Your Questions

Q: Dr. Eppley, I’ve read online that you do infraorbital rim implants. I’m really sorry to trouble you, but I have a concern regarding my upcoming procedure with these implants. Basically, my doctor has informed me that he will be using an intraoral approach for the Medpor Extended Orbital Rim implants, but every resource I’ve seen has said that the implants are placed through an eyelid incision. Do you think an intraoral approach is possible, and will the results be affected by using it? Should I at all be concerned that he isn’t going to use the eyelid incision?

A: The placement of infraorbital rim implants can be done either through an eyelid or an intraoral approach. Both are acceptable approaches and which one is done is based on surgeon preference. It is a little easier to assure good implant position on the bone from above (eyelid incision) as one does not have to work around the large infraorbital nerve. But an infraorbital implant can be effectively placed from inside the mouth, it is just a little more technically challenging to do so and the risk of some protracted lip numbness from infraorbital nerve traction will occur.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a bad scar across the back of my head from two previous hair transplants. After the first procedure the scar looked pretty good and was narrow. But after the second time it has gotten wider and more noticeble and I can not wear my hair very short anymore.  What is the nest way to improve this scar? Cab it just be cut out again and will it look better? Or should I just have hair transplants put into the scar? nd if hair transplant are done how would the grafts be taken and wouldn’t that just make another scar or risk making this on wider.

A: When it comes to hair transplant scalp scars, there are three approaches to consider. The first, as you have mentioned, is to simply re-excise the scar and reclose it. (scar revision) Whether this would make a successful improvement depends on how loose or lax your scalp  now is. Given that you have had two hair transplants with the strip method, it is likely your scalp has lost much of its elasticity or natural stretch. Wide scalp undermining would need to be done from above but how successful that would be at reducing tension on the scar revision closure is unpredictable. Another scar revision approach would be to first do a few weeks of scalp tissue expansion. Going through the scar scar in a first stage, a small tissue expander is placed above the scar and expanded every few days for a few weeks. Then the scar revision is done and it could then be assured that there would be no tension on the wound closure and a very fine line scar achieved. The third approach would be hair transplantation. But this would not be done using a strip method. Rather a follicular unit extraction (FUE) method would be done using the Neograft system. This method harvests the hair (follicular units) by using 1mm punches spaced out over the occipital and temporal donor area. These small extraction sites heal imperceptibly and the hairs are then transplanted into the scar.

Whether a scar revision or hair transplantation approach is best for your strip scar would depend on how much laxity your scalp has (or doesn’t have), the width and location of the scar and what your hair donor site look like.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a very deep cleft on my chin. A surgeon suggested dermal filler, saying that a chin implant would move because (he said) the dimple was too small. But my cleft chin is very deep and I am very unhappy with it. A doctor injected a syringe of hyaluronic acid into last year but with no visible improvement. I have placed a link to an image of my chin cleft here.

A: Very deep chin clefts in men are not usually the result of any underlying bone deficiency but are rooted in the soft tissue with a lack of tissue between the skin and the underlying muscle. Often the mentalis muscle is clefted as well. In addition the skin is very indented almost like a scar band. Thus a chin implant on the bone is likely to be of little benefit as pushing out from the bone will make little change in the depth of the cleft. Injectable fillers, as has been demonstrated by your experience, do not have enough stiffness and volumetric push to change the cleft. The viable treatment options would be either fat injections done with a subcision release of the vertical skin indentation or an open approach using a dermal-fat graft. In some cases the placement of a small implant in a midline bony groove can be of adjunctive benefit if it exists.

When it comes to chin cleft surgery, it is best to think of it as a reduction rather than a complete removal.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had Medpor jaw angle implants placed a year ago, but they did not provide sufficient lateral and vertical augmentation. I have been told that it would not be possible to replace the existing jaw angle implants due to Medpor’s tissue adherence, which is why I am thinking of getting a Medpor square chin implant with longer width to provide that augmentation.

That being said, I would very much prefer to get the Medpor jaw angle implants replaced, but I’m unsure if that’s possible. Do you think its removal would prove too difficult to be worth the risk? If not, could I replace it with another Medpor jaw angle implant at the same time?

