Your Questions
Your Questions
Q: Dr. Eppley, I am interested in getting a rhinoplasty. I’m looking for mostly tip narrowing and some nostril narrowing for when I smile, and also don’t like how close the bottom of the nose is to my lip when I smile. I’m wondering what you suggest.
A: It is important to recognize that rhinoplasty, like almost every other facial plastic surgery operation, is a static and not a dynamic procedure. The rhinoplasty operation is designed to fix anatomic problems in the shape and function of the nose that exist when one’s face is at rest and not smiling. Thus your nasal tip can be significantly narrowed and shortened and the nostrils narrowed, and that will have some positive impact on the appearance of the nose when smiling, but not to the degree that you may ideally like. The distance between the base of your nose and upper lip when smiling is a dynamic one that rhinoplasty will not really improve per se. Lifting the nasal tip may provide some illusion that it is improved but not by actual measurements between the nose and lip. That area of improvement is not an achievable or expected outcome from any rhinoplasty surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a question on upper lip lifts. A little of my lower teeth is already showing when my lips are slightly apart. This is probably due to a chin reduction I had via the intraoral approach. I am concerned that the show / visibility of my lower teeth will be exacerbated if my upper lip length is reduced further. Can the upper lift length be reduced without increasing the show of the lower teeth?
A: I am not aware that a subnasal upper lip lift ever increases the show of the lower teeth. It can increase marginally upper tooth show, perhaps by a millimeter or so in some cases. The further away a structure is from the point of pull, the less movement effect it has on it. In most lip lifts any increased tooth show is only temporary at best.
But if one wants to avoid any risks of tooth show in a subnasal lip lift, either the upper or lower teeth, no more than 1/4 of the measured philtral length in millimeters should be reoved. That is how you determine the amount of skin under the base of the nose to remove in a subnasal lip lift.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in another revision rhinoplasty. Are some noses by virtue of skin thickness or other unfavourable pre existing qualities simply not amenable to improvement? I have had 5 rhinoplasties already (the last procedure was done using autologous rib cartilage for the tip and silicone for the bridge. This was in march last year) and have seen little (if any) improvement in the size of my nose (which has always been my chief complaint). After the last procedure, ironically, I seemed to have ended up with an even bigger nose than what I had to begin with. The tip is now also drooping and the nose is long and heavy looking. Is there any hope at all for a smaller and more refined nose? My ethnicity is Asian but I do not think my skin is thicker than what would be considered typical for my demographic. I am willing to treat my nose as aggressively as is required so I can obtain the best outcome. I understand this may include taping the nose every night for the first 3 months and also kenalog injections for swelling / scar tissue resolution. In your practice, how beneficial have you found these adjunct therapies to be? Will/can laser help in thinning the skin to obtain a better rhinoplasty outcome?
A: Due to skin thickness, there are some noses where the ability to truly make it smaller or more refined is very limited. I would think after five rhinoplasties (four revision rhinoplasty surgeries) that has probably become true for your nose..even though I have never seen it. Regardless of what your nose’s original skin retraction capabilities were, that skin shrinkage capability is now probably lost. I do not know what the objective of your last rhinoplasty surgery was, but by adding rib cartilage and a silicone implant I can not see how it could have ever gotten smaller. By adding volume your nose would have predictably gotten bigger.
At this point I would not think that any amount of taping or steroids after a revision rhinoplasty is going to make your nose any thinner. That would be hard to imagine after so many revision rhinoplasty procedures. Laser is not a treatment for thinning the skin of the nose. There is no such procedure for doing so.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in rib removal surgery. I want a slimmer waist. It’s something I can’t achieve with working out unfortunately. The more I work out the more boy like my body becomes. I look more feminine in my body shape when I work out less because when I burn fat my body becomes very straight. I have narrow hips and a small butt. I don’t have much fat on my belly so I know that is not the issue. My body shape is just very straight. I would like to have a more curvy body (I am also considering butt implants but that is an entirely different procedure). I don’t know how many ribs would be needed to take out in order to achieve what I want. I am not obsessed with a slim waist line I would simply like to narrow it somewhat. I think I would need your guidance to know how many and what I can achieve. I don’t want anything that would look unnatural, and I don’t want to risk my health. Being able to work out is important to me and I don’t want to be limited in any way. I don’t want to look like a Barbie, I simply want a enhancement to my body, to look more attractive and more feminine. Please suggest. Thank you and looking forward to your reply.
