Your Questions

Q: Dr. Eppley, regarding cheek implants, what sort of augmentation produces the male model look and you have written that the ‘male model look’ is a vague term, denoting a wide spectrum of shapes. So let me use Johnny Depp as an example of what I envision ad the male model cheek look that I want. There is a distinctive and characterful line that runs around the side of the face and down to the chin. From my perspective it seems like for a cheek implant to create this characteristic look it would need to focus augmentation on the lateral and oblique portions of the cheek. This, is it possible for a custom cheek implant to create this lateral augmentation of the zygomatic arch?

A: When it comes to the male model cheek implants look, Johnny Depp is one of the most classic examples of the look men are seeking. You have described what creates that specific cheek look and as you may be well aware, there is no standard off-the-shelf cheek implant that is really designed to create that look. While one has to have the right midface soft tissue anatomy for a cheek implant to create this effect (thin), no currently designed cheek implant augments the lateral edge of the zygomatic arch and comes forward anteriorly into the submalar region and onto the maxilla. Malar shell and submalar implants exist and are often used to try to create this effect but rarely create that exact cheek look. A custom or semi-custom approach to the design of cheek implants is the most likely method of at least creating the correct amount and location of the bone augmentation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, regarding jaw implants is it not true that the large masseter muscle goes a very long way to creating the characteristic model look that patients are seeking? If bony anatomy is not the only factor does this not mean that a patient will fail to achieve an authentic looking result, seeing as the implant augments bony anatomy.

A: The concept of the male model look as it relates to the jawline is a variable one that does not have a specific look per se. While it is about a strong and well defined jawline, the front to back angulation of its inferior border and the height and flare of the jaw angles can be quite variable. I have been provided many desired male model jawline pictures from young men which have many variations.

While an exact male model jawline escapes an exact anatomic description, what is not unclear is that it is created by the bony shape of the mandible. While the masseter muscle can be very thick, it is rounded and lacks any defined or sharp edges. It creates bulk and not definition. It is only relevant in how thick it is as well as the thickness of the overlying subcutaneous fat. These tissue thicknesses can obscure any well defined bony shape or implant augmentative effect of the jawline.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in Earwell ear reshaping. I have a two month old son who has prominent cup like ears. I am emailing you to ask if it is too late to possibly use the Earwell product to prevent possible cosmetic surgery in the future. His ears are still pretty soft and fold over on themselves very easily. Please let me know if this is still an option for him or would even still be successful in treating his prominent ears! 

A: Technically, Earwell ear reshaping works best when initiated within two to three weeks after birth. The ear cartilages do not yet have any memory so they will stiffen up around the molded plastic Earwell framework over the next month or so of use. While this is the ideal time to start Earwell, the reality is that many parents only start to think about therapy for their infant’s misshapen ear(s) weeks to months later. So your request at two months of age is not rare. Having initiated ear reshaping therapy in some cases at 6 to 8 weeks, there usually is some improvement in ear shape but not to the extent of that is seen when the external reshaping framework is applied within a few weeks after birth. The ear may seem floppy and without much cartilage stiffness at two months of age but the cartilage has already started to develop some stiffness (memory and thus is more resistant to cartilage molding forces.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have wanted to have a tummy tuck for the last five years. I have had two children who were both born at over nine pounds. I am 5’ 7” and weigh 135 lbs. I have worked out a lot and got my stomach as toned as it can be. However I still have hanging skin if i lay on my side or bend over. I have no confidence when I have no clothes on.

A: A tummy tuck is often the only solution for loose skin on one’s stomach. Diet and exercise help with loosing fat but can not get rid of loose skin or tighten it up. Stretch out or loose abdominal skin is an irreversible problem short of surgery. Even women who are relatively thin and work out regularly find out that they simply can’t make this skin go away. Such a realization often drives them to seek out tummy tuck surgery. Whether one needs a full or partial tummy tuck depends on how much loose skin exists.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in forehead reshaping. I have two large forehead bumps that can be easily seen, even from a distance. I was wondering if these could be smoothed down and what the cost would be? Also how long it would take to get in for an appointment and if anything else like a CT scan would need to be done?

