Facelift

Q: Dr. Eppley, I am interested in a facelift and jaw angle implants. Does it make a difference if they are done together or separately? If they need to be done separately which one should be done first? I have already scheduled my facelift but my gut feeling says that the jaw angle implants should be initially done first. My questions are:

1. Since I should have the implants first…how long after should I schedule my facelift?

2. Do you do jaw angle implants and facelift at the same time? (If I decided to have the facelift with the implants).

3. Would submitting pictures help decide which way to go/

Thanks for your help!

A: While jaw angle implants and a facelift can be done at the same time, I think it is better to stage them doing the jaw angle implants first followed by the facelift three months later. Jaw angle implants cause a fair amount of swelling in front of the ear and jaw angle area. That swelling would seem counterproductive to the pull of a facelift and would work against what the facelift is trying to accomplish. You do not want to stretch out the very skin and tissues that have just been pulled up. (if the facelift is done before and at the same time as jaw angle implants) While I think the two procedures are complementary (both help create a much better jawline), they just should not be done together and the sequence of the staging (implants before lift) is important.

Dr. Barry Eppley

Indianapolis, Indiana

Plastic Surgery Career

Q: Dr. Eppley, I am writing a paper for my school on becoming a plastic surgeon and I need your help.Thank you so much for taking your time to do this…especially so promptly. Out of five plastic surgeons surgeons in my area all of them have practice managers who are like guard dogs to their doctors. I could not get a single one to return my calls or emails. You are amazing for doing this for me. You’ve definitely helped to save my grade and sanity! I am only in my second year to starting my path towards this career. I have a lot to learn yet on what all it will take, but I have my mind set to be a plastic surgeon regardless. If you have any other words of advice I am all ears!

Thank you SOOO much! You are a lifesaver! Alright here we go…

1. What made you chose this profession? Did you know before med school that this is what you wanted to do?

2. What are some of the benefits and drawbacks of your position?

3. Your experience with all of your schooling is really impressive! How long did it take you to complete all of it?

4. What are some of the benefits to becoming board certified? Would you recommend it? and what is involved in doing so?

5. If you had to do it over again would you still become a reconstructive surgeon?

6. What are the most important skills to obtain for this career?

7. What advice or information do you wish you had known when you were premed?

8. Is the compensation worth all of the expenses that it took to become a surgeon?

9. Was money coming in slow when you first started your career? Or were you able to start right out of school at a comfortable pay?

10. What was is like when you first tried to find a job? How long did it take you to become comfortable performing different procedures?

11. What is your typical day like?

12. About how many surgeries do you perform in a week? What are the most common procedures?

13. Are there ever any surgeries that make you nervous? if so, which one(s)?

14. What was the hardest part to becoming a surgeon?   

15. What do you think about the current status and future of this occupation?

16. Would you recommend this career to someone who was interested?

For my own personal information…was it hard to get accepted to medical school? I think that is my biggest fear. I stink at interviews and I am scared that they will pick me apart and I won’t know how to respond to their questions. One last question, so my absolute dream is to make money doing the elective surgeries then be able to do pro bono work for individuals who have been in accidents or have had something happen and are not able to afford to “be fixed” is that a completely unrealistic thought? Or is it something that I could expect to be able to afford to do while still living quite comfortably myself?

A: In answer to your questions:

1) My background is different than most plastic surgeons. I went to dental school first and then medical school. I was trained as an oral surgeon and then progressed through further training to become a plastic surgeon. So yes by the time I was in medical school I knew I wanted to be a plastic surgeon.

2) Like all surgeons, the personal and financial rewards are high but it is a lifetime commitment that can be all consuming being responsible for patients and the surgery they have.

3) Leaving high school until entering plastic surgery practice was 20 years.

4) You have to be board-certified today, it is not an option to not be. You will not be paid by insurance companies for surgery performed if you are not board-certified. Board certification is an additional written and oral testing after have you have completed plastic surgery training.

5) Life is full of many interesting vocations. While plastic surgery island has been my life, it would always be interesting to see what else would have been out there to do for a living.

6) Like all careers, persistence and focus are the keys to success. Nothing succeeds more than persistence dedication to a focused goal.

7) Nothing really. Education and the creation of a career is an evolving process than often takes one down different roads than one envisions. Keep focused on getting the best education with a propose is what I knew then and is what I would tell any college student today, a medical career notwithstanding.

