Your Questions

Q: Dr. Eppley, I feel like my cheeks are flat and that makes my face very non-descript and uninteresting. I think cheek implants would help but I have also read that you get get better cheeks with injectable fillers also. Which do you think is better? I have attached two pictures of my face as well as two examples of what I think are good-looking cheeks.  Will cheek implants or injectable fillers worko better to reach these goasl based on the structure and limitations of my facial bones?

A:  Your pictures do show malar or cheek flatness. Based on your desired goals by the pictures, cheek augmentation would definitely offer a big improvement towards improved facial balance and attractiveness. For ideal cheek augmentation and a better overall effect, an implant is the best choice in my opinion. Besides its permanent effect, it has a better economic value long-term. . If you are uncertain as to whether cheek implant surgery is for you, however, then initially have an injectable filler treatment done. Be aware that injectable fillers will not create exactly the same look as implants which have a very well defined shape. Injectable fillers create more of a less-defined mass effect although that will still be helpful to prove that cheek augmentation is or is not for you. When considering cheek implant surgery it is important to realize that there are different styles of cheek implants that accentuate subtle but different areas of the cheek. Selecting the right cheek implant  and size is critical as the main reasons for cheek implant revision is improper implant selection and inadequate sizing.

Dr. Barry Eppley

Indianapolis Indiana

Q: Do you do fat injections for breast augmentations? I read your article and have already been in to be seen and I am planning to have surgery in June. Is this a possibility for me? I did not know about this before the time I had my breast augmentation consultation or I would have asked. 

A: Fat injections for breast augmentation (FIBA) at this time is a procedure that is in a state of development. The reliability of the procedure and whom is the best candidate for it will take time to know better. The fairest statement one can make about the FIBA procedure is that the result can not guaranteed (breast volume and shape), can cost more than traditional breast implants, and may likely take two or three injection sessions spaced 3 to 6 months apart to get the desired result. Then there are the very real risks of fat necrosis and lumps throughout the breast.

To the best we know at this time, FIBA may be a reasonable alternative for a woman whose breast size goal is modest (B cup, maybe small C) and is willing to assume multiple procedures and the associated risks. This is not to mention that one must have enough fat to harvest on one’s body for transfer.

Compared to the success of traditional breast implants, FIBA is not for the vast majority of women considering breast enlargement today. It may be a different story (or not) five or ten years from now.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in having breast augmentation. I have had several plastic surgery consults and they have left me confused. One doctor told me that silicone implants do in fact appear more natural (less rippling on the breast) than saline after surgery. Another doctor told me that it doesn’t matter and I should get saline implants because they are cheaper and he could do it through a periareolar incison. Is the appearance difference between silicone and saline implants real or is this a myth?

A: What constitutes a natural appearance after breast augmentation is largely a matter of one’s viewpoint. Beauty truly is in the eye of the beholder. But the definition of what a naturally-appearing breast augmentation result is aside, the more natural appearance of a silicone implant compared to a saline implant is largely a myth. But as in all myths there is usually a kernel of fact hidden in them and this is equally true of this breast implant issue. With good breast tissue and a submuscular position, both types of breast implants will have a similar appearance and one could not tell the difference. However, differences in their appearance may be seen in very thin patients with little breast tissue particularly if they are placed above the muscle. The real differences in these implants is how they may feel, with saline implants having a higher risk of rippling which can be felt in the bottom and sides of the breasts where there is no muscular cover. I always tell my patients that choose saline implants that they can expect to feel riplping in their implants which affects show they may feel but not how they look.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am a 24 year-old male. I believe that I might have sagittal synostosis (scaphocephaly) and it has been quite a burden throughout my life. Furthermore, I have an extremely long face. I know that options are very limited for adults but I wanted to explore possible solutions (if any) to perhaps lessen the deformity. I am not sure whether the risks or thr trouble of surgery is worth and this is what I want to dicuss with you.

A: Thank you for your inquiry and photos. Scaphocephy refers to a horizontally long but narrow in width skull shape that is seen most prominently in the forehead. Ofthe this type of skull shape has a bulge in the upper forehead as well. In looking at your pictures, I can shortcut to the final conclusion fairly quickly. The risks and trade-offs of surgery are not worth it for you. You do not have enough of a ‘problem’ to justify any surgery so your assumption is correct. Your skull is not that deformed to merit a scalp or coronal scar to do some bone burring.  It is best to put these concerns behind you and move on with life…and feel fortunate that whatever bothers you is not significant enough to justify surgery. Many patients are not quite so fortunate with their skull and forehead concerns.

Dr. Barry Eppley

Indianapolis Indiana

Q:  I am 32 years of age and I have breastfed 3 children. I am 5’ 4” and weight 127 lbs. My current breast size is a 36B which measures about 7” I want to get bigger breasts but also want them to look natural. I don’t want my breasts to look like big round spheres. What size of breast implants do you think I will need to go up 2 sizes without looking fake but still having a good size?

