Your Questions
Your Questions
Q: Dr. Eppley, I would like to start by saying your website and blog have been so helpful as both a research tool and making me feel so much more comfortable in approaching this issue. It is one of the few sources I have found that really takes the time to properly explain things, that most people in plastic surgery don’t understand. I would like to have more balanced facial features and to improve my asymmetries to improve my facial appearance. I feel that I have a long lower face and chin compared to my forehead, which is very low and slopping. I can’t wear hats and have to spike up my hair all the time so I don’t get teased. I recently lost a lot of weight and with it my cheeks, with used to be very full. But I guess what bothers me the most is my nose – I have a deviated septum which makes me look crooked and my nose is very romanesque in appearance. I think that a rhinoplasty and cheek augmentation would help me best but I’m open to suggestions. I just want to be the most attractive me I can be. From my photos can cosmetic surgery help me?
A: Facial symmetry and proportion are the two most important components of facial attractiveness. In looking at your photos, I would agree that the deviated and dorsal convexity of the nose combined with flat cheeks are the two main areas to try and improve. I would propose a rhinoplasty whose objectives are to straighten the nose in the frontal view and bring down the dorsal line to one that is straight between the frontal-nasal junction and the nasal tip. The tip could also tolerate a bit of thinning as well. For your cheeks, anatomical style cheek implants secured high up along the flat malar prominence will bring some highlights to your midface and more angularity to your face.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a son whose ears stick out. When he was little, he was sometimes called dumbo which was cute at the time. Now that he is in school, he is called dumbo and it is no longer funny. I can tell that it bothers him considerably and he is very self-conscious about his big ears. I want to get him an ear pinning procedure, which I know is the right thing to do, but I need some more information about the operation. Please give me an overview of some of the specifics about this type of ear plastic surgery.
A: Ear deformities can be emotionally traumatic to anyone but it is particularly bothersome to young school-aged children and teenagers during their very important formative years of their self-image. The good news is that an ear pinning, known as otoplasty, is a relatively easy and highly successful procedure. As the ear is about 90% complete in its growth by age 5 or 6, an otpoplasty can be done before a child enters school.
Otoplasty is done under general anesthesia in children. The incision and resultant scar is placed on the back of the ear and will heal so that it is never seen. The ears are reshaped by giving the ear cartilages a new shape through the use of permanent sutures which folds the ears back. The operation takes about one hour. Dissolveable sutures are used to close the incision and a head dressing is applied for few days. There is some slight discomfort but it is not a painful experience afterwards. Once the dressing is removed, the results are immediately seen. While there is some slight ear swelling, there is usually no bruising.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am curious about the use of hydroxyapatite or kryptonite bone cement for the use of building up areas of the cranium that are asymmetrical. Is hair loss something that occurs over the area where either of those two materials would be applied or is hair growth unaffected by having those materials placed onto the cranium?
A: Hair loss is not a potential complication of any cranioplasty procedure. I have been asked this question many times and it is an understandable concern.The blood supply to the scalp is extensive as the scalp is one of, if not the most, vascularized skin structures on the body. More pertinently, the scalp is tremendously thick often being 1.5 to 2 cms in tissue thickness. The hair follicles reside just under the skin in the top layer of the scalp, being in the upper 10% to 20% of its thickness. When raising a scalp flap for any cranioplasty procedure, the entire thickness of the scalp is raised off of the bone. Thus the plane of dissection and flap elevation is far away from where the hair follicles may be injuried. The only risk to hair follicles is in the making of the scalp incision not in the raising of the scalp flap or from the cranioplasty material underneath it. Such limited damage can be avoided by careful angulation of the incision, not using cautery in the upper level of the scalp and in careful scalp incision closure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had implants for submalar augmentation placed through mouth on September 2nd and then had them removed one month later. I also had a small premaxillary implant put in through the nose. I removed them because they were too big and the premaxillary implant changed the way my nose looked. The implants have been out for one week. I know that some of the undesirable effects were swelling and that I didn’t give them a real chance. But the anxiety they were causing me on a daily basis was too much. I can’t find any information as to why my nose looks different still after removal, it is wider and the nostrils look rounder and slightly more upturned. Is it possible it won’t go back to pre op look? Could scar tissue have formed that quickly or is it just swelling and if so when should I expect it to truly resolve. The cheeks and lower face are still very swollen also, will this eventually return to pre op look also given that they were in and out so quickly? When can I expect to look like me again? My muscles are a bit tight but overall seem to be functioning without any issues to the nerves and I can smile. Thanks and I look forward to your response.
A: Certainly one week after implant removal, there will be residual swelling and facial distortions. By your own admission you know this and it will take several months before you can judge the final outcome. I would have no doubt that the cheeks area will return completely to normal. Whether the nasal base will is unknown. In placing premaxillary implants the attachments to the nose around the pyriform aperture and the anterior nasals spine are disrupted. This may cause the nostrils to end up slightly wide than before but this is a possibility not a certainty.You must wait three months after facial implant surgery, either after their placement or removal, before seeing the final results.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am in need of some breast help! I have had three children, all whom I have nursed. I have also lost 45 lbs over the past year through diet and exercise. This has left my breasts saggy. I know that I need a breast, that is without question. The only question I really have is whether I can get by with out breast implants.Do you think that’s possible with how my breasts look? I’m happy with the size of my breasts when I wear a good bra (currently 40D) but unhappy with how deflated and saggy they are without a bra.
