Your Questions
Your Questions
Q: Dr. Eppley, I need your help as I have no jawline. My chin is very short, the neck seems to be missing and it appears as I almost have no lower jaw. This gives a profile that I am very self-conscious about. I make every effort so people don’t see me from the side. I know you are an expert in facial surgery based on your writings and patient photos so what do you recommend?
A: Lack of a well defined jawline and neck angle can be due to any one or combination of the following; chin/lower jaw bone prominence, fullness/fat in the neck and loose neck and jowl skin. Most commonly, the combination of a chin implant and neck liposuction can make a dramatic difference in the younger patient who often has a short chin and full neck. In older patients the sagging skin factors in significantly and some form of a jowl or necklift may be needed. There are exception to these two categories, such as the early aging facial patient with a good chin prominence who just needs some neck contouring through a procedure known as submentoplasty. But when someone describes themselves as having ‘no jaw’, this would indicate the problem is more than just one of the three anatomic components that make up the neck angle and jawline.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, on your website you mentioned orbital implants. I have deep set eyes. Can these orbital implants be placed in the upper eye area to fill in the hollowness. Thank you.
A: No they can not. There is no easily accessible superior bone space above the eye to access without significant risk. Actual implants can only be placed on the floor of the eye socket in which that space is more easily accessible without risk of eye muscle injury. Hollowness of the eyes, however, is rarely treated by implants anyway. It is better treated by fat injections/grafting which is placed between the skin and the underlying muscle. This is far easier to do and more effective. Its risks are largely cosmetic, how well does the fat survive and how smooth is its outward appearance.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, are there any good non-surgical treatments for sagging jowls. I am 56 years old and my neck isn’t too bad. But my jowls make me look like I have a bulldog face. I am not afraid of surgery but am worried about the cost and the recovery.
A: Jowling is always a major facial aging concern for many people as they hit 50 years old and beyond. There are some reasonably good treatments for jowls which are device or energy-based approaches. My current preferred approach is Exilis. This is a treatment based on radiofrequency waves which heat up the jowl fat and skin. This causes some fat atrophy and skin tightening. It requires a series of treatments, at least four spaced two weeks apart, to get the best result. While not as effective as surgery, it can make a very visible difference in the right patient who jowls have not developed beyond what a non-surgical approach can treat. The most effective approach, however, is a jowl lift. Your concerns about recovery are excessive when it comes to this tuckup procedure as it is a quick turnaround from the procedure until you are back into your regular routinue. While sugery is never appealing if it can be avoided, solving the problem in a single setting of an hour’s time can change one’s perception of it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I want to have a more shapely and manly chest. I have worked out a lot and simply can’t build up my pectoral muscles very much. It almost seems like I have a muscular deficiency in this area, they just won’t build up to my liking no matter how much iron I pump. I think the only way I am going to get there is with chest implants. Can you tell about how the operation is done and what type of implants are used? I assume it is pretty much like breast implants for women.
A In many ways, you are correct about the similarities between male pectoral implants and female breast implants. Like saline breast implants, pectoral implants are put in through an armpit incision (transaxillary approach) and are placed under the pectoral muscle. Unlike breast implants, however, the positrion of pectoral implants does not extend below the lower border of the muscle. This is a subtle but important placement issue to get the best increase in pectoral muscle outline. The biggest different is in the type of implant used. Pectoral implants are made of a solid (non-fluid filled) silicone elastomer material. It is very soft and has a spongy feel. They can not rupture or ever degrade and will never need to be replaced, which is very different from breast implants which have a limited lifespan.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have read recently about a procedure that lifts up the cheeks using an implantable device. It is supposed to go away after it is implanted. This sounds appealing but I don’t understand how it works and what happens to it after it is put in. How can something create a permanent effect when it goes away? Since it is used and put in by plastic surgeons and is sold commercially, it obviously is legitimate but I am confused as to how it works. Can you explain it to me?
A: What you are specifically referring to is the Endotine Midface Lift Device. This is a small platform with small angled spikes on its outer surface that is made of a well known resorbable material known as poly-lactic acid. Many dissolveable sutures are made of the same material. The concept is that the sagging cheek tissues are lifted up back onto the cheek bones and are held there by this device. The device is attached to the bone and the small spikes face upward. The cheek tissues are lifted up on top of the device and are held in place by the angle of the small spikes. This repositions/resuspends sagging cheek tissues back up higher on the bone. The procedure is done through a small incision from inside the mouth. The device resorbs within a year after surgery and is replaced by scar tissue. In theory, the scar tissue then acts to hold the cheek tissues in place.
