Your Questions
Your Questions
Q: I read an article by you on non-surgical fat reduction and understand from your writings that you have one of Erchonia’s Zerona cold laser devices. I was wondering if you have had any experience or success with reducing large lipomas?
A: Your question represents a common and understandable misconception about lasers in general and the Zerona device in particular. Almost everyone envisions a laser as a device which shoots a beam which melts, explodes or destroys the target. This would be a high energy focused ‘hot’ laser and is the most typical laser concept that is employed around the world. The Zerona device, however, is a ‘cold’ laser meaning it does not shoot high energy beams toward its target. Rather it is a very low energy photochemical light which causes a reaction that has a much different effect on the targeted fat cells. It passes through the skin, without injury or discomfort, and causes the fat cells to become temporarily ‘leaky’. This releases some fat and, if done enough times, the fat volume in the targeted area will decrease in size.
Because of the way the cold laser works, its effect will not have any impact on the concentrated tumor fat of a lipoma. It simply is the wrong type of laser energy.
There is a laser method for lipoma treatment that does use a hot focused laser. Under local anesthesia, the fiberoptic probe of the Smartlipo (laser liposuction) machine can be introduced into the lipoma and activated for a few seconds. This melts the center of the lipoma and can definitely shrink its size and/or destroy it completely. This does require a tiny little incision into the skin to pass the probe through so it is a minimally invasive approach but would not properly be called a non-invasive procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am a 21 year old male who was involved in a car accident when I was 16 years old. As a result, I have a depressed area on my forehead. I would like to know if Kryptonite Bone Cement could be injected to fill the depression?
A: The reconstruction of frontal bone defects or contour issues is often done using onlay cranioplasty techniques. It can be a highly successful procedure as synthetic material is added onto the bone defect area. Various materials have been used over the years, most commonly acrylic (PMMA, polymethylmethacrylate) and hydroxyapatite. (HA) While there may be advocates and some minor advantages and disadvantages with them, both will do the job equally well from a bone reshaping standpoint. Both materials require, however, an open approach for placement. For men in the forehead area, a scalp incision may not be worth the trade-off depending upon the size of the forehead problem. If an existing scalp scar is present from a prior neurosurgery procedure, then that is a different matter and an open cranioplasty would be the best approach.
Kryptonite bone cement is the first cranioplasty material that has physical properties to make it injectable. This means it still requires an incision but it can be as small as less than an inch through which scalp tissue elevation is done around the bone defect area. The material is then mixed and injection through a long flexible introducer tube into the defect site. Shaping of the injected material is done from the outside by external pressure.
Indianapolis, Indiana
Q: I am interested in getting a breast augmentation but also have concerns about my nose. I think a rhinoplasty would almost help me as much as the breast augmentation in both appearance and my self-confidence. My questions is can I do them at the same time and is there any discount on getting more than one surgery at the same time?
A: Multiple operations during a single plastic surgery encounter is very common. Since one is going to be asleep under general anesthesia, it just makes sense to do as much as is medically safe and reasonable from a recovery standpoint. I have seen all sorts of different types of plastic surgery procedures put together and there really is no limitation as to what can be combined. The only limitation is whether the plastic surgeon feels comfortable doing all that the patient needs…and that the patient is healthy and can tolerate the surgery.
Breast augmentation is a relatively short operation, generally an hour or so, while rhinoplasty can take two or three hours to do depending on what type of rhinoplasty it is. These two operations combined are well within a safe operative time period of 3 or 4 hours and can even be done as an outpatient. I have performed these two plastic surgery procedures together more than one time. Younger women are exactly the type of patient who would commonly have one or both of these cosmetic concerns.
Any time multiple cosmetic procedures are combined, there is some economy to be had in both recovery and costs.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have drooling from the corners of my mouth and its embarrassing. I am 73 years old and have not had a stroke and I am still working everyday. What can be done for this corner of the mouth drooling problem. It was also occasionally get red and sore and painful. When this happens, it takes a fair while until it finally gets better. I have tried all sorts of antibiotic creams and salves but nothing seems to be that effective. I have read about a procedure called the corner of the mouth lift that removes the overhanging skin. Do you think this will help?
A: Downturning of the corners of the mouth, combined with aging which creates a skin overhang, creates a gutter effect at the corner of the mouth. This is the perfect setup for a runway for saliva. This problem can be further magnified with one has overclosure of their lower jaw due to a loss of teeth or ill-fitting dentures. This overclosure causes a lower lip inversion which makes the drool problem at the corner of the mouth worse. Localized infection at the mouth corners can happen due to the chronic wetness of skin that is not normally so like the lining inside the mouth. This is known as angular cheilitis. Topical steroids and antifungals can help but a change of the anatomy is more effective.
The corner of the mouth lift can be really helpful for this problem as it removes the skin overhang and lifts the mouth corner. This eliminates much of the spillway problem. There is a trade-off of a small scar that tails away from the mouth corner but this is not usually a significant cosmetic concern.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am bothered by my puffy cheek look. I feel that the area under my cheekbones is full and, as a result, does not give good definition to my cheek area. I had cheek implants placed but they didn’t give me that more sculpted look that I was looking for. I think the problem isin the full area below the cheek. I have read this is called the submalar area. Is it possible to have a tightening of the submalar soft tissues area. Is there such a procedure? I have simulated this concept in front of the mirror many times without knowing it was possible outside of a full facelift and really liked the improvement it makes in highlighting the cheekbone. How would such a procedure be done? Is there any external scarring or is it done completely intraorally? I would like to pursue this procedure seriously so any information you can provide would be much appreciated. Thanks again.