A: Breast lifts do an excellent job of lifting and tightening the shape of the breast mound. By keeping the same amount of breast tissue and lifting and tightening the ‘bag’ which contains them, this does create a less saggy and more round breast. This is particularly true in the bottom pole of the breast and less so in the upper pole of the breast. In the beginning right after breast lift surgery, the upper pole of the breast is quite round and full. But as the tissues relax and settle, much of the upper pole fullness will be lost. If one doesn’t ming some rebound flattening of the upper breast pole, then I think you would be fine with a breast lift alone. However, if your goal is to have a rounder and more full upper breast pole long-term, then a small implant will be needed to accomplish that breast shape goal.
Dr. Barry Eppley
Indianapolis, Indiana
Botox remains a popular and effective method of reducing unwanted facial expressions and wrinkles. While it is a highly desired anti-aging facial treatment, it must be introduced by a needle and preferably in a doctor’s office or a medical facility. While the injections are not terribly uncomfortable, if there was a way to avoid having needles put into one’s face these anti-wrinkle treatments would likely become even more popular.
The quest to find a ‘topical Botox’ or cream that would penetrate through the skin to reduce the source of facial wrinkles has been much like the search for the Holy Grail. There is a strong belief that such a cream exists but it has remained elusive. Many topical creams and serums claiming to have a Botox-like effect have been touted, but the real beneficiary of those products has always been the manufacturer .
At this year’s annual American Society of Plastic Surgeons meeting in Denver, a new botulinum toxin-based gel was presented that showed promise. Reporting results from a recent prospective double-blind clinical trial of nearly 100 patients, near 90% of those that had the active gel had observable reduction in crow’s feet wrinkles. This compared, interestingly, to just under 30% in those patients that have been treated by a non-active or placebo gel. In a second study that involved nearly 200 patients about 40% of those treated with the botulinum toxin gel had good results. In either study, the effects of the gel lasted around four months which was comparable to that of injectable Botox.
These study results are the first to show that dynamic facial wrinkle reduction is possible through topical application or a cream. It is no surprise that the studies have been done for wrinkles in the crow’s feet region to the side of the eye. This skin is very thin and the most easily penetrated down to the orbicularis muscle underneath. This is unlikely in the substantially thicker forehead tissues where an effective topical cream would be much more challenged to penetrate deep enough.
While it is encouraging that a botulinum toxin gel has been shown to noticeably soften crow’s feet wrinkles without needles, it remains to be seen how practical it will be. Does the gel work better than injectable Botox? Would it’s cost be similar, less or even more? This information awaits further clinical study which undoubtably is ongoing. Getting rid of some wrinkles may truly be just a dab away in the near future.
Dr. Barry Eppley
Indianapolis, Indiana
Being overweight is a well known health risk. Accumulations of fat, particularly around one’s midsection, contribute to the risk of heart attacks, stroke, and diabetes. Losing this weight through a sustained diet and exercise program is the best way to improve one’s health. There is a large number of medical studies that would support the health benefit’s of overall body fat reduction.
It has long been theorized that the surgical removal of body fat rolls through liposuction may offer some similar albeit less significant health benefits. To date, there has been no medical evidence that would support this belief. It was presumed that the amount of fat removed in most liposuction procedures was simply too small to make a difference. In addition, it has always been believed that the fat that really matters, from a health standpoint, was visceral or intra-abdominal fat. Subcutaneous fat or that which lies right under the skin only mattered because it made up those unflattering outer body rolls.
A recent study given at the 2011 annual American Society of Plastic Surgeons meeting in Denver presented some interesting findings on potential health benefits from liposuction surgery. In over 300 hundred patients who had either liposuction, a tummy tuck or both combined, blood levels of triglycerides, cholesterol and white blood cells were studied both before and after surgery. Triglyceride levels in patients with normal levels before surgery were unchanged. However, in patients with elevated triglyceride levels before surgery (defined as greater than 150 mg/dl), they showed a triglyceride level reduction of over 40 percent. Such significant level reductions are usually associated with drug therapies which often are even this effective. White blood cell counts, viewed as an indicator of chronic inflammation and disease inducer, dropped an average of 10 percent.
Does this mean that liposuction is good for your overall health? That is a stretch at this point but this study clearly shows that liposuction causes blood chemistry changes that reduce certain disease risk factors. Much more work needs to be done but it does provide some proof that subcutaneous fat may have a greater metabolic role to play than previously thought. It is not just an idle depot of excess fat whose only relevance is as the creator of undesired body rolls and bulges. At the least it may be comforting to know there may be some benefit, small as it may turn out to be, that liposuction removal of abdominal and waistline fat may also be good for more than just how you look.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had Botox for the first time a year and a half ago for free. A local doctor was training a woman on it and he did one side and instructed her on the other side. It was just okay, one side felt heavier than the other and one eye brow was higher than the other.
