Your Questions

Q: Dr. Eppley, I am interested in getting implants for my flat cheeks but am not sure what type of implant I really need. I have attached 4 images of three different individuals cheeks I really appreciate and believe to be prominent and masculine. They are Lars Burmeister, Fernando Torres, and Ben Affleck. All seem to have the prominence up on the side of the eyes and they wrap around to the front of the eye a bit. They all look more chiseled, narrow, and angular though, relative to the other examples of cheekbones I have attached. The other examples are of cheekbone structures that I would prefer to avoid. They are Zac Efron, Cilian Murphy, and Peter Facinelli. Their cheeks just cover too much surface area and look like an enlarged cheek mass, rather than finely chiseled cheekbones. They are prominent but look too feminine and bulky. Perhaps you can enlighten me more on what it is I both desire and do not desire in the above referenced cheeks.

Also, will I be getting the inferior orbital rim augmented as well? Reason being that my eye does indeed pass over this bone. Besides creating a better angular appearance to my face, I’m hoping the midface implants rejuvenate my face a bit and help me look less sickly when I get down to 10% body fat percentage or so. Would I need some kind of midface lift along with the implants to give myself this appearance? I am apprehensive to undergo a procedure that is often only discussed with people in their 40s or above.

Lastly I have attached a crude approximation of the area on my cheek I want to be augmented. The black marks denote areas I would prefer to see little to no enhancement on. They include the zygomatic arch, the base of the zygomatic bone, and underneath the front of the zygomatic bone beside my nose. Let me know if this is realistic.

A: Thank you for the detailed information about the desired cheek augmentation result. That is very helpful.

The first comment that I would make is that their is no standard or off-the-shelf ‘cheek’ implant that has exactly those dimensions that you have well outlined in your own photo. I would agree completely that the best aesthetic midface result for you is exactly what you have described, as you have a true combined anterior zygoma-lateral orbital wall-inferior orbital rim deficiency which is a reflection of the overall underdevelopment/flattening of the zygomatico-orbital complexes. Your issue is a bone problem not a soft tissue one so the concept of any form of a midface lift is not a consideration.

So it is not a question as to what you need but how to get there. In an ideal world from a bone standpoint, I would use Kryptionite bone cement/putty to intraoperatively fashion the implant exactly the way I want it and place it from above through a lower eyelid incision. This is most ideal not only because of the ability to create a truly custom implant but the area of augmentation needs to extend across the orbital rim (at least laterally). This infraorbital rim area is the ‘rate-limiting’ step in getting the ideal implant shape as it can not be accessed from below. (inside the mouth…the big infraorbital nerve is in the way) But due to cost considerations and that I nor you would be thrilled with making a lower eyelid incision, this ideal approach may not a good option for you. The other option is to pre-make a custom implant off of a 3-D scan and model, but again cost becomes a consideration with that approach as well.

With the ideal approach off the table, then we must look for using/modifying existing stock implants to achieve most of the cheek augmentation goals. One style of cheek implant, sometimes called the Malar II, augments the lateral orbital wall as well as cheek bone. It does not extend out onto the infraorbital rim to any degree which is its one limitation.

The other issue I would mention is that the use of these celebrity faces and pictures serve only as a direction that you want to go and that no cheek implant, even one custom made, will make you look exactly like them.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I got treated with Botox for migraines three months ago and it was not effective. It was done by a neurologist and when I asked why it did not work he said he did it in the “standard FDA” way by a band formation around the head, neck and forehead.  This is so disappointing and I paid around $3,000 to have it done.

A: That is certainly disappointing to hear not only because it did not work but because of the way it was done. There is no such thing as a ‘standard FDA’ way to do it. If that statement meant that it was done by using the clinical information and methods that was the basis for what made Botox approved for migraine treatment by the FDA, the ‘wrap around the head ‘ method was not it. Botox works for a select group of migraine patients who have identifiable peripheral trigger points in the frontal, temporal and occipital regions by both examination and history. It is these very specific points which are injected not in a random method. You may benefit by Botox injections if you have these trigger points so your lack of improvement is more likely due to that you are either not a good candidate or the injection approach was flawed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Is there a such thing as tarsal strip revision? I am also concerned with how this surgery  has left me with small and round eyes. Is tarsal surgery permanent? Is there a surgery that can reverse this? Have you performed revision tarsal strip surgeries in the past, or is this an unusual circumstance?

