Your Questions

Q: Dr. Eppley, I have recently lost 100 pounds. I still want to loose another 50 pounds but would like to get some information about doing an extreme tummy tuck since my skin and fat hang by my mid thighs. I would also like to get information about a breast lift.

A: Thank you for your inquiry. Congratulations on your success at such a significant amount of weight loss. I would agree that you should maximize your weight loss before any body contouring surgery is done to get the best benefit from the procedure. It his likely that the next 50 lbs will be harder to lose than the last 100lbs but the effort will still be worth it.

Anytime a female loses more than 75lbs there are always going to be the sequelae of loose redundant skin on the abdomen and waistline and the development of breast sagging. While weight loss causes the reduction of fat, no skin is lost and how much skin redundancy remains depends on its natural elasticity and its ability to contract which is often very poor. (men do much better in this regard with large amounts of weight loss) In the extreme weight loss patient, a standard type of tummy tuck is always inadequate so you are correct in that an ‘extreme tummy tuck’ is needed. At the least this is an extended tummy tuck but may be a flour-de-lis type of even a circumferential body lift to create the greatest degree of redundant tissue removal. I would need to see smoke pictures to provide you with a more accurate answer as to the type of tummy tuck you need. For the breasts, the vast majority of time one needs a full or anchor style breast lift. Whether implants would be needed to restore volume is the only issue to be determined.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Can I get a hair line lowering procedure, forehead contouring, and shaving of the brow browsing, lip lift, lip augmentation, corner lip lift and maybe jaw implants all during the same surgery? My goal is to feminize my forehead, the distance between my lips and nose is extremely far a lip lift would feminize my lips, and I’d like a heart shaped face and girls with heart shaped faces always have a nice feminine jawline.

A: What you are referring to is known as facial feminization surgery and in the classic use of that plastic surgery term refers to a type of transgender surgery. By your inquiry it does not appear that you are a transgender patient. But the concept is really the same and there is nothing unique or different in terms of the number of facial reshaping procedures that can be done on a male to female or a female patient. It is very common to perform up to a dozen or more different facial operations during facial feminization surgery. These are perfectly safe and are well tolerated to be done all at the same time. It does create the need for significant recovery, however, as the more facial procedures you do the more swelling that occurs as you might imagine.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I have a vermilion lip advancement a few years ago and am not too happy with the results. My scars are healed but it is too large which makes the distance between my nose and upper lip too close. My bottom lip is also too large that makes opening and stretching my lips difficult. Overall, my lips look unnatural and is too big for my face. My question is: is it possible to cut the vermilion again to bring it down making the size of the lips smaller and improve the shape? I don’t think a lip reduction will work because my vermilion will still sit to high. What would you recommend? Thank you.

A: Once skin is removed from the upper lip, whether it is from below the nasal base in a subnasal lip lift or above the upper lip in a lip advancement, there is no way to put the skin back. These are permanent lip enhancement procedures that change the skin-vermilion relationship by excision. The vermilion can not be moved back down, short of a skin graft which would look like a patch and be aesthetically worse than before.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 32 years old with a full 34C cup breast size.. I went for a plastic surger consult last week and I figured I would need a breast lift because my breasts were very saggy. I also wanted a breast lift with implants as I want perky very round (ok to look fake) looking breasts. I wouldn’t mind being bigger even a DD cup. My plastic surgeron said he won’t do a lift and breast implants at the same time. I was shocked that he would not do them at the same time as this ultimately means more money, recovery and longer to finally get the breasts that I want. Why won’t he do them together? And do you think just a lift will give me the perky round look I want?

A: It is important to understand the combination of breast lift and breast implants is a ‘ying and yang’ type or procedure where want (how much) is done in one will usually adversely affect the other. If I needs a big breast lift (lifts and tightens the breast skin) it will be impossible to put in very big implants at the same time. Conversely if one wants big breast implants the amount of lift obtained will be small and you will likely end up with some residual sagging.

When one needs a lot of breast lifting and also wants larger breast implants, it is best that the procedures are staged. That way you can get the maximal breast lift and then secondarily (3 months later) you can put in implants of the size needed to obtained the amount of fullness that you want. Trying to both at the asme time dramatically increases the your risks of complications and has a very high incidence of the need for revisional surgery. If you are going to get two surgeries anyway it is far better to have the second surgery on your terms…not managing complications from the first procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, You said that there is no deltoid implants but I found on internet that there is. I know about people get implants to their arms and belly to have muscles and six packs. so what kind of implants is it and can it be used for implants for the deltoid? o beside fat transfer/fat implants to the deltoid, is there any implants for the deltoid? Thank you.