8) Money is only a measure of educational costs and the services ultimately provided from using it. The worth of that education and career is really based on the joy one gets by the process of achieving it and then using it. One should never measure their success in life by a monetary yardstick. The value of the process is what it makes you as a person.

9) Comfortable pay is a relative concept. As long as the money coming is ore than your expenses, one should be comfortable. But yes working is more financially comfortable than training is.

10) I never had trouble find a job. Work was available as soon as I finished my training.

11) I start the day at 5:30AM in the office and usually get home by 7PM at night.

12) I perform between 10 to 15 surgeries per week. Since I do such a varied number of aesthetic and reconstructive plastic surgery procedures there is not really one common procedure. The procedures range anywhere from cleft lip and palate repairs, cosmetic breast augmentations to custom skull and facial implants.

13) No surgery makes me nervous anymore ayer having seen and done thousands of plastic surgery procedures. The only thing that makes me ‘nervous’ is my hope that each patient gets the best result and the outcome takes them to a better place.

14) Working when you feel too tired to do so.

15) Plastic surgery is such a diverse surgical specialty that it will always have a bright future. When the possibilities are so endless the future is only limited by the imagination and creativity of those who are trained to do it.

16) Interest in plastic surgery alone is not enough to make it a career. Passion about it is what is important. For that is what it takes to get through the process to becoming a plastic surgeon.

Getting into medical school has little to do with how one interviews. Just like college it is really all about the numerics, the grades and test scores.

While it it is not completely unrealistic to be able to do pro bono surgery, the reality is the medicolegal and social media risks of so doing will usually make that thought secondary in the real world of practicing surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Umbilicoplasty

Q: Dr. Eppley, I am interested in umbilicoplasty surgery. (technicaIly umbilical scar revision after a tummy tuck) I just recently had a tummy tuck 6 weeks ago and my belly button is off to the left a little… I want to correct this but I wasn’t sure how long to wait? And if this is something you can do?

A: If you have had a fully tummy tuck and your belly button is off midline, it can be moved back closer to the midline through an umbilicoplasty procedure. But there may or or may not be a residual scar out of the ring of the belly button scar based on how far it needs to me moved over. I would need to see pictures of your abdomen to better answer your question. Most likely when you say a little I would imagine it is probably no more than 1 to 1.5 cms at most. It is possible that just excising a crescent of skin towards the midline on one side of the bellybutton may be the type of umbilicoplasty (umbilical scar revision) that you would need. I would certainly vote for that approach even if it can’t be gotten completely to the midline because to will keep the scar confined to the circumferential existing scar around the belly button.

Dr. Barry Eppley
Indianapolis, Indiana

Skull Reshaping

Q: Dr. Eppley, I am interested in skull reshaping as well as jawline reshaping. Would insurance cover my surgery since it is due to congenital plagiocephaly? Also, any doctor in my area that you know of that could do the same surgery that I need? Thank you for everything you do.

A: Thank you for your inquiry. In answer to your questions:

1) It would be impossible to answer any of your questions without knowing what exact procedures that you need. What I could envision what they may be, I would need to see pictures of your face and a more specific description of the skull and facial asymmetries that you have. Skull reshaping and jawline reshaping are broad terms that apply to a variety of different procedures.

2) Only the insurance company can say whether any of the proposed procedures would be covered. To make that determination the treating physician would have to file a predetermination letter complete with a 3D CT scan (to show the deformities) so they can pass judgment on the operative plan. At best, it would be a 50% or less chance that they would cover any of the procedures.

3) Without knowing the exact problem and the needed procedures, I could not say what expertise exists in your geographic area. Skull reshaping and jawline reshaping are very specialized areas in plastic surgery that very few plastic surgeons do.

Dr. Barry Eppley

Indianapolis, Indiana

Facial Asymmetry Surgery

Q: Dr. Eppley, I am interested in facial asymmetry surgery. I developed facial asymmetry over past five years and it gets worth each year. I have very low self esteem and would want the least invasive procedure to correct this. I am interested in knowing the causes for this and learning more on options to correct. As you can see in this photo the right side of my face seems to droop. It is not as toned as the left side. To me it seems to be pronounced when I talk and less pronounced when I smile. The concern I have is why–about 5 years ago I didn’t notice this extreme droop at all and over the past few years it seems to get worse. I have always had a lazy eye and that never really bothered me but now that it has advanced to my lip it does concern me. What are causes for this? I get my eyebrows done and the technicians have told me it’s hard to get them to match because they are just different that is when I really began noticing. It just seems like the two sides of my face are totally different. I appreciate your time. 

