Your Questions

Q: Dr. Eppley, I had upper and lower eyelid surgery and a muscle needed to be stitched in my eyebrow where a cut injury once existed. I have just had Botox for frown lines. The doctor (different doctor) hurt me when injecting into that muscle. Within a few hours my eyelid is heavy, dropped eyebrow and when I raise my cheek in a winking jesture the whole of my cheek quivers very badly. Will the effect of the Botox go away and the lid raise? Does this sound permanent? Has the muscle been damaged by the Botox as it was scared tissue and stitched in 2008 in order to raise the eyelid? I would be so comforted by your response as I need reassurance before i return to my doctor for correction.

A: The workings of Botox is based on two fundamental principles, it affects the neuromuscular junction of the muscle causing weakness or paralysis and its effects are TEMPORARY. The biggest advantage and disadvantage to Botox is that its effects are not permanent. Patients who get good results with its use wish it was permanent while few patients who develop an undesired aesthetic effect are happy that it is only temporary. In addition, Botox has no adverse effect on long-term muscle function regardless of whether it has had prior surgery on it or not.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting my forehead reduced, now I know there’s only a certain point your eyebrow ridge can be reduced but how about the glabella and the upper third part close to your hairline? Also I would like my hairline lowered but was wondering If the price would be combined all into one or do I have to pay separately and how much do you think it will cost me about?

A: When one uses the term ‘forehead reduction’ that could mean a vertical skin distance reduction by hairline/scalp advancement, reduction of forehead/brow bone bossing or a combination of both. The hairline incision needed for advancing the scalp forward can also be used for frontal bone recontouring as well. The forehead bone including the glabellar area can be burred down. How much it can be reduced would depend on the bone thickness and the location of the underlying frontal sinus. Some people have frontal sinuses that cross between the eyebrows and other have a separate sinus-free zone in the glabellar area. A simple frontal and lateral skull x-ray will show the location of the frontal sinus and the thickness of the frontal bone. This will show how much bone reduction can be done in these areas. One could expect to pay in total surgical costs around $ 6500 to $8500 for a combined hairline advancement and frontal bone recontouring.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 24 year-old man who is interested in getting cheek implants for a more chiseled look. I guess some call it the male model look. Whatever it is called, I just want higher and prominent cheekbones. What are the risks of cheek implant surgery? I know there is the risk of infection but the onke that I am most concerned about is nerve damage. How likely is the risk of paralysis or nerve damage? 

A: Like all facial implants, there are some general risks such as infection but each implantation site has its own unique set of considerations. For cheek implants, the most common aesthetic risks are asymmetry because they are usually done as a pair. While it seems easy to place two symmetrical implants, because one is doing the exact same thing on both sides, the results are not always perfectly symmetric however. The other aesthetic risk is obtaining the patient’s exact aesthetic result. The cheeks are a unique three-dimensional structure that defies an exact quantitative method to determine the amount of augmentation needed in all dimensions. The implant style selection and size is purely an art form with little exact science behind it. When you factor in the unique underlying bone structure of each patient’s face, it is easy to see why achieving the ‘male model look’ cheek augmentation result is not always easy or assured. When it comes to the risk of nerve injury, you are referring to the infraorbital nerve. This is a sensory (feeling) and not a motor (moving) nerve. So the risk is one of temporary vs permanent loss of feeling in the upper lip and side of the nose. Fortunately, the infraorbital nerve is big and easily visualized during surgery so the risk of cutting it is virtually zero, thus permanent loss of feeling is very unlikely. Most patients will have some temporary numbness due to exposing the nerve with traction on it but this is rarely ever permanent. The surgeon must be very careful during cheek implant placement to not have the implant impinge on the nerve as this is often a likely source of persistent nerve numbness and pain after surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Do you do the pinch blepharoplasty? I only need skin tightened under my eyes and don’t have bags so I don’t think I would need fat removed. I read about the pinch procedure and it sound like what I would like to do because it seems fairly simple and less invasive.

