Your Questions

Q: Dr. Eppley, I currently have 300cc cc moderate plus silicone breast implants in place whichi were placed eight years ago. I have decided to go bigger and am going to get 650cccc high profile Mentor silicone breast implants through my old inframmary fold scar. My current implants were originally placed under the muscles with complete muscular coverage. Now that I am getting new implants I have read that most plastic surgeons now put them in a dual plane position instead of completely under the muscle. Do you think this dual plane location is better than what I have now and will it give me better results?

A: Historically breast implants were placed in a completely submuscular location. That technique today is largely passé and has been replaced by the dual plane method. What this means is that only the upper half or so of the implant is covered by muscle while the bottom half sits below it. The dual plane technique has become popular because it produces more natural looking results by not having the implants too high. This has also become necessary because the average size breast implant placed today is larger than that which was placed fifteen to twenty years ago.

This discussion for you, however, is largely irrelevant. When making a more than 100% increase in your breast implant volume, it will not be possible for the implants to remain completely under the muscle…even if you wanted it so.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to know your experience with breast augmentation revisions. Is this something that you have done often? I am considering revision from saline to silicone and believe I’d like to go smaller. My previous surgical site for the augmentation was axillary and can this be done again with a revision? Any information you can provide would be greatly appreciated.

A:Any plastic surgeon that performs a substantial number of breast augmentations will perform secondary breast implant surgery, given desires of changes in size later in life, change in breast shape due to pregnancy and weight loss and the eventual failure of most breast implants over a patient’s lifetime. So yes I have done many breast implant exchanges and revisional surgery.

I believe you are asking if your existing saline implants could be replaced with smaller silicone implants through your already present axillary scars. The answer to that question is maybe…and it depends on what size silicone implant needs to be inserted through such a small incision. In days past, I would say it would not be adviseable unless the silicone implants are fairly small (under 350ccs). But with today’s funnel insertion technique, much bigger silicone breasts implants can now be placed through much smaller incisions.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have an eye problem. My right eye is lower than my left by a few millimeters, I can tell because when I look straight in the mirror it looks lower as judged by the level of the pupil. I got punched in the face about five years around broke some bones around my eye but never had surgery. They said it wasn’t bad enough to have surgery at the time. But my eye has slowly sunk down over time. Is there a way to fix this?

A: What you have is called enophthalmos where the eyeball has dropped lower due to lack of bone support or fat support underneath. Most likely you had an orbital floor fracture which was not significantly displaced so surgery to fix it was not done at the time. But over time, fat atrophy may have occurred which is another well known cause of enophthalmos after such floor fractures. The best approach is to build the floor back up with a synthetic orbital floor implant. The question is whether you have enoughenophthalmos to justifiy the surgery. But then you likely would not be asking me about it if it was irrelevant to you. If done through a transconjunctival approach then the procedure would not create any new skin scars. The risks of such surgery would be persistent undercorrection, overcorrection, implant shifting and potential infection. The aesthetic side of these risks are more likely.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 25 years old and have a chubby face. I am slightly overweight but not as fat as my face makes me look. I am very self concious about my oversized cheeks. I also have a double chin which is very noticeable and unattractive. Do you think a buccal fat pad removal would help me? I have read on the internet that removing it may make your face look too thin down the road. However, I feel that I  will always be stuck with a fat face and chubby cheeks as both my parents look the same way. Please advise on what you think would be the best way to help reduce the fatness in my face. Also, are there any less aggressive or non-surgical ways to lessen the fullness of my cheeks and chin? I have attached some pictures of me for your review.

