Your Questions

Q: Dr. Eppley, I have a problem with my cheek implants and I need either cheek implant removal or cheek implant revision. I had a severe damage from buccal fat pad removals when I was younger and that left me sagging cheeks, downturned mouth corners, and jowls. Then I got medium sized submalar cheek implants to correct this problem. I looked fine and then I got a facelift which lifted the corners of my mouth and got rid of my jowls. But that has now left me with the cheek implants sticking out like shelves and my face looking like a skeleton. I got your information online that you have helped a patient with similar situation and I would like to get your advice.

Q: Between your previous buccal lipectomies and the pull of the facelift (which can thin out the submalar region by its sweeping effect) cheek implants can be come prominent and create an ‘hourglass’ facial deformity. The best approach would not be to completely get rid of the existing cheek implants as that will likely create a very flat cheek look creating another aesthetic problem. I would recommend downsizing your cheek implants (by at least 50%) and placing fat injection grafts below them to eliminate the ‘shelves’ and create a more natural and smoother facial contour. Cheek implant revision would be preferred.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, can micro iposuction remove lumps from fat injections or it can only help removing the natural fat that is already there? The problem in that I have fat lumps (10 lumps n both cheeks varies which vary size between 5-10 mm) mainly found near the mouth, along the nasolobial folds and two lumps in the bottom of the cheeks. If these lumps can’t be removed by micro liposuction, what would be the way to remove them? Does radiofrequency help melting the fat? I already took 3 sessions and will take three more (machine is Endymed, temp used was 40C and 37 Watts) Would it be effective in melting the injected fat whether it’s lumpy or soft?

A: Certainly removing undesired fat collections (lumps) is more challenging than the original fat injection procedure. Any technique for facial fat removal (small cannula liposuction or any energy-based external therapies) are more effective for general fat removal rather than discrete fat lumps. Either surgical and non-surgical methods have their advantages and disadvantages. Small cannula liposuction (aka microliposuction) can access all your involved more central facial areas from small incisions inside the corners of the mouth. It would also be somewhat effective at breaking up the harder fatty lumps and likely removing some of their mass effect. (probably more effective at breaking them up than removing them) Conversely, topical energy-based devices are non-surgical and require no incisions but they will have a heat field effect, meaning they will create an overall fat reduction in the fat not necessarily just the lumpy area. I would be somewhat concerned with these energy-based devices that you might trade off one problem for another.

Another option would be injection therapy right into the fatty lumps if they can easily be felt from the outside. Very low dose steroids and old-style ‘lipodissolve’ (deoxycholic acid) solutions can be effective and I have used them successfully in the past for the exact problem that you have. The better ‘lipodissolve’ solutuion, ATX 101, has recently been FFA approved for facial fat reduction (technically submental/neck fat) and would be the best injectable solution as soon as it becomes commerically available later this year

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in inner inner thigh liposuction. I want to create a space between my inner thighs, a so called thigh gap. How much total fat do you think you could harvest? If I take a big pinch of skin and fat at my inner thighs I can make a visible thigh gap. Would that be a realistic result from inner thigh liposuction. My weight is around 132 to 137lbs at 5’4” if that helps with any part of the assessment.

A: The thigh appearance you are showing, known as a thigh gap, can not be created by liposuction. That is asking liposuction to do more than it is capable of. Many thigh gaps that you see in ads and model pictures have been created by ‘Photoshop liposuction’ or the women are exceptionally thin and have it by genetics. If you don’t naturally have a thigh gap, surgery is not likely to create one.

The inner thigh area is a challenging area for good liposuction results because the skin is unforgiving (poor elasticity) and has little ability to retract and reshape. If one is very aggressive and too much fat is removed there will be contour deformities and indentations as a result…thinner but misshapen. Conversely, if one is more conservative and does not take too much fat, then the resultant change is very modest. This is why the inner thighs are the #1 body area for dissatisfaction from liposuction…the results are often not enough or another aesthetic problem has been created. You have to ‘pick your poison’ so to speak…a modest change with likely smooth skin or a more aggressive volume reduction and a higher risk of contour irregularities and skin dimpling.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I found your work through the custom implants work on your site and I’m interested in getting a chin implant, but with a twist… 

See, I’ve become aware of new research about the “estrogenic activity” of silicon-based implants. I was wondering, in your expertise, would it be possible to create a chin implant out of stainless steel or titanium instead of silicon or plastics-based materials (and have it be a successful operation)? 

