Your Questions
Your Questions
Q: Dr. Eppley, I would like to know how much of a cup size is lost after having a breast lift. I am currently a 42 DDD and my breasts really hang down after a 75 lb weight loss. I want them lifted but I definitely don’t want to be any smaller than a D or DD cup. I wonder if having implants would make up for any loss of size after a lift. I really don’t want to get implants but I don’t want to be any smaller either. What are your recommendations?
A: In a breast lift procedure, only skin is removed to create the lift and breast reshaping effect. So a loss of cup size should not really occur since no breast tissue is removed. But there is often a perception that the breast can seem smaller because the conical reshaping of the breast results in less overall surface area. What most women expect from a breast lift is to have not only an uplifted breast but one with more upper pole fullness as well. While this most certainly occurs early after a breast lift, the settling of the breast after surgery will cause some loss of upper pole fullness. That is the role that a breast implant plays in many breast lift surgeries, to get and maintain upper pole fullness. Given the size of your existing breasts and the amount of lifting that will be required, it is understandable why you would be on the fence about the need for implants in your lift. When in doubt, do the breast lift without the implants first. Let the six month results determine whether implants would really be beneficial.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like my nose to be in better balance to my face. I feel that my nose is too long for my face. Also I think that the tip and the nostrils needs to be narrowed. Can a rhinoplasty reasonably achieve these goals for my nose. I have attached some pictures for you to image so I can see what can possibly be done.
A: Thank you for sending your pictures. I have done some predictive computer imaging based on a rhinoplasty that shortens tip projection, does some slight upward tip rotation, tip narrowing, spreader grafts to the middle vault and narrowing of the width of the nostrils. In looking at your profile there is a mismatch between the projection of your nose and a horizontal maxillo-mandibular deficiency. Both your jaws are recessed which is also reflected in your thin upper and lower lips. This horizontal jaw projection deficiency makes the nose look longer than it really is. It is a bit long but not as long as it may seem which is confirmed by actual measurements of the nose. Only so much de-projection (shortening) of the nose can be achieved so combining a rhinoplasty with some increased jaw projection would be aesthetically helpful. I have added a chin augmentation to the rhinoplasty prediction with that concept in mind.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a small bump on my nose from when i was kicked in the nose when i was younger. I want a more curved shape nose like I used to have. Also I think my nose looks too big towards the end. Here are some pictures for you to see. What type of rhinoplasty do I need?
A: Your nose shows a great disproportion between the tip and the bridge. The tip of your nose is incredibly wide and thick. The lower alar cartilages can be seen to be very large and your nasal skin is quite thick. This is in contrast to the bridge or upper area of your nose which is much smaller in size and lower in height, albeit wide at the base. While there may be a small bump on the bridge of your nose, the key in your rhinoplasty approach is to not take down the bump. Rather in an effort to create better balance on your nose, the upper bridge needs to be built up while the tip needs to be narrowed. This will make for a more pleasing nasal appearance by creating better proportions between the upper and lower nose. This is of particular importance in your nose given your thick nasal skin which will limit how much reduction can be done in the tip of your nose. By building up the bridge this will help improve the appearance of the lower nose narrowing. I have attached some images which shows how these rhinoplasty changes would look.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, In early June I had Botox injections for migraines through my neurologist. I’ve suffered with migraines for over 20 years and tried just about everything protocol. The neurologist did a lot of injections in the forehead and temples and then a bunch in the back of my head/hair and at the base of my skull and a few along my shoulders. I was migraine free for a week for the first time in I don’t know how long. After a week, my neck became progressively weaker until it was like a bowling ball on my shoulders and I could no longer hold it up for simple things like looking down, brushing teeth, vacuuming, simple picking up the house, etc. It’s been almost two months now and while it’s not as bad as it was a month ago, my neck is not recovered to its former strength, and gets tired very easily. My neurologist has stated that we can do a lower strength and a different pattern in the future. I am leery of ever doing this again based on my reaction and unsure. Have you ever heard of this reaction?
A: I think you are merely experiencing the effects of Botox in the neck muscles which has resulted in some temporary muscle weakness. This is not a reaction but an expected response based on the muscles that were injected. In the treatment of migraines with Botox, the key is to inject the potential trigger points that are where the sensory nerves come through the muscle. In the back of the head, this is a very specific location that relates to the path of the greater occipital nerve. This is at the base of the occipital skull and can be precisely palpated. While this does involve injecting into the upper end of the splenius capitus muscles, this will not cause any neck muscle weakness. It sounds like neck muscle was injected below this point which is not helpful in determining the location of a trigger point and can cause some neck muscle weakness, particularly if a high number of units was injected. The good thing is that in another month or so your neck muscle problem will be self-solving as the Botox wears off.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was born with a face that to me looks a little crooked. It seems my jaw line is shorter on one side and it looks like my face is bent in one direction. Would you be able to look at the pictures I am enclosing and please tell me what you think. My face is definitely not even and my chin is crooked. I think it is too big, but is it also receded? I am so self conscious that I hide behind my hair and makeup. Thank you so very much for your time and please, any advice and recommendations would be greatly appreciated!