A:That is a lower eyelid procedure that I do all the time. As long as one does have significant bags, this can be a good lower eyelid tightening procedure that often is combined with either a chemical peel (25% or 35% TCA) or light laser resurfacing to get the best results. You are correct in your assumption that recovery is very quick. This is because the lower eyelid skin is not undermined and a skin-muscle flap is not raised. It can be an ideal procedure for the younger patient who has a small skin excess of the lower lid or an older patient who may have had a prior lower blepharoplasty and just needs a touch-up or some additional skin removal. The pinch lower blepharoplasty is often combined with a transconjunctival approach to fat removal to create a dual effect when one has bags but little skin excess of the lower eyelids.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a lower face lift done along with neck liposuction. The doctor did a skin only lift and pulled it to the side and incisions were made by ears and in back of  hairline. He redid 4 months later because it was not correct. It is better but I think my cheeks need pulled up, more like a vertical lift. I feel like my cheeks are hanging down by bottom of face. I have already invested $8,000 into this and wondered if I could now just have some vertical pull in cheek area?

A: A facelift (aka neck-jowl lift) never changes or rejuvenates the cheek area on its own in most cases unless a more extensive procedure was done. A neck-jowl lift moves sagging tissues obliquely back towards the ear while sagging cheeks require a more vertical lift as you are aware. However, in looking at your pictures I can not see a great benefit for such a procedure in you. A cheek or midface lift is a very technique-sensitive procedure to do since it often involves incisions along the lower eyelid and there is always the risk of lower eyelid malposition/sagging afterwards. Therefore, one should have a compelling reason to do the procedure. Cheek lifts can also be done endoscopically with a combined incision in the mouth and in the temples in more mild cheek sagging cases.

Dr. Barry Eppley

Indianapolis, Indiana

Dr. Eppley, I want to undergo chin implant along with lip reduction . I have some doubt in my mind if the result of the chin implant is permanent and will last for the whole life of a person. Also, I do wrestling . Does it not affect the implant if there is a injury to the chin? If there is a problem will I have to visit the  plastic surgeon or can it be handled by normal doctor?

A: The chin implant is permanent and will never dissolve or degrade it anyway. The position of the chin implant is fairly assured because I secure it to the bone with screws. In young men who participate in sports, I make it a point of emphasis to screw the implant to the bone in multiple places. In the rare event of a chin implant problem due to trauma, a regular doctor will not be of much help. You need to see a plastic surgeon who is familiar with chin implants.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I am currently looking for doctors who have experience with and are willing to place larger saline implants (900-1600cc overfilled). Please let me know if you are experienced in working with larger sizes, what the largest sizes you’ve worked with are, what your technique entails and if you have any example photo.

A:  As you may know, the largest saline breast implant that is manufactured for U.S. use is an 800cc implant. If you follow the manufacturer’s recommended fill volumes, the maximum fill should be 960cc. That is a fill volume established by the manufacturer based on the long-term tolerances of the silicone shell. I have filled 800cc implants up to 1200cc. At that point they start to become very hard due to the pressure of saline and the stretch of the implant shell. I would not recommend going any bigger than that given the high risk of shell rupture. It is important that you understand that anything beyond a 960cc fill volume would also nullify any warranty from the manufacturer once you exceed their FDA-approved fill volume.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 5’9” weigh 146 pounds and am a 36D. I had breast implants that were placed three years ago and were 500cc moderate silicone gel implants. Although I like the size, they look flat to me. My breasts are very wide and require a push up bra, otherwise they look flat in my shirt. They have given me reasonable cleavage but they are just so flat. What is the best way to improve their shape? What type of new implant do I need?

A: Moderate projection/profile implants have the  lowest projection and widest base of any of the breast implants. Because they are so wide, I actually never use in my breast augmentation patients. Changing breast implants to a more narrow base with higher projection seems logical. It would also be important to go up in volume somewhat so you get more outer and upward push of the breast mound. Therefore I would change to a high projection implant with a volume of 600ccs. This will provide more upper pole fullness and may even narrow your existing width somewhat. With your body frame, a 600cc implant would not be much bigger than your existing breasts…just more towards the shape you want.    

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, my left calf muscle is 2 to 3 inches smaller than my right. I do have muscle in my leg but it just will not enlarge with exercise. I am interested in getting calf implants. I was wondering how long I would need to stay after surgery.

A: Calf augmentation is done as an outpatient procedure. You could go home the same day, but if you live far away, you consider going home the next day.
A calf implant will help the size of the smaller calf but will not be able to make it match identically to the opposite normal side in shape or circumferential measurement. The tightness of the skin is the limiting factor in congenital calf asymmetry, the most challenging use of calf implants. In an ideal world congenital calf deficiency would be treated by a two-stage approach, a first-stage fat injection augmentation followed three months later by the placement of a calf implant. This is the ideal approach because the fat injections and the associated stem cells in it allows for some soft tissue expansion and a thicker soft tissue bed to ultimately receive the implant. But because of cost considerations, most patients have to go immediately for the implant.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I currently have breast implants which are inflated to 1200 cc’s. On the Purlz website there are references to 2000 cc implants and I am wondering if that is something which you actually do, since I am looking for extra-large implants near 2000 cc’s. In the seven years since my last surgery my skin has stretched enough that I think 2000 cc’s might be able to be achieved. Please reply with any information that you might be able to provide. Also, I am wondering if the sizers on the Purlz website fit nicely over breasts with existing implants? Thanks for your help.

