Your Questions

Q: Dr. Eppley, I was seeking a natural tummy tuck result. But after looking at the picture you provided to me, I now realize that removing the excess skin/tissue across my abdomen is not going to give me the “natural” look I was hoping for.  So my questions are:

1. What other procedures do I need which will help to reduce the flank areas and outer thigh areas (lipo, lifts, different abdominal procedure?).  I am not interested in the inner thigh at this point, but I would like surgery results closer to the “after” picture than what the one procedure appears to be able to provide.
2. By adding these procedures how much additional time or what will the total surgery time be? Given my age, do you consider this extended time to be a concern?
3. By adding these procedures what amount of recovery time do I need to plan for.  (My daughter is getting married in late June and activities are already planned for mid-June.)  Will a mid-April surgery date, if available, give me the necessary recovery time to fully enjoy the wedding activites, anticipating no surgery complications?
4. Will I need to plan more time off than just the day of and day after surgery? 

A: The concept of a ‘natural’ look after a tummy tuck is open to wide intrepretation and is subject to one’s own perception. But in answer to your specific questions:

1. It is important to realize that you are not able to achieve the after picture that you saw. Your body is completely different in many dimensions and no amount of additional liposuction will make those type of changes.
2. If there is truly a ‘dangerous’ part of abdominal contouring, it is large volume liposuction that may accompany the procedure. It is one thing to do a little flank liposuction as part of a tummy tuck, but major liposuction places certain patients like yourself at increased risks and exposes yourself to some of the greater risks and problems that you have heard with other people. I would not recommend it for you other than some small contouring liposuction at the back end of the tummy tuck incisions.
3. When you think of any significant event that someone wants to attend and be truly 100% fully recovered, the minimum time for the surgery before the event would be 8 weeks.
4. I would definitely plan for more than just one day after the surgery to return to work. For computer work at least a few days would be in order.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had combination malar submalar implants placed a year ago, but they were too big and I had them removed. I later decided to go with malar implants only, but they got infected and I had to remove them too. I guess you can say that I haven’t had the best of luck with these implants.

Anyway, what I’ve noticed is that there seems to be some sagging in the mid-face from the cheek implant removal, and I seem to have deeper nasolabial folds and some droopiness at the corners of my eyes too. I’m not too happy with this, and would like it fixed.

Would it be possible to explain to me what my options are? Are there any minimally invasive lifting procedures that can be done? I’m still young (mid-20s), so I would preferably like to avoid anything too extensive or invasive.

A: With cheeks implant removal of any style and size, tissue sag is inevitable due to loss of anchoring attachments of the overlying cheek tissues to the zygomatic bone. The only potentially effective treatment would be cheek soft tissue resuspension. There are multiple ways that cheek resuspension can be done from using intraoral, lower eyelid and temporal suspension points of anchorage. One can debate whether any of these techniques are less invasive or extensive than the other, but I would not make much of a distinction between them. It can also be debated as to which of these cheek resuspension techniques is more effective than the other. But that is probably more surgeon dependent than technique dependent per se. Lastly whether they can create the more complete improvement that you seek (midface sagging, nasolabial fold reduction and corner of eye droopiness correction) is asking a lot of them.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 29 year old female and I am interested in a midface lift in hopes of achieving a cat eye look. I love how my hair looks when pulled back into a tight high pony tail. It gives me Asian eyes and lifts my cheeks.
I notice celebrities are having this look, people refer as the PILLOW… I read they have a lot of fillers and botox but i want something that will last longer.
I once had a temple lift with Endotine and done by endoscopic. I loved the results. It gave me exactly what I wanted…slanted eyes and my cheeks raised. But unfortunately it lasted no more than a month. My skin, just went back to it’s pre-surgery state.

So will a midface lift help achieve this for me? I see other questions you answered involving lateral canthoplasty, would that help as well? Which is preferred? Thank you so much for your time Dr. Eppley!

A: What you have learned from your midface lifting experience is that simply pulling on the skin up and back, like a tight ponytail, is not going to create a sustained result. It simply is not that easy. Such endoscopic temporal lifts alone  always fail because skin pulling/shifting alone is not the answer for raising the corner of the eye and keeping the cheek tissue lifted. A direct approach to the corner of the eye (lateral canthopexy vs canthoplasty) is needed in conjunction with a high placed cheek implant and and an excisional temporal lift. Like a strair step approach, lifting and support needs to be added at three levels to get a better and more sustained result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m not able to find any image for a “custom made vertical” chin implant. I’m trying to figure out what a vertical chin implant might look like,where it will sit on the chin bone or where the screws will be fixed.

1. Please can you show an image for a custom made vertical chin implant and where it will sit on the chin bone. Hopefully this type of implant will be able to augment 4 millimeters vertically.I read that extended anatomical gives a more natural fit?)

2. If a patient  already has a CT scan (including DICOM) of their current jaw/chin bone in order to design a custom made implant; how many weeks will they have to be in Indianapolis to have the jaw angle/chin implants made plus have the surgery done and be safe before they fly out of indiana back to their country? (4wks,6wks?)