I realize this requires a complex answer, but feel free to keep your reply brief 🙂

A: I would be remiss if I did not mention that there are significant chemical differences between standard plastic materials (PVCs) and silicone which is a pure element. (#14 on the Periodic Table) There are no reports of any adverse effects on the body with silicone as evidenced by the extensive 15 year FDA study of silicone breast implants. (which is a gel and not even a solid)

A custom chin implant can be made of titanium although it would be very expensive to do so. (probably around $12,000 to make it) It would also be necessary to make it as a two-piece implant so it could be inserted through a reasonably small incision and ‘assembled’ once in place.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in facial reshaping surgery. Can I get a longer and slimmer face with strong jawline and cheekbone through the facial reshaping procedures? If no, what type of procedure will I need and how much will the total cost be . I feel like I can trust Dr Eppley for these life changing procedures.

A: In looking at your pictures, I can recommend several facial reshaping procedures that would make your face longer and slimmer. These procedures include vertical chin lengthening (vertical lengthening chin implant vs. open sliding genioplasty), cheek implants, buccal lipectomies and perioral mound liposuction. The effect of these procedures is created because multiple hard and soft tissue changes are occurring in different dimensions. When all are combined the effect of increased vertical facial height (real facial change) and decreased facial width (more of a visual facial) occurs.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I read your article on natural vs. artificial implants in rhinoplasty.  I was wondering why you prefer natural material. I also know diced cartilage wrapped in fascia has been offered fairly recently.  Do you know if this is a fairly new procedure or if this has been offered since 2009?  I am considering tip revision but also want to keep my bridge area in mind if need be.  I have an implant in my nose as mentioned earlier but do not know if these implants last a lifetime. I had mine placed when I was 38.  Is there some kind of average, for example, 20 or 30 years?  Thanks.

A: Significant nasal augmentation in rhinoplasty can be done with either nasal implants, usually made of silicone, or rib cartilage. There are advantages and disadvantages with each type of implant/graft and both can have successful long-term results. Silicone nasal implants never change in shape or structure, can not degrade or break down and never need to be replaced because they fail. The issue with any synthetic nasal implant is that the tissues change around them in some cases (if they are big enough) and this means that the skin over the implant thins. This can lead to potential long-term issues such as implant show, exposure or infection. This never happens with cartilage grafts which is why they are preferred in larger nasal augmentations if one is willing to invest the greater effort up front.(longer surgery, scar, expense)

The use of diced cartilage wrapped in fascia or surgical in rhinoplasty is not new and has been around for several decades. It s biggest advantage over en bloc or solid rib grafts is that there is no potential for warping or edging. They can be used to cover a nasal implant particularly in the tip area. But the use of ear cartilage would actually be better for this purpose.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, awhile ago you helped answer my questions about cheek lifts, as I was getting one to correct sagging from malar implant removal. Well, I had the cheek lift, and while it made some major improvements, I still have some sagging. 

Now I probably should just accept the remaining sagging at this point, but since I had NO sagging on my face while the implants were in, I am of course beginning to wonder if I should have just kept them or should replace them or get some sort of filler to fill out the loose skin at some point. 

My reason for removing the cheek implants was that unfortunately I felt they were not proportionate and looked a bit obvious –  but in retrospect I wish I had just waited for more swelling to subside and embraced the new look rather than removing them and making myself look older.

The issue remaining seems to be mostly skin (with a tiny bit of tissue). The pocket of looser skin is still in the shape of a malar implant.

