Your Questions

Q: I am interested in getting a chin implant to make my weaker chin look better. It seems like a fairly simple procedure but this bone resorption underneath the implant sort of scares me. Why does this happen? Is there any way to avoid this bone reorption if I get a chin implant?

A: The phenomenon of bone resorption under a chin implant is a much talked about finding for many decades. One of the reasons that it occurs is due to a pressure issue with the implant sandwiched between the soft tissues and the bone. While the implant pushes the soft tissue out, causing more visible chin projection, the soft tissues do apply a small amount of pressure or recoil back over time. Since the implant is not going to resorb because it is an inorganic synthetic material, that leaves the underlying bone to accomodate and relieve this pressure.

This pressure situation is really magnified with implants that are placed too high on the chin bone. This happens when chin implants are placed from inside the mouth and are not secured down to the lower edge of the bone. It can also happen from a submental chin incision approach but is much less common because it it easer to keep the pocket of the implant low. The observation that it does not occur with more contemporary anatomical chin implants is because the wings of the implant keep them from riding up higher, acting like lateral stabilizing bars. From either approach, if the implant ends above the basal bone of the chin (which is thick cortical bone) it rests on bone with a much thinner cortex. This is where bone resorption will be seen with chin implants. It is a function of bone position and is not an actual feature or result of the implant or its material composition per se. This bone resorption phenomenon (which is largely benign and not of any great signfiicance) can be completely avoided by proper implant position on the lower edge of the chin bone. This will also maximize the benefits of the horizontal projection that the chin implant provides, some of which is lost if it gets malpositioned higher as it slides up and back.

Dr. Barry Eppley

Indianapolis Indiana

Q:  I have an unusual question. I’m half Chinese but my eyes are more Caucasian-looking. So I was wondering if there is a surgery to create an epicanthal fold at the medical canthus? ( the one that half covers/hides the tear duct). Some doctor once told it’s possible with a w-plasty or a jumping man flap to create a fold in the inner most part of the upper lid. And is it possible to lower the height of the eyelid? Like taking apart the previous fold and resetting it at a lower position? Many thanks and sorry for all the questions

A: The epicanthal fold area is composed of very thin and delicate skin that is prone to poor scarring, particularly in the Asian patient. Because of this scarring potential, unless the epicanthal fold is really prominent and bothersome, I generally steer away from surgical manipulation of this delicate skin.  Many of the operations described for epicanthoplasty, like the w-plasty and the jumping man flap, create a lot of tiny skin flaps and often scar poorly. They look great on paper and in diagrams, and do get rid of the epicanthal fold, but their scar result may not be a good trade-off. For this reason, I prefer a smaller z-plasty technique for epicanthoplasty which helps open up the narrowing effect that the fold has on the horizontal dimension of the eye.

Your question is one of the reverse of an epicanthoplasty or the creation of an epicanthal fold. I have never heard of that being done and certainly nothing is written about it. In my opinion that is possible through a different orientation of a z-plasty but my concern would be the scarring. As the fold of skin that would normally make up the epicanthal fold would likely have a line of scar on it, that may or may not have a natural appearance.

When you speak of lowering the height of the eyelid, are you referring to the location of the lid margin or the height of the supratarsal skin crease of the upper eyelid?

Please send me some photos of your eyes for my further assessment.

Dr. Barry Eppley

Indianapolis Indiana

Q:  I have heard of rib graft nose augmentation. Is this method better than using silicone implants? It seems that most people use silicone so why rib? Can a rib graft be carved like silicone with  a nice shape ? Can it get warped  and twisted? How many people are fixing their nose using rib grafts? How many people need to be redone because of problems with the rib graft? I want to fix my nose but am scared of using a rib graft because of what I have heard about them.

A: Rhinoplasty with dorsal nasal augmentation can be done using either a synthetic implant or an autogenous rib graft. While there are advocates for both approaches, either one can have very successful results. It is not a function that one is better than the other, they just have different advantages and disadvantages. Synthetic implants to the nose are relatively simple to do and require less operative time and surgical skill to do but they have potential long-term problems such as infection and extrusion in some patients. Rib grafts to the nose are harder to do and require greater skill and familiarity in working with this type of graft as well as requiring a donor site but they do not have long-term problems of infection or risk of graft extrusion.

In my experience, diced rib cartilages to the nose eliminate the risk of warping or twisting and mold nicely for dorsal augmentation. Solid rib grafts must be very carefully harvested, shaped and secured to avoid the problems to which you refer. I have done both techniques successfully and decide between the two rib cartilage graft techniques based on the quality and shape of the rib graft harvest.

The vast majority of patients wanting primary dorsal augmentation rhinoplasty for esthetic reasons, such as the Asian patient, is going to choose a silicone implant because of its simplicity and lack of the need for a donor site.

Dr. Barry Eppley

Indianapolis Indiana

Q:  My daughter has grown in the past two years a strange looking abdominal growth. It doesn’t look like any abdominal pannus picture I have ever seen. She is very obese but has a normal looking white abdomen which hangs down a little. However, directly under (and separate from) this normal looking abdomen is a huge purple/red hanging balloon which is ulcerated and infected. It grows out from under the abdomen right above the pubis. She is scheduled for surgery in a month and the surgeon is acting like he doesn’t know for sure what it is. It is estimated to weigh about 50 pounds. Have you ever run across anything like this in your plastic surgery practice?

