Your Questions

Q: Dr. Eppley, I am inquiring about getting a calf implant. I had ruptured achilles on my right leg about 10 years ago and muscle never developed back properly.

A: One of the most common reasons for a calf implant is to improve lower leg asymmetry after such congenital problems as clubfoot or traumatic injuries. When the achilles tendon is ruptured, the soleus and gastrocnemius muscles which are attached to it can become atrophic due to immobility and subsequent muscle atrophy. Even with rehabilitation, the muscle volume does not come back. Calf implant augmentation can help restore some of the volume by adding volume under the fascia but on top of the muscle. Based on the size of the medial head of your gastrocnemius muscle (length and width) different sized calf implants are available to augment it. This is done an incision on the back of the knee.This is done as an outpatient procedure that usually takes about 30 minutes for the insertion of one calf implant. While calf augmentation surgery can involvhe significant recovery, having the surgery in just one leg makes it easier.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in scar revision surgery. Actually I would like it completely gone.  I have a 2 1/2 inch hypertrophic horizontal scar on my upper chest that is raised and tender. I would love to have it removed if possible. Here are the  some photos of it.  The scar is not a result of an injury or laceration. Suspected to be result of an ingrown hair follicle.

A: What you have is a hypertrophic scar and may be on the borderline of an actual keloid type scar. Its appearance and history suggests, in my experience, that may be ‘resistant’ to scar revision surgery. While it can surgically be excised into a fine line (there is no such thing as complete scar removal), its location on the chest gives it a high probability of recurrence, particularly with your darkly pigmented skin. That is the risk in doing it. When such a scar results from an otherwise innocuous event and remains painful for a long time and maybe even growing, this indicates that is exactly what will likely recur when it is surgically removed. The chest is a notorious place for poor scar formation. The best you can hope for is that the scar does not come back as wide as it once was. There will be some recurrent scar widening, it is just a question of how much.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to schedule a consultation for chin reduction. My chin is too long and slightly asymmetrical. I am from out of town. If surgery goes as planned how many trips will I have to make to see you in person?

A: Your pictures show a chin that is somewhat vertically long and has some asymmetry with a left-sided deviated chin point. The correct way to shorten and straighten your chin in through an intraoral genioplasty with an asymmetrical wedge removal for shortening and realigning the chin point. This is a procedure that takes about one hour under general anesthesia. You could return home within 24 to 48 hours. Any followups would be done by e-mail or Skype just like you are making this inquiry. Expect some substantial chin swelling afterwards that will take about 4 to 6 weeks to see the final result. Sutures inside the mouth are dissolvable so there is no need for their removal.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Would you give me more information on what the surgery for buttock implant removal would consist of. I would like to get them removed sometime next year since I spent so much on them already I need to save some money once again. I don’t know if it could damage the muscle that the implant is in since it has been split open. Would it heal together well enough to go back to normal activities? Will it leave my buttocks saggy to a point where exercise won’t help? Last what would you charge me for a procedure like this even though you didn’t place them?

A: Buttock implant removal has many similarities to placing them, minus the severe pain and swelling. It is a matter of reopening the incision and removing the implants from their location. Since the muscular pocket is already dissected and the implants are smooth silicone, they will slide right on out. Whether any fat grafting should be done at the same time to still end up with some augmentation effect depends on how much fat one has to give. Once healed (a few weeks) you may return to all normal activities. The interesting question is whether you would develop any buttock sagging afterwards. That is usually not the case since the implants are in the upper 1/2 of the buttocks and have not distended the buttock tissue on the lower half where sagging is more likely to occur. Suffice it to say that the cost to remove buttock implants is usually far less than what it was to put them in.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am seeking orbital floor augmentation. I have a mild case of orbital dystopia of my left eye. It is about 2mms as judging by the position of iris of the eye to the lower eyelid compared to the other side. How would orbital floor augmentation be done. Would there be any external scarring?

