Your Questions

Q: I had a botched chin and jaw implant procedures from an inexperienced surgeon who had never done the procedures before and things didn’t turn out well. I have had both the chin implant and the jaw implant taken out. That was about a year ago. Now there is significant scar tissue and also sagging along the jaw implant lines (but not so much on the chin). Could I send photos to you? Could you be able to fix my problem and me go back to the normal chin and jaw I had before? I have read much of your material on the web and would be very grateful if you could deal with my problem and fix it to the best of your abilities.

A: Facial implants expand the contours of the implanted bone site at the expense of soft tissue stretching as well. When implants are removed, the overlying soft tissue may or may not shrink back down to its former position. The larger and bigger the implant, the less likely the soft tissue will have any recoil. This is also affected by how long the implants have been in place.

In the jaw, chin implants typically pose the greatest problem with ptosis or soft tissue sagging after removal. Jaw angle implants usually cause less of a problem because most are of the lateral augmentation design and don’t disrupt the attachment of the pteryomasseteric muscle sling at the inferior border of the jaw. This is more of a potential concern in inferolateral augmentation jaw angle implant styles.

Correction of soft tissue problems as you describe may require muscle repair back to the bone or it may be improved by overlying soft tissue suspension. I would need to see some pictures of your issues and what type of implants were initially placed.   

Dr. Barry Eppley

Indianapolis, Indiana

Q: I was wondering if you had any experience using Acell Matristem tissue regeneration products? It is the stuff that was used to regrow finger tips, for scar revision/removal, and now in hair transplants. The reason I ask is because I have a medpor jaw implant and was considering having it removed but I understand that one of the difficulties with this is soft tissue damage. I’m under the assumption that the Matristem product would make this a non-issue but I wanted to know what your thoughts and possible experience has been with it.

A: I have used Acell Matristem and am very familiar with its working properties and its results. I have also revised and/or removed many Medpor facial implants and do not their removal as problematic as many suggest. They are not difficult to remove and do not leave behind significant soft tissue damage or tissue loss. They are only ‘difficult’ when you compare them to silicone facial implants which slide right out. So that assessment is a comparative one.

Your consideration of Acell particle implantation at the time of facial implant removal I assume is to repair the soft tissue damage left behind. That can certainly be done and may or may not be of benefit. If your intent is to implant Acell in the hope that it can replace the volume lost by removing the implant would not be a reasonable expectation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I have a weak jaw in terms of width and projection, coupled with a long and narrow face. I don’t wish to get any implants into my face as this idea scares me. I believe my only option now to add width to my jaw would be dermal fillers. How many mm can dermal fillers like Radiesse and others add to the jaw. I believe I am 10-15 mm deficient in terms of the jaw. What is the maximum the best dermal filler can give in terms of width? What is the name of this filler?

A: I am afraid that the very thing that scares you is the only good option to do. While Radiesse injectable filler can be added to any area along the jawline, it would take a lot of material to create 10 to 15mms of bony augmentation. That cost alone would well exceed $10,000 to $15,000 for a result that would last at best 1 year. That cost is comparable to surgically implanting multiple jaw implants which would be permanent and last a lifetime, provided they suffered no initial complications.

Injectable fillers for bone augmentation is to provide some subtle highlights that do not justify surgery or as a trial to see if implants might be a good choice. Facial implants are for significant volume and contour change that require broad surface areas of material. Your jaw problem is better suited to the latter. Injectable fillers are not a good option for you.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I saw a tummy operation on a TV show the other day that got me reallly excited. It was a new operation called the Smooth Tuck.  It was a impler way of doing a tummy tuck because no muscle repair is done and it uses a much smaller scar above the bikini line. The recovery is only one week. This sounds great! I was scheduled to have a full tummy tuck and I was dreading it. This sounds so much better. Do you think I should have this tummy procedure done instead? Is it too good to be true?

A: While I have no idea what your tummy problem is or looks like, I can make a predictive statement that it is too good to be true. The Smooth Tuck is nothing more than a mini-tummy tuck wrapped up with a slick sounding name. Whether the smooth refers to how your tummy will look after or what it is like to go through and recover from is unknown to me. And I am not saying that it is a bad operation. The key question is whether this is an operation for you. Does the solution it can provide match the size of your problem? If you are better suited to a full tummy tuck, then this lesser operation will leave you disappointed no matter how smooth it sounds. There are some tummy tuck patients who are ideally suited for this approach but it is usually only a minority of them. You understandably are interested in something that sounds easier than the traditional tummy tuck approach. Just be certain that the real limitations of this marketed operation do not leave you with the opposite of your desired result…an unsmooth tummy that should have had a different tummy tuck technique done.