A: What I said was that there are no preformed off-the-shelf deltoid implants that are made specifically for the deltoid/shoulder area. This is the same for other arm implants as well such as the biceps and triceps. The only body implants besides breasts that are commerically made are for pectoral, buttock and calf implants. It is unlikely that other body implants will be commercially made in the near future given their low demand. That does not mean that deltoid, bicep or tricep implants are not done as they are and I have done them as well. What is used for all arm and shoulder implants are the different sizes for calf implants.  They are soft long and oblong and usually the small or medium size works well for the deltoid area. There soft silicone elastomer helps simulate muscle tissue which they are designed to augment.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a rhinoplasty done and ever since something about it has been bothering me since I have done it. I’m not sure what the doctor called it since it’s been 4 years ago. I was concerned that the side of my nose was big. It was the bone beside the bridge of the nose. I originally thought I wanted it to  be smaller. I just realized after that what I was after wasn’t to get rid of that but I wanted my bridge to be smaller. I feel like now there is a hollow line of a downward from under eye to about 3-4 cm. And the width is about from the bridge to the side around 1-2 cm. I only remember him saying that he has made the bone in that area less thick. I think as a result, it leaves some kind of hollow, especially when taking picture that area seems to be looking deep and I don’t think it was like that before I did it. I think it’s not supposed to look like this. I think the doctor wasn’t skillful enough and removed too much bone and now I look kind of old. When I smile it’s the most obvious. 

Is it possible at all to fill it up with something permanent fixed to my bone beside the bridge(basically to make the bone on that area thicker) that wouldn’t move when I smile? I don’t want a fat graft which doesn’t last and would move or get pushed up when I smile. Or any other material ? I’m aware that there would be a curve at the bridge down to the sides. But I’m really not sure where exactly the doctor got rid of my bones. But it wasn’t by squeezing the bone, he literally kind of use some tools to get rid of the bone.

A: I can not tell from your description whether this high paranasal deficiency is the result of nasal bone infracturing done at the time of a rhinoplasty or whether this area was directly burred from an incision inside the mouth. Regardless of its origin, the paranasal/medial maxillary process region can be built up using a variety of different material from an inside the mouth approach. (paranasal augmentation) Having built up this area before, it is a highly sensitive areas to augmentation and it only takes a few millimeters to make a very visible difference. Whatever material is used the upper edges need to have fine tapered edges ti avoid any visible external transition areas.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have an umbilical hernia and have been told that a general surgeon would be needed for this procedure. In addition to needing a mesh piece placed in the hernia, I would like the resulting belly button to be aesthetically pleasing. I also have a c-section scar with some loose abdominal skin. Can you address all my concerns during a single procedure without an additional general surgeon in the OR at the same time?

A: What you are specifically asking is to have a tummy tuck done with an umbilical hernia repair at the same time. This is not a rare situation for a plastic surgeon to encounter and manage. During an open tummy tuck procedure most umbilical hernias are repaired by using your own natural tissue through midline muscle plication. It would be very uncommon for a plastic surgeon to have to resort to the placement of a synthetic mesh for hernia repair during a tummy tuck. The only concern is the fate of the belly button during an open tummy tuck operation. Many umbilical hernias have disrupted the attachment of the belly button to the abdominal wall. During a full tummy tuck the outer connection of the belly button is removed from the surrounding skin. If the umbilical hernia has also separated the base of the belly button, it may not have adequate blood supply to survive afterwards and be lost. So the objective of obtaining a better looking belly button may be a difficult challenge when a full tummy tuck is done with a concomitant umbilical hernia repair. This does not mean that the two should not be done together, as they should, but one has to appreciate the potential implications for the belly button and its postoperative fate.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I contacted you last year about liposuction. I’m finally ready to get the right procedure cause I’m not sure what would be best. I’m 5ft 7inchs tall and weight 283 pounds. I would like to lose as much as possible. Can you tell how much I might be able to lose just so I have an idea. I would like to get down to 195 pounds but I don’t know if that is possible or if that is dangerous. Can you please help me pick the safe and best procedure. thank you for your time.

A: I am afraid that you have the wrong idea about liposuction surgery and what it can accomplish. It is not a weight loss method nor would it be appropriate at your current weight of 283 lbs. Liposuction is a body contouring surgery to remove select areas of fat that are diet and exercise resistant.The only way you are going to lose 75 to 100 lbs through surgery is by a bariatric surgery approach with either a lap band or a gastric bypass. Liposuction at 283 lbs is not only dangerous but would be ineffective at making any substantive body shape or weight loss changes.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have mild muscular dystrophy that has left my right leg and ankle much smaller than my left. I have two calf implants in now but my ankle and the inside of my leg are still much smaller. Is there any way you think you could help?

