Your Questions
Your Questions
Q: Dr. Eppley, I had a facelift which left my pixie earlobes. I had three procedures to fix my pixy ear but it stretches back toward my jaw due to not enough skin or too tight skin. Is there any other technique for my case which you think would work better? The last two ear procedures where done three and one month ago by two different doctors. One doctor cut the skin around the earlobe and the other doctor chose only to cut behind the lobe in order not to push the cheek skin. In both cases I was not satisfied. I have attached two pictures, one before the scar and one the way I am now.. I used to have a small high based ear with square jawline that now I can't see due to bad ear position.
A: The pixie ear deformity is marked by a lack of a definitive separation of the earlobe from the face and an earlobe that is ether elongated or abnormal in shape. In essence the earlobe is pulled down. Usually small local procedures of releasing and tucking the ckin around the earlobe, while tempting and worth a try, do not usually produce a very satisfying improvement. This is because they do not recruit/move skin to make a separation between the earlobe and the face that stays and the problem quickly becomes a recurrent one. The options are either an earlobe release and reshaping with a resultant vertical scar below the earlobe in its wake or a secondary mini-facelift to move more skin underneath the earlobe for a definitive separation. These approaches will likely be more successful than your previous procedures.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I would like to have an upper lip reduction, along with a reshaping of my upper lip. Are you able to perform this surgery? If so, do you use laser surgery for the procedure?
A: I am a bit confused by the combination of an upper lip reduction and reshaping of the upper lip. What do you mean by reshaping and what are you trying to achieve? An upper lip reduction is performed on the inside of the lip at the wet-dry mucosal junction. A horizontal strip of dry vermilion is removed and the remaining dry vermilion is rolled inward, thus reducing the visible vermilion or size of the lip. While this reduces the size of the lip, I am not so sure that I would call it a reshaping. Lasers are never used for skin or mucosal surgery. While they have theoretical appeal because they seem like a better way to do surgery, they actually have worse outcomes, delayed healing and usually bad scars. Lasers essentially burn the tissues that they cut through which causes all the aforementioned problems. They are also associated with wound complications such as edge separation in the healing period because of the tissue burn at the wound edges. They actually cause a more longer healing period and are not used for any plastic surgery operation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I want to create dimension to my face by making bony features more prominent. I would like to correct my flat midface, drooped nasal tip, recessed chin, flat cheeks and forehead, and create a more prominent bridge to my nose. What procedures would you use and how would you make these changes?
A: To make those facial changes, I would perform forehead augmentation with PMMA, a rhinoplasty using either a synthetic implant or rib cartilage grafts, and cheek and chin implants. I have done a side imaging photo to illustrate what I believe you are after with this compilation of procedures, to pull your face out and provide projection to a face that is naturally flatter and more wide. The only thing that I couldn't properly illustrate in the imaging is the bridge of the projection that would be achieved. Your natural bridge is hidden behind the eye so its profile can not be pulled based on this one photo. Always remember that computer imaging is just a visual way to start the discussion about what changes one wants and how much they want those changes to be. All of these facial changes can be done in varying degrees. Finding the correct amounts when multiple facial areas is being done is the key to a successful result.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I want to get the size of my chin reduced but am afraid of pain. Is there any painless way to reduce the size of my chin?
A: What you are asking is not possible. The surgery to do reduce the chin may be painless during the procedure because you are asleep. But after surgery there would be some pain and swelling. Most chin reductions involve bone removal, which by definition, will cause some after surgery discomfort. For the most part, anything painless in plastic surgery also correlates with things that don't work.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 27 year-old male. I have my nipples removed 8 months ago because it was too sensitive. I know the male nipple can be highly sensitive sexually and most of the men enjoy it but in my case I am unhappy with this sensation from childhood because it is intolerable and disgusting. And you know more than 30% male do not like that. I am among those men. So if someone tell that it is one kind of mental disorder, I do not believe it since I have taken mental and skin treatments since 2007 but there was no progress and I do not want to spend anymore money for medication. However, after the reduction of nipple there is little sensation on the center of the areola until now. When this place is pressed, it make me feel of the same sensation that I felt before. Finally, I have decided to remove the areola totally and want to make this place permanently numb. So what I want to achieve is the following:
1. Permanent numbness on areola by removing them.
2. Removing breast gland. (Actually, I have removed breast gland before but just need to check whether any gland tissue left. If it is then need to remove it.)
3. Removing whole areola. (It is not just the upper surface but also inner part. I mean after removing areola it will looks like a hole on skin.Probably, numbness surgery and whole areola removing may be at the same time.)
#2 and #3 is not mandatory but #1 is mandatory for me. #2 is optional.