A: If the proper jaw angle implant style is not used, the vertical elongation of the jaw angle area that many patients really need will not be achieved. While Medpor facial implants are harder to remove than silicone, it is not true that it is impossible to remove them. I have removed and replaced numerous Medpor chin and jaw angle implants. If you are still focused on using Medpor jaw angle implants then it would need to be the RZ style of either a 7 or 11mm width. Removal and replacement of jaw angle implants is done at the same time as that would be the most convenient and efficient way to do it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have decided I am done having children and am considering a breast lift with implants. Two children and nursing have taken quite a toll of my breasts. They are just two sacks of hanging skin now. What type of implant or lift I need? I don’t want to look completely fake, but a more perky and fuller breasts would be a big improvement. Is this even achievable after having nursed two kids? How soon before surgery do I need to stop breastfeeding?

A: The ‘two sacks of skin’ breast look is very common after multiple pregnancies, particularly in women who have small to  moderately-sized breasts beforehand. When the breast tissue involutes (shrinks) after pregnancy, the stretched out skin collapses and falls over the inframammary crease. (lower breast fold) In each of these cases of breast sagging (with little to no breast volume), a combined breast implant and lift is needed. Usually either a vertical (lollipop) or combined vertical and horizontal (anchor) breast lift is needed and the resultant scar trade-off is unavoidable. A breast implant, regardless of size, adds volume but in and of itself will not lift the sagging nipple back up to a satisfactory position. You will need to stop breastfeeding three months before undergoing breast lift and implant surgery to give the engorged breasts time to fully ‘deflate’.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve had a considerably flat occiput since infancy as I’ve noticed in pictures from that time.  The vertex of my skull also slopes downwards towards the frontal lobe.  This gives a “cone-shaped” appearance to my head when my hair is cut short. This has never been a concern to me, but in recent years I have began to develop male pattern baldness.  Although I am currently taking drugs to hopefully slow its onset, I must be mindful of my skull shape should the treatment be ineffective.  Having spent a considerable amount of time browsing your website, I’ve determined I may benefit from an implant to the occiput of my skull.

My questions are: what is the cost of such a surgery?  Is there anything that can be done to flatten the vertex of my skull, or would an implant to the occipital lobe just exaggerate the slope?  Would surgery require me to shave my head?  Best and worse case scenarios, how big is the scar post-op? 

I appreciate your time and consideration.

A: It is always more effective to augment the occiput than it is to reduce the vertex. While some bone reduction can be done, there is a limit based on the thickness of the skull to around 5 to 7mms of reducytiopn. The augmentation of the occiput can be as much as 15 mms. But put together a significant change can occur.

For skull reshaping surgery we do not shave any hair although we always appreciate any patients who would like to do so. As a ballpark figure the total cost of this surgery is in the range of $9500.

While all of these issues are relevant, none are more significant than the consideration of a scalp scar in a male. That is the key issue of whether this may be a good procedure for any patient but particularly in men who may have less hair to camouflage it. The scar is placed more to the back of the head keeping it within the stable hairline of most balding men. It is a long scar (12 to 14 cms) but thin.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m looking at augmentation the jaw angles to the side of my chin to make it more horizontal and masculine looking. Would it at all be possible to get a Medpor square chin implant, and angle the wings down a little to achieve that effect, or will I require a customized chin implant for this kind of augmentation?

A: Your question has me a bit confused. A square chin implant does not reach the whole way back to the jaw angles. There are specific jaw angle implants to achieve that area of mandibular augmentation that are different from  chin implants. They are two completely different mandibular (jaw) implant styles. In some cases, a custom jawline implant can be made  that wraps around the jawline and goes from angle to angle including the chin.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I believe that one of my breast implants is leaking. I have saline, below the muscle and I have had them about 13 1/2 yrs. The size is fine 38D. I know I need to replace the leaking one  but is there some reason why I should mess with the left one, because it is the right that is leaking. And I don’t think I want to switch to silicone, because I heard they are not good for you if they burst and  I don’t think they feel as soft. Is the saline leak harmful?

A: Th saline leak is not physically harmful. While you can just exchange the  deflating breast implant alone, most patients choose to do both sides as they fear that the other side will soon develop a leak also. That is just a personal choice one of surgical opportunity and preventative maintenance.