Is it possible that replacing the malar implants in the future would help fill out this looser skin  –  or after all of these surgeries should I just give up on having tight  mid face skin again?  You can be honest, I know it’s a lot

Would replacing the malar implants after placement, removal, and a lift just be too much scar tissue and way too complicated? How long should I wait before making this decision?

I regret removing the implants, as they made me look much younger and I had no idea I’d have sagging if I removed them.

I just keep wondering if re-inserting the malar implants would lift that tiny bit of excess skin that is looser since removing them. Perhaps filler might do the trick too?

Also,  I forgot to mention that if you do think reinserting the malar implants would lift the skin a bit how long would I need to wait after the cheek lift. I was told that the sutures dissolve in 6 months. Would it be safe for the implants to be in there theoretically even if the sutures had not dissolved?

Any other suggestions about how to lift that sagging mid face skin are greatly appreciated, or if you think i should throw in the towel and quit and just accept the sagging skin now as it’s just too much surgery and scarring that’s understandable as well.

A: I think given your past history of cheek implants in and then out, any further efforts at cheek lifting should be done by either injectable fillers or fat injections.They both will provide more upper cheek fullness and will do some cheek lifting. Ultimately cheek implants could be redone now that you know their benefits. But you need to wait a full year after the cheek lift before replacing them with fillers or fat if they turn out to be inadequate.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in temporal augmentation. My questions are: 1) I would prefer to try filler first, with filler is it possible to do the whole region which I circled in red in my picture? From the implant I saw from your site, that goes really higher than the smaller ones (see the second picture). I’d like to cover all this zone with hyaluronic filler.
2-) I wonder since I have a flat upper head appearance from the front view, if I can create the effect of the guy I circled in green? His hair don’t seem to be flat on his side of the head. not sure if it’s clear. I’d like to have this volume to my head. (circled in red)

A: When it comes to temporal augmentation it is all about volume and what it costs to do it. You can certainly use injectable fillers but it will be really expensive to build up the whole temporal region (non-hair bearing and hair areas) for a six month result.  The only reason to consider such a temporary treatment would be to first see if you like the augmentation effect by ‘wearing’ it for awhile. The use of anterior and posterior temporal implants, which are permanent, are a more cost effective long-term approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want to know if there is a difference in the appearance between silicone cheek and jaw implants and medpor cheek and jaw implants. From pictures and my own knowledge I think it is clear that the Medpor looks and feels more like real bone. But I don’t know if this has an effect on the appearance outside the face. Does Medpor give a more chiselled appearance? I am concerned maybe silicone will give a softer, less angular look (even if customized to be angular). Is this true? I know the silicone is made in to harder material, but I have felt it and it is quite easy to cut (with scalpel). I also notice it can be bendy, and be twisted etc. I don’t think Medpor can bend like elastic, can it? I want a very sharp angle jaw and also cheek implants (sharper than angelina jolie even). Thanks in advance.

A: What creates an outer facial appearance is the shape of the implant that lies underneath. What composition facial implants are made of makes no difference at all. So that is a misconception. Do not get caught up in what the material feels or does outside the body. When any material is overlaid on bone it will feel as form and inflexible as bone.

Quite frankly Medpor is not a very good facial implant material that turns into a major problem if you ever have to revise it. And the potential revision of any type of facial implant should not be underestimated. Removing or revising a Medpor implant is very traumatic and destructive to the tissues. I take them out frequently from other surgeon’s work and I shake my head every time wondering why this material is ever put in.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in orbital rim and brow bone implants. I have a sunken eye area and eyes that seem to bulge out with droopy eyelids and bags under the eyes. What combination of procedures would produce the best results based on my overall appearance? I’ve also attached a picture of an actor whom I want similar features to.

A: While orbital and brow bone implants may be what is ultimately needed, that is not the first place to start. I would have fat injections done first to both the brows and the entire infraorbital area first. This would be initially done for three reasons; 1) To try and rid some of the hyperpigmentation of the lower eyelids. This is going to be a chronic skin color disorder which is both common with your ethnicity and may be unimproveable. 2) To improve the quality of the tissues particularly that of the lower eyelids if eventual implant surgery is desired and 3) it is possible that enough fat may be retained that implants may not be needed.