A: There are numerous options of how to do orbital floor augmentation. There are two choices to make in orbital floor augmentation, incisional access and the choice of augmentation material. Because your orbital dystopia problem is fairly slight (1 to 2mms), your young age, and your asian skin, I am loathe to consider any type of open procedure that involves an external lower blepharoplasty incision. While that is how I would normally do it, I just don’t think your amount of orbital floor augmentation justifies that degree of invasive surgery. That leaves either a transconjuncival approach or a purely injectable technique. Because it is the eyeball and for safety purposes, I would not do an injectable method. That leaves us with the transconjunctival approach. (internal eyelid) The next issue is the augmentation material. This is a choice between a natural material (like fat or cartilage) or a synthetic implant. This is a classic debate in orbital floor augmentation and just about anything will work. It just depends on your thoughts of a graft harvest (ear cartilage or fat harvest) or a synthetic material. (like a bone cement or gore-tex (PTFE) floor implant. There is also the issue of how much access the transconjunctival approach offers and the ability to get the augmentation material through it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, In looking for jawline implants for total jawline enhancement do you think a good combined solution for chin and jaw is the Medpor Matrix system, or do the chin and jaw implants separately? I currently have some hyaluronic acid directly on my jaw angle and line because I did not know about such implants until recently, so I think I should remove that with “Hylase” before determining implant sizes.

My final questions to understand the size and shape of the implants and surgery would be:

a) JAW: The horizontal width of the RZ mandibular angle implants is 11mm (or 7mm respectively) at the LOWEST point of the implant and diminishing gradually to the top – like a triangle, correct? And as you mentioned the  VERTICAL DROP is ALWAYS 10 mm regardless of the horizontal width of 3, 7, or 11mm? (which can be shaved down I guess if necessary?)

b) CHIN: With respect to a chin augmentation:  If, just theoretically, I am satisfied with the length (anterior projection) of my chin length but NOT with the lateral horizontal width and shape (which I want to be SQUARE and 5 cm ranging from one corner of the mouth to the other) – are there available or can you shave down an medpor RZ extended chin implant so that there is NO or only 1-2 mm anterior projection but the same lateral and inferior projection as the medium sized RZ Ext Square chin implant? So practically speaking a customized RZ Square chin implant augmenting only laterally the side parts of the chin (like an implant without or only a 1-2 mm middle part9). An implant which makes the chin look more square and broader, which augments the lateral parts of the chin. (hope I expressed myself properly)

A: If I have to use off-the shelf implants, I generally stay away from Medpor because they are hard to put in, never fit very well to the bone, hard to stabilize to the bone and very hard to revise if that ever needs to be done. (of which the risk is about 25% of that need) I have used them a lot and the more I use them the less I like them. None of their purported benefits are true, other than soft tissue adheres to the implants making them a near nightmare to ever revise. But I will still use them when patients insist and some patients, like you, have an affinity for it.

When it comes to total jawline augmentation with Medpor, I would use a three-piece chin and jaw angle approach and not the Matrix system. The Matrix system is extremely hard to put in and virtually impossible to ever remove or revise due to the features of the material as previously described. Since the chin implant is put in as a two-piece implant with a male-female connector, it is easy to make a square implant but how far or close the two pieces are put together. It is, in essence, and adjustable width chin implant. When in doubt about jaw angle widths with the RZ style, it is always better to go with the biggest size as it can also be reduced during surgery. (but you can’t add to it)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, How much for liposuction, specifically smart lipo, of the abdomen? Here is a picture of my abdomen. I am not interested in a tummy tuck scar and the recovery time. Thanks.

A: While I can understand why you would want to pursue some form of liposuction, it is neither the appropriate or effective contouring procedure for your abdominal problem. You have as much excess skin as fat as part of the loose abdominal overhang. Removing fat will only cause more loose skin and will not get rid of the overhang. It may likely leave your abdominal problem with no substantative improvement. While no one understandably wants a tummy tuck scar or the recovery from it, this is the only procedure that will be effective for your concerns. Do not waste money or effort on a liposuction procedure that will not work for you.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have just visited your website and it gave me some hope. I saw the archive where you response to people’s problems. I thought that I may try to ask you some questions. I attached the photo of my head and as you can see it is not proportional. I really do not like that my head is so wide and the forehead is so high. Could you tell me what kind of surgery operations I need to get my head look better and be smaller certainly. I thought about temporal reduction, cheekbone reduction and maybe lowering the hairline. I think temporal is the worst thing, not only muscle but I feel the bone aboue ears … I would like to know your opinion what can be done and what kind of effect I could expect. The last and probably the most important question is about the price of surgeries you suggest 🙂 I hope you will give me a hope for better future 😉 Thanks in advance!