A:  The perception of natural vs fake-looking breasts after breast implant surgery can have different interpretations amongst various observes. Beauty is truly in the eyes of the beholder. But natural vs unnatural breast implants results are usually interpreted by the shape of the breast primarily and size secondarily. A round breast (upper pole fullness) is usually what one perceives as fake. A breast with a tear-drop shape (lower pole fuller than the upper) is usually seen as more natural.

When a breast implant expands the breast skin, the shape it creates will be determined by the size of the implant and the amount of overlying breast skin. If one has tight breast skin, just about any implant size will make it look more round. In your case with having had three children that you have breastfed would indicate that you have some loose or lax breast skin, with or without a little sagging. This would mean that it takes more of an implant size than one would think and only8 a very large size would make you more round. The key to breast implant size selection is in knowing your breast base diameter measurement. With a near 7 inch diameter (17cms) to your breast, you have very wide-based breasts. You will likely need at least a 500 to 600 cc implant of moderate profile to get you increased by two cup sizes. That may sound large but it is only because you need more volume with a wide breast.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  I am very interested in buttock implants. I was initially treated with fat grafting and spent a lot of money but the results did not last. This is why I don’t trust fat grafting and won’t do it again. I was greatly disappointed when I looked the same 3 months after the procedure. Any suggestions would be greatly appreciated.

A: The choice between using your own tissues (fat grafting) versus an implant for augmentation of any body area can be a difficult one. The advantages and disadvantages of either approach are classic and predictable. A synthetic implant will produce a stable amount of augmentation but at the price of more invasive surgery and the risks of infection, seroma, implant migration and extrusion. Conversely, fat injection grafting has none of these risks but its volume retention and predictability of a long-term augmentation result is variable. In some cases, the results of fat grafting can be completely resorbed within a few months. For others, a second fat injection surgery is needed to get the desired augmentation volume.

Whether fat injections or an implant is best for anyone’s buttock augmentation starts first with the size and shape of one’s buttocks and what one’s end goal is. For some, the size of the buttocks one wants is very big and they have little to start with so an implant would be best. For others, their buttock size goal is more modest and they have something to work with from the beginning. For them, fat injections would be a good choice. If one has no significant fat to harvest on the abdomen, flanks or thighs, then implants will need to be used.

If you have had one unsuccessful fat injection surgery, then buttock implants become more appealing. You might feel differently if some of the fat from the first surgery survived. 

Dr. Barry Eppley

Indianapolis, Indiana

Q:  I want butt implants to give me a much larger butt. I was told that’s 400cc implant would give me the size I want but I think that’s too small. Can I send a picture of my butt and a picture of the size I want? Can you tell me what size implant would give me the results I want?

A:  Buttock augmentation using implants involves two considerations; size of the implants and implant location. (above or below the muscle) Size of the implant affects whether it can be placed above (subfascial) or below the muscle. Buttock implants are made of a soft flexible silicone material and come in either round or shaped configurations. Like breast implants, buttock implants are commercially available in different sizes (volumes) and dimensions. The most commonly used buttock implants are round shapes with sizes up to around 400cc with a projection of 5 cms. Larger buttock implants are available in shaped sizes up to about 550ccs but with less projection. The larger a buttock implant becomes the more difficult it is to place it under the gluteal muscle. When possible it is always best to place a buttock implant under the muscle.

When considering buttock implant size, the desired area of enhancement and its dimensions are important considerations in implant selection. These are drawn and measured during a consultation and are important in buttock implant selection. Whether one can achieve the the buttock size one sees in a picture may or may not be possible.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am 22 year old male who is seeking multiple procedures because I really do have numerous facial structures that need improvement as clearly evident in my pictures (attached).  My concerns and procedure desires are as follows:

1. Rhinoplasty: I’d like nasal hump reduction, narrowing of wide nasal bridge, and nasal tip contouring. I’d like my nasal tip to be more forward and slightly downward projecting.. I believe forward projection of my nasal tip will make it slightly pointed and thus give my nose a forward direction (rather than being bulbous and appearing as if it is just sitting on my face without direction). Also, all the parts of my nasal tip (i.e. the middle part and two sides) are curvy, and I believe increasing forward projection of my nose will stretch and thus straighten out all the curvy parts (For your reference, the vision I have for my nose is reflected in the nose of David Duchovny, the actor.)

2. Septoplasty: I’ve severely deviated & tortuous nasal septum that is almost completely obstructing airflow in my left nostril and also causing my nasal tip to be asymmetric and bulbous.

3. Lip enhancement: As evident in the picture, my upper lip is feminine-like because most of the visible lipular (pink) tissue is in the central part of the upper lip and sides have almost no visible lipular tissue. I’d like my upper lip to have even visibility of the lipular tissue.

4. Lip reduction: Also evident in the picture, my lower lip is quite large and droopy/bulky and I’d like to reduce it perhaps by at least 50 percent.

5. Chin and jaw/jawline implants: Also evident in the pictures, my jaw is really small in all dimensions. I’d like big chin implant and other jaw implants to increase the vertical height and width of the jaw in order to have more masculine look.