While orbital rim and brow bone implants can help make more deep set eyes when done together, they do require scalp and lower eyelid incisions to place.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in trach scar revision. I have a very ugly scar from a tracheotomy tube and am interested in knowing what my options are in terms of eliminating or reducing the appearance. The tube was removed mid-September of 2014. My doctors suggested waiting some months for everything to heal before considering any cosmetic surgery.There may also be some internal scarring, which seems to be inhibiting normal swallowing somewhat. What type of trach scar revision do you recommend?

A: Tracheostomy scars can be reduced/improved in appearance but never completely eliminated. Given that you are six months from the tube being removed, the treatment of the trach scar could be done any time in my opinion. The only reason to wait any longer, in any type of scar revision, is if one thought that more time had a chance to make it improve enough that surgery should not be needed. Because most tracheostomy scars are depressed, I prefer the use of  a small dermal fat graft to fill the defect at the same time as revision of the skin scar. This can also release the tether that is often seen when swallowing. This converts a round depressed scar into a flat linear scar.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in chin cleft reduction. How is it done and what is the best method? What is the cost of chin cleft reduction? Is it done under local or general anesthesia?

A: A chin cleft reduction can be done by several method depending on the etiology of the problem. For many patients the external chin cleft is the result of a mentalis muscle (soft tissue) deficiency. This is treated by injectable fillers for a temporary effect or by fat injections in the hope of a more permanent result. In a few patients the external chin cleft is the result of an actual cleft in the mandibular symphysis. (chin bone) In these cases the bony chin cleft is filled in with the use of a small implant placed intraorally or from under the chin. Only a physical exam examination can make that distinction between a bony versus a soft tissue chin cleft.

Since there are different methods used for chin cleft reduction, it would first be important to determine the exact treatment method. From fat injection to the use of an implant, the costs could range from $2000 to $3500. The procedure is usually performed under a combined IV sedation and local anesthesia.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I`m interested in jawline reduction, and I have some questions regarding this procedure. I have read that there is a risk of damaging the facial nerve during this procedure. How high would you say that this risk is? And should it happen, will it be possible to repair the damage afterwards? Is the risk smaller if the reduction doesn`t involve the angle, but the bone between the chin and the angle?

A: The nerve that is at risk for potential injury during jawline reduction is not the facial but the mental nerve. The facial nerve is a motor nerve which controls facial movements while the mental nerve is a branch of the trigeminal nerve which is responsible for feeling of the lower lip and chin. It is at risk for injury, not during jaw angle reduction, but in reducing the bone between the chin and the angle. This is where the nerve exits out of the bone at the mental foramen. The nerve is most frequently injured due to it being stretched which can largely recover on its own. This causes some numbness of the lip and chin which may be  temporary or some of it could be permanent.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 35 year old female and am interested in jaw angle implants. I have high jaw angles and my jawline looks deficient in the back. I’m interested but I would like to learn more about your experience with this specific procedure. How many cases did you complete that are similar to mine? And if there have been some revisions needed, can you share those stories as well? I understand that jaw angle implants have a high revision rate, and that it takes someone with a lot of experience. Anything you can share on this topic would really help me make a decision.

A: I have performed jaw angle implants for 20 years but the greatest number have been in the past ten years. The incidence between men and women historically is about 20:1 indicating not surprisingly that this is a male dominated procedure. Few women get them although that is slowly changing as more women become aware of their benefits and the desire for a more pronounced jawline has become more desired. As in men, the most common indication for jaw angle implants is in the high jaw angle where vertical lengthening is really needed. This has posed a vexing problem since all current styles of silicone jaw angle implants really only provide width (horizontal increase) and not much if any vertical elongation. This has led me to develop my own style of jaw angle implants that provide specific amounts of vertical lengthening and widths. Such jaw angle implant styles will be available later this year through the Implantech company and will be known as Vertical Jaw Angle Implants.

