Your Questions
Your Questions
Q: Dr. Eppley, I am a 48 yr old female. Over the past few years, the corners of my mouth have started drooping, to the extent that I am often asked if something is wrong (it appears that I am frowning all the time). I don’t want major surgery, and in researching options for my issue, the corner of the mouth lift seems to be a possibility. One additional note; the droopiness is more pronounced on the right side. I have attached some photos for your assessment.
A: Downturning of the corners of the mouth is a common aging issue. The lip line is the union of the upper and lower lip at rest when one is not smiling or has any oral animation or movement. It is like a level and one should be able to draw a straight line between the two end points to create a straight lip line. The corner positions of the lips or the commissures have a great influence on the appearance of the lip line. You don’t want them upturned (Joker look) or downturned (frowning or sad) as it gives one a static expression that is not favorable. Corner of the mouth lifts change the location of the commissures through a very small amount of skin resection and lip vermilion repositioning. It is a relatively simple procedure that can have a dramatic effect. It can be done under local anesthesia as an office procedure. It does the one thing that many people think a facelift does but does not. A facelift can not change the corner of the mouth because its pull is too distant. Changing the corner of the mouth must be done by direct excision.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I feel like the base of my nose is sunken in and needs to be built up. I know that implants are made for the paranasal area but I just don’t want a piece of synthetic material in me. How else can this be done, injectable fillers, bone grafts etc?
A: Paranasal augmentation is the buildup of the portion of the midface around the base of the nose. It should be differentiated from submalar and premaxillary regions of the midface of which they can often be confused. When considering paranasal augmentation, the most common technique is a preformed synthetic paranasal implant. But an implant is not the only paranasal option. Other choices include injectable materials and an autogenous graft. While there are numerous off-the-shelf synthetic injectable fillers, they all have only a temporary effect. For a permanent injectable material, I would use either hydroxyapatite or HTR granules which can be ‘injected’. This is not done in the typical percutaneous approach through a fine needle. Rather it is done through a small intraoral incision and placed on top of the bone underneath the base of the nostrils. The granules or beads are packed into a syringe but are only injected through the open end of its barrel so it requires an incision and some limited subperiosteal pocket dissection to be injected. These materials are non-resorbable and gets good tissue ingrowth. From an onlay graft option, small rib grafts taken from a very small incision at the bottom of the rib cage will also work well and will not resorb unlike onlay bone grafts.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have earlobes that go straight down. They don’t have the curve up, just a straight down line to the side of my face making my ears look big when they are actually very normal. Can you fix this without scarring?
A: What you have is a natural earlobe that attaches to your face without a break or upward curve. This lack of a well-defined earlobe attachment is known as a pixie earlobe. Pixie earlobes are usually thought of as an aesthetic complication of a facelift but they are also a natural earlobe shape for many people. Because of the downward and otherwise low attachment of the earlobe to the face, it does make the ear look longer. While there is a relatively simple solution to changing how the earlobe attaches to the face, it can not be done without some scarring. The earlobe can be released and reattached higher through a procedure known as a V-Y advancement. This will move the earlobe up almost a full centimeter and give it an upward curve to its attachment. This will result in a very fine line scar in the wake of where the earlobe attachment used to be. While it is a scar, it is a very fine line. This simple earlobe reconstruction can be done in the office under local anesthesia.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in cheek implants as I think they would make my face look better. My cheeks just seem to be so flat and weak. I would like higher and stronger cheekbones as I think they would match the rest of my strong facial features. I have attached some face pictures from different angles for your opinion.
A: In looking at your pictures, I think your goal with cheek augmentation is to create better facial balance by making your cheeks bigger to go better with your longer face and prominent chin. Your chin and lower jaw is your most prominent facial feature and, by comparison, your cheeks are far less prominent. Ideally, the best way to get better facial balance is a combination of cheek implants and vertical chin reduction. I have done and attached some predictive imaging which shows the result of cheek implants with and without vertical chin reduction. The ‘ying and yang’ approach to facial reshaping is often best as most facial imbalances are usually combination problems and not just one single feature alone. Through computer imaging, you can determine if larger cheek implants alone or medium cheek implants with vertical chin reduction produces a more appealing facial change for you.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 24 year-old Hispanic female who is interested in breast augmentation. My breasts have shown very little growth and I don’t think there is any chance that they will grow any further at this point. But besides that they are small, they also look peculiar. My nipples and areolas are so big for someone who has very little breasts. Whatever breasts I have just seem to be like a ball that is right underneath the nipple and makes them stick out and point downward. I have attached some pictures of my breasts so you can tell what type of implants I would need to make my breasts look not only bigger but better.
