Your Questions
Your Questions
Q: Dr. Eppley, Hi, I’m a female with a fairly prominent brow and small, receding forehead I’d like to improve. My face as a whole is convex rather than flat: Can the areas outside my eyes be “filled?” How would forehead augmentation affect deep wrinkles? Thank you!
A: Thank you for sending the edited picture. What I see is a mildly recessed forehead and a very recessed chin. The combination of the two is why your facial profile is convex. I have done some imaging for a forehead augmentation (not brow) and a chin osteotomy or sliding genioplasty. Your chin is too short for an implant and it also needs some vertical lengthening as well as bringing it horizontally forward. Also forehead augmentation usually will soften deep horizontal wrinkles as the skin is stretched out by the underlying material expansion.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I am bothered by the hollowing under my eyes. I am scared of injectable fillers placed so close to the eye . I’m thinking about the surgical procedure using implants. Have you done it ? How good are the results ? This hollowing thing really bothers me . It makes my pictures look bad. I don’t expect full correction, I’ll be happy with an improvement.
A: When you speak of implants for hollowing, you are referring to infraorbital rim implants. I can speak to the success of the procedure having done it numerous times. Done through a lower eyelid procedure, it is done through a lower blepharoplasty incision and the implants are secured to the bone with small microscrews. It provides a permanent correction to the lower eyelid hollowing problem. The biggest problem with them is the risk of palpability (being able to feel them) and asymmetry of the upper implant edges.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I had lap band 3 years ago and am looking to have excess skin removed, a breast lift and some liposuction in the arms and legs region, just wanting some prices and if my insurance would cover any of it due to being post lap band.
A: To answer your questions, the first thing I need to see is some pictures of what your body looks like. What I am particularly interested in seeing is the size of your abdominal pannus and the degree of breast sagging that you have. But in the interim, let me provide you with some reality about the bariatric surgery patient and and what insurance will or will not do wit the sagging skin that develops afterwards.
1) The only procedure that has any remote chance of being covered would be an abdominal panniculectomy, removal of the abdominal overhang or a simple amputation tummy tuck. But for this to even be considered, a pre-determination letter must be written that describes the medical symptoms the pannus is causing and pictures that show the amount of abdominal overhang. To qualify the pannus must hang over the groin creases and onto the upper thighs and there must be a documented history of treatment for intertrigo. (skin infections under the pannus) Based on this submitted information, it is up to the insurance company to make a decision about coverage.
2) Breast sagging and the breast lift with or without implants is not considered a medical necessary procedure and is not eligible for insurance coverage.
3) It would be extremely unusual for the extreme weight loss patients to benefit by liposuction. The skin quality is often too stretched out to respond well to fat removal alone.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am 34 years old and am 5’ 6” tall and 165 lbs. To my own credit I have lost 54 lbs over the past year with diet and exercise; It has been tough but I have done it and I am determined to lose even more. But I appear to have hit a point now that the weight is not budging. My problem is that I now have an apron of skin and fat that hangs over that has started causing a lot of discomfort during any form of exercise. I am doing all I can from a diet and exercise standpoint. Should I go ahead with tummy tuck surgery now or wait until I lose more weight?
A: Now that you have hit the proverbial wall and have an overhanging apron (pannus), I think you would benefit by a tummy tuck right now. The psychological benefits would be enormous and would empower you to lose the additional weight afterwards. I have seen this effect many times in patients who look just like you and have the identical story. Tummy tuck surgery itself will casue some additional weight loss by what is removed, which is usually in the range of 3 to 7 lbs. (everyone thinks the apron weighs a lot more than it actually does) But an identical if not more weight loss occurs from the recovery process. (burning calories to heal) This is why many tummy tuck patients like you will be down in weight 15 to 20 lbs by 6 to 8 weeks after surgery. That provides a good surge towards your eventual weight loss goal.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had muscle reduction done for my very bulgy temporal areas six weeks ago. While there is already visible improvement, I do have some minor concerns and wanted to know if what I am experiencing is normal. I have noticed that the temporal area in the non-hair bearing portion above the cheek arch seems to be a llittle bigger than before. It is soft and fleshy and does not hurt. Will it stay this way or go down with some more time? Also my mouth opening seems to be lityle less wide than before. I have no problem eating and speaking but it does not seem to go as far open as before. Will this stay this way or will it eventually return to normal? Right now it measures 38mms between my front teeth when I open as wide as I can.
A: Seeing the final result after temporal muscle reduction is a process that takes up to six months after surgery to see the final contour result. So at six weeks you have a ways to go. But to address your two specific concerns:
1) That bulging just above the zygomatic arch is very typical at this point. The muscle has shortened so the bulk of it, for now, is in this area. This is where the muscle passes under the zygomatic arch and is it’s thickest part. Also it also may appear bigger (even if it is not really bigger) because what was above it has gotten smaller. So it may be a relative perception issue. Like above, I wait for the full six months to see how the muscle changes.