A: For your very straight torso, waistline narrowing by rib removal would likely be effective. Rib removal surgery of at least #s 11 and 12 would be needed and possibly a part of #10 as well. This is both safe, does not preclude working out afterwards and produces a very visible indentation at the anatomic waistline level. Since this type of rib removal surgery is done in the prone position, one may consider concurrent buttock implant surgery as well since that also has to be done in the prone position and any amount of buttock augmentation would contribute to your overall more curvy body as well.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would love to discuss getting breast implants, keloid removal, and possibly upper lip injections. My questions are: 1. Would all three of those procedures be able to be done during the same surgery andin the same anesthetic if I so chose to do all three? 2. The keloids are on my right ear are from botched piercings/healing. This a substantial keoid on my earlobe, a more minor one on the upper ear cartilage. 3. In your experience, what products are the most natural looking, safest, and have the most longevity in the human body for breasts and same question for lips. Again, I appreciate all insight and hope to soon be one of your patients.
A: In answer to your breast augmentation, ear keloid removal and lip augmentation questions, I can provide the following answers. It would most efficient and prudent to combine all three procedures during the same surgery. Ear keloids are common and their removal often involves the concurrent use of steroid injections to prevent their known high rate of recurrence. For earlobe keloid removal the use of a postoperative compression earlobe device is recommended. The most assured and effective method of breast augmentation is the use of breast implants. Silicone breast implants offer the most natural feel and longevity over saline breast implants. For lip augmentation one should take advantage of the operative location and anesthetic to do fat injections for the lip augmentation. While no method of lip injections is assured, the use of fat at least offers the potential, is natural and is best done in an operating room location.
Dr. Barry Eppley
Indianapolis, Indiana
Q: D. Eppley,I am interested in a chin implant revision surgery. I had a chin implant placed through a mouth incision which has left me with a lot of issues. Will moving the chin implant to a lower and better location correct all the issues I’ve been having? Maybe even the dimpling. Don’t know if you can tell from some of the photos, but the doctor that put in the chin implant had also did a submental tuck. Will you be using the same implant or replacing with a new one? You mentioned moving it to a better location on the bone but you also mentioned that a new implant positioned lower may also be a possibility. I don’t want my chin to look bigger. So will placing it right on the chin bone make my chin look longer?
A: Whether a new chin implant is needed or not for your chin implant revision is not absolutely clear to me right now. If you are happy with what horizontal projection it provides and are not unhappy about its width then I would say just use the one you have. When moving the existing implant it may be necessary to shorten its height so it does not create a vertically longer chin. That would be the only reason to consider a new implant to prevent that occurrence. Knowing what style and size of chin implant you currently have in place would be helpful in that regard but that is information you may not likely have. Thus that is a judgment that would have to be made on an intraoperative basis.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 28 yo female who has a negative orbital vector bilaterally. I don’t have a history of zygomatic fractures, but I suspect the lower eye bone and cheek complex did not grow forward enough. Do you perform zygomatic osteotomies electively? I have seen your work in patients with old orbital fractures which really brings forward the cheekbones. Can such a zygomatic osteotomy technique be done for someone with a negative orbital vector.
