Your Questions

Q: Dr. Eppley, I am interested to know what can be done for my very short chin. I don’t know if I just need an implant or whether the jaw bone has to be moved. If you can answer a few questions for me I would appreciate it very much. 1) What is the biggest chin implant in terms of maximal horizontal projection? 2) How much can a sliding genioplasty move the chin forward? 3) Can sliding genioplasty be combined with an implant? 4) Can the entire lower jaw be moved without changing my bite? 5) How do you correct chin deficiencies larger than 10 mm? 6) How do you correct vertical deficiencies? 7) Does the implant feel natural and is there any risk of shifting after surgery?

A:  The person with a very short chin poses challenges that often neither a standard chin implant or a sliding genioplasty can ideally solve. In answer to your questions:

1) The maximum horizontal projection for most chin implants is 12 mms.

2) How much a sliding genioplasty can advance the chin depends on the thickness of the mandibular symphyseal bone. That could translate into a 10 to 12mm chin point forward movement.

3) Yes. An implant can be overlaid in front of a sliding genioplasty to gain more horizontal projection or width.

4) No. The mandibular body and ramus can not be changed without carrying the attached teeth with it also, thus changing the occlusal relationship to the upper teeth. By definition, jaw advancement surgery changes the bite.

5) Options include a custom designed chin implant or a sliding genioplasty with an implant placed in front of it.

6) Vertical chin deficiences require a custom implant and are a component of every horizontal chin deficiency greater than 10mms. When the chin is that short it indicates there is an overall jaw shortness.

7) The implant will feel like bone and is screwed into place to prevent the postoperative risk of shifting.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m trying to achieve a more aethetically appealing face, by whatever means necessary. I’ve noticed my forehead protrudes in respect the level my eyes are at, making them look sunken and my face more masculine. I don’t believe it’s my bossing that sticks out, just my forehead in general, so i’m not sure how much of a result I would see with surgery. I’ve been told my nose is large, so I’m considering rhinoplasty as well. Additionally, my lips appear to almost “hang off” my face. I know this isn’t your forte but do you believe jaw surgery could be a solution? In general, I was just wondering what procedures you would recommend. Thank you for your time and I look forward to hearing from you!

A: Thank you for sending your pictures. I have done some imaging predictions based on the one side profile that you sent. What I have done is a forehead reduction, rhinoplasty and chin augmentation . If you look carefully at those changes, the most dramatic effects come from the rhinoplasty and chin augmentation. The rhinoplasty is key because your forehead and brows look so pronounced because you have a very deep radix. (root of the nose). One of the key manuevers in your rhinoplasty is the buildup of the root of the nose. By doing so that makes the forehead less retrusive in appearance alone.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I had an otoplasty done just over one year ago. One ear is pinned back too far and the other doesn’t look or feel right; it twitches and is painful sometimes as though a stitch is holding it in place and is being pulled. I was reading comments on your website about grafts and I wanted to know how the procedure works and how much I should plan on spending. Thank you for any information. 

A: Otoplasty surgery can be associated with several unfavorable outcomes. Two of such problems are the over done otoplasty ear and the painful oitoplasty ear. When the antihelical fold is over created, this means that the bend in the cartilage has been too exaggerated. This can not be simply improved in most cases by merely releasing the scar tissue between the two cartilage sides on the back of the ear. The cartilage has likely lost its original memory (exceeded the limits of elastoc deformation of the cartilage) and will not just spring back out after one year of healing. Instead the cartilage fold must be expanded and maintained by an interpositional cartilage graft, acting as an ‘internal spring’ so to speak. This small cartilage sping graft can usually be havested from the same ear from the backside of the conchal bowl. In the painful otoplasty ear, even if the result is good, the discomfort likely comes from one of two sources. A concha-mastoid suture may have been used to help with repositioning and, in stiff or thick ear cartilage, this may cause persistent pain or the perception of spasm. This suture can be released at this point. The other pain problem that I have seen is that stiff ear cartilages may be bettered weakened and repositioned by cartilage scoring or wedege resection rather than just using sutures to overcome their shape.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I previously had cheek and jawline reductions to create a slimming/narrowing effect to my face. Unfortunately the surgery has had adverse consequences and has overly feminized my face.  I no longer have a square jawline and I find that the height is much too high at the rear portion of the jaw creating a very slim and weak jawline.  The angle at which the jaw was cut is too straight which portrays a more unnatural look that seems to elongate my face. Custom CT scanned jaw implants seem like the logical response to the amputation of the bone.  My questions in regards to this matter are related to muscle and tissue reattachment as well as unforeseen complications.  Would detachment of mandible muscle and skin tissue create any issues?  I am constantly concerned with sagging skin after performing my initial surgery.  Where would the jaw implant gain the needed skin envelope?  Does the skin tissue come solely from the neck or would it also pull and realign from my lower cheeks? As for my cheeks, there are multiple irregularities in regards to my mid-face after the cheekbone reduction. I am most curious as to what procedures could correct these irregularities.  As my initial surgery was to primarily address the width of my cheekbones, I would not like to add much more.  Could I address the problems without adding more width?