The revision rate in jaw angle implants has been historically high for a variety of reasons including inadequate/incorrectly chosen implant styles, asymmetry of surgical placement, natural jaw angle bony asymmetry, lack of screw fixation use (particularly in vertical jaw angle implants), lack of most plastic and oral surgeons experience in placing them and patient expectations of what they can achieve in jawline enhancement. These revision rates can be lowered down to that of other facial implant rates (10%t to 15%) with preoperative computer imaging, proper implant style selection, use of screw fixation and a surgeon who is very experienced in placing them.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m interested in having custom  jawline implant with you but I have several questions want to ask. I want to get jawline implant not because I want to be more masculine looking, but instead I think my flat and short jawline makes me look weird in oblique (45 degree) view. I had a chin implant but it didn’t help much. The chin length looks OK in frontal view (in fact I’d say a bit short for a male) and it protrudes enough in lateral view, but in oblique view it doesn’t look very projecting because of the vertically short jaw. It looks like Lindsay Price before she got a chin and jaw surgery. Besides that I don’t have the angle, my jaws go directly up to my ears. 

My questions are: 

 1) Is it possible to get a jawline implant but not make my face wider (no angled & lateral jaw), instead just making the jaw steeper? For example, like Cameron Dallas or Justin Bieber (they have very steep jawline)

 2) I have a V-shaped lower face, is it possible to remain the overall V-shape and sharp chin, but just make the overall length longer & steeper? Like my friend on the left, he has very long chin and steep jaw, but still has sharp chin.

3) I now have a chin implant, but I know that for a custom implant you need to design on a CT file. Is it possible to distinguish between the bone and implant, and design on a CT file with a current chin implant? Or I’ll need to take CT after removing the old implant? 

4) Is computer simulation possible for jawline and chin implant?

A: By the description of your jawline concerns and needs,  you need a custom jawline implant that is made off of a 3D CT scan that wraps around the entire jawline. It can be made with your chin implant in place which is then digitally removed during the the implant’s design process. The implant’s shape and dimensions can be made virtually anyway one wants it to crate their desired jawline shape.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in jaw angle implants for jawline enhancement. I already had a chin implant placed nine years ago but the lack of jawline definition is making my face look really long. Laterally you can see small bumps of saggy tissue along the weak jawline which has become more visible as I get older or when I lose weight.

A:  A weak or high jaw angle (steep mandibular plane) can become magnified with chin augmentation. This is particularly evident when the amount of chin augmentation is considerable, indicating an overall small jaw in both the horizontal and vertical dimensions. This indicates that you need vertical lengthening jaw angle implants rather than width only style implants. With vertical lengthening jaw angle implants the loose tissue which is now in the neck (‘saggy tissue along the weak jawline’) will became redraped over the new jaw angles that have been created. This will smooth out the jawline and make the back match the front for a better overall jawline effect.

Dr. Barry Eppley

Indianapolis, Indiana

 Q: Dr. Eppley, I am interested in chin implant revision. I had a chin implant done (via inside mouth) ten years ago. II think it was Medpor, 3mm. Profile is great. From the front view – one side is lovely, but the other side is way too long for my face. It’s put my whole face out of sync. I read that it is hard to remove Medpor, and it is great from side view, and one half of the front view – so, I am wondering if it’s possible to go in and shave down one side a little, to make it more even and smaller on that side. Also, what downtime would be like for this? Is this something you would be happy to do?

A: Medpor facial implants are difficult to remove due to tissue adherence but not impossible. But if you are happy with most aspects of your chin implant then it should be modified in place rather than removing it. Medpor is much easier to trim/shave once it has been in placed for awhile as the material softens slightly with tissue ingrowth. The easiest way to do your chin implant revision in which the goal is to trim one side of the chin implant which is vertically long is to do it from below (small submental incision) which provides the most direct access. This would also have the easiest and quickest recovery. It can be done, of course, also from an intraoral approach as well if the submental scar is a potential concern.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in knee lifts and after seeing your after surgery pictures I’m sold. I thought it would be much wider and more noticeable. The bottom after picture looks amazing. I have struggled for so long with this issue and I know it’s the only answer. I have read that the cost of the surgery is between $4700 and $5300 or something like that. Is that correct? How much time off work would I need? I’m a visiting nurse so it’s not strenuous at all. It’s exciting to think for once I’ll be able to wear shorts. How long would they be swollen?  I guess that would also affect my timeline for the surgery.