2) So-called normal oral range of opening is 45 to 55mms. for most people. (I just measured mine and it was 48mms) Anything over 30mms is very functional and would not cause issues with eating or speech. I don’t know what you were before surgery but i suspect maybe 10 to 12 mms more. I would g ahead and work on some daily stretching of it to see if you can get back up to 40mm plus. I suspect you will be able to do so.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have saggy breasts and I was hoping to avoid a lift so I would’t have scarring. Is it possible with a bigger implant not placed under the muscle that this can be achieved? I did try on 600cc with a bra and a shirt over and decided I wanted bigger. I was thinking of 800cc. I know I’m not the Dr. and this is something you would know more about. So with some of these things I’ve mentioned. Could you tell me if this can be a possibility. Thank you so much for your time.
A: One of the great dilemmas in breast enhancement surgery is that of the sagging breast. It is a common misconception that an implant is going to lift a saggy breast. While that is true for the very smallest amount of breast sag, it will simply not work for what most women perceive as breast sagging. If an implant can not lift a breast, a bigger implant will not do so either. As a matter of fact, the bigger an implant is in breast sagging, the worse the result may appear afterwards if a lift is not done at the same time.
So in what cases will an implant help lift a breast? Check where the position of the nipple is. If the nipple is at or just below the lower breast fold, some form of a lift is going to be needed. The other way is to do the pencil test. If a pencil placed underneath the breast stays, then a breast lift will be needed as too much sag is present.
In reality, implants help re-expand a deflated breast but it will not really lift a sagging one.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I recently (3 weeks ago) had a lip lift which I am very unhappy with. I have attached the before and after pictures. What I expected with the lip lift was to have more lips all through out the upper lip, not only in the middle where the cupid bow is (looks like a chipmunk). At the same time I wanted to reduce the length between the lips and the nose. I always had thin lips and always wanted more fuller lips , upper and lower lip with shorter distance between the lip and nose. With the lip lift , I thought the lip would of been less thin on top and would of done fat transfer to have some fullness afterward.
A: Thank you for sending me your before and after photographs. There must have been a miscommunication before surgery because your lip lift did exactly what it is supposed to do and can do…lift up the central third of the upper lip. It can not change the whole upper lip vermilion as the skin is only removed from the central third at the nasal base. The only lip enhancement procedure that can change the entire lip vermilion is a lip advancement where skin is removed alone the vermilion-skin junction from one corner to the other. That is a tremendously effective procedure but does produce a very fine line scar along the vermilion-cutaneous. That is why a lip lift is usually chosen for men although there is nothing inherently wrong with a lip advancement for men either.
You actually have a good early lip lift result. But although the operation may have been done appropriately, it may not have been the right operation for you as it turns out.
Lip lifts are irreversible, meaning you can’t put back the subnasal skin that has been removed. Your options at this point are the following:
1) Give the lip lift a few months to settle and relax because they all stretch out often up to 25% or more over time. Then decide what to do.
2) Jump in early and do lateral upper lip vermilion advancements (leave the cupid’s bow alone obviously) to make the lip vermilion more even and lifted across the lip. You can do fat injections at the same time but you may not need to do so with lip advancements.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, thank you for doing the imaging on the predicted changes from chin and jaw angle implants. I am blown away that this can actually be done. This is well beyond my expectations. What size implants would you be using for my jawline enhancement?
A: Quite frankly more extreme changes than those can be done but I kept at the limit of what I see as reasonable and not excessive. (I have attached some results so you can see how extreme it can be made if one wants…although I don’t advise that on you). Your imaged look can be approximated by a combined square chin implant (style II square 9mms) and bilateral jaw angle implants (lateral augmentation style silicone 11mms or Medpor lateral augmentation of 7mm size). If the chin would benefit by vertically lengthening as well, I would do a chin osteotomy for lengthening 5mms and bring it forward 7mm with an overlay of a small square chin implant style II of 3mms.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I am looking at building up the back of my head. In reading your blogs you say that you usually add about 60 grams of material. But I don’t know how that would look and whether that is enough. I went on with my experiments, but rather than water I used plasticine which conveniently has a density close to PMMA, to check the volume. I adapted it to the back of my head like an implant would be, and as you said the change is bigger than one would expect (I tried 60g and 80g). So if the trade-off for a bigger volume is ‘longer or more full coronal incision’, could you tell me what would be its size and location for 60g and 80g? (I’m not sure I’ve read around 10 centimeters for 60g on your blog) As a side question, how would you attach the implant to my skull?
