Your Questions

Q: Dr. Eppley, my Asian wife and I found your article entitled ‘Asian Breast Augmentation’ very informative and helpful.  Obviously choosing the right implant size depends on many factors that are unique to each woman. But we were both curious to know what implant propfile you used in that particular case as we both thought the results were excellent and very natural looking.

A:  Thank you for your kind comments. Choosing the correct implant size and profile to get any woman’s desired breast look is as much art as it is science. There is no precise scientific or measurement method that can assure any patient as to how it will look afterwards. But there are some general guidelines. The first is to choose an implant’s size  in which the base width of the implant does not exceed the woman’s natural breast base width. Many Asian women tend to be smaller in size with more narrow breast widths. This is very compatible with the general smaller breast size enlargements that most Asian women desire. Breast implant sizes of 300cc to 350cc are very common in this patient population. Smaller perkier breasts are a desired look and for this reason I will almost always a high profile implant, keeping the implant’s width more narrow with greater upper pole fullness. Incision location is also an important consideration due to potential hyperpigmentation from scars. Therefore, I use a transaxillary approach for saline implants and a small (3.5cm) inframmary fold incision aided by the use of a Funnel insertion device for silicone gel implants.   

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a  circumferential body lift performed in late 2008 during which my navel was also removed. Approximately a year later I noticed a sharp protrusion from my navel. I at first thought it was a bit of suture too close to the surface of the skin to snip off. About the middle of 2011 I noticed that there were small blood clots around the area. It progressed until I needed to clean the area daily, during which smears of blood were found. Approximately 3 days ago what appeared to be a knotted loop of green dental floss protruded from my navel. I made an appointment with the plastic surgeon, and the nurse told me that this was an extrusion. She said this was highly unusual this far after the original surgery date, but the doctor would look at it. I notice no pain, but the site is still numb. Is this unusual or dangerous? Each day more of the suture comes out, and now there is about 3-4″ clearly visible. I am concerned about what can be done and how much of this material is yet to protrude. Please advise as I am concerned about the consequences.

A: What you undoubtably have is extrusion of some of the abdominal fascial plication suture used for rectus muscle tightening in your tummy tuck. The knots often are around the navel area. Because the suture is permanent (non-resorbable) there is always the risk of lifelong issues with the embedded suture. (although they are uncommon) The fact that it appeared years later after surgery is not unusual and it just as easily could have occurred ten years later as opposed to three. It is a foreign body reaction that has appeared due to its close proximity to the skin and scar around the navel area. The suture merely needs to be cut back to where it lies deep under the tissues again. This may require opening up a small area of the incision to permit it to be ‘chased’ and removed until it is far from the incision line.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a question concerning my “puppet” lines around my mouth  that get infected often.  Are some type of injections a reasonable answer to this problem?   Thank you.

A: What you refer to as puppet lines are technically known as marionette lines. That is the groove area that develops as the face and jowls fall forward with aging against the fixed skin of the chin. They extend downward from the corner of the mouth to the jaw line. There are multiple treatment options for marionette lines, depending upon how severe they are. For mild to moderate depth marionette lines, injectable fillers may be a reasonable option albeit a temporary one. For moderate to deeper marionette lines, injectable fillers are not very effective at effacing them. Options include a jowl lift (mini-facelift) which really treats the cause of the problem or direct excision of them which may be a reasonable option in the older patient who does not want to undergo any form of a jowl lift. I would need to see a picture of your mouth or face to give you a more definitive answer.

You can always try injectable fillers first as they are easy to do in a few minutes in the office setting. An injectable treatment will prove, one way or the other, if it is effective. Whether that is ‘reasonable’ ultimately comes down to an issue of cost. Is the depth of the marionette lines worth that gamble? That is where seeing a picture of it will help.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a severe skull shape problem that has been with me all my life. My skull is weirdly shaped like an alien. I am tired of being made fun of because of my head shape. I have seen a few doctors by they all say that nothing can be done and I should just live with it. I know you are an expert in this area so I thought I would ask you as no one else seems able to help. Attached are some pictures from different angles.

