Your Questions
Your Questions
Q: Dr. Eppley, We are interested in chin reduction for our daughter. She is now 17 years of age. Through her orthodontist we have been told that she wiuld need a chin reduction. We have been to visit a plastic surgeon in our local area who is willing to operate on her but we would like to find someone with your level of expertise. We would like to what your thoughts are on what type of chin reduction surgery should be done. I have attached some pictures of her for your assessment. Many thanks.
A: That you for sending your daughter’s pictures which is extremely helpful. She has an unusual excessive chin problem as it is very horizontally protrusive but also vertically short. This creates a prominent chin ‘knob’ deformity. While I don’t know what the bone looks like underneath (it would be helpful to see a lateral cephalometric x-rays from her orthodontist who undoubtably has one) her excessive chin problem is both a bone and soft tissue issue. Both have to be addressed to produce a satisfactory chin reduction result, removing soft tissue alone will not work. While the bone may be horizontally excessive, her chin is also vertically short. Her entire lower face is actually vertically short compared to the rest of her face. Ideally you would want to convert the excessive horizontal bone to increased vertical chin height. This would stretch out some of the horizontally excessive soft tissue which is just following where the bone is. Then any excessive soft tissue could be removed. While this may be the ideal approach, it would entail two stages to do so. The other approach would be a one-stage submental chin reduction with removal of excessive horizontal bone which would then allow some of the excessive soft tissue chin pad to be removed and tucked under. This would still leave the chin vertically short but would offer significant improvement in a single surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I recently had scalp expansion (last surgery two weeks ago) and it looked great. Now two weeks later, I am losing most of my hair next to the suture line and where the expander at the top of my scalp was. Is this normal or will I now need yet another surgery to repair this damage?
A: Le me explain the infrequent phenomenon of scalp expansion hair loss. It is not rare to have hair ‘shedding’ (temporary condition) from the stress of a tissue expander if the amount of scalp expansion is large or is being done in the presence of existing scalp scars and tissue loss. This should to be confused, which is an understandable confusion, with actual hair follicle loss. (permanent condition) Hair is very sensitive to stress since it easily be changed into the telogen phase where the hair shaft separates from the hair follicle. Once the stress period is over (after the scalp surgery is complete) the hair follicles will resume growth at some point and new external hair will begin to appear. There may or may to be some scar widening from the tissue expander insertion site.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have had two chin reductions, a sliding genioplasty and bone burring and a chin lipectomy. Now my chin has collapsed, please help me to know what to do for a chin reduction revision?
A: Based on your history of two intraoral bony chin reductions, the overlying soft tissue appears to have ‘collapsed’ or become completely balled up over the chin. This is what can happen when intraoral approaches are done for horizontal chin excess. Intraoral bony chin reduction relies on the excess soft tissue chin pad to somehow shrink down and become less over a reduced bony chin prominence. While that may work for a very small horizontal chin excess, larger reductions result in the chin soft tissues just contracting down into a mass of distorted and indented soft tissue. This is why a submental approach which reduces bony and soft tissue is the better choice as it prevents what appears to have happened in your case by reducing the soft tissue as well as the bone.
The question is how best to release the contracted chin tissues and restore their volume. There are two basic approaches. First, if one is happy with the horizontal chin projection fat injections can be done to expand out the soft tissue a bit and try to soften it. The second approach is if one can tolerate a little more horizontal chin projection, the soft tissues can be released through a submental approach and a small chin implant can be used possibly with a little bit of fat injections.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a custom occipital implant three months ago. While I was initially thrilled with the results, I now feel that I wish it was bigger. Do you think it is too soon to consider a revision? Also my scalp is still somewhat numb, less numb than right after surgery, but somewhat still numb. Is this normal?
A: First, it really takes a good six months to have all normal feelings return to the scalp and to really ‘forget’ that one has a custom occipital implant on top of their head. It also takes one about the same amount of time to psychologically adjust to an extended body part and to put it in perspective. Thus you really are not there yet and what one feels today may or may not change later. So in the interim the following comments may be helpful to gain some further perspective.
It is extremely common, and almost expected, that every occipital implant augmentation patient eventually feels that they could have used more of an augmentation or some change in the augmentation location. They may feel that maybe the implant should have been designed bigger or placed differently or may even consider having a second implant done. This is known in the plastic surgery world as another ‘spin at the roulette table’ or ‘another bite of the apple’ to use a few common American phrases. I sum it up more psychologically as ‘cosmetic accommodation’.