A: Calf implants do a good job of increasing the size of the upper half of the lower leg between the knee and ankle. But its augmentation effect stops where the gastrocnemius and soleus muscle meets which is about halfway between the knee and ankle. One way to augment the lower half of the leg and continue the effects created by the calf implants are fat injections. As long as one has enough fat to harvest, fat injection augmentation can be done in the lower half of the leg. (leg fat grafting) Its biggest problem is in how well the fat will survive which can be difficult in the tight tissues of the lower half of the lower leg. Multiple fat injection sessions may be required.

Another option would be a custom made implant for the lower leg. But this has a much higher risk of complications than calf implants do because of its subcutaneous location as opposed to that of a subfascial one.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in your assessment of my jawline issues. and what you would recommend for surgical improvement. I have a weak jaw but a fairly good bite. Had orthodontics as a teenager and they never recommended any surgery. The other issue which may be helpful is that I have obstructive sleep apnea (OSA) and wear a mouth piece at night to push my chin forward. I am tall and thin so I do not fit the ‘typical’ body type for many OSA patients. I have attached pictures for your review. I have been to several plastic surgery consults but each one suggests a chin implant. While that might be somewhat helpful it just seems that it is an inadequate solution for my problem.

A: Thank you for sending your pictures. My assessment is that you have an overall short lower third of our face as evidenced by a horizontal and vertical deficiency of your entire jawline. (mandible) Besides the visually apparent facial third discrepancy, the fact that you have OSA and require the use of nighttime CPAP speaks to the potential contribution of a short jaw as a contributing factor.

The optional treatment for this type of jaw deficiency is a custom jawline implant that can augment smoothly the entire jawline in a wraparound fashion from jaw angle to jaw angle including the chin with tridimensional changes including increased vertical, horizontal and some width changes. (see attached predictive imaging) Having significant OSA, however, throws a variable into such a plan however as it would provide no functional improvement in your airway….and that seems like a shame given its potential lifelong occurrence.

A variation on the custom jawline implant would be to combine a sliding genioplasty to bring the chin down and forward (carrying the anterior attachment of the tongue muscles with it and potentially offering some OSA symptom improvement) combined with a pre made custom implant that would augment the rest of the jaw. This would be the only way to have a completely smooth transition from the posterior edges of the sliding genioplasty osteotomy line to the body and angle of the jaw behind it from an augmentative standpoint. Like the total custom wraparound jawline implant it would need to be made from a 3D CT scan from which the osteotomy and implant design would be done.

The ‘simplest’ option would be to just have a sliding genioplasty with standard off-the-shelf vertical lengthening jaw angle implants.  While offering aesthetic and functional jawline improvement, it would not create a perfectly smooth jawline from front to back.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a breast lift and tummy tuck. I’ve been thinking about the specifics of the breast lift and I’m hoping you can help with some questions. Attached are some images that will help guide our discussion. At the consultation we discussed the Wise pattern breast lifts with lateral extensions – Image1 is a quick sketch I did that represents my body type and my interpretation of what we discussed. What I’m unsure about is how much “pull” of excess lateral skin there will be with the breast lift and how much remaining fat will be left afterward. Also, would the lateral extension be an extension of deepithelialization from the breast lift or would there be skin and fat removal as is done in the tummy tuck?

If you take a look at attached images A and B you can see evidence of a pouch of fat lateral to the breasts post-surgery– this is what I’m hoping to avoid! Is this due to deepithelialization without fat removal? Images C, D, and E represent the flat appearance I’m hoping to achieve, all with different techniques. Image C is of a spiral flap procedure and this is the outcome I’m most fond of– though I’m not really interested in relocating the fat, just removing it from that lateral position! I’m wondering if this is the technique/outcome you had in mind or if this is something completely different.

A: Thank you for your questions about breast lift surgery. The issue at hand is how best to manage the excess tissue at the side of breast over the chest wall into the back. The Wise pattern breast lift procedure does provide some pull and tissue reduction to this area but will not produce a complete elimination of it. When the chest sidewall tissue excess is considerable, some direct management will be needed. Liposuction offers a ‘scarless’ method when fat is the main issue and one has good skin elasticity to allow for skin retraction. When there is a prominent skin roll extending the cut out from the breast lift into the sidewall and into the back is the most effective method for its reduction. But as your examples show it occurs with a price to be paid in terms of extended scars and scars that may not do as well as those of the breast lift or tummy tuck. But skin and fat needs to be removed from the side chest wall to be most effective.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a custom implant in the subnuchal region of my occipital skull. I know that fat grafting is another options to augment this area due to the neck muscles attaching to the skull there. My questions are what are the possible complications could be, and if you have seen these types of complications in any of the other skull shaping patients you’ve operated on.   Hypothetically, in my case, I believe that such an operation could involve clearing/removing a 2cm width band under and parallel to the nuchal ridge on one side before in order to have the implant attached.  Would this have a severe effect on head and neck movement and/or cause long term pain?