A: Thank you for sending your pictures. The shape of your skull appears to be the result of a congenital sagittal craniosynostosis condition that has been undiagnosed and untreated. This explains the very long, higher and narrow head shape that you have. Unlike the surgery done as an infant for this condition (take the bone apart, some of it completely off and put it back reshaped), that approach can not be done as an adult. The best that can be done now is to reshape the skull somewhat from manipulations on the outside. This would entail some reduction of the prominent midline ridge and some reduction contouring of the forehead. The sides would then be built up to make it wider. This type of cranioplasty requires being done through an open scalp incision for access to all of the skull areas. This would provide some definite improvement although it can never be an ideal or perfectly normal shaped skull.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m interested in essentially reducing my mandible to a more “V” shape, and the only place I could find that does this procedure is in Thailand (which, is alright, I have the resources to get there. But I’d feel more comfortable with surgery in America). I wanted to know if you knew anything about this surgery and if it would be possible for you to do? My second question would be how far you can go with a chin reduction. I have a really prominent chin and it’s completely destroyed my self-confidence, it’s hard not to be when you’re called Jay Leno as a young teenager and being told you have look like a man. I’d love to get a more feminine, small chin that is in proportion with the rest of my features. I do have example pictures of chins I love and I have to wonder if it’s even possible for me to get that type.

A: These are procedures that I do all the time so I am quite familiar with what can be done and can’t be done with them. You can not achieve your desired chin reduction based on where you are right now. You may be able to get about halfway there between what you have now and those images. The fundamental problem is the soft tissue excess, that is the major limited factor. I can reduce the bone all I want but the overlying soft tissues have to adapt to it to be seen. Too much reduction and the soft tissues will just hang or sag, a worse problem than where you are now. There are two fundamental approaches, intraoral osteotomy reduction with muscle tightening or submental extraoral ostectomies with a soft tissue tuck-up. Each has their own advantages and disadvantages. I would recommend a phone or Skype consultation to discuss further.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want to have a normal shaped-head. I have neurosurgery two years ago and the bone flap had to be taken out and frozen due to brain swelling afterwards. It was put back in at a second operation but as it healed it became very uneven. I have dents and visible screwheads throughout my entire forehead. One of the screws also became loose and had to be removed later. Also my forehead is so narrow and looks like an alien. I just want to look close to what I used to before the accident, a more normal shape head with noindents and bumps sticking out. You can see in my forehead photos how unusual my forehead looks.

A: The re-implantation of skull bone flaps, while necessary, is often fraught with bony resorption and irregularities. In addition, the metal hardware used to place it often become visible or loose as you have experienced. The good news is that vast improvement can be obtained by an onlay cranioplasty. Using your original scalp incision, the bone can be re-exposed, all existing metal hardware removed and the entire forehead and skull area covered and built up in a smooth and symmetrical fashion using any of the several available cranioplasty materials. This is a highly successful procedure that is not associated with any of your prior problems with bone flap replacement surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a recent consultation with another plastic surgeon and that surgeon believes I only need augmentation, no lift necessary. I am somewhat asymmetrical so I need about 50cc more on the right side. I want silicone implants placed under the muscle. I am a paramedic so I have recovery time concerns, but think I will have no problem recovering since I am very fit. The size I had looked at were around 420cc/480cc, but think I might go just a little bit smaller. I am basically a B-cup on the right and a C-cup on the left, but lost size and volume after breast-feeding three children. Fortunately, my nipples are in a good position still and I am not too droopy, just lost my size and fullness. I am 34 years old and weight 145 lbs, but I am an extremely fit size 6. Thanks.

