Your Questions

Q: Dr. Eppley, I have never been terribly overweight, however, I can’t lose the belly fat. I would also like to take a few years off my face. Most people tell me I look to be about 45, I’m actually 56. My looks probably matter more to me than most people as I currently work in a very visible public position so I feel I need to look my best so I can stay in this business until I retire. I would like to know what I can get done and not have to be off work any long periods of time. I am very interested in liposuction of my stomach/butt/thighs/ and arms, possible facial work later.

A: Since body contouring in your primary focus for now, I will keep my comments to that area. The most important question based on your inquiry is what is the best treatment for your body fat concerns. The abdominal area is always the one body area where the debate is between liposuction and a tummy tuck. It has been my experience that most people assume that liposuction can do too much, that it can magically remove a lot of fat and tighten up a lot of loose skin. While liposuction is a very good fat remover, it can do little for excess skin. Thus whether it is an appropriate surgical method for your abdomen, arm, thighs and buttocks issues will require a physical examination to answer. My concern for you is that the desire for great body contour changes and little time of work often do not go together very well.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in enhanced fat injections, but was told by a doctor that it was no longer allowed but see you are discussing it so you must be using it. I have a couple questions. I had a lumpectomy nine months ago with radiation. Can not get implants so I am looking at fat injections to fill the hole and add some volume as my beasts are quite small. Is this a procedure you would recommend for someone in very good health and 69 years old? Can injections be done on my other breast to increase volume?

A: The term ‘enhanced’ fat injections can have various meanings. Some use the term to simply refer to liposuction-harvested fat that is  concentrated and then injected. Other interpretations refer to actually adding a stimulant to concentrated fat such as PRP (platelet-rich plasma), stem cells or even insulin. I prefer to use this latter definition of enhanced fat injections as adding something to the concentrated fat.

Currently no one really knows if adding any agent to concentrated fat is helpful in creating better fat survival but it remains biologically appealing. The addition of stem cells to fat is the most intriguing and captures the greatest public interest. But the harvesting of stem cells, growing them in cell culture and putting them back into a patient is not presently permitted by the FDA unless it is part of a sponsored clinical study. (as no one knows what such concentrates of stem cells will really do) Fat, by its composition, already has a lot of stem cells so every fat injection is technically already ‘enhanced’ to some degree.

Since the addition of extra stem cells is not permitted, I prefer to add PRP to smaller volume fat injections. PRP is an extract of your own blood that contains platelets which are full of various growth factors. These have well known stimulant properties on wound healing, take a few minutes during the procedure to harvest and concentrate and are easily mixed in with fat.

Fat injections are an excellent treatment for lumpectomy defects particularly in tissues that have received radiation, regardless of the patient’s age. While fat can also be injected into breasts for general volume enhancement, the success of that breast augmentation approach depends on what your breast currently look like and what result you are expecting to achieve.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m wondering if a jaw surgery can correct my facial features. My jaw appears to start almost directly from my ears and angle downwards instead of forwards like you see in pretty people. My face is long and narrows towards a tiny recessed chin.  Actually, the lower third of my face angles backwards. My chin is slightly bumpy with my mouth closed, and very bumpy when I stick my bottom lips out. I have no bite problems since I’ve had braces when I was a teen (spacers for crowded teeth and a hyrax to expand my upper palete, but no headgear or tooth removal) I’ve heard that orthodontics can lengthen the face and lead to a recessed chin and humped nose over time. I’m not sure if my braces caused my facial problems or if it is genetic because my dad also has similar facial features and also had braces when he was younger. Is there a jaw surgery, or perhaps multiple surgeries that can fix the angle of my jaw and also my recessed features?

A: Your pictures show a classic case of a short lower jaw with a small chin and a high jaw angle. Your chin also shows a mentalis muscle strain which is why it is bumpy. (muscle fasciculations) Since you have no occlusal disharmony (bite problems), jaw surgery (moving the entire jaw forward) can not be done. Even if your jaw was moved forward the high jaw angles would not be changed. (the chin would be corrected however) The proper treatment for you now is a combined sliding genioplasty (moving the chin bone forward) combined with vertical lengthening jaw angle implants. This combination puts the shape of the lower jaw in better balance. (chin comes forward, jaw angles drop down)

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, Do you ever harvest fat from the pubic area for breast inhancement? I had smart lipo done on my abdomen and bra roll area. I have excess fat in the area of my pubic bone and inner thighs. I also have a small hump on my back below my neck. I am a young 64. I have execised and taken care of my body. My breasts are ok, they just need some filling out on the top to give me more cleavage.I have good elasticity. I also had smart lipo on my breasts about 10 months ago. They have lifted 2cm. I would be interested in an arm lift in the future.