A: I believe that you are confused about the Purlz products. These are breast implant sizers, not implantable breast implants. The only three manufacturers of FDA-approved breast implants for human implantation are Mentor, Allergan and Sientra. Only Mentor and Allergan offer saline breast implants that can be overfilled at the plastic surgeon’s discretion. Purlz offers presurgical sizers to be inserted over one’s breasts in a bra to help with surgical decision making about breast implant size for eventual surgery. They can not be used to be implanted either alone or over one’s existing breast implants.

Currently, the largest FDA-approved saline breast implant sizes are 800cc which are recommended from the manufacturers to have a maximal fill of 960cc. They can be inflated to more than that and around 1200cc , as you have, is around the maximum fill after which they get unnaturally very firm. Outside the U.S. larger saline breast implant sizes exist and are used but those devices are illegal to import into this country for use. The breast implant manufacturers are working on bringing larger breast implant sizes to the market but I could not tell you when that may be in the future.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 35 year-old transgendered woman who is interested in more of a feminine face. I do believe that my jawline and chin is what needs to be changed and would be the most beneficial to me. I have been living full-time as a woman since my gender transition eight years ago. At this time, other than having two teeth extracted and dental work, I have no other facial surgery or injuries. As a woman, I do have occasional passability problems. I feel that my face currently absolutely needs improvement and will boost my self-esteem and self-worth.

A: In looking at your pictures, I do agree that your jawline from the chin back to the jaw angles, is the most masculine appearing part of your face. Softening your jawline would be a beneficial step towards your aesthetic facial goals and is a potential part of many facial feminization surgeries. Reducing the entire jawline is never as easy as making it bigger but there are procedures that can help your its prominence. The jawline angle can be reduced by angular ostectomies where the sharpness and prominence of the angles are reduced along with some width reduction. This is done through an intraoral approach where a saw is used to removed the bony jaw angles (makes them less square) and taking the outer cortex of the mandibular ramus to make it thinner as well. Your chin needs to be vertically reduced and narrowed combined with lateral prejowl ostectomies to make the whole front part of the jaw more narrow. This also is done from inside the mouth where the chin bone is downfractured, shortened and narrowed and put back together. Then behind the chin osteotomy the body of the jaw is then narrowed by outer corticotomies. I have attached some predictive imaging of those potential jawline reduction results.

Dr. Barry Eppley

Q: Dr. Eppley, I would like a consultation for a breast augmentation. I have pectus excavatum and didn’t realize this until early adulthood. At this point in my life I would prefer cosmetic surgery as opposed to a more invasive surgery to correct my deformity.
Thank you and I look forward to hearing from you!

A: Breast augmentation can do a good job of masking/hiding minor to moderate degrees of a pectus excavatum deformity. When the chest plane is fairly flat with minimal breast mounds, a inward curvature or depression of the sternum (pectus excavatum) can be very noticeable. One would think that increasing the size of the breast mounds would make the sternal depression more obvious…but it doesn’t. Conversely it has the opposite effect and makes it ‘disappear’. This is because enlargement of the breast mound with an implant pushes up the inner aspect of the breast mound and part of the skin that makes up the edges of the pectus deformity. With two mounds emerging right next to the sternum, the deepest part of the pectus deformity now creates a natural cleavage effect and the sternal depression has now ‘disappeared’.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I am having a tummy tuck and liposuction and am concerned about the risks of a deep vein thrombosis (DVT) and pulmonary embolism. (PE) Do you ever prescribe blood thinners in addition to sequential compression devices (scds) for the legs? I likely am being overly cautious but as a nurse who audits charts all day long I see DVTs and PEs as common problems in the hospital.

A: The prevention of DVTs is of utmost importance in any procedure but particularly in women who are having abdominal/pelvic surgery, which is a higher risk group. During any plastic surgery procedure and in recovery SCDs are used. After surgery early mobilization/ambulation is encouraged. A tummy tuck with or without liposuction is not a procedure one wants to lay around for any extended period of time. Fortunately, I have yet to have a DVT in a tummy tuck patient. Because of the increased risk of bleeding and hematomas, any form of blood thinner (such as heparin or lovenox) is not used unless the patient is a known risk with a prior history of DVT or a diagnosed abnormal blood hypercoagulopathy.

