Your Questions
Your Questions
Q: Dr. Eppley, I am possibly going to have a chin reduction. Here is my serious concerns. I have a very thin face with hollow cheeks. My forehead is large and my chin is small. The problem is I have a projected or jutted out chin which is very pointy, especially when I smile. I have a very strong jaw line, and I just want to to get rid of the witch’s chin look but keep the exact same frontal look. I cannot afford to have my chin shortened. I want a softer look, but I am terrified that I am in for serious dissapointment. If I did this, I would want to do the submental approach and the burring teqnique because I don’t have a long chin. It seems safer, and by your articles it seems I may be correct. I want a softer, more feminine look without making my face look any thinner, and the projection gone. Is this possible?
A: Thank you for sending your inquiry and your pictures. I would take a slightly different approach to your chin. In the frontal view your chin is very square for a female and it needs tubercle reduction (side chin reduction) to soften it. From the side view, it needs some slight horizontal reduction and soft tissue tightening. I would not do any vertical length reduction. You need the length to fit the rest of your face.
This chin reduction procedure is best done, as you have mentioned, from the submental approach to manage the excess soft tissues that will result.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am interested in a rhinoplasty to build out my nose as it is very short. I am of Asian background and have a small flat nose which is inherited. I have read that it can be done with either a rib graft or using a synthetic implant. I would definitely prefer using rib as that would be more natural. I have done some imaging of my nose in profile to show how I would like it to look afterwards. Can this type of result be done?
A: In looking at your profile and predictive imaging, I would make two points. First, using a rib graft for the short nose is the best long-term approach. This is particularly true when there is a significant amount of augmentation desired. Large amounts of synthetic material will put the nose skin under tension ultimately leading to thinning of the skin and tissues and risks of exposre or extrusion. A little synthetic material on the dorsum of the nose can work well. A lot is a recipe for complications. Secondly and of equal importance, you have unrealistic results. That amount of augmentation is not possible no matter how it is done. The skin of the nose will simply not stretch enough to accommodate that much augmentation. And even if it would, you would not want it to. You should realistically expect about half of that rhinoplasty result that you are showing.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have a big overhanging belly that I want to get rid off. I have two small children and have lost over 30 lbs since my last one but the sagging belly persists. Will exercise be enough or do you think I need a tummy tuck?
A: While I have not seen a picture of you, your description alone of your belly has already answered the question. The idea of an overhang suggests a lot of loose abdominal skin. If some weight loss has not made a difference in its size, then you know exercise is not the final answer. Undoubtably some form of a tummy tuck is what you need. You can’t exercise off loose skin no matter how hard you try. Just ask any gastric bypass patient who undergo a lot more weight loss than you have. This is a surgical problem. When it comes to exercise and weight loss, however, I would recommend that you get in the best shape as possible for a tummy tuck. Preparing for such surgery, like training for an athletic event, will have you recover faster and may also help you achieve a better result.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Is Xeomin used in masseter hypertrophy? If it is, is the amount of diluent used the same as Botox. Thanks.
A: Xeomin will work the same as Botox for masseter muscle hypertrophy. It is just as potent and has the same onset of action as a full week after the injections. Like Botox’s other competitor Dysport, the unit dosing may be somewhat different from Botox and an exact replicative dose is not well established. For a cosmetic effect in the frown lines, reports indicate that Xeomin has similar dosing to that of Botox on a 1:1 unit basis. Whether such a dosing method works the same in the masseter muscle is completely unknown. If I was a patient knowing what I know, I would not switch from Botox for massteric hypertrophy if it is working. It will take a lot more clinical experience to determine what dosing comparisons are between Xeomin and Botox. For now, there is no known advantageous reason to make that switch and there is the risk of less effectiveness.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hello, I have been researching for a while now on getting a procedure done before my husband whose is in the service returns home from Afghanistan. I came across your page and was wondering if I could have a little more information on your Patriot Program? I am interested in getting a tummy tuck done. After having 3 children and losing a lot of weight, i am left with a loose stretch marked covered skin. I only weigh 120 lbs and am happy at the weight I’m at. But I just do not the appearance of my stomach. Any information would be greatly appreciated. Thanks so much!
