Your Questions
Your Questions
Q: Dr. Eppley, I hate my breasts! I am just 20 years of age and my breast looks like they are 85yrs. They sag and my nipples are huge. Due the weight I have lower back pains and my shoulders hurt. I can’t where certain clothes. For once I would to be able to a strapless bra or even not have a wear a bra at all with my clothes. I need a breast lift!
A: Large hanging breasts, even in young women, can be both aesthetically unattractive and cause symptoms of back, neck and shoulder pain. A breast lift with areolar reduction, and a little breast tissue removal, can create a dramatic improvement in their shape and reduction or elimination of their associated musculoskeletal symptoms. The trade-offs for these dramatic breast changes are scars in the classic anchor or inverted T shape. One has to decide whether these changes are worth it but most young women would say so. It is also important to understand that breast shape is variable over one’s lifetime particularly when one is still very young. Pregnancies and weight gain/loss will negatively affect the result of any breast lift/reduction procedure with the most common changes being further breast tissue loss (involution) and skin sagging. (pseudoptosis)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in intramuscular buttock implants. I don’t really feel comfortable with the subfascial pocket for them. Having said that if I go with intramuscular and 350cc or less in implant size, then which shape you would recommend? Can I get away with a round implant? Oval or anatomic? I would also like to have some liposuction for a better shape. Do you recommend to do them at a different time or together with the buttock implants?
After my first liposuction, I noticed that I have developed some fat around my bra area (bra rolls) that I hate. Here I attached some of my pictures with some assimilation on where I like to have the liposuction done. Can you please kindly let me know if they are relatively doable?
A: The most common intramuscular implant that I place is a 330cc anatomic implant that has a lower profile and more tapered edges than a traditional round or tear drop implant. This creates as more natural contour to the buttocks and will definitely avoid a rounder and more fake look. As most of the patients who undergo buttock implants are about your size (because they are not good candidates for BBL surgery), this implant volume is the right and maximum size that can be placed. Trying to ‘stuff’ a bigger implant than this in an intramuscular space is prone to causing other problems and even more prolonged recovery.
In regards to liposuction, you should definitely do it at the time of buttock implants due to the convenience of intraoperative positioning. You need to be in the prone position for the buttock implant procedure and this is the best way to liposuction the bra rolls and flanks as well. This fat could be used to fill in some of your indentations which would not likely go away with the push out of the implants way below them.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in correcting my coup de sabre involving my forehead and eye. What would be an approximate cost of correcting my linear scleroderma.
A: There are three approaches to treating your left forehead/orbital scleroderma (linear scleroderma en coup de sabre); forehead bone augmentation with bone cements, fat injections and the insertion of a dermal-fat graft. Which one would be appropriate for you would depend on how the tissues feel (skin stuck to bone with complete loss of fat) and whether there is an underlying bone defect on the orbital rim and in the frontal bone. (which almost always there is) Since there is usually both fat and bone defects along the line of scleroderma the most common surgical approach would be bone augmentation by bone cements combined with fat injections, either done together or in two separate stages.
To determine the ideal treatment needed for your linear scleroderma, a combined physical examination and a 3D CT scan is the best way to know exactly what to do. In many cases, these procedures are covered by insurance. But, at the least, fat injections can be done on a cosmetic fee basis and this is the most economical approach and would be part of any ideal surgical approach anyway.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am 5’3” and 115lbs, 48 years old, healthy, and work out regularly. I have tried the Brazilian Butt Lift surgery (BBL) but not only didn’t it work but it also made my buttock shape more square than round. It also gave me some indentations. I am now very interested in buttock implants. I consulted with a plastic surgeon in South America and one in Los Angeles. They are both saying intramuscular for the buttock implant location. One is using highly cohesive gel implant called from Silimed and the one in Los Angeles uses semi solid silicone. They are recommending 400cc round or 480cc oval. As I was researching I came across your site. I noticed that you don’t recommend anything bigger than 350cc. I appreciate if you could share your opinion with me. I like the softness of cohesive but safety of solid ones. I love round looking butt, not too big or too small. Thank you for your time and feedback.
A: Let me provide you with some basic information about buttock implants. All buttock implants used today, regardless of the manufacturer, are made of soft flexible solid silicone elastomer. In essence they are all highly cohesive semisolid silicone gel. There is really no difference in their material composition. There are some minor differences in the durometer of the semisolid gel used (slight differences in stiffness) between the manufacturers but tis is really of no consequence to the patient.
Buttock implants can be placed either inside the gluteus maximus muscle (intramuscular) or on top of it. (subfascial) There are arguments for and against each implant location. If there was one perfect location for buttock implants, that would be what everyone would use. Intramuscular buttock implants are technically harder to perform, have a significant recovery but have the lowest incidence of long-term complications. There is also a limit, no matter what a surgeon says, as to the size of buttock implant that can fit into the intramuscular space. In someone of your size, that is going to be about 350cc or less. I can not see how any buttock implant of 400cc or greater can truly fit into the tight intramuscular pocket…at least with someone of your small size. It is not a recommendation that I make, it is simple function of what the anatomy will accomodate.