A: Your breasts definitely show underdevelopment for the size of your chest but the real aesthetic challenge is their very wide spacing and a mild case of tuberous breast deformity. The small amount of breast tissue you have is herniating through the base of the areola, thus the very prominent nipples and protruding wide areolas with a very small breast base. This is the very definition of a tuberous breast deformity. Fortunately, the tuberous deformity is fairly mild and I believe could be adequately treated by breast augmentation alone. Given your ethnicity and to avoid a prominent breast scar, I would do a saline breast augmentation through a transaxillary (armpit) approach. I would wait and see how the nipple-areolar complex appears after being pushed out by the implant. There is the possibility that a revision of it may be needed after breast augmentation if it becomes more rather than less protrusive.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had my ears pinned back six weeks ago. Before surgery one ear did stick out further than the other and, even after surgery, it still does. Although both ears are much better looking they are still not as good as I had hoped. I would be happy if the left ear was brought back further to match the other one. When they get better with more time and, if not, when should I have the left ear revised?
A: The surgical techniques used in otoplasty rely on the use of sutures to reshape the cartilages. The final results are a mixture of skillful placement, tightening and their ability to hold as the tissues heal. Between swelling and tissue relaxation it will take up to six months after surgery to see the final result. Besides a good shape, it is also important to have symmetry between the two ears. Even though both ears are rarely seen at the same time, it is still important to have them look as close as possible. Perfect symmetry between the two ears in otoplasty does not always occur and about 10% of patients in my experience may desire some minor touchups to improve their shape and symmetry. In the case of one ear that still sticks out further than the other, this may require a revision to place another suture or two or to remove a little conchal cartilage to get the ear back into a better position. It is a better problem in otoplasty to have an undercorrection than an overcorrection. Undercorrected ears are infinitely easier to improve by an otoplasty revision. I would embark on that revision six months after your original procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 35 year African-American woman who is seeking to have a rhinoplasty to make some desired changes in the shape of my nose. Building up the bridge and lifting my tip and making it a little more narrow seems to be a standard rhinoplasty changes to my type of nose. I also want my wide nostrils narrowed but there seems to be different ways to do it. Some plastic surgeons place incisions on the inside of the nose and other place them on the outside. While I don’t want more scar than I need, I do want to see a very visible difference in the width and size of my nostrils? What do you recommend for nostril narrowing?
A: To do nostril narrowing, some nostril skin has to be removed. Whether nostril narrowing is done by incisions on the inside your nose or out is a matter of the extent of the incisions and their locations. Internal nostril narrowing incisions cut through and place scars on the skin of the nostril sill. It does create an external scar but it is very small and vertical in nature. By removing a vertical wedge of sill skin it pulls in the base of the nostril by the exact amount of sill skin removed. (usually around 5mms or so). An external nostril narrowing approach uses a similar vertical sill excision but extends it out to involve a horizontal resection of the side of the nostril as well. It is more effective at changing the width and shape of the nostril but does so with a longer scar that lies in the groove at the alar-cheek-upper lip junction. While poor scarring is possible, if done well the scar is well hidden and not visible.
Either nostril narrowing technique can be a very useful adjunct to the final rhinoplasty result. Which technique is better for you depends on the size and shape of your nostrils and how much of a change is needed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 33 year-old blonde female with fair skin. I think my skin is in fairly good shape as I have avoided the sun much of my life. However, even though I am young I have bags and dark circles under my eyes that are far worse early in the morning as compared to the evening. This makes me look tired and I am tired of always looking tired even though I think I get enough sleep. Do I need an eyelid job or will fillers be the right thing to do? I have attached some pictures to help you see my eye problem.
A: It is hard to imagine at your young age that any traditional form of lower blepharoplasty would be needed. These more ‘complete’ eye jobs usually involve skin removal and that is something you do not need. What your pictures show is some lower eyelid hollowing which creates dark shadows or circles. The use of injectable fillers is the treatment you need. This simple office treatment creates an immediate result that will quickly provide a visible improvement by adding volume into the hollows. This is a bit of a tricky area to inject to avoid bruising, irregularities and over correction. Injectable fillers in the tear troughs and lower eyelid hollows can last much longer than in other facial areas, often 12 to 18 months in duration. .
