Your Questions

Q: Dr. Eppley, I am interested in jaw implants to help correct my facial asymmetry. Although it is not noticeable to others,  if taking a picture straight-on and in certain lighting, it shows that my face is extremely asymmetrical. I was wondering if this would best be corrected with asymmetry surgery or could be corrected with customs jaw implants. Also- if corrective asymmetry surgery was performed, could you also add custom jaw implants at the same time to provide the most optimal facial makeover?

A: In looking at your pictures, your facial asymmetry is caused largely by a significantly deviated chin position. This has also has caused some jawline and jaw angle asymmetry although not as significant as that of your chin. There are two approaches to correcting your jaw asymmetry.

The first technique is to correct the chin by a sliding genioplasty that moves it back to the midline. Then the jawline and angles behind it could be augmented by standard jaw angle implants.

The second approach is to go completely with custom implant designs, leaving the chin bone where it is. Computer designing can make jawline-jaw angle implants for each side (that are obviously different but designed to create symmetry) that attach to the sides of the chin.

Either approach can make a big difference and each one has it advantages and disadvantages.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 26 year old female from who is looking to have rib removal done for ribcage narrowing. I saw online that you perform this surgery and was wondering if I would be a good candidate. My ribs have always bugged me because they protrude so much. I want them removed to create a smaller upper body and also because they stick out more than my breasts. I have attached some pictures of me laying down so you can see what I mean. I look forward to hearing from you.

A: Typically ribcage narrowing by rib removal is done  to make one more ‘high-waisted’ or to lengthen the distance between the bottom of the ribcage and the hips. This is done by removing the cartilagious portions of ribs 9 and 10 which are more to the side of the ribcage. What you have/are demonstrating is rib protrusion or ribs that stick out. This involves the inner portion of the ribcage closer to the sternum rather than the side. This is a slightly different rib location. This is seen when one stands up but becomes a lot more noticeable when one lays down. (as seen in your picture) This protrusion occurs because of the confluence of ribs 6, 7 and 8. They all join in this area and the way they come together (angulation) causes them to stick out. This section of ribs can be removed (and is actually commonly done in reconstruction of microtia ears) but will require a 4 to 5 cm incision along the lower edge of the ribs to do it. This results in a fine line scar and one has to be certain that this is a good aesthetic trade-off.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to know how  much it would cost for hairline lowering. Also if I could see before and after results from this procedure because there is only one picture on the website. 

A: The cost of hairline lowering is dependent on whether one needs a one or two-stage hairline lowering procedure. That would depend on how much hairline advancement one wants and what the natural looseness of the scalp is. To better help you with cost, I would need to see some pictures of your forehead and a line draining (use lipstick) of where you want the hairline to be. That will answer the question of whether it is a one-stage procedure or a first stage tissue expander is needed. As a general rule, 10 to 15mms of hairline advancement can be obtained in a ons-stage procedure. More than that will require a tissue expander first to create more loose hair-bearing scalp tissue to bring forward. If you try to create that much scalp movement in one-stage the brows will elevate significantly to cover the extra distance and not the hairline coming forward.

There are few pictures of this procedure on the website because patient confidentiality only allows postings that patients agree to show their face…and most people do not want that. And without patient permission we do not distribute patient photos on the websites or to prospective patients to honor their privacy requests.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting a combined tummy tuck and buttock implants operation. I won’t have the money for my surgery until April 2014. Is it a good option to have a consultation a couple months ahead or within a certain time frame prior to the surgery. Also how much approximately would it be to have both procedures at the same time?  Is there a discount for that or some type of deal for booking both at the same time?

A: I think it is always good to get accurate surgery and cost information way in advance of when any patient wants to do their surgery so they can plan accordingly. Doing it two or three months in advance is a good idea. I will have my assistant pass along some general cost information for a tummy tuck and buttock implants to you by tomorrow, although be aware that these are general numbers since I have no idea as to your exact tummy tuck needs.

Like all cosmetic surgery, bundling procedures together can result in a cost savings due to saving operating room and anesthesia charges. However, the combination of a tummy tuck and buttock implants done together would make for a really difficult recovery and this is not a recommended combination procedure. A tummy tuck and fat injections to the buttocks can be done at the same time but two muscular operations on opposing sides of the torso is not a good combination.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in multiple bariatric plastic surgery procedures. I had a gastric bypass done two years ago and have lost 140lbs. I now weigh 170 lbs, down from 310. I need a lot of work and want an arm lift, back lift, tummy tuck, thigh lift and liposuction with fat transfer to my buttocks and hips. Can this be done all in one surgery> It is safe to do all of these at once? Also, how long should I stop smoking prior to major body contouring surgery like this so I can heal properly?