A: The most improveable feature of your concerns, and the ‘easiest’ is the temporal reduction which narrows the appearance of the transverse width of the head. While it does require some vertical incisions on the side of the head., much of the temporalis muscle can be released with some bone reduction to make for a visible narrowing. (see attached imaging prediction) Hairline lower is not really an option for you unless you have a first stage scalp tissue expander placed to create more scalp tissue top bring forward. Cheekbone reduction can be done through an incision inside the mouth (and the back part of the zygomatic arch moved through the temporal incisions) but the usual inward movement averages about 5 to 6mms at best in most people.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am seeking facial scar revision. I have a straight facial scar from the corner of my ear to the corner of my mouth on the left side of my face. It was from a knife attack.  It happened when I was 16. I am now almost 47 years old. Could you please review my face?= and tell me if I am a good candidate for scar revision?

A: In looking at your pictures, the scar width is not terribly wide but it is a straight line from the mouth to the ear. As would be expected from an injury now thirty years old, the scar is quite mature. There is probably merit to excising the scar and placing some geometric changes along the line that breaks up its linearity, particularly in the locations of the smile lines. While there is no way to ever completely remove the scar, it is possible to make it less obvious than it is right now.

The key decision for your scar revision, however, is unique because of how old the scar is and your age. You have lived with it for so long it is an accepted part of your appearance. (I didn’t say you liked it but it has been with you for most of your life) Whether the time necessary for healing and having the scar mature again to get to whatever improvement can be obtained is a big sacrifice at your point in life. Whether the amount of improvement obtained is worthy of that sacrifice is very hard to determine beforehand.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Do I qualify for a tummy tuck based on my weight of 155 lbs at 5’ 6”? Also I would like to down size my 650cc saline implants to something considerably smaller.

A: Based on your pictures which show a double abdominal roll, you would definitely benefit by a tummy tuck which would eliminate that problem. You can also certainly downsize your implants and I will assume for now that you want to stay with saline implants. The one issue with downsizing is what will happen to the overlying breast tissue. You already have some breast tissue bottoming out and that will get more substantial with downsizing. I see the scars around the areolas which I presume is from a periareolar mastopexy with your original augmentation. To deal with these issues I would do an inframammary fold excision/tuck with your implant downsizing as well as possible a periareolar scar revision.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I believe I suffer from diastasis recti. I have had 2 pregnancies, and both were c-section deliveries. My first was emergency and my second was scheduled. I have all of the symptoms of diastasis recti, and have been to numerous doctors complaining of these symptoms over the last 5 years. None ever even mentioned diastasis. Have you done many surgeries to correct this? Are they successful? Thank you for your time!

A: Diastasis recti are a very common abdominal wall deformity after multiple pregnancies. It is important, however, to not confuse this with a hernia which is an actual hole in the abdominal wall. Diastasis recti is the vertical separation of the muscular union across the midline of the abdominal wall but has an intact wall unlike a hernia. In thin women a diastasis recti can be seen as a deep wide groove from the lower end of the sternum down to or past the belly button. Reapproximating or repairing the diastasis recti is a common part of an abdominoplasty or tummy tuck procedure, mainly because there is wide open access to do it and it helps produce some additional abdominal flattening. It is repaired by sewing it together with permanent sutures, hence the term ‘sewing the muscles together’ when a tummy tuck procedure is described. It is very rarely, if ever, done as an isolated procedure outside of a tummy tuck as there is no medical reason to do so since it is not an actual hernia. Unlike a hernia, women do not usually complain of symptoms from it other than the aesthetic look of it if they are thin enough to see it. It is also a procedure that is not covered by insurance whether it is done as part of the tummy tuck or even as a stand alone procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am having a rhinoplasty by you later this fall. I was planning on a facelift and breast lift with fat transfer to face and breast. It’s the  beginning of a body makeover. I would prefer having you since the surgeons in my area aren’t capable of correcting the nose. Can we do all of the surgery mentioned above, I would  really like to do as much as possible.

A: Such combined face and body procedures are often done together and the economy of time, cost and recovery are the obvious reasons why many patients seek to maximize their operative experience. But each patient must be assessed individually to determine if it is the right concept for them. In making that determination the important factors are two-fold; is it safe and is the best result achievable in one combined surgery? From a safety standpoint, 62 years old is perfectly fine for these procedures as long as one is healthy with no major medical problems. (which you are) For your immediate recovery, however, such combination of procedures should only be done if you are observed overnite in the facility. That would be particularly paramount since you are from out of town.