The nice thing about this device approach to a midface lift is that is fairly simple to perform and is done without scar from inside the mouth. Unlike a traditional midface lift, it does not disrupt the lower eyelid tissues and eliminates the risk of ectropion or lower eyelid sag. For the right patient if performed well, it can be a good midface lift operation. Understand, however, that no form of facelifting is permanent. As the device goes away and with time and aging, some cheek sagging will return.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I can’t figure out whether I need a full or a mini-tummy tuck. After having two children what bothers me most about my stomach is the little bit of loose skin and the stretch marks between my belly button and my mons. Interestingly, there is no loose skin when I am standing straight but it appears when I am bending over. I am 32 years old and in very good physical shape at 5’ 2” and 106 lbs. My abdominal muscles feel very taut and I don’t think they are separated at all. I also have a hole on the upper part of my belly button from a prior piercing that I would like removed.
A: Your description of your abdominal concerns is a common one and you are what I call a plastic surgery ‘tweener’. This means one is stuck between two procedures and can go either way. Either type of tummy tuck can be done on you.l Understanding which way to go requires an understanding of the trade-offs of making either choice. A full tummy tuck, removing an ellipse of skin from above the belly button down to the pubis, will eliminate all loose skin and will avoid the sag you now see when you bend over. But the final scar will be horizontally long and will end up high, about halfway between the new belly button and the pubic region. A mini-tummy tuck will result in a smaller scar that can be kept down quite low but will result in less skin removed and there will remain some small sag when you bend over. The decision comes down to whether you value the most amount of skin tightening or the best scar location and size.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had breast augmentation three years and had PIP breast implants placed. Since the scandal about PIP implants has been reported, I am concerned about whether my breast implants are safe to have in my body. I don’t want some inferior low-grade silicone material inside my body. Besides getting the implants out and replaced, I also want to go a little smaller. I currently have 475cc implants in and want to downsize them to 400cc, maybe 375cc. Do you think I will develop any sagginess of my breasts if I do so?
A: The answer to what happens to your breast tissue when implants are downsized is not straightforward. There are numerous factors that can affect what happens when the size of the balloon is deflated somewhat. The most important factors are the elasticity of your breast skin and what it actually looked like before the breast implants were placed. Also, whether the implants are positioned above or below the muscle also plays a role. Given that you are considering an implant downsizing of 75cc to 100cc, or 16% to 21% total implant volume, the overlying breast tissue will lose significant support. Sagging could develop with this implant volume reduction if your breast skin has limited elasticity or you had some loose breast skin previously. This is an issue to consider when determining what your new breast implant size should be.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Hello, I am 25 years old and have had twelve IPL treatments. It has disfigured my face, somewhat like a thermage side effect. I have lost all collagen, subcutaneous tissue, and tissue and facial padding. My skin just sags, there is no elasticity or tightness or shape in my face any more, just very thin skin. Would cheek, chin, forehead, and temporal implants help bring my face back? Or can that all regenerate and grow back after time?
A: You did not say why you had the IPL treatments, for what condition, and why so many. But that issue aside, IPL does create a subcutaneous heating effect. When done enough times it is possible to cause to cause subcutaneous fat loss. You are not the first person that I have heard that has had this effect. I would wait up to a full year after the last IPL treatment to see if any regeneration of tissue substance will occur. While I would not be optimistic that it will happen, time will answer that question. If not, then the first thing to consider is injectable fat grafting, perhaps even using a stem cell-enhanced method. You should try and replace what is lost as the first approach. While facial implants are bone-based methods of facial contour augmentation, and they may be appropriate for some facial areas, I would think fat replacement first by facial fat injection. Some combination of the two may also be considered. But I would need to see some pictures of your face for further assessment to provide more detailed recommendations.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am having breast augmentation surgery and am having trouble trying to decide between two different implant sizes. I can’t decide between 375cc and 400ccs silicone gel implants. They seem to look different when putting the implants in my bra. Also, which size will give better cleavage.