A: While all of these bariatric plastic surgery body contouring procedures can be done in one surgery, that is not advised nor would any plastic surgeon do it. This is why too much trauma to your body and it increases the risk of major affter surgery complications llike DVT, infection and wound separations. As I counsel every extreme weight loss patient, you simply can not fix all of your body concerns in one surgery.

Every extreme weight loss patient needs to draft a complete list of their body concerns and then prioritize them. This will then allow you to create a series of two or three separate surgeries, spaced three to six months apart to get every body area addressed, It is more reasonable and common to do in the first stage the tummy tuck and arm lift and then do the back and thigh lifts in a second stage.  It would be uncommon in a severe weight loss patient to have enough fat to harvest by liposuction to be able to do buttock or hip augmentation. It may be possible but not usually likely.

Regardless of how you sort and stage your body contouring procedures you must have stopped smoking months before. You need to stop once and for all at least 6 to 12 weeks before these surgeries. Otherwise, you are at high risk for major wound healing problems even if you ‘cheat’ on your smoking before and during the healing process.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in lower buttock lifts. Ten years ago I had liposuction on my buttocks, banana rolls, and inner and outer thighs. The gluteal band was broken and a double crease created. I have been searching for a solution. Have you have any successful buttock lifts due to botched lipo? Thanks

A: About half of all lower buttock lifts that I have done have been for liposuction deformities. Liposuction of the banana roll of the buttocks almost always makes it worse if the roll is on the lower end of the buttocks as the ligaments are released and a worsened skin roll results. This creates the double crease to which you refer which is a skin problem created by the removal of fat volume. Buttock lifts remove the excessive skin roll and create a new and more tucked in buttock-posterior thigh demarcation. At the least it always removes the double crease and converts into a more normal and desireable single lower buttock crease.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have an asymmetrical smile. When I was little I had a cross bite, I had an expander, braces, and retainers. My insecurity is that the sides of my mouth do not crease, or rise up the same. I can’t help but wonder if this is a result from the cross bite or vice versa. It makes my smile different on both sides and makes my mouth appear crooked. What is the procedure to correct this issue? How much does this average procedure cost? Thank you!

A: The asymmetry in your smile lines has nothing to do with your prior orthodontic history as your bite/teeth relationships have no impact on how the muscles of facial expression work. Your smile elevator muscles (zygomaticus and superior labii muscles) are working symmetrically as judged by the position of the corners of the mouth at maximal smile. (as seen in your picture) Your concern is actually that the depth of the nasolabial (cheek-lip) grooves are different when you smile. Your right side is much deeper than on your left. That is why your ‘smile’ looks different even though your actual smile (lip lines against the teeth) is actually the same. The attachments of the skin to the underlying tissues is what mainly creates the depth of the nasolabial fold in animation and that is a relationship that can not be reliably changed by surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have orbital dystopia that I want corrected. Here are a few photos and you can see that my left eye is noticeably lower on my face. As you may also notice from the top view, you can see that the left eye also protrudes forward a bit. My nose and chin also are off the center line and lean to the left as well but my eyes have always bothered me the most and the others I can live with. Again, this is something that has made things difficult for me and i’ve just reserved myself to the idea that I have gone this long and I may as well just live with it….until I shaved my head due to hair loss that is. Now my eyes are the very first thing that people notice and they stand out much more now. Any thoughts/guidance would be much appreciated.

A: I have seen your photos and the amount of orbital dystopia in the left eye seems to be about 2 to 3mms at most. That can be improved with frontal orbital floor augmentation and possibly orbital rim augmentation as well. That will bring up the vertical level of the eye but it will not change the more forward projection of the eye as seen from the top view. The key question in any case of orbital dystopia is what happens with the position of the lower eyelid for that is not a bone-based structure and thus will not change. With the eye coming up and if the lower eyelid position remains the same, some slight amount of increased scleral show may result. That is why a canthopexy is usually done to provide a bit of lower lid tightening/lift as well with the change in eyeball position.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in flat back of head surgery correction. I am ready to take the next steps for cosmetic skull augmentation surgery for the flat back of the head. I have a few concerns/questions and hoping you will be able to clear them for me. I have read the case studies and advice on your website and it gives me tremendous hope of having more normal head shape. My problem is that I have a rather flat back with bulges over both ears. My questions are as follows:

1)  Based on your articles, I see you can build up 10 to15 mms on the back of the head in one attempt. I believe I may need more than 20 to 25 mms, so can you add 10 to 15mms in first attempt and then stretch the scalp further and in the second attempt add the remaining 10mm? Is that possible?