If this is not a viable option I’m curious as to whether an implant could be placed in a pocket over the muscles/tendons and not directly against the skull.  I have read that implants used in other areas (ie. breast implants) are at times placed within or over muscles and are not secured to any hard body structure. Could an implant be placed in the subnuchal area over the tendons, thus avoiding their separation from the skull? Subsequently if there was an implant placed this way, and if a portion of the implant extended to an area of the skull without/ not covered in tendons, could it then be attached there? Alternatively is there a method of fixation to the skull that could occur through the tendons (i.e., with screws) to secure an implant in place. I ask this after reading of non-secured implants causing erosion of tissue with micro-movement over time.

At this time I am willing and able to pursue a surgery if there could be an intervention that was safe effective visually and that is stable over time. I would be grateful for any input you may have.

A: Placement of a subnuchal skull implant for low occipital/upper neck augmentation would have to be placed on top of the muscular fascia as opposed to under it against the bone. Stripping the muscular attachments off the bone is associated significant discomfort and  recovery of neck motion. Once in the subcutaneous tissue plane between the skin and the fascia the implant will generate a layer of scar around it which will keep it in placed. (much like a breast implant)

The only anatomic risk of placing an implant in this area is the greater occipital nerve. Fortunately this nerve lies under the muscular fascia and does not common through until higher up over the bone.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, First of all,  I want to thank you for the time that you took and will take to analyze my case,  I’ll be eternally grateful for any help that you can provide to me in order to improve my condition.I have been really traumatized over the years for this mistake on a surgery that  was made to me when I was 17 years old (I’m 39 years old now) Please see photos attached,  I’ll be waiting anxiously your answer.

A: Thank you for sending your pictures. You have a very classic gynecomastia ‘crater’ deformity from over resection of the breast tissue. This has left no intervening tissue between the nipples and the pectoralis muscle fascia, thus allowing the nipple to contract inward and scar down. Its appearance may have gotten a little worse as you have aged because the chest tissue around it (fat) may have gotten bigger allowing the inward nipple retraction look worse.

The correction of nipple retraction after gynecomastia reduction depends on the degree of severity and requires tissue grafting for release and improvement. Your case is fairly severe and you would ideally need an open release and dermal-fat grafts to level out the nipple contours. Dermal-fat grafts do require a harvest site somewhere which is usually done in the lower abdomen. Injectable fat grafting could also be done but that would definitely require multiple treatments to get the best result. There may also be a role for liposuction of the chest around the nipples to help optimize the chest contour also.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I have always felt that the areas right inferior to my zygomatic archs are way too thick and hard and widened.I am not sure about the specific name of that muscle, but pretty sure it is not due to bone.I know that Botox is commonly used to reduce jaw angle, but I don’t even have an angle so I don’t know whether it will help, as it is like the area above masseter muscles (or it really is upper masseter muscle?).

A: Botox will not be an effective or prudent treatment for the area you have highlighted for the following reasons:

1) There is a significant risk that Botox injections placed in this area will inadvertently paralyze the frontal and buccal branches of the facial nerve, thus rendering your forehead, eye and upper lip areas paralyzed for the duration of the effects of Botox. (around 4 months)

2) The upper masseter muscle in this area is largely more fascia than muscle thus making it far less responsive to reduction than that of the jaw angles

The effective method of reduction would be check bone reduction (zygomatic arch reduction) to carry the attachment of the soft tissue inward with the bone.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, It’s been one month since my sliding genioplasty surgery and I am starting to feel that my results are just getting worse every day.  I’ve attached some pictures for you to see. My whole right side of my face looks rotated upwards & even more crooked than before.  Is there any chance this is going to get better?  I have a dent and now I also have lines on my right side.

