Your Questions

Q: Dr. Eppley, I am a 21 year-old make who is trying to achieve a more dominant facial structure. I like the square face more than the oval shape that I have. I would also like a smaller nose feature and more open eyes. I have attached pictures and am open to your suggestions.

A: In listening to your concerns and looking at your pictures, you have the following aesthetic issues:

1) A long and wide chin. This makes your face appear long and oval. In short, it is too vertically long.

2) Your eyelids show a medial epicanthal fold, which is very similar to that of Asians. This makes your eyes look tired/droopy.

3) Your nasal tip is just very slightly long.

To make the facial changes you desire based on these concerns, I would recommend the following:

1) Vertical Reduction of chin by osteotomy (7mms)  with slight advancement. (2mms) This could be combined with jaw angle implants. Together this shortens your face and make sit more square.

2) Medial epicanthoplasties to get rid of the overhanging eyelid fold.

3) Tip rhinoplasty with shortening and narrowing of domes and nostril width narrowing.

I have attached some imaging to show what changes these procedures may create.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I have ‘ve lost about 80lbs from a good diet and exercise program.  I really feel great, but my neck has not been the beneficiary of this weight loss. I have too much skin on my neck and it really sags and hangs. My husband really looks young for his age (61), looks  more like 51. But my neck looks the reverse, it looks 71 and I am 51! I think I need some type of extreme necklift. I have read of something called a ‘bariatric facelift’ but I am not sure what that means other than it is for people who have lost a lot of weight.

A: Congratulations on your weight loss! Dealing with the neck after this weight is a lot easier than you having to lose that weight. As the weight loss removed the fat from the neck, deflated the balloon so to speak, the excess skin of the jowls and neck was left behind and now hangs. The so-called bariatric facelift is nothing more than a typical neck-jowlift  that removes a lot of the loose skin by moving it up and back around the ears, where it can be removed by well-placed and inconspicuos incisions around the ears. This is a very effective and successful procedure and many of these so called bariatric facelifts can produce some of the most dramatic before and after results.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I feel my cheeks are a bit large so want to reduce their appearance as well as my upper outer brow bone. From the side my eyes look sunken, not for the front though. I feel that maybe reducing the brow and cheek bone would make eyes stand out and not seem so deep set from side view. However, I also have hollowness on direct sides of nose by nostril and have tried filler but it didn’t help. I also like my nose profile but from front, it looks wide around the tip so also looking into narrowing it from front view. Thank you for your help!

A: In looking at your pictures. I would not disagree with your contention about altering the bone to try and open up the eye area. There are two fundamental approaches to doing it. One option is a tail of the brow reduction through an upper eyelid incision combined with intraoral cheek reduction either done by burring or an anterior body zygomatic osteotomy. The second approach is a coronal incisional approach for lateral brow, lateral orbital and zygomatic reduction. (I think this approach is more than you need) From a nose standpoint you are describing two nasal issue, a paranasal deficiency and a broad nasal tip.  Your nose concerns could be addressed by paranasal implants (placed through the same incision as for the cheek reduction) and a closed rhinoplasty for tip (dome) narrowing.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 68 years old and had a mini-face lift when I was 55 and a Lifestyle neck lift four years ago. While these have provided improvement, the areas around my cheek and eyes have not been addressed by these previous procedures. I was thinking of some fat injections under eyes and into upper cheeks to “pull up” some of downward sag.  I find I am more afraid of large incisions as I get older! Was thinking of correcting with long lasting fat injections first, and then see where that gets us?

A: Given that you have already had two versions of facelift surgery, you are correct in assuming that removing more skin even with longer incisions, probably does not have a great facial rejuvenation benefit. This would be particularly so in the cheek area and below. Fat injections for you are an interesting option. While they will provide more volume/fullness to the cheeks, I am not sure how much lifting effect they will have as they push out more than they push upward. There is also the additional issue of how long-lasting fat injections are in  someone of your age. But if you adopt the attitude of ‘let’s see where that gets us’, that is a good mental attitude to have about a procedure in which it is not clear how well it will achieve your objectives. But there is little downside to doing since it is a natural material. I do overfill a bit with the fat injections but it would be important to not overdo it so there is not a prolonged period of being too puffy. More injected fat does not always equate to better long-term fat volume retention.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I would like to have the following done for ssome facial changes:

1) upper lip lift to reduce the distance between the base of my nose and upper lip (lip to nose ratio reduction by more than half my current natural lip to nose ratio) I am a fan of the lip to nose ratio as typically seen in women even on men as well.

2)  I would like also a  reduction in the bottom lip to the size of my top lip

3)  I would like profile surgery, in specific mouth protrusion surgery to westernise the protrusion of my mouth which as you know is commonly seen in Asian and african americans.  I understand there are implants and other methods used to achieve a western profile.

4)I would like a medium chin implant to improve my profile, more projection towards the bottom, when carving the shape of such implant, please note the design of my beard which I purposefully shape especially toward the bottom to almost mimic or complement the shape of my cupids bow along the border of my top lip.  We can obviously discuss this more in detail if there are any misunderstandings as to the shape chin I am going for.  You can best describe such shape as masculine and very edgy.