(Just in case the implants may result in any infection, how many weeks should one really stay in Indianapolis and wait until it’s safe to know everything is OK before leaving Indiana/the US? Thank you

A: A custom chin implant can be made any way one wants or needs it to be shaped. It can provide the required vertical increase (4mms in your case) and has a lip or edge that goes up over the lower end of the chin bone so it can be secured into place by screw fixation. No standard or preformed chin implant today (other than my small vertical lengthening chin implant can create this type of chin change)

If one has an existing 3D CT scan that reflects the current jaw shape, it can certainly be used. The CT scan is simply sent to me and the implant design is done from here. There is no need for the patient to be here to have it done. The patient only comes in for the surgery and can return home in a few days. There is no need to stay here any longer. And staying here any longer has notbenefit from an infection standpoint. The infection risk is so low (less than 1%) with facial implants and its occurrence could be weeks or months later if it does occur.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am having breast implant replacements surgery one week from tomorrow.  I am going to send some photos of myself again and the final pic of what I would like to get close to ( yes I know I’ll never be them or anyone else) just looking to getting close to that result. I also realize you told me I’d have to give up silicone and go with saline overfilled. You had me at 655cc Sientra high profile silicone, but if I need to stay with saline to even go in that direction of a result I understand. Also, I understand you won’t be able to use my previous under the breast incision, but the aerola one. The picture I am sending is close to my stats, although I don’t know exact size I know I was an A before I ever got implants too and I don’t know her bwd measurement. Looks like she has 700 silicone ultra high profile, but then again I have the sag that filters in too. Thank you again for your patience! You don’t know how much it is appreciated.

A: Your breast implant replacements choice is a tough one because there is no ideal solution. Each implant size type choice has its own aesthetic tradeoffs. To get a really round look, it is going to take significant volume. Given that you have roughly 350cc implants in place now, you would have to triple that volume to create a very full round look. Only saline implants will allow that volume by taking 700cc/800cc implant and overfilling them to 900cc to 1000cc volumes. (e.g., Allergan high profile round saline 750cc implants)  That will pick up all the loose skin and fill it out but to do so will likely make you bigger than the pictures you have shown. Your natural breasts have a bigger base and a lot more loose skin than any of the ideal pictures you are showing. In addition, it is important for you to realize that even at these volumes your breasts are not going to be lifted per se. They are going to stay where they are and just bigger in that position. In conclusion with overfilled saline implants, it is important that you will have to accept a very large round size that sit slower in your chest wall than you desire. The only way to get around the sagging issues is to have a breast lift first and then six months have new implants placed. But because of the scars this is not on the table for consideration.

If we go with silicone breast implant replacements, it would have to be an ultra high profile implant at 700cc or 800cc volume with base widths of 13.5 or 14.2 cms respectively. (Allergan) In so doing you will get the most breast volume that can be achieved with silicone implants. But whether it will give that very round full look that you desire can not really be known until during actual surgery. It is just hard to predict what the skin will do with the volume. I suspect it will take the 800cc to get the best effect possible with this approach. Again, however, this will not lift up the breasts higher in the chest wall.

Regardless of the implant style and volume chosen, the safest approach in very large breast augmentations is with the areolar incision. This deuces the risk of bottoming out of the implants after surgery because it does not place a ‘weak point’ on the underside of the breast where a lower breast fold incision is placed. It is important to realize the stress of the supporting breast tissues that large implants place.

This should give you enough information to pick which implant type (saline or silicone) and their tradeoffs is most important to you.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I recently learned that I have two ruptured disc in my back and pressure on a nerve. I am wanting to know if I was to get a tummy tuck, liposuction, etc would it help with my back pain?

A: Whether a tummy tuck would provide any relief of our back pain would largely depend on the size of the abdominal overhang. Some tummy tuck/abdominal panniculectomy patients do report that they do have improvements in back pain after the procedure due to the loss of an overhanging abdominal pannus or even lesser amounts of skin and fat excess. But whether a tummy tuck would help you can not be predicted and is certainly not a common improvement that occurs after any abdominal reshaping procedure. Unlike breast reduction surgery which causes musculoskeletal symptom improvement in every patient, back pain improvement from a tummy tuck is far less assured. This is evidenced by the fact that no insurance company will approve tummy tuck surgery on the basis as a treatment for chronic back pain with or without ruptured discs and/or sciatic nerve pain.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in forehead and brow bone implants augmentation. I’m an Asian male, living in Korea, whose appearance is just like any other Asian’s. My eyes are very big for an Asian’s, but they are pretty much bulging. Besides, the prominence of my forehead and brow bone (I have heard that it’s called ‘supraorbital ridge’ or ‘supraorbital torus’) is very slight. It makes my eyes looked more bulging. And it also makes the distance between my eye and eyebrow look too far. All these all things make me look feminine. It’s really awful. Many people tell me that my eyes looked ‘faggy’.

So I’m considering the forehead and brow bone augmentation with intraoperatively applied bone cement. As you know, preformed custom implants easily makes
empty space between itself and forehead bone, and it can cause fatal side effects like dropsy. So I think bone cement will be better, but I want to know what
you think. I have wondered about this. For years, I have searched for a hospital who does forehead “including brow bone” augmentation surgery, but all hospitals in Korea told me it’s dangerous to use any implants on the brow bone, because there are much important nerve on brow bone region. So I had almost given up, and just at that time, I found your
website in google. So I wonder whether this surgery is really dangerous or not.
Finally, I wonder how much my forehead can be protrude by surgery. You know I am Asian, and I want to make my forehead and brow bone protrude as much as a Caucasian, if it’s possible. I really want to know whether it’s possible or not.

A: I have done forehead and brow bone augmentation over my career by every conceivable method including PMMA and hydroxyapatite bone cements, prefrormed Medpor implants and, more recently, custom forehead and brow bone implants.

Each of these methods have their own distinct advantages and disadvantages…neither one is perfect. Bone cements are very good to use but they require a lot of intraoperative shaping, can be very expensive (HA cements) and can lead to frontal bossing/protrusions if the forehead and brow bones is brought too far forward. (as bone cements should not extend beyond the anterior temporal lines onto the tenporalis muscle fascia where they will not adhere and can lead to visible edging). To place them well, they require a long coronal incision to get adequate exposure way down to the suprarbital ridge. They are also associated with modestly high revision rates particularly when the amount of augmentation needed/desired is significant.

