Your Questions

Q: Dr. Eppley, what can I do to make sure my breasts won’t be too far apart after getting breast implants? I know that breast augmentation doesn’t change where your natural breasts sit and that it only enlarges them. But I simply don’t want my new breasts to be too far apart. What can I tell my surgeon to make sure that my breasts are full and close together?

A: You are both asking a reasonable question abut a common breast augmentation concern and also answering it at the same time. You have correctly surmised that all breast implants do is make your natural breasts fuller. That may or may not necessarily make them somewhat closer together depending upon the size of the implants. But there is no guarantee that they will and there is not anything your surgeon can do to change the natural wide spacing between your breasts. You will need to accept that this is a limitation of breast augmentation surgery and is a function of your anatomy and not your surgeon’s technique or ability. At the least, every plastic surgeon recognizes and understands this implant spacing concern…and usually goes to great lengths to point it out and that your after surgery result is still going to have a sternal gap between the augmented breasts.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was wondering if it would be possible for you to perform a genioplasty subtle enough that my friends and family will not instantly wonder what happened to my face. I plan to not tell anyone about my surgery, so this is important. I really only want it moved forward a couple millimeters at most so that it comes closer to sticking out as far as my lips. I’m fine with the shape of my chin and the shape of my jaw. The effect will hopefully be more like “oh look he grew into his face” and less like “what happened to his face??” How much recovery do you think I will need until I look normal?

A:You can certainly only move a sliding genioplasty a few millimeters (3 to 5mms) of that is all one desires. And in looking at your profile picture, I would say that is all you really need anyway. While it appears you are set on moving the chin bone I might point out that cutting the bone for that amount of small horizontal change seems like a big effort. Such small sliding genioplasty movements are usually only done with it is part of an overall orthognathic surgery of the jaws where one is already in the operating room asleep and bones are already being cut. But when done as an isolated procedure a chin implant seems far simpler with a much quicker recovery.

For a sliding genioplasty I would give yourself 2 to 3weeks until you look fairly normal and have an unoperated appearance.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m very interested in deltoid implants. I have a very narrow biacromial width and an ectomorphic body type. Tendonitis in the wrists for years has lead me to be unable to engage in hypertrophy training with free weights so I’m looking for an alternative solution to help overcome the insecurity that comes from having narrow shoulders. How much width can be added onto the shoulders and how soon would I be able to have the surgery.

A: When considering deltoid implants, it is important to know the exact location that the deltoid muscle needs to augmented. While the deltoid muscle forms the rounded contour of the shoulder, it really as three distinct sets of fibers or heads. The front head extends from the lateral third of the collar bone over the front part of the shoulder. The lateral head arises from the acromion process and covers the middle portion of the shoulder. The posterior head extends from the spine of the scapula and covers the back part of the shoulder/upper arm. While all three heads can be independently augmented, most patients are interested in the lateral head as this creates the greatest shoulder width. Incision location is best done at the back-shoulder junction and the implant placed in a subfascial location.

There are no truly preformed deltoid implants although they can be custom made based on the patient’s measurements. As an alternative, calf implants can be used as they are preformed and the medium size can add up to 1.5 cms in width per side and increase the muscle mass by over 100 grams of muscle volume.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was wondering about something I have which are weird cholesteral spots on my eye lids. What do you have to do to get rid of those, I heard the only way was plastic surgery? What would you have to do?

A: What you have are xanthelasmas which are well known fatty (lipid) deposits around and on the eyelids. They may indicate one has high cholesterol and is at risk of athlerosclerosis disease. Many treatments for xanthelasmas have been proposed from chemical peels to laser resurfacing.  Usually they are best treated by excision through small incisions. This is particularly true when the xanthelasmas become bigger and more tumor-like. (known as a xanthoma) Each xanthelasma is a small flat hard white deposit of lipid material.While a small number of them can be treated under local anesthesia, large numbers may require more of an anesthetic to comfortably remove them.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, my question is in relation to transgender plastic surgery of the face and body. How close can I come to looking like a real woman?

A: The concept of what constitutes a real women is open to wide interpretation. Since you are not a genetic female, you will never be a real women per se. But the question you are asking is whether any amount of surgical effort can make you look the ‘part’ and passable as a woman. This is a very practical question from both psychological and financial perspectives. You do not want to get caught in the ‘middle of the stream’ so to speak. Some may argue that if you can not get to the other side then why start the physical journey at all.