A: I have had the experience of seeing numerousI have see men with the exact situation that you have. It is corrected by computer designed jaw angle implants that restores height but virtually no width. It is a unique-shaped jaw angle implant. It gets its soft tissue coverage by recruiting tissues from the face rather than pulling them up from the neck. Like the jaw angle implants, any cheek implant restoration is done using a 3D CT scan where any implant fabrications are done on the computer and can be perfectly corrected for any asymmetries as well as limiting any significant amount of width.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 47 years old with multiple lipoma on both the hands, back, stomach, and thighs with more than 100 lumps. Even my brother has it. Recently I underwent  Vaser lipo for lipoma treatment on both the arms. I know it may reoccur but for the time being I am happy with the results. Still I have many lipomas on my back, thighs etc.

My question is there any research being done for non invasive treatments. What is best for multiple lipoma treatment as on today? What can we expect in near future ?

A: In the treatment of solitary or, more pertinently, multiple lipomas in familial lipomatosis as you have, I know of no ongoing research that is looking at how to best treat them. Current treatment options include open excision, laser lipo probe ablation, various liposuction options and lipodissolve injections. All of these methods have variable effectiveness and, other then open excision, the effectiveness of one over the other is unproven.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like a consultation for getting hyaluronidase injected to remove too much restylane that has been injected into my cheeks. It looks extremely unnatural as I am 35 and did not want to look fake. Please help and thank you!

A: You are correct in assuming the the proper treatment for too much of a hyaluronic acid-based filler, such as Restylane, is hyaluronidase injections. This enzyme solution catalyzes the hydrolysis of hyaluron which lowers its viscosity and makes it rapidly absorbable. The action of hyaluronidase is very quick and starts to work immediately, with most of the effect taking place within 24 to 48 hours.

The most difficult aspect of treated overdone fillers with hyaluronidase is judging the amount required to dissolve a certain amount of filler. There is no table or established doses in units for how to treat any facial area. It is quite easy to undertreat the injected area. Patients should, therefore, expect the possibility that a second treatment may be required if some filler still remains.

There is the possibility of hyaluronidase injection side effects, although they are quite uncommon. It would be an inflammatory reaction with redness and swelling and is more likely to occur in those people who are allergic to bee stings.

The reversibility of hyaluronic acid fillers with hyaluronidase is one of many reasons that such injectable filler compositions are the preferred choice for most patient’s aesthetic facial needs as a non-surgical treatment option.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, It has been a year since my tummy tuck was done. I had a full spare tire removed and now I can finally fit into reasonable clothes again. I’m very happy with the results. However, I’ve noticed my pubic mound area seems to be bigger now and bulges out. Where the zipper is on my pants is really tight over this mound. My pants fit fine everywhere else on my waist and hips. But my pubic area now looks weird and puffy.

A: It is very common after very large tummy tucks or absominal panniculectomies to have loose skin and extra fat in the pubic area. The reality is that this pubic fullness was always there, it just never became apparent until the spare tire was removed. This this is not a new physical development just a new observable one to you. It is magnified because it sits below a more narrow waistline area abovhe it where the scar lies. This cane be very effectively flattened by pubic liposuction which may require a little bit of a pubic lift is there is any loose skin there.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have some questions about calf implant surgery. I have very small calfs, like toothpicks below my knees, due to being born with clubfeet. I know that I can never have normal size calfs but any improvement woutl be a plus. My questions about calf implants are:

 -What is a conservative estimate of the recovery period?

-What is the likelihood of needing a follow up surgery?-Where is the surgery being performed and what is the rate of secondary infections there?

-What are the chances and risk of other complications/what complications?