Custom forehead and brow bone implants have numerous advantages over bone cements. Computer designing the implants allows much greater precision and control over the amount and symmetry of augmentation. They can be designed with forehead widening in mind in large augmentations as the material can sit without complications on top of the temporalis fascia beyond the anterior temporal lines. The potential open space under the implant (which I have never seen to be a true problem) can be circumvenyed by screw fixation and the placement of numerous perforation holes in the implant to allows for tissue ingrowth through the implant and down to the bone. A custom implant also allows for a smaller scalp incision to be used to place it since it already has the desired size and shape through preoperative designing.

There is no truth at all that forehead and brow implants are dangerous. They are no more ‘dangerous’ than bone cements. They do not cause ‘dropsy’.  They do not have a greater incident or risk to the supraorbital nerves than bone cments.They require the same amount of tissue dissection down onto the brow bones that bone cements do. Forehead and brow bone implants are just as safe as bone cements, they just are another implant option to consider for aesthetic augmentation in this area that has its own unique advantages.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a few questions about facial implants. Do tear trough, cheek implants, and orbital rim implants become visible as the skin ages? If I need to get them removed will it leave obvious scars? If I get the facial implants but later decide to get a cheekbone reduction would it affect the implants? Thank you!

A: This is a good question about facial implants and is not the first time I have heard it. I have not seen increased visibility of midface implants with aging but that does not mean it does not exist. It would depend on the patient’s face and whether they suffer significant fat loss in the face as they age. It would also depend on how much fat one has in their face and the number and size of midface implants placed.

The removal of implants does not usually any more scars than those that were used to place them. If you get cheek implants and then elect later to have cheekbone reduction, the implants may or may be in the way based on how far back the tail of the cheek implant goes. Usually the implant would be in the way but it could easily be displaced so that the cheekbone osteotomies could be done.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have had a silicone implant in my nose for 6 years. No major problems yet. Just pressure in the bridge area. Will the bone under the nasal implant resorb?? Was thinking about removing the implant because I don’t want to lose what bone I have in the bridge area. I am half Korean and half Caucasian with a relatively flat bridge without the implant. Thanks.

A: Bone resorption under a silicone nasal implant is very rare…to the point that I have never seen it or have seen it documented in the medical literature. (but that may be because x-rays are rarely taken of the nose to look for it) The likely reason is that of the three elements involved in this equation, an unresorbable silicone implant, hard bone and a thin overlying soft tissue cover, the weakest link is what lies above the implant. Rather than the bone resorbing underneath the implant, the overlying soft tissue thins in response to any pressure caused by the implant. Whether this will actually happens depends significantly on the size/thickness of the nasal implant and its durometer. (measure of its hardness) In conclusion I would not remove the nasal implant because of any fear of bone resorption. Be aware also that your nose will look flatter than before having the nasal implant because the overlying skin has gotten stretched and is now thinner as well.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting a rhinoplasty to straighten and reduce the hump on my nose. My questions concerns that I do not wish to go under general anesthesia and wish to be sedated and under local anesthesia instead. Please also let me know what you think in regards to whether I should also consider reducing the size of the nose overall or nostrils. 

A: Thank you for your inquiry. When it comes to anesthesia options for rhinoplasty surgery, that is highly influenced by the type of rhinoplasty being performed. If nasal osteotomies with hump reduction and/or internal nasal surgery is being done (septoplasty, turbinate reduction), local anesthesia with sedation is a poor and unsafe choice. These types of rhinoplasty induce bleeding down the nose and into the throat and risk aspiration and laryngospasm, two potentially deadly problems. A general anesthetic with an endotracheal tube is the only prudent way to have such a rhinoplasty. If no bone work is being done and no cartilages grafts are needed such as in a tip only rhinoplasty, then local anesthesia with sedation would be safe and tolerable.

I would need to see pictures of your nose (front and side views, non-smiling) to see what type of changes you desire/need by doing some computer imaging.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in rhinoplasty surgery. I hate my nasofrontal angle, it is very deep. I am not sure if I need to build up the bridge, reduce the projection of the tip, or both… I would value very much your learned opinion and recommendations.

A: A deep nasofrontal angle is often cased by a combination of factors including a low nasal bone height, an overprojecting nasal tip and low dorsum and, of equal importance, brow bone bossing/protrusion. In doing some computer imaging (which is attached) you can see that the effects of a rhinoplasty (radix/dorsal augmentation and tip deprojection/rotation) lessen the depth of your deep nasofrontal angle by about half. When you add in a brow bone reduction with the rhinoplasty (see attached imaging) the deep nasofrontal angle problem is completely solved. So you see  in your case, which is not rare, that it is really a combination of low nasal bones (45% of the problem), brow bone bossing (45% of the problem) and very minimally impacted by nasal tip changes (10% of the problem). For a female you have fairly prominent brow bones and that is most certainly a big part of the problem. There is nothing wrong with a rhinoplasty alone you just have to realize its limitations…it will make it better but is not the complete cure for it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I reviewed the jaw angle implants imaging you provided and have some questions about it. The left side seems slightly asymmetric to the left and the two sides of my face are not perfectly even. Is this the way the surgery will turn out?

A:You are way over reading the jaw angle implants prediction images. I have stated in the past these are approximates so see what direction/dimensional changes someone is looking for. They are not meant to be nor should you interpret fine details in them such as some asymmetries or slight differences in these dimensional changes. These are the variabilities of computer imaging and I also doubt that you are perfectly symmetric either. I should also point out that there are going to be postoperative amounts of jaw angle asymmetry. You will not have a perfectly symmetric result, nobody does. If a patient finds that these fine details are unsettling or is going to critique their postoperative results in the smallest detail, then they are going to be unhappy and have a very high risk of revisional surgery. I make these comments not to be unkind or unfeeling, it is based on a vast experience with male patients and facial surgery. And the goal is not do end up having revisional surgery on any patient.