A: That is a clever way to see how much volume 60 grams of cranioplasty material is. Remember that it will also look bigger than you think when placed under the scalp skin. To get this amount of material on the back of the skull, an incision of 14 to 16cms long is usually needed. Onlay cranioplasty materials are fixed to the skull by first applying small screws to the skull bone allowing them to set up about 3 or 4mms above the bone. When the material is then applied this gives it something to hang onto to like rebar used in concrete. While screw fixation may not be absolutely necessary for augmentative skull reshaping, I prefer it since it is simple to do and adds a bit of security for prevention of implant mobility.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I had malar and para-nasal implants, also infra-orbital porex placed in 2006, and six months ago removed because the malar increased my gaunt look, provided only lateral projection, and started to show through my thin skin. The paranasal implants didn’t really do much for me in terms of anterior volume, since they were placed so low on my long face. Also, right infra-orbital implant became infected during removal of the malar implant and was also removed. Now I’ve got the left one still in there and, without the malars, the edges are poking through and it’s too small for my face. I trust my original surgeon and he wasn’t the one who removed the malar implants for financial and geographic reasons. Although the malars were kind of cool and from some angles gave me an “actor” look butI don’t want to replace them alone.
But, I do want to explore all options. That said, his idea is: 1) larger medpor tear trough plus midface lift. I realize the right eye is drooping. I also think there is some scar tissue where the paranasal was on right side that makes that cheek droop more and look puffy. I know that midface lift means basically 2-month initial recovery and can leave one funky-looking, and seems to not really last that long. I was thinking of the blepharoplasty to reposition the eye, instead??? (less invasive??) I like the idea of tear trough improvement , now that I can compare left vs. right, I see that my face needs it.
The groove and shadows beneath eyes are my biggest complaint. Because I realistically, with my long and gaunt face because of exercise, it would take a lot to fill it out. So I think a compromise of concentrating on eye area is the best option at this point. But I don’t want to go thru that recovery time and cost of the midface lift if it is going to fall in a year and the tear trough won’t be big enough and will start poking through….2) another surgeon I have worked with in past suggested malar-submalar combo, goretex. But is worried that any implant will just show through. I am also open to this, to give some structure to my flatness, lower healing time, lower cost. 3) This second surgeon prefers just to use injectables. I won’t do fat transfer because I will burn it off and it’s a waste of money and time. It would just leave the left infraorbital implant in and try to compensate on right and in lower cheeks with filler under eye. At this point, though, I would be looking at minimum $6000 in filler.
I had noticed the medpor porex tear trough implant and that, based on the brochure, seems to be what I’m looking for in terms of volume. But, I don’t think my present surgeon would go for something this big,and he had mentioned the Hoenig model. Again, anything anterior he is against in order to avoid hitting the nerve.
I’m not against the midface lift, but at this point would prefer to save any lifting for a mini-lift 5 years down the road, perhaps with submalar added…. with skin excision not just suspension, when I really need it. And for the massive recovery time. But, I have seen some awesome B & A of tear trough shadow improvement.
I don’t know…???? I started on this porex implant road and maybe just have to continue in this direction.
A: In answer to your questions:
1) Don’t do a midface lift. This is a longer recovery than most patients realize and with your facial skeletal structure you are at an increased risk of creating lower eyelid ectropion or an unusual look. With your thin facial tissues, you are always going to be at risk of tear trough implant palpability, visibility or asymmetry. But I can get more enthused about tear trough implants in you though than a midface lift.
2) A small thin malar shell implant for the cheeks is reasonable and far preferable to a midface lift. With your thin tissues there is not much room for error about implant size as it is easy to end up in you with a visible implant look as you have had in the past.
3) Injectable fillers or fat in your thin face will not only not work well but has a poor return on investment over time.
4) There should be no concern about ‘hitting’ the infraorbital nerve going over the edge of the infraorbital rim. The nerve is well below it. That appreciation is just a function of having placed implants there before.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am looking for a nicer more natural-looking side profile. I saw a before and after picture of a hispanic lady you did and like the result. I’m considering the following surgeries – brow bone augmentation, forehead augmentation and nasal bridge augmentation (higher nose bridge) to go with the newly adjusted brow bone.
I have a few questions…
1) Have you done this procedure on Asians before? If yes, mind sending me some before and after pictures?
2) How often do you do brow bone surgeries? I’ve done some research online and it seem that you’re the only surgeon that specializes in this.
3) How much are the costs to have the above surgeries?
4) What are some of the side effects/worst case scenarios?
5) Would you say I have protrusive eyes? I feel like there’s still some fat/excessive skin after eyelid surgery and my brows are too close to my eyelid.
Would also like to hear your recommendations.