A: The submalar area of the face is a non-bone supported area beneath the cheek bone (malar eminence) that is influenced exclusively by the volume of soft tissue that it contains. Thinning, or creating an indentation, in the submalar area is commonly done by buccal fat removal. While this simple procedure can be helpful in the right patient, it does not work well for every fuller face. And can even create too much of an indentation later in life when one gets older as natural fat atrophy occurs in most people.
An alternative procedure is submalar tightening. It is not nearly as well known but can also create a narrowing of the submalar triangle. Using the same intraoral incision and approach as one does for a buccal lipectomy, the underlying soft tissues are cinched down with a suture anchor placed into the underside of the zygoma. This can be done in conjunction with buccal fat removal for a combined submalar indentation effect.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dear Dr Eppley, I underwent a chin reduction with a jaw contouring operation about one year ago. As for the result, have always found that it looked odd. My chin was reduced by 1cm and now my mouth does not close properly at rest and there is a ‘balling’ shape to the muscle and a wrinkled look. I recently had a MACS lift as my jaw muscles also looked slack after the op. However my chin is unchanged and still feels loose, unattached and ‘balled up’. I have come across your writing online and think your expertise may help resolve this. What do you suggest?
A: If your chin reduction was done through an intraoral vertical osteotomy reduction technique, then you would likely end up with soft tissue excess over the chin area when a large amount (1 cm) is vertically reduced.. (mentalis muscle and skin) These excess soft tissues could very well end up looking like a ‘ball’ over the chin area. This could really be predicted beforehand as where is all of the soft tissue that covered the 1 cm that was removed supposed to go?
No form of a facelift would solve the excess tissue problems in the chin area nor should it be expected to. A MACS lift, like any form of a limited facelift, is a lateral or side of the face operation based on soft tissue pull. So it will tighten up any loose skin over the side of the jaw/jaw angle area/jowls, but will do nothing for the chin area. The chin area excess is a central problem that requires direct excision and tightening, most commonly done through a submental incisional technique.
Dr. Barry Eppley
Indianapolis Indiana
Q: Dr. Eppley, I had a Medpor Lateral Augmentation Onlay Mandible Angle Implant for mandibular augmentation about nine months ago. While I am satisfied with the results, I desire more lateral augmentation of his mandible. I know from reading that it is possible to reduce Medpor Implants in a second operation if the patient feels the implant provides too much augmentation. Is it also possible to enhance an implanted Medpor implant, by placing some further Medpor material on top of the implant surface in a second operation? I thought it could be useful to place smaller pieces from Medpor sheets and place and secure (screw) them over the existing mandibular implants in order to increase their lateral projection. Would you advise to place additional Medpor over an incorporated Medpor implant? Do you know if Medpor is designed for this or are there any problems that might occur by enhancing an existing Medpor implant with further Medpor material? Thank you in advance for your efforts.
A: I see no problem why you can’t add more material on top of an existing Medpor implant. The important issue would be good security (screw fixation) to the underlying implant. I would be concerned about shifting or palpability of a multi-implant reconstruction not any interactive material problem or reaction.
It would be far better and easier, I think, to remove the existing implant and add to it on the back table…to assemble a good solid construct and then re-insert during the surgery. This may make it surgically easier to do. Or why not change just to a whole new bigger implant and be assured you have a solid one-piece construction?
Indianapolis Indiana
Q: I have been developing droopy jowls over the past few years and it is getting worse. I am 50 years and I don’t want a facelift or surgery. Is there anything that may help them go away that doesn’t involve any cutting and scars? I have read about some fat dissolving injections which they say can make jowls get better. Is this true?
A: The development of jowls or jowling will occur in everyone eventually. These classic aging signs are when the skin and fat that used to be up on the side of the face comes sliding down due to time, gravity, and weakening of the skin’s attachments. There is no question that the preferred as well as superb treatment for isolated jowling is some form of a facelift. If jowling and not the neck is the main issue, then a more limited type of facelift will work quite well. These smaller facelifts (jowl lifts or tuckups) go by many different names, most popularly known as a MAC Lift or a short scar facelift. Regardless of the branded name, they are all essentially the same type of limited facelift operation.
Short of surgery, fat dissolving injections have been used for mild jowling. Known as Lipodissolve injections, these chemical concoctions do have the ability to break down small areas of fat and tighten just a little bit of skin. I have used them very rarely in the jowl area but, in the handful of cases that I have done, there was a definite amount of improvement and several of those patients were absolutely thrilled. The key is in patient selection. They must not have too much loose skin or too much jowling or these injections will have no benefit.
There are also other device-driven methods of jowl tightening such as Thermage, Skin Tyte and others. The concept is to treat the deeper skin and underlying tissues with heat, ultrasound or radiofrequency energy to create the tightening. These device approaches to jowling would be more mainstream and accepted as opposed to Lipodissolve injections.
Dr. Barry Eppley
Indianapolis Indiana
Q: I have several questions in regards to scar revision. When you perform a geometric broken pattern scar revision, then will you be cutting out more skin beside the original scar? What is the role of injecting Botox in the scar revision surgery?
A: Your assumption in how geometric scar revision works is correct. To make the various limbs and angles, some normal tissue in addition to the scar must be removed. This does not lengthen the scar in total visual length as the small tissue areas are taken from the sides of the scar not from the ends. If you straightened out the scar ins a single straight line, it would in fact be longer than the original scar by actual length measurement. But this increase in scar length is ‘internal’, staying within the original length of the scar.
