Your Questions
Your Questions
Q: Dr. Eppley, I would like to possibly get temporal zone migraine surgery or Botox injections. I have been diagnosed with chronic daily headache (migraine) and believe this would be beneficial. I have had it for approximately 3 1/2 years and normal medications and treatments do not correct the issue. The issue developed approximately 2 to 3 months after returning home from overseas. I do wear a TMJ mouth guard for bruxism and have daily muscle tension type headaches in both temples and above the ears. Since medications and the mouth guard do not fix the problem I believe that this procedure may provide some more permanent relief. Please feel free to email or send any additional information. Thank you.
A: By your description, it appears you have symptoms that involved both temporal and masseteric muscles. This, to me, more likely suggests myofascial pain syndrome of these muscles and fascia rather than a specific trigeminal nerve compression issue. The first place to start is with Botox injections into either the temporal or masseter muscles or both. Then see what the response is which, in my experience, I have yet to see a patient who does not get some significant reduction in their symptoms. Migraine surgery is reserved for those patients in which a specific peripheral neurovascular trigger can be found rather than overall masticatory muscle pain/headaches. That is the first place to start and is what should be done during the first visit.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in skull reshaping to reduce the width of my head. I have a large head and I’m embarrassed about it. I have to buy larger hats than everybody else and it’s a hassle to wear sunglasses or prescription glasses because my head is so large that it squeezes and gives me a headache. I have to order special made ones if I want them to be comfortable. I understand that it’s not really a problem, but I’ve been self conscious about it for years and I want something done to stop constantly thinking about it. I would like a procedure that would make my head smaller in width. What could you do?
A: Skull reshaping can provide numerous skull shape changes and one of those is in the reduction of its width. In looking at your head shape, it easy to see your concerns with a fair amount of temporal convexity, bulging of the anterior temporal lines and a general side to side large cranial outline. While there are limits to how much the skull be reduced, there are some visible changes that can be achieved. The bulging on the sides of your head (temporal area above the ears) can be reduced by temporal muscle reduction/shortening and the anterior temporal lines (transition between the sides of the head and the top) can be reduced by about 5 to 7mms. These manuevers will never make your head width as small as you would like but they can make a visible difference.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in jaw implants to give me a more defined jawline. I can see from your computer imaging that adding the chin implant to the jaw angle implants really does make a difference. I have a couple questions. Are the implants silicone? Do the size and type of the implants determine how chiseled my face would look? I’m trying to get as close to the ‘male model’ look as possible. I’m not sure if any other procedures would make as much of a difference as these.
A: Chin and jaw angle implants (jaw implants) are made of either Medpor or silicone material and I have used both extensively. However I much prefer silicone because implants made of this material can inserted much easier, shaped intraoperatively much better if needed and are far easier to revise/remove if needed. A good saying about silicone facial implants is…easy in, easy out and easy back in if needed.
The size and the shape of the implants play a major role in the look of the final jawline result, provided one has a fairly lean facial look to start. The thicker the overlying soft tissues are, the less defined the outline of the implants becomes.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in orbital floor augmentation to raise up my eye which is about 2 to 3mms lower than the other side. Regarding the graft material, I’d prefer to go with natural ear cartilage if that’s something you’re comfortable using. Have you used ear cartilage for orbital floor augmentations before? I also have several more questions about this procedure…
1. Could raising the eyeball via the orbital floor (as opposed to reconstructing the entire orbit in a different position) result in pressure on the upper part of my eye?
2. Is there any chance of this procedure affecting my vision?
3. How long would I have to abstain from wearing my contact lenses?
4. Could this result in unintentional horizontal movement, in addition to vertical movement? Is there any chance of ending up with a cross-eyed look?
5. Approximately how long will it take for my eye to settle in its final position, about 2mm higher than where it is now?
6. Approximately how long will the procedure take and how long will I be under anesthesia for?
7. Is there any way to do before/after 3-D imaging for this procedure? I think what I’m seeing in my head is a complete relocation of my entire eye – I’m having some trouble visualizing what it would look like just to have my left eyeball raised, while my eyelids, lashes, etc. remain in the same position.
A: Cartilage can be used for orbital floor augmentation and certainly would be a natural material. I am all for using a natural material when possible. Cartilage has the advantage somewhat similar to a synthetic implants in that it should not undergo any resorption. The only issue with ear cartilage is that the amount of graft material is fairly limited. Ear cartilage is great for the nose but the front part of the orbital floor is much bigger. Thus the only caveat is that the ear graft size may be somewhat insufficient for its intended purpose. In answer to other questions:
- This amount of orbital floor augmentation will not put any undue pressure on the eye.
