Your Questions

Q: Dr. Eppley, I am 74 years old and am really beginning to show my age. I really hate the loose skin on my face and my neck wattle. I have read about a facelift procedure that sounds almost too good to be true.. I like that it is done under local anesthesia and there is little recovery. Do you think that it would be a good choice for me? I have attached some pictures of what I looked like last year at our family Christmas party.

A: These marketed and franchised forms of facial rejuvenation are simply scaled down versions of a facelift.  This is typically a “mini” lift of the jowls (primarily) and the neck (secondarily and more limited) that is sometimes performed in the office with no general anesthesia. Understandably this makes it very appealing to some people. But just because it is appealing does not mean it is a good choice for everyone. Whether it can meet your expectations and is worth the cost is a key question for every patient who undergoes limited types of plastic surgery. This is particularly true when trying to improve the degree of facial aging that exists in someone 74 years of age.

You do have a significant amount of loose skin and the very presence of a neck wattle illustrates your degree of facial aging. On the one hand, these mini-facelifts will not produce an ideal result. So if your goal is a smooth and completely uplifted neck and jowl line, you will be disappointed. If, however, you can accept that some improvement is better than none then it may be a reasonable choice.

Rather than getting hung up on a marketed facial procedure, you would be likely better served to consult with a number of plastic surgeons and get a customized approach to your facelift needs.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have 38 DD breasts which sit on my stomach with the nipples pointing downward. I want them lifted back up but am afraid of the scars of a breast lift. I have seen some pictures and videos of the surgery and, quite frankly, it scares the hell out of me. I don’t want ugly scars on my breasts. What type of breast lift is available that does not leave any scars?

 A: Breast lift surgery is about moving the nipples up to a more central position on the breast mound and reshaping the breast mound so that it sits back upon the chest wall. This is done by a geometric rearrangement of the breast skin that involves a fair amount of breast skin removal. This where the typical inverted-T or anchor scar pattern comes from in a full breast lift procedure. While there are several more limited breast lift operations that involve less scarring, the amount of lifting and breast shape and position change is also a lot less. In short, there is no type of breast lift that does not involve scars. With the amount of breast sagging that you have, only a full breast lift will do any good. If the scars you have seen from breast lift surgery look worse than the sagging that you now have, then such surgery is not a good choice for you. Satisfaction after breast lift surgery is about feeling that the scars, undesireable that they may be, are a better problem than sagging unscarred breasts.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, While I think I am aging fairly well at 48 I am bothered by my jowls that I have developed. My neck is just a bit saggy as well but not too bad. I am not ready nor do I think I need a facelift but a little tuck might be good. I saw a doctor on TV advertising some type of quick facelift procedure. It sounds like it might be good for me but I am leery as it sounds too easy. Is this type of facial tuck-up procedure legitimate and is it really like what is advertised?

A: Facelift surgery is done in variety of operations based on how severe the facial aging is on each patient. Since the average age of a patient seeking a ‘facelift’ has gotten younger over the past two decades, many people now appear with early signs of aging such as jowling and  a little neck sag. These signs of facial aging can be treated by a smaller type of facelift, generally known as a limited or mini-facelift. The improvement is a smoother jawline and neck.

There is nothing unique or novel about this type of facelift and it is an operation that has been around since facelift surgery began. What is new is that the ‘limited facelift’ has become packaged and marketed by different companies. These types of facelifts essentially are forms of franchises that are sold or licensed to doctors to sell this scaled down form of a facelift. There is absolutely nothing wrong with the operations that are advertised. What you have to be careful about is who is really performing them, are they a good choice for you based on your amount of facial aging, and is it done under safe and comfortable environments. While these companies advertise and stress the rapid recoveries after these small facelifts, which can be true, it is still surgery and has all the risks that go with it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I  have a problem with one of my ears. My right ear at the top part that is supposed to curve inwards… doesn’t. It’s like it’s sort of unraveled and basically it looks like I have one ear that protrudes. i am not sure if I want to have a surgery done. Is there another way to fix it because it really effects my self-esteem. I can’t wear my hair the way I want as people will notice it straight away. Please help me.