A: Your forehead reshaping concerns present a common forehead anomaly that I see. Your forehead bumps are classic for what I call ‘forehead horns’. I have seen these many times and why they occur I can not tell you. But they tend to appear exactly where they are in you and are almost always bilateral. (on both sides) They are fairly easy to reduce and do not require a CT scan or x-ray before doing so. They involve the outer cortex of the skull bone and do not go ‘deep’ or past the diploid layer of the skull bone. When taking them down there often is an indentation below the bumps that, when the bumps are taken down, can make the forehead appear sloped backward. In these cases, I often apply a thin layer of bone cement to correct the forehead inclination. Whether this issue applies to you would require assessment of better pictures from different angles.

The forehead inclination issue aside, the far more important issue is how to get in to do the forehead bump reduction. This requires an incision somewhere and it is an issue of whether to use a more wide open scalp incisional approach or more limited incisions directly over the bumps. That is an issue for further discussion.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in having breast implants. I am currently a 34B and am interested in a full C or a small D cup. Also, I was previously 190 lbs and am now 135 lbs. I have a flabby area above my belly button which I would love to have tightened. I work out regularly, yet it just doesn’t seem to help. This area would be optional though, as my primary interest would be having breast implants. I saw the general fees for each procedure, and was curious if combining procedures offer any cost reduction. 

A: In answering your breast implants and tummy tightening questions:

1) When it comes to size of breast implants, I do not use the concept of cup size. While women understandably have that as a breast reference, implants come in volume (ccs) not cup size. And regardless of cups size or ccs, in the end all you really care about it how the breast looks…the number attached to it in that regard is not important as long as it looks the way you want. In choosing breast implant size in volume for any patient, I use a Volumetric Implant Sizing System. You can try on the various volumes and see how they look and then choose. I find this to be incredibly accurate which less to a very rare problem of patient dissatisfaction withe the outcome of their breast augmentation procedure.

2) Having lost 55 lbs, this raises the question of whether you have any loose breast skin or sagging. This is an important preoperative consideration since breast implants do not create a ‘breast lift’ effect and can make make a saggy breast look worse even though it is bigger. Seeing some pictures of your breast would help answer that question.

3) Your weight loss is also the source of the flabby area around your belly button. Since the belly button  is the only fixed point on the stomach, weight loss causes the skin around it to sag resulting in flabbiness and sometimes an actual upper belly button overhang. The only method to truly tighten loose abdominal skin is some form of a tummy tuck.

4) Your assumption is correct in that there is some cost savings when procedures are combined.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am in need of a sliding genioplasty revision. I had sliding genioplasty done which left me with a defect on the right side. The surgeon who performed the initial operation was going to take bone from jaw to fill the defect, but I was thinking it would turn out badly considering how bad it looked directly after the procedure.  That was more than 10 years ago. A second surgeon I consulted stated he would use artificial filler to patch the defect and a very small implant if I wanted a more triangular “pixie-like” look to the chin.  I definitely don’t want my jaw any wider.  In fact I’d like it symmetric and less squared off on the sides. I’m just looking into my options at this point. I had so much trouble after the first operation with permanent anesthesia of the lower gum and my lip being slightly crooked.  Scared it might end up worse.

A: What is have is a rather classic sliding genioplasty revsion problem. When the chin bone is brought forward, it narrows the chin and can leave at the bony tails an indentation or step-off at the back edge of the genioplasty. Whether this occurs depends on how far the chin bone is brought forward and the angle of the bony cut. Sometimes this lower jaw edge defect can only be felt, in other cases it can be seen as in your case. The two approaches to treat it are to fill in the bony defects, often with hydroxyapatite granules, or with an overlying chin-prejowl implant. But either approach will tend to make your chin somewhat wider. The other approach is to narrow or remove the bony edge by making it more v-shaped or narrow. Such a chin reshaping procedure would not be associated with the issues you had during the initial sliding genioplasty since the bone is not being downfractured.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was scheduled for a rhinoplasty but one week before the surgery I broke my leg playing basketball. I had it fixed and will be unable to to bear weight for another four weeks and therefore was unable to make my rhinoplasty surgery. I am still interested in doing the surgery as early as is possible. I have a follow up appointment for my broken leg this week so I should know more about the length of time I will be on crutches. I just wanted your input and opinion on what you think I should do next. 

