Your Questions

Q: Dr. Eppley, I had cheek and paranasal implants placed in another state 4 days ago before flying back (1 hour flight). I think I have developed a slight cold, and have a slight runny nose while coughing up some phlegm too. My biggest worry right now is that there is some ‘squishiness’ when I press on my left cheek. Are there signs of a cheek implant infection, and what can be done for it?

Anyway, I’m still taking my antibiotics as prescribed, and there are no other symptoms (no redness, excessive swelling or fever). I’m hoping that I don’t have to get these implants removed, which is why I’m seeking your counsel with regards to what I can do.

Thanks for any help rendered!

A: I would not consider this squishness to be a sign of cheek implant infection. Most likely it is due to the positioning of the implant and/or a little fluid around it since it is so early after surgery. Many cheek implants are placed partially off the bone and/or are not screwed into position. This will allow the implant to ‘float’ around for awhile until scar tissue settles and secures it down. Further healing will also allow any fluid around the implant to be resorbed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in jaw angle implant revision surgery. I just got jaw angle implants with facial liposuction. I’ve always wanted a more defined jawline. So I got the procedure done. My doctor did the type of jaw angle implant that widens. But I wanted the one that lengthens and wides a bit. So already he didn’t do the one I wanted and he went too wide. It’s 4 days after surgery. Is it bad to remove implants and replace with others? Is their risk involved? I’m very unhappy about how he did this.

A: Th first thing to realize is that it is just four days after your jaw angle implant surgery.  This is a time period of maximal swelling so it would be impossible to have any idea as to what the final result would be. It generally takes four to six weeks to see the final result. So the final result may or may not be what you want.

But let’s assume for the sake of this discussion that your current jaw angle implants are inadequate. It is very straightforward with no increased risk over the original surgery to replace your jaw angle implants with a new design. Because you have an existing implant pocket, the amount of swelling and recovery would be significantly less than the initial implant surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have been interested in liposuction for years because I feel my love handles / flanks make me look terrible. I knows I need to lose about 20 lbs but am not motivated because I believe the flanks will never go away. Admittedly even in basic training 20 years ago when I was very lean, but still had flanks. With that said, it has been a dream of mine to remove the ‘love handles’ even if it meant still having a little belly. My hope is that this change would motivate me to lose enough where I am happier with myself. I am 5’ 9″ and 195 lbs and still have decent muscle mass for age 39. With all that being said, how much could I realistically expect to have removed? Thank you for your assistance and honest feedback.

A: The flanks are one area of the body where the most aggressive liposuction can be done in a man or a woman because there is virtually no risk of any skin irregularities. Flank and back skin is fairly thick so it contracts down very well, particularly in men. I could not give an estimate as to how much fat can be removed unless I could see some pictures of the problem areas. Computer imaging can be done to give you a good idea as to what the result would like. Flank or lovehandle liposuction takes about one hour to perform under general anesthesia.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I recently had cheek implants done and I look terrible. I’ve never been this hideously ugly, and other people seem to instantly love their results, so I’m really scared and really depressed. I hope to eventually move my face normally and that sensation will return. I don’t know why he augmented one side such that the two sides will be off balance butI could see from day one before the swelling set in that the two sides were not even.

A: With time and healing your face will move again normally but that will be a process of up to three weeks or more. Feeling will also return normally but that will take a little longer.

I have done this type of facial implant work (cheek implants) for a long time and I can tell you that not everyone instantly loves their results.  Swelling and bruising causes a lot of facial distortions and it can be unnerving to see your face this way. But what you see now is not necessarily what it will be four to six weeks from now. But that is understandably hard for many patients to see. There are many patients who feel just like you do at this point so what you are experiencing is not unusual at all.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I recently had cheek implants and facial liposuction done just a week ago. While my face is distorted from the swelling I already know that the cheek implants are not right. They are asymmetric and in the wrong place. After speaking with my surgeon, he stated he would only remove the old 2.5mm implants and would be unwilling to place new implants at the time of removal. What I don’t like is that there is still no projection to my midface in profile, which is my primary reason for undergoing the procedure. I’m curious if a 4mm silastic implant would provide a better result. I wanted to look like Jessica Biel or Megan Fox. Please let me know your opinion. If your professional opinion is to keep the 2.5mm, then I would still like to try a filler for the area directly below my eye to give my midface more projection and also to discuss refining my chin/jaw. 

A: I am glad to hear that you have gotten to speak to your original surgeon as he is the one who knows what type of cheek implants were placed (I know its Medpor but don’t know the style)

While your cheek implants can certainly be replaced (cheek implant revision), an important issue would be to known what  is the starting point. While the swelling in your face has come down, there is still about 50% swelling to resolve. So my concern is that the shape of your face is not completely ‘known’ nor is the final effects of what the current cheek implants will look like. That makes to hard to know what cheek implant style to change into when you are working with a ‘moving target’ as the swelling goes down and the final shape of the current implants become evident. What you don’t want to do is to change the implants and then find out what you have changed into is no better for a different reason.

