Your Questions
Your Questions
Q: Dr. Eppley, I lost of a lot of weight and my face is asymmetrical. I have small jowls and not sure if I need a facelift or just a necklift and if face implants would be an alternative to a facelift. I want to look prettier and have a long, narrow face with high cheek bones but hollow cheeks underneath and nasolabial folds. I have tried to have my own fat injected into the nasolabial folds but it does not last very long. I also have very thin skin. Would you recommend a regular face lift or a smart lift? Thank you
A: In looking at your face and objectives, I see three procedures that would be simultaneously beneficial. Higher cheekbones are only going to be obtained by cheek implants. While chin or chin-prejowl augmentation is not a substitute for what some form of a facelift can do, a small vertically lengthening chin implant can help the jowls somewhat but more importantly contribute towards a longer more narrow face. Facelifts go by many names and their name sometimes indicates the extent of the procedure. You need more of a jowl lift type procedure which often carries the name of short scar facelift, Lifestyle Lift, Smartlift etc. Regardless of the name it is designed primarily to lift and eliminate the jowls. When done together with the chin augmentation your jawline should be fairly smooth.
Improving the nasolabial folds is difficult and fat injections, while worth a try, are rarely successful. The only technique that I have found consistently effective are dermal-fat grafts which are essentially autologous implants but they require a harvest site to use.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I recently had a tummy tuck and have noticed something unusual (at least for me) afterwards. I am experiencing intense increased sexual desire. This is far beyond what I would normally feel this way. Since it is very early in my recovery ( five weeks) I can’t attribute to the fact that my body has changed and I am experiencing increased libido because of my new body shape. Is it possible that loss of weight or the removal of fat has caused some hormonal change that would account for my increased sex drive?
A: This is not the first time that I have heard from a tummy tuck patient of an increased libido after surgery. I would agree with you that it is not simply caused by a change in your appearance or hormonal levels. The most likely explanation is the coincidental pubic lift effect that results from many tummy tuck surgeries. To close the large open wound from tissue excision in a tummy tuck, the upper abdominal skin flap and the lower pubic region are moved to close over it. This lifts and tightens the pubic region and may change the exposure or angulation of the clitoris. It may also be that that the tissue shift and increased clitoral exposure may allow its increased exposure to be more directly stimulated by the rubbing on clothes. The occasional increased sex drive in a postoperative tummy tuck patient, therefore, may be a simple mechanical effect.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a question about temporal artery ligation. You have mentioned that the ligation of the temporal arteries would not cause hair loss. So, I’m 18 years old and I started to get a receding hairline and some slight thinning. Is it possible that these ligations don’t cause immediate hair loss, but accelerate the process of male pattern baldness? The internet says weird things, some sites claim that you should increase oxygen in the scalp and that bald people have less blood circulation/oxygen in their scalp. On the other hand, I came across a study that claims that ligation of the temporal arteries would stop male pattern baldness. I’m very confused and I was interested if you’d have an answer.
A: Hair loss, in general, is genetically driven. There is no medical evidence in an otherwise normal scalp that changing oxygen levels affects how the hair grows or how long it is retained. The scalp is so richly oxygenated by an extensive vascular system that it is impervious to varying oxygen levels throughout the body. A simple example of that concept is the effect seen in smokers who have lower blood oxygenation levels but often have very full heads of hair throughout their life. In addition, if oxygenating the scalp was beneficial for hair loss prevention there would be many scalp treatments available that offer that exact therapy. While the topical drug Minoxidil (Rogaine) does improve hair growth and hair loss prevention, it has a very specific vasodilatory effect on the hair follicle itself.
As it relates to temporal artery ligation, there again is no evidence that it has any effect on hair growth patterns…either a positive or negative effect. However, because of its collateral circulatory effects and employing the principle of choke vessels, a conservative approach to temporal artery ligation would be to do one side at a time. This is more an approach to ensure there is no negative effect on scalp skin survival and not necessarily for its effect on hair growth.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like to know if I would benefit from a lip scar revision? I had a laceration on my right upper lip that goes from the mid lip to just a hair past the vermilion border. I had 2, absorbing 4-0 sutures put in. And it’s been just a year and the scar seems more pronounced… When I’m not smiling it’s not as bad. But when I talk and smile, it’s definitely noticeable. It’s bumpy and from time to time .i get self conscious when in interacting with people, they tend to stare at scar…The scar is not straight, it has a slight curve. Thank you in advance!
A: Thank you for your inquiry and sending your picture. If the scar is over a year old and is pronounced and bumpy then there is some hypertrophic scar present. This often present as a white scar line that is raised, firm and may offset the vermilion-skin lip border. The only improvement that can be obtained at this point would be an elliptical scar revision pretty much along the line that it lies. Fortunately the scar parallels fairly well the natural vertical lines of the vermilion. This is a simple office procedure done under local anesthesia.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I want to get the ligation of the temporal arteries done. I’ve heard from you from a forum on the internet with lots of success stories. But I still have a couple of questions. If you tie off the artery at several locations, isn’t it possible that there appear ‘new’ artery or that the capillary system ‘feeds’ the tied off artery, so blood returns to the artery? Is there any chance of hair loss? My temporal arteries bulge beyond my hairline, how can you determine to ligate it in the hair bearing region? How big are the scars? On my right there’s just ‘one’ artery, while the one on the left splits into three arteries, of whom 2 splits into 2 other very little arteries, so I’d need a lot of ligations on this side.