A: In answer to your questions:
1) Augmenting the forehead and nose to improve the profile is most commonly done in the Asian patient in my experience. They make up nearly half of all forehead augmentation patients in my practice. Building up the forehead with PMMA is the typical approach due to the volume of material needed. The end goal is to have a rounder forehead that eliminates any backward slope and flat profile to it. While the material can extend down and build up the brow bones as well, it is not possible to extend the material onto the radix of the nose to build it up as well. It may reach the frontonasal junction but true radix augmentation must be done from below as that area is part of the nasal dorsum not the forehead.
2) Brow bone and forehead augmentations are done by few plastic surgeons and those who do them almost universally have a craniofacial training/experience background as that is how you learn to do any type of skull reshaping surgery.
3) I will have my assistant pass along the costs of forehead augmentation to you by separate e-mail tomorrow.
4) The most common side effects are shape or contour issues. How smooth is the result? Are the edges over the temporal lines visible? Is the amount of augmentation enough? Contour irregularities are the main reason for any revisional surgery which has a risk of about 10% in my experience.
5) In looking at your pictures, I assume you recently had ‘double eyelid’ surgery based on the scar location. I will also assume that they didn’t take ouy any upper eyelid fat which commonly needs to be done in the Asian eyelid. Also, brow bone augmentation may increase the distance between the brows and the upper eyelid lashline.
6) Lastly, radix augmentation needs to be done through the nose and is often part of an overall dorsal augmentation in an Asian rhinoplasty. I know that you stated you recently had a rhinoplasty but I do not know what was done. Did they build up the dorsum and, if so, with what?
I have attached some imaging predictions based on brow/forehead augmentation and a nasal dorsal augmentation.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I am 55 years old and am interested in getting my saddle bags reduced that have bothered me my entire life. I am concerned, however, that I may end up with skin that is saggy afterwards given my age and the little bit of cellulite that already exists there. What do you think about using Liposonix instead?
A: When you use the term Liposonix you are referring to an energy-based form of assisted liposuction just like Smartlipo or Vaserlipo. All use different energies to loosen the fat before it is suctioned out such as ultrasonic or laser energies. These are all forms of liposuction that pose the same risk of skin irregularities that any other traditional form of liposuction does, because the support of the skin is deflated as the fat is removed and the quality of your skin is not improving. Of all these energy-based liposuction methods, Smartlipo may be best because the heat that it generates in the treatment process may have some mild skin tightening benefits.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I am sending you photos of my eye. I will let you know that about 13 years ago I went to a surgeon and he said it was the eye lid that was at fault and ‘drooping’, I did not agree, but I was 22 and I went with it in a desperate state to ‘fix’ it. He said he ‘crimped’ a muscle of my right eye lid and it did lift it but it looked even more obvious as it was not the fault of the eye lid. I can tell you this, and it sounds strange, but I know it to be true. When I was very young, I remember sleeping on my right side and the pillow was pushing against my eye ball and I remember thinking that I should not sleep like this, yet I did, and I didn’t move the entire night. In the morning my parents were very concerned and everyone at school noticed it and that is how it stayed. Years later I got eye lid surgery to ‘lift’ the eyelid. But i am VERY sure that the fault lays within the eye ball position and not the eye lid. I have looked, measured and worked out many things with my eye and I am beyond sure that it is the eye ball position in relation to the socket and the other eye that is off. You can clearly see that my left eye is flush against the ‘wall’ of the exterior [filling the entire area of lids upper and lower] and the right is somewhat ‘away’ from the outer corner, leaving a mm or 2 of ‘gap’. I want this fixed like no tomorrow. Now over to you and your expertise. Is this ‘fixable’?
A: Thank you for sending your pictures. In answer your question, I am first going to ignore what is a far more obvious deformity which is the difference in the horizontal position of the upper eyelids on the eyeball. You clearly had a right upper eyelid ptosis repair which has now left you with residual ptosis of the left upper eyelid which sits too low relative to the iris of the eye and asymmetric to the right upper eyelid. But since that is not your focus, let me address to what you are referring to.
Based on what I am seeing, the gap to which you refer at the corner of the right eye may or may not be due to the position of the eyeball. But the reality is that one can not move the eyeball from side to side so that is not a corrective option. To close that gap it would be far simpler to tighten or close down where the upper and lower eyelids meet by corner of lid tightening. That will bring the lid tissues in better approximation to the globe, thus eliminating the gap to which you refer.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I have spent considerable amount of time in researching fat transfers believing it to be the most viable option when done correctly, especially for thin older women. The stem cell benefits of properly done fat grafting add tremendous benefits as well. I understand although fat grafting has been around for a number of years, the harvesting and injection procedures have changed, creating greater success in keeping the fat cells alive. What methods do you use to ensure the success rate of your fat transfers, and what is the success rate you are currently having? One of the greatest difficulty for a patient, are the major disagreements in the medical field regarding the procedures used. Please understand I believe fat transfers to be one of the greatest positive changes in how we address aging skin, I want to have it done, but I am still very undecided due to the conflicting medical opinions out there. There is a very heated debate regarding the “dropplet” vs larger blocks, and the placement location.