A: The difference in volume between 375cc and 400cc is 25ccs or a 6% total volume difference between the two breast implant sizes. This is an insignificant difference that is not visible and is one you should waste o further time thinkingabout. When in doubt between two implants sizes that are so close, always go with the slightly bigger implant. This is because here is no chance that it will make you too big but there is a very real chance that you will have wished you went bigger later. Also understand that stuffing a round implant into one’s bra is not a very good method of implant sizing even though it is done all the time. A much more accurate method is the Mentor Volume Sizing System where the sizers have shapes that actually fit over one’s natural breast, rather than simply smashing it flat with a round breast implant. This provides a much more realistic volume result. Lastly, also understand that cleavage is rarely created by breast implants unless one’s natural breast mounds are fairly close together beforehand. Implants make bras much more effective at creating good cleavage.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting liposuction for my belly area. I am 36 years old and had very successful breast reduction surgery seven years ago. While I was put to sleep for my breast reduction and had no problems, I am more anxious now considering it since I have two small children. Do you think it would be better to have regular liposuction under general anesthesia or Smartlipo under local anesthesia? I think I want to flatten my hips area as well. It is time to get ready for the summer!
A: You are under a classic misconception that Smartlipo is a liposuction procedure done only under local anesthesia. While it can be done in some smaller areas under local anesthesia, the reality is so can regular liposuction. The type of anesthesia has little to do with what type of liposuction can be performed. But it often controls how good a result one can get from any type of liposuction procedure. How thoroughly fat can be removed from multiple areas largely depends on a patient’s comfort to do so. In my experience, better liposuction results are almost always obtained under general anesthesia. More body areas can be concurrently treated and a more aggressive approach can be taken with how much fat is removed. While Smartlipo can be done under local anesthesia, I have found in many cases that patient comfort and the desire to treat more than one body area make it less than an ideal approach to liposuction fat reduction.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have previously sent you photos of me for consideration of a rhinoplasty and a chin augmentation. You sent back some imaging results and, after reviewing them, I have a few questions:
1) Rhinoplasty – I like the overall effect! I just wanted to ask if there was anyway you could make the bridge a little more concave, and if it would also be narrower from the frontal view, and if the tip might be narrowed as well? I know you said that you usually provide an image of the minimum effect that could be achieved, and if this is it, that’s great – I’d still be happy with the improvement.
2) Chin – I think I like the implant a little more than I like the osteotomy, though of course it doesn’t fix the underlying skeletal problem. I might still consider the implant but I haven’t decided.
3) Cheeks – One more question regarding my “chipmunk cheeks”. While my friends and family call them “endearing”, I”ve always wondered if I couldn’t have a little less of a balloony cheek especially right below the corner of the mouth. Is there any way of filling in the tissue right at that spot, or (I guess) of removing fat from the cheek (though I do like my dimples!
Thank you for taking the time to answer my questions and being patient with me!
A: In answer to your questions:
1) Ideally I would like the front view rhinoplasty result to be more narrow, and it may be possible, but your thicker skin may preclude that from happening. For this reason, I have imaged it so that the amount of narrowing will reflect what I believe will happen… but I am pulling for more.
2) I would agree that the implamt effect, while not providing as much horizontal advancement as an osteotomy, seems to be more ‘natural’ looking. It is always best in chin augmentation in a female to be less rather than more. That still preserves a feminine look.
3) You are referring to what is known as the perioral mounds. a cheek fat area that is below the buccal fat pad. That can be effectively treated by small cannula liposuction done from inside the mouth.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have had five pregnancies and my muscles are separated as well as I have a skin flap that hangs down. My back hurts all the time since my stomach muscles are so weak. My skin flap hangs down and rubs on my thighs. I have done physical therapy but it doesn’t help. My insurance says they won’t cover it and I can’t afford to get it fixed on my own. Being in this plight, how can I get my insurance company to pay? It seems like they should but they just don’t understand. What do you suggest?
A: The reality of medical insurance today is that coverage will not be provided for ‘muscle separation’, medically known as a rectus diastasis. While this is a common occurrence after multiple pregnancies, it is not interpreted as medically necessary to repair by the insurance industry. There is no getting around this ruling nor do such symptoms as muscle weakness make it possible for insurance to pay for surgery. It is different if an umbilical hernia is present as this is a true defect in the abdominal wall. The same consideration applies to abdominal skin flap surgery, known as an abdominal panniculectomy. Only in large abdominal pannuses that hang way down onto the thigh and have associated chronic skin infections underneath will insurance consider coverage for its removal.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Hi. My jaw points down and my chin is very weak. I would like my jaw to appear more square shaped. I don’t think this is a problem with the growth of my jaw as my bite is excellent and I wouldn’t want to mess with it anyway. I considered a chin implant but that seem to just make my jaw longer as it would sit on a backward angled segment of bone. Also, my nose has a high bridge, so I am wondering if rhinoplasty might off set the look of the jaw. Right now, my jaw line and the bridge of my nose are almost parallel lines. What is your suggestions?