2) Is there ever of any possibility of this cranioplasty material getting loose? For instance if a person falls down etc.?

3) Will you be able to burr down the bulges on top of my ears? If so, how much?

4)  I am a man who is starting to lose hair a little bit. Will the scar be substantial and show up?

5) What is the total time required for surgery and recovery if it is 10-15 mm augmentation versus a second attempt for the additional 10mm?

A:  What you are describing is having a bilateral flat back of the head known as brachycephaly. (as opposed to flatness on just one side which is known as plagiocephaly) This is why you have bulges over both ears, the brain grew the bone out to the sides as opposed to pushing out normally in the back. This flat back of head surgery involves a build up across the back of the head with some width reduction. In answer to your questions:

1)      If you need to have as much as 25mm of occipital bone buildup, you first need scalp tissue expansion and then secondarily add all the material volume needed. Once the scalp is lifted and stretched, its becomes scarred and will have little stretch. So  trying to double the material volume later will not work. The choice is then settle for either two-thirds of what you need or make it a two-stage procedure.

2) Tiny titanium screws are first added to the bone and then the material is applied. This gives it something to forever be anchored, much like it done with construction concrete. Loosening of the material as yet to be a cranioplasty problem I have seen.

3) The protruding bone around the ears can be reduced about 5 to 7mms on each side.

4) While there is a scalp incision involved, it can heal remarkably well even in bald men. I am consistently surprised how well it heals in the scalp. Will there be a scar…yes. Will the scar be substantial…no.

5) The surgical time for a one-stage occipital augmentation is 2 hours. If it is a two-stage occipital augmentation procedure with a first-stage tissue expander the operative times are 1 and 2 hours respectively.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in knowing more about Mimix bone cement. Here are my questions:

1) What type of surgery is Mimix mainly used for? 

2) What is the biggest features of Mimix? Could Mimix be placed in any area of the cranial bone?

3) In Genioplasty are there any special techniques in using it?

4) Can Mimix be placed in the gap between a cranial bone flap and the native bone with titanium plating?

5) Can Mimix be used for small defect cranioplasty (less than 25 square cm) for pediatric patients

6) Have you ever experienced Mimix breaking after surgery?

7) Do you have any experience using Mimix on maxillofacial and mandibular bone?

A: Based on my extensive experience with Mimix bone cement in craniomaxillofacial surgery, the answer to your questions are as follows:

1) Mimix is used for two main cranial (skull) purposes: 1) inlay defects of the skull such as burr holes or larger skull defects and 2) as an onlay material for skull augmentation such as aesthetic forehead augmentation or to build up deficient skull contours. There are a wide variety of other maxillofacial uses which ranges from filling in small bone defects and as a contouring material, but the skull makes up the vast majority of its uses particularly as judged by volume used.

2) If one is looking for a natural method of bone reconstruction (hydroxyapatite is similar to bone in chemical composition) of the skull as opposed to using completely synthetic metallic materials. Mimix can be placed in any area of the skull. Since the skull is non-mobile and non-load bearing, it can be used in any location from the temporal fossa to the frontal sinuses.

3) When placing the material in a genioplasty as an interpositional filler, it is important that the implantation site is not too wet with blood. A very wet field interferes with the setting/curing of any hydroxyapatite cement.

4) As a general rule, no. if you are referring to using Mimix in conjunction with titanium plating for cranial flap fixation it can be done but there is little reason to do so directly underneath a fixation plate. It may be used for other bone gaps along the cranial bone flap if they are significant enough in width.

5) Filling in pediatric skull defects would be a common use for Mimix due to its advantages in the growing skull.

6) It is important when using any hydroxyapatite cement to ensure that there is no mobility of the surrounding bone. Mimix is not a bone fixation method, it is a bone graft substitute that must have good stability of the surrounding bone otherwise it may fracture. In my experience I have never seen Mimix fracture or pose a problem in this way but you have to know how and when to use it to avoid this potential concern.