The reality is that surgery is not an exact science no matter how much thought goes into its preparation and execution. It is an imperfect art practiced on asymmetric features that do not have completely predictable patterns of healing. Therein lies my caution to you. To have a satisfying jaw angle implant augmentation result, one must be prepared to accept some imperfections and realize that a close approximation of one’s goal needs to be good enough.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a lip corner uplift. The ends of my mouth are drooping and I wish to enhance the corners of my mouth so I don’t look depressed, when I am not! I have attached a picture of my droopy mouth for you to see what I mean. Thanks

A: A corner of mouth lift is the only surgical procedure that can change the inverted U-shape lip line into a straighter one. Injectable fillers can help provide some corner of the mouth lift but its effects are limited and only temporary.

While there is no question you would benefit from a corner of mouth lift, I do have some concerns about the small scars that result given your skin pigmentation. The most effective corner of the mouth lifts (traditional triangular excision) do leave some small linear scars that radiate outward from the corners of about 7mms. The other corner of the mouth lift technique is the ‘pennant method’ where all scars remain at the vermilion-skin border but it does not lift the mouth corners as much.

Given your Hispanic ethnicity I would tend to choose the pennant corner of mouth lift method so as to keep the scars at the vermilion-cutaneous location. I would accept the trade-off of a less result to reduce potential scar issues.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want to know the cost of fat transfer breast augmentation procedure. (fat injection breast augmentation) What is the time needed for prepping before surgery with the Brava bra? How long does the procedure take? Will there be any scarring?

A: Thank you for your inquiry. The first place to start in this type of breast augmentation is to determine whether you are a good candidate or not. There are many more variables in fat injection breast augmentation than in breast implant augmentation in determining a successful outcome. When using a breast implant, the final volume is assured regardless of the overlying breast soft tissues as the implant is firmer than they are and it provides a good push outward. Also whatever implant volume is placed will remain no matter the healing process and how the body responds to it. Picking a target volume is also assured although what implant creates the desired breast look is still as much art as it is science.

Fat injection breast augmentation is a completely different animal in  which achieving even a modest permanent breast size change depends on numerous factors. The key ones are how much fat you have to harvest, how much natural breast tissue you have, the tightness/looseness of the overlying breast mound, and what your breast size expectations are. There is also the unknown variables of how well the fat will survive, does one need multiple fat grafting sessions and is the use of the Brava device absolutely necessary. Lastly there is the expectation level of the patient and are they prepared to accept these unknown and costs that will substantially exceed what breast implant surgery costs.

To help you make this determination I will need to evaluate you. This can be done by sending pictures and height and weight numbers or come into the office for a more thorough one on one discussion.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I reached out to you last year regarding a consult for reconstructive facial surgery following an ATV accident several years ago. Since I have had several reconstructions and am now looking to improve my overall appearance and have reached out to you because of your experience in both aesthetic and reconstructive plastic surgery.  Your name was also mentioned in a report by Advance Medical as an expert in this area.

At the time, you had requested a CT scan of the face, which I did not have–but now have one.  I have attached photos, 3D reconstructed CT scan, and a brief medical history for your review.  The goals of surgery are:

– Improve symmetry of the face, especially involving the eye.  This includes the buldging of the eye ball itself, and position of the lid.  I fully realize that a full restoration of symmetry is not possible and that surgery on the opposite eye may be necessary to get the most aesthetically pleasing result.

– Reduce the appearance of the port wine stain on the left side of face, near the eye

– Reduce the appearance of the scar on left cheek

– Improve overall appearance, ie. what procedures could be done in combination to ENHANCE overall appearance. Would a strong chin/jaw divert attention from eyes?  Would other facial implants help?  Would removing the nose bump? (This is why I value your experience in aesthetic plastic surgery)

I know you are very busy and I appreciate you taking a preliminary look at this case for consult.

A: Thank you for sending your pictures and 3D CT scans. What they show is that despite an excellent anatomic reduction of the fractured zygomatico-orbital bones (and an infraorbital-malar implant) your face is not normalied. The problem now, and is a quite common one after facial trauma and multiple reconstructive surgeries, is that the original injured tissues have become ‘skeletonized’. There has been loss of subcutaneous fat with scar tissue that has caused lower eyelid scar contraction as well as the lower facial scar prominence. I think that the left eye does not really bulge but that the lower eyelid is vertically short and contracted, exposing more sclera in that eye.

From a reconstructive standpoint focusing on the original injured tissues, I would recommend the following:

1. Lower Eyelid Reconstruction with Dermal-fat Graft and Lateral Canthoplasty (your prior canthopexy was insufficient)
2. Left Geometric Facial Scar Revision (your prior laser resurfacing probably made little difference)
3. Injection Fat Grafting to Left Cheek and Infraorbital areas (the tissues don’t need suspending, they need more volume.

From an aesthetic standpoint, I would need more pictures for better assessment for both rhinoplasty and jawline enhancement.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m really pleased to know a chin implant can be a solution after my chin and jaw angle reduction surgery which has left my face deformed. I’ve sent pics to show how my chin dips in side profile and how the chin area directly below my lower lip protrudes when I smile. I think this is related to mentalis suspension? Really want to get rid of this protrusion, not normal looking.

1. Can vertical chin implant get rid of this protrusion under my lower lip?
2. Does a “mentalis resuspension” mean, cut along the gum line and stitch it again with a new stiching line in a different place? What does mentalis resuspension mean?
3. What is the risk involved in mentalis resuspension? ( Or could it result  in a worse bulge/protrusion or some other complications?) Or should I best leave it, if it’s going to risk resulting in a worse protrusion or some other complications.
4. The center that did my CT scans seem to think that my jaw angles have been over cut (surgeon took too much bone off?), it was not cut straight and I have indented jaw angles? Does it look as if my jaw angles have been over cut? ( CT  scan attached)
5. Is it best I get a chin implant and 2 jaw angle implants? Or is it best to get a one piece implant that goes from one side of jaw angle ,across the chin, to the other side of jaw angle?
6. Are there any down sides to having screws in your face bones? How many screws will it take to hold the implant(s)in place?
7. I read online that a silicone jawline implant does not give good defined bone shape/anatomy, but acrylic PMMA is able to give that defined bone structure, is there truth in this ?