-How extensive will scarring be?

-How is the size of the implants determined, what is the chance of them shifting, what would be the risk involved, and how would they be adjusted if necessary?

-What is the expected prognosis?—lifetime of implants? Eventual need for replacement implants? Longterm risk of side effects/complications?

-How will this overall affect Quality of Life?

-What are the other options and how do they compare?

A: in answer to your calf augmentation questions:

1. Recovery from calf implants is related to the ability to walk and fully flex one’s foot. Most patients return to normal after about 3 weeks from surgery.
2. Surgery is performed in my private outpatient surgery center. Because this is a facility where only elective surgery is done on healthy patients, unlike a hospital, the infection rate is very low. (way less than 1%)
3. The biggest risks of calf implants are infection (< 1%) and potential visibility of the implant’s outline in patients with thin tissues. (10%)
4. The implants are placed through a horizontal 3 cm wide incision in the skin crease behind the knee. (popliteal fossa) That scarring is minimal although in patients with more skin pigment there may be an initial hyperpigmentation reaction around the incision.
5. Calf implant sizing is done by taking measurements of the medial gastrocnemius muscle and matching the implant size to muscle dimensions. Calf implant size options range from small (5cm x 15 cm, 70cc volume), medium (6cm x 20 cm, 135cc volume) to large. (6cm x 24 cm, 170cc v olume) Calf implant shifting is very rare since the tissue pocket made is very narrow and the tissues are naturally tight.
6. Calf implants are made of soft low durometer silcioen elastomer material that will never degrade, break down or need to be replaced.
7. Like all body augmentation surgery, this is an operation whose intent is to make you feel less subconscious about your congenitally small calf size. if this objective is achieved then your self-image and quality of life in theory should be improved.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Will the silicone implants have to be custom made, or will you be able to carve them during the procedure? Out of curiousity, but why don’t more surgeons perform brow ridge augmentation with silicone implants? Being able to bypass a large scalp incision seems like a huge plus. Also, with silicone brow ridge implants, will it look unnatural if I smile or animate my face, especially since there doesn’t seem to be much soft tissue coverage in the region. I’m also assuming that the implants will be screwed in, will there be any substantial risks to this? Will recovery also take a long time?

A: The reason that any form of brow bone implants has not been historically done is for two reasons. First, there are no preformed brow bone implants that are available and, even if there were, there would likely be some fit problems. Secondly, only more recently has computer technology made it possible to take a 3D CT scan of the patient and make on the computer screeen exclusively the exact design and size that meets the patient’s aesthetic desires and will have a perfect fit to the underlying bone during surgery like a crown on a prepared tooth.

With the brow bone implant secured to the bone there will be no animation deformities, just like when open brow bone augmentation is done. The biggest risks to the procedure are asesthetic, does it look natural (not overdone) and is there good symmetry. (here is the value of computer-designed implants) Recovery is aesthetic, meaning how long for swelling and any bruising to go away. That will depend on the approach used to placed the implants, endoscopically (7 to 10 days) and through the upper eyelids. (3 weeks)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am trying to find solutions to reconstruct my face after permanent teeth extracted for braces. I have attached some photographs. hope it helps. What I want to achieve is more fullness and proyection to my face, like I used to have before the extractions. If you can give me any suggestion I’ll appreciate it.

A: Thank you for sending your pictures. Knowing that you probably had your maxillary bicuspids extracted for orthodontics would indicate that you have some paranasal flattening and even some premaxillary deprojection as well as a more obtuse nasolabial angle. All of this would have resulted from pulling the anterior maxilla back into the extraction spaces. That could be improved by the placement of a combined premaxillary-paranasal implant, adding about 5 to 7ms anterior projection of the maxilla and the base of the nose, thus pulling this middle part of the face forward.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want to get my forehead reduced so it can be the flattest it can be. However I’m not sure of which approach to take. I heard that with the burring its only a limit to how far you can take it but with the set back you can accomplish more with greater results. However from what I’m told the set back can’t be hidden well and you’ll be able to tell where your bone was broken removed and repaired with screws cements or whatever you guys use to hold it into its new position Is it an additional price from the average burring technique and do you also lift the bones of the eyebrows into a new place to heighten them or you just simply lift the muscle and skin around the bones to raise the brows.