A:Yes there is. Tarsal strip procedures are generally done in an effort to tighten/raise the corner of the eyes, for a variety of medical and cosmetic reasons. Revisions of this procedure may be needed when it is not entirely successful, such as inadequate tightening/lid positioning or widened scars in the corners of the eyes.When the corners of the eyes are tightened, the lateral aperture of the eye (where the upper and lower eyelids meet) can become less sharp and more blunted. This can very well create the appearance of a smaller and more rounded eye. Once a tarsal strip lateral canthoplasty has healed, it will be permanent. A revision can be performed to open up or change the amount of aperture closure although they are not always successful. But a milllimeter or two of aperture change may be aesthetically beneficial.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am giving serious consideration to getting cosmetic surgery to reshape my skull. I have an compressed area on the top right/middle section of my head near or along the coronal suture. The distorted area is roughly about 2 in by 3 in. It hasn’t been much concern for me until now that I am losing my hair. I found your page and now have hope that I won’t have to feel embarrassed every time I take off my hat for the rest of my life. My ideal plan is to have a one time low maintenance fix. I saw some of the work on your websiteand it seems very good and I think that you might be able to help me. I have attached a few photos from a couple different angles so you can see the indented area. Ideally, I am looking to simply smooth it out and make my head symmetrical without a dent or a bump.. However I’m not all to sure on the technicalities of the procedure or if it’s as simple as I’m hoping. I would appreciate your honest opinion as to whether the risk of the surgery might cause more off looking results, like a bulging area or something? I’m more than sure you a very busy person but all the information you can offer me would be appreciated. Having this surgery is a huge, potentially life changing decision. Even more so considering it is on my head and I will have to display, see, and live with the outcome. Let me know what you think.

A: Thank you for sending your pictures. I can see clearly the indentation across the top of your skull. The best and only way to treat this would be with an injectable cranioplasty approach. An open approach would leave a scar that I would not consider an acceptable trade-off. The injectable or minimal incision approach would use two very small incisions (about 1/2 to 3/4 of an inch) on both ends of the indentation. Through these, the material (Kryptonite) can be injected and molded. These incisions would heal up and be virtually undetectable later. This is a fairly simple procedure to go through with minimal pain and swelling afterwards. The only caveat to the simplicity of this approach is how even and smooth the augmentation would be. Since it is a blind procedure, all material molding is done from the outside by hand by pushing on the scalp as it sets up. As you have mentioned, it would also be important to not place too much material so the area does not become a ridge instead of an indentation. That is the artistry of the procedure. A good question is what is the likelihood of having a contour deformity that may need a secondary touch-up or rasping? In my experience so far, it has been about 50%.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had liposuction six months ago that has left me with some unevenness over the thigh areas. The skin has some dimpling and a few more obvious humps in the upper portion of outer thighs. My doctor told me to give it six months after surgery to see if they would smooth out and they definitely haven’t. Would Exilis be able to fix or improve how this looks? I have read about it and it seems like it would be one option. I don’t think there is a surgery that can fix this. My doctor said I would just have to live with it but she hadn’t heard about Exilis though. Thank you for your time.

A: Skin irregularities are the result of an uneven fat layer under the skin. They can become apparent after liposuction due to pre-existing cellulite, poor skin elasticity and an irregular layering of residual fat left behind. One has to look carefully at the lumps and bumps to determine if filling the indentations, decreasing the height of the lumps or some combination approach is best.

Exilis is a radiofrequency device that does spot fat reduction and has some degree of a skin tightening effect. I find it to be one of the best non-surgical approaches to treat liposuction deformities that are available today. It will likely have some beneficial effects on the contour of the thigh skin by helping to reduce the thicker or raised fat areas. It usually requires three or four treatments done in the office every two weeks to see the best effect.

But if the indentations are the main contour problems, those are best treated by fat injections.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would to get the big bump on the back of my head reduced. It sticks out and makes my head look odd from the side. I know that bone can be shaved down but I don’t know how far or much that can be done. I did have my doctor order a skull film and the report says that the ‘occipital bone thickness is 1.7cms at its fullest’. Does this mean I can get the back of my head taken down enough  to see a difference and still not injure the brain or be dangerous?

