Your Questions
Your Questions
Q: Dr. Eppley, I have saline breast implants in now that are 375cc in size. While my surgeon said they would be perfect, I knew from the beginning they were too normal. (maybe perfect for him but not for me) They are under the muscle and are smooth Mentor saline implants. They were placed through an incision under my armpit as I did not want any breast scars. After having had them for six months, I am more convinced than ever that I want to go bigger. I want to go at least 500cc and maybe 550cc. Can my current implants be removed and replaced by going through the armpit again? I still do not want any scars on my nipples or under my breasts. Should I use saline again or go with silicone implants this time?
A: In terms of a size change, you want to make sure that you are having a breast implant volume change of at least 30%, as that usually the minimum it takes to see a real cup size difference on the outside. That is why a change to 500cc (33% is the least you should go) and 550cc (46%) would be more ideal. You do not want to go through a second surgery and still fall short of your size goal.
Since the incision is an important concern for you, the armpit approach can be re-used and your saline implants exchanged for larger ones. While silicone implants can be placed through an armpit incision, there are some limitations of size. The size you have in now is about the limit for inserting silicone implants using a funnel technique through the armpit. There is no limit of size when it comes to saline breast implants through the armpit.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have lost a lot of the fat in my face particularly in the cheeks which has left them very hollow and sunken in. The area below my cheeks looks too full because it is indented above it. I havhe been told that fat injections would be the way to go even though fat transfer may not always stay. I know that cheek implants are permanent becuase they can not be absorbed. But I didn’t know of they come big enough to fill out the entire depressed cheek area. What sizes do they come in and do you think they are big enough to fill out the whole cheek area?
A:Your concept of considering cheek implants for helping restore facial volume loss is only partially correct. Cheek implants are not a substitute for fat injections when it comes to facial fat volume loss. The submalar style of cheek implant can help fill out the buccal area of the cheek (right below the cheekbone) but this represents only part of a larger surface area of the cheek and surrounding tissues which makeup the gaunt or skeletal facial look. Therefore, the use of this type of cheek implant may be a companion strategy with fat injections but is not a stand alone treatment for refilling out the deflated or fat-depleted face. Fat injections are more versatile because they can be placed anywhere. Cheek implants, even the submalar style, can not go very far from the edges of the bone and are more limited as to the facial area that they can cover.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, after enduring over twenty years of having an indented tracheostomy scar, I am finally getting it revised. I understand that up to 50% of the fat tissue that is used as a filler gets dissolved by the body while it is healing. Is it possible that one would need multiple visits over the years to keep adding filler injections or something of that nature? Also, if one were to avoid that route in favor of something “off the counter” which product would you recommend? Thanks in advance.
A:Most tracheostomy scars can be revised and the neck skin leveled by simply closing the deeper layers of the excised scar as it is closed. This brings in tissue from the side and fills the defect or area of missing tissue underneath the skin. Larger or more indented tracheostomy scars, however, do have a real subcutaneous tissue deficiency as a result of fat loss due to pressure atrophy caused by the indwelling tratcheostomy tube. When these are merely excised and closed, they will revert to some degree of inversion as the skin is essentially closed over an ‘open space’. This is why the placement of fat grafts can be so helpful in tracheostomy scar revisions. However, the choice of fat grafts is critical and should be a dermal-fat graft and not fat injections. These are small composite grafts that can be taken from many locations with a small resultant scar. There are no ‘off the shelf’ products, such as allogeneic dermal grafts, that are a good substitute for a supple dermal-fat graft.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have this weird-shaped head in the back sticks out. I have been teased about this since I was a child. As an adult, it has not gotten any better. They call me all sorts of names like football or peanut head. I have very low self esteem from this my whole life and I feel like people are always looking at it. I was just wondering if there is a way to flatten the back of my head or make it not stick out in the back as much. Please help me. This would change my life and give me great confidence.
A: While I can not provide any exact recommendations without seeing pictures of your head first from different angles, I can make the following general comments. When it comes to head or skull reshaping, the question is whether the bone needs to be reduced, built up or some combination to get a smoother and better-shaped skull area. Given that there are limits as to how much the skull bone can actually be reduced and that the amount of build-up is always much greater than what reduction can be achieved, the focus should be on whether an augmentative cranioplasty will help. The second general comment is that most cranioplasties, other than for very small areas, has to be done using an open approach. From a scar standpoint, this makes skull reshaping a more common procedure in women than men due to differences in hair densities.
Dr. Barry Eppley
Indianapolis, Indiana
Inadequate training and poor judgment account for a disproportionate number of complications and unsatisfactory results that occur from cosmetic surgery procedures. With so many different types of doctors doing cosmetic surgery, how can one make a safe choice? Historically, the use of the terms ‘board-certified’ and ‘specializing in’ were enough to demonstrate a doctor’s expertise, but today that is not enough.