Then an anesthesiologist friend offered to give me Botox injections as she does a small group of women from time to time and I wanted to try again. This was like eight months after my first try. Long story short, I had a furrowed left brow for a while which was not cool. Plus she diluted it big time which in hindsight was a blessing because of the furrowed brow. I was starting to think that there is definitely an “art” to this injection thing.
Then I was out of town visiting friends and a local doctor introduced me to Dysport. At the time I was totally feeling ugly and wanting to try anything to reduce the fine wrinkles in my forehead, just look fresh. Well he did a first rate job so I loved it! No heavy feeling in the forehead and it took almost immediately and looked great! I’m sold on Dysport for no other reason than it was my best experience to date. You will have to educate me on the cost vs Botox as I have no idea.
So here I am today, looking online for a reputable guy to help me out…I’m due for something, but will not go the route of using anybody but a professional ever again!
A: The apparent simplicity of facial injections does belie that there is actually some art to it. There is also an obvious benefit to knowing the underlying facial muscles and how their movement contributes to facial expression. It is slightly more sophisticated that just throwing darts at the side of the wall so to speak.
The actual differences between Botox and Dysport are very slight and there is no real evidence that one is more effective than another. Dysport may ‘kick in’ a day or two earlier than Botox but otherwise lasts and costs about the same as Botox. The differences you have had with two negative experiences with Botox and the favorable one with Dysport undoubtably reflects technique (injection location) and doses used. I have not seen any differences in my experience with either one. There is some evidence that Dysport may be slightly more effective than Dysport (because it spreads out better) but in the forehead there is no appreciable difference in effect.
All of that being said, you should continue with Dysport because you have had a good experience and there is no change what isn’t broken.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 36 year-old and I have a very thick and prominent brow ridge bone. A few years ago I suddenly lost my hair because of alopecia and now my forehead looks very unpleasant. I was wondering if you can offer bone reduction and reshaping solution for me. I have taken some photos of my facial profile which would be available if you required. I am serious to perform the procedure and at the same time have some concerns regarding the techniques to approach this procedure .
A: Brow bone reduction in a male, who is the most common type of patient who develops prominent brow bones, must always take into account the surgical approach. The only way to do brow bone reduction in any patient, male or female, is through a scalp incision. There is simply no other incisional method, even an endoscopic technique, that can provide the exposure for the instrumentation to do the procedure. In the male patient with no hair or a very sparse hair pattern the trade-off of a scalp scar must be considered very carefully. Essentially one is trading off one problem (prominent brow bones) for another. (scalp scar) This may be a reasonable trade-off but the magnitude of the brow bone protrusion has to be fairly significant and really deform the shape of the forehead to justify brow bone reduction in men.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, one year ago I underwent surgery for a medium chin implant and neck liposuction. Though I was initially pleased with the result due to the way the swelling made my chin look, after the swelling had subsided I was very disappointed with the outcome. I feel that my chin and jaw line are vertically short and that my chin is still a little bit horizontally short. Additionally, my jaw line lacks solidity and I think that my chin could stand to be a little wider/fuller. I have attached two photos of what my face currently looks like.
I would like to add roughly a 1/2 inch to my chin/jaw line vertically, as well as 3-5 mm horizontally (from where the current implant ends). I would like my jaw to angle down to my chin, so that the chin is lower than the rest of the jaw. As I previously mentioned, I would also like my chin to be a little bit wider and to add solidity to my jaw line as it gains fat easily.
In order to obtain the results that I desire and keep them long-term, what would be the best procedure for me? The three that I have been looking at are a sliding genioplasty, a geniomandibular implant with Gore-Tex strips or a custom jaw implant. Money is a little bit tight for me, so I’m hoping to avoid the custom jaw implant.
I appreciate your help and eagerly await your response,
A: I have taken a careful look at your photos and your desired aesthetic chin changes. While a custom implant is one method to achieve those changes, it is not the only way as you have pointed out and the cost of it eliminates it from consideration by your own admission.
Between a chin osteotomy and geniomandibular implants, each has its own advantages and disadvantages. A chin osteotomy (keeping the chin implant in front of it) would easily create 10mms of vertical lengthening, about 5mms of additional horizontal advancement and could be sectioned to create 5mms of horizontal expansion as well. It is done from the inside of the mouth and would actually be my preference in your case even over a custom chin implant. Geniomandibular groove implants could also provide up to 10mms of vertical lengthening and 5 to 7mms of horizontal widening as the implants can be placed with separation between the two sides. The problem with these implants is that you would only get about 2 to 3mms of additional horizontal advancement and your existing chin implant would have to be placed on top and in front of it to keep and enhance the horizontal projection that you already have. That is not a big problem, just that you have two implants stacked together. This procedure would need to be done from a submental skin incision from below the chin with a resultant scar.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Hi. I have a few queries about possible procedures which may enhance my smile and lip shape. First of all, I have quite a small mouth, as in the horizontal distance from corner to corner of my lips is quite short, and therefore my mouth at rest is small and my smile does not show many teeth. Is there any procedure, such as lip lengthening, which can make my mouth opening wider- hence make the horizontal distance of my mouth at rest longer, and to make my smile wider? My next issue- which I think is related, is that my top lip covers quite alot of my top teeth when smiling, and also I would like my top lip to be more outturned or ‘pouty’. Is there a surgery which can reduce the distance between the nose and the lip to reveal more vertical distance of the teeth when smiling, and to achieve a more “pouty” shape? I’m not sure if it would help to send photos, but I can if that is needed. Thank you in advance!
