Your Questions

Q: Dr. Eppley, I have some loose skin around and above my belly button after my tummy tuck which was three years ago.  I never though it was the tightest above my belly button right after surgery but the skin seems to have gotten a little more loose since.  I’d never heard of a reverse tummy tuck before I read about it online and am now curious about how the procedure works and where the scars would be placed?

A: The reverse tummy tuck is a distant cousin to the traditional tummy tuck, not only in location but to how it is performed to some degree. For those women who have loose skin around and above the belly button but not below it or have had a prior tummy tuck with loose residual skin above the belly button (the usual candidate for the procedure), a reverse or superiorly-based tummy tuck is the only skin removal option. A crescent of skin and fat is removed along the lower breast folds and across the sternum. This lifts the tummy above the belly button, just like pulling up with your hands along your rib cage. This places most of the scar along the inframammary breast fold with the exception of a small area that crosses the sternum. Unlike a traditional tummy tuck, no muscle usually needs to be tightened. In some reverset tummy tuck patients, I have only removed skin and fold under the breasts, keeping the scar from crossing the sternum. In the properly selected patient this can be a very good option if one can accept a scar along the lower breast folds. While always called a reverse tummy tuck, it should really be called a tummy tuck lift or superior tummy tuck.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was wondering if I can send pictures for your opinion of a chin pad re-suspension/jaw line augmentation. I have taken some pictures from different angles. I love the fact that you are also a Doctor in dental medicine, and you have a vast understanding of the chin and mandible bones, and have plenty of experience re-suspending the chin muscles to correct the appearance of “witch’s chin”, producing natural looking results as well.  I am 46 years old and a little more heavy by 10-15 pounds so the contrast between my round face and triangle chin is now more evident. My chin and pre-jowl area are looking worse as I age. I’m looking forward for your opinion.

A: I have looked at your chin/jawline issues and there are two different directions to go. The first is to simply resuspend the chin pad back up with submental liposuction. (illustrated in Facial prediction 2) The other approach is to build the chin and jawline out with submental liposuction. (illustrated in Facial Prediction 1) I think you have always had a smaller chin being a small women so your chin pad is more likely to become ptotic with age. It would seem more anatomic to pull the chin pad back up but the stability of keeping it there is suspect when the bone support is not strong. Conversely, the concept of some chin-prejowl augmentation is a more assured result but it does create a bit of a different (new) look for you. So you have to be certain this facial change (slightly stronger chin and jawline) is one you see as better. I personally favor the buildup as it automatically takes care of the chin sagging issue. Either approach incorporates submental liposuction which is a given as an improvement need.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a fairly muscular 20 year old guy and am a junior in college. I starting lifting weights about three years ago and, while my chest has gotten bigger, so has my nipples. I have to admit that I have been taking muscle building supplements until about six months ago. My nipples are puffy and stick out so when I am wearing shirts it looks horrible. I really need a fix for this so that I can go to the beach again and feel comfortable taking my shirt off. Even with muscles having puffy nipples does not make my chest attractive. I am at about 12% body fat now.

A: There is no question that there are certain stimulants that can cause breast tissue development and this is not the first time that I have seen it in bodybuilding young men. It is good that you have stopped taking the supplements even though that will not cause the breast tissue to regress. This will require surgical excision done through a lower areolar incision. Most likely they are lumps of firm breast tissue behind the nipple-areolar complex that is causing it to be pushed out and puffy. After surgery you will need to refrain from weight lifting for about 2 to 3 weeks to prevent the development of a seroma (fluid build-up) in the space where the gynecomastia was removed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I visited a craniofacial surgeon for advice because my right zygoma is lower, depressed and flat while the left one is just perfect (high, round, nice projection, and I want to leave it like that without surgical approach) He than diagnosed me with hemifacial microsomia. I asked him about the option of a custom implant on the right zygoma to make it just as high, round and projected as the left one.  He than said it is a bad idea to use implants for several reasons that sound convincing but proposed to use Beta-tricalcium phosphate granules trough a surgical approach to achieve the symmetry. He said it will act like an implant and also be permanent. He is a very well known surgeon and I do trust him, but I can’t find alot about this approach and that kind of worries me a bit. Are those granules really able to bring the zygoma (not the arch) forward?