A: The concise answer to your basic question is that fat grafting is in a state of evolution and development. It is far from a perfected science from the harvest to the injection methods. No matter what you read or is touted by any one surgeon, no one knows the best method to do fat grafting and just about everyone does it using the same basic principles. No matter what any surgeon claims, they do not have a magical method that works all the time and claims about how much fat survives, in many cases, are perceptions about fat graft take not actual measurements. How well fat graft takes can not yet be measured in any quantifiable way and is based largely on photographs and what the surgeons perceives has survived. Quite frankly as a surgeon I can tell that such perceptions are often skewed by what one wants to see and most claims of survival are likely overstated, some with good intent and others for pure marketing purposes. What may work well in one patient and one face or body area may not work well in the next patient. Fat grafting by injection remains an imprecise art with the science lagging far behind as of yet.
The most straightforward and honest answer that I tell prospective patients about fat grafting take is…no one can predict it and it will likely end up somewhere between 10% to 90%. While the goal is to have have maximal take on one procedure, every fat grafting patient needs to be prepared that more than one procedure may be needed.
Most fat grafting is done by injection because it is the only practical way to either treat a large area or get the material without undue scarring. En bloc fat grafts, also known as dermal-fat grafts, actually work and take very well. But their uses are very limited because a donor site is required and the size of the recipient site must also be relatively small.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I was interested in getting my hairline lowered as well as brow and frontal bone reduction. However I have a very thin hairline due to constant damage to my hair follicles. Any suggestions and how long after would I have to wait to get a separate surgery.
A: If I understand your question correctly, you would like hairline lowering/scalp advancement combined with frontal/brow bone reduction. The concern, which is both understandable and appropriate, is whether with a fine and thin hairline that you should have the procedure. The answer to that question would be based on what your frontal hairline looks like now (please send me a picture), how much scalp laxity you have and whether you were eventually planning on any hair transplantation along the hairline after the procedure. (as some people do for scar camouflage) The quality (hair density and pattern) of your frontal hairline determines how well the scar would do and its potential visibility. Your existing vertical forehead skin length and your natural scalp laxity determines how much scalp advancement/hairline lowering is possible and whether the result justifies the effort. Knowing that one may be considering the potential for hair transplantation later gives one more freedom to perform the procedure is someone with less than an ideal frontal hairline.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would love to smooth out the under eye area- fill in the depressions created when I smile, and add an over-all fullness that I have lost, most recently in the last year as I have gone through menopause. I experienced a rapid and major estrogen deficiency that truly took a toll, especially in my face to appearing almost gaunt. (being a woman is quite a life-time adventure in of itself!) Looking at pictures just one year ago show a noticeable loss of facial volume even though I have experienced no overall weight loss or gain. Again, thank you for sharing your time and expert skill with me.
A: In interpreting your facial concerns they are two-fold: lower eyelid hollowness and a general mid-/lateral facial involution below the zygomatic body and arch bone levels. While both of these are caused by loss of fat, they may or may not be treated similarly. For the generalized facial wasting, the only effective treatment is fat injections. This is the only way to help restore larger facial surface areas that have no underlying bony support. (what I call the facial trampoline area) The lower eyelids are a bit different because the thin skin exposes the use of fat injections to risks of asymmetry and irregularities with so little interface of tissue between the lower eyelid skin and the underlying orbital bone. Other options include the use of orbital rim implants and dermal-fat grafts but those are not without their own issues. (more invasive, palpability, donor site harvest) Given these issues I would favor fat, whether it is of the injected or en bloc variety.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I had a chin implant put in and removed within a few months about 4 years ago. I have slight chin ptosis, and read about “routine” procedures to reattach/tighten/lift the chin pad, like what you discuss above, but when I google search, I find no one who does this . I have googled “raising the introral sulcus”, “correcting bottom tooth show”(no one seems to have any suggestions for this), “correcting chin ptosis”, “submental tuck up” (which you have also talked about) and get like 2 results. and those that do these procedures have like one photo on their website. I would also like projection higher up on my chin so that overhead light hits a small area on the chin, the rest in shadow. The implant I had before just extended the downward line of my jaw and increased the area that the overhead light would catch, making my chin look longer. I feel a feminine chin not only projects, but curves slightly upward at the end of the jaw. On your chin implant page, the 7th one down has a nice curve up, as do many of your patients, the 8th one down does not, nor does the one on the bottom of page 1–you just continued the downward direction of these jaws and I don’t think it looks right. How do you avoid that?? Thanks.