A: In looking at your pictures, I can assure you that nothing short of surgery will help reduce the fullness in your face. I would recommend buccal fat  removal, submental/neck liposuction and maybe even a small chin implant. These are some standard techniques in faces such as yours to make a visible difference. While these will not necessarily make your face, they will go a long way to reducing some fullness. It is also important to realize that buccal fat removal does not address all areas of the cheek region in reducing fullness. You will also benefit from liposuction of the perioral mounds and above the nasolabial fold, two areas that are full but lie outside  any effects of buccal fat pad removal.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have previously had breast implants placed below the muscle and donut lift around the nipple. While I thought that would be the best way to get my breasts uplifted and have a batter shape and avoid skin scars, it did not turn out like I thought it would. My breasts are too big and the nipples point slightly downward. I have read that the nipple can die in these more aggressive or full breast lift surgeries. Obviously I don’t want that to happen. What can I do or how should the surgery be done that would afford me the least chance of blood supply problems and loss of the nipple?

A:  When it comes to getting the sagging breast really uplifted, I have rarely found the donut breast lift very satisfactory. So I am not surprised that you have had a similar experience. The one important thing that you can do with any type of breast lift or reduction surgery is to not smoke before or after surgery. If you are not a smoker, great. If you do smoke, you should quite one month before and continue cease smoking for one month after surgery. Fortunately, your breast implants are below the muscle so the blood supply to the nipple has not been previously disrupted. This makes the potential problem with nipple healing after more extensive breast lift surgery unlikely.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I don’t like the idea of losing consciousness under general anesthesia or IV sedation. Would it be possible to undergo cheek augmentation with malar cheek implants with only local anesthesia? I am very tough and I am not afraid of surgery or the sounds of surgical instruments at all, but I don’t want to feel any pain during the procedure. Is it possible to numb the midface area completely? Would you do cheek augmentation under local anesthesia if the patient is aware of the fact that this might be very uncomfortable?

A: While any type of procedure can theoretically be done under local anesthesia, that does not mean it is always a good idea. I have never done cheek implants under straight local anesthesia since it is a bone-based operation. I am sure one could get through it, but I could not promise that it would be completely pain-free. In addition, the most important aspect of the procedure is to get the implants into the correct position. You would not want anything to limit that objective. Always remember the purpose of the operation is about getting the best surgical result, not about how little anesthesia is needed. There are no rewards for seeing one ‘tough;’ one can be. In short, this would not be something I would advise or do… as I know well how this story would play out. To quote an anesthesiologist whose skill and experience I admire…‘the patient who states that will be just just fine under local anesthesia is exactly the patient who won’t be’. I would recommend that you do not have this operation unless you can come to the acceptance of doing it under sedation or general anesthesia.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want to get a flatter tummy, actually very flat. My hips may be a little big, which I can not change, but I know I can do something about my stomach. I have thought about a tummy tuck but wanted to know if a flat tummy is possible with just liposuction? If not am I a good candidate for a mini tummy tuck with less scar or do I just need a regular tummy tuck? I originally just wanted a regular tummy tuck to get rid of stretchmarks around my belly button. However, I think that if my tummy was flat by liposuction then the appearance of the stretch marks would be reduced. Does this make sense? I have attached some pictures for you to see what I look like.

A: While liposuction will reduce fat, it does not get rid of loose skin or stretch marks. It sounds like you intuitively know that a tummy tuck is a better choice but are hoping that you could get by with liposuction alone. Your gut instincts are correct. You will be happier with the results from a tummy tuck as excess skin is as much your stomach problem as fat. The debate between a full vs a mini tummy tuck is a classic one for many patients. The reality is that a full tummy tuck provides the best stomach contouring and is usually worth the extra scar length. Mini- tummy tucks are usually best in thinner women where a large skin excision would leave a very high scar placement.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a scar in on my abdomen (from surgery on my pancreas and spleen) running from my diaphragm to just below the belly button. It goes through my belly button, and thus my previously “innie” belly button is now a bloated mess, let alone the “train tracks” on the scar running through my abbs. I wish to remove the train tracks, fix my belly button (make it an innie again) and fade the scar as much as possible. I’m mainly looking if it can be done and how effective would it be?