Dr. Barry Eppley

Indianapolis Indiana

Q: Dr Eppley, I just read a reply you wrote to a patient inquiring about forehead and orbital rim with either implants or hydroxyapatite paste to which you reply that Kryptonite Bone Cement would be a better option. I want to get your opinion on which material is the best choice for filling out the outer brow bone area(just very slightly). I’m asian, I have eyelids and round shaped eyes but my brow bone looks very weak, which makes me look tired unless i wear eye shadows/shading which I think have lead to my eyelid skin aging prematurely. My eyelids have started looking a bit saggy and I’m only in my late 20s. I want to have the appearance of having more developed brow bones (which looks normal on an asian person) i think this should also help keep my lids from sagging. I want to know if Kryptonite Bone Cement would be a good option for the browbone in my case? Or should i try something else? I’m also considering fat grafts. Please get back to me and let me know what you think is best. Thanks very much.

A: When it comes to brow bone augmentation, it is my opinion that it is always better long-term to add to the bone with a material of similar hardness…provided that the trade-off to doing it (incisional approach) does not leave any significant scarring. Fat injection grafting is a reasonable option nd it does offer simplicity and ease to do with a natural material. (fat) But how volume will stay and what its shape will be is not always predictable.

You have said one key statement in your inquiry…‘filling out the outer brow bone area’. It is critically important to know what specific brow area one wants to augment. If it is just the outer two-thirds or tail of the brow, then that could be done through an upper eyelid approach and adding hydroxyapatite paste. That would by far be the best way to do it and is very straightforward. If one needs the entire brow augmented, then I would use an endoscopic approach with Kryptonite bone cement. By this approach,  it could be injected and then molded under endoscopic guidance.

Dr. Barry Eppley

Indianapolis Indiana

Q: My four year-old child had a surgery for repair of an elbow fracture. Screws were initially inserted to fix the upper arm bone where it attaches to the elbow. It went on to heal well and the screws were  removed three months later through the same incision. Now he has an ugly wide scar which lies on the outside of his elbow and is very visible. It is about 3 cms wide. We need it to be removed as soon as a possible.

A: Scars from orthopedic surgery, particularly around a joint area, can often end up less than ideal. This has to do with a variety of factors including the intent of the surgery (fix the bone fracture, the appearance of the scar is largely irrelevant), the pulling on the skin edges from the equipment used in bone repair, repeat surgery through the same incision, age of the patient, and the continous stretching on the scar from the motion of the joint. By far, the latter plays the major role in such scar widening and hypertrophy. While a scar revision will make an immediate improvement the question of whether some scar widening may still occur is relevant given that the elbow joint will be moving after surgery. So pulling and tension on the scar will not be eliminated. What degree of scar widening will occur after revision can not be predicted, but hopefully it would be minimal.

One concept about the treatment of scars that must be tempered is the concept of removal. There is no such thing as scar elimination or removal. Scar revision is all about how much improvement can be obtained. A complete scar ‘cure‘ or total eradication is not possible for any scar.

Dr. Barry Eppley

Indianapolis Indiana

Q: I have recently consulted with a maxillofacial surgeon who has recommended performing a chin osteotomy procedure. He intends to remove a 3mm wedge (for vertical reduction) as well as a 3mm advancement, with the osteotomy performed at a slight upward angle. I seem to have the unique situation of anterior mandibular vertical excess with a very flat labiomental fold (which would be enhanced by the advancement) What are your thoughts on the success of this procedure?

A: Without looking at photos and x-rays, it would be impossible for me to comment on whether this is a good procedure for your concerns or not. That is a technically sound chin osteotomy procedur and is very straightforward to do. The only question I would raise about it is that these bony movements (3mms) are fairly small. Such small movements are unlikely to make much of an external visible change, albeit a very modest one. To take down the chin bone by osteotomy for this amount of bony movement seems like a ‘solution that is bigger than the problem’. For a horizontal advancement of 3mms, an implant would be far less invasive. For a vertical reduction of 3mms, there is no other solution than osteotomy and bone removal. This makes it a difficult decision in my mind as to whether the problem justifies this degree of surgical effort.  I would look at your chin concerns carefully and would reconsider carefully the potential benefits and risks of this type of chin surgery.