It is also unclear as to what you mean by more ‘midface projection’. The term midface is an ambiguous one and means different things to different people so more clarification on this issue is needed. Cheek implants in general do not create midface projection, they create cheek projection.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am very interested in the rib cage narrowing surgery to achieve a thinner waistline. I am a very slender individual with a wide ribcage, so unfortunately diet and exercise alone have not been able to give me my desired silhouette. I have experimented in corsetry and own a few but the discomfort, inconvenience, and lack of real results have left me desiring something more extreme. I’m not sure which ribs I need removed but by my count it would be the 10th 9th and 8th ribs. As you can see from my pictures I do have a quite bulky rib cage so I believe narrowing anywhere above the floating ribs on its straight line would give me the desired results.

A: Ribcage narrowing, also called waistline narrowing, would be fair to be called a bit of an extreme approach. While there is a small scar on each side to access the ribs for removal, it can be a very effective procedure. It can certainly be uncomfortably initially as taking bony ribs is not without some discomfort from removing the attached intercostal muscles. Usually no more than two ribs are taken in any one location as the ribs do serve a purpose, they provide protection to what lies underneath. In addition you usually do not remove above rib #9 to stay below the level of the pleura/apices of the lungs.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have cheek asymmetry and wonder what type of cheek asymmetry surgery would fix it. My left hand side cheek is more bulged out than my right one. I also have a dimple on my right cheek and there is not one on my right cheek. In my pictures you can see what I mean  by the differences in my cheeks.

A: I can see that your left cheek does indeed bulge out more than the right and there appears to also be some other soft tissue asymmetries as well. The question is whether this bulge is due to a bony prominence or the overlying soft tissue. (or even a combination of both) I suspect it is due to bone because it is over the cheek bone prominence. A bone reduction (shaving ) may be all that is needed improvement. A cheek dimple could be made at the same time of desired.

To verify that it is indeed bone, a 3D CT scan would answer that question unequivocally. Bulging of the cheek prominence often occurs because of the union of the zygomatic and maxillary bones which form the anterior cheek prominence. Often it can be bowed out due to how the facial bones developed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 25 years old male inetrested in lip scar treatment. When I was 12 years old I had an accident which resulted in the need stiches in my upper lip.  Thereafter my moustache hairs will not grow in this area. Is there any chance for regrowth of hair in that scar part. Please let me know as that would be very kind of you.

A: Upper lip lacerations in men very commonly result in beard hair loss. This is because the scar tissue that repairs the lip tissue does not have hair follicles in it. The wider the scar is the bigger the lack of beard hair will be and the more visibly apparent the lip scar will be. Beard hair will not regrow into a lip scar. Hair follicles must be in the tissues to do so. Your options are either scar excision to bring the hair bearing lip skin closer together or hair transplants into the lip scar itself. Most of the time lip scar revision would be the appropriate initial course of treatment particularly if the lip scar has any width to it and is more vertical on orientation on the lip.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a sliding genioplasty to narrow my chin. I told the doctor that them when I smile, my face looks big at the side of the chin so he mentioned that he’s gonna cut or reshape the bone there and remove some muscles. I’ve attached the photo of the before and after surgery. Because after I did this, every time I smile or not even smiling, I see my line around my chin area looking like someone took a bite out of it and the bone there’s gone. Also I feel like my chin is more narrow not like before. I really don’t mind if it’s making my chin comes forward, but not like before. It is possible to reshape the chin bone in any way. Or just simply just cut the middle and then put the bone in front? 

A: Based on your pictures and the x-rays, what you had done was a sliding genioplasty that brought your chin forward and up a bit as well as had a central wedge taken from it to narrow it. This is clearly evident in the x-rays and by the plate fixation used.  What this has done, and is not uncommon, is to narrow the chin but there is a step off at the back part of the osteotomy cuts. I see where no other bone has been removed…and certainly no muscle or soft tissue has been removed. This has left you with a chin that is now too narrow for the rest of your jawline…hence your interpretation that it looks like a bite has been taken out of the jawline behind the chin. (hollow part)

You have two options to consider for your sliding genioplasty revision. Probably rather than moving the bone back, which can be done, you could simply fill in the bone defects left along the jawline. (provided you are satisfied with the way the front part of the chin looks)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a short lower jaw and feel that it needs improved from front to back. This includes the chin and jaw angles. I am uncertain as to the best way to do it. As a man, I do not lie walking around with a jawline that is not very masculine. My biggest concern about any type of jaw implants is that they might become loose or dislodged if I get hit or participate in any sports. What is your recommendation?

A: There are three different approaches to your type of jawline enhancement and include the following:

1) Standard chin and jaw angle implants (3 pieces)

2) Sliding genioplasty for chin and jaw angle implants (2 pieces)

3) Custom wraparound jaw implant (1 piece)

There are advantages and disadvantages to each jawline enhancement method. Your biggest concern about implant dislodgement would be completely avoided by a single one-piece jawline implant that has a custom fit by computer designing. This is because it is a single implant that with its wrap around effect has more surface area for implant fit and this becomes very difficult to ever move from its custom fit location.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am looking for a surgeon who can help me to decide how to improve my scar. I know it is hard to evaluate a scar from just pictures. I have a small scar 0.5 cm on my chin resulted from squeezing and scratching the spot and I got it infected. It was 10 years ago.The scar was just a very little raised and became white. I had radio frequency treatment done 5 months ago. And after a month the scar became a little more raised. I attached the picture of the scar so you can have a look. It is a slightly hypertrophic scar.

