Your Questions
Your Questions
Q: I had cheek implants placed over10years ago and an oral and maxillofacial surgeon told me one of them is infected. It started with a visit to the dentist.I had 2 fillings done in my upper molars.The freezing was in the same area the implants are and this somehow caused one of them to get infected. It is swollen and I am upset it happened and worried about the infection. I have been on antibiotics for about a month.I know infection is rare but I got unlucky and I was wondering how many times you’ve had to take one or both implants out?
A: You are correct in that infections with cheek implants are rare, but they are not unheard of. It has been reported that cheek implants can get infected with local anesthetic injections during dental treatment. An upper vestibular or intraoral nerve block puts the needle very close to a cheek implant and could very easily, unknowing to the dentist, touch or penetrate into the implant. This would be a source of bacteria brought into the implant capsule from the needle track.
Once a cheek implant, or any facial implant for that matter, gets infected, it is likely that it will eventually require surgical treatment. An implant is an avascular surface, that once contaminated, can not easily get rid of an infection. Antibiotics are a logical first choice but they will tend to only suppress it for the duration that you are them. Once off, the swelling and infection usually returns. If this does not work after a month or so, I would re-operate, remove and clean off the existing implant and either replant it or replace it with a new one. This approach will work. The opposite cheek implant is at no risk from the infection of the other one.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am 53 yrs. old and have very deep nasolabial folds (more so on one side than the other). I don’t know why they are so deep at my age but they are. I was interested in the “Cutting out” of the fold, however, my question is what happens to the cheek? Would the skin not sag? This is a problem I have and am very self conscious about it.
A: The development of nasolabial folds occurs in everyone as they age, some are more pronounced than others. How deep and early nasolabial folds appear is a function of numerous factors including thickness of one’s facial skin, thinness or fullness of one’s face, cheek bone support and how much cheek soft tissue sagging or ptosis develops. The nasolabial fold develops as the cheek tissues sag down over the more fixed and stable upper lip region. They are really tissue that is ‘falling over the fence’ so to speak.
By far, the most common treatment for softening the nasolabial folds are injectable fillers. But in advanced stages of nasolabial folds, an inverted-V deformity exists in the skin and injectable fillers do not produce a significant or worthwhile reduction. Usually inverted nasolabial folds are seen in older patients. (> 60 years of age)
In the inverted V or deep nasolabial fold, excision is a treatment option. Because this technique cuts out the fold, it is very effective at restoring a smooth transition between the lip and the cheek again. However, there is a trade-off of a scar which make proper patient selection critical. While this fine line scar does quite well, it is a scar nonetheless and that deformity trade-off is not right for everyone.
Another treatment option for the deep nasolabial fold is a ‘release and fill’ technique. A fine surgical wire is used to release the dermal attachments of the fold and an interface of injectable fat placed under the release. While this sounds like it would be theoretically successful, long-term follow-up has not borne out this theory.
Before considering nasolabial fold excision, one may want to try injectable fillers to be certain that their effect is not sufficient since they are reversible. Nasolabial fold excision is a one-way commitment.
Dr Barry Eppley
Indianapolis, Indiana
Q: I was just wondering if Dr. Eppley could do scar revision on old keloid acne scars. I went to a Dermatologist over 7 years ago and he told me that plastic surgeons could remove the scars with great success. I am very self conscious and I love to swim, but I haven’t really done it because I know people are staring and want to know why I have these ugly scars. I wish I could tell them to mind their own business but obviously I can’t. I have them on my shoulders, top of my biceps, and a couple on my chest area. I was just wondering if you had done this kind of surgery before and what was the outcome from the surgery?
A: The success of scar revision is measured by how much the scar appearance is improved. Improvement in problematic pathologioc scars as you decribe is ultimately measured by whether hypertrophy or keloiding reappears. There is no question that scar revision is successful early because the previous scar is cut out and temporarily eliminated, trading off a thick raised scar for a more narrow scar line. But what does the scar look like three or six months later?
How successful scar revision is depends on many factors, including skin type, anatomic location of the scar, and what caused the scar. Hypertrophic or keloid scars in thicker skin with darker pigmentation over stretch out areas such as the sternum and shoulders can be very difficult scar problems with a high rate of recurrence. They remain a plastic surgery problem where a better understanding of the science of scar formation is needed before more effective treatments are developed.