This is common in this type of surgery because the reality is that a one stage approach can usually only achieve about 60% to 70% of the ideal augmentation one wants due to the limits of the scalp’s ability to stretch. The most ideal results always come from a two stage approach with a much larger implant. This is a discussion to have up front as one has to choose between the more efficient one stage approach that produces less than one ultimately probably wants or a more costly two stage approach for the ideal result. Besides the initial expansion phase, a two-stage also requires a change in the incision to across the top of the head rather than low in the occipital hairline.
Your preoperative situation with an already existing occipital scar throws a variable into the occipital augmentation planning….as it becomes the only way to place an implant as any incision across the top of the head places the stretched and/or expanded skin between the two incisions at risk for skin or hair loss. You always only had the option of the use of your existing occipital scar whether you had tissue expansion or not.
From the occipital scar location, it would have never been possible to get an implant any further forward than where it is right now. You simply can’t get around the curve of the skull to make a pocket from an incision that low in the hairline. You should take some solace in that you have had the maximum thickness of implant placed as far forward as was possible given the constraints of the incisional access. (15mm height)
In a few cases I have had occipital implant patients who really want to go for a second implant to get an even greater result. Without tissue expansion this is usually not possible. But even it were I would caution any implant patient to resist the temptation to take an initial uncomplicated surgical result that is good, but perhaps not perfect, and try to make it better. The next time around they may not be so fortunate.
Hopefully these comments will provide some additional perspective on your recovery process and the final result as you eventually gain full perspective on it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have 2 questions about a custom jawline implant. Recently I tried to find photos of celebrities with similar skull width and face shape as me, but I noticed that among people with similar midface width, the shape of the jawline can be very different. I can basically tell 2 different types, and what I’m trying to achieve is the Type I effect. That is the “long sharp chin” effect while the jawline still looks 3-dimensional. My current chin implant is sharp, but the size of it is too small and still short and the weight of the entire lower face looks very unbalanced (jaw body vertically short and flat). Also my jawline looks very 2-dimensional.
I really don’t like an over-masculine jawline like a “squared jaw” that protrudes in lateral direction like a lot of bodybuilders might request…). I prefer a neutral but a little more “boyish” one as type I. But almost all results of jaw implants I’ve seen are sort of similar to Type II (it’s big and wide), so
1. I just want to ask whether it is possible to achieve Type I effect with a wrapped-around vertical custom jawline implant?
2. Although it’s obvious that they are different, but I can’t tell exactly what contributed to the differences… Can you tell me some differences between Type I and Type II jawlines?
A: The short answer to your question is that the ONLY way to achieve a more vertical jawline enhancement is with a custom implant approach. No standard or preformed off-the-shelf are designed for that effect, they are all width based implants because they are all sitting completely on the bone. That is why you see many ‘type II’ jawline enhancement results and not your desired ‘type I’ jawline augmentation result.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 33 year old male and am interested in skull reshaping of the back of my head. (occipital bone reduction) My occipital bone has always been really noticeable. Now I am quite bald it’s even more noticeable now. I often get remarks about it, people tend to touch the back of head to feel it, and I’ve heard people talking about it behind my back. Is it possible to reduce it? I’ve seen a similar case on your webpage.
A: The occipital bone prominence can definitely be reduced. It is only a question of how much and that would be based on the bilaminar thickness of the occipital bone.This is best determined by a simple lateral skull x-ray which will show its entire thickness and the thickness of the outer cortical table of the bone. A tracing of the occipital profile can be done on the x-rays to show what the realistic outcome would be from the procedure in the profile view.
The horizontal prominence of the occipital bone is a very common skull reshaping surgery in my experience. It involves making a small horizontal incision on the back of the head from which the occipital bone is burred down as much as possible. It is usually not possible to over reduce or due too much of an occipital bone reduction.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in some form of breast reshaping surgery I am torn as to whether a breast lift or a breast reduction is the right option for me. I have attached some pictures so you can help me decide between the two options.
A: Thank you for sending your pictures. In regards to your breasts it is important to remember that every breast reduction involves a breast lift and the associated breast lift is always a full anchor pattern lift. Thus the breast lift part does not change, the only variable in breast reduction surgery is in how much breast tissue should be removed (reduced) if at all.