A: The use of hydroxyapatite granules (or beta-TCP) in craniomaxillofacial surgery is an older approach for bony augmentation. It has a long history that dates back to the 1980s when hydroxyapatite blocks and granules became commercially available. I used it fairly frequently back then myself as there were no other non-bone material available. While it is a more ‘natural’ material, injecting/placing granules is an imprecise and relatively uncontrolled method of augmentation. For small amounts of augmentation that do not require a precise shape, it may still have a role in some select circumstances. But a ball of granules placed on the bone is easily compressible and displaced and defies being able to be accurately shaped. I have no doubt HA granules will provide you some augmentative benefit but it will not be effective in getting the most accurate and symmetric result to your normal side. It is simply a matter of the limitations of the material’s properties. The use of HA granules today is usually limited to older craniofacial surgeon’s who still have the historic belief that any synthetic material is ‘bad’. As for achieving perfect bone symmetry in the face to an opposite normal side, it is impossible to rival a custom computer-generated implant approach that creates the perfectly-shaped implant down to fractions of a millimeter. Such an implant on the zygoma/zygomatic arch is really conceptually the same as any other synthetic implant used in cosmetic cheek augmentation. I fail to see what makes that approach ‘bad’.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a mentalist strain and my chin is receding, I was told i needed a chin implant. Problem is that i’m not a fan of plastic surgery and I want to be natural. Is it still considered plastic surgery if I need it? Are there other options?

A: A small chin combined with a mentalis muscle strain is ideally treated with a sliding genioplasty. This brings the chin bone forward with the muscle and is a more effective and ‘natural’ (non-implant) solution to your problem.  It is more effective because, rather than just stretching out the strained muscle which is already short, moving the chin bone forward actually lengthens the muscle by the bony movement. (thus eliminating the muscle strain) You may consider that approach a reconstructive solution to your chin concerns rather than a pure cosmetic one if that makes you feel more comfortable.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Will getting the hair transplants have any adverse effect on brow ridge implants?  My surgeon has informed me that he’ll be using sheets of intermediate hardness silicone to build up the brow ridges while carving them to smoothen them out by hand. He will also only use sutures to secure them rather than using screws. Is this something that you do too, and should I insist on him using screws? For reference, the incision will be made via the upper eyelids.

A: My method doing brow bone implants (rather than cement) is quite different. Symmetry of the implants shapes and ideal location on the bone is a challenging issue when more limited access approaches are being done. I prefer to use either preformed brow bone inplants (made out of silicone and using designs from other patients) or have custom ones made off of the patient’s 3-D CT scan. Then I place them through en endoscopic approach and secure them into place with a percuatneous 1.5mm screw technique.

There are no adverse effects of hair transplants on the underlying brow ridge implants.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a few questions regarding occipital cranioplasty. the back of my head is kind of flat and it’s been bothering me since high school. As I get older I notice that it gradually get flatter, to a point where I don’t tie up my hair anymore because I am so self conscious about it. Now that I am 36 years old and am financially capable of fixing this problem, I am contemplating on getting the surgery done.

Below are my questions:

1. If I decide to have the occipital cranioplasty done, will I have to shave all my hair off for the surgery? 

2. Since I will have extra material at the back of my head will it affect the growth of my hair or the health of my scalp?

3. What are the possible side effects of the surgery?

4. Do you have patients who already had the surgery done for solely aesthetic purposes? And are the cases with these patients successful?

5. Where is the best place to have the surgery done? ( country/state/doctor)

Your advise will be much appreciated.

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

1) No hair is ever shaved to perform an occipital cranioplasty.

2) Any placement of material on the skull bone does not affect the growth of the hair or the health of the overlying scalp tissues.

