Your Questions
Your Questions
Q: Dr. Eppley, I got breast implants one year ago an am not happy with the size. They are too big. They are only 175cc but they are just too big for me. In exchanging the implants to something smaller, I am not sure what size implant to change to In reading around online, there is much discussion about the base width diameter of the implant like its the holy grail, even though, interestingly, opinions diverge. Some say stay the same implant diameter and no larger, a bit larger, can be smaller by up to one cm, thin women should have smaller, and on and on…. so no hard-and-fast-rule it seems. But 8.2 cm (diameter of smallest available 100cc implants) to my 10.5/11cm change does seem a lot, if base width diameter is typically a consideration that you guys seem to have strong opinions on. I recognize that results are harder to pin down than one might wish, but why do you think that’s better than 130’s with a 10cm diameter, or 125 mod-plus with a 8.9cm diameter, in my case? Related to that, do you think that a lower diameter will diminish the lateral projection that I do not like? Do you think that a similar or slightly smaller diameter than my current 175’s, even if the ccs are lower, will leave me with the same lateral projection “issue”?
A: When the fear from the initial implant is that is was too big, you want to make sure you don’t repeat the same problem. Given that the initial implants were only 175cc and the lowest selection is 100cc, you want to make sure you never say I didn’t go low enough. Thus choosing 100cc implants eliminates that possible outcome.
Implant base width diameter has merit but its biggest contribution in my opinion is in the initial breast augmentation when it is important to not exceed the natural width of the breast so the implants do not get too far to the sides. Once a pocket is established and the implant replacements are going down in size, that issue does not become that important anymore. For you, however, with a fear of too much projection you need to get the flattest and broadest implant base. possible…spread whatever volume there is over a wide base. But the decrease in based width diameter of a 100cc implant may also help the problem of too much lateral projection as well.
Dr. Barry Eppley
Indianapolis, Indiana
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Q: Dr. Eppley, I got breast implants one year ago an am not happy with the size. They are too big. They are only 175cc but they are just too big for me. In exchanging the implants to something smaller, I am not sure what size implant to change to In reading around online, there is much discussion about the base width diameter of the implant like its the holy grail, even though, interestingly, opinions diverge. Some say stay the same implant diameter and no larger, a bit larger, can be smaller by up to one cm, thin women should have smaller, and on and on…. so no hard-and-fast-rule it seems. But 8.2 cm (diameter of smallest available 100cc implants) to my 10.5/11cm change does seem a lot, if base width diameter is typically a consideration that you guys seem to have strong opinions on. I recognize that results are harder to pin down than one might wish, but why do you think that’s better than 130’s with a 10cm diameter, or 125 mod-plus with a 8.9cm diameter, in my case? Related to that, do you think that a lower diameter will diminish the lateral projection that I do not like? Do you think that a similar or slightly smaller diameter than my current 175’s, even if the ccs are lower, will leave me with the same lateral projection “issue”?
A: When the fear from the initial implant is that is was too big, you want to make sure you don’t repeat the same problem. Given that the initial implants were only 175cc and the lowest selection is 100cc, you want to make sure you never say I didn’t go low enough. Thus choosing 100cc implants eliminates that possible outcome.
Implant base width diameter has merit but its biggest contribution in my opinion is in the initial breast augmentation when it is important to not exceed the natural width of the breast so the implants do not get too far to the sides. Once a pocket is established and the implant replacements are going down in size, that issue does not become that important anymore. For you, however, with a fear of too much projection you need to get the flattest and broadest implant base. possible…spread whatever volume there is over a wide base. But the decrease in based width diameter of a 100cc implant may also help the problem of too much lateral projection as well.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I took my son to the Children’s Hospital to assess his deformational plagiocephaly and they told me that they would not address my son's skull deformity since it was not negatively impacting his facial features. They described the procedure as extremely painful and invasive. Where can I find more information describing the pros and cons of this procedure. I would also like to know more about the procedure itself in terms of surgery and recovery. Any information would be greatly appreciated. My son has a pretty severe flattening on the right posterior of his head. My pediatrician convinced me that helmeting was the wrong decision and his condition would improve over time. At this point, I regret listening to the pediatrician and am looking for solutions for my son.
A: What they were saying at the Children's Hospital is that major cranial remodeling surgery is not justified for a cosmetic skull deformity. That is certainly true, particularly if your son is older than 18 to 24 months old. An alternative treatment option is to build out the flattened occipital area with onlay hydroxyapatite cements. That may be able to be done in some cases with an injection technique or a small incision. This is a far simpler approach to major cranial bone reshaping and the risk:benefit ratio is much more favorable. Whether the magnitude of the occipital skull deformity justifies an onlay craniopasty procedure depends on many factors, most of which is the emotional concern of the parent about the shape of their child's skull.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am writing to you because you are an expert with osseous genioplasty and maybe you can help me. I had a sliding genioplasty 7 months ago. But after the surgery one little piece of bone was missing at the site of the osteotomy. Also I had asymmetry. So the result was ok except for the noticeable notching effect and asymmetry. So yesterday I had HA injection to make it look better and the results are great. But now I am wondering can this HA interact with the titanium plates I have? Maybe it can be dangerous? Also, can this HA interact with the bony remodeling which might not be completely complete? What do you think? Thank you very much for your help.