The best I can say is that those men who achieve that most successfully tend to be thin framed and thin skinned as these types of tissue can most easily reflect the surgical changes that are done underneath. This is true for both facial feminization surgery as well as body procedures like breast augmentation. Large facial features like a prominent jaw can be very difficult to size down to a more feminine look.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had perioral mound liposuction and buccal lipectomies a fews days ago to thin out my face. I have some questions about the facial swelling that I now see.

1) I’ve read there can be persistent fluid accumulation that could need to be aspirated…how do I know if I have this problem or just normal swelling?

2) Would wearing a compression garment facilitate faster resolution of swelling?

3) I’ve read massaging the liposuctioned areas can help resolve swelling…would you advise this or is it a better idea to just leave it alone and let it heal on its own?

4) The perioral region is much more swollen, stiff and numb than my cheeks. Is this normal? When I touch the area it feels hard under my skin. What is this? Swelling? Scar tissue? If scar tissue, how long will it take to shrink down?

A: What you are experiencing after facial buccal lipectomies and perioral mound liposuction is normal early after the procedures. But to answer your specific questions:

1) There is no fluid accumulation that will develop under the skin in facial liposuction. That is a phenomenon that is unique to body liposuction where large volumes are fluid are initially instilled (tumescent infiltration) to facilitate the procedure. Facial liposuction does not use this technique.

2) A compression garment will not facilitate the resolution of the swelling nor is it really practical to wear.

3) Digital massage (aka lymphatic therapy) can be beneficial for swelling resolution since it stimulates the lymphatic channels to open up by the pumping effect on the vessels.

4) The perioral region is stiffer and even more swollen than the cheeks because it is in a lower dependent position (gravity) and even the cheek swelling drifts down to that area. That is why the perioral tissues are so stiff.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Is it possible to install cheekbone implants while wearing braces? And if so, is it recommended? To be more specific, it’s reasonable to think that, once the braces will be removed and the teeth aligned, my face would appear different from now. Would it be unwise then, to undergo a surgery while not taking into consideration the aesthetic changes brought by the braces?

A: The question you are asking is whether braces distort the face so that it makes it more difficult to judge the effects of intraoperative sizing of cheek implants…or maybe whether cheek implants are even needed at all when the braces come off. The answer is no. Braces do create some lip distortion/protrusion but not above the dedntoalveolar facial level. They cause no facial changes at the cheek level. Only if the braces are in preparation for orthognathic (jaw) surgery with major jaw repositioning anticipated should the consideration of delaying cheek implants until afterward be considered.

From a technical aspect, braces do not impede or make the placement of cheek implants any more difficult than if they were not there. Cheek implants are placed through high maxillary vestibular mucosal incisions which are well away from the location of the orthodontic brackets and wires on the teeth.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, How accurate is computer imaging for various facial surgeries? I have had several plastic surgeons do imaging for a future rhinoplasty and it is interesting that are significant differences between what they show. It is hard to know what is realistic. I thought computer imaging would show a very accurate result. So why are these plastic surgeons imaging results so different?

A: While computer can take a picture and change a facial feature like a nose, the only way the software knows what to do is based on who is controlling the mouse. In essence, computer imaging is a reflection of what the plastic surgeon THINKS he/she can achieve. They are showing the type of changes they want to illustrate to you presumably based on their experience…and hopefully it is a reflection of what is likely to occur in their hands.

Therefore it is important to understand that facial computer imaging is a prediction…and hopefully that prediction can be achieved by actual surgery.

What I try to show in computer imaging is the MINIMUM result that I think can be achieved as that should be the basis of what motivates one for surgery. More may be able to be achieved but that should be viewed as a ‘bonus’ and not the basis of one’s satisfaction with the result. This becomes critically important in an aesthetic operation like rhinoplasty which is highly scrutinized by the patient afterwards.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I wanted to restore my cheekbones and the saggy soft tissue with an endoscopic midface lift after cheekbone reduction. I found a very good maxillofacial surgeon and a plastic surgeon who worked together to bring my zygomatic bone to the old anatomic position and lifted the sagging soft tissue. That surgery was exactly six weeks ago. I know that swelling from jaw surgeries are extreme and lasts a long time but I am very afraid because I still can’t see the Ogee curve and high cheekbones that I had before the zygoma reduction. There is an improvement but not so much. I don’t know if it is because of the swelling that are all around my mouth, nasolabial folds and upper lip or if he didn’t lift enough or what could be the reason for that? I know I have to wait six months until one year to see the result but what can I do if my surgeon didn’t lift enough. ( I trust him but I know that my case was difficult because of the cheekbone restoration at the same time) Is it possible to lift the fat pad again after one or two years or is it too difficult? Otherwise I don’t know what to do, it still look  a little bit saggy (maybe because of swelling)