A:When it comes to getting fat injections placed elsewhere in the body, particularly for the breasts which will require some volume,  you get it wherever you can. The pubic area can be a rich site for fat often offering as much as 100cc of good fat. That area combined with your inner thigh and knees may be just enough to get at least 200cc of concentrated fat for each breast. The arms would be another potential site of harvest since you may be gettings armlifts in the future anyway (as you have mentioned) and creating some skin laxity is not a concern.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a question. I had a chin implant done on Aug 6th and I am experiencing lower lip and chin numbness on the left side. My smile is not the same as it was and I am starting to get concerned. The numbness is my real concern as it is driving me crazy. I don’t know what to do and I am becoming depressed. I am only 22 years old and I do not want this feeling for the rest of my life. Do you think it will go away? Should I get the implant removed or will this cause more injury to the nerve? Please if you could get back to me I would really appreciate it.

A:  The recovery from chin implant surgery is almost always more significant than patients realize or have been told. (or what they have heard when the recovery part is discussed with them) It takes a good 6 weeks for about 90% of the recovery to have occurred. Chin stiffness, distortion, numbness and a lower lip or smile that is not normal is all part of the recovery process. Given that you are just one week from surgery, your concerns are way premature and you need to let the process work itself out for 4 to 6 weeks after surgery. Most of your current issues will either be gone or be well on the way to recovery that you will likely be happy than you had the procedure. Your lip numbness would be more concerning if it was still present in its current degree without any improvement at six weeks after surgery

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had cheekbone reduction using the L method. Now cheeks are really low. I want to ask can you put an implant on top of the cheekbones which have been cut and screwed in a lower position? Or is this not possible as it may make the already cut cheekbones move position or fall off??

A: Your cheek bone prominence can be restored by the placement of an implant on the cheekbone. Even though the face of the cheekbone has changed, cheek implants are screwed into position so there is no chance of shifting or falling off of the face of the cheekbone. Having a prior cheekbone reduction does not preclude the placement of cheek implants later.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, have you ever treated sufferers of migraines caused by (likely) the hard throbbing of the superficial temporal artery. My wife has 5 migraines a week, nearly all of which are in this area. We do not understand the root cause of the pulsations themselves, but it is possible these hard pulsations (lasting hours, or even days on end) are irritating the nerves local to the artery, and becoming interpreted as migraine in the brain. Given that medications (and neurologists and others) offer no relief, and she has suffered for decades, we are exploring procedures. Thank you.

A: While getting to the origin or even finding an effective treatment for migraines is never simple, the simple answer to your question is yes. It is very possible that high flow through the superficial temporal artery (STA) can be a source of migraines. While I would have initially thought it was possible but with a low probability, I recently treated a lady with a 30 year history of refractory migraines of the right temporal region with 2-point ligation of the STA with a dramatic and sustained reduction of her migraines. She felt that the pulsations she was feeling was a major contributor to her migraines and the origins was clearly on the temporal side with very visible pulsations. Given that there is no risk of any downside to STA ligation and it is a minor procedure with no recovery, it seemed like a reasonable thing to do.

While there would be no guarantee that STA ligationswould be effective for your wife’s migraines, and they should always be done from two points to eliminate recurrent pulsations due to retrograde flow, it would be relatively easy to eliminate this potential source.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to know the differences in the frontal view after orbital decompression and brow bone augmentation? I would like to get deeper set eyes but I know decompressions has a lot of side effects. Do you have photos of before after to show for brow bone augmentation? Thank you

A: Orbital decompression will not produce deep set eyes in a normal patient. While orbital decompression is effective for the patient with protruding eyes (exophthalmos), this is because it is an abnormal protrusion and dropping out the orbital floor bone will give the enlarged eye a space to fall back into. In the normal non-enlarged eye, dropping the orbital floor will only make the eyeball fall lower and not back. Thus in the frontal view, the eyeball may look lower and the pupil drops down closer to the lower eyelid margin. Conversely, brow bone augmentation combined with lateral orbital rim augmentation will make the eye look deep because it moves the bony rims around it further forward. This can be shown by looking at before and after pictures of brow bone/forehead augmentation which can be seen on my website in the Facial Reshaping section under those specific procedures.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to know if the implants that you use to replenish the infraorbital eyelids are the same used for the cheeks or are this special for this area? Last year I had put some implants under my eye this were the regular implants for the cheek but the doctor cut them to reduce them. My problem is that my skin is very thin under the eye and the implant shows the edges and feels hard so it looks and feels unnatural. Please tell me if there is a remedy. Maybe the implants you use look more natural.