A: What you are seeking is a horizontal widening of the corners of the mouth and a vertical shortening of the upper lip. There are surgical procedures for each of those changes. The upper lip can be vertically shortened, the upper lip become more pouty and more upper teeth can be shown through either a subnasal lip lift or an upper lip vermilion advancement. Which one is better for you would depend on seeing a picture of your lower face for my assessment and what location of scar would be preferable. (under the nose or along the vermilion-cutaneous border) The corners of the mouth can be widened through a commissuroplasty procedure where a v-shaped segment of skin is removed (about 5 to 7mms per side) and the corner vermilion advanced outward on each side. Whether that fine line scar around the corners of the mouth is acceptable would be the concern.
Dr. Barry Eppley
Indianapolis, Indiana
Breast augmentation remains a popular body contouring procedure for women. In as little as one hour, a woman can dramatically change her body shape in a very favorable way. Only breast implants can produce such a significant body change in such a short period of time. When it comes to breast implants there are two types currently available, saline -filled and silicone filled. Since 2006, silicone breast implants have returned which are filled with a new cohesive gel formulation that is much better than that used in the past.
Given these two choices, how does one decide which type of breast implant is better for them?
In reality, neither saline or silicone breast implants are perfect. If one was truly better than the other, there would be only one choice not the two that we have. Each type of breast implant is safe (FDA-approved) and has its own unique set of advantages and disadvantages. Both of them will do the job and do what they are intended to do… make the breasts bigger. But there are some differences between them and understanding these differences helps you make the best implant.
Saline breast implants have the advantages of a lower cost and can be placed through a small incision high up in the armpit that is not on the breast. That incision location may be an advantage in the Hispanic woman who may be concerned about any scarring around the breasts. Saline implant disadvantages are that there may be some implant rippling that can be felt on the bottom or sides of the breast and the risk of immediate deflation of the breast should the implant rupture.
Silicone breast implants have the benefits of a slightly more natural feel (no rippling) and the breast will not go flat should the implant rupture. However, they do require an incision in the lower breast crease and have higher implant costs.
Other than these implant differences, everything else about the breast augmentation procedure is the same including recovery time (one week or less) and how long the breasts will be swollen. (two to three weeks)
What is the best type of breast implant for you? I tell patients to make their choice based on which of their disadvantages you can live with the best. Both saline and silicone implants work for breast augmentation…which of their disadvantages is more acceptable to you?
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 46 year-old female. I would like to get an upper and lower blepharoplasty. However, I have problems with my nose due to a sinusitis and a collapsed septum. I got an x ray last week and the doctor said I have a deviated septum as well as thickening of turbines. I have been on antibiotics for five days. This problem wears me out a lot. I am often tired with headaches and my face always looks puffy due to continous allergy symptoms. My question Dr Eppley is what do you suggest for me to have first or not to have- a Rhinoplasty/Septoplasty to correct the nose issue and then a blepharoplasty? Please doctor I would appreciate your advise. I found your website very helpful, thank you again.
A: There is no question that septorhinoplasty and blepharoplasty can be performed together. This is not a technical nor a safety issue. It is an issue exclusively of how much recovery do you want and how long can you tolerate (socially and workwise) the way you will look during this recovery. When combining rhinoplasty and blepharoplasty the swelling and bruising around the lower eyes can be quite severe, particularly when nasal osteotomies are performed. Otherwise, there is no reason why the two facial procedures can not be performed together. There may also be other advantages beyond one single recovery period for combining them, such as cost.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a primary rhinoplasty over a year ago where my doctor used diced costal cartilage in fascia but I do not feel we had the same aesthetic vision. My nose is still larger and higher than I would like it to be (more masculine than feminine). I would like it to be smaller and more feminine. I am wondering were I to pursue revision rhinoplasty, would the diced cartilage with the fascia be shaved? If so, would new fascia (requiring a second operation site) need to be applied over the shaved sections? I am trying to assess the risks associated with revising a rhinoplasty that was done using diced cartilage and the likelihood that it can be reshaped. I can live with my nose today but don’t like it.
A: When undergoing a rhinoplasty, because it is a facial structural change, it is important to see what the result may be like through computer imaging before surgery. This is an operation that is about changing how you look so there is significant psychological overtones to how the result will impact a person afterwards. While computer imaging is a prediction and not a guarantee of a rhinoplasty outcome, it does shake out whether what the plastic surgeon envisions and what the patient hopes to achieve are closely matched.
