Your Questions
Your Questions
Q: I read your blog on plastic surgery after a large amount of weight loss. I’m pretty sure that you broke my heart, but I’m glad you wrote the reality. I am so completely disappointed. I joined a sight that said men donate to women like me for breast lift and breast augmentation surgeries. I now know that it’s hopeless. I am on disability and have no way to pay for these procedures. It would take me many years to save for the procedures I need desperately. I only wish that if medicaid or medicare could understand that these procedures are needed and not just for cosmetic reasons. Having low self esteem, a feeling of complete hopelessness, depression, and anxiety are all factors they should consider too. I really hoped that when I lost most of my weight that I would once again be nice looking. I used to weigh almost 280 pounds and I am now 145 pounds. It did not make one bit of difference because now I have sags and hanging skin. I would do anything to look good and feel confident again. Thank you for sharing your wisdom. Please remind people who can and do succeed with their procedures that they are lucky and truely blessed.
A: The unfortunate reality is that cosmetic surgery is not free nor are any health insurances going to pay for elective body contouring surgeries. This is of great disappointment to many massive weight loss patients that understandably feel that their loose hanging skin poses many physical as well as psychological problems. Even in the few body contouring procedures that some insurances may cover, such as a panniculectomy, plastic surgeons are very hesitant to do them because the reimbursements are so low, they take a lot of work with potential complications and there are always medico-legal risks and exposure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dear Dr. Eppley, I have a question about cheek and orbital rim implants. I have fairly wide cheek bones that I am considering reducing via osteotomy, but the frontal cheek area directly beneath my eyes seems deficient. Are there cheek implants (or fillers) that can push out this area under the eye (a slightly near the transition of the nose)? Can the results of such cheekbone implants make a wide/flat face look less wide and more defined? Also, does cheekbone reduction cause sagging skin/prejowl?
I have fairly large eyebrow ridges, which I am generally happy about, but the ridge area close to my radix is deficient compared to the prominent ridge area near my temples (I think it pushes my eyebrows up vertically near the side of the temples). Is there a way to augment the area near the radix so that it more smoothly matches the rest of my eyebrow ridge? Would the only way to do this be to have an open-scalp incision? What would be the complications of such a procedure?
A: It is common in wide cheek or zygomatic widths to have anterior infraorbital rim deficiency. This is part of the wide midface look. There are specific infraorbital-malar implants that augment this area exclusively. They come in a variety of styles and sizes although my preference is to custom carve implants out of a Gore-tex block at the time of surgery, particularly when the amount of rim/tear trough augmentation is small.
I don’t know if you would call a combined cheekbone reduction with infraorbital rim implants making the face more defined. But it will change its shape and proportions acroos the midface area to look less wide. Calling it increased facial definition is a stretch.
Building up the radic of the nose can be done with either injectable fillers or fat for a minimal or non-invasive approach or can it be bult up with either a very small implant or cartilage from an intranasal approach. A scalp incision would never be needed.
Dr. Barry Eppley
Indianapolis, Indiana
Q:I had a combined breast augmentation with a lift about 3 weeks ago. It seems like my implant on the left side is below my breast. It has been like that from the beginning so I should have asked the doctor aboutthat when I last saw him. I was just wondering if it is like that because of swelling still or is it going to stay like that. I know it has only been 3 weeks and my doctor said you really can’t critique it for 3 months, so I’m not overly concerned just wondering about it. Maybe my left one required more work, it’s still a little bruised. I didn’t know if I should try to do something to push it up? I guess I was wondering if this is normal. I probably wouldn’t think as much about it if both of my breasts did the same thing. I have attached some pictures for you to see.
A: Based on the pictures, the left breast implant is below your original inframmary fold of which some of that crease still exists. It is often necessary to lower an inframammary crease, particularly in cases where there is breast asymmetry. I would suspect that your original left breast was smaller with a higher imframammary fold prior to surgery. This made it necessary to achieve better symmetry during surgery by lowering the crease on that side so the implant will match better with the original larger right breast. This is an issue in which more time is going to be needed to see how the whole breast shapes out over time. Combined breast augmentation with lifts are always more complicated than when implants are placed alone, particularly when there is significant prior differences between the the breast mounds and the level of the inframammary folds. I think it would be alright now to begin wearing an underwire to give that left breast better support as healing progresses.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in breast augmentation. I want to get bigger fuller breasts, preferably a full C cup. I am attaching some pictures of my breasts for imaging to see how I would look.
A: Thank you for sending your pictures. While I can see why you desire breast augmentation, you appear also to have some significant breast sagging. That is partially camouflaged because you have your arms raised. That makes the breasts look less saggy than they actually are. You need to send me some additional pictures with your arms down at your side with a view from not only the front but also from the side. This is important because I suspect you will need some form of a breast lift with your implants, even if it is just a nipple or circumareolar type lift.