5) I would like an implant to give more height to my nasal bridge, with a tip that more length and projection without making the nose appear from the frontal view to be more bulky and thicker than its current state.

6) Finally a resection or crescent-shaped or wedge alar flare reduction to address nostril flare.  We can discuss what options would be best, maybe an alar suture cinch procedure or wedge resection.   

7) Remove fat underneath chin area.

8) Please use computer imaging for what potentially can be done as a valuable tool for us to communicate. 

A: Thank you for your inquiry and sending your pictures. Let me respond to your 8 issues/concerns as follows:

1) A subnasal lip lift can reduce the distance between the upper lip and the base of the nose, but not by half. That is too much and would create a very unusual looking upper lip. As a general rule, I reduce it either by 1/4 or up to 1/3 the vertical distance as measured along the philtral columns. This provides reduction but keeps a more natural look without the upper lip looking like a snarl.

2) The lower lip can be reduced by an internal horizontal wedge excision at the wet-dry vermilion line. Most lip reductions can reduce their size by about 1/3.

3) I am not absolutely sure what you mean by ‘westernized mouth protrusion surgery’ but I think you may mean paranasal base augmentation to help improve the concave profile around the base of the nose and the upper lip.

4) Your chin is horizontally deficient and an improved shape could be obtained by a chin implant that provides 7 -9mm increased projection and a more square shape.

5) A rhinoplasty using an implant for dorsal (bridge) augmentation as well as a columellar extension would help improve the nasal height and tip projection. This can also be done with a rib graft and their are arguments for both approaches (implant vs graft) based on their advantages and disadvantages.

6) Without question, the alar wedge resection for nostril narrowing is far superior to that of the alar cinch suture.

7) Submental liposuction for fat removal with the chin implant would be a good benefit.

8)I have attached some realistic imaging to give you an idea of what may be able to be achieved with these procedures.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, how much does cranioplasty cost, ranging from the lowest to the highest cost? In addition, can you make my eyelashes and eyebrows thicker by doing hair transplants?

A: In answer to your questions:

 1) The cost of cranioplasty can vary significantly based on what type and size of skull problem is being treated and what meterial may be used if augmentation is being done. But for the sake of some general cost ranges, it can vary from $6500 to $15,000. To better answer your question, I would need to know more specifics as to your skull concerns.

2) Eyebrows can be thickened with hair tranplantation techniques. The use of single follicle transplants are used with anywhere from 50 to 200 eyebrows needed per brow. 

3) Eyelashes are best thickened and lengthened with the use of the topical drug, Latisse. This popular drug is well known to increase lash length by 30%, thicken the shafts by 30% and make them grow faster. Essentially, Latisse for eyelashes is like Rogaine for scalp hair. If one has no eyelashes at all, hair transplants can be done but it rare to do so.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hope you doing great and you might recall our discussion regarding my cranioplasty last year (I have attached the mail and picture for you to recall). As you mentioned, I have flattening as well as surface is NOT even on back of skull, and I have hair loss as well. Would you recommend that I have hair surgery (FUE or FUT) method first and then go for surgery with you or surgery with you first and then hair transplant? Your advice will help me plan my surgery.

A: It is always best to have the skull augmentation first and then the hair transplant. Much like building a house, you should put the frame up before you can build the roof. Since the cranioplasty must now be done through an open approach (the injectable material is no longer available), the hair transplants can be used to help further camouflage the scalp scar if necessary.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, Are silicone breast implants better than saline? Which one will look better and feel soft? Can you get a warranty on your implants?

A: Silicone is always a better breast implant because it feels more natural and will not deflate should the shell (outer containment bag) get a hole or a tear. Because saline is essentially water, it will go completely flat when the containment bag loses integrity. When a silicone implant gets a hole or tear, it does not deflate because the material is more like ‘jello’ or gummy bear candy. Because nothing comes out, the implant does not lose volume and there is not an immediate cosmetic crisis. This is why silicone breast implants last longer as well, it usually takes a lot longer to discover that it has ruptured.(there is no medical harm in this delay) The manufacturers provide immediate warranties at no extra cost based on how long the breast implants have been in place. If a breast implant fails in the first ten years after surgery, the patient is entitled to a new pair of implants at no cost and up to $3600 reimbursement for the surgery to replace them. After ten years, the patient has lifelong free implant replacement but no compensation is provided for the surgery to replace them.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have interested in getting breast implants and have been researching the topic for the past six months. I have been to several consults and received differing opinions as to breast implant size. One surgeon even showed the result of an ‘extreme breast augmentation’ which frightened me. I take pictures of what I want into the consults but how do I know that is what implant size they will use? Some seem to listen to me while others I don’t think are and I am afraid they will just put in what they want.