*** It is notable that My problem is not gynecomastia. This surgery will be just for numbness on areola place to live rest of life with happiness. I think it can be done by local anesthesia.
A: The most likely reason you only lost partial nipple sensation is that only the tops of the nipples were removed. The nipple and its ducts extend deeper which is where it receives its nerve supply and sensation. While initially after surgery the nipples were completely numb, some feeling has returned because these deeper tissues remain. While the entire areola can be removed, it should not be necessary to do that to eliminate all sensation permanently. A lower areolar incision can be made and all tissues removed right up to the underside of the dermis of the areola. When this is done, the remaining areola is just a cosmetic feature on the outer side of the chest skin. As you have mentioned, removal of the areola will result in a purse-string type scar on the chest wall which may be indented. I am not sure that is a good trade-off but only you can make that decision. I would agree that either approach could be done under local anesthesia.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, One week ago I had a syringe of Juvederm injected injected under my eyes. So far, the results are not fantastic but at least It did not create bags, as I often read in “horror stories”. Maybe I look less tired. I know I won’t go for a touch up, I had a bruise which freaked me out and “perfection is the enemy of good”. But I m wondering… Does this HA create any long term side effect such as lumpiness or swelling months after the injection? Also based on your experience, how long does it really last? Because my injector said it could last for 3 to 5 years because there is no hyaluronidase in this part of the face (!!). And if people get treated again, it is because they have aged, the filler won't disappear. What do you think? Does HA under the eyes ever get broken down by the body? Thank you very much.
A: The information you have received about the longevity of Juvederm or any HA (hyaluronic-acid based) injectable filler is erroneous. No form of HA is permanent and they all eventually go away by the absorption of water which breaks down the filler. How long they last depends on the concentration of the HA in the filler and how it is cross-linked. It is true that they do seem to last longer in the lower eyelid/periorbital region, perhaps up to 12 to 18 months but definitely not three to five years. One of the real advantages of an HA filler is that it is a natural material as the body is composed of lots of HA material in its tissues. Thus there are no known untoward effects of repeated HA filler injections such as accelerated aging or tissued damage. Age also does not seem to play a role in how quickly or slowly any particular HA material persists.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I'd like to know based on your experience, how big of a chin implant would you consider as big enough to cause substantial amount of bone erosion From what I understand, chin implant of any size is bound to have some bone erosion to an extent whether or not it's substantially significant or just insignicant at all. Correct me if I'm wrong. When we talk about bone erosion, are we saying a 3-4mm bone erosion years after the surgery depending on the size of the implant? A surgeon suggested 1cm silastic chin implant and she said it's not considered big at all. I thought 1 cm is quite big isnt it so?
A: The issue of bone setting, not erosion, likely occurs with every chin implant to some degree. It is safe although speculative to say that the larger the implant the more settling into the bone that occurs. It is possible that implants of 1cm or more may have up to several millimeters of bone settling. While this is a frequently talked about phenomenon, I think it is clinically irrelevant. It has little impact on the aesthetics of the implant look and no other negative medical issues. It is only relevant if the implant is placed too high on the chin over thinner alveolar bone where implant settling into the bone may have adverse effects on the anterior incisor teeth. But a chin implant has no business being that high up on the bone anyway. It is also less of an issue today in anatomic or more extended implants where the pressure imposed by the implant on the bone is spread over a much larger area. In short, I would not concern yourself with this issue as I have never seen it to pose a problem when the chin implant is in good position over the lower basal bone.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am 48 years old and am tired of my ugly looking inner thighs. Not only do they touch and rub all the time, which is irritating and embarrassing, but the skin is loose and not very tight.I want to know if liposuction on my inner thighs will tighten them or make them even more saggy. I want some fat removed but I don’t want to make them look worse.
A: The inner thighs, although not a big area, represent a challenge for satisfying liposuction results. The quality of skin in the inner thighs is typically not good in that it has poor elasticity. This translates into a very limited ability to contract which is a critical factor needed to get good liposuction outcomes. As a result, liposuction of the inner thighs does not tighten the skin and in some cases may even make it look worse.While liposuction can help slim down the inner thighs, it is an area that is notorious for irregularities and unevenness. This is because the skin in this area does not shrink or tighten well after it is deflated by fat removal. It is also an area that is very difficult to get smooth results because it is a curved structure rather than a flat surface. While everyone's skin elasticity is different, your description of your inner thighs does not sound very favorable for good skin contraction after liposuction. This does not mean that you should not have it but that a conservative approach should be done with expected modest changes. You may want to consider liposuction combined with an inner thigh lift. That is a great way to hedge against the risks of loose and irregular skin by treating the skin problem at the same time.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I suffer from migraine at my right temple and rarely at the left. Because medicines never helped me, I had a surgery in last August,. The surgeon cauterized many arteries of mine. My quality of life improved but I still have pain at the same places, though less severe in general. Months before the surgery, I had tried Botox (injected by a neurologist) and it did not help at all. Will the auricular-temporal decompression surgery help me? I appreciate your attention to my concerns.