A: I have taken a look at your pictures and your concerns. I think there is no question that you have facial asymmetry that is almost completely due to the shape of the lower jaw. The differences in the jaw length has resulted in frontal chin asymmetry with the midportion of the chin being deviated to your right side. This can be corrected (straightened) through a chin osteotomy, sliding it over to the left until its midportion is in alignment with that of your nose and upper and lower lips. This may also require some vertical chin adjustment with a reduction of the left side or an opening lengthening on the right side, depending upon which aesthetically looks better. Your side view shows a mild amount of recession which, given that an osteotomy would be done, I would take the opportunity to give more horizontal projection to the chin as well. I have attached some predictive imaging of the potential outcome with this sliding chin osteotomy procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a long pointy head that is completely abnormal. It has looked this way since I was born. I have managed to get along in life and be a very productive person at 30 years of age. But I always wear a hat and never let anyone see me without it. My other brothers have completely normal head shapes. I would do anything to have a more normal head shape and live a more normal life. I know you have a lot of experience in reshaping of skulls, so I am very interested in your recommendations. I have attached pictures of me with a closely cropped haircut. Please help me.
A: Thank you for sending all of your pictures and describing your situation. I have great empathy for your head concerns. It appears you have a rather classic case of undiagnosed and untreated sagittal craniosynotosis. The AP cranial dimension is long, the transverse cranial dimension is narrow and there is frontal bossing which is wider than the occiput. This condition is rare to see in adults these days since almost all of them are treated as infants with the advent of widespread craniofacial surgery since the 1980s.
First, let me start off by saying what can’t be done. The traditional approach to sagittal craniosynostosis is complete cranial bone remodeling. But that can only be done in infants where the bone is very thin and pliable and one can work with the molding influence of the growing brain. As an adult, such a procedure can not be done as the bone is too thick and not pliable, the extent of surgery and the bleeding would have a high risk of significant complications, and there is not growth of the brain to fill the underlying dead space that is created.
While the bone can not be removed and reshaped, a camouflage skull reshaping approach can be done. This would consist of some burring reduction of the sagittal ridge and the frontal bossing and augmentation of the parasagittal skull and temporal regions. The combination of these reduction and augmentation procedures, while not making any shortening in the cranial AP dimension can give an improved appearance to the skull shape. I have attached some imaging which I think is achieveable.
To embark on this cranioplasty approach, good treatment planning is needed. This would consist of getting a 3-D craniofacial CT scan and then have an exact skull model made from it. It is off of this patient-specific skull model that the exact dimensional changes can be planned and the volume and shape of the needed implants fabricated.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dear Dr. Eppley, I would like to replace my existing saline implants which are now 10 years old with new ones. The original size was 800cc shells filled to 960cc which I was told was the maximum fill at that time. My annual mammogram is coming up and I worry about my decade old implants failing under the pressure (yes I know it is a remote possibility, but I still am concerned). In doing a replacement, I want much larger implants. It would have to be done with either custom made implants or largely overfilling the largest saline breast implants that are made. In doing a replacement I would want a lot more volume than 960cc with as much as a 200% fill to give me more upper pole fullness and more projection. In effect a “mastopexyless” breast lift (had one masto, don’t want to do it again). There are several surgeons in US who are doing very large fills of 800cc saline shells at a patient request. Fills of 1400cc to as high as 2000cc are documented in various internet implant breast forums.
A: While available at one time, custom breast implanrs are no longer made by any US manufacturer. Neither breast implant manufacturer will custom make any implant size at this time. The largest off-the-shelf saline implant are still 800cc of which the manufacturer recommended maximum fill is 960cc. (which you obviously know) The 800cc imlants only come in moderate plus projection. (Mentor) What any plastic surgeon is willing to fill to beyond the recommended fill is between the surgeon and the patient. Beyond the manufacturer’s recommended maximum fill, the patient risks losing the lifetime implant replacement warranty from the manufacturer. Nobody knows for sure how much overinflation affects the potential for deflation or rupture, although it may be fair to say that it has a negative influence. As the implant becomes highly overinflated it also becomes quite hard and unnatural feeling. These are all issues that a patient needs to consider when requesting and/or receiving high volume overfills.
I have heard rumors that the manufacturers have requested from the FDA approval to manudfacture and sell larger breast implant sizes than that which is currently available. (I can not verify that this is true) So larger implants with a base size over 1000ccs may be available in the future.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dear Dr. Eppley, I have a question for you concerning the removal of some subtle scar tissue. The scar is above my lip and was caused from a small burn from a do it yourself type laser hair remover. The initial wound was not very deep and I didn’t think it would even cause a scar, but it has in fact left my skin a bit irregular in a very noticeable place on my face. I was curious if the irregular area could simply be excised, since the effected tissue is not very deep, and then the new wound could be healed with ACell to restore normalcy to the skin in the area. Would that be possible?