6. Buccal lipectomy: I also feel that I’ve lot of fat on my cheek bones that is more evident when I smile. I’d like to remove this and possibly place cheek implant for more masculine look.

7. Zygomatic arch reduction: At last, my zygomatic arches are curved (rather than straight, which is Caucasian feature) giving my face broad and round appearance. Jaw implants would help balance this by widening my lower-face so it matches my wide mid-face, but I’d like to explore possibility of reducing my zygomatic arches.

A: Thank you for sending your pictures. In many ways, what you are really after is what I call the ‘male model face makeover’. You are trying to structurally change your face to be more and attractive and masculine. By definition, this involves numerous combined facial procedures. I have done some imaging and will answer your numbered comments as follows:

1) Septal and Rhinoplasty surgery is done together and is known as a Septorhinoplasty. The concepts of lowering the dorsal hump and narrowing the tip and nasal bones are standard. Your concept of lengthening the nasal tip and bringing it down is not how the tip becomes more refined and is not the movement you want the tip to go. The tip is narrowed and defined by how I change the shape of the tip cartilages. If anything, the tip is already too long and down too low. It actually needs to be slightly shortened and lifted to have more of a defined narrow tip. Also, it is not a good idea to use other people’s noses as targets. You have a completely different anatomy than that mentioned person (your skin is much thicker and your cartilages are much bigger) and you can not get that nose. You can only work with and modify what you naturally have, not make it look like someone’ elses nose.

2) Septal straightening and turbinate reduction is done at the same time as the rhinioplasty.

3) You would benefit by a subnasal lip lift to create more vermilion show but that can not be done at the same time as an open rhinoplasty.

4) Your lower lip can not be reduced as much as 50%, that is not realistic. Perhaps 10% – 30% reduction can be achieved.

5) A square chin implant and inferolateral jaw angle implants will make your jaw and lower face more balanced o your upper face.

6) Small cheek implants will a buccal lipectomy will enhance your cheeks. These are very difficult to image so those results can not be visually predicted very well.

7) I would leave your zygomatic arches alone. They are fine and only look big because of the smaller size of your lower face.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am interested in making my weak jaw look much stronger. My chin is very short and my lower face looks too small compared to the rest iof my face. The more research I do , the more I think I might have micrognathia (abnormally small jaw), and I don’t know that jaw implants would not be enough to make me look normal. I would have to make my jaw bigger through other means like surgery or appliances. All the maxillofacial surgeons I have talked to deny giving me surgery because they claim they only do surgeries for people who have bad bites/deformities etc. and not for people born with a genetically smaller face/jaw. My bite is normal and I have had orthodontics in the past. This is getting me really sad because I feel I have run out of solutions. I need to expand my lower jaw significantly before I get implants. What is a surgical or non surgical way to make the jaw significantly bigger? I am thinking about lower jaw expanders and then add your implants. Or possibly bilateral sagittal split osteotomies (BSSRO) to advance the jaw and then add your implants on top of them.

A: There is no mystery here or need to do research to figure out what you have. You have a short lower jaw…period. A short lower jaw = micrognathia. Your entire lower jaw can NOT be moved forward by orthognathic surgery or a BSSRO. You have to have a bad bite or Class II malocclusion to do so. Moving your lower jaw moves your lower teeth with it. You can do a BSSRO if you want to have a bite where you lower teeth sit in front of your upper teeth and they don’t fit or come together at all. Get the idea of ever moving your lower jaw out of your mind…..unless you want to spend 3 years in orthodontics to reverse your bite and prepare it for surgery by giving you a bad bite. Your lower jaw is so significantly short (> 15mms) that even the biggest chin implant will not provide ideal correction. This is why you need a CHIN OSTEOTOMY, most likely with a chin implant placed in front of the moved chin bone. There is no such thing as a ‘lower jaw expander’ nor are there any non-surgical treatment methods.Your only lower jaw options are jaw angle implants for the back and a chin osteotomy/implants for the front. Focus your attention on these considerations, rather than searching for something that doesn’t exist or can not be done on you. These are your only viable solutions

Dr. Barry Eppley

Indianapolis Indiana

Q: I am looking to go about getting a procedure to make my forehead larger in height (length) and width and also to build around the temple area. But also my hairline is very low and am wondering if I get the forehead implants would I somehow be able to move my hairline up to show more of my forehead? After forehead implants what can be done about my hairline when getting this procedure.

A: Forehead augmentation, technically known as frontal cranioplasty, involves applying a moldable material to the forehead that then hardens fairly quickly. During the hardening process, it can be shaped in all dimensions including projection, width and height. These materials must be applied to bone and not soft tissue. Therefore, you can not widen the temple area as this is muscle not bone. The temple area requires a differernt material/implant approach.

With forehead augmentation, there may be some small vertical lengthening of the forehead when it is ‘expanded’ by augmentation. It may be in the range of 1/4 to 1/2 inch greater distance between the frontal hairline and the eyebrows. There is a limited amount of length increase that can be done. But this small increase, combined with greater forehead convexity, may make it appear slightly bigger than it really is. It may be possible to lengthen and stretch the forehead skin after augmentation through a coronal or scalp type of browlift technique but I doubt one would find that necessary later.