A: With temporal migraines, the question is whether zygomaticotemporal and/or supraorbital nerve decompression would be helpful. A good diagnostic test would be Botox injections. Just because you have had Botox and had no benefit does not mean that the injections were placed in the proper locations. I have seen many Botox injections done by neurologists and other doctors that were not properly placed. They must be placed in the exact location of the course of the nerve to work. If effective, then these nerve decompressions could be very helpful.
I would not expect auriculotemporal nerve decompression/avulsion to be helpful based on the information provided. It rarely when done alone can produce significant migraine symptom improvement. If one is going to surgery, it would be best to do multiple nerve decompressions including the zygomaticotemporal, supraorbital and auriculotemporal nerves at the same time. This would be most likely to produce migraine intensity and frequency improvement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, my son was born with a bilateral cleft lip and palate. He just turned 9 years old. He is about to get his bone graft surgery in December. What is too early to have nose reconstruction? The surgeons said he would rather not touch his nose until he is age 15 or 16.
A: The nose deformity in bilateral cleft lip and palate is uniquely different from even that of a unilateral cleft. The lack of columellar skin and weak and short tip cartilages poses a significant reconstructive challenge that is present at any age that a patient undergoes any form of a rhinoplasty.
It is best to think of the nose reconstruction in bilateral clefts as done in stages. There are many variations as to how it is approached and will vary by surgeon. Fundamentally, it is divided into stages based on age and development. Under 12 years of age, the focus is on columellar lengthening, nostril narrowing and/or tip cartilage manipulation. After the age of 12, a full septorhinoplasty is done where the entire nose is reconstructed from the nasal bones down to the tip cartilages including the septal and turbinate deformity. At what age this full septorhinoplasty is done is open to debate but most plastic surgeons think more around the age of 14 or 15 years old when the face is essentially fully developed. There may be some modifications to this age based on the extent of the nasal deformity and the timing of orthognathic surgery (LeFort osteotomy) if needed.
In short, major manipulations of the septum and nasal bones should not be done under the face is more fully developed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I got breast implants one year ago an am not happy with the size. They are too big. They are only 175cc but they are just too big for me. In exchanging the implants to something smaller, I am not sure what size implant to change to In reading around online, there is much discussion about the base width diameter of the implant like its the holy grail, even though, interestingly, opinions diverge. Some say stay the same implant diameter and no larger, a bit larger, can be smaller by up to one cm, thin women should have smaller, and on and on…. so no hard-and-fast-rule it seems. But 8.2 cm (diameter of smallest available 100cc implants) to my 10.5/11cm change does seem a lot, if base width diameter is typically a consideration that you guys seem to have strong opinions on. I recognize that results are harder to pin down than one might wish, but why do you think that’s better than 130’s with a 10cm diameter, or 125 mod-plus with a 8.9cm diameter, in my case? Related to that, do you think that a lower diameter will diminish the lateral projection that I do not like? Do you think that a similar or slightly smaller diameter than my current 175’s, even if the ccs are lower, will leave me with the same lateral projection “issue”?
A: When the fear from the initial implant is that is was too big, you want to make sure you don’t repeat the same problem. Given that the initial implants were only 175cc and the lowest selection is 100cc, you want to make sure you never say I didn’t go low enough. Thus choosing 100cc implants eliminates that possible outcome.
Implant base width diameter has merit but its biggest contribution in my opinion is in the initial breast augmentation when it is important to not exceed the natural width of the breast so the implants do not get too far to the sides. Once a pocket is established and the implant replacements are going down in size, that issue does not become that important anymore. For you, however, with a fear of too much projection you need to get the flattest and broadest implant base. possible…spread whatever volume there is over a wide base. But the decrease in based width diameter of a 100cc implant may also help the problem of too much lateral projection as well.
Dr. Barry Eppley
Indianapolis, Indiana
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Q: Dr. Eppley, I got breast implants one year ago an am not happy with the size. They are too big. They are only 175cc but they are just too big for me. In exchanging the implants to something smaller, I am not sure what size implant to change to In reading around online, there is much discussion about the base width diameter of the implant like its the holy grail, even though, interestingly, opinions diverge. Some say stay the same implant diameter and no larger, a bit larger, can be smaller by up to one cm, thin women should have smaller, and on and on…. so no hard-and-fast-rule it seems. But 8.2 cm (diameter of smallest available 100cc implants) to my 10.5/11cm change does seem a lot, if base width diameter is typically a consideration that you guys seem to have strong opinions on. I recognize that results are harder to pin down than one might wish, but why do you think that’s better than 130’s with a 10cm diameter, or 125 mod-plus with a 8.9cm diameter, in my case? Related to that, do you think that a lower diameter will diminish the lateral projection that I do not like? Do you think that a similar or slightly smaller diameter than my current 175’s, even if the ccs are lower, will leave me with the same lateral projection “issue”?