A: Burns create unique scars that can be very difficult to treat. Rather than a more discrete amount of scar in a linear pattern, most burn scars have a larger surface area geometry. This often makes it very difficult to simply excise them because they are too wide. With burn scar excision, the surrounding tissues will often become distorted with the closure. There are exceptions to the burn scar problem which can do well with excision but they are in the minority.
I suspect when you are talking about excision combined with Acell you are referring to a topical approach. Rather than a full-thickness excision, you probably mean just remove the surface burned tissue and cover it with Acell. Your premise is that it would heal completely normal in appearance. Unfortunately, this is not what would happen and the result would not be an improvement and likely will look even worse. I believe you are assigning healing properties to Acell that are beyond what it can really do.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’ve read the section with patient questions about lipomas and I have a similar case. I had surgery 3 years ago that removed the biggest lipomas from my body but I still have multiple smaller ones all over my arms, upper legs and back. Maybe 20 on my arms, 20 to 30 on my legs and 3 to 4 on my back ( half of them are the size of a walnut). I’ve read that a combination of injections and laser treatment would be the best approach in my case . I completely understand that it would be just an estimate (and multiple treatments might be required) but I would like to know at least what would be the general range. I would appreciate your help in this matter.
A: While lipomas can be treated effectively by lipodissolve injection therapy and Smartlipo laser probe ablation, this approach is best used for a limited number of lipomas. This is because each lipoma so injected is associated with a significant inflammatory response (and pain) and will definitely require multiple treatments. When the lipomas number more than a handful, one is better off having an outpatient procedure where they are completely excised as this is simply more efficient and cost-effective….not to mention has less discomfort and an easier recovery compared to a multi-stage non-excisional approach. I would only consider an injection approach in a limited number of them to bother determine their response and a patient’s tolerance for it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like to get my upper arms reshaped. I am most interested in Smartlipo and having it done under local anesthesia.
A: The first question is whether any form of liposuction is appropriate for the upper arms. I ask this because I have seen many patients, particularly those interested in Smartlipo, who believe that the procedure can do more than what is possible. Most of these patients have more than fat with some amount of skin excess. While Smartlipo has some minimal skin tightening capability, what most patients need is far in excess of minimal. Smartlipo tightens skin in terms of millimeters, what most patients need is in the centimeters range. Millimeters signifies that just a small pinch of skin can be tightened. Many patients that want upper arm reshaping need inches of skin tightened/removed. What shape your upper arms have I obviously don’t know. So this would be my first concern. You may feel free to send me some pictures of your arms and I can tell whether Smartlipo liposuction is the appropriate procedure for your upper arm reshaping.
Secondly, while upper arm liposuction can be done under local anesthesia, I do not recommend it. This is because of two important reasons, results and cost. Arm liposuction done under local anesthesia will not get the same results as that done when the patient is asleep. It is a simple matter of you can only remove what the patient deems is comfortable. Because any procedure done under local anesthesia takes longer to do, the cost of doing it rises accordingly. Patients often mistakenly assume that a procedure done under local anesthesia will create the same result and cost the same as that done under an anesthetic…this is a wrong assumption.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dear Dr. Eppley, I am not sure if I need a lift or lipo on the love handles. That decision I would leave up to the expert. But I would love to have breasts that look like actual breasts and not deflated socks. I have never had breasts. Growing up there was just a small protrusion of breast itself but was mostly at the nipple.(hard to explain) My stomach has stretched out due to 4 pregnancies, 3 in quick sucession. I run sprints, lift weights, and eat very healthy, I have attached pictures for you to see what I am left with.
A: Thank you for sending your pictures. In reviewing them you can see many of the typical changes that have occured with multiple pregnancies and having very small breasts to start with. The little breast tissue you have has stretched out and the nipple now hangs down over your existing high lower breast fold. You will need both breast implants and a small vertical breast lift to get a much improved breast size and shape. The vertical breast lift is a key component of the procedure as an implant alone will provide volume but will not get the nipple up and centered on the newly enlarged breast mound. This results in fine line scars around the nipples and then down vertically towards the lower breast fold. Whether one wants saline or silicone gel implants is a matter for further discussion of their benefits and liabilities. From abdominal stand point, I would recommend a mini-abdominoplasty with flank liposuction. While there are stretch mark across a lot of your trunk areas, there does not appear to be enough of loose abdominal skin to justify a full abdominoplasty procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dear Dr. Eppley, do you perform scarless breast reduction? If so how is it done and how small and what shape will my breasts be afterwards?