Also every breast lift when done alone will reduce the size of the breast by almost one cup…and this is without taking out any breast tissue. (the removed skin is to lift and reshape the breast mound) In looking at your breasts I really see largely a breast lift with only enough breast tissue removed to ‘fit’ the remaining breast tissue into the lifted and reshaped overlying breast mound skin. Most likely you could get away with a full breast lift with no breast tissue removed at all.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I met with you for a breast augmentation consultation last week. Before I schedule my surgery, I have a few more questions about specific brands of implants. I believe you recommended Sientra, but I’ve been looking into Mentor implants. Specifically, the Mentor MemoryGel Siltex round implants. I’ m interested in the textured surface versus the smooth because the (perhaps dubious) Internet research done suggests textured surfaces lead to a lower rate of capsular contracture. And, Mentor appeals to me because of the enhanced warranty available for purchase. If my logic and/or research are wrong, please do correct me. If I did choose to go with Mentor, would there be a price difference from the original quote I received?
A: Thank you for the additional questions about breast augmentation and specifically about breast implants. Let me preface my comments with the understanding that it does not make any difference to me what brand of breast implants a patient uses. From my perspective, the three major breast implant manufacturers offer comparable devices for surgical implantation. The manufacturers, of course, see it differently and often promote and advertise relatively miniscule purported advantages to their devices.
When it comes to smooth and textured breast implants, it is important to understand what their advantages as well as their disadvantages are …as you will pay more to use them. (they are more expensive because it takes an extra step in their manufacture to add the textured surface onto the implant) Textured breast implants have only been shown to reduce the risk of capsular contracture when the implants are placed above the muscle. There has never been shown any differences in capsular contracture rates when they are placed below the muscle. The greatest reduction in capsular contracture, what was once a common breast augmentation problem, was the change in implant location from above to below the muscle. The type or surface of the implant is irrelevant when placed in the submuscular position. In my breast augmentation experience, which spans over 20 years and over 800 breast augmentations, I had yet to see a capsular contracture from a primary breast augmentation. In that time I have only performed a single above the muscle breast augmentation. All the surgeries have been done using smooth breast implant devices. This is a testament to the value and importance of the submuscular (technically the partial submuscuar or dual plane location.
It is also important to be aware that textured breast implants, besides costing more, require a slightly bigger incision to place and have a slightly higher risk of infection as any textured surfaced implant does. (the rough surface offers greater opportunity for bacterial adhesion than a smooth surface does) Due to their thicker shells they will feel more firm and will move less freely (due to tissue adhesion) than smooth breast implants.
Today, all breast implant manufacturers offer the identical warranty…lifelong implant replacement and a 10 year for surgery warranty of new implants plus $3500 towards the cost of surgery to replace them. (technically Sientra offers $3600 towards the surgery cost on the first ten years and also has a capaulat contarcture warranty so one could argue their warranty is better than Mentor and Allergan)
Again, it does not matter to me what breast implant manufacturer, style or size any patient desires. I will surgically place whatever they want. The only thing I do care about is that patients make an educated choice and that they understand the advantages and disadvantages of those choices.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’ve had 3 syringes of Restylane Silk and 1 syringe of Radiesse over the past year placed under my eyes and on the cheeks. The injections were placed down deep on the bone. When these fillers dissolve would there be any side effects? The reason I am emailing you is because I was so impressed by your answers on many plastic surgery boards. Is there no risk of underlying tissue or muscle becoming ‘lax’ from fillers especially with four ccs. of injectable fillers in just 12 months? I appreciate your time in answering my concerns.
A: All of the mentioned fillers are completely resorbable and they are not known to cause any long-term problems because of their relatively short duration of effects. Your question, however, is a good one but I am not aware of such injectable filler volumes causing lax skin or muscle tissues. That is because, while the injection volume creation process is acute, the resorption process is very slow giving the tissues time to recover due to its natural elasticity. Once the tissues deflate after such volume, however, I could understand how one could believe they are more lax because of the getting used to the volume that had been present.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m interested in cheeckbone reduction and maybe jaw reduction to make my face smaller and oval shape. My question is, do I need a jaw reduction or the cheeckbone reduction is enough to slimmer my face? Also, I had a rhinoplasty done about ten years ago. The tip is very visible. It looks like a small pimple on my nose, probably because my skin was thin. I’d like to have a revision. Please let me know what you recommend.
A: When it come to narrowing the wide Asian face, one procedure or changing one facial area is rarely enough to have a significant effect. Combining cheekbone reduction with jawline reduction (jaw angle, masseter muscle and chin elongation) is the most effective approach. Of course each patient must be individually assessed to determine if one of these facial changes would be the most dominant and, in your case, there most certainly is. The width of your cheek bones is by far the widest part of your face and would be the one procedure (cheekbone reduction) you would absolutely do if there was only one procedure you wanted to do.