A: It sounds like what you may need is some form of a tummy tuck. Whether this is a full tummy tuck or a more limited variety will depend on how much loose skin you have. In most cases if one can tolerate a longer scar, a much better abdominal result is obtained with a full tummy tuck. The Patriot Plastic Surgery Program was established to provide some reward for those and their families that are in the active military. It is not a free surgery program but substantial cost reductions are offered. To get an exact cost, please send me some pictures of your stomach for my review and my assistant will forward you that information.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Six months ago I had breast implants with an around the nipple type of lift, I had 350cc silicone implants placed in each breast. Right after the surgery, there were a noticeable difference in the shape of my left breast. It sat lower on my chest and appeared smaller than my right breast. Can this be fixed? I have attached pictures from different angles so you can see the difference.
A: In looking at your pictures, I see a fairly good result. While I do not know what you looked like before surgery, this is an overall nice result, I do see a slight difference in the breasts with the left breast having a small amount of inferior and lateral positioning, This may or may not have to do with the location of the implant.
For the sake of discussion, let us assume that it is an implant location issue. One of the most common reasons for revisional surgery after breast augmentation surgery is implant asymmetry or malposition. This presents in many ways from an implant being too high, too low, too far to the side, to being too far to the middle. Invariably, there is always the good breast and then the bad one. (or as I call it the good sister and the bad sister)
Implants that are too low or too far to the side can be corrected using an internal suture technique decreasing the size of the pocket and moving the implant to a more symmetric position to that of the other side. Expect improvement but not perfection. It is unlikely that your breasts were perfectly symmetric from the beginning and this surgery has likely unmasked that pre-existing issue.
I would also think very carefully about revisional surgery for a minor amount of breast asymmetry. All surgery involves risks which are always greater when a synthetic implant is involved. Those risks are not necessarily less than that of the original breast augmentation/lift surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I had liposuction surgery of my stomach and waistline four months ago and I think it was botched. My surgeon removed too much on one side of my waistline and left the other side straight. I can still feel that there is fat remaining at the love handle area of the straight side. It is very odd looking in appearance to me. How can there be such a difference between the two sides? There are also dents in different areas across my stomach. Can all of this be fixed and made to look better? I am very upset about the way it looks as I used to have a very smooth and even waistline before even if it was too fat.
A: While I can understand how you feel, calling your result botched is most likely an inaccurate assessment. Liposuction is an art form and not an exact science. Irregularities and asymmetries are not rare from liposuction even in the best of hands. It is a blind procedure done by feel and how it looks from the outside in the face of fluid distention and the patient laying horizontal….distortions that assure some degree of imperfections in most results. There is also the influencing issues of your skin and how well it adapts to the fat removal…a variable not controlled by the surgeon. Your issues can most likely can be improved by some refining liposuction of the bigger love handle and fat grafting into the stomach indentations. Expect improvement but not perfection from any revisional liposuction procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a breast augmentation about three months ago. My problem is that my implants are literally touching each other. There is no gap between them. While I wanted better cleavage, this is too much. In addition, when I move my arms more than just a little bit, both implants jump to the sides which is freaky. I now know that my implants are too big and I want to go smaller. I currently have in 450cc and want to go down to 350ccs. Will I need a lift if I go down to that size? Will switching to smaller implants stop them from touching each other? I’m attaching a picture, how would you correct my problem?
A: What you have are several implant issues. First, the implant pockets nearly join over the sternum, This is known as symmastia. Downsizing your implants will not correct that problem. Correction requires the pockets to be sewn down in that area and may even require an allogeneic graft placed along the sternum to prevent recurrence. Secondly, your implants are definitely too big as they are wider than the base of your natural breasts. This is why you have both symmastia and that the implants go too far to the sides. Downsizing your breast implants by 100ccs and changing to a high profile implant will make them look more natural. Based on your pictures, you will not need a lift if you go smaller in implant size.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had gynecomastia surgery one month ago. I have noticed that my nipples are depressed inward. Is this just a temporary look and will it go away and the nipples even out with more time? The tissue directly under my nipple is still hard and stiff. I know I may be panicking but I don’t want it to stay like this.