A:  I will have my assistant pass along the actual cost of knee lift surgery to you next week. It is most economical to have the procedure done under local anesthesia with IV sedation. The knees do not swell up that much, it is only necessary to keep them wrapped with ace wraps or Coban wraps. The biggest issue is to just be careful to not bend the kneed beyond 90 degrees for about a month after surgery to not place too much stress/stretching on the incisions. How that would affect your work would depend on that issue. I suspect it would not be more than seven to ten days.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My question has to do with a certain actor. Is the difference in his jaw from the first picture to the 2nd picture from implants and is this outcome possible through mandibular jaw implants.

A:  I can not tell you with any certainty as to whether this male actor had jaw angle implant surgery or not. Al I can do is speculate based on my extensive experience with jawline enhancement and numerous types of chin, jaw angle and jawline implants to create an augmentative effect.

I believe that he has NOT had jaw angle implant surgery. What you are witnessing between the two pictures of this actor is the effect of masseteric muscle bulging. In the ‘before’ picture his jaws are relaxed but in the ‘after’ picture he is clenching his jaws which causes his naturally larger masseter muscles (and thin face) to bulge out. This creates the impression that he has had jaw angle implants when he has not.

Such an effect can be created by jaw angle implants provided they are placed in the right kind of face (thin with little fat) and that the implants have the right shape and thickness. Such implants would have to be custom made since no standard preformed jaw angle implants have such an exaggerated shape.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had subfascial buttock implants placed three week ago. My doctor wanted to keep the skin stitches in for a long time so that it would heal without coming apart.  I’ve been keeping an eye on my stitches now that I able able to see them better. I am seeing an opening develop that I did not see until now. This opening in the incision worries me. Should I get it restitched to assure that it closes properly when I go in for my one month checkup?

A:  What you are observing after your buttock implants is very common and, quite frankly, expected. This is why I keep the the intergluteal incisional sutures in for so long. Every intergluteal incision will develop small openings such as you have and they never occur until 2 to 4 weeks after surgery. I do not close them because the sutures will never hold. They need to be allowed to heal in on their own. There are 3 other layers of tissue suturing under that of the skin closure so such small openings are not a concern. I would recommend topical Silvadene dressings which will help the small open area granulate in faster and is a potent antibacterial as well.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have an unusual question. I know you are an expert at the corner of the mouth lift. My lips turn up at the sides too much as it is. Is there  any way you could perform a subtle corner of the mouth ‘drop’…a reverse corner of the mouth lift if you will. This would be a reverse procedure. When I pull my lips down slightly they look as good as possible and being a professional entertainer I could really use this improvement. Also can the lower lip be lengthened slightly– thank u so much for your time!

A: I have to admit that I have never done a ‘reverse’ corner of the mouth lift nor has anyone ever requested it before. But like a traditional corner of the mouth lift, the reverse can be done I am sure. Some lengthening of the lower lip could be done at the same time. Unlike the corner of the lift which is done on the upper lip, a corner of the mouth ‘drop’ would be done on the lower lip.

I would need to see pictures of your mouth to give a more qualified opinion.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in midface augmentation. I’m 25 years old and I have problems with my facial aesthetics. My forehead is more protruding than my midface and my lower third. This is easily observeable in sunny places, my forehead is highlighted but the rest of the face (except the nose) in shadow. Since my bite is good and my jaw quite strong, I would think a chin implant is a good idea, but is there an really effective method to bring the midface forward without a LeFort osteotomy?