A: There is no such thing as true scarless breast reduction. The only ‘scarless’ method of breast reduction is liposuction. This can remove some volume of breast tissue but it can not improve any shape features of the breast. It can not lift or tighten skin, reduce the size of the areola, elevate the position of the nipple-areolar complex, nor give the breast a rounder or even a more conical shape. For most breast reduction patients, these changes are just as important as the amount of breast tissue removed. Liposuction of the breast, in fact, can even make the shape and the sagging of the breast worse. As you reduce the breast volume, but do not change the skin that contains it, the breast will sag worse. At the least, the amount of breast sagging will certainly not improve.
There is a very limited role for liposuction or scarless breast reduction for a few select patients. But they have to have large breasts which sit adequately high on the chest wall, have a good nipple position and fairly tight breast skin. Most women with large breasts that want a reduction do not have these breast shape features. This is why the traditional method of breast reduction with scars is needed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting my nose built up. I think it is too small. I really don’t want to have a rib graft taken so I am looking at synthetic implants. I am trying to decide between a Voloshin and a Shirakabe nasal implant. Does a Voloshin or Shirakabe implant give a more streamlined appearance? Which implant enhances the nasal tip more? Is the Shirakabe Nasal tip too narrow? Secondly,what is the purpose behind using the Brink Peri-Pyriform Implant in rhinoplasty?
A: The fundamental difference in the Shirakabe nasal implant from that of the Voloshin is that it provides some augmentation to the base of the nose. But that is irrelevant if one is going to have a peri-pyriform (premaxillary) implant. The Shirakabe tip is a morenarrow, particularly across the tip, compared to the Voloshin. One thing you have to be very careful of is to not make the entire nasal tip cartilages (dome) completely covered by the implant. While one can get away with big sizes in facial implants that are covered by muscle, the risk for implant problems (infection, extrusion) that are covered just by skin (such as the nose) is not so foregiving. So I would not get hung up in trying to give the nasal tip too much projection with an implant. That places the skin under tension and is a setup for the aforementioned problems. If one wants to push the envelope of size and tissue tension in the nose, it is far better and less risky to do this with a rib graft.
The purpose of the peri-pyriform (premaxillary) implant in rhinoplasty is to build out the base of the nose in cases of midface deficiency and a smaller nose. This opens up the nasolabial angle, increases the fullness of the upper lip and pushes out the base of the nostrils. This in effect creates a pulling out of the nasal base.
Dr. Barry Eppley
Indianapolis, Indiana
Botox is commonly recognized as an injection treatment to either turn back or slow down the hands of time. By reducing the wrinkle lines of the forehead and around the eyes, a more relaxed and often a less scowling appearance is achieved. But the use of Botox continues to find new medical problems for which it is effective. Allergan, Botox’a manufacturer, is already a multibillion company which continues to experience record revenue and earnings growth.
The newest FDA-approved indication is in the treatment of migraines. Approved last year it works for migraines just like it does for wrinkles, by relaxing muscles. But it is injected around those nerves in the head which are being squeezed by muscles and thus serve as the trigger for the migraine headache. These are commonly in the eyebrow, temple and at the base of the skull in the back of the head. For some patients the temporary relief is a near-miracle which will last about four months. Botox in migraines is also a test which proves that doing surgery by removing this muscle around the nerve can have a more permanent effect.
Botox has long been approved for halting severe underarm sweating, an embarrassing condition known as hyperhidrosis. This disorder causes so much perspiration that some sufferers are forced to carry several changes of clothing to make it through the day. The excessive sweating is caused by over stimulation of the sweat glands by the nerves of the autonomic system. Botox interferes with the nerves responsible for this drenching. It has a similar benefit to those who also suffer excessive sweating in the palm of their hands. (palmar hidrosis)
Botox is effective for cervical dystonia, a condition that causes the neck to twitch, twist, and go though repetitive movements and carry the head in abnormal postures. This happens because of involuntary muscle contractions which the injections directly weaken. It is similarly effective in cerebral palsy in which patients have stiff spastic arms and legs caused by abnormal signals from the brain to the muscles. Botox interrupts this communication between the nerves and the spinal cord which then causes the muscles to relax.
Overactive bladders are also benefiting by these injections. Caused by muscle spasms of the bladder muscles, urinary incontinence can make it difficult for some patients to undergo even short car trips. Some patients end up wearing adult diapers. Botox overcomes bladder incontinence by weakening or paralyzing those muscles which contract inappropriately and squeeze out the urine involuntarily.
Botox can also stop chronic pelvic pain which can make it difficult to have sexual intercourse or undergo an examination or a pap smear test. This type of pelvic pain is caused by tight over-contracted pelvic muscles.
While often perceived as a drug of beauty, the many medical benefits of Botox makes its few precious drops life-changing for more just a better look in the mirror.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like to have a chin implant to add length to the lower half of my face. However, I am 21 years old and have partially erupted wisdom teeth that I have neglected to have removed for several years. Is it necessary to have them removed before getting a chin implant?