A: At only one month after surgery, it is too early to say that what you are seeing is the final result. However, a retracted nipple appearance this early after gynecomastia surgery is not a good sign. This indicates that either too much tissue has been removed directly underneath the nipple or the surrounding tissues beyond the nipple have not been adequately feathered to make for a smooth transition into the nipple area. I would much rather see a slightly puffy nipple at this point as all of the swelling from surgery has not yet gone away. Once it does the nipple will likely retract some more. The other reason is that too much residual nipple tissue is an easier problem to treat than when too much is removed. I would wait a full three months and even as long as six months to make your final assessment. This length of time is needed to not only allow the chest tissues to fully heal and relax but because revisional surgery would not be done before this time anyway. If the nipple retraction persists, this is going to fat grafting for correction.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in creating a more symmetrical look to my face via fillers and eventually implants. As a result of my jaw being asymmetrical, the right side of my lower face appears fuller and more defined than the left. I have attached some pictures for you to see.
A: Thank you for sending your pictures. I have taken a careful look at them and the fundamental issue is that the two sides of your face are different. The asymmetry is that the entire right side of the face is lower than that of the left. This can be seen from the eyebrow down to the bottom of the lower jaw. the right eyebrow is lower, the right orbital box and eye is lower as well as the lower eyelid, the cheek is lower and more recessed and the inferior border of the mandible is more inferiorly positioned. In short, you have a classic case of facial asymmetry where the two halfs have developed differently. For the sake of any correction, you have to take the position that the left side of the face is the good side or the objective for the right side to try and achieve. No form of injectable filler can make any significant difference in such facial asymmetry. A variety of surgical procedures can be considered from top to bottom including right endoscopic browlift, right orbital floor-infraorbital rim implant, right lower eyelid tightening by canthopexy, right cheek implant and right inferior border mandibular shave reduction.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I want to get rid of my frown lines between my eyebrows. I know that Botox is most commonly used to treat them but I am looking for something more permanent. I have read that a browlift operation can be used to get rid of those scowling muscles. What I am now confused about is whether a coronal or an endoscopic browlift technique would be better.
A: The first thing to understand is that the idea of permanently getting rid of frown lines by surgery does not exist. Browlift methods can help reduce their action but can rarely permanently eliminate their effects. Their action can be reduced by partial muscle avulsion through either an open (coronal) or closed (endoscopic) browlift. There are indications for either type of browlift depending upon the anatomy of the eyebrow and forehead, the location and density of the hairline and the vertical length of the forehead skin. These features are what decides which browlift approach is best, not the action or depth of the frown lines. There are some that would say that an open browlift approach is more effective at getting more frown muscles out due to the open exposure. But those very skilled in endoscopic browlift techniques may be able to offer similar results. For now, however, Botox injections remain as the most effective method of obliterating frown lines even though its effects are not permanent. This effectiveness over that of surgery is one reason why Botox and its competitive analogues are so successful commercially.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in kryptonite bone cement treatment as a craniomaxillofacial treatment for a small skull deformity. I have an area just below my hairline where there is a bonelike material that protrudes a few mm from the rest of my forehead and is unsightly but doesn’t hurt at all. It happened after an accident a few years ago. Can kryptonite be injected into the surrounding area to make the surrounding area more natural in appearance? If so how much? And what are the likely complications?