Secondary revision of a prior dorsal augmentation with diced cartilage can be done. The augmented cartilage can be shaved down or completely removed depending upon what creates the best aesthetic result. It almost sounds like in your case that the need for an augmented dorsum may not have been desired at all since you now realize that a smaller and lower dorsum is desired. You have correctly pointed out, however, that dependent on how smooth the diced cartilage reduction is done that some graft coverage may be needed. If there are some irregularities that are best covered by a graft, I would choose an allogeneic dermal graft (less than .5mms or less) rather than another fascial harvest.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, four years ago I had a hair transplant procedure done. The procedure left me with a wide, deep and very visible scar in the back of my head. I want to do anything that is possible to reduce the scar. Can you please help?
A: The traditional method of hair transplantation uses the strip method from the back of the head for the donor hairs. One of the problems with this donor site is that it can leave a large scar due to its horizontal orientation, which exposes it to the downward pulling forces of the lower scalp and neck skin. This can result in a wide scalp scar if not closed properly or if this donor site is used more than once, which is frequent. If a man at some point decides to give up on hair coverage on top and wants to shave his head or have a close-cropped haircut, this scar can become an aesthetic liability. This is why the contemporary approach of FUE, follicular unit extraction (Neograft), is better because it does not leave a single long scar for the posterior scalp harvest.
When it comes to improving the wide horizontal scalp scar from a hair transplant, there are two approaches. A traditional scalp scar revision can be performed which means that the entire scar is removed and re-closed, making it a much finer and more narrow scar. The other approach is to use an FUE technique. The scar is contracted by the punch excision of scar tissue and hair transplants are inserted. Both have their merits and I would need to see pictures of the scar to determine which may be best. If there is significant scalp laxity, then scar revision is a good choice. If the posterior scalp is very tight, then the FUE approach may be better.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am writing to you because I am interested in getting a custom implant made for my jaw/chin to improve my profile. I currently have a chin implant that I am not satisfied with because it only advances my chin horizontally. I am interested in vertically lengthening my chin. I saw on your website the case study of vertically lengthening using a custom implant and I wanted to see if this could help me to achieve the results I desire. Specifically, I want to know if a custom implant can both vertically and horizontally lengthen my chin and front of my jaw. I have attached some pictures of what my face looks like before and after the original chin implant surgery.
A: In looking at your desired chin change, there is no question that a significant vertical lengthening as well as some further horizontal advancement is needed. There is two ways to get there.
1) Custom Chin Implant – There is no off-the-shelf implant that can remotely make this amount of chin change. Based on a mandibular model from a 3-D CT scan, I can custom make an implant to the exact specifications that will work. Your existing chin implant would then be replaced by this new one. This is the ideal implant approach and adds additional costs to the base surgery to make the actual implant and have it ready for surgery. (the CT scan cost would be in addition and is based on the facility fee charge)
2) Chin Osteotomy – Keeping your current chin implant in place, a chin osteotomy is performed above it and the entire chin with implant is brought forward and vertically lengthened with an interpositional hydroxyapatite block used as a graft. This is what I call the extreme chin augmentation approach, combining an implant with an osteotomy.
In looking at your pictures, I think #2 is a viable option but I would need to confirm that by looking at a lateral cephalometric x-ray. (standard orthodontic/oral surgery film.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have saline breast implants in now that are 375cc in size. While my surgeon said they would be perfect, I knew from the beginning they were too normal. (maybe perfect for him but not for me) They are under the muscle and are smooth Mentor saline implants. They were placed through an incision under my armpit as I did not want any breast scars. After having had them for six months, I am more convinced than ever that I want to go bigger. I want to go at least 500cc and maybe 550cc. Can my current implants be removed and replaced by going through the armpit again? I still do not want any scars on my nipples or under my breasts. Should I use saline again or go with silicone implants this time?
A: In terms of a size change, you want to make sure that you are having a breast implant volume change of at least 30%, as that usually the minimum it takes to see a real cup size difference on the outside. That is why a change to 500cc (33% is the least you should go) and 550cc (46%) would be more ideal. You do not want to go through a second surgery and still fall short of your size goal.
Since the incision is an important concern for you, the armpit approach can be re-used and your saline implants exchanged for larger ones. While silicone implants can be placed through an armpit incision, there are some limitations of size. The size you have in now is about the limit for inserting silicone implants using a funnel technique through the armpit. There is no limit of size when it comes to saline breast implants through the armpit.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have lost a lot of the fat in my face particularly in the cheeks which has left them very hollow and sunken in. The area below my cheeks looks too full because it is indented above it. I havhe been told that fat injections would be the way to go even though fat transfer may not always stay. I know that cheek implants are permanent becuase they can not be absorbed. But I didn’t know of they come big enough to fill out the entire depressed cheek area. What sizes do they come in and do you think they are big enough to fill out the whole cheek area?