A: Everything that you are saying or have heard about brow bone reduction is relatively true. It would be very rare that a burring technique alone can significantly reduce prominent brow bones or make them as flat as possible. Thus, the formal brow bone setback is the better procedure to do for maximal change.It is true that in the thinner-skinned forehead patient it may be possible to potentially see the outline of the brow bone work. But I have learned to lessen the likelihood of this problem by either avoiding or minimizing the use of any plates and screws (use mainly resorbable sutures if possible) , use only very miniature plates and screws (1mm profile) if they are used, be meticulous about contouring the surrounding bone into and around the setback area and using a thin film or overlay of hydroxyapatite cement over the setback area for smoothness. Whether a simultaneous internal browlift is done depends on the patient’s current eyebrow positions, the degree of brow bone reduction and the patient’s desires. The internal browlift is done by suturing the underside of the eyebrow area onto the bone of the osteotomized brow bone edges or to any fixation hardware used in the brow bone setback.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want to know if I am a good candidate for liposuction. I have a stomach bulge but as I have been searching various internet sites I have seen bigger women than me that have only had the liposuction and show good results. I don’t want a tummy tuck because of the scar. I have never been pregnant and have no stretch marks just a big bulge. Will liposuction be the best option for me? Is losing a little bit of belly weight before a good idea for me?

A: The ideal candidates for abdominal liposuction is primarily defined by the quality of the overlying skin. Nice taut skin that has good elasticity without excess will always produce the best liposuction result, regardless of the liposuction technique used. Skin that has the natural abiity to tighten will do better than any method of skin tightening that various liposuction devices tout. Being a female and never having been pregnant, by definition, makes you a good liposuction candidate in most cases. It is always good to begin any weight loss efforts before liposuction so you will already been in the lifestyle change that will help ensure you enjoy the long-term benefits of the liposuction procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve read your articles on brow bone augmentation and was wondering if silicone implants could be used instead of hydroxyapatite or PMMA? Apart from the scalp incision, could the silicone implants be placed through any other incision (upper eyelid)?

A: Performed silicone brow bone implants could be placed either through an upper eyelid incisional approach or through an endoscopic technique through two small scalp incision. Because they would be made of a flexible silicone material, they can be inserted in two separate pieces and ‘assembled’ once inside. If this brow bone augmentation technique is done, it is best to make the preformed silicone implants beforehand using a 3D CT scan of the patient.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am wanting a breast lift and augmentation. I am 24 years old and my left breast is a cup size larger than my right. After having a baby a year ago and breast feeding for 6 months, the all around shape and liveliness has headed south. I want to get some information about a lift. I am interested I’m how much of a difference just a lift would make, is it better to do both augmentation and lift, and what is the likeliness of breast feeding if I were to have children in the future and would it bring the breast back down. Thank you

A: Breast asymmetry is always one of the most challenging of all breast reshaping surgeries to do. In interpreting your question, it sounds like you are just interested in doing something with the original larger left breast. That may be a reasonable approach if a lift can approximate the position or shape of the opposite right breast. In many cases of breast asymmetry, before or after pregnancies, it usually takes treating both breasts to get the best result. Whether this is done with implants, lifts or combinations depends on the size and shape of the initial breasts and their degree of asymmetry. Regardless of what is done, future pregnancies and breast feeding will negatively impact the surgical results that are obtained.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have read on your site about the injectable sternoplasty (bone cement) and read about successful operations correcting mild to moderate pectus excavatum. I have mild pectus excavatum and was wondering about the approximate cost of the whole operation.

A: The Kryptonite material is no longer commercially available so that treatment option no longer exists. Other injectable treatment options include hydroxyapatite granules and fat. The hydroxyapatite granules are mixed with platelet-rich plasma (PRP) and made into an injectable putty-like material. Fat injections can be done provided that one has enough fat to harvest, of which it usually takes about 100cc of aspiration harvest to get 20cc to 25cc of concentrated fat for injection.  Whether either one of these would be appropriate for you depends on the size of the pectus and your body habitus. I would need to see some pictures of your chest to make that determination.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have noticed that my son who has just turned 21 years old has quite a prominent protruding brow. In fact, I noticed it a few years ago and I am quite positive that it has become larger in the past 12 months. He is 6ft 5in (195cm) tall – a very slim built person; a sports man. Other body features, such as face and head, are all normal in size and do not have the ‘giant syndrome’ disease – which I recall most people with a large protruding brows have. I am wondering – will the brow bone stop growing or could it become larger? Should we be concerned? Should he see a physician? Is this a particular condition or syndrome which needs investigation? Look forward to your early response. With sincere thanks.