A: An occipital bone thickness of 1.7 cms is a measurement that involves the three layers of the skull. These include the inner and outer cranial table (solid bone) and an inner marrow space layer. (soft bone) Think of the skull like an oreo cookie. With a thickness of 1.7 cms, that indicates that safe cranial reduction can be done.  But the real question, as you have asked, is how much could be done and would the results justify the effort. I would need to get a digital copy of the x-ray so I can take a measurement of the outer cranial table thickness and do a tracing to be sure that enough reduction can be done to make a visible difference. The outer cranial table and the marrow space can be reduced but the inner bone table can not. Assuming that each section of skull thickness accounts for 1/3 (which it may or may not), then a 2/3s or close to a centimeter may be capable of being removed in a skull reduction procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Wwhat kind of temporal implants do you use? I have read that Medpor temporal implants has to be screwed under the temporal muscle onto the temporal bone. Is that the way you do it? Will the scalp incisions be bad in that case? Thank you very much.

A: There are different indications for temporal augmentation and that determines the type of implant used and its location. For cosmetic augmentation and in mild muscle atrophy after a craniotomy, the implant is placed under the fascia (on top of the muscle) in most cases. I prefer the use of soft flexible silicone rubber temporal implants when it is placed in this more superficial location. This is done through a very small vertical incision in the temporal hairline that heals inconspicuously. In more severe atrophy cases after craniotomy or at the time of a craniotomy, the implant is placed next to the bone and often needs to be larger. This is where a Medpor temporal implant is used as it is meant to be placed next to the bone and is usually screwed into place. It is placed through an existing larger scalp coronal incision.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Can you tell looking at a person if the fat is herniated prior to surgery and is the entire fat pads removed in bilateral upper lid surgery? Also, you mention a strip of muscle excised…is it removed from inner to outer corner of the eyes or is this just done for blepharospasm?

A: Photos are generally very helpful to determine if one has herniated eyelid fat. Most herniated fat generally occurs in the lower eyelids and less so in the upper eyelids. The lower eyelids have three distinct fat pockets that often herniate and are removed. The upper eyelid, however, has only two fat pockets that may be treated as the lateral compartment of the upper eyelid contains the lacrimal gland which should not be removed. It may be tucked back up with sutures if needed. The concept of removing the entire fad pads is not done either in the upper or lower eyelids as creating a ‘skeletonized’ and more aged looking eye area is possible with too much fat removal.

A strip of orbicularis muscle is often removed in upper and lower blepharoplasty surgery. It is done in the upper eyelid to help create more of an upper eyelid fold and is done on the lower eyelids to get rid of fullness below the lashline, often called an orbicularis roll. The condition of blepharoplasm is treated with Botox injections, not muscle removal.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am writing you in regards to my daughter is now two and one-half years old. The back of her head is flat (plagiocephalus) and asymmetrical (1cm difference). According to the doctors there was no need to treat with a helmet. Still the deformation is quite obvious. Is there anything that can be done about it at your clinic? I suppose she has to wait until she is 18 years old?

A: At this age, there is no form of helmet or external molding therapy that will change the shape of the skull. It is too thick at this point to be externally molded. It can be treated for its cosmetic deformity by an augmentation cranioplasty on the flattened side. That can be a very effective procedure and in some cases this is done by an injectable cranioplasty approach. This is probably the ideal procedure for plagiocephaly deformities that are mild to moderate. In laregr degrees of flattening, an open approach is better. The question is at what age should that be done. There are no hard and fast rules about the age to do this procedure. That is a personal choice of the parents. I have had requests to do them as early as age  but the timing of cosmetic correction of a plasgiocephalic skull is psychological not physical.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to have my temporal muscle on both sides reduced. They are overdeveloped and makes my face look awkward. I would like to have face proportioned right on both sides. Please tell me some options that I might have. Thanks.

A: Thank you for your inquiry and sending your pics. Yes you do indeed have very big temporalls muscles, probably one of the biggest that I have ever seen by proportion to the rest of the face. The largest portion is just above the zygomatic arch where the bulk of the muscle lies. It is the bulge between the side of the forehead and the position of the zygomatic arch that is aesthetically disproportionate. A line drawn between the two should be either straight or have a slight concave curve to it. Significant convexity of the temporal area makes it stand out and be very noticeable.

Reducing the size of a temporalis muscle is a very rare procedure. I have done a lot of cosmetic temporal surgery, all of which has been to create the opposite effect of temporal augmentation. The only option to reduce the temporalis muscle size is surgical through reduction and thinning of the muscle. You need an approximate 50% reduction in the size of the muscle. This would need to be done through a scalp incision approach to access the attachments of the muscle to the skull to lift and thin it. This would create actual muscle debulking and reduce the visible bulge.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in correcting the asymmetry of my face. The right side of it, particularly in the jaw angle area, is tilted upwards and shorter. I have read that a jaw angle implant may be able to correct this tilt.Would this implant make the right side look closer to the left and would I feel the difference? Would a cheek implant help along with the mandibular angle implant to even out the balance? I don’t want the right looking more full and balanced then the left.  Would braces help fix or improve the jaw tilt/angle?