From a visible nasal tip standpoint, which I assume may be from prior tip graft or implant,the tip can be either modified (tip point reduced) or over grafted. (cartlage graft on top of the tip) It would be helpful to know what exactly was done from your rhinoplasty now 10 years ago.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I read on your website that you are able to perform Adam’s Apple Augmentation (as opposed to the usual reduction) and I was wondering what the approximate cost would be for this surgery, and what the cost and recovery differences would be if the patient opts to use the intercostal cartilage rather than synthetic materials?
A: Adam’s apple augmentation or tracheal sugmentation can be done used either a Medpor nasal shell style implant or carved rib cartilage. There are advantages and disadvantages with either approach. An implant is preformed, requires no donor site harvest and easily shaped to overlay on top of the existing thyroid cartilages. Because the implant is performed, the operative time is shorter and this costs less. It is an implant, however, so theoretically the risk of potential infection is higher. (although I have not seen that occur) Rib cartilage requites a donor site harvest, is harder to shape and adapt to the existing thyroid cartilages and costs more to perform. It is, however, a natural material and this would suffer a lower risk of infection.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in temporal augmentation but I have questions regarding it and how it may be used for hollowed temples and cheeks on one side of the face. It appears to myself that the areas where the buccal fat pad would sit on one side of the face is abnormally thin. This contributes to a visibly old-like or sick appearance one one side of the face, but the other half looks healthy and normal for a young adult. My concern is more so on the temples than the cheeks. Is there enough protection of the temples on that side? (are there concerns regarding temple injuries) It also concerns me that I look “unhealthy” and abnormal because of it. What do you suggest for my temporal augmentation? Thank you for your time.
A: Temporal augmentation surgery is very safe and there are no concerns about ‘temple injuries’. Temple augmentation is about developing an increased muscular appearance using either implants placed in the subfascial location or fat injections directly into the muscle. Each temporal augmentation method has advantages and disadvantages with the primary difference being one has an assured permanence (temporal implant) while the long-term fate of fat injections can be more variable.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have some questions about implant rhinoplasty for my Asian nose. The original surgeon who performed my first rhinoplasty knew that I did not want an implant initially but sold me on the implant because the only thing that he offered that would be equivalent in terms of withstanding the test of time is fascia. He described it as a thin piece of skin from the scalp area that would show little difference. He never mentioned anything about rib grafts or diced cartilage wrapped in fascia. I feel that I was mislead purposely. Is it common for plastic surgeons in the United States to do this to make a buck and is this medically ethical?
A: There are numerous approaches to augmentation of the Asian nose including implants and rib cartilage grafts as you have mentioned. It is certainly true that fascia alone would provide no nasal augmentation at all due to its very thin and pliable tissue characteristics. It is good to encase a diced cartilage graft but is not an augmentation material per se.
Surgeons naturally present and offer to patients for any surgical procedure what they know and are comfortable performing. Presumably what they have to offer for any cosmetic condition is what they feel will work well and is in the best interest of the patient. It is also far easier for surgeons to offer implant rhinoplasty over rib grafts for nasal augmentation because it is simpler, easier to perform and costs the patient less. Even if presented with the rib graft option, many patients initially choose implants for all of those reasons also.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have along protruding chin and am interested in chin reduction surgery. What is the best way to reduce/reshape it so it looks smaller and more proportionate to the rest of my face?
A: In chins that are both vertically long and horizontally protrusive, there are two surgical approaches. A submental chin reduction technique is done from an incision below the chin where the bony chin can be vertically and horizontally reduced and any excess soft tissue removed. This is the best technique for bony chin reduction but does leave a fine line scar under the chin. That is somewhat of a concern with your ethnicity and skin type. The alternative approach would be an intraoral one where a vertical wedge bony genioplasty is done with horizontal setback. This leaves the question of what happens to any soft tissue excess, which may or may not contract back down but it is an externally scarless surgery.
As you can see, each chin reduction approach as its advantages and disadvantages. It all comes down to how the patient perceives the submental scar and what the risk of a redundant chin pad is after the bone is reduced.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in forehead reduction. I have had 3500 FUE strip harvest hair transplants done five years ago. While the grafts have taken well without hair loss I have a remaining large forehead. I still have some elasticity to the scalp and am interested in seeing what a forehead reduction can do.