Your perceptions about silicone implants is not accurate. They are perfectly safe, they can’t burst or deflate and actually feel more natural than saline as they don’t have of the rippling effect that many saline implants do. While silicone implants can develop a rupture, they are composed of very cohesive gels that act more like solids than liquids. Thus the concept of a leaking silicone breast implant is not accurate, it is a rubbery formed jelly that just sits there inside the surrounding capsule that you body naturally forms. This is why silicone breast implants do not deflate.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am having quite a bit of dental surgery in my mouth, two 2 dental implants were put in this past April.. Hopefully, I will be having the customized permanent titanium abutments put in next month.  After that I will be having permanent crowns put on these abutments.  When these crowns are finished, I will then be having another crown put on another tooth unrelated to my dental implants.  I am concerned about having any eyelid lift surgery so soon after my dental work.  Should I be worried?  Should I space several months in between the time I have my last dental work and my cosmetic surgery? Should I be taking an antibiotic before each the above dental procedures? How can I prevent any chance of infection from occurring in my eyes? I would so appreciate your input regarding this matter.

A: There is no solid scientific or medical evidence that would link the bacteremia that may emanate from skin surgery to causing infection around osseo-integrated dental implants, particularly when the placement of the implants were put into the bones months before. Or in reverse. I think it is unnecessary to take antibiotics before your dental procedures but that is a decision between you and your dentist. I see no connection between any of this or your family history to any risk of infectivity from having eyelid or blepharoplasty surgery, particularly since antibiotics are given during this surgery anyway.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had liposuction in buttock area  which was a big mistake and it has sagged and become loose. The lower crease has gone down and is asymetrical. I am not a big person and the amount should not be that much. I am interested in a buttock wedge excision. I have several questions:

1)) Does this require general anesthesia or can it be done just by local? Is IV sedation needed and can that make it riskier? I had general for the surgery initially and did not like it at all.

2) When the tuck is done can I still run and do aggressive exercises?

3) How permanent is the result? I want to make sure if I stay within 5 pounds of current weight the results don’t evaporate over time and follow up procedures are needed.

4) What are the risks involved? Since it is in the legs is it more riskier to get embolisms? Can this be fatal?

5) How long is the recovery? If out of town how long do i need to stay there and any flight restrictions?

6) I did check here locally and they told me the total procedure is 1 hour with Local and IV sedation. I was interested as you have more experience and they have not done it before and how long does it take?

7) If i am out of town how are complications handled if any?

Thank you a ton, and look forward to your response!

A: I am not a fan of liposuction to the buttocks and your outcome is exactly why. A lower buttock lift, what you call a wedge excision, can be a very effective solution ot ptosis or sagging of the lower buttocks. In answer to your questions:

1) It could be done under IV sedation. While it could be done under local anesthesia that is not how I would have it done.

2) You can return to all forms of exercise but you should wait 4 to 6 weeks before doing so.

3) It is a permanent result.

4) Embolisms are not a concern with lower buttock lifts.

5) You could fly home the next day or two.

6) I have done many lower buttock lifts over the years and I find the results very effective and satisfying in the properly selected patient. The procedure will take one hour to do.

7) The biggest ‘complication’ in buttock lifts is suture extrusions or small openings…all self-resolving problems. If any questions, send pictures of concerns by e-mail. That is how we handle all postoperative concerns from afar.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I am looking into getting a breast lift and possibly an implant. Does you do the breast lift with a vertical incision under  the nipple down?

A: There are four basic types of breast lifts which differ in the amount of lift and length of scars that are created. As a general statement, when breast lifts are done in conjunction with an implant, the most common type of lift performed is the vertical type. (lollipop) The breast implant also helps in creating somewhat of a lifting effect as well. When a breast lift is done without an implant, the most common lifting technique is the anchor or inverted T scar pattern where there is a combined vertical and horizontal scar. Without an implant more of a lifting effect is usually needed and that must come from the amount of skin removed and tightened.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in undergoing hair transplantation but do not want the scar across the back of my head. I have read about the ‘follicular unit extraction’ technique that can be done without having the scar. How does this work and does it produce good results?

A: Follicular unit extraction, known as FUE, is a minimally invasive technique for hair transplantation. It enables the surgeon to extract single follicular units which contains the hair follicles, sebaceous glands, muscle and very small pieces of skin and fat. Within each follicular unit, there may be 3 to 4 hair follicles. These units are extracted individually from the donor scalp areas without a scalpel. This also means there will be no stitches or a linear scar. The FUE extractions sites will heal quickly within a few days, leaving no visible scars and with the donor area looking normal again after a week from the procedure.  One of the most exciting things about FUE is what it offers for men with very short hair in which a linear scar may create another aesthetic scalp concern.

The FUE technique has become more efficient with a breakthrough mechanical device introduced in 2008 called NeoGraft. NeoGraft is a powered suction device that works like an extension of the human hand to help harvest hair follicles efficiently from the scalp at a rate of speed that is significantly faster than manual extraction. The Neograft hair restoration system is the state-of-thepart approach to FUE today.