I got a lot of different options from the doctors. Nothing has been done yet, I am very careful as the scar is on the face. A few doctors recommended to me that laser CO2 fractional would be the option for me and some of them said that excision of the scar will give me a more significant improvement and I should have a scar as fine line. Two doctors recommended steroid injection to flatten my scar but it will not reduce the white color.Another doctor said that it could make another complications like pigmentation surrounding skin. I do not want to try laser CO2 as I had radio frequency treatment done on my face and my scar became a little more raised and white.

I would go for excision but a few doctors said that my scar could look worse because of the location. One doctor explained to me why he would not do excision as the scar is on the chin and there is no loose skin so if he cuts it out it will have to be closed under tension which could make my scar worse.

Another surgeon told me something different please read below:

‘The existing scar is not big enough that there should be much tension on the surgical scar. With a good surgeon, and a good post-operative healing process, should leave you with a fine white line. I would place it in a curve or oblique line that parallels the curve of your chin pad – this is called a resting skin tension line (RSTL). The deeper layer of sutures should be dissolving, but the last layer at skin level should be non-dissolving for the best chances at a good result.’ 

Another surgeon told me this:

‘One of the surgeons you have seen is right to say that it does depend a little on how much loose skin there is but in general, there is ample laxity in facial skin to perform an excision of this kind without distortion.  So long as the new scar is placed carefully in relation to the natural lines of relaxed skin tension the new scar should be favorable, but it will still be a scar.’

What do you think about it?

What would you recommend after excision, i need to know your opinion to get the best care after excision.

One of the surgeons wrote me this:

‘I ask my patients to cover their wound/scar with Micropore for the first 3-4 weeks as this provides some mechanical protection to the wound, and traps some sweat and waxes from the underlying skin, which is good for the scar.’

Silicone sheeting is applied after 3-4 weeks, as the scar undergoes a change in how it is behaving. For the first 3-4 weeks, a scar is depositing collagen bundles in a random manner to build up strength. After that 3-4 week,s it enters the remodelling phase, where the scar starts to pull down the random collagen bundles and arrange them in the best possible direction for the scar. At this stage, the body also send in new blood vessels to help that process. This is when scar management such as scar massage and silicone sheeting will help. Starting to do these things earlier than 3 weeks can weaken the scar and cause it to widen.

What do you think about it?

A: The short answer is…if you want to have any chance of a visible improvement in your scar, you have to excise it. There is not an issue of inadequate skin laxity ti close it. Scar revision has ittl chance to make it worse, it is only a question of how much improvement can be gained.

When it comes to scar therapy, I do not believe there is any magic. Given the very small size of the scar, I would recommend topical steroid gel applied at night only.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I did lots of research before my jaw angle implant surgery. But I guess not enough to find the difference between lateral jaw implants to vertical implant. I have a high jaw, and I didn’t want it much wider. Just further down with slight wider. I told my surgeon this and he said that there’s only one implant for the jaw. The lateral one. I now can see the width that I will have but of course there’s swelling. The width is too much and it’s not down where I was wanting my jaw to be. So that’s why I would like to do the vertical lengthening jaw implant. I’m trying to see if my doctor can remove it this week. My doctor did not place screws with my implant, he just placed the silicone implant in the pocket of my jaw. I don’t think my doctor was an expert on jawline enhancement and I think that was my first mistake. I’m actually freaking out thinking I just ruined my face. Is it possible to fix my jaw implant problems? Not only did he do the wrong implant, he also went too large.  Please comfort me with info and what I can do.

A: Unfortunately your research on jaw angle implants was indeed inadequate. Of the three decisions you have to make about jaw angle implants, the very first one is whether the implants should be of the lateral width style or the vertical lengthening style. The second decision is what sizes or thicknesses should theses styles be. Lastly, there is the issue of material choice. (silicone vs Medpor)

By far the most common jaw angle implant is the vertical lengthening style with some width. (but usually less than that of the vertical length increase) Pure width (lateral width) jaw angle implants are used in 10% or less of all jaw angle implants in my experience.

You did not ruin your face, the implants can always be converted to the vertical lengthening style at any time. With your facial shape, you likely need a 7mm vertical lengthening and 3mm width style jaw angle implant.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a lot of orbital bossing of the skull which may be pinching the supraorbital nerves causing daily migraine pain. I guess this surgery would be called forehead reconturing/orbital bony contouring/brow bone reduction of that region. I was hoping to get a surgery that could take care of the functional as well as the aesthetic. I have a 3D Ct scan of that region and was wondering what a rough estimate might be for that surgery. Would insurance cover this procedure? I know that the same incision is made across the hairline for both the migraine surgery and the recontouring of the orbital bony area of the forehead. Listed below are descriptions of the surgery I have in mind. Thanks!