A: With the scarred tissue from these two surgeries (cheek bone reduction and cheek bone elevation and fixation), it is highly unlikely you will get significant improvement with any type of attempts at midface or cheek lift. The tissues are both scarred and atrophic and their elevation will be both difficult and limited. While you need to let the swelling subside so you can judge the final result, I doubt it will be much different than before surgery. (remember the result is going to look worse as all swelling subsides.

Any effort at cheek sagging improvement in the future can only use the approach of adding volume to lift the sagging tissues…but that is exactly what you were looking to avoid from the beginning. (too much cheek fullness) I am afraid you have reached the point where the cheek result you have is as good as it is going to get unless you are willing to acccept other trade-offs.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 21 years old, 5 ‘0” and weigh105 pounds. Am I qualified for butt augmentation with fat. (Brazilian Butt Lift) If not what do I need to do to gain more weight or is there anything I can take to gain weight?

A: At your low weight, you are not a candidate for buttocks augmentation by fat injection. And there is no amount of weight that you could reasonably gain to get you to the point where there would be enough fat to make the procedure worthwhile. Even if you did gain a large amount of weight, the fate of the fat that is harvested and placed into the buttocks would be suspect with subsequent weight loss. Only buttock implants would be effective in someone who is so small with very low body fat.

Buttock implants are more reliable in terms of the volume that they provide (fat survives vary variably) but they have a higher rate of potential complications because they are an implant which is not naturally there. I would not say they are any less safe that fat, just that there is more potential complications and recovery than just using you own natural fat as the ‘implant’.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, A few weeks ago I had a saline filled testicular implant. While the surgery went successfully, I am very unhappy because the size is about half the size of my opposite natural testicle. I saw on your website that you use a silicone implant that is more customizable, would it be an option that I could have the implant changed? Also I live in California, but would be willing to travel to you if it was practical, whats generally the amount of visits and time between consult and surgery with this type of procedure?

A: Provided your scrotal skin can stretch to accommodate a larger size, I see no reason that an immediate or delayed implant exchange can not be done. It would be important to know what the size of the opposite testicle is by measurements as perhaps the current problem is because no specific sizing method was done. But your original implant efforts are not lost as, at the least, it has served to stretch out the scrotal skin.

While it is true that silicone testicle implants can be custom carved that is not usually necessary. With the largest silicone testicle implant being of the dimensions of 4.5 x 3.0 cms in size, that would be big enough for just about any man.

The surgery can simply be planned from afar. I would just need to know the current size (volume filled) of your current testicle implant. You could just come in for the surgery and any followup ‘visits’ would be done by Skype or email. For far away patients I have to be very practical about the patient’s travel issues. There is nothing one can not show me on a picture or Skype that would be unclear to me.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a rhinoplasty with rib graft. The surgery was to reduce the height in the bridge of the rib graft. Now the center vault of my nose feels soft, mushy. I think the surgeon removed my graft in the center bridge area. I am afraid, another surgeon said that if you remove the rib graft without replacing it, the nose can retract. Is this correct? How long do i have after the surgery to get a rib graft to replace what was taken out? Question, how soon after surgery can I have the rib graft replaced? I hope I phrased this correctly. Please help.

A: If I understand your situation correctly, you originally had an augmentative rhinoplasty with a rib graft. Then 11 days ago you had a revision to reduce the height of the rib graft in its upper portion over the bridge. Now there is a concern that the middle portion of the nose (or rib graft) is ‘missing’.(soft and mushy) It is unclear if the actual height of the graft in the bridge/radix area was adequately reduced or not. Since the tip also feels soft and high, I assume this revisional procedure was done through an open approach.

