Your Questions

Q: Dr. Eppley, I am interested in having an abdominoplasty performed. But a a little history…I was overweight my entire childhood, finally reaching 320 lbs by late 2011. I made some big changes and lost most of the weight very quickly, about 90 pounds in the first year. I have been hovering around 190 lbs for over a year now and am generally happy with my weight. I have completely changed my diet and know I will never go back to my old ways. The only evidence of my former self resides in my chest, stomach, and inner thighs. There is some loose skin on my upper arms as well, but I’m not too concerned with that. I’ve attached some pictures to get your opinion. What kind of procedure do you think would be best for me?

A: From an abdominal standpoint, the roll of excess skin goes all around the waistline so a tummy tuck must be a near circumferential technique to really get all the excess skin out. Male tummy tucks are unique because they never require muscle tightening since there is no rectus diastasis from prior pregnancies. So it is essentially getting out all the loose skin and that probably encompasses at least a ‘300 degree’ excision length. The chest is always the most challenging in any male weight loss patient due to the skin and nipple sag and the inability to tolerate the scar locations from traditional breast lifting procedures that women undergo. (since they are being left with a breast mound while men want the chest flat) In my experience, all such chest reshaping procedures in many male weight loss patients leave me wanting for better results than they often produce, but the key is to not have any procedure that leaves with the trade-off of unsightly scars. In your case, I would recommend a periareolar reduction technique with liposuction. Whether any more than that would be indicated would require a true frontal picture so I can better assess what degree of chest sagging you have. (your current chest picture is taken from below and that may make it look less saggy that it really is)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,I  am a young African American woman. I have a larger forehead which I can live with. The problem I have is that since my forehead is wide and protrudes and my nose is stubby, it makes my glabella look flat and too wide. I would like a glabella that makes my face look more define. What do you suggest? Thank you.

A: Thank you for your inquiry and sending your pictures. What you really have is a combined glabellar (forehead) and nasal bridge ‘defect’ or recessed area. This glabellar-nasal area lacks the protrusion and dimensions that the rest of your face has so it is disproportionate.  (or as you have accurately stated…too flat) Building up this area could be done in multiple ways. The simplest would be fat injections but that carries with it the unpredictability of how well the fat would survive. The best approach is to really have a custom glabellar-nasal bridge implant made as a single piece. A standard preformed nasal implant will not augment the globular region of the forehead. Such a custom nasal implant would be placed through an open rhinoplasty approach (low) with an endoscopic technique from above. Other strategies include a preformed nasal bridge implant combined with bone cement augmentation of the glabella. As you can see there are various augmentative strategies using different materials.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I would like to know what can and cannot be done about untreated plagiocephaly in terms of facial asymmetry surgery procedures. I am still young (19), which is why I want to explore my options now so I can put this ongoing struggle in the past. I have very noticeable facial assymetry, particularly evident in my cheeks and jaw angle. I also have some forehead assymetry as well due to the soft spot on the left back side if my head. Regardless of this, the area of immediate concern is my cheeks and jaw. The left side of my face is much more prominent and “fuller” due to the Plagiocephaly. My eyes are also assymetrical because of the different orbital positions making it seem as if I have a lazy eye when looking in certain directions. Another area of concern for me is my flat midface; it seems as if I need at method to someho w “pull out my face.” My face needs to gain a more 3D look so my eyes don’t seem deeper than they actually are. Also, as you can tell from the pictures, not only do both halves of my face look drastically different from the side, my head lacks length from the front of my head to the back, as well. I would like to gain your input on what would be the most effective methods to improve my facial features.

A: What you are describing are very typical facial findings from congenital occipital plagiocephaly. While there is a long list of facial and skull changes that can be done for our facial asymmetry surgery, the question is which ones have the greatest value and are the most economically efficient. You have pointed out the most important to you currently and that is the flatter and more deficient cheek and jaw angle on the affected side. A cheek and jaw angle implant will help in that regard. But it is important to point out that the eye on the same side is also a major focal point and addressing it with orbital floor augmentation and a corner of the eye adjustment would also be important. ideally the best way to treat all three facial skeletal issues would be a 3D CT scan to make the implants match the facial structures on the opposite side the best.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a woman with square jaw who just wants to have her angles rounded off, nothing extreme…so far, the people I’ve seen who have had jaw angle reduction/resection were left with no angles at all and I found it unnatural and unattractive. I saw a professor who talked to me about bone decortication, removing a little bit the angles without touching the bone or touching the muscle and that it can be done under local anesthesia with little risks and would give a natural result. But he said that asymmetries are common with that type of method. Is that all correct?

A: Jaw angle reduction/recontouring can be done by two basic methods, bicortical (amputation) or monocortical. (decortication) While the historic and still most commonly used technique is bicortical removal, you are correct in that such amount of bone removal can make the jaw angle ‘hollow’ and create a soft tissue sag or indentation over the jaw angles. For many patients, a monocortical approach may be better as it lessens jaw angle width but without losing jaw angle shape. The best candidates for this type of jaw angle reduction surgery are those that have radiographic comfirmation of an angle flare that sticks out beyond the external oblique ridge of the mandibular ramus. This makes it technically possible to reduce the jaw angle flare with the instruments that are available to do it.