A: The treatment of a negative orbital vector would not be done using zygomatic osteotomies. They will not being the cheek and orbital rims forward. Zygomatic osteotomies increase cheek width but not anterior projection. Only onlay bone augmentation will do so and that is best done by custom made implants. The creation of infraorbital rim-malar implants placed through a lower eyelid incision is the best way that I know to effectively treat a negative orbital vector. It is commonly believed that these bones can be moved forward, like the jaw bones below them, but such bone osteotomies are unduly complicated and associated with bony irregularities. It is far easier and more effective to create custom infraorbital-malar implants from the patient’s 3D CT scan to treat a negative orbital vector.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Six months ago I had a small dent on the top of my head repaired using an injectible cranioplasty technique. Since then, I have noticed a small piece has broken off and the implant is a bit more raised then I expected. The doctor that performed the procedure said that it may feel raised for up to a year and we should readdress it at that point. I’ve read a lot of your articles and in hindsight I should have come to you for the procedure. However, I must deal with the issues as they are. My questions to you are: is it normal for a piece to chip off? Should the area be slightly swollen up to 6 months? What are my repair options?
A: Thank you for your inquiry. Can you tell me more about this injectable cranioplasty technique. What material was used and how was it injected? While this is a complication that I have not seen, I could envision it occurring depending upon the material. It could only really occur with a hydroxyapatite cement material not with PMMA bone cement. But more likely than not it is not a broken off piece of material. It likely is an edge or surface irregularity that has become apparent as the swelling subsided and the scalp tissues adhered back down. Since this takes months to occur, the visible edge may not have been seen for awhile. What you see now is not going to go away. If it is just only one area, a small incision directly over it to remove it would seem the logical approach. Also a small incision can be used to introduce a rasp to smooth the material down if it is an hydroxyapatite
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I just recently read an article that said that you did a rib removal surgery on a woman. This is something that I have been interested in for a very long time. I was born with a disfigured ribcage and there’s nothing I hate more. The left rib protrudes more then my left side! I used to have pectus excavatum, I had a surgery where the doctor inserted a metal bar in my chest which was removed! Please let me know if you can help me. I feel like this is something that I need to actually be happy with my body.
A: Thank you for sending your pictures for consideration for rib removal surgery. Your subcostal protrusion is due to the prominence or bowing out primarily of ribs #7 and #8. (and a little bit from #9) This is not uncommon in pectus excavatum which you obviously had having undergone the Nuss procedure. (placement of the pectus bar and its subsequent removal) It would be necessary to remove ribs #8 and #9 and either do a shave or beveling of #7. (subtotal removal) The only aesthetic issue with this rib removal surgery is that you need a direct subcostal incision to do so. You would need a 6 to 8cm along the subcostal margin on each side. One has to decide whether a fine line scar is a better aesthetic concern than that of the rib protrusion.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have some questions about facial implants. I want to improve the narrowness of my face. You have posted many articles on face widening, but it seems there are so many options. I am hesitant to simply stuff my face with implants to solve this problem. Particularly, I feel my temple area and zygomatic arch should go more laterally than they do, which may contribute to the narrowness. Would fat injections be a viable option here? Does the fat just reabsorb like many people say? I looked into submalar implants, but, again, I would hate to go down that road unless I had do. It also worries me that they are placed through the mouth when I’ve had issues with the chin already. Are they at least screwed in? Because my chin implant is not.
A: The options for facial widening are only facial implants, fat injections and injectable fillers. While fat injections can be done to create a facial widening effect, and there is certainly no harm in doing so, one has to be prepared to accept the unpredictability of both its survival and persistence.
Even compared to fat, temporal facial implants are so simple and effective that I would not even consider fat in that area as a first option.
Any cheek facial implants placed through the mouth are always secured into place with small microscrews so they will never be dislocated from their optimal placement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, My forehead is very noticeably high. And it makes my long narrow face even worse. I only style my hair certain ways to cover it (or try to). I’ve been wanting a forehead reduction for years and I certainly do not want to go to just anyone. I know you are very experienced in this procedure. Is it possible to still preserve the roundness of the hairline? I’m a little frightened by some results I see where patient’s new hairlines look like they were drawn across their forehead with a ruler! Also, my forehead lacks projection. I realize I am female and I certainly don’t mean I want the big masculine brow bone! But my forehead goes straight down to my eyeball. I feel like the brow should at least come out a little to be aesthetically pleasing. I know foreheads are often shaved down during this, but can ‘bone’ or something else be added?