A: When it comes to temporal artery ligation, the key is to perform proximal ligation to cut off the very high anterograde flow and distal ligations of any identifiable branches to eliminate any retrograde flow. If all lines that feed into the visible ‘pipes’ are tied off, there is no way any blood flow can return to the artery. There is no capillary system that feeds into the arteries. This always requires an incision (10mms) in the temporal hairline and small incisions (5 – 7mms) beyond it in the forehead area wherever the distal and feeder branches cab be identified. There is no risk of hair loss with this procedure. The blood flow to the scalp is extensive and has many other feeder vessels for scalp and hair survival. If ever in doubt, you only do one side at a time.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Can you do liposuction on the pubic area of a woman? The mons pubis I believe? I have attachments some photos of mine which is oversized tremendously. (as you can see in the attached pictures) How much would a procedure like this cost? How is it performed? What is the recovery?
A: It is very common to do liposuction on the mons area (pubic liposuction) and it can provide a significant reduction. However, your mons problem is going to require more than just liposuction due to the excess skin. You need a combined pubic lift to remove and tighten the loose mons skin that will result from it being deflated of fat at the time of the liposuction. Think of it as a reverse mini tummy with an incision in the skin fold at the upper end of the pubic region. This combined liposuction and lift of the mons area is technically know as a monsplasty. This is a one hour outpatient procedure done under general anesthesia. Its total cost is in the range of $4500. There is usually swelling and bruising of the pubic region and mild discomfort and it will take a full six weeks until the true final resut will be seen.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 25 year old male who currently has braces. Wondering if I should have BSSO mandibular advancement or sliding genioplasty. My jaw is strong but my chin is weak especially when biting.
A: The answer to the choice between a mandibular advancement or a sliding genioplasty to improve your profile is literally ‘between your teeth’. Since you are in braces, the key question is what is your bite relationship and what does your orthodontist to tell you? Is your bite correctable by orthodontics alone or is the discrepancy between your upper and lower teeth significant enough that the lower jaw needs to be brought forward to put your bite together properly and, if so, how much does it need to be moved forward.
There are three possibilities. #1 Your bite is going to be corrected by orthodontics alone and then a sliding genioplasty is needed. #2 Your bite is far enough apart that the lower jaw need to come forward significantly (7 to 10mms) and the profile will be corrected completely by that movement alone. #3 Your bite correction requires a small amount of mandibular advancement and a small sliding genioplasty will be needed as well.
Regardless of the type of mandibular or chin movement needed, I have attached a prediction of the type of change needed for normalizing your facial profile.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Do you do liposuction on “cankles” and calves?
A: Cankle liposuction is more than a myth, It is very real surgical procedure! Reshaping the legs from the thighs down to the ankles are liposuction procedures that I commonly do. Do not think of reshaping the lower extremities as a 360 degree circumferential procedure as that is not the approach that is taken. The most effective thigh, knee, calf and ankle liposuction technique is known as ‘silhouetting’. This is done by selectively changing the inner and outer contours to give the entire leg more shape as seen from the front. This means that the inner and outer thighs are done, the knees from across the top, inner aspect and curving below the knee into the upper calf and tapering the lower calf above the ankle area above both areas of the ankle bones. This is how one uses liposuction to make the leg more shapely from top to bottom.
While effective, cankle liposuction invokes a lot of persistent swelling around the ankles that takes months to completely go away and see the final result.
Dr. Barry Eppley
Indianapolis, Indiana
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in revisional rhinoplasty. I have had two reputable doctors turn me down for revision saying that I do not have enough natural cartilage left to build up the nose and that I have too much scar tissue preventing the tip definition and bridge length and height I desire. Please let me me know whether you can revert my current nose to my birth nose – longer, more heightened bridge and defined tip.
A: In revisional rhinoplasty, having adequate building materials (cartilage) is often the key to any degree of success. When it comes to using cartilage for the nose, there are three sources…septum, ear and rib. One is never out of enough natural cartilage because the ribs are an endless source for the amount needed in any nose. The issue may be that your septum and ear from prior surgeries has been used or the cartilage volume demand exceeds what they can supply. While I don’t know your prior rhinoplasty surgery history, most likely they were more reductive procedures so your septal and ear cartilage sources may still be available. But in augmenting your nose throughout its length, the amount of cartilage needed probably exceeds these sources. Thus you do have enough natural cartilage to use but you may not prefer or your other surgeons do not do rib cartilage harvests. But to get nice straight pieces of cartilage that are needed for this type of augmentation rhinoplasty, rib graft cartilage would be best.