Trying to computer image breasts in an effort to see what final size a patient wants is interesting and even entertaining, but not really valuable from a surgical planning standpoint. It is fraught with distortion problems and ideally requires a small breast with a centrally located nipple with no breast sagging. In trying to help your plastic surgeon choose your desired breast size, it is just as helpful if not more so to show images of other breast augmentation results that have the desired breast size look. Choosing breast size is really about getting a look, not necessarily a specific cup size or implant volume.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley. I have a rhinoplasty with a silicone implant several years ago. It has had to undergo several subsequent revisions where it was shaved down to get it to look right. I am now at the point with it that I just want to get rid of it. Iwas told that it would be very difficult if not impossible to remove now by surgery because it would be ingrown into the surrounding nasal tissues. Is it possible to remove the remaining silicone implant by melting it?
A: The answer to your question is no…nor would you want to. As a chemical element at 14 on the periodic table, it has a very high melting point at around 1400 C. That number is when it is in a very solid form. As a facial implant, silicone is not as well polymerized so its melting point is lower. But regardless of its melting temperature, it is far too high and your own tissues would be burned long before the silicone melted. I do not believe there is any validity to the idea that it can not be surgically removed if it is a solid implant, regardless of how much whittling had been done to it. However, if it was a ‘rhinoplasty’ done by injected silicone, that is a different story. There is no way to remove silicone oil particles, short of wide excision of tissues which on the nose would cause a lot of scarring and deformity.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hi, Dr. Eppley. I have a really flat head. I can hide it by blow drying my hair, using gels and any volumizing products to make my head look not so flat. My hair is very short and has lots of layers at the back of my head so it hide it pretty well.. Is there a surgery for flat heads to make it not flat? If so, what’s it called? Have you done any surgeries for flat heads before?
A: When most people refer to having a flat head, there are talking about the back part. Sometimes it is one side but, most of the time, it is both sides. This is called occipital plagiocephaly, either unilateral (one-sided) or bilateral. (both sides) This flatness is always at the upper part of the back of the head, which is the bony or skull part. Down low, it become more neck muscle and less bone. Building this area ouot (augmentation) is done the same way as it is in the forehead through an onlay cranioplasty technique. This is done by adding a bone-like material onto the top of the bone in the amount that will satisfactorily expand out the bony contour and make it more rounded. The critical decisions about occipital cranioplasty is what type of incision to place and what type of cranioplasty material to use. The type of cranioplasty material influences the incisional approach. A vertical incision is used down the back of head (open technique) where either acrylic or hydroxyapatite materials can be placed. This offers the best and smoothest shape. A smaller vertical incision can also be used (endoscopic or injection technique) in which only Kryptonite material can be used. While offering a smaller incision, the trade-off is in the difficulty in getting a perfectly smooth shape.
Indianapolis, Indiana
Q: Dr. Eppley. I am interested in getting liposuction to make my upper arms smaller. They are so big I can not get shirts over them and it has been an annoyance for a long time. They flop around and it is so embarrassing. I only wear long sleeve shirts so they stay hidden. I think liposuction will help make them smaller but I am confused as to what method of liposuction is best. Should I get Smartlipo, Cool Lipo, Vaser Lipo or Lipotherme?
A: While it is understandable why you are considering liposuction for your upper arms, it will not produce the result you are looking for not matter what the liposuction technique. Based on your description of your arms, it sounds like you simply have too much skin to get the arm reduction you desire. Ideally you need liposuction combined with an armlift or arm skin reduction procedure. This does result in an upper arm scar so you have to consider that carefully as a trade-off. There is nothing wrong with doing liposuction alone but your expectation of the arm reduction results should be appropriately tempered. As liposuction removes fat, it makes the skin of the arm like the belly of a pregnant women who has just delivered…deflated and more loose. This is why consideration must be given to the resultant skin excess after arm liposuction alone.
Dr. Barry Eppley
Indianapolis, Indiana
When a product or manufacturer calls itself ‘smart’, there should be a good reason. Such is the case with the plastic surgery method known as Smartlipo. Highly touted as a better and more efficient method of liposuction, its name clearly suggests that it is better than traditional or ‘dumb’ liposuction. Grandiose claims are made all over the internet, most of which by doctors who use this liposuction technique. The manufacturer of the liposuction device, Cynosure, focuses on the established science behind it.
Smartlipo is a laser technique for melting fat to make it easier to extract. By first heating up the fat to a specific temperature, like oil in a cooking pan, it is turned from a solid into a liquid. This is done by using a laser probe that is passed through the fat area until the right temperature is reached. Then a liposuction cannula is used to remove by vacuum the oily liquid and any other fatty chunks in the area.