A: The only thing that a chin implant and wisdom teeth have in common is that both occur on the mandible or the lower jaw. But beyond being on the same bone, there is no correlation between the two. The wisdom teeth or third molars are located at the junction of the body and ramus of the mandible at the back. A chin implant is done on the symphysis or front part of the lower jaw. One does not affect the other. However, if you need both done it would be most convenient that they are done during the same surgery. I have done that combination numerous times. The key to this surgical ‘opportunity’ is to find a surgeon who is qualified to perform both procedures.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have suffered an accident to my lip. I cut my lip pretty deep and it resulted in the need for stitches. The cut is not that big, however, it’s been 3 weeks and its healed fine apart from a little bumpy scar tissue. It’s the same color as my lip and slightly raised. Do you think this is a scar or is it still healing? I have been applying Vitamin E twice a day and massaging it. It’s quite a new scar so is there anything I can do to minimize the appearance and do you think I’ll be permanently scarred? Please help Thank you.
A: All incisions and lacerations will leave a permanent scar, it is just a question of how significant it will be. Any laceration that is deep enough to require stitches has entered or passed the dermis of the skin. That is going to evoke an inflammatory response and collagen production to heal the wound. Collagen production equates to the formation of scar tissue. Many factors affect whether that scar will be particularly noticeable or not. Fortunately on the lip, most lacerations run parallel to or along one of the visible lines or grooves of the vermilion of the lip. This is the most favorable location for the least amount of scarring on the lip.
Because collagen and scar production is in full swing during the first month after the injury, the lip scar will become both firm and usually raised. It will require many months until this scar tissue relaxes so one can not predict what you are currently seeing will be like that six months from now. While there is nothing wrong with applying Vitamin E and massaging it, you are trying to treat a natural healing process. Quite frankly, these maneuvers are more psychotherapy than making any real difference in the scar outcome. Time is the best scar therapy on the lip. If it seems to be a persistent problem after six months, then I would consult with a plastic surgeon about possible scar revision.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m trying to remove my cauliflower ear in which I been having for years. Can it really be improved in the way the ear looks and how is it done?
A: The well known cauliflower ear, in appearance much like the vegetable plant, is the result of ear trauma. Specifically it is the production of cartilage as a response to its covering, known as the perichondium, being sheared off from its underlying cartilage. Ear cartilage is an avascular tissue that receives its blood supply and nutrition from its enveloping perichondrium. When it gets torn away from the cartilage, it bleeds and creates a blood clot between the two. This serves as a stimulus for the cartilage to grow and eventually replace the space where the blood was. Since the ear’s shape (with the exception of the earlobe) is determined by the shape of the cartilage, the traumatized ear becomes deformed in appearance.
Surgical treatment of the cauliflower ear is done by removing a flap of skin over the deformed area, shaving down and reshaping the cartilage, and then putting the skin flap back in place. The key to the success of the procedure us two-fold. First the skin flap over the deformed ear part must be raised in such a way that its blood supply is not destroyed and skin necrosis results afterwards. Secondly, the skin must be held into place with intimate contact to the cartilage after it is reshaped so blood does not form between the two and re-create the original problem. This form of ear reconstruction is done as an outpatient procedure under anesthesia.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would love to know how to book appointments for people outside the U.S. I plan to come to the U.S. and have some work done. Can a consult be done without actually having to visit you first? I obviously want to minimize my travel due to the cost and my work schedule. Thanks.
A: Thank you for your inquiry. I have many patients that come from all over the world so plastic surgery consultations are done by numerous convenient methods. Usually we start by having the patient send some photos of their concerns. Then we can consult by phone or Skype video to discuss their concerns and treatment options. Much can be accomplished by this form of indirect consultation as almost everything in plastic surgery is visible to the eye. If one develops confidence and is comfortable, a surgery date and all the details involved can be done from afar. The patient then arrives the day before surgery where an actual hands on consultation is done to review and/or modify the next day’s surgical plan. Surgery is done (e.g., sutures and any dressings) to try and ensure that the patient does not have to return for any regular follow-up care. Any postoperative concerns or questions can be handled similarly by sending photos and discussing by phone or Skype.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting rid of my sagging jowls and neck. Do you think Thermage or radiofrequency treatments would work? If not, would you recommend a lifestyle lift or a mini lift? What about laser tightening for face & neck vs these lifts?
A: While I have never seen what you look like, I can only speculate about your neck and jowl concerns. However, almost any patient that I have ever seen with a sagging jawline and neck rarely would benefit significantly by any non-surgical or non-invasive treatment method. By and large, the use of non-surgical methods of neck and jowl improvement produce very minimal benefits and most patients would consider them unsatisfactory. They are best used when the patient has a very minimal problem or when the patient is fairly young with just the very beginning of any sagging. Most certainly, what often is paid for the hope of some of these non-surgical methods would have been better invested in a surgical solution. In short, any non-surgical method of jowl and neck tightening does not compare to the results achieved by more conventional surgical techniques.