A: There are two schools of thought about any type of surgery while recovering from another surgery/injury. One approach is to wait until one is fully recovered and then do the elective surgery at a more convenient time. The other approach is to have the elective surgery while one is recovering from the first surgery or injury since one is laid up anyway. Which approach is better depends on the nature of the injury and what the elective surgery procedure is. When one is young and healthy, the recovery from one surgery (a broken leg) does not affect the healing of the subsequent surgery. (rhinoplasty)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am not sure if I  need Lipodissolve or a tummy tuck. I have gained 15 pounds or more since I have turned 40 and now can not seem to lose it.  I am not sure what I need to get my clothes to fit right again. Does the lipodissolve work? How much is the cost between them? What is the diffenence? How much time will be needed off work for a tummy tuck?  Will the weight come back right away? The weight is around my middle, love handles and my thighs and butt.

A: Choosing between liposuction and a tummy tuck is a common dilemma for many women, although many times it is a more hopeful wish that liposuction alone will create the result they want. While I don’t know what you look like, I am absolutely certain based on your description that lipodissolve injections are not the answer. They are for very discrete small areas of fat which is not what you have. The question is only then whether it is liposuction alone or liposuction combined with a tummy tuck. Seeing a picture of your stomach would be helpful in answering that question. There is no doubt you need liposuction, it is just whether there is enough loose skin across the stomach to justify a tummy tuck as well.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have narrow shoulders i wander if there is any plastic surgery that can put a small implant to make my shoulders somewhat wider because whatever i wear my body looks like child’s body because of my small shoulders. I drew an imaginary picture about the size of the implant if it is possible to be done.

A: The shoulder implant to which you refer is known as deltoid implants. Making the shoulders bigger/broader requires deltoid muscle augmentation. Implants are available to augment this muscle and the key to their placement is the location of the incision, the position of the implant over the muscle and the size of the implant. The deltoid implant is unique amongst all body implants because it is placed over/near a moveable joint. (shoulder) While deltoid implants can be placed by a direct incision over the shoulder, the prominence of that scar merits it being done from an incision behind the shoulder at the junction of the shoulder and the back.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, how soon after having a rhinoplasty can I play basketball. I am having a rhinoplasty in two weeks and would like to be ready to play sports again in a month after surgery. Do you think this is possible or is it too early?

A: Whether one is having a more limited tip rhinoplasty or a more complete one with osteotomies, there are always important recovery issues of which patients are understandably concerned. One of these frequent recovery issues is that of physical activity. When thinking about physical activity after rhinoplasty there are issues of being able to breathe comfortably through the nose (for exercise) and the risk of trauma to the newly reshaped nose. (participating in sports) It would be fair to say that participating in sports will be delayed longer than just non-contact exercise so let’s focus just on that issue.

The bone and cartilage of the nose takes months to heal after a rhinoplasty and that could be anywhere between three and six months after surgery. So yo can see that is a long time and many people simply aren’t going to wait that long. Thus it is all about assessing the risks of being hit in the nose based on the activity being done. If you are just shooting a basketball by itself, then three to four weeks afterwards should be fine. But if you are playing in a team situation where contact my be likely, it is all a gamble for many months after surgery. Getting hit in the nose within three to six months after a rhinoplasty will likely cause undesirable changes so that is a risk you will have to determine if it is worth  it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, you have written in regards to facial implants that the translation of bone augmentation to an exterior soft tissue facial change is not a 1:1 ratio. Does this mean that a 3mm malar implant may not necessarily provide 3mm of augmentation? If so, do implants tend to give more or less augmentation than their specified dimensions? Additionally, what is the reason for it not being a 1:1 ratio?