A: I would like to see a picture of your abdominal scar to determine what is possible. But having seen many such scars before, I would imagine that it can be completely excised including the suture tracks if there is enough lateral abdominal skin laxity. At the least, the scar can be narrowed considerably. The convex shape of the belly button can be converted back into a concave or inverted form at the same time. Given that the vertical abdominal scar runs completely vertical and perpendicular to the relaxed skin lines of the trunk, a subcuticular skin closure needs to be done with a secure suture such as that offered by the Quill line of barbed resorbable sutures. This can produce a very nice improvement from abdominal scar revision.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in reduction rhinoplasty, alar base reduction, cheek bone reduction, and jaw reduction. I have diamond face jaw bones and cheek bones which are prominent and also have a big nose with an asymmetric alar region. I need a beautiful symmetric face with small nose and beautiful cheeks. Do you think this is possible? I have attached some pictures for your review and imaging.

A: Thank you for sending your pictures. I have taken a careful look at them and have imaged an open reductive rhinoplasty.  Your nose, as you know, is the largest feature on your face and is disproportionate in size to every other facial feature. While there is a limit as to how refined your nose can become given the thickness of the overlying skin, you most certainly can obtain significant improvement. When it comes to cheek bone or jaw angle reduction, however, I fail to see how those procedures will make any significant improvement. Your facial skin and tissues are too thick to reveal any bone reduction underneath. You are better off leaving the bone structure as it is to support the thick heavy overlying soft tissues. Your soft tissues will simply not permit a delicate and more refined facial structure that you desire.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have read about nipple reduction surgery and think that it is what I want to have. I am 45 years old but have long had nipples that stick out too far. There is barely any type of shirt that I can wear that hides them. My teenage son who is 15 years old has the identical problem (bad gene!) and I don’t want to see him suffer as I have over the years when there appears to a good solution. Would he qualify for this surgery? Also since we are from out of town can we have a consult and the surgery the same day? Thanks!

A: With parental consent, your son would qualify so there is no concern with that issue. Consults can be done by phone, Skype or e-mail so there is no reason to come for in for ani nitial evaluation when the problem is so visually obvious. I would just send me a picture or two of your and your son’s nipples for my assessment. Obviously they are too long and protruding but it would be nice to see them anyway in advance.

Usually nipple reductions are done under local anesthesia as a simple outpatient procedure. They should not be confused with more complex procedures like gynecomastia reductions.Whether a 15 year-old could handle that or not under local anesthesia I do not know although I suspect so. The toal cost of the procedure is $1500. You would just book the procedure(s) through our office after I have evaluated the pictures so it would be a one-time visit. Dissolveable sutures are used so there is no return follow-up needed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have had injectable fillers placed along the back side of my jaw to give me more of a sharper angle appearance. It was Radiesse and it took two full syringes to get a modest effect. The result was good but I wished it was stronger and more pronounced. I have heard that if you keep getting the fillers they will build up overtime and you will get a permanent effect. Is this true? If it is not, then do you think jaw angle implants will give me what I want?

A: There are no synthetic injectable fillers currently approved in the U.S. that are permanent. So it is not true that repeat treatments of any injectable filler will lead to a long-lasting build up of any facial bone site. Most certainly injectable fillers are not a substitute for the volume and permanency that can be provided by jaw angle implants. What your injectable filler treatment has done is to demonstrate that augmentation of the jaw angle region is aesthetically beneficial for you. That can be very helpful when uncertain if such a facial change is worthwhile. This should give you the confidence of proceeding forward with this implant surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am very unhappy with the result of a rhinoplasty that I had done two years ago. It was a closed rhinoplasty and I wanted to have a more refined and pretty nasal tip. It has ended up, however, being just a balled up fat tip with nostrils that now look bigger. What type of rhinoplasty do I need now to fix it? And can it be fixed?