While your nose undoubtably has scar tissue, that would not be a limiting factor in increasing dorsal height and bridge length. It can very well be a limiting factor in improving tip definition however.
One important realization is that you at never going back completely to your original nose. You may get close but it will never be able to return exactly to what it was before surgery. That well may be exactly what your two doctors were really saying…they may have felt that what you wanted to achieve is not possible and for what can be achieved may leave you wanting and disappointed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like to explore a lip lift and corner lip lift. I have an unusually long upper lift (distance from bottom of nose to top lip) and would look much more balanced if that distance could be shortened. However, I have an over rotated upturned nose from previous rhinoplasty. This means there is no crease or space in the shadow of a nose that a scar could hide and it would mean that if there was nostril distortion, it would be very visible and unattractive. Given how little room for error my nose allows for this lip lip and corner lip lift, should I consider this surgery or let it go?
A: When it comes to a subnasal lip and corner of the mouth lifts, the most important issues are the potential scars and not overdoing either type of lift. Prominent scars or an overcorrection (which is virtually impossible to correction since you can not add back skin) are aesthetic tradeoffs that one needs to avoid. While I have not seen a picture of you, you may have answered your own question…if there is little to no room for error…why take the chance? I have never seen nostril distortion and have only rarely revised a subnasal lip lift scar but your concerns do have merit.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had an hydroxyapatite chin augmentation several years ago. The hydroxyapatite was semi-solid or loose when implanted- mixed I believe with some fluids, but it was not cut from a block. It was implanted intraorally. Besides not doing much from my chin, it appears that the chin tissues are more loose now and hanging somewhat. I would like to see if we could perhaps fix this problem as much as possible. The tissue also appears more red in color that the rest of my face after surgery. I have attached some pictures of my face for you. I did take them myself from short distance so they do appear a tiny bit distorted, but they give you a good look at the chin and jaw angles in particular. In terms of enhancement to my jaw, I am not necessarily looking for a massively dramatic distal increase in size- just a moderate one to give a sharper look to the lower part of my face and to help with structure as I age.
A: Thank you for sending your pictures. I can’t say that I see any significant soft tissue detachment of looseness per se but the chin is horizontally short. It may feel somewhat looser as the hydroxyapatite granules are not structurally supportive. The hydroxapatite paste put in the chin usually have very little push to it so its augmentative effect is very minimal and often can be very irregular. I am not sure why the chin button area is slightly red as hydroxyapatite is usually very biocompatible. Certainly the hydroxyapatite granules can be removed and other forms of chin augmentation done. A more stouter form of chin augmentation will do a better job of picking up the loose chin tissues as well as providing more of an augmentative effect. At the same time, jaw angle augmentation focusing primarily on vertical length can be done as part of an overall jaw enhancement strategy.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a LeFort I osteotomy some years ago to help correct my bite, my upper jaw was very recessed. My upper jaw was moved slightly forward and corrected my bite, but it is still a bit recessed gives my midface a sunken look. Also, even though my teeth and bite look really good i do not show enough upper teeth, will the paranasal augmentation alleviate that a bit?
A: While midface augmentation through a variety of bone locations (cheek, infraorbital rim and paranasal regions) can help make the part of the face at or above the LeFort 1 level match and have equal augmentation, they will not create greater upper tooth show. Even though paranasal implants are placed iclose to the upper teeth, its augmentative effect is very unlikely to raise up the upper lip for increased tooth show. If paranasal augmentation is skeletally beneficial there are other ancillary procedures that can help create upper tooth show such as a subnasal lip lift or horizontal internal mucosal upper lip resection done at the high vestibular level.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Is BSSO mandibular advancement reversible at all and what are the complications of that? Whatever was wrong with my face got accentuated with this procedure, e.g. flatness of my cheeks, flatness on sides of my face, nasolabial distance, short nose, etc. There was a few mm space between my teeth and I just didn’t expect much change to my face nor was told there would be much change nor a bad outcome to my facial structure. My face wasn’t great but with some good cosmetic procedure would have been looking good but now I am not sure what to do about it and how can this be at least partially reversed and if reversals are performed and with what results? I just want this jaw shorter and simply removing the genioplasty probably want give that much of an improvement, I feel I would have a long jaw with flat chin and the effects of my face wouldn’t be reduced, the pulling down part. I don’t gain weight easily on my face nor at all so it’s not like any fat is going to cover this bad outcome and the most I don’t like how the face got all pulled down and how bad it looks, I didn’t really know that would be the outcome of this surgery. If reversal is possible, what would be reversed in the facial structure, would it just be a bit of length of the jaw or would the changes to gonial angle/movement of ramus bone be reversed to any degree? I guess it doesn’t work for every facial type, certainly didn’t work for my face. My orthodontist told me there could be some adjustments over time to my jaw, but I am certain there wouldn’t be any as so far there wasn’t any adjustments and it’s been over 5 months now. The more the swelling went down, the worse my face began to look. I feel now it’s probably the final result except for still swelling on my chin area a bit.