1. Forehead reconstruction or cranioplasty where the glabella bone is taken apart, thinned and re-shaped, and reassembled with small titanium wires or titanium microplates and screws.

2. Or the compression technique in appropriate cases where the wall of bone is first thinned and weakened, and then compressed into place. It then heals in the new position.

A: Certainly orbital rim recontouring by brow bone reduction and decompression of the supraorbital nerves can be done at the same time. Only brow bone reduction uses an open scalp incision. Isolated supraorbital nerve decompression for frontal migraines is usually done by an endoscopic limited incision technique. But the open approach does afford great access to the nerves for the best decompression possible.

Most brow bone reductions are best done by an osteoplastic flap technique where the outer table of the frontal sinus is removed, reshaped and then put back in its reshaped form by either resorbables sutures or very plates and screws.

Neither is aesthetic brow bone reshaping or supraorbital nerve decompression for migraines covered by insurance. Prominent brow bones are not a recognized craniofacial deformity by insurance companies. Nerve decompression for migraines is currently viewed as ‘experimental’ surgery without long-term clinical studies to be currently viewed as an approved medical procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in facial reshaping surgery. I can not figure out what my face needs to look better. I’d really appreciate you taking your time for this. I have been given different surgery options from doctors here in Australia. However my opinion is that the best doctors are located in America, especially for facial surgery. It has been recommended to me that I have cheek implants, buccal lipectomy and a chin implant. But I want to know your opinion since you are regarded as one of the best surgeons in the world for facial reshaping surgery.

A: In looking at your pictures, your facial reshaping/restructuring goal would be to shorten your longer face and provide some more central projection. You have a more flat paranasal/midface and thus you have to be careful with how you change things to not look worse. I would recommend the following:

1) Chin augmentation but by sliding genioplasty as your chin needs to come forward but should become vertically shorter not longer. (implants tend to make the chin longer or at least neutral in vertical length)

2) Malar/Submalar implant augmentation with emphasis on providing with anterior projection not so much width

3) Avoid a buccal lipectomy. That would be one of the worst things you can do to a face that already lacks projection and could easily end up looking gaunt.

4) Paranasal augmentation to build out the base of the nose and the maxilla. This complements what the dimensional changes of the cheeks and chin and avoids ‘leaving the area between the two behind’.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m interested in getting a forehead reduction with the hairline lowering included. However the bossing of my forehead is the entire bone, top middle and down to the bottom over the brow bones. Can these areas be burred and reshape with the same approach you use on the brow ridge and eye orbits sockets as well?

A: The entire forehead can be reduced by burring. The only exception or caution would be over the brow bones where the underlying frontal sinus exists. The bone on the front of the frontal sinuses (brow bones) is usually very thin and may be only 3 to 4mms thick before the frontal sinus is encountered. A lateral skull film x-ray is needed before surgery to measure the thickness of the bone to see how much it can be reduced by burring. If more reduction is needed than just burring can allow, then an osteoplastic bone flap technique is needed to maximize the lower end of the forehead reduction. In a woman this is rarely needed however.

That is a long answer to say that a burring technique can sufficiently reduce the amount of bossing of the frontal bone and is often done on conjunction with a hairline lowing/advancement.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in the Brazilian Butt Lift and would like to know how many procedures you have performed? I have attached two pictures and would like to know what kind of results you would expect with my body type. I am not wanting a big Kim Kardashian booty just some volume to add some shape. Looking at my attached pictures do you think this is achievable?

A: It is a good thing that your Brazilian Butt Lift (BBL) objectives are not like that of Kim Kardashian as you simply do not have enough fat to harvest to achieve that amount of buttock size increase. The success of BBL surgery depends on two important factors, how much fat does one have to give and how much fat will survive after being processed and injected. When you realize that less than 50% (at best) of what comes out as liposuction harvest ends up as buttock volume addition, the reality of what is achievable by the BBL procedure comes into focus.

What one means by ‘just some volume to add some shape’ is open to interpretation, the question is really whether the procedure is worthwhile. There is only one guarantee with the BBL operation and that is the body contouring that results from the liposuction harvest. When one does not have a lot of fat to harvest and process, a realistic buttock augmentation goal should be ‘just something more than what I have’. As that is the only assurity you can get from the procedure.

Many successful buttock augmentation results occur from the combination of reducing what lies around the buttocks and augmenting what lies within…more so than a real substantial buttock size increase. Such would be the case with your body type.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I did not know i could have cheekbone reduction in the U.S.. I had it done in Asia where my friend had that done too. I am of Asian descent and I have wide prominent cheekbones. I had the cheekbone reduction procedure without plates and screws and now I am afraid of non union of the bones, misalignment and dislocation of the fragments of the zygomatic arch. I hear a clicking sound. My surgeon in Korea says it’s normal and will disappear, but I wanted a second opinion from you. 

if you don’t use fixation how you make sure the bones stay in place how you prevent sagging and scleral show after the cheekbone is collapsed. Once you push the zygoma arches in and there are gaps and dents, does new bone is created in years to fill in those gaps or do they remain depressed?