There is no difference between a Lifestyle Lift, minilift or any other branded and marketing name for an operation that has been around for decades…a reduced version of a facelift.
It is understandable why patients seek anything but surgery for their aging concerns of their lower face, but they often end up chasing a solution that does not exist…and waste money along the way.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am a former patient of Dr. Eppley. I had buccal fat removal and love my results… however, I am still interested in having facial liposuction to sculpt my cheeks out a bit. I am wondering if he can do this and this is possible.
A: The removal of the buccal fat pads is the largest fat depot that can be surgically removed on the face aside from the neck. Its removal creates a slimming change in but one region of the face, the submalar region or the area right below the cheek bones. There are no other distinct or encapsulated fat areas to remove on the face. The rest and majority of facial fat is located in the subcutaneous level or right under the skin. This is much more difficult to remove and can only be addressed by small cannula liposuction. Many such facial fat areas are not even treatable by liposuction.
When patients seek a slimming effect of the face, they often are referring to the side of the face from the cheeks down to the jaw line. This leaves a lot of facial areas beyond the submalar or buccal fat region. Most of these areas can be treated by liposuction if done carefully and not done too deep. The buccal branches of the facial nerve lie on top of the muscle layer just underneath and injury to them should obviously be avodied. The question is not whether it can be done, but whether any significant change can be achieved. In general you can not make a wholesale facial slimming change by facial liposuction but small discrete areas may be able to be improved.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have chin scar which is still new and is about 3 months old. I got it falling off a skateboard falling onto asphalt. It is in the central and lower area of my chin and is slightly indented I am uncertain as to exactly what to do. I hope it does not stay this way as it heals further. I have attached some pictures of it for your advice? Is there going to be a substantial improvement in the way it looks in the next few months? I am worried about the indentation and the whitish color of the scar line. I appreciate any advice you can give.
A: Thank you for sending your pictures which show the chin scar well. As scars heal there are certain features which will improve with time and others that won’t. Scar redness and a feeling of firmness are the main features that will improve with time. A raised scar is also a scar feature that can settle down and get flat as it matures. The two features that won’t improve significantly with time are scar width and depression or indentation. Scars over bony facial prominences, such as the chin and cheeks, often end up indented as fatty tissue is lost underneath it from the trauma of the injury. When combined with scar contracture/tightening as it heals, the scar can seem like it is being pulled inward.
In looking at your scar, although it is still early, the width of the scar and its indentation suggest that it may not improve greatly as it heals. I would give it the benefit of some more time. But if you see no substantial change in the next few months, then I would consider early scar revision. The good news is that the scar width and indentation can be significantly improved by scar revision techniques.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dear Dr. Eppley, I am interested in getting jaw surgery for my sleep apnea. My lower jaw is short and my doctor tells me it is a likely cause of my sleep problems. I had a chin implant put in several years ago which made it look so much better but now I am interested in getting the whole jaw moved forward. I know that orthodontics will be be needed before the surgery. The orthodontist said a year of braces would be required and that he estimated 5 mm of advancement would be possible. He also said it was uncertain whether the advancement would open my airway, but the first surgeon I meet with seemed more optimistic. I was going to attempt the surgery anyway because it would be nice to fix the malocclusion even if the apneas do not completely disappear. Do you ever advance the upper jaw along with the lower to increase the total advancement? Breaking my upper jaw along with the lower does not sound pleasant, but I obviously want the surgery to work.
A: The causes of sleep apnea are numerous and a short lower jaw is but one of them. In cases of a really significant mandibular deficiency, such as 8 or 10mms, it would be fair to say that jaw advancement has a very high probability of reducing some of the symptoms of sleep apnea. Since yours is only about 5mms, I would not be as optimistic. It is true that upper and lower jaw advancements (bimaxillary surgery) would allow the lower jaw to be moved forward much further. (probably 10mms in your case) But you have to look at the impact of that procedure on your facial aesthetics as you don’t want to trade off one problem for another, even if it just is an aesthetic one. Another option with your mandibular advancement is to remove the chin implant and do a bony genioplasty advancement at the same time. This would not only maintain your jawline and facial profile aesthetics but doubles your changes of just lower jaw surgery alone helping your sleep apnea. As the chin comes forward, it brings the genioglossus muscle and tongue forward as well. As the jaw advancement has a similar effect, the synergism of the two procedures might just be what would significantly improve your sleep apnea.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a very short forehead and really want it to be longer. (more skin) But I have been told that a browlift will also make my brows lift up as well as lengthen my forehead which I don’t want. I have read about the use of tissue expanders to make more skin. Do you think the use of tissue expansion is too invasive for someone with a short forehead?