It is important to recognize that a hospitalized patient with a medical problem is a different situation than an otherwise healthy person having elective plastic surgery…so this would explain the dramatic difference in incidence of DVTs in these two populations. But they can happen in any surgery patient so SCDs and early ambulation are the established standard of care in tummy tuck patients.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I am getting a tummy tuck and flank and thigh liposuction done in a few weeks. Honestly, I don’t have much of a pain tolerance so I am concerned most about that issue. I know I will be getting oral pain medication but my plastic surgeon didn’t mention a pain pump. Should those be used?

A: Pain pumps are a common method employed by some plastic surgeons for postoperative pain control after a tummy tuck. I have not found them particularly useful, however, in my experience because I infiltrate the muscle prior to closure. The main source of pain after a tummy tuck is due to the midline rectus muscle fascial plication, not what is done with the skin. I prefer to place 50cc of a Marcaine and epinephrine solution into the muscles during the procedure. This seems to be as effective as using a pain pump, saves the patient about $250 and avoids additional skin exit holes for the pain pump tubing. That being said, there is absolutely nothing wrong with using pain pumps also has an additional preventative measure of postoperative pain control.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I’m hoping that the full facial laser ablation will help greatly with my acne scarring. My only concern is that I have a few scars on my cheeks that are noticeably larger than the rest (they look more like “boxcars” whereas the others just look like large pores) Would you recommend doing the full facial laser ablation first then tackling any punch excisions if needed? Or would it be better to do punch excisions on the few larger ones immediately prior to full ablation in order to maximize success? Of all of the aesthetic goals I’m trying to achieve, having a beautiful “poreless” face is of the most importance.

A: The most important concept about laser resurfacing of facial acne scars is that perfectly smooth and poreless skin is not possible. Improvements in skin texture and irregularities can be obtained, it is just about how much improvement can be obtained and whether one treatment alone is adequate. This can not be specifically gauged beforehand in any patient and more in that regard will be known after the results of the laser treatment is seen. Acne scars that are amenable to excision (ice pick scars, not boxcar scars) should be done beforehand. That way those scar revisions get the benefit of the laser resurfacing as well.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I know a tummy tuck focuses on the abdomen below the belly button. However, I have two fat “dumplings” immediately above and to the left and right of my belly button. If this skin gets pulled down because the lower skin is excised, I was worried that these two fat “dumplings” would look like a new pannus. (if that makes sense).Is liposuction ever being performed on the area immediately above the belly button during a tummy tuck also?

A: In a tummy tuck, the excision of full-thickness skin and fat in the lower half of the abdomen results in an advancement or stretching of the undermined upper abdominal skin flap. This will ‘unravel’ much of the upper abdominal fullness and irregularities because this tissue unit must now stretch out and cover twice the surface area that it used to. Liposuction is never done on the upper abdominal skin flap during a tummy tuck because of blood supply and healing concerns. By doing so there is a very significant risk of causing skin necrosis and wound healing problems of the tummy tuck incisional closure. Once the upper abdominal skin flap is undermined to allow it to stretch out, the perforating vessels feeding the tissues are cut off from the underlying muscles. The skin is now surviving on the more superficial vessels near the skin that comes in from the sides. Liposuction will injure those vessels and make the central upper abdominal tissue have jeopardized vascular perfusion. The small increase in aesthetic improvement is not worth the risk of major tummy tuck wound healing problems. But those areas you are referring to above the belly button are not going to be carried lower as they now exist. They should be completely flattened out for the most part.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I’m having surgery in a few weeks consisting of a full tummy tuck and liposuction of the, flanks and outer thighs. How much fat did you estimate in inches that can be removed from each of these areas? Particularly with my outer thighs, I was hoping that whatever amount of fat was removed would be visibly noticeable to the eye.

A: While I don’t have the advantage of knowing what your body/thighs look like, there would be little purpose in having the procedure if the change was not noticeable. I never like to use inches as a circumferential measurement outcome for any liposuction-treated area or a tummy tuck because the visible change can be substantial but the circumferential measurement change can be less impressive. This, of course, highly depends on the body type and the size of the original problem. But you have to remember that only one section of the thigh (outer) is being treated not the circumferential thigh so that measurement will never be impressive as the outer profile or silhouette view. For a tummy tuck, only the front half of the body is being treated so the amount of ‘inches’ reduction will depend on the existing size of the frontal abdominal fullness and/or overhang.