But no jaw angle recontouring method can really be effectively done under local anesthesia. (nor can I imagine who would want to) It is necessary to lift the masseter muscle off the bone to provide visualization for the bone reduction. Any method of jaw angle manipulation (augmentation or reduction) run the risk of asymmetry because they can not be seen as a ‘pair’ surgically and most people do not have perfect jaw angle symmetry beforehand.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a silicone forehead implant placed through a scalp incision after an injury which left an indented forehead. I still have a high hairline so I want to do hair grafts or transplant. My question is can they still put hair transplants over silicone implant or will the hair not stay and grow? The implant goes from my brow bone all the way to middle of scalp. 

A: The location of any skull implant, like a forehead implant, is way down at the bone level. This is numerous tissue layers away from where the hair follicles are located which are just under the skin. Thus any forehead or skull implant will not have any negative impact on hair transplants anymore than the overlying existing hair that is there now. You can freely have hair transplants done along the frontal hairline without fear that they will not take and subsequently grow. I have had numerous patients have this done, including women, with very successful hair transplant results.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 40 year old female in good health and I have a 7mm epidermoid cyst on my forehead, just above my right eyebrow. I had an ultrasound scan which shows that it is quite deep near the skull. The report states that it is a benign looking 7mm cyst which looks subgaleal and is located in the region of the right glabella. However it is having an effect on my self-esteem and I would like to know what options I have for removal and whether a direct excision would be the best and safest option or to if it is worth getting it removed by endoscopic surgery?

In particular I am worried about what the scar will be like if I get it removed directly since I am of Asian origin and am I am concerned about the scarring. I am exploring whether having it removed endoscopically would be worth-while given my concerns over scarring.

Because my cyst is located further down near the eyebrow would this be more of a risk and more difficult to remove by endoscopic surgery? By doing an endoscopic surgery would this cause an indent or depression where the cyst was removed?
Would the benefits outweigh the risks and would there be any risks of a depression at the location after the endoscopic removal?

I would be interested in hearing your views about this and whether this is an option worth exploring. I would greatly appreciate your feedback.

A: Dermoid cysts are exceedingly common around the eye area and are often located down at the bone level. In many cases, they will even leave a little depression in the bone. While an endoscopic approach would be preferable from a scar standpoint, the question is whether this approach can technically be done given how low it is on the forehead. I can not really comment on this technical aspect without seeing a picture of where it is on the glabella region. Most likely it can be removed endoscopically having done it this way myself numerous times.

Whether its removal will leave a depression can not be predicted. But given its relatively small size, I suspect it may not. But you can always hedge that bet by placing a small fat graft in its place at the same time.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I went to Asia and had mandible angle jaw reduction. Now my face looks deformed with a protruding bulging area as well as indented area on my jaw line. Please can you have a look at my attached images. I now have  CT scans. Please let me know what you think has happened. I need help and just don’t understand what has happened. The surgeon in Asia was suppose to only cut the posterior jaw angles off to get rid of the square jaws. However, something has gone wrong and I really need help. Please see my CT scans, I would really appreciate you giving me an idea of what might have happened. (I may need some kind of jaw implants for a corrective surgery. However, it is alright with me if you are not happy to give me a corrective surgery as I understand most doctors don’t like doing corrective surgeries. ) I’m trying to find out what might have happened from my previous surgery /jaw angle reduction, and I don’t understand the  CT scan. ) I would appreciate any help as I really need help.

A: What happened to your jawline is very simple. They cut off the angles completely. The bump you see on the jawline is the front end of the cut where it is not smooth with the rest of the jawline. The indented area is the loss of bone support for the soft tissues from the removal of the jaw angles. You are a classic example of why the jaw angle reduction with an amputation technique is usually not a good operation. It would be better to have a lateral shave of the jaw angles so the bony support is not completely lost. Restoration will require some form of a jaw angle implant that provides vertical length but no width.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to make a few enquiries regarding facial implants.
My plan is to have bespoke implants fitted precisely over my current facial skeletal bone structure to adjust the appearance. I am interested in various different locations on the face, and I know fairly precisely the dimensions of the facial appearance I would like to have. I was wondering if you have an information pack for new patients for this procedure and some advice on getting started?

My second questions is in regards to the materials used for the implants. On your website, you mention two materials – silicone and Medpor. I was wondering if you ever work with, or would consider working with 3D printed titanium implants. the reason I am particularly interested in this material is the strength advantage it has over others.

A: The best way to get started is to send me some pictures of your face and a detailed list of what you want to achieve and where you envision the augmentations to be done. Using that information, custom implant designs can be done on a 3D CT scan which you would need to get. That CT scan can be done in your local community.