A: Every plastic surgeon has their own approach to choosing breast implant size. Presumably the size selection should be what the patient wants. In my opinion, within reason, one should try and get as close as possible to the patient goal by using pictorial help. In the end it is not really about volume in ccs or bra cup size but what breast look the patient wants.  With few exceptions, just about any implant size can be put in most patients. I find pictures very helpful as I use them in the OR as a visual guide with the initial placement of sizers, only pulling the sterile implants once the breast looks like the pictures with the sizers in place.

There is a definite trend today, used by some plastic surgeons with great rigidity, that they will not place breast implants ‘that exceed the tissue support to sustain them’. That is a bit of a subjective assessment but what it means for some patients is that they will get smaller breast implants than they really want. While smaller breast implants are often associated with fewer long-term problems than larger ones (tissue stretch and sag), it can be a delicate balance between meeting the patient’s goals and keeping the implant size from stretching the breast tissue too much. I would sit down with the plastic surgeon in which you are most comfortable and put your objectives and concerns on the table for an open discussion.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 24 years old and my brow bone gets getting bigger. Is there something I can do to stop it expanding? Why is it doing it? Can an incision be made on both eyebrows to perform procedure? What would be your best idea without doing a coronal incision? Can a cut be made in my eyebrow so you can burr it down. ( wouldn’t be much) Then somehow either inject a filler into the top part of my forehead to smooth out… what about some kind of implant for the top part of the forehead? Does that need a coronal incision to be placed in?

A: At your age, your frontal sinus development is complete and should no longer be expanding. That is a function of skull growth which is long over now.

An incision can be made along the eyebrows known as the ‘Open Sky’ approach. It runs along the upper eyebrows and crosses over the nose. While it can be done, it is an historic approach that has largely been replaced by the coronal incision. I am not so sure that wouldn’t be more obvious than the coronal incision quite frankly but I wouldn’t yet rule it completely out

The key question about incisional approaches is what exactly needs to be done to the brow ridge to reduce it. In the vast majority of cases it requires infracturing or an osteotomy of the outer plate of the frontal sinus bone. This can only be done through a coronal approach. Usually simple burring is inadequate BUT if one has just a few millimeters of bone that need to be taken down and the area above it is built up with cement, the eyebrow approach may be reasonable. That could be determined beforehand by one simple x-ray known as a lateral skull or frontal sinus film. That would tell us precisely how thick the frontal sinus bone is and how much can be reduced by simple burring.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I havge silicone implants that were originally placed way back in 1986. They have served me well and have felt fairly natural until recently.  They now have sgtarted to leak and the right side has become contracted nad harder. I have had two plastic surgery consultation with conflicting opinions on how to replace then not remove them.  One recommendation was to use a Sientra silicone implant staying on top of the muscle with a lift. The other surgeon would use a Mentor silicone gel implant, placing it under the chest wall muscle, along with a lift. These two opinions have me confused, what do I do?

A: Your original breast implants have served you well, getting over 25 years of service out of them. That has been a good value but their failure was an eventuality and now you must decide how they are going to be replaced, hopefully lasting another 25 years. If you look closely at those two recommendations, they only substantially differ in whether the new implants are placed above or below the muscle. There is no clear cut answer and plastic surgeons will differ in their opinions on this issue.

When it is a primary breast augmentation, the decision for above or below the muscle is more optional and good results in most patients can be obtained  either way…albeit with some minor differences when it comes to silicone implants. But when it comes to replacement surgery in someone with established ruptures which will require total capsulectomies, you are going to be better off going under the muscle. (actually partially under the muscle) This is better for prevention of recurrent capsular contracture and infection of which you are now at higher risk.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have few questions about cranioplasty for my infant son.

1) I’ve read when it comes to cranioplasty, if done correctly and of course by the right surgeon, the scar would be generally “fine” not thick and the hair would eventually regrow on the scar after healthy healing, any truth to this theory?

2) If my recollection serves me correctly, I read when you inserted Kryptonite it was basically sort of like rolling the dice for the most part, because you didn’t EXACTLY know how it was going to turn out. It was basically a wait and see approach. Is it like this with the approach of inserting material in the skull? Or you pretty much have a good general idea by measuring and/or imaging of what it’s possibly going to look like before the surgery?

3) Since my son needs augmenting on the top of his head (right side) to correct/improve the head height differential, and also needs the reconstructing of his parietal bone, can this be done with one incision? Or you need 2 incisions?

4) For cranioplasty the scar will be approx. 4 inches correct (give or take)?

A: You have wisely and correctly interpreted what you have read. All four assumptions are correct.

1) Scalp scars in infants tend to be very fine. I would not always assume that hair will growth through the scar however.

2) Open cranioplasties do not generally have the contour/smoothness issues that are associated with an injectable approach because you can see what you are doing.

3) Only one incision would be needed.

4) The scalp scars are generally not longer than 8 to 10 cms.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I changed almost my entire face bone structure by Medpor inplants and osteotomies (high lateral cheek implants, sliding genioplasty, paranasal implants, lateral supraorbital rim implants and forehead reshaping) All in all I am happy with the results but there are a few things that can’t be addressed by implants. Although I got the largest Medpor cheek implants that were placed very high and lateral, I still would like a little bit more lateral projection. (I like faces with a very wide midface in the frontal view) I know this isn’t possible with additional implant placement. The only other option would be a soft tissue filler. I want a permanent result so I want to use a permanent filler. I would also like my lips and temples filled with the permanent filler. 