3) While infection is always a concern when any material is placed in the body, that is not a problem I have yet seen in cranioplasty. The most common side effects for any form of cranioplasty are aesthetic is the material smooth, even and symmetric? Was the buildup enough?

4) Most skull augmentations that I perform today are done exclusively for aesthetic purposes. The most common type of aesthetic cranioplasty that I perform is to treat a flat back of the head.

5) I can not speak for who else in the world performs aesthetic cranioplasties, I only know that I do.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, can someone who is overweight have a tummy tuck with liposuction? I’m 36 years old and am 5’4” and 195lbs. I have very bad back pain due to my large stomach. I have not been very successful with any efforts at weight loss and my doctor feels it is due to the medications that I am on. Would a tummy tuck with liposuction help me? I think it would be very beneficial for my back not to mention my self-esteem.

A: The question is not whether you can have a tummy tuck at your weight but whether you should. It would take a physical examination to feel your abdominal area and see how much of the tissue can be removed. In some overweight stomachs the skin is very tight and the yield on a tummy tuck is not as much as one would think. For these patients, weight loss is key so that they create the necessary loose tissue to make the surgical effort most beneficial.  In other patients, particularly those with an abdominal overhang (pannus), the results of a tummy tuck are more significant and even back pain may be improved as the strain from the weight of the overhang is removed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I read about you on some forums and was recommended to contact you regarding this issue. Anyway, based on your website, you seem to be one of the few surgeons who perform brow ridge implant and eyebrow hair transplants. Basically, I’ll be getting my brow ridge implants done next week, but I also have an appointment set up for my eyebrow hair transplants a month later. However, the surgeon doing the brow ridge implants has asked me to wait 6 months between procedures, whereas the hair transplant surgeon has advised me that it shouldn’t be too big of an issue to space them 3-4 weeks apart. Based on your experience, do you think it will be fine for me to get the brow ridge implants done, recover for 3-4 weeks and let majority of the swelling subside, then get the eyebrow transplants? Or, should I wait 6 months? I understand that it’ll take 6 months for swelling to subside fully, but will the small amount of residual swelling at 3-4 weeks post-op present a major risk to the eyebrow hair grafts? I sincerely thank you for taking the time to answer this as you are doing me a huge favor.

A: I see no biologic reason as to why eyebrow hair transplants can not be done a month or so after brow ridge augmentation. The blood supply to the eyebrow tissue is unaffected by the underlying implants, regardless of whether the overlying tissues have fully resolved their swelling and achieved final tissue adaption. In addition, the access incision for the brow bone implants is far away from the eyebrows and has no deleterious effect on their blood supply, even if a revision may be needed and done on them later.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have silicone breast implants which have hardened from lack of sex and age of implants. What can be done to get them replaced and have nice soft breasts again?

A: Many old silicone breast implants originally placed in the 1980s are very firm today due to capsular contracture. There are many reasons why these old implants have this aesthetic pathologic condition, from gel bleed to implant ruptures, but there is no scientific evidence to correlate a lack of sex as one of them. While massage of breast implants was preached as a necessary technique to prevent capsular contracture back then, this is not needed today. The best approach for your implant problem is to have them removed, perform total removal of all surrounding breast scar/capsule (which often shows signs of calcification) and have new breast implants placed under the pectoralis muscle. While the cause of breast implant capsular contracture is still not fully understood even today, what is known is that an under the muscle implant position (submuscular) is much better than on top of the muscle (subfascial) for prevention of it developing.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, For an injectable sternoplasty approach for a minor pectus proble on one side, is it possible to apply the hydroxyapatite granules in layers in order to avoid over correction? Can a mold of my good side be done, using it to fix the deformed side. I am asking all these questions because I wouldn’t want to proceed with the operation knowing it will not result in a positive outcome.