A:  Cheek bone reduction surgery can be compared directly to have a facial fracture…albeit a surgically controlled one. The best way to ensure that the bones stay in the desired position and heal is to use some form of bone fixation. (plates and screws) The clicking you hear is the bone segments that are unstable and are moving with their edges rubbing together.

Since the zygomatic arches are not functionally loaded bones, like the lower jaw for example, one can argue that it is not critical that they are stabilized. They will eventually go on to heal even if it is by fibrous rather than bony union. When it comes to cheek bone reduction, however, the position of the bone is just as important as whether it heals. Sagging or dropping of the bone is associated with soft tissue sag and even potentially lower eyelid sag. This is why some form of bone fixation should be done.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, After perusing your blog extensively (thank you for it, it has been a tremendous help!), I’ve finally decided to get cheek implants. My issue is that I had a sinus infection 2 weeks ago,and my doctor put me on antibiotics for a week. It has since cleared up and I don’t have any symptoms of sinusitis anymore. As I will be getting my cheek implants in two weeks, will enough time have passed for me to get the implants safely, or will I be an increased risk of infection due to the prior sinusitis?

A: It would be logical to assume that there could be a correlation between cheek implants and maxillary sinusitis. And certainly one should not undergo any elective cosmetic procedure if any active head and neck infection is ongoing. While they are anatomically very close, the placement of cheek implants on top of the zygomatic bones and the sinuses located below and behind the front wall of the maxilla are distinctly separate areas that do not connect. Even an active maxillary sinus infection does not contaminate the tissues where a cheek implant would be placed.

But having a two week period where the maxillary sinusitis is cleared would be prudent. But the typical antibiotics given for facial implants (usually Keflex) is not the type of antibiotics that should be prescribed for maxillary sinusitis since it does not provide adequate antimicrobial coverage.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am in search of a very skilled revision rhinoplasty surgeon and am impressed by your work. 

I had my first septorhinoplasty with right inferior turbinectomy around 18 years ago.  My nose looked wide and had bulbous tip and pinched nostrils on birth and I had breathing problems. During first surgery the doctor took too much of my bridge away. My breathing problems got a bit better but my nose looked totally deformed.  I am of course very depressed due to that and am very much judged by people in life when they see me before I even open my mouth due to my appearance. 

I long to have a normal nose, I would like to have my bridge built up.  These pictures were taken in 2012 just before tip plasty.  I am sending the same pics to you for evaluation as the doctor did not even touch the bridge, only the nasal tip (hook) noted on left profile was made smooth, but everything is the same no difference at all. I did not want my bridge touched at that time as I thought things will get worst but am prepared now to take the plunge with the right surgeon. 

I was told that I did not have any septal cartilage left for grating but never had ear or other cartilage or implant used so far.  What do you think could be done to improve my nose? I do not want any synthetic implants in my nose, thus the only option is my ear or rib cartilage? 

I want to have an elegant nasal bridge, and have the pinched nostrils look better and start to live life better. I would be ever so grateful for your feedback.

A: In looking at your pictures, you do need a dorsal augmentation by a cartilage graft and a rib donor source would be the best and really only good choice in your revision rhinoplasty. This provides an adequate amount and shape of the dorsal augmentation that you need. You would also benefit by alar rim grafts to provide improved support to your nostril rims so they do not collapse downward. Slivers of rib cartilage graft would be an excellent source of the straight thin grafts that are needed here.

Dorsal augmentation would bring the upper two thirds of your nose in better balance/proportion to the tip.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in lower eyelid bag removal surgery. I have dreadful eyebags that won’t go away. I have tried all the home treatments and nothing works. I’m a young female at age 28 and the bags last all day. There are two bags under each eye. The past two years everyone has been asking if I’m exhausted or sick. It’s really affecting my self esteem. Can you help me? I am getting married next year and and I don’t want him to lift the veil and see my tired baggy eyes. Thank you for your time.

A: Lower eye bags are the result of fat that is sticking out from under the eyes and pushing out on the eyelids. Because there is a ligament of sorts that normally holds back this fat, when it protrudes it is known as herniated infraorbital fat. Usually it occurs as a result of aging but there are younger people who have it naturally. Known as congenital herniated infraorbital fat, I have seen and treated it as young as 14 years of age. Because you would be normally too young to have this as a result of aging, we can assume this is the result of a congenital weakness in the lower eyelid tissues that can not contain the fat.

This is a very correctable problem. There are two lower blepharoplasty techniques that can be used to eliminate the lower eyelid bags. The first is a transconjunctival (inside the eyelid incision) to just remove the protruding fat. (transconjunctival lower blepharoplasty) This is usually the best approach for younger patients or those that have no excess lower eyelid skin. The other approach is to reposition rather than remove the excess lower eyelid fat done through either internal or external incisions. The decision between the two depends the patient’s anatomy, age and their facial type.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in jaw wiring. I had a back injury about five years ago and then my weight was 130 lbs. Now it is 210 lbs. If I could get down  about 30 to 40 lbs I think I could exercise and really make it work. Does this sound realistic?