A: The reason that augmentation of bone (a hard substance) does not translate exactly to the exterior surface of the overlying soft tissue is the compressibility factor between the two different types of tissues. If the enveloping soft tissue was as hard as bone then augmenting the bone would create an exact 1:1 ratio translation. But the soft tissue of the face has varying  thickness and is soft, thus pushing on it from below is somewhat ‘blunted’. Thus the ratio of bone surface change to external soft tissue change would be less than an exact 1:1 relationship. This would be influenced by the thickness of the overlying soft tissues. The thicker it is, the less is the 1:1 relationship, the thinner it is (less fat) the closer it is a to a 1:1 relationship. This phenomenon is well established in orthodontics and orthognathic surgery where these hard:soft tissue relationships have been studied by cephalometric analysis.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I understand that you do infraorbital rim implants. (tear trough implants) I had malar implants placed last year, but it hasn’t provided the tear trough augmentation that I need. I also had some fat grafting to the tear troughs, and 2ccs of Aquamid (permanent filler) to each malar region. First, I have a hypothetical question. The surgeon who placed the Aquamid said that he injected it to the deeper tissue layers. Is there any chance that some (or most) of the filler could have been suctioned up in the process of placing the malar implants and creating the pockets? Secondly, I have lumpiness along my tear troughs from the fat grafting. I understand that an eyelid approach can be use to place the infraorbital rim implants. Would it be possible and convenient to also try and remove some of the fat grafts in the process? Lastly, I’ve always wanted to get a canthopexy. Would you recommend getting it done at the same time as the orbital rim implants?

A: One would never expect that malar implants would provide any tear trough augmentation so your experience is not unexpected. As for your Aquamid injections, i doubt that elevating the pocket for the malar implants removed much of the material but this is really a question that is better answered by the surgeon who placed the implants. Lumpiness from fat grafting to the tear troughs is not uncommon if they are not placed down as deep as possible along the orbital rim area. Whatever fat grafts are evident below the level of the orbicularis muscle during the placement of infraorbital rim/tear trough implants through a lower eyelid incision can be removed. When using the lower eyelid incision in implant placement, it is standard to perform a lateral canthopexy to prevent lower eyelid ectropion or a corner of the eye deformity.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a custom  jawline implant. As I understand the process of design off of a 3D CT scan, one “see” the skeletal changes butI am having difficulty envisioning the appearance of my jawline outside “with skin on it”. I am very serious about having this procedure done and want definite improvements to both my jawline and my chin/profile, but I also want a final result that looks natural and keeps all my facial features in good perspective with one another. Is there a way for me to “see” the proposed changes from an exterior view?  For example, can I take photographs of my face so predictions could be made from them with the designed implant in place?

A:  There are several facets of the custom jawline implant process that is important ofr anyone to understand that wants to have the procedure done. While computer imaging can do a great job of making the implant design to perfectly match the bone, the translation of what the bone changes would be to how it looks on the outside is not currently possible. That is because the translation of bone augmentation to an exterior soft tissue facial change is not accurately known. It is assumed that it is a 1:1 relationship and that is probably more true than not. There is also the issue that there is no radiographic method to capture your soft tissue, overlay it on the bone, and then change it based on the underlying bone changes. This would obviously be tremendously beneficial but that technology has not yet make it to this application in any cost efficient manner as of yet. Thus radiographic assessment and implant design processes are still very bone-based.

What all of this means is that I have to design the dimensions of such a jawline implant based on a non-scientific artistic manner. While that sounds very dubious and obscure, it is not. I have a lot of experience designing these custom implants and have a very good feel for whether it will actually fit (having enough soft tissue to cover it) and how it will look on the outside when placed. That is precisely the role that our prior computer soft tissue imaging played before I designed the implant. I was trying to get a feel for the type of jawline changes you were looking for and what you could tolerate. Having done this a large number it times there are some general rules that I following in a wrap around jawline implant design. One of the very first thing one learns in doing these is that it is very easy to make them too big. While you can design anything on the computer you have to take into account the thickness of the overlying soft tissue as that will add to the volume as well. It is always better to slightly ‘undersize’ it as oversizing will always lead to revisional surgery.