A: Obviously no patient or doctor wants to do a procedure that does not have a good chance of a positive outcome. But the reality is that there is no precise method to figure out how much hydroxyapatite to apply in an inejctable sternoplasty approach. A mold of the size of the defect would be done before surgery to estimate the volume of the material needed. And, at surgery, it is always better to place less material rather than too much as more can always be added later and too much would be problematic to remove. I have found that using these guidelines is very helpful in getting the best outcomes, but the limited approach of a small site injection delivery method always introduces variables that do not exist when operations are done in a more open incisional approach. (which is not an advised option due to the scar in your case)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had an upper blepharoplasty done 6 months ago where too much skin was removed. My eyebrows were pulled down and my eye shape changed! They become widely open and I can’t completely close my eyes when I’m asleep. I have got dry eyes every morning. Can skin graft be performed so that my brows can go back to the normal position? After the skin graft, will my eye shapes change back to original shape? Does skin graft on eyelid look natural? Or very noticeable? How long does it take to heal?

A: The only effective treatment for too much skin removal in a blepharoplasty is skin grafting. Certainly a skin graft will restore 3 to 5mms of extra skin which often is the margin between an aggressive and an overly aggressive upper blepharoplasty. In theory replacing lost upper eyelid skin should restore your brow position. A skin graft will have a slightly patch look as their is no other place on the body where a skin graft can be harvested that has the exacft thickness and perfect color match. But this is more of an issue when the eye is closed than when it is open. Skin grafts heal quickly in the eyelids but it will take a few months for them to settle in and achieve their final aesthetic result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to have PRP treatment on my face. My best friend who is a dermatologist in another country told me that the treatment is wonderful.

A: When patients use the terms “PRP Facial’ or “PRP Treatment of the Face’ that can imply multiple types of facial treatments using PRP. (platelet-rich plasma)  They fundamentally breakdown into either topical or injectable approaches. PRP injections can be done either alone or mixed with fat or filler to create a volumizing effect and are often dubbed as PRP facelifts or  even the marketed Vampire Facelift. When applied as a topical treatment, it is done in conjunction with either fractional laser resurfacing or the dermaroller, both methods which create channels into the skin by which the PRP can be absorbed and exert its effects. You would have to clarify for me whether you are interested in either a topical or an injectable facial treatment.

While the science of whether PRP really provides an immediate or a sustained long-term effect in facial rejuvenation is unknown, having it injected with other agents (fat, injectable fillers) seems the most plausible for having its high levels of growth factor exert a tissue stimulating effect.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Have you ever heard of ANS reduction in conjunction with Maxillary advancement (i.e. jaw surgery). My surgeon is proposing this but has been vague about the aesthetic and functional effects. From what I have read, it makes the nasolabial angle more obtuse. Would this mean removing the ANS results in longer upper lip and turned up nose? He is also advancing the upper jaw 3.5mm and rotating it ccw 3mm. Finally, would removing ANS during surgery preclude me from a future nose job should I need one? Thank you!

A: I not only have heard of ANS reduction with LeFort osteotomies but have done that many times in conjunction with them. The reason ANS reduction may be done in large maxillary advancements is that it may cause the tip of the nose to rotate upward or, at the least, widely open up the nasolabial angle. Removing it would prevent that concern. Whether removing the ANS is necessary in just a 4mm maxillary advancement, however, is different as it may not really be needed if the total bony movement is simple forward. But if there is any upward rotation of the upper jaw it would be needed. I would trust your surgeon in that decision. But whether it is removed or not, it does not preclude or maake difficult any future rhinoplasty efforts.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to have my lower jaw length reduced and a more tapered shape (lean 40 year old male). Is this possible without ending-up with an excess of soft tissue? I believe a big difference could be made with minor over-all length reduction, but especially a tapering of the front at the chin where my jaw is currently just a broad, rounded mass. I would also like to have otoplasty.