A: At five months after facial skeletal surgery, I would agree that you are essentially looking at the final result. Like the genioplasty, the BSSO mandibular advancement is reversible but the implications of doing so are not as simple as that of the chin. Moving the mandible back is going to change your bite to an unfavorable realtionship. The whole effort at presurgical orthodontics and then the surgery was to change you into a new and good bite relationship. While the BBSO can be undone and moved back, the bite will subsequently be off. Whether that is subsequently in the range of being correctable by orthodontics is a question for your orthodontist since I have no idea what your bite was before surgery or now. There is also the repeat risk of nerve injury (numbness to the lip and chin) with the repeated BSSO procedure.
It would be extremely helpful to see some before and after surgery x-rays (lateral ceph films) which your orthodontist and surgeon undoubtably have. That would provide the critical answers to how far was the mandibular and chin bone segments advanced. (in mms) That would tell me what contribution each made to your now overprojected mandible, where the most likely bone setbacks should be done for the greatest change and the risks involved in doing so. As I had stated previously, undoing the chin is far simpler and has less risk than undoing the BSSO.
Your pictures actually look satisfactory to me and I see no major facial imbalance problems. (I see a slightly strong chin and high gonial angles) But…this is your face and clearly the structural changes are unacceptable to you. While it is common with any form of facial skeletal surgery (what I call facial structural surgery) to have a period of psychological adaptation to their new face, generally that has happened by 6 months or so after surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in rhinoplasty surgery. Is it possible to to do nostril narrowing making my nostrils smaller and the tip of my bulbous nose smaller, what would you suggest ? I want a thinner and more defined nose altogether.
A: Your rhinoplasty questions are good ones and are fairly common in ethnic African-American rhinoplasty. What you have is a nose that has little underlying cartilage support with thick overlying skin. This is why it is wide, short and ‘turned up’ so to speak. It simply lacks much underlying support to hold the skin up. While it is tempting to think that just thinning out the cartilages on the nasal tip, defatting it and then narrowing the nostrils will create the desired effect, it will not. In fact, such an approach may likely end up making it look worse. What you need is an augmentative rhinoplasty (not a reductive one) that builds up the bridge of the nose and tip and pulls the skin upward (and somewhat downward at the tip or derotation) to create a thinner and more defined looking nose. If the nose is augmented then narrowing the nostrils will be more effective. I have attached some imaging of your nose to demonstrate that effect. How to achieve the augmentation is a classic debate between a rib graft or an implant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in liposuction of multiple body areas including the abdomen, love handles, thighs and knees. But I have a few questions that I hope you can answer for me.
1. As I age, if I gain a bit of weight (I’ve been within these same 20 pounds since I was a late teenager—I don’t intend to go out and purposely gain weight!), where will it go? One plastic surgeon told me since he’d “be removing all the fat cells” from under my breasts to my knees that the fat couldn’t return there, but would go to my bottom or my breasts. Now that we’re doubting most things he told us, can you please confirm or deny this?
2. Does doing this liposuction once mean I’ll need to do it again in years to come because it will look unnatural or lumpy when I’m 65, 75, etc? How will things “settle?” I guess I’m unsure of the “deconstruction” you’re doing and how naturally my body will function afterward (and years later as my life goes on).
3. I read your packet of information and wonder about revision surgery. I certainly know you can’t tell me I would never need it, but I do know you said I am a rare “good candidate” for his procedure. I’m hoping this fact significantly reduces the possibility for needing revision surgery. Your packet says roughly 15% of patients need it. I’m just curious where you think my risk for that lies (of course, I know there’s always at least a little risk).
4. Will the sudden removal of this fat have negative implications for my metabolism? Does fat secrete the hormone that controls metabolism? What happens if a lot of that fat is suddenly gone?
A: Your questions are all good ones about liposuction and many of them touch on the basic science of fat metabolism. While fat has been studied for over 100 years, it is still not a body tissue that is completely understood and it is more than just a blob of fat tissue that sits there only to accumulate excess calories. It is best thought of as a dynamic organ with complex metabolic and hormonal functions. How the removal of some body fat by liposuction affects its functions beyond a simple contour change is, again, incompletely understood. In answer to your questions:
- Liposuction does not and can not remove all fat cells from any body area, that is an impossibility. Some fat cells (and probably more than just some) always remain in the liposuction treated area. There is just less fat cells than there were and that is why the body contour is less full or convex. If one does gain weight in the future, the treated area can change because the existing fat cells can accumulate more fat. (the cells get bigger) One can not grow more fat cells but the existing cells can themselves get bigger. Whether excess ‘calories’ will be prone to be deposited from whence it was removed or whether it goes elsewhere differs for each individual. Ultimately it has to somewhere so the long-term sustainability of a liposuction result is highly dependent on the stability of one’s weight.
- The contour results from a liposuction procedure are generally fully known by three months after the procedure. This reflects the final external appearance of the evenness of the fat removed. It is not an issue where it continues to change or settle for years.