Are they board-certified in plastic surgery or another specialty? Many new cosmetic surgeons are board-certified but not in plastic surgery. Their board certification may be in General Surgery, Dermatology, Oral Surgery or Ob-Gyn to name a few. Some may even have an additional board-certification in cosmetic surgery. But this self-created board should not be assumed to be equivalent to those certified by the American Board of Plastic Surgery. There is a significant difference between board-certified plastic surgeons and board-certified cosmetic surgeons that makes them not equivalent at all.
How experienced in doing your procedures of interest is the doctor? This can be a hard piece of information that is not easy to ascertain. Certainly asking the doctor is an obvious way to learn how many the doctor does, but that is not the exclusive source I would use. Look at their websites and see how many before and afters of the procedure are posted. Ask for before and after photographic results and to talk to some more recent patients. (done in the past 3 to 6 months) Word of mouth still remains as a good method of recommendation. Willingness to easily and quickly divulge this information is a good sign. Hesitancy or avoidance of doing so would be of concern.
Hospitals are obviously certified and have to meet highs standards of care and comply with stringent regulations. Surgery centers can be quite different and you want to have your surgery in one that has been accredited by either the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF), the Accreditation Association for Ambulatory Health Care (AAAHC) or the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). This accreditation and a state license to operate means the facility adheres to safe operating conditions. Doctor’s office are fine for minor surgery but most are not accredited for more significant surgeries and any anesthesia that may be needed.
The cost of cosmetic surgery is always of concern and no one wants to overpay for their procedure(s). But the cost of cosmetic surgeries is influenced by market factors just like any other retail business. This makes a fairly consistent price range for procedures in any given geographic region. If after getting several consultations one price is considerably lower than another, the question should be why. Where are the costs being reduced to offer such a lower price? This is what makes the whole concept of Groupon and other discount programs for cosmetic surgery so unnerving.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 50 year old woman and am fairly thin being 5’3″ and weigh 117lbs. I have had what I think is fat on the back of my neck for as long as I can remember. It looks like a buffalo hump and it runs in my family. I have exercised all my life and continue to this very day. I have always been concerned about my posture so this buffalo hump is quite disturbing. I HATE IT! I have had liposuction on my stomach and thighs but no doctor seems to want to address my neck problem. I have had xrays and I do have a greater curve in my upper back than most people. Looking at me from the front my posture is impressive, but when I turn to the side it looks thick like there is a flap of thick fibrous fat. I can grab and feel it. I am self-conscious about wearing my hair up. Now blouses do not fit properly and often I have to alter clothes for them to fit. Please, I hope that you can help me.
A: Buffalo humps on the back of neck are almost always collections of fat. Why you have it there in an otherwise thin person who is very active is unknown. Seeing that your relatives have it indicates that it is genetic in origin and not from one’s lifestyle. An attempt at liposuction would certainly seem to be worthwhile. The fat in the buffalo hump is different than that in other body areas being more fibrous and not pure fat. This is why an open excision is the most effective approach but the midline scar may not be worth it. I would recommend laser liposuction (Smartlipo) as a better liposuction technique in fibrofatty areas.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had breast implants with a lift over one year ago. While they do look better than before they are very asymmetric. I had 375cc silicone gel implants and vertical breast lifts. The left breast is considerably larger than the right and the implant sits lower and more towards the side of my chest. My plastic surgeon wants to redo the lift on the left and tighten the pocket. Rather than place a bigger implant in my right breast, he wants to take more breast tissue on the left to make them more even. This doesn’t make sense to me and I think it would be better to place a bigger implant on the right to make them look more even. I think he is wrong with his plan but he won’t do it the way I think it should be done. What do you suggest I do?
A: One of the most difficult body contouring procedures to do and get a symmetric outcome is breast reshaping. The combination procedure of lifting sagging breasts and adding volume (an augmentation-mastopexy or breast implants-lift) is challenging and the need for secondary revisions is remarkably high. (25% to 50%) When planning a revision of this operation, there can be multiple options to manipulate including more of a lift or tightening the breast skin, increasing the size of one or both implants, or even removing some breast tissue. Any or all of these may be needed and there are advantages and disadvantages to any of them. While you would prefer to exchange an implant for a bigger size, your plastic surgeon has recommended otherwise. I would make the assumption that he has a lot more experience in doing this surgery and has a good reason for making this recommendation. I would suggest you sit down with your plastic surgeon and discuss your differences. Unless the final result is perfect, and it is likely that it won’t be (better but not perfect), you will never be happy with any outcome unless you understand and agree with the revisional plan.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I want your advise on getting suitable cheek implants. I currently have a Medpor midface contour implant. They were placed six months ago. My implants were placed unmodified. Although I have achieved a decent level of midface augmentation, I feel the implant is too large, surface area wise. It is too close to my eyes and is also too low and close to the top of my teeth. I also have visible edges on both the left and right side near my eyes.I did previously have a Lefort 1 osteotomy for my bad bite in the past but the central part of my face wasn’t really improved. What I was looking for in cheek implants was something to improve my midface. The current implants have alleviated midface flatness but I do still feel I look at bit gaunt but less so. However they are just too big, so looking for opinion of porex alternatives which might be appropriate. I was looking at either RZ 5m, or the 4mm extended malar, basically something to emulate the middle third or so of my current implant. I have attached pictures for you to see my face and what my current implants have done.