A: Thank you for sending your pictures. What appears to have happened is that you have lost cartilaginous support of the tip due to overresection of the lower alar cartilages and the caudal end of the septum. The thick overlying tip skin has now just contracted inward without adequate support, resulting in a ball-like tip with excessive nostril show. Your nasal problem most definitely can not be fixed by any closed rhinoplasty method. It will need a rhinoplasty revision using an open approach and cartilage grafting to restore support for the tip to create a more natural shape and decrease nostril show. You will need a columellar strut graft and alar rim grafts to help correct the retraction as well as tip reshaping. These type grafts are best placed through an open rhinoplasty, particularly in the face of a nose that has scar from prior surgery. Presumably these cartilages grafts can be harvested from the septum and the ear.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a chin implant, neck liposuction and a submentoplasty with fat removed under the platysma muscle one month ago. I am 32 years old and had a double chin that could not be improved by any other method.  I wore a neck compression garment faithfully for three weeks after surgery. Despite this, I have very visible lumps and creases which did not exist prior to surgery. Will this resolve? What else can I do to help?

A: A submentoplasty combined with liposuction is a very good but aggressive procedure for neck recontouring. There is no question that it can do a good job of removing fat and tightening muscle, significant anatomic changes to improve a neck profile, but it does not remove skin. Thus it relies on the elasticity of skin to shrink down and produce the final shape. It is not uncommon for this procedure in some patients to end up with skin redraping issues. (irregularities, indentations, creases) That is the one knock on the procedure in my experience. It is still early so some of these skin issues will definitely get better with time. Whether they will completely go away remains to be seen and I doubt if there will be 100% resolution. But this is an issue of time and you will know more by six months after surgery. You would probably benefit by neck treatments such as massage or Exilis treatments which can help with skin smoothing and now is the time to do them before a lot of scar sets in.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a question about Kryptonite bone cement. Can it be used to build up the jawline. I was born with hemifacial microsomia and my jaw on one side is short not very full. My bite has been corrected by a jaw osteotomy previously but the overall side of the jaw is still small and too thin. Would this be a good use for this type of bone cement material? Also what would happen it is got infected after surgery?

A: Kryptonite bone cement is FDA-approved for all craniomaxillofacial bone applications whether it is as an inlay, onlay or any combination thereof. Therefore, it is appropriate  to use it as an onlay augmentative material for the mandible or any other facial bone for either reconstructive or cosmetic indications. So it could be safely used for jaw onlay augmentation.

Having 20 years experience as a craniofacial plastic surgeon with a lot of experience in biomaterials in the craniofacial region, Kryptonite has a very steep learning curve with its use. It handles completely different than every other bone cement material used in craniomaxillofacial surgery.  It would also be a challenge in getting into a site with difficult access such as the jawline. What I have learned in complex cases like yours is to first get a 3-D craniofacial model made from a CT scan. Then use that either to premake the desired implant for other synthetic materials or use it sterilized during surgery to custom make an implant intraoperatively out of Kryptonite. This will help tremendously in getting the best contour shape and in its placement.

Once  an implanted material gets infected, Kryptonite or otherwise, antibiotics will not usually solve it. The material must be removed to cure the infection. The material is simply inoculated, particularly a porous material, and you can’t get rid of the bacteria with drugs alone. They will only provide a temporary amelioration of the infection which will return as soon as the antibiotics are stopped. Clearly this is a problem to be avoided which is why I always mix in antibiotic powder with any bone cement material in the preparation process.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 22 years old and am bothered by my small lower jaw. It is small with about a 1/2 inch discrepancy between my upper and lower teeth. I really dislike my profile.  I had an appointment with an orthodontist last week and he recommended getting braces and then having a lower jaw advancement. This sounds too extreme to me. I was wondering if I can just get a chin implant if I’m that unhappy with my looks. If you were me what would you do?