A: It would be helpful to see some pictures of your face for a more definitive assessment. But your concern about potential soft tissue excess is always relevant when losing some bony support. Whether that would actually be a real problem depends on three factors; 1) how much bony, 2) the technique used for the bone reduction and 3) whether soft tissue resuspension is employed. (for the chin) But in looking at your pictures,  I believe you are right on the money in regards to what you need. This could be achieved by an intraoral vertical reduction genioplasty (7mms) and lateral chin tubercle ostectomies done concurrently to reduce the vertical height of the chin and make it less square. An otoplasty could be done at the same time. I have attached a predicted image of what I envision the result to be from these procedures. Lastly, I see no concerns about loose skin after this procedure as muscle and soft tissue tightening would be done at the same time as closure of the intraoral incision.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I have a forehead issue that has been bothering me since I was like 14 years old. I know I need more than just one thing done to my forehead but my finances won’t allow me to do everything so I just try to do one step at a time. What do you suggest? I hate taking pics of myself but here are some for your review.

A: Thank you for sending your pictures. I am assuming that you are referring to/bothered by the deep horizontal crease that goes across your forehead. I doubt that forehead crease is caused by an underlying bone issue but rather is an indentation into the soft tissues over the bone. The one and only thing you can do is to have the crease released and injected with your fat. How well the fat  injections would survive and how much improvement would be obtained is uncertain but this is the safest and most natural approach to a facial skin indentation problem. You will never be able to eliminate it but fat injection will be able to reduced the depth of it. Given that a line is never going to be able to be completely eliminated, another possible approach is to excise (cut out) the groove and close it so that it is at least smoother and not indented.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was looking through your cases and saw some where the ANS was reduced. Does this cause the nose to “droop”, either immediately or long-term, due to losing bony support? If it doesn’t, can you explain why not?

A: Your question is not as simple as mere anterior nasal spine (ANS) reduction. That specific procedure is always done as part of an overall rhinoplasty so the effects on the nasal tip are also influenced by what else is being done. Otherwise, the tip is primarily supported by the septum (tentpole effect) and the suspension of the lower alar cartilages. The influence of the removal of a small spicule of bone (maxillary spine), in and out of itself, is not that signficant if at all on the nasal tip if done in isolation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 52 year-old male and am concerned after some weight loss that my lower abdomen is still fatty, and my pubis area is sagging. This is not exactly the look I want, what can I do? I have attached some pictures for your assessment from the front and the side.

A: Thank you for sending your pictures. What I see is mainly a pubic sag issue, not so much go an abdomen overhang. While there is some fat in the pubic area, an equal contributor to the problem is loose skin. Your options for improvement are either liposuction alone or liposuction combined with a pubic lift. A pubic lift, in essence, is really an inverted or reverse mini-abdominoplasty.  It lifts the skin from above along the waistline.

There is also some abdominal fat, but no real excess skin that I can see. Thus liposuction of the abdominal area could be performed at the same time.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a cosmetic issue with one side of my chest. My right pectoral bone/cartilage formation is good but my left inner pec seems to be either missing the inner bone or it may be indented like a minor pectus excavatum. What are my options for fixing this cosmetuc chest issue. I have attached a picture so you can see the area I am referring to.

A: Thank you for sending your picture. I do think it is a very minor manifestation of a pectus excavatum. I think given its very minor cosmetic issue and its location, I would only an  injectable sternoplasty technique. One option is fat injections which can be precisely placed and are not a foreign material. While its volumetric survival can not be assured and there certainly is a question of whether you have any fat to donate at all, but that would be my first choice. (although lack of a donor site may make it not an option) The other reasonable option would be injecting hydroxyapatite (HA) granules onto the sternum. These granules can be mixed with PRP (platelet-rich plasma) to form an injectable gel that can be molded once placed into the defect area.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was wondering if you could answer a quick question for me: Is there a way to perform a sliding genioplasty without having to cut the mentalis muscles? Is it possible to use an extraoral incision under the chin (if the patient didn’t care about small scars) to reduce damage to the underlying muscles of the lips? I am tired of hiding my face but I don’t think I’m brave enough to risk damaging the nerves or musculature of my lower face. How risky is this procedure?