- There is no risk of vision loss with this procedure.
- You can wear your contacts as soon as you feel comfortable and can get them in.
- The procedure will not result in any unintended horizontal movement.
- The final results from orbital floor augmentation can be critically judged 6 weeks later. Always the eye will look a little higher than the ‘normal’ eye for awhile.
- This is a one hour procedure done under general anesthesia.
- Computer imaging can be done of the eye moving up but it will create a distorted view. Computer imaging can only show more or less of what is already present. Thus moving the eye up should show a similar amount of iris exposure but it will look elongated and will not show a natural iris to lower lid margin relationship. I am happy to do it but you will probably not find it helpful.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in some form of facial freshaping. I have some issues regarding a long face, and more importantly a long midface. It’s just been seriously bothering me for years to the point where it is causing problems. If you could take a look at these pics and just figure out what is so wrong with it, i would really appreciate it.
A: While I would not disagree that your face is a little long and the guilty component is your midface, there are other facial structural issues that are magnifing that impression. A horizontally short chin and a long nose with an acute nasolabial angle make the midface loo longer than it already. When you combine that with a very skeletonized face (little facial fat), the effect becomes even more so. There really are no true midface shortening procedures other than a maxillary impaction which is only used for vertical maxillary excess that has a gumkmy smile. (which does not apply to you) But what you can do is change some of the other factors that are accentuating the midface elongation effect. This includes a sliding genioplasty to bring the chin forward, a rhinoplasty to rotate the tip and decrease its length and submalar cheek augmentation to procide some more width to the midface. Together, these facial structural procedures can help shorten a long midface appearance.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’ve been wanting to get a rhinoplasty for awhile to augment my radix and glabella. My goals are to widen and raise the radix so that there’s a smoother transition between the nose and the brow ridge. Anyway, I have two questions:
1) Will I be able to achieve this through cartilage grafting, and if so, how long a recovery should I expect?
2) I’m hoping to get it done next year. As such, could fillers be injected into the radix and glabella in the interim? It would also serve the purpose of giving me an idea of the kind of augmentation that can be achieved. Also. if fillers can be used, how much filler will actually be required? Thanks!
A: The long-term solution to a deep radix is augmentation, albeit done with a synthetic implant or a cartilage graft. There are arguments to be made for either an implant or a graft but I will leave that subject alone for now. If that is the only thing that is being done to the nose, there is a very short recovery since such augmentation can be done through a closed rhinoplasty technique. If one is uncertain as to how one would look with radix augmentation, one could do either computer imaging or place injectable fillers as a ‘surgical test’. Usually most injectable radix augmentations take about .3 to .4cc of material to create the desired effect. While there are many different type of injectable fillers, one should use those that are composed of hyaluronic acid as these can be placed in the smoothest fashion and the timing of their resorbability can be adjusted based on the specific product used.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a revision rhinoplasty. Do yout have experience in removing medpor L shaped implants? This nose has become tight and hard.
A: Revision rhinoplasty often involves removal of synthetic implanted materials. I have removed more than my fair share of Medpor implants all over the face. I am assuming when you say an L-shaped Medpor implant you are referring to its use in the nose for dorso-columellar augmentation. Contrary to common perception, medpor implants can be removed without undue difficult even though they get fibrous tissue ingrowth into them and can be quite adherent. Their removal from the nose is the ‘trickiest’ area to do it because of the naturally thinner tissues of the overlying skin. The tissues may be very carefully lifted off of the implant so as not to damage the blood supply to the overlying skin. I have removed such nasal implants numerous times over the years but the key questions is…what do you want to do to replace it? Depending upon its size, the tissues can contract and become distorted after its removal. In other words, your nasal skin and its shape is not going to return to what it was before the initial implant surgery. This is the more important concept to consider in your revisional rhinoplasty.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in some form of skull or face reshaping. I would like to know based on the photos/info provided what would you assume is the cause of my skull/face defects? So basically I have a protrusion of my right forehead area as well as on the scalp area (right side mainly)and extends but decreases to the left side of my top head area giving a “Gumby” appearance, slanted, lopsided wichever one. I also have a cone looking shape on the back top of my head, as well as my right jaw is sunken in slightly, my right ear is further back than the left, and my right eye slightly bulges. Hopefully this info gives you some clues to let me know what I may have. I would also like to know the best approach to fix the issue and if possible see what it could look like if corrected. Thanks a lot.
A: Everything that you are describing and demonstrating in your pictures is most likely the result of a congenital skull plagiocephaly anomaly. This is fundamentally a developmental problem with the skull base from which the skull and face shape becomes slightly twisted and asymmetric. The key question now is what can and should be done with the constellation of skull and face asymmetries that exist. While there are numerous surgical procedures for all of these issues, they are aesthetic trade-offs (scars) for doing so and these must be considered very carefully. The question that I would ask you is which one or two of these issues bothers you the most and would like to see improved/corrected?
