Q: Dr. Eppley, I was wondering what your opinion was regarding a buccal fat removal to enhance my cheekbones and remove some of the fullness from the middle of my cheeks. Is that something you’d recommend for me or do you think the ROI/ROE is not worth it?

A: Buccal lipectomies for you I would not do. You already have a thin face and extracting  buccal fat today may likely create a very gaunt face down the road which is hard to correct. I don’t say this to many buccal lipectomy inquiries but yours is the one young face to which this applies. Thus to make your cheeks bigger you should take a direct approach and turn to cheek implants

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have 2 questions. 1). I have cheek implants in my face and am interested in having my eyebrows microbladed. Is it safe to have my eyebrows cut at the dermis level or do I risk infection? Should I take antibiotics before and after microblading procedure? 

2). I am interested in chin implant. What type of chin implant do you use, Silicone or Goretex? I am a male 30’s . Thank you

A: In answer to your cheek and chin implant questions:

1) There is no risk of infecting cheek implants by microblading of the eyebrows. Before and after procedure antibiotics are not necessary.

2) I use whatever material the patient prefers…if the dimensions needed for the chin augmentation exist or can be designed in the implant.

Dr. Barry Eppley 

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in custom infraorbital rim-malar implants and canthopexy to correct negative canthal tilt to a slightly positive one whilst reducing my slight amount of sclera show)

I just was wondering if I could see this simulated and how it would realistically. If it looks good to me then i’ll be ready to book the surgery within the next couple of months. 

My only concern is in regard to the eye region. I know you’re a well regarded surgeon but I just simply don’t know if i’d be making a bold decision by going the direction of a non oculoplastic surgeon to work on my eye region in regard to canthoplexy. 

Essentially I just want infraorbital rim implants to get rid of my tear troughs in sync with the mid face implant to enhance the zygomatic region for aesthetic purposes. I don’t mind it being fairly conservative and nothing too crazy. 

Also in regard to the eye region I have negative canthil tilt and droopy eyes but i’m not sure if they’re as a result of the lateral canthus. In an ideal world I slightly reduce the amount of sclera show I have to make them slightly deeper set whilst making the tilt go from negative to slightly positive. 

Do you think this sounds feasible and is very possible? Do you think the result will look similar to the morph and do my goals sound realistic?

A:Thank you for your inquiry. In answer to your questions:

1) I have done one front view imaged picture for modest custom infraorbital-zygomatic implants. Whether the lower eyelid would become that smooth is open to speculation but your natural lower eye appearance looks the way it does now because it is volume deficient. The only way to get close to that prediction is to add volume. The custom implant approach is the best method as it increases both vertical height and some horizontal projection of the infraorbital rim as well as blends the augmentation out onto the cheeks.

2) The solution to raising your lower eyelid margin for less scleral show (droopy eyes) is not a canthopexy or a canthoplasty. In my experience a canthopexy is a protective corner of the eye procedure to prevent postoperative sag. A canthoplasty is a procedure to actually raise the level of the corner of the eye. But neither procedure can effectively raise the level of the lower lid margin across the entire lid and, most importantly, at the pupillary level of mid lower eyelid. In short you can’t just pull up the outer corner of the eye and raise the lid margin…that never works in any sustained fashion. It may look like it does on the operative table but not in a healed vertical position later.

3) To raise the level of the lower eyelid margin you have to add support. (build up the lower eyelid and not just try and stretching it)  This can be either a soft approach with an interpositional graft at the middle lamella or a hard tissue approach by raising the level of the entire infraorbital rim. (custom implant) Either method helps drive up the lower eyelid margin and can keep it there in a sustained fashion. 

Dr. Barry Eppley

Indianapolis, Indiana 

Q: Dr. Eppley, I already got my rib removal surgery quote thank you I have to save more money because I only got 10k. I got one question can you tell me how much inches usually reduce this surgery? I just want to know to to see if is good enough to expend all my savings.

A: As a general outcome statement, most patients report to me that their waistline reduces anywhere from 1 to 3 inches.

Since you have chosen to reveal your economic issues with his type of surgery, I can provide the guidance to you that no patient should ever put themselves in an adverse financial position for elective aesthetic surgery ….unless the face or body deformity they are facing is disfiguring and negatively impacts their life in a major way. I would not qualify the desire for waistline reduction in a young lean female as fulfilling that criteria.

In short you should never expend your savings for cosmetic surgery of any kind. That is not a good financial decision.

Dr. Barry Eppley

Indianapoli, Indiana 

Q: Dr. Eppley, I’m contacting you in hopes of getting some information on how I might address an issue I have. I am a transgender woman, and have undergone Facial Feminization Surgery recently. This addressed several of my issues, but I still find that I have a quite flat, hollow, and long face. From my research, these issues (the first two, anyway) appear to be due to “midface hypoplasia.”

I would be interested in hearing what options exist for correcting this which Dr. Eppley is able to offer. From my research, the main approaches appear to be either a LeFort I osteotomy or facial implants (specifically, paranasal and submalar). I have concerns with the LeFort approach. This is partially due to the aggressiveness of the procedure, but also because I feel that the zygomatic bone and the region below it and approaching the maxilla are also underdeveloped. To my knowledge, a LeFort I osteotomy only corrects the maxilla itself. Ultimately, though, I am not a doctor and not really qualified to make the assessment as to what would or would not work myself.

To aid with an assessment, I have included a link below to a set of pictures. These include head shots of me from the profile (both directions), three-quarters angle (both directions), and front. These were taken in bright lighting from roughly 6 feet away. Resolution isn’t amazing, as I unfortunately do not have a high-quality camera. I have also included CT scan images of my skull from roughly the same angles.