A: I think it is important to understand that four weeks, which seems like an eternity when one is the patient, is a very brief time after surgery and many issues have yet to resolve or become clear. In intraoral genioplasties I do not judge the aesthetic outcome and any functional issues for at least six months. When the mentalis muscle is disassembled, the bone cut and moved and the muscle then reassembled, many expected short-term issues will appear. Stiffness and aberrant movements (soft tissue distortions) of the chin pad will initially develop as it heals as one might expect from such disruption of the anatomy. These almost always resolve but it will take time and patience to get there. Until all swelling, numbs and stiffness of the tissues resolve, you are not close to what the final functional outcome may be. The resolution and complete adaptation of the soft tissues down to the bone always takes much longer than any patient thinks. It would be impossible that your face is more crooked than before surgery given exactly what was done. Again the six month time period is when the true final outcome can be determined.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,I am mainly looking to improve  my profile and get more projection from my chin although I think I would benefit from slight additional vertical length as well.  I have done a fair amount of research about the various options for recessed chin (jaw surgery/ sliding genio/ chin aug) and understand chin aug to be the least invasive of them all.  I have an overbite that was made slightly better with braces about 2 years ago, but during the process I had 4 teeth extracted which seems to me has made my jawline/ dental arch narrower(may be just in my head).  My dentist has said that my overbite is not too bad but I want to make sure that a chin aug alone would be sufficient for my needs or should I be looking more at orthodontic options.

A: Thank you for sending your pictures. With your amount of horizontal chin deficiency and your dental/orthodontic history, there is on doubt that the origin of your chin concerns is a result of overall lower jaw growth deficiency. While major jaw surgery/orthognathic surgery would more ideally address that problem, it would be a very difficult and long road to go through orthodontics before and after surgery not to mention the actual jaw surgery itself. And you would still need some type of chin surgery done with the jaw surgery. Thus this leaves you with either a chin implant or a sliding genioplasty as more practical treatment options. To really add a vertical increase to you chin as well as a horizontal one, you ideally should have a sliding genioplasty. A chin implant to achieve that same type of result would almost have to be custom made to achieve similar dimensional changes.

Dr. Barry Eppley
Indianapolis, Indiana

Dr. Eppley, I am looking for temporal implants due to significant thinning of my face with age and weight loss. I would also be interested in possible fat transfer or other procedures to fill my cheeks in some. Would like to consult on what my options are. Here is one old photo of me 30 years ago, I don’t ever expect to look that young again, but I would like my face to be plump or full looking again like it used to be. I’ve lost a lot of weight and my face now looks sunken and sickly. Please help me. I am embarrassed by my appearance.

A: Thank you for sending your pictures. You have very classic panfacial soft tissue volume loss which is very common in significant weight loss particularly in an older person. It affects some individuals more so than others. This is most manifest in your temporal region where it has turned into a complete concavity from the zygomatic arch all the way up to the anterior temporal line on the forehead. It is seen less severely in the cheek area only because your naturally high cheek bones have preserved some of the volume. (there is no bone protecting the temple areas) For your temporal areas there is no question that an extended temporal implant is the preferred procedure as it will create a permanent volume solution to that problem. It requires an extended temporal implant as opposed to the standard one given that it needs to reach all the way up to the forehead. For the cheeks your options are submalar cheek implants or fat injections. Each one has their own merits. (fat is better at total area volume addition but its survival may not do well given your age and lack of natural fat in the area…an implant has assured permanent volume but only provides volume to one specific area) In facial volume lose cases like yours I will often combine submalar cheek implants with fat injections to get the best of what each has to offer.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in umbilicoplasty surgery. My belly button has been this way for about 10 years, ever since the birth of my son. It has been the source of my insecurity and I am so self-conscious about it that I can’t even wear a fitted shirt because it clings to my belly button and creates this weird looking indent. I hate it and fixing it would make me so incredibly relieved and ecstatic. I can’t afford a tummy tuck and even so I would hate to go thru all that just to fix one little thing. I really sincerely hope something can be done.

A: Quite frankly, your belly button concerns are due to the excessive surrounding tissues that are collapsing around it and engulfing it. This is not a belly button problem per se, it is due to excessive abdominal skin and fat. Thus there is no umbilicoplasty surgery that is going to correct it nor would it even be wise to spend any money trying it as it will not solve your concerns. What you need is a fully tummy tuck which will treat the real source of the belly button problem by removing all the excessive tissue and in the process create a new belly button. While you may not be able to afford it now, it is much better that you wait until the day you can and then have the correct operation. That is a far better financial decision as an umbilicoplasty surgery now would be a disappointment and waste of money.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting a cheek implant. I was in a car accident ten years ago and had reconstructive surgery on right side of face. You can see that my fave is fuller along the jawline and lacking fullness on the apple of my cheek. I’ve had fillers for years to temporarily fix the problem area but I hate it. I’m ready for a permanent fix so I can feel beautiful. You can see in my attached pictures my facial asymmetry problem.