Dr. Barry Eppley

Indianapolis Indiana

Q: I would like to ask you some questions concerning cheek implants. I am a 23 years old male, my eyes have an outer tilt to them, there is no scleral show between the iris and the margin of the lower eyelid, my eyes are rather slightly deep set and i have already high lateral cheek bones. Although my cheek bones are already high, they are not very well defined and for this reason I want to get them bigger and to get a more dramatic and contoured look. I managed to get me samples of all cheek implant designs from Porex Surgical. I think the implant, that would provide the look, that i am desiring, could be the Extended Malar Shapes with a 5 mm augmentation that is shown in the picture. Recently I heard that such an implant that is placed near the infraorbital rim could pull down the lower eyelids. I like the shape of my eyes and if there is any risk of lower eyelid distortion downwards, I would rather go without these cheek implants. What is your opinion on this? Do you think there is any risk of lower eyelid distortion downwards with these kind of implants? Have you noticed such changes on the lower eyelid with this high and lateral cheek implants, yet? Thank you in advance for your reply.

A: The simple answer is no. The longer detailed answer is that there is no chance of any lower lid effects when placed through the mouth as the implant actually pushes up on the lid. There is a chance of lower eyelid ectropion if a cheek implant is placed through a lower eyelid approach however. This is a function of the incisional approach and how it is closed, not because of the position of the cheek implant.

In addition, the size of the cheek implant you have shown is way too big and positioned too far back on the zygomatic arch. One can do anything on a skull model as there is no soft tissue to go through and there is no appreciation of how it will look from outside later. I find that many of Porex’s midface implants are designed too big. There is a big difference between designing them on a skull model and actually putting them in and using them in real patients. The other issue is that small augmentations in the midface and cheek area can look more dramatic than you would think by just looking at the skull model. A little goes a long way in the cheek area. Oversized cheek implants is a common complication that I see from this type of facial implant and is due to this effect.

Dr. Barry Eppley

Indianapolis Indiana

Q: I’m a 21 year-old female of Chinese descent. I want to narrow and sharp my nose tip and wings and make the nose bridge higher. In the upper eyelids, I want to take out the fat and make them more deep and wide. I also want to open my eyes in the inner canthal area. Lastly, I want to reduce cheek and jaw and augment the chin so that the face looks more narrow and longer. I know some of these are common to the  Asian face. I have provided some pictures for you to do computer imaging. Thank you very much!

A: Thank you for sending your pictures. I will do some imaging on them but I am limited as to what I can show because the quality of the picture and the angles from which they are taken are inadequate. The most useful photos for compiuter imaging are front and side views taken on a clean background (solid color wall or door) that are non-smiling.

In reference to your specific procedure requests: I can make the following comments:

1) Your nose reshaping/rhinoplasty requests are fairly standard for your ethnicity. Changing the nose by narrowing the tip and flare of the nostrils and making the bridge higher is common for this type of Asian rhinoplasty.

2) From an upper eyelid standpoint, you are referring to a double eyelid procedure with defatting and creating more of a prominent upper eyelid crease…which will make your eyes more wide or open looking. From an inner eye/canthus standpoint, you can get rid of the skin overhang with an epicanthoplasty but the scar trade-off must be carefully considered.

3) For facial narrowing, cheek and jaw angle reduction can be done from inside of the mouth. Whether this is best done by burring or oteotomy/ostectomy reduction is an issue for discussion.

4) The chin can be augmented with a specific female-type chin implant that makes it longer and comes to more of a point.

Dr. Barry Eppley

Indianapolis Indiana

Q: Dr Eppley, I came across this page while doing research on scars. My 6 yr old daughter had a traumatic injury to her left cheek about three wks ago. A face laceration in the shape of an anchor, right in the front of her cheek. As her parent I was and still am very upset that this has happened to her. Not only for cosmetic reasons but I’m worried about her self esteem later on. I’m hoping it will heal better than I can imagine. Currently we have seen two plastic surgeons and they had me in tears with their negativity. I was wondering if you could look at her picture and have some advice. When or if the time comes, we plan on doing what we can for her. Thank you for your time and I hope to hear from you with your expertise.

A: I obviously would have to see pictures of your daughter’s scars before rendering an opinion. But having taken care of many hundreds of facial lacerations to children over the years, what often looks very discouraging and grim early on can go on to heal, either just by time or plastic surgery scar revision, to look much better than one would have ever thought. She will have a residual scar for sure but the goal is to see how minimal it can become. The cheek area can be a difficult area for scars because it is a bony prominence and is under some tension. But the healing potential of young growing tissues is significant so there is no reason to be discouraged no matter how it looks right now.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am  Korean and I would like to have more of an oval face shape. My face seems too wide and I would like a narrower lower half of my face that looks less puffy and flabby. I am thinking that maybe jaw angle reduction nd facial liposuction would be what I need. Here are some pictures for you to see what my face looks like.