Thank you so much.

A: Thank you for sending your pictures of you and your 3D CT scan after your jawline narrowing or V line jaw reshaping surgery. In answer to your questions:

1) Vertical augmentation of your chin will help with the protrusion as the origin of the problem is the loss of volume from the previous chin reduction.

2) Mentalis resuspension is an intraoral technique where the mentalis muscle is repositioned higher on the bone.

3) The only downside with mentalis muscle resuspension is in how well it works. It has no other downsides and will not make what you have now worse. I do not think, however, that mentalis resuspension is needed for tour chin problem and implant augmentation alone is a better approach.

4) Your jaw angles do look over cut with a severe 45 degree angle to them. That matches with how you loo on the outside of your face. (the indentations over the angles)

5)  Unless you want the side of the jawline augmented (which I do not think you do as there is a reason you had the original surgery…a narrower jawline), I would go with a three piece chin and jaw angle implant approach. They need to be custom made and I would design them as a single attached jawline implant (because it will cost you less to do so) but in surgery I will convert it to three pieces.

6) There are no downsides to have small 1.5mm screws in your jawline for fixation of the implants. They are roughly the size of the screws used in eye glasses.

7) A custom jawline implant, made of silicone, creates the best jawline definition and shape over any other material. PMMA would be the worst material to use since you have to shape it during surgery and achieve any symmetry and good shape between the two sides of the jawline would and be virtually impossible. Anyone who would say so otherwise is inexperienced and ill informed and does not have a contemporary understanding of facial implant materials and how to design and place them.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in facial fat removal after fat grafting. Two months ago I had fat injected to my bottom cheeks (30 ccs of fat) and the result was horrible! Is there a way to remove this fat? Would be difficult to remove it all? Won’t be there any side effect resulting from the liposuction?  And what about Lipodissolve (phosphatidylcholine), does it help melting out the fat? Would Lipodissolve eventually at the end of the required sessions would melt the unwanted fat? Unlikely liposuction, lipodissolve can be injected to muscles, right? Actually I am desparate and am going through a very difficult time because of my face and want to remove/melt as much of the injected fat as possible. How many sessions of Lipodissolve do you think I might need? And how long should I wait to get my old look back?

A: Thank you for your inquiry and sending your picture. Most likely some of the fat can be removed by small cannula liposuction. (microliposuction) It is important to realize that all of the fat may not be removeable. If some of the fat is on the muscle then that portion can not be removed. One must also be careful to refrain from too aggressive liposuction is this area to avoid injury to the buccal branches of the facial nerve.

The use of fat melting solution like phophatidylcholine (aka Liposdissolve injections) is that their effects are unpredictable and will require mutiple injections sessions to do so. For one week after each injection session the treated area will be swollen and double in size. There is no assurance that any chemical method can get rid of all of the fat. It is unpredictable. You never inject Lipodissolve solutions into muscle unless you want to potentially damage facial muscles as well.

It is also important to realize that the Lipodissolve solutions used in the past were made by compounding pharmacies and were not FDA-approved. The only true Lipodissolve solution that exists today is known as ATX-101 and is under clinical trials by the FDA and is not currently available for patients outside of the clinical trials. (it is only being tested for the reduction of submental neck fat) It will likely be fully approved for general patient use in later 2015 or early 2016. Thus there is little reason to continue the pursuit of Lipodissolve injectiojns as it is not available currently. (unless one wants to use unapproved solutions from compounding pharmacies)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a tummy tuck with breast augmentation at the same time. Do you include contouring with tummy tuck? Will I still have all the feelings in my breasts after augmentation. I want to go up one to two sizes. What would the cost of these surgeries.

A: Thank you for your inquiry and sending your pictures. You are a good candidate for breast augmentation and most patients will not lose nipple or skin feeling in their breasts after the surgery in the long-term. However, at your current weight and with the amount of intrtaperitoneal abdominal fat that you have you are not an ideal candidate for a tummy tuck based on what I am seeing these pictures. With this amount of abdominal fat, it will be limited as to how much skin and fat can be removed and most certainly your stomach will not be flat and will remain round. (less so but round nonetheless) You would get a better tummy tuck result if you lost some weight first.

There are numerous variables that affect the cost of breast augmentation and tummy tuck surgery. (type of implant, type of tummy tuck, how much liposuction is needed) So I will make some assumptions when I ask my assistant to send along the general costs of both procedures to you on Monday.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I got temple implants and they are causing me so much pain whenever anything touches the side of my head. Could it be pressing a nerve? Will I have saggy skin if I remove them? It was silicone  temple implants and I can feel a bump on one side (the side which hurts). It is like maybe the implant has shifted in to a strange position because it isn’t painful or bumpy on the other side. Is it quite easy to remove?

Also I notice it made my cheek look fuller and less hollow. Is that because they rest inside the zygoma arch? And therefore my previous hollow cheeks are not as hollow anymore? Does that happen as a result? I miss my sculpted cheeks. 

A: I am sorry to hear of your problems after temporal implants. Having done a lot of temple implants, these are symptoms that I have never seen nor can I imagine why they are occurring. In my experience, I place silicone temporal implants under the fascia so they sit on top of the temporalis muscle belly. They have never caused any pain or muscle dysfunction by doing so. I would have to know more about your temple implants (material, location of the implant and the incision used to place them) to see if I can determine if there is some explanation. But rest assured that if you removed them, there would be no loose or saggy temple skin.