Dr. Barry Eppley

Indianapolis Indiana

Q:  I had an injury and got a little scar over my right eyebrow. Because of this I have slightly lees eyebrow hair over that eyebrow. Is this something you can fix? I only need to fix 5-10% of the eyebrow hair on the right side.

A: Lacerations that cross into and through the eyebrow will frequently result in a bald spot or a scar area that is missing hair. This is the result of either actual injury and loss of hair follicles, separation of the eyebrow hairs by scar, or both. Depending upon the size of the eyebrow defect, there are two approaches to restoring eyebrow hair continuity. In many cases, the scar can be excised and the eyebrow hair margins brought back together through simple scar revision realignment techniques. This works well for small eyebrow defects. In larger eyebrow defects, it may not be possible to bring the normal eyebrow margins together without shortening the horizontal  width of the eyebrow or distorting its shape. In these size defects, eyebrow hair transplants are needed. The hair grafts are harvested from behind the ear. It may only take 10 to 25 hair transplants to correct most eyebrow defects. Meticulous placement is needed to get the right hair orientation that matches the natural changing orientation of the hairs as they go from the inside of the eyebrow out to the tail of the eyebrow.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am in the military.  I am 40 years old and have been  selected for promotion to Commissioned Officer.  I have a large build and constantly struggle with the military’s height vs. weight standards.  A secondary circumferential method is used for the neck and waist.  I am always just at or above the limit.  I have found it even harder now that I am older. I think liposuction would get me ‘over the hump’ with some stomach and waistline shaping as I just need to drop an inch or so around the waistline. I have attached some photos for your assessment and would I qualify for the Patriot Plastic Surgery program.

A: I receive a fair number of requests from men and women in the military for plastic surgery and it is almost always about trying to pass the measurements that are used in the service’s fitness evaluations. While the physical part of these required tests are based on push-ups, situps and a 2 mile run, there are also circumferential measurements done with an important one being that of the waistline. To help men get to their desired waistline measurement, liposuction can be very effective by aggressively treating the entire abdomen and the flanks as they head around into the back. For some women this is effective also, but there are some women that really need a tummy tuck to get rid of the excess skin and overhang if they have had children. We do offer discounts for these surgeries for active military peronnel.

Dr. Barry Eppley

Indianapolis Indiana

Q: I just had a large chin implant placed two weeks ago with neck liposuction. I didn’t really feel I needed the implant in tyhe first place as I had a good chin. The implant is way too large and I don’t like how it feels. I am going to have it removed and I understand there can be sagging skin or nerve damage. Please please give me your advice as to what I can do to correct the sagging skin or rippling in the event that it does occur.

A: The first thing that I can say is it is only two weeks after surgery so there is still swelling, so it is hard to say yet that it may be too large. Also, it is very common to have a chin that feels stiff and wooden for weeks after surgery. This is a very unnatural feeling but it will eventually pass by six to eight weeks after surgery. So whether your feelings about the chin implant would be the same two months from as they are today is hard to say. Since I have no pictures of you, either before and after surgery, it is impossible for me to comment on whether the chin implant should or should not be removed.

That being said, if you are convinced that the chin implant needs to be removed then the sooner the better. The less time the chin soft tissues are stretched out the better. I would have no concern about nerve damage as removal does not cause that problem. It is all about whether the tissues will shrink back down without developing a sag. This problem can usually be averted by doing some soft tissue suspension during the implant removal.

Dr. Barry Eppley

Indianapolis Indiana

Q: I would like to know some information for breast augmentation. Specifically I need to know about the recovery time as well as any long term problems associated with breast implants.

A: Depending upon what kind of work you do affects recovery time after breast augmentation. For a less active sit-down occupation, one could return to work with 5 to 7 days. For more physical or strenuous activities, it may take 10 to 14 days until one is completely comfortable with those efforts. There are no restrictions after surgery other than one’s level of comfort. I place my patients on range of motion arm exercises beginning the first night after surgery. The more and the sooner you move your pectoralis muscles, the quicker you will recover and feel better. Breast augmentation is essentially two big pulled muscles. Like rehabilitation from any muscular injury, early active range of motion is important.

While breast augmentation is exposed to all of the traditional risks of surgery (infection, bleeding), those risks are relatively small. The biggest concept to grasp about breast augmentation is that it is an implant-driven operation…meaning that most of the risks long-term are related to having an implant. One has to recognize that the implant is not going to last forever, they will eventually ‘fail’ and need to be replaced. This is not a maybe, it is a certainty. It in just a question of when it will occur. On average, many patients experience 10 to 20 years of use before replacwmwnt of one or both becomes necessary. So one needs to bear in mind that all breast augmentation patients will over their lifetime have more than just the initial placement surgery.