- Being a good candidate for liposuction means that the quality of the overlying skin is good (has the ability to shrink down to a lesser contour after the procedure) and the fat is not too excessive that a good result can be obtained. Unfortunately being a great candidate for liposuction does not preclude the possibility of revisional surgery although it may make that risk less. Revisional surgery in liposuction is almost always done to even out any irregularities or asymmetries in the treated areas. In my experience, some small touch-ups may be desired in about 10% to 15% of all liposuction patients.
- The amount of fat removed in liposuction is rarely ever enough to have any impact on one’s metabolism. If this were true, many diabetic patients would be treated by liposuction to lower or eliminate their insulin needs.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interesting in a variety of facial procedures to create an overall facial reshaping effect. I have done a lot of research and have concluded that I would like the following done:
1) Corner of Mouth Lifts
2) Upper Blepharoplasties
3) Tail of the Brow Lift (Transpalpebral Browlift)
4) Fat injections to the Lower Eyelids/Infraorbital Rims and Upper and
Lower Lips
5) Cheek Implants
6) Chin Implant
7) Jaw Angle Implants
8) Rhinoplasty
9) Brow Bone Augmentation
10) Temple Implants
Do you think the result could still appear natural with so much procedures? Can they all be performed at one time?
A: I would not disagree with you that this list is a lot of facial reshaping surgeries although I have performed such a list before on a handful of patients. While a large number of skull and facial procedures can be combined in a single operation, whether that can and should be done is based on the practical issues of cost, extent of recovery, will the objective of overall facial reshaping be achieved and whether so many facial changes will look natural.
When it comes to looking natural from extensive facial changes, the key is that no single one of the components of the procedure should be ‘overdone’. The more aesthetic operations in proximity that you do, the changes they make will be cumulative and more obvious. Thus each element of the plan should be done conservatively to not look out of proportion or distorted later.
While many facial procedures are done as an outpatient, this collection of procedures would require that the patient stay overnite after surgery. You must also consider how long your face will be swollen and when you will be presentable for work or other socially scrutinizing activities of daily life.
Cost is almost always what pares down a very long list of desired facial procedures to the most practical or those procedures that produce the greatest value or facial change per investment. A good exercise to do is to rank all of your chosen procedures in order of importance to you from the most important to ‘it would be nice but I can live without it.’
Putting the issues of recovery, a natural look and cost together will determine for you whether this number of facial surgeries can be done in one operation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in your facial fat grafting procedure. I am a fairly young guy, 38 years old and in good physical shape. I have always had a very tired look under my eyes. I had cheek implants and orbital rim implants placed. They helped, but the problem is still there. I could also use more volume in the upper cheeks, and help with rounding out the edges of the implants. My questions are as follows:
1) How many facial fat transfers do you do per year?
2) Can fat grafting be done on someone with orbital rim and cheek implants?
3) Have you personally operated on many people with cheek/orbital rim implants?
4) Is there a chance of your needle touching the implant and causing an infection?
5) Is the procedure done under general anesthesia or would I be awake?
A: Fat grafting to the face today has become very popular and is commonly performed despite the reality that the survival of the injected fat is far from assured. It has reached the current state of widespread use because of its easy introduction to nearly any facial area, its natural composition and the potential benefits of some cellular survival particularly its stem cell component. In answer to your questions:
- I perform fat grafting as part of many facial procedures, either done alone or in combination with more invasive procedures. I would estimate that it exceeds over fifty facial fat grafts per year.
- Fat grafting can be done on someone with any indwelling form of facial implants and may be placed in the soft tissue overlying them.
- I have placed fat grafts in patients with indwelling cheek and infraorbital rim implants and at the same time as the placement of the same implants
- Fat grafts are placed by blunt cannulas, not needles, so there is little chance of injecting into the actual implant pocket. I suspect that even in the rare instance where fat may have been injected directly into the implant pocket no adverse sequelae would result.
- I have performed facial fat grafts under local, IV sedation and general anesthesia. The choice between the anesthetic type depends on the patient’s preference, the amount of fat to be injected and the location and size of the donor site.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 42 year old man who is interested in getting a chin implant. This is something I’ve considered for most of my adult life. I have a very hectic and busy work schedule. My down time is very important to know. I’m concerned on how long I’d be out of it after surgery. Also when I can resume my duties at a 100% level. I’m in very good health and the only vice I have is smoking. Aside from that I have no issues that would stop me from surgery.
A: The recovery from chin implant surgery is more of a social rather than a physical recovery. A social recovery refers to you how one looks after surgery…how much the swelling and chin distortion is and when you feel comfortable returning to the rigors of your work schedule based on your appearance. There are no physical restrictions after surgery and the chin swelling and discomfort is not usually that physically limiting. Thus you can return to work as soon as you feel capable. Depending upon the type of work you do that may be anywhere from 3 to 7 days after surgery. There is nothing you can do to adversely effect the outcome of the chin augmentation surgery short of getting hit or falling on your chin.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am looking to have a Chin Implant surgery and I heard a lot about you across the internet from satisfied patients. I have some concerns about the surgery. I grow facial hair (beard) relatively fast like in a week. Will it cause or disturb the stitches made under the chin. and When can I start shaving after the surgery?