A: The key factor in determining the need for a breast lift is where the nipples are positioned. If they are above the lower breast fold still, then an implant alone will suffice and no lift will be needed. With asymmetrical breast sizes before surgery, placing different implant volumes is common. But be aware that this may improve the asymmetry but it is unlikely they will be perfectly matched after surgery since they are other tissue factors that affect breast size other than just breast tissue volume. (e.g., skin envelope) Most breasts are asymmetric for multiple reasons and a breast implant only addresses one of them.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Here you will find attached some crude pictures of myself on the webcam. They are not the highest resolution but it might give you a first impression. I personally think that the overall look of my eyes and eyebrows is a bit sad or tired. I thought of rim implants to push forward and fill a bit the depression  and also maybe reduce the scleral show? Not really sure if  its possible or if I will go for a tilt of my eyelids as I think that a simple narrowing will do. I was also curious about what a jaw angle implant could do for me even though some how I’m not so concerned about it overall. Please feel free to comment. For me this is more of a structural improvement rather than an anti aging procedure I am seeking as look younger than my actual age. Any procedure that you think could be beneficial to make me look more handsome without obvious work being done is welcome. Thank you for your advice and time.

A: Thank you for sending the detailed pictures. It shows that you have a recessive infraorbital rim-malar region which you already know. This is why you have undereye hollowing and weak lower eyelid support with some mild scleral show. Orbital rim implants do add volume in this area and can provide a bit of an upward push to improve lower eyelid support and position. This may provide a bit of decreased scleral show in which  a lateral canthal tightening or adjustment is a good combination with them.

While jaw angle implants can provide some significant lower facial changes, you do not consider them on a casual basis. They are the most difficult of all facial implants to undergo and recover from so you have to be really motivated to undergo their placement. Since you are not concerned about the jaw angle at all, this is not a procedure to consider for you.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had silicone placed in my upper lip and now I want it reduced a little. Is this possible? I have attached a picture of my lips.

A: Thank you for sending your pictures. I am assuming that your are referring to silicone oil droplets for your lip augmentation as opposed to silicone formed cylinder implants. Silicone oil droplets can not be easily removed from the lip tissues (without a lot of tissue destruction) because they are spread out in many small droplets through the lip tissues. This is the same whether it is in the lips or anywhere else in the body. Depending upon the lip problem (size vs lumps or granulomas), the treatment would be different. Lip size concerns is best dealt with by a lip reduction procedure based on some vermilion excision at the wet-dry line. Lumps or granulomas have to be treated by individual excision or drainage based on where they are located. I am assuming that your lip concerns are that of size.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, approximately six weeks ago I had a medium chin implant and super petite malar implants placed by anoral surgeon. All of the implants were Medpor material. In my initial consultation the doctor told me that such implants were completely reversible if I did not like them, or if something happened to the implant. In addition, he told me that they were of a silicone type material. Two weeks after surgery when I was expressing that I didn’t think I like the chin implant he told me that it was Medpor of which my understanding is it is more difficult to remove. Now I am six weeks after surgery, and while I think the chin implant has improved slightly, I still do not think I will end up with the result I wanted. I think the chin is too big. The doctor keeps telling me it looks great do not worry about it. I went to see another surgeon, (a facial plastic surgeon) he said that he believes that he can take out the chin implant and has done a few before. He said he is unsure if the chin will assume its original appearance and that the risk of permanent nerve damage to the chin for removal is quite substantial. The original implant was placed via a submental incision and I had loss of sensation for a month or so the first time. In your experience how often is the nerve damage permanent after removing this type of implant? Should I learn to live with the chin implant that is making me self-conscious?

A: Three comments based on my experience with a wide variety of chin implants:

1) You need to wait a full three months after any type of facial implant to get an accurate assessment of the final shape. It takes that long for all tissues to settle.

2) Medpor implants can be removed fairly easily in my experience. The risk of nerve damage is not much greater with its removal than with its placement in most cases. But it depends on the size of the implant and how long it has been in place.

3) Whether the chin will resume its normal shape depends on the size of the implant placed and how much the tissue has been stretched. If in doubt at its removal, the expanded soft tissue should be tucked and tightened to avoid any soft tissue ptosis.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I wanted to have a well defined face shape, so I am thinking of doing buccal fat removal but at the same time I want high cheek bones. Is it possible for me to do buccal fat removal and at the same time still put Juvederm fillers in right under my eyes? Does that make sense?