In skilled hands, the FUE technique yields hair graft survival rates that are similar to that of the linear strip harvest methods. Both techniques yield follicular unit grafts that have similar survival after being transplanted.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, my question is can I have calf augmentation implants because I have polio since 10 years old from feet to my knee. My right leg is really thin and my left leg is normal. Thank you!

A: There are many causes of calf asymmetry in which one calf is smaller due to gastrocnemius muscle atrophy or lack of development. Club foot and polio would be two examples that can result in smaller heads of this calf muscle. There is no reason why you could not get a calf implant into the affected leg. The question is how small or tight is the skin on that leg. In cases of severe muscle atrophy the enveloping skin may be very tight. This will control or limit whether a calf implant can be inserted and be big enough to  make a visible difference. When using implants for correction of calf asymmetries, the question is never whether one can make the affected calf normal in size (because you can’t) but how much improvement can be obtained.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a revision rhinoplasty several weeks ago. My first rhinoplasty left me with an obvious silicone nose with a dropping tip and big flare nostrils since I am Asian. At that time I was concerned about the bridge only. After the revision (they used rib), it looks natural and even a bit slimmer since they did fracture it as well. But somehow I feel it was shorter than my silicone nose. I asked my surgeon about this and he told me that my skin is so thin that it would look fake if they put something in to increase the height of the bridge. He even said he had to dice the rib bcause of this. I just wanna know is there still any hope to make it higher without being unnatural because of this thin skin. Thank you.

A: I believe what you refer to as a ‘shorter nose’ really refers to the height of the dorsum rather than the actual length of your nose. By your description, your silicone implant was bigger than the rib graft that replaced it. This is particularly evident as the rib graft was diced, most likely done because the harvested rib was not straight and dicing it ensured that the risk of warping after surgery was eliminated. Large silicone implants do tend to thin the overlying nasal skin due to pressure and the lack of an underlying vascularized surface doing the outward push. When replacing such an implant one certainly doesn’t want to place a bigger implant or even one that is exactly as big in height. (implant thickness) But in using rib grafts in rhinoplasty, particularly in a diced form, the graft size could have a good height as this more natural material allows blood vessels to grow through it. This rduces the risk of further thinning of the skin or skin compromise.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like a nipple reduction and have it lifted as the same time. What are my options for having this done? I have attached some pictures of my nipple concerns.

A: Thank you for sending your pictures. In my experience, there are two basic types of elongated nipple deformities. The first type has a narrow base and the nipple length is usually 3x to 5x longer than the base width which is why it hangs down like a willow tree branch. This is the easiest and most successful nipple reduction result as shortening the nipple length immediately lifts the nipple back to its base level. The second type of elongated nipple has a very wide base and the nipple length is only 2x or so of its base width. It is heavy and the entire nipple base sags due to its weight. This is a bit more challenging to get an optimal result as shortening the nipple length with such a side base can lead to a potential ‘pinched’ nipple look. Based on your pictures, you have a type 2 elongated nipples

In addition, there are two types of nipple reduction techniques. The first is a wedge reduction technique where the nipple is bivalved at the desired level and sewn back together. This places the fine suture line across the top of the nipple. This may reduce nipple sensation. This is the best technique for a type 1 elongated nipple. The second nipple reduction technique is a base circumferential (donut) reduction method where a ring of nipple tissue is removed from around the nipple where it joins the areola. A central core of nipple tissue is preserved and the remaining outer nipple is then pulled back and sewn to the areola. This places the suture line around the base of the nipple and preserves nipple sensation. This is often more appropriate for a type 2 elongated nipple though the amount if nipple reduction and lift is less.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 42 year old female who is 5’ 3” and weighs 122lbs. I had liposuction done several years ago to remove some fat but now I have loose skin. I would love to have a very flat and tight stomach with a six-pack look. I think I need a tummy tuck to get there but the scar and the shapes of the bellybuttons I have seen scare me. I don’t know if my tummy is bad enough for a full tummy tuck, maybe just a mini-tummy tuck will do. I want a very low and thin beautiful scar and a small almond-shaped belly buttons. I would like to be able to bend over and not grab a handful of stomach skin.