But what makes this liposuction so smart and why is it better? First, what it isn’t. Because a laser is involved, many potential patients think it is not invasive surgery. It is just as invasive as traditional liposuction which means there will be a recovery. This is not some magical approach that works from outside the body. Just because it is a laser, it doesn’t really zap the fat like a video game. It is about raising the temperature of the fatty zone until the fat begins to melt. The laser is just a way to heat the fat like the burner on the stove.
What makes Smartlipo better is that it creates a global melting effect which removes more fat than suction alone. Because of the heat damage, more fat is lost later than just what comes out at the time of surgery. Fat continues to die days to weeks later, thus the full effect of the fat removed is not really seen for months even though the early results are apparent within weeks after the procedure. This heating effect also accounts for its skin tightening capability. Such an effect, however, is almost always overstated and over expected. Do not expect Smartlipo to replace what a tummy tuck or armlift can do.
While many doctors tout Smartlipo as being done under local anesthesia with little recovery, this is often not so. Because there is considerable heat generated during the procedure, it is not hard to see that local anesthesia is often not enough for a comfortable operative experience. One can only remove enough fat if the patient is comfortable and will allow it. It is not a test to see who is the toughest. This is why I recommend a general anesthetic. The best result in the shortest period of time can be done when the maximal amount of fat can be comfortably removed.
Recovery from Smartlipo is not much different than traditional liposuction. While the amount of fat removed can be better, this does not mean there is less recovery. The laser does result in less pain and bruising but the amount of swelling is about the same, requiring months to eventually see the final body contouring effect.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dear Dr. Eppley, I had a revision chin surgery to correct chin ptosis. Ever since, I am unable to protrude my lower lip when speaking. I also noticed that when I smile, the right side of my lower lip remains elevated while the left side goes down into a natural smile position. My ENT stated that the sulcus is unusually high, and the speech pathologist stated that they can not help me improve my speech as it a mechanical issue. My question is…Can the sulcus be lowered to my natural state and can the mentalis or the depressor labi inferior muscle (whichever was suspended..not sure) be released to enable me to speak, smile, etc..normally once again? I greatly appreciate your time.
A:With a high or scar contracted vestibular sulcus of the anterior mandible, the lower lip may well be restricted in movement. The role of the vestibule between the lip and the teeth is a valuable one and allows independent lip movement from that of the jaw. The key to successful vestibular lengthening is to appreciate that this represents a loss of mucosal tissue. Simply releasing scar or moving tissues around in an attempt to deepen or lengthen the vestibule will not work. It will simply be negated by scar contracture. What is needed is a vestibular release combined with a small skin or mucosal graft. Buccal mucosa is my preference for small amounts of vestibular deepening. The graft must be held in place for 7 to 10 days with a specially-designed small intraoral bolster.
Indianapolis, Indiana
Q: Dr. Eppley, I don’t like the deep vertical lines on my upper lip. Those lines are really the only thing I don’t like on my face. I have a read that there is a three-step process to get rid of them. An injectable filler, like Restylane or Juvederm, is first placed into the upper lip to fill them. Then a small amount of Botox is injected into the sides of the mouth to weaken the muscles that cause them to pucker and make those lines. Lastly, one treatment with a fractional CO2 laser is used to wipe them away. There is only up to a week of redness and swelling after the procedure. According to what I read this combined treatment can last up to 10 years. This sounds wonderful but is it really true?
A: When it comes to any facial anti-aging treatment, there are few things that can last years let alone a decade. This is no where more evident than in the upper lip line problem. This is a particularly pesky facial aging problem that largely affects Caucasian women with fair complexions, thin skin, and often a thin to moderately-sized upper lip. The three treatment strategies described are all useful for decreasing upper lip lines and, when combined in a single treatment, are particularly effective. But they in no way will last a decade, at best the result will last a year. The reason is simple…Botox last 4 months and fillers less than a year. With loss of upper lip volume and the muscle action returning, there is nothing to resist the lip lines from returning. This combined treatment strategy, while effective, must be repeated every year or so to maintain the initial excellent results.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a chin implant placed about 4 months ago. After I got my implant I was delighted as I thought the chin projection made my face look more defined and also gave a nice strength to it both from the front and the side. As the initial swelling decreased over time it still looked acceptable. Now it has gotten to the point where I almost hate it because it makes me look too much like I used to earlier especially from the front. I have always hated how my mouth would be so overprojected and my chin slightly receded. While this problem had gone away after I got the implant is, it has now come back and I couldn’t be more dissapointed. I also hate how round my chin appears now. I was talking to my Dr about it and he just said its just how swelling goes down but I hate this final result. I want my final result to be what it looked like around a month and a half ago. I have asked my Dr how to recapture that and he mentioned maybe a square chin but he didn’t seem convinced at all. As a patient I cannot figure out what is it I need. That is why I wanted your opinion on this but I have also been skeptical of a larger implant cause I don’t want to add unnecessary length to my face.