A: Your description sounds like a common protruding ear problem. It is not rare that it may only affect one ear. The ear is indeed unraveled so to speak as the antihelical fold is either weak or absent in that ear. This makes the ear stick out rather than being folded back with a more natural shape. It can easily be corrected through a simple otoplasty procedure with the placement of one two horizontal mattress sutures from behind the ear. This is the only way to correct this ear problem as there is no non-surgical method that can reshape the ear cartilage.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in building up the back of my head.  It slopes backward and is flat and makes my head look asymmetric and unbalanced. I have attached pictures so you can see that the back of my head slopes downwards in an abrupt manner. By adding a round and nice piece my head would maybe look normal and my ears would even look smaller. But I have a few questions:

1. So what would be the next step for me?
   2. Seen from the pictures, do you assess that significant scalp stretch is required?
   3. What if I’m active in sports and wrestle alot ie, is there a risk of misshape in the future?
   4. What method do you feel is the most adequate for my head?
   5. Would hair transplantation be necessary?
   6. What is the recovery time?
   7. What are the approximate costs?

I am aware that there may be scalp scars but that’s less severe than the current situation.

A: In answer to your questions:

1) The next step is to have either a phone or Skype consultation. This would be the best way to go over the different cranioplasty methods and their advantages and disadvantages. No cranioplasty method is perfect and each patient make make their choice based on good information. I have done occipital cranial augmentation by every conceivable method so I am very familiar with each of them and their indivdual pluses and minuses.

2) Stretch of the scalp is always needed because the material occupies space. The question is how much stretch can the scalp safely do. That is what limits how much material/augmentation can be achieved. 

3) All cranioplasty materials set up and become solid like bone so no deformation will occur later with impact or trauma.

4) The best method for you require your understanding of each approach.

5) I do not envision hair transplantation being needed for the scar later. 

6) The recovery is quite quick, being just a few days.

7) The cost will depend on the technique used, which is yet to be determined. The costs could range from $6500 to $9500 depending upon what cranioplasty material is used.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am looking to have corrective jaw surgery for my long face.  I don’t have an under/overbite but I do have longer face which I would like to be shortened. What are the options  available for doing this? I have attached a picture for your assessment.

A: There are two fundamental approaches to aesthetically shortening the long face. The first is a vertical chin reduction osteotomy in which only the chin length is reduced. (shortening of the lower third of the face) I have attached an imaging picture of what that may look like on you. This would be the simplest technique but it only deals with one area of vertical excess, the chin. A true long face is most people involves the entire face. The second approach, which is usually combined with vertical chin reduction, is a maxillary impaction or shortening. This requires that the patient has a vertical maxillary excess to start with as reflected in having a lot of tooth exposure and/or a gummy smile and lip incompetence. This shortens the middle part of the face which when combined with vertical chin reduction gives the maximal shortening effect. This is a more extensive approach requiring a LeFort I osteotomy and, again, requires that the patient have vertical maxillary excess. Your pictures suggests that you have that to some degree based on your tooth show/lip incompetence at rest. This is a harder area to image given that it is in the middle part of the face.

Which approach is best for any patient depends on how much vertical shortening they need and what one is prepared to got through to get what degree of shortening.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had my buccal fat pads removed nearly fifteen years  ago at age 31 for some facial sculpting. Now that I am older, I look completely different. My face is very flat and not as attractive. What can I do to look like before? What are my choices for making my face now a little fuller?

A: As you have aged, your face likely has lost overall fat and the prior removal of the buccal fat pads has only accentuated this natural fat involution process. There are several options available to consider for facial volume restoration. The first approach is fat injections which focuses on replacing like with like. The only question is how much fat will survive after transplantation. This is an overall facial volume approach. The next approach is focal or spot treatment, just adding volume to the buccal or submalar area. This could dbe done with either submalar cheek implants or injectable fillers. The real value of injectable fillers in your case, in my opinion, is to be an initial test to determine if augmentation of this area is what you are looking for. It serves as a test to determine if more formal augmentation (implant) is worthwhile.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a tummy tuck done two months ago and am unhappy with the results. While the front part of my tummy is flat like I wanted, the sides stick out. It now appears that liposuction of my hips should have been done with the initial tummy tuck. My doctor said that I didn’t need liposuction at the time of the surgery. Will it help now and can it be done in the office under local anesthesia?