Subfascial buttock implants are technically easier to perform, have a shorter recovery and permit implants of larger sizes to be placed. It would be no problem to placed implants of 400cc or greater in the subfascial space. You have one important issue that may make this buttock implant location more favorable than it might be for others…you have had a prior fat injection procedure. While it may not have accomplished your overall buttock augmentation goal, it has provided some increased tissue and vascularity to the buttock tissues. I think given your desire for a very round looking buttock of intermediate size, you are likely better off with subfascial buttock implants.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a young man with symptoms of moderate plagiocephaly. The left-back side of my head is flat, the left eye and cheekbone is slightly higher and more prominent, my right eyebrow is lower and the eyelid sags heavily compared to the left, my right ear is pushed outwards and pulled back compared to my left one, and my jaw is wider on my right side. I noticed this completely about a year ago but most of my life I have felt like there was something off about my face. I’ve never been “bullied” by my appearance but I’ve been told from friends that I have a weird head or crooked eyes. Most people probably don’t notice right away but I feel like it is holding me back from completely enjoying my life and being content with my appearance. For example I cannot wear glasses because they look crooked when I put them on and I’m afraid to get a haircut because it is very noticeable how much larger the right side of my head is than the other.
A few potential surgeries in helping my appearance maybe be augmenting the left back side of my head, reducing some of the thickness on the right side by burring the bone and removing some temporalis muscle, adding prominence to my right cheekbone and filling out my left jaw. I’m not looking for perfection, but I feel that adding and taking away from the right spots and micro-adjusting my features would help me look a lot better.
I’ve done quite a bit of research on my condition but I cannot find any clear answers on what would help me. I would greatly appreciate any input you have on how I could improve my facial balance and asymmetry and bring out the natural good looks I believe I deserve to have.
A: Without seeing pictures of you I could not make any specific recommendations, but all the face and skull procedures you have mentioned are classic ones for correcting craniofacial plagiocephaly issues. (crooked face and skull) Occipital augmentation of the flat side of the back of the head and burring reduction of the contralateral protruding side of the back of the head are good skull reshaping options. Unilateral cheek augmentation and unilateral jaw angle augmentation are good facial ershaping options. Since you have identified those areas they would undoubtably all be collectively beneficial for improved craniofacial symmetry.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in making some changes to my face and I would value your expert opinion on what needs to be done for this type of facial reshaping. My face does not seem very proportioned and I can’t completely put my finger on why or how to change it. I have attached some pictures of my face from various angles to help you in this assessment.
A: I have taken a look at your pictures and have some changes to the following facial features based on what I see are their disproportions/imbalance.
1) Forehead = high hairline with forehead that slopes backwards at a severe angle. Treated with hairline advancement and upper forehead augmentation to shorten and round out the forehead.
2) Nose = high bridge, protruding tip and bifid tip (wide with split and separated dome cartilages) Treated with open rhinoplasty to lower bridge, deepen nose/forehead junction, shorten and narrow tip, and decrease nostril width.
3) Chin = vertically short chin, protrusive chin pad and deep labiomental fold. Treated with vertical lengthening bony genioplasty.
Attached are some predictive images of all of these potential facial changes put together for their overall composite facial reshaping effect. Together they make for a significant change.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I first contacted you in March and have taken awhile to get a consultation scheduled. I am now down to Breastfeeding once a day, so even though my breasts don’t look exactly like they will once I’m completely done, I thought maybe I would still be able to get a good idea about what I need/want. As you’ll see in the pics, my right one is bigger. It is by far my dominant breast where Breastfeeding is concerned. I didn’t realize just HOW bad they look until I took these pictures!! Talk about being even more depressed. Lol. Anyway, I’ve been looking at doctors who offer the Rapid Recovery Breast Augmentation as I have a 1, 3 and 5 year old. I see now from the pictures that I may need a lift as well as implants. I’m very interested in the teardrop shaped moderate profile textured gummy bear implants. Ones with a warranty is preferred. Also, will I be screened prior to the surgery to make sure there are no cancerous lumps or anything? Any info you can give would be great!
A: In looking at your pictures, if you go large enough with the implants I am not sure that you absolutely needs a lift. But you has a lot of skin and it will take substantial volume to fill it out. If you go with a ‘small’ breast implant size, then some type of lift/skin reduction will be needed.
In regards to our breast asymmetry, while two different size breast implants can be used, you are going to have to accept that there will always be some asymmetry between your breasts. Implants alone will not completely solve most breast asymmetry issues.
Rapid Recovery Breast Augmentation uses a combination of early arm range of motion with intraoperative muscle injections to return the patient back to their normal life as soon as possible after surgery.
All breast implants have warranties that come from the manufacturer. These include lifelong implant replacement for device failure and a ten year from surgery contribution towards surgical cost ($3600) plus free implant replacement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had very prominent brow bossing which I had burring done on by a physician who doesn’t perform these procedures frequently. After the burring, my brow ridge looked better, but I am left with strange indents on my forehead. My surgeon attributes this to scar tissue forming from where he burred the bone down, so he injected steroid into two spots on my forehead, which have resulted in additional dents. He has said he will fix the steroid dents free of charge but I really just want someone’s opinion who performs forehead procedures. I’m so bummed my forehead looks worse than before 🙁 is there any way, preferably the most conservative available option, to correct this? Thx so much for your time.