A: The time to judge the final outcome from most facial implants, and particularly a chin implant, is around 3 to 4 months after surgery. That is when all of the visible swelling is gone and, most importantly, the chin tissues have adapted and settled around the implant so you can see the final shape and size change. Since you are at this time period, you are now looking at the final effects of the chin implant that is in place. Based on the way you feel about the result, it appears that you feel it does not have adequate horizontal projection and it provides too round of a chin contour. A new implant with more horizontal projection and a more square-shaped or non-anatomic shaped (less lateral wings) implant style is needed. It would be helpful to know exactly what type of implant and its dimensions that you currently have to make more specific new chin implant recommendations.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Hello I live in Europe and would like to do the lip advancement as an alternative to injectable fillers for permanent lip enhancement. But I would like to know where you do it and how much it costs?
A: Most lip (vermilion) advancements are done in the office under local anesthesia. Using initial infraorbital nerve blocks (like going to the dentist) and then followed by direct infiltration into the lips, the procedure thereafter is painless. If a patient prefers it can also be done supplemented by oral valium or Xanax or even IV sedation for a completely comfortable experience. It takes about 90 minutes to perform. The amount of vermilion advancement is determined by the patient prior to the numbing by making marks using calipers and a fine marking pen…and then having the patient approve the amount of lip increase with a mirror. There is some mild lip swelling afterwards and very minimal discomfort. Patients generally do not take any pain medication afterwards. For patients that are geographically close to me, I place tiny 7-0 size sutures that are removed 10 days after surgery. For my far away patients, I use a fine 6-0 dissolveable sutures and skin glue so no return is necessary for suture removal.
For the properly selected patient, lip advancements are a powerful lip enlargement procedure that produces a permanent result.
The total costs of the procedure are around $ 3,500.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a medpor chin implant placed in me about 18 months ago. I would like this removed and replaced with a smaller implant for several reasons (mechanical problems and aesthetic reasons). Can you remove the implant given the time frame I have had it? Thank you for your time.
A: Despite the fact that the Medpor material does allow for some superficial tissue ingrowth, it is by no means impossible or even that difficult to remove. The material gets the reputation for being difficult to remove as it is compared to silicone, which has a smooth and slippery surface which slides in and out of tissue pockets quite easily. But Medpor facial implants can be removed, it just requires a little more surgical effort and sometimes removing the old implant in pieces. The chin implant being in place 18 months does not impact the removal process anymore than if it was there 18 weeks or 18 years. Tissue ingrowth into the material occurs rapidly and very early after implantation. It does not get worse with longer times of implantation and, contrary to many opinions, does not get any bony ingrowth into it either. Since the tissue ingrowth just occurs into the outer layers of material, it does not get deeper or penetrate further beyojd a certain point.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a question regarding browlift surgery. I have a low hairline which is only about 2 inches from my eyebrows to my hairline. Would a browlift/forehead lift increase my forehead length and can this be done without moving my eyebrows higher. I am young but I have a lot of laxity in my forehead. Thanks!!
A: The simple answer is…no. You can’t lift/stretch the forehead skin upward without moving the eyebrows to any significant amount. Since the whole forehead skin must be loosened to get any movement, the eyebrows will naturally be raised although not to the degree that the skin is lifted since they are the furthest away from the location of the pull. You might get a half inch up to an inch if your forehead is really lax but no more. Browlifts, by definition, raise the eyebrows.
It is possible to really lengthen your forehead through tissue expansion but this is a two-step surgical process. This is where a tissue expander is initially placed under the forehead skin during the first procedure. This is gradually inflated by saline injections over four to six weeks to make the forehead skin ‘grow’. Once adequately expanded, the tissue expander is removed and the forehead lengthened with the extra skin created. This can increase the forehead skin length by several inches if desired.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting cheek and jaw angle implants. My jaw angles are very steep which got worse after jaw surgery for a bad bite several years ago. My cheeks have always been flat and I get Radiesse in them which makes them look better. Can you tell me what types of implants I should get and what are some of the complications that could happen that I should be aware of. I have attached some pictures for you to see what my face looks like.
A: Thank you for sending your pictures. I have reviewed all of them. The key to your successful facial implant surgery is to have appropriately-sized implant selections. For the cheek area, you would benefit by implants but they must be small to not overwhelm your feminine face. Small malar shell style would work well for your face. For your jaw angles, you need implants that provide some vertical lengthening but minimal width increase, otherwise you will create a wider fatter face and not a nice jawline enhancement that fits your face. Small Medpor RZ angle implants (3mms width and 10mms length) should work nicely, but no bigger.