A:Your concept of considering cheek implants for helping restore facial volume loss is only partially correct. Cheek implants are not a substitute for fat injections when it comes to facial fat volume loss. The submalar style of cheek implant can help fill out the buccal area of the cheek (right below the cheekbone) but this represents only part of a larger surface area of the cheek and surrounding tissues which makeup the gaunt or skeletal facial look. Therefore, the use of this type of cheek implant may be a companion strategy with fat injections but is not a stand alone treatment for refilling out the deflated or fat-depleted face. Fat injections are more versatile because they can be placed anywhere. Cheek implants, even the submalar style, can not go very far from the edges of the bone and are more limited as to the facial area that they can cover.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, after enduring over twenty years of having an indented tracheostomy scar, I am finally getting it revised. I understand that up to 50% of the fat tissue that is used as a filler gets dissolved by the body while it is healing. Is it possible that one would need multiple visits over the years to keep adding filler injections or something of that nature? Also, if one were to avoid that route in favor of something “off the counter” which product would you recommend? Thanks in advance.
A:Most tracheostomy scars can be revised and the neck skin leveled by simply closing the deeper layers of the excised scar as it is closed. This brings in tissue from the side and fills the defect or area of missing tissue underneath the skin. Larger or more indented tracheostomy scars, however, do have a real subcutaneous tissue deficiency as a result of fat loss due to pressure atrophy caused by the indwelling tratcheostomy tube. When these are merely excised and closed, they will revert to some degree of inversion as the skin is essentially closed over an ‘open space’. This is why the placement of fat grafts can be so helpful in tracheostomy scar revisions. However, the choice of fat grafts is critical and should be a dermal-fat graft and not fat injections. These are small composite grafts that can be taken from many locations with a small resultant scar. There are no ‘off the shelf’ products, such as allogeneic dermal grafts, that are a good substitute for a supple dermal-fat graft.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have this weird-shaped head in the back sticks out. I have been teased about this since I was a child. As an adult, it has not gotten any better. They call me all sorts of names like football or peanut head. I have very low self esteem from this my whole life and I feel like people are always looking at it. I was just wondering if there is a way to flatten the back of my head or make it not stick out in the back as much. Please help me. This would change my life and give me great confidence.
A: While I can not provide any exact recommendations without seeing pictures of your head first from different angles, I can make the following general comments. When it comes to head or skull reshaping, the question is whether the bone needs to be reduced, built up or some combination to get a smoother and better-shaped skull area. Given that there are limits as to how much the skull bone can actually be reduced and that the amount of build-up is always much greater than what reduction can be achieved, the focus should be on whether an augmentative cranioplasty will help. The second general comment is that most cranioplasties, other than for very small areas, has to be done using an open approach. From a scar standpoint, this makes skull reshaping a more common procedure in women than men due to differences in hair densities.
Dr. Barry Eppley
Indianapolis, Indiana
Inadequate training and poor judgment account for a disproportionate number of complications and unsatisfactory results that occur from cosmetic surgery procedures. With so many different types of doctors doing cosmetic surgery, how can one make a safe choice? Historically, the use of the terms ‘board-certified’ and ‘specializing in’ were enough to demonstrate a doctor’s expertise, but today that is not enough.
Are they board-certified in plastic surgery or another specialty? Many new cosmetic surgeons are board-certified but not in plastic surgery. Their board certification may be in General Surgery, Dermatology, Oral Surgery or Ob-Gyn to name a few. Some may even have an additional board-certification in cosmetic surgery. But this self-created board should not be assumed to be equivalent to those certified by the American Board of Plastic Surgery. There is a significant difference between board-certified plastic surgeons and board-certified cosmetic surgeons that makes them not equivalent at all.
How experienced in doing your procedures of interest is the doctor? This can be a hard piece of information that is not easy to ascertain. Certainly asking the doctor is an obvious way to learn how many the doctor does, but that is not the exclusive source I would use. Look at their websites and see how many before and afters of the procedure are posted. Ask for before and after photographic results and to talk to some more recent patients. (done in the past 3 to 6 months) Word of mouth still remains as a good method of recommendation. Willingness to easily and quickly divulge this information is a good sign. Hesitancy or avoidance of doing so would be of concern.
Hospitals are obviously certified and have to meet highs standards of care and comply with stringent regulations. Surgery centers can be quite different and you want to have your surgery in one that has been accredited by either the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF), the Accreditation Association for Ambulatory Health Care (AAAHC) or the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). This accreditation and a state license to operate means the facility adheres to safe operating conditions. Doctor’s office are fine for minor surgery but most are not accredited for more significant surgeries and any anesthesia that may be needed.
The cost of cosmetic surgery is always of concern and no one wants to overpay for their procedure(s). But the cost of cosmetic surgeries is influenced by market factors just like any other retail business. This makes a fairly consistent price range for procedures in any given geographic region. If after getting several consultations one price is considerably lower than another, the question should be why. Where are the costs being reduced to offer such a lower price? This is what makes the whole concept of Groupon and other discount programs for cosmetic surgery so unnerving.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 50 year old woman and am fairly thin being 5’3″ and weigh 117lbs. I have had what I think is fat on the back of my neck for as long as I can remember. It looks like a buffalo hump and it runs in my family. I have exercised all my life and continue to this very day. I have always been concerned about my posture so this buffalo hump is quite disturbing. I HATE IT! I have had liposuction on my stomach and thighs but no doctor seems to want to address my neck problem. I have had xrays and I do have a greater curve in my upper back than most people. Looking at me from the front my posture is impressive, but when I turn to the side it looks thick like there is a flap of thick fibrous fat. I can grab and feel it. I am self-conscious about wearing my hair up. Now blouses do not fit properly and often I have to alter clothes for them to fit. Please, I hope that you can help me.