The concept of what a ‘natural’ jawline result is can be a very individual one. But again that is the role of the initial computer imaging. That helps me determine how extreme a change any patients wants. And you are correct, you don’t want a jawline change that overwhelms or is out of proportion to the rest of one’s facial features.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 21 year old female wanting to have liposuction to get rid of my stomach and reduce the fullness on my sides. I feel it would give me a much better figure and more of the hourglass look. My questions is whether doing it at my age would be a waste since eventually I am going to get pregnant. I want to look better now but I also don’t want to throw money away either. Please advise.

A: You have to recognize that many cosmetic procedures are not always going to create permanent results. This is particularly true when it comes to fat removal liposuction procedures. There are a lot of factors that influence the long-term retention of liposuction results, of which future pregnancies are certainly one of them. You also have to recognize, which you already know, that whether you have liposuction or not that an eventual pregnancy is going to change your stomach and waistline area. These changes will effect skin more than fat but they would not be considered to be beneficial at keeping the look of a liposuctioned result. The issue with looking at the ‘value’ of liposuction is how soon after were you planning to become pregnant. In other words, how much time would you enjoy the benefits of liposuction? If you were looking to become pregnant within the year after the procedure then it would not be a good use of your effort and money. But if there are no foreseeable plans for pregnancy as far as you can see in the future (years), then the benefits of liposuction may outweigh its cost when it amortized over that period of time. To put it any other way, how much would you pay a month to have a better looking stomach over that period of time?

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, if I had maxillofacial surgery, would a chin implant and mini facelift be out of the question for me? Does having had the facial/jaw bones being worked on exclude the possibility of having implants placed on top of the bone or the outer skin lifted like in a facelift?

A: Any type of a facelift and chin implant can be done on someone with a prior history of  orthognathic surgery, whether it was a LeFort 1, mandibular advancement/setback or genioplasty or any combination of them. What is done down at the bone level has no impact on the adjustments of the facial soft tissues along the jawline or on the side of the face. A chin implant can also be done over a previous sliding genioplasty even though there may be some more scar or tissue adhesions around it. To illustrate this point, it is not rare in my experience to place facial implants at the same time as having orthognathic surgery or to do a second stage after orthognathic surgery to place them. Given that the bone is at a completely separate layer than the skin or the SMAS tissues, there is no impact on having any type of a facelift later.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am seeking information for breast augmentation and possible breast lifts. Here are my questions. I am a 45 year-old female who is 5’ 7” and weighs 125 lbs.

1) In order to achieve my desired look, will augmentation suffice OR would a lift also be necessary?

2. Would silicone be preferred over saline breast implants for the most realistic feel? (Prefer the round look over teardrop)

3. For inframammary incisions, what is the likelihood of decreased sensitivity in the breast? Is an armpit incision ever the best choice?

4. Is a caregiver necessary? I am from out of town, I would prefer to travel alone.

5. How soon after surgery can I return to work? How many days would I need to remain in the area?

6. How far out is surgery currently being booked?

Much thanks.

A: Thank you for sending your pictures. In answer to your breast lifts/breast augmentation questions:

1) You would need a vertical breast lift, the raising of the arms in the pictures proves that need.

2) Silicone implants do have more of a natural feel to them.

3) Very low risk of any nipple feeling loss with the inframammary approach. Since you need a breast lift, that would exclude the benefit of an armpit incision.

4) No caregiver needed.

5) Returning to work would depend on what type of work you do. Five to seven days for a sit down job, ten to fourteen days for a very physical labor job.

6) Surgery is booked based on your schedule. You are the one making the big effort so we accommodate your schedule.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in facial thinning. I have a soft tissue region around the jaw area (just below the TMJ), it is a narrow strip that runs along the back border of my jaw as it goes from the angle to the TMJ. This region flares out and gives the appearance of an overly wide face. I have been to some parotid specialists and they have confirmed that I have no parotid swelling and that it is other tissue – SMAS/fatty tissue. I am about 10% body fat, so it is not because I am overweight. I was wondering if you could reduce this region of the face by removing this tissue?