A: It has been my experience on any type of forehead or skull reshaping by burring that the final shape seen on the outside is a direct reflection of how the bone looks underneath.(particularly when adequate healing has occurred after three months) Scat tissue forming irregularities is not something I have seen. Even though the forehead and scalp tissues are quite thick, it will not hide even the slightest irregularity on the underlying bone when it is fully healed. Injecting steroids is not going to solve these irregularities (because they are bone based) and has a high risk of making them worse by shrinking the fat under the skin.
The only minimally invasive way to try and fix these forehead contour issues now is injectable fat grafting. But the unpredictability of fat take after injection has its own issues when trying to correct relatively small forehead contour issues.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have been doing some research and I found some info on Refine Suture lift and mesh lift with fat grafting. I was wondering about these procedures and if you would suggest this over the traditional lift with implant. I have read that these help with the lifts lasting longer and upper pole fullness, but wanted a professional opinion.
A: Your research and questions into these developing methods of breast reshaping are timely and insightful and merit a full explanation to put them into perspective and how they may or may not apply to you and your breast reshaping goals.
While implants for volume increase and lifts for repositioning the breast mound and nipple upward are the traditional and time-proven methods of reshaping the deflated and sagging breast, they rely on a synthetic implant and scars to create their effects. So understandably alternatives have long been sought for either a more natural result (non-implant) and breast lifting methods that create less scars and more resistance to any lower pole breast relaxation.
Historically these searches for improved breast reshaping methods have been met with disappointment. But the three techniques you have mentioned (fat grafting, Refine anchors and internal mesh supports) have recently come into play and are promising…although they are still in various stages of development. Thus their use does not have a long track record so the initial enthusiasm must be viewed with guarded optimism.
Fat grafting can work in restoring volume to the deflated breast but what it can only achieve moderate volume increases. Fat grafting can not create large increases in breast size. This translates into an implant volume of about 200cc or less. If one has enough fat to harvest, then fat grafting can be a good substitute for this low volume increase which is usually perceived as ‘just adding a little extra upper pole breast fullness’. The only caveat about fat grafting is that its volume retention is not assured. As a genera statement, the volume of injected fat into a breast that survives and is maintained is around 50%…but some may have more or less volume retention.
Refine suture anchors for internal breast tissue suspension (internal breast lift) is based on placing a matrix of sutures with small plastic anchors that pull up the breast tissue upward and help anchor it to the upper pectoralis muscle fascia. As one of the few Refine-trained plastic surgeons in Indiana, I am very familiar with this device and its use. For small amounts of breast lifting, particularly in conjunction with fat grafting, it can have a useful role in breast lift surgery. But it will not provide a major lift when the transposition of the nipple-areolar complex must be moved significantly upward. In addition, its long-term effects are not well known as the device remains in clinical trials with long-term follow-up data yet to be reported.
The long-term stability of a breast lift is largely based on the skin tightening of the lower pole of the breast. This naturally relaxes to some degree in many breast lift patients, particularly when the breast mound is not supported by an underlying implant. The concept of adding a sling of support across the lower pole of the breast during a breast lift is both logical and has been tried in the past. But the use of non-resorbable synthetic meshes (hernia repair mesh) in the past has been met with wound healing and infectious complications. The concept has enjoyed re-emergence today because of a wide variety of cadaveric dermal slings and resorbable synthetic meshes. The two resorbable synthetic meshes currently available (GalaFlex and SIRI scaffold) offer a very adaptable thin mesh-like scaffold that be easily sutured across the bottom pole of the open breast lift patient. They are resorbable and are eventually replaced by new collagen tissue. Their use is gaining in popularity with good results and few complications and probably better long-term breast shape results. But they will not attain use in every breast lift patient as the cost of the mesh is around $2000 per breast. This adds substantially to the overall cost of the surgery which currently limits their use to the high-risk or revisional breast lift/implant placement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 25 year old male. I am interested to coming to see you for some procedures to help me get the model look. I have some areas of my face I am unhappy with. One being the width of my face (too wide) and the other being the contour of my forehead/supraorbital rim/temple/eye area. I read a method of making wide face slimmer by zygomatic osteotomy. I read bone heals itself in new position after zygoma osteotomy so I wondered is it possible to do zygoma osteotomy and shift the entire zygoma arch upwards slightly (and also inwards)? I believe this would give a good high but narrow cheekbone appearance, as I don’t want flat cheekbones.
My next problem is my forehead/eyes/temple area. My temples are very hollow and I have asymmetrical supraorbital rims. The supraorbital rims protrude which are more apparent due to hollow temples. My forehead is very backward sloping, despite it being protruding and having prominent frontal sinus area.
I had considered options of frontal brow bossing reduction and then adding custom made implant on the forehead extending from forehead to supraorbital rims or to the temples. I always wanted supraorbital rim implants because I like the look of small squinty deep set eyes. I do not want to look feminine. I have added pictures of my forehead and eyes and pictures of how I want my eyes/forehead to be. I had an endoscopic browlift as an attempt to create the model look few years ago (because the surgeon said it would create a model look) but I feel it didn’t and needs to be reversed. I can’t work out what makes male model have eyes like that? They have strong foreheads, and is it the supraorbital rim that makes them have that model look? Along with a more hooded eye, and supraorbital rims that blend into the temple area? I really would appreciate your expert advise on this because you seem to be so knowledgable on your field.