My surgeon told me of two options; Bio-Alcamid gel and Silicone injections:

1. Bio-Alcamid: (I know that it is not FDA approved in the USA but I am from Germany)

He has experience with this filler for almost 10 years. It has the consistency of gummy bear gel and and can only be injected through a 14 G or larger cannula. It doesn’t get hard because it attracts water. When it is injected in larger depots a fine capsule forms around the Bio-Alcamid and it doesn´t infiltrate the surrounding tissue. He told me while most patients do very well with a Bio-Alcamid implant a Bio-Alcamid implant is more likely to become infected. Two of his patients got a Bio-Alcamid implant infection after they had a tooth root infection near the implant. The advantage of this implant is that in all two patients he could remove the Bio-Alcamid completely through a 3 mm incision by suction and irrigating it out and they didn’t look worse than before the Bio-Alcamid implantation. Because of this he thinks that Bio-Alcamid has a very high safety profile and although it is a permanent filler it doesn´t cause permanent problems. It is more like an implant because you can take it out again if problems should occur.

2. Liquid silicone oil injections with Silikon 1000 or PMS 350: He told me he would inject small amounts of silicone oil in micordroplet technique and after 5 weeks own tissue growth is induced by the injected silicone. The desired volume has to be built up very slowly over several month. Late infections are very rare and theoretically could be treated with antibiotics. A big advantage of silicone oil injections is, hat most of the volume is provided by your own tissue. But he warned me that despite of using medical grade silicone and the right injection technique, some patients develop little granulomas.

And of course silicone is irreversible.

I personally like the idea that Bio-alcamid is more like an implant and is reversible, but I also like the idea of tissue growth induced by silicone. Another advantage of silicone over Bio-Alcamid is, that it feels very soft and more like your own tissue. A friend of mine has Bio-Alcmaid in this naso-labial folds and it feels like an compact implant made of gummy bear.

 I know, that there lies a very important facial nerve below the skin of my very lateral cheek bones. When a silicone granuloma should form and pushes on the nerve or silicone that sticks around the nerve gets inflamed, I could permanently look like I had a stroke (I already looked like this for a few weeks after my cheek implant surgery). Bio-Alcamid doesn’t´stick or “melt” with the tissue and because it is injected in a big deposit that becomes surrounded by a capsule, the formation of granulomas is very unlikely. Because of this I think that I am on the safer side with Bio-Alcamid. However I know that a dental infection could lead to the loss of the implant… fortunately I never had any problems with dental infection due to a consequent oral hygiene.

What would you use if Silikon 1000 and Bio-Alcamid were your only two options?

(I know there are other options, but they don´t seem to provide stable volume) Is it true that silicone can migrate even if it is injected in micro droplets and held in place by scar tissue and why can it migrate in spite of this? Have you seen patients at your office who have been injected with Silikon 1000 microdroplet technique and got complications from this injections? What do you think of the concept of Bio-Alcamid? I have searched the internet and the only problem that seems to occur with Bio-Alcamid is implant infection when the Bio-Alcamid pocket is contaminated due to trauma or dental work and sometimes it is a little bit harder but never impossible to remove the implant, if it hasn´t been injectet in depot technique.

Thank you in advance for your reply.

A:Thank you for your  long and detailed history and questions. If I have learned one thing about implant materials in my entire surgical career it is that they all can cause problems, most have more problems with their use than are reported and if you live long some of these problems will appear in some patients. For this reason, I always think about reversibility with any implanted material. This is the one thing that bothers me about so-called permanent injectable fillers. That being said, the answers to your questions are:

1) There is no question that the use of the Bio-Alcamid filler would be preferable to silicone oil. While I have not used Bio-Alcamid I am very familiar with its composition, properties and the literature on it. I have seen numerous problems, however, with silicone injections as you have mentioned including migration, lumpiness and some foreign-body type reactions. As you have mentioned, once its is injected it is impossible to remove.

So while I think Bio-Alcamid injections are better, I would have some reservations about where you want to place it. I don’t think it matters what long-lasting/permanent injectable filler is used, the lips are just a bad place for particulated filler materials. Lip tissues are very different than the rest of the face and any particulated injectate is going to cause lumps and maybe even some foreign-body reactions. They are too thin and supple to tolerate particulated injections. I have seen lots of problems with other particulated materials in the lips such as Radiesse, Artefill etc. so I would not be enthusiatic about it. In addition, the temples are a potentially problematic area as well for such fillers. While it can be done into the soft tissues above the temporalis fascia, be aware that the frontal branch of the facial nerve lives there. That nerve has the potential to be injured during the injection process (low risk) as well as during removal of the material (high risk) if necessary.