A: In theory, frontal sinus development is almost always complete by the later teen or early 20s. Your son is a large man so his frontal sinus development may be normal for his size…or it could represent an underlying endocrinologic disorder of the pituitary gland or excessive growth hormone. I would  recommend that he be initially seen by an endocrinologist to rule out this potential medical condition even though it may be unlikely. X-rays of his frontal sinus would also be helpful to determine its size. If there is not an endocrinologic basis for his frontal sinus development and it is an aesthetic concern, brow bone reduction/reshaping is a surgical option

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I see that you have a post on various implants that can be implanted in the body. My left thigh (inner part) is more curved and less developed than my right thigh. I have attached some pictures of my inner thighs. I’m wondering if you perform implants of this kind. Can you please let me know? I cannot find any surgeons in the U.S. who perform this kind of implant. Thank you. 

A: I did get your pictures and can see the inner thigh difference in contour to which you refer. The question is whether an implant is the appropriate solution to that problem. I ask that question for two reasons. First there will be a noticeable scar in the inner thigh through the implant must be placed. While it is not a long scar (3 -4 cms), the inner thigh is a sensitive area in terms of less than ideal scarring. Secondly, the location of the implant would be between the sartorius and the vastus medialis muscles which is a good submuscular location. (although this is a superficial inner thigh muscle) Since there is no true thigh implant, the best body implant choice would be a calf implant which is long and slender and would seem to have an appropriate shape for this location and the overlying muscle. Current calf implant lengths are 15 cms (small) to 24 cms long.(large) It would be helpful for you to outline on your leg your perceived length of the contour area and what is lengths in cms. is.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 35 year-old male born with a significant facial asymmetry. I have a prominent left sided zygomatic prominence, a left ptosis and a slightly recessed left sided forehead. I also have prominent inverted-U shaped supra-orbital bossing, which divides my forehead into two, and cast unaesthetic shadows especially when I stand under light. I do understand that there are limitations to what could be corrected but I will like to explore what can be corrected. My surgical objectives would be; 1) repair of left ptosis, 2) reduction/shaving of the zygomatic prominence, 3) zygoma fossa augmentation and 4) 

forehead contouring with burring/infracture of supra-orbital bossing +/- forehead augmentation. I have attached images for your review. I have also used a plastic surgery simulator to put my desire in a picture form. I would appreciate your review and consult.

A: I have taken a careful look at your pictures, including the simulations, as well as your goals and can make the following comments.

1. The width of the zygomatic body/arch can be narrowed by an anterior and posterior osteotomies. (infracture method)
2. The prominent brow bones could be reduced by osteotomy/infracture method. (brow bone reduction)
3. #1 and #2 could be done through a coronal incisional approach. Since #2 mandates that this be used, #1 would take advantage of that approach also.
4. You are showing a high temporal augmentation in the superior temporal zone. I believe you are incorrectly calling this area the zygoma fossa which I think you mean temporal fossa. This area could be augmented through the same incisional approach as #1 and #2. This would require an onlay augmentation using PMMA given the quantity of material needed as well as the size of the surface area.
5. To optimally smooth out the forehead above the brow bones, some augmentation would need to be done as well above the brow bone infractured area.
6. Your left upper eyelid ptosis appears to be in the 1mm to 2mm range which could be treated by an internal Mueller’s muscle resection.
7. I also noticed that you have performed rhinoplasty for narrowing of your nose and lower lip reduction as well.

As you can see in the above description, the key to most of your desired changes is the need for a scalp or coronal incision to do them.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My upper lip is big and hangs over my teeth. i am looking for a lip lift. I am in my mid 50s Am I good candidate for it. Will my upper lip look bigger or the same.

A: An upper lip lift, presumably through a subnasal incision location, would produce only a minimal amount of lip lift as it relates to improving tooth exposure. It would make the central part of the upper lip look bigger. If you are happy with the current size of your upper lip, a subnasal lip lift would not be the appropriate procedure. If you do not mind more vermilion upper lip enlargement, then it would be a reasonable procedure to do. But it may take a concurrent lip tuck-up done from the inside the lip as well to get the desired amount of improved tooth show.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I underwent mandible angle and cheekbone reduction surgery over a year ago.  I am disappointed with the changes as it has feminized my previously masculine face. I find that the angle reduction from my jaw is unnaturally high and much too straight to be considered normal.  What options could I consider to replace the previous bony structure?  Another issue that I am faced with is substantial mid to low face sagging.  Several areas seem to be affected such as the infra-orbital muscle (clearly visible, elevated on cheekbone), nasolabial folds, and soft tissue isolation (sides of mouth, fat cheek look).  Could you explain the causes of these irregularities and possible procedures that I could undertake? 