A: What you are showing is the problems with stock midfacial/cheek implants which are now, by your own illustrations, demonstrating that their shape is not adequate in multiple dimensions. This leaves you with three implant options:
1) Modify your existing indwelling implants by tapering the bothersome edges and adding/removing the areas to create better convexity.
2) Remove and replace your existing implants with new implants that would likely need a combination of infraorbital rim and cheek implants. The medpor RZ4 or the 4mm extended malar are reasonable options but they will need intraoperative modifications.
3) Remove your existing implants and replace with custom-made implants that are designed off of your own skull model.
While all of these are possible, they each have their own advanatages and disadvantages. Modifiying what you have in, while seemingly simple and easy, will not likely make a significant or the desired changes that you want. (but it is always worth a try) Replacing them with new stock implants I suspect will put you in the same position you are now, better in some areas but inadequate in others. There simply are not stock implants that can fully meet your aesthetic goals. Custom-designed cheek/midface implants are the most likely to really meet all of your aesthetic midfacial goals as all of the planning and adjustments of them are thought out before surgery. The only downside is the increased cost to do so.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was in an accident that fractured my nose, eye socket, cheekbone and jaw. I had 1 reconstructive surgery to place the bones back in place. After the surgery, months past and I was hoping for my face to begin to look the same as before. It has almost been a year and I hate how I look. Afraid of what the world has to think or say, I cover my face with sunglasses. I hate how I look and since then I’ve had a very low self esteem. I want to look for answers. Can my face be fixed? Or will I ever look the same or close to it? I can provide pictures of my face to determine if my face is at all repairable or if it’s just too late. Thank you.
A: Thank you for sending your pictures. I can see that you have a classic post-traumatic facial deformity, known as zygomatico-orbital displacement on your right side. While your initial facial fractures may have been surgically treated, they did not properly place your orbital and cheek (zygomatic) bones back into anatomic position or there were not supported well after reduction. Either way, your right ZMC complex is displaced downward showing the visible problems of orbital dystopia (eyeball in lower position than the other side) and the cheek bone being displaced downward and outward with increased midfacial width.
Your facial problems can be improved by a revision or re-do of your original facial fracture repair. This would be a zygomatico-orbital osteotomy with bone grafts to lift the eye back up and reshape the cheek area. Before considering this surgery, you need to have a 3-D CT scan to confirm this diagnosis and provide a detailed assessment of these and the surrounding facial bones.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am currently looking to having my Goretex chin implant removed after five years. I have always been unhappy with it as it is simply too big for my face. Can you please let me know how it is removed, any issues I should know and what How To Get A Ex Back At 14 the process to do it involves.
A: Thank you for your inquiry. When it comes to removing a chin implant, it is often necessary to tighten the mentalis muscle/chin tissues at the same time to prevent chin ptosis or sagging afterwards. This is particularly relevant if it is a large implant and produced a significant stretch of the chin tissues. Much like a breast implant, what happens to the overlying expanded soft tissues on removal? The approach used for chin implant removal, intraoral vs. submental incision, would depend on how it was originally placed and how much loose chin tissues are expected to result. This could mean an intraoral mentalis muscle resuspension or a submental tuckup from underneath. There are, of course, some cases where simple implant removal is all that is needed…but these are only a minority of cases.
Regardless of what needs to be done, this is an outpatient done under sedation or general anesthesia. There is minimal recovery and discomfort afterwards. There are no restrictions after such surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m interested in cheek implants and a few other things that might be needed depending on your recommendation. My goal is to have a defined cheek/jaw line like some male model pictures that I have attached. I will get the buccal fat removed also if that is required. The 1st model model might have the cheek implants because the cheek area is not as pronounced as in the 2nd picture. I have attached pictures of myself from different angles so you can see the shape of my face. I look forward to your recommendations.
A: I have done an analysis on the photos that you have sent. The frontal photo is of excellent quality, the side view is not good quality but useable. I have also looked at the model photos that you have shown, and while they illustrate a facial shape goal, I hope you realize you can never look quite like them as you have a completely different facial shape.
Where I think your face can be improved is in multiple areas including vertical chin lengthening with some horizontal advancement (chin osteotomy), cheek augmentation with implants, buccal lipectomies, rhinoplasty with tip thinning and nostril narrowing and earlobe reductions. I have attached some computer imaging to show you a realistic potential outcome.
With your thick skin and existing facial shape, there are limits as to what can be achieved. I thinik this is the best approach to obtain some increased facial angularity.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a short face length with a small/narrow lower jaw. From the profile view my face looks even shorter because of my short forehead and short jaw. Could jaw implants fill out my lower jaw and make my lower/overall face look ‘bigger’? I’ve already had a chin implant, but it didn’t do much for vertical length. My plastic surgeon says a sliding genioplasty wouldn’t look good. Should I get a second opinion? Is it safe to get a sliding genioplasty and jaw implants at the same time? Thank you for your time.