A:Thank you for sending your pictures. You have the classic cheek deformity that often occurs after a zygomatico-maxillary (cheekbone) fracture where the projection of the cheek is ultimately lost from inward translocation of the arched cheek bone complex. Given your naturally very high cheekbones (as seen on your left side) it would be easy for such a fracture and even its repair to match the naturally high cheekbone projection that you have. You are correct in that there is a simple fix to that concern by placing a cheek implant on top of the most depressed portion of the bone. This is done through a small incision inside the mouth.The key is both the proper cheek implant shape and size.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I had a chin implant placed through a submental incision three months ago.  I’m really in a tough spot with the chin implant because I really can’t live with this crooked smile I’ve had since post op, but no doctor knows what’s causing it or how to correct it.  I’m seriously thinking of removing it without replacement in the hope that my smile will return, but I have concerns about post removal complications like witches chin deformity or scar tissue balling.  If I remove it, it will be five to six months post op at the earliest. This was a large extended anatomical implant, and I’ve read doctor opinions on Real Self where they’ve expressed concerns about removing a large implant without replacement more than a few months post op.  What is your take on all this?  Should I only have a doctor perform this procedure if he does it a certain way?  For example, only go with a plastic surgeon that can recognize, during surgery, if a submental tuck up is needed, as well as one that has me wear a chin compression sling post op?  I wonder too if, since my jaw is on the smaller side, could this implant be ‘too tall’ and be limiting my mentalis muscle, in turn affecting my smile? If I were to go with another implant, should I be sure the doctor’s comfortable shaving it down to be no taller than say 1.0cm or even less than that? The large Terino implant is 1.3cm at its tallest point in the center.  Please see the 2 attached 2 X-ray’s taken recently if they are of any help in your assessment.Thanks for your help!

A: With a chin implant that is only adding 6mms of horizontal projection, I would have no great concerns that removing it would create a witch’s chin deformity or a chin ptosis. If the implant is removed I would see no reason that a submental tuck would be needed. Simply putting back and tightening the mentalis muscle should be enough.  When trying to solve a problem, don’t complicate it by adding too many variables. Either simply remove the implant or have the one you have now repositioned a bit lower on the bone. It is sitting just a tad high on the bone right now. While that may or may not solve issues, these are simple chin implant revision maneuvers that at the least will not create any further complications.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like your opinion on something. Over the past few months I have noticed deep ridges in my forehead which run a long the forehead veins. I went to see a dermatologist for fear it was en coup de sabre, but was told the skin didn’t seem like that. I’m 46 years old, thin and female. I am extremely depressed about it as it looks like I’m a Klingon when I look at myself in shadowy light. in bright light it is OK. I was thinking of having a face lift in the UK later in the years so don’t know if anything could be done about it then. Is this something you could address? I was wondering whether maybe forehead cement but then would that be possible with the veins where the ridges are and would that push the veins up to make them bulging instead. Yours desperately.

A: Thank you for your inquiry. I would have to see pictures of them but most likely it is forehead veins and not linear scleroderma. I have seen this quite a few times. These veins, when deflated, can leave long vertical grooves in the forehead which is often paired. How to treat them is challenging. The concept of bone cement on the surface makes sense but would likely leave raised ridges and may likely cause its own aesthetic problem. The other alternative is fat injections placed around them. Since fat is injected with blunt cannulas there is little risk of entering the veins or disrupting them.

The key issue is what these forehead grooves look like in three positions, when standing up, laying down and then with your head bent over. (head lower than your heart) This will make the diagnosis that this is indeed forehead veins. Those three pictures would be very helpful.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in rhinoplasty and have several specific concerns/goals I want to achieve.The only other thing about my nose that I am most uncomfortable with is the lower part of my nose. It appears that my columella is hanging or sagging. I really don’t like the way that part of my nose looks. The nostrils also appear higher than the bottom part of my nose and you can see the inside. I am not sure if this is because of natural Alar retraction or because the columella is hanging down? Both? Neither? The nostrils themselves are kind of “pinched”. They are very narrow and a lot of times I feel like they are the biggest cause of my breathing problems as they seem to collapse some even during normal breathing. Also, Is it possible to change the angle of the tip more upwards? It may just be the bottom part of my nose that makes it looks like its not angled up but I am really not sure? I know that you have said that anytime you make the nose smaller you risk making breathing problems worse. Is it possible to make the nose wider? Like the nostrils or the base itself? If so, would this help with breathing? 

A: I would not call your columella a true hanging columella. This is controlled/treated by the reduction of the caudal end of the septum (which is necessary to tip rotation) and removal of any redundant columellar mucosa.

One of the hardest things to improve in any nose is nostril show. This will be potentially magnified with any degree of tip shortening/rotation that is done. Alar rim grafts are placed to combat it but there is no guarantee that it will not be a persistent issue. Pinched nostrils are treated through the use of batten grafts to provide improved lower alar cartilage support.