Dr. Barry Eppley

Indianapolis Indiana

Q:  While I don’t think that I am bad looking, I feel that my jaw line is weak and small. My receding chin greatly distracts from my features and I am hoping a jaw and chin augmentation can help balance my lower face and give me a stronger, more masculine appearance. Ideally I would like to substantially increase my chin size horizontally, to or past my lower lip when viewed in profile as well as add vertical length as my chin is rather short. I also desire to add horizontal width and volume as well as increased vertical length when viewed from the front, or in other words a more “squared” appearance. Along with my pictures, I’ve included a rough depiction of what I am trying to achieve. The altered versions are a “goal” and perhaps you can tell me if they are realistic or not. The problem is I realize extending my chin out this far requires substantially augmentation (probably around 12-15 mm) and don’t really know if my goals are realistic. I’ve been researching your website and understand you do chin osteotomy in conjunction with chin implants. Would this be a possibility? If so are there greater risks in terms of potential nerve damage and bone resorption? Also, with such an invasive surgery, are there any long term complications after say a decade or more?

A: Your own predictive computer imaging is greatly helpful and shows exactly what you want to achieve. I could not have the done the imaging any better myself. Because you desire both horizontal and vertical chin lengthening and are a very young man, I would recommend a chin osteotomy which does a better job of such combined dimensional changes. The chin can probably be advanced about 12mms or so and that should be enough to get that look. The chin can become more squared with an osteotomy by splitting the downfractured chin bone and expanding it apart to create more width. As you mentioned, an implant can also be added to the front of the chin osteotomy to create the same effect. I would have to see intraoperatively which would work the best.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  My daughter fell when she was 18 months old. Since then she has had a dimple in her left cheek. It has seemed to be getting worse as she loses baby fat. Is there anyway we can fix this? I do not want to implant any foreign body into her face.

A: Trauma to a facial region, particularly that of the cheeks, can cause subcutaneous fat atrophy. This is the result of the focused blunt trauma and hematoma formation which causes fat cell death and an overlying skin indentation. The best method of reconstruction would be a fat graft using the patient’s own tissues. It could be done using either an injectable fat technique or the placement of a dermal-fat graft. My feeling is that the dermal-fat graft is the best approach and would be placed from an inside the  mouth incisional approach, unless there is an external scar in the indentation. It is important to release the contracted skin and then place the interpositional fat graft between the skin and the deeper tissues. A dermal-fat graft about the size of a quarter is needed could be taken from the either the groin or buttock skin crease. This is a fairly simple one hour procedure performed under general anesthesia as an outpatient.

Such fat would be the best ‘implant’ material as it will grow into and become part of her natural facial tissues and grow evenly with the rest of her face as she matures.  

Dr. Barry Eppley

Indianapolis, Indiana

Q:  I have had two mastopexy procedures for my breasts with gamma radiation for hypertrophic scars. Which was great but funny enough I was a flat chested as a teenager and loved it. I am now postmenopausal and without a gall bladder.  I weigh 170lbs although others say they cannot tell.. My breasts have now grown from a B to a D again and I want all the tissue removed with a very small implant placed. If all the tissue is removed please tell me they won’t grow back again.

A: As a general rule, once one has most of their breast tissue removed (commonly known as a prophylactic mastectomy), it does not grow back. This would be particularly true if one is now postmenopausal. With little breast tissue present, the risk of capsular contracture after breast implant placement is higher. For this reason be certain that your breast implants are placed in a submuscular position.

Dr. Barry Eppley

Indianapolis, Indiana

Q: You have mentioned that there are some risk with smoothness issues with injectable Kryptonite cranioplasty. If the cement were to not feel smooth once set, could it still be smoothed out later? Is there a more appropriate age to do the kryptonite procedure? Is 4 years old too young to have it done?

A: Like all plagiocephalies, there are numerous other skull deformities as well. Your son is no different is that he has right occipital protrusion as well as his left occipital flattening. The back of his head is asymmetric as a result of both and not just the flattening alone. But since it is only practical through a limited incision approach to do augmentation, all that can be done is to build up the flatter left side.

