done by bony reduction by burring but this creates a scar which you have eliminated as an option. Deltoid implants are not appropriate for camouflage as this type of implant fits over the larger muscle belly of the deltoid which is more to the side of the shoulder. The only scarless treatment option would be injectable fat grafting. Since a thin fat layer is one reason why a prominent clavicular knob is seen, fat grafting around the knob and out into the deltoid muscle belly provides the best treatment option. While fat graft survival is unpredictable and survives least in areas of thin fat with tight overlying skin, it is the one true scarless camouflage method. What may be helpful is deltoid augmentation by fat grafting not implants.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, what scar revision procedure would you recommend to help improve this widened, red/pink, rough, indented scar above my upper lip? As you can see, the mustache hair follicles were killed in the car, so there is no hair growth. It is a year old and seems to be done improving on its own. Please help.
A: Your upper lip scar, as you know, is wide, indented and hairless. Fortunately it lies in a near vertical direction which is a perfect orientation for a straight line scar revision. The existing scar needs to be cut out and hair-bearing upper lip skin brought together after removing the indented scar. This brings healthy tissue back to healthy unscarred tissue. This alone may be sufficient and will make a big improvement. Depending upon beard hair growth around the scar afterwards, a few hair transplants could be done if there is not good hair density across the scar. But you don’t want to do any hair transplants before formally removing the scar as that would never look as good. This type of scar revision is an uncomplicated office procedure done under local anesthesia. By removing the lip scar the surrounding beard hair will be closer together and the lip depression removed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a revision rhinoplasty that lengthens my nose. I had a rhinoplasty several years that ended up shortening and lifting my nose too much. This is not a good look for a man. I have read that the best way to do the procedure is with cartilage grafts and the rib may be the best source if substantial lengthening is needed. Does the rib graft make the nose feel any different such as being very rigid?
A: When considering revision rhinoplasty for tip lengthening and derotation, it is important to understand the anatomy of the nasal tip cartilages. The nasal tip cartilages are the only structures in the nose that are ‘free floating’, they are not attached to the underlying septum or upper lateral cartilages by fixed rigid attachments. This is why one can move the tip of the nose around freely and it is compressible, unlike the upper nasal bones or cartilages for example. When any tip lengthening procedure is done, which requires cartilage grafts, by definition more structural support is added and it will become more rigid. It will never be as soft and compressible as when it has less cartilage support. How rigid it may become is a function of the type and amount of cartilage grafts that are needed and how they are placed.
The cartilage grafts needed for significant tip lengthening/derotation must be placed between the fixed structures of the nose and the free floating tip cartilages. This is the way you drive down the tip of the nose. In essence, you are building up the underlying support to push out and down the tip. The grafts can not merely be placed on top of the nasal tip cartilages, that is only effective if you need just a few millimeters of lengthening or derotation effect. To really be effective for tip lengthening, straight pieces of cartilage are needed that are placed in an almost tripod fashion behind the tip cartilages. The use of a rib graft ensures that an adequate amount of cartilage is available.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in removing my breast implants and doing fat grafting as a replacement. I’ve had two children and after their births, I lost a lot of volume and my areolas stretched quite a bit. Currently, I have 350 cc saline implants making me a full C-cup. I was hoping to get a donut lift with areola reduction and fat grafting. I don’t expect to be a full C-cup again but what type of volume replacement could I expect?
A: While breast implants can be ‘replaced’ with fat grafting, it is important to appreciate several concepts about breast fat grafting. The success of any fat grafting procedure is dependent on the amount of fat one has to harvest and how much of the injected fat survives. Each part of the fat grafting process has a depreciating value. This means for example if 1000cc of fat aspirate can be harvested, when it is reduced (concentrated for each injection) the amount of fat available for grafting will be 1/3 to 1/2 of the harvest. (1000cc = 500cc) When the fat is injected only a percent of it will survive. While that percent can be quite variable for each patient (0 to 100%), let us assume the average take is 50% of the injected fat. (250cc) When you do this math for each breast, the final volume replacement of a 350cc implant will be 125cc of fat volume. (and this assumes that you would have 1000cc of fat to harvest) So you are correct in assuming that you would not be a full C cup with fat replacement but more likely a small to medium B cup. Thus it is easy to see that replacing implants with fat grafting is not close to a 1:1 exchange and the trade-off for a natural replacement will be loss of 50% to 75% of what the implant volume provided. Of course it is also possible that you may have greater than a 1000cc fat aspirate obtainable and then the volume replacement will be somewhat better.