A: Your facial asymmetry is congenital where the entire right side of your face sits lower than the left. Yo have known this inadvertently for a long time because of the eye asymmetry (‘lazy eye’) but it has become more apparent now as the entire right face is dropping as you age. That is why it is much more apparent now and gets better when you smile since smiling picks up the sagging tissues.

There are no ‘minimally invasive methods of facial asymmetry correction. This is a problem that will respond only to surgery. The simplest and most effective approach to your facial asymmetry surgery would be a combined right endoscopic brow lift and right lower facelift/jowl tuck up procedure. This will resuspend the tissues up higher so the right facial droop is corrected and better matches the left side of your face.

Dr. Barry Eppley
Indianapolis, Indiana

Occipital Augmentation

Q: Dr. Eppley, I am interested in occipital augmentation surgery. My 5 year old son has a flat spot on the back of his head. We consulted out pediatrician about it from an early age and were told it would “round out”. It didn’t so at 18 months we paid out of pocket for a helmet and got minimal results because of he was passed the age of best results. 

This has caused a lot of pain and regret for us even though my son doesn’t have a clue that anything is wrong. At what age is it safe to consider doing something about the issue? We don’t want him to face any social issues because of bad advice from our pediatrician and late action on our part. What are our options?

A: The aesthetic correction of unilateral occipital plagiocephaly by occipital augmentation can really be done at just about any age in my opinion. Correction involves building out the bone with hydroxyapatite bone cement (at at early age) or a custom made implant at older ages. Whatever is placed on the bone will grow with the slowly expanding skull growth. I think hydroxyapatite cement is most appropriate for young children since its the inorganic mineral content is most similar to bone. The decision and timing for occipital augmentation surgery at this point in your son is a personal one and is most appropriately done when you and your wide deem it most psychologically protective.

Dr. Barry Eppley

Indianapolis, Indiana

Orbital Hypertelorism

Q: Dr. Eppley, My eyes are too wide- apart which is the biggest regret in my life. I have normal to level 1 of hypertelorism (advised by one doctor before) and I think I am close to no deformity. I would like to know if orbital box osteotomy can be performed in non-deformed patients through milder approaches, like via infra-orbital or oral incisions since my inter-pupillary distance is not as wide as the deformed cases. In my home county and East Asia, there is very rare information about this procedure. I would like to know if any osteotomy procedures can be done to my eyes. Much appreciated and awaiting eagerly for your response. Many thanks doctor!

A: Orbital translocations, aka orbital box osteotomies, can only be performed through a coronal/scalp incision with a frontal bone flap craniotomy removal. There are no effective more limited ways to do an orbital hypertelorism procedure. The only less invasive way that the eyes can be made to appear closer together is with some camouflage procedures such as nasal bridge augmentation and/or medial canthoplasties/medial epicanthoplasties. These small changes to the nose and inner eyes, particularly if done together, can often have major influence on how close the eyes may appear.

Dr. Barry Eppley

Indianapolis, Indiana

Jaw Angle Reduction

Q: Dr. Eppley, I am  looking for a surgeon who has proper training to do “mandible angle reduction”surgery. (This is a form of plastic surgery, aesthetic not reconstructive, to reduce the square jaw angles for patients who do not have jaw angle deformities but just wish to reduce square jaw angles.) However, I am not sure what training a doctor should have to perform this type of surgery.

a) Is it enough for a plastic surgeon to attend a 3 day forum for “ Surgical-Orthodontic Approach to Dentofacial Deformity”, to  perform “mandible angle reduction”and cut people’s square jaw angle bones?

b) Would attending a 3 day forum on “Surgical 0rthodontic Approach to Dentofacial Deformity” be RELEVANT to equip a plastic surgeon to perform “mandible jaw angle reduction?

c) I cannot find information on line about “Orthodontic Approach to Dentofacial Deformity” so I have no knowledge/understanding. What is this about? Orthodontic is a branch of dentistry so I cannot quite see how this 3 day forum relates to doing mandible jaw angle reduction.

d) What training should a plastic surgeon have, which would be relevant or adequate to perform “ mandible jaw angle reduction” ?

A: The question you are asking about what qualifies a surgeon to perform jaw angle reduction surgery is not a simple one as that training/experience could be gathered from a  variety of different experiences. Any surgeon that would perform this procedure would be trained and very experienced in facial bone surgery. This could come from a plastic surgeon with craniofacial surgery training or an oral and maxillofacial surgeon with good orthognathic surgery experience. Jaw angle reduction surgery, while simple in concept, is technically challenging as is all surgery of the mandibular ramus due to the limitations of surgical access.