As for custom facial implant materials, only silicone is currently available for use as a custom facial implant material for 3D CT fabrication. While I am certainly not opposed to using any other material, such as titanium, you have to factor in other important considerations such as cost and access. Very stiff materials, such as titanium, require much larger incisions to place dependent on their size and location. This is an issue that patients never think about but can be a very limiting issue. In addition, there is no advantage to a stiff metallic material as an implant. Since bone is the backing for all implant materials, they all become firm and ‘bone-like- once in place.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a very burning question about calf augmentation by fat injection .I know my appointment is coming up soon on the 22nd but the closer it gets, the more anxious I am. I know not to have too much expectations but is there a away to enhance the outcome, for example, do you add anything to the fat to make them more viable?And is there anything I can do to improve the results?I totally think my calves are the skinniest anyone can ever imagine and so will I really have enough fat to make them as bigger as possible? If I will need a touch up, do I have to go through the entire procedure or do you  preserve some fat from the first procedure. Thanks.

A: The methods to enhance fat injection graft take are how the fat is concentrated at the time of its harvest prior to its injection. Some enhancement of fat graft survival has been noted from adding PRP (platelet-rich plasma, a blood extract) but that evidence is not conclusive. Since it is your own blood extract it is perfectly safe. But whether it truly improves fat graft take is not clear.

Harvested fat can not be preserved for a secondary or touch-up procedure. It is technically possible to do so but it has been shown that none of that frozen fat will survive when injected later.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had mid-face (mid-face rim and paranasal) implants placed last year to address my facial concavity caused by my underbite. Anyway, I’m happy with the results, but I’ve finally decided to get my bite fixed via jaw surgery.

I understand that I will require a CT scan. My question is – would it be possible to ‘erase’ the implants (and their screws) from the scan, or would I have to get these implants removed prior to getting the scan so that they don’t show up?

A: If you are having orthognathic surgery, presumably a LeFort 1 advancement, you would not necessarily need a CT scan. Traditional cephalometric x-rays can be used and the implants would not interfere with assessing the tooth relationships. If one is having their surgery planned by VSP (virtual surgery planning), then a 3D CT would be needed. But the implants can be digitally removed (although that is not really necessary) to make the virtual maxillary advancement and create the splints off of stone models.

For a LeFort 1 advancement, however, the paranasal implants will be in the way and would have to be removed to make the bone cuts. But that could be done as the same time as the LeFort surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in facial asymmetry surgery to even out the two sides of my face. As you can see in these pictures my right side of my face is lower, along with my right eye. I was wondering if it is somehow possible to have my eyes on the same level and take that bump from my chin away. And on top of that my head temples are narrowing. Is it somehow possible to fill them and make my head more round. Thank you for your time.

A: You have a complete right facial asymmetry which is lower than the left side of your face as you know. The corrective procedures for your facial asymmetry surgery would include the following:

Right Supraorbital Brow Bone Reduction with Right Transpalpebral Brow lift (all done through right upper eyelid incision)

Right Orbital Floor Augmentation with Lateral Canthoplasty (lift the eye up as well as the corner of the eye)

Right Inferior Border Chin Ostectomy (shave of the lower border)

These three procedures would lift up the lower parts of the right side of the face.

The temporal hollowing could be addressed by temporal implants placed under the temporalis fascia done through a small vertical incision in the temporal hairline.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Thank you for taking the time to generate this computer modeling image for me. Although striking, I find the jaw line in the modeling too bold or strong for my liking. Perhaps I need time to acclimatize to the new look. I am more inclined to a long slim straight jaw line with small round (almost but not quite pointy, but not square or large round/oval) chin as in the first attached image.

I understand that you would be making a custom implant from the CT Scan I will provide. But from my limited web research, I have made the following observations. If Implantech implants were used, the back of the jaw would just be built out to appear 1” below the ear as opposed to the modeling of 2” below the ear (using a jaw angle lateral width implant versus an vertical lengthening jaw implant). I understand that the chin implant (such as the vertical lengthening chin by Implantech) would add projection reducing pre jowl sulcus as well as help with the angle under the chin. (See second attached image).

My big concern is with my neck angle in profile. Would a neck lift with removal of playsmal fat banding create a nice sharp neck angle (horizontal as opposed to 45 degree angle)? Would the above mentioned vertical lengthening be appropriate to correcting this problem?

A: The main role of computer imaging is to see what type of changes a patient is looking for. So having thrown that first draft out there, you have provided the direction I was looking for in regards to your jawline shape goals.

When making custom implants, there are different than what standard stock chin and jaw angle implants have to offer. They can be made to any dimensions one desires and would be connected between all three. That is a significant advantage when it comes to addressing any loose skin around the jawline and neck lift as it will pick it up to some degree through a volumizing effect. This effect combined with a small neck lift should address any neck issues and create more of a well defined and sharper cervicomental angle.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am about three months post op sliding genioplasty to advance my chin forward 6mm. The surgery made my lower part of face more narrow with a clear step off in my jaw line which was not there before and I still have mentalis strain. Actually I like my face before and I didn’t want it to change in the frontal view, just wanted a little projection to improve my profile. My surgeon told me nothing will change in front but now I see dramatic changes. I’m thinking of reversing the surgery and I have questions regarding that option. In case of full reversal am I going to regain my old look and the step off will go away? Risk of skin sagging? And when I can use injectable after surgery? Thank you.