In my patients for your concerns, I would take a different approach to permanent temple and lip augmentation. I would use new silicone temporal implants which are easy to underso, no real risks in doing it and produce an immediate and permanent change. They are placed under the deep temporal fascia on top of the muscle. For the lips I would consider either fat injections or Permalip silicone tapered tube implants which are easy to insert and are completely reversible.

As for more projection from your cheek implants, be aware that custom implants exist that offer enhanced dimensional changes over what stock cheek implants can create.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 28 year old woman with slim build. I have been unhappy with my facial structure and feel that the lower half is “heavy” and undefined while from cheekbones up, it is narrow and flat. I am considering buccal fat removal to even out my lower cheek/ jaw. I wan a slimmer face as well as a more delicate mouth and rounder forehead. A more heart-shaped face, as opposed to my triangular one (bottom heavy) What is your opinion? Thank you!

A: This is what I had thought your concerns were. From a lower face standpoint, what makes your face heavy is the wide lower jaw/masseter muscles. This is due to your ethnicity as you know. There is no type of fat removal, buccal lipectomy or otherwise, that is going to make that change as the problem is not one of fat. It is due to your musculoskeletal structure. Typical options include repeated Botox injections to the masseter muscle to cause it to shrink/atrophy and/or bony jaw angle/inferior border mandibular reduction. There are advantages and disadvantages to either approach which is demonstrated in their injectable (non-surgical) vs surgical approach. From a forehead standpoint, a rounder and more convex forehead is achieved through an augmentation material using a hydroxyapatite cement to build it out. (forehead augmentation) This is done through an open scalp approach.

When these procedure are combined (upper and lower face), this is how a truly effective facial shape change can be achieved.

Dr. Barry Eppley

Indianapolis, Indiana

Q:Dr. Eppley, I suffered a zygomatic fracture three years ago and its aftermath has caused my entire zygoma to protrude specifically on the arch bone. I think an osteotomy or removal of the bone would be the best way to create more symmetry. I was reading two posts on your website about Zygomatic Osteotomies but they mainly were about osteomizing and removing bone from the anterior cheek area in which it would be performed through an incision in the mouth. My problem is mainly my zygomatic arch and I am wondering if osteotomizing this bone would be difficult while trying to avoid facial nerves or other serious mishaps. How would this be performed and could facial plastic surgeons do this as simple as other facial surgeries or would they be not as keen in doing so? I have attached pictures for your assessment.

A: What I see in the pictures is that the depressed arch fracture is now showing the anterior edge of the temporal process of the zygomatic arch because this is the thicker and unfractured portion behind the more anteriorly depressed arch. It would require that anterior edge to be burred down to get rid of the bulge. Now that I have seen your pictures, I can answer your questions better. To reduce that posterior zygomatic arch bulge, it can not be reached from inside the mouth. It is to posterior to the temple region to do that. The best way to treat it is to osteotomize it from a temporal incision where the  bone can be fractured and pushed in. This is done below the deep temporalis fascia so it is below the path of the frontal branch of the facial nerve. This type of surgery, while not complex, is not something I suspect that most facial plastic surgeons would feel comfortable doing. You need to see someone who has experience in doing these procedures and that means a plastic surgeon with craniomaxillofacial surgery experience.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a severe flat spot on the back of my head. I am 58 years old and there is not one single day goes by that I don’t despair due to this problem. I would be willing to be subject of a videoed production of the procedure to demonstrate the effectiveness and results of cranial reconstruction for those who may be considering such a procedure. I know there are alot of us out there and like myself, prefer to avoid the subject if possible, which is probably why the problem is addressed so seldomly. I have never reached out to a professional such as yourself because for most all of my life I have felt there was no hope for resolution to my problem, until now. I would be willing to send pictures if requested and any type of communication with you is possible at any time.

A:  Your concern proves that it is never too late to care about a long-standing physical concern. Even at your age, it is perfectly safe and possible to have an occipital cranioplasty performed. There is nothing unique about your age that would prevent this extracranial augmentation being done very successfully. Skull augmentation, at any location from the forehead to the back of the head, is the simple addition of a material on top of the bone. It is almost more of a scalp surgery (incision and scalp flaps) than it is bone surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was looking into breast implants but I just want to know do I need a breast lift and an implant? I am 27 and have 4 kids, all of which I breast fed so they do hang low. I want fuller looking boobs. Also What is the best kind of breast implant to get?

A: Even if you had not stated that your breasts hang low, it would be highly unlikely in the vast majority of women that have had four children that they wouldn’t have significant breast sagging. Therefore, in seeking the goal of fuller looking breasts you are going to need a lift. What type of breast lift (and there are four types) I can not tell you by your description alone but I will assume it is a full version. Remember that breast implants do not lift sagging breasts, that is a common misconception. While the size and type of breast implant is important (silicone gummy breast implants are best), your more important consideration is the need for the breast lift and the resultant scars that will be needed to perform it. In addition, the combination breast lift with implants is the hardest aesthetic breast surgery to perform to get the best symmetric results with significant revision rates for aesthetic adjustments.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley,I was wondering If your technique for breast augmentation after care is the “rapid recovery” technique. Or is it the standard which generally I’ve read takes about a week to two to feel better? 