The best strategy to manage breasting difficulties in a rhinoplasty are middle vault spreader grafts to help open up the internal nasal valve.

The combination of extensive cartilage grafting (columellar strut, alar rims, batten and spreader grafts) is the most one can do to improve nasal tip support and open the anterior nasal airway as much as possible.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I got a 7mm Medpor Chin Implant put in on January 20, and I want it removed ASAP. Its too bulky and makes my face look less feminine than before. What are the chances of my face going back to the way it was before? Would another implant need to be put in? my doctor doesn’t do silicone chin implants for their tendency to drop overtime so Medpor it was. I’ve heard how difficult these implants can be to remove, what’s your experience with removing them? If I was to replace with a silicone implant, is it better to do it when removing the other or a few months later?

A: I am not surprised that a Medpor implant is too bulky for a female. While that implant needs to be removed, it is important to always remember that you had a chin implant placed for a reason and that was to correct a chin deficiency. This may be the wrong implant but that does not mean that there is no merit to having a chin implant at all. A better shaped and more feminine chin implant made from silicone would offer horizontal advancement with far less width if any at all. I would strongly consider replacing the implant rather than merely removing it. I have to see you throw away the complete effort.

I have removed many Medpor implants. While they are not as easy to remove as silicone it can be done. I have never heard of silicone implants ‘dropping over time’. There jus no biologic explanation for that and something I have never seen. It is better to remove and replace at the same time (with screw fixation of the new silicone implant) than to delay. The only reason to delay/stage it is if you are uncertain that you really want an implant at all. But that will change what is done during the implant removal. If you are just removing then you need to do a submental tightening of tissues since the tissues have been expanded to avoid a chin pad drop/ptosis.That ail not be necessary with a chin implant replacement.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I contracted polio when I was an infant from a vaccination, which resulted in atrophy of my left leg. Would fat grafting or thigh and calf implants help to make my legs more symmetrical? I know the discrepancy looks severe so I don’t have expectations of perfection but I’m hoping something may be done to lessen..  possibly with the combination of both procedures. 

A: Thank you for sending your pictures The easiest and less severe component of your leg asymmetry is that of the calf. One calf implant placed on the inner half would go a long way to improve symmetry below the knee. Two calf implants would produce near symmetry inj size to the other side.

The thigh deformity is the bigger part of the leg asymmetry and the more challenging to improve due to its magnitude. Injectable fat grafting would be the only treatment that can be done and its success is partially dependent on how much fat you have to harvest. This combined with how much fat survives determines that outcome. Based on the performance of the first procedure (and how much fat you have to harvest) you may need a second fat grafting session to get the best possible outcome.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, is there a chin implant that can make a cleft chin? I would like to get a cleft with my chin implant augmentation and I am told that cleft chin implants exist but do they work?

A: Contrary to popular belief, a chin implant that has a central cleft in it either manufactured that way or intraoperatively put in it will not create the appearance of an external chin cleft. It seems like that chin implant approach would work but it does not.

The key to making a vertical cleft in the chin when using an implant is to use/make a clefted chin implant but then the overlying soft tissue must be thinned out and then sewn down into the implant cleft or even all the way down to the bone. What makes it work is the suture technique down to the bone.

I wish it was as easy as putting in a cleft chin implant and creating a visible external chin cleft…but it is not.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I recently had rhinoplasty (4 weeks ago) and I am extremely unhappy with the result. I asked my surgeon to remove the bump on my nose but it is still there and also my nose looks extremely wide. I was wondering if this could still be due to swelling- and if so, how much can I hope for it to go down, and if not, how soon do you think I could get a revision – I really want to be able to feel comfortable with myself before I go to back to school in September. I’ve attached some photos – as you can see my bridge is very wide and there is still a noticeable bump- could these just be caused by swelling, is there a chance they could go down completely/a lot?

A: In trying to answer your questions, I am at a significant disadvantage. I do not know what your nose looked like originally and know no details of how your rhinoplasty was done. These pieces of information are critical to know as to whether the eventual resolution of swelling will produce a favorable outcome or not.

But let us assume that the outcome of your primary rhinoplasty is not favorable, the timing of any revision rhinoplasty would depend on what needed to be done. This would not be before three months at the minimum and likely six months after the original rhinoplasty procedure. The nasal tissues need time to heal and have all the swelling fully subside.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have this terrible vertical line in the middle of my forehead and I really want it gone. Can you help me?

A: Vertical wrinkles in the forehead are a result of overactivity of the corrugator supercilii muscles. These are small muscles that run obliquely from the inner aspect of the eyebrow under the more superficial frontalis muscle and pass inward towards the central area between the eyebrows to insert to the underside of the skin. When these muscle contract they pull the inner half of the eyebrow inward. With both sides pulling inward together this creates the vertical lines between the eyebrows that many people have. This is why the name corrugator supercilii, which comes from Latin, means the ‘wrinkler of the eyebrows’.

