Your Questions

Q: Dr. Eppley, I am interested in a chin implant revision. I had a chin implant about six months ago and the doctor said it would look just like I wanted. Well it hasn’t and he appears to have chosen the wrong implant. What I wanted was a much wider and more square chin look and it doesn’t look that way at all. I have done some imaging on my picture to show you what chin look I am after. What is the best type of chin implant to achieve my desired look?

A: The imaged change that you desire in the width of your chin can not be made by almost any off-the-shelf preformed chin implant. Even square chin implants do not add that much width. If you look carefully, the widest part of the chin goes past a vertical line dropped down from the corners of the mouth. That is beyond the widths of most existing chin implants.

There is however a way to do it with one and only one preformed implant, the Medpor RZ extended square chin implant. It is possible to exceed its natural width because of its central connector. It is actually inserted in two separate pieces and then attached once in place. You can increase the width of the chin by a full centimeter by not snapping it together but by leaving the two pieces spaced apart and made ‘one-piece’ by only the thin bridge of the connector.

The other option is to make a one-piece design out of silicone that contains all the desired dimensions and is placed as a single piece implant. (aka custom chin implant)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a revision rhinoplasty about ten years ago. I had a Medpor nasal shell put in. It was a thicker shell which augmented my nose too much in width, but I’ve always liked the right side and the profile is good. However, the left side is too bulbous and makes my nose look too big. I have talked to two rhinoplasty surgeons who have given different opinions although both are very confident about working with Medpor. One suggests removing the shell and replacing it with a smaller implant or a rib graft. The other said to leave the implant in and just carve into it on the left side and make it smaller. What’s your opinion? What do you think will yield the best results, but also be the safest in preventing infection and is less intrusive?

A: The concept of narrowing your existing implant rather than replacing it with a new implant or a rib graft is a sound one to me. If you like most of what you have in place and just need a little tweaking of it, then you should just modify the existing implant. Doing so also has the advantage that it is really what I call an ‘autoimplant’ at this point. It is part implant and part autogenous since you have tissue ingrowth into it. I would also contend that using the existing implant has less of an infection risk than placing a new one, since the ability to get it inoculated with bacteria into its porous structure is less due to the existing tissue ingrowth.

Whether you carve it in place or take it out to reshape the existing implant is matter of nuances. Either way you have to do a complete dissection over the top and both sides of the implant. Even for in situ carving, you need the space to work. The only difference is that in removal you have to release it underneath from the  cartilage-bony framework. Based on my experience, I could not tell you until I was in there which way I would do it. If I had good access with it in place, I would carve it down without removing it. If I could not get a space to work and was concerned about the overlying skin, then I would remove it, carve it down and re-insert. I don’t think any surgeon can tell you which exact method is best until they are in there. What matters is which way will give the best rhinoplasty revision result and not injure the overlying skin cover.

I have never found Medpor implants hard to remove. Surgeons say it is hard because they have never done it or are comparing it to silicone implants which slide out quite easily. Medpor implants require more care and finesse in their removal to not injure surrounding tissues but they can be removed even though they are more adherent to the tissues.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I need a sinus setback procedure. I think it is called the brow bone. but my brow bone is a bit asymmetric. Will a browlift be needed after this surgery? Is in the quoted price also the hospital care and everything? How many days should I stay in your town all together? Also is it possible to make some sort of insurance arrangement in case something goes wrong so that I am fully covered in this case? Finally have you not seen or have you also not heard of anybone resorption with this procedure? Long term consequences really scare the XXX out of me.

A: In answer to your questions:

1) Generally, a browlift is not needed after a brow bone reduction. It does not usually cause the brow bone to fall.

2) Any price estimates given to you is all-inclusive of the surgeon’s fee, OR and anesthesia costs. A formal price quote can be given based on reviewing pictures of the patient. Most patients return home 48 to 72 hours after the procedure.

3) I can not think of anything that could go wrong with this type of surgery that would require hospitalizations. But most insurances will cover medical problems, regardless of the origin of the problem.