A: When the chin is moved forward by sliding genioplasty there are almost always two aesthetic ‘side effects’ of the procedure. It is not a question of whether they will be there but how much and how noticeable will they be to the patient. First, as the chin comes by bone movement the front end of the jawline will appear more narrow. This is a simple principle of a U-shape that is being extended, the U will become more like a V. Secondly, the back ends of the sliding genioplasty will leave some degree of step-off along the inferior border of the jaw. The bigger the bony chin advancement the bigger these step-offs may be.

In a sliding genioplasty reversal, it is important to recognize that you probably will never be 100% exactly like it was before. The bone may be perfectly repositioned back but how the soft tissues, which have been traumatized and stretched, will respond is unknown but to be 100% like you were before can not be guaranteed. If you are young there should be no residual chin soft tissue sagging and the bony step-off should be gone. Most of the time the issue will be how the lower lip responds with a two-time mentalis muscle disruption/repair.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m interested in chin reduction due to the fact that I feel as if my chin is way too large vertically. When I happen to smile there is also enough loose “bulk” to pinch on to skin or muscle, not sure exactly what you’d call it in the doctor world. Horizontally my profile does not bother me. I’ve been reading a lot about chin reduction lately and have seen pictures on websites of your work. And I would like to know exactly what kind of procedure I would need done for me to obtain the chin that I want. (Included)- are two photos the on of me smiling is a perfect example all together of what bothers me about my chin. In the second photo is what I would want my chin to look like…my dream chin 🙂 by the way thanks for your time.

A: What you are seeking is a vertical chin reduction that is best done through a submental incisional approach. To achieve your goals it is necessary to remove approximately 7mms of vertical chin reduction across the bottom of the chin bone. With this amount of vertical chin reduction, two additional issues need to be addressed. First the lower border of the jawbone behind the chin must be reduced lest you would be left with a ‘bulge’ of bone along the jawline behind the chin. Secondly, This amount of bone reduction will require soft tissue removal as well, known as a submental tuck. All three of these combined procedures fall into the procedure I call a ‘chin and jawline reduction’ operation.

It would be helpful to see a non-smiling front and side view picture for computer imaging as well as a panorex x-ray (usually a dental film) so I can measure the amount of of bone that can be safely removed from the chin and jawline. (location of tooth roots and the mental foramen and path of the inferior alveolar nerve)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a kidney transplant six years ago. My transplant team believes I could have a procedure to diminish the abdominal-flanks area. The side where the kidney is is larger. I weight 195 lbs and am 5’11”. I dislike being lopsided and have exercised (I am in pretty good shape). I was interesting in you because of your experience with a few transplant patients. There are great surgeons where I live but I trust you more.

A: I can see in your picture the protrusion/lop sidedness of the left side. That is the same side as your kidney transplant as can be seen by the location of the oblique abdominal scar. However, the bulge that is sticking out I doubt is where the kidney is. Generally that would be under the incision away from the bulge sitting on top of the abdominal fascia. Thus I do think that the protrusion could be reduced by a combination of liposuction and skin excision. (tummy tuck) The skin excision could extend across the whole abdominal incision as there may be skin excess there as well.

You would be on some level of immunosuppressive medication currently and we compensate for that by giving ‘stress steroid’ dosing at the time of surgery. Any other considerations/needs based on your transplant doctors input is also important.

I would estimate that you would need to be here no more than three to five days based on whether the placement of a surgical drain is needed. (which I would work towards not using.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in jaw augmentation implants, specifically ones for vertical chin enhancement and lateral jaw angle implants. I have previously had a standard chin implant that only gave projection but did not correct a weak jaw. Your custom implants look like what I need. Do I need a CT scan for these or can I be assessed in person or on Skype?

A: Your story is a very common one, having had a standard chin implant which helped but left one way short of a more complete total jawline enhancement. What you undoubtably need is a more comprehensive approach with a custom wrap around jawline implant. This is designed from the patient’s 3D CT scan which you can get locally. (just let me know were you want it done and an order will be feed to them) In the interim, please send me some pictures of you face (front aide and three quarter view) from which I will do some computer imaging to see what type of jawline changes you are seeking in the vertical, horizontal and width dimensions. We can then have a Skype consultation to review these dimensional choices and discuss the details of the surgery.

I will have my assistant pass along the cost of the surgery and to arrange for a Skype consultation time next week.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am wondering if you could perhaps further explain how exactly a cheek lift lasts – and by that I mean how it permanently elevates the cheeks? I am confused on how it works. You mentioned that the tissues are elevated and suspended. Are the sutures used always dissolvable, or are they sometimes permanent? 

It is assumed that during the months following the cheek lift, the tissues reattach to the bone in a higher position. Is this inevitable and natural for the body because of the sutures lifting the tissue or can it ever “not” happen ? Do some of the tissues ever not reattach in the upright position over that period? 