A: When evaluating someone for a tummy tuck, I always look carefully at the fullness in the flanks and at the sides of the waistline…areas that lie outside of the zone of excision of the tummy tuck. As these areas will not be improved by what happens in front of them. It is actually uncommon in my experience that most tummy tucks would not benefit from liposuction of these areas at the same time. Once the tummy area gets very flat, these ‘muffin tops’ can appear. They actually were there all along but have now become ‘bigger’ because the front area is much flatter. That is a matter of a change in perspective. Flank liposuction can be done in the office, and many doctors do perform it that way, but it is not a a preferred choice of mine. You have to be very aggressive in the flanks to get a substantial result and having an awake patient often makes that difficult.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had breast implants six months ago. I initially was a small A cup and became a full B cup after surgery. While I am happy with the size and shape of the right breast, the left breast is not even close to the same and is very uneven. It is smaller and hangs lower. My doctor said my breasts were different from the start and this is why they look uneven now. I want a revision to make them look more even but fear that this might happen again since no one seems to know why this happened in the first place. I have attached some pictures for your review. Can you tell me why they look so different?

A: While identically-sized and shaped breast implants are twins, that doesn’t always mean the result will be perfectly symmetric and have twin breasts also. What breast implants really do is take what someone already has and makes it bigger. If there are significant differences between the two breasts initially, those differences may become greater afterwards. Asymmetry of breast implants is one of the most common reasons for revisional surgery in breast augmentation. In looking at your pictures, however, that does not appear to be the case. You left breast implant has bottomed out and sits much lower than the right one. This can be significantly improved by breast implant repositioning and tightening of the lower pole of the surrounding capsule. Your breast asymmetry appears to be surgically induced and not a naturally-occurring one.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, my cheeks are very low and I would like them to be higher. When I pull upwards on them, my face looks better. That also helps soften the lines around my mouth. Will cheek implants create this effect or so I need some form of a facelift to get that look?

A:The question you are asking is an important one because there are clear differences between what cheek implants and a cheek lift achieve. Cheek implants are about creating a bony highlight for improved facial contours purposes. While there may be some cheek lifting effect, it will be relatively minor and one should not think of cheek implants as a soft tissue lifting method. (even though it can complement cheek or midface lifting surgery) A cheek lift is about lifting and resuspending sagging soft tissues that have fallen off of the cheek bone. This does create an effect sometimes similar to a cheek implant but it is more similar to what most patients thinik that a ‘facelift’ does in that area. This will help soften the nasolabial folds because it is pulling upward the soft tissues that lie above it. Based on your description, I suspect you would benefit more by a cheek lift than cheek implants. Whether that is a worthwhile surgery for you depends on numerous factors including your age, your cheek bone and lower eyelid anatomy and how much malar soft tissue ptosis you have.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I work out almost every day during the week and am very adamant about a healthy diet. But despite these efforts, I have the same stubborn fat areas that will not go away. I am 5’ 4” and weight 118 lbs so I know I am at a very good weight, so more weight loss and conditioning is not the answer. My problem areas are my saddle bags on the outer thighs, my upper arms and my chubby cheeks. As a result, I have been considering liposuction for awhile. My question is can all three areas under liposuction at the same time? Or is this too much?

A: What you have is a common problem, some fat areas that are not really responsive to reasonable amounts of diet, exercise and weight loss. And these are some of the classic body areas in which the fat that is there is not that ‘metabolically responsive’. That is because it is a different kind of fat and its primary purpose for being there is not as a fat depot site. It is more of an insulating or contouring fat role. In essence, you are trying to modify the way your body was built not get rid of accumulated fat from too much storage. That is a surgical problem not a lifestyle one. Those are all areas that can be treated with liposuction as a single procedure. It is very common to treat numerous body areas with liposuction at the same time. And as long as the total volume of fat removed does not exceed 5 liters or take more than few hours to do, you are well within what would be considered  the safety zone for liposuction. Be aware that the cheeks may be bettered treated by direct lipectomies from inside the mouth rather than liposuction.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley  I´m a 34 year old healthy man interested in enhancing my poor defined jaw line. Have read some awesome reviews of your work and feel really drawn to having this aesthetic implant procedure performed by you. It would be easier and less expensive to go to another country but I really feel you should be the one to treat my case. I would like to know the average cost and the downtime it will require.  I´ll be more than greatful for any info you can provide me with.