A: Your dilemma is a classic one and the decision is ultimately affected by a patient’s age, whether they have any masticatory functional symptoms, the magnitude of the jaw discrepancy and what they are willing to go through. From a long-term standpoint at your young age, both functionally and aesthetically, you should have the combined orthodontic and jaw advancement surgery. It is most certainly not extreme and is a routinue maxillofacial surgical procedure. A chin implant, while comparatively simple and providing an immediate aesthetic benefit, would offer no functional improvement for your bite, jaw function and TMJ health.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I have a problem from a previous closed rhinoplasty. I am very unhappy with the tip of my nose. It has been lifted too high and this has exposed my nostrils unfavorably. It also makes my face look flat. What I want is correction through a closed rhinoplasty. Will that work for me and my nose problem?

A: When the nasal tip becomes too shortened after a rhinoplasty,  it will produce a set of classic aesthetic issues including an obstuse nasolabial angle with excessive nostril exposure. It can be corrected through tip lengthening/de-rotation through cartilage grafting. This is not best done through a closed rhinoplasty. The grafts would be hard to place and secure through such limited visualization. An open rhinoplasty would provide much better exposure to accurate place tip grafts and/or septal extension grafts to create a de-rotation effect. The one exception to this approach is if the amount of tip lengthening needed is small. Then the placement of limited tip grafting could be done through a closed approach. I would need to see photos of your nose to determine which rhinoplasty approach may work for your revisional surgery. The only question I would ask is what is the basis for your deference to an open rhinoplasty? The scar is inconsequential and the results are more consistent and superior.

Dr.  Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I am a 27 year old man and I’m thinking to have a surgery to reduce the size of my brow bone. My question is if the look of my eyes would change. Because I have read in other forums that such surgery might change the deep of my eyes of which I love their appearance. I would appreciate very much your esteemed opinion to my concern. Is it justified or not? Thank you very much.

A: It has not been my experience that the depth of one’s eyes appears any different after brow bone reduction surgery. This is because brow bone reduction in men, in particular, is about changing the bulge or convexity of the anterior table bone of the frontal sinus. It does not change very much the lowest edge of the brow bone or reduce it posteriorly which would make the eyes look less deep. I would have to see some pictures of you, particularly from the side view, to make that determination more specifically however. 

Dr.  Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I am having a tummy tuck later this spring and look forward to a beach vacation this summer with my new body! My question is how soon after surgery can I begin tanning? If I have my surgery in May could I get into the ocean by July? How much time should I allow between surgery and these activities? I don’t want to do them too soon and affect my results but I know I will be anxious to do them.

A: The answer to both questions resolves around the tummy tuck scar and making sure it is healed enough to not be affected by these activities. Getting into ocean water, which will have organisms in it that do not occur in chlorinated water,  should be deferred until 6 to 8 weeks after tummy tuck surgery. At this point, you should be well healed including any small areas of potential suture extrusions. The effects of tanning and sun exposure on your tummy tuck incision, however, is a much different concern.  Both tanning bed and sun rays can adversely effect how the scar may eventually look so such exposure should be deferred until it is well healed for at least three months after surgery. If you must use the tanning bed, I would cover the tummy tuck scar with tape until then to block these undesired rays. 

Dr.  Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I have saline breast implants placed under the muscle now 11 years ago. I have been very happy with them and have had no problems at all. I was originally told by my plastic surgeon that they will last anywhere from ten to twenty years. Now that I am past the ten year mark, I am wondering if I should just have them replaced now since a deflation could happen anytime now.

A: It is important to realize that breast implants are not life-long devices. They will eventually fail, which means the containment bag will develop a leak. With saline this means the fluid is coming out and the implant will deflate with an external flattening of the involved breast. How long saline breast implants will last and when they will deflate can not be accurately determined. While your breast implants are living on borrowed time, I see no reason to preemptively just replace them. You might as well get the value out of them for as long as you can. While this will someday result in a breast implant ‘emergency’, it can be replaced within a matter of days with no significant recovery. (unlike the first time)  

Dr.  Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I need your help as I have no jawline. My chin is very short, the neck seems to be missing and it appears as I almost have no lower jaw. This gives a profile that I am very self-conscious about. I make every effort so people don’t see me from the side. I know you are an expert in facial surgery based on your writings and patient photos so what do you recommend?