A: When the fear from the initial implant is that is was too big, you want to make sure you don’t repeat the same problem. Given that the initial implants were only 175cc and the lowest selection is 100cc, you want to make sure you never say I didn’t go low enough. Thus choosing 100cc implants eliminates that possible outcome.
Implant base width diameter has merit but its biggest contribution in my opinion is in the initial breast augmentation when it is important to not exceed the natural width of the breast so the implants do not get too far to the sides. Once a pocket is established and the implant replacements are going down in size, that issue does not become that important anymore. For you, however, with a fear of too much projection you need to get the flattest and broadest implant base. possible…spread whatever volume there is over a wide base. But the decrease in based width diameter of a 100cc implant may also help the problem of too much lateral projection as well.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I took my son to the Children’s Hospital to assess his deformational plagiocephaly and they told me that they would not address my son's skull deformity since it was not negatively impacting his facial features. They described the procedure as extremely painful and invasive. Where can I find more information describing the pros and cons of this procedure. I would also like to know more about the procedure itself in terms of surgery and recovery. Any information would be greatly appreciated. My son has a pretty severe flattening on the right posterior of his head. My pediatrician convinced me that helmeting was the wrong decision and his condition would improve over time. At this point, I regret listening to the pediatrician and am looking for solutions for my son.
A: What they were saying at the Children's Hospital is that major cranial remodeling surgery is not justified for a cosmetic skull deformity. That is certainly true, particularly if your son is older than 18 to 24 months old. An alternative treatment option is to build out the flattened occipital area with onlay hydroxyapatite cements. That may be able to be done in some cases with an injection technique or a small incision. This is a far simpler approach to major cranial bone reshaping and the risk:benefit ratio is much more favorable. Whether the magnitude of the occipital skull deformity justifies an onlay craniopasty procedure depends on many factors, most of which is the emotional concern of the parent about the shape of their child's skull.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am writing to you because you are an expert with osseous genioplasty and maybe you can help me. I had a sliding genioplasty 7 months ago. But after the surgery one little piece of bone was missing at the site of the osteotomy. Also I had asymmetry. So the result was ok except for the noticeable notching effect and asymmetry. So yesterday I had HA injection to make it look better and the results are great. But now I am wondering can this HA interact with the titanium plates I have? Maybe it can be dangerous? Also, can this HA interact with the bony remodeling which might not be completely complete? What do you think? Thank you very much for your help.
A: Notching along the inferior border of the mandible at the back end of a genioplasty is very common, particularly when a significant horizontal advancement is done. The injection of HA into the notch areas is a perfect treatment for this secondary genioplasty deformity. It has no negative interaction with the indwelling titanium plates and screws. Filling in the bone defects will not change any residual bone remodeling and may, in fact, help the process.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, After breast feeding, my breasts are less than perfect. My confidence has drastically decreased. I'm in incredible shape but my breasts are just mush. What kind of breast procedure do I need, augmentation or a lift?
A: For many women, the decision between needing an implant or a lift is very straightforward. Breast sagging after childbirth may be improved by implants if there is not too much loose skin and the nipples do not hang below the lower breast fold. If there is significant breast sagging then a combined implant and lift will be needed. It would be very rare to get a breast lift alone unless you already have substantial breast tissue volume. Having breasts described as ‘mush’ indicates a significant loss of breast tissue so some amount of volume through the use of implants is needed. With enough added volume, the loose skin may be adequately filled out and the nipple will sit in a good position. But if there is too much loose skin and the nipple sits even a little bit too low beforehand, the implants will not lift the nipple upward enough and some form of a breast lift will be needed.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I have breast implants placed in 2008 but I want to replace them and go smaller. Right now I have Mentor smooth round gel breast implants that are 500 each. I am a full D cup size. I prefer to be a C. I am 5'4” and weigh 127 lbs. I really don't know how the cc's translate to actual size. I imagine 350 to 375 each would be better though. I explained at the time of my surgery that I thought they were too big but the doctor encouraged me to wait. I've waited and still feel they are too big and do not want to return to the same surgeon.