A: The right style of jaw angle implants will vertically lengthen the posterior face. But the wrong style of jaw angle implant will only make it wider (fatter) and not longer.
Chin implants will not provide any vertical length, just horizontal projection. No stock chin implants are made for vertical chin elongation.
The statement that a sliding genioplasty won’t look good is a nonsensical opinion. A sliding genioplasty is the only option to provide vertical chin lengthening or lengthening of the anterior face. Just because a surgeon can’t do an osteotomy doesn’t mean it won’t look good or be a good choice for a particular patient.
It is common in my experience to do jaw angle implants with a chin osteotomy and/or an implant. They are often needed together to create an overall change in jaw shape.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in having liposuction of my perioral mounds done. I just hate those blobs of fat to the side of my mouth. My only concern about the procedure is that I have read that there are a number of facial nerves near the perioral area. My question is could they possibly be damaged by perioral liposuction. Is this a real concern in your opinion and, if so, what are the risks and side effects of this type of complication?
A: The perioral area is located between the buccal and the marginal mandibular nerve branches of the facial nerve as it comes forward from the ear. Therefore, liposuction is in a safe zone from a facial nerve injury standpoint. So this is not a concern I have as I have yet to see any nerve problems with liposuction in this area.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Hello! I am 31 years old and I used to be 375 lbs until I had gastric bypass surgery two years ago. Today I weigh 157 lbs, but now I suffer from loose skin on my abdomen, arms, buttocks, and thighs. I have a “skirt” of abdominal skin that reaches down to my groin area, and I suffer from irritation, yeast, and sores due to this excess skin. My breast size also went down significantly. I currently am on Medicare and Medicaid, and I was wondering if you offer a procedure that can remove this abdominal “skirt” that is covered by Medicare. Furthermore, I am also interested in getting a breast augmentation, and was wondering if my Medicare will cover it if it will cover the “tummy tuck” surgery. Thank you, and I look forward to your response!
A: Thank you for your inquiry. While you would do well with a circumferential body lift or even a frontal abdominal panniculectomy, I am not a Medicare provider so I can not be of assistance to you.
While there is the chance of some coverage by Medicare for an abdominal panniculectomy, there is no chance that they would ever cover a completely cosmetic procedure such as breast augmentation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a very prominent fat pad (?) on the left side of my face. I am 62 years of age and had a facelift eight years ago. I have a rather thin face which has lost with age some fat which I guess is expected. This lump has created a chipmunk effect like I have a big piece of bubblegum in my mouth all the time. What is the cause of this problem? Is it fat? What can be done about it? I have attached some pictures.
A: Thank you for sending your pictures. By your description and pictures, you have the classic findings of a ‘ptotic buccal fat pad’. Underneath the cheek bone sits the large cheek or buccal fat pad. With age, and sometimes after a facelift, this large pad can fall downward as the space in which it normally lives becomes loose and it leaves where it normally sits. This buccal fat prolapses or herniates outward, falling down to the level of the perioral (corner of the mouth) region. Patients will describe it as a wad of tissue that is inside the lower end of their cheek.
That being said, the question is what to do with it. There are two approaches, removal or resuspension of the buccal fat pad. While in some cases I would recommend resuspension, that may lead to some facial asymmetry as where it needs to go above is already symmetric to the other side. (usually done only when the problem exists on both sides) Therefore, removal would seem most judicious in your case. That could be done by small cannula liposuction from a small incision inside the corner of the mouth.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Over the last two and a half years, I have lost 225lbs naturally through better eating and exercising. I am now stable at this weight and in need of surgery to remove a lot of thet excess skin, specifically around my midsection and groin. I couldn’t be happier with where am I today, but know that I am still not myself with all this excess. While there is a lot of extra skin now, where do you recommend surgically to start the process of remaking this thinner but saggy body?
A: Thank you for your inquiry and congratulations on your weight, loss all on your own efforts. Not many people could have made that much progress and sustained it on their own. With that amount of weight loss comes the expected skin excess throughout the trunk region. This is a very common issue that I see, in both men and women, after bariatic surgery where this amount of weight loss is more typical. Your pictures shows that a circumferential lower body lift is a good place to start to remove a lot of this excess skin. Tightening the waistline and getting rid of most of the redundant skin and overhang is always a good starting point on the body makeover process. This is the largest surface area of skin to be removed and needs to be done first before any procedures are considered above or below this area.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am considering a chin implant and I also like to grow facial hair… My question is can or will a person lose hair follicles on the chin due to the incision/scar of to a chin implant? I am seriously considering a chin implant, but I do not want to have a spot on my chin where hair cannot grow any longer.