A: Thank you for sending your pictures. It appears that your desire is to narrow the lower third of your face, which is most affected by the shape of your jaw located at the angle area. The consideration of a jaw angle reduction is reasonable, it is a question of how much reduction can it achieve. That question is best answered by knowing how much the bony jaw angle is actually contributing to the fullness in that area. While it clearly makes some contribution, particularly with your ethnicity, the question is whether it is enough to make it worthy of reducing it. That question can be answered by a simple dental films, a panorex and a lateral cephalometric x-ray. They will show the exact amount of flare at the angle as well as the thickness of the bone. That information is crucial in determining whether jaw angle reduction can be justified.

Facial liposuction will make but a very minor contribution to any facial narrowing effect. I can see in your pictures the value of submental/neck and lateral facial liposuction as a possible complement to jaw angle narrowing.

From a loose flabby skin standpoint, only some type of skin tightening procedure (e.g., jowl tuck-up) would be of benefit and you seem too young for that effort at this time.

Dr. Barry Eppley

Indianapolis Indiana

Q:  I had a free nipple graft breast reduction almost 6 months ago, and I want a 2nd opinion. The surgery went well, but I don’t have an actual nipple. I only have the areola part. Is that normal? There is no nipple at all. It is just flat… That is why I am concerned. Also, what will happen when I get pregnant? Will milk leak out, or will it not even produce since it starts before baby is born. Is there any info you can give me about pregnancy after free nipple graft. Thank you.

A: In a traditional breast reduction, the nipple is left attached to the central mound of the remaining breast tissue. While the nipple and areolar complex will survive, it is possible to have loss of nipple projection and/or erection. This may occur after this type of breast reduction as the nerves that supply the nipple may not fully function afterwards. This is uncommon however and may not be seen at all.

If you had a breast reduction in which the technique used was a free nipple graft, then you will not only have no feeling, no nipple projection and no ability to produce milk. When the nipple-areolar complex is removed and then applied as a free graft (like a skin graft), there are some predictable outcomes. Most such free nipple grafts actually have the surrounding areola survive but the nipple, which is thicker, usually dies completely and is just replaced with scar tissue. This makes it flat and often lighter in color than the surrounding areola, which is the opposite normal color arrangement.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Hi there. I see that you list Evolence filler on your website and wondered if you are still offering this? Also, do you offer Selphyl (“filler” using patient’s own blood plasma)? I am interested in these options for superficial glabellar wrinkles. I prefer using natural, non-toxic products. Botox is not something I am interested in at this time. Thanks!

A: The injectable filler Evolence has been pulled from the market and discontinued from being manufactured by J & J in 2009.

Selphyl and Platelet-Rich-Plasma/Acell mixtures are procedures that I do but neither would be a good option for superficial facial wrinkles. That is not what they are intended to be used for as the needles for injections are bigger than that of the fine wrinkles.

For glabellar wrinkles, the use of any type of injectable filler, without prior treatment with Botox is a wasted effort and exactly the opposite of what should be done. You must first control the muscle activity first, otherwise the unchecked muscle motion will make the injectable filler disappear quite quickly. There are no permanent injectable fillers and muscle action working against them makes them dissipate much quicker than normal.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am interested in rhinoplasty and cheek implants and have had a consultation done which included computer imaging. The profile images show a nice improvement but in the front view I can see very little change around the cheeks and eyes. Will the actual surgery fill out these areas nicer than what I see in the imaging? What about the nasolabial folds, don’t they also diminish with cheek implants? Do you think larger cheek implants are better for me? (I heard small ones are unnoticeable)

A: While I have no idea as to the quality of the computer imaging that was done, it is difficult to show much cheek improvement from a front view. Computer imaging works best on facial structures that are not overlapped or in profile. That is the problem in the cheek area, it is not a profile structure unless it is imaged in the oblique or three-quarter view. Most likely, cheek implants will produce a much better result than what those images show…particularly if the cheek implants are a size beyond the very smallest. You are correct in that small cheek implants in most patients ones can barely be seen or are very subtle.

Cheek implants may create some lessening of the nasolabial folds but it will not be substantial. That is not an intended or known effect from cheek implants. However, paranasal implants can make a bigger difference as they are placed right behind the nasolabial folds so they create more of a push outward, thus lessening the deepest upper portion of the nasolabial fold.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  I had silicone breast augmentation last year in 2010. I just read that I am supposed to get MRI scans every couple years to make sure they are not ruptured. My doctor never mentioned that I needed to do this. Should I get them and who is going to pay for them?

A: With the release of silicone gel breast implants back onto the market in late 2006, the FDA recommended regular follow-up magnetic resonance imaging (MRI) scans for women so implanted to detect rupture. Silicone implant rupture is ‘silent’, meaning it can not be detected by sight or feel. This is quite different from saline breast implants which will spontaneously deflate or go flat should there be a problem with them.