A:  The most important decision in regards to jawline enhancement with implants is whether stock preformed  or custom implants would be most beneficial. I can make that determination by looking at some picture of your face from different angles. The critical determinants of whether custom jaw implants are needed  are the size of augmentation that a patient desires, whether there is any significant vertical increase needed in the jaw angle (and the chin) and whether a smooth continuity of the jawline from the chin back to the jaw angles is desired. Until that determination is made, it is not possible to give an accurate cost quote. But as  general guideline, off-the-shelf chin and jaw angle implant surgery is around $8500 while custom chin and jaw angle surgery will be nearly double that cost. Either way, recovery is the same which is largely about facial swelling which takes about three weeks to go down and look normal again.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 24 year old male. Seven years ago I was diagnosed with a right frontal lobe tumor and underwent craniotomy. The procedure went well and all has healed medically well. However the bone flap due to the nature of the cutting process sits slightly lower than my normal skull. Not by a huge amount but about 2-3mm at the most, but is noticeable. I am wondering if cranioplasty can be performed to build a couple millimeters on the flap and thus smooth the forehead/skull? I already have an incision scar in the hair bearing area which starts in the top centre of the forehead and extends to just behind/above the right ear. I presume this can be re-opened. The bone flap is fairly well aligned just above the ear, but towards the top and front, slightly lower. It is the step in the visible part of the forehead which is of most significant in improving. Can you able to advise on possibility, risks, and estimated costs? Much appreciated.

A: An onlay frontal cranioplasty will solve the forehead contour problem of your bone flap very successfully. Using your old scar, the area to be augmented can be easily accessed and built up. While there are a variety of cranioplasty materials to use, and that selection affects costs, I would  prefer to use an hydroxyapatite paste material which hardens shortly after application. That would be the most ‘natural’ material to use that would serve you best over your long remaining lifetime. This would be a one hour procedure done under general anesthesia and the estimated total costs would be in the $7500 to $8500 range.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, can a temporal implant be placed on top of the temporalis facia instead of under it? Or is the risk it to become misplaced easier on top of the fascia? As the hollowing is deepest just above the zygomatic arch, so can the implants be used to correct this? And can you tell me how much this surgery costs? Many thanks.

A: A temporal implant is usually placed under the deep temporalis fascia. It can be placed on top of the deep fascia, if the aesthetic need dictates, but this does pose some potential risk for nerve injury. The frontal branch of the facial nerve is exposed to risk of  injury as it courses through this area under the skin, resulting in either temporary or permanent forehead/brow paralysis. As long as one stays directly on top of the deep temporlais fascia while doing the pocket dissection, this risk is very low. Since the hollowing is usually in the middel portion of the temporal zone, that is exactly why placing a temporal implant under the fascia corrects that area the best. But in cases where the deepest indentation is right up against the zygomatic arch, placement of the implant on top of the deep fascia may be needed to fill out that area.  The complete costs of temporal implants is in the range of $5500 which may vary based on what type of implant material is used.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want cheek implants to help balance out my face. I have a strong jawline but no cheekbone definition whatsoever. I think that some type of a cheek implant would help balance out my face a bit more. However, I don’t want the implants on the apples of my cheeks but just on the top of my cheekbones to give me a more defined face. Is this possible? I’ve seen some awful examples of cheek implants where the apples of the cheeks have ended up looking way too large for the face they were on.

 A: Choosing the placement and size of cheek implants is critically important in obtaining an improved but natural looking result. It would be essential to know exactly what part of the cheek you want augmented and a feel for how much volume you like. If in doubt, you should first try an injectable filler to get the exact location identified and make sure you like the result. The cheek area is one of the aesthetically sensitive facial areas and quite frequently poor results happen because of improper implant style and/or size selection. Cheek implants are a good example where a little volume goes a long way.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a question regarding the potential complications of performing breast reduction surgery on a breast that has been previously radiated for cancer. I was irradiated for a localized ductal carcinoma five  years ago. The irradiated breast has finally softened a bit and the skin appears pink and healthy after significant initial burning at the time of radiation. Six months ago, a plastic surgeon performed reduction surgery on the normal breast (from a size DDD to a size C) in an attempt to alleviate chronic back pain. He unfortunately removed so much tissue from the healthy breast that the radiated breast remains 2 cup sizes larger than the post-reduction normal breast. I am quite upset with the unsightly asymmetric results. The plastic surgeon did not want to attempt reduction surgery on the previously radiated breast due to the risk of poor healing etc. This seems to be good advice but doesn’t solve the current lop-sided result. The plastic surgeon suggested that I undergo a full mastectomy and flap reconstruction but that seems a bit much. Do you know of any reduction alternatives or surgical techniques that can overcome the complications of operating on irradiated tissue? Thank you for any information or advice you might have.