A: In the ideal correction of facial asymmetry, it rarely is just one facial area that is shorter or asymmetric. In most cases of facial asymmetry, the entire side of that face is shorter. For this reason, jaw angle and cheek implants together are often done and produce the greatest amount of facial lengthening and correction of the shorter side.

Braces change how the teeth fit together but will not change the tilt of the jawline.

The goal of facial asymmetry correction with facial implants, the most common treatment method, is to try and get the best match between the two sides as possible. While perfect symmetry is never possible, the closer the two match the better. In the spirit of that goal, it is always better to be slightly less full than too full when deciding about implant sizes.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve heard that you perform temporal implants. Where does these implants go, is it under the superficial temporal fascia or the deep  temporal fascia? I have heard the deep temporal fascia cannot stretch to cover an implant. Is that true? Also, does this implant reach down to the zygomatic arch and can these implants become infected? Thank you so much.

A: They are almmost always placed under the deep temporal fascia. There is no problem with the fascia stretching to cover it and the fascia is often released along the lateral orbital rim and superior zygomatic arch to accomodate bigger implants. I have rarely put temporal implants on top of the deep temporalis fascia as there is the possibility that the dissection or the pressure of the implant may injure the frontal branch of the facial nerve. The lower edge of temporal implants almost always extends down to the zygomatic arch. Like all facial implants, there is a risk of infection but this is usually very low around a 1% chance.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am confused about the whole facelifting thing. I am 53 years old and am beginning to show it. My neck and jowls are getting droopy and they make me look like a bulldog. I saw one plastic surgeon who said I needed a complete facelift (which I didn’t agree with) and I would need two or three weeks for recovery. Then a second plastic surgeon told me I just needed a ‘tuckup’ (I forget the name that he actually called it but it was something that used the word fast or quick in it) and I would be fine in a week. Why is there such a difference between the two recommendations and what do you think I really need? 

A: The concept of facelifts and their variations that have evolved in the past decade can be confusing. Combined with how they are marketed and advertised also lends an almost mystical quality to them. In reality, it is far simpler than what it appears. Facelift surgery traditionally speaks to correction of aging of the lower face only, the neck and jowls. As we age, jowling develops first which then leads to neck sagging and eventually wattles. Thus facelifts can be done either as a partial (aka mini-facelift) or a full version. The partial facelift is done when jowling is the main problem and any neck issues are either non-existant or minor. A full facelift is needed when the neck problem is the main issue or just as prominent a concern as that of the jowls. Thus, partial or limited facelifts are usually done on younger patients (less than age 55 or so) who have yet to develop significant neck sagging. The recovery from mini-facelifts is quicker because the operation is shorter and less invasive. These are also the type of facelifts that have become very popular, largely driven by people in the workface trying to look younger and refreshed to remain competitive. They have been given a lot of different marketing names that imply less surgery and faster surgery and recovery, all of which is true. But don’t let the names fool you, they are all very much the same surgery. A full facelift is usually needed in patients 55 to 60 years and older when the neck is a noticeable aging feature and either flaps around and/or gets in the way of shirts and neck wear. In these more complete facelift patients, other procedures may be beneficial and are combined with it such as eyelid tucks and browlift surgeries.

Between the mini- and full facelift patients lies an almost third category and may well be where you lie. In this facial aging patient, a partial facelift is not enough and a full facelift maybe more than they need. (this may be why you had two ‘different’ opinions.) In this type patient, I use what I call the 3/4 facelift whose level of invasiveness and recovery is somewhere between a partial and full facelift.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am confused about whether a just need liposuction or a tummy tuck. I am 5’ 3” and weigh 128 lbs. I have had two children but do not have stretch marks, I can only stretch my skin about an inch or two but it definitely is not loose. I have some excess belly fat  which looks strange on me given how thin I am everywhere else. My stomach muscles are tight and I don’t think there is any separation in them.