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had liposuction done in my abdomen, lower back, inner and outer thighs and knees six weeks ago. I was told that just over two liters was removed. The day after surgery I definitely felt smaller. But now, six weeks later, I feel that What Can You Do To Get Your Ex Girlfriend Back I am back right where I started. I see no changes and I don’t look any different in the mirror nor do my clothes feel any looser. I know that swelling takes a long time to go away and I may still be swollen but when am I going to see changes in my body? Could this be fat coming back so soon?
A: There is always going to be some considerable swelling after liposuction but the usual course of swelling resolution is as follows. Within the first day or two after surgery when the garments are taken off to shower, it is a very encouraging sign when patients say it is already better. If not does not look smaller already, that is not a bad sign for the long-term result but I would prefer to hear it is already looking better. Swelling will then set in and much of the initial improvement can be seen to ‘disappear’. By three weeks after liposuction, one should be in the visible benefits phase where the improvement is clearly evident. By six weeks after surgery, much of the improvement in the body contours is even better even though further improvement can continue up to three months after surgery.
How much improvement any liposuction patient will see after surgery is largely volume dependent. How much fat has been removed will determine how visible the changes will ultimately be. While I don’t know what you looked like to start with and how much fat you had, removing two liters of fat aspirate from all those body areas seems like a small amount. While the final verdict awaits six more weeks, I would question if you had enough removed to really make a noticeable change. Whay we do know is that it is definitely not fat coming back at this point.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am 44 years old and have had silicone implants for just over 10 years. I have noticed recently that under my left breast near the sternum it has gotten sore. I also have had chest, back and arm pain on and off over the past year. My doctor sent me for a mammogram and I also got an ultrasound at the same time. Both were negative for any problems. Do you think my breast implants are a cause of my problems.? Can a breast implant release harmful chemicals or toxins? I want tio keep my breast implants but if they are dangerous then I want them out.
A: It is impossible to say with an certainty that there is a relationship of the symptoms you are having and your breast implants. What we do know for sure is that breast implants do not release toxins, poisons, or any other harmful chemicals. While you have had a good breast screening work-up, mammograms and ultrasound are not 100% accurate when it comes to detecting an implant rupture. If anything, that is where my suspicion would lie as it relates to your left breast pain. If it persists or increases in severity, I would consider getting an MRI which is the most accurate test we have to detect breast implant rupture.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I don’t like having a large forehead. I would like it reduced by at least an inch. I understand by having the eyes done that will also can help. I also hate how one eye brow is lower than the other one. I am sending pictures from the front and side views so you can what I mean.
A: Thank you for sending your pictures. I can see the three issues of concern, your very long forehead, eyebrow asymmetry and extra skin on the upper eyelids. Most frontal hairlines (forehead reductions) can be advanced close to an inch, depending upon how mobile one’s scalp is after it is freed up. The advancement is always greatest in the middle and tapers out towards the temporal hairline. To improve your eyebrow asymmetry, more skin would be taken out on the left side than the right as it tapers outward. The upper and lower blepharoplasties would be done in the conventional fashion with skin and fat removal. The combination of all three would make for quite a periorbital and forehead rejuvenation effect.
Dr. Barry Eppley
Indianapolis, Indiana
The second edition of MAXILLOFACIAL TRAUMA AND ESTHETIC FACIAL RECONSTRUCTION was released in late October 2011. It is a follow-up addition to the very popular first edition by the same name that was initially released in 2003. Since no one surgeon has a monopoly on the wisdom and experience of every aspect of facial trauma, this new edition brings together input from 57 authors from plastic surgery, maxillofacial surgery, otorhinolaryngology and ophthalmology in 33 chapters. Covering the broad topics of Principles, Definitive Management, Secondary Surgery and Innovations, the texts covers the entire scope of the treatment of facial injuries up through secondary revisions which are the norm and not the exception. Dr. Barry Eppley, Indianapolis plastic and maxillofacial surgeon, personally either wrote solely or made major contributions nearly 1/3 (ten chapters) of the book. Covering the topics of Etiology and Prevention of Craniomaxillofacial Trauma, Medicolegal Implications of Facial Injuries, Principles of Facial Soft Tissue Injury Repair, Alloplastic Biomaterials for Facial Reconstruction, Surgical Access, Nasal Fractures, Primary Repair of Facial Soft Tissue Injuries, Reconstruction of Large Hard and Soft Tissue Loss of the Face, Facial Burns and Secondary Rhinoplasty for Traumatic Nasal Deformities, Dr. Eppley shared his broad experience in this field as a double-board certified Plastic and Oral and Maxillofacial Surgeon.
Q: Dr. Eppley, Is it possible to have a baby after a tummy tuck and hip liposuction? I already have two children, and don’t think I want another one, but you never know. I am a single mom and in case I decide to remarry I might want another child. Can pregnancy occur normally after a tummy tuck and how long should I wait until it’s safe? Thanks for your time!