A: In today’s world of early breast cancer detection and treatments, it is no longer rare to see a patient for breast reduction that has had either a biopsy or lumpectomy and radiation. I have performed several cases of breast reduction previously without undue wound healing. This being said, it is important to realize that the effects of radiation on wound healing do not actually improve with time. The sclerosis of the microvascular of the skin actually worsens past the early post-irradiation period, so there is never a completely safe time to operate on an irradiated breast. The risk of wound healing problems is very real and the extensive devascularizing nature of a breast reduction procedure can unmask how compromised the circulation of the breast skin is.

There are two approaches to operating on the irradiated breast for a reduction. The first is to change or alter the surgical technique used. Using a standard breast reduction approach, the inferior pedicle is keep very wide (10 cms) and the raised skin flaps are kept thick. (2 to 3 cms) The amount of breast reduction that is internally removed may be less than that of the opposite breast so ideal symmetry in breast size will not be obtained. But maximal microcirculation is obtained. It is also extremely important to keep the skin excisional pattern conservative so no tension is placed at the intersection of the vertical and horizontal closure. The surgical technique can also be altered to be a free nipple grafting method where the breast resection is through the central mound and the circulation to the remaining skin flaps is completely unaltered. The second technique is the safest and may allow the reduction to be optimally matched to the opposite but the appearance of the nipple-areolar complex will be slightly different and nipple sensation and erection will be lost.

The second approach, and one that is reserved for the most severely radiation-damaged breast, is a two-stage technique. The breast is initially injected with a combination of stem cella and PRP (platelet-rich plasma) to improve the vascular quality of the breast mound. Three months later, the breast reduction is performed.

Which of these approaches is best would be based on how the breast looks and feels and the radiation dose and length of time from when it was done.

I would agree that immediate conversion to a mastectomy and flap reconstruction is overtreatment and should be reserved in case there is a major healing problem…and can always be done.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I am a 31yr old female looking to improve the side profile of my face. I have a lot of fat under my chin and this causes an awful side profile. It also shows from the front. From what I’ve read about neck liposuction this could be a good option. But I’ve also read that chin implants can be useful for improving one’s profile as well. Which one would be best for me or do I need both?

A: Improving the profile of the neck and jawline must take into consideration whether excess fat and loose skin exists and the amount of bony chin projection. Given your age loose skin is not an issue so any consideration of a jawline tuck-up is not needed. The combination of neck liposuction and chin augmentation can be a very powerful changer of one’s profile, assuming one has a weaker chin to start. The best way to answer whether chin augmentation is beneficial is through computer imaging. See what your profile would look like with neck liposuction with and without chin augmentation. Seeing is believing.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dear Dr. Eppley, my breasts are slightly droopy and I want them to be more perky. I thought I needed a lift but one doctor that I consulted with said that I needed more volume in my breast instead of a lift. He said this could be done with an implant or fat injections. The length between my nipple to sternal notch is 22.5 cm. Should I have breast lift or breast augmentation? If augmentation is best, which treatment is better an implant or fat injections?

A: The key to knowing whether a lift or the addition of volume can make the breast look better depends on the position of the nipples. If it sits above the lower breast fold, then volume is the answer. While I do not know exactly what your breasts look like, knowing that the distance from your nipples to the sternal notch is only 22 cms tells me that your nipples are definitely above the inframamammary folds. That is essentially a completely normal or ideal nipple position. (the normal range is 18 to 22 cms depending in the length of one’s torso)

Since more breast volume is the answer, the question of whether it can be done with an implant or fat injections becomes very relevant. The use of fat injections for augmentation of a variety of body areas has become very popular in plastic surgery recently. While it is widely accepted for volume augmentation of the face and buttocks, its use in the breast is currently controversial. This is because there already exists an augmentation method that works well and is very reliable, an implant. For overall breast augmentation, an implant works better, is a one-step procedure, and will cost less. If there is just one area of the breast that needs filled in, then fat injections becomes the preferred treatment.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dear Dr. Eppley, what is the difference between craniofacial and maxillofacial surgery? I am thinking that they use the same surgical procedures and the same materials like bone cement? I am interested in getting my forehead reconstructed from a dent in it  due to an injury but don’t know which type of surgeon to go to. And are you practicing both craniofacial and maxillofacial surgery?