The MRI evaluations was one of the conditions imposed upon the manufacturers and it is so stated on their websites, marketing materials, and in the package insert. Plastic surgeons are instructed to advise their patients about the MRI recommendations. With this MRI recommendation, however,  there are no guidelines for tracking whom has this done, their compliance and most importantly from the patient’s standpoint whom is going to pay for these tests. It is clear from the FDA viewpoint that this cost is to be borne by the patient and/or their health insurance carrier.

But a recent article in the March 2011 issue of the journal Plastic and Reconstructive Surgery raises questions about the accuracy of such MRI scanning, especially in women without any breast symptoms such as pain or breast hardening. Beyond the issue of accuracy, the authors of this paper also point out that such screening tests are generally performed to detect diseases with serious health risks…and silicone breast implants are not known to have such significant risks

There is also a concern that there may be an overestimation of the ability of MRI to detect ruptured breast implants, particularly when scans are performed for screening purposes in symptom-free women.

This being said, your awareness of the recommendation of screening MRIs after silicone breast augmentation is important. What you do with this information is a matter of voluntary compliance and should be discussed with your plastic surgeon.

Dr. Barry Eppley

Indianapolis Indiana

Q:  Hello Dr. Eppley. I would like to inquire about brow bone implant. Do you mind taking the mind to answer some of my questions? 1) Are there any limitations to brow bone implant? Can it stretch as much as we want? 2) Will the eyes change its expression after the implant? I tried pulling out the skin at my eye brown area and there seems to be a difference. 3) Will the eyes appear bigger or smaller after the implant? 4) Lastly, is lowering my eye browns accurate to determine how I would look like after the brow bone implant? Thank you for your attention. Hope to hear from you soon.

A: In answer to your questions about brow bone augmentation, let me clarify that building up with brow area is done using typical cranioplasty materuials and not just a carved or pre-shaped implant. With that being said: 1) The size of brow bone augmentation can be done to just about whatever size someone wants. 2) The muscle activity around the eyes will not change after brow bone augmentation. But a stronger brow appearance may make the eye area look different. 3) While the actual size of the eye will not change after brow bone augmentation, they may look little deeper set in some patients. 4) The horizontal position of the eyebrows does not change after brow bone augmentation. They are pushed outward and perhaps a millimeter or so downward but they do not shift downward to any significant degree.

Dr. Barry Eppley

Indianapolis Indiana

Q: Hello, I have severe facial wasting. I am not an HIV patient, I had a normal plump face as a young child and by about the third grade my cheeks had completely sunken in and has given me a much older and skull-like appearance. I am only eighteen years old. I would like to have a procedure to correct this done this summer before I begin college in the fall. I would like to know if you handle this sort of procedure and what you would suggest to be done. I have attached some pictures with this e-mail inquiry.

A: Thank you for your inquiry and sending your pictures. You have a classic case of facial lipatrophy, type IV (type V is more consistent with HIV related facial lipoatrophy) Your history is classic for it as most patients convert from the plump face of childhood to a thinner more gaunt facial look during grade or intermediate school. Of the augmentation methods for treatment (implants and fat injections), I think you need a combination approach. I would place submalar cheek implants that specifically builds up the area right under the cheekbone known as the buccal area. This implant is placed through the mouth under the upper lip. Then I would do fat injections with Acell collagen particles to the area below the implants out into the side of the face and down to opposite the corners of the mouth. The goal is to add some fullness to the sides of your face and help reduce your more skeletonized appearance.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am 27 years old and want to get Botox injections. I don’t want to get those lines in my forehead that my mother has and I think that this will be preventative. Am I too young for Botox?

A: In recently published statistics from the American Society of Plastic Surgeons, nearly 30% of the 5 million people that underwent some form of cosmetic surgery in the last year were under 30 years of age. There is no question that, while more aged patients are getting corrective treatments, younger patients are interested in aging prevention. This is both a reflection of the widespread availability of Botox in the past ten years and the shifting attitudes towards anti-aging of a younger generation. This is often also influenced by a relative, usually from a mom getting Botox and their daughters seeing this and thinking that they might be able to prevent wrinkles before they ever form. With the relatively low cost of Botox, such prevention is as affordable as many high-end topical creams and serums.

Is Botox wrinkle preventative? The answer is both yes and no. Botox will not alter the aging process but, at the first sign of seeing an undesired expression such as excessive frowning between the eyebrows, it can soften the appearance of the future location of wrinkle lines the earlier one starts to get the injections. The age of 27 would not be too young for Botox if…one has very strong forehead or crow’s feet expressions.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Hi Dr Eppley, I have read your article about  chin reduction. I am a female and I have  a long chin and my self-confidence is affected by it. I have attached some pictures for you to see what can be done about it. By the way, I wear a full lower dental denture (one original tooth left) and I have partial upper denture. Most of my remaining teeth has been root canaled. Thank you and looking forward to hear from you.