A: To get the flattest and tightest result you need a full tummy tuck. A mini-tummy tuck will make some improvement but will not meet the muster of the flattest and tightest abdominal result. Keeping the scar low as one would like depends on how much loose skin one has. Scars from tummy tucks are influenced largely by how the patient heals not necessarily by the plastic surgeon who makes them. A full tummy tuck will not get you a six-pack, only a flat tight stomach. The shape of the belly button, like the scars, is highly influenced by how you heal and your natural belly button shape. A tummy tuck does something that no amount of diet and exercising can do but getting one involves trade-offs and realistic expectations. Bending over and expecting there will be no skin to grab is one of those not realistic expectations

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I know that a lot of plastic surgeons use computer imaging for facial surgery. What I don’t understand is how do they know what is really going to happen since surgery and healing doesn’t work like a computer. How do I know I will get what the doctor has shown me by imaging?

A: From my perspective, the role of computer imaging in plastic surgery is different than how you are interpreting its use. It is mainly a communication tool to see if the direction of the various changes are what the patient sees as beneficial. It does necessarily guarantee any result  nor the magnitude of the changes that may occur. (lesser or greater) This is why I am always going to image conservative changes or the very minimum that I believe that can be accomplished. I want patients going into surgery knowing that they will at the very least see these changes. More change may likely happen but it would not be very fair or ethical to show dramatic imaging if that is not what is surgically possible. Anything can be done on the computer but it is up to the plastic surgeon to not overpromise what can be accomplished.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I had paranasal implants placed last week. About how long will it take before my smile looks normal? And how long should I wait to attempt to smile?   Also, I can feel a hard knot like object on the left side about less then 1/2 an inch below my inner corner of my left eye next to my nose.  What is that?  Is that the paranasal implant.  I thought paranasals was supposed to be on the side of my nostrils but I can feel this bulky area below my eyes right alongside my nose way up high. The bulky area extends down to the middle of the side of my nose.  I feel it and see it on both sides but it is bulkier, harder, higher and more obvious on the left.  I attached a pic of my swelling progress. Sorry but I’m not so pretty.l My lips nose cheeks are  all numb and I keep getting strange shooting pains on the left side of my face.  Sometimes they startle me bad.

A: The general rule on any facial structural change, such as paranasal implants, is that 50% of the result will be evident by three weeks, 75% by 6 weeks and the full result by three months after surgery. Therefore, any issues related to the way it looks or feels must go through these time periods. What one sees and feels at one week after surgery will likely change or become irrelevant in another month. Swelling, fluids and tissue shrinkage take time just as it did for your rhinoplasty. When it comes to functional recovery after facial structural surgery it has a similar time course although usually much faster. Nornmal feeling and mouth movement will take 4 to 6 weeks until things are nearly normal. Paranasal implants are very much like cheek implants, they are placed around the large infraorbital nerve which supplies feeling to the side of the nose and the upper lip. (and is actually the nerve the dentist injects with local anesthetic when working on your upper teeth which is why it feels similar) By  working around this nerve it is normal that it will go numb for awhile after surgery and takes some time to get its feeling back. As the nerve recovers from being stretched it will have many strange feelings including shooting pains or shocks. This is how the nerve recovers somewhat similar to when your foot goes asleep and feeling comes back into it.

Thus, being just one week out from surgery everything that you are experiencing is perfectly normal and expected. If this were two months out from surgery it would be a different story. But this is still early in the process and the only thing you can do at this point is let healing takes its natural, albeit long for you, course. You should smile and move your mouth as you feel comfortable. What you feel up high in the side of your nose is not the implant (as that would be impossible) but swelling.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have severe Grade 3 nipple inversion since birth and had a procedure earlier this year with high hopes. It was a release and then attached to a plastic device onto which the nipple was sewn. It did not work and I am extremely disappointed. What are my options at this point?