A: Maxillofacial surgeons are usually dentists (with or without a medical degree) that have trained in facial bone surgery below the forehead, mainly of the jaws. Craniofacial surgeons are plastic surgeons that have done extra training in craniofacial deformities and have much greater experience in bone surgery above the jaws. Most maxillofacial surgeons will have very limited experience if any in forehead surgery and cranioplasty.

While there are exceptions to either of these types of surgeons and training and experience can vary by country and geographic region, these are general guidelines. I can speak to their differences quite clearly as I have trained and am board-certified in both specialities. You should seek out a plastic surgeon who has considerable experience in cranioplasty and the various materials used to do this type of forehead surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dear Dr. Eppley, I want a rhinoplasty and as part of  it I’d like a wedge excision procedure to reduce the alar flare without reducing nostril size. However, there seems to be a lot of concerns with the wedge procedure as it leads to some external scarring. I wouldn’t mind this if the scar itself was camouflaged within the alar crease. My main concern is that there might be an obliteration of the facial alar groove with this procedure. Is this a real concern? What is the best way to go about this without obstructing the alar crease?

A: There are two basic skin excisional approaches in rhinoplasty to change the bottom shape of the nostrils. The first technique is the removal of a vertical wedge of skin inside the nostril just next to the lateral nostril wall. This will reduced the flare of the ala with minimal narrowing of the nostril width. This leaves no visible external scar and will not alter the alar-facial groove. This appears to be what you may need. The other technique is where this inside the nostril excision is extended out along the ala-facial groove. This results in significant nostril narrowing as well as flare reduction. This does place a scar in the alar-facial groove which, if well placed, is not a visible scar concern. It does not result in any chance of effacement of the alar-facial groove.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had an accident when I was 16 that resulted to a dent between my eyebrows. I had a surgery to elevate that dent 10 months ago and it was done by my neurosurgeon because my frontal sinuses were also indented. My forehead now is improved but I can still see a slight dent which is very acceptable. My question is if the bone cement on my forehead will deplete overtime resulting to a more indented forehead again?

A: What you had sounds like an outer table fracture of the frontal sinuses, also known as brow bone fractures. Because this portion of the forehead has only a thin layer of bone in front of the underlying air-filled frontal sinuses, it can be pushed inward with a significant traumatic force. This buckling inward creates the outward appearance of an indentation of the forehead just above the eyes. When a delayed repair is done, it is much easier to build up the contours of the brow bones that it is by repositioning the displaced bone. This is done using any of the available cranioplasty materials. While I don’t know what type of cranioplasty was used for your brow bone augmentation reconstruction, none of them are resorbable. They all are stable biomaterials that do not degrade over time. So your current result will stay stable throughout your lifetime.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I’m very interested in chin and jawline enhancement, particularly the solid one piece custom made framework. I have very little time off these days due to the economy so time off and downtime is of great concern for me. I loved the before and after pictures and would be ecstatic to get rid of my beard which I have worn since I was 19. I have had several other surgeries with great success and am very pleased with their outcome. I look forward to hearing from you.

A: Thank you for your inquiry. There are numerous types of preformed and custom jawline implants, depending upon one’s lower jaw and neck anatomy. Most are three-piece assembled units (extended chin and jaw angles) as opposed to a single-piece unit. The only one-piece unit is when only vertical elongation of the mandible/chin is being done which is the least common.

Whether one can be augmented with available preformed implants or requires a custom approach depends on what one wants to achieve as it relates to the jawline. I would need to see some pictures of you and do some computer imaging of the options to see the differences between a preformed vs a custom approach. The basic difference is that custom jaw implants offer increased augmentation sizes and can create a smooth straightline jawline from the chin back to the jaw angle. There has to be a compelling reason to use the custom approach as it requires a CT scan from which a model and the implants are made and thus costs more.

Whether preformed or custom jaw implants are used, the recovery is no different. While there are few physical limitations afterwards (other than some temporary restricted oral opening), there is considerable facial swelling which takes up to three weeks until it largely passes.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a sliding genioplasty four years ago. Everything went well and I like the result. My surgeon told me that he could remove the titanium plates and the screws but it wouldn’t be a problem if they stay inside me for the rest of my life. So I decided to let them stay inside of my chin. Last week I meet another surgeon who said that titanium plates and screws should be removed in younger patients. On ‘House MD’ it has been shown that titanium plates can severely burn soft tissue and skin when an MRI is needed. Is this true? Should my titanium plates be removed because they can lead to bone resorption or other problems in the future?