A: The area on the face to which you refer is composed of the parotid gland and the SMAS layer. Undoubtably the greater fullness in this area is whatever size the parotid gland is. The SMAS layer is not that thick particularly at only 10% body fat. Can the SMAS layer be thinned out/removed in this area? Yes although there are branches of the buccal facial nerve that are at some risk of injury and removing the SMAS over the parotid gland creates the risk of a parotid sialocoele or salivary leak. All of these risks associated with lateral side of the facial thinning are done without knowing whether it would make much of a difference. The best way to answer that question is to get an axial MRI of the face where that question can be answered.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  When you do a chin reduction, how do you determine beforehand how much bone can be vertically removed. You mentioned about the panorex film (I think this is just a dental x-ray but I could be wrong) I think it is pertinent that I get you a copy so you could realistically tell me how much of a reduction I could likely achieve. This way I will know for sure whether there is a noticeable reduction. I would prefer more of a noticable reduction so it seems like the submental approach is advisable- but what about the scar on my chin, how long will it be and where exactly is it made?

A: A panorex is the ‘wraparound’ dental film that you may likely already have in your dentist’s office. In a submental chin reduction, the incision is on the underside of the chin and the key is to keep it curved (following the curve of the jawline but behind it) and to not have it extend any further underneath the chin horizontally than the distance between vertical lines dropped down from the corners of the mouth.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in temporal implants. Anatomically speaking, can you please explain to me where exactly the temporal implant will be placed- I have a vision in my mind but it may not be accurate. Will the apex of projection be between the eyes, higher up near the brow ridge, or lower beneath the eyes. Also the size of the implant, vertically speaking, how much length does it typically occupy- I imagine 5 cms or so.

A: The temporal zone can technically be divided into five regions based on the its aesthetic problems and the procedures needed to treat them. But in your case I am only going to refer to zones 1 and 2. Zone 1 (the most common area augmented when treating temporal hollowing) is between the zygomatic arch and the mid portion between the vertical distance of the zygomatic arch and the anterior temporal line. (just above the eyebrow level) Preformed implants are placed beneath the fascial covering of the muscle (not directly under the skin) to augment this area from an incision way back in the temporal hairline. Zone 2 is the area between the top portion of zone 1 and the anterior temporal line and is rarely augmented this high unless one is looking for a completely smooth transition from the forehead and the temporal region which also implies one is looking for greater convexity/fullness in the upper temporal area. Such Zone 2 augmentations can be done with large preformed implants (although they will far somewhat short of the anterior temporal line) or custom temporal implants made to fit on top of the fascia. (subcutaneous location) The vertical height of the preformed temporal implants ranges from 4 to 4.5 cms.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a subnasal lip lift. When you perform them, how is the healing of the scar? I know the scar is placed at the base of the nose, but I have seen some horror stories where the incision is just below the nose and thus is very visible. Do you also pull the muscle or just the skin with the lip lift? I have a 21mm gap between the base of my nose and my upper lip. After my rhinoplasty (which I am having first) I am presuming this gap will stretch to approximately 23mm- in any case I am hoping to have a 15mm gap.

A: The key to a good subnasal lip lift scar is two-fold; place it exactly in the nasal-lip crease and it should follow the shape of the nasal base (wavy) and not a straight line. You never manipulate the orbicularis muscle in a subnasal lip lift, that is an assured way of causing tightness and smiling animation deformities. With a 21 to 23mm lip to nose distance and using a 1/3  distance reduction (amount of skin excised), you should be reduced to a 15mm vertical length.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in treating my tear troughs and knowing more about the Lobe procedure for treating them. I already have orbital rim/tear implants in to fix my lower eyelid depressions but they are not quite enough. A plastic surgeon that I consulted with mentioned that I might be a good candidate for the Lobe procedure but didn’t tell me what is was ot how it was done.

A: Fat transposition of the lower eyelid was originally described by Dr. Loeb in 1981 for treating tear troughs. Rather than removing fat from the lower eyelids, he was the first to describe sliding it or moving it over the lower eye socket rim to fill in the tear trough depression. As the tear trough problem has come front and center today, the concept of such fat transposition as taken on a new life and is now very popular. Different techniques have been described for doing it with subtle differences between them. It can be done either through a transconjunctival or open lower eyelid approach. It now has a place in the realm of tear trough treatments which include injectable fillers, fat injections and tear trough/orbital rim implants.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am in need of a special type of lower blepharoplasty. I had artefill injected under my eyes and have been having problems with it. Have you ever removed artefill in combinaion with a lower blepharoplasty before?