While in many patients, inches do come off from a tummy tuck, that can be avery disappointing assessment criteria when looking at outer thigh liposuction…that is rarely an inchess off procedure.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I recently had a breast augmentation with 175 cc implants placed under the muscle.. I went round and round with the surgeon, who had never placed implants that small. I showed him an “A” bra that I was interested in filling (I was a double A) and he assured me that that was where I would end up. No such luck. I am a very full B, and very much doubt that waiting for swelling to go down, drop and fluff, etc, will attain the very, very, very moderate look I wanted: again, an A cup. I had explained to him that I was looking to acheive an “A”, no more, to restore my former breast before the 20-lb weight loss. I am very upset to be so thin (5′ 10 and 120) and have much bigger breasts than I have ever had in my life! Would you deem me a good candidate for revision?

A: It is true that breast augmentation with implants under 200cc in volume is very rare. But yet they do make them as small as 125cc in volume. But most of such implants are used as an adjunctive component of breast lifting surgery.

Had I seen you before your desired breast augmentation procedure what I would have said is that no size of existing breast implant will make you an A cup, no matter how small you started. Even putting in a very small breast implant is going to make most women some form of a B cup even if it is a small one. Granted you are very tall and thin, but even a small breast implant will make some degree of a visible mound which is by definition a B cup.

That being said, where you do go from here…how do you revise what you have to reach your size goal? It would be extremely helpful to know whether you have saline or silicone gel implants and what projection/profile they are. For the sake of assumption, let us assume that you have silicone gel implants. There is no where to go in terms of size as the smallest silicone gel breast implant is 170cc, regardless of the manufacturer. If you have saline, then there is the possibility of downsizing particularly if the 175cc are overfilled. The smallest saline breast implant made is 125cc in the lowest or moderate projection style. By switching to this smaller saline implant, you would realize a 30% reduction in size (maybe more if they are overfilled) and perhaps some less projection if they are anything higher in projection than a low profile implant.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I am writing in reference to what I have read in a posting on your site: Case Study: Lower Buttock Lift for the Saggy Derriere from Friday, July 20th, 2012. It seems as if the procedure you perform is one that sutures de-epthelialized dermal flaps to the gluteal fascia, thus redefining the infragluteal  fold. My situation is that I lost about 15 pounds a few years ago, resulting in a saggy buttock. This is also likely age related as I am 45 years old. I am happy enough with my buttock per se, which although small might be redefined by the removal of the offending skin, I’m thinking. If I send you pictures would you be able to tell if this procedure would work for me? Thank you in advance for your time and responses to my question.

A: Pictures of your buttocks will do quite nicely in determining your eligibility for a lower buttock lift. Please send a picture from a full back and side view of your buttocks. You are correct in how a lower buttock lift is performed, de-epithelization of the excess buttock fold skin in a horizontal orientation and then suturing the skin edges down, if possible, to the buttock fascia. All skin sutures are placed in a subcuticular location and are of the barbed dissolveable variety so no suture removal is necessary. The only dressing used is glued on tape. There usually is very little discomfort after this procedure. One just needs to avoid bending over at the waist beyond 90 degrees and strenuous exercise for 3 to 4 weeks after the procedure.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I had scar revision on my knee area. The surgery helped my scar to look thinner but there is still this image of a straight line cut. I had my operation last September 5, 2012. I am planning to undergo laser treatment for my scar. Can I have it done by December of same year?

A: While you certainly can treat your scar revision by laser resurfacing in the early months after a scar revision, I would not expect it to change how it looks. (like a residual straight line cut) Laser resurfacing is almost always perceived as if it is a ‘magic eraser’ but that is not how it works at all. Lasers do not have the capability to wipe away scars and often are overused and overhyped.

A scar, no matter how thin, is a full-thickness layer (most of the time) of abnormal tissue that is largely white and unpigmented tissue. Laser resurfacing removes a layer of the top of the scar but doing so will only reveal more of the scar. Only in the most superficial of scars can laser resurfacing reveal more normal underlying dermis which then can re-epithelize. Thus in full-thickness scars no improvement will be seen. And after surgical scar excision, your scar is most certainly full-thickness.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I’m going to ask you a question you probably heard 10000 times. What procedures do I need to perform in order to get “the male model look” and look handsome?  I think(I may be wrong) I need: Skull Reshaping, Cheek Augmentation, Chin Advancement, cheek and chin;jaw/mandibular Implants,  nose rhinoplasty; lip reduction; Neck Contouring; I’ve attached a few photos of me. My face looks fat. That’s because i have about 20 pounds of excess fat. 