A: Most hairline advancements that I have seen done have a rounded effect across the hairline. This is almost unavoidable because the greatest amount of hairline advancement is in the center of the forehead and less so as it goes back into the temporal areas. A hairline advancement can not really just create a perfectly straight line across the forehead.
Brow bone augmentation can be done using bone cements or a custom brow bone implants. When done in conjunction with a hairline advancement, the open exposure provided by this procedure allows any of the brow bone augmentation options to be used.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have always had a long and narrow face that lacks definition and bothers me. I was also born with a recessed chin. Over the summer I decided to have a chin implant, but after waiting months for the swelling to go down, I don’t feel happy with the results. I feel my chin implant sits too high up (intraoral approach was used) both in looks and in function. I have not been able to close my lips without due strain since the surgery and I could this before the surgery. There’s no swelling or tightness left either. Not to mention they used the smallest implant possible, so it’s not that the implant is simply too large. Because of this I am afraid that the height of the implant and the nature of the oral incision could be to blame? I cannot find any answers online and my surgeon says t hat everything is fine. Thoughts?
A: Intraoral chin implant placement has a known propensity to place the implant too high. If the chin implant does not sit down at the bottom of the chin bone, its aesthetic effect will not only be diminished but it can interfere with mentalis muscle function and a competent lip closure. Just based on the description of your symptoms, I suspect your conclusion about the location of the chin implant is correct. Chin implant revision would consist of repositioning of the implant to the proper position and repair of the mentalis muscle.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a custom chin implant but have some questions about it. I’d like to add significant height and projection to my chin (while avoiding a deep labiomental fold). I’d also like to add some slight width to the jaw while maintaining my well-defined cheekbones. To what extent could a custom chin implant achieve this desired look?
A: A custom chin implant (really a modified jawline implant) is the most effective method for creating the chin projection and slight jawline width that you seek. It is best because one controls the dimensions of the implant in the pre surgical design and allows a smooth jawline to be created from the chin on back to the jaw angles. This is not an effect that any off-the-shelf chin implant design can do.
You will not, however, avoid deepening the labiomental fold (technically the labiomental sulcus) with a custom chin implant. The depth of the fold is a fixed point so any substantial increase in the horizontal projection of the chin, and yours would be considered substantial, will deepen the fold. This can not be avoided short of leaving your chin where it is.
Dr. Barry Eppley
Indianapolis, Indiana
Dr. Eppley, I am interested in facial asymmetry surgery. I have an an asymmetrical face due to irregular growth of the jaw bone. Will the chin reduction on the right side correct it? I also notice that the right side of my face has less soft tissue so will the jaw angle implant balance out my face? Thank you.
A: Your facial asymmetry correction surgery approach certainly appears to be the correct one. Based on your pictures, the right side of the chin is longer and the width of the right jaw angle is more narrow than those two jawline areas on the left side of your face. So a right vertical chin reduction and right lateral width jaw angle implant should create improved facial symmetry. The only question is whether one wants to make the judgments for the amount of vertical chin reduction an the amount of width needed in the jaw angle up to the surgeon’s aesthetic sense or whether to make a more scientific quantitative assessment of them. That may be best done using a 3D CT scan or, at the least, get a panorex and lateral cephalometric x-rays to make some preoperative measurements.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am currently an A cup and would like to set up a consultation to review my eligibility for breast augmentation. I would like to consider a full B cup. Some information about me – 32 year old female, kidney transplant recipient five years ago and on dialysis for seven years prior to the transplant.I have wanted to have breast augmentation for many years and after a lot of research I have not been able to find anyone locally who has previously done this type of plastic surgery on a kidney transplant recipient. Please let me know your thoughts, I see that you do have previous experience in this specialized procedure.
A: I have done various types of cosmetic surgery in kidney transplant patients from breast augmentation, breast reconstruction, tummy tucks and facelifts. I have not seen any complications from any of these procedures despite the patients having a kidney transplant and being on immunosuppression. I think as long as your transplant doctors so not see a contraindication you should have an uncomplicated postoperative course.