A: While I don’t know exactly what your skull area of concern looks like, the use of injectable Kryptonite can work very well for small skull contour problems. Done through a small incision close to the skull defect, it can be injected into and around the area of bone irregularity as an onlay contouring material. The biggest challenge with its use is to get an absolutely smooth contour and not to overcorrect the problem or build out too much of a contour. Other than that this is a very simple technique with very little to no real recovery, particularly in such small skull areas The cost of the procedure depends on the size of the defect and the amount of material needed. I would need to see a picture of the problem to determine the suitablity of an injectable skull contouring approach and an accurate estimate of the cost.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am going to get breast implants and have had several consultations. One confusing point for me is whether the implants should be above or below the muscle. Of the two consults I have had one says above the muscle and the other is adamant that they go below the muscle. What do you think?
A: There are is no absolutely best position for breast implants in any particular patient. There are advantages and disadvantages to both approaches. The vast majority of patients today have implants placed beneath the muscle for better pocket stability, a more natural look (upper pole shape), better tissue coverage, a lower rate of rippling and less interference with mammograms. The one downside to under the muscle is that there will be animation deformities, meaning the implants will be pushed to the side unnaturally with pectoralis mucle contraction when the arms are extended. The one benefit to an implant being above the muscle is when there is some breast tissue sagging, it can fill out the sagging tissues better. The other under the muscle benefit is for someone who was looking for less recovery time and pain and could not avoid adjusting their fitness regimen or someone who has to have the procedure done under local anesthesia for medical and fear of anesthesia reasons.
In the end, one has to weigh these advantages and disadvantages from the perspective of their own breast anatomy and shape. As a general rule, always remember that any implant in the body always does better in the long run (i.e., less complications) when placed under a thicker soft tissue cover particularly when under well-vascularized muscle.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in creating a more symmetrical look to my face via fillers and eventually implants. As a result of my jaw being asymmetrical, the right side of my lower face appears fuller and more defined than the left. Additionally, my upper jaw is recessed. I have consulted with oral surgeons but none believe my problems are severe enough to warrant jaw surgery as my jaw is fully functional. What do you recommend?
A: The use of injectable fillers does have a role in facial reshaping/contouring but it is more limited than most patients appreciate. Because of the volumes of fillers needed to create visible facial contour changes and their temporary effects, the use of fillers must be done judiciously. For lower jaw asymmetry, and particularly for midfacial flattening, injectable fillers have very little role to play in a long term improvement strategy. Lower jaw asymmetry is often the result of a smaller jawline or mandible on one side. That is best addressed with the consideration of a jaw angle implant. Midfacial flattening, particularly done at the upper jaw level (maxilla, LeFort 1 region), needs horizontal volume augmentation. This is best done with either paranasal, premaxillary or both types of lower level midfacial implants. These would be far more effective than any type of synthetic filler injections.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I recently had a breast augmentation with a lift six weeks ago. My lift was the vertical type and my implants were silicone gel above the muscle. While I know it is still sort of early and the breasts are still settling into place, I am concerned that I am experiencing that they already sit lower than I would like and they have some rippling on the sides. This rippling is most apparent when I bend over and goes away when I push the implants upward. I am concerned that I will need another lift in the near future if they sit this low already. Should the implants have been positioned higher in the first place?
A: The combination implant-lift breast reshaping procedure (augmentation mastopexy) is a tough one to get just right. It is an artistic balance during surgery of implant size and positioning and how much lift and tissue tightening needs to be done. On top of these difficulties is the unknown variable of how the whole breast settles and what support the breast tissue and skin provides. While six weeks is not the final result, more settling may or may not occur. It would be best to wait a full six months before considering any revision. The rippling you have is a result of the implant being above the muscle and the lack of a substantial breast tissue thickness between the implant and the skin. This might be improved by a higher implant position or a change to an under the muscle position…but there is no guarantee that even with these changes that it will be completely gone.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have read more and more about people having a tummy tuck and the doctor did not use a drain aftewards. I am interested in getting a tummy tuck but the whole drain scares me. I just can’t get over the idea of having a tube sticking out of me. Is this a safe type of tummy tuck? Are there additional risks to this procedure? Is there an additional cost to have a tummy tuck without a drain?