A: Lack of a well defined jawline and neck angle can be due to any one or combination of the following; chin/lower jaw bone prominence, fullness/fat in the neck and loose neck and jowl skin. Most commonly, the combination of a chin implant and neck liposuction can make a dramatic difference in the younger patient who often has a short chin and full neck. In older patients the sagging skin factors in significantly and some form of a jowl or necklift may be needed. There are exception to these two categories, such as the early aging facial patient with a good chin prominence who just needs some neck contouring through a procedure known as  submentoplasty. But when someone describes themselves as having ‘no jaw’, this would indicate the problem is more than just one of the three anatomic components that make up the neck angle and jawline.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, on your website you mentioned orbital implants. I have deep set eyes. Can these orbital implants be placed in the upper eye area to fill in the hollowness. Thank you.

A: No they can not. There is no easily accessible superior bone space above the eye to access without significant risk. Actual implants can only be placed on the floor of the eye socket in which that space is more easily accessible without risk of eye muscle injury. Hollowness of the eyes, however, is rarely treated by implants anyway. It is better treated by fat injections/grafting which is placed between the skin and the underlying muscle. This is far easier to do and more effective. Its risks are largely cosmetic, how well does the fat survive and how smooth is its outward appearance.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, are there any good non-surgical treatments for sagging jowls. I am 56 years old and my neck isn’t too bad. But my jowls make me look like I have a bulldog face. I am not afraid of surgery but am worried about the cost and the recovery.

A: Jowling is always a major facial aging concern for many people as they hit 50 years old and beyond. There are some reasonably good treatments for jowls which are device or energy-based approaches. My current preferred approach is Exilis. This is a treatment based on radiofrequency waves which heat up the jowl fat and skin. This causes some fat atrophy and skin tightening. It requires a series of treatments, at least four spaced two weeks apart, to get the best result. While not as effective as surgery, it can make a very visible difference in the right patient who jowls have not developed beyond what a non-surgical approach can treat. The most effective approach, however, is a jowl lift. Your concerns about recovery are excessive when it comes to this tuckup procedure as it is a quick turnaround from the procedure until you are back into your regular routinue. While sugery is never appealing if it can be avoided, solving the problem in a single setting of an hour’s time can change one’s perception of it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want to have a more shapely and manly chest. I have worked out a lot and simply can’t build up my pectoral muscles very much. It almost seems like I have a muscular deficiency in this area, they just won’t build up to my liking no matter how much iron I pump. I think the only way I am going to get there is with chest implants. Can you tell about how the operation is done and what type of implants are used? I assume it is pretty much like breast implants for women.

A In many ways, you are correct about the similarities between male pectoral implants and female breast implants. Like saline breast implants, pectoral implants are put in through an armpit incision (transaxillary approach) and are placed under the pectoral muscle. Unlike breast implants, however, the positrion of pectoral implants does not extend below the lower border of the muscle. This is a subtle but important placement issue to get the best increase in pectoral muscle outline. The biggest different is in the type of implant used. Pectoral implants are made of a solid (non-fluid filled) silicone elastomer material. It is very soft and has a spongy feel. They can not rupture or ever degrade and will never need to be replaced, which is very different from breast implants which have a limited lifespan.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I have read recently about a procedure that lifts up the cheeks using an implantable device. It is supposed to go away after it is implanted. This sounds appealing but I don’t understand how it works and what happens to it after it is put in. How can something create a permanent effect when it goes away? Since it is used and put in by plastic surgeons and is sold commercially, it obviously is legitimate but I am confused as to how it works. Can you explain it to me?

A: What you are specifically referring to is the Endotine Midface Lift Device.  This is a small platform with small angled spikes on its outer surface that is made of a well known resorbable material known as poly-lactic acid. Many dissolveable sutures are made of the same material. The concept is that the sagging cheek tissues are lifted up back onto the cheek bones and are held there by this device. The device is attached to the bone and the small spikes face upward. The cheek tissues are lifted up on top of the device and are held in place by the angle of the small spikes. This repositions/resuspends sagging cheek tissues back up higher on the bone. The procedure is done through a small incision from inside the mouth. The device resorbs within a year after surgery and is replaced by scar tissue. In theory, the scar tissue then acts to hold the cheek tissues in place.