A: As for the chin implant I would need to see pictures to make a helpful comment on its benefits for you. There is a very effective method to bring the level of the face around the nose forward which would create the equivalent of LeFort I osteotomy effect. Combined paranasal/premaxillary- maxillary implants can have a very powerful midface augmentation effect. Cheek implants are also useful but they create a zygomatic augmentation (upper midface) not a maxillary (lower midface) augmentation effect.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have questions about temporal augmentation. I just got cheek implants and am modestly happy with them. I wanted to know if temple implants can co-exist with cheek implant. My surgeon has explained to me that temple implants are not safe due to a sensitive nerve in that area, and something he does not practice, nor advises. 

A: I am afraid to say that what your surgeon is telling is inaccurate and anatomically incorrect about temporal augmentation. Temporal implants are placed in a subfascial pocket through a small incision in the temporal hairline. There are no nerves in the subfascial temporal plane which is directly on top of the temporalis muscle. Your surgeon is likely referring to the subcutaneous temporal location where the frontal branch of the facial nerve runs. The subfascial is below that location and is perfectly safe.

Cheek and temporal implants can co-exist because they are in completely different tissue pockets even though they are right next to each other. Cheek implants can make the temporal region above it look hollow/deficient and it is not rare in my experience that the cheek implant patient subsequently goes on to have temporal implants.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had facial fat grafting six months ago with 30 cc of on each side of the face into the bottom of the cheeks, smiles lines, nasolobial folds and near the mouth! This has unfortunately lead to a very bad new look! Fat lumps develop in the above mentioned areas as fat was injected too superficially. I read a recommendation from Dr Eppley on RealSelf that fat can be surgically excised! Would like to know more about this procedure! is it done from outside the cheeks or from inside the mouth?

A: There are numerous methods to try and reduce excessive fat contours after facial fat grafting. Surgical excision is rarely used unless the fat is located in an area that is easily accessible through a facelift or blepharoplasty incisions. Small cannula or microliposuction is the most effective method near the central face and mouth areas. This is usually done through a small incision inside the corners of the mouth.

Other non-surgical options to get rid of fat grafting lumps include steroid injections (low dose Kenalog) and the use of deoxycholic acid solutions. (originally known as Lipodissolve injections and now under clinical trial investigation as ATX101 by Kythera)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a breast asymmetry problem. I am 26 years old and the mother of one. During the period of breastfeeding, my child developed a likeness to my left breast which cause it to fill faster with milk and now my breast has stretched to such an extent that my right breast is almost half the size of my left breast, I live in Guyana, but the expertise is not here in this area (plastic surgery) I would like to know which one of the surgeries for the breast would be right for me and also do you deal with clients who may come from another country for plastic surgery.

A: There are multiple approaches to treating breast asymmetries and the choice of procedures depends on the size and shape of each breast and their differences. The first and most important question is…is one of the breasts the size and shape that is desired? In your case that would mean is the right breast the goal to try and make the left one look like again? If so, then a breast lift and/or reduction on the larger left breast may be all that is needed. If neither breasts are ideal or even the  ‘better’ one needs improved, then bilateral breast reshaping procedures would be needed.

A unilateral breast lift is a relatively straightforward procedure that could be done as an outpatient under general anesthesia in about an hour of surgery. I will have my assistant Camille, who handles all of my far away patients, contact you later today.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 70 years old and got saline breast implants forty years ago. Recently my left saline implant ruptured. Need surgeon with your skills. I am  confused about options with my saline breast implant deflation. I saw you on Real Self. Can you help me please? Thank you. 

A: Having saline breast implants that have lasted for forty years is way beyond what one would expect them to last without suffering a deflation. The duration most saline implants are typically expected to last is in the ten to twenty-five year range. I have never heard of a saline breast implant lasting four decades!