Until that day arrives, we must consider traditional scar excision and see what happens. I would recommend to do just one of the scars and see what happens, using it as a ‘test’. Based on that outcome one can determine if the other scars are worth the surgical effort.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hello Dr. Eppley. I’m a 25 yr old male who is dissatisfied with my cheeks. They are very round and full, and give me a infantile or boyish look, rather than a more angular, defined, masculine one. I’m pretty thin so weight loss is not an option. I’m wondering what my surgical options are. Apparently plastic surgeons don’t think buccal fat reductions are a good idea. Would creating a cheek dimple help? What do you think?
A: Full cheeks do contribute to a more round facial shape although they are just one factor in creating that appearance. Depending upon how one defines the cheek area, a full cheek can be due to a prominent cheek bone, a large buccal fat pad, a thicker subcutaneous fat layer across the cheeks and face, or some combination of all three. It is obviously important to know what in the cheek area is creating that look when one tries to figure out how to change it.
From a practical standpoint, the only reliable method of ‘cheek’ fullness reduction is partial or complete buccal fat pad removal. While this is a very simple procedure, one has to appreciate what type of facial slimming effect that it will create. Buccal fat removal will create a soft tissue indentation below the cheek bone prominence. If you put your finger under the prominence of the cheek bone, this submalar or under the cheek location will be the area effect. The slimming effect will not go down or past the corner of the mouth.
For most patients, buccal lipectomies will create a mild reduction in cheek fullness in the submalar area, but never dramatic. It is a good procedure, in my opinion, in the properly selected patient. It has gotten a bad reputation because of poor patient selection and over aggressive fat removal. In patients with thin or lean body types, the short-term facial sculpting effect may not be worth the potential for a long-term facial atrophy look with aging.
In trying to create a more sculpted face, it is also important to look at other potentially useful procedures such as chin augmentation, neck liposuction, and maybe even mild cheek augmentation. When put together with buccal lipectomies in the right face, a signficant more defined facial look can be obtained.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am writing to you because I have a very troublesome scar on one of my cheeks. The scar has been there for a long time since I was 5 years old. At that time I had some type of cyst removed which left a bad scar. It has bothered me for over 20 years and has very negatively affected how I see myself. I have tried the best that laser resurfacing (Fraxel) has to offer as well as Botox and filler injections, all with no visible improvement. I have paid good money for these treatments and I was really disappointed to see that they did not make a difference. What do you recommend?
A: Your question has me at a disadvantage as I can not see your facial scar. Having seen and operated on children for facial nevi and other tumors, however, it is like that your scar is plagued by multiple adverse scar factors including being wide, is deeper or more depressed than the surrounding skin, and is positioned over a prominent facial area. I can say that with some confidence because you were still young when the scar occurred and your face has grown much since that time. Facial growth always causes scars to stretch and be thinner than the surrounding skin.
The only hope of any improvement is actual scar excision. Cutting all or part of the scar out and then re-closing it can narrow it. Often this takes two stages to get the scar narrowed as much as possible. Thereafter laser resurfacing may be beneficial but may not be needed at all. When one considers serial scar revision, including healing and scar fading time, this is a process that easily can take a year or longer to get to where you want to be. A patient must be prepared to make such a time commitment. You are still young so such lengthy efforts will still have a long lifetime of benefits.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am writing to inquiry about a calf implant for my daughter. She has developed a rather significant difference in the size of her calfs now that she is a teenager. While it was slightly apparent as a child, it has become real obvious as a 15 year-old teenager. It bothers her to the point that she will not wear shorts or go to the pool with other teenagers. She walks fine and as no disability from the calf size difference. I know that calf implants can be done for body builders and others who want both calfs to look bigger, but can just one calf implant be done? I could not find anywhere where just one was done.
A: Calf augmentation with implants is an uncommon body contouring procedure. While it has been done for decades, it is far less common than breast or buttock implants. While most people think that only body builder types do the procedure, it may surprise you to know that their use for ‘reconstruction’ of congenital calf deformities makes up about half of all calf augmentation procedures.
Calf implants are made of specially-shaped soft flexible silicone rubber. They are surgically placed through a small incision behind the knee. They can not really be put inside the calf muscle but are placed on top under its fascial covering. They can be placed on either the inside, outside of the calf, or both. Most commonly, they are placed on the inside half (medial) which is where most of the calf’s definition can be visually seen.