7) Mimix in the maxillofacial region is used as an inlay method only to fill in small bone defects that might otherwise require a graft and into which a dental implant is not intended.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in temporal implant augmentation. I am a 35 year old male who ever since I was a child I have had one temple that was somewhat misshapen and sunken in. As I have gotten older and lost my baby fat, in addition to becoming leaner all around, it has become more and more noticeable and the way it looks bothers me. I see you have temporal implant treatments and I am wondering what the general ballpark amounts are for something like this. Keep in mind that only my left side is abnormal. 

A: A very simple and effective solution for temporal hollowing is a temporal implant. Placed in the subfascial plane on top of the temporalis muscle, it can immediately add permanent volume to temporal hollows. For just one side, it can be placed in a 30 minute procedure under local or IV sedation. There is very little swelling and no recovery afterwards of any significance. I would have to see some pictures of your temporal hollowing to determine its extent and exact location. Temporal implants work best for when the hollowing is deepest in the temporal region just above the zygomatic arch.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting a rhinoplasty. (nose job) I’ve always wanted to have my nose reconstructed so it would look better and more petite. I’d like for it to be a bit pointier and not so flat. I am completely clueless on what steps to take. I have a few pictures so you can see what I mean.

A: When it comes to considering rhinoplasty surgery, you have already identified the the first and most important step…how would I like my new nose to look? In looking at your pictures,  what you have is known as a bifid nasal tip in which the lower alar cartilages are completely separated. This accounts for why you have such a wide and flat nasal tip. The key to improvement is that the tip cartilages need support to obtain more projection through a columellar strut cartilage graft and the lower alar cartilages need to be brought together and narrowed.

While the quality of your nose pictures is very grainy which makes them hard to image, I have done some surgical predictions of nasal tip narrowing results that could be obtained through an open rhinoplasty procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have severe breast implant rippling. I had saline implants placed ten years ago. They were ok but then I had a baby and now there is severe rippling. I was thin to begin with but now have little breast tissue left. Rippling is bad on top of my breasts, even when standing straight. Recently found a mass of thicker tissue below and slightly off center of my left nipple. It looks a little puffy in the mirror. Ultrasound reveals normal breast tissue, but slight bump on implant below lump. What are my options for improvement of the appearance of my breasts?

A: Between being thin, having had breast implants for a period of time and then having a baby, you have lost most of your breast tissue and the natural rippling of saline implants has become evident. This can become really significant if the implants are above the muscle.With little breast tissue scar tissue around the valve can make it appear as a lump. Significant improvement of the rippling can only be done by changing the implants to silicone, trying to thicken the tissue interface between the skin and the implants by fat injections or allogeneic dermal grafts or both.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in ribcage narrowing. I came to your website as I was researching a couple procedures. I am 33 year old male to female transsexual. My waistline and hip area have always bothered me. I have pretty good shape but I have always wanted curvy hips and waistline. I have spoken with many physician’s everywhere and located a couple of options for rib resection. I thoroughly enjoyed your article on ribcage narrowing. I have been studying the process and anatomy for a long time and this was a very nice description and summation. It seems as though you’ve had some hands-on experience in this procedure. I am having my breast implants replaced in a couple months. My surgeon mentioned tummy tuck at sometime in the future. I know I have a little pooch and would like that. But I really would like it by aiding access for Thoracoplasty at the same time. The other procedure is an enhancement to my nipples. I have large breast 36D but sadly I have short, flaccid & small diameter nipples and would like them to be fuller length & diameter and also perkier. Thank you once again for your time.

A: Rib resection can be done at the same time and through the same access as a tummy tuck…depending upon what type of tummy tuck is being done. In a full tummy tuck, the elevation of the upper abdominal skin flap is done right up to the subcostal margin which provides direct access to the lower rib cage. However, during a mini-tummy tuck, there is little to no elevation of the upper abdominal skin flap and the access is better done by direct incisions over the lower rib cage.

From a nipple enlargement/enhancement standpoint, the only really effective approach would be fat injections. Injecting fat can both thicken, lengthen and stiffen the nipples with a minimal risk of any loss of feeling.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have had three prior facelift efforts and none have been effective at giving me an upward look to my face that crrently looks pulled down. It’s been recommended to me that a MACS lift might help pull upwards somewhat without involving the same incisions around the ears from the 3 previous facelifts. (I’ve been told that opening previous incisions could be risky.) Does a MACS lift have to include opening up the previous incisions around the ears or could it somehow be done otherwise. I am trying to get rid of my ‘hound dog’ look to my mouth and the deep creases above my lips.