A: You are correct in assuming that I have been asked that question a lot….and have subsequently done a lot of male facial sculpting surgery. In getting a better balanced and more defined facial shape in a male, there is a list of procedures to consider most of whom you have mentioned. But each face is different and therefore has different needs to improve its proportions and get closer to a more sculpted look. There is also the issue of priority and the associated cost to do them so making the proper diagnosis as to the anatomic problems is extremely important in surgical procedure selection.

Your most glaring anatomic problem is your severe lower jaw/chin deficiency. A short lower jaw makes the entire lower face both horizontally and vertically short. This is what contributes to your impression that your fat is fat…it is not. It is just that the lower 1/3 of your face is overpowered by the upper 2/3s. This is further accentuated in profile by a moderate nasal hump which makes the facial convexity worse.

Your most important procedure is to get the lower 1/3 of your face in proportion. This is beyond what a chin implant alone can do. You really need a chin osteotomy (sliding genioplasty) combined with a small square chin implant placed in front of it. Removing your nasal dorsal hump would then complement your facial profile. (see attached side profile prediction) These are the two most important procedures. Secondary consideration could also be given to cheek implants. (see attached front view prediction)

While some other procedures may be complementary, this is the foundation for helping you get closer to more of a ‘male model look’.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 24 year-old guy looking out for skull reduction surgery. I have very wide skull especially above ears, also muscle over the portion is so hard and overdeveloped it is creating very absurd symmetry. I don’t want to have Botox reduction as it is temporary solution hence looking for permanent solution through reduction surgery. Can you please tell me is it possible to reduced muscle to large extent? Also I want skull side to be reduced to some extent. I am looking for narrow skull with vertical indentation. I feel very upset and depressed because of this. Please advise me as soon as possible. Really looking forward for your help.

A: You are correct in assuming that the full area above your ears is as much temporalis muscle as it is bone. Temporal bones are often quite thin so even though they may protrude they can not be reduced very much, usually no more than a few millimeters Muscle reduction is the primary tissue to reduce for narrowing/thinning. Reducing the temporalis muscle is a combination of muscle release and muscle resection. The temporalis muscle is a very large fan-shaped muscle that  extends from above the zygomatic arch up to thue anterior temporal line at the top of the skull as well as back to the occipital region. To do temporalis muscle reduction, the enture muscle is released from its origins for the lateral orbit up and across the skull. A central wedge of kmuscle is then taken. Much of the reduction ultimately comes from the contraction and atrophy of the muscle which can take up to six months after surgery to be fully realized. Because it is a muscle of mastication and inserts into the lower jaw, expect some temporart restriction and soreness with mouth opening after surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had chin and cheek computer imaging done to show me what the effects of this surgery would be on my face. I notice in looking at the images that there is some asymmetry with one side being different than the other. Is this what I can expect from the outcome of the surgery?

A: There are some basic concepts of computer imaging in plastic surgery that are important for every patient who undergoes it for any procedure to understand. First, the quality of computer imaging is only as good as that of the original pictures. In your case, you provided the pictures which were not of great quality.  (slightly blurry and out of focus) When these pictures are magnified for imaging, the quality is not good enough to create very good detail. Second, computer imaging is designed to serve as a method of  communication so the patient and the surgeon can see if they are on the same page, it is not intended to be an exact replica or a guarantee of the result. Contrary to popular perception, there is no computer that does the imaging. It may be done on the computer but ultimately it is the hand of the operator (often using Photoshop) that is creating what he/she thinks the effects will be from the surgery. That is the reason it is called ‘computer prediction imaging’…it is a prediction not an assured result. Third and most important, Plastic Surgery is not Photoshop. The body does not respond to trauma and healing like pixels do on a computer screen.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, does the mandibular angle implant bond to the bone through time?  Or is it just the screws that hold it in place for the rest of my life?

A: There is no synthetic facial implant materials that truly bond to the bone in the truest sense of the word. Bonding denotes an actual bone ingrowth and attachment to the underlying bone without the interface of scar, much like a dental implant where bone bonds directly to the metal. That does not happen with either silicone or Medpor materials.