A: Fluid buildups, known as a seroma, after a tummy tuck is common. The use of a drain is to prevent that build-up from occurring. A drain will stay until there is enough healing inside that the body stops producing so much fluid. Most drains stay in for a week to ten days after surgery. While drains are very effective at decreasing fluid-related problems, they obviously are an inconvenience to say the least. This has led to the concept of a ‘drain-free tummy tuck’ or a ‘no-drain tummy tuck’. This is slightly more than just not using a drain but an actual modification of how a tummy tuck is done. Less skin undermining is done and the underside of the skin is sutured back down to the abdominal wall to decrease the open space where fluid can build-up. This does take more time to do and involves the use of more expensive suture. Whether a plastic surgeon charges more for this tummy tuck technique varies by the practice. I have done many tummy tucks with drains and some without. Some drainless tummy tucks do go on to build up fluid which has to be drained in the office later however…so the technique is not infallible.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 48 year old female and have begun to notice some fat under my chin, some jowling and some neck wrinkles. I have had gotten two plastic surgery consultations with differing opinions. One said I needed liposuction of my neck with a submentoplasty and fat injections to the jowls. The other said I needed neck liposuction with a jowl tuck-up. These choices seem so different that I am confused. Both plastic surgeons are board-certified and respected in the community.I don’t know which one is right. Any advice would be appreciated.
A: In reality, both are right and these are just two different options for the same facial aging problem. It is clear that you are what I call a ‘tweener’. Your aging issues are not quite enough for a more extensive facelift (neck-jowl lift) but are more than what liposuction alone can ideally improve. In other words, you have a mild amount of excess skin along the jawline and in the upper neck. As these two options are different in technique, they will also produce different results. I think the right answer for you is defined by how much you want to go through for what result. While neither operation is a big procedure, the liposuction/fat injection approach is less invasive but will not tighten the jowl line as much as a limited facelift with liposuction. (jowl lift) It would help to define what bothers you the most, jowling or neck fat. If it is neck fat go with liposuction. If it is jowling, go with the lift.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m a 33 year-old that doesn’t like how my nose and upper lip looks. At one time I was considering a lip lift but decided against it due to scarring. I am in orthodontic braces as I write this and have been told that I would need to postpone any nose surgery until my braces are off. But I wanted to get your recommendations for my nose as I would like to lessen the upturn of my nose and straighten it. I have no hump to be taken down. It is just the tip that needs to be refined. I have attached some pictures for you to see what my nose looks like.
A: Based on your pictures, the upturn of your nose makes the upper lip look longer than what it really is. You were wise to pass on the lip lift. The tip of your nose is short or underprojected as we call it. This makes your nostrils appear bigger and gives you a lot of columellar show. (strip of skin between the nostrils hangs down too much) The type of rhinoplasty you need is one that would lower your nostril rims and decrease your tense septal angle. (high supratip area) This will require some cartilage grafting from your nasal septum to bring the entire tip downward. This rhinoplasty approach will give your nose and lip a more pleasing appearance. It is not that your upper lip is too long, it is that the tip of your nose is too short.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 32 year old female that is considering a breast lift. I actually have fairly large breasts being a 36D and with a bra on they look great. But when the bra comes off they look gross. They hang down like two old ladies. I had one Is It A Good Bad Sign If U See Ur Ex For The Past Week At The Same Time child ten years ago and nursed him and this appears to have put the whammy on their once nice shape. What I want is a more uplifted and better shape. I do not want them any smaller or larger They are the ideal size for my body shape in my opinion. Will a breast lift do what I want and is there bad scarring as a result?