After the sutures dissolve over a period of time (assuming dissolvable sutures are used), what ensures that the tissues just do not fall back down? What if some did not attach before the sutures dissolved?

The second doctor I consulted with stated that since in his experience he has never re-done a patient’s cheek lift and he has been doing them for thirteen years, it should last me a minimum of ten years. He stated that I will age at a natural rate after the cheek lift. However, I have read dissimilar answers on Realself where other doctors have stated that it can last a mere 3 years! What is your general estimate on longevity? Would I age any faster or would my tissues fall faster having had the cheek lift done or are the effects of aging unknown?

A: The exact lifespan of any cheek lift can not be precisely predicted and is dependent on why it was done, age of the patient, how they genetically age and the technique used. Thus no average number of years can really be accurately stated for cheek lifts.

A cheek lift is a subperiosteal tissue elevation and resuspension. (which makes it quite different than that of a facelift for example and ore similar to that of a browlift) In theory, its initial stability is held by the sutures but the healing of the tissues is ultimately what holds it elevated. Therefore the use of permanent sutures offers no advantages long term over dissolveable sutures and runs the risk of suture reactions later if non-resorbable sutures are used.

Once the cheek tissues have healed, how they age is going to be reflective of the natural aging process of the patient and how the cheeks may have aged (dropped) had the procedure not been done. Think of a cheek lift as restorative to what you were before the cheek implants. How the cheeks may age could be better than had nothing ever been done since they would be further elevated than had the cheek implants never been placed.

Dr. Barry Eppley

Indianapolis, Indian

Q: Dr. Eppley, I would like to know if you do Artefill or Radiesse injectable filler in the legs?Because I have skinny lower legs and I would like some volume. Also do you do butt injections for lift. Thanks!

A: Injectable fillers are never used to provide volume for such large body areas as the lower legs. Besides that fact that they are only temporary, the sheer volume of injectable fillers needed would cost $25,000 to $50,000 to create the desired effect. All of which would go away in less than six months. Injectable fillers are only used in the face where smaller volumes can have a more profound effect.

The correct injectable filler to be for augmenting any body area, including the legs and the buttocks, would be your own fat. Fat injections are the most common method used for buttock augmentation, known as the Brazilian Butt Lift. They could also be used for the legs such as in calf augmentation. Whether you have enough fat to harvest to have a successful buttock or leg augmentation procedure is the key question and is the rate limiting step in any patient considering a fat injection augmentation procedure. That could be determined by seeing some pictures of your body.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a bimaxillary correction surgery last year. After the surgery I’ve lost my jaw angle.My jaw angle was near 90 degree.I have before-surgery-x-rays and want it back,but I’m worried if that doesn’t look good on me. I heard that you prefer silicone with a 3D custom implant fabrication. Would that be slippery? (compared to medphors) In my case,I only need a verical lengthning (a lot).

A: It is not rare that orthognathic surgery, specifically sagittal split ramus osteotomies, change the shape of the jaw angles. This can be due to an actual change in the jaw angle bone shape with advancement movements, loss of masseter muscle mass or both. It can also occur in short jaws where the jawline and chin move forward but the jaw angle position remains high, thus causing an illusionary change in the jaw angle shape. Regardless of the cause, restoration of the jaw angle can be done using jaw angle implants. You specifically have pointed out the dimensional change needed which is vertical lengthening. Of the available off the shelf preformed jaw angle implants, vertical lengthening styles are available in either silicone or Medpor materials. Either type of vertical lengthening jaw angle implant is secured into position by a screw which is important when half of the implant is placed below the level of the bone. Depending upon asymmetry issues, which may occur after mandibular advancement surgery, a custom implant approach may be preferred to create the most optimal symmetry between the jaw angle sides. If one is concerned about how lower and more prominent jaw angles may look, computer imaging can be done to help with that assessment. I would need to have some pictures of your face to do that computer imaging assessment.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had cheek implants placed 4 months ago together with a buccal lipectomy. However, they got infected 2 weeks post-op, but I’ve only managed to get time off to remove them in 2 weeks. I’ve been taking antibiotics to control the infection in the meantime.

Anyway, I’ve read that removing these implants can cause some sag, and I’m particular worried because I’ve also had my buccal fat pads removed. I have read that a temporal mid-face lift can help. However, I have a few questions:

1) Should I do the lift during the removal? Or, should I wait till I get the implants replaced? Will getting the mid-face lift during the removal limit my options should I decide to get more implants in the future?

2) If I wait to get the temporal mid-face lift, is there anything I can do to help minimize the sagging after removing the implants? Would taping my face during recovery help prevent sagging? 

Thank you!

A: In getting cheek implants removed, no everyone will get a midface sag. It depends on how large the cheek implants were, their location on the bone, and how long they have been in place. Thus by having your cheek implants removed you do not know if you will develop this problem or whether it will be problematic even if it does occur. It would then make the most sense to remove the cheek implants and not commit to another invasive procedure that is done to treat a problem you do not know if you will even get.