A: One of the important issues with infraorbital rim implants is their positioning along the inferior orbital rim. Depending upon the aesthetic purpose, they may be used to provide more horizontal projection to the bony rim but still stay below the edge of the bone or they may be used to treat under eye hollows and are raised above the level of the bony rim. Depending upon their size and shape of the implant there is the risk of palpability of the implant edge. More uncommonly there is also the potential for actually being able to see the implant edge through the thin skin of the lower eyelid. I don’t know what type of implants you had placed (Medpor vs silicone) or exactly where on the bone they are located. If standard cheek implants were used and then modified for the infraorbital rim area, it would be unlikely they would have perfectly smooth edges. Based on just your question alone, the remedy may be to have implants that are actually made for that facial bony area.

It would be helpful to have some more information, such as a picture of you showing exactly where the edge of the orbital rim implants are that you feel.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 22 years old. My question is in regards to my face which is crooked. It does not have the best shape. The right side of my face is not equal with the left side. (see attached picture) Because my face does not look good, I have no confidence. Please suggest to me what I am supposed to do.Your advise is highly appreciated.

A: Your picture shows that you have significant facial asymmetry. The left side of your face shows hemifacial hypoplasia (hemifacial microsomia) as demonstrated by significant left chin deviation, a flattened left cheek and an inferiorly positioned (low) left eye and eyebrow. There are a variety of facial plastic surgery procedures that can help improve your facial asymmetry. Beginning from the bottom of your face and working up, the chin can be brought back to the facial midline by a sliding genioplasty, the left cheek built up by an implant, the eye raised up by an orbital floor implant with repositioning of the left canthus (corner of the eye) and the lower brow lifted by an endoscopic browlift. While all of them done together will produce the best degree of facial symmetry improvement, treatment of the chin and cheek asymmetries are the most important as well as the most improveable of the facial deficiences.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I recently had an injectable filler treatment done for my hollows under my eyes. Besides a few lumps there is one lump that actually has a bluish color to it. I thought that it may be because it was bruised. But three weeks after he injections it has not changed. What is causing this coloration and will it eventually go away?

A: You undoubtably were injected with one of the hyaluronic acid-based injectable fillers which is the most common one used in the thin skinned area under the eyes. What you are seeing is known as the Tyndall effect, a well known phenomenon from injectable fillers which can be seen when they are placed right under the skin too superficially. Because the injectable fillers is really a colloid and not a solution, there are large molecules of the hyaluron chains that are floating around in the gel solution. When injected too close to the skin the superficially placed filler material allows light to be scattered off of the floating particles. It appears blue because only the scattered longer wavelength blue light is reflected back to the viewer while other light wavelengths are less scattered. While aesthetically disturbing it is not harmful and will eventually resolve itself as the material absorbs. Because filler can last a very long time in the eyelids, you may consider hyaluronidase injections to help it dissolve much sooner than its expected implantation duration.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have recently had a medium Terino style 1 chin implant and medium lateral jaw angle implants, with another surgeon. I wasn’t happy, and I had the jaw implants removed a week later. For some reason the 2 implants didn’t seem to go together, the jaw implants made my chin look like it was recessed again, and the sides of my jowls looked very narrow, even though they improved the back of my jaw. I now wonder if it was the chin implant I should have removed and replaced instead. I wonder if it was the combination of sizing that was the problem, I want to have a strong jaw that flows all the way to the back. I have a thin face and the sides of my chin, near the corners of my mouth, still look very  narrow. What could be done to solve this problem? Thanks

A: Standard chin and jaw angle implants rarely overlap and, even if they do, will rarely ever make for a straight jawline from chin to jaw angle. That is beyond what they capable of doing. When a patient agrees to have off the shelf stock implants they should know that is the look they can not achieve. Only a custom-designed one-piece jawline implant will provide a straightline effect from front to back because it is made to do so.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, my husband had maxillofacial surgery for an under bite and put cheek implants in to balance his facial features about five years ago. He has had problems with the left cheek implant moving slightly and when he blows his nose his left cheek gets swollen and you can feel bubble like things moving around implant. It has caused him a lot of pressure and pain and this happens more often. I have begged him to go to the Dr but the entire experience of the surgery has traumatized him and so I’m trying to figure out what’s wrong. Please help me try to help my husband.