A: While it is unusual, I am certain it is not a mystery per se. There are only a certain number of conditions that it could be. Possibilities include a granulomatous reaction from a ulcerated wound in the skin fold, an area of  lymphedema with resultant ulceration, ballooning subcutaneous fat necrosis or benign growths such as large lipomas, hemangiomas or even a teratoma. Whatever the final pathologic diagnosis, it will be removed by wide excision down to the underlying abdominal wall  with a modified abdominal panniculectomy. It does not sound anything like a hernia of which it is in an unlikely location and a CT scan would easily rule that out. A CT scan would also rule out any tumor growths from deeper structures, such as the ovaries.

With a weight of 50 lbs, however, it is much more likely that this is a benign tumor growth of solid tissue rather than any reactive mass.

Dr. Barry Eppley

Indianapolis Indiana

Q:  I want to have breast implants done. I am not happy with the way my breasts look. But I have lupus and am not sure that I can have this procedure with this medical condition.

A: Whether breast augmentation with the medical history of lupus is a good idea would depend on what the extent and how symptomatic this autoimmune disease is in you. Do you have any known healing problems as a result of your lupus? Have you had surgery in the past and did you have any problems with healing or infections after surgery? Are you on any steroids or other immunosuppressive medications? What symptoms do you currently have from your lupus? What are your titer levels of ANA and other blood tests from your doctor?

 Ultimately, what your doctor or rheumatologist would say about your lupus condition would have a lot to say about the adviseability of breast augmentation for you. Despite the past allegations that silicone breast implants cause autoimmune disease from the 1990s, that has now long been disproven.

The issue is are you more prone to breast implant complications from your lupus? Infection risk in the short term and capsular contracture in the longer term are the issues. If you have skin problems, such as banding and contractures, than you would be likely to get problematic breast implant capsules. If not and your lupus is stable and relatively asymptomatic, then breast augmentation may be a satisfactory procedure for you.

Dr. Barry Eppley

Indianapolis Indiana

Q:  What do you think of hyaluronic acid for buttock augmentation? It seems like it would be  a lot easier to do than using your own fat or putting a synthetic implant in your body.

A: While the family of hyaluronic acid fillers are commonly used for very small volume facial augmentation, they are very rarely or never used to try and fill other body areas which require much larger volumes. While it may be a biologically sound concept, it is an economically terrible idea. The volume of hyaluronic acid needed, if we use fat as an analogy, would be around 350cc per buttock or 700cc per procedure. If we use the cost factor in the U.S. of $375/1cc syringe for Restylane that would be a buttock augmentation at a cost of $262,500…all for a result that would last 3 to 4 months. Using Juvederm, which would last twice that long but at a cost of $550/1cc syringe, the procedure would cost $385,000.

While your own fat make not always be reliable in terms of volume survival, it is easy to see that it is a far more economical approach for buttock augmentation.

Dr. Barry Eppley

Indianapolis Indiana

Plastic surgery, unlike some medical specialties, seems to always find its way into the news. 2010 was no exception in this regard. As a plastic surgeon, most of the items that become newsworthy were an incredible mix of the freaky, incredulous and even fantastic events.

Breasts always seem to make the news and the more freaky seems to be better. Whether it is basketball-size implants of quadruple FFFF proportions, dancers subject to IRS scrutiny trying to write off their surgery, or breast augmentation as part of a marathon makeover (aka Heidi Montag), women who seek their ten minutes of fame marr the perception of an otherwise highly successful body contouring surgery. While the real breast augmentation news this coming year will be the introduction of a new form-stable (gummy bear) implants, this will likely be overshadowed by the media’s never-ending focus on celebrities, their breasts and Hollywood’s version of silicone valley.

There is always the continued incredulous news of patients suffering complications and even death at the hands of so-called cosmetic surgeons. This seems to be most evidenced with liposuction, largely due to its popularity and the larger body surface areas that it treats. There is an obvious difference in the size of the trauma to the body from abdominal and thigh liposuction from that of a nosejob or eyelid surgery for example. Liposuction attracts a large number of inexperienced and often unscrupulous practitioners because of the relative ‘simplicity’ of the procedure and easy access to new liposuction devices. It only takes a medical license and a credit card to buy the newer laser liposuction machines. Equipment manufacturers are more interested in sales than safety as evidenced by their marketing and selling behavior. Patients died last year from one coast to the other at the hands of doctors with dubious credentials. The public would think that better regulations would exist but they would be wrong. Doing your homework is your best protection.

Botox continues to show its fantastic benefits and those are not only in those worried about their frown lines or crow’s feet. Last year Botox was approved by the FDA for the treatment of migraines. For some migraine sufferers, Botox injections can be a miracle even if its effects are only temporary. The benefits of Botox have translated into an actual migraine surgery procedure developed by plastic surgeons. If Botox injections relieve one’s migraines, a relatively simple muscular decompression around the nerve trigger points can provide a more permanent amelioration of one’s migraine pain and frequency of attacks. It’s a rare example of a cosmetic treatment turning into a really useful medical or reconstructive surgery, usually that works in reverse.