A: Rapid recovery breast augmentation is my technique of immediate exercise beginning the night of surgery and regular dosing of Ibuprofen anti-inflammatory medication. It does get patients recovering faster after breast implant surgery, which is largely nothing more than a pulled pectoralis muscle with a small tear at the bottom on both sides. Like all muscular injuries, early range of motion and physical therapy is the key to quick return of full function and faster resolution of discomfort. I do find that it provides rapid recovery compared to doing nothing other than pain medication.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 57 yrs. old woman with sagging jowls and a double chin. My jowls started sagging when I was just 38 yrs. old. I’m very self conscience of this. I need your help so I can wear my hair up again and look my age.

A: Everyone ages differently and some, by genetics, environmental or weight changes, age much sooner than others…or at least looks older sooner. (in theory we all age similarly at the molecular level) The combination of jowls and a double chin is a revealing description because it speaks to the amount of tissue sagging that is present. This means that only a full lower facelift will be effective and no more limited or minimally-invasive neck and jowl procedure will be effective. A full lower facelift means a neck and jowl procedure that removes fat from the neck, tightens the platysma muscle, redrapes excess skin and removes it from the jowls and neck. This is done through incisions around the ears that ultimately lie behind the tragus in the front of the ear and in the crease of the back of the ear. The true success of a lower facelift in your case is when you feel comfortable wearing your hair back in a ponytail or up again. Based on my experience, you had better prepare yourself by getting new ponytail ties and other items to hold your hair in a bun…as you are going to need them!

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, l’d like to know of any promotions offered for breast augmentation surgery. My friend and I both would like to have breast implants. I have had four children and at 31 years of age I would like to feel like pretty woman again. We both have A cup breasts and would like a normal, beautiful cup size. Please contact me when possible and thank you for your time.

A: Breast augmentation is one of the few cosmetic surgeries that is often viewed like a  traditional retail product. Because it is commonly done by every plastic surgeon and is a highly sought after procedure, it is one cosmetic procedure for which there are often specials and promotions for it. Most of these promotions are based a certain amount of money off the standard cost if done in a timely manner or whatever the deadline that is provided. You are also asking about what is know as the ‘two-fer’ procedure, discounting based on two people signing up and having the procedure in a timely manner. This is another well known breast augmentation discount approach.

There is no question as to the benefit of breast implants in a woman who has lost all of her breast tissue after having had four children. It can make a world of difference in her self-image and feeling like a total woman again.

Dr. Barry Eppley

Indianapolis, Indian

Q: Dr. Eppley, I am an Asian female with prominent jaw angle. I would like them reduced to be more angular. They are also causing pain to my neck and shoulders. I want to make them more narrow so my neck isn’t as tight.

A: Thank you for your inquiry and sending your pictures. I can clearly see your flared jaw angles which seem not to fit the rest of your face. I have not heard of prominent jaw  angles causing neck discomfort and tightness but you would know best how it feels on you.  The jaw angles are enveloped by the pteryomassteric muscles and not any neck muscles per se so I can not speak for how successful they would be in reducing your neck and shoulder pain. Your jaw angles could be reduced by a sagittal saw reduction technique to narrow them as opposed to a complete transection technique of the entire angle. This is my preferred method which I think gives a better aesthetic result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 37 year old female with microtia of the left ear. I have thought long and hard about pursuing the reconstructive surgery but I have decided not to proceed with it. I think I have become a little more comfortable with the situation just understanding more about the condition and I am also deterred by the uncertainty and expense. I am however interested in any minimally invasive option to improve my facial asymmetry. Are facial implants an option to do so?

A: Thank you for sending your pictures. As I suspected in left hemifacial microsomia, the jaw on your affected side is smaller with no jaw angle present. Surprisingly the rest of your face above the jawline has minimal to no effect in terms of underdevelopment. You are correct in assuming that a jaw angle implant would be helpful. An implant could be placed that builds out the left jaw angle and jawline as it comes forward. This implant would be placed through the mouth and then screwed into the existing jaw bone. There are two ways to go about choosing the jaw angle implant style and shape. The ideal way is to custom make an implant off of your jaw model that would be made from a CT scan. While this is ideal, it adds considerable expense to the cost of the surgery. The other way is to use an off-the-shelf jaw angle implant and modify it during surgery to fit. It would not create as good a result as a custom implant but it would still make good improvement for you.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  two months ago I received surgery which was to rebuild my jaw bone deficiency due to prior jaw reduction surgery. This was done with jaw angle implants placed through the mouth. But I am not satisfied with the result. I have heard of custom made implants? Can I get to my previous appearance by using this method? If it is possible, how much does it cost? And can the Medpor jaw implants with screws be removed?