A:  I could not think of a better description of the indications for liposuction than in your question. A tummy tuck is needed when  one can grab more than an inch or two of skin, have one or more fat rolls, and can feel that there is separation of their vertical rectus muscle in the midline. Improving any or all three of these undesired abdominal features can justify the low horizontal scar that is the necessary sequelae of any form of a tummy tuck. The lack of stretch marks is significant because that signifies that your abdominal skin still has some elasticity…a key element in the successful obtainment of smooth abdominal skin after liposuction.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I am looking for help in fixing facial deformities and asymmetries. I have been to an Oral surgeon and a Maxillofacial surgeon before but they didn’t seem to care. I have a right sided facial deformity that bothers me alot. I would like to find some help for this problem. The right side of my face is under developed and I can see it and even feel it. My left and best side is more fuller and straighter.  My right side is smaller and recessed and less defined. Can an angled tilt in the jaws on one side be fixed? I have attached some pics for you to see.

A: Thank you for sending your pictures. I can see quite clearly the tilt to your jawline and the less full right mandibular angle area. It is not possible to cut the jaw bone and angle it downward without changing your bite on the right side. But it can be more simply and effectively treated by a mandibular angle implant, using specifically a type of jaw angle implant that extends the length of the jaw angle downward as well as making it more full. This would be done through an intraoral approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I plan on getting a rhinoplasty, chin, cheek and jaw angle implants this summer. It makes sense to me to have them all done at once. I have limited time off from work and only have a few weeks to recover at this time of the year. The one plastic surgeon I saw said he wouldn’t do them all at once as it would be too hard on me. I am not sure what he is talking about as I am young and healthy. I am aware that doing more surgery increases the overall risk of potential problems such as infection, but are there other risks to be taken into consideration, such as blood loss, that I am not aware of? Do you think it is safe and reasonable to have all of these facial procedures done at the same time?

A: In my experience and practice, I routinuely perform three, four, five or more facial procedures at the same time. For the reasons you have mentioned, such as recovery and other considerations such as cost, it is desirous to do a ‘facial makeover’ as a single stage procedure. There are no increased health risks for doing combination facial surgery in an otherwise healthy person. Blood loss is not a concern. With that being said, there is one risk that occurs in multiple facial restructuring procedures particularly those that involve facial implants…an increased aesthetic risk of implant asymmetries and the need for revisional surgery. The more procedures you do, the more risk there is for less than perfect results. Each individual procedure comes with its own aesthetic risks which are increased as more procedures are combined. Patients need to appreciate that the likelihood of the need/desire for revisional surgery is multipled as procedures are combined.   

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 42 years old and I had Smartlipo last month. My main reason for having it was to get rid of my neck and chin waddle. I see a difference in my lower face and chin, but I still see the waddle just like before surgery. I have worn my neck garment faithfully but I see next to no improvement in the neck waddle.  When should I be seeing results? The doctor told me it would take up to three months to see the final result as it takes time for the skin to tighten.

A: At your young age, it would seem logical that whatever neck and chin fat you have should respond well to liposuction. But the final results of liposuction performed anywhere depends on how well the skin tightens. Again at your age the skin should still have good elasticity. It is true that you should wait a full three months to see the final neck contour results. While the Smartlipo liposuction method does have some skin tightening capabilities, I emphasize to patients that this should be perceived in millimeters and not centimeters. Thus depending upon how much skin your waddle has, you may or may not see significant reduction over the next several months. If not you may need to consider a secondary tightening procedure such as some form of a necklift.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I am 49 years old and am interested in the LeFort 1 procedure. Please see attached photos and give me your advise, I had brace work done twenty years ago because my top teeth were behind my lower front teeth. I think a LeFort 1 procedure would have been more appropriate. Can it be done now? Please advise me as to what surgery would give me a more attractive face.

A: Thank you for sending your photos. What they demonstrate is that you have a midfacial hypoplasia and you are correct in that a LeFort I advancement done years ago would have been better for facial balance and midfacial fullness. But doing it now is not possible because it will change the way your teeth meet. This is why LeFort surgery and orthognathic surgery in general is done in conjunction with orthodontics. I have done them in patients your age and older but only if they were edentulous and wore dentures as new dentures are relatively easy to make.

What you can do now is camouflage your midfacial hypoplasia with paranasal/premaxillary facial implants to bring the base of the nose and the central maxilla more forward. This can be demonstrated with computer imaging. 

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I have been trying to figure out certain things about chin surgery. I have asked a couple of Plastic Surgeons about what is the difference between chin filling with injectable fillers and chin implants? Will either give you the same type results? Also, I would like to have a more pointed chin like that of the feminine version. Which procedure would give me this look, a chin shaving or chin implants?