4) I have not seen or heard of any bone resorption afterwards with this operation.When properly done with good surgical technique, brow bone reduction should not result in any long-term bone resorption problems.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dear Dr. Eppley, i have really hollowed temporal areas and I have heard that there are temporal implants which can correct this. So can an implant be placed under the skin of the temporal regions? Also, can the implant be misplaced or is it screwed in place to stay there? Thanks a lot doctor 🙂

A: There are very specific temporal implants for the correction of different degrees of hollowing.  These temporal implants can be used in the various sizes or can be custom carved to fit any shape or size of the hollowing. They are placed through a small vertical hairline incision and their flexibility (silicone rubber) makes them capable of being inserted through a much smaller incision than one would think possible based on the size of the implant. They are not bone-based implants so they can not be screwed in to any of the surrounding bone. Rather, they are placed right underneath the temporalis fascia in a tight pocket so there is no chance that they can migrate or move from this position. It is a procedure that is associated with virtually no pain afterwards and very little swelling.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley I have a question. I did open rhinoplasty and now I’m 3 months post op. I have stopped taping my nose but now I feel like my tip is more bulbous than it used to be. When I was taping it was more rounded and big. Now it feels firm with slight pain if I try to move it. Is that swelling? Will this shape change with time? I’m so confuced and I don’t want to  undergo a revision.

A: Your questions are the most common concerns that most patients have after rhinoplasty. While I obviously don’t know anything about before surgery nose or what exact rhinoplasty maneuver were done, I can make some general comments. If you have read my four phases of rhinoplasty recovery blog, you will see that you are currently entering phase 3. Tip swelling is very common in this phase and often the tip may even appear bigger than before. The fact that it is firm and slightly painful indicates that you still have significant tip swelling. What you can know for sure is that the tip is going to get smaller. How much smaller and whether it will end up better than before surgery remains to be seen. You will know that all the tip swelling is gone when it feels soft again and can be freely moved without discomfort. The consideration of a potential rhinoplasty revision is a long way off and you must wait a year after surgery to be certain you are really looking at the final result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want a rhinoplasty to change the shape of my nose. I have attached a picture of the type of changes that I want done to my nose. This is my effort at a little computer imaging with Photoshop. The first plastic surgeon I saw told me that  all I need is tip work while another plastic surgeon told me I have to do a  complete rhinoplasty to get that look. Please let me know what you think as I am confused.

A: The first thing I would say is to not get confused trying to decide whether you need a limited or full rhinoplasty. There are fee and recovery differences between  a tip rhinoplasty and a full rhinoplasty but the most important issue is what rhinoplasty techniques will give you the best result. The fundamental difference that separates the two rhinoplasties is that a more complete technique involves osteotomies or the narrowing of the nasal bones due to significant hump reduction. When you have a difference of opinion between two board-certified plastic surgeons on a limited vs a full technique it is usually because you could go either way. This is computer imaging can be so useful. Imaging allows discussion about different changes and how they might affect the overall look.  The techniques used to achieve those goals are up to the surgeon at that point. You have shown only one photo of your nose from an oblique angle. It is impossible to say for sure what you may need from just this one angle. A front and side view would also be very helpful as the nose must be considered from numerous angles when considering a rhinoplasty change.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 22 year old female who is 5’6″ and weighs 165 lbs. I used to weigh 220lbs. I seem to be at a plateau for weight loss over the past year of which I am comfortable with that. But I have a remaining overhanging stomach pouch (I think it is called a pannus ??) that has not really gone away that much with the weight loss. It has gotten less full but now hangs down  more. I have very large breasts and thick thighs and butt so I know I will never be tiny, but I would like my overhang gone and to have a flatter stomach area. Should I get liposuction or have a tummy tuck?

A: This is  classic question posed by many patients who have some amount of a stomach overhang. By definition, the description of an overhang signifies that there is a skin excess problem as well as too much fat. Liposuction alone will only magnify the prior result of what weight loss has done, it will deflate the overhang (aka pannus) further but it will still leave a flap of skin. You need this cut off by a tummy tuck. Liposuction is only useful in your case when combined with a tummy tuck, as it may help contour the waistline better to the sides where the tummy tuck excision does not go. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a breast augmentation done seven years ago. Just last week I had a deflation and went back to my plastic surgeon. I am having both redone due to wanting to go fuller. I was an A cup before first surgery and now a C cup using a 350cc MP saline implant. I want a full D and he suggested a 550cc HP saline implants. I am m looking for a much fuller breast with less sagging. I want to make sure that when I go through this again that I get what I want. Does this size implant sound like enough?