A: Correcting chin ptosis is anything but a routinue plastic surgery procedure. There is not much written about it because its correction is not easy and the results not always predictable. I have learned that the most predictable way to get sustained improvement is to do a lower periosteal/mentalis release, elevation of the chin pad by suture anchorage to a higher position on the bone, a V-Y lower lip mucosal advancement and a shortening vestibuloplasty. Combining all four maneuvers will always correct a some degree of a sustained chin pad repositioning and maybe some slight lower lip elevation.
Getting a chin pad that curves upward with implant augmentation depends on numerous factors including the presurgical shape of the chin pad, chin implant style and size (women usually do better with a central button style chin) and whether an intraoral or submental approach is used.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I would like to get a new shape to my eye that is more narrow and uplifted. I have attached a picture of the kind of eye look that I would like. I was able to create that look by using elastic bands attached to tapes as was seen in a video on Youtube to create an instant ‘facelift’.
A: Thank you for sending your pictures. What you are illustrating I would consider an extreme lateral eye reshaping result which I am not sure can come completely from a lateral canthoplasty alone. I know you were using tapes that pulled the corner of the eye AND the skin around it so it made a very artificial and not surgically achieveable look without pulling the temporal skin back with it. That issue aside it does illustrate that a subtle change in the corner of the eye will not be enough for you. The entire lateral canthal tendon will have to be shortened and pulled way back onto (through) the lateral orbital bone to create that much change. While that is possible it is likely to create a skin fold at the corner of the eye that can only be eliminated by combining that with a temporal lift.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, Please see the photos I have included regarding my interest for a breast lift and abdominal procedure. I am a fit individual in that I work out 5 days a week, and try to keep a balanced diet. Your advice and expertise would be appreciated.
A: Thank you for sending your pictures. From an abdominal standpoint, I agree that liposuction on the abdomen and around the waistline would be beneficial. Certainly no form of an excisional procedure (tummy tuck) is needed. For the breasts, however, that is a different story. As you have also mentioned, a breast lift is needed. There is simply too much skin for the amount of breast tissue you now have. The type of breast lift needed is most likely a blend of what I call a type III (vertical or lollipop lift) or a Type IV (anchor or inverted T lift) These names relate to the degree of lifting they achieve and the type of scar pattern that occurs as a trade-off. I think you could only get by with a Type III lift if you were doing a simultaneous implant for volume enhancement as well.
Both a breast lift and abdominal and flank liposuction can be done at the same time for your trunk makeover.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I have had two cheek implant surgeries. Initially I had 4mm malar shell implants which were barely noticeable. Then I switched to 6mms implants which are now too big. I have a question regarding projection size. I’ve attached two photos showing my face with Conform Terino Malar Shell medium implants with 4mm projection. As you can see, I didn’t feel that these 4mm implants gave me enough definition in my cheekbones or enough outward projection. Therefore, I just had these implants exchanged with Terino Malar Shell 6 mm, but I now feel that the 6mm projection sticks out way too much. I’ve heard that a 1 mm difference in implant thickness (projection) is equivalent to about 1/2 inch difference in actual cheek shape. So, looking at the attached photos (and now that I know through trial and error that 6 mm projection is too large), do you think the same implant with a 5mm projection would still look too large, so I should go with a 4.5mm implant when I exchange the implants next month?
A: It is not true that 1mm of cheek augmentation equals a half inch difference in how the cheek looks. What I can tell you is that it can be striking how a few millimeters in the cheek area can make a big difference. So I think the statement that a little augmentation goes a long way in the cheek area. You case illustrates that in particular. If 4mms is too small and 6mms is too big, one would logically assume that 5mms would be the right size for you. Be aware, however, that in any cheek implant style and size that not just the thickness changes but overall size of the implant (height and width) as well. It is unfortunate that you will have had to go through three surgeries to finally get the right size implant. But there remains no quantitative way before surgery to determine how any amount of cheek implant augmentation will look
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, two months ago I got 6 mm silicone malar shell implants put in. I have flat cheekbones and full cheeks so the goal was to achieve higher, chiseled cheekbones (without placing them too laterally because I didn’t want the overall width of my face to look wider). To be clear, I do not have a combined malar/submalar implant because I did not want to augment my submalar region. Is the malar shell the implant you would have used or would the Medpor RZ malar implant work better to achieve prominent, high cheekbones? Thanks so much.