A:  The use of injectable fillers vs an actual implant in the chin creates very different effects. One should not be confused with the other in terms of outcomes obtainable. Injectable fillers create small changes in chin projection and shape that are temporary. Implants create large amounts of chin projection and shapes that are permanent. The only role for injectable fillers in the chin in my practice is a test for some patients who are uncertain about proceeding with the placement of a permanent implant.

As to the best method of creating a more feminine pointed chin, that would depend on whether you are happy with your current chin projection both vertically and horizontally. If the present chin position is satisfactory, then it can be reshaped by lateral ostectomies through an intraoral approach . If the chin position is deficient in any dimension then a chin implant can be used to improve projection as well as shape. To obtain a pointy chin with an implant, a central button style should be used.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I read about your method of skull surgery. I am a young man with male pattern hair loss. Since no real cure is available I think I should just cut it very short or even shave it. The problem is that I have a skull indentation. I have never heard of this treatment. Should I go to a plastic surgeon or to a neurosurgeon to get some advice on this matter? Since I deliberately do not cut my hair that short for it to be noticeable I could not take a picture of it where you would be able to see it. I have attached a picture of a human skull and circled the area. It is an oval shaped indentation about 2″ long or thereabout and slightly less wide. It is at the part of the skull that is bending towards the top of the head. For this reason it is noticeable even though it does not appear to be a very deep indentation. I hope you are able to get a general idea of what I am talking about.

A: The relatively small skull indentation that you have is ideal for the minimal incision/injectable cranioplasty technique. Using Kryptonite bone cement, it is injected into the indented skull area after the scalp has been elevated. This is done through a very small incision of less than 10mms. Once the cement is injected in a putty state, it is molded from the outside until it sets firm, a process that takes about ten minutes from injection to set time. The trick to this technique is to get a smooth result that is not overcorrected.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 22 years old and had 12 IPL treatments. My entire face has gone flat with no underlying support as the laser had a laserlipo affect where all the fat was melted, turned into liquid and digested by my body. However I read your article on fat returning after liposuction, so in a couple of years will the fat cells and all fat regrow back in my face, especially if I gain weight?

A: IPL is not a laser but high intensity pulsed light, hence the acronym IPL. Regardless of the semantics, it creates a subcutaneous heating effect which can affect fat. While not a typical effect, reports do exist like yours where facial fat has been resorbed. Whether the effect you are seeing is temporary or a long-term result is unknown. You will know your answer by one year after your last IPL treatment or if you attempt to gain weight. If not you may need to consider injectable fat grafting for restoration of certain facial areas if they are aesthetically problematic.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a subnasal lip lift last month and I hate the scar that has resulted. The scar is around 2mm height, goes from one nostril to the other and is indented about 1mm in depth. Would a scar revision help and would it cause any change to the current lip shape? (I want no more changes only want the scar removed) Another surgeon told me fat grafting to the scar can help. Is it true? How would a scar revision differ from the original cutting technique and closure? If it is the same, would  it will lead to the same problem? Thank you again for taking time to answer my questions.

A:  In theory scar revision may eventually be helpful but it is too early to make a final judgment on what your scar will look like in its mature state. But to answer your specific questions, any scar revision would not change your lip shape long-term. There is always lengthening and relaxation of the lip even when 4 or 5mms of vertical height is removed. While I love fat grafting and it can be very useful for many facial volume problems, I fail to see its benefits in your subnasal lip scar concerns.I would not think that any type of scar revision would be radically different from the initial procedure…other than less tissue is being removed and that places less downward tension on the scar. That may may the difference in the outcome. 

The most useful comment that I can probably make is to not jump too soon into doing anything, particularly in the first months after surgery. The tissues are chronically inflamed and will not respond well to manipulation no matter how well done or cleverly designed the procedure will be.  Ideally, you should wait it out for six months before having scar revision (if eventually needed) and allow all tissues to heal completely and undergo scar relaxation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was looking at possibility of laser resurfacing for my arm scars. My left forearm arm is completely covered on the bottom side from about two inches from the wrist to my elbow. Many are not deep, but several are. There are more than I can count. All scars are at least 2 years old. Also I was wondering if you had an estimated cost for something like that. I don’t have much money, but will be saving for this because it would allow me greater freedom with work and life in general, but we need a target to save for.