A: Having had three prior facelift type procedures, it should be obvious by now that any type of facelifting effort is not going to improve the central aspect of your face. That is simply not where the pull from facelifts have their effects. Facelifts never improve sagging around the mouth and deep nasolabial folds. Thus, not type of MACS lift or any other variation of a facelift that uses the ears as the location for the direction of pull will work. Your prior facelifts have not failed because they did not improve these central facial areas as they have donen a good job with your neck and jawline which is where they work teh best. You are going to need to consider other more direct procedures such as corner of the mouth lifts, midface lift or even direct nasolabial fold excision to get this part of your face looking as rejuvenated as the jawline and neck.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in forehead augmentation. I would like it built out so there is more ‘space’ between my low hairline and my brows.How much volume and depth can be added to the forehead area? How large can the implant be?

A: I assume you are investigating forehead augmentation as a means to enlarge your vertically short forehead.  (distance between eyebrows and frontal hairline) The limitation to the size of a forehead augmentation (bone cement or implant) is exclusively based on how much the overlying forehead skin/scalp tissue will stretch. That is the only limiting factor. Yours is an interesting forehead problem because it is on the border of needing tissue expansion to make a really significant difference (extend the hairline back 1 to 2 cms) or would it be enough to build out (create increased convexity) with just a one-stage forehead augmentation. I think enough forehead augmentation could be obtained in one-stage but that would depend on the type of change you are looking for. It would be helpful to see a side view image of your forehead/face and then I could some computer imaging to see how much forehead augmentation would be acceptable.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had paranasal implants placed four months ago. Is it  possible you could have put one of the implants upside down.?I ask because even since the beginning of healing I can feel around the peripheral of each implant and the shapes are totally different. I have been wondering for a while. I say this because I truly wonder if its upside down. Even I can see that the fleshy higher cheek on the right was improved right next to to the lateral nostril but the fleshy cheek on the left is a lot flatter next to the nostril but then highe up the area comes forward.  It is like they one is flipped upside down from the way it looks and feels.

A: I would say that the chances of a paranasal implant being upside down is very unlikely. And I say that for three specific reasons; 1) The shape of the implant has a convex and a concave side to fit into the concave shape of the paranasal region. Trying to make it fit upside down would be very obvious as it wouldn’t lay flat against the bone very well, 2) Each implant has an L (right side) or a reverse L shape (left side). Putting it in upside down would have the L facing the wrong way which would be very obvious, and 3) When placing a small screw to fix the implant to the bone, it is put into the outer flange of the implant and is only 5mms long. If the implant was flipped, its outer flange would be sticking up and the screw would not be long enough to get to the bone.

Having said that, because of the paired nature of facial implants (cheeks, paranasal, jaw angles), slight differences in their positions between the sides can be really obvious. This is particularly true the closer one gets to the facial midline. (paranasals) If the implants are even off a few millimeters up or down or side to side, such differences can be easily seen and felt. That is is the more likely scenario with your paranasal implants than that one has been placed upside down.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had breast augmentation three months ago. Can I lift weights if my breast implants are under the muscle? I am almost three months after surgery. I have 450cc silicone implants put in under the muscle on both sides. Do I have my final result now? I want to know if I can go ahead and lift weights. I don’t want to work so much on my chest but to start doing biceps and triceps to tone my arms with light weights and more reps. Can I do that now?

A: At three months after your breast augmentation surgery, it is fair to say that you are looking at the final result. Even though the implants are under the muscle (partially),  there is no reason you can not resume any form of chest or arm workouts. I usually let my patients resume any activity that involves pectoral muscle activity as soon as possible after surgery so they recover faster. Three months from surgery is more than an adeaquate amount of recovery time.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am inquiring about getting a calf implant. I had ruptured achilles on my right leg about 10 years ago and muscle never developed back properly.