A: Buffalo humps on the back of neck are almost always collections of fat. Why you have it there in an otherwise thin person who is very active is unknown. Seeing that your relatives have it indicates that it is genetic in origin and not from one’s lifestyle. An attempt at liposuction would certainly seem to be worthwhile. The fat in the buffalo hump is different than that in other body areas being more fibrous and not pure fat. This is why an open excision is the most effective approach but the midline scar may not be worth it. I would recommend laser liposuction (Smartlipo) as a better liposuction technique in fibrofatty areas.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had breast implants with a lift over one year ago. While they do look better than before they are very asymmetric. I had 375cc silicone gel implants and vertical breast lifts. The left breast is considerably larger than the right and the implant sits lower and more towards the side of my chest. My plastic surgeon wants to redo the lift on the left and tighten the pocket. Rather than place a bigger implant in my right breast, he wants to take more breast tissue on the left to make them more even. This doesn’t make sense to me and I think it would be better to place a bigger implant on the right to make them look more even. I think he is wrong with his plan but he won’t do it the way I think it should be done. What do you suggest I do?
A: One of the most difficult body contouring procedures to do and get a symmetric outcome is breast reshaping. The combination procedure of lifting sagging breasts and adding volume (an augmentation-mastopexy or breast implants-lift) is challenging and the need for secondary revisions is remarkably high. (25% to 50%) When planning a revision of this operation, there can be multiple options to manipulate including more of a lift or tightening the breast skin, increasing the size of one or both implants, or even removing some breast tissue. Any or all of these may be needed and there are advantages and disadvantages to any of them. While you would prefer to exchange an implant for a bigger size, your plastic surgeon has recommended otherwise. I would make the assumption that he has a lot more experience in doing this surgery and has a good reason for making this recommendation. I would suggest you sit down with your plastic surgeon and discuss your differences. Unless the final result is perfect, and it is likely that it won’t be (better but not perfect), you will never be happy with any outcome unless you understand and agree with the revisional plan.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I want your advise on getting suitable cheek implants. I currently have a Medpor midface contour implant. They were placed six months ago. My implants were placed unmodified. Although I have achieved a decent level of midface augmentation, I feel the implant is too large, surface area wise. It is too close to my eyes and is also too low and close to the top of my teeth. I also have visible edges on both the left and right side near my eyes.I did previously have a Lefort 1 osteotomy for my bad bite in the past but the central part of my face wasn’t really improved. What I was looking for in cheek implants was something to improve my midface. The current implants have alleviated midface flatness but I do still feel I look at bit gaunt but less so. However they are just too big, so looking for opinion of porex alternatives which might be appropriate. I was looking at either RZ 5m, or the 4mm extended malar, basically something to emulate the middle third or so of my current implant. I have attached pictures for you to see my face and what my current implants have done.
A: What you are showing is the problems with stock midfacial/cheek implants which are now, by your own illustrations, demonstrating that their shape is not adequate in multiple dimensions. This leaves you with three implant options:
1) Modify your existing indwelling implants by tapering the bothersome edges and adding/removing the areas to create better convexity.
2) Remove and replace your existing implants with new implants that would likely need a combination of infraorbital rim and cheek implants. The medpor RZ4 or the 4mm extended malar are reasonable options but they will need intraoperative modifications.
3) Remove your existing implants and replace with custom-made implants that are designed off of your own skull model.
While all of these are possible, they each have their own advanatages and disadvantages. Modifiying what you have in, while seemingly simple and easy, will not likely make a significant or the desired changes that you want. (but it is always worth a try) Replacing them with new stock implants I suspect will put you in the same position you are now, better in some areas but inadequate in others. There simply are not stock implants that can fully meet your aesthetic goals. Custom-designed cheek/midface implants are the most likely to really meet all of your aesthetic midfacial goals as all of the planning and adjustments of them are thought out before surgery. The only downside is the increased cost to do so.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was in an accident that fractured my nose, eye socket, cheekbone and jaw. I had 1 reconstructive surgery to place the bones back in place. After the surgery, months past and I was hoping for my face to begin to look the same as before. It has almost been a year and I hate how I look. Afraid of what the world has to think or say, I cover my face with sunglasses. I hate how I look and since then I’ve had a very low self esteem. I want to look for answers. Can my face be fixed? Or will I ever look the same or close to it? I can provide pictures of my face to determine if my face is at all repairable or if it’s just too late. Thank you.
A: Thank you for sending your pictures. I can see that you have a classic post-traumatic facial deformity, known as zygomatico-orbital displacement on your right side. While your initial facial fractures may have been surgically treated, they did not properly place your orbital and cheek (zygomatic) bones back into anatomic position or there were not supported well after reduction. Either way, your right ZMC complex is displaced downward showing the visible problems of orbital dystopia (eyeball in lower position than the other side) and the cheek bone being displaced downward and outward with increased midfacial width.