A: It is absolutely no problem to carry a normal pregnancy after a tummy tuck, whether the muscle is sewn back together or not. I have seen more than a dozen women over the years who have gotten pregnant after a tummy tuck and it has never been a problem. It may not be aesthetically desireable and is not a good way to protect your investment but it is perfectly safe.
Obviously getting pregnant is not the concern, but whether the abdominal muscles will stretch out as the fetus grows. Even if the rectus muscles have undergone midline plication, they will stretch out to accommodate the growing fetus. The amount of abdominal protrusion may be slightly less but there will be no risk of ‘compression’ of the fetus. This is because pregnancy is a slow form of tissue expansion that takes place over nine months. Such a slow rate of expansion can stretch out just about anything. Pregnancy might be a problem after a tummy tuck if the gestation period was just a month or two, but a nine month period of expansion allows it easily to happen. I don’t think there is any specific safe period for getting pregnancy after a tummy tuck. I recently had a patient who learned she was pregnant just six weeks after her tummy tuck!
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a scar question.What about when a dog ear scar is right in the middle of your cheek. I hate it and I have had it for almost 7years. I am scared to undergo a scar revision as the excision will make the scar longer. Are there any alternatives?
A: Dog ears are excess tissue at the ends of scars or healed incisions. They are usually composed of skin and fat. To get rid of many dogears, it does require a scar revision by excision which will result in a lengthening of the scar. But some dogears can be flattened by defatting alone without skin removal. Through the end of the scar, fat can be excised without extending the scar. This technique relies on the overlying skin to flatten as the fat underneath it is removed. The fat can be removed through either direct excision or sometimes microcannula liposuction. Short of this approach, there are no other alternatives to the dog ear scar problem.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, lastyear ago I had a septoplasty to correct a severely deviated septum that resulted from a broken nose when I was a teenager. My surgeon removed a sizeable bone spur that was obstructing my breathing and that improved it a lot. Unfortunately, it did little to correct the aesthetic appearance of my nose. The septum is still very deviated midway up the nose so it has maintained its crooked appearance. Furthermore, my right nasal bone is caved in slightly.When I consulted a plastic surgeon a recently about the possibility of a revision of the prior procedure, he said it would not be worth it considering a lot of cartilage was removed. This would make it hard to re-anchor/attach the septum and would also increase the risk of perforation. What can I do to fix this asymmetry? Is a rhinoplasty still possible?
A: A septoplasty, in and of itself, will rarely make a significant change in the correction of a deviated or asymmetric nose. This is because deviation of the nose is a multi-factorial problem that is caused by aberrant anatomy than involves more nasal structures than just the septum. While it is true that a secondary septoplasty will be difficult due to scar tissue, there is no way to really know beforehand if it will be a good source of cartilage for the rest of the rhinoplasty. I have found more times than not that there is still some cartilage to be harvested. When combined with ear cartilage, there will be enough graft to so a more complete septorhinoplasty procedure. I would still approach your nasal concerns as a correction of the entire anatomy of the nose rather than camouflage techniques such as injectable fillers.
Dr. Barry Eppley
Indianapolis, Indiana
The removal of unwanted fat through liposuction does not always result in the shape of the desired body contour. This has lead to a liposuction concept known as liposculpture. What is liposculpture and how is it different? Is it a better at achieving natural body contours and a more attractive body shape? Who is it best used on?
Liposculpture moves beyond the removal of just localized areas of too much body fat to a more artistic approach to fat removal. Instead of using large bore cannulas which indiscriminately remove fat rapidly, smaller size cannulas are used. These tools are more selective about how much and where fat is removed. Smaller cannulas may also be combined with powered equipment such as oscillating, ultrasonic and laser-assisted liposuction devices.
But the most important element in liposculpture is that of the surgeon. There has to be an appreciation of what makes up natural and pleasing body contours. The tools used are only as good as the hands that are directing them in shaping new contours. There also has to be an understanding of what the structure of fat looks like underneath. In some areas there may only be a thin fat layer which can reveal an improved body contour through superficial cannula extraction. Such aggressive right-under-the skin fat removal must be applied carefully to avoid scarring and undesireable skin retractions. Areas such as the inner knee, neck, back rolls, axillary breast and flanks are good examples of where superficial liposculpture must be used to get good contouring results as there are not deeper fat layers.