The use of Botox in scar revision remains, at this point, entirely theoretical. Its use in scars is more hope than proven science. While Botox does seem to be good for a lot of problems, it is not good for everything. Botox works by decreasing nerve output, usually to muscle. Scar and any resultant hypertrophy or widening is not usually a muscle or nerve problem in most cases. Poor scarring is more related to tension on the wound edges and the type of skin and mechanism of injury. It is not clear why Botox would work for most scars unless it is weakening any pull on the scar edges from the underlying muscles in the critical scar phase of the first six months after its creation.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am considering breast augmentation but am just insure about what size to go to. I have been an A cup all my life and have no real idea what would like right on me. Do you have any suggestions to offer in choosing size?
A: When it comes to breast size, beauty is truly in the eyes of the beholder. While there are certainly trends in each culture that reflect the ‘average breast size’, that has little to do quite frankly with what you want for yourself and how you want to look.
Breasts should be proportionate to a woman’s body frame and build. The historic concept of 36-24-36 inches, though quite exaggerated, basically refers to breast size being equal to the hips, with a significant narrower waist in between. This creates that classic hourglass figure but that may not be right for everyone and probably is more uncommon than common.
It is important to consider a woman’s body build in determining the most suitable breast size because if one’s arms or tummy is bulky then the breasts will have to be bigger to give the right profile. In thinner women smaller sized breasts will give the same look of fullness in the breasts.
With all of that being said, the one single parameter that seems to work for most patients is to choose a breast size (implant) whose base width matches the natural base width of your breast. This is a simple horizontal measurement. As breast implants increase in diameter as they get bigger, having an implant that is no wider than your natural breast will never give one a final breast size that is too big. (which is the most common fear of most breast augmentation patients before surgery.
Dr. Barry Eppley
Indianapolis Indiana
Q: I have a burn scar on my leg from several years ago. I am sending a picture of my burnt leg, which I can stretch and bend easily meaning I can move it freely. I would like to know what you can suggest for getting the best scar result. I have heard about scars and that its impossible to make them disappear. Thanks in advance.
A:Thank you for sending your picture of your leg burn scar. Burn scars (deep 2nd and degree burns) create the worst outcomes in terms of eventually doing much with the scar because they have changed the entire thickness of the skin into one complete scar. The tissues are just never normal and do not have the ability for much normal tissue regeneration.
The good news is that you can move your leg freely without scar contracture or restriction. The bad news is that I don’t believe there is anything that will provide a substantial improvement in its appearance by any form of scar revision. Hypertrophic burn scars have changed the entire thickness of the remaining skin into one large white scar. It may be possible to get some improvement with combined fractional and CO2 laser resurfacing but the improvement may not be significant enough to justify the effort. That form of laser treatment may make it a little flatter but it will not make the scar disappear nor make it look like normal skin. Those goals are not possible. If the objective is some level of improvement then such effort may be worth it. But if the objective is to make it look like there is no scar there then any form of treatment should not be pursued as disappointment will surely follow.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am 36 years old and have had fairly deep forehead lines for quite a few years now, which appear to be getting worse. Is there something other than plastic surgery or Botox that I can do to help my problem? I am desperate!
A: The simple answer is…no. But let me explain why. Wrinkles on the face form perpendicular to the direction that the underlying muscles move with facial expression. The well known horizontal lines on the forehead are a result of the large frontalis forehead muscle that attaches to our eyebrows and goes across our forehead the whole way to the back of our head. As you move your forehead with expression, the muscle lifts the eyebrows and creates the horizontal lines. The only way to stop them from forming, therefore, is to stop moving your forehead. Notice the difference in the depth of the forehead wrinkles when your forehead is still and not moving versus when you are lifting your eyebrows. (that difference is important for treatment considerations below)
There are only two non-Botox and non-plastic surgery options that can reduce your forehead wrinkles. A state of permanent facial paralysis is one option, otherwise known as death. Very effective but not appealing. The other option is to retrain your facial expressions so you don’t move your forehead anymore. Theoretically possible but if you are successful you will be the first human to have successfully done so.
I tell you this so in your desparate state so you don’t chase worthless treatment options and throw away money…or actually transfer your assets to the benefit of someone else. So do not chase the illusion of innumerable skin lotions, potions and facial exercises that promises a miracle wrinkle cure.
That leaves you with exactly what you want to avoid, Botox and forehead surgery, Unappealing but actually the only things that will work. Back to the depth of your forehead wrinkles when they are still versus moving. If the depth of the forehead wrinkles is acceptable when your forehead is still, then Botox would be the preferred treatment. If the depth of the forehead wrinkles at rest is still not acceptable, then a forehead lift with muscle removal would be the better treatment.
Dr. Barry Eppley
Indianapolis Indiana
Q: Is it possible to have a vertical chin that points downward as a result of fleshy tissue and not bone? My chin is vertically too long for my face and projects downward especially when I smile. I’d hate to have complications from having the bone burred down on the tip but would also hate to have titanium plates & screws in my chin from a wedge of bone being cut out to reduce the chin. I live in Texas and I don’t’ know any surgeons here that are properly certified and experienced in chin reductions. Please let me know. Thanks.
A: A long vertical chin can be the result of too much bone, too much soft tissue, or a combination of both. In most cases, vertical chin excess is a combination of both. By definition, a chin that is too long because of bone must have extra soft tissue to go with it. Making the proper diagnosis helps one correct the right chin reduction procedure. Not properly addressing the right problem, or inadequately treating it, is the reason so many chin reductions have unsatisfactory results.