A: In reviewing your pictures, you undoubtably have a very long chin. But, equally relevant, is that your face has a great imbalance between your upper jaw (maxilla) and your lower jaw. Your midface is very flat and recessed, partly because of your ethnicity but also because it is underdeveloped. This is magnified by your loss of teeth which contributes to your maxillary atrophy from a horizontal projection standpoint. Your lower jaw is very long with a high jaw angle. This combination has created a significant maxillary-mandibular mismatch (short maxilla, long mandible) and is a major contributing factor to your appearance of a ‘long chin’. One of the missing  pieces of information is what your bite (occlusion) is like. With these facial bone relationships, you may also have a Class III malocclusion or underbite.

From a corrective standpoint, the ideal approach is to move the entire lower jaw back and the upper jaw forward. This would ideally solve this long chin appearance. But that may be more than you want to do, although having most of your occlusion done by dentures, it is not so far fetched. Short of orthognathic surgery, the other combination would a vertical chin reduction osteotomy and possible paranasal augmentation of the midface. This would not make as big of a change as orthognathic surgery but it would be a noticeable difference.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I have a problem with the shape of one side of my jaw. I had a fibular free flap surgery done several years ago as a result of an osteosarcoma tumor that was removed from my right bottom mandible. I have since recovered nicely from surgery and I now have dental implants. However, one thing that bothers me from the surgery is that my right bottom mandible is not in alignment with my left bottom mandible. My left mandible is defined and square whereas my right mandible is “heart-shaped.” Side pictures of me are especially embarrassing as well as the stares I get from strangers. What can be done to give me a more normal shape to the reconstructed side of my mandible?

A: Having dental implants placed into a mandible reconstructed with a fibular free flap suggests that you have had a very successful outcome. It takes good bone stock and alignment of the reconstructed jaw segment to the upper jaw to be able to get such dental reconstruction. I suspect that the deformity to which you refer is that you have no defined angle of the mandible on the reconstructed side. This can happen due to the take-off of the fibular graft from the ramus of the mandible. The joining of the fibular bone flap and the remaining mandibular ramus forms a new jaw angle. If this is not done at a 75 to 90 degree angulation, the jaw angle will be blunted or more obtuse. This can be confirmed by a panorex dental film, which you undoubtably have from your dental implant reconstruction, which shows the entire mandible and its shape from side to side quite clearly. This could be improved by the simple placement of a jaw angle implant. This would be best done through your existing neck incisions.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I want to know how much is radiation therapy after a keloid is removed from the earlobe? I had a large keloid removed several months ago and now it seems to be returning. I have read that radiation therapy can be very helpful after surgery.

A: For radiation to be beneficial in the management of keloids, it must be done immediately after the keloid is removed. This is low dose radiation that is done within days after the excisional procedure and continued daily for a very short period of time. The purpose of radiation is to disrupt the formation of collagen fibrils in the very earliest phase of wound healing. But decreasing the early and aggressive collagen response of keloid-prone tissues, it is hoped that the over-production of scar tissue would be halted and the keloid would not return. Once the keloid is formed, radiation will not be useful.

Radiation therapy is not usually an out-of-pocket expense and, when done as an adjunctive treatment in keloid surgery, should be covered by your health insurance. That will require a pre-determination letter to verify that it is a covered benefit.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I have some questions about the lip lift. I know that this procedure is quite controversial in cosmetic medicine. The plastic surgeons in my area will not perform it. However, after doing some research I have found that there are ways for it to be done successfully without cutting the orbicularis  muscle. What is your opinion and experience with this procedure?

A:  When you say lip lift, I will assume you are referring to the subnasal lip lift. (aka bullhorn lip lift) This is where skin is removed from under the nose to lift up the central third of the upper lip and shorten the long upper lip. Despite a lot of hesitancy from plastic surgeons to perform this lip enhancement procedure, I have found it to be very straightforward and uncomplicated. There is no reason whatsoever to remove any orbicularis muscle when shortening the upper lip. This is fraught with problems if done including a tight upper lip and an abnormal smile. While muscle resection probably does prevent any vertical relapse, it causes irreversible lip problems. Relapse is a much more easily treatable ‘problem’ so only skin should be removed. As a general rule, no more than one-third the vertical distance along the length of the philtral columns should be removed. One can expect 1 to 2mms of relapse in the first few months after the procedure.  

Dr. Barry Eppley

Indianapolis, Indiana

Q:  I have scleroderma and there are quite a few things that bother me about my face. Because of the scleroderma, it has caused a lot of damage to my appearance and the whole left side of my body is smaller than the right. If I could change how I look, I would want to look as close to normal as possible. I know I won’t look perfect but just looking like I’m not sick is good enough for me. My main issues are my cheeks which are sunken in, my chin which is uneven, my lips in which the top and bottom left sides are smaller and my nose which I think is too pointy. There is also an indentation on my forehead and the area under my eyes seems very hollow, all these affected more on the left side. I would really like to hear your opinions are on what I mentioned and your recommendations. I have attached a series of pictures for you to review.

