Breast Implant Removal

Q: Dr. Eppley, I am considering breast implant removal. I have bilateral breast implants and now they are encapsulated the left is going under my armpit when I lay down. My insurance is paying for removal of implants and encapsulation removal. My Dr said it would cost $7000 to have new ones put it. I can’t afford that as I’m on Medicaid. I can afford the cost of implants themselves but not for the surgery room, anesthesia and the drs work even though I’ll already be having the other surgery paid for by insurance. My question is how bad will I look after this surgery. I’m so depressed and scared that I’m going to look deformed again.

A: I can not really answer your question without seeing pictures of your current breast situation. But it would be fair to say that the removal of breast implants does not usually return one to their pre surgical breast look. One’s breasts will usually appear worse than they originally were due to the stretched out skin and loss of further breast tissue. This if you felt that your breasts were deformed before the implants were put in then it is very likely that you will feel more so when these implants are removed.

Dr. Barry Eppley
Indianapolis, Indiana

Breast Fat Transfer

Q: Dr. Eppley, I am interested in breast fat transfer. I am average in weight and size (5″8 and 137lbs), but seem to develop fat around my obliques (stomach and lower back) and arms much more than the rest of my body; plus I have very small breasts and buttocks. I am very healthy and no matter how much I work out and eat a great diet, those areas of fat won’t budge. I would like to transfer fat from my stomach, lower back, and arms toward my breasts (and possibly my butt depending on the cost). How experienced is your team in breast fat transfers, because I know that it takes multiple people to keep the fat alive while transferring it?

A: While any fat harvested from liposuction can be used for transfer, it is not likely you will have much to actually put into the breasts. And most certainly there would not be enough for both breasts and buttocks. Thus you would need to concentrate any fat harvested for your breast fat transfer.

To give you some perspective on what success breast fat transfer may achieve in breast augmentation, it is important to understand the ‘halfing’ rule. The relevance of this is in getting a visual idea of how much breast size increase may realistically be obtainable. To start let’s make the basic asssumption that it takes about 150cc of fat (or an implant) to make a cup size difference. I will assume based on your description that between the stomach, arms and lower back you may have 1200ccs to harvest. (and that may be a generous estimate but I will use this number) When this amount of liposuction aspirate is then concentrated during surgery (and it is not true that it takes multiple people to keep the fat alive), it usually amounts to in women that around 40% will be end up being concentrated fat and available for injection. This leaves 480cc to be evenly divided between the breasts or 240cc injected per breasts. Then one can estimate that only 50% or half if the injected amount will survive or 120cc per breast. (the percent survival could be higher or lower…but it is almost always lower and rarely higher)

In conclusion you may be able to get a 1/2 cup size breast increase and that is if you can get 1200ccs aspirate and 50% of what is injected survives. The point being is that you might as well take whatever fat is harvested and use it for transfer into the breast but at best the breast augmentation result will be very modest in size. It is important, therefore, to have very realistic expectations. I would consider your procedure as liposuction first and anything that comes of the breast augmentation efforts as a bonus result.

Dr. Barry Eppley

Indianapolis, Indiana

Rib Removal Surgery

Q: Dr. Eppley, I have some questions about rib removal surgery: 

1. Is the surgery life threatening?

2. Is the surgery considered major surgery?

3. Once the ribs are removed, what negative aspect does that subject your body to, if any?

4. What is the procedure as far as surgery, hospital stay, aftercare, and recovery time?

5. Is the surgery performed in a hospital or the doctor’s clinic?

6. What is the price of the surgery? Does that include aftercare?

7. Are there any additional costs and what would they be and if applicable what would they be

8. How many rib removal surgeries has the doctor performed?

9. Looking at the before and after photos I provided, does the doctor feel he can achieve the result provided in the after photos with the rib removal surgery?

A: In answer to your questions about rib removal surgery:

  1. The surgery is most definitely not life threatening.
  2. It depends on how you define major surgery. Compared to surgeries like breast augmentation it would be considered major. But compare to surgeries tummy tuck and BBL surgery, it would be considered less severe.
  3. I am not aware of any negative aspect of rib removals other than the fine line scars it takes to do perform the procedure.
  4. This is done in a private surgery center under general anesthesia as an overnite stay.
  5. It is done in neither a hospital or a clinic but in a surgery center.
  6. My assistant will pass along the cost of the surgery to you tomorrow. Whether you need any aftercare or not depends on whether you are traveling along or with someone.
  7. The surgical quote will be all inclusive of the surgical experience.
  8. I have removed hundreds of ribs for a variety of body contouring and recostructive surgeries.
  9. I do not think the result you are showing is realistic unless you do a lot of additional waist training after the surgery. By itself it can produce about half of your imaged result.