I can speak about the forum you have mentioned in the context of your question since I have not seen or attended the program. Although that is clearly a course in orthognathic surgery of which aesthetic jaw angle reduction would not typically be a part of that course curriculum.

Dr. Barry Eppley

Indianapolis, Indiana

PRP Hair

Q: Dr. Eppley, I would like to get some information about the PRP hair injections for hair loss. I have been diagnosed with Telogen Effluvium. I believe it may be CTE now as its going on a year. Will this treatment help stop the shedding as well as help with growth?

A: PRP (platelet rich plasma) has had good success with a variety of medically induced hair loss problems, not just for androgenic male hair loss only. (PRP Hair) Since telogen effluvium is a reactive process and not genetically induced it should theoretically respond to a variety of stimulatory agents. PRP contains platelets which are concentrated sources of high levels of growth factors. Such growth factors are known to stimulate a variety of cells including the follicle cells in the hair bulb. For hair loss PRP is mixed with other hair growth agents such as niacin to maximize its effects. It is administered through a number of small droplet injections throughout the scalp using a very small 30 gauge needle. While there is no guarantee for response in any patient, the autologous nature of PRP has no downside to its use. PRP hair treatments can also be combined with other hair regrowth methods such as minoxidil for a synergistic effect.

Dr. Barry Eppley

Indianapolis, Indiana

Chin Reduction

Q: Dr. Eppley, I am interested in chin reduction surgery. Here are my questions:

1. What is your recommended approach for me…burring down vs. cutting the bone, intraoral vs. submental, etc? Just the chin or the jaw also? Changes to the fat/muscle/skin?

2. What can it achieve (can you simulate it with a digital image)?

3. What are its limitations and possible side effects?

4. What are the risks and how do you minimize them?

5. What can I do to ensure the best results possible? Are there limitations on travel?

6. Can you share before/after photos of women who have undergone this surgery?

7. Your site states $6500 for chin reduction – does this include anesthesia, operating room, surgeon’s costs? Does the cost differ by surgical method?

8. How much time to I need to plan to take off work and/or work from home?

9. How many trips would be required? (pre-op, surgery day, post-op/follow up?)

10. Would you recommend doing rhinoplasty and chin reduction at the same time or separately?

11. What are your Care Credit terms (6,12,18 months no interest?)

12. Do you require dental x-rays or some other type of imaging?

13. Would liposuction be effective in achieving a more defined chin/jawline? Is this considered a separate procedure from the chin reduction? Is there enough fat in your estimation that re-injecting it to my cheeks would produce a good result? Would  a future pregnancy alter the results?

A: Thank you for sending the detailed questions about chin reduction. My answers to your questions are as follows:

1) If vertical chin reduction is all that is needed than an intraoral wedge bony genioplasty approach would be used (this would include narrowing the chin  if desired) But all other chin dimension reductions are best done by a submental approach.

2) Computer imaging is always done before any facial reshaping procedure. Chin reduction is no exception.

3) Scar (if submental approach is used), asymmetries, uneven jawline, soft tissue redundancies are all potential risks and complications from chin reduction surgery.

4) As you can see in #3 the risks are essentially aesthetic in nature. Knowing how to manage the soft tissues in a chin reduction is actually more important than the bony reduction part of the operation.

5) Preoperative choice of the correct chin reduction procedure is the most important step to ensure the best result.

6) Because of patient confidentiality, there are very few before and after pictures that can be shared. And this is coming from someone who has done a lot of them.

7) This is a logistical question for my assistant Camille. Until we know the exact chin reduction procedure she can not give you an absolute number.

8) Recovery is all about the swelling and when you feel comfortable being seen in public. Everyone is different in that regard. It could be one week for some and three weeks for others.

9) One trip for the surgery is all that is needed. All followups can be done electronically.

10) Rhinoplasty and chin procedures are commonly done together. That is a personal choice.

11) Another economic question for Camille.

12) No preoperative x-rays are needed unless one is getting an intraoral bony genioplasty.

13) Liposuction rarely, if ever, can make a more defined jawline. Such changes are a reflection of what happens to the bone not the soft tissues. Any fat injections done would need a harvest site not from the neck. The amount of fat needed exceeds what can be obtained from the neck. Chin reduction surgery will not be affected by pregnancy.

Dr. Barry Eppley

Indianapolis, Indiana