Q: The key element of a successful forehead reduction (and I assume you mean hairline advancement and not bony reduction) is the scalp elasticity as you have already noted. That scalp elasticity comes from the back of our head primarily and not so much the top when the scalp is advanced. If you have had 3500 transplants that would indicate to me that you have had at least two harvests procedures and a linear scar exists across the back of your head. (unless it was done by Neograft or Artiss) That does not bode well for much scalp mobilization no matter how loose it may seem. (although I can not say for sure about the scalp elasticity just by looking at pictures) Secondly there is also the issue of needing a frontal hairline incision. This is always a little bit more risky for prominent scarring in men as opposed to women. Hair density along the frontal hairline is important so that issue also needs to be considered.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, can you elaborate on a question I have regarding the effects of Accutane on hair transplantations? I am on a pretty small prescription of Accutane right now that isnt going to end for a while. I’ m on around 30 to 40mg/week which s considered a very tiny dosage and considered “maintenance”. I actually get some medium depth Jessners chemical and Salicylic Acid peels while I’m on this medication and have had no true healing issues.
I keep hearing that Accutane shouldn’t be taken for 6 months or more after a hair transplant because it can stifle healing but since I’m on such a small dosage would it even matter? I personally would be patient if my wounds did take slightly more time to heal.
I do have other concerns though such as what other problems could arise? Would the expected graft retention outcome be less or is it just a matter of the wounds taking slightly longer to heal. The former would make me want to wait until my dosage is finished but I don’t mind if my grafts took longer to sprout as long or if my wound took slightly longer to heal, as long as the end outcome would be the same. Its the amount of grafts that I retain and the quality of them that is the most important to me and if Accutane does affect this then i would be fine with waiting. Thanks.
A: A hair follicle is an epithelial derived structure. Accutane impacts how epithelium regenerates and heals. Thus it is easy to see that Accutane can potentially adversely affect both the healing and potential take of FUE grafts. Whether a maintenance dose of Accutane would have any effect on hair transplantation at all is speculative. Healing from light chemical peels would suggest that it doesn’t. But given that every transplanted hair follicle is ‘valuable real estate’, why chance it? If you were my patient I would not let you do it whether you wanted to or not.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have 3 procedures I am considering. The breast reduction and/or lift is something I definitely want to do, as I’m very uncomfortable from the weight pulling on my neck. Over the past few year I have noticed facial asymmetry developing. It seems to be from an enlarged masseter muscle and I’m curious what my treatment options are for this. Lastly, regardless of how thin I am, I have always had somewhat of a double chin. My chin is not very pronounced and I’m curious if a chin implant would be a good option to fix this? Do you offer discounts when multiple procedures are done? Anything information you can provide would be greatly appreciated. I can provide pictures. Thanks for your time.
A: The breast reduction surgery is fairly straightforward and the inferior pedicle technique with the anchor scar pattern is well known. Masseter muscle hypertrophy is most commonly treated by Botox injections which can have a profound but often temporary effect. Surgical reduction through electrical cautery reduction is also an option if one happens to be undergoing another surgery. When it comes to the double chin, chin augmentation by an implant ir sliding genioplasty is often done. But often this alone may be inadequate so neck liposuction or a submentoplasty combined with it usually produces the best double chin correction. I would need to see pictures of your chin/neck to give a more educated recommendation for your double chin anatomy.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a very particular question regarding cheekbone reduction fracture. I had cheekbone reduction abroad where they pushed the sides of the arch of my cheekbones in to make my face narrower. However, the posterior end of the arches somewhat move outward on and off a bit, making my face wider. I was wondering if it was possible to place plates on the posterior ends of the zygomatic arches to keep them in. Thank you.
A: When it comes to cheek bone reduction osteotomies, the posterior end of the zygomatic arch is cut and moved inward. Many times a small plate with screws is placed to keep it positioned inward. This may not be necessary if a larger plate with screws is placed on the anterior cheek osteotomy. But if there is persistent mobility and rocking of the posterior segment, it can be stabilized secondarily. The best fixation method to stabilize it inward is to make a small step plate and secure wit with a screw to the remaining temporal process of the zygomatic arch. The bent step plate is then used to push the posterior end of the zygomatic arch inward and keep it from moving back outward.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I just recieved otoplasty and earlobe reduction one month ago.I The surgeon did a wonderful job thus far but there is still some minor sweeping and obviously the ears will change shape a bit over next few months. However I don’t believe enough length was removed from the earlobes. My ears still feel long and large. (not protruding) I’ve been through multiple of your surgery photos and reviews and honestly love what you do with the ear anatomy. What I would like to know is if you could take an additional amount from my earlobe to sort of shorten the ear. I would love to do my revision with you. Please let me know if and when and I have attached pictures for your review. I would love to get out opinion. Thank you for your time and I look forward to hearing from you.