A: Whether you go from inside the mouth or from below the chin, the mentalis muscle has to be cut. Even in a chin implant the muscle has to be cut. In skilled hands, a sliding genioplasty is a very safe and effective procedure with no long-term muscle or lip issues. The key is not whether the muscle is cut but if the surgeon knows how to put it back together.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Is there a wait time needed for healing after the original scar has developed? I had an accident this past February where I injured my forehead. The ER doctor said that it was hard to pull the wound together because I had skin lost and the wound might need to be reopened and restitched. Well I had the stitches removed and it left a scar that is about 2.5cm long and at its widest less than .5 cm wide. Please let me know if there needs to be a certain amount of time before scheduling an appointment. I look forward to your response.

A: My approach to scar revision may differ from the historic approach of waiting one year or more before having a revisional procedure. Waiting on scar maturation is advised when the problem that is making the scar visible will improve with time. If the scar is narrow, has a relatively even surface contour and is red in color, then time will help the scar’s color to fade. (although even that problem is treated earlier today with BBL therapy) But if the scar is wide, indented or raised (color aside), time will not improve those scar characteristics. This scar revision may be undertaken as early as 3 months after the injury when much the inflammation from primary healing has subsided.

Please send me a picture of your forehead scar for my assessment.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a large chin implant placed three months ago.  It looks OK but it has pulled my lower lip in to my mouth and I have no projection of my lower lip.  The implant was not screwed in and is rising up and the bottom of the implant is not parallel with the bottom of the chin. When I have my mouth closed and lift my lower lip up higher into my upper lip it feels like muscle is wrapping around the implant and causing a very tight feeling.  Will I aways be able to feel the implant?  If so that is ok. but I would like for someone to at least be honest with me.  If you do not know, that is ok.  Just say so.  I have only been able to talk to people that have had it as long as me or people who have removed the implant because they still felt it.  Would sliding genioplasy solve that?

A: When I hear chin implant experiences like yours, it usually indicates that an intraoral placement route was done and either the implant was initially placed low enough but has slide upward (silicone) or was never quite placed low enough. (Medpor) Everything you are describing indicates that the implant is riding up too high in the chin. In conjunction with an intraoral route of placement (if that was done), the mentalis muscle may be partially disinserted or scarred down creating an inversion of the lower lip. With good implant placement and size selection, all edges of the implant should blend fairly smoothly into the surrounding bone. Until I have some more information about your chin implant surgery (route of insertion, size and type of implant) I can not yet answer the question as to whether improvement will come from implant repositioning/muscle repair or removal and replacement with a sliding genioplasty.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I  had an appt with you to talk about  a limited facelift and upper lip laser resurfacing and a bilateral lower blepharoplastics. I am having these items done to look younger for myself esteem and for my son’s wedding in November. I hope that telling you that  bit helps you remember me. I know you are a very busy man. I have a few questions about the upper lip laser resurfacing. Will this be like scar tissue that stays red or white color for life or will my natural face color come back? Also how long will this take to heal? Scale of 1 -10 pain wise ? I am a huge baby when it comes to pain. We mentioned my crows feet and my forehead with like three vertical lines.  I wanted gone do they need be resurfaced too if you do these other procedures how much extra would it be?

A: I remember you just like it was yesterday. When it comes to laser resurfacing, the skin is NOT turned to scar or does it remain red forever. There is definitely a ‘pink’ phase of the skin once it heals after the first week but that generally is gone by 4 to 6 weeks later. This would be particularly true in the white Caucasian (Fitzpatrick Type 1) skin that you have.

Most facial procedures, surprisingly, don’t have a lot of pain. Think back to your original lower blepharoplasty procedure years ago and, it may have looked bad, but it was not particularly painful.

As for your crow’s feet and vertical forehead lines, those are best treated by Botox injections. The most economical way to have that done is to have my nurse Lora do it. She is trained by me and provides those injectable treatments at 1/3 less cost than if I did them.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I just want breast augmentation with implants and don’t want a lift. But based on my pictures do you think I need an uplift. My sternal notch to nipple distance measures 24 cms on each side. I had one plastic suregry consultation and was told I need a lift with breast implant. I would prefer them filled out and was hoping the use of an implant would lift them up. I have lost weight and breastfed so I have lost the fullness they once had.