A: The issue with forehead tissue expansion is not whether it is more invasive as it does not involve much more tissue dissection than any form of a browlift. The question is whether it is worth the effort. It is a two stage process with the first procedure being the placement of a tissue expander and a second stage about 6 to 8 weeks later for removal and the retropositioning of the frontal hairline. So it becomes two operations…neither are very complex or extensive nor is recovery difficult or extended. Then there is the intervening interval between the two when the inflation of the tissue expander occurs. Once a week saline injections are done to gradually stretch out the upper forehead. Patients often do this on their own. Through this tissue expansion phase, it will become obvious that there is a bulge in the forehead, so this is a socially awkward period. As you can see from this description, one has to be fairly motivated to be willing to go with this effort. But tissue expansion works really well anywhere on the skull or forehead because it is pushing off of a solid platform underneath. (bone)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like to see if it is possible to improve 3 areas around my chin. The areas I want to improve are my jawline. I would like it better defined. I would also like to create a better angle on neck underneath the chin for better profile. I would also like to create better balance and harmony on my chin. Maybe lengthen it to try and release some of the mental crease. I’m not quite sure what will work. It’s a pretty deep crease. I was born with it. Feels like a huge step below my lower lip. I have attached a front and side view of me for you to see what I mean.
A: What you have is a classic issue of an overall short lower jaw. Your lower jaw is short in both horizontal and vertical dimensions which is most manifest in the chin area. While I can not see your occlusion (bite), I suspect it is a Class II malocclusion where your lower teeth are somewhat behind your upper teeth and do not meet in an edge-to-edge fashion. That is also why you have a deep labiomental crease. The lower lip is not well supported by the retropositioned lower teeth so the crease deepens while the lower lip rolls forward. What you need for correction is a vertical lengthening chin osteotomy that also brings the entire chin bone forward. I would estimate that it must be vertically lengthened by 8mm and brought forward 10mms. A hydroxyapatite block needs to be added to the step-off in the osteotomy to help build out the labiomental crease or at least prevent it from becoming even deeper. Lengthening the chin will actually help soften the depth of the crease as it pulls the soft tissue of the lower chin down and forward.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dear Dr. Eppley, I’m writing to you in regards to plastic surgery options. You were recommended to me as a highly qualified professional. I’m a 24 year old and I wish to transform my face for it to be more balanced and more aesthetic in general. Enclosed please find pictures for my face from various angles and a picture that I did in Photoshop which outlines how I would like my face to look. Is this realistic? Here are things that concern me by order of importance:
1) Jaw/chin is too prominent, protruding and simply too large. I would like bit smaller jaw and chin, making my face look more compact, yet remaining sharp and angular.
2) Cheek bones. As you see, mine are quite flat. Cheek implants would probably benefit here.
3)Nosejob – make my nose more prominent and fill the radix.
4) Eyebrow transplant
I would like to know my facial surgery options. This is very important for me so I would kindly ask you to provide me with a professional and honest opinion.
Thank you in advance.
A: Thank you for sending your pictures. As you have already done a nice job with Photoshop on your face, and I think all those changes are both possible and realistic, my task is to comment on how to accomplish those potential changes.
The reduction in the chin is of a horizontal nature. There are two ways to accomplish that task, either a setback genioplasty or an open submental burring reduction. I would feel more confident with the open submental approach so there are no irregular bony edges and an excess soft tissues can be excised and tightened. That is done from an under the chin (submental) incision. The other alternative is to do a setback chin osteotomy with the possible need of a submental tuck-up later is needed.
I agree about the need for cheek enhancement and stronger cheek bones using implants would be beneficial, particularly to balance out the stronger chin. (a ying and yang effect if you will)
Your ‘deficient’ nose is part of the overall flatter or less well developed midface. A dorsal augmentation rhinoplasty, in combination with cheek augmentation, would put the middle third of the face in better balance with your jawline. The real debate here is what material tio use to build-up the nose. My prerference would be your own cartilage.
Eyebrow hair transplants are the only other choice besides tattooing for improving congenitally deficient eyebrow hair density.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Hello, I was reading the article on the knee liposuction procedure that you do. I had liposuction in the knee area and now I have an actual fold of skin over the right knee. Is there anything that can be done? It is not fat but actual skin that hangs over the knee. Thank you so much for your response. I need to get something done because it is so ugly!!!
A: Liposuction in the knees can be one of the most satisfying body areas to treat. However, this is primarily in the medial or inside area of the knee. The skin retracts very well on the inside of the knee so few contour deformities arise with the elimination of the inner knee bulge. Many patients also have a fullness across the top of the knee, known as the suprapatellar region. While liposuction can be done in this area with good fat removal, it can result in an unflattering roll of skin. This is because the skin across the knee must be very flexible to allow for knee extension and, most importantly, knee flexion. (bending) This skin ‘excess’ is hidden when the knee is fuller but becomes unmasked when it’s volume is deflated. Improvement of this suprapatellar fold of skin is very difficult. The absolute cure is skin fold excision but the resulting scar is unacceptable with significant widening and an aesthetic outcome that might be worse than the original problem. The only reasonable treatment option is additional small cannula liposuction into and above the skin fold to try and get it flatter. The success of that approach is one of some improvement but no absolute cure.