A: In looking at your pictures, your mandibular plane angle does parallel the dorsal line of your nose. This is not a nose problem as its shape and size looks good. A rhinoplasty you most certainly do not need. You need to reorient the plane of your mandible. This would be best done by a combined chin osteotomy and jaw angle implants. The chin osteotomy would bring the chin forward but would also bring it upward due to the angle of the osteotomy cut. This will actually shorten the vertical length of the face. The jaw angle implants will bring down or lengthen the ramus of the mandible of posterior length of the face. These two procedures together will create a counter clockwise rotation of the mandibular plane angle.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, my labiomental crease is very deep and I don’t like it. When you look at me you would first think that I have a big chin. But then when you look at the rest of my face you see that compared to everything else my chin is fine. My labiomental crease is so deep probably because my teeth are located far back in my head. And it looks like I have an overbite, but I really do not have one. I would be very interested to hear what you could do to improve this. I know that fat transfers do not last in this area, so I am looking for some kind of implant for a permanent result.
A: Based on your side profile, one reason your labiomental crease is deep is because of your prominent chin. The more chin projection one has, the deeper the crease will be. Otherwise, a Class II malocclusion can be a cause due to the overprojecting front teeth and the recessed lower teeth…but this does not seem to the case in you.
Short of a chin reduction, reduction of the depth of the labiomental fold can only be done by some type of implant. But the implant can not be primarily bone-based because the labiomental fold is not influenced much by bone augmentation as it is a soft tissue structure situated just in front of the anterior mandibular vestibule. Over the years, I haved used many types of implants from fat injections, intraoral dermal-fat grafts, mersilene mesh bone augmentation, and Advanta (Gore-ex) tubular implants. Of all of these, I have found that Advanta implants work best because they are placed directly under the skin and have permanent volume.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting a forehead augmentation. I know that there are different materials to use, one of which is PMMA. I have a few questions about PMMA. Does PMMA bone cement have a risk of granulomas like PMMA injections? Are the outlines of it visible? Does it have a risk of extrusion? Thank you!
A: In answer to your questions:
1) PMMA cranioplasty material does not cause granulomatous reactions. That is a unique phenomenon of small PMMA particles in soft tissue
2) Besides getting getting the right contour and amount of augmentation, one of the major objectives of any form of cranioplasty is to get a smooth transition form the material to the surrounding bone. This usually requires intraoperative burring of the edges after the material is set to have feather edges so there are not visible outlines after surgery.
3) There is no risk of extrusion of a PMMA cranioplasty. Extrusion of any implant material occurs because it is either placing excessive pressure on the overlying soft tissues or is infected and it is being pushed out by the pressure of the purulent fluid build-up. A PMMA cranioplasty is rigidly fixed to the underlying bone by microscrews prior to it being placed as a rebar method. This prevents any micromotion or displacement after surgery. The material is also impregnated with antibiotics which provides several weeks of antibiotic release after surgery for infection prevention.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have had a problem since I was in 10 years old. I have visited many doctors but none have had a proper remedy. Ever since I have started feeling it, I am been taking medicines. And right now I am frustrated with taking medicines. The problem is that my face clamps down suddenly on my right upper and lower jaw while I am talking, eating, brushing or even when I am not doing anything. I have visited many neurologists and finally visited orthopedic surgeons but nothing works. I was just going through some internet sites and visited yours and would be very kind if you could help me out. Thank you.