One other piece of fantastic plastic surgery news from last year has been the emergence of face transplants. While once thought impossible and something more akin to a movie or science fiction, more and more partial or complete face transplants are being done around the world. While the patients who need them are last resort problems of massive facial deformities and tissue loss, that is the history also of all organ transplants which are commonplace today. From the extreme technical advances of today come spinoffs that will benefit many more facial reconstruction patients in the future.

No telling what this coming year will bring, but if past history is any predictor of future events, plastic surgery will continue to make the headlines…let us hope it is largely in the fantastic category.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I would like to get my eyelids done as they are very heavy looking and make me look bad. People tell me all the time that I look tired even though I am not. I am sick of hearing that! My only real concern about the surgery is recovery. How long is the recovery and what will I look like?

A: Thank your for your inquiry. Recovery after blepharoplasty surgery is largely social…meaning how do I look? (how much bruising and swelling will you get) That would depend on whether one is doing only upper eyelids, only lower eyelids, or all four eyelids.. When all four eyelids are done, most people will have noticeable bruising and swelling for up to 10 to 14 days after surgery. If only one set of eyelids is done, it will be less than that. Lower eyelids develop more welling and bruising than the upper eyelids after surgery. There are also different types of blepharoplasties done in which the overall swelling and bruising may well be less, what we call limited blepharoplasties which are either of the pinch type or lower eyelid which use only a transconjunctival (inside the eyelid incision) approach.

There are numerous strategies for keeping the amount of swelling and bruising as limited as possible. This includes pre-and postoperative oral Arnica, keeping one’s head elevated above one’s heart for the first few days and a good icing of the eyes the night after surgery. I also use gentle surgical technique with delicate amounts of cautery to keep down the amount of bruising that can develop.

Dr. Barry Eppley

Indianapolis Indiana

Q:  I am interested in getting pec implants. I have always had a very flat chest with little muscle definition at all. I have done a lot of chest exercises but I have not seen a lot of improvement or at least the amount that I want. I have tried protein supplements, testosterone and even some human growth hormone but I just can’t get the size of pecs that I want. This has brought me to the conclusion that the only way I am going to get there is with an implant. Do you think pec implants will finally help me get what I want?

A: There is no question that pectoral implants will increase the perceived size of your pectoral muscles. Increasing the bulk of the muscle is what they do best from their subpectoral or under the muscle position as they push the muscle forward. Implants are not quite as good as improving pectoral muscle definition with the exception of the lower lateral pectoral border. The question you are really asking probably relates more to implant projection…or how big can the pectoral muscles be made to look.

Pectoral implants have, at most, up to 3 cms. of projection or forward push of the muscle. How significant that is depends on how thick the muscle is to start with. In other words, a flat chest with a thinner pectoralis muscle will show more but it will not be a ‘bodybuilder-like’ result. An already thicker pectoralis muscle in someone who is fairly developed will have a much more prominent result.

Dr. Barry Eppley

Indianapolis Indiana

Q:  I currently have silicone breast implants that became hard and encapsulated. This was treated by having the scar tissue removed and new implants placed. Unfortunately, my implants became encapsulated again. In searching for what to do now, I have several consults with different plastic surgeons and have gotten differing opinions as to my options. One plastic surgeon suggested that I try the scar removal again with the use of dermal grafts and PRP. (??, not sure what this is) Another plastic surgeon suggested that I remove the implants and replace them with fat injections. Is this a reliable method? What would you recommend?

A: Recurrent capsular contracture, although uncommon, can be a difficult breast implant problem. The conventional approach is total scar removal, with or without replacing the implants with those that have a textured surface. If the implant was originally above the muscle, relocating it to a submuscular position can also be tremendously helpful. These combined techniques are probably effective about half the time, maybe more. But when they fail, different strategies need to be explored.

One alternative approach is to wrap the new implant partially in a dermal graft after the repeat capsulectomy. This ‘out-of-the-box’ graft is intended to heal around the implant lessening the risk of new scar formation, essentially serving as a part of the new capsule rather than fresh new scar tissue which has a high propensity for contracture. PRP, also known as platelet-rich plasma, is a concentrate from the patient’s blood which can be sprayed onto the internal breast tissue surfaces. Its theoretical benefit is that it causes less scar tissue to form. The addition of a dermal graft is a more proven capsular contracture approach but the use of PRP has no downside and is simple to apply.

Fat injections as an alternative to the use of a breast implant for the treatment of capsular contracture may be novel but is both unproven and biologically flawed in my opinion. The survival of fat injections in breast augmentation is based on the graft being injected into the midst of healthy tissue where it can survive by revascularization. Injecting fat into a large empty open space would not only have it not survive but would likely become a liquefied pool of oil and fat that is prone to infection.    