A: When it comes to lower eyelid procedures, I have seen may different materials placed in the lower eyelid tissues and along the bony orbital rims and orbital floor.  I have removed in the past lumps of fat, clumps of artefill/artecoll, goretex strands and Medpor implants while doing lower blepharoplasties. Many of the particulated injections are often in the orbicularis muscles but because they are usually in clumps. Most of the material can be dissected out and removed as part of the lower blepharoplasty procedure. Your case illustrates the potential problems with using particulated fillers in the thin tissues of the lower eyelids. The appeal of a permanent filler is great but every particulated filler with non-resorbable particles has a great propensity for clumping and fibrosis.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am writing because I have a quick question regarding cheek implants, which we had briefly discussed, vs fillers. I may have rheumatoid arthritis and I’ve heard that injectable fillers aren’t the best route with autoimmune disorders. I’m curious to know if cheekbone implants would be any better, and if you offer any that are non-silicone.  I would be grateful to read your thoughts on this topic.

A: The use of injectable fillers in patients with known autoimmune diseases is a bit of a mix bag. Historically the thought was that only collagen fillers should be avoided since they are a foreign collagen processed from a bovine source, hence the understandable apprehension when the body is injected by that material.  But more recent anectodal reports have come out that indicates even the very popular and well tolerated hyaluronic acid-based fillers may pose some concern. This has not been definitely proven and it may just represent the general ‘reactivity’ of the autoimmune patient to any stimulus, but the safest route would be to avoid any injectable fillers and lower the risk of that concern to zero.

This, of course, raises the question of whether any cheek implant, regardless of the material, might not pose the same risk…although they have not been to my knowledge in the medical literature or experience. Your concerns about silicone cheek implants is understandable although that feeling undoubtably comes from fluid-filled silicone breast implants of yesteryear and not solid preformed silicone facial implants. But alternative materials for cheek implants include PTFE-coated silicone, Medpor (porous polyethylene), pure PTFE and mersilene mesh. Whether these are all chemically and structurally different than silicone, whether one is better in the automimune patient is not known.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in the FATMA lip augmentation procedure. I was born with a strawberry mark on my top lip. I had two surgeries to remove it, one at 6 months old and the other one at six years old. This has left me with a notch deformity in my upper lip. I am now looking into the FATMA procedure to help enhance the top lip to look more even and natural.

A: The FATMA lip procedure, as you undoubtably know, is an acronym for combining fat grafting with a mucosal advancement. While the acronym makes it sounds like it new and novel, the reality is that such lip reshaping procedures have been done for decades. The most common use of these two procedures historically is in reconstruction of the cleft lip deformity of which there is often a notch deformity at the vermilion. An internal V-Y mucosal advancement/roll out is done to lengthen and level the deficient vermilion edge and then a fat graft is added underneath it for volume. In this case the fat graft is usually a solid composite dermal-fat graft. The so named FATMA aesthetic lip reshaping procedure applies these same principles to a small but normal shaped lip using two internal muscosal advacements and fat injections. Whether your lip deformity should be treated by which variation of the FATMA procedure awaits seeing some pictures of it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a Brazilian Butt Lift (fat injections to the buttocks) but I have a few questions. I want at least 900ccs of fat injection done. Are you able to meet this request or do you have a fat injection limit? I want my upper and lower abdomen, flanks and lower back for the taking of the fat to accentuate my buttock. Please let me know if this is possible. Thanks