In theory the elective placement of a synthetic device, like in breast augmentation, in a patient on immunosuppression seems one that would be fraught with peril but that has not been my experience.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, As for back of the head surgery (occipital augmentation) I have a few questions?
1) how much in cm or mm can I expect the head to become rounder using implants?
2) if the implants get infected how dangerous is it? Can it be prevented or treated?
3) Very important question – So the back of my head is flat but it is not level. The right hand side it is about 1 cm bigger than the left so basically I have Plagiocephaly and brachephly. (I think) Can a good result still be achieved and how? Are you able to shave some bone off the skull to get it to the same level and then insert the implant?
A: Thank you for your inquiry. In answer to your questions about occipital augmentation by an occipital implant:
1) Usually 12 to 15mm is the maximum implant thickness that most scalps will accommodate.
2) I have never seen an occipital augmentation infection. But the implant can be easily removed if needed.
3) With skull asymmetry the implant would only be placed on some side to have the two sides match. In these cases, the best way to make the implant would be from a 3D CT scan to get the best match between the two sides.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Hi, I had some questions about cost and procedures for the fat transfer breast augmentation/liposuction. I am 28 year-old Caucasian weighing around 130 lbs and have been doing exercise over the last couple months to reduce my body fat percentage however there are some problem areas that while they decrease I can’t seem to get the results that I want in particular stomach/thighs/triceps areas. Also unfortunately with my overall weight loss I am noticing I am losing volume in my breasts, not a significant amount, but enough to where I am considering the fat transfer from unwanted areas to my chest.
A:Thank you for your inquiry. Fat transfer breast augmentation, while understandably very appealing, is for only a few very well selected patients. First and foremost, one has to have enough fat to be able to do the procedure to make it worthwhile. Being only 130 lbs this already make you a bit suspect in that regard. Then there is the issue of your athleticism and focus on weight loss which bodes very poorly for fat survival and retention. That is why in young athletic fairly lean women fat grafting is often not a viable option. Breast implants offer a more assured outcome and do not prohibit one from any type of physical activity.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I met with a plastic surgery this week for a consultation and asked about the posterior jaw implants. He said no one really does them any more because the implants are known to slip and move a lot. What do you do different to combat this complication? Is this a frequent problem you have dealt with? Thanks.
A: I am afraid that your surgeon is misinformed and not up to date on the most contemporary techniques and use of jaw angle implants. Not only have the styles of jaw angle implants changed but it is now routinue to secure them into place with a single small microscrew. This obviates the entire problem of jaw angle implant slippage after surgery and does a much better job of maintaining intraoperative positioning. There can still be issues with malposition due to intraoperative placement like any other bilateral implant procedure but secure fixation to the bone is the key to obviating the potential movements of jaw angle implants in the submasseteric pocket location.
Along with the understanding that fixation is needed is the development and use of new styles and sizes for jaw angle implants. Vertically lengthening has been an inability to be achieved with older style jaw angle implants.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m a plastic surgeon and I did some internet search on options for treating prominent temporal artery and I came across your opinions and website. I have chatted with a few of my colleagues and seniors and nobody seems to have experience with this ! Have you had success in treating the prominence with temporal artery ligation? I have a bald male patient who is very bothered by the prominence and is looking at surgical options. I would totally appreciate it if you would give me your opinion on the temporal artery ligation procedure.
A: This is a procedure that I have done many times and with good success. It is not, however, performed as has been historically done for temporal artery ligation for temporal arteritis or for temporal artery biopsies. It requires careful tracking of the arterial branches with multiple ligation points to prevent back flow and to get any feeders coming into the main anterior branch of the superficial temporal artery. The other key element of the procedure is that the incisions must not exceed 5mms in size and requires loupe magnification and head light to meticulously work through such small incisions and tie off the small arterial branches. One must also be prepared to venture out into the forehead to get the distal branches and do careful dissections to avoid the frontal branch of the facial nerve.