A: Many women suffer from age and child-bearing a skin-breast tissue mismatch. As a result they have good size to their breasts but the stretched out skin gives them a low sagging appearance. While some breast sag is aesthetically acceptable, when the nipple sits below the lower breast fold it is rarely pleasing to anyone. This is exactly the condition where breast lifts work the best, removing excess skin and reshaping the breast so the nipple and the entire breast sits higher on the chest wall…many times back where it used to be. While there are some minimal incision breast lift procedures, they are only effective for the most minimal amounts of breast sagging. Most really effective breast lifts requires longer scars, much of which lies in the lower breast crease. Whether the part of the scar that goes around the nipple and vertically downward toward the lower crease is acceptable will vary amongst different patients. Seeing pictures of breast lift results with close inspection of the scars is critical for you to determine your level of scar tolerance.
Dr. Barry Eppley
Indianapolis, Indiana
Is It A Good Bad Sign If U See Ur Ex For The Past Week At The Same Time
Q: Dr. Eppley, I have reviewed your rhinoplasty computer images of what my nose may look like after surgery. While I like the changes that have been done, what I would like to know is if my nose can get even a bit smaller than what you have showed in your imaged pictures?
A: When it comes to reducing the size of one’s nose, what limits the result is how much skin one has and its thickness. All of the maneuvers in rhinoplasty surgery are about changing the underlying cartilage framework. In reducing a large nose that framework is reshaped and made smaller. While the supportive framework of the nose can be changed, the final result seen will also reflect how well the skin shrinks as well. How well the skin contracts is key and the thicker the skin is the less likely it will contract as much as the cartilage has been reduced. The wild card in every rhinoplasty surgery is how the overlying skin will reshape to the new framework.
I try to show on computer imaging realistic results and often the most minimal changes that I think will happen. While anything can be done on Photoshop that does not mean it can be achieved by actual surgery. You should make a decision about whether surgery is worth it based on the least amount that can be achieved…not on the most that you hope can be accomplished. This is particularly true in reduction rhinoplasty.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I want to lift my breasts but I am completely opposed to getting implants and that is not even a consideration. So please don’t even try to convince me to get them whatever their purported benefits may be to how the breast may look by using them. However, I am undecided as to whether it is worth the effort to undergo a breast lift. I would be happy if only my nipples were positioned higher as they sag down quite a bit now. I don’t have to have my breasts fuller after a lift and it wouldn’t bother me if they even end up a little smaller as a result of the lift. I just don’t know if the scarring and the cost would be worthwhile.
A: While implants are often used at the same time as a breast lift, they do not always have to be. If one is willing to accept a slightly smaller breast and no upper pole fullness afterwards, then one may do well with a breast lift as that is what it accomplish in most cases. The real question, and a hard one to answer for many women with sagging breasts, is whether the scars to lift them are a good trade-off. The best way to answer that important question is to look at numerous after surgery results of breast lifts and look carefully at the scars. Your reaction to those breast scars will answer the question of your acceptance of breast scars from a cosmetic reshaping operation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 36 year-old man who has lost 40 lbs within the last year and a half and can’t lose anymore. I work out vigourously three or four times a week, eat a sensible diet and cannot lose any more size in my abdomen. My legs and arms have little visible fat and good tone. I am looking to reduce my waistline, love handles and abdomen. I am not sure about what procedures that I need to achieve my objectives.
A: Many people in their weight loss efforts face the same circumstances that you find yourself in. You have put good effort in losing weight and getting your body in better shape and have lost some substantial weight. But now you have ‘hit the wall’ and are short of what you want your body to look like. For many, the remaining excess fat may be quite resistant or there may be rolls of skin that no diet and exercise will ameloriate. Regardless, this is where surgery can help one make the final step. For most men, it is the use of liposuction in the abdomen, flanks and waistline that is usually needed. In extreme weight loss, there may be a need for some stomach skin removal as well. For many women, liposuction combined with some form of a tummy tuck is what is needed to get a flatter stomach.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting breast augmentation and a tummy tuck. I have had a child and am not planning on any more. I have numerous tattoos across my rib cage. My concern is what will happen with my tattoos when my breasts get bigger and my stomach skin is pulled downward. I have attached pictures which show where my tattoos are and the location of where my stretchmarks are on my stomach. Will these tattoos be affected by these procedures and will my stretchmarks still be visible after surgery?