A:  Undoubtably what your husband is experiencing is what one may call a ‘blowhole’ in the simplest of terms. When a maxillary osteotomy (LeFort I osteotomy) is done, the bone cut across the upepr jaw exposes the entire maxillary sinus. While most osteotomy lines experience complete bony healing afterwards, some do not particularly larger maxillary advancements and those that may have been vertically elongated. Any large unhealed bony openings allows air to escape from the maxillary sinus up into the cheek facial area, particularly when the air is forced such as blowing one’s nose. A cheek implant may be laying right next to or even over the original osteotomy line. This air being forced into and around a cheek implant (if it is not secured with a screw) make make it move slightly from the air pressure. Air into the subcutaneous tissues of the face is known as crepitus, which you more commonly call ‘bubbles’.

Thus there is a bony hole right next to the cheek implant as the culprit of all of these symptoms. This is a relatively easy problem to fix by covering the bone hole (sealing the sinus from the face) and stabilizing the implant to the bone with a screw. This is a simple outpatient procedure done under general anesthesia with minimal recovery. The only question is what to use to seal the bone hole as a variety of materials can be used to accomplish that end.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to have the adam’s apple reduction procedure. I am a natural man and I don’t like the size of my adam’s apple. It is very big but I have doubts whether I should do or not do the surgery. I have researched photos of men who have this surgery but I found a few pictures and a few angles but some of the results didn’t seem good. What has been your experience with adam’s apple reduction surgery and how good are the results?

A: I have performed many adam’s apple reductions and about half of them are for men who just have a very prominent thyroid cartilage that is more than just a neck bump. The amount of visible reduction, however,  can be variable based on the anatomy of the thyroid cartilage, the thickness of the tissues overlying it and the aggressiveness and experience of the surgeon doing it. I suspect for most men who just want less of a neck bump size, rather than a completely flat neck profile, that the results are very satisfactory. It certainly can be difficult in some patients to get complete elimination of it but that it is not usually the goal of men looking to make a big adam’s apple prominence smaller.  I would suggest that you send me some pictures of your neck, particularly from the side, for my assessment to see if this procedure would be worthwhile for you in terms of the amount of reduction that could be achieved.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am considering labial reduction surgery with a tummy tuck. It seems like a good time to do both since they are in proximity to each other and I assume that the bigger recovery comes from the tummy tuck anyway. My plastic surgeon was fairly thorough on the after surgery instructions for the tummy tuck but told me nothing about what to do after the labial reduction. What do you tell patients after this kind of plastic surgery?

A: While the size of the area operated on in labiaplasty is relatively small, it is in a sensitive area. Good hygiene with sitz baths or a spray bottle several times a day is needed and the application of antibiotic ointment for a week after surgery. Since you are having a tummy tuck, cleansing the area with a spray bottle will need to be done. Oral antibiotics are given and will be taken for a week after surgery. If you have a known problem of developing yeast infections while on antibiotics, Diflucan will be given along with the antibiotic. Narcotic pain medication will be needed for the tummy tuck so this will cover the labiaplasty as well. Expect some swelling and a little bruising of the labia for a =few weeks afterwards. Cool compresses can be used to help alleviate pain and help with the swelling. From an activity standpoint, moderate exercise can be resumed after three weeks. One should not have intercourse for a month after surgery to prevent irritation of the suture lines and possible wound opening. Other activities that require straddling a seat such as horseback riding and bicycle/motorcycle riding should be similarly avoided.  For the same reason, tampon use should be avoided for a month as well. Be aware that scar tissue will form along the suture lines and this will initially feel hard and sometimes a little sensitive. This will take several months to soften. By six weeks after surgery you should be able to return to all activities without restriction and be fully healed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I just got stitches above my top lip. The stitches go across the ridges under my nose. I’m so worried it’s going to leave a ugly scar. My dog jumped on the couch and his hind foot landed on my face. He felt like he was losing his balance and used his claws and that is how I got the cut in my face. The ER doctor did a good job on stitching up the cut. The cut goes from my lip to my nose. What can be done to keep the scarring down?