A: I have seen a few cases just like yours where the jaw angles have been completely amputated. The angular shape and the vertical height of the ramus of the mandible can be restored by jaw implant augmentation.  But the implant shape can not be a standard jaw angle implant. it needs to be shaped to just have a vertical augmentation only that has an oblique superior shape to match the oblique cut. That can be done by either using one of the custom jaw angle implant shapes that I have previously used or have one made off of a 3D CT scan.

As for the other facial changes those are obviously a result of the cheekbone reduction. I am going to assume that this procedure was done intramurally with n obliquely oriented osteotomy of the zygomatic body and a posterior osteotomy of the zygomatic arch. That has caused loss of support of the surrounding cheek tissues which not sag creating an orbicular is muscle edge show, deepening of the nasolabial folds and sagging in the submalar area. Like the jaw angle issue, adding back some skeletal support would seem like a logical approach. That effectiveness, however, is not as clear as it would be in the jaw angle area.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My 5-year old daughter has protruding ears, and I was interested in looking into costs associated with having them fixed and if she is currently a candidate or if it is best to wait until she is a little older.
A: Thank you for your inquiry. Otoplasty surgery can really be done at any age after two years old from a biologic standpoint. Ear growth is not affected when performed after this age. Thus, otoplasty in children is done when the parent(s) feel that it is in the child’s best psychological interest to do so. It is historically common to perform the procedure before school formally starts which is where the ‘by age 6’ concept has its origin. Since some form of formal schooling is not occurring earlier than age 6, it would not be rare today to do the surgery by age 4 or 5. This is really a parental decision not a plastic surgery one.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I’m interested in cranioplasty augmentationsurgery but have a few more questions. 

1. Is this correction permanent meaning is it reversible? is it expected to last a lifetime?

2. You mention PMMA is harder than hydroxyapatite, will i feel the difference? 

3. Is the hardness of hydroxyapatite similar to real bone? Will it feel more natural to me?

4. Will I experience foreign body sensation with this “implant”

5.  I’m not an expert on the anatomy of the skull but i’ve read that there are gaps between the bones of the skull even when they are fused. how will this type of correction subtle dynamics of contraction and expansion of my skull bones, once a material like hydroxyapetite is plastered onto them? 

6. Is there potential for leakage/breakage of material and if so what are the health, carcinogenic, or risks.

7. Is there risk of allergic reaction to the material?

Thank you for the work that you do.

A: In answer to your questions:

1) All cranioplasty materials are permanent,  meaning that they do not degrade, break down, and never need to be replaced because they wear out. They are, however, fairly easily removed so they are completely reversible.

2) There is no external feeling difference between PMMA and HA. Their biomechanical differences are largely that of laboratory testing.

3) There are no feel differences between PMMA and HA and they will feel both natural and just like your own bone.

4) Patients do not report that they feel like they have a skull implant in place. It feels just like bone.

5) There are no gaps between adult skull plates. That is an in utero and neonatal phenomenon.

6) Cranioplasty materials are fully polymerized and do not break down, leak, or degrade over time. There are no long-term health or carcinogenic risks.