A: I think there is no question that what makes for the so called ‘male model look’ is facial skeletonization…meaning an enhancement of facial skeletal areas such as the forehead, brow bones, cheeks, chin and jawline/jaw angles. As for the forehead in general, a backward sloping forehead angulation is not desirable regardless of what degree of brow bone prominence one has or does not have. A fuller more vertical forehead shape that allows for a noticeable brow bone break is the most masculine of all forehead shapes.
A endoscopic brow lift would work exactly against this type of male look as brow elevation and retro movement of the frontal hairline, particularly in a forehead that already has a backward inclination, will usually make it more feminine appearing. You may have discovered that in your own experience.
Blending the supraprbital rim/forehead into the temporal regions would be relevant for the high anterior temporal one but for the low one or the classic zone of temporal hollowing. That is much more effectively treated by standard subfascial temporal implants.
As for the zygomatic bones/arches, I do not feel that yours is wide and there would be little benefit to try to move the bone to accomplish any external aesthetic benefit. If you want further enhancement at the anterior zygomatic or high zygomatic arch levels, that would need to be done with a custom designed implant. That would be far more effective, predictable and have a much more rapid recovery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am specifically looking for angle of the mandible implants (jaw angle implants) to increase the width of my jaw as well as increasing the vertical height to give it a more angled, defined look to my otherwise high, weak jawline. I am wanting to have a simultaneous chin implant to compliment the jaw implants.
While I can find endless information on chin implants, jaw angle implants seem rather non-existent and very few plastic surgeons perform them which has me a little apprehensive as to why this is. Would you be able to tell me more about this wrap around style implant and the advantages/disadvantages of having this over a simultaneous angle of the mandible/chin implant?
A: The history of chin and jaw angle implants are quite different even though they are located on the same bone. Chin implants are ‘end of the bone’ augmentations that are easy to predict the outcome, simple to place and have minimal morbidity and recovery because the overlying muscle and soft tissue cover and disruption is small. The first chin implant was developed in the 1960s and was and continues to be the most recognized and important bony facial profile enhancement technique. Chin implants have gone through many different designs and shape changes over the years to meet the differing needs of many different types of aesthetic chin problems.
Jaw angle implants, conversely, are very much the opposite of chin implants. They are ‘middle of the bone’ augmentations whose aesthetic reqiurements are harder to predict, require more skill and experience to place, and have more morbidity and recovery because the largest muscle on the face (masseter muscle) is being disrupted.The first jaw angle implant was introduced in 1995 without any design changes since then…with an original design (width only) that is inadequate for most patient’s jaw angle deficiencies. (vertically short)
With an increasing public demand for more complete jawline enhancement, there is a need for neeawareness offew surgeons however have ever performed them or had any training to do so. My experience with jaw angle implants and overall jawline enhancement in general is considerable as I have focused on changing how jaw angle implant surgery is done through new implant designs and the surgical techniques in placing them.
The fundamental difference between using a preformed 3-piece or a custom one-piece jawline enhancement is the connection between the chin and the jaw angle augmented areas. If one wants a perfectly straight line between the chin and jaw angle, then a custom jawline implant is the approach of choice. Custom implants are also needed when the dimensions of the jawline changes are desired exceeds the size or shape of what is available ‘off-the-shelf’.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I exhibit a weak jawline and recessed chin. I have had several consultations with doctors in the Los Angeles area. The most logically sounding consultation seemed to be a custom jaw implant. I see that you do this procedure yet also use off the shelf products as well. My question is…is a custom implant truly superior and does the higher cost justify this type of implant? The doctor made a compelling argument for custom implants however the price was extremely high. Look forward to your reply.
A: The key decision between off the shelf and custom jawline implants is in what you are trying to achieve. Depending upon the nature and magnitude of the dimensions of the jawline changes desired, only a custom implant will work for some patients. In fact, in some of these patients they should not have the procedure at all unless they go a custom fabrication route, For others, a custom implant may have no significant aesthetic advantage and off the shelf implants will work just fine. You would have to supply me with the exact jawline changes you are seeking and some pictures to better answer your question about what will work for you.
When it comes to cost, it is important to realize that custom facial implants today are not significantly more expensive than preformed off the shelf implants. Why? While the material cost of the custom implant is higher than the material cost of preformed implants, they are capable of being surgically placed ini half the operative time. Thus the extra cost to design and fabricate a custom jawline implant is partially offset by the savings of a quicker operation. You also have to consider the risk of revisional surgery, where if it were necessary due to an aesthetic issue, any savings from using off the shelf implants would be completely wiped and exceeded.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had jaw angle surgery and it was over-resected. I want to reconstruct my jaw angle (vertical height) and widen my front chin . I have a before and after x-rays of my mandible and I want to have it reconstructed as before. Also I want to get rid of my titanium screws. I enjoy boxing and i am really worried about this reconstructing surgery.
1) Can silicone be broken or bent or destroyed by punches?
2) Can silicone be moved or migrated by punches? Even if I get a 3D customized fit and screws attached? ( I’ve heard that it happens quite often)
You told me before that silicone would never move no matter how hard it is traumatized and I can enjoy every sport. However I’ve seen many cases of silicone implants moving. If your word is true please explain me how does that work.
A: While I don’t know where you are getting your information about jaw angle implants, I can only tell you what I know based on my experience answering questions and treating patients from all over the world in the past two decades with this type of facial implant surgery. I have yet to have an actual patient or an inquiry where someone has had jaw angle implant displacement from trauma. Perhaps this has happened to someone in the world, but I have yet to ever hear about it or treat anyone for it.