From a procedure standpoint, combining a rhinoplasty and facelift (with or without fat transfers) is very common. The nose is a central facial procedure and the facelift is a lateral facial procedure so one does not affect the other. For a breast lift, however, volume augmentation by fat injections may or may not be affected by the lift. That would depend on what type of lift is being performed and what quadrant(s) of the breast fat may needed to be added. Depending upon your degree of ptosis (sagging) you may only need the Refine internal suspension lift with outward superior nipple lifts. That would allow the maximal volume of fat to be added at the same time. I would need to see some pictures of your breasts to better answer this procedural question.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I am interested in getting a pectoral implant on just one side. I have pectus excavatum on the right side of the sternum/chest and have been treated with fat inejctions. They did not do as much as I wanted due to some fat resorption. I think if I just had a small pectoral imnplant as opposed to a full one on that side that would make it much better and no volume would be lost. My question is how would this implant behave with years of abuse (contracting the muscle) through physical work, and working out the chest. and since it would be placed under the muscle it should be rather invisible during the movement of the muscle right? How long have your patients gone with implants? A silly question about this implant, would it be permanent and to my understanding the longer the implant would be under the muscle the more the chances of complications(movement) decrease?

A: Physical activity and chest muscle action have no negative effects on a submuscular pectoral implant or vice versa. Pectoral implants (whole or partial) under the muscle are not seen on the outside. It is implants that are above the muscle in the chest that have concerns in these regards. Pectoral implants are made of a soft silicone elastomer that does not degrade, this it is permanent and would never need to be replaced. I know of no pectoral implant patients who have ever had long-term problems with their implants. The only potential issues are short-term after surgery with the very low risks of infection or seroma formation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a question about nasal airway obstruction surgery. I am a 25 year old female who ever since I can remember,I had difficulties breathing. My right nostril’s been doing almost all the job of breathing, while my left nostril had difficulties breathing and sometimes wouldn’t breathe at all, like it’s clogged. I thought it is a normal thing to do for a nose until recently someone told me that both nostrils are supposed to breathe at the equal intensity. I asked my mother if I ever broke my nose when I was a child, she said “no”. I recently found out from my father that I actually did fall on my face/nose more than once when I was six or seven years old (I vaguely recall the incident). He also told me that they never took me to see a doctor, although I had been bleeding from the nose, I had blue circles under the eyes and a swollen nose.  As a result I am soon planing on getting my nose x-rayed to find out if it is broken or not. But even if it’s not broken, is there a way to enlarge nasal canals to make breathing easier (or maybe change the shape of the nose to help easier breathing)? I’ll greatly appreciate your response. Thank you for your time.

A: While nasal breathing may not always be completely equal between both sides of the nose, it is not normal to have a feeling of being completely blocked on one side. With your history and those symptoms, this strongly suggests that you do have an internal nasal obstruction either from a septal deviation, inferior turbinate hypertrophy, middle vault collapse or some combination from all of the above. While you can get an x-ray (CT scan) to see the complete anatomy of the internal nose, a good physical examination will can also make the diagnosis. Undoubtably some form of a septoplasty and inferior turbinate reduction may be beneficial at the least.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had gynecomastia reduction surgery and subsequently developed scar tissue under the nipples that has caused them to still stick out. I have been told it is scar tissue and will be getting some steroid injections to see if it will help. If that does not work and I were to get the scar tissue excised, would I be at risk of the scar tissue coming back again like this time and having the same issue?

A: In gynecomastia reduction revision surgery, the key to preventing this scar tissue problem is to eliminate the so-called ‘dead space’ that occurs after any tissue is removed from under the skin. If not it fills with some fluid and leaves a residual space where scar tissue can form. This dead space management is done by three different methods, suturing the space closed during the surgery, using drains for a few days if necessary, the wearing of a circumferential wrap for several weeks after surgery. Should it recur despite these maximal management methods, then the immediate use of steroid injections need to be done as soon as it occurs. (when they can actually be most effective)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had saline breast implants done 19 years ago. About 3 years ago I noticed my implants felt wrinkly and softer and had a more unnatural feel to them. I can even see dents in my breasts in the mirror. This as about the same time that I had lost some significant weight. My old plastic surgeon said he could fill them up with more saline. He said he can do an ultrasound to see if they can be refilled. Is this common?