Dr. Barry Eppley
Indianapolis, Indian
Q: Dr. Eppley, My problem is that my jaw line is low which gives me a rectangular/long face look. But honestly I don’t really mind that… I prefer having a softer angle. Mine is really low. If it was higher it would be good. But I’m wondering if you can actually do this surgery in several appointments? Like each time cut/thin off a tiny bit of the bone, so that it’s safer and faster… Honestly i’m scared that the results will be too drastic.
A: On a practical basis, you would really only go through a single jaw angle reduction procedure….and be certain that it is not too radically done. It is possible to do it in stages, and there is nothing wrong with that approach (and might end up that way anyway with a conservative reduction and if you like the improvement and want more), but most patients would only want one surgery. But the key in jaw angle reduction in general is too simply not over do it. It is somewhat easier to do more than to add back. Whether the jaw angle reduction procedure takes off a little or a lot, its safety, time to do the surgery and recovery would still be the same.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am seeking Facial Feminization Surgery (Rhinoplasty, Lip Lift, Chin Implant, Trachea shave, Brow shave). Please let me know if I am a good candidate. I am very serious/committed to doing this. What is the lead time between consultation and scheduled operation typically?
A: My definition of an ideal candidate for Facial Feminization Surgery (FFS) is a male who has the greatest chance of making a successful gender transformation based on their existing facial features. I would say you are about as ideal as it gets because you have a soft small thin face with a less distinct facial skeletal structure. With a few changes you would look quite feminine. The procedures you have chosen are the ones that I would agree are the only ones you need to make for a very successful FFS result. I will work on some computer imaging of these changes and get them back to you tomorrow.
As a general rule, I try and get patients into surgery as soon as they would like to have the procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’ve been reading about various types of facelifts and have a couple of questions and comments.
Questions:
1) Will he be tightening the muscles beneath the skin as well as cutting away skin?
2) Where will the fat injections go? I don’t want to look like Kim Novak did at the Oscars this year—so bloated my head seems too large for my body.
3) Can you send me pictures of previous facelifts you has performed on other people?
Comments:
1) I am not wanting to look 25 or 30 but to go back 10 to15 years would be nice.
2) I’ve attached 4 pictures of what I looked like from 1985 through 2005. I hope you’ll be able to get me back to 2000.
A: In answer to your queries:
Questions:
1) The only muscle that is tightened in a facelift is the plastysmal muscle in the midline of the neck. The SMAS layer on the sides of the face, which lies above the muscle, is lifted and tightened.
2) The only place fat injections go are in the nasolabial folds and the cheek pads.
3) There are many before and after pictures of facelifts on my website.
Comments:
1) Most facelift patients do turn the clock back by about p to 12 years. But it is important important to understand that a facelift only affects the neck and the jawline…and has not affect on the mouth area. To affect other areas of the face, other procedures needs to be added to areas such as the eyes and mouth. It is a common misconception that many people confuse a facelift with a more comprehensive total facial rejuvenation of which a facelift is just a part of it.
2) Whether you can get back to what you looked like in 2000 depends on an understanding of exactly the facial areas you want to improve and what procedures you want to do to get there.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Will a sliding genioplasty improve my lip incompetence? I would like my chin moved forward. My chin also looks long when I force my lower lip up to close my mouth. Would a slight vertical reduction be beneficial as well? First picture shows my lip incompetence (my teeth are touching) and second picture shows the increase in vertical length. Thanks for your time.