A: That does make sense with the exception of it is unclear how that will give you high cheek bones. Buccal fat reduction provides some submalar ccontouring which helps in some small amount of facial thinning in that area but will not, by itself, give you high cheek bones. The Juvederm filler will help with tear trough filling but also will give not give you any cheek bone augmentation effect. Those two procedures make sense for what they are intended to improve but neither one will create the illusion of high cheek bones. For that result, you should consider a small cheek implant which can be placed through the same incision as tha of buccal fat removal. That combination will create a more shapely cheek look.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a question regarding revising a sliding genioplasty. About a year ago, I had a sliding genioplasty that moved my chin forward by 8mm. The recovery has been uneventful, and all numbness and swelling is gone. One problem, however, is that my upper chin/below my lower lip feels pretty tight. It takes a bit of effort to close my mouth completely and sometimes bothers my speech.  Is there any way to fix that?

A: What you have is tightness of the mentalis muscle and shortening of the anterior mandibular vestibule. Because a sliding genioplasty is done through an intraoral approach and must take down the superior mentalis muscle attachments, the combination of stretching them (from the advancement) and scarring will cause the muscles to be short or adhered. This can likely be improved through a mentalis muscle release and resuspension with a V-Y mucosal inner lip advancement. I have seen this problem numerous times and successful improved it through this soft tissue repositioning approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am writing because I am concerned about my mother having a facelift. She is 57 years old and I am her 24 year-old daughter. I know lots of people have facelifts but that is them and this is my mother. I am concerned about its safety and I don’t want anything to happen to her. Like me, my brother and sister don’t understand why she wants this surgery. She is a beautiful women who may be aging but still looks good to us. My father just shakes his head but is going along with it. What can I say to talk her out of it?

A: While I obviously don’t know your mother or you, I can share some general comments about ‘older’ people having plastic surgery. Children’s concerns about their parents undergoing some form of face or body rejuvenation is actually very common. Many parents have told me that their children don’t understand or approve of them having elective surgery over something they view as unnecessary. While there may be some understandable medical concerns, most of the apprehension comes from what I often say…’when you don’t have the problem, you don’t see the need’. When one is young and invincible, it is hard to imagine that one day aging and body changes will come knocking. When you develop that sagging neck and jowls or those love handles and stomach that won’t go away no matter what you do, you may have a different perspective on the merits of plastic surgery. I would respect your mother’s desire to look and feel good again for herself. A good self-image knows no age limits. Facelift surgery is very safe and most patients look remarkably recovered in just a few weeks. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 28 year-old woman who doesn’t like the shape of her breasts. They are very saggy and not even. One is smaller and hangs lower than the other. In addition, my areolas are huge and way out of proportion to the size of my breasts. I am young and these breasts like old lady breasts. I have attached pictures for you to see. What type of breast reshaping procedure do I need and will there be scars?

A: Thank you for sending your pictures and expressing your interest in breast reshaping/rejuvenation. Breasts like yours pose real challenges in getting uplifted fuller symmetric breasts while minimzing scars. There are two fundamental approaches that can be done. The first would be a periaroelar mastopexy (breast lift) with implants. This approach would make the breasts larger and would have have scars limited to around the smaller areolas. Its downside is that only a minimal lift and an improvement in symmetry would be achieved, so you would have larger breasts that still hang. The second approach would be vertical breast lifts combined with implants. This would be infinitely more effective an uplifting your breasts, improving their symmetry, making the areolas smaller, and providing improved fullness. The one downside is that there would be scars around the smaller areola and then vertically down to the lower breast fold. (and perhaps some scar along the breast fold crease as well)

As you can see, neither approach is perfect and one has to accept either low hanging breasts with minimal scar or uplifted fuller breasts with more scar.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 26 year-old Middle Eastern male and I want to change the shape of my face. I think the problem is my lower jaw. My bite is good but my chin seems to be short. I have a very long and thin face with a real narrow nose. If my jaw is bigger in some way I think my face would look less long. I have attached some pictures so you can tell what you think I need.