 During surgery, the molding of the material is done externally until it feels smooth, But since you can’t see it, it is impossible to know absolutely for sure. One can tell what the final result will be about 6 to 8 weeks after surgery when the swelling has subsided and, most importantly, the scalp skin has shrunk down and become adhered to the material and skull bone. Then you can feel the final result with certainty. If any irregularities or edges can be felt, secondary smoothing can be done through the same limited incision using shaping rasps just like we use in smoothing the nasal bones during rhinoplasty.

 The age in which to consider the procedure is entirely open to debate and is more psychological than chronological. One can have the procedure when they are certain the skull is no longer substantially changing and the parents think that it is in the best interest of the child from a self-image and social interaction standpoint.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I was wondering what kind of doctors perform septoplasty?  Are plastic surgeons the only types of doctors that can perform septoplasty?  I was reading that some health insurance can cover a septoplasty but you have to prove to them that your deviated septum is causing you breathing problems.  Is it safe to get a septoplasty/rhinoplasty together?  Can you get a septoplasty first.. and a rhinoplasty later or will that be considered a revision?  Thank you very much for your time Dr Eppley.

A: Septoplasty can be performed alone (if the only objective is to correct breathing problems) or it can be done in conjunction with rhinoplasty. (known as a septorhinoplasty if both breathing and the shape of the nose are concerns) Most major rhinoplasties always include a septoplasty as the septum provides a source for cartilage grafting which is necessary for many nasal reshaping surgeries. Septoplasty and rhinoplasty are never separated into two stages if one’s intent is to address both function and aesthetics of the nose. Septoplasty may be covered by insurance if there is evidence of significant septal deviation and/or inferior turbinate hypertrophy.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Hi Dr. Eppley, my question is about the Kryptonite used on plagiocephaly. My 3 yr old son has plagiocephaly with a very flat head which is a little asymmetrical. I have been told that his head is still growing and changing and that it could improve, but I don’t think so. In the past year and a half it has actually gotten worse. I want to know with his head shape if Kryptonite could be a great option for when he gets a bit older. Also are there any side effects? Does it cause irritation of the skin rubbing on the Kryptonite? His head also has a bit of slopping and is more narrow towards the front of his head. I’ve attached photos. Also with the amount of Kryptonite, how much would you say for his case if he is a good candidate for the procedure. Thank you!

A: Injectable Kryptonite cranioplasty can be a good option in the treatment of plagiocephaly because it helps build out the flatter side of the skull through a minimal incision approach. It is an onlay cranioplasty technique that causes no irritation to the underlying bone or the overlying skin. The biggest risk of this cranioplasty method is some irregularities of the augmented area given that it is done without visible molding or contouring of the material. In looking at your son’s photos, I would estimate that the total amount of material needed is about 10 grams, at most 15 grams. The material does expand as it sets so less is always needed than one thinks.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  I am interested in exploring the option of using Botox to help with my migraines.  I have had them since I was a teenager and am now on Topomax twice a day and rotate with Treximet, Imitrex, and Maxalt.  I am 42 now.  Is there any chance insurance would pay to try this?

A: Botox can be quite effective in the relief of migraine headaches, provided it is the right type of migraine. Specifically, one must have a migraine history and head and neck location that can be specifically linked to one of the peripheral triggers. This means that where it starts can be pointed to exactly one of these sites. This includes the occipital region (base of the skull), temporal region (side of the head), supraorbital (brow) and the septal (nose region) If you can specifically point your finger on the origin and location, then a Botox injection into the trigger area can serve both as a treatment and a surgical predictor. If you get good relief with Botox, then you can continue with these injections every 4 months or so as an effective treatment. Or one can go on to surgical decompression of these sites, of which three are directly related to sensory cranial nerves.

While Botox is FDA-approved for the treatment of migraines, my Indianapolis plastic surgery practice does not process insurance for these treatments. The typical cost would be around $300 to $350 for two or three injections sites.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Good Day! I am Miss Ameena Williams living in United Arab Emirates. I want to book for breast reduction surgery in your clinic. I and 6 of my colleagues will be spending our vacation in your country for three weeks in the month of May 2011 and I want to use this opportunity to have this breast reduction surgery done. I am 40 years old. Kindly confirm the best dates for you in the month of May and how many days it will take you to finish the surgery and also confirm if your firm will be able to handle this so that I can make my booking immediately.What is the total cost of the surgery in your clinic so that I can make the deposit payment. Payments is via credit card because of my location now in offshore and I hope your clinic do accept credit card.
Awaits your reply with the required info above. Kind Regards, Ameena Williams.