A: While I don’t have the insights that would be provided by an actual examination or knowing what treatments you have had, your description sounds like a condition known as hemifacial spasm. This is caused by involuntary contractions of the muscles of mastication, the temporalis and masseter muscles. Since you have visited neurologists I will assume that causes of intracranial pathology (brain tumors, vascular lesions) has been excluded. I would recommend a series of Botox injections into those muscles which exhibit spasm. Botox is very effective for masseteric spasm in the treatment of bruxism and myofascial pain disorders.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I got punched in the face a year ago and my eyeball has been sinking since. I am pretty sure that I fractured my eye socket but it was never treated. I didn’t go to the hospital when it happened at the time. My eye got very bruised and swollen afterwards and it took about three weeks for all of it to go away. I’d like to know if my eye will keep sinking. Please see the photo and let me know if you think this problem can be fixed. Thank you.
A: The description of your facial injury most certainly sounds like an orbital floor fracture. This is classic for orbital trauma as the thin bone of the floor of the eye blows out and downward as a decompression mechanism for protection of the eyeball. When displaced and untreated, the eyeball will sink downward afterwards as the floor that supports it is lower. After a year, the eyeball should sink no lower as the soft tissues under the eyeball has fully settled into the hole in the orbital floor. The level of your eyeball can be restored by orbital floor reconstruction. The scarred soft tissues under the eye can be freed up and the bony hole rebuilt/covered with either thin synthetic materials or bone grafts. This will bring the horizontal level of the eyeball up to its preinjury position.
Indianapolis, Indiana
Q: Dr. Eppley, I am 52 years old and had eyelid surgery, both uppers and lowers, a month ago. My problem is my right lower eyelid droops. It is not level with the other lower eyelid and a lot of white is showing. It was worse the first week after surgery and then it got a bit better. But it has not improved anymore since then. My doctor told me to be patient and keep ointment in the eye at night, massage it several times a day, and keep it taped up at night. My doctor said he can fix it later by tightening the corner if it does not improve. How long should I wait before having it fixed?
A: What you have is ectropion or lower eyelid drooping at the outside corner due to loss of structural support from the transcutaneous lower blepharoplasty. This is one of the known potential complications from this surgery. You are following management instructions which are what should be done in the first month or two after surgery. As long as the lower eyelid position is slowly improving and/or eye symptoms such as dryness, itchiness or excessive tearing are not too severe, the more healing time the better. Improvements in ectropion can continue to improve several months after it has occurred. A full three months should be allowed to pass before undergoing lateral canthal/eyelid resuspension, which is the definite answer to ectropion. This can be done earlier if eye symptoms warrant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had gynecomastia reduction surgery two years ago. Breast tissue was removed through incisions on the underhalf side of the areola. No liposuction was done. The incisions healed well and, while it looks a lot better than it was, my nipples are still a bit puffy. My doctor said it was swelling for several months after surgery but it never got better. I want my nipples completely flat with no puffiness at all. I don’t want to see them poking out through a shirt. I can not feel any hard lumps under the nipples so I think it is just fat. The puffiness has a soft feel to it. It pushes in easily. I am thinking this residual fat may be able to be gotten rid of by exercise or losing some weight. Do you think this will work?
A: Gynecomastia surgery, when done through an open resection of glandular breast tissue, is an art form in terms of how much tissue to remove. There is no precise method during surgery, when the patient is laying horizontal on the operating room table, to determine if the nipples will lay completely flat afterwards. The one thing a plastic surgeon wants to avoid is over-resection or removing too much breast tissue. This will create a crater deformity after surgery. To avoid this problem, surgeons will be more conservative rather than aggressive in tissue removal. This means that in some cases after surgery that most of the nipple protrusion is gone but it does not lay completely flat. This is due to residual breast tissue or incomplete resection not fat. This can only be improved by secondary gynecomastia reduction surgery to remove more breast tissue. It will not respond to any method of fat burning or weight loss.
Dr. Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I don’t like the shape of my jawline as it goes from front to back. I would like the front of the jaw profile to be less angular and also look deeper. I think this would improve my face shape and make it look more symmetric. I have attached a few pictures. What type of operation do I need to make this improvement?
A: I am not sure I understand what you mean by the desire to have the ‘jaw front profile less angular and also deeper’. I would need a better explanation to be sure what you see. But looking at your pictures, I think you mean that the chin is pointy (rather than square) and the jawline from the chin angles back sharply as opposed to being more square and vertically longer. The angular chin/jaw line is more associated with females while the square and broader chin is associated with a stronger male look. This could be improved by geniomandibular groove implants that fit on the bottom of the chin and go back to the anterior body of the mandible. They can be used to widen the chin as well as provide structure at the turn of the chin into the jawline so that there is a stronger jawline appearance. This is done through a submental incision and the two implant halfs are assembled into a unified implant with screws once into place. How close or separated they are in the midline affects how much the chin width is increased.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in trying to make my face more symmetric. My main problem is around my eyes and they are not even. One eye is definitely higher than the other one or it could be that one eye is lower than the other. I am not sure which eye is the right one, all I know is that they are different. I think though that the left eye is too high as I like where the right eye is as it sits on my face. I have attached a front picture for you see what I mean. Is there anyway to make the eyes more even?