With a recent saline breast implant deflation, the simplest and most economically efficient option would be to simply replace the ruptured implant with a new saline implant. Breast implants replacements are easy because there is an established implant pocket already. You could, of course, switch to silicone implants in both breasts if you still want implants and want to eliminate any future risks of an implant deflation. (since silicone implants do to deflate)  As an alternative option, you can simply remove both implants if you no longer desire to have them and wish to most assuredly eliminate any future breast implant concerns.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am seeking a custom brow bone implant. My problem is that my brow bones are very low, typical Asian. My eyelids are protruding.I believe this makes me look too soft, messy in the eye area, sad etc. not manly. I have thought of this for at least five years. My  brow bone is less protruding or equal to eyelid protrusion.

For men the brow bone should be substantially more protruding than the eyelids, almost close to protrusion of upper lip.

What I wish for is a permanent brow bone implant. I want an attractive manly forehead and supraorbital rim area. I want the brow bone to protrude more than eyelids and close to protrusion of upper lip based on analysis of male faces I want to look like.

A: What you are seeking is a custom brow bone implant. Most likely this would have to be a combined forehead brow bone implant to create the best overall effect. This type of custom made implant is made off of the patient’s 3D CT scan. Its final shape requires some artistic design but how much brow bone augmentation is needed can be determined by looking at the difference in the brow-eyelid position in the profile view. Thus type of facial implant would need to be placed through a scalp incision.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in double chin correction. Attached you will find some pictures that I took–today during my lunch break! Looking at me straight on, at a flattering angle, you can tell I have a round face but the double chin isn’t noticeable. When I smile widely, laugh, or am viewed from my profile, it is clearly evident. What are my treatment options? Will liposuction alone work as another doctor told me? Let me know your thoughts!

A: Thank you for sending your pictures. While there is certainly some subcutaneous fat to liposuction, that will give you a modest improvement only. Necks like yours almost always have a subplatysmal collection of fat in the midline that will not be changed by liposuction. This requires a submentoplasty technique to maximally tighten the neck angle. You also have a bit of a horizontally short rounder chin. This adds a third factor to the double chin appearance. Adding a small central button style chin implant will add a little more horizontal projection and change the frontal chin shape to more of a tapered chin look.

In conclusion, it is all about the degree of double chin correction you are seeking.Liposuction alone will produce a modest improvement, a submentoplasty (which includes neck liposuction) will make a good change and the final addition of a chin implant will make the best overall double chin correction. As you can see neck liposuction is the most basic approach but does not produce the best double chin correction.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Twenty years ago, I had a facelift done. Until six months ago, all was well. However, for some time, I have noticed that along my hairline, little “slits: appeared followed by something quite hard. Recently, my face has begun to drop dramatically to the point I’m embarrassed to be in public. The comparative pictures are unbelievable. I have Medicare and Tricare for Life. Is there any possibility insurance would cover the repair or for a new facelift? I’m desperate at this point. 

A: Twenty years is a tremendous amount of time to get the benefits of a facelift. Most facelifts have largely degraded and the benefits lost by ten to twelve years after the procedure. I have no idea what the issue is with the ‘slits’ /hard knots in the hairline. Although most plastic surgeons use dissolvable sutures for their facelifts, your surgeon may have placed permanent sutures deep and they may be working their way to the surface after so many years. That would be the only explanation I could fathom for their presentation. No medical insurance is going to pay for facelift surgery. This is a purely cosmetic procedure that is paid for upfront undoubtably just like it was twenty years ago.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a custom jawline implant placed about six months ago by another surgeon. It is not adequate at all and now what the surgeon promised the result would be. Besides its size my other concern is the location of the exterior scar on my face?  It seems to be very close to the front of my chin, in fact on some  ‘shrugging’ type expressions it seems to roll over to the front.  Would this be in a better location upon my custom jawline implant revision? 

A: One of the things you learn in placing custom jawline implants or even vertical lengthening chin implants is the typical location for the submental incision will be too far forward if not changed from its traditional submental skin crease location. When the chin is lengthened vertically and comes forward, the typical location of the submental incision is too far forward and will almost end up on the chin point as opposed to being tucked on the underside of the chin. Therefore, the incision  needs to be placed further back than most surgeon’s think as the implant rolls it forward. That incision location can not really be changed now.

Dr. Barry Eppley

Indianapolis, Indiana