A: When considering changing breast implant size, it is important to look at volumetric or percentage changes. As a general rule to drop a full cup size, one should drop volume by at least 30% or more. Thus having 500cc implants, your perception of changing volume down to 350cc is spot on. This represents a change of 150cc or 30% in volume. This will make a perceptible change in breast size. It will not decrease the width of the breasts much but will decrease projection. The good news about replacing existing breast implants is that it is a lot easier than the first time. With an existing pocket and the muscle already elevated, the postoperative pain and recovery is minimal…a far cry from the first surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a bulging blood vessel on the right side of my forehead. I have been told that it is an artery from a dermatologist and a vascular surgeon because it has a pulse in it. I want to get it tied off because it really sticks out and sometimes feels uncomfortable. How is this procedure done and roughly what percentage would you say were completely happy with the results versus some improvement versus not happy at all with the outcome? I would like to get an idea of what scarring can be expected. Any potential side effects specific to this procedure other than scarring? Read somewhere about a pretty important nerve that hangs around this artery, obviously you would avoid this, but what are the chances of any problems?
A: Ligation or tieing off of a prominent vessel in the forehead can be done to reduce its prominence. This happens because the flow through the vessel is cut off. The surgical approach for arterial ligation to a prominent forehead vessel is done through a small incision inside the temporal hairline (to get the anterior superficial temporal take-off from the main trunk of the superficial temporal artery) and a very small incision on the forehead where the most distal end of the branch can be seen. In rare cases, a third nick incision is needed in the forehead if there is an additional feeding branch) These are very small incisions and scarring is not usually a concern. The nerve to which you refer is the auriculotemporal nerve which is a sensory nerve that only supplies feeling to the temporal region. It is not an important nerve in that it is not a motor nerve responsible for facial movement. That nerve is identified and preserved as the dissection is done in the temporal region while searching for the anterior superficial temporal artery branch. The primary risks of the procedure is how well it works, reduction vs elimination of the visible artery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, my son is 2 yrs old with mild to moderate plagiocephaly. One side of his head is noticeably flat on the back. I’ve read on here about the procedures available to fix this, in particular the cement injections. My question is if we decide to do this now at his age will the material expand with his head growth or will the procedure have to be done every so often throughout his life until his head reaches its final size? Thank you
A: The application of a calcium phosphate cement to the outside of the bone, known as an onlay cranioplasty, builds out the contour of the bone. It does not influence the growth of the skull in anyway. It allows it to grow as it normally would, albeit in its misshapen form. Knowing that non-synostotic occipital plagiocephalies do not display progression of the deformity, it is safe to assume that an altered/improved occipital shape achieved at a young age would be relatively stable as they grow. I would not envision that a periodic addition of material would be needed until the child reaches skeletal maturity. The skull grows by resorbing bone on its inside and adding it to the outside. When done at age two, I would imagine that much of the added material would be incorporated into the bone as the child grows.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a tummy tuck three weeks. I had my drained pulled after 8 days and I developed a fluid collection right after. My doctor removed the fluid by needle twice and the third time today there was no longer any fluid. Since I had no fluid today and I don't have to come see my doctor until another six weeks can I go ahead and start exercising?
A: Given that you have an abdominal seroma after your tummy tuck, I would wait another week before you should start exercising again. Even though your recent tap was negative (empty), that does not mean you may still not build up a little fluid. The most assured way to make that happen is get very active. Strenuous activity increases lymphatic flow to the tummy tuck area which could cause more fluid to build up again. Give your body another week to heal and not show any evidence of further fluid buildup before ‘stressing’ the competency of the sealed lymphatics at the surgery site.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I suffer from a congenital malformation of the face and skull. The shape of my face and my head is too skinny and started with me this problem since I was 15 years old. I am now age 29 years old and I want a solution to my problem. But before that I want to know the answers to the following questions:
1. Is it possible to find a surgical solution to my problem?
2. In the case of the possibility of surgery, you could be a final solution?
3. Can surgery be done through the addition of natural bones?
4. How serious is the surgery and what is the success rate?
5. How long will I need to heal, and to engage in normal life?
6. What will be the cost of surgery?
A: I would be happy to answer all of your questions but I will first need to see some pictures of your head for any assessment. It would be impossible to give an opinion without first seeing what the exact problem is. But what I can tell you without even seeing your skull problem is any correction can not be done by using bone grafts or natural bone. They will simple melt away and be absorbed. Skull surgery requires an incision across the top of the head so this is a trade-off you must be willing to accept. Most patients have full recovery after skull reshaping in just a few weeks.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 40 year-old male and my eyebrows are bothering me. I have read that they can be lifted by opening the the upper eyelid and putting in some device to lift them. I know that this procedure does not lift much however. Do you think that it can resolve my problem or do you have another suggestion for me. Please find me some solution to lift my brows. Perhaps a mid-forehead lift will lift my brows and then you can even take the excess skin that I have in my forehead out. I have two very deep long wrinkles in my forehead that you can use. I know that there will be scars even inside the wrinkles but we can not have something without scars so I am willing to correct a problem that is bothering me and accept scars that I can treat later with laser. Or you can do the direct brow lift by making a scar right above each brow. Please I want to lift those brows so there has got to be some way to do it for me.