The good news is that silicone temple implants are easy to remove. You did not tell me whether they are above or below the fascia but you probably don’t know that detail. (that would be in the doctor’s operative note) The difference between the two sides suggests that they indeed are in different positions. (maybe one is below the fascia and the other above it)

With subfascial temple implant placement (the proper temple implant location), there should be no change in the appearance of your cheeks. Sitting under the fascia and not really inside the zygomatic arches (they sit above it), they would not cause any change in cheek contour. Only if they are sitting above the fascia would a change in cheek appearance occur as they would make the cheek look fuller up top. It would be helpful to see pictures of your face and these implants to better answer this question.

It is unclear based on your problems as to whether our temple implants should be removed or placed into their proper position if they are indeed above the temporalis fascia.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a chin implant placed submentally in June 2014 and removed in September 2014 due to neuralgia and difficulty smiling/moving. The implant was placed through a submental incision, medium mittleman pre-jowl implant through same incision. Now that 4 months has gone by, my chin sags and the muscles are stretched. It looks fine at rest but when I smile it rolls off the chin and dimples. I am devastated. I am determined to have this fixed. How long should I wait before considering surgery to repair?

A: As you have surmised, chin implant removal can cause sag of chin tissues which often is most apparent in dynamic motion such as smiling. With your face type why you had placed a longer winged pre jowl implant is puzzling but that is beyond the scope of this answer. That longer style implant strips off more tissue along the lower edge of the chin and mandibular bone. While usually that would restick back down into place after such a short period of implantation, yours obviously has not. How to treat this type of chin ptosis is difficult but there are two basic approaches. A submental approach aims to remove and tuck the loose tissues from the underside of the chin but does so at the expense of a submental scar. An intraoral approach aims to tuck the loose tissues back down/up but its success often depends on placing a small chin implant (button type) that helps fill the space where some of the original implant once was. (center of the bone) There are advantages and disadvantages to either approach as I have mentioned.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am looking to get breast implants. I am 5’ 9” inches tall and weigh 165 lbs. I am currently a B cup and would like to go to a C. My husband wants me to get DDs. I am not completely opposed to that. I just want to make sure they will be proportional to my body. How do you go about making sure that the breast implant size is not too big and looks disproportionate to the rest of your body?

A: As for choosing breast implant size, I use volumetric sizers in the office to help me the best choice for you. We do not choose breast implants by cup sizes since they do not come that way. Rather they come in ccs (250cc, 350cc etc) and the goal is to see what breast look you prefer and feel is proportionate. Whatever cup size that ends up being afterwards is unknown and largely irrelevant since that is just a number. What you ultimately care about is how your breasts look whatever the numbers turn out to be. (volume or cup size) The look of the augmented breasts are far more important than any numbers.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I need calf augmentation for club foot. I just read about Stem cell fat muscle augmentation. I would prefer that because its more natural and fat would be taken from the same body. Besides, I learnt that with age implants would have to be removed because of blood circulation. I want something permanent for the rest of my life. I am a size 8-10 and hoping you would find some fat in my thighs (though small) and other areas to work with. Kindly advice.

A: Unfortunately you have numerous misconceptions about fat grafting and calf implants. While fat grafting is an option for calf augmentation, you do not have enough fat to harvest to make the procedure worthwhile. Small thigh areas are not going to cut it for adequate fat donor sites. Besides the donor fat issue, there is also the variability of how well fat will take and persist. In thin people this is usually very poor. Tight tissues, like a small calf in clubfoot, also work against fat graft survival and ‘squeeze’ out most of the injected fat. Fat grafting still may work if one is willing to do two or three fat grafting sessions to bypass these issues, but again there has to be enough fat to repeatedly harvest for the procedure. Lastly anytime you see the phrase ‘Stem Cell’ associated with any plastic surgery procedure, that is all hype and marketing. There is no proven science that demonstrates the role that stem cells have in fat transplantation. It sounds good but, in the end, it is just fat grafting.

The only proven procedure for calf augmentation for clubfoot is an implant. That is the only way to assure a visible volume result that will be permanent. I have never heard or seen the issue of ‘implants having to be removed because of blood circulation’. If that have any validity every breast implant would eventually have to be removed because of it. This implant contention has no scientific basis.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m interested in knowing more about the liposuction for calves and ankles. I’m 24 years old and am 5’ tall and weigh 140 lbs.. Many surgeons where I live have refused to perform liposuction in that area because of the risk of prolonged edema. I was wondering how much you would charge for liposuction of the entire leg( thighs, calves and ankles). Also, can I expect the whole leg to be done in one session? Thank you very much. I look forward to hearing from you.

A: What you referring is, as you have mentioned, total leg liposuction or near circumferential extremity liposuction. Your surgeons are correct in my opinion that performing liposuction on the whole leg will result in prolonged edema. And it is even possible that some of the edema may even be permanent. (rare risk) It is much more prudent to think of trying to thin the whole legs in two stages, upper (thighs) and lower liposuction. (knees to ankles) The lower legs should be done first, followed six months later by the upper leg section. This is the safest approach to prevent prolonged lower leg edema and also provides an opportunity to touch up any uneven or under corrected areas on the lower leg.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a mini tummy tuck. My main concern is the recovery. I exercise daily, Pilates and tabata a few times a week. I just think of the time away from that and I cringe. Recovery time is a concern also because I travel a lot and if I’m going to do this I want to do it soon before our next scheduled trip in June. I have attached a picture. I know with the stretch marks I’m going to be scarred anyway but losing the excess skin would be fantastic.

A: Thank you for sending your picture and expressing your concerns about the procedure.  Between the picture and your concerns, the reality is that the mini tummy tuck is probably the not best procedure for you. In addition your recovery concerns are not going to be surmounted by having a ‘smaller’ tummy tuck operation. You have so much loose lower abdominal skin that a mini tummy tuck is going to produce a very subpar result. Even with a mini tummy tuck when you bend over there is still going to be loose skin that hangs between your belly button and the lower scar line. To really get rid of the maximum amount of loose lower abdominal skin a full tummy tuck pattern is needed in your case. While there is nothing wrong with choosing a mini tummy tuck for a smaller and lower scar, it is important to understand and accept that its improvement will be far less than you may expect.