Dr. Barry Eppley

Indianapolis Indiana

Q: I would like a normal chin size without cutting or moving bone. Just with a chin implant or injectables. is it possible? I´m not interested in a major surgery such a sliding genioplasty. It seems that I have overbite but my dentist says that my bite is ok and I don’t need any orthognatic procedure. I ´d like to have neck liposuction too. I have a little extra fat below my chin and round the neck. The truth is that I don´t want to go under a major surgery but I also want a stronger chin. Can I achieve this result? I want it to look like a good male chin and not weaker or like a girls´s chin. I have looked at different projections of chin implants and I think that an 8 mm implant would work. I think that an implant with some little liposuction would be ok. I want it to be bigger but maybe more than 8mms kwill make my chin to look like very big. Please tell me what you think?

A: When it comes to chin implant size, there is a fine balance between too much vs too little. For a male, the chin position should ideally be even with the most protrusive part of the lips when see in a side view. While this is a classic anthropometric measurement, and one that is historically espoused in the concept of male beauty, that does not mean it is the most ideal aesthetically for any individual. Some men prefer their chin to be stronger than this measurement suggests while others prefer it to be a little shorter. When trying to decide between two chin implants sizes of a few millimeters difference ask yourself this question…would I prefer to ‘error’ on the side of having the chin turn out to be a little too strong or a little too weak? Obviously you want it perfect but knowing that choice will help make the decision between those two implant sizes.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am a 52 year old female that weighs 127 pounds. Several years ago I was down to 117 pounds and the lower belly pouch didn’t get much better. At that time I was exercising 4 days a week and doing everything I could to lose that belly. This seems to be a family trait as both my mom and her sisters had it. Do you think liposuction can remove this lower belly pouch?

A: There is no question, even without seeing most patients, that the description of a lower belly pouch signifies that they have some excess fat there. So the use of liposuction for abdominal fat reduction is going to be useful. Whether liposuction would be of benefit, therefore, is not really in question. The issue is how much lower abdominal skin do you have and what will happen to it when the lower belly is deflated so to speak. In other words, do you need some type of a tummy tuck with the liposuction? The aesthetic outcome of liposuction is predicated, partially, on how well the skin contracts down once there is less volume. If there are a lot of stretch marks and you can pinch  more than an inch or two of skin, then it is likely than some skin removal (mini-tummy tuck) may be helpful also. If there is a question as to whether skin removal is really needed, you can always do the liposuction first and let that outcome make that decision for you. I would use Smartlipo (laser liposuction) for your abdominal liposuction as that has the best chance of shrinking down the skin you have the best.

Dr. Barry Eppley

Indianapolis Indiana

Q:  Dr. Eppley I need your help with my cheek. Several years ago I was involved in a fight and got struck on the left side of my face. At the hospital they diagnosed me with a cheekbone fracture but I never got it fixed since I didn’t have insurance at the time. The left side of my face is asymmetric now to the other side and I want to get it fixed. I will describe the problem as I see it. If you look at about an inch down from my left eye, that area from the middle of the top portion of the cheek toward the edge of my nose is flattened. It has no definition like my other cheek. The flatness extends down toward the middle portion of my ceek also. It appears to me as the complete area is shaped like a sideways triangle toward the rear. Also in the same area about an inch under my left eye, right on top of the upper portion of my cheek, it appears as if that area has dropped down. Do you think the bone needs to be rebroken to be fixed or can some type of implant be used to fix it? Thanks for your time.

A: Your description of the left cheek/midface deformity is exactly what one would anticipate from an incomplete zygomatic or cheekbone fracture. As the zygomatic complex, when fractured, can only rotate downward and inward toward and into the maxillary sinus you will lose some cheek and underlying anterior maxillary projection. Because you have described no changes in the eye area or numbness of the cheek and teeth (infraorbital nerve impingement) your original zygomatic fracture is incomplete and less severe than a fully displaced fracture. Given the age of the injury and the now healed bone, a modified cheek implant placed across the anterior maxillary wall and up onto the anterior zygoma should do nicely to restore the bone fullness lost. Given the modified position of such a cheek implant, it would need to be secured by multiple screw fixation.

Dr. Barry Eppley

Indianapolis Indiana

Q: I have had two babies in three years and have lost nearly 50 lbs through an aggressive diet and execise program. While I have defnitely seen some body changes, I am not happy with the way my breasts and stomach look. I thought with all of this working out that my stomach would look better. I have loose skin and stretch amrks around my belly buttonm and my breasts droop and are floppy. I have read about a plastic surgery procedure called the Mommy Makeover.  What is sone in this procedure and can it be done all in one surgery. I am worried about recovery time and getting back into the gym for my workouts. Thanks!