A: Quite frankly I would have used neither. All silicone malar shell implant styles are fairly wide which are going to give a round look to the cheek more than a high angular look. The medpor RZ implant is a lower projecting cheek implant style that will not give a high lateral look either. In reality, there is no really one good cheek implants style that will give that highly placed chiseled look in many patients. The best cheek implant that I have found is to either cut the silicone malar shell implants in half so that only the highest part stays or to use a so-called anatomical (style 1) implant that only imparts fullness to the high malar region.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have got a knife scar on my face since I was 5 years old. It is about one and half inch long, is not very deep by any means. I can really see it from 3 feet away. However, it still bothers me sometimes. Is there a way to make it disappear? Thanks a lot.
A: Scar ‘disappearing’ is not likely in any scar. Its further reduction in appearance may be possible, but there is no such thing as scar elimination. The involved skin can never be made completely normal. Scars can be made more narrow, more smooth and have a more normal color, but they can never be completely eliminated or made to completely disappear. Whether any of these techniques or changes will be beneficial to your scar, I would have to see pictures of the scar to provide a more specific scar revision recommendation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I saw a doctor for a genioplasty consultation and he is supposedly a guru in the field. I have Class II, deep v shaped labiomental fold and my lower lip is behind my upper and my chin height is short and retruded back. He said a sliding genioplasty to horizontally and vertically lengthen my chin will work, but he also said he wanted to inject some kind of new stem cell bone material on my chin underneath the fold which will create new bone and fill in the valley on my chin, which would push out the soft tissue of the fold. I’ve never heard of this. He said bone augmentation was superior to soft tissue implants or fillers, and that this technique is very new.
A: What you are referring to is the simultaneous management of a deep labiomental fold during a genioplasty. Even though vertically lengthening the bony chin with the horizontal advancement will not deepen the fold any further, it is also unlikely to make it more shallow either. Filling in the bone gap of the osteotomy, while often thought as helping push out the labiomental fold area, does not. It is below the level of the labiomental fold. Thus a soft tissue approach is needed to help fill out the deep labiomental fold. That can be done by a variety of methods from injectable fillers, fat injections, allogeneic dermal grafts, and even silicone rubber (Permalip) implants. So-called stem cell injections (usually just concentrated fat injections) is a hot topic for injectable soft tissue augmentation. It is certainly a safe technique to do but its effectiveness is far from established.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, why are tear trough implants such a rare procedure? Can the implants pop out of place? What are some bad things that could happen with tear through implants? I am very young with very dark eye circles and I look terrible and need to do something about it.
A: Tear trough implants are very uncommon because other simpler alternatives exist such as the use of temporary injectable fillers or fat injections. These are far more appealing to many patients, and in the appropriately selected lower eyelid defect, they can be a good and effective choice. At the least, an injection approach is a good trial to see if this more non-surgical approach can be effective. For a defnitive permanent solution to the lower eyelid tear trough/infraorbital rim deficiency, a bony-based implant can be an effective choice. Tear trough implants are placed through a lower eyelid incision. They are attached to the bone by small screws so there is no chance of them ever moving out of place. The only issues that I have ever seen with tear trough implants is that you may be able to feel them through the very thin lower eyelid skin. In addition, carving and shaping them down so they have a natural flow into the surrounding bone is important so that there are no unnatural step-offs is an important aesthetic contouring step.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting liposuction to reduce the size of my waist and hips. Attached are some pictures of my waist and hips. I am after achieving very specific circumferential measurements in these areas. I have a measurement of 34 inches on my waist, and 46 inches on the widest part of my hips/ buttocks. I am 5 foot 8 inches in height. I need to be at least a 32 inches in my waist and 40 inches in the widest part of my hips/ buttocks. I am also interested in getting my thighs done. Is this possible.
A: Thank you for sending your pictures. On a realistic basis, I do think it is possible that your waist could go from a 34 inch down to a 32 inch waistline. However in the hip/buttock area a 6 inch reduction is simply not realistic. This is an area whose diameter is highly influenced by the hip and pelvic bones as well as the thickness of the attached muscles. Fat plays a role in its shape but not the level of a 6 inch reduction. A more realistic goal would be 1 to 2 inches, and maybe even 3, but I am not sure with your body shape how realistic a 3 inch reduction would be. My concern for any patient that comes in for any form of liposuction body contouring that is going to use a quantitative measurement as a determination of the success of a procedure is that they may end up disappointed.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, Oh dear, my pictures show how bad my neck really is. It looks worse in pictures than in real life! How you are going to fix it I don’t know. But I suppose you’ll be able to figure it out. The horizontal necklines I’ve had all my life. I recall a closeup when I was 20 that showed them clearly. But the sag is relatively recent. In the last 5 to 7 years I started to notice sagging. The wrinkly skin aspect is newer and that’s what I really hate! If I tighten my chin it doesn’t show, but I can’t go around looking as if I’m spoiling for a fight! Thank you.