A: What you want to do to get the best lip scar result is the following. First, get the lip sutures removed in no more than 5 to 7 days after surgery. I don’t know if the doctor used  a layered closure or what size the skin sutures are. If there is no dermal buried sutures below the skin sutures, then have a glue dressing (e.g., Dermabond, Indermil) applied once the sutures are removed. Second, beginning three weeks after surgery begin to apply a topical scar treatment twice a day. There are many type of scar gels and strips but on the lip a scar gel is far more practical. Continue twice a day scar gel application until three months after the injury. At three months after injury it is time to evaluate the scar. If it is quite narrow and flat and the redness is fading fast then I would only consider scar gel for another month. If the scar is fairly narrow and flat but still very red, then I would do BBL (broad band light) therapy to work out some of the redness sooner. If the scar is irregular in contour or slightly wide then I would have some fractional laser resurfacing done to even it out. Only if the scar edges are widely separated and irregular would actual surgical scar revision be necessary. Expect the final scar result to take a full 9 to 12 months until the final and best scar outcome is seen.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, which has the most effect on your buttock size, implants or fat injections?Which has the better results because I do have some fat from having a baby. 

A: The choice between fat injections or implants for buttock augmentation depends on numerous factors. The most significant are how much fat you have to donate and how much buttock size increase you desire. Whether ‘some fat’ is enough to achieve a visible change depends on what your body looks like now. The largest donor source of fat is the stomach area although it can be taken from many other places as well such as the flanks and thighs. The minimum amount of fat one should have should be at least 1.5 liters to be able to put reduce it down to 400cc to 500cc per buttock. I wold consider this to be the minimum to justify the surgical effort. For some women, much more may be needed. If fat is inadequate then the only option is going to be implants.

If you could send a picture of your body and your height and weight that would be helpful in providing a more specific answer.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was wanting some more information about the Smart Lipo and discounts under the Patriot Program. 

A: Thank you for your inquiry. I would need to know what body areas you desire for liposuction and what they look like before a cost quote could be provided. You may feel free to do that by description or sending pictures, whichever conveys what you need. I would also point out that although I use Smartlipo technology for liopsuction it is done under general anesthesia and not local anesthesia to achieve the best results possible.

The Patriot Program is a discount program for plastic surgery for active military and their families. The amount of discounts from regular surgery fees are determined on a per patient basis. As a general rule, we make a 25% reduction from the normal surgeon’s fee for the procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Do you use stem cell therapy to fix atrophic rhinitis…to regenerate nasal bone, tissue and mucosa, particularly, nasal mucosa? I have a bad dry nose which is primarily atrophic rhinitis three years after the partial removal of nasal turbinate. All the medication from doctors does not help much. So I can’t wait to find out how stem cell therapy and tissue engineering are going on for help with atrophic rhinitis.  I read on other webpages that one plastic surgeon says you are the only doctor in the states doing this. Is that true? Thank you very much for your time. I’d really appreciate if when you kindly answer my question.

A: The treatment of atrophic rhinitis is a difficult problem for which there are no known therapies that are universally effective. The use of injectable autologous therapies offer promise for a lot of difficult clinical conditions in which some regeneration of function or regeneration of actual tissues would be therapeutic. Current autologous injection therapies include PRP (platelet-rich plasma) fat and stem cells. PRP is an extract of one’s own blood that contains platelet concentrates which have numerous potent growth factors in them. Fat concentrates are centrifuged or filtered aliquots of fat and stem cells. Stem cells can be isolated from fat but must be done concurrently as a direct isolate from the patient’s fat and immediately re-injected. The FDA currently bans the growth of stem cells from the patient as an isolated step in cell culture as a delayed reimplantation procedure.

The best approach currently for treating non-healing wounds and dysfunctional tissue elements, in my opinion, is the combination of PRP with a fat/stem cell concentrate. The entire nasal lining, septum and middle turbinates could be injected with up to 5ccs of this combined autologous therapy with the goal of reducing the degree of atrophic rhinitis. Understand that this is not exclusively stem cells but is a mixture of autologous elements that does partially include some stem cells. Whether this would be effective for atrophic rhinitis is not known as the primary problem is that the main producer of the moisturization of air (inferior turbinate) is missing. But whether the middle turbinate and other areas of nasal lining can compensate for it but being stimulated is the theoretical basis of the injections. Because it is an autologous therapy, there is no harm…it is just a question of how much benefit, if any, can be achieved.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I have a 16 yr. old son who was diagnosed with plagiocephaly at a year old.  He wore a helmet for several months and I’ve tried various therapies over the years but at 16 his head is still a little flat on the back right side of his head.  It’s really only noticeable from a bird’s eye view and not straight on.  He never talks to me about it and it is slight but I would like to offer him an alternative if it becomes bothersome to him.  I’ve read about the injectable kryptonite and want to learn more about this.  My son is a soccer player so I wanted to ask you if heading the ball would be an issue with this if he were to ever have the procedure done.  Thanks so much!