A: In the submental approach to chin or jawline implant placement, a skin incision is made under the chin through hair-bearing skin in men. I close the skin portion of the incision with a 5-0 plain suture in a subcuticular fashion (under the skin) so no suture removal is needed later. It is then covered with thin flesh-colored tapea that are glued on. Once get the tapes wet and shave around as soon as one feels comfortable doing so. It is expected that the growth of the beard skin will push the tapes loose in a matter of days. Once can then shave over the incision beginning one week after surgery. This is an incision management strategy that has worked well over the years in chin and jawline implants in men and has never posed an implant infection or hair growth problem.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 63 year old female who is interested in a direct neck lift but am concerned about the scar that will result. I have had two facelifts but each one has failed to really improve my neck like I want. I have been recommended now to have a direct neck lift because they say there is no more loose skin to tighten. I value my face and neck very highly since I had double mastectomy years ago and never had any type of reconstruction. What is your advice about the direct neck lift scar?
A: As I always say to patients with difficult scar choices, the only way to be sure of having no regrets is to never have the scar in the first place. In listening to you, I just don’t see that the scar no matter how it is done is every going to truly be acceptable. And you don’t merely want to tradeoff one problem for another and then just dislike your neck for a different reason. The only way any form of a direct neck lift would even be acceptable to any patient is when they can unequivocally say that the scar is absolutely better, no matter how it looks, than what it is a substitute for. This is clearly not the case for you. As a plastic surgeon I would certainly not be comfortable placing a scar in an aesthetic operation when the patient is very equivocal about its trade-off. This is magnified in you who now values the importance of how their face and neck looks as a some form of ‘compensation’ having lost other body parts.
On a different note and tact, I would question why none of your facelifts could not adequately address this neck issue. That is very uncommon/rare in my experience. I suspect this is a technique issue and thus I would question the statement of ‘ there is no more loose skin that can be tightened’. You may merely have reached the limits of what your surgeon can do. I would not take that as gospel that further neck improvement can not be obtained by a facelift approach.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Do I need a facelift to correct my chin sagging after being burred? I had a procedure done three months ago where the surgeon burred under and shortened the chin. It was done intra orally and the lower chin and my face is slack and looks like there is a protrusion. In other words it still looks like I have a double chin despite everything. I am not sure which procedure I need but I did include pictures. Also could a slight buccal fat removal be done in conjunction with this?
A: Intraoral chin reduction is almost always associated by loose chin skin afterwards and often fails to make a big improvement in the amount of chin projection. A submental approach to your chin reduction would be more effective. Whether this is addressed only by a submental tuck (submentoplasty) or would be rolled into a lower facelift would depend on where you see the area of improvements needed and whether you want the whole jawline tightened. It is not crystal clear in the pictures and the real test would be what happens when you bend your head down and where the skin rolls appear.
When referring to the buccal area, there is the area right below the cheekbone (the true buccal fad pad area) and the area that lies much lower near the mouth and jowl area known as the perioral mounds. (which is often confused with being the buccal area) I believe you may be referring to the perioral mound area by description and in the pictures. Perioral mound liposuction can be done in conjunction with any submental chin tuckup or facelift procedure
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in revision rhinoplasty. I have had two previous rhinoplasty surgeries and have thick skin on the tip of my nose. Is it possible to reduce and sharpen my nasal tip? Can my nasal profile be reduced? I have attached some pictures of where my nose is now.
A: Reducing the profile of your nose, of which I assume the biggest need for that is up high at the bridge, seems like it could most certainly be done. In looking at your pictures, I am assuming it is the high radix of the bridge and perhaps the overall bridge itself that is the aesthetic concern. When it comes to the nasal tip area, particularly in men, the challenge as you know is what your thicker nasal skin will allow to happen. Whether such a change is realistic would partially depend on what was done to this area in your prior rhinoplasty surgeries. I assume that efforts were made in that regard to do so but did not work. To the best of your knowledge can you tell me what was done in those procedures and how long ago was the surgeries?
There is always the old adage that past history predicts future behavior. Thus, if considerable effort was made for tip narrowing (times 2) and this is the result, I would not be optimistic that a third effort would be more successful. But the key question is what exactly was done to your nose in the prior two surgeries.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have few question regarding forehead augmentation and back of the head augmentation. I would appreciate your kind answers to each of them one by one.
1. Which procedure is more durable, bone cement or implant?
2. Can you please tell the advantages and disadvantages of each?
3. Is it possible that bone cement is filled without cutting the scalp, so we fill the scalp by injection three to four time(interval of ten days) and it may increase the whole head size?Because i fear of cutting scalp and tissue expander.
4. Is bone cement strong enough like skull bone?
5. Which procedure do you recommend?
A: For forehead and occipital (back of the head) augmentation, there are two basic materials that be used…bone cement and preformed implants. In answer to your questions:
- Both material are equally durable. Neither can degrade, be broken down or will ever need to be replaced because they ‘wear out’.