A: You are expressing an understandable concern that is fortunately not usually an issue. One of the unique aspects of chin implants in men is that the submental approach goes through skin with beard hair. If not properly handled, it is possible that one could be left with a more visible scar due to surrounding hair loss. Avoiding that submental male scar problem is done by the technique used. The initial incision in the skin is made with a scalpel and not cautery to avoid burning the skin and any hair follicle bulbs. The incision is made parallel to the direction of the hair growth as they emerge from the skin. This is why I wear loupe magnification to see this hair direction very carefully. Once through the skin a scalpel, not cautery, is used cut through the tissue all the way down to just above the chin bone. This is because the hair bulbs, which can clearly be seen, are on the very underside of the skin and are still subject to injury During skin closure, small bites are taken through the skin to avoid entrapment and any strangulation of the hair bulb in the loop of the suture being tied down. With these techniques, my experience has been that submental scars from chin implants in males do not develop beard skin hair loss.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like to know if anything can be done to improve my arms scars. I have a history of being a ‘cutter’ but am now over that self-mutilating problem. I would like to put the reminders of this phase of my life behind me. I have sent you some pictures of the arm scars. The first picture is the left arm and the second is the right. I’ll look forward to hearing if there is anything that can be done to make these less noticeable. Thanks for your time.
A: Thank you for sending your pictures. Due to the large number of transverse scars on each arm, I see no significant improvement that could be obtained by any type of individual scar revision or laser resurfacing methods. Those approaches would be hopeless in your arm scar problem. In a few of these type extensive arm scar cases, I have done complete removal of the scarred forrearm segments and replacement it with a skin graft. This is a more radical approach, and replaces one scar problem for another, but at least the social stigmata of the visible scarred forearms is gone and may offer one a better social opportunity for explanation.That may be a satisfactory approach for the right patient.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a facial asymmetry problem. Even though I know that everyone has a little asymmetry to their face, mine is not that little. It is quite visible. My cheek bone on the right is a little higher than that of the left. So is the eyeball area above it. I also don’t like my very bushy eyebrows and my left eyebrfow is lower than my right side. My left ear is lower than my right one and that makes it difficult to wear glasses or sunglasses comfortably. I am attaching a frontal picture for your assessment and recommendations. I am leaving this up to you as there seem to be few doctors that know how to treat facial asymmetry and because of your good reviews plus you can help me in all my problems.
A: Thank you for sending your picture and expressing your specific concerns. Your overall issue is one of facial asymmetry with the left orbito-maxillary region as a unit being lower on the left side. The lower positioned left ear would be part of that overall problem. As a general concept to gain better facial symmetry, the lower facial side has to be raised rather than trying to lower the higher side as that is surgically more possible.
With the objective of raising the left sided facial issue, I would make the following recommendations/thoughts. The left ear could be raised somewhat through suspension sutures from the cartilage to the fascia. A slight setback of its protrusion (sticking out) may be considered. This would be done through an incision on the back of the ear. A left eyebrow lift could be through an upper eyelid approach (transpalpebral browlift) which is the most common approach in men. I would remove a slight amount of left upper eyelid skin (blepharoplasty) which also serves as the access for the browlift. The lower eyelid marginj could be raised slightly on the outside with a lateral canthopexy/lid wedge excision. Raising the eyeball, even a few millimeters, can be difficult but a small orbital floor implant could be placed for a slight lifting effect. A small cheek implant would be used to provide some upper cheek fullness. Eyebrow waxing can be done to reduce fullness and are a good start to determine if their thinning is aesthetically advantageous. If so, you can then consider laser hair removal which is best done locally due to the need for a series of regularly spaced treatments to get some permanent reduction.
Although all of the individual surgeries are small in nature, they can collectively make a noticeable difference. All os this is said with the understanding that your facial asymmetry can be improved but a perfect match to the right side is not possible.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have 350 cc breast implants placed over the muscle. I have had implants for 25 years, with replacement from silicone to saline fifteen years ago due to rupture. This time the left side has deflated. I was desiring either the option of total explantation or downsizing. I had a consultation with a breast implant specialist that stated he would not downsize me but wanted to go to 425cc and would not downsize due to the compromise in results. He will either increase the size or perform a total explant. I am personally not interested in increasing my size at age 50 whatsoever but am wanting to go towards my baseline look as much as possible because this will be the last time I have implants when they need to be replaced in the future. Is there a way a compromise can be reached for a slightly smaller look? I have read cases where many people have downsized. I realize 350 cc is not large. I could accept the same size if there is no compromise. I don’t expect perfection and I realize that the result would be less than perfect and I can live with that. What is difficult about the idea of total explantation is the bagginess.
A: I would agree that total explantation would be an aesthetically difficult choice due to the resultant loose skin and breast sagging, not to mention the volume loss. While it is always better from an aesthetic outcome (pickup of loose skin) to go bigger in a breast implant exchange in older patients due to the skin expansion of loose skin, if that is not what the patient wants then it is not better. What the plastic surgeon was saying about downsizing was that there will be more skin sag (ptosis) afterwards if one goes smaller. While this is intuitively true, the real question is how significant it would really be at, let’s say, a 300cc implant which is roughly a 15% volume difference. I suspect that it would not cause a significant sagging change. Therefore, I see no reason why you could not go to 300cc or 325cc with a new implant. And you have already stated that you can live with a less than perfect result.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have facial asymmetry of which my left eye area is a big part of why it looks the way it does. I am interested in brow shaving and a canthopexy to improve the eye area. My biggest concern with orbital rim shaving would be losing frontal bossing over that orbital rim. Let me ask you if you have ever performed shaving of the orbital rims for the purpose of better balancing facial asymmetry?