A: One of the most common reasons for a calf implant is to improve lower leg asymmetry after such congenital problems as clubfoot or traumatic injuries. When the achilles tendon is ruptured, the soleus and gastrocnemius muscles which are attached to it can become atrophic due to immobility and subsequent muscle atrophy. Even with rehabilitation, the muscle volume does not come back. Calf implant augmentation can help restore some of the volume by adding volume under the fascia but on top of the muscle. Based on the size of the medial head of your gastrocnemius muscle (length and width) different sized calf implants are available to augment it. This is done an incision on the back of the knee.This is done as an outpatient procedure that usually takes about 30 minutes for the insertion of one calf implant. While calf augmentation surgery can involvhe significant recovery, having the surgery in just one leg makes it easier.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in scar revision surgery. Actually I would like it completely gone.  I have a 2 1/2 inch hypertrophic horizontal scar on my upper chest that is raised and tender. I would love to have it removed if possible. Here are the  some photos of it.  The scar is not a result of an injury or laceration. Suspected to be result of an ingrown hair follicle.

A: What you have is a hypertrophic scar and may be on the borderline of an actual keloid type scar. Its appearance and history suggests, in my experience, that may be ‘resistant’ to scar revision surgery. While it can surgically be excised into a fine line (there is no such thing as complete scar removal), its location on the chest gives it a high probability of recurrence, particularly with your darkly pigmented skin. That is the risk in doing it. When such a scar results from an otherwise innocuous event and remains painful for a long time and maybe even growing, this indicates that is exactly what will likely recur when it is surgically removed. The chest is a notorious place for poor scar formation. The best you can hope for is that the scar does not come back as wide as it once was. There will be some recurrent scar widening, it is just a question of how much.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to schedule a consultation for chin reduction. My chin is too long and slightly asymmetrical. I am from out of town. If surgery goes as planned how many trips will I have to make to see you in person?

A: Your pictures show a chin that is somewhat vertically long and has some asymmetry with a left-sided deviated chin point. The correct way to shorten and straighten your chin in through an intraoral genioplasty with an asymmetrical wedge removal for shortening and realigning the chin point. This is a procedure that takes about one hour under general anesthesia. You could return home within 24 to 48 hours. Any followups would be done by e-mail or Skype just like you are making this inquiry. Expect some substantial chin swelling afterwards that will take about 4 to 6 weeks to see the final result. Sutures inside the mouth are dissolvable so there is no need for their removal.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Would you give me more information on what the surgery for buttock implant removal would consist of. I would like to get them removed sometime next year since I spent so much on them already I need to save some money once again. I don’t know if it could damage the muscle that the implant is in since it has been split open. Would it heal together well enough to go back to normal activities? Will it leave my buttocks saggy to a point where exercise won’t help? Last what would you charge me for a procedure like this even though you didn’t place them?

A: Buttock implant removal has many similarities to placing them, minus the severe pain and swelling. It is a matter of reopening the incision and removing the implants from their location. Since the muscular pocket is already dissected and the implants are smooth silicone, they will slide right on out. Whether any fat grafting should be done at the same time to still end up with some augmentation effect depends on how much fat one has to give. Once healed (a few weeks) you may return to all normal activities. The interesting question is whether you would develop any buttock sagging afterwards. That is usually not the case since the implants are in the upper 1/2 of the buttocks and have not distended the buttock tissue on the lower half where sagging is more likely to occur. Suffice it to say that the cost to remove buttock implants is usually far less than what it was to put them in.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am seeking orbital floor augmentation. I have a mild case of orbital dystopia of my left eye. It is about 2mms as judging by the position of iris of the eye to the lower eyelid compared to the other side. How would orbital floor augmentation be done. Would there be any external scarring?

A: There are numerous options of how to do orbital floor augmentation. There are two choices to make in orbital floor augmentation, incisional access and the choice of augmentation material. Because your orbital dystopia problem is fairly slight (1 to 2mms), your young age, and your asian skin, I am loathe to consider any type of open procedure that involves an external lower blepharoplasty incision. While that is how I would normally do it, I just don’t think your amount of orbital floor augmentation justifies that degree of invasive surgery. That leaves either a transconjuncival approach or a purely injectable technique. Because it is the eyeball and for safety purposes, I would not do an injectable method. That leaves us with the transconjunctival approach. (internal eyelid) The next issue is the augmentation material. This is a choice between a natural material (like fat or cartilage) or a synthetic implant. This is a classic debate in orbital floor augmentation and just about anything will work. It just depends on your thoughts of a graft harvest (ear cartilage or fat harvest) or a synthetic material. (like a bone cement or gore-tex (PTFE) floor implant. There is also the issue of how much access the transconjunctival approach offers and the ability to get the augmentation material through it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, In looking for jawline implants for total jawline enhancement do you think a good combined solution for chin and jaw is the Medpor Matrix system, or do the chin and jaw implants separately? I currently have some hyaluronic acid directly on my jaw angle and line because I did not know about such implants until recently, so I think I should remove that with “Hylase” before determining implant sizes.