Dr. Barry Eppley

Indianapolis, Indiana

Occipital Knob Reduction

Q: Dr. Eppley, I had contacted you about a year ago about my occipital knob reduction surgery. I have since been saving money for this procedure with you. I have also been following procedures you have performed and posted on your website. One that I found very impressive was the occipital implant with knob reduction using a custom implant. I have taken some more profile pictures and played around with possible outcomes. I have attached those to this email. If you could please give me your suggestions and opinions on this that would be great.

A: Good to hear from you again. What you have shown would be a beautiful addition to your occipital knob reduction since you really have a combined occipital problem of a lower protrusion (occipital knob) and an upper deficiency. (occipital flatness) Normally an occipital implant is done by a custom approach using a 3D CT scan. But I have done so many of these occipital implants that in some cases, to save money and still get a good result, I will use another patient’s occipital implant design. (this is known as a semi-custom implant) That saves a fair amount of money and the shape of the flat back of the head is only minimally different amongst most patients as long as there is not a significant occipital asymmetry. The implant is also flexible so there is a lot of give for its fit onto the bone. (once on the bone it feels hard just like bone however)

Dr. Barry Eppley

Indianapolis, Indiana

Reversal Jawline Reduction Surgery

Q: Dr. Eppley, I am looking for reversal jawline reduction surgery to undo my prior V-line jaw reshaping. I have sent you a 3D CT scan. Cal you tell me what procedures I need to get back the jawline that I had?

A: I have reviewed your 3D CT scan and I can now report on what was done on your jawline reduction procedure. You had a straightforward sliding genioplasty of maybe 5mms advancement. (very small) There were three plates used for its fixation. No width reduction as done on the chin, it was simply brought forward. There are no appreciable changes to the rest of the bony jawline. The jaw angles remained structurally intact  (no amputation of the angles) There may have been some burring done for a little width reduction but not much.

In conclusion your reversal jawline reduction procedure to return you as close to where you were before would consist of the following:

1) Reversal setback genioplasty

2) Width only jaw angle implants of a small size. (3mm)

Based on the 3D CT scan I do not see the benefit of making custom implants. The chin needs to be set back and performed srandard jaw angle implants can be used too restore the jaw angle width.

Dr. Barry Eppley
Indianapolis, Indiana

Kybella

Q: Dr. Eppley, I have been researching Kybella treatment for my moderate jowl laxiity. I consulted with a plastic surgeon and he rejected me suggesting that I lose weight. I am 53 years old, 5’6″ and weigh 150 lbs. I averaged 127lbs through my 40’s to the present. I have great confidence in my dermatologist and she has recommended two treatments of Kybella,and has told me there is a 4% chance of a temporary drooping of the mouth. Most of my research says that Kybella is not recommended for the jowls. I am writing to you because you are the first I’ve come across to suggest that it can be effective for that area. Could you tell me with your experience to this date, if you still think it can be relatively safe and effective in smoothing a mild/moderate jowl sag? Many thanks in advance for your response.

A: The concept of injection lipolysis (Kybella is the one brand name for now) can be done anywhere there is fat. It is not a question of whether it can be done but whether it will be effective and has a low risk of problems in doing so. Thus the jowls can be injected and some mild improvement may be capable of being achieved. It will not be as effective as small cannula liposuction or even a small jowl tucked however. The risk of injecting the jowls is injury to the marginal mandibular branch of the facial nerve. Such injury will not cause month drooping but rather will cause lower lip elevation and smile asymmetry. Such an injury can occur from the intense inflammatory reaction that the injected deoxycholic acid solution causes. Such a reaction occurs in a 1 cm zone around each injection site. As long as one stays well away from the marionette line area of the chin this complication can be avoided. I have never seen it occur in the patients I have injected.

Dr. Barry Eppley
Indianapolis, Indiana

Facial Fat Grafting

Q: Dr. Eppley, I am interested in facial fat grafting. Can volume loss in face due to no back teeth for a number of years be restored for a fuller face by the use of fat grafting?

What method of fat removal do you use?

What harvesting method do you use?

What is the cost?

Will my face be widen from this procedure?

Can a brow lift be performed at the same time or will fat injections serve the same purpose as a brow lift?