A: The simple answer to your question is that none of what you have heard or been told is true. Titanium is the most biocompatible metal in the body which is why it is so commonly used. In facial plates and screws it is a nearly pure metal to which bone will bond directly (and often grow over) and it is non-ferromagnetic so it is not affected by the powerful magnetic influence of an MRI. There is no reason whatsoever, therefore, to remove your chin osteotomy plates and screws. Of all the places on the face where rigid fixation is used, the chin is the one area where I have never seen any long-problems such as loosening, irritation, or interference with function. Removing them may be a good exercise for the surgeon but is of no benefit to you at all.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My son required a decompressive craniotomy after being injured in a sporting event. His replaced bone flap subsequently got infected and had to be removed. He is now awaiting  a second cranioplasty for replacement of his bone flap. Could you provide any insight to titanium versus PMMA and/ or PEEK custom manufactured implants? Any added information would be most appreciated.

A: There are many materials that are available for reconstruction of cranial defects, particularly those in replacement of a lost cranial bone flap. The three you have mentioned are all synthetic materials and will all work when well handled. No one can tell you that one is superior to the other and surgeons will have their own opinions and preferences. All of these materials can be custom fabricated from the patient’s 3-D CT scan to create a near precision fit implant. The one material that has the longest history in cranial reconstruction is a modified form of PMMA known as HTR-PMI. This is a porous material of sintered HTR granules (PMMA-Poly-HEMA) that creates a solid material that is both porous and hydrophilic. These properties allow the material to become ingrown with  blood vessels and connective tissue, which always bodes well long-term for any implanted material in the body. There have been over 10,000 cases of HTR-PMI cranial implants placed since 1990 with an impressive history of success and resistance to infection. (in non-irradiated wounds) This would be my choice if I had to have a cranial flap replacement.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I know that there are silicone and Medpor facial implants for the tear trough areas. But I have also read about the use of Gore-tex material as well. I don’t know if there are specific tear trough implants for Gore-tex though. My question is how easy are they to remove if the need arises sometime later in the future? Is it like Medpor  in that it can be difficult to remove later in life? Thank you

A: Gore-tex is one of the available facial implant materials although it does not have many preformed shapes available. There are no specific Gore-tex tear trough implants. It is a material that largely comes in sheets and blocks that can be cut and carved into almost any shape. It is also a softer and more spongy material. While these material properties are disadvantages for many typical facial implant locations, I do not consider it so for the tear trough area. In fact, it is my preferred material for this area and the orbital rim and floor…exactly because it can be custom carved and adapted along the infraorbital rim and is soft. It is a smooth slippery surface material so it must be screed into place to keep it from being displaced. Because it offers a smooth surface, it is also as easy to remove as silicone and quite unlike Medpor in that regard.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley My problem is that I look pregnant even though I am not. I was very athletic until  I went through three pregnancies and never had time to get back to exercise between them. My underlying stomach muscles feel tight and I can suck in my stomach but there still remains a pouch. If I wear tight clothes it hides it but otherwise it just sticks right out.  I’ve had a c-section but I do not want a tummy tuck because of the scar. Would liposuction help reduce the size of this pouch? Thank you in advance as I would value your opinion.

A: If any form of a tummy tuck is not acceptable, the question then becomes how much of a difference liposuction can make. No plastic surgeon can say for sure without at least seeing some pictures of you. But knowing that you have had three pregnancies spaced fairly close together suggests that the quality of your skin may not be good. (poor elasticity) This is  relevant in that as the fat is removed what will happen to your abdominal skin. If your pouch is less but your skin sags and hangs worse, you may not consider that a good aesthetic trade-off. Liposuction is always an option as an alternative to a tummy tuck, the question is whether it is a good one. Not all fat reductions necessarily make the body part better looking even though it may be smaller.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr Eppley,  I would like the fat tip of my nose made slimmer and the size of my nostrils reduced. While I like the shape of the upper part of my nose, the lower part is too big and disproportionate to how small the rest of my face is. Is this something that rhinoplasty can do, just change one part of the nose without affecting anything else? I do not want to change the shape or height of my bridge. I don’t know how difficult it is to just change the shape of the tip. I also fear that the tip could become too small and give me a reverse problem than what I have now. I do not want  a petite nose with a pinched tip, just one still looks like me only in better balance. Thanks