A: The eternal question about weight loss is whether any method that provides an immediate and short term effect will provide a sustained weight loss change. The most effective long-term methods of weight loss are significant lifestyle changes in diet and exercise. But that issue aside it is well known that wiring one’s jaws together (e.g., orthognathic surgery) will cause weight loss by the limitations of what one can take in orally. (lack of solid food)

It is important to remember that while jaw wiring can certainly initiate weight loss while they are in place when they come off the onus will then be on the patient. But if you are confident that somewhere between a 20 to 30 lb weight loss over a several month period will help, there is no medical contraindication to doing so. The only question is how long to leave the jaw wiring in place which is usually between 6 to 8 weeks.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, When placing a tear trough implant through the eyelid with internal scar and no stitches, are the tissues peeled off the bone as they are with cheek implant placement? I had cheek implants in and removed quickly which left me with mid face sagging and worse eye bags than before, minimal, but the tissues adhered a few millimetres lower than before the operation. Is this a risk with tear trough placement and or removal?, or is a mid face lift usually performed in conjunction with a tear trough implant? Which nerve functions are at risk with this implant?

A: A standard preformed tear trough implant can be placed through a transconjunctival (inside the eyelid) approach. Like all facial implants, it is necessary to make a pocket for the implant which is usually subperiosteal although is can be placed preperiosteal as well. Given the very thin nature of eyelid tissue over the orbital rim, it is best to placed it as deep under the tissues as possible. I would consider the tissue pocket locations between the orbital rim and cheek bones as different as well as the size of the implants that are placed. Cheek implants are placed from below with wide subperiosteal underming and dissection, releasing much of the midface tissues on the bone to place a moderately large implant. Thus it would not be surprising that removal of a cheek implant places one at risk for a subsequent midface sag of some degree. Conversely, the tissue pocket for a tear trough implant is much smaller and is over the medial orbital rim where the detachment of tissues will not cause a midface sag like that of the cheek area.

Tear trough implants pose no risk of nerve injury. The only close nerve is the infraorbital nerve which lies below the orbital rim and where the implant is placed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have lost a lot of weight and the one area that bothers me the most is that of my buttocks. It hangs down with a lot of loose skin onto the back of my thighs. I don’t mind its size now but I can’t stand the loose skin at the bottom. And exercise will not get rid of it. What type of buttock lift do I need?

A: When it comes to large amounts of weight loss, the buttocks like every other area of the body is not spared from an overall deflation effect. The deflated buttocks loses both volume from fat loss and exaggerated amounts of sagging due to such volume loss. Buttock reshaping after weight loss can include either volume addition, tucking or lifting the sagging skin or some combination of both.

Buttock lifts can be separated into a true buttock lift (done from above as part of a circumferential body lift) or a lower buttock lift. (which is really a tuck after excision of overhanging skin.

A lower buttock lift is a lower excision/tuck procedure that is done along the infragluteal crease. (or makes a new one) It removes excess tissues and creates a new higher and more tucked in fold. It is not a difficult procedure to go through nor to recover from it. The biggest issue is to just not stress the incision lines (like bending over far) for a few weeks as the area heals. All sutures are under the skin and dissolvable so no suture removal is needed. The incision lines are heavily taped for support and serve as the only dressing. One can shower the next day and only strenuous activities need to be avoided for awhile until the incisions are more fully healed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am searching for a facelift opinion. I know you are an expert so I would value your opinion. Can a facelift correct this droopy mouth and marionette lines? I have lots of sag and volume loss. My skin seems firm with good elasticity but aging and gravity does take its toll. Is a long lasting correction possible? There are so many options for facelifts these days I don’t know which is the right one. Every doctor seems to have their way to do a facelift and they all claim their way is the best. I will only be able to financially do this once, so I’m looking for the best information to get the best outcome for me.

A: You are correct in that there seems to be many ways in which facelifts are done. And any time there are so many ways touted to do something you can be assured that there is no one single best way to do it. Nor does one facelift method work best for everyone as today’s facelift patients range anywhere from 35 to 85 years old…and simple logic would indicate that the facial aging concerns and anatomy amongst patients are quite different.

Facelifts fundamentally differ in three ways, extent (incisions and dissection), degree of SMAS manipulation and adjunctive procedures done at the same time. Putting together all these areas is what makes facelifts different and customized for each patient. But what does make them somewhat similar and serves as the basic elements of a facelift are the amount of skin flap dissection and SMAS redraping. With significant marionette lines and a droopy mouth, it is clear that you need a fuller type facelift with long skin flaps as opposed to a short scar or more limited type facelift. (e.g., Lifestyle Lift) SMAS manipulation is handled differently by various plastic surgeons but suffice it to say that extensive redraping of it is needed.  Such manuevers are needed to help get rid of the marionette lines and improve the jawline and neck.

What a facelift will not do is correct droopy mouth corners. As a result, a separate small procedure will be needed with your facelift that directly treats this problem…a corner of a mouth lift.