A: Thank you for sending your photos. I can see your concern about jaw enhancement. You have a very long and thin face with a slightly retrusive chin. Enhancing your jawline will help make your face look not so long. There are three highlight areas of the jaw to change, the chin and the two jaw angles. Bringng your chin forward is needed but it is also important to not have it become more narrow as its horizontal prominence increases. That will only continue to make your face look long and narrow. The chin shape should get wider or more square as it comes forward to help increase lower facial width. That will counteract the current longer face width. Jaw angle width needs to be increased but the jaw angles should not be made vertically longer. Again, the importance of increasing lower facial width.

To achieve these objectives, I have done some imaging (attached) showing a square chin implant and width expanding  jaw angle implants.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have read and is interested in your procedures concerning temporal implants, I have  read that if placed on top the fascia the temporal branch that moves the forehead can be damaged, now I know there is also another nerve in that area which controls the upper eyelid muscles, so can this nerve also be injured if the implant is placed on top the deep fascia?

A: You are correct in assuming that the frontal branch of the facial nerve has the potential to be injured with placement of an implant on top of the deep temporal fascia. This small singular nerve branch is known to course through the tissue layer just above the deep temporalis fascia. While that tissue is easily raised off of the deep temporalis fascia, it can still be potentially injured during this dissection or even from the pressure of an implant beneath it. With frontal branch nerve injury, movement of the forehead (frontalis muscle) will be affected. If this nerve should be injured, recovery may or may not occur as this nerve branch has no cross-innervation from other nerve branches. For this reason, I generally place temporal implants deep to the fascia. But in some cases to get the desired aesthetic result, the implant must be placed on top of the deep fascia. and the potential risk of nerve injury must be accepted.

Frontal branch nerve injury, as might occur with a temporal implant placed above the deep temporal fascia,  does not usually affect the eyelids. Sensory innervation of the eyelids is through terminal branches of the ophthalmic nerve (cranial nerve 1) and maxillary divisions of the trigeminal nerve. (cranial nerve 5) The levator palpebra superioris (upper eyelid levator nuscle) is innervated by the superior branch of the oculomotor nerve. (cranial nerve 3) This is why when one looks upward, the eyelid moves upward as well.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have been using Botox for 10 years now and I have found that this last year it is lasting half the time it used to. I do my entire forehead and around the eyes. My esthetician suggested using a different product but same limited result occurred. Is there anything permanant that can paralyze the muscles in those areas? I forgot to mention I have used the same nurse in a board certified plastic surgeons office the entire 10 years so I know she knows what she is doing.

A: While uncommon, there is definite resistance to the effects of Botox over time that has been described by numerous anectodal experiences. It does not seem to occur in the vast majority of patients but I suspect we will see more of it in the next ten years as the number of people who have received it over a long time is increasing. The mechanism of resistance is not yet known. Once it occurs, there is no known reversal or alternative treatment other than trying the other approved botulinum toxins that are available which have slightly different molecular structures. (Dysport, Xeomin) There is no method of permanently paralyzing facial muscles, injectable or otherwise.

 
Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I had submalar implants (Binder silicone submalar implants) done one year ago, large size. I could not smile fully, corners of my upper lip did not go high enough, so I had them removed 3 months ago. Now, everything is fine with my smile, and I would like to have submalar implants again, may be smaller size.I would like to ask few questions: Is it common that patients which use submalar implants have difficulties with smiling or that smile looks different that before? Can it be due to too large size used in my case or…?

A:  While this is not a problem that I have ever seen from submalar implants, it is theoretically possible. Unlike malar implants, a significant portion of the submalar implant hangs down off of the bone. Given that the levator anguli oris muscle runs from the corner of the mouth up to the cheek bone and its contraction is responsible for lip elevation, it is easy to see how a large submalar implant could interfere with its action. It is either that or the sheer size of the implant simply interfered with mass tissue movement. (more likely) Either way, your experience demonstrates that it happened as proven by a return to a normal smile with their removal. While I have no idea what size submalar implant you had or exactly where on the bone it was placed, I suspect that a smaller size implant would be less likely for this problem to recur.