A: Notching along the inferior border of the mandible at the back end of a genioplasty is very common, particularly when a significant horizontal advancement is done. The injection of HA into the notch areas is a perfect treatment for this secondary genioplasty deformity. It has no negative interaction with the indwelling titanium plates and screws. Filling in the bone defects will not change any residual bone remodeling and may, in fact, help the process.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, After breast feeding, my breasts are less than perfect. My confidence has drastically decreased. I'm in incredible shape but my breasts are just mush. What kind of breast procedure do I need, augmentation or a lift?
A: For many women, the decision between needing an implant or a lift is very straightforward. Breast sagging after childbirth may be improved by implants if there is not too much loose skin and the nipples do not hang below the lower breast fold. If there is significant breast sagging then a combined implant and lift will be needed. It would be very rare to get a breast lift alone unless you already have substantial breast tissue volume. Having breasts described as ‘mush’ indicates a significant loss of breast tissue so some amount of volume through the use of implants is needed. With enough added volume, the loose skin may be adequately filled out and the nipple will sit in a good position. But if there is too much loose skin and the nipple sits even a little bit too low beforehand, the implants will not lift the nipple upward enough and some form of a breast lift will be needed.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I have breast implants placed in 2008 but I want to replace them and go smaller. Right now I have Mentor smooth round gel breast implants that are 500 each. I am a full D cup size. I prefer to be a C. I am 5'4” and weigh 127 lbs. I really don't know how the cc's translate to actual size. I imagine 350 to 375 each would be better though. I explained at the time of my surgery that I thought they were too big but the doctor encouraged me to wait. I've waited and still feel they are too big and do not want to return to the same surgeon.
A: When considering changing breast implant size, it is important to look at volumetric or percentage changes. As a general rule to drop a full cup size, one should drop volume by at least 30% or more. Thus having 500cc implants, your perception of changing volume down to 350cc is spot on. This represents a change of 150cc or 30% in volume. This will make a perceptible change in breast size. It will not decrease the width of the breasts much but will decrease projection. The good news about replacing existing breast implants is that it is a lot easier than the first time. With an existing pocket and the muscle already elevated, the postoperative pain and recovery is minimal…a far cry from the first surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a bulging blood vessel on the right side of my forehead. I have been told that it is an artery from a dermatologist and a vascular surgeon because it has a pulse in it. I want to get it tied off because it really sticks out and sometimes feels uncomfortable. How is this procedure done and roughly what percentage would you say were completely happy with the results versus some improvement versus not happy at all with the outcome? I would like to get an idea of what scarring can be expected. Any potential side effects specific to this procedure other than scarring? Read somewhere about a pretty important nerve that hangs around this artery, obviously you would avoid this, but what are the chances of any problems?
A: Ligation or tieing off of a prominent vessel in the forehead can be done to reduce its prominence. This happens because the flow through the vessel is cut off. The surgical approach for arterial ligation to a prominent forehead vessel is done through a small incision inside the temporal hairline (to get the anterior superficial temporal take-off from the main trunk of the superficial temporal artery) and a very small incision on the forehead where the most distal end of the branch can be seen. In rare cases, a third nick incision is needed in the forehead if there is an additional feeding branch) These are very small incisions and scarring is not usually a concern. The nerve to which you refer is the auriculotemporal nerve which is a sensory nerve that only supplies feeling to the temporal region. It is not an important nerve in that it is not a motor nerve responsible for facial movement. That nerve is identified and preserved as the dissection is done in the temporal region while searching for the anterior superficial temporal artery branch. The primary risks of the procedure is how well it works, reduction vs elimination of the visible artery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, my son is 2 yrs old with mild to moderate plagiocephaly. One side of his head is noticeably flat on the back. I’ve read on here about the procedures available to fix this, in particular the cement injections. My question is if we decide to do this now at his age will the material expand with his head growth or will the procedure have to be done every so often throughout his life until his head reaches its final size? Thank you
A: The application of a calcium phosphate cement to the outside of the bone, known as an onlay cranioplasty, builds out the contour of the bone. It does not influence the growth of the skull in anyway. It allows it to grow as it normally would, albeit in its misshapen form. Knowing that non-synostotic occipital plagiocephalies do not display progression of the deformity, it is safe to assume that an altered/improved occipital shape achieved at a young age would be relatively stable as they grow. I would not envision that a periodic addition of material would be needed until the child reaches skeletal maturity. The skull grows by resorbing bone on its inside and adding it to the outside. When done at age two, I would imagine that much of the added material would be incorporated into the bone as the child grows.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a tummy tuck three weeks. I had my drained pulled after 8 days and I developed a fluid collection right after. My doctor removed the fluid by needle twice and the third time today there was no longer any fluid. Since I had no fluid today and I don't have to come see my doctor until another six weeks can I go ahead and start exercising?