My final questions to understand the size and shape of the implants and surgery would be:

a) JAW: The horizontal width of the RZ mandibular angle implants is 11mm (or 7mm respectively) at the LOWEST point of the implant and diminishing gradually to the top – like a triangle, correct? And as you mentioned the  VERTICAL DROP is ALWAYS 10 mm regardless of the horizontal width of 3, 7, or 11mm? (which can be shaved down I guess if necessary?)

b) CHIN: With respect to a chin augmentation:  If, just theoretically, I am satisfied with the length (anterior projection) of my chin length but NOT with the lateral horizontal width and shape (which I want to be SQUARE and 5 cm ranging from one corner of the mouth to the other) – are there available or can you shave down an medpor RZ extended chin implant so that there is NO or only 1-2 mm anterior projection but the same lateral and inferior projection as the medium sized RZ Ext Square chin implant? So practically speaking a customized RZ Square chin implant augmenting only laterally the side parts of the chin (like an implant without or only a 1-2 mm middle part9). An implant which makes the chin look more square and broader, which augments the lateral parts of the chin. (hope I expressed myself properly)

A: If I have to use off-the shelf implants, I generally stay away from Medpor because they are hard to put in, never fit very well to the bone, hard to stabilize to the bone and very hard to revise if that ever needs to be done. (of which the risk is about 25% of that need) I have used them a lot and the more I use them the less I like them. None of their purported benefits are true, other than soft tissue adheres to the implants making them a near nightmare to ever revise. But I will still use them when patients insist and some patients, like you, have an affinity for it.

When it comes to total jawline augmentation with Medpor, I would use a three-piece chin and jaw angle approach and not the Matrix system. The Matrix system is extremely hard to put in and virtually impossible to ever remove or revise due to the features of the material as previously described. Since the chin implant is put in as a two-piece implant with a male-female connector, it is easy to make a square implant but how far or close the two pieces are put together. It is, in essence, and adjustable width chin implant. When in doubt about jaw angle widths with the RZ style, it is always better to go with the biggest size as it can also be reduced during surgery. (but you can’t add to it)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, How much for liposuction, specifically smart lipo, of the abdomen? Here is a picture of my abdomen. I am not interested in a tummy tuck scar and the recovery time. Thanks.

A: While I can understand why you would want to pursue some form of liposuction, it is neither the appropriate or effective contouring procedure for your abdominal problem. You have as much excess skin as fat as part of the loose abdominal overhang. Removing fat will only cause more loose skin and will not get rid of the overhang. It may likely leave your abdominal problem with no substantative improvement. While no one understandably wants a tummy tuck scar or the recovery from it, this is the only procedure that will be effective for your concerns. Do not waste money or effort on a liposuction procedure that will not work for you.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have just visited your website and it gave me some hope. I saw the archive where you response to people’s problems. I thought that I may try to ask you some questions. I attached the photo of my head and as you can see it is not proportional. I really do not like that my head is so wide and the forehead is so high. Could you tell me what kind of surgery operations I need to get my head look better and be smaller certainly. I thought about temporal reduction, cheekbone reduction and maybe lowering the hairline. I think temporal is the worst thing, not only muscle but I feel the bone aboue ears … I would like to know your opinion what can be done and what kind of effect I could expect. The last and probably the most important question is about the price of surgeries you suggest 🙂 I hope you will give me a hope for better future 😉 Thanks in advance!

A: The most improveable feature of your concerns, and the ‘easiest’ is the temporal reduction which narrows the appearance of the transverse width of the head. While it does require some vertical incisions on the side of the head., much of the temporalis muscle can be released with some bone reduction to make for a visible narrowing. (see attached imaging prediction) Hairline lower is not really an option for you unless you have a first stage scalp tissue expander placed to create more scalp tissue top bring forward. Cheekbone reduction can be done through an incision inside the mouth (and the back part of the zygomatic arch moved through the temporal incisions) but the usual inward movement averages about 5 to 6mms at best in most people.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am seeking facial scar revision. I have a straight facial scar from the corner of my ear to the corner of my mouth on the left side of my face. It was from a knife attack.  It happened when I was 16. I am now almost 47 years old. Could you please review my face?= and tell me if I am a good candidate for scar revision?