 
Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in having botox injections in my armpits to prevent sweating.  I have had sweating issues for years and have tried perscription deodorants and pills but haven’t had any luck.  I have Anthem insurance and wonder if this would be covered.  What would I need to do to get my insurance company to approve this?  What is the cost of the procedure?  Thanks!

A: Botox can be remarkably effective at significant sweating reduction for up to one year after an injection treatment. Typically, I like to start at a dose of about 35 units per armpit (70 units total) and see the response. More units is obviously better but we want to find the minimum effective dose to keep the cost down. At this dose range, the cost of a single treatment is around $950. I can not answer the insurance coverage question as we do not process insurance for these treatments. Some physicians may provide such treatments through insurance but insurance reimbursement , even if approved, is slow and does not usually even cover the cost of the Botox to the physician.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was reviewing your Patriotic Program for plastic surgery. Honestly, I never in my wildest dreams thought I could receive a military discount for cosmetic surgery. I’m interested in having a consultation for an Tummy Tuck and liposuction around my knees. I have been waiting for close to 10 years to do this surgery. I think now is the time. My husband of almost 20 years  is now serving in Afghanistan.
He should be home in the next two months. That being mentioned, I would like to be healed buy the time he comes home and look fantastic or at least as good as it gets. My husband has been telling me to go ahead and do it but I never do. I always find other ways to spend the money. I know I will feel so much better when my clothes fit nice and I don’t have to wear spanks…especially in a formal gown. Yep, I know I have at least 4 more formals to attend before retirement because of my four children. Thank you so much for taking your professional time to support our troops and their families using your gift.

A: Tummy tuck surgery can make a dramatic difference in your body shape and how you fit in clothes. Since you are done having children the results of a tummy tuck can last a lifetime and is one investment that cap pay dividends for decades.

We have offered military discounts for years for a wide variety of cosmetic surgery procedures. We are happy to do so and  try to make a small contribution to those that serve or have served to protect the freedoms for what we have the opportunity
to choose to do every day.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I had an otoplasty for protruding ears one year ago. From the beginning my left ear has not been symmetrical to my right ear. The top part sticks out a little bit more and it bothers me. I want to have revisional surgery for it. I am assuming that a revision otoplasty is simpler with less recovery than the first one? Also, how likely is it that the ears will end up the same? It would seem like it is easier now that only one is being changed as opposed to two ears. Lastly, since the left ear will have had two surgeries will it end up being weaker than the right? If it gets hit is it more likely to spring back out again if it is weaker?

A: You are correct in assuming that only one ear is less invasive and easier than operating on both ears. Also a revision of an otoplasty in any one ear is less invasive than the original since usually only an additional plication suture or two has to be placed. Given that yours is just the top part of the ear, only the upper half of the incision has to be re-opened for suture placement. This also means that such a revision can usually be done under local anesthesia. Certainly a revision is going to get your ears closer in symmetry but I would not expect perfection. It is unlikely that your ears were perfectly the same before surgery so you should not expect perfect ears after surgery either. The revised ear will not end up being weaker since no cartilage is removed, it is just folded back further.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My nose has a lot of things about that I don’t like and want to change. It has never been broken or anything so I think I was just born with this shape of a nose. What bothers me about it are several things. First, I don’t like the thick broad tip that I have. It needs to be thinned and made more narrow. I also think the tip is too long. Second, I don’t like the nasal bump that I have. My nose is not smooth from between the eyes down to the tip due to this bump. I also think that the bump makes the nose broader up top. I guess when you put these two things together, I pretty much want a whole new nose. I am wondering if a lot of these changes are possible.

A: Essentially your redo of your whole nose is known as a complete septorhinoplasty. Through an open approach all segments of the nose are addressed. The hump is taken down, the upper nasal bones are narrowed, the tip is reduced and narrowed and the dorsal line of the nose is made smooth. If needed the septum is also straightened, or at the least, used for cartilages grafts which are almost always needed. This is a complete overhaul of the nose and substantial changes can be obtained. All of what you are describing is both possible and also common im rhinoplasty surgery. Make sure you get some computer imaging done before surgery so you will be prepared for what these structural changes will potentially look like.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 34 year old woman who has had two children. I am done having children and now want to address the damage done to my breasts by pregnancy and breast feeding. I have lost all of my breast volume and they sag. I want breast implants but I don’t want a breast lift. I don’t want the scars from the lift. I would be ok with small hidden scars but nothing that goes beyond the border of the nipple and the skin. I have attached some pictures of my breasts. Can you tell me if what I am asking is reasonable?