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am 48 years old and have thinning hair on top to the point of shaving it all off. Unfortunately, I would describe my skull as having an embarrassing mild case of some type of craniosynostosis. In simplest layman’s terms, it could be described as having a dip where the soft spot was. In a little more medical terminoligy, it appears that the coronal sutures (which can be seen) move forward from the center instead of lateral or straight across. Towards the front from there, a dip shows where the anterior fontanelle was. I realize that only a very limited diagnosis can be done from this description without photos or an office visit, but if any of these questions can be answered, it may be in my interest to further pursue treatment. After reading some of your blogs, it sounds like there may be some type of injection that can be used (instead of surgical implant. Is this true? If so, what does it entail….how good and permenant are the results or what are the side effects?; Are there scars left? Is that something that can be done as an outpatient procedure? Can it be done in one visit? What is the complete process of steps to do from start to finish? Do you have an approximate cost? Do you know if any insurances would cover such a procedure? An implant is probably out of the question, but that may be the only option.
A: Your fundamental question is whether an injectable cranioplasty may be an option for your skull deformity. Bt description, you have what I term a large skull ‘dimple’, a circular depressed area somewhat like a crater. They often occur where the original anterior or posterior fontanelles were and represent delayed or incomplete fusion of the bone. (usually just a contour deformity where the four bone edges merged to close the soft spot) You are correct in assuming that an open cranioplasty with the application of an hydroxyapatite bone cement to recontour the area would be the perfect skull contour solution. However, a larger scalp incision in a balding male may have its own aesthetic issues so the pursuit of an injectable approach has merit.
The concept of an injectable cranioplasty should not be confused with that of traditional injectable fillers for aesthetic facial applications. It does require a very small incision which is necessary to lift up the adherent scalp tissues around the bone defect and to make a pocket for the injectate to be placed. What makes it injectable is that the characteristics of the bone cements are such that they can be placed through this small incision by a syringe or tube and molded into and around the defect by hand from the outside. Thus, an injectabr cranioplasty is probably better termed a ‘limited incision’ cranioplasty as it relates to the surgical access and not just the flow characteristics of the bone cement material.
An injectable cranioplasty is a fairly simple procedure done in a one hour procedure under general anesthesia. There is very limited recovery and no physical restrictions after surgery. General cost ranges would be between $4500 and $5500 for the procedure. This is not a procedure that would be covered by insurance since it is an aesthetic skull contouring and is not provided any functional improvement. While almost all such skull dimples are partial-thickness contou defects, it never hurts to get a preoperative 3D CT scan to clearly visualize the skull defect.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a non-surgical rhinoplasty. I really need my nose fixed. I’ve been so depressed about my nose for about 7 years. I’m 20 years old now. I know I can’t afford surgery so I thought hopefully I can afford this. Why stay sorry for myself when I can do something about it, please help ! I have attached a picture so you can see my nose shape problem.
A: Based on your picture, you are not a candidate for a non-surgical rhinoplasty. This very limited nose reshaping technique uses injectable fillers to build up certain parts of the nose. Almost always that is done to build up the area above a hump or bump in the upper nose. What you have is a wide or fat nasal tip due to large lower alar cartilages and how they come together…or don’t come together. Correction of the wide nasal tip requires an open surgical approach with cartilage reduction and reshaping with sutures. That can be tremendously effective in reshaping the tip of the nose but it is a surgical procedure. Just for a tip rhinoplasty procedure done in a one hour procedure under general anesthesia the cost is around the $4,000.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in some type of revisional rhinoplasty. I had a major depression on the tip of my nose for which I got fat grafted to the tip. But now I feel I have a bigger nose than before and the tip doesn’t really have any definition. What should I do now?
A: With fat grafting to the nose that kind of result would be expected given that a ‘blob of tissue (fat graft) was done. Fat grafts fill space and provide no definition as it is an amorphous graft filler. Why was this method chosen as opposed to fixing the tip depression by cartilage reshaping methods which can fix the depression and give the tip more definition?
Generally major depressions on the tip of the nose that have been present since birth are known as a bifid nasal tip. This is where the natural separation of the meeting of the lower alar cartilages (known as the dome of the nose) are too widely separated and this separation extends down into the medial footplates. (over the columella) This creates a groove or visible split down through the tip of the nose. This is repaired by cartilage suture techniques that bring the widely splayed cartilages together.