The apparent negligible incidence of silicone jaw angle implant displacement can be explained by an understanding of its biomaterial composition and the biology of encapsulation around it. The solid silicone elastomer of facial implants can not be fractured or broken, regardless of the imposing force, because it is not a brittle material. You can take a hammer to a facial implant and you simply cannot break into pieces. The bonds between the silicone molecules are flexible nor rigid. Thus when I say putting a silicone implant against a facial bone acts like a bumper, that is because of what it actually does and behaves like.
The long-term stability of any facial implant is ultimately determined by the body creating a layer of scar around it, a process known as encapsulation. This capsule (layer of scar) is what holds the implant in place and preventing future migration or displacement. The purpose of screw fixation of facial implants is to hold the smooth surfaced material securely in place until this enveloping scar tissue forms. For most patients, the screws beyond this point (6 weeks or so after surgery) have little value. But in the patient who may be exposed to some periodic facial trauma (e.g., boxing), the screws add extra insurance against any potential risk of implant displacement
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a minor case of asymmetry to my jawline .the right side of my mandible is angled higher and shorter in length to my left side. My right side is also weaker than my left side . if there is one thing I am pleased with about my right side it would be the shape. I like the shape of my right side better than the left. My question is is there any way my right side can be made the same length and just as prompt as my left side? And can my left side be made to shape my right side?
A: There is only one way to do what you want to do with precision for improving your jaw angle asymmetry….and I would submit that without this precision for your ‘minor case of jawline asymmetry’ it should not be done. Computer designing of the right jaw angle implant could be done using left side as the model from a 3D CT scan. Only a computer design process can match up the jaw angle sides. In short, you need a custom right jaw angle implant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have sent you a lot of pictures and will try to explain my questions! I definitely have some skull asymmetry. The back of my head is kind of flat and it looks really weird when I have s short haircut. I also feel that the space between my chin and neck is very small.
I also have facial asymmetry and one side is bigger than the other. One eye is than the other although I feel both sides of my face are not matched. My neck on the lower eye side also feels tight and I can’t move my head straight.
It’s a mess and doctors here say I was born like this but it has gotten worse over the years.
Thanks for reading this. Hope to here from you.
A: By your pictures and your description of symptoms and physical findings, you appear to have a relatively classic case of craniofacial scoliosis caused by occipital plagiocephaly as an infant. There are three potentially improvable craniofacial problems:
- The back of head flatness can be corrected fairly well through skull augmentation by either bone cements or a custom skull implant.
- You asymmetric eyes (orbital dystopia = one eye lower than the other) is improveable by orbital floor augmentation with or without eyelid elevation. Fortunately the eyebrow appears to be in a symmetric position.
- The tightness in your neck may be unsolveable. Unless there is a very distinct and palpable band (cord) along the sternocleidomastoid (SCM) muscle (i.e., band torticollis), the tightness may be a function of congenital shortness of the neck muscles. If there is a band, then it can be surgically released although this would be an unusual finding in an adult. One non-surgical option to consider is Botox injections into the tightest area of the SCM muscle.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, you and I spoke previously about temple implants. cheek implants, and forehead fat grafting. You did some imaging for me as well, and I realize you understand my goals in reshaping my face better than anyone. With this said, I would be interested to see how the overall look of what we discussed previously would first look by using injectable fillers to achieve the results in widening my face and adding more volume.
A: The issue with fillers for augmentation of various facial areas is one of pure volume and the associated costs. When it comes to small areas like the lips (1cc) or even the cheeks (2ccs), voluminization by hyaluronic acid-based fillers is reasonably cost-effective even though the effects will not be permanent. Beyond these volumes one has to look to the use of a filler like Sculptra to achieve a broader or wide-based facial volume effect. While these longer-lasting particulated fillers can achieve better volume enhancement of the cheeks and temples, the need for multiple treatments to achieve their effects and an increased risk of reactions to the implanted ‘seeds’, it is usually better to venture into the realm of injectable fat grafting where there are no volume restrictions or risks of any injectate reactions.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am intersted in finding a physician that can do A Fleur De Lis tummy tuck with hernia repair after weight loss for “reconstructive repair” that will accept and submit to insurance. I know there are lots of patients getting this covered by insurance. It is how the surgeon submits it to insurance. Educated staff staff do know how to submit as medically necessary and not cosmetic. I was just wondering if your office was one that was able to do this procedure and have insurance cover it. Having a hernia, rashes, back pain, etc. is how it is covered, reconstructive, after weight loss is how it is worded. Thank you for your response. I don’t need to waste my time or the physician’s if they are not experienced in this area.
A: While I appreciate your perspective, from someone who does this for a living, it is not true that any one that wants it can just get it approved by insurance. And there are not lots of patients who are having this surgery being covered by insurance. The latest plastic surgery journals report that less than 20% of all bariatric patients ever have some type of a tummy tuck and even fewer are able to get it approved through their insurance.