A: There is no question that custom implants made off of a patient’s mandibular model is the best way to get whatever desired jaw angle shape one wants. Nothing can be more accurate than premaking an implant for the exact defect. Off-the-shelf implants, while successfully providing a new look in many cases, do not work well when one is trying to restore their original anatomy. That is not what they are made for. I have removed/modified many Medpor jaw angle implants, and although they are certainly not easy to remove, it can be successfully done. The sooner they are removed after placement the better but even if in place for years they can still be successfully extracted.

The cost of manufacturing custom implants adds about $3500 in addition to the overall cost of jaw angle implant surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had extensive surgery involving a large number of facial implants and forehead augmentation and back of the head skull reshaping two weeks ago. While I knew there would be a lot of facial swelling, I think much of the swelling is gone now and I am concerned about some of the areas that have been augmented, particularly the forehead and cheeks. Both areas seem too big or prominent although each day they seem a little different. At what time would you consider revisional surgery?

A: With any single facial implant and certainly with multiple implants, you are far from having all swelling gone or are looking at the final result. I set the minimum time of three months before I would pass judgment on the result. This is not only to let all facial swelling resolve but it also takes time to adjust to one’s new look. This is a hard psychological time for patients to go through but it is very important to not rush to judgment on a ‘moving target’. It is good to remember over the next few months, these skull and facial shapes will change, go up and down, one day look good and the next day uncertain, until the final evolution appears months later. This is a lot to endure and watch evolve. How you feel today might be different next week. It also doesn’t help, and is not unfortunately therapeutic, when all you have to see and talk to about these issues is yourself. That is a good way to lose perspective not only on facial surgery in particular but on life in general. One of my tasks as a plastic surgeon for my patients is to not let them lose perspective and make premature decisions and judgments. I can never tell anyone what they should like, but I can guide them as when their surgical results are finalized.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in skull reshaping for a prominent ridge down the center of my head. But I am concerned about the scar that is needed for the surgery. What are your thoughts on the scar and what can be done to make it heal the best?

A: The scalp scar in men for any type of skull or forehead surgery is always an issue to ponder very carefully. Whether it is worth it or not depends on a variety of factors including the magnitude of the deformity and one’s concern/focus on it, hair follicle density and hair style and the location of the scar on one’s scalp. I have done numerous skull reshaping procedures on men who are bald or shave their heads and the scar for them has been worth the trade-off. But I am certain that it was an acceptable aetsthetic trade-off because this very issue was discussed at great length beforehand and they have had plenty of time to make the proper determination for themselves about the scar trade-off. Scalp scars generally heal very well and how well they heal is largely determined by how the incision was made and how carefully it is closed with respect to preserving hair follicles.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 29 years old woman, married, and haven’t any children with a positive family history for  breast cancer in my mother and sister. I had two lesions removed from my left breast (intraductal carcinoma) with clear margins recently. The surgeon suggested for removal both breasts and replacement prosthesis. But there is a limited size of prosthesis in Iran and the plastic surgeon said that my breast size is too small for the smallest  size of  prosthesis that there is in Iran. In your opinion, is there a solution for this problem? How much would this type of surgery cost in your country? Is there any charitable surgery in your country for this type of surgery?

A: It appears that with your family history and recent breast lesion pathology that you would benefit from bilateral prophylactic mastectomies with immediate breast implant reconstruction. I am unclear as to the statement that ‘your current breast size is too small for even the smallest breast implant’. That makes no sense to me nor would I believe that is true. Breast implants come as small as less than 200cc so there is a size of an implant that would fit you. Your solution is a straightforward subcutaneous mastectomy with immediate implant placement. I know of no charitable organization that would provide free care for this standard prophylactic breast cancer surgery for foreign visitors. I would be happy to provide you a fee for what this costs in my center. In the interim, it would also be helpful to see what your current breast status/size is with a few pictures if that is possible.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m contacting you regarding my chin. I have looked at many pictures of mine and my conclusion is that its too long, has too much soft tissue at the bottom, my right bottom tip is lower than the left and I think that maybe the bottom half of my lower jaw is a little too narrow and not symmetrical to the rest of my face. Also I think its too round. I have a big head and strong features and want my chin and jaw to look balanced. I noticed that my chin was too long  and pointy when I was 16 so I want to do something about it because I think it detracts from my looks and that I could look a lot better with it corrected. I would like to know what you think and what you would recommend.

A: Thank you for your inquiry and sending your pictures. Your long chin appears to be largely comprised of excessive soft tissue. There may be a slight bony excess but that clearly is not the major component. The ‘proof’ that the soft tissues are a major element of your chin problem is in how your chin looks between the non-smiling and smiling images. When excessive soft tissues are the problem with chin hypertrophy this requires a submental chin reduction approach. Only from below can the tissues be excised, tucked and closed. A small amount of bone can be burred down as well if needed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My 15 year-old son needs his forehead reconstructed after an injury last year. He lost a portion of his forehead from the fracture and now has a large indentation from his brow up to just under his hairline. Which is better for his reconstruction, a cranial bone graft or a bone cement?