Implants should be placed that fit the face. As it turns out cheek and jaw angle implants are the most highly revised of all facial implants. The problem with many cheek implants is that they are too big. The problem with many jaw angle implants is that they are improperly positioned and/or secured.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am looking for an opinion regarding correction of my steep jaw line. I had orthognathic jaw surgery in 1998 to correct an underbite, but over the years I feel that the angle of my jaw has gotten steeper, giving my profile a “harsh” look. A doctor has suggested jaw angle and cheek implants to balance out my chin and soften my face. I am hesitant to go under general anesthesia and am concerned with the risks of the procedure and, most importantly, whether it will improve my look. I was told that another option is filler in the jaw line, but that an implant would provide more correction.What would you recommend for me? Do you think that jaw angle implants would improve my look? Do you think I could achieve good results with just filler? After going through orthognathic surgery, I was hoping to have achieved a better result and I feel self conscious about my jaw line. I have attached some pictures for you to review.
A: Based on the viewing of your side profile, your jawline is characteristic for someone who has had a mandibular setback osteotomy for a Class III malocclusion due to an original mandibular prognathism. This can adversely shorten the jaw angle and increase its plane angle. I can understand the proposal of jaw angle and cheek implants to give your face more skeletal balance. The real questions are, however, will it make a positive change and is it worth undergoing surgery for it.
There are two ways to provide insight to those questions. First, computer imaging should be done with jaw angle implants alone and then combined with cheek implants. While computer imaging is an estimate and not a guarantee, I have always found it very helpful for prospective patients. I have done that for you and it is attached. These are based only on a side view. The front view you have provided is not good for imaging because you are smiling and it doesn’t show the jawline/angle all that well. The three-quarter or oblique view is the next most helpful view to evaluate. Secondly, injectable fillers can be an alternative to see if the concept of implants would be appropriate. When placed next to the bone they can provide some bone augmentation. But they will never produce the same effect as adding implants because of the sheer volume differences. Injectable fillers are never a comparative substitute for facial implants but they may provide some insight into whether bony augmentation is the right concept. If one is not absolutely certain that implants are the right answer, try fillers first.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hello Dr. Eppley: I had a kidney transplant in 2006 in which my donor was my identical twin sister. Therefore, would I still be a high risk for the surgery? Fortunately, I do not take any anti-suppresent medications. Thank you.
A: I do have experience performing elective plastic surgery on kidney transplant patients. Ironically, about 10 years ago, I performed face and breast surgery on two sisters who were cadaveric kidney recipients. I performed multiple procedures on them and never had a problem. Just a few months ago, I performed a facelift and rhinoplasty on a man who had a family-given kidney three years previously. In his case as well, he healed without any problems.
The management of surgery on a kidney transplant patient is to first check with their nephrologist and let them know of any surgical plans and get their clearance. As long as there is no risk of excessive bleeding that would drop one’s intravascular volume and/or require high volumes of fluid or blood products (which no cosmetic procedure involves), then there are no major risks to the kidney or healing. One should not use any anti-inflammatory medications or oher drugs that would have any nephrotoxic effects during or after surgery. Other than these considerations, there should be no problems with undergoing plastic surgery or healing from it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had in orthognatic surgery several years ago for a bad bite that gave me a lot of problems with my teeth and pain in my jaws every morning. While the surgery went fine from a technical standpoint (my bite is better) it left me with a very bad look. I think it is because he made some mistakes with repositioning the masseter muscle as my face shrunk on the sides and left me with a lot of loose skin. This makes me look 10 years older then my age. I’m now 50 and I look older. I am used to always looking much more younger than I am. I’m very unhappy and I don’t think normal lifts of skin will help because what is missing is underneath, it needs to be filled in. I need deep tissue filling not just stretching the skin. Here are some photos for you to see what I mean.
A: What I see on the photos is lack of jaw angles and loose jowl and neck skin. The jaw angles actually appear both high and indented or concave. I think the jaw angle issue is a result from your orthognathic surgery but it was not a mistake by the surgeon. Mandibular osteotomies involves elevating the masseter muscles off of the bone to perform them. There is no such thing as having to reposition them during the surgery as they simply fall back into place. But what can happen is muscle atrophy/shrinking from the trauma of the surgery and I believe this is what you have experienced. Because of the lack of a jaw angle, you would benefit by small lateral augmentation style of jaw angle implants. This could be combined with a limited neck-jowl lift (facelift) to create a more youthful jawline and nek appearance.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have concerns about cheek implants that I had placed about six weeks ago. My cheek implants were Medpor implants that were screwed into place. What I am worried about is that I have numbness of my left lip and cheek ever since the surgery. I thought it would be gone by now but it hasn’t. Is this normal? Also, it feels extremely tight around my nose. I think all of the swelling has gone away so I thought they would feel more normal by now. What do you think? Thanks.