A:  Unfortunately, there is a significant difference between what you need for a good breast result and what you want.  You are not alone in this position as many women need a breast lift but don’t want the scars. You have too much sagging to get a good result using breast implants alone. In fact, implants without a lift is going to make your breasts look worse not better. They will create a mound above the current level of your hanging breast tissue and will merely end up placing your nipple on the bottom half of the implants. This will create a breast appearance that you will likely not find better.  It will just be trading into a different type of breast deformity.

If you are not ready to accept scars as of yet, you can always have breast implants first and let the result prove to you whether that look may be acceptable.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am entertaining the thought of a breast lift only. So I am researching a little bit. I am 50 yrs old and have always had nice naturally large breasts but with age they are hanging low but not flat yet. I’m a Size D now. My question is with a lift only does the procedure reduce the size when they are lifted? I’m sure some liposuction etc is needed so that seems to me it would take them down at least one size naturally. Is that correct? I’m thinking it would not be so bad as with age our backs take a toll carrying them around our whole lives, so smaller could be a good thing. Thank you for your time.

A: A breast lift, in its purest form, does not reduce the size of the breast. It lifts it, tightens the skin envelope and moves the nipple position into a more central position on the breast mound, but it removes no breast tissue. This is what separates it from a breast reduction procedure which also removes a significant amount of breast tissue. But variations can be done to a breast lift procedure to provide both a lift and a small amount of breast reduction. It is this procedure that you appear to be seeking by description. This combination breast lift-reduction procedure involves the removal of between 100 to 200 grams of breast tissue which will reduce the size of the breast by a ½ cup or so. Liposuction can also be done on the side of the breast into the back, an area which is outside the direct effect of any breast reshaping procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have finally decided  as an adult to have my cleft lip scar and nose asymmetry repaired. What I don’t like about my face is that I have a prominent lip scar, a downturned and twisted nose and an overall flatter face. I have attached some pictures so you can clearly see what I mean. What specific procedures do you think I will need and how are they done?

A: Thank you for sending your pictures. You have many of the very typical lip/nose/midface cleft-induced deformities that many so affected patients have. In analyzing how to make a significant improvement, I would recommend the following approach. A full septoprhinoplasty is needed to straighten out the whole nose and give the tip more projection and some narrowing. You would need a cartilage rib graft to build up the base of the nose (pyriform aperture/paranasal regions) by onlay grafting and as a columellar strut to improve tip projection and support. Your cleft lip repair is pretty good at the cupid’s bow area but I would excise the philtral scar and re-unite the underlying orbicularis muscle better.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have one calf that is extremely lager than the other, I always had nice legs and nice calves, I dont have bulging veins, but because I am very fair in complexion, my veins were very visible, so i had the vein injected by a podiatrist . ever since that my left calf has progressively gotten bigger. Please let me know if I can get plastic surgery to reduce this calf as to me it is unsightly, so much i dont want to wear a dress. Help!!!!

A: The first question is how long ago was the vein injected and why did it become bigger after. Calf enlargement is not an expected outcome from sclerotherapy, unless has developed a deep vein thrombosis. If the injection was done recently and you have pain in that calf, then I would recommend that you have it evaluated with an ultrasound to make sure you have not developed a DVT.

From a calf reduction standpoint, there are only two approaches. Either reduce the fat around the calf via small cannula liposuction or muscle reduction. Muscle reduction can be done by Botox injections or denervation but there are considerable costs and some surgical risks with either approach. Liposuction contouring is the simplest and whether that would be effective depends on how much subcutaneous fat exists around the calf area. At a minimum I at least need to see a picture of calfs to determine if that is possible.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I currently have mandibular angle implants but they are just slightly too large and I would like to get them shaved or switched for a slightly smaller pair. 1.) How difficult is the process of shaving them down? 2.) Is the recovery time just as bad as when they were first placed? 3.) Do you recommend shaving them down or switching them out for a smaller pair? Thank you in advance for your response.