A: Given that you have an abdominal seroma after your tummy tuck, I would wait another week before you should start exercising again. Even though your recent tap was negative (empty), that does not mean you may still not build up a little fluid. The most assured way to make that happen is get very active. Strenuous activity increases lymphatic flow to the tummy tuck area which could cause more fluid to build up again. Give your body another week to heal and not show any evidence of further fluid buildup before ‘stressing’ the competency of the sealed lymphatics at the surgery site.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I suffer from a congenital malformation of the face and skull. The shape of my face and my head is too skinny and started with me this problem since I was 15 years old. I am now age 29 years old and I want a solution to my problem. But before that I want to know the answers to the following questions:
1. Is it possible to find a surgical solution to my problem?
2. In the case of the possibility of surgery, you could be a final solution?
3. Can surgery be done through the addition of natural bones?
4. How serious is the surgery and what is the success rate?
5. How long will I need to heal, and to engage in normal life?
6. What will be the cost of surgery?
A: I would be happy to answer all of your questions but I will first need to see some pictures of your head for any assessment. It would be impossible to give an opinion without first seeing what the exact problem is. But what I can tell you without even seeing your skull problem is any correction can not be done by using bone grafts or natural bone. They will simple melt away and be absorbed. Skull surgery requires an incision across the top of the head so this is a trade-off you must be willing to accept. Most patients have full recovery after skull reshaping in just a few weeks.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 40 year-old male and my eyebrows are bothering me. I have read that they can be lifted by opening the the upper eyelid and putting in some device to lift them. I know that this procedure does not lift much however. Do you think that it can resolve my problem or do you have another suggestion for me. Please find me some solution to lift my brows. Perhaps a mid-forehead lift will lift my brows and then you can even take the excess skin that I have in my forehead out. I have two very deep long wrinkles in my forehead that you can use. I know that there will be scars even inside the wrinkles but we can not have something without scars so I am willing to correct a problem that is bothering me and accept scars that I can treat later with laser. Or you can do the direct brow lift by making a scar right above each brow. Please I want to lift those brows so there has got to be some way to do it for me.
A: As for browlifting in young men, there is never a completely satisfactory solution. The endotine device to which you refer lifts the male brow slightly but does not nothing for the rest of the forehead or wrinkles. Whether the amount of lifting that can be achieved, which is just the middle to outer brow area, is enough show be considered carefully before surgery. No scar across the forehead would ever be acceptable in any male but an older one who already has deep horizontal forehead wrinkles. A mid-forehead or direct browlift is a major concern in younger men where the trade-offs for doing something are worse than the original problem. Male browlifting is a challenging issue, particularly in the younger patient. The endotine device approach through the upper eyelid is the only browlift option I would consider at your age.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I developed an infection after getting with jaw implants. I had them taken out right away. However after the surgery my incision is having a hard time closing and I was able to express some pus from the area about 0.1 cc. The abscess from the previous infection is not back but it appears to be not healing well. I think it might be related to the closure as the mucosal remnant next to the teeth was narrower than 1cm that you try to keep when you make the incision. Or it could be that the original infection caused that mucosa to shrink a little bit. What do you do in this situation?
Also I was wondering what you find are some of the common reasons for one to get the jaw implants infected.
A: What you have is contracted or inverted mucosal edges which lead to of fluid and food debris trap as it struggles to heal. If this is a chronic problem of months then I would excise and reclose the wound in layers. If if just weeks or a month old, I would give it more time. Most of these wounds will heal but it is slower when you have a previous underlying implant pocket.
Having done a lot of jaw angle implants with every conceivable implant option, I have learned the following about the risk of infection and how to prevent it.
- Good wound closure is paramount, a two-layer closure with muscle reapposition over the implant and then a good water-tight mucosal closure. This starts with an incision placed away from the vestibular tissues so you have good tissue on both sides of the wound to close.
- Medpor implants have a higher infectivity risk than silicone due to its porous material. Pre-soaking, vacuum infiltration and antibiotic irrigation must be done.
- Avoid using the final implant as the sizer and developer of the pocket. Use the manufacturer’s sizers for this process during surgery. That way you grab and insert the final implant but one time through the mouth, a so-called minimal implant handling technique.