A: The surgery that I have evolved to today with a unilateral occipital plagiocephaly is a minimal incision cranioplasty using PMMA.  (acrylic bone cement) The kryptonite material is no longer available. This is the same technique only using a different material. Through a 1.5 inch incision in the scalp, the material is placed into position using a funnel technique and then shaped externally as it sets. Most patients need somewhere between 30 and 60 grams of material to provide better skull symmetry between the two sides. This material is actually stronger than bone so it is more resistant to blunt head trauma than your native skull bone.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I reviewed some of your work and like what I see. Does breast augmentation affect nipple sensitivity or the ability to be erect? Where are the scars located? What is average cost of the procedure?

A: The potential influence of breast augmentation on nipple sensation and erection is always a possibility in this surgery but the incidence of it occurring is very low. Various studies have shown that the incidence is around 1% to 3% regardless of the differing incisions used for implant insertion. (under the breast, the nipple or the armpit) The choice of incision location is somewhat dependent on what type of breast implant is chosen. (saline vs. silicone) Silicone implants can now be placed through the armpit using a funnel insertion device but there are size limitations which are usually less than 400cc to 450ccs in implant volume. Any size saline implant can be placed through the armpit since they are inflated after they are put in place. The cost of breast augmentation is affected by the implant type with saline breast augmentation being less costly than that of silicone breast augmentation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, At the moment, I am at a complete loss of what to do about my profile. I have had so many consultations now and have advice ranging from ‘do nothing’ to ‘have a neck lift, fat removal and chin implant at the same time’. I need to do something as it’s making me very self conscious and I hate seeing photos of myself from the side.

My problem is that I am only 27 and am apparently not a candidate for neck liposuction alone because of my bone structure. It has to be explained to me that I have a low hyoid bone that is creating a blunted neck angle so that my neck blends into my chin. My teeth do align so it is not a problem with my bite but I do also have a weak chin. 

From my own research it seems like a chin implant might provide me with the illusion of an improved neck angle but my concern is how it will impact my face front on and my smile- lots of reviews seem to say their jaw looks to masculine after a chin implant or that they can no longer show their bottom teeth when smiling. At the moment when I smile I show my bottom teeth, which I like, and my chin points slightly in feminine way. I also have a small indent in my chin when I smile and am unsure if a chin implant would make this worse. 

Do you have a recommended approach to this sort of problem? Given my age, I don’t want to risk ruining my face with anything too drastic! I do need to do something though as it’s making me really self conscious. 

Thanks in advance for your help. I do wish I was a more straightforward case!

A: Quite frankly you are a very straightforward case. The combination of chin augmentation and neck liposuction is the correct approach. The key to a successful chin augmentation in you is to understand that in the profile view there needs to be both a horizontal and vertical dimensional change and in the front view the chin shape needs to stay a triangular shape and not become too round or full which is more masculine. There are two ways to achieve these chin changes. An implant needs to have some vertical elongation and must be more of a central buton style that has no significant lateral wings to it. The other option is a sliding genioplasty which can be brought forward as well as down. (vertical lengthening) Sliding genioplasties will always keep a narrow chin or make one more narrow as it comes forward because it is a U-shaped that is being brought forward. The indent in your chin, whether the augmentation is done by an implant or an osteotomy, will not change.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, The shortened version is that I first got lipo on the backs of my thighs 15 years ago about age 20. The surgeon took too much fat out under my buttocks creating banana rolls. I had several corrective lipo surgeries and subsequent three fat transfers. The fat transfers seemed to transfer the fat too low (not in the crease under the buttocks) creating a more pronounced banana roll and more rolls beneath. No exercise will help and I just don’t want to go through life with these legs. It’s hard to even wear pants without the rolls showing. I found you beause I saw a surgery you did removing skin, (more on the lower buttocks I think) and because it seems like you do a lot of body implants. I’m afraid to cut the rolls out because of the scar and particularly because the scar could spread due to my active lifestyle.  I would consider it however. I’m wondering if you think a combination of lipo and some implants in my legs would be a possibility. I don’t care if it makes my thighs bigger I just want them to look even. I have a one year old and am hoping to get pregnant within the next year. 