A:I would have to say that the vast majority of your facial asymmetry is based in the eye area as you know by looking at your pictures. The position of the two orbits/eyes is the most striking issue. Either eye position is acceptable but it is just that they are different and they are side by side. While one can have a debate about which one is the ‘goal’ to achieve (the good looking one), that discussion is largely irrelevant since you really can not correct one fully to be level with the other. Their differences are too great. The left eye can not really be brought down as far as the right and the right can not be brought up as far as the left. They are also lid issues with those movements, particularly the position of the medial and lateral canthi.
That being said, the only approach I envision that could work is a combination of making changes on both eyes, build up the floor on the right orbit and drop the left eye down. Each could be moved 2 to 3mms and together this ‘ying and yang’ approach could overcome the 5 to 5mm difference that currently exists in the horizontal pupillary levels. This may not create perfect orbital symmetry but it would be an improvement.
Indianapolis, Indiana
Q: Dr. Eppley, I am looking for a non-surgical way to reduce my belly fat. I have had two kids and as a result I have a little loose skin on my lower belly but it is really not too bad. I don’t have any stretch marks except a few fine ones. My problem is this little bulge below my belly button which just won’t go away no matter how much I exercise or do situps. I can’t justify in my mind to go through liposuction surgery to get rid of it and I know my husband would never permit it anyway. I have read about several non-surgical methods but what do you think is best and do they really work?
A: Let us start with the premise that surgery, liposuction, is the most effective method of SPOT fat reduction that we know. And any non-surgical method is never going to be as good. Whatever result any non-surgical method can achieve can never compare to that of actual surgery. And thus by comparison it will be a have a poorer return on one’s economic investment.
Once one accepts that premise then the consideration of non-surgical fat reduction can begin. While there are many energy-based devices that currently exist to reduce fat without surgery, my current one of choice is Exilis. This is a deep radiofrequency device that targets fat below the skin but can also do a little skin tightening as well. (I said a little skin tightening, not to be confused with more than a small pinch) Treatments are fairly comfortable and a series of 4 to 6 sessions over 6 weeks can make a very visible reduction. The radiofrequency energy breaks down fat cells walls, causing them to spill their lipid contents which is then absorbed. In addition, there is no recovery or pain afterwards and one could go and work out immediately afterwards if they were so motivated. For the devout non-surgical person with some localized fat collections, this can be a good alternative to liposuction. You might also consider Smartlipo done under local anesthesia. While this is still surgery, small areas can be done without being put to sleep for the best result in the shortest period of time.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have had some computer imaging done for some facial change that I want to make but I am not completely happy with the imaging predictions. I’m very particular of what I’m trying to go for, but I don’t even know if it’s possible. I went on facetouchup.com last night. Have you heard of it? It’s like photo shop and you can adjust any part of your face to your liking. I played around a bit with my nose and I really like the end result. I attached it on this email. If that’s not possible, I understand, but I was wondering actually, if you could tell me, if you could do absolutely anything with my nose what would you change? Also I’m not too crazy about the use jaw implants from the front view. I guess it’s one of those things that work on someone else’s face but not on mine. The main purpose of wanting a jaw and chin implants was to make my face less round more oval shaped. Do you think you can get a similar result like the attached male model example?
A: Programs like Face Touchup are for fun, not for reality. You can do anything on these programs or with more sophisticated programs like Photoshop. This does not mean that it can be created surgically. Photo imaging is about communicating goals, not about guaranteeing a result or the ability to create that exact look. You are much better off considering and undergoing surgery with what may realistically happen,, nto with what you hope will happen. A plastic surgeon driving the imaging program is going to be closer to reality than any patient doing it.
I don’t think jaw angle implants are for you. You don’t have the anatomy for it to create the right effect. Your facial tissues are too thick and all those implants do is make your face fatter not slimmer. The only slimming effect that will work for your face is a vertical lengthening chin osteotomy and buccal fat removal.