A: The first thing to realize about breast implants is that they are not lifelong devices. Many breast augmentation patients have either never been told this or they did not hear it prior to their initial breast implant surgery. Most saline breast implants will last an average of 10 to 20 years, a few will spontaneously deflate in just a few years while a few others may last more than two decades. But none will last as long as over a long patient’s lifetime. At 17 years after their initial placement, your breast implants have served you well but they are coming to the end of the functional use. What you are feeling is not deflation but the rippling and folding of the implants as they have gotten older and you have had some natural breast tissue atrophy which makes the implant profiles more obvious. It is time to start thinking about their replacement whether it is with new saline implants or silicone implants who do not have some of the same aging concerns that saline implants do.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,I am interested in a LeFort osteotomy. My bite relationship is significantly off, though, and I’m still wearing braces.  I’d suspect my upper jaw exceeds my lower jaw by at least 7-10 mms.  My orthodontist is under the impression that my bite relationship is fine, but I think that either extractions or upper jaw surgery would be necessary to shove my upper jaw back and even out my profile view.  I think the jaw surgery might be a better bet than a chin implant, in this case, since i like my lower jaw position but not my upper jaw position.  Do you perform upper jaw surgeries?  Could you show me an image of what an upper jaw surgery might look like, in terms of shoving my jawline back?

A: I have performed many maxillary (LeFort osteotomy) upper jaw surgeries. You can not really push your upper jaw back more than 1 to 2mms. It may go significantly up (impaction) or forward but it can not be moved any significant amount back as a total jaw unit. You may have the first premolars removed and have the pr maxilla (bone that contains the front 6 teeth) moved back by orthodontics or even by a premaxillary osteotomy but whether that is a reasonable thing to debased on your tooth relationships and facial profile is a questions for your orthodontist and their participation in integral in this process.

Dr. Barry Eppley

Indianapolis, Indiana

 Q: Dr. Eppley, when it comes to lip reduction surgery I have one question for you that I have been thinking about lately. As you written previously with a lip reduction the dry vermilion on the lip is what is removed but how does this affect the lip’s functionality? Currently because the dry vermilion bothers me so much I peel it off as it begins to flake and after peeling it off it grows back hours late in a continuous cycle. Now if the dry vermilion is removed does that mean skin will never grow back in that area? And if this is the case what is left on the top lip in the area in which the dry vermilion has been removed?

A: In a lip reduction procedure, whether it is for size reduction or for the treatment of chronic dry/chapped lips, a portion of the dry vermilion is removed in front of the wet-dry line. The dry vermilion removed is ‘replaced’ by the wet mucosa which advances forward from the inside of the lip. The wet mucosa is very soft and supple and thus its replacement of a portion of the dry vermilion poses no functional limitations to the lip.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, first thank you for offering such great jaw angle and chin implant surgery to patients. I have found your website on the internet, as I have been looking for Medpor RZ angle implants and chin implants for years and I definitely intend to do that surgery. Of course a final recommendation can only be done personally in your office, but I would be very thankful for your first indication based on a picture of my current jaw line and chin position attached. 

My initial questions prior to the surgery would be:

1. JAW ANGLES:

a. Which Medpor RZ angle implant size would you suggest to achieve a projection like on the celebrity pictures and my computer animated picture, assuming that I augmented my cheek and cheekbone prior to the jaw implant surgery? 7mm or 11mm or 11mm shaved down to 9mm?

b. What is the horizontal width of the 7mm and 11mm Medpor RZ mandibular angle implants?

2. CHIN: which mm size of the chin implant would you suggest for a masculine chin projection, 6mm or 8mm?

A: In answer to your questions:

1) The vast majority of jaw angle implants rarely need to be more than 7mm. An 11mm implant, when both sides are factored in, increases the bigonial width by 22mm which is considerable. The numbers 3, 7 and 11mms refers to the width or horizontal dimensions of the implant. It is a standard 10mm vertical drop with these style of jaw angle implants.

2) I would have to see your pictures and see what degree of chin horizontal shortness you have, but generally 8mms is going to be a better choice than 6mms for most men.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had gynecomastia reduction surgery performed back in March of this year.  The results immediately afterwards were amazing, everything was completely flat.  A month or so after I started developing scar tissue which hasn’t gone away and has made my nipple area protrude once again. My plastic surgeon said I probably needed a steroid injection to help with the scar tissue.  Since it is much further to travel back to him I went to a local plastic surgeon, but he thought it was just some leftover breast tissue and didn’t want to do the Kenalog injection. No offense to him, but I don’t feel like he had much experience with gynecomastia and I definitely feel like it is scar tissue since the results after surgery were a completely flat chest with no feeling of any tissue whatsoever. That led me to come across your website where some people had asked about Kenalog injections for scar tissue after gynecomastia surgery. Based off what I have told you, does it sound like scar tissue to you or is it possible that the gynecomastia has actually grown back?  I would be interested in seeing you for Kenalog injections if you believe they would be beneficial. I have attached a picture of the before and immediately after surgery.  I would really appreciate any information you could give me so I can get this behind me for good.