When it comes to a ‘lasting correction’, it is important to understand that a facelift essentially buys time. It is not a permanent procedure and its effects will last years, perhaps 8 to 10 years, but eventually some or much of the correction will be lost. Facelifts help reverse the clock but they can not stop it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had cheek implants recently and developed right after a weakness of my right upper lip and nostril. I was reading up on people that have had similar issues like mine and what other doctors have recommended and can across this (read below). I’ve also read the longer you wait to get the issue checked out the worse the outcome will be if your trying to fix it. So I’m torn on waiting if it lowers my chances of resolving the problem. I’m terrified this is permanent and was wondering if conducting a nerve test would be a smart thing to do. Maybe the nerve just needs to be decompressed, or if it was damaged or cut then nerve grafting would be the way to go. But the longer I wait the less my chances are to fully recuperate to the way I was before. 

What do you think?

‘The usual risks have been well presented by the other physicians. However, based on observed cases, there is a risk for temporary weakness of a cheek or upper lip especially with the larger implants which have to be placed beneath a branch of the facial nerve which is stretched. When and if this happens , Botox therapy can be used for symmetry until the nerve function returns.’  

A: Facial nerve injury is a very rare occurrence after cheek implants as the dissection is done under the muscle where the nerves supply them. But it can happen. In almost all cases complete nerve recovery would be expected.

I would be very careful about what you read and try to interpret about facial nerves injuries…as they are quite different based on where the injury to the nerve occurs and what type of injury that it is. Most of what you are reading refers to a proximal injury to a facial nerve branch, whereas what you have is a distal or terminal branch type of nerve injury. In essence if you draw a line between the corner of your eye and the corner of your mouth what lies towards the ear would be considered proximal and what lies on the nose side of that line is distal. Distal facial nerve injuries, where the nerve fibers are smaller than a human hair, are not treatable by any surgery or other therapy. Time and healing is all that can be done for them. This is particularly true for the distal branches of the buccal nerve which supply the upper lip and nostril. The buccal branch has a particular propensity to recover, unlike many other facial nerve branches, because there is considerable cross connections between these terminal nerve fibers. So even if one little branch is injured, the cross connections will allow other signals to supply what has been lost. This is particularly true in stretch injuries. (which is the only type of injury you could have) Thus it is not true that the longer you wait the worse the chances of recovery are. Waiting is the treatment and the longer you wait (there is nothing else to do) the better the chances of recovery will be. This is a process which is unknown as to how long it will take…it could be days, weeks or even months. Although I would guess some improvement will start within four to six weeks, it could take longer and complete nerve recoveries have been seen out to even a year after the event.

Botox injections can be done on the opposite side for facial symmetry, although if recovery on the affected side starts weeks later, the facial asymmetry will persist until the Botox wears off. (around 4 months) Since facial nerve recovery is usually progressive (starts working a little at a time), I would wait a few weeks or month to see if the nerve will slowly start coming to life. If not, then you can get Botox on the opposite to provide some temporary improvement in facial symmetry with smiling.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I hate my breasts! I am just 20 years of age and my breast looks like they are 85yrs. They sag and my nipples are huge. Due the weight I have lower back pains and my shoulders hurt. I can’t where certain clothes. For once I would to be able to a strapless bra or even not have a wear a bra at all with my clothes. I need a breast lift!

A: Large hanging breasts, even in young women, can be both aesthetically unattractive and cause symptoms of back, neck and shoulder pain. A breast lift with areolar reduction, and a little breast tissue removal, can create a dramatic improvement in their shape and reduction or elimination of their associated musculoskeletal symptoms. The trade-offs for these dramatic breast changes are scars in the classic anchor or inverted T shape. One has to decide whether these changes are worth it but most young women would say so. It is also important to understand that breast shape is variable over one’s lifetime particularly when one is still very young. Pregnancies and weight gain/loss will negatively affect the result of any breast lift/reduction procedure with the most common changes being further breast tissue loss (involution) and skin sagging. (pseudoptosis)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in intramuscular buttock implants. I don’t really feel comfortable with the subfascial pocket for them. Having said that if I go with intramuscular and 350cc or less in implant size, then which shape you would recommend? Can I get away with a round implant? Oval or anatomic? I would also like to have some liposuction for a better shape. Do you recommend to do them at a different time or together with the buttock implants?

After my first liposuction, I noticed that I have developed some fat around my bra area (bra rolls) that I hate. Here I attached some of my pictures with some assimilation on where I like to have the liposuction done. Can you please kindly let me know if they are relatively doable?

A: The most common intramuscular implant that I place is a 330cc anatomic implant that has a lower profile and more tapered edges than a traditional round or tear drop implant. This creates as more natural contour to the buttocks and will definitely avoid a rounder and more fake look. As most of the patients who undergo buttock implants are about your size (because they are not good candidates for BBL surgery), this implant volume is the right and maximum size that can be placed. Trying to ‘stuff’ a bigger implant than this in an intramuscular space is prone to causing other problems and even more prolonged recovery.

In regards to liposuction, you should definitely do it at the time of buttock implants due to the convenience of intraoperative positioning. You need to be in the prone position for the buttock implant procedure and this is the best way to liposuction the bra rolls and flanks as well. This fat could be used to fill in some of your indentations which would not likely go away with the push out of the implants way below them.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in correcting my coup de sabre involving my forehead and eye. What would be an approximate cost of correcting my linear scleroderma.