The corrugator muscles are known as the frowning muscles and they produce a variety of vertical line patterns between the eyebrows. The most common are a pair of vertical lines, known as the 11s, and is the basis for the use of Botox injections to reduce their prominence. In some people a single deep vertical line appears, just like the one you have. They are often very deep and are the hardest of all vertical forehead lines to treat.

This is definitely not scleroderma which appears more liken shallow groove and does not appear in the midline. This is a deep expressive wrinkle (deep vertical line) which shows deep inversion. I would not think some much of fixing it as it is not that simple…but treating it to make it less noticeable. This is caused by excessive muscle action but not has become a deep etched vertical line which will not be resolved by simply weakening the muscle. (e.g., Botox injections) The hardest part of its treatment is to get the deep indentation back up and level with the surrounding skin. The simplest and most effective approach, but the least appealing, is to cut out the indentation and put it back together in a geometric closure pattern. (small running w-plasty like forehead scar revision) There is no more effective long-term skin leveling strategy than this approach but it is like trading one scar pattern (indented and vertical) for another pattern. (smooth and small irregular line) One could certainly argue that this is probably a much better ‘scar pattern’ than what you have now. The alternative non-excisional treatment would be to place something under the indented scar such as fat injections, a small dermal-fat graft or temporalis fascia. This would create less of an indentation that would not be quite as deep.

As you can see, the ‘fixing it’ strategy is not what can be achieved. It can only be improved and it is just a question of how one feels about either the options of a smoother fine line scar or simply less of a vertical indentation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m wanting to do a Brazilian Butt Lift lift. Can that be done at the same time as with a Mommy Makeover?

A: A Mommy Makeover (breast and abdominal reshaping) and a BBL (Brazilian Butt Lift) can be done at the same time but it create a very difficult recovery. It would all depend on what the exact Mommy Makeover procedures need to be and whether such a combination may negatively impact the results of any of the three procedures. For example if the Mommy Makeover needs to include a full tummy tuck there will be less fat that can be harvested for the BBL to avoid compromising the healing of the tummy tuck incision. I would need to make that evaluation during an actual consultation or you can send me pictures of your body type for a preliminary evaluation.

While it is always desirous to maximize the number of operations one can do in a single setting for economy of recovery and economic resources, there are operative combinations that can ‘fight’ against each other and may even compromise their results. This needs to be looked are carefully in these type of body contouring procedures.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in orbital rim implants. I am 23 years old with severe depressions under my eyes. I’ve had them since I can remember. I’ve tried everything. Special vitamins, creams, makeup, nothing works. I also have dark colors as well. I am more concerned with the depressions though. You can cover up color, but not hollowness. I went to see a local plastic surgeon and he basically told me nothing could be done. “Try our cream, and makeup” is basically all they said is necessary. I am tired of looking this way. How much does the implant surgery cost? I am so desperate. Thank you.

A: When it comes to infraorbital hollowness/tear troughs, this is an anatomic problem of either lack of soft tissue volume or inadequate bone projection.  These are most commonly treated today through the use of temporary injectable fillers. In my opinion, however, these should only be used a trial method to see if soft tissue voluminazation would be effective. They are certainly not a long term strategy particularly when ine is very young and this is a congenital anatomic issue.

Longer-term surgical treatment options would be either the use of injectable fat grafting or infraorbital rim implants. (sometimes called tear trough implants although these are not necessarily the same) Each has their role and the choice between the two would depend on what your depressions under the eyes look like. I would need to see some pictures of your eyes to make a more definitive recommendation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in breast reduction surgery. I am 24 years old, 5 feet tall and pregnant. I was a 32C before and am currently a 32G. You have high reviews on Real Self. I struggle with stretch marks on my breasts and have no faith in my breasts shrinking after because of them. I am interested in a combined breast reduction and lift. 

A: While you may ultimately need some combination of a breast reduction/lift, it would be important that you wait a full six months after delivery before having the procedure. You want your breasts to fully shrink down and be a stable size with whatever sagging may ensue. In essence you want to have a ‘stable target’ to operate on so the breast reduction result does not change appreciably afterwards due to still evolving changes in your breasts.

You may also be surprised how much your breasts will shrink after delivery. What seems like a breast size that can never go down adequately can actually even end up too small later. The sagging will not improve with time and a breast lift may ultimately be needed but it is way too early to say that you need a breast reduction as of yet.

Dr. Barry Eppley

Indianapolis, Indiana