A: Besides a change in the horizontal position of the chin, you are describing what a sliding genioplasty can do really well…vertically shorten the chin and improve lip competence. By bring the chin forward and making it vertically shorter, the position of the mentalis muscle is changed and an upward push occurs on the lower lip. Together this produces improvement or complete elimination of any non-iatrogenic lower lip incompetence problem. It is now just a question of the different millimeters of movement, how much horizontal movement (probably 4 to 5mms) and how much vertically shorter (probably 3mms) in just looking at your profile picture.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have researched the Brazilian But Lift procedure for quite awhile and have been to two doctors for consultation. One discussed the Aqualipo option but they could only show me two pictures and the results were slight. I have attached some photos of myself to give you a better idea and to see if it is feasible. I do want a noticeable result–the more the better! Lastly, I am getting married at the end of the month and will leave immediately on a cruise. I am trying to find the most feasible option for me right now to where I could be healed up enough for the honeymoon, possibly a surgery date the first week of June. Thank you for your time!
A: Based on your pictures, I could not see you getting a significant buttock augmentation effect with fat injections alone. (Brazilian Butt Lift) You have to have enough fat to harvest to inject and then there is the variable of how much of the injected fat will survive. Between these two issues, you are more likely than not to end up with a moderate augmentation effect at best. While everyone’s definition of a dramatic outcome is different, my experience is what most patients want as dramatic is not what you would be able to achieve. Unless you combined the fat injections with an intramuscular implant, I do not see a dramatic result occurring.
That issue aside on a realistic basis, it would be very close to having this kind of procedure and being ready to go on a honeymoon (and enjoy it) just three weeks after the procedure. Six weeks of recovery is best in advance of this type of body operation. The liposuction harvest portion would be extensive (you would need every cc of fat you could get) and your body will be enduring a fair amount of trauma in so doing.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a recessed chin (no overbite as orthodontics aligned my bite) and a very deep labiomental crease. My question is, am I a candidate for a chin implant? I feel like I am not a good candidate as an implant would only exaggerate my pre-existing issue. Please see attached pictures.
A: Almost anyone can undergo a chin implant if their chin is deficient enough. The real question is whether someone is a good candidate for the procedure. Since you appear to be using the criteria of any deepening of the labiomental fold as not being a good candidate, then you would likely be correct. If the depth of the labiomental fold bothers you know, then it may bother you more after chin augmentation. Any chin implant procedure changes the pogonion position of the lower chin but leaves the depth of the nasolabial fold unchanged as it is not a bony supported structure. Whether it would be significantly deeper depends on the size of the chin implant, the shape of the implant and whether the labiomental fold is augmented at the same time. Since your chin augmentation needs do not appear to be large, the labiomental fold may not be changed significantly.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in one-stage frontal hairline lowering? How big will the scar be? As long as the scar isn’t noticeable, I’m definitely interested. How long is surgery? How long is recovery? Will I have to take any medication before surgery? Will I be completely out? Will I accomplish what I’ve wanted all my life, to be able to wear my hair off my face/forehead immediately?
A: For forehead reduction/frontal hairline lowering, there are two techniques based on how much advancement of the frontal hairline is needed. If the amount of advancement is in the 1 to 1.5 cm range, then it can be done in a single operation. Larger amounts (> 2.5 cms) would require a first stage placement of a tissue expander to create the amount of scalp needed to move forward. Frontal hairline lowering is done through a hairline or pretrichial incision and is best thought of as a ‘reverse browlift’. Instead of the forehead skin being lifted from the pretrichial incision, the scalp behind is advanced forward and forehead skin removed where the new hairline will be. While this does place the incision/scar right at the new hairline, it usually heals very well and is barely detectable in patients with little pigment in their skin. (Caucasians) It is a procedure performed under general anesthesia and takes about an hour and a half to complete and is done as an outpatient. Recovery is very quick and there is no swelling of the eyes that is usually seen. One can shower and wash their hair the next day.
Dr. Barry Eppley
Indianapolis, Indiana