While not every case of multiple point temporal artery ligation will result in complete elimination of the prominent vessel, it always results in significant reduction in their visibility.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in custom cheek implants. I have sent in a picture of the design I want and where I want it to cover over my cheeks. I appreciate your comments that you think the design is too big and I understahd what you’re saying. But given the cheek implants I currently in place now, and it is a strength that works for a look of health, that is a strength I would hope to keep. Is it that you object to the look of it, the safety of it, or simply that is has not been customary in your practice?
A: I never professionally care what shape or size the custom implant design that a patient wants. Custom cheek implants would be no different. What I care about with custom facial implants and what I look at carefully in the planning are only two things. First, can I safely make the implants fit into the tissues and close the incisional entrance. Secondly will the implants be too big and the patient will then have a 100% probability of needing a revision to downsize it. Having performed more computer designed custom skull and facial implants that probably any surgeon in the world, of almost every conceivable shape and size, I have a acute awareness of what will work and what will turn into a problem. I am merely trying to guide you in avoiding the latter. The single greatest error when patients provide their design layouts is that they have no understanding of the powerful effect of a custom implant that covers a large surface area over that of what a traditional implant shape does. Custom cheek implants are very powerful in the size you are envisioning and it would be very easy to make them too big, particularly in a more lean face like yours.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like to do fat transfer to lips from chin and neck and also possibly contour my face. I want my face to have a more defined shape and my lips to be bigger. I think the combination of the two would really make my face look better!
A: While fat injection lip augmentation can be done, there is not enough fat that would be removed from the neck or any other facial area that would provude enough injectable volume. Fat injections are based on premise of concentrated fat which is liposuctioned fat that is processed so that only the cells are left and one of its liquid content. You would need to use another donor site as the abdomen (though the umbilicus) or the inner knees or thighs. These donor areas provide better quality fat and more of it.
Contouring of your face through buccal lipectomies, perioral mound liposuction as well as sumental/neck liposuction can be done at the same time as the fat injections to the lips. While some fat would obviously be removed from these procedures the volume or quality of the fat would be unacceptable for reliable lip augmentation in my experience.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have always wanted to have a more defined, chiseled, sensual facial appearance and have been considering cheek, chin, and jaw implant along with rhinoplasty. However, I am wondering which one or which combination would be most beneficial aesthetically? Would any of these also help with the slight droopiness of my lower cheeks? Attached are examples of the characteristics I’m interested in and different angles of faces that I like.
A: Thank you for your inquiry and sending the link to your pictures. There is no question that the single greatest procedure you could do would be a special jaw implant, a total jawline augmentation including the chin and jaw angles. That would best be done by a custom jawline implant, the single most powerful changer of the jawline. This would be followed by a close second for the rhinoplasty. While cheek augmentation would be helpful, it is a distant third compared to the jaw implant and rhinoplasty in having a significant impact towards your facial goals. It is also important to be aware that there is only a limited amount of facial change that is possible in anyone’s face and, while your pictures are helpful in understanding your basic objectives, you are never going to end up with those very well defined and angular facial features.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, You gave advice to someone with jowls on Real Self where you advised to have jowl liposuction. But everywhere else I read that jowl liposution is dangerous because risk of nerve damage. Could you explain why are in favor of jowl liposuction in that area.
A: The safety and effectiveness of jowl liposuction depends on the quality of the overlying skin and how one chooses to access the jowls. With good quality overlying skin that is not associated with a facial jawline sag from aging, jowl liposuction can be effective. The only potential risk of injury to the jowls is the marginal mandibular nerve (which controls the movement of the lower lip) which does not actually run through the jowl area proper. The risk of injury to it is in the approach or access angle to it. If you come from below in the traditional submental approach to neck and jowl liposuction, as many plastic surgeons do, the risk of injury to that branch of the facial nerve is very real. But if you access the jowl area from a small incision inside the corner of the mouth and come from above, there is no risk of injury to that nerve branch. As I have done many perioral mound liposuction procedures, which is the area right above the jowls, it is straightforward to continue further down and treat the jowl area also if needed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am in need of a sliding genioplasty. I have visited an orthodontist, oral surgeon and plastic surgeon so far. My goal is to improve my profile, solve the mentalis strain and lip incompetence, balance my front face (not a too long or too short chin) and most importantly, not to create more problems. The concern I have now is that how I can improve my profile without making my chin too long. I have a very round face and I will be happy to keep it that way if possible.