For calf asymmetry, placing a calf implant on the smaller side can help make their size discrepancy less apparent. If your teenager is that bothered by it, I would seriously consider the procedure. It is really the only good plastic surgery option for such a calf problem.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have a strange question for you Dr. Eppley but I am very curious. I am going to get breast augmentation in the near future and am an avid swimmer. My friend told me that it might interfere with me swimming. She said she heard that breast implants will act like floats and slow me down or could weigh me down and make it harder to stay afloat. Is what she is saying true?
A: Your question/concern about the impact of breast implants in the water is neither strange nor new. Women have asked me about that numerous times in my Indianapolis plastic surgery practice. One the one hand, millions of women over the past thirty years have had breast implants and such potential problems have never surfaced or been reported. This would strongly suggest that what your friend is telling you is nothing more than an urban myth.
From a scientific standpoint, the question is one of the buoyancy of breast implants. Depending upon the type of breast implant, the answer differs slightly. Saline implants are neutrally buoyant, meaning that they will neither float nor sink. This makes perfect sense since they are essentially the same density as the water in which they are immersed. The two fluids are only separated by the thin containment shell of the implant. Silicone implants, however, are a little more dense than water and will have a slight sinking effect.But they will not completely sink and essentially float as well. This can be easily demonstrated by placing both type of implants in a sink filled with water.
When placed in the body, however, the buoyancy of breast implants demonstrated by benchtop testing becomes irrelevant. Their impact will be the same as any other enclosed body part. Their only potential impact on swimming is on the aerodynamics of the body shape, which is only relevant if one is an Olympic or competitive swimmer.
Dr. Barry Eppley
Indianapolis, Indiana
Q : I had a facelift right after this past Christmas. While it turned out great and I wouldn’t change a thing, I forgot to ask my plastic surgeon how long it would last. What is your take on the longevity of facelift surgery? What can I expect to look like five years from now? Will I eventually look like I did right before the facelift?
A: The simple answer is…you will eventually outlive the results of your facelift. In fact, I would argue that is your goal, to be able to live long enough to need some type of tuck-up or secondary facelift. In that answer lies an important truth…facelift surgery is not permanent. Its lack of permanency is because the surgery treats the symptoms of the problem but not the problem itself which is unstoppable aging.
The complex answer is that it is very difficult to predict how long the results of a facelift will last. The rate at which people age is highly variable and depends on the interplay of numerous factors including heredity, sun exposure, stress, smoke and environmental poison exposures and nutrition. The quality of one’s skin, its thickness and elasticity, and the shape and support of the underlying facial bones play a major role in the stability of a facelift result.
The age at which a facelift is done is also an important factor as aging accelerates at different stages of life. As an example, the results of a facelift performed at age 50 can be expected to last longer than the results of a facelift done in a 65 year-old.
But for those that like numbers, on average, most patients will get at least five to seven years of good longevity of a facelift. Some patients make take as long as ten to twelve years to see a significant return of jowling and loose neck tissue again.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m hoping you will be able to advise based on your article on conservative vs aggressive liposuction and the trade-off with skin contouring. Would you please tell me what my options are to correct the skin irregularities on my upper arms as a result of liposuction done severalyears ago? Would weight training or weight gain or massage help? What are the odds that a second liposuction procedure on the arms would correct vs worsen the skin irregularities? Thank you!
A: The number one complication after liposuction is contour irregularities, i.e., lack of perfectly smooth skin. Certain body areas are more prone to that problem than others. The arms is one of those potential areas and that has to do with how liposuction is performed in an axially-oriented extremity…usually from one direction. It is very difficult, from an access standpoint, to treat the back of the arms from different directions. The concept of cross-tunnelling, an old liposuction concept, still has merit even with today’s advanced liposuction technologies.
Massage therapy done early after liposuction surgery can help with working out any irregularities and uneven areas. However, months to years later when the tissues have healed, make such tissue manipulation unsuccessful. Weight training or arm toning would be unsuccessful as the contour problem does not lie at the muscular level.
