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The Book entitled ‘I Feel Bad About My Neck’, that came out a few years ago, bespoke of an inevitable aging problem. Necks unfortunately don’t lie. The folds of skin hanging down from one’s jawline are like rings on a tree. While Botox, injectable fillers and lasers can do a lot for the face above the jawline, the neck has been the poor sister of non-surgical rejuvenation. The neck can even look comparatively worse as the rest of the face above it gets a few less wrinkles and becomes more plumped with these treatments.

While a necklift is the only sure thing for the most ideal and long-lasting improvement, not everyone has a wattle that is so deserving. Less-invasive options have cropped up over the past few years that are promising and have caught a lot of press. One of the more recent ones uses ultrasound waves to help grow collagen under the skin to create a tightening effect. Targeted towards early neck aging patients, usually under the age of 55 years old, it can improve some of that loose skin under the chin. This has led to it being touted on numerous popular TV shows and magazines.

Enigmatic of many new and inadequately studied cosmetic treatments, Dr. Oz (a heart doctor) proclaimed on his show that this was the equivalent of a non-surgical facelift. He spoke how it could get rid of a sagging neck immediately and that it was pain-free. Its discussion on the show also left a distinct impression that such a device was cleared by the FDA for neck treatments… when it is not.

The reality is that ultrasound, and other collagen-stimulating treatments, do have some skin tightening properties but the effects take months to appear…and numerous treatments. Any immediate effects are temporary due to the heat created in the skin but real collagen takes much longer to form. The manufacturer claims that these results can last up to a year or longer but actual clinical trial data has only followed patients up to 3 months after treatment. Costing up to several thousand dollars, most patients won’t be happy with that investment even if the results did last for one year.

While many people think that surgically tightening the neck also requires that the face be lifted as well are not aware of more recent advances…that catch much less press than trendy devices. There are isolated necklift procedures and many more men get isolated necklifts than women. Most women are concerned about the jowls and the neck while most men are actually more focused on just the neck alone. The influence of time on a man’s face, even including baldness, is pretty well tolerated but a neck wattle is usually not viewed as a graceful sign of aging. I have had many men tell me that the only thing that they think makes them look old is their neck.

While creams, exercises and these newer skin tightening devices all have purported neck benefits, most people by the time they notice their neck problem are beyond the help of these approaches. Something less appealing, but infinitely more effective, is the spectrum of necklift surgery options.

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

The recent tragic events that are ongoing in Libya actually have some plastic surgery implications. It was recently reported that a Brazilian plastic surgeon says he performed cosmetic surgery on Libyan leader Moammar Gadhafi in 1995. This included harvesting fat from Gadhafi’s belly and injecting it into his face to smooth wrinkles as well as giving him hair plugs.

The plastic surgeon stated that while he really needed a facelift, he refused and wanted something that would have a less noticeable change. Gadhafi reportedly told him that he had been in power for 25 years at that time and that he did not want the young people of his nation to see him as an old man. (even dictators can be vain) Interestingly, the Libyan dictator insisted on using local anesthesia and interrupted surgery at one point to eat a hamburger.

While this story may be mildly amusing and seemingly ancient occurring over 15 years ago, it was an early use of a plastic surgery concept that has become very much in vogue today…that of facial fat grafting.

All faces age by loss of fat and the stretching of skin, gravity just compounds the problem by making it look worse in certain positions. By losing fat, the skin gets closer to the underlying bones of the face and sags as well. To ideally restore a more natural and youthful appearance,  the skin must be expanded outward by lifting it away from the underlying bone. This is where the role of fat grafting has come into play. By harvesting fat from another part of your body, it can then be artistically injected back into the face to restore some youthful contours. From the method by which liposuctioned fat is processed prior to injection, it contains a good number of stem cells. (fat has been shown to have 300X to 500X more stem cells than bone marrow) This may partly explain why patients tend to notice improvement in their skin as well as more youthful contours with facial fat grafting.

When facial fat grafting alone is not enough to fill out the deflated face (too much sagging skin), lifting procedures can be done as well. Many types of facelift procedures are done today, which can be lumped into the concept of short incision face lifts. These incisions do not disturb the hairline and results in a very fine line scar around the natural curves of the ear, extending slightly behind the ear. These limited types of facelifts result in some small amount of neck and jowl tuck-up. By adding fat grafting to them, a real 3D (three dimensional) face lift can be achieved.

The Libyan leader was way ahead of his time by getting facial fat grafting before the technique was as developed and understood as it is today. You may say that such fat grafting to the face is the ultimate form of recycling or ‘green 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

The eyes are the focal point of the face, at least in everyday conversation, and a more youthful appearance contributes substantially to the impression a person makes. Bags beneath the eyes, wrinkled and drooping layers of skin on the eyelids, and sagging eyebrows give the entire face a perpetually tired and sad expression.