A: Thank you for sending your pictures and x-rays in consideration of a sliding genioplasty. Given your young age and your degree of chin deficiency, I think you are a very good candidate for a sliding genioplasty. How much horizontal advancement is yet to be determined but it would be at least 7mmm to 8mm. Such horizontal advancement should resolve your mentalis strain and lower lip incompetence. To maintain the vertical height of your lower face, the angle of the bone cut should be slightly angled backward and the chin vertically shortened as it is brought forward. Unlike a chin implant only a sliding genioplasty can bring the chin horizontally forward and make it vertically shorter at the same time.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in laser scar revision. I unfortunately was diagnosed with a sarcoma in my abdominal wall and had resective and reconstructive surgery two months ago. I’m just looking into options to help make my scar look as normal as possible. I was researching laser scar revision and I came across your website and thought you could help with the treatment. I’m just looking at all options at this point. I know now is a bit early since I just had surgery, but I want to continue to stay as proactive as possible and I want to know all my options moving forward. I have attached a picture of my abdominal scar.
A: Thank you for sending your abdominal scar picture. This is an early scar which fortunately is fairly narrow. It is still very red and is not close to eventual scar maturation. (when the redness of the scar will face) So certainly there will be some improvement in the appearance of the scar by the pure passage of time. When it comes to any form of scar therapy, however, now is the time to act not later. Scar treatments have their best effect between 3 weeks and 3 to 4 months after surgery…not a year later. So your looking into scar treatments now is the appropriate time. The best scar treatment at this time is going to be fractional laser scar revision treatments. A series of three laser treatments spaced 4 to 6 weeks apart is my scar therapy approach followed by intervening topical silicone gel applications. These are treatments that can be done in the office under topical anesthesia. While will never make your scar completely disappear, laser scar revision will make it look better in the long run than just natural healing in its own.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I saw that you mentioned that Botox injections to the posterior temporal area is a possible alternative to surgical resection. I am personally quite interested in this approach, as I’d like to avoid surgery if possible. A few questions:
1. Would the effect after a few sessions be permanent? You mentioned that the posterior temporal area is not used much in chewing, so would this mean that the shrinking of the muscle would stay?
2. Would there be any risk of the Botox ‘spreading’ to the anterior temporal area and causing a hollowing effect?
3. How much temporal width reduction can be achieved with Botox compared to surgery?
Thanks for your time.
A: Like all masticatory muscles, Botox injections can be done to induce muscle atrophy. How permanent the effect size reduction would be is unpredictable. The posterior temporal muscle is much thinner than the anterior temporal muscle but whether the effects of Botox injections is more profound or more permanent is unknown. Botox injections do not migrate more than that of a 1 cm diameter from the point of injection. Compared to surgery, Botox injections at best would produce only about half the the thinning effect of total muscle removal.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a lip scar revision. I am a 26 year old female. My lips were very thin and I had gull wing lift operation on my upper lip in November 2013. The result was terrible with many scars on upper lift. I have waited for recovery over 1 year and the situation did not change. I subsequently had two laser resurfacing treatments and a revision to reduce vermilion height with inner stitching. As you can see in my most recent photo, my lips do not look natural and that disturbs me very much even with make up. I want to have better lips and return to my daily life.
Now my doctor offers another operation this month to reshape the whole vermillion border of my upper lift. He will cut my skin in order to discard distorted surface and he will move down the top layer of the skin in order to elongate the skin layer until the pink line to shape the border.Could you please tell me whether it is possible to stretch the top layer of the skin to stretch down to the vermilion? Any kind of information will be very helpful, looking forward to hearing from you very soon.