What does ultimately stabilize and maintain a facial implant into a secure position is the development of a surrounding layer of scar known as a capsule. This takes several months to form a solid capsule around the implant. So the primary purpose of implant screw fixation is to maintain the desired position until a good capsule forms. Medpor material does develop a more robust capsule formation than silicone but early implant stability can only be completely assured by screw fixation as that still takes time to develop. Medpor material also has a much higher frictional resistance (which is also why it is much harder to insert and usually needs bigger incisions) so this may help a little with early implant stability. But that is not enough for me to rely exclusively on this material property. Silicone has little frictional resistance and pocket development alone does not provide assurance that implant migration/mobility will not happen after surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a large bump on my forehead that has bothered me all my life. I am a 25 year-old man and this kind of gives me a ‘horned’ appearance. What are my options for getting rid of it? I have attached some pictures from different angles and it becomes really prominent when I raise my eyebrows and put wrinkles on my forehead.

A: Thank you for sending all your photos. The involved forehead area is quote distinct and, interestingly, does not allow any wrinkles to form across it. I suspect that is from the effect of pressure where the overlying forehead tissues are being pushed out more. The cause of this forehead ‘bump’ most likely is just a thicker area of forehead bone but I would always confirm that with a simple lateral skull x-ray before operating on it for burring reduction. This bump is moderately large so the issue is one of surgical access. I would definitely not make a hairline (pretrichial incision) because your hairline, like most males, does not appear stable for the long-term. The endoscopic approach could work but that also placed a sagittal (vertical) incision behind the hairline, that once again, may not prove stable. I think the best and most direct approach would be to use a horizontal forehead wrinkle line. This would also provide access to get the greatest amount of assured bony reduction which is obviously the intent of the operation. This form of frontal skull reshaping is actually very simple with minimal recovery, it is just all about how to get in to do it and where to ideally place an incision.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a gummy smile. I would like to see what options are out there to correct this issue. I have attached pictures of me smiling and not smiling for you to see how much gummy smile I have.

A: Thank you for sending your pictures. The first thing I can say is that you are not a candidate for any bone surgery (maxillary impaction) for your gummy smile (thank heavens) as one has to have lip incompetence at rest…which you do not. Therefore, any effort for improvement in your gummy smile has to be directed towards soft tissue management. While there are internal soft tissue lengthening procedures which will have long-term benefits, your long upper lip (skin between your nose and upper lip) poses some concerns. One has to be careful that you don’t fix the gummy smile but then also lengthen the upper lip. (may not be a good trade-off) The good news is that there is a test before doing the procedure to see how the result of the surgery might work. That is Botox. A few units of Botox (generally 2 – 4 units per side) on each side of the nose will simulate the effects of a muscle release and mucosal lengthening. if you like the result of the Botox injections, you can just continue with the Botox (much less units and cost than the typical injection sessions done in the forehead which are usually 20 to 30 units) or then proceed for the surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had buccal fat removal upon the misleading instruction of a doctor . Now my cheeks look sunken and dented. After reading your article “Contemporary Cheek Enhancement – Malar and Submalar Zone Considerations”, I have the following questions which are consistently suffering me.:

1. Will the removal of buccal fat pad lead to great fat loss (lipoatrophy)? e.g. due to loss of the supporting fat. I just found myself look like dying.

2. I guess the doctor just removed the whole fat pad, which was not told to me. May I know if there are any suggestions for repair with the least potential risks? I consider fat grafting, but it seems so unpredictable. Do fillers like Juvederm or Artefill work in my case?

I will move US next year and I think surgeons of US are better. Wish you can save me out of this. Thanks a million for your great help!

A: Buccal fat removal can be beneficial for facial reshaping in the properly selected patient, such as someone with a very thick and round face with full tissues. But in the wrong type of patient or if too aggressively done it can result in a gaunt overresected look. I suspect by your description you fit into the latter category. In answer to your questions:

1) I do not know how far out from surgery you are. But if you are six months or more after surgery, the result you see is likely stable. The degree of surgically-induced ‘lipoatrophy’ that you see could be worsened with additional weight loss or further facial fat loss with progressive aging. Whether this occurs or not depends on your facial type.

2)  Synthetic injectable fillers is certainly a simple albeit a short-term fix. I would not rule out injectable fat grafting. Its volume retention results may be unpredictable but the cheek  is one of the best areas on the face for fat transplant survival. Other options include submalar implants placed intraorally and even dermal-fat grafts placed through a limited facelift incision.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am very excited about my upcoming breast augmentation procedure. I am sending you some photos of the breasts in which I DO like and some in which I DONT~ let me know your thoughts when you get the chance. I want a round high full look but I don’t want the implants to go too far to the sides and I don’t ant a big gap between my breasts.