A: I have done a lot of open areolar gynecomastia reduction surgeries in young men just like yours. What you are experiencing is not uncommon. It looks really flat in the beginning but a slow nipple protrusion develops. The tissue under the nipple-arolar complex feel firm, sometimes harder than before the initial surgery. You are correct is that it is scar tissue and not breast tissue. But often considerable scar tissue develops and the mass effect is almost like it was before surgery in some cases. I have done my fair share of steroid injections into this scar tissue and that seems to be the logical approach to do. But I have yet to see a case in which the steroid injections were successful, particularly at over six months after the initial procedure. My experience is that the only thing that solves the problem is to surgically remove the scar tissue, very much like the original surgery. While there is no harm in doing steroid injections, and the protocol would be a series of three injections spaced three weeks apart, I have little optimism that it will lead to a complete resolution of the problem.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have attached some pictures of my stomach pannus. Please let me know if I would be a good candidate for an abdominal panniculectomy. It is the most troubled part of my body. I have backaches and some times irritation underneath due to my jeans. I wear a size16 in pants but that is underneath my pannus. If I got pants to go over my pannus they would not fit my legs and hips properly. I hate this stomach!! 🙁

A: Thank you for sending your pictures. I do believe you are a good candidate now for an abdominal panniculectomy. The size of overhang of your pannus is significant and much functional improvement would come from its removal. You are not going to have a flat stomach from the procedure, however, and of this you should be aware. It will still be round due to the amount of intra-abdominal fat but there will be no overhang. In preparation for an abdominal panniculectomy, hopefully in the near future, I would still continue to make efforts to lose weight no matter how slight it may be. That will only enable as much stomach tissue to be removed as possible.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am in need of mouth opening surgery. I’ve been to all the doctors in my area but not one of them can solve my mouth problem. I’ve had all my teeth pulled out, which was very hard for me because my mouth cannot open widely. It cannot stretch as big as normal mouths can. I wanted to make my dentures but I couldn’t because they couldn’t measure my gums because the measurement thing cannot fit into my mouth. I’m so so sad because I am ashamed to talk like I used to because I have no teeth. Can you give me some advice please.  One doctor said that he could cut the sides of my mouth but there will be scars afterwards.  I hope that you can help me with some advice. I cannot go on with my life like this, a toothless 34 year old and i cannot even fix my dentures.  Thank you for your time.

A: The correct procedure for increasing mouth opening (oral aperture) is the oral commissurotomy or mouth opening surgery. The sides of the mouth are opened by making an incision in the skin away from the corners of the mouth and the lining of the inside of the mouth is moved out to cover the new opening. While this does create scars, they are along the new lip margins…not ending up in the skin in a line running away from the corner of the mouth. This is a favorable location for the scars along a natural tissue border. This would provide improvement provided that the reason you can not get into your mouth is tight skin at the corners of the mouth.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had cheek implants placed over 25 years I have lost weight and would like to know if facial fillers can be used close to the implant. Is there and increased chance of infection? Thank You

A: Cheek implants that have been in place for 25 years had to have been some of the first cheek implants every put in, usually of a small ovoid shape that were positioned on the anterior end of the cheekbone. This location creates that ‘apple cheek’ look that is very appropriate for many women. While the bony augmentation has remained stable, over the years the soft tissue around the implants has undoubtably changed becoming thinner and developing some malar sag. Thus the impetus for injectable fillers to recreate some lost cheek highlights due to aging. Generally it should be no problem to place injectable fillers in the tissues overlying such ‘old’ cheek implants. Having removed several cheek implants of a similar age, the scar capsule that surrounds them can be incredibly tough and even partially calcified. It would be probably be unlikely that a needle could even penetrate the capsule should it inadvertently come into contact with it. This is also a good use of the microcannula method of injectable filler placement which has a blunt tip and would have zero chance of breaking through the cheek implant capsule and inadvertently injecting into the implant itself.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am seeking gynecomastia reduction by liposuction only. I am 24 years old with a body mass index of 26. I have developed glandular gynecomastia with enlarged areolas. All my endocrine labs are normal. Can I have Smarttlipo done using the axilla as access for the probe? Will this work for male breast reduction? I have attached pictures for your review.