A: From a growth standpoint, his skull/forehead is essentially fully formed so the method of reconstruction is not really important from that standpoint. What counts is how smooth it can be after it heals and will have the least chance of irregularities down the road when all swelling truly subsides. Either a bone cement or bone graft has their own advantages and disadvantages in this regard. A bone cement will give the smoothest contour result by far because it can be molded completely into the defect and smoothly contoured to the surrounding bone edges. While it is a synthetic material, it is made of hydroxyapatite which is the inorganic composition of natural bone so ti is very biocompatible.  While bone grafts are an autogenous material, they are prone to some resorption and hence irregularities down the road. Even though the forehead has thick soft tissue, plate and srew profiles inevitably become evident unless very low profile (< 1mm) devices are used. It is likely that I would do a combination frontal cranioplasty, using bone grafts to obliterate any frontal sinus exposure and bone cement to fill the defect and contour into the surrounding forehead.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m just trying to achieve a more manly look….more of a chiseled face. I feel like I look like a 12 year old when im actually 21. I want a stronger brow…more defined cheeks and finer and stronger nose and chin. I would like to know if this is all possible to do in one sitting? I would also like to know the price. Thanks very much

A: When men want stronger facial features, particularly a more chiseled face, there are two general facial features they are trying to change. Conceptually, it is about accentuating or increasing the convex facial bony prominences and decreasing the intervening soft tissue concavities between these prominences. The facial bony prominences to consider augmenting are the chin, jaw angles, cheeks , nose and brow ridges. The soft tissue concavity to deepen, or at least appear to deepen, is the soft tissue triangle that lies between lines from the cheeks, chin and jaw angles as well as the temporal fosa. It is also important that the neck/submental area be as flat as possible. Not every man can achieve this look and, in general, thinner men with less facial fat are more likely to achieve a more chiseled facial look, sometimes known as the ‘male model look’.

You do have a very desireable face to achieve this more chiseled look because you are young, have a thin face and already have some evident facial prominences albeit weak. I have done some imaging based on an ideal surgical approach to your desired result including brow bone augmentation, rhinoplasty with dorsal line augmentation, tip refinement and nostrail narrowing, and cheek, chin and jaw angle implants. All of this can be done at the same surgery and is common to do so.

While all of these procedures are helpful, I always find that for each male patient some are absolutely essential and others are of secondary importance. I categorize these into primary and secondary procedures based on their benefit because one has to always be vigilant about cost. Your primary benefit procedures are chin augmentation and rhinoplasty. These will provide the most benefit at a lower cost. Cheek and jaw angle implants and brow ridge augmentation provide secondary benefits. Together, all five are ideal but at a minimum the chin and nose need to be changed to help get a more defined facial look.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was thinking if I would be a good candidate for a custom implant? I had a chin implant done two years ago but had it removed six months later because it did not look and appeared unnatural and asymmetric. This time, I want the implant to address the asymmetry of my chin and also add length and width to my jawline while also lengthening my chin. I have attached pictures to try and show you what I’m looking at getting resolved. Also, are custom implants significantly more costly? My left side of the chin is about 3-4 mm shorter than my right side. Also when I feel where my chin transitions to my jawline, there is more of a “dip” in the bone on my left side. I would like a more smoother jawline transitioning to my chin and a more prominent jawline on both sides as well. I have outlined the area of jawline I am referring to and that I would like it both extended horizontally and vertically. I have attached the picture of my previous implant to show the increase in asymmetry that the implant caused. I think the asymmetry caused the implant to not fit snug and was also the reason why I was able to move the implant from side to side even months after.  And finally I have re-attached the ideal chin and jawline. I think what i’m looking to fix would give me the desired look.

A: Based on your pictures and your good illustrations, the only way you would get that chin result is with a custom chin implant. There is no off-the-shelf chin implant that would have those exact dimensions and shape. Why your first chin implant resulted in that undesired look is not known to me because I don’t know what style and size of chin implant it was. It may have been inappropriate for your chin based on a variety of factor6s including style, size and technical placement of the implant.

That being said, there are three ways to go about getting a ‘custom chin implant’. They are different because of how they are done and their cost.

#1.The least expensive way, because it costs no more than a standard implant, is to select a certain chin implant style and size and custom carve it either before and during surgery based on the illustrations you have shown. The limitation is that it is an approximation of the underlying chin anatomy.

#2 The second way is to get a 3-D CT scan and have an exact mandibular model made. From that model, I can then take an off the-shelf implant and then carve it to shape by placing it on the model. This is better than #1 because we would know the exact chin anatomy. The limiting factor is how close existing chin implants are to your needs. Besides the cost of a 3-D CT scan of your mandible (which your insurance will likely cover) is the cost of having the model made. ($ 1100)

#3 The most ideal way to get a custom chin implant is to take the mandibular model and I will then hand-care out a completely custom implant which will then be sent out for formal implant manufacture. The total additional cost of this approach is $3500

As you can see there are multiple ways to get a custom chin implant. But when it comes to having a chin implant that blends smoothly back along the jawline, a true custom chin implant is the only way to get that result in most cases.

Dr. Barry Eppley

Indianapolis, Indiana