A: While it is true that breast implants do stretch out the overlying breast skin and a tummy tuck has a downward pull on the upper stomach skin, their distorting effects on the outer skin are limited to the local area. Given that your tattoos are located on the side of your rib cage, they will not be affected at all by either breast augmentation or a tummy tuck. The tattoos are simply too far away to be altered. In regards to your stomach stretch marks, however, these will be dramatically changed by the tummy tuck procedure. In a full tummy tuck, all stretch marks that lie between the belly button and the pubis will be permanently removed with the skin and fat that has been cut out. Those stretch marks that lie above the belly button will be pulled down lower with the skin closure of the tummy tuck. With the creation of a new belly button, many women will have no stretch marks or loose skin around this central indentation. Some stretch marks may remain but they will be below the belly button closer to the low horizontal scar.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 25 year-old man looking for a type of rhinoplasty that will change the appearance of an upturned nose. I have had this nose shape since I was born. It is not only upturned but it is concave across the bridge with excessive columellar show from the very profile view. I am very tall which really accentuates the problem as you can literally look straight up my nose. What type of rhinoplasty do I need to make my nose look more normal and would it make enough of a change to make the operation worthwhile. I can’t seem to find any pictures on the internet of this type of rhinoplasty correction.
A: What you have is a congenitally short nose that sometimes is also called a saddle nose although this is not completely accurate. In a short nose, the length of the nose is diminished from the radix to the tip and is due to an underdeveloped nasal septum. Your description of this nasal type is exactly what one sees from a saddle-shaped bridge to an upturned nasal tip. It actually is not rare and a short nose can also occur from traumatic injuries as well as natural development. The correction of the short nose depends primarily on the use of cartilage grafts along the dorsum and columella to extend its length and direct the tip downward. The end of the septum must be extended as well. This is done though an open rhinoplasty. While cartilage from the septum can serve as the donor source, it is frequently inadequate in the amount and dimensions needed. This is why rib cartilage is frequently used in the lengthening of the short nose.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting some minor plastic surgery work done. I had a kidney and pancreas transplant done over a year ago.. I am wonder if being on immunosuppression drugs would it be unsafe to have some minor facial work completed?
A: In answer to your question regarding the ability to do some minor plastic surgery work on immunosuppressed patients, the answer is maybe. It would depend on what type of immunosuppression you are on (how significant), what procedures you are considering and their risk of infection and ultimately what your transplant doctors feel is adviseable. I have done numerous plastic surgery procedures on transplant patients all without any problems. Almost all of these have been on kidney transplant patients only .I have not done any work on someone who has had a pancreas transplant or combined kidney and pancreas transplants. However, as long as your transplant doctors know what you are considering and give it their blessing, then some facial plastic surgery work can be done.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had brain surgery for a tumor over 10 years ago. This left me with a scar in my scalp which initially was not a problem. As I have gotton older and more hair has fallen out, the scar and some depressions along it has become more noticable. I thnk if the holes were filled in it would nto be so obvious. I was trying to determine if I would be a candidate for using injectable fillers to fill holes and creases left by the surgery. I have attached some pictures for your review.
A: What you have, as you know, are the skull depressions from the craniotomy burr holes from your original surgery. They have sunken in due to lack of full-thickness skull bone support from underneath the scalp. These are quite common from craniotomy surgery. Leveling them out is very straightforward by building up the smoothness of the underlying skull bone. I would not use injectable Kryptonite in these cases because the scalp tissue is quite stuck down into the hole and needs to be released from the burr hole and then built up and leveled with bone cement. This is much easier to do and will create a smoother result by opening up a small portion of the scar directly over the depressions and placing hydroxyapatite bone cement directly into the underlying bone defects. This is a ‘spot’ form of cranioplasty. This is not much more invasive than an injection approach and is more likely to get rid of the scalp depressions with a smooth transition into the normal surrounding bone and scalp.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 24 year-old male seeking help and guidance about my head shape. I have caphocephaly which was untreated from childhood and now as an adult I find the appearance of my head very troubling. I am concerned in particular about the temporal hollowing and frontal bossing of my head shape. Is there something that can be done about this?