A: This is one of the more challenging types of gynecomastia to treat because of the enlarged areolas and the skin excess on the chest. Trying to do gynecomastia reduction with liposuction only, regardless if the incisional access is not likely to result in the best outcome. With glandular tissue present under the areolas, any form of liposuction is not going to be able to completely remove it. I would do a combined open gynecomastia excision with liposuction and see what happens with the areolas and skin excess. (how much shrinkage occurs) One has to be prepared for the potential of the need for a secondary procedure that may involved a periareolar reduction with scars around the areola. One could argue that should be combined with the intial procedure but that would depend on he patient accepting those scars from the beginning.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am lookin into abdominal panniculectomy surgery. I have a large pannus that goe to my sides. It hangs below the pubic line but not completely covering the pubis. I am a larger woman but my stomach is the largest problem I have and I am interested in getting it removed. I am currently 290lbs but if you see me you wouldn’t think that because I have large muscle mass also. Do you operate on larger patients? I am currently eating healthier and it seems that my stomach has shrunk a few inches but will not go away. Please help. 

A: The decision to undergo an abdominal panniculectomy is largely based on how large the pannus is and how much can be removed given the tightness of the abdominal skin. The one problem with the removal of any pannus near 300lbs is that only a limited amount can be removed given the tightness of the abdominal skin due to the distention from the underlying weight. A much more effective and larger abdominal panniculectomy could be performed when one’s weight is 50 to 75 lbs less as this loosens up the skin’s tightness. This doesn’t mean that at 290 lbs you can’t have the pannus removed, it just means it is a more effective procedure if you weighed less. I would need to see some pictures of your abdominal area to give a further assessment about whether it is a good idea to have the procedure at your current weight.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had my jaw fractured and repaired several years ago. Even though it is fully healed, it has never been quite right. I have attached multiple photos. When my jaw is relaxed, my bottom teeth show fully. I don’t know off hand what type of  mentalis muscle resuspension surgeries were done. However, both were done making use of screws but the first one made use of multiple screws. That one completely failed after about 4-6 months. The second one which I underwent only about 3 months ago, the surgeon removed the other screws and  used only screw where he went in under the chin with small incision and also sewed the soft tissue below the bottom lip to my inside gumline. where I have a dental bridge and no teeth blocking (also as result of trauma). Both of these surgeries seemed to focus on central part of the chin and muscle.

The lower right side where mandible was most severely fractured and had the most work done to it seems to be where the suspension needs to be done and muscle reattached. Left side is now and always has been slightly higher than right leaving smile looking crooked and chin with no definition but just hanging below. It looks as if I have a much larger chin or even an implant when in fact it’s just unattached muscle hanging. However, it’s more than just the looks but the sensation and placement of nerves as both times recently after resuspension, it feels good and right and then after time goes by and starts slipping again then feels as if I am sucking on my lower jaw because the muscle has slipped below chin and lower teeth and jaw gives feeling as if further inside my mouth (If that makes any sense).

Do you think there is anything that can be done to attain a semi permanent resolution to this matter that has plagued me for the past two years or am I stuck with what I have currently? I don’t want to keep undergoing more surgery for no added benefit but just to accumulate further edema and added scar tissue.

A: The low hanging lip, regardless of the cause, is always a difficult problem to correct. Having had two ‘failed’ attempts at chin pad/mentalis muscle suspension is not an encouraging history and would suggest that any further efforts would meet a similar fate. You have even had the ultimate mentalis resuspension surgery procedure which is only possible when there are no teeth in the central alveolus. With that not working, there are no other suspension techniques available. I didn’t see mention of a V-Y mucosal lip advancement with the suspension although this alone is not the magical missing piece.

The right side of the chin/jawline issue is not really a muscular problem as there are no significant muscles that attach there. It is a soft tissue sag although not muscular per se. That is a difficult area to try and reattached because of the mental nerve and the potential of any existing metal hardware in the area. Do you have any x-rays that show the lower jaw and the repaired fracture?

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting a custom chin/jawline implant. I’ve been doing some more research into cheek and chin implants and wanted to ask your advice. Based on my photos do you think a standard  chin implant modified to fit just the left side would be adequate? Or is it best to stick with the plan for a custom implant? I know a custom implant would be pretty pricey and since I’ll be needing lots of other work done to correct my Parry Rhomberg syndrome so I’m just trying to figure out the best options. I also wanted to get your thoughts on cheek implants. One surgeon I spoke to thought I only need a cheek implant on the left side and that the right side could be built up with fat or filler. However another surgeon insisted that I needed implants on both cheeks, so now I am confused. Would you suggest a cheek implant just on the left side or both sides to make things as symmetrical as possible? I’ve attached the other surgeons photo simulations of a standard chin implant, fat transfer, and left side cheek implants. Do these simulations seem like attainable results to you?  Any feed back would be greatly appreciated.