A:  When changing breast implant size to go bigger, you want to make sure that you are getting at least a 30% to 40% increase over your prior implant size. Anything less will likely not be that visible. That means going from a 350cc implant, you need to go at least 150cc  bigger if not more. Thus the 550cc implant size sounds good to me. I have no doubt you will be visibly bigger and rounder. Whether your sagging will be improved to your liking, however, may be a different matter. Getting bigger does not always mean your breasts will be more uplifted, as defined by the nipple getting higher and more centered on the breast mound. Make sure you discuss this with your plastic surgeon beforehand to be certain you may not simultaneously benefit by some form of a nipple (areolar) lift with your breast implant exchange.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, You have some great results for jaw augmentation! For the man pictured below, what biomaterial did you insert and were they custom made implants? If not, what kind and shape of implants did you use? And how many mm width and length? My facial shape is somewhat similar to the man below after a botched jaw reduction surgery. By the way, since there is bone erosion over time with these kind of implants, I was wondering if this will be more of an issue since I had my outer bone removed, leaving the marrow or softer bone inside exposed. Also, since my softer bone is exposed, would there be higher chances of infection?

A: Those are preformed lateral augmentation silicone jaw angle implants. Although in someone with missing angles from a jaw reduction, you may be better off with an inferolateral style (Medpor) which is better at creating a more defined jaw angle. Otherwise, I am not aware that there is any bony erosion with jaw angle implants. I have removed many from other surgeons over the years and have never seen that issue. Having had jaw angle reduction previously, this does not increase your risk of infection or difficulty with jaw angle implant placement in my experience.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I had liposuction of my stomach done three weeks ago. A total of nearly 1500cc of fat was removed. The very next day I looked great and my stomach was flat. But by the next few days, my stomach got bloated and bigger. Then I got my period and got even more bloated. For now my belly pouch is back although it is smaller. Is this normal and will it ever go flat again?

A:  What you are describing is a very typical sequence of events after liposuction. When you see yourself the next day due to the compression applied by the garment and with no real swelling yet present, the amount of improvement created by the fat removal is seen. Then the swelling and the temporary impairment of lymphatic outflow occurs and some of the improvement appears to be lost. What I tell my patients is that what they see the next day will eventually return but it will take at least 4 to 6 weeks to get back to that. This is the time needed for all swelling to go away and much of the normal lymphatic circulation to return. So you will get to where you want to be but it requires more time and patience. This is a normal part of the recovery process from liposuction.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a facelift just one week ago. I expected to be a little swollen and bruised but not like this. I was told before surgery that I could return to work two weeks after the surgery. I was also told that by that time I would not be completely healed but that no one will notice that I would have had surgery. Based on the way I look now, I can’t see how this will be true in just another week. I am a bit panicky now because I can’t go to work remotely looking like this. I’d have to quit my job if I went in looking like the monster that I do now. Any suggestions or advice on how to make this swelling and bruising go away faster?

A: The amount of swelling and bruising after a facelift that any patient gets will vary and is most affected by the type of facelift that one has. Unless it is a very limited type, I would never tell a patient that they will comfortably be able to go back to work in just two weeks. Three weeks after a more complete facelift is more realistic. That is now water under the bridge so to speak so what can you do now? Largely the  speed of the improvement you are going to get is by your won natural healing process. But the use of Arnica tablets and topical gel for the bruising, don’t sleep completely flat (head up) and taking some bromelain (for swelling) may be of help. You may also be surprised what another week of recovery will do. I suspect you will be much better by next week and with a little makeup you will be largely ‘undetected’ for having a facelift.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dear Dr. Eppley, I had liposuction six months on my stomach, saddle bags, flanks and inner thighs. The doctor told me he removed 4 liters of fat. I am very happy with the results with the exception of my inner thighs. I now have some saggy skin and irregularities of the inner thighs. Is this common afterwards? Can some form of non-surgical skin tightening be done to make it better?