The best approach to ‘hedging the bet’ against midface sagging with cheek implant removal is to do an immediate reattachment of the cheek tissue back to the bone. This is done by placing a small resorbable bone anchor or screw into the midbody of the cheek bone onto whoch the cheek tissues are reattached to. This would be far better than any form of external taping or dressings.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I hope you don’t mind but I have a plastic surgery related question I was wondering if you could answer.  I would like to explain my unique case and see if you have any recommendations. Any advice at all would be helpful.

Earlier this year I had a cheek augmentation to fill out my flat mid-face with cheek implants. I had great malar prominence but was lacking in the submalar region. There was unfortunately some miscommunication between my surgeon and I on what I wanted. I believe that this miscommunication occurred because I did not have a consultation with the surgeon until a day before the surgery due to long distance. I had wanted the inner, lower area of the cheeks (submalar region) augmented, but instead was given medium malar shell implants. The malar implants did not flatter my feminine face like I believe the submalar implants would have done due to their outer location and also perhaps their size and projection. I had the malar implants removed after 3 months which left me with mid-face ptosis than I never had before.

I am now debating on what to do in order to correct this mid-face ptosis and restore my cheeks to their original lifted position. I had not expected this to happen as I was prepared to be satisfied with my cheek implants had they been the right type and size. However, since I now have this sag, I assume that it is not best to get the submalar implants I had originally wanted because they will simply “augment the sag” so to speak. Also, on the off chance I again did not like them, I would end up back where I started. In general I don’t think that re-inserting submalar implants is the answer.

I have assumed that the answer to this mid-face ptosis is a cheek lift. There seems to be many different kinds. I am most worried because in all of my research it seems as though all of the procedures to lift the mid face are fairly new and mid-face ptosis is a relatively difficult area to correct. In many of the before and after photos I have seen from various doctors, there isn’t much of a difference in the after photos. Basically it seems like the results are subtle and barely noticeable. It also seems as though perhaps the results do not last very long either. Please let me know your thoughts and whether you agree or disagree with these concepts.

So far, I have only contacted two doctors regarding my case. Unfortunately one of the two doctors refused to consider my case due to my young age, which I am completely understanding of. However, I was disappointed as his mid-face lift results were astounding. He not only lifts the sagging fat and tissue but he also does skin removal from the mid face in order to ensure that it’s tight again. This eliminates the nasolabial fold completely. I personally feel that my skin was significantly stretched from the implants and swelling twice both upon placement and removal and I know that a tiny bit of skin removal might be beneficial however considering my young age it is highly possible that just simply elevating the tissues will do the trick. 

The second doctor I contacted did agree to consider my case and upon examination in my consultation he recommended a cheek lift without skin removal and perhaps a minor correction of the lower eyelids following my healing from the cheek lift. I’m not sure of exactly his technique but I will try to get more information. All l I know that he uses sutures that dissolve in 6 months. According to him he has never re-done a patient in 10 years, which to me implies that it lasts, however there’s no guarantee and perhaps these patients just did not feel like going through the stress and swelling again in order to have it redone.

I was wondering your own personal thoughts on the cheek lift techniques because I have seen many of your answers on Realself as well as your videos regarding submalar cheek implants. I am trying to figure out what the best option is for me that will not only give me the most optimal result but will also have longevity.

What is the best method in your opinion? Any advice you can give me on what is the best course of action to correct mid-face ptosis after cheek implant removal would be helpful. Thank you in advance.

A: There is no doubt that the entire concept of cheek or midface lifts are muddied with a wide variety of techniques, many of which the doctors claim their approach works the best. Any time you see so many different ways to treat an aesthetic problem should tell you that there is no one single way to do the procedure…or that there is no one best way.  This does not mean that midface lifts can not be effective or long lasting but each patient must be looked at individually and the advantages and disadvantages of the different techniques considered.

What makes midface lifts unique is that it involves surgery around the eye and the sensitivity to any changes of the eyelids is highly visible. This is quite different than a facelift where the changes around the ear and hairline are more obscure from a high level of scrutiny. In essence, a midface lift is a more ‘risky’ surgery and can be unforgiving of  even a minor technical error. Thus undergoing a midface lift must be considered carefully in terms risk vs. reward.

I fundamentally divid midface lifts into either an endoscopic temporal or open eyelid approach. There are numerous variations amongst each subset and there can even be cross over between the two. All midface lifts rely on subperiosteal tissue mobilization and suture suspension. The vector of that suspension highly influences how effective or powerful the midface tissues can be lifted. In simplicity, endoscopic temporal suspensions produce more moderate results but have little risk in doing so. A midface that incorporates an open eyelid incision, particularly with cranial suspension, produces the most significant lifting that lasts the longest. But it involves the risk of a lower eyelid malposition and visible lateral canthal scar.