A: As for browlifting in young men, there is never a completely satisfactory solution. The endotine device to which you refer lifts the male brow slightly but does not nothing for the rest of the forehead or wrinkles. Whether the amount of lifting that can be achieved, which is just the middle to outer brow area, is enough show be considered carefully before surgery. No scar across the forehead would ever be acceptable in any male but an older one who already has deep horizontal forehead wrinkles. A mid-forehead or direct browlift is a major concern in younger men where the trade-offs for doing something are worse than the original problem. Male browlifting is a challenging issue, particularly in the younger patient. The endotine device approach through the upper eyelid is the only browlift option I would consider at your age.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I developed an infection after getting with jaw implants. I had them taken out right away. However after the surgery my incision is having a hard time closing and I was able to express some pus from the area about 0.1 cc. The abscess from the previous infection is not back but it appears to be not healing well. I think it might be related to the closure as the mucosal remnant next to the teeth was narrower than 1cm that you try to keep when you make the incision. Or it could be that the original infection caused that mucosa to shrink a little bit. What do you do in this situation?
Also I was wondering what you find are some of the common reasons for one to get the jaw implants infected.
A: What you have is contracted or inverted mucosal edges which lead to of fluid and food debris trap as it struggles to heal. If this is a chronic problem of months then I would excise and reclose the wound in layers. If if just weeks or a month old, I would give it more time. Most of these wounds will heal but it is slower when you have a previous underlying implant pocket.
Having done a lot of jaw angle implants with every conceivable implant option, I have learned the following about the risk of infection and how to prevent it.
- Good wound closure is paramount, a two-layer closure with muscle reapposition over the implant and then a good water-tight mucosal closure. This starts with an incision placed away from the vestibular tissues so you have good tissue on both sides of the wound to close.
- Medpor implants have a higher infectivity risk than silicone due to its porous material. Pre-soaking, vacuum infiltration and antibiotic irrigation must be done.
- Avoid using the final implant as the sizer and developer of the pocket. Use the manufacturer’s sizers for this process during surgery. That way you grab and insert the final implant but one time through the mouth, a so-called minimal implant handling technique.
- Implant stability is really important but most paramount for silicone jaw angle implants. Their smooth surface makes them predisposed to being displaced after wound closure and working their back toward whence they came…getting near the incision and even work its anterior edge through it in some cases. I always use screw fixation with jaw angle implants, most easily done through a percutaneous approacsh using 1.5mm self-tapping screws.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I wrote you before to inquire about a Skull reshaping using implants. I saw the archive “Cranioplasty Category” in your web site which shows the case were a 42 year old male was operate, and an implant was inserted in the back of his skull (occipital) in order to lengthen and correct a deformity, in this case a flat spot area. I must to say that it is a great job.
I have a similar problem, although it is not exactly like the example posted, in my case the flat spot is less notorious, but the overall profile of my skull is short. Moreover the rear of my skull is slightly above the level of the forehead. I think its because of some postural plagiocephaly caused when I was a baby.
I have some questions I want to ask you.
1) How much my scalp could be elongated in the back of my skull and the final appearance would look natural?
2) Would there be a very visible scar ?
3) Would I have to shave my head for the operation?
4) There is a risk that no hair grows up in the area of the implant ? cause i´m not bald
5) How long would I be hospitalized before and after the process?
I want to have the shape of the occipital area more pronounced. in order to have a more symmetrical shape of my skull. I know it´s difficult to answer my questions without seeing any images, So I could send you pictures of my two profiles to have a better idea.
A: In answer to your questions:
- A s a general rule, the skull can be expanded 10 to 15mm across the back without making scalp closure to tight or precarious for good wound healing.
- All forms of craniplasty require access through an incision. It heals as a fine line but there is a scar nonetheless. That needs to be taken into account when considering a cosmetic skull procedure.
- We do not shave any hair for cranioplasties. It is easier for the surgery if a patient did shave their head but we do not do it if the patient does not want to.
- The only risk of any hair loss is at the scar, not in the raised scalp flaps.
- This is usually done as an outpatient procedure in a surgery center, not a hospital.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had an endoscopic brow lift 2 years ago. It was pulled far too high and has formed what I can only describe as crater-like vertical depressions. This is so strange looking. I was so much better before with my normal horizontal thin lines. Is there anything that can fix this….is a reverse brow lift successful….could fillers wk….or hair transplant to cover the high long forehead?