A: Liposuction can be tremendously effective for many body areas and the inner thighs are no exception. But inner thigh skin does not usually have much ability to contract so only conservative fat removal should be done in this area and patient expectations should be tempered as to how much size reduction can be done. If too much fat is suctioned out, the inner thigh skin can be made to sag with irregularities. There are numerous non-surgical skin tightening devices that can be tried and they have all have some effect. My current favorite device is Exilis which uses monopolar radiofrequency energy to create skin tightening through a series of treatments. If this is not successful, you may need a definite inner thigh lift which will solve this concern.  

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dear Dr. Eppley, I am an amateur bodybuilder and I have very large pectoral muscles as you can see in my photos. I feel I have achieved as much size as I can through exercise and that my only options for increased size are implants or anabolic steroids. Since steroids are illegal, I am interested in knowing whether I would be considered for pectoral implants and what amount of size and projection increase I could expect.

 
A: The common use of pectoral implants is for men who either need reconstruction for congenital pectoral/chest asymmetry or cosmetic chest enhancement for those that have not had good success with pectoral enlargement. Your chest shows considerable pectoral muscle enlargement as you have mentioned and your picture shows. The question is not whether you can have pectoral implants but whether the sizes that are commercially available will make enough of a difference to justify the effort. The typical size of the largest pectoral implants is around 350ccs with maximal projection of about 3 cms. How much of a difference that will make in your chest size in not exactly predictable. Knowing your exact chest dimensions in height, width and thickness for each perctoral area would be helpful in answering this important question. Based on the picture alone, I would estimate that the change would be in the range of a 20% to 30%  increase…but that should be interpreted as a guess based on inadequate information as of yet.

 
Dr. Barry Eppley
Indianapolis, Indiana

Q:  Dear Dr. Eppley, I would like to get Medpor malar and paranasal implants. However I am a bit concerned about the possibility of implant infection. Although I know that impregnating these porous implants in an antibiotic solution prior to implantation combined with good oral hygiene usually works well, I also would like to go for a dental dam that limits the contact of the implant to the mucosa during surgery. Would you use a dental dam if the patient asks for this? Do you think a dental dam can lower the risk of implant infection if the implant is placed through the mouth?

I know that malar and paranasal implants are inserted into the same pocket through the same incision. Considering this, do you usually charge for the combined malar and paranasal procedure like this would be two separate facial implant procedures or do you charge only a bit more than for a malar procedure alone plus additional cost of the implant material? Thank you in advance for your reply

A: Porous implants like those comprised of Medpor material do have a higher risk of infection in my experience. Thus everything that can be done to limit this potential problem is done from antibiotic soaking and irrigation, limited insertion and removal for try-ins, and a change in gloves when the implants are finally inserted. You are correct in assuming in assuming that the risk of infection is highest when placed through an intraoral approach due to potential contamination from the oral mucosa. The dental dam is an interesting but impractical method of recipient site isolation. The dental dam is used in tooth restoration because it wraps around the neck of the tooth being worked on so the rest of the mouth is covered. This places the tooth in front of the covered mouth. It can not be used effectively in reverse because the inside of the lips and the maxillary vestibular mucosa is still exposed to the recipient site even if the teeth are not. So no I do not think it would be an effective method for reducing the risk of implant infecrion.

While the malar and paranasal implantation sites can be done through the same incision, the work to place the implants is still doubled. Shaping, placing and fixating the implants is the bulk of the operation. Four implants require twice as much work as two implants. Making the incision and closing it is but a minimal amount of time for either operation. Some cost reduction is seen when both types of facial implants are done together based on the time saved as it relates to incisional management.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dear Dr. Eppley, I was born with a condition known as right hemifacial atrophy, also known as Romberg’s syndrome. I was operated on two years ago with corrective orthognathic surgery. Both my upper and lower jaws were cut, leveled and my bite put back together. The result is good but I still have some right facial asymmetry. I want to reshape my right cheek bone, nose and orbital region. I would appreciate if you can give me some advice on what procedures I need. I have attached some pictures and x-rays from my surgery.