A: The Mommy Makeover has become a popular plastic surgery procedure amongst mothers between the ages of around 25 to 45, although it can be done at any age. It has gotten this catchy name because the procedures involved help reverse the effects that pregnancy has ravaged on a woman’s body. These procedures have been commonly done for many decades so they are not new. They have just been put together and ‘packaged’ for this specific set of female body problems, that being the breasts and the stomach areas. Breasts frequently have lost volume (deflated) and sag and the tummy has loose skin and stretch marks. The combination of breast reshaping (implants with or without a lift) and some form of a tummy tuck (with or without liposuction) is the backbone of a Mommy Makeover. They are almost always done together if a patient’s economics permits. While this combination of a breast augmentation and tummy tuck will have a dramatic change on one’s body, you must tone down the concern about getting back to working out as soon as possible. This is a setup for after surgery problems. It is understandable that you have an addiction to working out as you would not have gotten this far without doing so.  But that same addiction, which you think is good, is not so good after this kind of surgery. You must mentally plan on 6 weeks before getting back to working out like you are now. Remember that in a span of a few hours you are going to make changes that you can’t do by working out for the rest of your life. The risk is not worth it for a few extra workouts that, in the big picture, will gain you nothing.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am going to get cheek implants but am concerned about them moving around afterwards. I am an extremely athletic person who works out a lot. This involves running and jumping around a lot. I do participate in conatct sports such as basketball and flag football. However, I don’t do boxing and am not planning to get punched in the face. (who does really?)  My cheek implants will be the Conform malar shell type so they are not small. Do you think just suturing them in is enough or should they be secured with screws. Which method is best for me?

A: What makes cheek implants different from other facial implants is their bony position. Sitting on the side of the cheek bone, with no bone support underneath them, makes them more prone than many other facial implants to shifting or malpositioning. This risk is magnified by their path of insertion from inside the mouth which opens up the southern avenue for shifting. While most cheek implants do not experience these problems, the risk is not zero. Because of this concern, it is my preference to almost always screw fixation for cheek implants. This makes me feel the most comfortable that the postoperative risk of implant shifting is virtually eliminated. the appeal to me of screw fixation is that it is also easy to do, involves no risk, is done at minimal extra cost, and adds essentially no extra time to complete the procedure.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am interested in Female Feminization Surgery which would encompass brow bossing reduction, hairline lowering, rhinoplasty, chin and jaw shaving and breast augmentation. I am considering doing the FFS either all at once or in two parts. I am male to female transgender. Can you provide me some details or specifics about what I need to consider for each of these procedures.

A: All of those Facial Feminization Surgery (FFS) procedures certainly can all be done as a single procedure and are not too excessive for one operation. If you were to do them in stages, I would separate them into the facial procedures as one set of procedure and the breast augmentation as a separate procedure.

A few comments about your proposed FFS procedures:

Hairline lowering – Whether that is possible would depend on your hairline now and where it is located. Some FFS patients have to consider hair transplants instead if their hair density is very thin or too far back.

Brow Bone Bossing – There are two methods based on the degree of bossing, burring reduction (tail of brow only) or frontal sinus wall setback (if the whole brow is very prominent) It is impossible to know which is best for you without seeing a picture. The relevance to this difference is prinarily a cost issue. Frontal sinus wall setback requires some tiny plates and screws to hold the reshaped bone and takes a little longer to do.

Rhinoplasty – There are two different types of rhinoplasty, limited and full. The full rhinoplasty requires more work and is almost always needed when there is a hump reduction needed. Limited rhinoplasty is where only the tip is manipulated/changed.

Chin and Jaw Shaving – For most FFS patients, this is largely burring reduction or saw shaving of the inferior border although sometimes the chin bone may need to be shortened vertically as well as setback.

Adam’s Apple – Any issues here? I am supposing not since you didn’t mention it.

Breast Augmentation – The only issue here is saline vs silicone gel breast implants. That is just a cost difference issue

Dr. Barry Eppley

Indianapolis Indiana

Q:  Hi, I’m 25 and have a really flat area at the back of my head. I’m very self-conscious about this since I was 15. Is there any way that I can fix this for a cosmetic purpose. Can something be implanted at the back of my head? You are my only hope now. If I can get the new round back of the head, I will also get a new life with your help. I have attached some of the pictures of my head taken on the side. Whenever I look at it, i just want to cry. And I’ve mentally suffered from this flat head shape since I was a teenager. If you could possibly please tell me, what needs to be done, and how long does it take to recover after the operation, I would appreciate your help and time so much.

A: Thank you for sending your pictures. I can see how flat the back of your head. The best and most economical way to augment and expand the back of your skull is through an onlay cranioplasty method. This involves putting a material on top of the bone to build it out. Given the amount of material needed, I would recommend acrylic or PMMA. Other materials exist but they are exponentially more expensive. There is even an injectable technique using Kryptonite Bone Cement, and that would be a good option for you, but that would be a cost issue.

To summarize, you can do an occipital cranioplasty by either:

1) An open cranioplasty approach with acrylic or PMMA, PMMA is a very firm material, is the least costly and must be put in through an open approach. (meaning a long fine line scar in the hairline) It would be a two hour procedure under general anesthesia.

2) The other option would be an injectable approach using Kryptonite cement. This would only need about a 2 inch incision. This procedure would take about an hour to do.

The fundamental difference between the two procedures, besides the incision/scar, is the cost of using the material.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am 23 years old and am interested in breast augmentation. I know that there are different types of implants but I am most intrigued by the gummy bear implants that I have read about. They sound like the best type of breast implant to get but are there any real downsides to them? What do you think of them?