A:  The usual scar pattern for arm scars secondary to self-inflicted injury is fairly typical. A large number of horizontal scars are usually present, often between the elbow and the wrist. Some may be longer and more wide but most are more narrow and short. The large number of the scars makes the consideration of surgical excision to narrow them impractical. A few large ones can be excised but most of the smaller ones will not be improved by excision and re-closure. While laser resurfacing seems like it would be effective, it rarely is. The scars go full-thickness through the skin so thinning of the skin by burning off the top layer will only expose more of the scar not less. In some cases I have performed laser ablation to create the effect of a full-thickness burn. This creates a large scar which is easier to explain than the many small ones from knife wounds. I have also done a wide excision of the entire area of arm scars and then covered it with a split-thickness skin graft. This creates a skin-grafted arm appearance which again provides a visual appearance that is easier to explain. When considering this route, a skin graft would be preferable to creating a full-thickness burn.

To give you a quote for surgery, I would first need to see some pictures of your arm scars to determine the best approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have been debating about getting a Brazilian Butt Lift for the past two years and I’m finally ready to do it. I have waited so long out of fear that I will pay all this money and then the fat will just resorb. Is there any further encouragement that you can give me?

A: All surgery has risks and there is no doubt that the biggest one in the Brazilian Butt Lift is the unpredictability of how much of the fat will survive later. Fat survival rates vary widely but my observation is that up to 50% of the injected fat is retained after six weeks. There is a lot of variables that go into a successful fat injection transfer from the harvest method, to fat preparation and to the injection technique. You, of course, have no control over how the surgery is performed so make sure you choose your surgeon wisely and one that has a proven history of successful patient outcomes with fat grafting. The one benefit that you will absolutely be assured, however, is the contouring that will come from the fat harvest. Most commonly, fat is taken by liposuction from the stomach and flanks as these areas offer the greatest amount of available donor material. Other sites can be used as well but usually only contribute small amounts of fat. Regardless of the harvest sites, you can be assured of the contouring benefits of the procedure. That is the one guarantee result that comes with every Brazilian Butt Lift.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, what can be done to fix my muffin tops after a tummy tuck? Six months ago I had a full tummy tuck and and a new belly button made. Right after surgery I noticed  these bulges above my hips. My surgeon say it was swelling and it would go away but that has not been the case. They look terrible with my now flatter tummy. When I asked what he could do about them at my last check up, he told me to exercise and do abdominal twists and they would go down. I feel like he is just avoiding my concerns and doesn’t want to deal with me anymore now that she has my money. What are your thoughts on my dilemma?

A:  Abdominal contouring for many patients is not just a 180 degree proposition. The excess fat can wrap around the whole way to the back. Thus abdominal and waistline contouring should be thought of as at least a 270 degree or greater approach. A tummy tuck, even a full one, however only affects the front of the trunk and its benefits stop at the front of the hip bones. This is why flank liposuction is a part of many tummy tucks in my Indianapolis practice. If not noted before surgery and left out of the operation, one could be left with very visible muffin tops after a tummy tuck. The goods news is that it is an easily solveable problem with liposuction and those bulgy muffin tops can be turned into a very pleasing inward curve to the waistline. The bad news is that it does require further surgery but it is a much smaller operation with a very quick recovery.  

Dr.  Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a chin implant and buccal fat removal several years ago to make my face less round. While that has provided some significant improvement, I still feel my cheeks are too fat. The fullness that bothers me is the fat pad below the buccal fat area. I have had several consultations with differing opinions. One surgeon suggested liposuction with a mini face lift while another recommended a deep plane facelift with removal of fat under the cheek muscle. I am confused.

A: The specific cheek area to which you refer is below the buccal fat pad and is known as the perioral mounds. This is a fat layer that is separate from the buccal fat pads and will not be affected by their reduction/removal. It is a common misconception that buccal fat removal will thin out this area as well. Perioral mounds can be reduced by small cannula liposuction done through a small incision inside the corners of the mouth. I have found that ‘chubby cheek reduction’ usually needs a combination of buccal fat pad reduction and perioral mound liposuction to get the best reduction possible. In some cases, small cannula liposuction also needs to be done above the level of the nasolabial fold at the subcutaneous level. While a mini-facelift may help with tightening loose jowl and neck skin, it will not make a significant effect on the thinning of your cheeks. Skin tightening will not make a dent in the thinning of full cheeks.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in skull reshaping if that´s possible. I´m a 45 year-old male and I wish to know if there is any procedure to implant some type of  material at the occipital area in order to increase that part of my skull and make it a little more aesthetic, because I have that part very flat. I would also like to know if that would leave me with very visible scars?  I would like my skull elongated in the anteroposterior axis. Thanking you in advance. 