A:Thank you for your inquiry and sending all of your pictures and 3D CT scan. Your diagnosis is an overall midface skeletal deficiency. You are correct in that a Lefort I osteotomy would only correct a subtotal portion of the problem….although you would need a LeFort I advancement combined with a mandibular advancement since your lower jaw is also over rotated as a result of the midface deficiency. But given that you have a normal occlusion such orthognathic surgery has additional limitations. From an implant standpoint augmenting the entire midface including the infraorbital and lateral orbital rims with a custom design would be the alternative and superior aesthetic outcome approach that would also be far less invasive with a quicker recovery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m in the middle of preparing for a surgery. I will be getting custom PMMA cheek implants modelled off a 3D printed model of my skull. I’m planning on widening my face a little bit and hoping that this will improve my sagging cheeks from my zygoma reduction procedure.

I understand that all implants have a risk of infection and that the highest risk time is in the early post-operative period. However, how common is it for facial implants to get infected without good reason in the long-term?

From my understanding and research, I understand that dental anesthetic or fillers in the implant capsule could potentially inoculate the implant with bacteria and subsequently get an infection. I’ve read about patient experiences where Medpor implants get infected out of the blue years after surgery. Is it possible for an infection to pop out of nowhere without reason?

A: In all due respect these are questions you should be asking the surgeon who is going to perform the procedure. Presumably they have both the skill to not only do the procedure but also the experience to know what the long-term risks are.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I found your profile on RealSelf and it appears you seem to be quite experienced and knowledgeable about facial implants.

I’m of Asian descent and one year ago I had my chin narrowed and moved forward in Korea. I’m near happy with the results of the surgery but I desire more horizontal movement. I regret asking my original surgeon to stay conservative but I guess I would prefer less than too much. 

I’m thinking of going abroad again to get a small chin implant, as I think recutting the bone for such a small additional movement is overkill. Surgery in my home country is also unbelievably expensive and not exactly very well versed when it comes to asian aesthetics.

The only thing is that I am deathly afraid of getting an infection. I’ve read on RealSelf that most infections tend to show themselves in the first week up to three weeks post operation. What’s the likelyhood of infection appearing after this period? 

More so, I worry about the implications of cutting through the mentalis muscle twice. As I am Asian, I have been rejected for extraoral incisions due to the scarring implications. Does cutting through the mentalis muscle again have consequential possibilities such as a drooping lip or chin sagging? 

Thank you for your insight.

A: The way to lower the risk of infection to the lowest possible is to use a submental skin approach. That also avoids cutting through the mentalis muscle and quickens recovery. That is a 1 cm incision which I have not seen that to be a ‘scarring’ issue. I have done many Asian male patients through that approach.

But since that approach is off the table, the risks of infection with intraoral placement are higher, how much higher no one can really say. Such infections do not occur in the first week or so but 3 to 6 weeks after surgery. That is typical take period for all facial implant infections.

I don’t consider cutting through the mentalis muscle twice of major concern.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in buttocks implants, however, I am worried about a new worldwide discovery of “implant illness”. Do you think this could happen even with solid silicone implants used in buttock augmentation or only breast implants? My second question is can I get buttocks implants and rib removal at the same time so I do not have to be under general anesthesia twice? Do they both have to be done under general?

A: In answer to your question:

1) You are referring to a low grade lymphoma that has only been associated with one type of textured breast implants. This has been associated with the way the textured surface was applied. I do not see a correlation with smooth surfaced silicone buttock implants.

2) I could not think of two body procedures who would need general anesthesia any more than rib removal and buttock implants. These two procedures should not be done, either together or separately, without general anesthesia.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting a forehead reduction and forehead implant. Can these procedures be done together or are there limitations? Will this result in a higher chance of shock loss or negative side effects?

A: By your description I believe you are referring to a hairline advancement (forehead reduction) and a simultaneous forehead augmentation. (implant) Whether such a combination of forehead procedures can be done depends on how much forehead augmentation is desired as well as how much forehead reduction is needed. I would need to see some pictures of your forehead as well as your goals to determine whether they can be done together or would need to be staged.

If the desired hairline advancement is not extreme and the size of the forehead implant is not too big, then I suspect both can be safely done together. But a hairline advancement greater than 10mms and a forehead implant thicker than a few millimeters, then there may be some tissue restrictions with combining the two procedures.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a temporal implant procedure done 10 years ago which I’ve not been happy with as the size and thickness of the implants is too large in my opinion. I would want them to be replaced with much smaller and thinner implants.

Some of the notes I have are:

– the original physician does not have records other than it was methylmethcrylate implants, formed from putty at the time of surgery

– I had a consultation with a physician in southern California, he concluded the methylmethacrylate implants are placed along the temporal bone bilaterally after reviewing MRI

– the MRI report is attached but is not too conclusive

– the right side implant is definitely a little thicker, more convex shape than the left side, I particularly dislike the right side result

– I’ve attached 3 pics, the first one I think shows how the result makes my head look bigger which I don’t like, an extremely subtle augmentation is what I’d prefer.  The sideview shows the faint scar line.

A: Thank you for sending all of your prior temporal augmentation information. As I suspected these are PMMA intraoperatively fabricated implants placed under the muscle down on the bone….a common technique done before the availability of standard silicone temporal implants. I could easily identify in your pictures the surgical incision used. Knowing its location and length would be crucial in determining how ‘easy’ it is to revise/replace them. It is one thing to place a moldable putty through a small incision and shape it and allow it to harden than it is to try and get a solid implant out in reverse. It can be how to extract the proverbial ‘ship in a bottle’. However knowing that PMMA is usually inserted through ‘larger’ incisions, which I suspect you have, suggests that it can be similarly removed. 

Dr. Barry Eppley

Indianapolis, Indiana