A: Inverted nipples present in differing severities which have been classified by grades and reflect the degree the nipple is inverted and ho scarred in it is. (milk duct fibrosis) Fundamentally, grade 1 nipple inversions may only occasionally retract and are easily pulled ouot if they do. (no soft tissue deficiency) Grade 2 nipple inversions can be pulled out but retract quickly when released. (very little soft tissue deficiency but with some scar) Grade 3 nipple inversions are very hard to pull and may not even be able to done. There is considerable retraction and scarring and a true soft tissue deficiency exists underneath. While the technique of release and sustained retraction by suturing to an external plastic device is the standard treatment, it is not one I have ever liked and there is risk of nipple necrosis with such sustained retraction. I find that release of the nipple and the placement of an interpositional dermal-fat graft to be a more effective solution.  The key is that scar tissue and the natural shortage of nipple length will pull the nipple right back into hole from whence it came. This is an issue of a tissue defect, not just a release. Constant traction on the nipple by an external device allows the filling of the defect with scar tissue which is highly prone to scar retraction and recurrent nipple inversion as it  heals. A revascularized dermal-fat graft provides a better resistance to scar contracture.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I undergone a genioplasty 18 months ago where a 5mm medpor implant was inserted through the chin. It improved my profile view and made my face more masculine, but it hated how it looked from the front, making my lower face square while I originally had a V-shape that I liked. The new chin was larger and squarer than my lower dental arch, so it looked weird at different angles. I asked for a revision 6 months ago where my surgeon shaved the wings off and tried to better adapt to my natural asymmetry. Today it still looks weird to me, even though it made me get some of my original features back. The bulging is now more isolated in the front, which is another kind of weird, as a matter of speak. I am now fairly certain I want it out, even if it means losing the profile improvement.

My questions:

– How dangerous is it to remove medpor after 18 months ? I know you wrote it’s only relatively more difficult compared to silastic (my surgeon says the same), but it is my face I have to be really careful with what I do next. Am I facing some loss of tissue/bone/muscle ? Do I risk some sagging (perhaps having reduced the implant’s size first will help in that regard ?) ? And if I getsome sagging, does getting more weight (planned anyway) will also fill up the skin so that it’s not so much of an issue ?

– when the medpor wings were shaved, doesn’t that necessarily suppose shaving integrated tissue/bone ? If so, does that mean I have now less bone structure than before ?

– Is there any way of moving a chin forward without making wider (and still blend in with the mandible) ? Is sliding genioplasty better at maintaining the original shape (since the bone already has the patient’s natural shape) ?

Thanks a lot for the time you spend helping out online.

A: One of the most overlooked features of chin augmentation is how it can change the front view. Most chin implants, particularly those of Medpor designs, will have an appreciable widening effect. When removing a chin implant, the issue is always one of the potential for soft tissue ptosis or sag. Just like a breast implant, once the tissues are expanded, they may not go back to their original shape. That is going tgo highly depend on the degree of expansion (size of the implant) an how long it has been in place. This can be partiually or completely overcome with mentalis muscle resuspension. Removing a Medpor implant does not mean losing any bone. The concept of bone ingrowth into Medpor is overstated and does not really occur to any appreciable degree, if at all. Removing the implant and doing a sliding genioplasty is a better alternative than just removing the implant alone. By so doing you will still end up with the profile improvement, keep a narrower chin (all sliding genioplasties actually keep or make the chin more narrow not wider) and will pick up any soft tissue and avoid/treat any soft tissue sagging.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in breast augmentation. One of my breasts is bigger than the other. I would like to even them out and go up a couple of sizes. I would like to do the “gummy bear” implants. My goal would be to get the most natural look possible.

A: Generally when breast asymmetry exists, it is very rarely adequately corrected by two different sized breast implants. This is because the amount of skin, nipple position, and any degree of sagging is often quite different between the two. But for the sake of a starting point (and perhaps this will be all that is needed) I will assume that it is just a matter of two different sized breast implants for now. Otherwise the concept of a natural breast augmentation result can mean different looks to different people. While implant size is certainly one factor that goes into a ‘natural’ result, there are other factors that can also play a role in creating that outcome including  the use of round vs. shaped (tear drop) breast implants.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I really want a bigger butt but realize that I don’t have any fat in which to inject. I am too thin to get much of a anything. That leaves my only option as buttock implants but I have heard only bad things about them. Are they really that bad? What is the real truth about them?

A: Buttock implants have gotten a historic bad reputation that to some degree is undeserved. When placed by an experienced surgeon into the intramuscular location, they can produce some very good results that fat grafting can not. Intramuscular buttock implant placement will be limited to usually under 400cc for most patients although this can make for a very impressive change despite the seemingly small volume. Buttock implants can also be placed above the muscle in the subfascial location, where much larger implants can be used, but the risks of complications such as infection, fluid collections and implant shifting are higher. Buttock implants can be a very effective and safe buttock augmentation option but what is bad about them is that the recovery is going to be longer and more difficult than that of fat grafting.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have some loose skin around and above my belly button after my tummy tuck which was three years ago.  I never though it was the tightest above my belly button right after surgery but the skin seems to have gotten a little more loose since.  I’d never heard of a reverse tummy tuck before I read about it online and am now curious about how the procedure works and where the scars would be placed?