While liposculpture sounds appealing, it is not a method that is needed for most liposuction patients. The most common liposuction patient has larger amounts of fat on the abdomen, waistline, thighs and arms. In these areas there are two distinct fat layers, superficial and deep. Extraction from the deeper layers is needed and should be the first layer that the cannula enters. Treating the superficial layers as well, while improving the amount of contour reduction, will increase the risks exponentially of surface contour irregularities. The abdomen, arms and inner thighs are particularly at risk for this problem with superficial liposculpture. The quality of the skin, its thickness and elasticity must be assessed to determine if it is wise to attempt removal of fat right under the skin.
While good marketing and pictures of models (who have never had the surgery) are appealing as sales tools for liposculpture surgery, it is important to remember that traditional liposuction methods with solely deep fat removal will satisfy most patients. Liposculture techniques should be applied judiciously and applied to areas that are best served by them. It is a liposuction technique that takes into account the anatomy of the fat and the contouring goals and not a method that replaces traditional liposuction for most body areas.
Dr. Barry Eppley
Indianapolis
Q: Dr. Eppley, I am unhappy with the shape of my breasts after breastfeeding two children and then losing 35lbs after the delivery of my last child. I do not like how loose and droopy my breasts are. I am happy with the size and I would like to avoid implants. I also would like to know how to get rid of the stretch marks on my breasts. Can you tell me if a breast lift without implants will be enough to remedy those issues? Also, after research I’m expecting to need an anchor lift, is that what you would recommend? I have attached a front and side picture of my breasts for you to see how droopy they are.
A: I think much of your assumption about the need for an anchor or full breast lift is correct. That is certainly what your pictures show with the nipple being positioned just below the inframammary fold in the side picture. While this will lift the nipple above the fold and will tighten the skin and lift the breast tissue higher up on the chest wall, a lift alone will not be able to create any persistent upper breast pole fullness. But if that is not a necessity then you could get by without an implant. The sole purpose for an implant in a breast lift for many patients is to create upper pole fullness that will persist after the breast lift/tissues relax and settle downward.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I want to have liposuction done on my stomach and waistline but don’t know the best kind to get. There are many different types out there and they all seem to suggest that each one is the best. I went to two different plastic surgeons, one using Smartlipo and the other Vaser, and they both said the way they do it is the best way. This has left me confused. What do you think is best?
A: When you see many different methods of doing the same thing being advertised or touted, this likely means that there is not one single best way to do it. For if there were, we would all know about it and it would be the only way to do it. It is easy to get caught up in technology and machines, particularly when it comes to performing liposuction. The reality is that the results of liposuction is most influenced by the skill and experience of the person performing it, not the specific device, machine or technique. No one type of liposuction is better than another, but there are better doctors than others that do it. Some do it well with great artistic flair and get very good results with minimal skin irregularities and others have less refined outcomes. Unfortunately, this is the aspect of liposuction that is impossible for you to evaluate clearly. You have to rely on your gut feeling of the doctor, their posted results and any reviews of satisfied patients that are unsolicited.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have had breast implants in place now for over 24 years. They were originally placed in 1987 above the muscle and are silicone implants. I am scheduled to have a mammogram at the end of the month and am afraid the the mammogram might rupture my implants because they are so old. Do you think I should get a mammogram or is an ultrasound just as good?
A: The premise of your question is a little concerning. It suggests that either you have never had a mammogram or have not had one for many years. It would be very important that you get breast cancer screening and, no, an ultrasound is not a good substitute for a mammogram. It is not nearly as sensitive for breast cancer detection. If you don’t want to get a mammogram, then you need to get an MRI. I would have no concerns, however, about getting a mammogram as there is no evidence that they increase the risk of breast implant rupture. With the age of your implants, there is a very good chance that you have silent rupture in one or both of them already. The time is on hand to consider replacing your breast implants anyway so getting a mammogram will help answer the dual concerns about implant rupture and for breast cancer detection.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a breast augmentation done in November last year. Initially I was very satisfied with the results but now they are starting to sag and I need a breast lift. I remember that I had a discussion with my plastic surgeon before the surgery about doing a lift at the same time as my implants but I decided against it because of the scars that would result. Now that I am ready for a breast lift will I have to have the implants removed, have the breast lift performed, and come back at a later date for new implants? Or can the lift be done with the breast implants in place that I have now?