A: The term, gummy bear breast implant, is a layman’s term and not an actual name of a breast implant. I am not sure of the history of this name but I have heard the term was coined by a plastic surgeon. It is a new generationand innovation of a silicone breast implant, technically a third-generation gel filler material. Think of the original silicone filler material as a Type I which is more runny like thinner molasses syrup and existed up until 1991 when it was removed from the market, A type II gel implant filler is in newer and current breast implants, released commercially again in 2006, and is more cohesive like very thick molasses syrup. A gummy bear implant would be a Type III gel filler and is much more cohesive or stiffer like the gummy bear candy. (hence the name)

From a manufacturer’s standpoint, they have been known as the 410 implant (Allergan) and the CPG implant (Mentor) and have been in clinical trials for years. All manufacturer’s clinical trials with these implants are now closed and under FDA evaluation. It is possible that they may be commercially released by the FDA in 2011 but that is not a certainty.

The biggest advantage to the gummy bear implant is that the gel filler material is more cohesive and has no risk of leaking. It does feel more firm which some patients may feel is an advantage. It will be introduced initially as an anatomically-shaped (tear drop) shape with a textured surface. Because of these features, it must be placed through a lower breast fold incision to ensure proper positioning of the shaped breast implant.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I had saline breast implants placed in 2003. Last week I developed some mild discomfort in my right breast which was just sort of achy. I thought my right breast was getting smaller right after but now I know for sure. My right breast looks much smaller than my left now so I think I have developed the dreaded deflation. I remember something about a warranty program in case this happens. What do I have to do now to get my breast implant replaced for free?

A: The risk of saline breast implant deflation is always a lifelong possibility. While most patients will enjoy the benefits of their saline breast implants for an average of 10 to 15 years, deflation can certainly occur much earlier. Since breast implant failure is one of the known complications of breast augmentation, patients need to be aware of the manufacturer’s warranties. There are two levels of implant manufacturer warranties; implant replacement and monetary contribution to the cost of replacement surgery. Over the years these two warranties have changed and it is important to contact the manufacturer (Mentor or Allergan) and find out what was in effect from that manufacturer in 2003.

In general, replacement of a failed breast implant is usually lifelong and never goes away. Money to be provided to help defray the cost of replacement surgery is usually time limited at 10 years currently. (less in 2003) That amount was $3500 in 2010 but likely was only $1200 in 2003. That money is not given up front to the patient but only months after the surgery is completed so patients have to wait to get their partial reimbursement. (the failed implant must be returned and evaluated first to determine the cause of failure)

One important point of confusion in replacement surgery is that the warranty is given by the breast implant manufacturer as it is a medical device. These warranties do not apply to the implanting plastic surgeon, operative facility or the anesthesiologist.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting my fatter face and neck thinned out if possible. I am sending pictures for your review (frontal and profile) so you can see what I mean. I am interested in a buccal lipectomy procedure and submental lipectomy. I have always thought my face has made me look, in pictures, 30-40 lbs heavier than I actually am. I have also looked at people that are obese or considerably heavier than I am in pictures, comparatively, and noticed that my face make me looks extremely heavy which I am not. I would like to have the procedures done if the changes are significant. I would also like to know if the procedures can be done under local anesthesia. Please advise.

A: Thank you for sending the pictures. I can see your concerns with the fuller tissues around the jawline and into the neck. Certainly fat reduction by neck liposuction and buccal lipectomy is all that is appropriate or should be done. The good question is how much improvement will be seen. That is a tough one to answer as the final result is determined by how well the skin adapts and shrinks down. The limiting factor in your result, and in other male patients who look just like you, would be controlled by the subplatysmal fat at the cervicomental angle (it is not all just above the platysma in the neck angle area) and the subcutaneous fat layer around the jaw angle and over the parotid. Subplatysmal neck fat can be removed by direct excision but the jaw angle fullness is more limited because it can not be treated neither by liposuction or direct excision because of the marginal mandibular branch of the facial nerve. While changes will clearly be seen, I would use the term moderate improvement rather than a dramatic change. Because of the variabiity of the result, you should only undergo the procedure if you can accept modest to moderate improvement. If it turns out to be significant or dramatic in your view then that would be a bonus.

To get the best result possible, doing the liposuction and lipectomy procedure under local anesthesia would not be my approach. That limits how much can be done as patient comfort then takes precedence over the extent of the result.

Dr. Barry Eppley

Indianapolis Indiana

Just when I thought I had seen every conceivable variation of a plastic surgery reality show, a new twisted version appears. If your entertainment schedule has not allowed you to catch E!’s newest reality television disaster, Bridalplasty, consider yourself fortunate.  If you haven’t seen it, it a summary is that it is a bride-against-bride elimination-style show where 12 women compete to have various cosmetic plastic surgery prizes- ostensibly to turn them from ducklings to swans just in time for their weddings.  Or, as E!’s tagline cleverly states, it’s the only competition show on television where “the winner gets cut.”

If you are thinking- as I was, You have got to be kidding me, seeing it will only make you feel worse. The household of brides-to-be initially compete in difficult wedding challenges that would test the mental limits of the average grade school child. These ‘prize’ for winning each of the  competitive challenges is a surgical procedure intended to help transform the prospective bride closer to physical perfection.  Each week one of the contestants gets eliminated while the others receive their dream plastic surgery procedures along the way. Eventually one bride-to-be will receive the wedding of her dreams…and will head down the aisle in a designer dress as a transformed woman ready to surprise her soon-to-be husband.