A: Your pictures show an undeniable need for a combined breast lift and augmentation surgery. Implants only provide some degree of a lift if the nipples are initially at or above the lower breast crease. (inframammary fold) If not, the nipples will only be driven lower as the breast volume get bigger. Having a breast lift is really about accepting the scars as a trade-off for the improvement in breast shape. This is easier for some than others but is the defining decision about whether to do anything at all. There is another option, often called the ‘minimal’ or  ‘crescent breast lift. It is not really a breast lift at all but does lift the nipple a bit by removing a small crescent of skin at the upper nipple skin edge. For those women that have a minor amount of sagging, nipple lifts with implant placement must just be enough to get them an acceptable result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a woman that has a very square chin with a cleft in the middle. What can I do to make my chin more feminine looking?

A: A bony chin reshaping procedure is needed to both narrow the chin and eliminate the vertical cleft. This is done by filling in the cleft of the bone in the middle of the chin, repairing the overlying split muscle and shaving down the lateral tubercles (sides) of the chin. This would give your chin a more narrow shape without losing projection and get rid of the vertical cleft as well. This is a procedure that is done from the inside of the mouth, although it could be done from a external submental approach as well. Feminizing the chin is a common procedure in facial feminization surgery but is also occasionally requested by a woman who simply has too strong of a chin as well.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested to know what can be done for my very short chin. I don’t know if I just need an implant or whether the jaw bone has to be moved. If you can answer a few questions for me I would appreciate it very much. 1) What is the biggest chin implant in terms of maximal horizontal projection? 2) How much can a sliding genioplasty move the chin forward? 3) Can sliding genioplasty be combined with an implant? 4) Can the entire lower jaw be moved without changing my bite? 5) How do you correct chin deficiencies larger than 10 mm? 6) How do you correct vertical deficiencies? 7) Does the implant feel natural and is there any risk of shifting after surgery?

A:  The person with a very short chin poses challenges that often neither a standard chin implant or a sliding genioplasty can ideally solve. In answer to your questions:

1) The maximum horizontal projection for most chin implants is 12 mms.

2) How much a sliding genioplasty can advance the chin depends on the thickness of the mandibular symphyseal bone. That could translate into a 10 to 12mm chin point forward movement.

3) Yes. An implant can be overlaid in front of a sliding genioplasty to gain more horizontal projection or width.

4) No. The mandibular body and ramus can not be changed without carrying the attached teeth with it also, thus changing the occlusal relationship to the upper teeth. By definition, jaw advancement surgery changes the bite.

5) Options include a custom designed chin implant or a sliding genioplasty with an implant placed in front of it.

6) Vertical chin deficiences require a custom implant and are a component of every horizontal chin deficiency greater than 10mms. When the chin is that short it indicates there is an overall jaw shortness.

7) The implant will feel like bone and is screwed into place to prevent the postoperative risk of shifting.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m trying to achieve a more aethetically appealing face, by whatever means necessary. I’ve noticed my forehead protrudes in respect the level my eyes are at, making them look sunken and my face more masculine. I don’t believe it’s my bossing that sticks out, just my forehead in general, so i’m not sure how much of a result I would see with surgery. I’ve been told my nose is large, so I’m considering rhinoplasty as well. Additionally, my lips appear to almost “hang off” my face. I know this isn’t your forte but do you believe jaw surgery could be a solution? In general, I was just wondering what procedures you would recommend. Thank you for your time and I look forward to hearing from you!