A:  I have taken a look at your pictures and your overall problem which is two fold; a short lower face and a lot of soft tissue thinning and atrophy. (more on the left than the right) In making an effort to get you looking better, you need a two-level approach. First, it is necessary to change the bony foundation by making the chin longer, more even and further forward by a chin osteotomy as well as a rhinoplasty to bring the nose/middle part of the face back into better balance. (this is what is imaged in the side views) Cheek implants are also needed to add some fullness to the cheek area. (this is what is imaged in the front views) The soft tissue deficiencies, which are difficult to image, are addressed by the placement of multiple dermal grafts and/or fat injections (if you have any fat elsewhere on your body to harvest) in the forehead, lower eyes, side of the face below the cheeks and in the left upper and lower lips. All of these could be done in one single surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q:   I have a question about jumping genioplasty. I am curious, if you have had previous chin surgery with indwelling plates and screws as well as possible internal scarring of the muscle that causes creases in your chin when you smile, can you still undertake a jumping genioplasty? Or would the scar tissue and plates and screws from the previous ostetomy prevent this? I understand this makes surgery more difficult to carry out. I was just wondering if it is still possible.

A:  While you are correct in that it is more difficult, it is not impossible and sometimes is fairly uncomplicated. The only limiting factor is the plates and screws used from the first osteotomy and how easy they are to remove. The typical osteoplastic genioplasty, if the chin has been advanced, is a step titanium plate with 4 or 6 screws. As long as bone had not completely grown over these metal devices, they are often fairly easy to unscrew and pry out the step plate. But if bone has completely covered these devices, their removal can be very difficult and destructive. Fortunately, complete bony healing over the plate and screws is not common. Once the devices are removed, the osteotomy is straight forward and the prior chin surgery actually makes it easier to complete a secondary bone cut.  

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Hi there, I was interested in your lip lift procedure and wondering if you did fat transfer to the face for reshaping/volumizing, and a butt lift using fat transfer.  I’ve been researching for several months and I’m ready to have it done, but I’m wanting to find the right surgeon for me.

A:I do a lot of fat injection surgery, most commonly to the face for volumetric enhancement and to the buttock for augmentation, otherwise known as the Brazilian Butt Lift.  Fat transplantation by injection is a really exciting approach for numerous face and body contour problems even if its ultimate survival is not always assured. The exact technique for fat preparation varies by surgeon and there is no absolute agreement as to how it should be done.  I use a fat concentration technique and then mix it with PRP and Acell Particles to enhance survival and volume retention. These are by far the most common recipient locations. The key is whether one has enough fat to harvest which is an issue for the buttocks and not the face.

Lip ‘lifts’ can be done as either a subnasal lip lift or a vermilion advancement depending upon the shape of the upper lip and the patient’s scar tolerance. Please send me some photos of your lip for my assessment. Both approaches can be very successful when properly done. Vermilion advancements produce the most dramatic change in lip size and shape. True subnasal lip lifts are more limited in how they change the shape of the upper lip.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am a 35 year old mother of two. I’m 5’4″ and 144 lbs. I have been planning my mommy makeover for a while now and have put a alot of thought and research into it. I need a breast makeover with a lift and implants and a tummy tuck. The other area that bothers me a lot is my inner thighs. I have very little fat just loose skin with a lot of stretch marks. I know an inner thigh lifts creates scars and I am not wild about that idea. I know that thse groin scars can move downward as they heal which could be a problem in a swimsuit. Would a body lift be a better option? I know the scar goes the whole way around but how well would it lift the inner thigh area? What are your thoughts?

A: Your thought process is a good one but you have an understandable misconception about what the the lower body lift or circumferential lipectomy procedure can do. By removing skin and fat all the way around (360 degrees), it will make significant changes to your abdomen, lower back, buttocks and outer thighs. But it will have little if any effect on the inner thigh area. You wouldn’t do a lower body lift if you thought one of its main advantages was improvement in the inner thighs. The only way to improve the inner thighs is to treat them directly with an inner thigh lift. This would be far easier and more effective than a lower body lift. With well-placed incisions, the scars should remain fairly hidden in the groin creases.

Dr. Barry Eppley

Indianapolis Indiana

Q: My forehead sticks out from the side is there anyway you could make it flat and look at least normal? I have attached s side view of my forehead so you can see how far it really sticks out.

A: Thank you for sending your picture. It does show a fair amount of convexity to your forehead. The amount of convexity could be reduced but it can not be made to be flat. The bone thickness will not support that much reduction.

Here is a computer image of what I think is the best that could be achieved with a burring reduction of the forehead bone. There is one way to know absolutely for sure how much reduction can be done and that is to get a simple lateral skull film x-ray. On that x-ray the thickness and, most importantly the thickness of the outer cranial table can be seen. The skull (forehead) is composed of three layers; an inner and outer hard cortical bone layer in between which exists a softer marrow diploic space. The amount of horizontal reduction of the forehead is limited by the thickness of the outer cranial table. It can only be reduced until one gets close to the diploic space. Measuring that on the x-ray could show how much the forehead could be reduced in thickness. A tracing of the before and after cranial contour could then show you the exact profile change that could be achieved.

Dr. Barry Eppley

Indianapolis Indiana