A: Depending upon the style, size and location of the cheek implants, they likely extend around the infraorbital nerve which comes out of the bone just below the rim of the eye socket. This is a big nerve that is responsible for the feeling of the skin around the nose, upper lip and teeth. (but not movement) When cheek or midface implants are placed around this nerve, it would be common to have a period of numbness to the areas that the nerve supplies. The key about this numbness is whether it is improving or not. If there has been some gradual improvement in the amount of numbness six weeks after surgery, then it is likely going to go away in a few more months. If it is just as numb today as it was the first week after surgery, the implant may be putting pressure on the nerve and may need to be repositioned. Screw fixation of cheek implants can sometimes be a double-edged sword. The implant is rigidly fixed into place and if it is leaning up against the nerve, there is no relief from the pressure of the implant.
As for the tightness of the face, this is a feeling that should go away as the swelling subsides and the overlying tissues adapt to the ‘push’ of the implant. Since the implant and the bone on which it sits is rigid, the overlying tissues must adapt to them. As a general rule, you should not judge the look and feel of a cheek implant for at least 3 months after surgery to these tissues time to relax. It is also possible that the tightness is because the implant is too big, so you need to see how it looks as the swelling goes away.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Will massage make my Botox go away more quickly? I got Botox to my forehead several weeks ago and love the results! I regularly get facials and massages and am worried that putting pressure on my forehead or rubbing bit too much will make the Botox wear off. I have read that this can happen. Is is true?
A: I have heard that question many times from numerous patients and I can tell you emphatically that it is not true. When you understand how Botox actually works, and more importantly, how it wears off you will see that rubbing or massage has no bearing on the length of its effectiveness.
Current understanding of how Botox works is that it goes into the nerve endings and blocks the release of the neurotransmitter, acetycholine, from the mitohondria where it is produced. This is why it takes days for Botox to work. The nerve ending must use up the acetycholine that still exists (has been released) into the nerve ending. Once depleted (and it is not making anymore) the nerve ending can no longer send its chemical signal to the motor end plate of the muscle and make it move. Conversely, Botox wears off by growing new sprouts or axons from the nerve around its non-working ending to attach to the muscle to start working again. To the best of our knowledge, massage or any other manipulation does not increase the growth rate of these axons. Thus, you can’t really make the muscle start working by pushing around on it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, you have mentioned your experiences with porex facial implant removals. I am looking to get my pair of porex cheek implants removed that were placed about a year ago. I am 26 years old and hoping my face will be able to return to its pre-surgical state, but given the scar tissue must be removed am I setting my expectations too high? I am worried that if they are removed my cheeks could be even more depressed than before my original surgery.
A: I have heard and read about the ‘scar tissue’ that must be taken with Medpor facial implant removals numerous times. From my perspective, it is largely a myth and not reality. It is very similar to them being hard to remove as well. Both those issues stem from a comparative experience with that of silicone facial implants. Compared to the very easy removal of any silicone-based implant (it is very smooth so it slides in and out easily), the porous outer surface of Medpor does make it more ‘difficult’ but then anything would be hard compared to silicone. Medpor implants can be removed with just a little more effort and there is no reason to be taking out any scar tissue (known as the surrounding capsule) with them.
Therefore, when it comes to removing your Medpor cheek implants, a potential loss of volume in the cheeks will not come from having had scar tissue removed. But it is likely that it will occur due to a common implant sequelae known as tissue expansion. Depending upon the size of the implants you have in, there will likely be some cheek volume loss and/or sagging due to the stretching of the overlying tissues and the separation of the attachments of the tissues to the bone. Once the implants are removed, these tissues may not stick back down just the way they were before surgery. This potential problem can be countered by either inserting a smaller replacement implant, performing soft tissue resuspension, or inserting a dermal graft into the implant space to act as a ‘natural’ implant volume replacement. Whether any of these are appropriate for you is impossible me to tell based on the information that you have provided.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had extractions and braces before as a child and it left me with a very flat face. I am now having the teeth brought back forward and the spaces re-opened. However even with the lips looking normal I’m thinking my midface my still be a bit concave and am wondering if bone grafts for the missing upper bicuspids would fill in the midface paranasal area or would I be better off just getting something like paranasal implants?
A: Any adjustment at the tooth or alveolar bone level, orthodontic or otherwise, is only going to affect the lip that sits in front of it not the facial profile. The base of the nose and the rest of the face sits above the level of the upper tooth roots. Therefore, bone grafting into the bicuspid space would not be helpful even if it could be done. Bone grafts on the paranasal area, while in the right place, are associated with almost complete resorption due to a lack of stimulation through masticatory forces. The predictable solution would be paranasal implants which are structurally stable and can be carved or shaped into any thickness that matches the needs of the patient’s paranasal augmentation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting cheekbone reductions and fat injections at the same time. I think with the cheek reductions I don’t want my face to be too narrow, long and look too old. Does this make sense to you? Also where are the incisions for the cheek reductions? I know that these are uncommon surgeries for Americans so what is your experience with them?