Blepharoplasty (eyelid tuck) for men has become increasingly popular and is the second most frequently performed male cosmetic procedure, surpassed only by liposuction. It can provide tremendous benefit to a man’s appearance as it corrects sagging upper eyelids and puffy bags underneath the eyes. The procedure can also correct vision impairment caused by saggy skin on the upper eyelids.

While the surgical technique for cosmetic eyelid lift surgery on a man is fundamentally the same as that used on a woman, there are several different considerations. It is important that men retain their masculine image rather than the more stereotypical feminine result. A quick search of celebrity photos on the internet or magazines will reveal whom sought out a plastic surgeon than understood this difference. (Kenny Rogers, Bruce Jenner, Gary Busey to name a few) Poorly performed eyelid tucks that give a man a wide-eyed open appearance will quickly find that celebrity’s pictures’s on many websites that portray poor plastic surgery results.

In general, most men are seeking a more conservative (less obvious) change. Like women, men want their results to appear natural. But there is a gender difference in what is considered a natural result. While most women want a very clean eyelid look with smooth skin, such a look in a man will look ‘done.’ Too much eyelid skin removal in a man will create the appearance of having had plastic surgery and, in some cases, can just look plain bizarre. It is quite acceptable for a man to retain a little extra skin and a few wrinkles on the eyelids after surgery.

Patients are always understandable concerned about whether incisions or scars will be visible after surgery. The key to a non-visible male eyelid tuck scar is proper placement. This is especially important given that men can not wear make-up to hide any scars. Knowing that a man’s natural upper eyelid crease is lower than a woman’s helps put it in the best place so no scar can be seen after surgery.

Besides an eyelid tuck to make the eyes look less tired, there is also the consideration of low hanging brows and the potential need for a browlift as well. The classic handsome male brow is full, low and horizontal while a female brow can vary from full to thin but almost always has some degree of an arch to it. In my opinion, few men cosmetically benefit by a browlift, and there are too many browlifts done in men. A browlift in a man, where the brow gets elevated to an unnaturally high position and now has an unnatural arch to it as well, is the main reason men can look peculiar after such surgery. If a browlift is needed or wanted, the approach should be that less is more.

Men should not fear blepharoplasty surgery as it can make a real difference in their appearance. The key to a natural result is that the man’s features should be preserved during eyelid tucks as well as to not over-correct or remove too much skin. As men age, their eyelids will differ from those of their youth and blepharoplasty for men should appreciate this subtle difference.

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: 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

The Guinness Book of World Records has a lot of peculiar and  unusual human achievements. Plastic surgery makes up but a few of them. One such record is that of a 55 year-old woman from Ohio who has had the most number of cosmetic surgeries. With 52 plastic surgery procedures to her credit, she appears to hold this dubious record.

By her own admission she has had five facelifts, two sets of blepharoplasties, liposuction to her stomach and knees as well as regular sessions of Botox and injectable hand rejuvenation.  She has spent over $100,000 in fees over the past 25 years. With such a vast personal experience, it is no surprise that she makes a living as a cosmetic surgery consultant and has authored a book on what she calls cosmetic surgery secrets.

While most would understandably view this accomplishment as just another attention-seeking addict heading down the Michael Jackson highway, there is actually a more interesting and relevant side to this story. While few will ever even come close to this number of plastic surgery procedures, there is no denying that for 55 years of age she looks exceptional and not a bit unnatural or having an ‘operated look’. This certainly separates her from many other celebrities who undoubtably have spent a great deal more and do not look nearly as good.

Why she has turned out better, despite a large number of anti-aging endeavors,  is a result of two efforts. First, she has stated that her goal in all of this was to look authentic and  remain natural looking. She never wanted to look like she had anything done. This seems obvious and I have seen few patients who wanted to look unnatural after surgery. Just wanting to have natural-looking results after surgery, however, is not enough. The key and the contemporary approach to plastic surgery is to do smaller operations earlier in life.

Despite her many plastic surgeries, the vast majority of these were not major surgeries. Most of her surgeries were more ‘nips and tucks’ and many of her procedures were injectable in nature, although counted as if they were operations. In essence, she used more minimally-invasive procedures that were then done on a periodic basis. Like the regular maintenance on an expensive car, she intervened at earlier stages of facial aging and not waited until she had ‘broken down’ and needed a major overhaul. This avoids extensive surgery and the associated drastic change and operated look that can appear afterwards.

This is the contemporary approach to the treatment of aging…intervene early and control its effects by taking advantage of today’s injectable and less invasive plastic surgery procedures. Botox, injectable fillers, laser and light therapies, and more limited operations such as the Lifestyle Lift and numerous other facial tucks have created this new way of thinking. Like in many other areas of life, today’s plastic surgery illustrates that less can truly be more.

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 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