A: Thank you for sending your pictures. I can see your neck skin concerns. This is due to the traditional sagging of skin that occurs with time and gravity. Your long-standing horizontal neck lines act like clothesline across the neck and the sagging skin now hangs between them. That is why your neck looks like it has multiple rolls.The fact that you can stick your chin out and it makes the neck skin smooth supports that a necklift (lower facelift) will be the definitive answer…and then you won’t need to constantly stick your chin out to have a good looking neck.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I am interested in jaw angle reduction surgery but I am worried about the risk of asymmetries. In most before and after pictures that I have seen, I do notice asymmetries… one side of the jaw is thinner than the other. Why is that happening since X rays are being taken before surgery? Is it difficult to see where to shave during surgery? Is that a common risk? I also have seen some patients complaining about bumps and dips on the jawline (bony irregularities), why does that happen? Is that a common risk? Thank you so much.
A: As you have observed with excisional jaw angle reduction surgery, symmetry can be difficult to achieve. Having an x-ray before surgery is not helpful in executing the actual procedure. Doing the procedure inside the tight confines inside the mouth is quite different than making drawings on an x-ray. It may help estimate how much bone one wants to remove, but during surgery there is no way to see both sides simultaneously and no way to know if one side matches the other. In essence, excisional jaw angle reduction surgery is a guess on each side of the angle of the bone cut and how much bone is being removed. This problem can be magnified if the patient already has some existing asymmetry in the shape of the jaw angles. Converselly, burring or shaving the jaw angle is different. Because you are keeping the existing outline of the jaw angle bone and merely making it thinner, the risk of irregularities/asymmetries is dramatically reduced.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, can jaw angle implants be custom made out of Porex? I had Porex jaw angle implants placed to restore my jaw bone deformity after jaw reduction surgery. but I am not happy with the result. I realized off- the self implants do not suffice in my case. I am considering my implant removed and replaced with custom made ones. All I have seen of custom made implants is to be made of silicone. Is it difficult to make a custom made implant out of Porex or too much expensive?
A: Quite simply, the manufacturer of Porex implants is not willing to make custom jaw angle implants. This is undoubtably because the Porex material has to be machined (milled) to create the implants which is both time-consuming and expensive. Conversely, silicone implants are poured into a mold which is far easier to manufacture and more economical. It sounds like you had jaw angle reduction surgery (amputation of angles) and then had them restored by jaw angle implants. I have seen this scenario numerous times. It may be that only custom implants are an appropriate solution for your problem or it could be that the implants you have in place have either not been the right style or not well placed. Medpor (porex) jaw angle implants are notoriously difficult to properly position. So unless your surgeon has tremendous experience in doing jaw angle implants the problem may be in the implant selected or how it was positioned. Unless you have a 3-D CT scan of your face/jaw done it would be hard to know what the real problem is.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, At the age of 23, I am in the Navy, and I have always had a tough time with the tape measuring. I was doing some research for liposuction reduction on my butt, thighs, and waist, so I wouldn’t have to worry about the measuring around my hips and waist. And I came across your website. I live in Florida, but I can get time off to complete a liposuction surgery. I was just wondering how much the procedure would cost? Thank you for your time and please reply.
A: I am very familiar with the tape measuring that is done to pass a fitness test as that is the number one reason most people in the service have liposuction in my practice. So your request is not a rare one. How effective that would be in your case, how much fat could be removed and what that would cost would depend on what your areas look like. In other words, what do I have to work with and how big are they? If you can send me a few pictures of the areas in question that would be very helpful. In the interim, I will have my assistant send you an estimated cost based on what I would envision the areas to look like. That may or may not change based on a review of any pictures you would send.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am possibly interested in a limited facelift. I am generally taken for younger than my 64 years and have been told by physicians that I have very good skin. But my neck, to me, is hideous. There are some other signs of aging about my face, but in general I can live with those–it’s the neck that upsets me in my mirror view. I assume you do consultations? Are there brochures you could send or websites to recommend? Thank you.
A: While the entire face ages in everyone, many people are most concerned about the changes in their neck as they get older. The neck angle opens up and drops as skin sags, fat accumulation develops and platysmal muscle separation occurs. In women in particular they will often develop wrinkled or creepy skin as well. At age 64 the only good and effective solution is going to come from a lower facelift, often called a necklift or a neck-jowl lift. This procedure lifts up and redrapes all of the neck skin back up over the jawline and around the ear. In essence, putting the tissues back up from where they came and turning back the clock on how the neck looked 10 to 15 years earlier.
The best way to a consultation with me is to send me some pictures and we can initially talk by phone or Skype. You never have to leave your home to get all the information you need to know!
Dr. Barry Eppley
Indianapolis, Indiana