A: My recommendation is that you wouldn’t do fat injections at the same time. That would be counterproductive. The reason is cheek bone reduction, at its best, can never make your face too long or sunken in. The procedure never overshoots the goal, at best it will underachieve. There is a limit as to how far the cheek and zygomatic arch can be moved inward…it is known as the masseter and temporalis muscles. That is what lies underneath the width of the arch so they are a rate-limiting step as to how much facial narrowing in this area can be achieved. Therefore, I think the idea of simultaneous cheek fat injections is both presumptuous and unnecessary This is a good example of the plastic surgery principle…let the results prove that you need more surgery.
Cheekbone reductions, as I have described, are done from two approaches. The front part from inside the mouth and the back part from a small incision in the temple hairline.
You are correct in assuming that almost all cases of cheek bone reductions are in Asians. (although I have done one Caucasian patient to date) No one’s experience in the U.S. is extensive with this procedure since the demand is so low. But this is a cosmetic procedure that has its origins in cheek bone fracture repair and reconstruction of which a plastic surgeon with extensive craniomaxillofacial experience is very familiar.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in changing the look of my nose. I am Asian and my nose looks too much like a button on the end. I would it to be slimmer. I have attached some pictures of my face. What type of rhinoplasty do you think I need or would be helpful to achieve this goal?
A: Your nose has many typical Asian features marked by a short columella and broad tip with thick skin. There is no definition to the tip which I assume is what you mean by a button tip. But the shortness of your columella has also created a nasolabial angle that is less than 90 degrees. This magnifies the ‘button’ appearance of the tip of the nose and certainly make it look flatter. This could be improved by a rhinoplasty that reshapes the tip through a columellar strut graft onto which the lower alar cartilages can be reshaped. This would help open up the nasolabial angle and provide a little bit more length to it. This would produce tip narrowing and elevation, effectively changing the flat and wider tip to a more shapely one. The thickness of your nasal skin will limit how much narrowing can be done but improvement can certainly be obtained. I have attached some rhinoplasty predictive imaging of the front and side views to illustrate these potential changes. These are provided with the understanding that they are predictions and not guarantees of the rhinoplasty outcome.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am Asian and interested in making my face more narrow. It is too wide in the cheek area. I also think my chin is too long and would look better if it was shorter. I woud like my face to be more oval and not so wide and square. Do you think cheek and chin reduction will achieve what I want? I have attached a picture for you to see my face from the front and show me what the changes would look like. Thanks!
A:I have done some imaging based on the single photo that you have sent me. It is a partial smiling photo so it is not ideal to use but it is acceptable to give you a general idea of the proposed changes. This predictive image is based on the following two procedures:
1) Cheek Reduction with osteotomies at the zygomatic body (front) and the temporal end of the zygomatic arch. (back) Your frontal facial photo shows a wide or bowed zygomatic arch from the cheek on backwards. This is best treated by total zygomatic arch narrowing as opposed to zygomatic body reduction. One would need a submental (vertex) x-ray before surgery to look at the extent of the bowing and determine how change (inward movement) of it could be done.
2) The chin reduction is a vertical shortening which is what I think you mean by chin reduction. I have no side view of your chin so I can not comment on any horizontal issues.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like to get Medpor cheek implants for higher and more defined cheekbones. My question is, since I am relatively young (25), will Medpor implants hold throughout my entire life if they don´t get infected or damaged by an accident? Could I be, let’s say 100 years old, with a Medpor implant in my midface since I was 25 years old? Do Medpor implants show any tendency to dissolve over time? Is it true that Medpor becomes more like a part of your body due to its porous nature that allows blood vessels grow into the implant?
A: Medpor facial implants are composed of a porous polyethylene (PPE) material. This is a well known medical implantable synthetic material that is most commonly used on orthopedic implants as the lining of joint surfaces. (high molecular weight PPE) As a facial implant, it is a lower molecular weight which gives it some flexibility. Pertinent to your question, it is a stable material that does not degrade. There is no enzyme in the body that can break it down…ever. Your facial implants will be found on your skeleton thousands of years from now. Medpor does have surface porosity so there is some tissue growth into the outside of the implant. This property is often touted as being a superior implant feature but its main benefit is that it helps fix and secure the implant into place. Screw fixation obviates the need for that material feature. This material property does make the implants more difficult to remove should that be necessary so it is a double-edged feature.
Rather than getting hung up on the material composition of a facial implant, one should focus more on does it have the right shape and size for the desired result. Medpor cheek implants do have less options for styles and sizes than silicone-based cheek implants.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have read a recent blog post of yours about an implant for the treatment of temporal hollowing with great interest. I have a depression on my left temple as a result of a craniotomy performed to clip an unruptured brain aneurysm. I would like to know more about this implant including the manufacturer, case studies of its use, and any before and after photos if available. Many thanks for your help.