Your facial problems can be improved by a revision or re-do of your original facial fracture repair. This would be a zygomatico-orbital osteotomy with bone grafts to lift the eye back up and reshape the cheek area. Before considering this surgery, you need to have a 3-D CT scan to confirm this diagnosis and provide a detailed assessment of these and the surrounding facial bones.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am currently looking to having my Goretex chin implant removed after five years. I have always been unhappy with it as it is simply too big for my face. Can you please let me know how it is removed, any issues I should know and what How To Get A Ex Back At 14 the process to do it involves.
A: Thank you for your inquiry. When it comes to removing a chin implant, it is often necessary to tighten the mentalis muscle/chin tissues at the same time to prevent chin ptosis or sagging afterwards. This is particularly relevant if it is a large implant and produced a significant stretch of the chin tissues. Much like a breast implant, what happens to the overlying expanded soft tissues on removal? The approach used for chin implant removal, intraoral vs. submental incision, would depend on how it was originally placed and how much loose chin tissues are expected to result. This could mean an intraoral mentalis muscle resuspension or a submental tuckup from underneath. There are, of course, some cases where simple implant removal is all that is needed…but these are only a minority of cases.
Regardless of what needs to be done, this is an outpatient done under sedation or general anesthesia. There is minimal recovery and discomfort afterwards. There are no restrictions after such surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m interested in cheek implants and a few other things that might be needed depending on your recommendation. My goal is to have a defined cheek/jaw line like some male model pictures that I have attached. I will get the buccal fat removed also if that is required. The 1st model model might have the cheek implants because the cheek area is not as pronounced as in the 2nd picture. I have attached pictures of myself from different angles so you can see the shape of my face. I look forward to your recommendations.
A: I have done an analysis on the photos that you have sent. The frontal photo is of excellent quality, the side view is not good quality but useable. I have also looked at the model photos that you have shown, and while they illustrate a facial shape goal, I hope you realize you can never look quite like them as you have a completely different facial shape.
Where I think your face can be improved is in multiple areas including vertical chin lengthening with some horizontal advancement (chin osteotomy), cheek augmentation with implants, buccal lipectomies, rhinoplasty with tip thinning and nostril narrowing and earlobe reductions. I have attached some computer imaging to show you a realistic potential outcome.
With your thick skin and existing facial shape, there are limits as to what can be achieved. I thinik this is the best approach to obtain some increased facial angularity.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a short face length with a small/narrow lower jaw. From the profile view my face looks even shorter because of my short forehead and short jaw. Could jaw implants fill out my lower jaw and make my lower/overall face look ‘bigger’? I’ve already had a chin implant, but it didn’t do much for vertical length. My plastic surgeon says a sliding genioplasty wouldn’t look good. Should I get a second opinion? Is it safe to get a sliding genioplasty and jaw implants at the same time? Thank you for your time.
A: The right style of jaw angle implants will vertically lengthen the posterior face. But the wrong style of jaw angle implant will only make it wider (fatter) and not longer.
Chin implants will not provide any vertical length, just horizontal projection. No stock chin implants are made for vertical chin elongation.
The statement that a sliding genioplasty won’t look good is a nonsensical opinion. A sliding genioplasty is the only option to provide vertical chin lengthening or lengthening of the anterior face. Just because a surgeon can’t do an osteotomy doesn’t mean it won’t look good or be a good choice for a particular patient.
It is common in my experience to do jaw angle implants with a chin osteotomy and/or an implant. They are often needed together to create an overall change in jaw shape.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in having liposuction of my perioral mounds done. I just hate those blobs of fat to the side of my mouth. My only concern about the procedure is that I have read that there are a number of facial nerves near the perioral area. My question is could they possibly be damaged by perioral liposuction. Is this a real concern in your opinion and, if so, what are the risks and side effects of this type of complication?
A: The perioral area is located between the buccal and the marginal mandibular nerve branches of the facial nerve as it comes forward from the ear. Therefore, liposuction is in a safe zone from a facial nerve injury standpoint. So this is not a concern I have as I have yet to see any nerve problems with liposuction in this area.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Hello! I am 31 years old and I used to be 375 lbs until I had gastric bypass surgery two years ago. Today I weigh 157 lbs, but now I suffer from loose skin on my abdomen, arms, buttocks, and thighs. I have a “skirt” of abdominal skin that reaches down to my groin area, and I suffer from irritation, yeast, and sores due to this excess skin. My breast size also went down significantly. I currently am on Medicare and Medicaid, and I was wondering if you offer a procedure that can remove this abdominal “skirt” that is covered by Medicare. Furthermore, I am also interested in getting a breast augmentation, and was wondering if my Medicare will cover it if it will cover the “tummy tuck” surgery. Thank you, and I look forward to your response!
A: Thank you for your inquiry. While you would do well with a circumferential body lift or even a frontal abdominal panniculectomy, I am not a Medicare provider so I can not be of assistance to you.
While there is the chance of some coverage by Medicare for an abdominal panniculectomy, there is no chance that they would ever cover a completely cosmetic procedure such as breast augmentation.
Dr. Barry Eppley
Indianapolis, Indiana