A: The reverse tummy tuck is a distant cousin to the traditional tummy tuck, not only in location but to how it is performed to some degree. For those women who have loose skin around and above the belly button but not below it or have had a prior tummy tuck with loose residual skin above the belly button (the usual candidate for the procedure), a reverse or superiorly-based tummy tuck is the only skin removal option. A crescent of skin and fat is removed along the lower breast folds and across the sternum. This lifts the tummy above the belly button, just like pulling up with your hands along your rib cage. This places most of the scar along the inframammary breast fold with the exception of a small area that crosses the sternum. Unlike a traditional tummy tuck, no muscle usually needs to be tightened. In some reverset tummy tuck patients, I have only removed skin and fold under the breasts, keeping the scar from crossing the sternum. In the properly selected patient this can be a very good option if one can accept a scar along the lower breast folds. While always called a reverse tummy tuck, it should really be called a tummy tuck lift or superior tummy tuck.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was wondering if I can send pictures for your opinion of a chin pad re-suspension/jaw line augmentation. I have taken some pictures from different angles. I love the fact that you are also a Doctor in dental medicine, and you have a vast understanding of the chin and mandible bones, and have plenty of experience re-suspending the chin muscles to correct the appearance of “witch’s chin”, producing natural looking results as well.  I am 46 years old and a little more heavy by 10-15 pounds so the contrast between my round face and triangle chin is now more evident. My chin and pre-jowl area are looking worse as I age. I’m looking forward for your opinion.

A: I have looked at your chin/jawline issues and there are two different directions to go. The first is to simply resuspend the chin pad back up with submental liposuction. (illustrated in Facial prediction 2) The other approach is to build the chin and jawline out with submental liposuction. (illustrated in Facial Prediction 1) I think you have always had a smaller chin being a small women so your chin pad is more likely to become ptotic with age. It would seem more anatomic to pull the chin pad back up but the stability of keeping it there is suspect when the bone support is not strong. Conversely, the concept of some chin-prejowl augmentation is a more assured result but it does create a bit of a different (new) look for you. So you have to be certain this facial change (slightly stronger chin and jawline) is one you see as better. I personally favor the buildup as it automatically takes care of the chin sagging issue. Either approach incorporates submental liposuction which is a given as an improvement need.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a fairly muscular 20 year old guy and am a junior in college. I starting lifting weights about three years ago and, while my chest has gotten bigger, so has my nipples. I have to admit that I have been taking muscle building supplements until about six months ago. My nipples are puffy and stick out so when I am wearing shirts it looks horrible. I really need a fix for this so that I can go to the beach again and feel comfortable taking my shirt off. Even with muscles having puffy nipples does not make my chest attractive. I am at about 12% body fat now.

A: There is no question that there are certain stimulants that can cause breast tissue development and this is not the first time that I have seen it in bodybuilding young men. It is good that you have stopped taking the supplements even though that will not cause the breast tissue to regress. This will require surgical excision done through a lower areolar incision. Most likely they are lumps of firm breast tissue behind the nipple-areolar complex that is causing it to be pushed out and puffy. After surgery you will need to refrain from weight lifting for about 2 to 3 weeks to prevent the development of a seroma (fluid build-up) in the space where the gynecomastia was removed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I visited a craniofacial surgeon for advice because my right zygoma is lower, depressed and flat while the left one is just perfect (high, round, nice projection, and I want to leave it like that without surgical approach) He than diagnosed me with hemifacial microsomia. I asked him about the option of a custom implant on the right zygoma to make it just as high, round and projected as the left one.  He than said it is a bad idea to use implants for several reasons that sound convincing but proposed to use Beta-tricalcium phosphate granules trough a surgical approach to achieve the symmetry. He said it will act like an implant and also be permanent. He is a very well known surgeon and I do trust him, but I can’t find alot about this approach and that kind of worries me a bit. Are those granules really able to bring the zygoma (not the arch) forward?