A: Thank you for sending your pictures. I have done some imaging predictions based on the one side profile that you sent. What I have done is a forehead reduction, rhinoplasty and chin augmentation . If you look carefully at those changes, the most dramatic effects come from the rhinoplasty and chin augmentation. The rhinoplasty is key because your forehead and brows look so pronounced because you have a very deep radix. (root of the nose). One of the key manuevers in your rhinoplasty is the buildup of the root of the nose. By doing so that makes the forehead less retrusive in appearance alone.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I had an otoplasty done just over one year ago. One ear is pinned back too far and the other doesn’t look or feel right; it twitches and is painful sometimes as though a stitch is holding it in place and is being pulled. I was reading comments on your website about grafts and I wanted to know how the procedure works and how much I should plan on spending. Thank you for any information. 

A: Otoplasty surgery can be associated with several unfavorable outcomes. Two of such problems are the over done otoplasty ear and the painful oitoplasty ear. When the antihelical fold is over created, this means that the bend in the cartilage has been too exaggerated. This can not be simply improved in most cases by merely releasing the scar tissue between the two cartilage sides on the back of the ear. The cartilage has likely lost its original memory (exceeded the limits of elastoc deformation of the cartilage) and will not just spring back out after one year of healing. Instead the cartilage fold must be expanded and maintained by an interpositional cartilage graft, acting as an ‘internal spring’ so to speak. This small cartilage sping graft can usually be havested from the same ear from the backside of the conchal bowl. In the painful otoplasty ear, even if the result is good, the discomfort likely comes from one of two sources. A concha-mastoid suture may have been used to help with repositioning and, in stiff or thick ear cartilage, this may cause persistent pain or the perception of spasm. This suture can be released at this point. The other pain problem that I have seen is that stiff ear cartilages may be bettered weakened and repositioned by cartilage scoring or wedege resection rather than just using sutures to overcome their shape.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I previously had cheek and jawline reductions to create a slimming/narrowing effect to my face. Unfortunately the surgery has had adverse consequences and has overly feminized my face.  I no longer have a square jawline and I find that the height is much too high at the rear portion of the jaw creating a very slim and weak jawline.  The angle at which the jaw was cut is too straight which portrays a more unnatural look that seems to elongate my face. Custom CT scanned jaw implants seem like the logical response to the amputation of the bone.  My questions in regards to this matter are related to muscle and tissue reattachment as well as unforeseen complications.  Would detachment of mandible muscle and skin tissue create any issues?  I am constantly concerned with sagging skin after performing my initial surgery.  Where would the jaw implant gain the needed skin envelope?  Does the skin tissue come solely from the neck or would it also pull and realign from my lower cheeks? As for my cheeks, there are multiple irregularities in regards to my mid-face after the cheekbone reduction. I am most curious as to what procedures could correct these irregularities.  As my initial surgery was to primarily address the width of my cheekbones, I would not like to add much more.  Could I address the problems without adding more width?

A: I have had the experience of seeing numerousI have see men with the exact situation that you have. It is corrected by computer designed jaw angle implants that restores height but virtually no width. It is a unique-shaped jaw angle implant. It gets its soft tissue coverage by recruiting tissues from the face rather than pulling them up from the neck. Like the jaw angle implants, any cheek implant restoration is done using a 3D CT scan where any implant fabrications are done on the computer and can be perfectly corrected for any asymmetries as well as limiting any significant amount of width.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 47 years old with multiple lipoma on both the hands, back, stomach, and thighs with more than 100 lumps. Even my brother has it. Recently I underwent  Vaser lipo for lipoma treatment on both the arms. I know it may reoccur but for the time being I am happy with the results. Still I have many lipomas on my back, thighs etc.

My question is there any research being done for non invasive treatments. What is best for multiple lipoma treatment as on today? What can we expect in near future ?

A: In the treatment of solitary or, more pertinently, multiple lipomas in familial lipomatosis as you have, I know of no ongoing research that is looking at how to best treat them. Current treatment options include open excision, laser lipo probe ablation, various liposuction options and lipodissolve injections. All of these methods have variable effectiveness and, other then open excision, the effectiveness of one over the other is unproven.

Dr. Barry Eppley

Indianapolis, Indiana