What can be done for your nose now is to remove the fat graft and repair the depression with either cartilage suture shaping techniques or crushed cartilage grafts for your revisional rhinoplasty.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in nose reconstruction (cleft rhinoplasty) for my teenage daughter who was born with a cleft lip. She is fourteen and is looking to have surgery this coming year. I am looking for a plastic surgeon who is experienced with rhinoplasty in clefts and just want her to be comfortable with her appearance.
A: All orofacial clefts (with the exception of isolated cleft palate) has some detrimental effects on the development and appearance of the nose. While the entire nose is almost always affected, the greatest deviations from normal occur in the nasal tip. Because the tip shape is controlled by the underlying septal end and the paired lower alar cartilages, it is particularly susceptible to very noticeable and classic tip shape deformities. Most commonly the lower alar cartilage on the cleft side is weak and misshapen, resulting in it being positioned lower (slumping) and having a widened and oblong nostril. This is exaggerated as the end of the septum is deviated away from the cleft side into the opposite nasal airway. This causes the entire nasal tip to be asymmetric and have the classic slumped appearance. For reasons unknown, the vast majority of cleft noses have a thicker skin cover, an issue that has great relevance in the outcome of rhinoplasty correction efforts.
Most cleft noses need a full septorhinoplasty approach to both optimize correction of the bony cartilaginous framework but also to correct any internal airway obstructions (septum and turbinates) which are almost always present. The relevant question is always the timing of the rhinoplasty surgery given the congenital nature of the nasal problem and the sensitive psychosocial development of children and teenagers. The traditional thinking of doing any rhinoplasty is when facial development is near complete, age 16 or older. However, I have always taken an earlier approach to some rhinoplasty patients particularly the cleft patient and I don’t think age thirteen or fourteen is too young.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am wanting to get saline breast implants. I am probably considered and A cup and would like to be around a full C cup. One of my biggest concerns is cost. How much would it cost from start to finish to have breast implants done by you? (Including any pre and post-op appointments). I am hoping I can find a good surgeon that is able to do the procedure in my price range because my husband would be the one paying for it and he takes a lot of convincing 🙂 Thank you!
A: As a good working number for saline breast implants, the cost of $4700 can be used. This includes the before surgery consultation, all surgery costs (implants, anesthesia, operating rom fees, surgeon’s fee) and any after surgery visit up to six months after the procedure. You may use this number in your ‘negotiations’ with your husband. May it work favorably for you in these discussions.
The advantages of saline breast implants are their lower cost, the ability to place them through hidden armpits incisions and the capability to adjust the volume of the implant during surgery for any differences seen in the two breasts as they are enlarged.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have breast implants but I want to be bigger. I think I may have maybe 300ccs ?? But I want to go bigger like 500 cc’s. My only concern is that I am really thin and weight about 110lbs. However, I think they should go that big . I have had 3 kids nursed and had weighed more. I have a really small frame I don’t want them too big but I want a DD . Right now they don’t look big at all. I think it’s because of weight loss and having children.
A: One of the advantages of having existing breast implants is that you have a reference about size. (volume) As a general rule in breast implant exchange for larger breasts you should always go at least 100 to 125cc bigger to see a cup size difference in most patients. Obviously that number changes based on the body frame of the woman. (smaller frames may be 100ccs, larger frames may be 150 to 200ccs) Based on your description, the size change of 200ccs sounds about right in your case. If 300ccs is not big at all and a DD cup is your goal, then at least 200ccs would be appropriate in my experience for your breast implant exchange.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in jaw implants to help correct my facial asymmetry. Although it is not noticeable to others, if taking a picture straight-on and in certain lighting, it shows that my face is extremely asymmetrical. I was wondering if this would best be corrected with asymmetry surgery or could be corrected with customs jaw implants. Also- if corrective asymmetry surgery was performed, could you also add custom jaw implants at the same time to provide the most optimal facial makeover?
A: In looking at your pictures, your facial asymmetry is caused largely by a significantly deviated chin position. This has also has caused some jawline and jaw angle asymmetry although not as significant as that of your chin. There are two approaches to correcting your jaw asymmetry.
The first technique is to correct the chin by a sliding genioplasty that moves it back to the midline. Then the jawline and angles behind it could be augmented by standard jaw angle implants.
The second approach is to go completely with custom implant designs, leaving the chin bone where it is. Computer designing can make jawline-jaw angle implants for each side (that are obviously different but designed to create symmetry) that attach to the sides of the chin.
Either approach can make a big difference and each one has it advantages and disadvantages.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 26 year old female from who is looking to have rib removal done for ribcage narrowing. I saw online that you perform this surgery and was wondering if I would be a good candidate. My ribs have always bugged me because they protrude so much. I want them removed to create a smaller upper body and also because they stick out more than my breasts. I have attached some pictures of me laying down so you can see what I mean. I look forward to hearing from you.