A: Your upper lip scar revision poses a dilemma. While the scar can be cut out, it is not going to stretch downward. Rather the vermilion will move up to the top of the cut out. This is due to the tightness of the skin and the relative looseness or stretchability of the vermilion tissue. The operation will not work as you have shown or hoped. It will get rid of the scar but at the trade-off of a much fuller or bigger vermilion. For your lip scar revision I would think more about a subtotal scar excision and consider doing it in stages.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I need diastasis recti muscle repair. I need to see if your office can do a pre determination through my insurance for this procedure. I have chronic low back pain and do not want to continue to take 500-1000 mg of Naproxen for life or Cortisone injections.. I have joined weight watchers and lost 15 lbs and I am not morbidly obese but my back makes my quality of life poor. I cannot jog, run. I cycle 30-60 miles or more a week indoor spinning. I cannot lose my belly since my csection no matter how hard I work out. Can you please help. My back is getting worse and I’m at my wits end. I know that insurance can pay for alot of the procedure but I know I will need abdominoplasty also, but please can you help!
A: Thank you for your inquiry but I am not sure where you are getting information that would indicate that insurance would pay for a diastasis recti muscle repair…as they will not. Insurance only covers two adbominal type procedures for medical reasons…a hernia and in some cases an abdominal panniculectomy. A hernia is not the same as a diastasis of the rectus muscles. A hernia is an actual defect in the abdominal wall where bowel may or may not poke through. A diastasis is a separation of the midline of the vertically oriented rectus muscles but is not an actual defect of the abdominal wall. Most women have a rectus diastasis of various widths from pregnancies. Insurance will cover repair of an abdominal wall defect (hernia) but not for a muscle separation that is not associated with a hernia
In tummy tuck surgery it is common to have a diastasis recti muscle repair with the removal of extra skin and fat. While it is part of almosyt every cosmetic tummy tuck it is not a medically necessary procedure as defined by insurances.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in custom jaw angle implants. Could Porex implants be removed and replaced with custom made ones from three 3 years after surgery? I had porex jaw angle implants placed to restore my jaw bone deformity after jaw reduction surgery. But I’m not happy with that result. I realized now that off-the-shelf implants do not suffice in my case. So I have decided to make my implants removed and replaced with custom jaw angle implants. But a long time has passed since the implants were placed. I have heard it is very difficult to remove Porex implants especially after years. The doctor who did the surgery to restore my jaw angle with Porex implants said… You would risk damage to the masseter muscle which has already been manipulated by your previous surgery when trying to remove them. He told me that he found the left side of my jaw muscle was torn by the careless reduction surgery. In this worst scenario, Is it still possible to remove and replace them? If it is possible how much cost it? I hope your reply soon.
A: I have removed numerous Porex jaw angle implants and, although it is far harder than removing silicone implants, it can be successfully done. You would be correct in that a custom jaw angle implants would be the most effective jaw angle restoration method now. I do not think that the masseter muscle would be any further damaged by the implants removals. Where the implants are most adherent to is the underlying bone. They do peel off of the muscle without a lot of difficulty.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am in need of a sliding genioplasty to treat sleep apnea. Can a sliding genioplasty be billed to insurance at all?
A: The question that you are asking is whether insurance will pay for your sliding genioplasty as a medical necessity for your sleep apnea. That is not an unreasonable question but one that can only be determined by the submission of a predetemination letter to your insurance carrier. To do this requires the following information to be submitted:
1) Pictures (which you have)
2) Sleep study results that show you have a high AHI
3) X-rays which show a short jaw.
Once I have this information then a pre letter can be submitted. Only the insurance company can make the decision for approval or denial for the sliding genioplasty but they must have all of the required information for you to have any shot at all of potential coverage.
As an aside, I am not aware that a sliding genioplasty is a primary procedure for improving sleep apnea. It may offer some mld improvement but major skeletal advancement through maxillomandibular osteotomies is usually what is required to make a major improvement in severe sleep apnea problems. A sliding genioplasty is an anterior pull procedure while maxillomandibular osteotomies are a push procedure which is more effective for opening the airway.
Dr. Barry Eppley
Indianapolis, Indiana