- Implant stability is really important but most paramount for silicone jaw angle implants. Their smooth surface makes them predisposed to being displaced after wound closure and working their back toward whence they came…getting near the incision and even work its anterior edge through it in some cases. I always use screw fixation with jaw angle implants, most easily done through a percutaneous approacsh using 1.5mm self-tapping screws.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I wrote you before to inquire about a Skull reshaping using implants. I saw the archive “Cranioplasty Category” in your web site which shows the case were a 42 year old male was operate, and an implant was inserted in the back of his skull (occipital) in order to lengthen and correct a deformity, in this case a flat spot area. I must to say that it is a great job.
I have a similar problem, although it is not exactly like the example posted, in my case the flat spot is less notorious, but the overall profile of my skull is short. Moreover the rear of my skull is slightly above the level of the forehead. I think its because of some postural plagiocephaly caused when I was a baby.
I have some questions I want to ask you.
1) How much my scalp could be elongated in the back of my skull and the final appearance would look natural?
2) Would there be a very visible scar ?
3) Would I have to shave my head for the operation?
4) There is a risk that no hair grows up in the area of the implant ? cause i´m not bald
5) How long would I be hospitalized before and after the process?
I want to have the shape of the occipital area more pronounced. in order to have a more symmetrical shape of my skull. I know it´s difficult to answer my questions without seeing any images, So I could send you pictures of my two profiles to have a better idea.
A: In answer to your questions:
- A s a general rule, the skull can be expanded 10 to 15mm across the back without making scalp closure to tight or precarious for good wound healing.
- All forms of craniplasty require access through an incision. It heals as a fine line but there is a scar nonetheless. That needs to be taken into account when considering a cosmetic skull procedure.
- We do not shave any hair for cranioplasties. It is easier for the surgery if a patient did shave their head but we do not do it if the patient does not want to.
- The only risk of any hair loss is at the scar, not in the raised scalp flaps.
- This is usually done as an outpatient procedure in a surgery center, not a hospital.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had an endoscopic brow lift 2 years ago. It was pulled far too high and has formed what I can only describe as crater-like vertical depressions. This is so strange looking. I was so much better before with my normal horizontal thin lines. Is there anything that can fix this….is a reverse brow lift successful….could fillers wk….or hair transplant to cover the high long forehead?
A: One of the trade-offs for an endoscopic browlift is a longer forehead because this type of browlifting procedure is really an epicranial shift…it moves the scalp backwards to create the browlift below. The length of a patient’s forehead must be assessed beforehand and this effect considered when choosing any type of browlift.
The vertical depressions that you have are the effect of the internal fixation technique used to secure the uplifted scalp near or in the hairline. They are reflective of a really pulled up scalp and perhaps too aggressive browlift.
In terms of improvement, endoscopic browlifts can be partially reversed by the same method that caused the initial effects. Wide forehead and scalp loosening done through the same incisions as the initial operation may allow some reshifting of the tissues back to less stretched look. This may provide some improvement in the vertical depressions and partial lowering of the hairline. Fillers and hair transplants are also options to deal with the problems you now have but I would first try and treat the cause of the problem before exclusively treating the symptoms of the problem first. Those are always options if tissue loosening and reshifting is not entirely successful.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like information on liposuction and butt augmentation. I would like information on estimated cost and recovery time. Thanks I hope to hear from you soon.
A: Thank you for your inquiry. The questions you have asked are broad with different options and make your questions impossible to answer without being very procedure specific. I would need to know more specifics about what exact liposuction and buttock augmentation procedures you desire.
1) What areas of fat removal by liposuction are you seeking? How many different body areas?
2) For buttock augmentation, is it by implants or fat injections?
This information is vital because much of the costs of surgery are based on the time that it takes to do them. For the sake of the most common method of buttock augmentation, which is fat injections from abdominal and flank liposuction harvests (aka the Brazilian Butt Lift), I will have my assistant pass along some costs to you later today for this approach. Those costs will range between $6500 and $8500 depending on how much liposuction is done/needed. This combination has the dual advantage of contouring multiple body areas by reduction of body areas around the buttocks which makes any buttock size increase look even better. Depending on the type of work that you do, I would anticipate a minimum of 10 to 14 days until you get comfortably back to most normal activities of daily living.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have been reading for quite some time on your website and I found a lot of terrific information. I am looking for what you describe as the “Male Model Look”. Could you please tell by the enclosed photos what procedures you would suggest for my face in order to achieve this look. I have been reading about jaw angle, jaw, implants and cheek implants but would like to know what you suggest for my particular face. What else would you suggest? I am 38 years old. I have already had my ears pinned one month ago. Could you also do a custom facial imaging so that I have an idea how I will look (more or less).