A: This is a classic example of an internet scam that is directly specifically at plastic surgeons. I have seen many examples of this in different versions but the story is always the same. Out of the blue without any prior interactions, a patient from another country (usually the United Kingdom or Saudi Arabia) sends an e-mail and requests surgery with a specific date in mind. Money is asked to change hands by credit card but the plastic surgeon will eventually be asked to front them money for travel. The plastic surgeon will initially be paid by their credit card. (stolen no doubt) In the end no patient will ever arrive and the plastic surgeon will be out the advanced travel monies.

As the old motto goes….beware those that come bearing gifts.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Several years ago I was involved in a cycling accident in which I landed on my face and broke a lot of my facial bones, including my jaw, nose and cheeks. My face was initially reconstructed and looked quite good, almost like it was before the accident. But after 6 months, I began to notice that my cheeks looked a little flat. This appears to have gotten worse and now they look even flatter than a year ago. I don’t like to look at myself in pictures because I look so flat in my face. I know that swelling does take many months to go away but this seems more than just swelling. Why has this happened and what can I do about it? Do you think cheek implants would be a good idea? Wouldn’t they be hard to get due to scar and the metal plates that were used to fix the bones back together?

A: It is not uncommon after extensive facial fracture repair that particularly involves the cheeks, that there is cheek flattening with time. This can happen due to the cheeks not being put back to their original projection or can even happen with the most accurate realignment of the fractured bone segments. This is the result of underlying soft tissue atrophy, particularly the fat which is very sensitive to trauma. As a result fat dies (atrophies) over time. This may make the cheek prominence, which initially looked good, become flatter as the face heals up to a year or so after the injury. Cheek implants can be a good secondary reconstructive procedure. It is important to get the right style and size of cheek implants to get a good result. It would be expected that there would be scar and even some plates and screws in the path of re-entry over the cheeks but this does not prevent the secondary placement of cheek implants.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am a 46 year-old male who has lived with HIV for over 20 years. Due to the medications I take, they have caused  fat to collect under my jowlws and into my chin and neck area. I look like I have a small tire underneath my jawline that wraps around to the back of my neck. I want to see whether it could be removed by whatever means you see appropriate and safe. I’m going to forward several pictures to you for your viewing.  Please let me know at your earliest convenience if you can help me.

A: Your pictures and your medical history show the classic HIV-related lipodystrophy that occurs in the head and neck area. A large tissue collection develops giving a bullneck appearance that is particularly large around the parotid gland and ears. While this is often thought of as just fat, the tissue composition is more of a fibrofatty growth which makes it more difficult to easily remove.

Treatment of this cervicofacial lipodystrophy can be done in one of two ways. Liposuction, specifically Smartlipo or laser liposuction, is the easiest approach to try and debulk some of the fat. How much can be reduced with this method of liposuction alone is difficult to predict and it does not come out as easily as regular fat that occurs by weight gain.  The biggest risk with liposuction is that only a moderate change may result.To get the most amount of removal/debulking, an open approach can be used throughba facelift flap approach. This is the most effective method of cutting out the excess fibrofatty tissue but there are some real risks of facial nerve injury and after surgery fluid buildups. (drains are used for the first day or two)

These two approaches have their advantages and disadvantages and each has to be weighed carefully to balance the amount of improvement vs the risk of complications.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Hello Dr. Eppley, I am interested in having a stronger structured jawline. I have been wanting this and am now prepared to have this done. I am tired of seeing a round fat face and with your expertise I think I can get the sculpted jawine that I have always desired. Here are some pics of myself and pics of jawlines that I want to look like. I think my jawline needs to be built up with a chin and jaw angle implants. Let me know what you think.

A:Thank you for sending your pictures. I have reviewed them and done some realistic computer imaging. My comments are as follows:

1) A big reality check is needed here. You can not get to or look like any of those examples. You have a completely different anatomy and skin and fat thickness of your face. While an admirable goal, it is not realistic. You can be improved and maybe end up about halfway between where you are now and those examples. All I can do is take what you have and make it more defined as much as possible.

2) A square chin implant will help the front of the jaw. Your chin needs to come forward and down to become the leading point of your face.

3) You need aggressive neck and side of the face liposuction with removal of your buccal fat pads. As much facial defatting needs to be done as possible.

4) I do not think that jaw angle implants will help you. You don’t need a wide lower jaw in the back. It is plenty wide, you need better definition of what you already have. Jaw angle implants will just make your face look fatter with no better definition.

Dr. Barry Eppley

Indianapolis Indiana

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