A: Many times modestly sagging breasts get by initially with implants alone. But when the breast tissues relax after being pushed outward, they slide off the implant creating ptosis off of the edge of the implant. If you are happy with the size of your implants and they are in good position, I see no reason why you can’t proceed forward with the lift with the implants you already have in place. Most likely, you will need a vertical breast lift to get the breast tissues up in proper position over the implants. While it is never a pleasing revelation that you will need a second surgery to get the breast result you want, take solace in the fact that a breast lift is much easier to go through than the initial breast augmentation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I need to have a pannciuectomy. I had weight loss surgery in November 2010. I was originally 375lbs and I lost over a hundred pounds. I have had this overhang since I was in my teens and it now hangs to touch my upper legs. Will my insurance pay for it? My out of pocket expense is met for this year so surgery should be paid in full. Please please can you help me?
A: Many overweight people have a large abdominal overhang initially that is then aggravated by their weight loss. As the weight comes off and the ‘balloon deflates’ so to speak, this skin overhangs worsens and sags lower as it has lost volume. This creates complete obliteration of the groin creases and their pubic and genital regions creating the well known hygiene and skin irritation issues. As you have described, your abdominal pannus now hangs down completely into your thighs. By definition, this is one of the criteria that insurance uses to determine coverage.
While I would agree that it sounds like your panniculectomy would be covered by insurance, my opinion is irrelevant and is meaningless from the insurance coverage perspective. This is why we always file a predetermination so the insurance company has enough information for them to make a decision. It is their decision not mine. As a plastic surgeon, I am merely a vehicle by which I can help the patient be put in a position so their insurance company can make an accurate review and determination. This predetermination involves a written letter by me describing your condition, the problems that it is causing and photographs which show the size of the abdominal pannus. That is mailed to them and then you await a written response as to their decision about coverage for your abdominal panniculectomy.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had breast augmentation about six months ago. I went from a 34B to a 34D and they are under the muscle. While the size is satisfactory, they still feel and look fake. They still feel hard, although not as hard as right after surgery. One breast is also higher than the other one and they have not dropped like my surgeon said they would. What do you recommend I do now?
A: While it is true that breast implants can initially be high due an immediate skin expansion effect, some settling or dropping of them can usually be expected as the lower breast skin relaxes. This is an effect that will occur within the first few months after surgery. I usually like to see it happen by no later than six weeks after surgery. While some settling can still occur up to several months later, you are at a point in time where no change will be seen. Besides a high position, your breast implants feel tight because the tissue pocket that contains them is somewhat too small. A small pocket around a bigger implant will feel tight or hard. What you need now is revisional surgery. The breast implant pockets need to be opened up on the lower pole, one side more than the other. This will drop down and even out the implants and, with larger pockets, make them feel softer. Breast augmentation revision is your next step.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am 38 years old and have had very noticeable nasolabial folds for the past several years. I have had injectable fillers, specifically Juvederm Ultra XC, placed into them with some improvement. I also had my cheeks injected also. Now, less than 6 months after the injections, my nasolabial folds are just about back again. I would like to something that is more permanent and may even have a greater effect. Do you think a cheek lift will work? Or should I just wait until I am older?
A: Deep nasolabial folds at a young age can be a very difficult problem. Some facial shapes and skin types are simply more prone to them and, if this is an issue at the young age of 38, it is going to continue to be a long-term facial issue. Injectable fillers for the nasolabial folds offer both advantages and disadvantages. Their advantage is that they work when properly placed. There is great debate of the many fillers as to which one is better but none has ever been shown to be really be ‘better’, they all work. Some simply last longer at a greater price. They work instantaneously and generally have no significant problems. Their disadvantage is that they are not permanent. No injectable filler is permanent, no matter what is said by some. However, a cheek lift is not the solution either…for now. You are too young to justify such surgery and it is not a permanent solution either. You would be best served to continue with injectable fillers at this point even though they have limited duration. The effectiveness of cheek or midface lifts depends on mobility of the cheek tissue across the zygoma or cheekbone. I doubt if you have much of at your age. This is why such cheek lifts are years away for you.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting fairly large breast implants. I am only 5′ 2” and 107lbs. I’m currently a 32A. I have been told that I would need multiple surgeries to get my desired size of 650cc. One plastic surgeon I consulted with suggested that I start with a 400cc implant and then have a second implant later to get to my size. My breast width is about 13cm. What is the largest implant (style and cc)that I can get based on my breast width?
A: There are some issues that you may be aware of when you place large implants in women with small breasts, primarily which is the stretching out of tissue support. This can cause some long-term problems such as tissue thinning, bottoming out and an increased risk of the need for revisional surgery. But I will assume you know these so I will answer your specific question.