A: Thank you for sending your pictures. You have made good improvement from your orthognathic surgery. To further improve your hemifacial hypoplasia/asymmetry, I would recommend the following right-sided facial reshaping/augmentation procedures:

 1) Right orbital floor-infraorbital rim implant

2) Right lateral canthoplasty

3) Right cheek implant

4) Rhinoplasty

5) Right jaw angle implant

6) Opening wedge genioplasty (right side lengthening) – I was little surprised they did not do this during your orthognathic surgery

This would be my optimal plan to address all of your right facial issues. While all of these procedures do is to lengthen and expand the shorter right side of your face. I think you would get as good, if not even better, aesthetic improvement than you have had from your prior orthognathic surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dear Dr. Eppley, I consulted with a board-certified plastic surgeon who says he can round the corners of my chin and reduce about 5mms of projection without any ptosis or deformity. I have seen his before and after pictures and they are stunning. Best I’ve seen. Should I still be concerned about sagging. Also he wants to put me on a course of antibiotics, steroids and put a drainage tube in my chin to make sure no fluid collects for several days. What are your thoughts?
A: There is no chin reduction procedure of any significance in which the risk of soft tissue sagging does not exist. By definition when you make the supporting bone structure smaller, you have an excess of overlying soft tissue. With proper soft tissue management and suspension this potential concern can be avoided whether it is done from an intraoral or submental approach. The use of antibiotics and steroids are standard practice. The use of a drain is surgeon’s preference. It is not something that I have ever used for any chin procedure but I know there are some surgeons that do.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I had a nose job six months ago from which I am not at all happy. It was a closed septorhinoplasty with the objective of lifting the tip of my nose and narrowing it. While right after surgery the tip was up, it fell down just weeks later. My nose is now not only pointing downward but is bent to the right to boot. I am very unhappy. The doctor told me that the stitches either became loose and weren’t strong enough to hold it up. What should I do now?

A:  One of the problems with a closed rhinoplasty is that it can be more difficult to get idelal tip shaping and rotation. This is not to say that it can not be done but it takes more experience to do so than in the more commonly used open rhinoplasty. There are numerous reasons why a tip does not get or sustain adequate rotation including a suture retention issue, inadequate caudal septal reduction, inadequate columellar tip support or some combination. Regardless a revisional rhinoplasty procedure will need to be done through an open technique now because of internal scarring and a failed first procedure. As long as this approach is used, you should be confident that you still can get the end result that you initially desired.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am very disappointed with my Smartlipo results. Over four months ago, I had the procedure on my abdomen and flanks to try and improve my waistline. The laser was used but no suctioning of the fat was done. While everytime I go back the doctor tells me to be patient, I surely would have thought I would have seen some improvement by now. I am getting frustrated as I spent all this money and have yet to have anything to show for it?

A: I am afraid to tell you that if you have not seen results by now, you are not going to. It is not common practice, nor do I think it is even reasonable, to perform Smartlipo without simultaneous aspiration. While there is some heat-related effect to Smartlipo, you simply can’t rely on that effect alone to create a result. The main benefit of Smartlipo is that it makes the fat easier to suction out and enables better fat removal. Smartlipo is not a Star Wars game where you shoot and vaporize the fat instantly. Nor does it cause enough fat release that lymphatic drainage will remove enough to make a visible difference. Without simultaneous liposuction, it is not possible to make a significant improvement. It pains me to see some practitioners use this non-suction approach to Smartlipo and its lack of results which makes people unhappy as well as gives Smartlipo a bad name. This is a doctor problem not a device-related one.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I have been bothered by the appearance of my nose for a long time. The problem is that the  tip is big, long, and droopy. Because the tip hangs down, it also affects my smile. It makes my smile look unnatural as the upper front teeth are barely visible. I have spent a lot of money on orthodontic work and I want them to show. Would a rhinoplasty improve this problem?