A: Thank you for your inquiry. The so called Male Model Look is really about accentuating some or all of the skeletal highlights of the face. These include the brow bones, nose, cheeks, chin and jaw angles/jawline. One has to not have too thick of facial soft tissues to see the effects of the augmentations. When analyzing your face, you have the right amount of soft tissue cover to show these effects well. You are most deficient in the jawline area (chin and jaw angles) and secondarily in the cheeks. For starters, I have just focused on these three areas as you can see in the attached computer imaging. There would be the 'best value' procedures for your face. The only other thought would be some nasal thinning in the tip area. (but I have not done that so you can focus on the more important areas for now)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am at wits end. 🙁 I had goretex implants in nasal-labial folds about 12 yrs ago. They capsulated shortly after and I looked hideous. So I've been filling around them for years even had a face lift. Finally, about 6 months ago I had them removed and replaced with Alloderm.. It looks worse!!! One side is hard and they both show thru the skin. The company will not give me info. Can they be successfully removed??? Today, I am having Ultherapy in hopes of tightening to minimize the awful protrusions.:((I used to be a model and now I can't even look in a mirror)
A: I see no problem with easily removing Alloderm. It does not usually incorporate much into the surrounding tissues. It gets encapsulated, almost like your original Gore-tex implants, which is why it contracted and became distorted. In hindsight, that probably was not the best choice for a replacement for the Gore-tex as it did exactly what could have been predicted in that situation. I would not expect Ultherapy to make any difference. That approach is a hopeful but flawed concept. A much better replacement once they are removed would be dermal-fat grafts or fat injections, a natural tissue that will heal into the surrounding tissues adding volume and will not develop contractures.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am getting quotes and suggestions on liposuction and a breast lift. I already have implants but looking to go smaller and I'm up in the air on replacing them, removing, or keeping the ones I've got. I've have breastfed 4 children and also need a lift and full contouring. What are your prices and are you running any promotions?
A: Unfortunately based on the information that you have given me I can not be of much help to you. It is impossible to give reasonably accurate pricing when you don’t really know what the patient needs. Liposuction can be done on 12 different areas of the body, there are four different types of breast lifts and two types of breast implant options. That leaves a tremendous number of variables to consider all of which take differing amounts of time and effort needed to do the surgery…and that hugely impacts cost. The best way to figure out what you may need is to either see some pictures of your concerns or give me a very specific set of procedures that you want to do. I suspect you need at least a full breast lift but knowing what to do with your indwelling implants is a very important consideration. Remember that when you do a breast lift, the actual size of the breast gets smaller. Taking out indwelling implants with any degree of sagging will leave you with very flat breasts despite the fact that they may be in much better position higher up on your chest after a lift. When it comes liposuction, I suspect you may be focused on your abdomen and waistline. But whether that would be an effective contouring technique in someone who has had four pregnancies with likely loose skin and stretch marks is an issue yet undecided.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a combined breast lift with implants nearly 5 days ago. My recovery is going well I think, however, the appearance of my breasts concerns me. I've attached two photos (front & side view). My concern is that my breasts are oblong with a definite, large “indentation” above the nipple. In the photos, you see the implant sitting high, then a big indentation above what, I think, is my own breast tissue below. This seems abnormal to me. My breast shape looks kind of like an eggplant. Is this a cause for concern?
A: When undergoing a combined breast implant and lift for severe breast sagging, the early appearance can be disturbing. This is because the implants often ride early and in conjunction with swelling can push the breast tissue forward and down. This creates the exact appearance that you are seeing. It is important to remember that it is early and many changes will take place. One of those is that the implants will drop. This can be helped by wearing a breast band to encourage the implants to move south into the bottom that has been created for them. Putting gentle sustained pressure on the upper pole of the breasts will help the bottom tissues to expand and allow the implants to drop. It will take 6 to 8 weeks before you have a clear idea as to how much dropping they are going to do. They will definitely drop, it is just a matter of how much. Once that happens the breast tissue in front of them will move up into a better position on the implants.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 28 year old male. I would like to have Restylane injected under my eyes in order to reduce the appearance of my eye bags/dark circles. Is this something that you would do often at your clinic? Am I a suitable candidate? I would also like to increase the definition of my jawline/chin. Have you ever made a more male, square, enhanced jawline/chin by using fillers alone, such as Radiesse? Or would I need to get jaw and chin implants? Do you do this procedure often? I don't like the way there is a slight double chin at certain angles, as you can see in the photo, would fillers get rid of this or would I need a chin implant? The last three photos are of jawlines that I would like mine to be more like.
A: When you look at all of your facial issues combined, they have a similar theme…an underlying bone deficiency. In the words, you are structurally weak. This is particularly relevant in the lower eyelid area where the problem is a recessed infra-orbital rim and cheek bones. That is why you have this appearance at such a young age. The chin and jawline issue is not as weak as it is just your desire for a much stronger one.