- Each material type has its own unique advantages and disadvantages. Bone cements must be mixed, applied and shaped during surgery thus taking more operative time to do. Preformed implants are made before surgery off of a 3-D CT scan of the patient’s skull. By computer design they provide the best and most symmetrical augmentation with the least risk of any irregularities at the implant-bone transition areas. They can also be done with less operative time. From a cost standpoint, they are roughly equal.
- With either approach, a scalp incision is needed. There is not injectable cranioplasty technique for this size of skull augmentation areas. There is no need for a tissue expander with your dual augmentation.
- The resistance to fracture is roughly equal between PMMA bone cements and skull bone.
- I find both procedures can make for successful skull augmentations. The choice between the two is a matter of personal preference and which one sounds better for each patient. Both type of forehead and skull implants can be done very successfully.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in skull reshaping and brow bone reduction surgery. I know you probably get these comments a lot, but I have always been very self conscious about my head shape and eyes. First my head is I guess a triangle oval shape but from a straight view it makes my head look very square and the top of my head is sort of flat. I absolutely hate it, it bothers me everyday. I wake up because even when I wear hats my head still looks square. I want the top of my head to look more smooth and oval shaped like a normal head but my head just looks fat. Also on top of that my eyes are really really puffy and close set which bothers me a lot also. I hate the boney parts at the end of my eyebrows. I feel they make the close set eyes look worse and how the bottom of my eyes are so pockety. This is destroying my self confidence day by day. I need to know if there is anything possible I can do so I will be happy in the end and not disappointing nor satisfied with a procedure. I have attached a couple pics for you to see my troubles. I love my hair but this head shape hurts my self-image. Also when I have short haircut it is embarrassing to me.
A: Based on your description of your concerns, it appears that a skull reshaping procedure with augmentation and lateral brow bone reduction is what is needed for improvement. Because you head is flat across the top, it can be built up between the two temporal lines to more of an oval shape by applying a bone cement material. There is a limit as to how thick it can be based on the scalp stretches but I would imagine that about 1 cm thickness in the very middle can be added. The tail of your brow bones (boney parts at the ends of the eyebrows) can also be reduced. All of this can be done through either a scalp incision or a smaller scalp incision combined wth upper eyelid incisions.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a direct neck lift but have concerns about the length of the neck scar. I have had two facelifts but my neck wattle persists so I am tunring towards a more direct approch. Here are some pictures as I do not like my profile. Can I direct neck lift be done with a shorter scar?
A: There is no question that the final ‘piece’ to optimizing your facelift result is the central neck area. In a traditional direct neck lift, the bottom portion of the scar ends in an inverted T shape excision of skin along a horizontal skin crease which is usually over the thyroid cartilage. (most people perceive that it ends in a straight vertical line but that is a misconception) It ends like that to work out any excess skin. What really creates the sharp neck angle (besides the tissue excision) happens above that at the cervicomental angle) In a shortened or more limited version of a direct neck lift, the lower end of the scar can be completely vertical. (the upper end is now an upright T at the submental skin crease) This now becomes what is more classically perceived as a submentoplasty. This can certainly improve your neck wattle but not to the degree of the classic direct neck lift with the lower scar location. In conclusion, as long as the scar does not drop below the cervicomental angle area then that would be a good compromise between improvement and the creation of a scar.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am inquiring about chin implant replacement. I had a Medpor chin implant placed six months ago. As time has gone by with healing,and my face has slimmed down a bit, the chin implant looks too boxy. Here are some questions I have:
1. Could removal of the medpor implant cause any damage, or unsightly scarring? That’s why we wanted to explore shaving it while still attached. It just sounded so much easier than ripping it out, and possibly causing problems with the underlying bone, etc.
2. The implant that was put in was much more square than my original chin and I was never happy with it but was encouraged to give it the “time” test. Time only made things worse. My worry now is upon removal is the stretching that has occurred in the skin and tissues. Would there possibly be sagging if we go to a smaller implant?
3.. If we sent you some pictures, is it possible to only come out there one time — for the surgery?
4. Finally, I should mention that I am a cleft lip and palate patient who went in for a rhinoplasty (which we’ve already had a revision), and the doctor suggested the chin augmentation. We agreed it needed to be done, but we got WAY too much of a good thing. Thanks so much for your expertise and advice.
A: Having removed numerous Medpor chin implants, I have found them not unduly difficult to remove or particularly destructive to the surrounding tissues. It is always helpful to know what style and size Medpor chin implant was removed beforehand to plan for its replacement and to choose a more smaller more feminine type of chin implant design.
I rarely would advise trying to modify a Medpor chin implant in place as that usually does not turn out well. The access and visibility is difficult and asymmetry of some kind is often the result. Most of the Medpor chin implants that I have removed and replaced have that exact history…initial placement and subsequent revision (with asymmetry) and now they want it removed and replaced.
As long as some type of chin implant replacement is done, soft tissue sagging is not usually a concern. It is the total removal and no replacement where that is more of a potential issue.