Your question is whether this missing portion of the rib graft should be replaced due to fear of irreversible skin contraction. I would not have similar concerns about the middle vault skin irreversibly contracting. While some skin contraction may occur, it can always be stretched out later to accommodate more graft material. If the tip in a rib graft rhinoplasty loses considerable underlying support, skin retraction there may be kore problematic. The real question is not skin retraction but whether you feel there has been adequate reduction in the bridge and/or too much reduction in the middle of the graft. While only being 11 days after surgery, swelling would usually make that hard to judge. But you are very familiar with after rhinoplasty swelling so you are in a better position to judge these early results than many. If one is convinced too much cartilage has been removed or additional adjustments needed, then that may be a valid reason for an additional revisional procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a large outie belly button that appeared after a prior abdominal surgery about ten years ago. Having had two children afterwards the size of the outie is increasing. Besides the outie, my belly button is way too wide and looks like a ‘sombrero’ to think of the closest analogy that I can. I have attached a picture for your assessment as to how fix this saucer-sized outie belly button. I absolutely hate it!

A: Thank you for your inquiry and sending your picture. Your large outie is likely the result of an umbilical hernia from your original abdominal surgery. (noting the midline abdominal scar above and below the umbilicus) Your belly button repair (umbilicoplasty) would require a combination of correcting the hernia and simultaneously converting the outie into an innie umbilical shape. This can usually be done successfully, particularly when one has the ‘advantage’ of being able to use some of the abdominal scar above and below the belly button. But the key is to repair the hernia which is pushing out on the belly button thus creating its outie appearance. The outie skin can then be tacked back down to the abdominal fascia, recreating an innie funnel look.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am looking into on behalf of my fiancé a tummy tuck. She has had two babies and has a bit of loose skin on her stomach that really gets to her. She wants it removed along with the stretch marks. We are just wondering roughly how much this would cost?

A: There are numerous types of tummy tucks based on the length of the incision, how large a segment of skin and fat is removed and whether it includes liposuction of areas beyond that of the excisional tissue removal. These different types of tummy tucks involve variable amounts of time to perform and this will affect the overall costs of the procedure. This creates a potential range of tummy tuck costs anywhere from $4500 to $8500. Obviously the bigger the type of tummy tuck needed the longer it takes to perform and the more it will cost.

Stretch marks will only be removed if they lie within the zone of tissue excision. Since the vast majority of stretch marks usually emanate in a radiating pattern from the umbilicus, those that lie above it and beyond it will remain. Full tummy tucks remove more stretch marks than limited or mini- type tummy tucks.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 39 year old male who had a left-sided sphenoid wing meningioma removed two years ago. The temporalis muscle didn’t reattach properly and is bunched above the zygomatic arch. I was wondering if you had experience correcting this asymmetry. You mention patients not losing function with a reduction of the posterior temporalis. Have you had the same results with the anterior temporalis? I’m am going to get Botox injections into the muscle bulge in a few weeks. If this doesn’t work well what are my surgical options? Thank you very much for your time.

A: Your pictures show well a detached anterior edge of the temporalis muscle which has contracted and bunched up done at the zygomatic arch as you correctly surmised. Since it is not possible to free up the muscle and stretch it out and resuspend it, temporal muscle reduction of the bulge would be the only treatment approach. Unlike the posterior temporalis, the large anterior belly of the temporalis muscle does carry with it some greater functional significance since it is attached directly to the coronoid process of the mandible. I think the approach of Botox injections is worthy of an initial treatment approach. Sometimes that can work extremely well while in others other moderate muscle reduction is obtained. This muscle bulge can be reduced surgically and that may be reasonable with augmentation higher up in zone 2 of the muscle since that now has more hollowing than the other side due to the muscle retraction. But I would first see how effective Botox may be before considering that approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I called you last week regarding my upcoming skull surgery with Dr. Eppley. I was wondering if there are clearly defined size restrictions on the silicone implant. My head is small all the way around so I’d like to augment both the front sides and the back. However I’m not sure if this would be possible without tissue expansion. Presumably, the answer would depend on how much I wanted to augment each area, so I’m wondering if there are some kind of numerical limits on that. 

I am primarily concerned with augmenting the frontal sides, so I need to figure out how much width I would need to sacrifice there in order to be able to do a little bit of an increase in the back as well. This is not something I would want to guess on or eyeball, so a little more clarification would be really helpful. 