A: Thank you for your inquiry. In answer to your questions:

1) The area to which you are referring ( the soft tissue trampoline area between the cheeks and the jawline) can only be augmented by facial fat grafting. This is a non-bony supported area so only soft tissue augmentation will work.

2) and 3) There is only one method of fat graft harvest and that is by liposuction aspiration.

4) My assistant will pass along the cost of the procedure to you tomorrow.

5) Your face will become fuller/more convex in the soft tissue area between the cheek and the jawline.

6) Facial fat grafting is not a substitute for a browlift. Adding fat to the brows will not lift them.

Dr. Barry Eppley

Indianapolis, Indiana

Midface Implants

Q: Dr. Eppley, I am interested midface implants. Two years ago, I had a Lefort surgery to advance my upper jaw. I plan on getting a rhinoplasty at a future date. At the present time, I am only interested in getting facial implants to augment the tear trough/cheek areas and the midface. Specifically, I am interested in knowing if I am a candidate for a premaxillary implant and if premaxillary implants are often used on patients who have already had orthognathic surgery. Thank you for your time.

A: In my experience it is not uncommon at all to have patients who have undergone a LeFort osteotomy to subsequently want midface augmentation with implants. This is because, as you have experienced, the Lefort I osteotomy essentially moves the teeth and the lower nasal base forward (or upward) but leaves the rest of the midface ‘behind’.

The key question about midface augmentation is whether standard preformed midface implants will suffice or whether a complete custom midface implant is needed. Standard midface implants include cheek, tear trough and paranasal/premaxillary implants which augment the respective names areas. A more complete total midface implant is designed to create a total augmentation from the infraorbital rim/cheeks down to the lower level of the pyriform aperture/maxilla.

Dr. Barry Eppley

Indianapolis, Indiana

Hydroxyapatite

Q: Dr. Eppley, I know that the Hydroxyapatite in the  world using only a few professional surgeons.  But I know that it is difficult to remove if something goes wrong. PMMA bone cements is more cheap than hydroxyapatite but how much it’s better ?  I do not like silicone implants. Their many uses silicone implants since it is easy for surgery but I do not feel that it will give a nice aesthetic effect. And now I am confused choosing between hydroxyapatite or PMMA bone cements. 

Could you explain please what is better to use and advantages and disadvantages between . I still do not really understand A: You have several misconceptions about the materials. Hydroxyapatite is fairly easy to remove just like PMMA and silicone implants. In the brow bone area PMMA produces a better aesthetic shape and is easier to place in that area to create the effect. Regardless of the material used, the aesthetic result is based on its shape not the material composition. Quite frankly the best way to brow bone augmentation is a 3D silicone implant made from a CT scan. It is best because the shape and dimensions of the brow bone augmentation is designed and controlled BEFORE surgery. The surgeon’s job then is just to place the implant correctly. All other materials, such as hydroxyapatite and PMMA, require intraoperative shaping and that is far less precise.

Dr. Barry Eppley
Indianapolis, Indiana

Temporal Artery Ligations

Q: Dr. Eppley, I am interested in temporal artery ligations. I am talking to a couple of consultants here also and plan to make a decision once I have all the information I need.  It appears that you are the most experienced on this procedure – would you mind informing me how many you have done on the past? My main concerns are around potential scarring and hair loss.

I first noted the prominent temporal arteries appeared about six months ago – first on the left side and most recently on my right temple.  No idea what is causing them and have not been able to find out but I do get a throbbing/ shooting sensation in them most of the time.

Would the surgery eliminate the throbbing sensation I get as well as the appearance? I have attached pictures for your reference.

A: In answer to your temporal artery ligations questions:

1) I now perform about 1 to 2 temporal artery ligations per month from patients all over the world.

2) The incisions to do the procedure are very small (around 5 to 7mms) and usually heal imperceptibly.  Whether you  need just one proximal ligation (one point) or a combined proximal-distal ligation (two point) can not be determined until during the procedure. (The vast majority of patients receive a proximal and distal ligation) I have yet to have a patient have an issue with the scars. (at least a patient that has ever told me so)

3) Hair loss is not an issue with this procedure. It has not been seen or reported.

4) With a reduction in the temporal artery flow I would think that the throbbing sensation would decrease or be eliminated. That is what most patients who have these symptoms so state afterwards

5) Your pictures show a classic pattern of an enlarged anterior branch of the superficial temporal artery with its typical snakelike pattern coursing towards the forehead.

Dr. Barry Eppley
Indianapolis, Indiana