Depending upon whether you are choosing a saline or silicone gel implant, there are different size consideration either of which would be a high profile style implant. I only use Mentor breast implants so I can only speak of those sizes. A 560cc high profile saline implant has a base width of 13.4 cms which can be maximally filled to 650cc. At maximal fill this will narrow its base to 13.1cm. For silicone Memory gel implants, a 650cc implant has a base width of 14.4cm.
As can be seen by these numbers, I do not know why you can not reach your desired breast implant size in a single breast augmentation surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Cosmetic plastic surgery is now more than a $10 billion a year industry in the United States that has seen increases in number of procedures across all age groups. The largest growing population of patients, however, are those in their later years. Due to Americans being healthier, living longer and being more active later in life, millions of them want their looks to keep pace with how they feel. As a result, many are turning to cosmetic surgery to help them look younger and feel better about themselves.
In 2010, over 600,000 Americans age 65 or older choose to undergo some form of cosmetic surgery. Compared to ten years ago, that is a five times increase in number of procedures done. However a significant of these procedures, and a big reason for the large surge in numbers being done, is not actual surgery. In the interest of of wanting to look younger and fresher, many are going the injectable route choosing such popular products as Botox and Juvederm. While not as effective as surgery, they do help give one an extra edge in their appearance by decreasing frowning and plumping up certain wrinkles and folds.
Such injectable procedures involve only a minimal amount of discomfort by being placed right under the skin. Between wrinkle reduction and tissue plumping, these injections help give the face a smoother more youthful appearance. These are all procedures that can be done fairly quickly with a limited recovery time and are more economical options compared to surgery. When combined with a variety of available skin refreshening procedures such as chemical peels and light laser resurfacing, one can really take off a few years with next to no recovery or downtime.
While injectable treatments have lead the way in number of procedures for older Americans, ironically they are not the most effective given the amount of aging changes that are usually present. Injectables are more effective in younger patients simply because they have less wrinkles, lines and sagging skin. This is why surgery is also growing in numbers for the Baby Boomer generation with popular procedures being eyelid tucks, browlifts, and face and neck lifts. These anti-aging facial plastic surgery procedures can be done alone or, ideally in combination with surgery, to remove loose and sagging skin that creeps its way across our faces as we age.
We all look for that extra something to look and feel better as we age. My older and more mature patients clients are traveling, playing sports, exercising and doing all of the right things in life to look, feel and stay young. But, unfortunately as we age, all of the activity and exercise won’t make your face look any better. Looking better requires a effort, just of a different kind than that of feeling better.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was wondering if you performed jaw augmentation using bone grafts.What do you think about using bone grafts to increase the mandibular angle? Would you recommend it? And if you prefer other materials, why is that? I was browsing the web for some before and after photos of jaw augmentation using bone grafts, but to no avail. If you perform this procedure, and have done so in the past, would it be possible to see some of your work? Thank you!
A: There is a good reason why you can not find jaw angle augmentation using bone grafts…it is not done. It would be a very poor procedure for cosmetic jawline augmentation for the following reasons. First, onlay bone grafts to the face undergo partial or complete resorption. For the purposes of volume augmentation, much of the grafts would likely be lost or they would lose shape. Secondly, the amount of bone graft material that could be obtained and its thickness is very limited. Even using skull, hip or rib bones, it would be difficult to get enough material to adequately do both sides. This is not to mention the pain, discomfort and scars that would result from their harvest. Thirdly, most jaw angle augmentations require vertical lengthening which would mean placing part of the bone graft out into space. This would completely resorb.
For these three major reasons, and a few minor ones that I didn’t mention, synthetic implants are far superior to bone grafts for jaw angle augmentation.
Dr. Barry Eppley
Indianapolis, Indiana
The pursuit of the perfect or idealized female appearance is not a realistic goal for any woman, regardless of what plastic surgery has to offer. Improving your own body through diet and exercise, and perhaps a little plastic surgery if desired, is a more common sense approach. Women should only want to have a pleasing face and good body proportions that fall within what their natural genetics will allow.
The Barbie doll, introduced in 1959 and celebrating her 50th birthday in 2009, has always been a controversial figure when it comes to body image. One of the most common criticisms of the doll is that it promotes an unrealistic or unattainable body image for young women to try and emulate. Based on her 1/6 scale at a height of just under 12 inches, she would be the equivalent of 5’ 9” with a weight of 110 lbs with measurements of 36-18-33. Technically at these dimensions she would have a body mass index of around 16 which would classify her as anorexic.