A: The use of hydroxyapatite granules (or beta-TCP) in craniomaxillofacial surgery is an older approach for bony augmentation. It has a long history that dates back to the 1980s when hydroxyapatite blocks and granules became commercially available. I used it fairly frequently back then myself as there were no other non-bone material available. While it is a more ‘natural’ material, injecting/placing granules is an imprecise and relatively uncontrolled method of augmentation. For small amounts of augmentation that do not require a precise shape, it may still have a role in some select circumstances. But a ball of granules placed on the bone is easily compressible and displaced and defies being able to be accurately shaped. I have no doubt HA granules will provide you some augmentative benefit but it will not be effective in getting the most accurate and symmetric result to your normal side. It is simply a matter of the limitations of the material’s properties. The use of HA granules today is usually limited to older craniofacial surgeon’s who still have the historic belief that any synthetic material is ‘bad’. As for achieving perfect bone symmetry in the face to an opposite normal side, it is impossible to rival a custom computer-generated implant approach that creates the perfectly-shaped implant down to fractions of a millimeter. Such an implant on the zygoma/zygomatic arch is really conceptually the same as any other synthetic implant used in cosmetic cheek augmentation. I fail to see what makes that approach ‘bad’.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a mentalist strain and my chin is receding, I was told i needed a chin implant. Problem is that i’m not a fan of plastic surgery and I want to be natural. Is it still considered plastic surgery if I need it? Are there other options?

A: A small chin combined with a mentalis muscle strain is ideally treated with a sliding genioplasty. This brings the chin bone forward with the muscle and is a more effective and ‘natural’ (non-implant) solution to your problem.  It is more effective because, rather than just stretching out the strained muscle which is already short, moving the chin bone forward actually lengthens the muscle by the bony movement. (thus eliminating the muscle strain) You may consider that approach a reconstructive solution to your chin concerns rather than a pure cosmetic one if that makes you feel more comfortable.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Will getting the hair transplants have any adverse effect on brow ridge implants?  My surgeon has informed me that he’ll be using sheets of intermediate hardness silicone to build up the brow ridges while carving them to smoothen them out by hand. He will also only use sutures to secure them rather than using screws. Is this something that you do too, and should I insist on him using screws? For reference, the incision will be made via the upper eyelids.

A: My method doing brow bone implants (rather than cement) is quite different. Symmetry of the implants shapes and ideal location on the bone is a challenging issue when more limited access approaches are being done. I prefer to use either preformed brow bone inplants (made out of silicone and using designs from other patients) or have custom ones made off of the patient’s 3-D CT scan. Then I place them through en endoscopic approach and secure them into place with a percuatneous 1.5mm screw technique.

There are no adverse effects of hair transplants on the underlying brow ridge implants.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a few questions regarding occipital cranioplasty. the back of my head is kind of flat and it’s been bothering me since high school. As I get older I notice that it gradually get flatter, to a point where I don’t tie up my hair anymore because I am so self conscious about it. Now that I am 36 years old and am financially capable of fixing this problem, I am contemplating on getting the surgery done.

Below are my questions:

1. If I decide to have the occipital cranioplasty done, will I have to shave all my hair off for the surgery? 

2. Since I will have extra material at the back of my head will it affect the growth of my hair or the health of my scalp?

3. What are the possible side effects of the surgery?

4. Do you have patients who already had the surgery done for solely aesthetic purposes? And are the cases with these patients successful?

5. Where is the best place to have the surgery done? ( country/state/doctor)

Your advise will be much appreciated.

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

1) No hair is ever shaved to perform an occipital cranioplasty.

2) Any placement of material on the skull bone does not affect the growth of the hair or the health of the overlying scalp tissues.

3) While infection is always a concern when any material is placed in the body, that is not a problem I have yet seen in cranioplasty. The most common side effects for any form of cranioplasty are aesthetic is the material smooth, even and symmetric? Was the buildup enough?

4) Most skull augmentations that I perform today are done exclusively for aesthetic purposes. The most common type of aesthetic cranioplasty that I perform is to treat a flat back of the head.

5) I can not speak for who else in the world performs aesthetic cranioplasties, I only know that I do.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, can someone who is overweight have a tummy tuck with liposuction? I’m 36 years old and am 5’4” and 195lbs. I have very bad back pain due to my large stomach. I have not been very successful with any efforts at weight loss and my doctor feels it is due to the medications that I am on. Would a tummy tuck with liposuction help me? I think it would be very beneficial for my back not to mention my self-esteem.

A: The question is not whether you can have a tummy tuck at your weight but whether you should. It would take a physical examination to feel your abdominal area and see how much of the tissue can be removed. In some overweight stomachs the skin is very tight and the yield on a tummy tuck is not as much as one would think. For these patients, weight loss is key so that they create the necessary loose tissue to make the surgical effort most beneficial.  In other patients, particularly those with an abdominal overhang (pannus), the results of a tummy tuck are more significant and even back pain may be improved as the strain from the weight of the overhang is removed.

Dr. Barry Eppley

Indianapolis, Indiana