A:  I think you have to separate the nose problem from the lack of upper tooth show. While the nose and lip are next to each other, they do not often directly cause a cosmetic problem for the other. A long downturned nasal tip does not cause the upper lip to be pushed downward. Therefore, while a rhinoplasty will make a very visible difference in the shape of the nose and how the overall face looks, it will not have the effect of improving upper tooth show. Pulling the tip of the nose up will not create a shorter upper lip or at least not significantly. You will need to consider some type of upper lip shortening to create that effect, such as a subnasal lip lift.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I need to get rid of my saddlebags. I don’t know why they are there as they do not fit the rest of my body. I am 5’4″ and about 110 pounds. My body fat percentage is quite low as you can probably tell from my weight. I work out all the time and no matter what I do I can not get rid of these pesky saddlebags. Quite frankly, it drives me insane as I just hate them. I was trying on clothes in the store this past weekend and could really get a good view of them from behind in the jeans I was trying on. Given my small size do you think liposuction will work to get rid of them?

A:  Despite being lean and very weight appropriate for their height, I have seen many women who have this saddlebag problem. While I suspect it is a problem of small saddlebags given your height and weight, they are nonetheless disproportionate. The good news is that this is an easy problem to solve with liposuction. Just because you are small doesn’t mean they are not abnormal collections of fat. I would guess your saddlebag problem could be treated by an office procedure under local anesthesia using Smartlipo. This would minimize the process and recovery and provide a solution that truly matches the problem.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had liposuction of my neck and jowls several days ago. The doctor who did my surgery told me to keep my head elevated when sleeping with two pillows and wear a neck  compression garment. How important is it to wear this garment and does it affect the final result?

A: The purpose of the compression garment, as the name suggests and it is probably obvious, is that it applies some pressure on the treated area. Its only benefit is that it may help keep down some of the swelling in the first week after sugery. In most cases of liposuction, compression doesn’t usually make a big difference long-term in the result. You undoubtably are asking this question because neck compression garments, in particular, are a nuisance to wear. What I tell my patients, whether it is neck liposuction or a facelift, is to wear it regularly for the first two days after surgery and then just at night for the first week after surgery. Thereafter it may be discarded as it no longer provides any benefit and the patient’s tolerance for it has been reached.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I have a rather big nose (and it become much more bigger when I smile or grimace). How much of it can be reduced by rhinoplasty? Can I have nose like, for example, Angelina Jolie? And the other question is will my nose get bigger the (when I smile or grimace) after nose job?

A: The first concept to grasp about rhinoplasty surgery is that you can not have  a nose like someone else. While it is important to have a surgical goal, looking like someone else’s nose is not realistic. This is particularly true when it comes to a large nose with thick skin. There are simply limits as to what can be achieved based on the amount and thickness of the nasal skin cover. Whether rhinoplasty is worthwhile for you, or any patient, requires some sense of what the result may be using computer imaging. When done carefully by an experienced rhinoplasty surgeon themselves, you will get a much better sense of whether rhinoplasty can make enough of a difference to justify the effort. When I do rhinoplasty computer imaging, I always show the most conservative or least achieveable result that I think can happen. That way if the patient chooses to have rhinoplasty surgery, they will not be disappointed and make even be pleasantly surprised if even more of a result develops.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I am interested in getting my cheeks lifted. I am 48 years old and my cheeks sag which makes me look sad.  My face is plenty full as it is very round. What is the best non-invasive method to lift them up?

A: The first thing that I would tell you is that there is not a non-surgical way to lift up the cheeks. There is almost nothing that I know that can lift any part of the body without some form of surgery. Some doctors may tout that they can lift up parts of your face with injectable fillers and in some small amounts that may be possible for some patients in some facial areas. However, with an already full and round face this injectable approach is likely to make you even rounder…and have no real lifting effect anyway. There are cheek lifting operations but really good results from these procedures come from very careful patient selection. Whether you would be a good candidate or not would depend on seeing some pictures of you. As a general rule, very round and full faces are chcallenges for any lifting operation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am going to get breast implants and need some help in selecting size. I am currently a 34B with one breast about a quarter of cup larger than the other. They are perky but just not full. I am uncertain on whether to get saline or silicone implants and am looking for the most natural result possible.