Additionally, I want to make sure that if for any reason I have problems with the implant, I can get it removed quickly and for a small/ reasonable fee. I’m sure I will love it, but I just want to know that it can be removed if I really hate it for any reason. 

A: Your assumption that there are size limitations for skull implants based on how much the scalp can stretch is a correct assumption. Unfortunately there are no established methods or means to determine what that limit. It is exclusively based on my experience in doing skull implanty procedures. If the implant is being placed through an open coronal approach, the scalp does become fairly ‘stretchy’ and good numbers are about 7mm to 9mms all the around. That may not sound like much but in skull implants which cover a broad area that effect can be quite profound and more than one would think.

The beauty of silicone skull implants is that they are relatively easy to place and reverse if desired.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in jaw angle implants for the asymmetry between the fullness/width at my mandibular angles. I am lookingfor a Oral surgeon/plastic surgeon combo who has experience working in the mandibular area because a few years ago I had a BSSO and after the surgery this asymmetry became more apparent to me. I had synthetic fillers placed on the deficient side a few months ago and they worked well but I don’t know if this is something I am interested in doing for the rest of my life and possibly want a long-term fix. You seem experienced with this type of surgery and therefore I am reaching out.

A: Many times after a BSSO mandibular procedure there will be changes in the shape of the jaw angle area. This is due to either how the proximal and distal segments of the BSSO were put together, bone resorption or both. Jaw angle implants can reshape these areas nicely and the only question is whether they should be custom or off the shelf implants…that would depend on the magnitude of the deformity and how asymmetric the two sides are.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am very petite female 5′ 1″ weighing 1055lbs but have a weird lower body appearance with fat thighs. I got smart lip done on legs (outer thighs and above knees) almost 3 years ago. There was a lot of bruising and scars that diminished a lot after a year but I can never wear anything that is above my knees anymore thanks to the unevenness in the back of my thigh, loose skin and multiple banana roll like appearance right below my buttocks.What can be done to fix this? Looking forward to your advice and guidance. I have attached my picture. Is there any hope for fixing my banana rolls?

A: Your picture shows a triple banana roll on the left side and a double banana roll on the right. I assume this came from the volume deflation from the Smartlipo and perhaps the disruption of the infragluteal crease as well. Regardless of the cause, significant improvement can be obtained through a lower gluteoplasty procedure. (lower buttock excision and tuck = aka lower buttock lift or tuck) The banana rolls can be removed and a single infragluteal fold recreated.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m sure a surgeon at your level is capable of the best possible cheek augmentation results. However, for cheek implants performed in general, I am a little concerned about having found an average self-reported procedure satisfaction rating of only about 60% from this site called Realself. Could you tell me more about satisfaction-levels and potential complications for these procedures? Could they affect the shape of the nose?

A: It does not surprise me that the satisfaction rating for cheek implants is around 60% or roughly two-thirds of the patients that took the time to register their experience. While it is an apparently ‘simple’ procedure, it can be plaqued by problems of implant asymmetry and an inability to have achieved the desired cheek augmentation effects. It is important to remember that all facial implants, cheek implants included, are based on styles that presumably fit the average person. Often these implant styles, in my opinion, are dated and may not reflect contemporary aesthetic objectives. Thus surgeons are relegated to using cheek implant styles that are not really specific to the patient’s anatomy and may not always have a realistic chance to achieve the patient’s cheek augmentation goals. But plastic surgeons may due with what they are provided and try to get the result with the cheek implants that are available.

It is also important to note that cheek implants are paired unlike a chin implant which is singular. Since they must be placed independently and without full view of either one at the same time, the potential risks of implant asymmetry are increased.

Lastly, there is no training manual or intuitive aesthetic ability for plastic surgeons to knowing how to pick a cheek implant style and size. Cheeks, unlike chins, are more than just a single horizontal measurement seen in just one profile view. (which is how most plastic surgeons simplistically see the chin…unfortunately) Rather the shape of the cheeks is truly a three-dimensional structure (with four different aesthetic zones) where number and measurements do not help in knowing how to make a successful cheek augmentation change.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a rhinoplasty. I have consulted with a plastic surgeon who said I had thick skin and results would be minimal. I can accept this, however, I do believe that at least suturing the tip cartilage together would minimize the width. My goal is a narrower nose in general, but particular attention to the tip. Perhaps narrow the bone structure? I have always kind of wiggled my nose down which elongated it and made the tip smaller and less noticeable. Of course it manipulated my upper lip. Is it possible to take a pie shape of skin out of the side of each nostril to bring it down and narrow it? I do always seem to have a congested nose. If I pull outwards beneath my eyes I can breathe significantly better. My profile is acceptable. I appreciate your consultation greatly! 