A: As I mentioned during our consult and as a general breast augmentation comment, breast implants mainly accentuate or magnify the exiting anatomy (positive or negative) of one’s natural breasts. The most perfect breast augmentation results typically occur in those women who have good breast anatomy  to work with, albeit smaller than they want. (good breast skin with the existing mounds high up on the chest, spaced close together and with the nipples centered on the mounds pointed straight forward) You have three ‘negatives’ that must be understood/managed in trying to reach the best result possible, moderate breast sagging, low and outwardly pointing nipples and widely spaced breast mounds.

The spacing between the breast mounds and a high very round upper pole look is purely related to volume and projection of the implant. While we had discussed 375cc high projection silicone  gel implants, your desired pictures suggest that more volume than that would be needed to expand the mound properly. If all we do is use implant volume to mainly expand the upper and inner poles, the nipple position will be driven further down which will not be completely negated by the nipple lifts. Therefore I think a slightly higeher volume like 435cc will be needed. Also although the nipple lifts will help, they will not end up perfectly centered on the mounds without a vertical breast lift…which I would not do in you for scar concerns. Any persistent or undesired low nipple position can be managed by a secondary additional nipplel ift down the road if desired when the tissues have relaxed and more upward movement may again be possible.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am looking for an experienced surgeon to preform gynecomastia surgery. I have hard tissue build up under the nipples caused from weight lifting supplements. I have a muscular body but I am self conscious about taking my shirt off and people staring at my nipples.

A: Supplement-induced gynecomastia is an increasingly common type of gynecomastia that I see. The patient type is very typical having a fairly lean and more athletic type body with the localized development of hard nodules underneath and around the nipples. It is a very glandular-type restricted mainly to under and around the areolas. While it may feel small, it can be quite surprising as to the actual size of the masses when they are removed. (often being 2 to 3X bigger than what they feel like) Because of the firm tissue quality, these areolar gynecomastias are best removed through a lower areolar incision. Peripheral liposuction is rarely needed and direct excision of all hard tissue back to normal soft fatty tissue is done. Drains may or may not be used depending on the size of the excision. A chest compression wrap is important should be worn for up to two weeks after surgery. It would be important to avoid strenuous chest exercises/lifting for 3 to 4 weeks after surgery to prevent a fluid build-up which can convert to scar tissue creating a partial return of a mass effect.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had silicone 4.5mm Malar implants place 9 years ago. I have never been happy with the implant look after placement due to their large size but have been scared of the unpredictable result if they were removed. (i.e. facial sagging) Unfortunately I developed an infection due to a facial injury and need them removed. I am wondering if you could tell me if preforming a soft tissue suspension typically works in these circumstances and how long (days/weeks) does a soft tissue suspension takes to “set” per say. Also is there anything that can be worn on the outside of the face to help hold the tissie up while its healing ie tape or a surgical mask? Thank you for your time answering my questions.

A: Because a cheek implant (actually any implant in the body) creates a circumferential capsular lining which is very smooth and avascular, implant removal leaves two sides of the smooth capsule to collapse together. Because of the soft tissue expansion caused by the implant and the fact the cheek bone is like a rock ledge on the side of a cliff, removal of the implants has the definite potential for the outer cheek tissue to slide down off the cheekbone as the smooth surfaces of the capsule will not stick together, resulting in post-implant removal cheek sagging. Whether this is a significant risk for any cheek implant removal patient depends on numerous factors such as the size of the original implant, the prominence/angle of the cheekbone and the existing quality and looseness of the overlying cheek soft tissues.

To prevent or manage the risk of cheek sagging after implant removal, there are various strategies. One intraoral approach is to either suture the two sides of the implant capsule together with some permanent sutures (sliding the outer cheek tissue up as high on the bone as possible) or to replace the implant with the Endotine cheek lift device to provide uplifting support. Extraoral or external strategies can be done with either a transcutaneous lower eyelid approach to cheek soft tissue suspension or en endoscopic temporal or scalp approach to elevating the cheek tissues. Which approach is based would be based on the degree of cheek soft tissue sagging a patient has. If it is a pure preventative approach then use either of the intraoral technques. If cheek sagging is evident even with cheek implants in place, then an external approach would produce a better result with cheek implant removal.

Dr. Barry Eppley

Indianapolis, Indiana