A: Tip rhinoplasty is a very common nose procedure and only changes the shape and size of the lower third of the nose. Whether that will look more balanced without the need to alter any other part of the nose is best determined before surgery through computer imaging. You may very well be right but it can be surprising sometimes other areas look when one part of the nose is changed. Just be certain beforehand by some computer imaging work. It would be rare to take a big tip of the nose and make it too thin. (discounting Michael Jackson who had many nose procedures and is a result that should not be seen as the norm) Usually the question is whether as much tip refinement can be achieved as the patient hopes, particularly if the nasal skin is thick.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 29 years old and have always had heavy legs. For whatever reason, I got stretchmarks on my inner thighs during my teen years and they have never gone away. I want to get liposuction and was wondering if my stretchmarks would affect the result in any way. Will it not look as good afterwards if the skin is stretched out to begin with. If so, is there an alternative to liposuction that would be better? Thanks!

A: You have brought up a very good question, particularly when one is contemplating liposuction of the inner thighs. The inner thighs is a common area for patient dissatisfaction after liposuction. This is because the skin of the inner thighs does not have as much elasticity as other body areas so it is prone to not adapt well (shrink down) after fat reduction. This can lead to an inner thigh with irregularities and more loose skin after liposuction. This is why liposuction of the inner thighs must always be done more conservatively than in many other body areas and patient should expect modest improvements only. This would be particularly true when it it recognized before surgery that the skin is of questionable elasticity. Having stretch marks put you into the questionable skin quality category. One must think carefully about liposuction in this area under these circumstances and, without examining you, I can not tell you whether you would be wise to have liposuction or not. There are some emerging non-surgical technologies that are good alternative choices. Radiofrequency devices, like Exilis, can be very beneficial for skin tightening and some fat reduction. Whether you should have this alone or done after your liposuction surgery is a good question that can only be answered by an examination.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, five years ago I got Medpor malar implants. I am very happy with my cheek implants that provide me with very high and prominent cheek bones – a look that I have always wanted. I also like the fact that they integrate with my own tissue. But recently I have read this on the internet:

“Explantation of nonsilicone facial implants that have integrated into the surrounding tissues can be very difficult to remove, and in some cases it can contribute to nerve injuries. Any implant, regardless of material, can produce nerve injuries if a portion of the implant is in direct contact with a main branch of the sensory nerve.”

I know that one wing of the malar implants is directly below the foramen infraorbitale, where the infraorbitalis nerve comes out of the bone. Now I am worried that I could get serious nerve damage if the implant should have to be removed for a medical indication in future. What is your experience with explantation of Medpor malar implants and the risk of permanent nerve damage? Does this nerve stick to the Medpor implants?

A: While your concerns are understandable, you are worrying about a problem that you do not have and are very unlikely to ever get. Unless you now have infraorbital nerve symptoms (pain and/or numbness), your implants are not impinging on the infraorbital nerves and are not even that close to them. Thus, if you ever should need the implants removed, they should be able to be explanted without nerve injury. While Medpor facial implants are frequently stated to be very difficult and destructive to remove, that has not been my experience.

Dr. Barry Eppley

Indianapolis, Indiana

Q:Hi Dr. Eppley. I will be 17 years old next summer. I’m looking to get some implants as I get a little older. Is there any way of creating a custom jaw/chin implant? If so, would this cost extra? If so, how much? Much appreciated. Also, what is the minimum age requirement if one wanted to get some facial implants? I’d like as much information as possible please. Much appreciated.

A: The timing of chin and jaw implants is based on two factors; the degree of jaw deficiency, one’s bite or occlusion and the near completion of jaw growth. At this age you want to be sure that you do not have a correctable malocclusion by a combined orthodontic and orthognathic surgery approach. If not, then chin and/or jaw angle implants may be appropriate. I certainly would not perform that surgery before the age 18 when jaw growth is closer to being complete in a male. Custom chin and jaw implants can be done and I do them on a regular basis. But whether they are really needed and offer any advantage over stock preformed implants must be determined on a regular basis. It is hard to give any reasonably accurate pricing when I don’t know whether one needs just a chin implant or whether one needs a combined chin and jaw angle implants for total jawline enhancement. In either case, custom implants will double the price of the surgery due to the need for special design and fabrication. For this reason, one has to have a very compelling anatomic need to justify the expense of a custom facial implant process.

Dr. Barry Eppley

Indianapolis, Indiana