7) While infection can occur from their surgical placement, there is no known risk of an allergic reaction to HA and very rare risk to PMMA.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am seriously interested in reducing size of my stomach/abdomen with minimal down time and invasion. Is this what laser liposuction can do? I am researching my options.
A: It would be good to talk you through many of your liposuction options and get a realistic understanding of how they work and what can be achieved. There is no such thing as any liposuction method that has any different amount of invasiveness or recovery. That is a misconception propagated on the internet by various marketing and promotional efforts as well as many device manufacturers. While there are numerous liposuction techniques that use different energies to achieve their effects, they all are invasive surgery, traumatic the tissues significantly and involve recovery that would not be considered quick or minimal particularly over a large area like the abdomen.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I’ve been browsing your website for a couple of weeks and it has proved a tremendously useful resource on rhinoplasty. This is something I’ve been thinking of getting for a while, but I would like your opinion on the options available. From what I’ve read, silicone implants tend to come with a risk of extrusion, which is why many surgeons recommend rib grafts. However, I would prefer to avoid the scar and a more invasive procedure.  After posting on various forums, I have been recommended to get a silicone implant for the bridge, but to use ear cartilage to reinforce the tip and to further build up the bridge and radix. Do you think that this will be a viable alternative to rib grafting? Lastly, as I’m from out of the state, would you be able to perform a rhinoplasty on me, and how long should I expect to have to stay before flying back home?
A: It is understandable that many patients want to avoid the use of a rib graft for their rhinoplasty. The use of an implant makes the operation far less complex and much easier for recovery. But, as you have pointed out, the use of an implant for nasal augmentation must be carefully done to avoid its well known complications. For implant nasal augmentation, I currently prefer the use of a PTFE-coated silicone implant as it allows some better tissue adhesion than pure silicone alone but avoids the severe scar adherence of a Medpor implant. The key to prevent long-term complications is to avoid too much pressure on the overlying skin, particularly that of the tip. For this reason, many surgeons will cover the tip with an ear cartilage graft which is a perfectly valid approach. When possible, I prefer to place the end of the implant under the nasal dome cartilages which have been lifted, narrowed and sewn together over a columellar strut cartilage graft. This achieves the same purpose but buries the implant under more natural tissue. This can only be done when the nasal implant is a dorsal style only and not a dorso-columellar style implant. Many times the dorso-columellar style can be avoided with columellar strut grafts. It is unclear to me yet as to what your nasal augmentation needs are.

With a rhinoplasty that uses a nasal implant, the recovery is only a matter of days until one can return home.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, My surgeon indicated that he wants to perform a mandibular osteoplasty to reduce the squareness of my angles; this is why he would need to use screws. He told me that the bone is so hard to reach that he doesn’t use the angles osteotomy, he doesn’t know how to do that. He is a maxillofacial surgeon and not a facial feminization surgeon.
Are you aware of the mandibular osteoplasty surgery? Is that appropriate to reduce mandibular angles? Does that give a more natural result to the angles? One that causes less asymmetry or sagging skin? Is a maxillofacial surgeon appropriate for that type of surgery? (purely aesthetic as I have no functional problems)
A:  The term, mandibular osteoplasty, is a generic term (means jaw bone reshaping) that does not imply any specifics about the surgical technique. You would have to ask him to draw exactly what this technique is to understand what is being proposed. However, I suspect he is talking about doing a sagittal split ramus osteotomy as this would be the only jaw angle procedure in which screws would be used to fix the bone back together. I do not see any reason or indication in this approach for what you are trying to achieve aesthetically. I suspect you are correct in that this particular maxillofacial surgeon is taking a functional rather than an aesthetic approach to your concerns.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I am a 28 years old transgender female. I would like to do a hip augmentation with implants and at the same time a liposuction and fat transfer to the butt or maybe butt implants and hip implants together. I would like to know what is the best solution to create more feminine curves in the butt and hips areas.
A:  I would need to see some pictures of your body to see the dimensions of your hips and buttocks and see what the best solutions are. But I will assume for now that you do not have enough fat to successfully do any amount of fat injection transfer for augmentation. This usually requires at least 2500 to 3000cc of liposuction aspirate to get 300cc to 400cc of concentrated fat per buttock to inject…which will create a very modest buttock enlargement. This leaves the only options for either buttock and hip augmentation using implants. The decision for buttock implants is whether to go above or into the muscle. I usually prefer the intramuscular approach since this implant location has a lower risk of complications and better long-term results. Hip implants are always placed in the subfascial location and the size of implant that can be placed depends on the tightness of the pocket right below the level of the trochanteric prominence.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, there is something wrong with my face but I can’t figure it out. I used to think it was all because of my nose which is big but I think it is more than that. There is some other part of my face that just isn’t right that makes me look unbalanced or disproportionate. I have attached some pictures for your insights and recommendations. 
A: Thank you for sending your pictures. What I see about your facial proportions are two things:

1) A nose that is very broad at the tip and middle 1/3 and a bridge/dorsal line that is low.

2) A forehead that is narrow and very flat.