A physical exam can usually tell which component make up the vertically excessive chin. In some cases, a simple panorex dental x-ray can also be helpful. The observation that your chin soft tissues pull downward when you smile is common and indicates that it a combined bone and soft tissue problem.
Chin reductions can be done by bone only reductions (intraoral horizontal reduction osteotomy) and bone and soft tissue reductions. (extraoral submental bone burring reduction and soft tissue resection and tightening) Because these two procedures are so different, one can see the importance of making the correct diagnosis of excessive tissues.
Dr. Barry Eppley
Indianapolis Indiana
Q: Does Dr. Eppley perform non-surgical rhinoplasty? If so, how many has he done and what does it cost?
A: I have performed non-surgical rhinoplasty, otherwise known as using an injectable rhinoplasty. It is about using an injectable filler most commonly in the upper part of the nose (radix) to treat (hide) a hump. I have done that office procedure numerous times. It is only good to fill the bridge area above a hump to make it smooth. In a few other cases, I have used injectable fillers for small areas of fill-in for dents and asymmetries in other parts of the nose. But you can’t do a complete rhinoplasty or even a partial rhinoplasty in a non-surgical fashion. So the concept of an injectable rhinoplasty is for filling in small defects in the nose. It is also important to realize that these effect are temporary (one year or less) and not permanent.
I would have to see pictures of your nose to determine if this procedure is for you. If so, the usual injectable filler used is Radiesse because it lasts the longest although other fillers can be used. (e.g., Juvederm)The cost of the procedure is based on how much filler is used and what type. It could range anywhere from $350 to $850 depending on those factors.
Another form of injectable rhinoplasty is that using diced cartilage. While it does require a septal graft harvest, the cartilage is diced and injected through small syringes from an incision inside the nose. This injectable rhinoplasty procedure does require an anesthetic to perform and so it is better called a minimally-invasive rhinoplasty.
Dr. Barry Eppley
Indianapolis Indiana
Q: Several of my friends have had breast augmentation with you and have loved their results. I am 41 years old and have always wanted larger breasts. My problem is my doctor has informed me that it would not be a good idea go under general anesthesia. The reason being is my mother at age 45, my brother at age 29, and a sister at age 22, all passed away all while under general anesthesia. They never identified a specific cause although my doctor said it is genetic and has told me if I want to do any sort of plastic surgery it would need to be done under a local. Is there any hope for me finding a plastic surgeon who would do my breast augmentation under a local, epidural or something while I am conscious. This is something I have longed for over 15 years. Please respond as soon as possible. I don’t want to go to a cosmetic surgeon and have this done. I want a reputable plastic surgeon such as yourself to perform this. Thank you so much for your time.
A: That family history is the most tragic that I have ever heard in all of my surgical experience. One family member dying under this general anesthesia is rare enough, but three is beyond comprehension. While their diagnoses may not have been known at the time, it is highly likely that your family has the gene for Malignant Hyperthermia. (MH) While not recognized decades ago, it now is and every operating room that does general anesthesia has an emergency kit for its treatment. There is no blood or genetic test for MH. Family history is the only ‘test’ for its presence. Your family history is more than suspicious for this diagnosis.
While you have a likely family history for MH, this does not mean you can not have general anesthesia. The known anesthetic drugs that trigger MH is the muscle paralyzer, succinylcholine, and all of the inhalation agents. General anesthesia without these drugs can be done using narcotics and a propofol infusion, a common combination used in many plastic surgery procedures.
But given your family history, it is also understandable that no matter how a general anesthetic is done you would never feel completely comfortable. Therefore, having a breast augmentation under local anesthesia is possible. (with some oral sedation drugs beforehand) The key to this approach is to place the implant above the muscle (subglandular) and infiltrate the breast first with a tumescent solution for local anesthesia. (much like what is done for liposuction surgery)
Dr. Barry Eppley
Indianapolis Indiana
Our skin is the largest body organ that we have and has more medications and treatments per surface area than any body part. The skin care world is chocked full of thousands of products that claim to either protect it or make it look younger. The sheer cacophany of skin care products clamoring for our attention leaves most women (and a few men) completely confused about what to use.
One newer type of skin care technology is that of antioxidants. Besides the obvious psychological appeal of not wanting to be ‘oxidized’, products containing antioxidant ingredients are popping up everywhere. While the scientific benefits of antioxidants and how they work are better reserved for a classroom or as a replacement for melatonin before retiring, it strikes me that we are seeing what’s old becoming new again…through the wonders of modern chemistry.
Antioxidants in skin care is actually a bit nostalgic and reminds us that our great grandmothers had the right concept all along. Most of today’s antioxidant skin care potions derive their properties from the naturally available fruits, vegetables, and whole grains that were once the main ingredients of age-old facials and historic healing compounds. They may not have known why it worked, and may not have had the right proportions of ingredients, but their organic approach was rooted in science after all.The fruit acid facials of today (also known as alpha hydroxy acids, or AHAs) derive their ingredients from extracts of grapefruit (procyanidin), lemon (vitamin C) or apple cores (vitamin C and phenols), are actually quite old. I have had more than one older patient who has told me they used to rub lemon juice or the cut edge of an orange on their face to reduce wrinkles or on their scars to make them look better. The ancient use of green tea facials (and you thought it was only for drinking) has been found to contain catechin which has potent antioxidant properties.