The concept of a show in which women compete for the grand prize of a plastic surgery makeover in order to be the perfect bride for her wedding day would normally be funny… if it weren’t so sad.   At its most basic, the show is a societal commentary on our contemporary fairytale wedding culture where so much effort is spent in both time and money for just a few short hours. Maybe its greatest entertainment value is in seeing how the fully complicit contestants are willing to trade any dignity for some free plastic surgery and a little bit of fame. I suspect the show’s creators are well aware of this self-deprecation but the contestants are clearly completely oblivious to it.

While Bridalplasty may be the pinnacle of self-parody for reality TV,  the participation of the plastic surgeon in the show violates some of the most stringent  ethics of the American Society of Plastic Surgeons. The most egregious ethical violation is the very premise of the show – all ASPS members are prohibited from giving away free plastic surgery as a prize in any contest. To encourage any prospective patient to undergo surgery because it will be free encourages patients to cast aside any consideration of its risks and expectations. Part of what any ethical, well-trained plastic surgeon should do is to educate the patient about both the benefits and the risks of their procedure(s) of interest. Reaching for a little fame here seems to have affected more than just the brides-to-be.

‘Bridalplasty’ is cringe-worthy TV at its finest, and brings the practice of medicine and surgery to a whole new low point.  What’s next, ‘Who wants to win a quadruple bypass’?

Dr. Barry Eppley

Indianapolis Indiana

Q: I would like to have my Advanta lip implant removed – it has been in place for greater than 10 years. Do you have experience with this and how many have you removed? Any problems with lip asymmetry? Thank you.

A: The Advanta lip implant is composed of PTFE (Gore-Tex) and is a single tube in configuration. It is often confused with the original PTFE lip implants placed in the 1990s which were multiple strands in their geometry. That distinction is more than just in the name as Advanta is relatively easy to remove because it is a tube which can be easily extracted without much trauma. The stranded lip implants can be incredibly difficult to remove and very traumatic to do so. They are often best left alone.

 It sounds like you are fairly certain that you have Advanta lip implants. Over the years, I occasionally have removed them without any great difficulty. As for resultant lip asymmetry I can not speak as to whether that will result or not. That depends on whether any lip asymmetrywas present to begin with and how the lip tissues contract and heal back down after the implant is removed. That outcome would be beyond the control of whomever removes the implant. In general, I would not think that is a common problem afterwards and have not seen it in those patients that I have removed. But whether that would be an issue for you afterwards can not be determined beforehand. 

Dr. Barry Eppley

Indianapolis, Indiana

Q:  I am interested in buttocks injections and basically wanted to know a little more about the procedure. I would like fat removed from my waistline or abdomen area and injected into the buttocks. I would like a fuller bottom and a smaller waistline. I am an active member of the Indiana National Guard and also wanted to know more about the Patriot Program.

A: Thank you for your inquiry. How you have described the procedure is exactly how it is done. Fat is removed from the waistline and flanks and then transferred by injection to the buttocks. The issue with buttock augmentation with fat injections is how much fat will survive afterwards and how much of a size improvement will there be. The first part of the procedure, fat reduction, is assured in that you can be guaranteed your waistline and stomach areas will be less full and have less fat.

The other issue with the Brazilian Butt Lift, also known as fat injections to the buttocks, is whether enough fat can be transferred to create the size that you want. Unlike a buttock implant, where the size increase can be bigger and its postoperative volume increase stable, fat injections may or may not be be to reach your buttock size increase goal. However, the ‘ying anf yang’ effect of a smaller waistline helps the buttocks look bigger and more shapely regardless.

The Patriot Plastic Surgery program provides free consultations and surgery fee discounts to all those that quality.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am unhappy with the shape and length of my upper lip. It bulges out right under my nose. I would like to meet with a Doctor who has experience with lip lift surgery to see if my upper lip could be made to look better and to get rid of the bulge right under my nose. Here are some pictures of my face. My wife took the pictures and we were trying to show how my upper lip bulges out in the middle under my nose. All I want is to have the bulge removed or maybe even have it to where my lip would be more concave right under my nose. I really don’t even care if my lip is lifted or made shorter, just as long as the bulge is gone and made smooth or even hollowed out some. Thank You.

A: Thank you for your inquiry and sending the pictures. They illustrate well the bulge underneath your columellar area of the nose in the upper lip area. Interestingly that bulge is likely not just excess lip tissue alone. Undoubtably your anterior nasal spine is excessive in length and size as well. You may not be familiar with this small area of nasal bone that juts out undereneath the base of the nose. I have attached some anatomy pictures of where it is, and when it is excessively long in combination with the front of the nasal septum, how it can contribute to an upper lip bulge. I suspect that this small piece of bone and cartilage is making some contribution to that bulge along with some excessive lip soft tissue. That can be immediately confirmed by simply feeling under the upper lip as well as pushing down on the bulge at the same time.