A: Typically ribcage narrowing by rib removal is done to make one more ‘high-waisted’ or to lengthen the distance between the bottom of the ribcage and the hips. This is done by removing the cartilagious portions of ribs 9 and 10 which are more to the side of the ribcage. What you have/are demonstrating is rib protrusion or ribs that stick out. This involves the inner portion of the ribcage closer to the sternum rather than the side. This is a slightly different rib location. This is seen when one stands up but becomes a lot more noticeable when one lays down. (as seen in your picture) This protrusion occurs because of the confluence of ribs 6, 7 and 8. They all join in this area and the way they come together (angulation) causes them to stick out. This section of ribs can be removed (and is actually commonly done in reconstruction of microtia ears) but will require a 4 to 5 cm incision along the lower edge of the ribs to do it. This results in a fine line scar and one has to be certain that this is a good aesthetic trade-off.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like to know how much it would cost for hairline lowering. Also if I could see before and after results from this procedure because there is only one picture on the website.
A: The cost of hairline lowering is dependent on whether one needs a one or two-stage hairline lowering procedure. That would depend on how much hairline advancement one wants and what the natural looseness of the scalp is. To better help you with cost, I would need to see some pictures of your forehead and a line draining (use lipstick) of where you want the hairline to be. That will answer the question of whether it is a one-stage procedure or a first stage tissue expander is needed. As a general rule, 10 to 15mms of hairline advancement can be obtained in a ons-stage procedure. More than that will require a tissue expander first to create more loose hair-bearing scalp tissue to bring forward. If you try to create that much scalp movement in one-stage the brows will elevate significantly to cover the extra distance and not the hairline coming forward.
There are few pictures of this procedure on the website because patient confidentiality only allows postings that patients agree to show their face…and most people do not want that. And without patient permission we do not distribute patient photos on the websites or to prospective patients to honor their privacy requests.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting a combined tummy tuck and buttock implants operation. I won’t have the money for my surgery until April 2014. Is it a good option to have a consultation a couple months ahead or within a certain time frame prior to the surgery. Also how much approximately would it be to have both procedures at the same time? Is there a discount for that or some type of deal for booking both at the same time?
A: I think it is always good to get accurate surgery and cost information way in advance of when any patient wants to do their surgery so they can plan accordingly. Doing it two or three months in advance is a good idea. I will have my assistant pass along some general cost information for a tummy tuck and buttock implants to you by tomorrow, although be aware that these are general numbers since I have no idea as to your exact tummy tuck needs.
Like all cosmetic surgery, bundling procedures together can result in a cost savings due to saving operating room and anesthesia charges. However, the combination of a tummy tuck and buttock implants done together would make for a really difficult recovery and this is not a recommended combination procedure. A tummy tuck and fat injections to the buttocks can be done at the same time but two muscular operations on opposing sides of the torso is not a good combination.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in multiple bariatric plastic surgery procedures. I had a gastric bypass done two years ago and have lost 140lbs. I now weigh 170 lbs, down from 310. I need a lot of work and want an arm lift, back lift, tummy tuck, thigh lift and liposuction with fat transfer to my buttocks and hips. Can this be done all in one surgery> It is safe to do all of these at once? Also, how long should I stop smoking prior to major body contouring surgery like this so I can heal properly?
A: While all of these bariatric plastic surgery body contouring procedures can be done in one surgery, that is not advised nor would any plastic surgeon do it. This is why too much trauma to your body and it increases the risk of major affter surgery complications llike DVT, infection and wound separations. As I counsel every extreme weight loss patient, you simply can not fix all of your body concerns in one surgery.
Every extreme weight loss patient needs to draft a complete list of their body concerns and then prioritize them. This will then allow you to create a series of two or three separate surgeries, spaced three to six months apart to get every body area addressed, It is more reasonable and common to do in the first stage the tummy tuck and arm lift and then do the back and thigh lifts in a second stage. It would be uncommon in a severe weight loss patient to have enough fat to harvest by liposuction to be able to do buttock or hip augmentation. It may be possible but not usually likely.
Regardless of how you sort and stage your body contouring procedures you must have stopped smoking months before. You need to stop once and for all at least 6 to 12 weeks before these surgeries. Otherwise, you are at high risk for major wound healing problems even if you ‘cheat’ on your smoking before and during the healing process.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have an asymmetrical smile. When I was little I had a cross bite, I had an expander, braces, and retainers. My insecurity is that the sides of my mouth do not crease, or rise up the same. I can’t help but wonder if this is a result from the cross bite or vice versa. It makes my smile different on both sides and makes my mouth appear crooked. What is the procedure to correct this issue? How much does this average procedure cost? Thank you!