As for injectable fillers, they are a poor treatment for the under the eye area and are absolutely a contraindicated treatment for the chin and jawline. While injecting Restylane under the eyes can be done, I have never been that impressed with its results for your particular problem and it is only a temporary fix at best. Irregularities are very common in this area with injectable treatments that will persist as long as the filler lasts. You would be much better served by a combined infra-orbital/malar implants in this area which would correct the entire problem from the rim to the cheek and be permanent. From a jawline perspective, every young male shows me male model/actor pictures just like the ones you have shown. Those type of results are only obtainable with chin and jaw angle implants, ideally custom made ones that connect the chin and jaw angles in one smooth line.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am 35 years old and am 5’ 4” and weight 138 lbs. I had my last child one year ago and am back to my prepregnancy weight but can’t get rid of this loose tummy skin and fat. I went to a plastic surgery consultation and, in addition to a tummy tuck, was told that I needed liposuction as well. Do I really need to get liposuction on my love handles with my tummy tuck to get the best result? Since I am going for surgery I want the best result. I'm pretty happy with my general size, I just want to be firmer and smaller around my stomach.
A: It is a common misconception as to how far the effects of a tummy tuck reach. The main effect of a tummy tuck is seen between the hip points, it is essentially a 180 degree procedure of the trunk.. One must remember that waistline reshaping is closer to a 270 or 300 degree procedure. To extend the benefits of a tummy tuck, whose tissue excision and scar stops at the hips, fat removal by liposuction must be done to continue the narrowing benefit around the corner of the hips and into the back. This liposuction effects what most people call the love handles or the flanks. This not only flattens or indents the love handles but also decreases the risk of dogears or fullness at the ends of the tummy tuck incisions. I would estimate that about 2/3s of abdominal reshaping patients in my practice need the combined tummy tuck and flank liposuction procedures for the best result.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, what is a mini facelift with a simple subtuck treatment? Is a subtuck treatment to the neck area, and how is it performed?
A: When you use the term ‘subtuck’, you are referring to the submental area of the upper central neck. That is an area that will not be affected by a mini-facelift unlike a full or regular facelift. In a mini-facelift (aka Lifestyle Lift amongst many names) the jowls and the face behind them is effectively lifted and tucked. But the submental area is not changed by a mini-facelift because it is a more limited type of facelift that does not reach this far forward. This is why some type of submental treatment, such as liposuction or a submental tuckup, often needs to be done at the same time as the mini-facelift to get a more complete result. These submental procedures are done through a small incision underneath the chin.
Not every mini-facelift needs to have submental manipulation, it just depends on how much loose skin or extra fat is in this area. I would estimate that two-thirds of mini-facelift patients do need submental attention as well.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, One month ago I underwent surgery on my left cheekbone which was fractured fixed after being punched in the face. The surgery was done through a lower eyelid incision. My surgeon warned me that there was a chance that my lower eyelid would sag lower afterwords and, if it did, he recommended massaging of the lower eyelid and cheek a few times a day for a few minutes. If time and massaging is unsuccessful at bringing my lower eyelid back into place, what can be done? How long should I wait before having additional surgery to fix the lower eyelid sag?
A: Lower eyelid sag, also known as ectropion, is a known potential complication from any surgery that passes through the lower eyelid. Scarring of the layers of the lower eyelid or loss of lateral canthal tendon support can result in lower eyelid malposition. In some cases it is temporary until the swelling from surgery goes away and the lower eyelid skin relaxes. But if it is persistent or significant still at 3 months after surgery with no significant change, then a lower eyelid revision procedure will be needed. There are a variety of options to get the lid back up to a more normal horizontal position, the most common being release and lateral canthal tightening. This works satisfactorily when the ectropion and scarring is not severe. In more difficult cases, the release and lateral canthal tightening needs to be combined with a dermal graft in the middle lamellar tissues to add tissue that is scarred and provide good support for lateral canthal attachment.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I’m an Asian patient who underwent augmentation rhinoplasty 4 months ago with diced rib cartilage, but the augmentation isn’t enough. When I consulted the surgeon, he said the diced cartilage technique either undercorrects or overcorrects the nose. With bloc rib rhinoplasty, it’s easier to control precision of the augmentation required but subject to warping. Is that true? I’m planning to have another revision to augment the height again using bloc rib cartilage. What do you think? How long more do I have to wait for a revision? I just wish to push for more height. Thanks.
A: In general, diced cartilage for total dorsal augmentation can be a very satisfactory technique if the amount of height required is no more than 3 or 4mms. For most Asian rhinoplasties, sufficient dorsal height is usually closer to 7mms. Thus a diced cartilage dorsal augmentation may be insufficient because the push of the skin at this amount of augmentation is significant and the diced cartilage construct is not strong enough to resist it. So even if the diced cartilage roll was 7mm in height, it would be pushed back down and flattened somewhat. A bloc cartilage graft is much more successful in displacing the dorsal nasal skin upward the required amount for the obvious reason thatit is solid and can not be deformed. While it is true that bloc cartilage has the risk of warping, the key to prevention of that problem lies in the harvest. Rib grafts are absolutely needed and getting a fairly straight cartilage graft of 3.5 to 4cms in length can be difficult but it can be done.