While the Barbie look is not one young women should really admire, it is perhaps interesting to know what plastic surgery procedures one would have to go through to achieve it. In the October issue of O magazine, former model Katie Halchishick served herself up as a example of what she would have to do to achieve Barbie proportions. Posing for a photographer, she used her body to diagram out what she would surgically have to do to change her features to achieve the equivalent of Barbie’s proportions and shape.
Based on this photographic diagraming, it was shown that she would need facial plastic surgery consisting of a browlift, jawline reduction and thinning, nose reshaping, neck contouring and a chin augmentation. For her body she would need a breast lift, upper arm thinning by liposuction and a tummy tuck…and that is for just above the waist. And it was not like this former model didn’t have an attractive face and body to start with.
While this is an entertaining and even humorous bit of photographic morphing, it does actually have a serious message. Trying to have so called ideal body proportions, or even an unrealistic body shape like that of Barbie, is not a healthy pursuit…even if plastic surgery could make it possible. On a more common request, trying to look like a certain model or entertainer is equally unrealistic. Plastic surgery should be used to enhance the face and body shape that women already have rather than pursuing excessive surgery to try and achieve what one isn’t meant to be. This is a healthy and psychologically balanced approach to plastic surgery that many teenage and younger women would be advised to follow.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am 35 year old man and I have always been heavy since I was a teenager. Last year I decided to do something about my weight and I worked out alot at the gym and started eating better and I lost 120 lbs. Doing this made me feel great while I am fully clothed. However when I am naked I look terrible and am not confident whatsoever. I have the classic excess skin around the tummy area and the back and the breast area. Also I have excess skin between my Scrotum and my Bottom cheeks between my legs. I would really appreciate some advice on what procedures I can have done for this excess skin. It is for me that I want to do this not for other people I want to be able to feel as good naked as I do fully clothed. What can I do? Any help you can give me would be gratefully appreciated.
A: The loss of a lot of weight, whether it be by bariatric surgery or non-surgical methods, creates a very classic pattern of excess skin. For men, the primary skin excesses are around the waistline, the chest and the inner thighs. These require a surgical approach which usually consists of a waistline tummy tuck with a low horizontal scar, chest lifts, and inner thigh lifts. These are the three primary targets of male body contouring after weight loss. They often can all be done at the same time. The key concept to grasp is that there are scar trade-offs for removal of this excess skin.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting breast implants. I am fairly small framed, some call me petite, at ‘m 5’0” and 102lbs. I’m currently a 32A cup size. I have had one consultation and tried on sizers and it seems like 550cc implants seem to be the best fit for me for the size I am after. I have been told that this is a large implant for my type of body but this is the look I really want. My goal is a 34 DD. With implants of this size would it be possible for me to get a teardrop breast shape despites the large implant size on my small chest? Two other questions, will my areola stay the same size and what is the best implant and incision to use?
A: There is no doubt that you are interested in a very large implant for your frame. While it is every women’s right to choice any size implant they want, there are many plastic surgeons who will not accommodate an implant size that they feel may lead to loss of breast tissue support in the long run. That being said, whether it is a saline vs a silicone implant, you need a high profile implant to accommodate that volume with the most narrow implant base diameter so it does not end up too far to the side getting in the way of the swing of your arm. I would lean towards a saline high profile implant because it can be placed through a small armpit incision and gives the most projection with the narrowest implant width. As the skin expands to accommodate the breast implant underneath, your areolar size will get bigger.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, My teenage daughter was born with a hairy giant nevus in her scalp. It required three procedures of subtotal removals before it was completely gone between the ages of two to four years of age. While the scars from the removal procedu Smart Sales Blueprint res are largely hidden in her scalp, it has resulted in one of her eyebrows being much higher than the other. She is now a teenager and her eyebrow asymmetry is of understandable source of concern and embarrassment for her. I am looking into seeing if some plastic surgery procedure can be done getting her left eyebrow lowered to match her right eyebrow. Do you have any suggestions for how this may be done?
A: Eyebrow over-elevation can be a common sequelae from nevus excision of the scalp or forehead. It is obviously the result of either the scalp resection or actual forehead skin removed as part of the nevus excision. Thus the eyebrow malposition is because there is a forehead tissue deficiency. It is unlikely therefore that the eyebrow can be lowered by a ‘simple’ forehead and scalp tissue loosening, a reverse endoscopic browlift so to speak. The most successful and likely only effective procedure is to create more forehead skin or loosening through tissue expansion, thus allowing the eyebrow to move downward. Unlike eyebrow elevation through standard browlift techniques, eyebrow lowering is a much bigger challenge.
I would need to see a picture of eyebrows and forehead to determine what may be possible.
Dr. Barry Eppley
Indianapolis, Indiana