The amount of abdominal skin to be excised aside, it is a significant misconception that the recovery time for a mini tummy tuck is really smaller than a full one. The stark reality is that regardless of the tummy tuck operation chosen you will need a minimum of three weeks away from such strenuous activities that you love.  The biggest risk and complication that every tummy tuck patient faces is that of developing a fluid collection (seroma) due to early and excessive physical activity. Once a seroma develops it will set back recovery a month and will result in the need for weekly aspiration of fluid and the risk of lower abdominal skin contracture/deformty. It really doesn’t matter whether it is a mini- or full tummy tuck this risk is the same. In fact it is a higher risk in mini- tummy tucks because the patient often thinks it is ‘less’ of an operation and they can go back to full activity as soon as they feel like it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Would temporal implants cause any facial muscles movments difficulty? For example, it wouldn’t look natural when doing facial expression?

A: Temporal implants are placed in a subfascial position over the temporalis muscle. The temporalis is a muscle of mastication (chewing) not of facial expression.  It can not affect any aspect of how the face moves in making any form of facial expression. The temporalis muscle is attached to the lower jaw and it major responsibility is in elevating or closing the lower jaw. But since the immplant sits on top of the muscle (but under its fascia) it causes no interference with jaw movement or jaw closing either.

Temporal implants are designed to be add visible volume to the temporalis muscle in the area above the zygomatic arch and to the side of the eye. It is maintained in its subfascial location by being bigger than the circumference of the space inside the zygomatic arch and the bony coronoid process beneath it. Because the implant is smooth the temporalis muscle glides smoothly under it without interference or scar contracture. Its add permanent volume which makes it superior to temporary fillers and fat injections.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Thank You so much for your time and your quick response to my questions about maxillary setback surgery. Would there be any possible alternative to the use of orthodontics which I’m hesitant of because of my age? (65 years old0 Perhaps wiring the mouth shut post surgery for a longer than normal period of time?

One reason I chose to contact you is because I could see from your website your practice  seems unique in that you do a wide variety of plastic surgeries and are involved with developing research and studying the latest techniques while at the same time you have a of experience in maxillofacial surgery as well. When searching for a doctor I had originally thought of those with practices limited to oral and maxillofacial surgery but I felt led to contact you when I saw your website. I have contacted no other physician as I am praying you can help me.

I know you have to be incredibly busy but I would greatly appreciate it if you could give me a few minutes of examination time and take a chance on me. Thanking you again so much for getting back to me.

A: In traditional jaw surgery the key element is how the teeth will fit together when one or both bony jaws are moved. That is the actual purpose of orthodontics…to get the teeth aligned for their new jaw position and to correct any malocclusion or dental aligment issues that result afterwards. So keeping the jaws more immobilized (wired together) is not a solution for overcoming malocculsion issues that may be created by any jaw movement issues.

At 65 years old it is perfectly understandable, however, that orthodontics in not in your ‘future’ and is not the best from either a periodontal/root resorption issue or the time involved to do so. Thus an alternative approach must be looked at and there are viable options based on the exact nature of your overbite/upper jaw problem. A premaxillary setback (with premolar tooth extraction) is an option that would allow the upper teeth in the front (incisors and canine) to be moved back into the premolar extraction defect. This would also allow your existing molar occlusion to remain as it is which is critically important for eating. This is also a less extensive procedure than a complete maxillary setback and allows more setback movement anyway.

The way for me to know the feasibility of a premaillary setback is to see you and analyze your dental models and x-rays. All I need is for your dentist to make simple stone dental models and a panorex x-rays. (which most dentists can easily do) Looking at you in person with that information will answer the question if this will work for you

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Here you have some pictures 3 months post op from my custom malar-infraorbital and custom jawline implants. As you can see all (or almost all) of the swelling in the jaw and chin area has subsided. There is still some swelling (or puffiness) under my eyes but that is slowly improving. To this date is a bit better than in the pictures. The scar under the chin is almost imperceptible and I can shave without feeling anything.The blepharoplasty scar at the corner of my eyes are less noticeable. I am happy with the result and I think it definitely is an improvement. I’d like to ask you about your opinion on a second implant advancing my chin still a bit and pushing the jaw angle a bit backwards (I am happy with the width of the jaw but I wonder how feasible it would be to take it a bit lower and backwards)

A: Thank you for the followup. In looking at your before and after pictures, I would agree that there has been overall improvement in both the eye/cheek area as well as the jawline. It looks natural and not overdone. I would also agree that we certainly did not overdo the jawline (which was an initial concern) and there is room for further chin and jaw angle improvement through a redesigned implant. The good news is that a new custom jawline implant is so much easier the second time because there is already a pocket in place so the trauma of extensive soft tissue dissection is over. Also we have the advantage now of knowing what the existing custom jawline implant does and that makes it much more predictable in terms of how to redesign a new one for added augmentation benefits.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve given it a lot of thought and done some research over the internet. I’ve been having problems resulting from a previous jaw/chin reduction. And I really want my face bone structure to go back to where it was, or close to my original chin/jaw line. I need help and really want a chin/jaw implant(s).

See my chin in 2013 CT scan. A surgeon reduced my chin in 2013, I had a CT scan in 2014 and realised the surgeon took off about 4.27 mm. Until this day, the soft tissue (chin area) just has never felt right. It feels out of place, uncomfortable. I’m always pulling my chin skin down. The chin skin dips down when I smile. (side profile) I have 2 new dimples. My chin area, just right below my lower lip(right side), protrudes when I smile. (very noticeable) I hope this is not to do with mantalis suspension. The stitching line which the surgeon has done does look lower than my original mantalis line along the gum line right below my lower teeth. Saliva also drips, when I sleep, drips down the corner edge of my right side lower lip (I’m not so bothered. But I don’t know if it’s implication of any issue? 