The nice thing about this device approach to a midface lift is that is fairly simple to perform and is done without scar from inside the mouth. Unlike a traditional midface lift, it does not disrupt the lower eyelid tissues and eliminates the risk of ectropion or lower eyelid sag. For the right patient if performed well, it can be a good midface lift operation. Understand, however, that no form of facelifting is permanent. As the device goes away and with time and aging, some cheek sagging will return.  

Dr.  Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I can’t figure out whether I need a full or a mini-tummy tuck. After having two children what bothers me most about my stomach is the little bit of loose skin and the stretch marks between my belly button and my mons. Interestingly, there is no loose skin when I am standing straight but it appears when I am bending over. I am 32 years old and in very good physical shape at 5’ 2” and 106 lbs. My abdominal muscles feel very taut and I don’t think they are separated at all.  I also have a hole on the upper part of my belly button from a prior piercing that I would like removed.

A:  Your description of your abdominal concerns is a common one and you are what I call a plastic surgery ‘tweener’. This means one is stuck between two procedures and can go either way. Either type of tummy tuck can be done on you.l Understanding which way to go requires an understanding of the trade-offs of making either choice. A full tummy tuck, removing an ellipse of skin from above the belly button down to the pubis, will eliminate all loose skin and will avoid the sag you now see when you bend over. But the final scar will be horizontally long and will end up high, about halfway between the new belly button and the pubic region. A mini-tummy tuck will result in a smaller scar that can be kept down quite low but will result in less skin removed and there will remain some small sag when you bend over. The decision comes down to whether you value the most amount of skin tightening or the best scar location and size.  

Dr.  Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had breast augmentation three years and had PIP breast implants placed. Since the scandal about PIP implants has been reported, I am concerned about whether my breast implants are safe to have in my body. I don’t want some inferior low-grade silicone material inside my body. Besides getting the implants out and replaced, I also want to go a little smaller. I currently have 475cc implants in and want to downsize them to 400cc, maybe 375cc. Do you think I will develop any sagginess of my breasts if I do so?

A: The answer to what happens to your breast tissue when implants are downsized is not straightforward. There are numerous factors that can affect what happens when the size of the balloon is deflated somewhat. The most important factors are the elasticity of your breast skin and what it actually looked like before the breast implants were placed. Also, whether the implants are positioned above or below the muscle also plays a role. Given that you are considering an implant downsizing of 75cc to 100cc, or 16% to 21% total implant volume, the overlying breast tissue will lose significant support. Sagging could develop with this implant volume reduction if your breast skin has limited elasticity or you had some loose breast skin previously. This is an issue  to consider when determining what your new breast implant size should be.

Dr.  Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hello, I am 25 years old and have had twelve IPL treatments. It has disfigured my face, somewhat like a thermage side effect. I have lost all collagen, subcutaneous tissue, and tissue and facial padding. My skin just sags, there is no elasticity or tightness or shape in my face any more, just very thin skin. Would cheek, chin, forehead, and temporal implants help bring my face back? Or can that all regenerate and grow back after time?

A: You did not say why you had the IPL treatments, for what condition, and why so many. But that issue aside, IPL does create a subcutaneous heating effect. When done enough times it is possible to cause to cause subcutaneous fat loss. You are not the first person that I have heard that has had this effect. I would wait up to a full year after the last IPL treatment to see if any regeneration of tissue substance will occur. While I would not be optimistic that it will happen, time will answer that question. If not, then the first thing to consider is injectable fat grafting, perhaps even using a stem cell-enhanced method. You should try and replace what is lost as the first approach. While facial implants are bone-based methods of facial contour augmentation, and they may be appropriate for some facial areas, I would think fat replacement first by facial fat injection. Some combination of the two may also be considered. But I would need to see some pictures of your face for further assessment to provide more detailed recommendations.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am having breast augmentation surgery and am having trouble trying to decide between two different implant sizes. I can’t decide between 375cc and 400ccs silicone gel implants. They seem to look different when putting the implants in my bra. Also, which size will give better cleavage.