A: Modification of jaw angle implant size is certainly easier than the first procedure. This is because the submuscular/subperiosteal pockets have already been made. This is what causes the real trauma and swelling from their original placement. While there will be some swelling the second time around, it will not be as bad as the first. Whether you modify in size or get new jaw angle implants depends on what type of implant was placed (silicone vs medpor) and what is the dimension that you want changed. If it is a silicone implant, I would just replace it with a smaller size as their cost is very low. If they are porous polyethylene (Medpor), I would shave down the existing implants because their cost replacement is substantially higher and they are easy to shave down after they have been implanted for awhile. (get softer with hydration)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,I would like to know if I am a candidate for short scar upper arm lift. I had liposuction of the upper arms done 1 1/2 years ago. Since then, my upper arms sag moderately. Thank you

A: Without seeing pictures of your arms, I can only conjecture as to the utility of a short scar armlift in your case. But having had liposuction previously with ‘moderate’ sagging now present, you may well be a candiddate. It depends on exactly where the greatest amount of sagging skin is. The closer it is to your armpit or upper half of the arm, the more likely a limited armlift may be of benefit. It will result in no improvement near the elbow or lower half of the arm.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have what I would consider a significant amount of lipoatrophy in my face (and I’m HIV positive for almost 4 years).  I also unfortunately had a small amount of buccal fat removed when I was younger.  That, combined with the lipoatrophy, has left my cheeks, buccal, and temporal areas looking quite thin (and in my view, gaunt).  What do you feel is the best way of treating this fat loss?  I’m not really interested in an implant due to cost and I really am interested in restoring volume.  I have had Sculptra treatments previously, but the results were not long lasting and did not restore an adequate amount of volume in my view.  I have considered facial fat grafting, but am concerned about the reliability of whether that fat would survive (especially in someone with HIV).  I am interested in your thoughts as to what the best course of treatment may be for something that is not short lasting and not outrageously expensive.

A: The only reliable permanent method of restoring volume in the malar, submalar and temporal regions are with implants. Malr shell and temporal implants will do well in those areas. Injectable fat grafting is another alternative, and the least costly one, but its reliability on someone on antiviral medication is very suspect. Even in a patient not on such medication, fat grafting is not always reliable anyway. Unfortunately, there are no treatment options that combine the concepts of ‘not short lasting and not expensive’ when it comes to facial volume restoration. Your best choice under these circumstances is fat grafting and one has to accept that it is unknown what will happen with volume persistence. Another option is to combine temporal implants with malar/submalar fat grafting. Temporal implants are the easiest and least costly of all facial implants to put in and can easily be done under IV sedation as can fat grafting.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want to change the look of my breasts. I don’t mind having small breasts but I just don’t like the sag. Do you think a  breast lift alone will give me a good result? What are the benefits of implants with a lift? Is the combination better than a lift alone?

A: Your breast sagging and your questions about how to improve them are fairly classic. Your dilemma is not new and it can be hard to figure out what exactly to do. So let me break down into the structural problems. In sagging breasts, there are three elements to them that bother women. First is the lack of upper pole fullness. While a lift may make some immediate improvement, it will not be sustained. This is what implants are used for to create some permanent upper pole fullness. The next issue is the low nipple position that is either pointing forward but low on the breast mound or is pointing downward to the floor. This is what a lift does best, reposition the nipple back up higher and in a more centric position on the breast mound. Lastly, is the bottoming out of the lower breast tissue that hands over the lower breast fold. This also is what a lift helps with by removing skin and tightening the tissues on the lower pole.

This being said, I find in many cases that a breast lift alone can be disappointing particularly in the thin-skinned small breasted patient. It really requires an implant to create sustained upper pole fullness and some upward movement of the breast

Dr. Barry Eppley

Indianapolis, Indiana