One reality that you will have to accept is that your face is never going to look as refined and angular as the faces of the model images that you have shown. (aka male model look) You don’t have the right facial tissues for it. The best you can achieve is somewhere between what your face look like now and those pictures.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like to get information on cost and recovery time for different lipo procedures for various parts of my body – arms, chin, stomach, hips and thighs. I’d like to explore smart lipo and lipo dissolve, but would like to know if I can get good results.
A: Fat reduction by liposuction has a myriad of considerations including effectiveness, cost and recovery. It is impossible to give any reasonable answer to these questions without actually seeing a patient and evaluating each one of their body areas of concernb. The variables that affect these issues you have asked, such as thickness and size of the fat, quality and amount of overlying skin, how many and what body areas would be treated and what one’s physical health and occupation is makes any answers to these questions truly an individual one. I would recommend that you have an actual consultation with a plastic surgeon to get meaningful answers to your very relevant questions. While many people would like fat reduction, most commonly done by liposuction, it may not be the right answer for everyone.
Dr. Barry Eppley
Indianapolis, Indiana
There are many options to tighten loose skin in the neck and jowls, the most common aging problem in the bottom half of the face. One of the most significant developments in the past decade has been to limit the scarring that goes with the more traditional forms of facelifting. These procedures have become known by a lot of names including short scar facelift, S- lift, MACS lift and dozens of other catchy marketing names. But in the end, there are all ‘Mini-Facelifts’.
These smaller facelifts tighten up sagging jowls and droopy neck skin and do so with less scar. The scarring that is eliminated is in two specific hairline places, in the temples above the ear and in the crease behind the ear. Why is it important, if possible, to eliminate such scarring? The issue is one of scar widening and hairline displacement. When a facelift scar runs up into the temple hair, it will always move one’s sideburn hair up. (not important for men who can just grow new sideburns) When scars are placed back into the hairline behind the ear, they will become noticeable if one has very short hair or wears a pony tail that may expose the scars.
The incisions for a mini-facelift starts at the top of ear, goes inside it behind the tragus (bump of cartilage in front of the ear), and then tucks around the earlobe. It stops in the crease of the ear just above the earlobe. This incision pattern (and ultimately the scars) prevents loss of the tuft of sideburn hair and eliminates scarring behind the ears. This allows one to wear their hair any way they want without being ‘discovered’.
While less scarring would be an important part of looking better, these mini-facelifts are not for everyone. The vast majority of patients that benefit by them are under the age of 60. Today many people seek neck and jowl improvement by age 45 or 50. These short scar procedures are designed to smooth out the jawline, soften the nasolabial folds and restore a more sinuous and curved facial shape. As one ages, sagging of facial skin and jowls create a more square or ‘bulldog’ look for some. A mini facelift reverses this facial shape change into a more triangular shape which is more synonyous with youth.
The one disadvantage to a shorter scar facelift is it is not as good as improving the significantly droopy neck as that of a traditional lift. This is why older patients with more advanced neck problems have to accept the trade-off of greater scars from more extensive facelifts.
Many mini-facelifts are done with other facial aging procedures as well to get the maximal benefit. When potentially combined with such procedures as liposuction of neck fat, removal of excess eyelid skin and chemical or laser skin resurfacing, that tired aging look can be completely wiped away in a few short hours.
Q: Dr. Eppley, I had a sliding genioplasty two years ago and have suffered with iatrogenic chin ptosis since. I have read in your writings that there is the possibility to resuspend the mentalis muscle using bone anchors to a higher level. Also you have recommended a VY lengthening of the mucosa of the lower lip at the same time.What is very hard to find out is how the patients feel after this surgery concerning to the ability to move the lip sidewards and forward and the movement to evert the inferior lip. Is this type of lip movement uncomfortable afterwards? How is the patients’ sensation moving their lips after a mentalis resuspension? Does it continue to be uncomfortable because of the devascularing nature of the intraoral incision or the mentalis muscle turning it out into an atrophic scar? My concern is that my most important issue that I would really like to repair is functional and I would really like to correct the discomfort I have. Would really appreciate if could please write a few lines about how patients feel moving their lips after this procedure.