A: With facial bone asymmetry, it is a given that a custom jawline implant would be superior to any off-the-shelf implant. There is no question about that. The question you are asking, understandably, is there something that would cost less that could do a reasonably similar job as a custom implant. When it comes to any existing standard chin implants I would say no because the bone deficiency extends all the way back to the jaw angle. However, I have been using a new wrap around jawline implant for men and women that I believe would work that is not yet available to the general public. (sold by the manufacturer) I think half of this implant could be added from your left chin back to the jaw angle and would do a great job of building out your deficient chin-jawline. (the custom implant would probably look somewhat similar) This would reduce the cost of the procedure considerably over a custom jawline implant.

As for the cheek areas, go with cheek implants on both sides. The cheek implants would not be the same size of course. But never try to compensate for a skeletal deficiency with unpredictable fat grafts when you are already committing to doing a cheek implant on one side. You may still need some fat grafting but just don’t try to make it work for the bone part of the facial problem when there are more predictable solutions.

When it comes to computer prediction imaging, understand that it is not a guarantee of how the surgery will turn out. It is Photoshop where anything is possible by moving pixels around. It is the surgeon’s estimate of what he/she hopes is accomplished and is the goal to aim for but whether that is completely attainable is determined by the surgeons skill and ability and how realistic the imaging has been done.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am looking for a consultation on breast augmentation. I have asymmetry issues and would be curious about not only evening out, but enlarging both breasts from a small B to a full C.  I am not familiar with what a price would be for such a procedure, but I would appreciate a range/estimate to know what I’m getting into.

A: Breast asymmetry comes in many forms but your description suggests that it is a volume issue as opposed to one breast being smaller and sagging as well. (which poses different considerations) If it is a pure volume issue, then breast augmentation surgery alone may suffice…just using different implant sizes to make the mound ssomewhat more symmetric. While one can never achieve more symmetry or evening them out perfectly, breast enlargement with two mounds that are more symmetric is possible. This, then, other than having two different sized implants is a straightforward breast augmentation procedure. The cost of breast augmentation is dependent on what type of implants are used. (saline vs silicone) and not on the implant size so knowing your implant choice would be helpful in answering the cost question.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am  41 years old and weight 96 lbs. I have sagging, wrinkled loose skin at elbows and knees and was wondering if an elbow/knee lifts would be an option. I’ve never had a large weight loss but did lose 10 lbs about 2 years ago. Thanks so much for any info.

A: My guess is at your age and relatively stable weight, this is simply loose skin due to lose of elasticity of thin skin. This is very common at the elbows and knees due to the frequent flexion movements across the joints. It is not really question of whether elbow and knee lifts can be done…but should they be done. There is the aesthetic trade-off of a fine line scar which I consider more of a potential issue in the knees than the elbows due to the visibility. The good news is that thin skin usually scars the best, so this is a consideration not necessarily an impediment to doing it. I would need to see some pictures of the knees and elbows in the straight position (extended) to judge how much loose skin is present. It is that determination that makes the decision about whether elbow and knee lifts (so called ‘joint lifts’) are worthy of that scar trade-off.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 42 years old and have had 600cc implants for over a decade. While the number makes them seem big, and they are not small, I am 5’9” and weight 140 lbs. I now would like to go up to 1000ccs or even 1250ccs. What do you think?

A: When one considers very large breast implants (at least based on the volume measurement), the most important long-term issue is whether the breast tissue will hold up and support them. If not, the implants will eventually drop (bottom out) and this will become a really difficult problem to correct. For most women going to that size initially would be impossible given the amount of breast skin that they have. But in someone with existing implants there has already been some significant expansion. So the concern then becomes where releasing the existing capsule to enable a larger size to be placed will exceed the surrounding soft tissue support. The other issue is that such a larger implant size will have a larger base width to it so one shoudl expect that the sides of the implant will go past the outer chest wall area and closer into the swing of the arms. (which many women do not like) The last consideration is that these will have to be saline implants as the largest prefilled silicone breast implant size only goes to 800cc. The largest saline implant size is 960cc but that can be overfilled up to 1100ccs if desired.

All of that being said, it is not a question of whether it can be technically done but whether it should be done. Having breast implants in place, you are in a good position to make an educated decision about what new size breast implants you want.

Dr. Barry Eppley

Indianapolis, Indiana