A: Earlobe reduction can be done at the same time as an otoplasty or any time afterwards. The blood supply to the earlobe is not affected by any type of otoplasty procedure or even a prior earlobe reduction. The best vertical earlobe reduction technique is the helical rim type which places no visible scar on the outer surface of the earlobe. You probably need another 5 to 7mms vertical reduction. I can not completely tell from your pictures as to what type of earlobe reduction you had done but it does not appear to be of the helical rim variety. Regardless another earlobe reduction can be still be done.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have few questions about facial implants:
1. how much will it cost approximately to get customized cheek and jaw implants done at the same time?
2. how long does it take to manufacture facial implants?
3. do you personally use screws to secure both cheek and jaw implants in place?
4. lastly, is it possible to get jaw implants just to have defined jawline without the width being added (meaning that i don`t want for my oval shaped face to change into a square shape but i definitely want the very sharp defined jawline) is it possible?
Thank you very much and I look forward to your response.
A: In answer to your questions about custom facial implants:
- My assistant will pass the cost of custom cheek and jaw implats on to you tomorrow.
- From the time of receiving the CT scan until the implants are designed, manufactured, sterilized and shipped, it would be on average about 6 weeks.
- I secure almost all facial implants with small titanium screw fixation.
- Custom implants can be designed just about any way the patient wants as long as the implants can be made to fit and secured on the bone.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a problem with my cheek implants and I need either cheek implant removal or cheek implant revision. I had a severe damage from buccal fat pad removals when I was younger and that left me sagging cheeks, downturned mouth corners, and jowls. Then I got medium sized submalar cheek implants to correct this problem. I looked fine and then I got a facelift which lifted the corners of my mouth and got rid of my jowls. But that has now left me with the cheek implants sticking out like shelves and my face looking like a skeleton. I got your information online that you have helped a patient with similar situation and I would like to get your advice.
Q: Between your previous buccal lipectomies and the pull of the facelift (which can thin out the submalar region by its sweeping effect) cheek implants can be come prominent and create an ‘hourglass’ facial deformity. The best approach would not be to completely get rid of the existing cheek implants as that will likely create a very flat cheek look creating another aesthetic problem. I would recommend downsizing your cheek implants (by at least 50%) and placing fat injection grafts below them to eliminate the ‘shelves’ and create a more natural and smoother facial contour. Cheek implant revision would be preferred.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, can micro iposuction remove lumps from fat injections or it can only help removing the natural fat that is already there? The problem in that I have fat lumps (10 lumps n both cheeks varies which vary size between 5-10 mm) mainly found near the mouth, along the nasolobial folds and two lumps in the bottom of the cheeks. If these lumps can’t be removed by micro liposuction, what would be the way to remove them? Does radiofrequency help melting the fat? I already took 3 sessions and will take three more (machine is Endymed, temp used was 40C and 37 Watts) Would it be effective in melting the injected fat whether it’s lumpy or soft?
A: Certainly removing undesired fat collections (lumps) is more challenging than the original fat injection procedure. Any technique for facial fat removal (small cannula liposuction or any energy-based external therapies) are more effective for general fat removal rather than discrete fat lumps. Either surgical and non-surgical methods have their advantages and disadvantages. Small cannula liposuction (aka microliposuction) can access all your involved more central facial areas from small incisions inside the corners of the mouth. It would also be somewhat effective at breaking up the harder fatty lumps and likely removing some of their mass effect. (probably more effective at breaking them up than removing them) Conversely, topical energy-based devices are non-surgical and require no incisions but they will have a heat field effect, meaning they will create an overall fat reduction in the fat not necessarily just the lumpy area. I would be somewhat concerned with these energy-based devices that you might trade off one problem for another.
Another option would be injection therapy right into the fatty lumps if they can easily be felt from the outside. Very low dose steroids and old-style ‘lipodissolve’ (deoxycholic acid) solutions can be effective and I have used them successfully in the past for the exact problem that you have. The better ‘lipodissolve’ solutuion, ATX 101, has recently been FFA approved for facial fat reduction (technically submental/neck fat) and would be the best injectable solution as soon as it becomes commerically available later this year
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in inner inner thigh liposuction. I want to create a space between my inner thighs, a so called thigh gap. How much total fat do you think you could harvest? If I take a big pinch of skin and fat at my inner thighs I can make a visible thigh gap. Would that be a realistic result from inner thigh liposuction. My weight is around 132 to 137lbs at 5’4” if that helps with any part of the assessment.