Old vegetable masks contained tomatoes, which are rich in lycopenes and carotenoids, to help control oily skin and reduce wrinkles. Oatmeal powder and other grains contain ferulic acid which has an antioxidant effect…not to mention the skin calming benefits of the well known oatmeal bath. Curd contains lactic acid which is a chemical peel. Cucumber and pumpkin have high levels of the potent antioxidant vitamin C. (the benefits of reducing eye puffiness from sliced cucumbers is not because they have a magic ingredient, it is that they are cold…a cool washcloth works just as well) Honey and egg yolk have been used in facials dating back to ancient Egypt. Honey contains flavinoids and vitamin C while egg yolks have the antioxidant carotenoid in them.
Before we wax romantically and start rubbing lemons and green teas leaves on our face, it is important to realize that science has several advantages over nature. Through purified and concentrated extracts from these natural sources and using technologically advanced delivery systems, what does come out of that expensive bottle is easier to use and does work better.
Indianapolis, Indiana
Q: I am currently faced with several problems. My face looks wide because I have prominent cheekbones. I have deep set eyes because of very prominent and bulgy orbital rims. It’s not so much the width of my face that bothers me but it brings everything out of place. Because of the small eyes and the rest of my face is pretty crowded together. When looked from the side, the orbital rim covers nearly everything of my eye while other people still have a part of the eye visible. My cheekbones are bulgy both in the front and the side. Is there any procedure to help me?
A: What you are referring to is prominent orbital rims which make up 3/4s of the orbital ‘box’ that encases the eye. When this outer circle of bone is prominent, it makes the eye seem deep or hidden. It is possible to reshape the orbital rims, particularly the brow bone (upper orbital rim) and the side. (lateral orbital rim) It is not so much whether it can be done but whether the trade-off for doing so is worth it. To surgically access this area, a scalp or coronal incision is needed. This allows the skin to be lifted to get to the area for reshaping. For many women this is not a rate-limiting consideration. But for many men it understandably is.
The width of the cheek bone can be narrowed by a vertical wedge bone removal right below the eye bone which is done from inside the mouth.
Indianapolis Indiana
Q: I have an extremely deep acne scar on my cheek from cystic acne that has tunneled under the skin. Subsequent healing has resulted in some type of contracture and folding of the skin so that an indentation extends under the skin itself. The indentation extends for about 15 millimeters and seems to follow the track of a hair follicle. The opening is broad, about 9 millimeters and regular. I would happily trade this scar for an excision scar. Can you tell me if this can be done and is it a good idea?
A: Acne scarring can be quite severe and deep. This is particularly true on the cheek area which shows such scarring prominently due to the tighter skin stretched across the bone. I have seen this exact cheek acne scar situation that you have described several times before. What it really represents is the loss of subcutaneous fat underneath the skin due to the infection with the skin edges healing inward. You have described it quite accurately as a scar contracture.
As a result, the problem with this type of cheek scar is that it is not only indented but is missing tissue underneath. So while cutting it out is an important step (scar excision), replacement of deeper fat at the same time is also important. If not replaced, there is a chance of the wound edges pulling downward as it heals to a space with less fill underneath. For this reason, I would do a scar revision with the simultaneous placement of a fat graft underneath the skin edge closure. This would be particularly important in the tight skin that overlies the cheek.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am looking to have what I think is called a Mommy Makeover. I have it on TV shows and read about it on the internet. For the breast implants, I am looking to have saline implants done. I would like them placed behind the muscle if possible. I am not sure what my ‘true’ cup size is. I know it is between an A and B. I would like to be a full C to a small D. I do need a slight lift but I am concerned about scarring. I would like the incisions to be as discreet as possible. As for the tummy tuck, I think I only need a mini-tuck. I have a little bit of fat in my lower stomach that stays and I cannot get rid of it. I also have a little bit of stretched skin that needs to be removed. I am looking to have the problem fat suctioned out and the muscles to be sutured back together and the little bit of stretched out belly skin removed. After looking at pictures and watching animated videos on tummy tuck; I realize that my tummy problem is quite small compared to majority of the pictures I have viewed. I am a small frame as it is. I am about 5’2” and weight about 115 pounds.
The issues I have may not seem like anything to someone else; but they are BIG to me. I look at myself each day and do not see a young beautiful woman. I wonder each day how in the world is my husband still attracted to me. I am wanting to do this for my self. I would love to love myself again! Does this sound like it can be all done in a single operation?
A: Mommy makeovers are typically a combination of breast and abdominal reshaping. Improving the very problems that being a mommy has created. Saline breast implants can be placed from a remote incision high up in the armpit that will never be seen. The most limited incision breast lift is that of the superior crescent mastopexy, also known as a nipple lift. It puts a fine line scar at the top of the nipple only right at the junction of the areola and skin. Given your body frame size, you are describing perfectly what a limited or mini-tummy tuck accomplishes.
Both breast augmentation with a lift and a mini-tummy tuck can be done in a single outpatient procedures. The combination of the two truly makes for a new body for Mommy!
Dr. Barry Eppley
Indianapolis Indiana
Q: I need a chin augmentation because my chin is definitely short. I know there are two ways to do it, either with an implant or an osteotomy. I would ultimately prefer the implant over an osteotomy. Is it possible to get some vertical lengthening with an implant, maybe in the range of 2 or 3 mms? Is it possible to get an implant without making the labiomental indentation deeper?
A: When significant vertical lengthening of the chin is needed, an osteotomy is really needed. But when the vertical height increase needed is small, a chin implant can achieve that dimensional change. It is necessary to place the implant as low as possible on the chin bone, almost as if it was on the edge of the bone. To maintain that position, I prefer to place a single metal screw into the bone to secure it. That way there is no risk that it can move upward even a single millimeter.