This is the type of procedure where you come the day before to meet, have surgery and return home the next day. There are no other visits needed beforehand or after. Any follow-up can be done by phone, e-mail or Skype.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I think I am interested in a direct neck lift. I am 68 years old, slim and sporty. I have had two face lifts, the second had to be redone completely five months later so this makes in reality three face lifts with the last one being done five years ago which still holds pretty well except for the neck. My surgeon suggested to have a direct neck lift, since I have no skin elsewhere to cut off. I saw that you are a specialist in direct neck lifts. I hesitate to have this vertical scar, although my scars fade away pretty well but in the middle of the neck would be awkward. I do dancing for my pleasure and my friends in the class would see the scar. There is little skin to be taken away. I have still a nice line around my face, but the profile is not nice looking, it makes a direct line from the chin to down to the neck. If I turn my head or lift it a little it is ok. Did you ever do a direct neck lift on a lady? How is the scar? Many thanks in advance.
A: I have done many direct neck lifts with the vast majority being in older men. I have done a few in older women as well but these were for considerable amounts if neck sagging and they were seeking an economic solution for their neck wattles. In a female I do not consider it as good a scar as in men. Based on your description of having only a little loose skin and being very sensitive about the scar in advance, I would be hard pressed to say this is a good procedure for you. While there is no questioning the simplicity and effectiveness of the procedure, it is simply an issue of the aesthetic trade-off. Is it better to have no scar and a loose neck or a sharp neck angle with a fine line scar? You simply have to choose which aesthetic problem would bother you less…and based on your description alone it sounds like a scarless but undesireable loose neck skin would be better than the scar trade-off.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have been waiting for my family physician to get me a referral to a plastic surgeon to consult me on a breast reduction. I have several health reasons for considering this type of procedure. I have a bulging disc along with deterioration of the tail bone and arthritis of the spine. I am about 50 pounds over weight, but have lost around 80 pounds in the last year or two. I have diabetes and kidney stone disease, so my losing weight was a must and I thought my pain would get better, but it has not, because I haven’t really lost any of my breasts. I would love to get a consultation with you, but I do not have the money to pay out of pocket and would like my insurance to pay for this procedure. That is why I wanted a referral so the insurance understands that it is not for cosmetics. What do you recommend for me to do in my situation. Thank you very much!
A: When using insurance you have to go through the proper channels (by the book) as this will ultimately effect the pre-determination process and decision for breast reduction surgery by your health insurance carrier. So you are going to have to get the referral from your family physician first before you can have a consultation. Most certainly they are never going to pay for a consultation without the referral.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in breast lift surgery. I have severe ptosis of my breasts. I had weight loss surgery in 2012 and my breasts turned into nothing but skin! I am let with extremely saggy breast.s I assume I need a reduction and then implants because my breast tissue is non existent at this point. I just know that I need new breasts. I want to know what my approximate cost would be to have the type of augmentation I need done. A breast lift with free nipple grafting may be the route to take. I just want nicer breasts. I don’t expect the nice set I once had but anything would be better than what I currently have! How can I achieve my goal?
I weigh 230lb, am 34 years old, and am a non smoker. I can be 180 to 200lbs in 30-45 days which is my target goal. I am ready to take the next step. I just need to know what procedure would work best to fix my horrible breast. Can I have decent looking breast with surgery? I want full breasts that aren’t saggy.
A: Many patients that have undergone extreme weight loss after bariatric surgery are left with saggy breasts and little internal breast tissue. While there are a number of types of breast lifts, these patients always require a combination of breast implants with a full breast lift, also known as the classic anchor pattern lift/scar pattern. The issue in very extreme cases of breast sagging like yours is whether the implants and the lift should be done together or whether it should be staged. (breast lift first followed by implants later) To avoid complications and the risk of loss of the nipple, you are one of the rare cases of breast sagging in which I would probably stage it. Besides risking loss of the nipple as a single combined procedure, you are at a very high risk (probably 100%) of needing a revision surgery anyway. It is just too hard to get teh amount of lift you need, put in implants for volume and have them be very symmetric all in one surgery.
Dr. Eppley
Q: Dr. Eppley, I am interested in skull reshaping surgery. My head shape is not normal. It is flat from the back side and inclined backward at the forehead making it smaller on the top as a whole. My face is not much wider as well resulting in a small head. I want to increase head size especially from my back side and forehead areas. Please tell me which procedure I need whether it is an implant or bone cement filling.
A: When it comes to skull reshaping and the aesthetics of your skull, you are talking about a sagittal (front to back) deficiency. Your forehead is slanted backward (retroclined) and the back of the head is flat. (or has a reverse retroclination compared to the front. This is treated by two different methods of dual forehead and occipital augmentation. It can be done with either a bone cement filling material (usually takes 150 grams) or custom forehead and occipital implants made from 3D CT scan. There are advantages and disadvantages of either approach but the end results of either one are the same with a potentially dramatic difference in the volume of your skull from front to back.
Dr. Barry Eppley
Indianapolis, Indiana