A: By your description, it sounds like a rhinoplasty that includes tip width reduction by cartilage reduction and suturing, nostril narrowing and possible middle vault spreader grafts (although this would widen the middle third of your nose) and/or inferior turbinate reduction would help improve your nasal appearance and function. While it is true that thick skin does not a limiting effect on rhinoplasty results, I would not say that the results would necessarily be ‘minimal’ and that the desired tip changes seem achievable.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am aware of the custom cheek implants option and am actually looking to get those done. But before I get in to the questions I have a little disclaimer- the photos I’ve attached are merely for reference purpose. I know that these women have been photoshopped and what not and/or are genetically blessed with great cheekbones. I don’t look like them, nor do I intend do. Please don’t mistake the photos for me trying to get cheeks exactly like the celebrity. In your honest opinion, looking at the attached photos of the cheeks on these women- I’m talking about the placement on the face, the shape, the definition of the zygomatic tail etc. All of those factors put in, what cheek implants would give me a result closest to these photos. Malar implants? Or combined submalar implants? 

A: For many women, combined malar-submalar shell cheek implants would work the best as an off-the-shelf style. These can be placed high on the cheek bone and come forward to cover the submalar area. Probably the implant would have to be modified a bit (the tail and posterior submalar areas narrowed) to make sure that the arch portion does not get too wide in a superior-inferior direction.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve been looking into getting cheek implants for a while now, and I came across your helpful blog on my numerous exhaustive searches on the Internet for cheek implants. I was hoping I could get your opinion on one big question that I have- what kind of implants will give me the high prominent cheeks look, but with some fullness in the front of the face too. (The pictures show the look that I’m after) (I’d also like to point out that those pictures are just for reference, I do know that cheek implants won’t turn me into Rosie Huntington-Whiteley) want both, the definition from the side, the high placement and also some frontal fullness. Thank you.

A: While there are many different styles of cheek implants, it is important to realize that the look you are after is not likely to be achieved by standard stock implants. If you translate the look you are after to the type of cheek implants available, it is fairly easy to see that no such cheek implant style exists. (at least none that I would feel comfortable placing hoping to achieve that type of cheek augmentation effect) In my opinion, only custom designing cheek implants can create the style and size you seek. Then there is also the factor of your own cheek bone anatomy and how it may help or hurt the desired look…hence the benefits of a custom designed cheek implant style.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a male that has Scheuermann’s Disease and would like to know if having abdominal liposuction may help relieve some of the discomfort and strain from my back and neck? It makes sense to me since less fat would mean less strain Your thoughts on this?

A: I know of no medical evidence that supports abdominal liposuction as providing symptomatic or preventative benefits with this form of spinal issue. (kyphosis) Having said that perhaps if the abdomen was big enough and the liposuction of sufficient volume that there could be some potential benefit. However, most of abdominal fat in men is intraperitoneal and is not treatable by liposuction extraction. That is a fundamental difference between men and women in their abdominal fat distribution and shape.

Thus I am not sure if liposuction alone would produce an adequate relief of the abdominal ‘load’ that would translate into some form of back pain relief or prevention of further spinal kyphosis. It would make more sense to me that an abdominal panniculectomy would have such back benefits since removing an overhanging and heavy pannus is known to reduce lower back strain due to its size and the pulling on the trunk from hanging down below the waistline.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have very heavy looking eyelids. Would I be a good candidate for an endoscopic browlift or an eyelid lift? I have some concerns about making my forehead higher.

A: Your question is not an uncommon one as many people with ‘heavy’ upper eyes do have a combination of some degree of brow ptosis and redundant upper eyelid skin. In looking at your pictures, I think your heavy upper eyelids do fall into this ‘combo’ category and are caused by a combination of slightly low brows and upper eyelids that have too much fat and just a touch of extra skin. The question is whether a browlift alone (pretrichial not endoscopic so your hairline will not only not get longer but can even be lowered if desired), some upper eyelid skin removal and defatting or both would be optimally beneficial.