A: The new temporal implant to which you refer is manufactured by Osteosymbionics in Cleveland Ohio. While it is not the first temporal implant ever designed, it is unique due to its shape and flexible design. You would have to contact the company for their clinical experience to date. I have not yet used this implant although I have used about every conceivable material for temporal augmentation and reconstruction. The material of this implant is a soft and flexible elastomer, which is what composes the vast majority of facial implants used.
For temporal defects from craniotomies, the size and extent of the depression must be carefully assessed and the implant matched to it. Some defects are due to mild to moderate atrophy of the temporalis muscle. This will appear as a more central indentation most prominent above the zygomatic arch and to the side of the forehead. An implant like this new temporal one may work well for this type of depression. Other temporal defects are bigger and are due to atrophy and a retraction of the attachments of the posterior and superior skull attachments. This creates a larger temporal depression and a bigger implant or other form of temporal reconstruction must be used.
Indianapolis, Indiana
Q: Dr. Eppley, I found your website researching the vermilion advancement or gullwing lip lift and wonder if you could help me. I had a subnasal or bullhorn lip lift procedure done a month ago in order to show upper teeth when keeping my mouth open. I have always had a long philrum. Before surgery it was 20mm in length and now it is 13mm. Just like before, however, I do not show any upper teeth when my mouth is open or when I talk or when i smile. I do not have any more swelling at this point so I know this result is final and am considering a revision. Do you think a gull wing lip lift help me show my upper teeth?
A: With a central reduction of upper lip length from 20 to 13mms, that is a 1/3 reduction which is about the limits of this centrally-based upper lip shortening procedure. It is surprising that you have not made even a little upper tooth exposure with that reduction. But your anatomy and direction and vectors of lip movement may be working against you to achieve any better dental show. I would not be optimistic that a lip advancement would produce the desired dental uncovering. Lip advancements are great at making the lips bigger but I have never seen them result in any increased dental show of either the upper and lower lip. Lip lifts (bullhorn) are more effective at that than lip advancements. (gull wing) It may be possible but is not the primary intention of that procedure.
I would have to see pictures of your lips, both at rest and smiling,to give you a more qualified answer. It is also possible that you may benefit by an internal mucosal reduction which provides the ‘missing link’ in complete upper lip shortening.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am considering some facial surgery to improve my overall aesthetics. I have previously been through a rhinoplasty, chin implant and cheek implants. While these have been helpful, I still want to get better results. I am hesitant in doing any more surgeries, however, unless the results will be a significant improvement in facial aesthetics and symmetry. To help me visualize what I want I have used a facial aesthetic program which morphed the “ideal male ” with mine. The pictures seem to make the chin width smaller and less square and with an even jawline to the posterior angle of jaw. The images seem to downsize the cheek implants and to make the tip of nose more symmetrical and smaller with a raised nasion. I have attached a few of these pictures. The first two pictures are that of an ideal female face with mine. The last three are the ideal male face combined with mine. Thirty points on my face were used for my facial proportions to generate these pictures. Is it possible to achieve this morphed look since it seems the resulting face is more aesthetic.Your thoughts and concerns are greatly valued regarding what is achievable. If you have a software program regarding what the postop look will be regarding the different procedures I would be interested in seeing those results.
A: Thank you for sending your images and your thoughtful morphing overlays. While I think they are helpful to see what direction you ideally want to go, I do not find them realistic or that those type of results are achievable. Images like this set the standard of how the patient will judge their outcomes afterwards and it always leads to results that fail to hit the mark and are disappointing. Their greatest value lies in helping the patient determine whether surgery is worthwhile, particularly the patient who has been through previous surgeries and is in the ‘revision mode’. Quite frankly, I and probably most plastic surgeons shutter when a patient goes through this exercise because the results will always fall short. Since I do not feel your results would meet these imaging goals, at least in my hands, I would recommend that revisional plastic surgery may not be worth the expense and recovery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am wanting to get the size of mons pubis reduced. I am so ashamed of its size and it restricts me from doing many things in my life. I am not obese or grossly fat, just about 30 lbs overweight. I have been losing weight but the mons will just not go down in size to any significant degree. I will continue to diet and exercise but I have no confidence that it will get any smaller. The skin tone over the mound is good and not loose. It feels firm but can be pushed in so I feel certain that it is fat and not bone. If liposuction is done and the fat from the mons reduced will that in any way affect sensation in this area?
A: Liposuction of the mons pubis or suprapubic liposuction is a very successful spot area of fat removal. It can be surprising how much fat is in the mons and how much of a difference it can make when it is done. Like all body areas treated by liposuction, there will be some temporary numbness of the overlying skin for up to six to eight weeks after surgery. This loss of skin sensation will completely return. The procedure will not, however, affect any feeling of the clitoris or sexual sensation. I have even had a few patients who have told me that their sexual sensation was actually improved after mons reduction, presumably due to an uncovering of the clitoris. Suprapubic mound reduction in men can have a similar effect due to exposure of greater penile length.
Dr. Barry Eppley
Indianapolis, Indiana