There is not magical statements or way to juggle how its coded to make it medically necessary for insurance. There are very specific ICD9 codes for the diagnosis and CPT codes for the procedures. There are no guarantees that insurance will cover it no matter how it may be coded. It is not a function of ‘how it is worded’. Insurance does not care how it is worded. What they care about is does the patient meet their very specific criteria and have the medical documentation to support the procedures that are coded for. The criteria are well known and published and include two main issues:
1) An abdominal pannus that hangs over the groin and onto the upper thighs. (photos from three different angles)
2) A history of skin rashes under the pannus that has proven refractory to topical treatments over a 3 to 6 month period. (photo documentation of the existing rash and medical records that show it has been treated for at least 3 months)
Any insurance submission that does not include these two minimum criteria will be automatically denied.
If approved, insurance provides coverage for an amputation abdominal panniculectomy (infraumbilical panniculectomy), not a fleur-de-lis tummy tuck which is an extension of a panniculectomy. Any modification/extension of that basic procedure will be at the patient’s expense.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in chin and maybe jawline implants. Do you favour the intra-oral or extra-oral approach for chin implants? Also, do you use silastic or porous implants? I have attached some pictures so you can see how short my chin is.
A: The first question to decide before one considers how to augment the jawline is exactly what type and degree of changes does one seek. As you can see in the attached imaging, you could just do chin augmentation only (side view prediction) vs. total jawline augmentation of chin back to the jaw angles. (oblique view prediction) Your chin is so short because your entire lower jaw is underdeveloped so your jaw angles are rotated up and backward (high) as well. There is also a debate to be had about your chin as to whether that should be done with an implant or a sliding genioplasty. Therefore, options include:
Chin implant only
Chin and jaw angle implants (performed)
Total jawline implant (custom)
Sliding genioplasty alone
sliding genioplasty combined with preformed jaw angle implants
But when it comes to using jawline implants of any configuration, silicone implants are far superior to Medpor and a submental approach (vs intraoral) is easier with a quicker recovery. The small skin scar is inconsequential.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, In elementary school I was diagnosed with Linear Morfia but I have also heard the doctors call it scleroderma as well. I am now in college and it effects the right side of my face. I notice it on my forehead, under my eye continuing down to my cheek and a little on my nose, on the corner of my lip, and also some places under my chin and on my neck. The places on my neck are barely noticable so I’m not sure if they are even fixable but all other places I think would be able to be improved. I’m not sure what procedures would be needed but I’ve heard a lot about fat grafting. I would love to hear from you on what you could possibly do for me to make me feel better about it. I am attaching a picture of the left side of my face to compare to the picture of the right side of my face. Thank you for your time.
A: Fat grafting is the best treatment that we currently know for the soft tissue atrophy that linear scleroderma causes. Since fat loss is a big part of the tissue thinning effect it creates, it is logical that fat replacement would be a key part of its treatment. Harvesting fat by liposuction and then processing it for concentration is how injectable fat grafting is done. Injectable fat grafting is very versatile so it can be placed almost anywhere on the face.I have done this many times for linear scleroderma and it is certainly the one treatment that can help. While historically any treatment for linear scleroderma was recommended to be done once the disease processhad burnt itself out, my feeling is that fat grafting should be done even if the atrophic process is ongoing. It may help abort further tissue atrophy. Sinjce fat grafting is harmless since one’s own tissues are used, there are no adverse effects with its use and it can be repeated as many times as is necessary for optimal soft tissue volume restoration.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Since you are always up on the latest cutting edge techniques I was wondering if you were aware of Biotimes Renevia scaffolding gel injectable which was created to be a 3d scaffolding to be mixed with mesechemal stem cells from fat and then injected sdubcutaneously for lipatrophy defects. Biotime has granted Stem Center in Spain to do the clinical trials last year. I am thinking of going there to get injections for the post rhinoplasty defects I have to the soft tissue on my dorsum. The Renevia is composed of a special hyaloronic acid, collagen gel, polyethelyne glycol and stablizing agents. Do you have any opinions of this new technology?
A: While in theory this type of synthetic implant sounds promising, it is inportant to remember that this is a European clinical trial. A clinical trial means that there is no yet proven effectiveness for this product’s theoretical benefits…and it is not yet clear as to what clinical indication this product will be studied in. Just because it is going to be studied unfortunately does not mean it will work…this is why it is being studied.
Renevia is a type of hydrogel that resembles the network of molecules outside the human cell membrane, known as the extracellular matrix. Injected as a liquid and combined with some type of stem cells, the hydrogel forms a tissuelike scaffold that anchors the new cells onto existing ones, allowing for more effective tissue regeneration. This is the company’s statement and it all sounds very promising but has yet to be proven to work as such in a human subject for any specific clinical problem.
While the concept of stem cells delivered by any method is always very appealing, to date none of the clinical trials conducted on them have shown convincing and consistent benefits. This does not mean they never will but it is important to temper what they theoretically could do with what they may actually do. There is predicate story from nearly 25 years ago that may or may relate to stem cells and that is growth factors. Much euphoria, enthusiasm and research was put into turning their well known benefits into clinical products. To date few such useable medical products have ever made it to market.
We are a long way off from seeing what stem cells do during natural development into a clinical product that can have such amazing tissue regenerative properties in fully developed adult tissues. For now, you would be far better off to use conventional means of dealing with dorsal rhinoplasty defects such synthetic fillers, fat injections, crushed or injected cartilage. There are all more reliable and currently available soft tissue augmentation materials in the nose that have a well established track record of success.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a brain tumor surgery (meningioma) the size of a tennis ball taken out three years ago and I would like to know if bone cements for forehead augmentation/ reconstruction has any after affects. What consequence could the use of this material have on me. Where would the incision be done? How good could the outcome from forehead augmentation be?