The labiomental sulcus or groove is located below the lip and really represents the location of the mandibular vestibule inside the mouth where the mentalis muscle attaches to the bone. Because of its superior fixed location, it will usually become a little deeper after chin implant augmentation. This is because it doesn’t change but the soft tissue of the chin moves forward, making it look a little deeper. When the amount of chin advancement is significant (8 to 10mms), the labiomental fold will get deeper in most patients. That effect will be lessened when the implant is placed on the lower end of the chin bone with vertical lengthening as the push underneath the labiomenal fold is less due to the lower position of the implant.
Dr. Barry Eppley
Indianapolis Indiana
Q: I came across your website, while doing research on cosmetic surgery. I currently have depression. After three pregnancies, I feel like my body is mangled. I know that my self-image is what brings on most of my depression. I know that depression alone is not a reason to have surgery. I have been treated for depression for about three years now. I have thought about cosmetic surgery just as long. After the pregnancies and losing weight, gaining weight, and losing weight, my belly definitely needs a tuck. I breastfed all of my children. I breastfed only for about 2 months with the first child but about a year with the last child. With breastfeeding and losing weight; I barely have any breasts at all.
I am only 28 years old. I want to feel young and beautiful again! I know I deserve to and my husband deserves to have a wife who feels good about herself again. My kids deserve a mother that feels comfortable enough to take them swimming. I would love to be able to eventually wear a bikini.
I know that some people may get depressed after they have surgery; whose to know how I will be after surgery. Seeing that a lot of the causes of my depression are due to the way I feel about myself or view my body. I know surgery could not make my depression worse; if anything it will help improve the way I see myself and think about my body. The only way surgery would worsen my depression is if I had surgery by a surgeon who did a lousy job.
I am not interested in looking fake. I just want to look normal again. I would like to either be a full C or small D regarding my breast.
I suppose a ‘Mommy Makeover’ is what I am really looking for. What are your thoughts?
A: Of your situation and feelings, I understand completely and could not be more emphatic. Pregnancies can definitely take a toll on your body, and between the skin stretching and shrinking and the inevitable breast involution (loss of breast tissue), some women can not even recognize the current skin and body that they now have.
As you have correctly pointed out, surgery is not a cure for depression. But at least it can improve one recognizeable and understandable cause of it…the way one looks. The body problems can definitely be improved and, hopefully with that, one’s self-image elevates. In my experience with women and these type of popular ‘Mommy Makeovers’, patient do report a dramatic improvement in their self-confidence and clothing options.
The classic ‘Mommy Makeover’ is some form of combined abdominal and breast rehaping plastic surgery procedures. This is usually a tummy tuck with or without liposuction and breast implants with or without a lift. In about a four hour surgery (or less), a dramatic body transformation can occur.
Dr. Barry Eppley
Indianapolis Indiana
Q: I have had a beard for years and now I have a job that will not allow facial hair. This has made my insecurities over my chin to resurface. I am especially interested in a chin implant. After review a lot of before and afters you have seemed to me to do the best work. What is the best type of chin implant ti use?
A: Facial hair on men provides uniqueness to one’s facial appearance and is often a fashion statement. Many times, however, facial hair serves as either a distraction or camouflage technique. This is especially true for upper lip and chin concerns in men. A beard or a goutee adds at least 5 to 8mm of pseudoprojection of the chin depending upon how long the hair is allowed to grow.
When it comes to chin implants, there is no one single style or type of material used that is the best. There are over a dozen chin implant styles, which initially seems confusing, but that allows for a chin implant style that goes best with a wide variety of chin concerns and objectives. Chin implants should be looked at as more than just providing horizontal projection. The frontal view of the chin and jawline should also be taken into consideration in term of vertical height and width of the chin area. It is important to go over all chin dimensions with your plastic surgeon so the best chin implant style is chosen for you. When it comes to different materials of chin implants, there are certainly advocates for each type. I personally find the material composition of chin implants largely irrelevant and am more interested in making sure the style and the patients desires match the best.
Dr. Barry Eppley
Indianapolis Indiana
Q: My problem is that one side of my actual jawline is naturally lower than the other. I had jaw angle implants placed and now it looks worse. The look, now with the implants, is even more asymmetric and unbalanced. The shorter side needed to be lengthened but, with the conventional Porex implant selection, obviously that was not possible. It looks like I will need to pursue the CT scan and customized implant option, yet my concern is not only the price, but also when this will need to be dealt with. I know these types of implants unite with the bone tissue quite strongly and as years go by, it becomes even more difficult to remove them from the face. I know it causes a great deal of trauma and involves a lot of risk on both the part of the patient and surgeon. I would appreciate your thoughts and help.
A: While the custom approach is certainly a possibililty (it adds about $5000 onto the procedure to get the final implants in hand and sterile), I am not certain that may be exactly what you need based on your description.
It sounds like asymmetry was the original issue and that is now exaggerated because of the implants used. Contrary to your perception, there are six different styles of jaw angle implants from Porex some of which are lateral augmentation and others which are inferolateral augmentation types.Choosing a different style of implant for each side may well have made for a better result. When asymmetry exists, it is important to first get a panorex film to look at the height and shape of the jaw angles. Then one can decide if the existing off-the-shelf implants may suffice.