The only option for improvement would be another liposuction surgery. The scarred and irregular subcutaneous tissues must be released for any better contour to be achieved. Since the old motto of ‘plan B should not be the same as plan A if you want a different result’ applies, how the liposuction was done and what was done afterwards should be different. In my Indianapolis plastic surgery practice, I would use laser liposuction (Smartlipo) as a different method, access the area from both at the elbow and from behind the arms, and institute massage therapy beginning two weeks after the liposuction surgery. While no guarantee can be made that it would be better, my experience is that it would. If the same technique was used as the last time, the odds are higher that it could be worse.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am wondering about reducing an area of my upper lip. Here is the problem. When I was younger, I had an incident that cut an area of my upper lip. My lip healed fine and the cut mark is no longer there. However, it appears that an excess of fat or tissue (not sure what it is) has collected in that part of my lip. I am guessing the procedure may be something like liposuction or something like that. It looks rather simple to do and perhaps could just be fluid in there. Please advise.
A: The bump on your lip that you are seeing is undoubtably scar tissue. It is not fluid or fat. This is an absolutely classic case of scar formation that occurs after a significant cut or laceration on the lip occurs.
While scar forms anywhere on the body after injury (this is how things heal), the lips are uniquely different from what occurs in skin…because they are not skin. Lips are a combination of wet and dry mucosa which is much thinner and more elastic than skin. It has to be so that the lips can be flexible. There is a reason that you can pull on your lips and really stretch them out without tearing them. (up to a point) Wet mucosa is more flexible than the dry mucosa which is the part of the upper and lower lips that we externally see.
The thinness of mucosa, particularly the dry mucosa, makes it very susceptible to forming a thicker scar. This can particularly occur with many lip lacerations which are often left to heal on their own. Such secondary healing almost always leads to a thicker area which disrupts the smoothness of the horizontal lip lines.
Lip scars can easily be re-excised and closed with successful smoothing of the lip line. Lip scar revisions can usually be done under local anesthesia.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I had my face injected with fat and it was initially overfilled. The doctor that did it said it would go down and look more normal but it has not. Can anything be done to make the fat go away or at least become less full?
A: Fat injections to the face is a good and safe technique for adding soft tissue volume to specific areas. Its almost sole problem is that its volume retention (aka how much survives) is not completely predictable. Studies have shown that certain areas of the face do retain transplanted fat better than others. For example, the cheek and side of the face do much better than that of the lips. Thus, it is standard practice to overfill or add more volume than one thinks is really necessary. How much one should overfill has never been precisely defined. Some plastic surgeons may do it just a little, others may significantly overfill.
Despite overfilling, the most persistent fat injection problem is that not enough ultimately remains. It is rare, but I have seen it, that too much fat remains. One should wait at least 3 months after facial fat injections to judge the outcome. By then, one is most likely looking at how much fat volume will be maintained.
There are two basic methods for reducing overfilled fat facial areas. If the location permits, ‘micro-liposuction’ can be done if a small incision can be cosmetically tolerated. The other approach is using injection therapy. I have seen successful use of either a steroid (Kenalog or triamcinolone) or very dilute Lipodissolve solutions. (phosphatidylcholine) The two can be combined together to create a mild fat dissolving solution that does not cause a lot of facial swelling afterwards. Injection therapy as the advantage of a non-surgical approach in which the treatment can be done in very discrete spots. It is also a more gradual process that lowers the risk of removing too much fat and causing the reverse contour problem.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Can you undo cheek dimple surgery I had done about 10 years ago? If so, how is it done?
A: The surgical making of cheek dimples is different from what causes natural cheek dimples. Anatomically, natural cheek dimples have been shown to be present from a split in the zygomaticus nuscle which runs from the upper lip to the cheek above. Because of this natural split in the muscle, the overlying soft tissues are pulled down or tethered into the split muscle, creating an overlying indentation in the cheek. Depending upon the size of the muscle split and the amount of tethering, this is why some dimples don’t appear until one is smiling or those that have them at facial rest get much deeper with smiling. The surgical creation of cheek dimples is done by going from inside the mouth, splitting between the zygomaticus muscle, and sewing the underside of the desired spot on the cheek down to the muscle.
Reversing cheek dimples is a matter of releasing the tethered skin and placing something between the skin and the muscle as a soft tissue filler or spacer. The best filler for that, in my opinion, is fat. The easiest and most convenient place to harvest fat is the buccal fat pad which is anatomically close to where one would be working for the cheek dimple release.