A: The asymmetry in your smile lines has nothing to do with your prior orthodontic history as your bite/teeth relationships have no impact on how the muscles of facial expression work. Your smile elevator muscles (zygomaticus and superior labii muscles) are working symmetrically as judged by the position of the corners of the mouth at maximal smile. (as seen in your picture) Your concern is actually that the depth of the nasolabial (cheek-lip) grooves are different when you smile. Your right side is much deeper than on your left. That is why your ‘smile’ looks different even though your actual smile (lip lines against the teeth) is actually the same. The attachments of the skin to the underlying tissues is what mainly creates the depth of the nasolabial fold in animation and that is a relationship that can not be reliably changed by surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have orbital dystopia that I want corrected. Here are a few photos and you can see that my left eye is noticeably lower on my face. As you may also notice from the top view, you can see that the left eye also protrudes forward a bit. My nose and chin also are off the center line and lean to the left as well but my eyes have always bothered me the most and the others I can live with. Again, this is something that has made things difficult for me and i’ve just reserved myself to the idea that I have gone this long and I may as well just live with it….until I shaved my head due to hair loss that is. Now my eyes are the very first thing that people notice and they stand out much more now. Any thoughts/guidance would be much appreciated.
A: I have seen your photos and the amount of orbital dystopia in the left eye seems to be about 2 to 3mms at most. That can be improved with frontal orbital floor augmentation and possibly orbital rim augmentation as well. That will bring up the vertical level of the eye but it will not change the more forward projection of the eye as seen from the top view. The key question in any case of orbital dystopia is what happens with the position of the lower eyelid for that is not a bone-based structure and thus will not change. With the eye coming up and if the lower eyelid position remains the same, some slight amount of increased scleral show may result. That is why a canthopexy is usually done to provide a bit of lower lid tightening/lift as well with the change in eyeball position.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in flat back of head surgery correction. I am ready to take the next steps for cosmetic skull augmentation surgery for the flat back of the head. I have a few concerns/questions and hoping you will be able to clear them for me. I have read the case studies and advice on your website and it gives me tremendous hope of having more normal head shape. My problem is that I have a rather flat back with bulges over both ears. My questions are as follows:
1) Based on your articles, I see you can build up 10 to15 mms on the back of the head in one attempt. I believe I may need more than 20 to 25 mms, so can you add 10 to 15mms in first attempt and then stretch the scalp further and in the second attempt add the remaining 10mm? Is that possible?
2) Is there ever of any possibility of this cranioplasty material getting loose? For instance if a person falls down etc.?
3) Will you be able to burr down the bulges on top of my ears? If so, how much?
4) I am a man who is starting to lose hair a little bit. Will the scar be substantial and show up?
5) What is the total time required for surgery and recovery if it is 10-15 mm augmentation versus a second attempt for the additional 10mm?
A: What you are describing is having a bilateral flat back of the head known as brachycephaly. (as opposed to flatness on just one side which is known as plagiocephaly) This is why you have bulges over both ears, the brain grew the bone out to the sides as opposed to pushing out normally in the back. This flat back of head surgery involves a build up across the back of the head with some width reduction. In answer to your questions:
1) If you need to have as much as 25mm of occipital bone buildup, you first need scalp tissue expansion and then secondarily add all the material volume needed. Once the scalp is lifted and stretched, its becomes scarred and will have little stretch. So trying to double the material volume later will not work. The choice is then settle for either two-thirds of what you need or make it a two-stage procedure.
2) Tiny titanium screws are first added to the bone and then the material is applied. This gives it something to forever be anchored, much like it done with construction concrete. Loosening of the material as yet to be a cranioplasty problem I have seen.
3) The protruding bone around the ears can be reduced about 5 to 7mms on each side.
4) While there is a scalp incision involved, it can heal remarkably well even in bald men. I am consistently surprised how well it heals in the scalp. Will there be a scar…yes. Will the scar be substantial…no.
5) The surgical time for a one-stage occipital augmentation is 2 hours. If it is a two-stage occipital augmentation procedure with a first-stage tissue expander the operative times are 1 and 2 hours respectively.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in knowing more about Mimix bone cement. Here are my questions:
1) What type of surgery is Mimix mainly used for?
2) What is the biggest features of Mimix? Could Mimix be placed in any area of the cranial bone?
3) In Genioplasty are there any special techniques in using it?
4) Can Mimix be placed in the gap between a cranial bone flap and the native bone with titanium plating?