As for the timing of the revision, since you know you desire more now that the initial swelling has gone down you could proceed at any time with a revisional rib graft rhinoplasty.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, hello, I am 37 yrs old and I have a 100% overbite with a deep labiomental fold. I want to have that fixed and get a better jawline and chin and don’t know what procedure would work for me.
A: In looking at your pictures, I can see the external symptoms of the 100% overbite to which you have described. The jaw is overrotated upward causing a vertically short chin (albeit with a touch too much horizontal projection) and a deep labiomental fold. Thi is what happens when there is not an adequate occlusal stop on jaw closure. (overbite should usually be about 10 to 20%)
Correction can be done by one two approaches. One option is a vertically lengthening chin osteotomy with an interpositional hydroxyapatite block graft. This would need to be at least 1 cm (10mm) of vertical lengthening if not more. This would create more of a prominent chin and would help lessen the visible depth of the labiomental fold as it stretches down the chin tissues downward. I have attached some computer imaging of that potential result. The other option is a custom chin implant that would vertically lengthen the chin as well as back along the jawline. In either case, a labiomental implant could also be used to shallow the depth of the fold although this may not be needed with the chin osteotomy as the fold naturally becomes a little less deep as the soft tissues are moved downward with the bony movement.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, What I am wanting to do is just reduce the high ridge on my head. That’s the only problem I have. My head seems as it has a bump right on top. I have attached three pictures to show you what I mean. it is pretty obvious.
A: What you have is a common condition that I see in aesthetic skull deformities, the prominent sagittal or midline ridge running from the front to the back. This gives the head a high arching or a triangular shape. What is important to realize about this skull deformity is that it is more than just a prominent midline ridge, the sides of the skull next to it are also too low. It is the combination of the two that makes it look that way. Thus to do its correction and achieve a rounder skull shape, both problems must be simultaneously addressed. It is more than just burring down the midline ridge as there is a limit as to how much that can be done. (usually 5 to 7mms) The sides along the ridge out to the temporal line must be built up as well with cranioplasty material. When done together the desired look is obtained as I have illustrated in the attached computer imaging prediction.
While this skull reshaping can certainly be done and is not difficult to go through, the key decision as to whether this is right for you is whether the incision and the resultant scar to do it is an acceptable trade-off. An incision would be needed across the top of the head with a resultant fine line scar.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I want to know what kind of result to expect by injecting 1cc of fat grafting in the upper lip. Thanks for your answer.
A: Your question in regards to fat injection grafting of the upper lip has a two-fold answer. First, fat injections to the lips are associated with a very high rate of reabsorption often being completely gone within 6 weeks of the procedure. This is the most difficult area of the face in which to get fat to be persistent. Lip tissue is different than the rest of the face and their near constant motion all contribute to the low rate of sustained augmentation. When fat injections into the lips are done, overfilling is a common technique in the hope that even if most of it is reabsorbed some will remain. Based on this premise, usually 2 to 3ccs of fat is injected into a lip. Second, while 1cc of a synthetic injectate would be considered more than adequate for any lip (because the objective is to have an immediate but not overfilled result) that would not be a good approach with fat for the reasons just described.
Thus 1cc of fat injected into the upper lip will produce an immediate and satisfying result (just like that of a synthetic filler), I suspect most of it will be gone before a month has passed after the injection.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had silicone jaw implants placed last year but I feel that they have added too much lateral width and not enough vertical lengthening. Would you recommend replacing them with the RZ Jaw Angle Medpor implants or would it be better to just shave down and reposition my current implants? Also, are Medpor implants much more expensive than their silicon counterparts?
A: The biggest problem with current silicone jaw angle implants, regardless of manufacturer, is that they provide little to no vertical lengthening and only width or lateral augmentation. Most of these implants have been designed based upon a normal jaw angle shape from skeletal models, which patients desiring augmentation do not have. A ‘weak’ jaw angle is as much vertically short as it is narrow. Increasing jaw angle definition, given that it lies at the intersection of the posterior and inferior mandibular borders, is a three-dimensional consideration.
Your aesthetic result from silicone jaw angle implants is not a rare one. It would be extremely difficult to try and reposition your existing silicone implants because they are not designed to engage the lower border of the jaw and would thus be unstable. The smooth surface of silicone would have the implants sliding back up and out of position before the wound would even be closed. In addition, the design of current silicone jaw angle implants makes it virtually impossible to stabilize their position on the bone with screws placed from an intraoral approach. The Medpor RZ implant to which you refer would be one of the few choices that would offer you an improved jaw angle result. The cost of any Medpor implant is appreciably more expensive than silicone.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 22 year old female who underwent a forehead lipoma removal by a neurosurgeon two years ago. He did a bicoronal flap and a small frontal craniotomy because part of the lesion that was tethered in the bone and he didn’t want to just pull it for fear of intracranial extension. The pathology showed it was a lipoma and I now have plate and screws in the forehead which are palpable. I now have a 3cm x 3cm area in the middle of my forehead that is excess tissue where the lipoma was. It is basically a balloon (hollow) with slightly thinner skin. I attached some photos.