A: One of the trade-offs for an endoscopic browlift is a longer forehead because this type of browlifting procedure is really an epicranial shift…it moves the scalp backwards to create the browlift below. The length of a patient’s forehead must be assessed beforehand and this effect considered when choosing any type of browlift.
The vertical depressions that you have are the effect of the internal fixation technique used to secure the uplifted scalp near or in the hairline. They are reflective of a really pulled up scalp and perhaps too aggressive browlift.
In terms of improvement, endoscopic browlifts can be partially reversed by the same method that caused the initial effects. Wide forehead and scalp loosening done through the same incisions as the initial operation may allow some reshifting of the tissues back to less stretched look. This may provide some improvement in the vertical depressions and partial lowering of the hairline. Fillers and hair transplants are also options to deal with the problems you now have but I would first try and treat the cause of the problem before exclusively treating the symptoms of the problem first. Those are always options if tissue loosening and reshifting is not entirely successful.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like information on liposuction and butt augmentation. I would like information on estimated cost and recovery time. Thanks I hope to hear from you soon.
A: Thank you for your inquiry. The questions you have asked are broad with different options and make your questions impossible to answer without being very procedure specific. I would need to know more specifics about what exact liposuction and buttock augmentation procedures you desire.
1) What areas of fat removal by liposuction are you seeking? How many different body areas?
2) For buttock augmentation, is it by implants or fat injections?
This information is vital because much of the costs of surgery are based on the time that it takes to do them. For the sake of the most common method of buttock augmentation, which is fat injections from abdominal and flank liposuction harvests (aka the Brazilian Butt Lift), I will have my assistant pass along some costs to you later today for this approach. Those costs will range between $6500 and $8500 depending on how much liposuction is done/needed. This combination has the dual advantage of contouring multiple body areas by reduction of body areas around the buttocks which makes any buttock size increase look even better. Depending on the type of work that you do, I would anticipate a minimum of 10 to 14 days until you get comfortably back to most normal activities of daily living.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have been reading for quite some time on your website and I found a lot of terrific information. I am looking for what you describe as the “Male Model Look”. Could you please tell by the enclosed photos what procedures you would suggest for my face in order to achieve this look. I have been reading about jaw angle, jaw, implants and cheek implants but would like to know what you suggest for my particular face. What else would you suggest? I am 38 years old. I have already had my ears pinned one month ago. Could you also do a custom facial imaging so that I have an idea how I will look (more or less).
A: Thank you for your inquiry. The so called Male Model Look is really about accentuating some or all of the skeletal highlights of the face. These include the brow bones, nose, cheeks, chin and jaw angles/jawline. One has to not have too thick of facial soft tissues to see the effects of the augmentations. When analyzing your face, you have the right amount of soft tissue cover to show these effects well. You are most deficient in the jawline area (chin and jaw angles) and secondarily in the cheeks. For starters, I have just focused on these three areas as you can see in the attached computer imaging. There would be the 'best value' procedures for your face. The only other thought would be some nasal thinning in the tip area. (but I have not done that so you can focus on the more important areas for now)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am at wits end. 🙁 I had goretex implants in nasal-labial folds about 12 yrs ago. They capsulated shortly after and I looked hideous. So I've been filling around them for years even had a face lift. Finally, about 6 months ago I had them removed and replaced with Alloderm.. It looks worse!!! One side is hard and they both show thru the skin. The company will not give me info. Can they be successfully removed??? Today, I am having Ultherapy in hopes of tightening to minimize the awful protrusions.:((I used to be a model and now I can't even look in a mirror)
A: I see no problem with easily removing Alloderm. It does not usually incorporate much into the surrounding tissues. It gets encapsulated, almost like your original Gore-tex implants, which is why it contracted and became distorted. In hindsight, that probably was not the best choice for a replacement for the Gore-tex as it did exactly what could have been predicted in that situation. I would not expect Ultherapy to make any difference. That approach is a hopeful but flawed concept. A much better replacement once they are removed would be dermal-fat grafts or fat injections, a natural tissue that will heal into the surrounding tissues adding volume and will not develop contractures.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am getting quotes and suggestions on liposuction and a breast lift. I already have implants but looking to go smaller and I'm up in the air on replacing them, removing, or keeping the ones I've got. I've have breastfed 4 children and also need a lift and full contouring. What are your prices and are you running any promotions?