For cheek sagging that has resulted from the removal of cheek implants in a younger patient, I would lean towards the endoscopic temporal approach. But that is based on no idea of what you look like now or before or cheek implant surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am curious as to whether it would be possible to increase the distance between my eyes. Generally I feel this is the most significant weakness in my face! Alternatively, to shorten my midface area vertically would also be a very positive change, or failing that, any procedure that could give that *impression*

Final thing, and this is a bit obscure, but when I wake up, my face generally seems quite puffy, but it looks better in that state. My eyes seem wider, thiner, more masculine and postiively titled. I can’t think of any cause of this he beyond a gathering of fluid from my sleeping position during the previous night – which surely, it is in theory possible to replicate with fillers/injections. Any chance you do this/could do this in the near future?

A: I am afraid that the three things you are asking in terms of facial reshaping are not possible to achieve. There is no procedure, even a camouflage one, that will make your eyes look further apart. There is also no procedure that can vertically shorten your midface, short of a maxillary impaction which will bury your teeth under your upper lip. Only if you have a gummy smile would this operation be aesthetically beneficial. In some cases increased midface projection can create that illusion but that would depend on your natural facial profile. Lastly, adding facial volume (as occurs in your morning temporary facial edema) can not be replicated with synthetic injectable fillers. It may be possible that fat injections in selective area could be beneficial but not in an overall facial effect.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have had this problem for over 16 years since I was young. I was injected a couple of times when I was sick but now these holes have become permanent and it  makes me feel ugly about myself. I can’t wear tight clothes or talk of leggings because it looks so ugly and weird. I am alway covering it up with shirts and long clothes. I feel like an outsider and so embarrassed to show myself naked. I am seriously considering a surgery but don’t know exactly what I should do. I don’t want butt implants. I am okay with my butt size. I just want the holes off or maybe filled. Any kind of miracle to make my butt even so I can be able to wear leggings without covering up my butt. I just want a normal butt.

A: As best as I can tell from the one picture you sent and knowing that these buttock deformities came from injections to treat an illness, it appears you have areas of fat atrophy (which is why they dip in) and hyperpigmentation. This is not rare from medication injections done decades ago when administered as a child or teenager. The indentations can be filled with fat injections. Whether the overlying hyperpigmented areas can be excised (cut out) and closed as an improvement will require seeing some better pictures. Ideally, fat injections to the various buttock areas should be done as a first stage followed by the excisions.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a chin implant procedure last year with a medium silicone chin implant. The picture on the left (attachment) shows me right now with the implant, the picture on the right is me with a photoshopped chin projection. I downloaded this plastic surgery app that allows users to play around with digital imaging, and so I extended my chin horizontally to my ideal and dream chin projection. I also took a Qtip and placed it on my lips straight down and then measured the space from where the Qtip drops down to where my chin is at now, and it seems that I am 10 more mm’s away from having the chin in the photoshopped picture. But remember, the current chin implant now gave me 5mm’s, so technically if it’s taken out I would need a total of 15mm’s to achieve my ideal projection. I wish I would of known all this prior because it looks like all the money I spent on this current implant is now going to go down the drain as I am not even half satisfied and just keep dre aming about the chin on the right. I came across your site, and I guess my question to you is that with all that said, how can we go about getting me to the projection I want? Would I need both a genioplasty and implant together? Because I know the biggest implant made is only a 10mm. I just want to do it right this time so I never have to deal with it again.

A: Given that you have a chin implant already in place, it may be best to do a sliding genioplasty for your chin implant revision. (technically chin augmentation revision) The chin implant would stay on the front edge of it, so you still get value of having done the prior procedure, and move the chin forward 8 to 10mms. Otherwise, you would have to have a custom chin implant made to cover the total 15mms horizontal projection desired.

Dr. Barry Eppley

Indianapolis, Indiana

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Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a “QuickLift” on March 17th 2014. This did not include a submentoplasty however the Doctor did address the platysmal bands during surgery. Photo number 3 is how I looked post surgery 7 days. I was elated. Since then there is now lax skin under my neck along with very slight jowling. (See following emails for photos taken about a week ago)  I approached the Doctor and was he agreed I was in need of a revision and wants to do a submentoplasty using a 4 to 5 inch incision. I can’t do it and am hoping for revision with a small incision under my chin.  Then I found you. The last thing I wanted to think about was more surgery. I am praying a submentoplasty with a small incision will address the issues. My goal is to look like my early after surgery picture with a  firm neck and jowls with a youthful contour. What are your thoughts? 

A: While I do not have any idea as to what you looked like before your Quicklift, the neck problem that you now have is excessive skin and prominent platysmal bands. This has occurred for one main reason…you had excessive neck skin initially and the Quicklift has merely unmasked this issue. (and maybe even made it worse) As the neck was defatted by liposuction (which I assume you had done) the hope was that your skin would shrink back down and tighten and no formal neck work would be needed. That unfortunately has not happened.