A: I assume you had a frontal craniotomy/bone flap done to remove your meningioma and this has results in some contour deformities of your forehead. This is common as the frontal bone settles and heals with irregularities around the burr holes and the plates and screws used to fix them into place. These forehead defects/irregularities could quite easily be smoothed over/augmented by any of the different bone cements. The best bone cement to use would be that of a hydroxyapatite composition. There are no adverse consequences of this material on your bone or the overlying scalp. You would some or all of the same incision for your forehead recontouring that was used for the neurosurgical tumor procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 32-year old woman and I have been searching for a solution to my protruding mouth (or perioral mounds)…I have had this all my life, and recently got some filler in my chin to balance out my bottom lip protrusion and also have Invisalign to correct my teeth. However, none of these treatments will get rid of the fat around the corners of my mouth and under my bottom lip. I saw a great case study on your web site and I’m wondering if I might be a candidate for the corner of the mouth lift and perioral mound liposuction. My big concern is that surgery could affect the muscles, leaving irreversible damage. Also, I wanted to comment on the results in the case study were very appealing to me because it appeared that the mouth lift and liposuction actually gave the patient an illusion of dimples, which I think is very attractive.
A: Small cannula liposuction can be done very successfully on the sides of the mouth, known as the perioral mounds. But it can not or should not be done below the lower lip as, not only will not be effective, but may cause injury to the depressor muscles of the lower lip. (as you have correctly surmised)
Tweaking up the corners of the mouth with perioral mound liposuction can certainly create the appearance of dimples as the mound area goes from convex to concave with enough fat removal.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had jaw resection surgery.But it was overresected. So I am thinking of my jawline reconstruction. In theory would it be possible to have a strong and tough jaw by having my mandible reconstructed with 3D printed customized titanium alloy additive? Usually I heard that silicone or PMMA is often used to make a jaw line but they are not as strong as titanium and don’t have osteointegration properties. I love sports like boxing and I want to know if I can enjoy the sport with my reconstructed titanium mandible.
A: You can have your jaw angles reconstructed by using a 3D method to fabricate titanium implants rather than silicone. However the cost to do so may be prohibitive as the costs of the implants alone will come close to $10,000 and that does not include the surgical fees to place them. While this can be done, I don’t see the advantage of a metal reconstruction over the option of custom silicone jaw angle implants. They offer similar protection, would be easier to place, cost far less to manufacture, provide protection to the bone by acting as a ‘bumper’ and can be securely fixed to the bone so that they would have no problem withstanding any sports activity.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am getting cheek implants next week but I became worried because my surgeon says he does not use any screws to secure the implants to the bone…just uses a pocket and wait for the scar tissue to hold implant in plance. Should I find another surgeon?
A: Just because your surgeon does not use screw fixation for cheek implants, that does not mean it will not be a successful surgery and outcome. Surgeons do use different techniques in facial implant placement and, as long as it works successfully in their experience, then that technique is adequate. I would say that those surgeons who secure their cheek implants with screw fixation is far fewer than those who don’t. The most common type of cheek implant fixation is pocket positioning that may be combined with sutures or even an external cotton bolster into which the sutures around the implant is passed. (this is generally removed in one to two days after surgery)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a long face shape but small forehead. (like Sarah Jessica Parker). I really hate my face shape and would like to make it shorter. My nose is long and I was wondering if it were possible to shorten my nose, raise my mouth and then make my chin a lot smaller so that my face is a lot shorter but still in proportion. I also have a bump on my nose that I would want straightened.
I’m not sure if such thing is possible but if you could let me know if there is anything that could be done. I have attached a picture of what kind of thing I would like done. The picture on the left is what I look like now and the one on the right is kind of how I would like to look like after. The third picture is of the bump on my nose and whether this would be able to be corrected as well. Thanks!
A: Based on your pictures and goals, I would say that two of the three facial changes you would like are achievable with fade shortening surgery. A rhinoplasty can be done to eliminate the bump on your nose and provide some further refinement. A vertical reduction genioplasty can be done and the bone removed behind it back to about the mid-body of the mandible through an intraoral approach. It can achieve the amount of vertical reduction you are showing on our imaged picture but it is the most that can be done. probably about an 8mm reduction in anterior chin/mandibular height. Lastly, it is not possible to surgically raise your mouth (lips).
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Can you tell me what the cost of jaw surgery would be to shorten and recontour the face? I attached photos which show my face length.