I really want my old chin back with a chin implant; hopefully it will solve some problems. I’d rather have chin implant incision under my chin, it sounds like the incision inside the mouth can affect the muscle or tissue affecting the lips?

1. Is it possible, that I have my chin augmented so that it will be the same as my original chin in 2013 CT scan? (Unfortunately, the CT scan in 2013 is all pictures, no raw data, so I don’t know if that  CT scan can help in making a chin implant to achieve the original chin size or length?)(However, my new 2014 CT does have the raw data needed to make custom jaw/chin implants. But my chin has been reduced on 2014 CT)

2. What kind of chin implant will I need, vertical or horizontal? (I dare not do chin sliding osteotomy.)

3. Logic tells me I will also need to do a jaw line augmentation to line up with my desired chin. I’m thinking it’s best to do a custom chin/jaw implant. So will this be  3 pieces implant or 1 implant that wraps around? For best results.

4. What material will the implant(s) be made of? If silicone, what kind of silicone exactly? Heard of silastic but usually associated w/ chin implants. 

A: Thank you for sending the pictures and a detailed description of your chin concerns. Based on the pictures I assume your chin reduction was done through an intraoral approach. An intraoral approach to a vertical chin reduction should be done by a vertical wedge ostectomy through the middle of the chin bone (vertical reduction bony genioplasty) to preserve the attachments to the bottom of the chin bottom to prevent soft tissue ptosis. (or an empty soft tissue pocket as the chin tissue will fail to adhere to the bone) In looking at the CT scan, and it may be a function of your drawing, it looks like just the bottom of the chin was cut off. (a lower chin ostectomy) That would be a very unusual approach to a vertical chin reduction but would account for many of your current symptoms. This you have two current problems, an aesthetically shorter chin (which perhaps may not be a concern for you) and soft tissue chi ptosis/mentalis sag.

The optimal way to correct these chin concerns is a custom chin implant with a jawline extension as a one piece implant. (one could argue that a vertical lengthening bony genioplasty would also be appropriate but you have excluded that option. While there is no true way to know exactly match your previous chin (since the DICOM data is not available), the design could be reasonably guessed. It is only a question of how far back along the jawline one wants to go. This looks like it would be a pure vertical lengthening chin implant. Such custom chin implants are made of solid silicone material. The term silicone and Silastic are synonymous. The name Silastic was trademarked in 1948 by the Dow Corning company for their silicone polymer product and it is name that is still occasionally used today been though the Dow Corning company no longer makes any aesthetic silicone products.

This custom chin implants should fill in the loose tissue at the bottom of the chin and eliminate that feeling of looseness of the soft tissue at the end of the chin. The only residual concern is that of your salivary drooling and that raises the question of whether mentalis muscle resuspension should be done at the same time. If you have lower lip incompetence/sag I would say yes. But if not I would leave it alone and see effect the chin bone restoration achieves.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am an otherwise very thin healthy 42 year old female searching for a forehead augmentation solution to my upper forehead contour defect. I had what would be considered minor trauma in 2010 (struck forehead on breakfast bar) with a resultant depressed skull fracture. To fix the resultant indentation I have had 2 fat grafts and several Radiesse injections with no resolution. Is there any hope of a repair with a closed procedure; something akin to Artefill w/o Bovine Collagen (allergic)?  Bone graft?  Stem cells?  Can frontal bone be shaved down to create a smoother contour endoscopically?

A: I am not surprised that your frontal defect in the upper forehead could not be adequately contoured/restored with any of the injectable methods that you have had. They simply will not work for a bone contour defect nor is there are injectable material like fat or any other synthetic filler that will work.

There are a variety of minimally invasive procedures, however, that will work for your type of forehead augmentation. Through a small incision in the scalp (3 to 4 cms) done endoscopically, a variety of implant materials can be introduced to smooth out the upper frontal bone depression. These can include PMMS or HA bone cement or even a small semi-custom or custom implant. These are all procedures that can be done under local anesthesia/IV sedation. The most economical approach would be PMMA bone cement. I will have my assistant Camille pass along the cost of the procedure to you tomorrow.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, about four years ago I emailed you with questions surrounding an injury I sustained to my eye and cheek area some 20 years ago. Again briefly, I was assaulted and never had my cheek and eye fixed. Now I would like to because of the appearance I see in the mirror of a flattened left cheek and slight drop under my left eye. I could not have the procedure done when I first contacted you because of the finances and then the collapse of the economy. But now I am in a position to have the work done and I think and feel you are the best doctor qualified for the job. Can you please provide me again with what would need to be do be done as far as if a CT scan is needed, measurements need to be made and things of that nature. In the light, up close and when I smile, I look fine. But when the lights are dimmed and looking at my face from a distance, the obvious damage and asymmetry is noticed. It is as if I can see the imprint of a fist on my face. I want the left side of my face to be even, full and balanced like my right side. I have included some new pictures. Thank you for your time and please respond and help me if you can.

A: I remember your inquiry and your face problem quite well. You obviously had a cheekbone fracture that resulted in flattening of your cheek bone area as well as along the infraorbital rim. Fortunately your eyeball position looks fairly even with the right side  (at least based on the pictures) so no orbital floor or lateral canthal work needs to be done. I think cheek augmentation alone should suffice and the cheek implant needs to be put up high on the flattened cheek bone. Fat injections also need to be done to build up the cheek area where the implant will not reach. We could get a 3D CT scan but that will probably not change your surgical needs unless we decided that a custom made cheek implant would be used for the reconstruction.

Dr. Barry Eppley

Indianapolis, Indiana