In natural cheek dimples, or in surgically created ones of long-standing, the result will be a softening or less prominent depth of the dimple. This is because some of the dimple presence is due to inverted or indented skin, which an intraoral approach alone will not solve. The skin also could be completely leveled but this would require a skin incision to do so. This creates a small scar in the skin as a replacement for the dimple which may or may not be a good trade-off.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am unhappy with what was done to my jaw angles. The procedure was done using a saw-like tool that was used to cut off bone from my jaw angles. I think they took too much bone. I don’t want to go back to exactly the way my jaw angle was before, however, I would like to get some prominence back. I think too much was shaved down and it looks too weak now. Also, both sides are uneven so my left and right profiles do not match which just shows how much my last surgeon was lacking in skill and technique. What can be done now to fix it?
A: Jaw angle reduction is done for prominent or flaring jaw angles which make the lower face too square. This is most commonly done in Asian populations due to their ethnically more square facial shapes. From inside the mouth, am oscillating saw is used to remove the tip of the jaw angle in an angulated bone. How much bone to remove and how steep to make the angle of the cut is a matter of intraoperative judgment and experience.
Restoring a now too obtuse and short jaw angle can be done with jaw angle implants. Placed from inside the mouth, the implants are inserted under the muscle back over where the bone had been cut out. The implant’s size and shape, like the original bone cut, is a matter of aesthetic judgment. While the jaw angle implant’s size should be small, positioning them to correct jaw angle asymmetry requires precise and secure placement. Using a panorex x-ray before surgery, measurements can be taken to get a good idea about the differences in bone shape around the jaw angle. This can be useful to appreciate when placing the implants as both sides can not be seen at the same time.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I don’t have a butt and my tail bone sticks out further then my butt. I have an pronounced tail bone and don’t have a butt. It hurts to sit long periods of time because of my tail bone and having no butt. My butt is really small and has no outside fat or butt to it. I can never find pants to fit because of having no butt to hold them up. I don’t wear bathing suits because of what little butt I have. I am 26 years old and would like to have a butt and not be embarrassed to wear tight jeans and/or a nice bathing suit in the summer time. I would like to see if you can help me with this. I had Ricket’s as a child and that is why I didn’t grow a butt. That is what the doctor’s told me and I would like to finally have a nice butt. Please help me if you can.
A: Buttock augmentation can be done by either injecting your own fat or using synthetic implants. While I usually prefer fat injections for buttock enlargement in my Indianapolis plastic surgery practice, there are certain limitations to its use. You have to have enough fat to harvest for transfer and there has to be some subcutaneous fat in your buttocks to put fat into. Fat grafts need an adequate fat bed to be implanted and grow. With absolutely no buttock substance at all (completely flat), fat injections are not a viable option. With such lack of buttock volume, the body habitus of such patients is that they would not have adequate fat to harvest anyway.
Buttock implants are the only option with such severe buttock hypoplasia. While the recovery and risks of buttock implants are important to consider, their submuscular placement is necessary if any significant buttock enlargement is to be obtained in a very thin patient.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am a 31yr old mother of two kids. I got out of a five year relationship where I got too comfortable and gained a lot of weight. About six months ago I started working out and lost over 30lbs along with a strict diet. I still have about 25lbs to go to reach my goal weight but I know that dieting alone will not give me the final results I want. I am interested in a tummy tuck, a monsplasty, and breast augmentation. I was born with one breast about 1 cup size bigger. I would like them to be equal in size along with a lift. Can all of these procedures be done in a single operation?
A: Congratulations on the results you have obtained so far. It is always surprising what effort and discipline can do for one’s weight. You should be proud that you have gotten this far. In pursuit of your goal weight, think of the plastic surgery as an incentive to get there.
The first step in body contouring is weight loss but this alone is often not enough to get the shape that one wants. There is no better combination than a combined breast and abdominal procedure to change a woman’s appearance between the shoulders and the waistline. In a few hours of surgery, some dramatic changes can be obtained. Putting these two operations together is very common and I have done it many times in my Indianapolis plastic surgery practice. Breast enhancement and tummy tucks together can still be done as an outpatient procedure.
Many larger tummy tucks require reduction of a large mons at the same time. It is done as part of the tummy tuck by modifying the location and orientation of the lower incision. Complete mons reduction may still require a secondary liposuction procedure for optimal flattening. Breast enhancement in most significant weight loss patients requires a combined lift with an implant, known as an augmentation mastopexy.
Dr. Barry Eppley
Indianapolis, Indiana