A: The thigh appearance you are showing, known as a thigh gap, can not be created by liposuction. That is asking liposuction to do more than it is capable of. Many thigh gaps that you see in ads and model pictures have been created by ‘Photoshop liposuction’ or the women are exceptionally thin and have it by genetics. If you don’t naturally have a thigh gap, surgery is not likely to create one.
The inner thigh area is a challenging area for good liposuction results because the skin is unforgiving (poor elasticity) and has little ability to retract and reshape. If one is very aggressive and too much fat is removed there will be contour deformities and indentations as a result…thinner but misshapen. Conversely, if one is more conservative and does not take too much fat, then the resultant change is very modest. This is why the inner thighs are the #1 body area for dissatisfaction from liposuction…the results are often not enough or another aesthetic problem has been created. You have to ‘pick your poison’ so to speak…a modest change with likely smooth skin or a more aggressive volume reduction and a higher risk of contour irregularities and skin dimpling.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I found your work through the custom implants work on your site and I’m interested in getting a chin implant, but with a twist…
See, I’ve become aware of new research about the “estrogenic activity” of silicon-based implants. I was wondering, in your expertise, would it be possible to create a chin implant out of stainless steel or titanium instead of silicon or plastics-based materials (and have it be a successful operation)?
I realize this requires a complex answer, but feel free to keep your reply brief 🙂
A: I would be remiss if I did not mention that there are significant chemical differences between standard plastic materials (PVCs) and silicone which is a pure element. (#14 on the Periodic Table) There are no reports of any adverse effects on the body with silicone as evidenced by the extensive 15 year FDA study of silicone breast implants. (which is a gel and not even a solid)
A custom chin implant can be made of titanium although it would be very expensive to do so. (probably around $12,000 to make it) It would also be necessary to make it as a two-piece implant so it could be inserted through a reasonably small incision and ‘assembled’ once in place.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in facial reshaping surgery. Can I get a longer and slimmer face with strong jawline and cheekbone through the facial reshaping procedures? If no, what type of procedure will I need and how much will the total cost be . I feel like I can trust Dr Eppley for these life changing procedures.
A: In looking at your pictures, I can recommend several facial reshaping procedures that would make your face longer and slimmer. These procedures include vertical chin lengthening (vertical lengthening chin implant vs. open sliding genioplasty), cheek implants, buccal lipectomies and perioral mound liposuction. The effect of these procedures is created because multiple hard and soft tissue changes are occurring in different dimensions. When all are combined the effect of increased vertical facial height (real facial change) and decreased facial width (more of a visual facial) occurs.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I read your article on natural vs. artificial implants in rhinoplasty. I was wondering why you prefer natural material. I also know diced cartilage wrapped in fascia has been offered fairly recently. Do you know if this is a fairly new procedure or if this has been offered since 2009? I am considering tip revision but also want to keep my bridge area in mind if need be. I have an implant in my nose as mentioned earlier but do not know if these implants last a lifetime. I had mine placed when I was 38. Is there some kind of average, for example, 20 or 30 years? Thanks.
A: Significant nasal augmentation in rhinoplasty can be done with either nasal implants, usually made of silicone, or rib cartilage. There are advantages and disadvantages with each type of implant/graft and both can have successful long-term results. Silicone nasal implants never change in shape or structure, can not degrade or break down and never need to be replaced because they fail. The issue with any synthetic nasal implant is that the tissues change around them in some cases (if they are big enough) and this means that the skin over the implant thins. This can lead to potential long-term issues such as implant show, exposure or infection. This never happens with cartilage grafts which is why they are preferred in larger nasal augmentations if one is willing to invest the greater effort up front.(longer surgery, scar, expense)
The use of diced cartilage wrapped in fascia or surgical in rhinoplasty is not new and has been around for several decades. It s biggest advantage over en bloc or solid rib grafts is that there is no potential for warping or edging. They can be used to cover a nasal implant particularly in the tip area. But the use of ear cartilage would actually be better for this purpose.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, awhile ago you helped answer my questions about cheek lifts, as I was getting one to correct sagging from malar implant removal. Well, I had the cheek lift, and while it made some major improvements, I still have some sagging.
Now I probably should just accept the remaining sagging at this point, but since I had NO sagging on my face while the implants were in, I am of course beginning to wonder if I should have just kept them or should replace them or get some sort of filler to fill out the loose skin at some point.
My reason for removing the cheek implants was that unfortunately I felt they were not proportionate and looked a bit obvious – but in retrospect I wish I had just waited for more swelling to subside and embraced the new look rather than removing them and making myself look older.