As for secondary surgery on Porex implants, I have not found that it is unduly difficult to remove or that it has ever grown to the bone. Much is talked about that concern, but it is largely overblown in my experience. Yes it is much more ‘difficult’ than removing silicone implants, which by comparison slide right in and out, but it is not impossible or causes significantly more tissue trauma than that of the original implant surgery. All synthetic implants get a scar capsule around them. That capsule with Porex implants is more adherent due to some tissue ingrowth. But they do not unite with the bone or become part of them as an onlay implant.
Dr. Barry Eppley
Indianapolis Indiana
Q: Dear Dr. Eppley, I wonder whether you could give me some advice about forehead recontouring. I have a very prominent brow and two bony protusions on my forehead. I look fine straight on but at 45 degrees I look extremely hollow-cheeked and my eyes look abnormally deep-set. I tried cheek implants about 15 years ago (they have since reabsorbed) but of course these only made my eyes look even deeper-set. I also have a very strong chin and nose but can’t reduce these either because they go some way to balancing out my brow line. Would you be able to provide me with some idea as to my suitability for surgery? Thank you very much.
A: Occupying the upper one third of one’s face, the shape and size of the forehead can impact significantly one’s facial balance and appearance. Your description illustrates that quite clearly. The brow bone area, known medically as the supraorbital rims, is a bony prominence like the cheeks and chin in the lower two-thirds of the face that has cosmetic significance. When it is normal (not protruding) one does not give it a second thought. When the brow bones are excessive, however, it can change the look of one’s entire face…and changing other parts of the face will not really ‘hide’ the brow protrusion or its impact on how one’s eye area looks.
While the shape of the forehead and brows is significant, it is not commonly surgically changed. This is not because the possible forehead recontouring procedures are difficult, have high risks, or involve a long recovery, as they do not. It is because it requires an open approach with a scalp incision and a resultant scar in the scalp. For women this is not usually a major stumbling block, but for most men it is. Since many more men have forehead concerns than women, this makes the number of cosmetic forehead contouring procedures that are done fairly small.
Indianapolis Indiana
Q: I recently came across an article written by you regarding jaw angle implants for male patients. I went through this particular surgery and I am saddened to say I am not exactly happy with the results. It is a tough situation to be in, but now I realize I should have pursued a CT scan and customized implants, though it was not an option for me or the doctor who treated me at the time. What do you recommend for me now?
A: There are multiple reasons why dissatisfaction can occur after jaw angle implant surgery. The two main reasons are implant size and implant style. Like any implants placed anywhere in the body, they can end up being too big or too small. But that is not the impression that I am getting about your dissatisfaction. Implant style, or how the implant actually changes the shape of the jaw angle, is actually the most common problem. One type of jaw angle implant merely makes the existing jaw angle wider, known as lateral angle augmentation. Most men interested in improving their jaw angle definition, however, don’t suffer from an exclusive width problem. They are interested in a wider and more defined angle which means extending the angle lower as well. That is a different jaw angle implant style, known as inferolateral angle augmentation, and is more difficult to surgically place. Getting lateral jaw angle augmentation when you really need or want inferolateral jaw angle augmentation will only make your jaw look puffy and wide and not get that more sharply defined angle that many men are seeking.
The other jaw implant problem is when one really needs vertical lengthening of the entire lower jaw line but they end up getting lateral jaw angle implants. Vertical jaw implants are ideally made on custom basis for each patient off of a 3-D model from a CT scan. But a combination of an inferolateral jaw angle implant combined with a prejowl chin implant may suffice in some cases. Since you mentioned a CT scan and custom implants, this may be the problem to which you refer.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am interested in having a dimple put into my chin. I do modeling and I feel it would add more definition to my face. What do you think? Will it be easy to tell I have had it done? How long does it take to heal? Will I need bandages on it?
I have attached a few images of myself to show you what I look like. I have also added a picture of a gorgeous girl I know who has a dimple that I really like. Will it look anything like hers?
A: Creating some form of a concavity in the chin, whether it be a dimple or a cleft, is about providing some character and uniqueness to a facial feature. I don’t think it necessarily creates more definition to the face but it provides a highlight feature that many people find attractive. In creating this chin feature it is important to differentiate between a chin dimple and a chin cleft. They look different and are surgically created with different nuances of the same basic procedure. You have stated your interest in a chin dimple which is a rounded indentation in the middle portion of the soft tissue chin pad. The picture of the model whose chin you like, however, appears more like a chin cleft which is more a vertical indentation from the middle of the soft tissue chin pad down to the edge of the bone. Both can be created, it is just important to know exactly what you want.
Whether it is a chin dimple or a chin cleft, the operation is done from the inside of the mouth. It is a very simple procedure from the perspective of what it is like to go through and recover. It is usually done under local anesthesia or IV sedation. There are no external bandages after surgery. The sutures inside the mouth are dissolveable so their removal is not necessary. There are no restrictions after surgery in terms of eating or activities. There is some chin swelling but no bruising. The chin dimple or cleft can be seen immediately after and it may initially be a little more indented or clefted that it will be when the swelling goes down. It will take about two to three weeks until the chin feels completely normal again.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I recently had a buccal fat extraction procedure 6 weeks ago. I had minimal discomfort and recovered quickly. I am concerned now, however, about the symmetry in the final result. I initially thought that the swelling on one side may go down more quickly than the other and I wanted to give it time to see if it was indeed the swelling or not. I did have slightly more removed out of one side than than the other because when I smiled it seemed to be bigger. I didn’t consider that it may it could end up being more sculpted on that side at rest (not smiling) than the other. At this point the one side is definitely “chubbier” than the other. So, I am wondering if think that it may even out a bit more if I wait longer?