Ideally a rhinoplasty with tip narrowing and dorsal line augmentation would make the nose more proportionate. Also a forehead augmentation to give it greater convexity from the brows up to the hairline would also be an aesthetic addition.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I need to know if  I need liposuction, a mini-tummy tuck or a full tummy tuck? I am 28 years old and have had two children. I had breast augmentation done three years ago and go pregnant right afterwards. I have a big hard stomach and can’t seem to lose it even though I work out and try to eat right. I am 5’ 8” and weigh 190 lbs. I think surgery is only thing I can think of to help but I am not sure what I need, liposuction or some type of a tummy tuck. Please help!
A: With a relatively high BMI (body mass index) and a ‘hard and big’ stomach, I have concerns that any form of plastic surgery is appropriate for you at this time. You need to lose some weight by some method before considering any tummy reducing plastic surgery procedure. A hard stomach indicates that the skin is tight and a tummy tuck, while it can be done, would not produce a result that may be worth the effort. (the tight skin would not allow that much to be removed) A better yield on a tummy tuck would occur if you dropped 20lbs to 30 lbs, creating greater looseness of skin. Similarly liposuction would produce less of a result that expected as some of your fat is intraperitoneal (located behind the abdominal muscles) where it is inaccessible to a liposuction cannula.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I am Mexican-American and have large cheekbones. Would you do me the honor to address my affliction. Malarplasty and chin implant are my considerations. I have attached pictures in which I did not shave to accentuate jawline and chin. Hope I didn’t goof. Thank you very much for your time.

A: Thank you for sending your pictures…and you did just fine. In looking at them, the problem with your chin is that it is vertically short as the predominant issue with only a mild horizontal deficiency. I think when the chin/front part of the lower jaw is expanded by an extended vertical chin implant, it makes the more prominent cheek bones less signficant. Your cheek bones to me only seem large because the bottom 1/3 of your face is short. I have attached some predictive imaging illustrating what happens when the chin is vertically lengthened.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m contacting you as I am seeking some comments from yourself in relation to what I suspect is either unilateral coronal synostosis or plagiocephaly. Given the nature of the problems I present I am not to comfortable with sending photographs

If I were to describe my observable problems I would summarize them as follows:

1.       Slight right-sided anterior ear displacement (very obvious asymmetry of the ears)

2.       Mild right-sided occipital flattening

3.       Frontal bossing with excessive protuberance of the upper portion of the squama frontalis over the supraorbital margin – slight right to left cant with the right being more forward

4.       Vertical orbital dystopia – right side slightly higher than the left (I would say the entire zygomatico-orbital bone complex on the right is higher as I have an asymmetry and protuberance in the zygoma region)

5.       Nasal root deviation to the right with deviated septum to the right (What I mean by this is that the entire nasal bone pyramid complex is off to the right)

6.       Chin deviation to the left

7.       Asymmetry in the vertical height of the mandible – left side is higher than the left

8.       Uneven cheek fullness – slightly greater degree of fullness on the right side.

9.       Malocclusion – no functional occlusal contact left side and buccal crossbite right side in centric relation, posterior bilateral open bite in centric occlusion. Mandibular mid-symphysis deviates slightly to the right in centric relation, and slightly to the left in centric occlusion. Left condyle is both posterior and superior in the mandibular fossa compared the right.  There is a slight transverse cant of the maxillary occlusal plane observable in frontal view, which gets more significant as you approach the region of which is inclined.

If I were to describe my visual appearance in worm-eye view I would say that there is a slight twisted effect to the skull from right to left, as can be seen looking at the frontal bone and the supraorbital margin, the nose, the zygoma’s, and the mandible.

I have looked at some photos of myself as a child and it seems quite apparent to me that I had a slight degree of vertical orbital dystopia. I do not believe however that I had the “harlequin eye” deformity looking at these photos.  

Do you have any comments or advice, and what treatments may be available to tackle my asymmetry?
A: Your description is fairly classic for this deformational type of skull deformity. Usually the best camouflage approach is to level out the chin and jawline by osteotomy/implant, correction of lower orbital dystopia by cheek augmentation, building up the floor of the eye and adjusting the ipsilateral lateral canthus and possible brow bone contouring. Rhinoplasty to straighten a deviated nose may also be useful. If the ear sticks out on the more anteriorly positioned side, an otoplasty may also be done. Usually I leave the occipital skull deformity alone unless it is really flat.

Dr. Barry Eppley

Indianapolis,Indiana