The issue remaining seems to be mostly skin (with a tiny bit of tissue). The pocket of looser skin is still in the shape of a malar implant.
Is it possible that replacing the malar implants in the future would help fill out this looser skin – or after all of these surgeries should I just give up on having tight mid face skin again? You can be honest, I know it’s a lot
Would replacing the malar implants after placement, removal, and a lift just be too much scar tissue and way too complicated? How long should I wait before making this decision?
I regret removing the implants, as they made me look much younger and I had no idea I’d have sagging if I removed them.
I just keep wondering if re-inserting the malar implants would lift that tiny bit of excess skin that is looser since removing them. Perhaps filler might do the trick too?
Also, I forgot to mention that if you do think reinserting the malar implants would lift the skin a bit how long would I need to wait after the cheek lift. I was told that the sutures dissolve in 6 months. Would it be safe for the implants to be in there theoretically even if the sutures had not dissolved?
Any other suggestions about how to lift that sagging mid face skin are greatly appreciated, or if you think i should throw in the towel and quit and just accept the sagging skin now as it’s just too much surgery and scarring that’s understandable as well.
A: I think given your past history of cheek implants in and then out, any further efforts at cheek lifting should be done by either injectable fillers or fat injections.They both will provide more upper cheek fullness and will do some cheek lifting. Ultimately cheek implants could be redone now that you know their benefits. But you need to wait a full year after the cheek lift before replacing them with fillers or fat if they turn out to be inadequate.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in temporal augmentation. My questions are: 1) I would prefer to try filler first, with filler is it possible to do the whole region which I circled in red in my picture? From the implant I saw from your site, that goes really higher than the smaller ones (see the second picture). I’d like to cover all this zone with hyaluronic filler.
2-) I wonder since I have a flat upper head appearance from the front view, if I can create the effect of the guy I circled in green? His hair don’t seem to be flat on his side of the head. not sure if it’s clear. I’d like to have this volume to my head. (circled in red)
A: When it comes to temporal augmentation it is all about volume and what it costs to do it. You can certainly use injectable fillers but it will be really expensive to build up the whole temporal region (non-hair bearing and hair areas) for a six month result. The only reason to consider such a temporary treatment would be to first see if you like the augmentation effect by ‘wearing’ it for awhile. The use of anterior and posterior temporal implants, which are permanent, are a more cost effective long-term approach.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I want to know if there is a difference in the appearance between silicone cheek and jaw implants and medpor cheek and jaw implants. From pictures and my own knowledge I think it is clear that the Medpor looks and feels more like real bone. But I don’t know if this has an effect on the appearance outside the face. Does Medpor give a more chiselled appearance? I am concerned maybe silicone will give a softer, less angular look (even if customized to be angular). Is this true? I know the silicone is made in to harder material, but I have felt it and it is quite easy to cut (with scalpel). I also notice it can be bendy, and be twisted etc. I don’t think Medpor can bend like elastic, can it? I want a very sharp angle jaw and also cheek implants (sharper than angelina jolie even). Thanks in advance.
A: What creates an outer facial appearance is the shape of the implant that lies underneath. What composition facial implants are made of makes no difference at all. So that is a misconception. Do not get caught up in what the material feels or does outside the body. When any material is overlaid on bone it will feel as form and inflexible as bone.
Quite frankly Medpor is not a very good facial implant material that turns into a major problem if you ever have to revise it. And the potential revision of any type of facial implant should not be underestimated. Removing or revising a Medpor implant is very traumatic and destructive to the tissues. I take them out frequently from other surgeon’s work and I shake my head every time wondering why this material is ever put in.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in orbital rim and brow bone implants. I have a sunken eye area and eyes that seem to bulge out with droopy eyelids and bags under the eyes. What combination of procedures would produce the best results based on my overall appearance? I’ve also attached a picture of an actor whom I want similar features to.
A: While orbital and brow bone implants may be what is ultimately needed, that is not the first place to start. I would have fat injections done first to both the brows and the entire infraorbital area first. This would be initially done for three reasons; 1) To try and rid some of the hyperpigmentation of the lower eyelids. This is going to be a chronic skin color disorder which is both common with your ethnicity and may be unimproveable. 2) To improve the quality of the tissues particularly that of the lower eyelids if eventual implant surgery is desired and 3) it is possible that enough fat may be retained that implants may not be needed.
While orbital rim and brow bone implants can help make more deep set eyes when done together, they do require scalp and lower eyelid incisions to place.
Dr. Barry Eppley
Indianapolis, Indiana