A: In looking at your pictures, the scar width is not terribly wide but it is a straight line from the mouth to the ear. As would be expected from an injury now thirty years old, the scar is quite mature. There is probably merit to excising the scar and placing some geometric changes along the line that breaks up its linearity, particularly in the locations of the smile lines. While there is no way to ever completely remove the scar, it is possible to make it less obvious than it is right now.

The key decision for your scar revision, however, is unique because of how old the scar is and your age. You have lived with it for so long it is an accepted part of your appearance. (I didn’t say you liked it but it has been with you for most of your life) Whether the time necessary for healing and having the scar mature again to get to whatever improvement can be obtained is a big sacrifice at your point in life. Whether the amount of improvement obtained is worthy of that sacrifice is very hard to determine beforehand.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Do I qualify for a tummy tuck based on my weight of 155 lbs at 5’ 6”? Also I would like to down size my 650cc saline implants to something considerably smaller.

A: Based on your pictures which show a double abdominal roll, you would definitely benefit by a tummy tuck which would eliminate that problem. You can also certainly downsize your implants and I will assume for now that you want to stay with saline implants. The one issue with downsizing is what will happen to the overlying breast tissue. You already have some breast tissue bottoming out and that will get more substantial with downsizing. I see the scars around the areolas which I presume is from a periareolar mastopexy with your original augmentation. To deal with these issues I would do an inframammary fold excision/tuck with your implant downsizing as well as possible a periareolar scar revision.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I believe I suffer from diastasis recti. I have had 2 pregnancies, and both were c-section deliveries. My first was emergency and my second was scheduled. I have all of the symptoms of diastasis recti, and have been to numerous doctors complaining of these symptoms over the last 5 years. None ever even mentioned diastasis. Have you done many surgeries to correct this? Are they successful? Thank you for your time!

A: Diastasis recti are a very common abdominal wall deformity after multiple pregnancies. It is important, however, to not confuse this with a hernia which is an actual hole in the abdominal wall. Diastasis recti is the vertical separation of the muscular union across the midline of the abdominal wall but has an intact wall unlike a hernia. In thin women a diastasis recti can be seen as a deep wide groove from the lower end of the sternum down to or past the belly button. Reapproximating or repairing the diastasis recti is a common part of an abdominoplasty or tummy tuck procedure, mainly because there is wide open access to do it and it helps produce some additional abdominal flattening. It is repaired by sewing it together with permanent sutures, hence the term ‘sewing the muscles together’ when a tummy tuck procedure is described. It is very rarely, if ever, done as an isolated procedure outside of a tummy tuck as there is no medical reason to do so since it is not an actual hernia. Unlike a hernia, women do not usually complain of symptoms from it other than the aesthetic look of it if they are thin enough to see it. It is also a procedure that is not covered by insurance whether it is done as part of the tummy tuck or even as a stand alone procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am having a rhinoplasty by you later this fall. I was planning on a facelift and breast lift with fat transfer to face and breast. It’s the  beginning of a body makeover. I would prefer having you since the surgeons in my area aren’t capable of correcting the nose. Can we do all of the surgery mentioned above, I would  really like to do as much as possible.

A: Such combined face and body procedures are often done together and the economy of time, cost and recovery are the obvious reasons why many patients seek to maximize their operative experience. But each patient must be assessed individually to determine if it is the right concept for them. In making that determination the important factors are two-fold; is it safe and is the best result achievable in one combined surgery? From a safety standpoint, 62 years old is perfectly fine for these procedures as long as one is healthy with no major medical problems. (which you are) For your immediate recovery, however, such combination of procedures should only be done if you are observed overnite in the facility. That would be particularly paramount since you are from out of town.

From a procedure standpoint, combining a rhinoplasty and facelift (with or without fat transfers) is very common. The nose is a central facial procedure and the facelift is a lateral facial procedure so one does not affect the other. For a breast lift, however, volume augmentation by fat injections may or may not be affected by the lift. That would depend on what type of lift is being performed and what quadrant(s) of the breast fat may needed to be added. Depending upon your degree of ptosis (sagging) you may only need the Refine internal suspension lift with outward superior nipple lifts. That would allow the maximal volume of fat to be added at the same time. I would need to see some pictures of your breasts to better answer this procedural question.

Dr. Barry Eppley

Indianapolis, Indiana