1. Would thigh implants be possible or would skin need to be removed?

2 . Should I wait until I have recovered from my next child? I only want to have two.

A: Thank you for sharing your story and pictures. You now have a double roll lower buttock deformity. There is a defined roll both above and below the infragluteal crease. Without knowing your history one would say to just try liposuction…but that is of course how you got here in the first place. The only way you are going to eliminate those rolls is to treat the problem which is too much skin and fat through excision. (lower buttock tuck/lift) This is not a problem that is amenable to implant augmentation or further liposuction. By removing a horizontal wedge of skin and fat both above and below your existing crease line the rolls can be eliminated and a more defined infragluteal crease can be obtained. While this does create a scar, I have not found it to be problematic for any patient. Significant scar spreading has been seen even in active patients. One does have to avoid strenuous exercise that pulls the gluteal crease apart for about 6 weeks after surgery. Whether this is something that is done before or after your next pregnancy is a personal issue. I don’t think pregnancy has any affect on the scar or the long-term outcome.

I hope this is helpful,

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I currently have separate Medpor chin and jaw angle implants. I also understand that you do custom facial implants using a person’s CT scans. My question is, assuming that I would like them replaced with a custom one-piece total jawline implant further down the road, would I have to remove the current implants before proper modeling can be done, or will you still be able to customize the jawline implant with the current implants still in place? Also, would the removal of these Medpor implants be possible? I’ve been to your blog and I understand that you’ve always stated that Medpor removal is possible, but hearing many other surgeons claim that it is impossible makes me a little afraid. Anyway, my preference would be to have the removal of the existing implants and placement of the new implants done together, as it would mean one surgery only. Regardless. kindly let me know what my options are.

A: The answers to your questions are as follows:

1) You can have CT imaging done with your Medpor implants in place. Medpor implants are not picked up especially well by CT scans and they do not appear in the images.

2) Your Medpor implants can be successfully removed, I have done it many times. They are not nearly as easy as silicone to remove but far from impossible to do so.

3) Removal of your existing jaw implants and their replacement would be done during the same surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, is there a way to reduce my forehead size or flatten my forehead? I have some substainal bumps from being tripped when I was 11 years old and they haven’t ever reduced or went down in size. The bumps are not too large on the front part of my forehead. Is that possible?

A: Bony forehead reduction can be done to some degree based on the size of the bone bumps and the thickness of the outer table of the frontal bone. Raised bumps can easily be reduced down to the level of the surrounding forehead. Beyond that about 4 to 5mms of forehead bone can generally be reduced before the diploic space between the outer and inner cranial tables is breached. Depending upon the exact nature of your forehead irregularities it can be very effective or at least offer some contour improvement. Burring reduction of the forehead area can be done through a pretrichial or hairline incision.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had Medpor chin and paranasal implants placed close to 3 weeks ago. The implants were both placed intraorally.However, I still have issues with stiffness and a little difficulty with lip closure. Can I just check whether these issues are normal at this stage of recovery, or is it something I should be worried about? The stiffness in movement is one that concerns me the most, as it does affect my speech a little. Lastly, if this isn’t typical, would removal of these implants be possible? 

A: What you are experiencing for these types of facial implants is extremely typical. My experience and what I counsel my patients on before surgery is that to expect the following recovery as it relates to swelling, function and aesthetics…50% by three weeks, 75% by 6 weeks and 100% by three months. Thus you are being way premature to even consider implant removal as you have not gotten yet to see what the final result will be. Your perception of what you thought your recovery would be is undoubtably much less than that and this accounts for your concern at this early recovery point. Patients understandably do not appreciate that this is, in essence, very similar to bone surgery even though it is done for aesthetic purposes.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to learn of the options available to repair elongated earlobes following a facelift in 2011.