My surgeon gave me the following options for correction:
1) A hairline incision appraoch but that would pull my already normal brows up.
2) A bicoronal incision would already raise my already high forehead and pull my brows up.
3) A direct horizontal incision (I have no forehead rythids) but maybe this is the best option and I have to settle for a scar? If I have a direct excision it gives my surgeon the advantage to go subperiosteal and remove the plate which is palpable.
I am stuck in terms of knowing what to do and would really appreciate your opinion!
A: The simple answer to your case is why don’t you just do a bicoronal incisional approach? You already have the scar and a bicoronal flap does not raise up the eyebrows unless scalp skin is removed and that is the intent of the procedure. This will provide a direct approach to removing the plates and screws and possibly filling in the craniotomy defect/irregularities with hydroxyapatite cement.
I would never do a hairline incision when a bicoronal incision exists behind it. You have no way of knowing how well the vascular inflow to the intervening skin segment between the two incisions is and there is a real risk of scalp necrosis.
For a cosmetic forehead problem in a young woman, it would be a near surgical crime to put a horizontal scar on your forehead, trading off one cosmetic problem for another…and the scar will likely look worse than what you have now. This would be particularly egregious when a bicoronal scalp scar already exists and there are no cosmetic trade-offs for using it.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, if I was to have a rhinoplasty to augment the bridge of my nose and a forehead/eyebrow augmentation, which should be done first? Will having the raising of the nose bridge first and then the forehead/ brow augmentation mess up the profile of the nose together with the brow ? Which procedures should I do first for best results ? Does it make a difference ?
A: I think the best aesthetic sequence is to do the forehead before the rhinoplasty. That way the position of the nasal implant can be optimized to that of the frontonasal level of the brow augmentation. That is a lot easier to do than the other way around. Getting a significant augmentation of the brow, particularly in the glabellar area, is more difficult that just forehead augmentation where you leave the brow area alone. Once a forehead/brow augmentation is done it is very difficult to change particularly if you are trying to add more to the brow or glabellar area. Therefore, create whatever brow/forehead augmentation that can be done and then set the level of the nasal bridge to that. In essence, work your way down from the top based on the difficulty of doing the procedure. When brow augmentation and rhinoplasty is done at the same time, it is easier to make both meet in the ‘middle’ so to speak.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in buttock augmentation. However, looking at the before and after pictures, it doesn’t look like much of a difference. I would like a really big butt.
A: While the definition of a really big butt is open to various opinions, let me give you the overview of buttock augmentation options and the reality of their outcomes and the process.
SYNTHETIC INJECTIONS Known as black market injections of silicone oils and even caulking compounds, this is an illegal procedure that has a high rate of conplications. While a much larger buttock size can be immediately obtained at the cheapest price, this is not a good trade-off when one risks severe buttock lumpiness, skin pigment changes, infection, chronic pain and even death from necrotizing fasciitis and pulmonary emboli. But when you injected in a hotel room or house by someone of absolutely no training with non-medical and non-FDA approved materials, these results should not be surprising.
FAT INJECTIONS This is the most common method of buttock augmentation today and the most popular. The name Brazilian Butt Lift is what it is most known by. While it is the most popular, that does not mean it is the most effective because it isn’t. Improvements in buttock size can be expected to be modest as best. It is popular because it is a natural material and there is the concomitant body contouring benefit of the liposuction procedure that is needed for the fat harvest. The survival of fat, no matter what you may read, is far from assured and even at its best a 50% survival of what was be injected I would consider a spectacular success.
IMPLANTS The most assured method of sustainable buttock augmentation is with the use of FDA-approved soft buttock implants made from silicone gel elastomers. Implants will produce the biggest size that will last but is a more invasive surgical procedure with a significant recovery and costs. There are two ways to place buttock implants, above and inside the gluteal muscle, and this will also influence the result and the recovery. The best place to put implants is inside the muscle. (intramuscular) This is the best for implants long-term and is associated with the least potential complications but the size increase will be moderate (350cc or less) and the recovery is the hardest. In a small person the buttock size change can be very significant. In larger patients, it will be more moderate. If the implants is placed above the muscle, the largest available implants can be placed in most people (up to 600cc) and the recovery is less than when placed inside the muscle. But there are higher risks of infection, fluid collections and implant shifting than when the implant is placed inside the gluteal muscle.
In short, you can now see that different methods of buttock augmentation have different outcomes, risks and recovery associated with them. So when your goal is a ‘really big butt’, your only good options is a buttock implant placed above the muscle. Whether someone is willing to expend that effort is why so many patient opt for fat injections…but should only do when they are understanding of what the final result will likely be.
Dr. Barry Eppley
Indianapolis, Indiana