What I know unequivocally is that no form of a submentoplasty, regardless of the incision size, will significantly improve your neck. The only method to get your neck like you would like (smooth neck and jawline) is to do the one thing that you have tried to avoid from the beginning…a formal lower facelift. Anything less will be a waste of surgery and money.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I came across your web site and would like to ask what would cause a persons chin to recede. I am now in my 50’s and have noticed a distinct change in the lower portion of my face. I am considering corrective action but I have never had surgery. Can a chin implant procedure be done without general anesthesia?  Also, what is the usual time required for healing when this type of surgery is done. Thanks for any feedback you can provide.  I appreciated the case studies and the beautiful outcomes you shared.

A: The observation that one’s chin seems to be getting smaller as one ages is not rare. But only in exceptional cases does the chin bone actually recede or lose bone structure. Most of the time it is really a change in the neck that creates that impression. As the neck drops or begins to droop, the change in the neck angle can make the chin appear more recessive even though it has not really changed.  This effect can be magnified in someone who may have always had a slightly recessive chin but never considered it so until this aging effect appeared.

Chin implant augmentation can be done under local or IV sedation fairly comfortably provided that is the only procedure they are having done. Recovery is really just limited to swelling with no functional restrictions. One can expect about 3 weeks until most of the chin swelling is gone.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have buttock implants placed into the gluteal muscle right now. 500cc each. It doesn’ t look good. They are to high, it gives my buttock a pointy projection that I don’t like at all.  I think I need subfascial placed buttock implants, probably custom made as well. I am looking for a fuller volume in the lower part of my buttocks. I need wider implants with less projection and as far I understand -that is only possible with a subfasial placement of the implants. Hope to hear from you soon. I added some pictures of how it looks now.

A: Generally, it is very difficult if not next to impossible to get a buttock implant greater than 350cc to 400cc in the intramuscular space. Even if they were initially placed there, they likely would herniate back through the muscle and end up in some modified location partially under the fascia but mostly in the subcutaneous space. Your pictures suggest that this is so with a very high and visible outline of the implants. All intramuscular implants, even in the right location, will look higher in the buttocks than subfascial implants. It would also be helpful to know the dimensions of your existing implants which likely are round with a relatively narrow base.

You are correct in assuming that only the subfascial location will allow more of the lower buttocks to be augmented. And it will take a very broad-based implant with less projection to cover the area you have shown. It would be interesting to know what is the diameter in cms that you are showing by the marks in the pictures you have attached. The largest round implant diameter is just over 18 cms and what you are drawing may or may not be wider than that. It is impossible to have any sense of scale in close-up pictures.

In planning any buttock implant replacement surgery, it would first be important to get a non-contrast MRI of your buttocks to have an accurate idea as to exactly what tissue plane the implants are currently located in. That will help with surgical planning and to see how much subcutaneous fat exists between the skin and the fascia. From there it could be seen if any stock sizes will meet the dimensions you need or whether a custom design is really needed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hello! I am sending this request with my photos. As you may notice, the right side of my face is “larger” than my left, I feel its mostly the cheek bone. Hence I wanted to inquire about “cheek bone reduction” for my right side. I know it is not that simple, but to not make this very long I am writing in the most general way possible. I understand perfect facial symmetry with surgery is realistically impossible, I just wish to find a way that my facial cheek bones may be more proportioned, (with out the use of an implant or fillers), this cheek bone asymmetry is an insecurity I have when people look at me. I look forward to hearing back and thank you for taking time to read. 

A: I can see the asymmetry in your cheek area and, for now, we will assume this is due to a difference on the zygomatic (cheek) bones between the two sides. Right-sided cheek bone reduction can be done but it would be very important to know where the differences in the bones are so that the right bone reshaping technique can be used. In make that assessment, a 3D CT scan of the face is needed so that exact location and magnitude of the cheek bone differences can be seen and the right surgical plan done. Whether yours would be a ‘typical’ cheek bone reduction (anterior and posterior bone cuts) or just anterior awaits what the 3D CT scan shows.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting the abdominal and flank liposuction. However, I currently need to get surgery done on my ankle by an orthopedic surgeon.  The surgeon will not do it, however, until I quit chewing tobacco. Therefore, I want to ask you another question. Could both surgeries be done close to each other or do I wait a period of time between both? Should I get liposuction first or does it matter? The chewing tobacco issue is still a work in progress but my ankle is hurting worse by the day and I need to get it fixed soon.

A: Quitting tobacco is a good idea regardless of any type of major surgery you are considering. The nicotine in tobacco has as very negative effect on bone healing, particularly in the lower extremity. Certainly these two surgeries can be spaced relatively close together (one to two week sapart) and the order is dependent on how one affects the other in terms of recovery. It is question of which one is going to make you more immobile and what type of physical therapy would be needed afterwards. I assume that the ankle surgery will put you in a boot/cast with some limitation of movement afterwards. it would make the most sense then to have the liposuction first and then the ankle surgery afterwards. There is also the issue of typical bacteremia (release of bacteria in the blood stream) which occurs after any surgery. With a load of bacteremia released from liposuction, you do not want that to adversely affect the ankle bone healing. (seed the healing bone with bacteria) This would also require input from your orthopedic surgeon to see his thoughts as well as on this issue.

Dr. Barry Eppley

Indianapolis, Indiana