Therefore, I would propose that he best solution for your upper lip bulge is a combination of a modified lip lift (use the incision to remove some soft tissue and muscle underneath bulge and only do a 2 -3 mm lift) and an anterior nasal spine resection. Anterior nasal spine reductions are commonly done in rhinoplasty surgery so its effects and benefits are well known.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am going to undergo orthognathic surgery in the coming year. My maxilla will be brought forward as well as my mandible. This will also help my sleep apnea problem. I was told with the advancement of my maxilla, my nose would move as well. That is why I am also having a rhinoplasty. It is supposed to be more of a tweak. To complement my mandible, a sliding genioplasty will be performed. I also have incompetent lips, so a v-y advancement of mu upper lip will also be done. What are your thoughts on the mandibular angle implant? I want more of that model look that I read about on your blog. Will it look right on me? Is my facial geometry even capable of changing with a mandibular angle implant to what I desire? Am I being too ambitious?

A: In answer to your questions, my overall statement is that you are being overly ambitious as you have already admitted. While jaw angle implants would be beneficial from a facial shape standpoint, it should never be done in conjunction with orthognathic surgery. That would require the implants to be placed directly on top of or next to the sagittal split mandibular osteotomies. That would be a recipe for infection and the potential to interfere with the healing of the mandibular osteotomy sites. In essence, a disaster from a jaw healing standpoint. While that may not happen, it is a real risk and one that isn’t worth it.

 You need to go through the orthognathic surgery and adjust to your new face for a full year and allow everything to heal well. Only then should you reconsider jaw angle implants through computer imaging and further facial analysis. 

Dr. Barry Eppley

Indianapolis Indiana

Q: Do you do forehead augmentation to make a flat forehead rounder using PMMA? If so how much does this cost and how is it done?

A: Forehead augmentation can be done with a variety of materials. The use of PMMA (acrylic) is historic for forehead augmentation and offers the most economical approach for the procedure. It generally costs in the range of $8500 to $9500, all surgical costs included.

 Forehead augmentation with PMMA requires it to be done through an open scalp approach due to the working characteristics of the material.

 There is a technique for forehead augmentation using Kryptonite Bone Cement which can be done through an injectable approach using very small incisions. Its cost is higher than that of a PMMA frontal cranioplasty. 

Dr. Barry Eppley

Indianapolis Indiana

Q: Have you heard of Cryoshape treatment for keloids and hypertrophic scars? I have read some favorable reviews on the internet about its success. What is your opinion of it?

A: I am familiar with the technology but must confess that I have never used it. Given the fact that keloids are the most difficult scar problem that exists, any potential treatment is welcome. Cryoshape is a method of delivering cold or freezing therapy via a probe that is inserted into the keloid. By freezing the keloid, it is hoped that it will not only stop growing but shrink down as well. This is another intralesional therapy for keloids of which the most commonly used is steroids and 5-FU injections.

I am certain that Cryoshape has its share of successful keloid reductions but it will have its failures also. Keloids are extremely refractory and difficult scar problems that no one treatment can be universally effective. Whether it is any more effective that steroid injections is unknown.

The value of Cryoshape, in my opinion, is as a pre-excisional treatment method like we currently use steroid injections. For those patients that want more than just a shrunken keloid, excision needs to be part of the keloid treatment approach.

Dr. Barry Eppley

Indianapolis Indiana

Q: Hi, I am located out of the United States. I am 42 years old and have a temporal artery on the left side of my head that has become very prominent over the last year and I am looking for someone to do a temporal artery ligation. I came across a forum where Doctor Eppley was commenting on the procedure saying that it was relatively straightforward. I would like to know if this is a surgery that he could do for me. I would be willing to travel to Indianapolis for it.

A: The superficial temporal artery (STA) branches off of the main trunk of the temporal artery just above the ear. It then courses forward until it crosses high in the forehead from the temporal hairline. It leaves the camouflage of the hairline at this point to cross into the forehead skin. For most people the STA is not usually seen although it can be palpated in the temple or forehead region. In a few people it becomes more noticeable. Whether this is because it is just simply more superficial or actually enlarges in size is unknown.

The STA can be ligated to eliminate its pulsatile visibility. However, it has to be done both high and low to prevent backflow. That may mean that the high ligation point may not be in the hair-bearing temporal scalp and require a small skin scar. Loss of the STA causes no known problems so it can be ligated without any vascular consequence.  

Dr. Barry Eppley

Indianapolis Indiana

Q: I found your article fascinating on injectable rhinoplasty. I had a rib cartilage graft done 16 months ago but still have a depression to the  left side of my mid bridge. I have banked rib cartilage left in my chest. Could the same technique be used with rib cartilage?

A: Any source of cartilage can be used in the injectable rhinoplasty technique. That is the very beauty of its use. Whether it be septum, ear, or rib, cartilage of any size or amount can be diced and injected. When an injectable rhinoplasty procedure is used, it is because only a small amount of cartilage is needed for the correction of a precise nasal defect.

Your banked rib cartilage would be a perfect donor source because it is likely more than adequate in the amount needed. It can be diced into a syringeable graft regardless of its present configuration.

Dr. Barry Eppley

Indianapolis Indiana