A: When it comes to the Brazilian Butt Lift (BBL) and the amount of fat that is injected, the first important question is how much fat does a patient have to give. Liposuction is used to harvest fat from as many body sites as is needed. In thin patients with little fat, a BBL procedure may not be possible. In patients a moderate amount of fat will have to accept a modest BBL result. In patients with more fat then a large amount of donor material can be obtained and a bigger result will occur. The second issue in a BBL is to understand that concentrated fat is injected not just the liposuction aspirate only. Just because 2 liters of fat aspirate is obtained, for example, does not mean that 1liter can be injected per buttock. Rather the liposuction aspirate must be filtered and concentrated so that only pure fat is injected. As a general rule, about 1/3 of the liposuction aspirate turns into concentrated fat. Thus 2 liters of aspirate becomes roughly 700ccs of fat and that means 350cc can then be injected into each buttock.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a sliding genioplasty revision. Four weeks ago I had a sliding geniplasty but I now think it was moved too far forward. It is easier to change the chin bone now or wait until it heals. Will the chin bone become harder to correct with time? I was not aware as I thought the soft tissues should be healed as to not disrupt muscles etc (this apparently takes 12 weeks), and I still have numb areas on the right side of my chin.  Weighing up the pros and cons overall, when is the best time to perform the operation to achieve a better chin result?

Also, I had a rhinoplasty two years ago but have never been happy with my tip. It is still bulbous, maybe even bigger than it was before. Should the revision be done open or closed?

A: A revision of a sliding genioplasty can really be done at any time whether the bone is completely healed or not. The time to do revisional surgery on your chin is based on two considerations, when you are certain that the result you have is aesthetically unacceptable and the state of the bony union of the osteotomy. On the one hand, you would ideally like to change the chin before the bone has completely healed. (6 to 8 weeks) On the other hand, you never want to do a revision before the final result is seen so the patient has time to both adjust to the new look and is certain that a change is needed. You can see how both of these concepts must mesh to pick the ideal time for a revision. The state of the soft tissues (muscles) has really nothing to do with it.

In regards to the nose, the best chance for an improved outcome is an open approach where the needed and desired tip changes can be done under direct vision.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a rhinoplasty that changes the upper part of my nose. The lower half of my nose is fine but I have a large nasal hump and would like to get it reduced. In playing with some online imaging programs, I have noticed that removing the nasal hump actually looks worse in my opinion of the nasal radix is not also reduced. If the radix is not reduced it makes my nose and forehead appear as one with a sloped straight line, making more forehead looking like ‘volvo windshield’ in a profile view. If I am not given more of an obvious nasofrontal angle, my forehead will look weak Getting a good nasofrontal angle is the most important point of a rhinoplasty to me. How can this be effectively be done?

A: One of the more obscure aspects of rhinoplasty surgery is radix reduction.  Radix augmentation is more common in many hump reductions. But in very large hump reduction in which the nasal bones are high and extend into the glabellar region of the forehead, radix reduction may be needed. In looking at your pictures your assessment is correct, a break between the forehead and your nose is needed to avoid a complete connected slope effect of the forehead down through the nose. Significant radix reduction as part of a rhinoplasty can be done by one of two methods; a guarded rotary burr or a percutaneous osteotomy method. Having done both, I find the osteotome method to work well when a really deep notching of the frontonasal angle needs to be done. This is done by using a 2mm osteotomy placed through the skin at the bridge of the nose creating one bone cut into the frontnasal angle, The other osteotome cut is done from inside the nose to complete the 90 degree angle creation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a chin reshaping/chin reduction procedure. My chin is fairly square and big and I feel very insecure about it. It’s not big to the point where it’s the first thing people notice, but I hate it so much and I think it makes my otherwise feminine face look disproportionate. What can be done to reshape a chin? It seems to be one plastic surgery procedure where very little is written about it and very few plastic surgeons actually do it. How is it done and what is the recovery like?

A: There are numerous option in chin reshaping/reduction surgery. Your chin is wide and square for your face and even maybe a bit vertically long. It does not appear to be to protrusive or horizontally long which is a key feature that affects how chin reshaping is done. .Your chin can be reshaped to be slightly shorter and more narrow through an intraoral genioplasty approach. From inside the mouth, the bone is cut, like a sliding genioplasty, and narrowed and then put back together, thus leaving no external incisional scars. This will create a more tapered chin that is more triangular shaped rather than square as it is now. Any bony chin surgery is associated with a fair amount of swelling that will take about three weeks to enter the benefits phase and a full six weeks to see the final result.

Dr. Barry Eppley

Indianapolis, Indiana