A: Chin ptosis after a chin osteotomy is very unusual as the bony movement forward (typical direction) picks up any loose tissue. But it is possible if the chin osteotomy is used to vertically shorten the chin and move it backwards (not a good idea), if the surgeon does not tighten the now excess soft tissues. In my experience with chin ptosis repair, complaints about difficulty with moving the lips or loss of feeling have not been voiced. This does not mean that they may not exist, but that they were not considered significant. I suspect I have have not heard of them because they do not turn out to be problems after surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am wanting to get rid of a scar on my forehead. Here is my picture and I’m hoping that this is something that you would be able to erase. I hate this scar on my face. I am getting married in three months and I need this scar off so I can look my best for my wedding and pictures. Please let me know how soon I can get in and how many sessions it will take to get rid of it.
A: The scar on your forehead that runs vertically down through your eyebrow and into the top of your nose can definitely be improved. But one reality that needs to be faced about scar treatments is that such outcomes as ‘being erased’, ‘gotten rid of’ and ‘removed’ are not possible. Scars can be improved but, in general, there is no such result as being removed like it was never there. The realistic result of scar revision efforts is to lessen its appearance. Some remnant of the scar will always be there. The features of your scar would be best treated by surgical scar revision and an irregular closure pattern. Because the scar will be initially red and will take time to mature and lose its color, having scar revision done three months before your wedding is the minimum amount of time you should allow.
Dr. Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have indentations on my forehead. On my right side, there is less volume so I have more loose skin and my eyebrow droops. I would like to get the indentations filled in so my forehead looks smoother. Since filling out the area would make my skin more taut, would it fix my eyebrow into a more normal position so it doesn’t droop anymore? My brow bone is also smaller on the right side. Could bone cement build up my brow bone? If so, could that also help lift my eyebrow up? If some skin removal is also necessary, would it cost a lot more?
A: Forehead augmentation (onlay cranioplasty) by virtue of adding volume would potentially make the skin tighter. There may even in some cases be a slight browlifting effect, although this would be greatest with the brow bone is directly built up. Whether this would occur or not would also depend on how much volume is added. To ensure that this stretching and lifting effect occurs, it would usually be best to do a browlift with the forehead augmentation. This would be easy enough to do since there would be a coronal incision already present. It would not add any appreciable time or expense to do so because of then existing scalp approach for the forehead augmentation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am 55 years old and am interested in doing some with my aging face. I think I need a facelift or something along those lines. I do have numerous medical problems including rheumatoid arthritis which is under control at this time. I am taking Methotrexate, Arava and Plaquenal for it. I also take medications for high blood pressure, high cholesterol, underactive thyroid and I smoke one pack of cigarettes per day. I would be willing to quit. I am 5’ 2” and weight 180 lbs. I also have restless leg syndrome and back pain. I also take Xanax, Xanaflex and a sleeping pill.
A: Thank you for your interest in facial rejuvenation surgery which may possibly include a facelift. You are correct in assuming that you would need to quit smoking at least one month before surgery and for at least one month after any procedure. In addition, however, you have multiple other medical problems that need to be addressed before you should consider any type of elective facial surgery. It would be best that you loss some weight before surgery, getting you down to at least the 155 lb to 160 lbs range. This may also help your high blood pressure and back pain. Because of your rheumatoid arthritis medications, they do place you at risk for healing problems. I would have to talk to both your primary care doctor about your general health and your rheumatologist about your medications and their dosages to see if any of these can be reduced for a short period of time around surgery. You would also need to be done some supplements to help with collagen production and healing, such as temporary high doses of Vitamin A and C. While you may benefit greatly by a facelift, you have numerous medical issues that must either be improved or management strategies implemented for them for you to have a successful and uncomplicated outcome from any type of facelift surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I want to have a chin implant, I want to ask you is a chin implant with a screw holding it into position a must so that it won’t move? One doctor said screw is not necessary as she said you can extend anteriorly more than 1 cm it and it depends on how the doctor carves out the implant so it won’t move place. Is what she said true and effective?
A: How any surgeon secures their facial implants is a matter of personal preference and experience. I prefer to screw all facial implants into place when possible to get the best aesthetic result (assured position) and never have to worry about them every moving or sliding from where I want them. That is my personal preference and has served me and my patients well over the years. Just because other surgeons make not choose that technique of implant fixation, or any fixation at all, does not make them wrong. That is obviously what works for them.
Dr. Barry Eppley
Indianapolis, Indiana