A: The concept of facial shortening by double jaw surgery is based on whether you have vertical maxillary excess and a gummy smile. If one does not, then shortening the lower facial bones is going to bury your teeth under your upper lip which has a very negative aesthetic outcome. The pictures you sent do not show you smiling but I suspect you do not have true vertical maxillary excess as, even with non-smiling, one would have an open mouth posture or show evidence of mentalis muscle strain when the lips are together. Without true vertical maxillary excess, one has to look at a variety of other compensatory facial procedures like vertical chin reduction, subnasal lip lifts and rhinoplasty (that shorten the facial look) and potentially procedures that increase facial projection. (e.g., cheek augmentation) To determine the potential impact of any of these procedures on your face I would need to see some better pictures for computer imaging. (front and side views that are non-smiling)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in skull reshaping, specifically a reduction of a sagittal ridge. Not sure what to expect, I got a high top ridge at the back of my head (covered by hair, so a photo does not really show it) – rising maybe 2.5 cm above the rest of the skull top, which looks strange. Would you have reduction experience for that kind of surgery? Can one expect a great change in appearance. (assuming only 5-7mm can be reduced)? Thanks for your advise. 🙂
A: With very high sagittal ridges in which bony reduction alone can not make it confluent with the parasagittal skullbone, one can consider a combined sagittal reduction with augmentation of the areas right next to it. However, the first question to answer is really how much bone can be reduced. In very high ridges the bone may be quite thick and more than the typical 5 to 7mms could be reduced. This would require a CT scan to determine the sagittal ridge thickness and what type of reduction change to expect. It is also possible that in many sagittal ridge reductions I have seen that the bone is much thicker than normal and more may be possible to be reduced. This will be seen in a CT scan.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I wanted to ask you a quick question regarding jaw implants revision. I am a 29 year old male and have had silicone jaw and chin implants placed previously. I am very happy with them, however, as time has gone on I feel like the jaw implants could be slightly larger in width(1-2 mm each side at most). I am perfectly happy with the chin implant. I know you had said this desire for further augmentation is a common occurrence among young men and clearly you were right. I guess my question is a two part question. The first question is if fillers can address the slight augmentation desired, and if so which filler should be used? Any risks associated with this since there is a pocket and an implant already there? The second question is that were you to suggest surgery, would it be a very difficult procedure to remove just the jaw implants and replace them after nearly 3 years? I would of course like to do this as minimally invasive as possible.
Thank you so much for sharing your knowledge and providing this valuable advice.
A: Whle you certainly can have fillers done, I dount they will be very satisfying in the long run. Since you have jaw angle implants in place, it would be important to make sure that the injections avoid violating the implant capsule under the muscle. I don’t think the type of injectable filler used matters , they all will work. The injection technique is more important that want is placed.
For a permanent increase in jaw angle width, you can either replace the implants you have or use a wafer or wedge technique to augment what is in place alreasy. It is much easier that the first jaw angle implant surgery as you have an established pocket to do either. The simplest, and probably the most the most effective to do what you want accomplsih is the wafer method. This is where a wafer of implant material is put behind the existing implants to create the increased thickness. This does not necessitate the need to remove the implants, merely lift them away from the bone to slide the wagfer of extra material.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m 21 years old and I have average sized cheekbones. I’ve always dreamed of having very prominent and chiseled cheekbones, such as those of Mads Mikkelsen (even though I’m a girl) that have more projection on the outer corners of the zygomatic bone as opposed to the classic apples in the area below the eyes. I would like to augment a good part of the bone, yet pay much more attention to the area adjacent to the zygomatic arch. Many people would recommend me to aim at a natural and light outcome, but I want a very noticeable difference. I’m also a bit confused about the procedures. So far I’ve read a fair few articles regarding PMMA bone cement as well as Kryptonite and something about Medpor, still I have no clues whatsoever which one would suit my needs best. I would like something that is permanent, that endures time, that is at least as strong as the bone itself and that doesn’t get loose. As to the volume to be added, would it at all possible to have a 7mm or over projection.
A: When it comes to cheek augmentation, it is very important in any patient that the correct zone (s) of the cheek or zygomatic bone is augmented or highlighted. You have described exactly where you want the maximal augmentation to be done (posterior malar) as opposed to anteriior submalar which, as you have corrected stated, is the usual highlight augmentation zone for a female. That is is very helpful as then the correct cheek implant style can be chosen.
When it comes to cheek implant augmentatation material, no form of bone cement would be appropriate. What is used are preformed implants made of either silicone or Medpor material. Both are permanent materials that will never degrade or change shape and when fixed to the bone will be just as strong as the bone underneath it. Their ability to stay in place is more about how the pocket is made and how they are secured than it is about the material. There are advanatges and disadvantages to either solid silicone elastomer ot medpor, but my preference is for silicone as there are many more styles and size options and it is far easier to revise should that ever need to be done.
As for size of the cheek implant, 7mms would be a very strong change and may or may not be too much. Such thickness numbers may seem small but when it comes to putting an implant on your face, it can easily end up being much larger than one would have initually predicted. When it comes to facial implants, a slightly too small change is always better than one that is too big…as that will always lead to revisional surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m breast feeding now. How long should I wait after I stop before I come in for a breast augmentation consultation? How soon can I have breast augmentation after breast feeding?
A:You should wait for breast augmentation surgery until your breasts have returned to their natural size after breastfeeding. By so doing you can gauge properly the implant size you need and the type of breast lift if necessary. But one can come in even while breastfeeding to get an initial evaluation and some general information about the combined breast lift and breast augmentation procedure. That will answer most of your questions and help you prepare for the surgery when your breasts are ready. Then you just have to stop in for a quick implant sizing appointment right before the anticipated surgery date. While there is no hurry to get the ball rolling so to speak, you certainly can if you desire.
It is also important to note that many women who have breast augmentation after breast feeding may note that they have some milk production after the surgery. This is due to the pressure of the implants on the milk glands that can cause additional discharge from the swelling of surgery.
Dr. Barry Eppley
Indianapolis, Indiana