Regarding chin implants. Given your extensive experience with these, especially in ideal jaw surgery candidates who refuse surgery (retrognathic lower jaw), I’d like to ask you if it’s a realistic possibility to recreate the appearance of a jaw when it is in a prognathic position, using a chin implant with wings? What I mean is when I slide my jaw as far forward as I can, creating what is dentally considered mandibular prognathism, I reallylike the aesthetic appearance it has on my jawline, probably because my jawline is retruded by default so when I manipulate my jaw into a prognathic position it actually just ends up looking relatively normal (with the exception of my lower teeth pushing my lower lip forward which is the only giveaway). Basically I’m asking if a chin implant with wings can provide anterior projection to the entire jawline, not only the forward most point of chin but also along the mandibular body of the jaw, bringing most of the jaw (except the mandibular angles) more forward relative to other parts of the face, like what happens when you push your jaw forward in your face.
Also another big question Ive always had about chin implants is how does the placement of a chin implant effects the lower lip? Do chin implants push the lower lip forward at all? And what about augmentation of the chin groove, can this be moved “forward” or augmented at all to avoid the formation of a huge indentation in the chin groove between the bottom lip and chin implant? As it would seem the larger the chin implant you use, the deeper this groove would become.
A: In regards to orbital rim shaving is done through an upper eyelid incision, it removes the bottom portion of the orbital rim not its anterior projection. So there would be no risk of losing frontal bossing which is a horizontal brow feature. Inferior orbital rim shaving is done almost exclusively in cases of facial/brow asymmetry. There would be no other reason to do it. The result is subtle, not dramatic, and is in the range of 3 to 5mms depending upon the degree of superior orbital rim asymmetry.
If you are jutting your jaw forward and getting the desired look, then a chin implant with match that horizontal result. It may be a little thinner at the sides. The most ideal thing to do is to make a custom chin implant which would overcome that issue.
The lower lip never changes position no matter whagt is done to the chin. That can only change with an entire jaw advancement procedure. You are correct in that the labiomental groove will be come deeper as the chin position changes below it but the labiomental groove is not changes by an isolated chin procedure, implant or osteotomy. That can be overcome with a custom chin implant which builts up that area whereas a conventional chin implant does not.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a facelift several years ago that I am ok with the results in the jowls. However, it has resulted in my earlobes being pulled down which I believe is called a pixie ear deformity. My surgeon who did the facelift has died and a different doctor has attempted to fix the ears two years ago by putting a suture behind the ear and pulling them up. After a week when it healed the ears came right back down. Is there another way to fix the ears that is not too extreme? I have read your web site and I really hope that you can help me. Thank you.
A: A pixie earlobe deformity results after a facelift because the tension on the lifted facial skin has not been properly anchored or supported. This results in elastic recoil of the skin, pulling downward over time on the non-cartilage supported earlobe. This results in it being stretched end elongated. When thinking about what the cause is, it should be no surprise that simple earlobe tuck or suture is destined to fail. The only real way to effectively treat the pixie earlobe is to re-raise the anterior skin flap or perform a more limited form of the original facelift, known as a tuck-up facelift. While it may sound extreme it is nothing like your original procedure and could be performed under local anesthesia. The skin flap needs to be lifted up in front of the ear again and raised up to cradle the earlobe. This will both shorten the earlobe and redistribute the skin forces better so that it does not recur.
Dr. Barry Eppley
Indianapolis, Indiana
Aging is inevitable and it begins to appear first around the eyes. While eyelid and brow lifts provide immediate and significant improvements, many would prefer to lessen these eye flaws without the costs and recovery of an operation.
There are a variety of non-surgical eye treatments combining neurotoxins, fillers, lasers devices and topical products. Which ones are used often follows the age of the person. Those in their 30s and 40s usually just need Botox to control their frowning and squinting wrinkles. Fillers and light and laser treatments are added for those in their 40s and 50s. At age 50 and beyond, surgery is needed to remove extra upper eyelid skin and lower eyelid bags. But these non-surgical treatments are still needed to preserve one’s surgical investment.
Botox is the most known name when it comes to facial wrinkle reduction by injection. But it is not alone as two other injection drugs, Dysport and Xeomin, are also available. While there are some that believe one is better than the other, they all are really comparable. They all take a few days to a week to start working and their effects will last from three to four months. One is not more powerful than the other nor does one cost less. These injections are given by the unit and the cost per unit varies for each one but so does how they are prepared. As such their treatment costs are all about the same.
While Botox is the most common non-surgical eye treatments, injectable fillers can also play a role. Many people will develop shadowing and tear troughs under the lower eyelid, sometimes as early as the late 30s. This can be treated with fillers to plump the area out. While they are over a dozen types of injectable fillers, the hyaluronic acid-based fillers (e.g., Restylane and Juvederm) are preferred. They can be delivered under the thin tissues of the lower eyelids with a low risk of lumps and irregularities.