A: A buccal lipectomy, or buccal fat extraction, is a simple procedure. But despite its ease of doing it, the final result does take some time to see. Because swelling goes away fairly quickly, within a few weeks, most patients understandably think that will be the final result. But the second phase of healing from this procedure is the contracture or scarring down of the space where the buccal fat was removed. This takes much longer, at least 3 to 4 months, before one can appreciate the fine details of the ultimate result. Whether your submalar areas will eventually even out and stay asymmetric can not be predicted. But I can say that it is too early to make a final judgment. Time is your friend at this point.
Indianapolis Indiana
Q: I have developed a half grape-sized keloid from a piercing behind my ear. It has completely crippled my self esteem to the point where I have become reclusive. I can’t live like this anymore, so I was wondering if you could tell me how I could best get rid of it and what it would cost to do so. I lost my job, and my family might be willing to pay for it if I can gather information. You seem to be the leading plastic surgeon in the area, so I hope to hear back from you soon. Thank you for your time.
A: Keloids of the earlobe are particularly difficult scar revision problems. This is so for two diametric reasons. When removing keloid scars it is critical to get it out completely, not leaving even a miniscule amount of keloid behind. If one does, it will surely come back. The earlobe, however, is a small piece of ear real estate and wide excision of the earlobe can make it nearly disappear or at least distort it when putting it back together. This is balancing act that can make for a difficult decision if the earlobe keloid is of any appreciable size.
The other concept to grasp about its removal is the high propensity for keloids to recur. This recurrent rate can be reduced if all of the keloid is removed and someone is not genetically prone to them. (in other words, not have developed them in other areas of the body) Yours is a primary keloid problem and was caused by an inciting event. (ear piercing) These may be favorable for a lower risk of recurrence but the risk remains nonetheless.
Because the plastic surgery techniques for ear keloid removal can be different, it would be important to see the keloid problem before you could get a cost estimate.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am a transgender person with HIV. I am healthy and on medication. I am really having a hard time finding a cosmetic surgeon that is willing to do surgery on me, perhaps because they feel uncomfortable about my HIV or are unsure if I am more prone to infection afterwards. I have read that you have performed plastic surgery uneventfully with people who have HIV. I hope you can help me with my questions:
1. Any advice with the anesthesia ( I read a few stories that it could interfere with medication and that could lead to coma). I am on a medication called Atripla.
2. What is the best CD4 count I would be reasonable to continue with surgery?
3. Any suggestions with antibiotics and anti inflammatory medication to avoid infection and promote good healing?
Dr, your advice and help would be much more appreciated. I hope to hear from you very soon.
A: There is a growing body of evidence that HIV patients are not at increased risk for infection or wound healing problems from surgery in general and plastic surgery in particular. Recent published studies in plastic surgery dispel this myth, provided that the patient has good CD4 counts and is not an immunosuppressive medication. One study has shown that there may be an increased risk when plastic surgery is done through the mouth as opposed to the skin. But it can also be said that such may apply to the general population as well. In my Indianapolis plastic surgery experience, I have not seen any increased problems operating on HIV patients for either cosmetic or reconstructive plastic surgery. To answer your specific questions:
1) Atripla is a multiclass retroviral drug commonly used in the treatment of HIV. It has no known adverse effects on wound healing which is the most important consideration in surgical outcome. From an anesthesia standpoint, there is a drug interaction with Versed, a common drug in the anesthesiologist’s pharmaceutical cornucopia. This drug is mainly used to treat anxiety immediately before surgery done on an intravenous basis. It is not absolutely necessary to use it for general anesthesia as other drug options exist.
2) Patients with CD4 counts greater than 200 and low viral loads have surgical risks that are similar to the general population. There is no evidence to support the historic contention that they have poor or compromised wound healing. Increased surgical risks are in those patients whose CD4 counts are less than 200 or have viral loads greater than 10,000.
3) The usual use of antibiotics and pain medications, as is usually done on any other patient, is all that is needed. No extra dosing of antibiotics or prolonged duration of antibiotic use has any proven benefit on reduced infection risk.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am a 30 year old African-American female. I have had three breast augmentations and the scar from the first augmentation was too high leaving me with visible scars. My last augmentation left me with even longer and more hypertrophic scars. I have tried laser in the past and I am considering deep resurfacing and then using the ACell micronized particles (Matristem powder) as this may help smooth the skin out. What do you think? The alternative will be to open the scars and redo them but that would not help as I have done 3 boob jobs and still scarred. I would like to give the laser a go and use the particles as I believe that if it can heal a finger without scars it should at least prevent the skin fromover healing and it will heal to a more even tone. Please email me your thoughts.
A: Hypertrophic scars from breast augmentation, even in an African-American female, is not common. But when it does occur, as yours obviously has, it can be a real problem to improve. Searching for another solution than what you tried (scar excision and re-closure) is understandable.
Matristem collagen particles, derived from porcine bladder, is a new wound healing agent that is certainly touted as having regenerative properties. But do not confuse how a fingertip will heal with that of hypertrophic breast scars. Those are two completely different types of wounds and they do not translate in terms of results. Lasering your scars is probably the worst thing that you could do. It would result not only in loss of skin pigment but creates a secondary healing event that is more prone to scar hypertrophy than your prior scar excisions. I doubt that the ‘magic’ of Matristem particles will overcome your body’s robust healing response in that setting.
I would be more enthused about re-doing your scar revision using Matristem particles placed into and between the wound edges at closure. They are then better placed to exert their beneficial effects at the site of where the active wound healing process is occurring.
Dr. Barry Eppley
Indianapolis Indiana