This type of periorbital decision can be difficult as you do not want to over operate but, by the same token, you do not want to under treat either.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Earlier this year I had my cheek implants removed and I feel a lot better that I did. The only thing is the hollowness that it created under eyes and lower cheek area. I feel that that this is due to the loss of cheek attachments and you have even mentioned so in one of your blogs. Do you know of any method to reattach the tissues to cheek and under eyes?

A: You are correct in that I have written in the past about your exact situation. Like breast implants once the cheek tissues are detached and stretched out for implant placement, they may not recover their original position after cheek implant removal. It is not so much from the tissue stretching but all of the cheek tissue attachments have been stripped off from the bone. Unless there was some specific method to reattach these tissues or lift them at the time of cheek implant removal, they may develop some sag off the cheek.

There are several methods to resuspend sagging cheek tissues. This can include a mitek suture anchor resuspension done intraorally or a suture suspension done through a combined temporal and intraoral approach. It is important to realize that this will help with cheek sagging and will have no effect on undereye hollowness.

An alternative approach is to simply have fat injections done to restore cheek volume and  fill in the under eye hollows at the same time. Or resuspend the cheek tissues and save the fat injections just for the under eye hollows.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a rhinoplasty done about a year ago to extend and derotate my tip and columnella. In the process I also had a premaxillary implant which was inserted in the nasal spine area through an incision through the inside of my upper lip. All of these were rib cartilages.

Whatever the cause, my smile has been warped for the worst. Before surgery, when I smiled, my upper lip used to be mobile, flip up, and thick and my columnella and tip would also droop down resulting in a nice natural smile that wasn’t tense. Now my smile is frozen looking. My upper lip is thin, tense and my nose tip and columnellar are also wooden looking and do not move with my smile the way it used to. It looks off and disturbing according to many of my friends. I am very upset with this. Is this my tip and columnella rib work that is doing this or is it a result of my premaxillary graft? I would certainly like to remove my premax graft if this will fix my smile. Thank you very much.

A: When you add a lot of rib cartilage grafts to the tip of the nose and the underlying pyriform aperture/nasal spine area, there is the possibility of stiffening how the upper lip moves. While it is possible that it is the combination of the effects of all the cartilage grafts (I have no idea as to teh details of where they were placed exactly and their size), the most likely culprit is the premaxillary graft. Its removal would be a good place to start and would also not affect to any significant degree the rhinoplasty result. Whether it will produce a complete normalization of your smile can not be predicted and it is not known if that could ever be achieved even with removal of all of the rib cartilage grafts.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I wanted to thank you for the kind and professional treatment by you and your staff during my stay in Indianapolis for my occipital augmentation surgery. My scar on the back of my head is healing nicely! I almost can’t see it when I use a mirror to see the back of my head. Overall, in terms of the shape of the back of my head, I’d say there’s a 60% to 70 per cent improvement. However, as you correctly noted during our visit the day after my surgery, my head is/was really flat in certain areas, and the implant may have not been created with sufficient thickness/volume to create a “rounder” effect. It’s funny, with the CT scan, I’d have thought the outer implant shape would be super-precise. So I am wondering about the possibility of doing a revision. I am grateful for the improvement so far, but I sometimes think that the back could be a bit “rounder”, and hence, I start pondering my options. Do you think it would be worth doing a revision for more occipital projection?

A: Let me provide with some insight as it it relates to a result that has ‘60% to 70% improvement and what a ‘revision’ really means.

First, the computer design process did a very precise job of making the implant perfectly. What the computer can do is to make it fit the bone perfectly, make the implant symmetric based on differences of the shape of the underlying bone and make its outer surface and edging as smooth as possible. That is has done wonderfully. What the computer can not do is to inherently know what the shape and thickness of the implant should be based on aesthetic goals. That is the role that I play and it will only follow the design that I instruct it to do. My job is to design an implant that will fit given the tolerances of the overlying scalp and be able to be placed through the smallest incision possible. Occipital implants that are too big can cause catastrophic problems, such as scalp and incisional tissue necrosis, hair fall out, non healing wounds, infection and the need to do a lot of ‘wittling’ on the implant trying to make it fit. (resulting in irregularities and asymmetries) It is my experience and judgment that allows for these type of problems to be avoided. That is why your implant, like many patients, is not designed to be thicker than 9 to 10mms as this is what I have learned to be a safe implant thickness that will always avoid any of these concerns. Most of the time patients will say down the road that they wish it was a little fuller after they get past the initial euphoria of having some augmentation effect. But it is always better to have a 70% result that has never experienced any complications vs. having the perfect volumetric result that has developed a complication.