Barry Eppley
Indianapolis, Indiana
Q: Dear Dr. Eppley, I have seen on your website you are very experienced with scars and would very much appreciate your opinion please. I incurred an injury to my upper lip which caused the lip to split open and require stitches. The scar remaining, now 2 years old, is within the attached picture. It appears to have 3 elements: the line which is indented, discolouration of the red part of the lip and the bump on the lip. The bump on the lip is the element which is concerning me most in terms of my appearance. Is there anything I can do to improve this such as massage or oils? Is surgery the only remedy?
A: What you have is a classic lip vermilion scar. The edges are mismatched which creates the bump and the indentation. This is very similar to a cleft lip scar after a primary repair which I have seen many times. Given that it is two years old, it is a mature scar. Therefore, no external treatment methods will be successful like massage or even injectable steroids. To get improvement, you need a scar revision. The scar must be excised and the vermilion realigned and leveled by suturing. This can be done as a fairly simple procedure done under local or IV sedation, whichever makes you the most comfortable. I would expect good improvement as the scar is oriented parallel to the natural lip lines of the vermilion…which is always a good sign for a favorable lip scar revision outcome.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have clubfeet and even with exercise, my calfs are still smaller than my forearms. Would calf implants make a difference in their appearance? Also I have really good insurance, would I be able to use it for a procedure like this?
A: Your questions are two-fold; 1) Will calf implants improve the appearance of your calfs, and 2) will insurance pay for it? While calf implants can improve the size of one’s calfs, the person born with congenital calf hypoplasia (clubfeet) poses a unique problem. The skin over and around the calfs is very tight as the muscle never fully developed. This ‘shortness’ of skin limits the size of calf implants that can be safely placed. It also makes it very difficult, if not impossible, to get subfascial placement so the implant will lie completely in the subcutaneous fat space. Secondly, insurance will not pay for calf implants because they do not provide any functional medical benefit, such as improved range of motion, more calf strength, etc. Since only appearance is improved, the procedure will be deemed cosmetic in nature.You may feel free to send me some pictures of calfs for my assessment. Please send them directly to me at the following address:
beppley@ologymd.com
I shall look forward to receiving them and giving you my recommendations.
Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I want to get implants for my saggy breasts. I want them to be at least a full C, maybe a D cup. My breasts also sag but I think implants will take care of the problem. What do you think? I have attached some photos for you to see what they look like.
A: Thank you for sending your photos for review. While it is clear that you have had near complete breast involution (breast tissue shrinking) and would benefit by the substantial addition of volume (implants), you also have a significant breast sagging issue. You can not achieve your desired results unless a vertical breast lift is done at the same time as implant placement. Contrary to the perception of many patients, breast implants will not cause any significant lifting effect. Rather they will take the breast tissue the way it lies and make the breast much bigger but have the nipple and the existing breast tissue hanging off of the bottom of the implant. This is not likely the look you are after.
The key to knowing whether a breast lift is needed at the time of augmentation is the determination of where the nipple and any breast tissue hang relative to the level of the lower breast crease. (inframammary fold) If the nipple and any breast tissue is at or below the lower breast crease, some type of breast lift will be needed. Your photos show that, not only the nipple, but at least half of your breast tissue and skin is at or below the breast crease.
There are different types of breast lifts but I think you would do well with one in which the scar goes around the nipple and down to the lower breast crease. (hence the name, vertical breast lift) Your nipple needs to move up several inches so that it can be centered around a substantially enlarged breast mound.
Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am serious about getting a bullhorn lip lift. I am a model and, although I am considered very attractive, I do not feel my mouth area looks the best. My lips are reasonably full but my upper lip is too long and I don’t show any teeth even when I smile. That is why I think a lip lift would enhance my appearance. I have attached some modeling photos for you to see what I mean. What do you think?
A: Thank you for sending your excellent photos. While you do have a very nice shape to your upper lip, I can see your concerns that it is vertically too long between the base of the nose and the upper lip vermilion. I think you would be a good candidate for the subnasal lip lift as it would decrease this vertical skin distance, give more pout to the central cupid’s bow portion of the upper lip, and has a chance of increasing some tooth exposure between the canines.
This is an office procedure done under local anesthesia. (infraorbital nerve blocks and direct infiltration into the base of the nose) The key is to have a wavy excisional pattern for the lift so the scar blends in along the base of the nose. As an out of town patient, I would use tiny dissolveable sutures for the final skin closure so no postoperative visit is necessary. There is always about a 20% to 30% relapse of the lip lift over the first six months after the procedure so it is a little ‘over-corrected’ in the beginning to compensate for that event. However, it is very important to never remove too much lip skin as there is no way to reverse that problem. You can always take more if needed so undercorrection is always better than overcorrection.
Barry Eppley
Indianapolis, Indiana