A: Unfortunately based on the information that you have given me I can not be of much help to you. It is impossible to give reasonably accurate pricing when you don’t really know what the patient needs. Liposuction can be done on 12 different areas of the body, there are four different types of breast lifts and two types of breast implant options. That leaves a tremendous number of variables to consider all of which take differing amounts of time and effort needed to do the surgery…and that hugely impacts cost. The best way to figure out what you may need is to either see some pictures of your concerns or give me a very specific set of procedures that you want to do. I suspect you need at least a full breast lift but knowing what to do with your indwelling implants is a very important consideration. Remember that when you do a breast lift, the actual size of the breast gets smaller. Taking out indwelling implants with any degree of sagging will leave you with very flat breasts despite the fact that they may be in much better position higher up on your chest after a lift. When it comes liposuction, I suspect you may be focused on your abdomen and waistline. But whether that would be an effective contouring technique in someone who has had four pregnancies with likely loose skin and stretch marks is an issue yet undecided.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a combined breast lift with implants nearly 5 days ago. My recovery is going well I think, however, the appearance of my breasts concerns me. I've attached two photos (front & side view). My concern is that my breasts are oblong with a definite, large “indentation” above the nipple. In the photos, you see the implant sitting high, then a big indentation above what, I think, is my own breast tissue below. This seems abnormal to me. My breast shape looks kind of like an eggplant. Is this a cause for concern?
A: When undergoing a combined breast implant and lift for severe breast sagging, the early appearance can be disturbing. This is because the implants often ride early and in conjunction with swelling can push the breast tissue forward and down. This creates the exact appearance that you are seeing. It is important to remember that it is early and many changes will take place. One of those is that the implants will drop. This can be helped by wearing a breast band to encourage the implants to move south into the bottom that has been created for them. Putting gentle sustained pressure on the upper pole of the breasts will help the bottom tissues to expand and allow the implants to drop. It will take 6 to 8 weeks before you have a clear idea as to how much dropping they are going to do. They will definitely drop, it is just a matter of how much. Once that happens the breast tissue in front of them will move up into a better position on the implants.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 28 year old male. I would like to have Restylane injected under my eyes in order to reduce the appearance of my eye bags/dark circles. Is this something that you would do often at your clinic? Am I a suitable candidate? I would also like to increase the definition of my jawline/chin. Have you ever made a more male, square, enhanced jawline/chin by using fillers alone, such as Radiesse? Or would I need to get jaw and chin implants? Do you do this procedure often? I don't like the way there is a slight double chin at certain angles, as you can see in the photo, would fillers get rid of this or would I need a chin implant? The last three photos are of jawlines that I would like mine to be more like.
A: When you look at all of your facial issues combined, they have a similar theme…an underlying bone deficiency. In the words, you are structurally weak. This is particularly relevant in the lower eyelid area where the problem is a recessed infra-orbital rim and cheek bones. That is why you have this appearance at such a young age. The chin and jawline issue is not as weak as it is just your desire for a much stronger one.
As for injectable fillers, they are a poor treatment for the under the eye area and are absolutely a contraindicated treatment for the chin and jawline. While injecting Restylane under the eyes can be done, I have never been that impressed with its results for your particular problem and it is only a temporary fix at best. Irregularities are very common in this area with injectable treatments that will persist as long as the filler lasts. You would be much better served by a combined infra-orbital/malar implants in this area which would correct the entire problem from the rim to the cheek and be permanent. From a jawline perspective, every young male shows me male model/actor pictures just like the ones you have shown. Those type of results are only obtainable with chin and jaw angle implants, ideally custom made ones that connect the chin and jaw angles in one smooth line.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am 35 years old and am 5’ 4” and weight 138 lbs. I had my last child one year ago and am back to my prepregnancy weight but can’t get rid of this loose tummy skin and fat. I went to a plastic surgery consultation and, in addition to a tummy tuck, was told that I needed liposuction as well. Do I really need to get liposuction on my love handles with my tummy tuck to get the best result? Since I am going for surgery I want the best result. I'm pretty happy with my general size, I just want to be firmer and smaller around my stomach.
A: It is a common misconception as to how far the effects of a tummy tuck reach. The main effect of a tummy tuck is seen between the hip points, it is essentially a 180 degree procedure of the trunk.. One must remember that waistline reshaping is closer to a 270 or 300 degree procedure. To extend the benefits of a tummy tuck, whose tissue excision and scar stops at the hips, fat removal by liposuction must be done to continue the narrowing benefit around the corner of the hips and into the back. This liposuction effects what most people call the love handles or the flanks. This not only flattens or indents the love handles but also decreases the risk of dogears or fullness at the ends of the tummy tuck incisions. I would estimate that about 2/3s of abdominal reshaping patients in my practice need the combined tummy tuck and flank liposuction procedures for the best result.
Dr. Barry Eppley
Indianapolis,Indiana