While eye wrinkles can be held in check with Botox and fillers, they can not reverse certain skin problems. Blood vessels and brown spots can be removed with pulsed light treatments. These are often confused with lasers which they are not. When it comes to improving skin texture and reducing fine lines and wrinkles, laser resurfacing can provide improvements beyond what an eyelid lift can do.
Topical skin care products complement eye the benefits of injectable and energy treatments. The skin around the eyes is so thin that it responds well to many Vitamin C, retinoid and antioxidant-containing products. A new topical product, Latisse, is great for thinning eyelashes and eyebrows and it works like nothing else. Eyelashes and eyebrows can become one-third longer and thicker in a few months.
While surgery may be needed or inevitable for some, younger and less tired looking eyes may be just a few injections or the wave of a laser wand away.
Dr. Barry Eppley
Indianapolis, Indiana
Without explanation, everyone seems to know what a neck wattle is. While not seen as an endearing neck ornament as one gets older, this sagging piece of skin and fat is often a source of considerable anguish of one’s appearance.
The good news is that neck wattles can be successfully eliminated and usually much easier than one thinks. The trick is matching the proper solution for the size of the neck wattle. Some wattles are small, others are quite large. Different wattles need different approaches.
The two things that we know about neck contouring is what doesn’t work. There has yet to be a cream that has a real ‘neck rejuvenation’ effect. The winner in that transaction is always the seller of the magical potion. If there was a cream that could really change your neck, we would all know about it and it would cost thousands of dollars per jar. The other scam is that of neck exercises. If a neck wattle was really due to loose muscles, this approach might have some benefit. But it is loose skin and fat for which the ‘neck gym’ remains no better than those creams in a jar.
Getting rid of that neck wattle requires a necklift, also known as a facelift. There are different varieties of these lower facial lifting procedures depending upon how the size of the wattle. Smaller or more limited versions are popularly known as Lifestyle Lifts. They are great for jowling but not for the bigger neck wattle. For a neck that hangs more, a full facelift is what is needed. It has a powerful change effect on making that neck more shapely and tucked up again.The difference between the two is the location and extent of the incisions around the ears and the time of recovery.
To really change the neck in more significant wattles and sagging, the facelift must have an incision that goes up behind the ear and back into the scalp. It is the pull from behind the ear that draws up and tightens the loose skin in the middle of the neck. When needed, the extra recovery is worth the investment.
The other neck wattle surgery that few people have ever heard of is the direct necklift. It is the real wattle reducer and is the simplest of procedures to go through with but a few days of recovery. By cutting out the wattle directly, it is gone forever and creates a neck shape that will last for decades. The tradeoff for this simple wattle eliminator men is a fine line scar down the center of the neck. For men who have beard skin, this scar heals beautifully and may be the procedure of choice in the older male. For women, this potential scar must be considered very carefully.
Q: Dr. Eppley, I am a 51 year-old female that is unhappy with my upper lip. It has become flaccid with age and my philtrum is elongated and flat. My lip droops over my teeth and subsequently you do not see my upper teeth when I smile. I want to shorten my philtrum and open up my smile to see more of my teeth and try to look more youthful. I am open to all suggestions.
A: Thank you for your inquiry. You are describing perfectly the need and benefits of an upper lip or vermilion advancement. This is an excisional procedure where a predetermined amount of skin in a very specific shape is removed and the vermilion of the upper lip advanced or moved upwards. This will not only shorten the upper lip, between the base of the nose and down to the top of the cupid’s bow of the upper lip, but it will also cause more upper tooth show. To get the philtral columns more pronounced like ridges and not completely flat, dermal graft inserts can be placed vertically along their length at the same time as the upper lip advancement. This can be a procedure done under local anesthesia in an office setting.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, can we practice an onlay cranioplasty with tkryptonite in the front of the skull and end up having a smooth forehead shape? Are the most common complications of kryptonite cranioplasty surface irregular and a palpable demarcation between the bone of the skull and the kryptonite in certain areas? What is the likelihood that a second would be needed to smooth the surface of the kryptonite? If the demarcation between the bone of the skull and the kryptonite is especially annoying on the forehead after surgery, what is the solution?
A: In answer to our specific questions:
1) It will not likely create a smooth contour.
2) What you have mentioned are the two aesthetic complications with an injectable or minimal incision kryptonite cranioplasty.
3) It can be done endoscopically (small scalp incisions) with a long handled rasp.
4) It will be and it is corrected secondarily as mentioned in #3.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I desire a more womanly face. My face is very big and square and is way too masculine looking. I am not sure if my jaw angle needs reducing or if Botox injections will suffice. Can you please advise? I have attached some pictures for you to see my big square face.