A: The difference in volume between 375cc and 400cc is 25ccs or a 6% total volume difference between the two breast implant sizes. This is an insignificant difference that is not visible and is one you should waste o further time thinkingabout. When in doubt between two implants sizes that are so close, always go with the slightly bigger implant. This is because here is no chance that it will make you too big but there is a very real chance that you will have wished you went bigger later. Also understand that stuffing a round implant into one’s bra is not a very good method of implant sizing even though it is done all the time. A much more accurate method is the Mentor Volume Sizing System where the sizers have shapes that actually fit over one’s natural breast, rather than simply smashing it flat with a round breast implant. This provides a much more realistic volume result. Lastly, also understand that cleavage is rarely created by breast implants unless one’s natural breast mounds are fairly close together beforehand. Implants make bras much more effective at creating good cleavage.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting liposuction for my belly area. I am 36 years old and had very successful breast reduction  surgery seven years ago. While I was put to sleep for my breast reduction and had no problems, I am more anxious now considering it since I have two small children. Do you think it would be better to have regular liposuction under general anesthesia or Smartlipo under local anesthesia? I think I want to flatten my hips area as well. It is time to get ready for the summer!

A: You are under a classic misconception that Smartlipo is a liposuction procedure done only under local anesthesia. While it can be done in some smaller areas under local anesthesia, the reality is so can regular liposuction. The type of anesthesia has little to do with what type of liposuction can be performed. But it often controls how good a result one can get from any type of liposuction procedure. How thoroughly fat can be removed from multiple areas largely depends on a patient’s comfort to do so. In my experience, better liposuction results are almost always obtained under general anesthesia. More body areas can be concurrently treated and a more aggressive approach can be taken with how much fat is removed. While Smartlipo can be done under local anesthesia, I have found in many cases that patient comfort and the desire to treat more than one body area make it less than an ideal approach to liposuction fat reduction.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have previously sent you photos of me for consideration of a rhinoplasty and a chin augmentation. You sent back some imaging results and, after reviewing them, I have a few questions: 

1) Rhinoplasty – I like the overall effect! I just wanted to ask if there was anyway you could make the bridge a little more concave, and if it would also be narrower from the frontal view, and if the tip might be narrowed as well?  I know you said that you usually provide an image of the minimum effect that could be achieved, and if this is it, that’s great – I’d still be happy with the improvement. 

2) Chin – I think I like the implant a little more than I like the osteotomy, though of course it doesn’t fix the underlying skeletal problem. I might still consider the implant but I haven’t decided. 

3) Cheeks – One more question regarding my “chipmunk cheeks”. While my friends and family call them “endearing”, I”ve always wondered if I couldn’t have a little less of a balloony cheek especially right below the corner of the mouth. Is there any way of filling in the tissue right at that spot, or (I guess) of removing fat from the cheek (though I do like my dimples!

Thank you for taking the time to answer my questions and being patient with me!

A: In answer to your questions:

1) Ideally I would like the front view rhinoplasty result to be more narrow, and it may be possible, but your thicker skin may preclude that from happening. For this reason, I have imaged it so that the amount of narrowing will reflect what I believe will happen… but I am pulling for more.

2) I would  agree that the implamt effect, while not providing as much horizontal advancement as an osteotomy, seems to be more ‘natural’ looking. It is always best in chin augmentation in a female to be less rather than more. That still preserves a feminine look.

3) You are referring to what is known as the perioral mounds. a cheek fat area that is below the buccal fat pad. That can be effectively treated by small cannula liposuction done from inside the mouth.

Dr.  Barry Eppley

Indianapolis, Indiana