When it comes to a ‘revision’, this is often a poor term to use and the incorrect way to think about it. Understandably patients think that ‘just adding a little more’ or ‘making an adjustment secondarily’ is easier than the first time. But the reality is that it is exactly the opposite. It is now harder because the tissue are more scarred and the scalp is less flexible. You may be able to place an implant that is 4 to 5mm thicker but it will likely require a bigger incision, a whole new implant, and will increase the potential for any of the complications that I have previously described. (the risk may be still fairly low but it is higher than the first time). Thus one has to weigh the risk vs. benefit for that extra 20% to 30% gain of improvement that could be achieved.

While I am happy to place a whole new implant, and I have done it many times for patients with many different kinds of skull and facial structural surgeries, it is important to understand that every surgery has risks. Just because it worked perfectly the first time is not a guarantee that it will be so the next time. Manipulating otherwise uncomplicated aesthetic results should be considered carefully if not more so than the first time.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had cheekbone reduction surgery done five years ago and I felt it left me with asymmetric cheeks. CT scan pictures after the surgery show that the cheekbones were probably removed too much and they were placed in different positions vertically. There are ‘gaps’ in the cheekbone area. I wonder if this can be fixed.

A: It is not rare to have some asymmetry in the position of the bones after cheek bone reduction surgery. Besides the fact that most people’s cheek bones are not really symmetric initially, there are always going to be differences in the angle of the cuts and the bone fixation points  between the sides since they are not independent of each and can not be view intraoperatively in a simultaneous fashion. That being said you do have external cheek bone asymmetry with the right side being more medial or moved inward that the left. I will assume by your comments that your ‘good’ side is the left one and the side you seek improvement is the right side. That could be improved by either repositioning the anterior end of the right cheek bone or adding a small implant over the osteotomy site.

In regards to the cheek bone gaps seen on the CT scan, that is an early after surgery x-ray. At this point years later, those bone gaps have likely filled in and healed with bone. If not, they have a fibrous union and there is no aesthetic benefit to having those bony gaps ‘fixed’.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Does your age such as 60 years old matter on results on liposuction if you are not over weight and have some loose skin but not bad. I’m in great shape and health as this has been my whole life lifestyle so not sure why my age would have anything to do with results. I understand skin changes with age but again I see a 30 year looks like my situation such as same shape or worst. Is this true?

A: Generally speaking, skin does not retract very well at age 60 as compared to age 30. There is an overall loss of skin elasticity as one ages. So liposuction results tend to not be as ‘good’ when one is older. The fat can be removed equally well, regardless of age,  but the smoothness of the skin tends to be more irregular and imperfect once the fat has been removed at an older age. As long as one can accept that trade-off, there is no reason one can not have liposuction at age 60. This can also change by the body area being treated such as the flanks will always do better than the thighs for example at any age.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like your input on the possibility of me being a good candidate for an arm lift procedure. I am 28 years old, I have lost 80lbs through diet and exercise, while I still have more weight to lose, I do not think that my arms will see any more of an improvement. I have also had abnormally large arms, as the photo shows, my left is approximately 2 inches larger than my right. Do you believe I could be a good candidate for this procedure? Is liposuction an option? I am concerned about bad scarring given that I am African American.

A: By your pictures which show large hanging ‘bat wings’, you would be an excellent candidate for arm lift. I would agree that the size of your arms is not going to change at all with more weight loss. The biggest issue is the amount of arm skin that you have which can neither shrink nor disappear with liposuction. The only way to get improvement is with an excision procedure where the excess arm skin and fat is removed. This would drop your circumferential arm size down to about half, if not more, than what it is now.

The dilemma that you have is that no change can be done to your arms without the scar. Nothing else will make any difference. You do not have the luxury of having a scarless operation that will work. You have to decide to balance the scar and its associated risks vs. living with your arms the way they are. I can not say I have seen any worse scarring in African Americans with arm lifts than any other patients who have had the procedure.

Dr. Barry Eppley

Indianapolis, Indiana