A: When it comes to getting a natural breast augmentation result, it does not matter whether a saline or silicone implant is used. That has nothing to do with making a difference between looking augmented or not. Rather it is a function of implant size and implant location (above or below the muscle) as well as what your breast tissues look like now. As a general rule, it is almost always better  to go below the muscle so that there is a natural slope in the upper pole of the breast. If you keep the implant base width at the same size or less than that of your natural breast base width, you will almost always look fairly natural. The size of breast implants is directly related to their base diameter. The larger the base diameter, the larger the implant. A simple tape measurement of your breast base diameter would help considerably in making a good implant size selection for you. 

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dear Dr. Eppley, I am a young women and am very insecure about my forehead. It’s very large and I’m tired of bangs. As you can see in the pictures, my forehead sticks out because of the “horns” I have smacked in the middle of my forehead. It feels hard. It may just be the bone but I still want to see if any procedure can be done to make them go away or, if not, make them less noticeable when light is shown on them.

A: I can see by your pictures that you have an upper frontal bone bulges, often what people refer to as ‘horns’. There are two approaches to making your forehead smooth and less prominent. The simplest approach, and I suspect the one of most interest to you, is to do a burring reduction of these bumps to make your forehead smooth and less prominent. This would be done through an incision way back in the scalp. The other approach to forehead smoothness is to build up the forehead below and around it with a cranioplasty material. This would not only make your forehead smooth but would also give it greater convexity which is viewed by many women as a desireable forehead feature. Both of these forehead reshaping/reduction approaches will work to make the forehead smooth adn get rid of the bumps, it is just that the shape of the forehead in profile view will be different depending upon which one you would choose.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dear Dr. Eppley, I had a submaxillary Gore-Tex implant placed at the same time as a rhinoplasty over fifteen years ago. It was done to elevate the area below my nose to improve the shape of the angle between my lip and nose. Later it was determined by an oral surgeon that I needed upper jaw surgery but that would be extremely difficult as this implant sticks to the bone and therefore he would not operate on me. I can live with all of the above; however, this implant is annoying as on the right side it continues to dig down into my right upper gum area. I have been told that this type of implant can be very difficult to remove and that it would be best to just leave it alone. What is your opinion on getting it removed?

A:  To clarify the issues in regards to your Gore-tex facial implant, here is what I think:

1) To be exact, it is a premaxillary implant not a submaxillary implant. Because it is Gore-Tex and placed during a rhinoplasty, it was inserted through a nostril base incision initially. It was done to open up the nasolabial angle.

2) Gore-tex does not adhere to the bone and is the one of the least ‘sticky’ implants to remove. It is smooth and the body places a capsule around it.

3) Because it was placed long ago, it is likely a multi-stranded Gore-tex implant rather than a solid one-piece implant composition. This makes it a little more difficult to remove but certainly far from impossible.

4) Your premaxillary implant can be removed through an incision inside the mouth as that is just as close as going through a nasal base incision.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dear Dr. Eppley, I am 32 years old and two years ago I weighed 220 pounds. By diet and exercise, I have been able to get down to 170 lbs and I seem to be stuck at this weight now. It won’t budge no matter what I do. The skin on my stomach is very loose and I have old stretch marks that I want removed. I want a tummy tuck but do I need to lose more weight before having surgery?

A:  Your question is both a good and a common one. While many people have been successful with a fair degree of weight loss, they sooner or later ‘hit the wall’ and can just not lose anymore. Ideally, I tell my patients that if you are within 15 to 20 lbs of the weight they desire then a tummy tuck is reasonable. If you weigh much more than that then you should wait until you lose the extra weight so you do not create loose skin after surgery should you undergo more weight loss. Realistically, however, once the weight wall is hit for most people that is as far as they will usually get so that has to be taken into consideration. Most patients that I see for tummy tucks appear when they are frustrated with their ongoing lack of weight loss results. You should also understand that only the stretch marks from your belly button to you pubic hair line will be removed.  Any stretch marks above the navel will still be present after surgery, they will just be moved lower to a new position below the belly button.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dear Dr. Eppley, I had a browlift several months using a hairline approach. While the surgery was uneventful, I have had a persistent scab along one side of the scalp incision that only recently I was able to get off.  The scab was stuck to what appears to be the dissolveable sutures that were used. It now looks like an area of infection with some sort of red tissue between the scalp and foreheads of a few millimeters wide. Why is this and what do I do now? I have attached a picture of the area so you can see what it looks like.