A: A square face, by definition, is when the lower jaw width is just as wide as that of the cheekbones. The width of the jaw angle area plays a major role in creating the horizontal dimension of the lower face in the frontal view. The width of the back part of the jaw (jaw angles) is created by three anatomic components; the thickness or flare of the jaw angle bone, the thickness and volume of the masseter muscle and the flare of the jaw from the front (chin) to the back. (posterior border of the ramus) Only the thickness of the masseter muscle by Botox injections and the flare of the jaw angle (ostectomy or jaw angle reduction) can be reduced. The key question is which one of these two is making the greatest contribution to the width of your lower face. While I suspect it is more bony than muscle by your pictures, it is important to make the right diagnosis. I would recommend getting some simple x-rays (frontal, side and submental plain x-rays) where the bony anatomy will be very apparent. A frontal and lateral cephalometric film (orthodontic type x-rays) with a panorex will also suffice for making this diagnosis.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, The problem with my face is it’s very skinny when I don’t smile. When I smile I have the biggest fattest face ever! I have these fat pockets around my nose. And instead of a smile I look like I’m sneering. I was in an auto accident and it caused nerve damage to my left lip. I want to fix my smile so its even again and you can see more of my teeth. I also have a brow that I hate and would like to get rid of. I also would like some work done on my chin because I hate the way that looks. And also when I smile I have “jowls” and I’d like to get rid of those and my double chin. My double chin is hereditary and being tall and skinny this looks very strange. I would also like to get a nose job because I have my fathers nose and I think it looks very masculine. Overall what I am trying to achieve is a slimmer face, with more feminine features and a better more applying smile. I don’t feel like my face goes with my personality, and how I feel. Also anything else you see that needs to be done please let me know.
A: Thank you for sending your pictures. In looking at your face and reading your objectives I would consider the following procedures. A rhinoplasty is needed to make your nose thinner and less wide, particularly in the tip. I would also recommend buccal (cheek) fat pad removal (subtotal) and small cannula liposuction of the fullness above the nasolabial (lip-cheek) grooves. A lip lift (vermilion advancement) done with differential skin removal (left greater than the right) will help with better lip symmetry and overall fullness. A submental chin reduction is needed to decrease the amount of chin prominence and protrusion. Liposuction can be done in the neck and jowls to remove fat in these areas.
Unfortunately, I can only do limited computer imaging because your pictures are inadequate. Smiling photos make a lot of facial feature distortion.
You mentioned a dislike for your brows but I am uncertain what specifically you do not like about them. Until I know more, I can not make any recommendations on whether they can or cannot be favorably changed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I recently had Botox injected into my lips to help treat my lip lines. I was not pleased with the results at all. Besides not getting rid of any of the wrinkles it also gave me the unhappy effect of making my upper lip look funny (not in a good way) when I smile. I happened to have heard on my way out when paying my bill that this was the first time the doctor had ever injected Botox into a lip. I am upset that I paid for not only no result but that it may me look worse. On my own investigation I read on the internet that Botox is only approved for use in the forehead. I think I should get my money back and maybe even sue the doctor. What do you think?
A: Botox is used for a wide variety of aesthetic facial applications. It was initiallystudied and subsequently cleared by the FDA for glabellar (between the eyebrows) wrinkles and is known as an ‘on-label’ use. Despite this one approved cosmetic use in the face, it is a perfectly acceptable medical practice to use Botox for numerous other expression-reducing/wrinkle reduction indications. This is known as ‘off-label’ use and is commonly done with many drugs. It is neither wrong nor malpractice to do so. The use of Botox in the upper lip can be effective at wrinkle reduction but is technique and dose sensitive. Unfortunately for you, this effort did not turn out to produce the desired effect. The good news is that your Botox will wear off in a few months and you will return completely to normal. I would discuss your dissatisfaction with the treating doctor and see what accommodations they may be willing to do.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have heard alot about you and even read alot about the scar revisions you do on the internet. I found your website very helpful. I had a car accident in January, 2010. I had an injury under my chin. I was taken to the hospital and the doctor just cleaned the wound and put a band-aid on it. After a month when i shaved i had two scars under my chin. one in oval shape and one in small line red-pinkish in color. I showed it to a plastic surgeon and he told me to use Kelo-cote gel for two months. i used it for 2 months and the scar was a little bit soft but not much result was seen. Then n November, 2010 i had a revision surgery on both the scars. One remained the same and the other was reduced to 60% of the original since doctor had told me she will reduce the whole scar in two surgeries. I am not satisfied with the results from the first surgery. The scar is very visible and is pinkish in color and is even more visible now. I am attaching a picture of my scar before surgery and after revision. I would welcome your recommendations.
A: In looking at your submental or neck scars, I can see that both scars are fairly wide and in need of further scar revision. The biggest scar from the beginning was a tough assigment given its very large width. I have no idea as to the type of scar revision that was performed but I suspect it was a simple linear excision. Both scars would fare better with geometric approach to scar revision to distribute the tension on the closure better to decrease the amount of postoperatve widening. This is particularly needed when the excisions are wide and in an area prone to scar stretching influences.
Dr. Barry Eppley
Indianapolis, Indiana