A: Elongation of the earlobe after a facelift is the result of either too much tension placed on the earlobe when the facelift is closed or too much skin at the earlobe. The natural release of tension (skin relaxation) and gravity to gradually pull the earlobe down making it longer. This is a well known adverse facelift sequelae and has even been given a specific name, pixie ear deformity. There are two techniques for correcting these elongated earlobes. The simplest is a direct V-Y skin closure technique that can be done under local anesthesia in the office. The only negative to this approach is that there will be a visible vertical scar from the shortened position of the earlobe down to where it was maximally elongated. The other approach is to re-do a portion of the facelift in front of the ear using the same incisions, known as a mini-, limited, or short scar facelift. This lifts up and tightens the skin back up shortening the earlobe in the process. While this does require a one hour procedure in the operating room under sedation anesthesia, it does not leave any visible scar below the new earlobe position.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am having trouble deciding whether I need a breast lift alone or should have implants with it. I am 35 years old, had 2 kids and am a fairly full 34C. I do struggle to keep them in a C bra however. While I am happy with the size of my breasts I am not so with their shape. I just want back my fbreasts back up where they used to be and were nice and perky. I know I need a lift but am uncertain about whether an implant is necessary? I have several plastic surgery consutations and have been given different opinions, one says I definitely need it the other I cn have it or not. Neither doctor seems to be able to explain why in terms that I can understand and, quite frankly, they both seemed a little uncertain themselves. 

A: The breast issue that you have is a common one, once full breasts have fallen even though they have not necessarily gotten smaller. This has happened because of two breast tissue changes, there is now more skin and less internal breast tissue. That combination makes the change from a perky to a saggy breast. While you are happy with your breast size now know that they appear the same size because of the extra skin. When they are lifted, the breasts may appear smaller because a lot of extra skin has been removed. While breast lifts do not remove volume, this is why some women will have the perception that their breasts are a little smaller after a lift. There is also the longer term issue in that most breast lifts will lose the initial upper breast fullness that exists right after surgery as they settle with tissue relaxation. The role that a small breast implant may play for you then is in maintaining upper pole fullness and avoiding the fear that you may look a little smaller after a lift alone.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 47yrs old and I have had four children and over the years I have tried to lose the belly fat and the fat in my thighs. Question can you use the belly fat to enlarge my breast and not saline or silicone implants. I am a 36B and would just like to stay that way just want them to look fuller and firm.

A: While the appeal of breast augmentation with fat is undeniable, it has significant limitations compared to the use of traditional saline or silicone implants. It is different in the following ways:

1) It will cost 2x to 3x more

2) It will only increase the size of the breasts a 1/2 cup in most cases

3) It requires an adequate amount of donor fat

4) How well the fat takes is unpredictable, 100% almost never occurs

5) It may require more than one fat grafting session/surgery

6) Breast lumps and irregularities may occur

7) If you need a breast lift also, this must be done first and wait three months before doing the fat grafting

8) It requires one month before and one month after surgery of using the Brava breast suction device 8 to 12 hours per day

In short, breast augmentation with your own fat is not a comparable operation to doing it with synthetic implants. As we know it today, it is more expensive, less effective and not as efficient. It is best done on patients that have the proper motivation, expectations and breast and body anatomy. This will likely change in the future but for now it is only a good option for a very select few breast augmentation patients.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a sagging buttocks problem that started when I had liposuction done many years ago. No matter how much I diet and exercise the lower buttocks will not  tighten up. I have seen some pictutes of your buttock lift results and they show MAJOR improvement and the scarring seems minimal. Based on my pictures, would you anticipate my having similar results?  Do you have any concerns with my age (47) or the fact I have had previous lipo done?  What is the recovery like? As you can see, I have volume, I work out like crazy.  I want a symmetrical lifted butt.   Please tell me there is hope.

A: This is precisely the improvement I would expect. When you cut out the buttock overhang and tuck it, that is always the result one will get. It is an operation that just works. As long as one keeps the side part of the scar no further than the lateral edge of the lower gluteal crease, the scar is not visible. The fact that you have had liposuction previously is probably what may have contributed to the problem and, if anything, is more helpful than harmful as it enables the tuck to be done more effectively due to the loose skin that it has created. I have seen women have this procedure from age 30 to 72, but I don’t think age as anything to do with the success of the procedure. It is all about the anatomy of the problem. If there is overhang, it can be removed and tucked at any age. The recovery from a lower buttock lift is fairly easy. It is not a painful procedure afterwards, just a feeling of tightness in the lower buttocks. (which, of course, one should have if the procedure is done adequately) The only destruction in the first month after surgery is that one has to be careful about bending over which pulls on the incision line…but one is well aware of that because of its tightness. The biggest restriction of that is that one will not be doing any significant exercise that involves the legs.

Otherwise, this is a one hour procedure done under general anesthesia

Dr. Barry Eppley

Indianapolis, Indiana