5) Can Mimix be used for small defect cranioplasty (less than 25 square cm) for pediatric patients
6) Have you ever experienced Mimix breaking after surgery?
7) Do you have any experience using Mimix on maxillofacial and mandibular bone?
A: Based on my extensive experience with Mimix bone cement in craniomaxillofacial surgery, the answer to your questions are as follows:
1) Mimix is used for two main cranial (skull) purposes: 1) inlay defects of the skull such as burr holes or larger skull defects and 2) as an onlay material for skull augmentation such as aesthetic forehead augmentation or to build up deficient skull contours. There are a wide variety of other maxillofacial uses which ranges from filling in small bone defects and as a contouring material, but the skull makes up the vast majority of its uses particularly as judged by volume used.
2) If one is looking for a natural method of bone reconstruction (hydroxyapatite is similar to bone in chemical composition) of the skull as opposed to using completely synthetic metallic materials. Mimix can be placed in any area of the skull. Since the skull is non-mobile and non-load bearing, it can be used in any location from the temporal fossa to the frontal sinuses.
3) When placing the material in a genioplasty as an interpositional filler, it is important that the implantation site is not too wet with blood. A very wet field interferes with the setting/curing of any hydroxyapatite cement.
4) As a general rule, no. if you are referring to using Mimix in conjunction with titanium plating for cranial flap fixation it can be done but there is little reason to do so directly underneath a fixation plate. It may be used for other bone gaps along the cranial bone flap if they are significant enough in width.
5) Filling in pediatric skull defects would be a common use for Mimix due to its advantages in the growing skull.
6) It is important when using any hydroxyapatite cement to ensure that there is no mobility of the surrounding bone. Mimix is not a bone fixation method, it is a bone graft substitute that must have good stability of the surrounding bone otherwise it may fracture. In my experience I have never seen Mimix fracture or pose a problem in this way but you have to know how and when to use it to avoid this potential concern.
7) Mimix in the maxillofacial region is used as an inlay method only to fill in small bone defects that might otherwise require a graft and into which a dental implant is not intended.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in temporal implant augmentation. I am a 35 year old male who ever since I was a child I have had one temple that was somewhat misshapen and sunken in. As I have gotten older and lost my baby fat, in addition to becoming leaner all around, it has become more and more noticeable and the way it looks bothers me. I see you have temporal implant treatments and I am wondering what the general ballpark amounts are for something like this. Keep in mind that only my left side is abnormal.
A: A very simple and effective solution for temporal hollowing is a temporal implant. Placed in the subfascial plane on top of the temporalis muscle, it can immediately add permanent volume to temporal hollows. For just one side, it can be placed in a 30 minute procedure under local or IV sedation. There is very little swelling and no recovery afterwards of any significance. I would have to see some pictures of your temporal hollowing to determine its extent and exact location. Temporal implants work best for when the hollowing is deepest in the temporal region just above the zygomatic arch.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting a rhinoplasty. (nose job) I’ve always wanted to have my nose reconstructed so it would look better and more petite. I’d like for it to be a bit pointier and not so flat. I am completely clueless on what steps to take. I have a few pictures so you can see what I mean.
A: When it comes to considering rhinoplasty surgery, you have already identified the the first and most important step…how would I like my new nose to look? In looking at your pictures, what you have is known as a bifid nasal tip in which the lower alar cartilages are completely separated. This accounts for why you have such a wide and flat nasal tip. The key to improvement is that the tip cartilages need support to obtain more projection through a columellar strut cartilage graft and the lower alar cartilages need to be brought together and narrowed.
While the quality of your nose pictures is very grainy which makes them hard to image, I have done some surgical predictions of nasal tip narrowing results that could be obtained through an open rhinoplasty procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have severe breast implant rippling. I had saline implants placed ten years ago. They were ok but then I had a baby and now there is severe rippling. I was thin to begin with but now have little breast tissue left. Rippling is bad on top of my breasts, even when standing straight. Recently found a mass of thicker tissue below and slightly off center of my left nipple. It looks a little puffy in the mirror. Ultrasound reveals normal breast tissue, but slight bump on implant below lump. What are my options for improvement of the appearance of my breasts?