A: As you have well described, you have a classic case of mild to moderate scaphocephaly with bicranial narrowing from front to back with a midline ridge. While the bone can not be changed at this point, there is room for substantial cosmetic improvement through cranioplasty techniques. I envision a cranial reshaping procedure in which some of the midline ridge from the forehead is reduced but, more effective, would be augmentation in the parasagittal areas from the forehead to the top of the head. This would produce some greater width or roundness to your forehead and frontal skull. Due to the volume of material needed, I would use PMMA for cost purposes. This would need to be done through a bicoronal incision in the hairline. The temporal narrowing could be partially improved by either extending the cranioplasty into the upper temporal area or placing temporal implants in the subfascial plane.
While you can not completely correct the skull and forehead narrowness, substantial improvement can be done which would be enough to no longer be seen as having scaphocephaly.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a chin implant placed over a year ago that ended up with my chin being asymmetric. I had a Ct scan which showed that the implant was ‘cockeyed’ in position with the left side being much higher than the right. I then had a revision done on it and my surgeon placed a new implant but it still does not look right even though it is only one month after surgery. I am going to get another CT scan but if it shows that it is still not symmetrically placed what should I do now?
A: Chin implant displacement can occur because the implant wings are asymmetrical or the entire chin implant is positioned too high on the chin bone. Asymmetry of the implant wings has become more common today due to the widespread use of newer chin implant designs that have extensions or wings with fine feather edges. While they are of great value in creating a more natural chin appearance, particularly in men, great care must be taken to get symmetric pocket developments that are long enough to accomodate the length of the implant. Too high of an implant position is quite commonly seen with the intraoral approach for insertion. In either case, secondary correction is straightforward with implant repositioning/pocket adjustment with secure fixation of the implant to its new bony position. To do that I prefer the use of screws to assure what I have obtained in surgery forever stays that way. Why chin implant revision was not successful is most likely that a new more symmetric implant pocket was not created and the implant was securely fashioned to the bone.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am 57 years old and am interested in getting breast implants. I have always had small but nice and perky breasts even for my age. But due to a recent divorce, I would feel more confident if my breasts were fuller. Since I have gone through menopause when I was 50, I was wondering if this hormonal change in any way causes long-term problems with having breast implants?
A: There are more ‘older’ women over the age of 50 having breast augmentation than ever before. Of equal relevance is that 50 plus year-old women are having their old implants replaced. They are part of the first group of women who had breast implant placed in the 1980s. They are now at the point where their implants have ruptured or deflated and are in need of replacement. The point being is that lots of women of this age group either have or are getting breast implants. There are no known adverse hormonal effects of a women receiving breast implants. The potential risks and complications of breast augmentation are the same, either before or after menopause.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Is there a limit to what volume of cranial augmentation can be done in a single procedure ? I imagine that the lack of loose skin in that area will restrict the amount of filler material that can be injected, because the skin would have to stretch to accommodate it. Does this mean that the procedure must be staged over several visits ? Or do you employ those subcutaneous balloon dilators to generate excess skin before you start ? Many thanks for your time.
A: You are correct in your assumption that the overlying skin can be a limiting factor in how much cranial augmentation can be achieved. If a significant amount of augmentation is needed, then the use of tissue expanders may be necessary. This is very rare due to the obvious staged nature of the process, but more extreme cases may necessitate it.
Based on my experience, frontal augmentation cranioplasties can take up to 120 grams of material and still get a coronal incision closed. Conversely, an occipital augmentation due to the tighter scalp in the area can only accomodate 30 to 60 grams without compromising incisional closure. While these implant volumes will achieve the results most patients want, there are exceptions where less amounts of augmentation have to be accepted or the use of a first stage tissue expansion must be done.
Dr. Barry Eppley
Indianapolis, Indiana