A: It is now clear as to why you have had this scab this long and why it looks the way it does now. The scalp has a tremendous blood supply and this is why infection and necrosis of skin and scalp tissues is very uncommon. Neither of these have been what has happened to you. It appears that you have had separation of the wound edges in the early weeks after surgery, undoubtably due to the combination of tension on the scalp closure (which is normal) and the dissolveable sutures used. It appears that in your case those dissolveable sutures were just not sturdy enough to hold the skin edges together as they were healing. I used these all the time and have never seen this problem before.  

Whenskin edges come apart, the body then creates its own bandage (i.e., scab) to cover the open wound it as it heals underneath it. This explains why the scab was stuck on so well for so long. That is a natural reaction of the body to an open wound. Once the gap in the skin edges fills in with granulation tissue (beefy red tissue that you see in your wound), the scab will get loose and be capable of being removed. This now leaves the gap filled in with granulation tissue that is now level with the surrounding skin. This is a good and healthy sign of a healing wound despite how it may look. This granulation tissue looks very red and angry but this is just due to the many blood vessels that it contains.

What will now happen is that the surrounding skin can now grow over it to make it a completely healed wound. This should take just a few more weeks to happen. The combination of granulation tissue, with a very high level of cells that contract, and the new skin will make the width of the wound and final scar once it heals much smaller. In the interim, of course, you have to persist with this unsightly wound in an area that is impossible to hide.

This leaves you with two approaches at this point and each has its own advantages and disadvantages. The first approach is to let the wound heal and contract and manage the residual scar at a later date. This is the most ideal approach from a long-term scar standpoint. This will leave a much more narrow scar area to excise and the tissues will be of better quality to manipulate so there is not a recurrent problem. The disadvantage is that you have to exist with this unsightly area in the interim. The other approach is to intervene earlier before it heals and excise and re-close the wound now. This has the advantage that it deals with the cosmetic appearance of it earlier but the tissue quality is not as good and how well the wound edges will hold together is a bit unpredictable.

 Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a question about nose hump removal. I know that rhinoplasty surgery works well for taking down a large bump on the bridge of the nose. But I would like to avoid surgery if possible. May I ask if you`re familiar with nose magic product? Is it worth trying? The company responded quickly to my inquiry, saying that it can help by moving cartilage.

A: I am very familiar with Nose Magic and use a companion device occasionally on my postoperative patients to manage their persistent tip swelling. Do I think it will work to permanently take down a nasal hump…no. Did I think you have anything to lose by using it…no. It has its effect by temporarily squeezing the fluid out of the tissues causing a slight change in shape, just like when you pinch it and hold it for awhile. The problem with a nasal hump is that at least half of it is bone whose shape will not be altered by any form of external pressure. While nothing sells like hope, at least you can prove to yourself one way of the other, of this non-surgical approach to nose reshaping. You will find in the end, however, that only a surgical rhinoplasty will really work.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Earlier this year I had breast augmentation using 400cc saline implants under the muscle. I really wanted bigger implants above the muscle but my surgeon told me that they would ripple too much and the folds of the implant would be seen when I bent over. I went from a 32A to A DD cup but they don’t look that big at all. I would like to go bigger but still want to look natural. Would I have looked bigger if I had the implants placed above the muscle? If I wanted to go bigger can I have them switched to above the muscle?

A: There are a lot of advantages to having breast implants under the muscle, only one of which is less risk of rippling. Lack of mammographic interference, a less acute transition at the upper pole into the implant, and most importantly, a thicker and more vascularized soft tissue cover. (even if only the upper half of the implant is covered) I think you are confused that there will be some perceptible size difference if the same implant is placed above or below the muscle…there is no appreciable difference. While you certainly can increase the size of your existing implants, I would leave them in the same submuscular location. Being a thin-framed woman I would be cautious about getting too big of an implant that may not have adequate soft tissue support in the long-run. This can result in the breast implants bottoming out, a difficult problem to fix satisfactorily.

Dr. Barry Eppley

Indianapolis, Indiana