A: There are numerous methods of skull augmentation or expansion. They all rely on adding synthetic materials to the deficient skull area in the desired shape. The two basic methods are cranioplasty materials, such as PMMA (acrylic) and hydroxyapatites, and a custom-fabricated silicone or silastic skull cap or prosthesis. There are advantages or disadvantages to each approach which fundamentally comes down to cost and the ability to get a smooth contour and the maximal amount of expansion. The limiting factor in how much expansion can be obtained is how much the scalp can expand and to get a relatively tension-free scalp closure over the augmentation material. In my experience, a safe amount of skull augmentation is about 10mm in thickness. That may not sound like a lot but it creates an effect more significant than the number suggests. All of these methods require an open approach with a scalp incision to place them. This results in a fine line scar across the upper back of the head, somewhat similar to the location of a hair transplant harvest scar.

Dr. Barry Eppley

Q: Dr. Eppley, I’m interested in having Smart Lipo to remove some fat on my chin.  However, I have a chin implant that I got 16 years ago. One doctor told me that the risk of infection would be higher and the heat from the laser could move or melt the implant.  He advised me to get another opinion and to ask the doctor before I make the appointment because some doctors’ immediate answer may be no.  Can you please tell me about the risks and whether this is a good idea or not. Thanks very much.

A: My question to you  is what you mean by ‘chin liposuction’. Do you mean having liposuction on the chin pad proper (which is highly unusual and associated with risks of irregularities) or do you mean liposuction under the chin area, formally known as the submental region?

Either way, I would see no negative effect of the laser probe on a chin implant. The location of a chin implant is deep and against the bone and is beneath the fat layer of the chin. There is also the mentalis muscle which exists between the chin fat pad and the implant. In addition, the melting temperature of polymerized silicone is quite high (over 350 degrees F) and the heat generated by a fiberoptic laser probe does not create or should not create field temperatures higher than 145 degrees F. In addition, inadvertent touching of the end of the laser probe to the implant (which should not happen based on the previous description of where the implant is located) will still not cause it to melt.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a breast reduction  done when I was a teenager (now age 30)and now, if you can believe it, am thinking about getting breast implants. I am currently a 34B and was thinking of getting 350cc silicone gel implants if this will not make me too big. I am trying to get some fullness not necessarily be really big again. My main concern is am I more likely to have something go wrong or it is more difficult since I already have had breast surgery?

A: Surprisingly it is not rare that a former breast reduction patient will one day later desire a breast augmentation. This is a testament to the fact that a woman’s breasts are not stable throughout life. Their size and shape are affected by many factors. Teenage breast reduction has the potential for this to happen in particular as the reduced breast will be exposed to pregnancies which cause breast involution or breast tissue shrinkage. When coupled with the prior breast reduction, a woman can eventually end up with almost no breast tissue at all. The desire for augmentation after reduction may also occur if the amount of breast tissue removed was excessive.

Prior breast reduction surgery has no negative influence on the subsequent placing of breast implants. Reduction surgery occurs above the muscle, implants are generally placed below the muscle.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a few wrinkles and extra skin on my lower eyelids that I would like to get rid of.  I don’t think I need any blepharoplasty surgery and have read about lasers and chemical peels. Which of these two lasts the longest or do they both last a comparable amount of time? Which is most natural looking result or is there no difference? Which is least likely to excessively tighten skin? I am curious as to why laser resurfacing is so popular over chemical peels. Which has the least downtime?

A: There is no evidence that either method,  laser vs TCA chemical peel, is more effective or long-lasting on lower eyelid skin rejuvenation. Laser do have a higher risk of hypopigmentation. Both are commonly used and it is a matter of comfort and experience as to which method plastic surgeons use.

It is likely you may also benefit by a pinch lower blepharoplasty with a TCA peel but I would have to look at your lids to answer that question. This is a favorite method of mine for the lower eyelids because it works very well with a very small amount down time. It is also the most minimalist method to guarantee that lower lid skin would be tightened to some degree.

Lasers are more popular than peels today for a variety of reasons. First they are more ‘high-tech’ and with that comes the assumption that they produce better results. In addition, their high cost and the need for the manufacturers to sell them drives a lot of more visible marketing efforts.

Dr. Barry Eppley

Indianapolis, Indiana