A: Between being thin, having had breast implants for a period of time and then having a baby, you have lost most of your breast tissue and the natural rippling of saline implants has become evident. This can become really significant if the implants are above the muscle.With little breast tissue scar tissue around the valve can make it appear as a lump. Significant improvement of the rippling can only be done by changing the implants to silicone, trying to thicken the tissue interface between the skin and the implants by fat injections or allogeneic dermal grafts or both.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in ribcage narrowing. I came to your website as I was researching a couple procedures. I am 33 year old male to female transsexual. My waistline and hip area have always bothered me. I have pretty good shape but I have always wanted curvy hips and waistline. I have spoken with many physician’s everywhere and located a couple of options for rib resection. I thoroughly enjoyed your article on ribcage narrowing. I have been studying the process and anatomy for a long time and this was a very nice description and summation. It seems as though you’ve had some hands-on experience in this procedure. I am having my breast implants replaced in a couple months. My surgeon mentioned tummy tuck at sometime in the future. I know I have a little pooch and would like that. But I really would like it by aiding access for Thoracoplasty at the same time. The other procedure is an enhancement to my nipples. I have large breast 36D but sadly I have short, flaccid & small diameter nipples and would like them to be fuller length & diameter and also perkier. Thank you once again for your time.
A: Rib resection can be done at the same time and through the same access as a tummy tuck…depending upon what type of tummy tuck is being done. In a full tummy tuck, the elevation of the upper abdominal skin flap is done right up to the subcostal margin which provides direct access to the lower rib cage. However, during a mini-tummy tuck, there is little to no elevation of the upper abdominal skin flap and the access is better done by direct incisions over the lower rib cage.
From a nipple enlargement/enhancement standpoint, the only really effective approach would be fat injections. Injecting fat can both thicken, lengthen and stiffen the nipples with a minimal risk of any loss of feeling.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have had three prior facelift efforts and none have been effective at giving me an upward look to my face that crrently looks pulled down. It’s been recommended to me that a MACS lift might help pull upwards somewhat without involving the same incisions around the ears from the 3 previous facelifts. (I’ve been told that opening previous incisions could be risky.) Does a MACS lift have to include opening up the previous incisions around the ears or could it somehow be done otherwise. I am trying to get rid of my ‘hound dog’ look to my mouth and the deep creases above my lips.
A: Having had three prior facelift type procedures, it should be obvious by now that any type of facelifting effort is not going to improve the central aspect of your face. That is simply not where the pull from facelifts have their effects. Facelifts never improve sagging around the mouth and deep nasolabial folds. Thus, not type of MACS lift or any other variation of a facelift that uses the ears as the location for the direction of pull will work. Your prior facelifts have not failed because they did not improve these central facial areas as they have donen a good job with your neck and jawline which is where they work teh best. You are going to need to consider other more direct procedures such as corner of the mouth lifts, midface lift or even direct nasolabial fold excision to get this part of your face looking as rejuvenated as the jawline and neck.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had paranasal implants placed four months ago. Is it possible you could have put one of the implants upside down.?I ask because even since the beginning of healing I can feel around the peripheral of each implant and the shapes are totally different. I have been wondering for a while. I say this because I truly wonder if its upside down. Even I can see that the fleshy higher cheek on the right was improved right next to to the lateral nostril but the fleshy cheek on the left is a lot flatter next to the nostril but then highe up the area comes forward. It is like they one is flipped upside down from the way it looks and feels.
A: I would say that the chances of a paranasal implant being upside down is very unlikely. And I say that for three specific reasons; 1) The shape of the implant has a convex and a concave side to fit into the concave shape of the paranasal region. Trying to make it fit upside down would be very obvious as it wouldn’t lay flat against the bone very well, 2) Each implant has an L (right side) or a reverse L shape (left side). Putting it in upside down would have the L facing the wrong way which would be very obvious, and 3) When placing a small screw to fix the implant to the bone, it is put into the outer flange of the implant and is only 5mms long. If the implant was flipped, its outer flange would be sticking up and the screw would not be long enough to get to the bone.
Having said that, because of the paired nature of facial implants (cheeks, paranasal, jaw angles), slight differences in their positions between the sides can be really obvious. This is particularly true the closer one gets to the facial midline. (paranasals) If the implants are even off a few millimeters up or down or side to side, such differences can be easily seen and felt. That is is the more likely scenario with your paranasal implants than that one has been placed upside down.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had breast augmentation three months ago. Can I lift weights if my breast implants are under the muscle? I am almost three months after surgery. I have 450cc silicone implants put in under the muscle on both sides. Do I have my final result now? I want to know if I can go ahead and lift weights. I don’t want to work so much on my chest but to start doing biceps and triceps to tone my arms with light weights and more reps. Can I do that now?
A: At three months after your breast augmentation surgery, it is fair to say that you are looking at the final result. Even though the implants are under the muscle (partially), there is no reason you can not resume any form of chest or arm workouts. I usually let my patients resume any activity that involves pectoral muscle activity as soon as possible after surgery so they recover faster. Three months from surgery is more than an adeaquate amount of recovery time.
Dr. Barry Eppley
Indianapolis, Indiana