A: There are three approaches to treating your left forehead/orbital scleroderma (linear scleroderma en coup de sabre); forehead bone augmentation with bone cements, fat injections and the insertion of a dermal-fat graft. Which one would be appropriate for you would depend on how the tissues feel (skin stuck to bone with complete loss of fat) and whether there is an underlying bone defect on the orbital rim and in the frontal bone. (which almost always there is) Since there is usually both fat and bone defects along the line of scleroderma the most common surgical approach would be bone augmentation by bone cements combined with fat injections, either done together or in two separate stages.

To determine the ideal treatment needed for your linear scleroderma, a combined physical examination and a 3D CT scan is the best way to know exactly what to do. In many cases, these procedures are covered by insurance. But, at the least, fat injections can be done on a cosmetic fee basis and this is the most economical approach and would be part of any ideal surgical approach anyway.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 5’3” and 115lbs, 48 years old, healthy, and work out regularly. I have tried the Brazilian Butt Lift surgery (BBL) but not only didn’t it work but it also made my buttock shape more square than round. It also gave me some indentations. I am now very interested in buttock implants. I consulted with a plastic surgeon in South America and one in Los Angeles. They are both saying intramuscular for the buttock implant location. One is using highly cohesive gel implant called from Silimed and the one in Los Angeles uses semi solid silicone. They are recommending 400cc round or 480cc oval. As I was researching I came across your site. I noticed that you don’t recommend anything bigger than 350cc. I appreciate if you could share your opinion with me. I like the softness of cohesive but safety of solid ones. I love round looking butt, not too big or too small. Thank you for your time and feedback.

A: Let me provide you with some basic information about buttock implants. All buttock implants used today, regardless of the manufacturer, are made of soft flexible solid silicone elastomer. In essence they are all highly cohesive semisolid silicone gel. There is really no difference in their material composition. There are some minor differences in the durometer of the semisolid gel used (slight differences in stiffness) between the manufacturers but tis is really of no consequence to the patient.

Buttock implants can be placed either inside the gluteus maximus muscle (intramuscular) or on top of it. (subfascial) There are arguments for and against each implant location. If there was one perfect location for buttock implants, that would be what everyone would use. Intramuscular buttock implants are technically harder to perform, have a significant recovery but have the lowest incidence of long-term complications. There is also a limit, no matter what a surgeon says, as to the size of buttock implant that can fit into the intramuscular space. In someone of your size, that is going to be about 350cc or less. I can not see how any buttock implant of 400cc or greater can truly fit into the tight intramuscular pocket…at least with someone of your small size. It is not a recommendation that I make, it is simple function of what the anatomy will accomodate.

Subfascial buttock implants are technically easier to perform, have a shorter recovery and permit implants of larger sizes to be placed. It would be no problem to placed implants of 400cc or greater in the subfascial space. You have one important issue that may make this buttock implant location more favorable than it might be for others…you have had a prior fat injection procedure. While it may not have accomplished your overall buttock augmentation goal, it has provided some increased tissue and vascularity to the buttock tissues. I think given your desire for a very round looking buttock of intermediate size, you are likely better off with subfascial buttock implants.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a young man with symptoms of moderate plagiocephaly. The left-back side of my head is flat, the left eye and cheekbone is slightly higher and more prominent, my right eyebrow is lower and the eyelid sags heavily compared to the left, my right ear is pushed outwards and pulled back compared to my left one, and my jaw is wider on my right side. I noticed this completely about a year ago but most of my life I have felt like there was something off about my face. I’ve never been “bullied” by my appearance but I’ve been told from friends that I have a weird head or crooked eyes. Most people probably don’t notice right away but I feel like it is holding me back from completely enjoying my life and being content with my appearance. For example I cannot wear glasses because they look crooked when I put them on and I’m afraid to get a haircut because it is very noticeable how much larger the right side of my head is than the other. 

A few potential surgeries in helping my appearance maybe be augmenting the left back side of my head, reducing some of the thickness on the right side by burring the bone and removing some temporalis muscle, adding prominence to my right cheekbone and filling out my left jaw. I’m not looking for perfection, but I feel that adding and taking away from the right spots and micro-adjusting my features would help me look a lot better. 

I’ve done quite a bit of research on my condition but I cannot find any clear answers on what would help me. I would greatly appreciate any input you have on how I could improve my facial balance and asymmetry and bring out the natural good looks I believe I deserve to have.

A: Without seeing pictures of you I could not make any specific recommendations, but all the face and skull procedures you have mentioned are classic ones for correcting craniofacial plagiocephaly issues. (crooked face and skull) Occipital augmentation of the flat side of the back of the head and burring reduction of the contralateral protruding side of the back of the head are good skull reshaping options. Unilateral cheek augmentation and unilateral jaw angle augmentation are good facial ershaping options. Since you have identified those areas they would undoubtably all be collectively beneficial for improved craniofacial symmetry.

Dr. Barry Eppley

Indianapolis, Indiana