Your Questions

Q: Dr. Eppley, I had a subnasal lip lift last month and I hate the scar that has resulted. The scar is around 2mm height, goes from one nostril to the other and is indented about 1mm in depth. Would a scar revision help and would it cause any change to the current lip shape? (I want no more changes only want the scar removed) Another surgeon told me fat grafting to the scar can help. Is it true? How would a scar revision differ from the original cutting technique and closure? If it is the same, would  it will lead to the same problem? Thank you again for taking time to answer my questions.

A:  In theory scar revision may eventually be helpful but it is too early to make a final judgment on what your scar will look like in its mature state. But to answer your specific questions, any scar revision would not change your lip shape long-term. There is always lengthening and relaxation of the lip even when 4 or 5mms of vertical height is removed. While I love fat grafting and it can be very useful for many facial volume problems, I fail to see its benefits in your subnasal lip scar concerns.I would not think that any type of scar revision would be radically different from the initial procedure…other than less tissue is being removed and that places less downward tension on the scar. That may may the difference in the outcome. 

The most useful comment that I can probably make is to not jump too soon into doing anything, particularly in the first months after surgery. The tissues are chronically inflamed and will not respond well to manipulation no matter how well done or cleverly designed the procedure will be.  Ideally, you should wait it out for six months before having scar revision (if eventually needed) and allow all tissues to heal completely and undergo scar relaxation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was looking at possibility of laser resurfacing for my arm scars. My left forearm arm is completely covered on the bottom side from about two inches from the wrist to my elbow. Many are not deep, but several are. There are more than I can count. All scars are at least 2 years old. Also I was wondering if you had an estimated cost for something like that. I don’t have much money, but will be saving for this because it would allow me greater freedom with work and life in general, but we need a target to save for.

A:  The usual scar pattern for arm scars secondary to self-inflicted injury is fairly typical. A large number of horizontal scars are usually present, often between the elbow and the wrist. Some may be longer and more wide but most are more narrow and short. The large number of the scars makes the consideration of surgical excision to narrow them impractical. A few large ones can be excised but most of the smaller ones will not be improved by excision and re-closure. While laser resurfacing seems like it would be effective, it rarely is. The scars go full-thickness through the skin so thinning of the skin by burning off the top layer will only expose more of the scar not less. In some cases I have performed laser ablation to create the effect of a full-thickness burn. This creates a large scar which is easier to explain than the many small ones from knife wounds. I have also done a wide excision of the entire area of arm scars and then covered it with a split-thickness skin graft. This creates a skin-grafted arm appearance which again provides a visual appearance that is easier to explain. When considering this route, a skin graft would be preferable to creating a full-thickness burn.

To give you a quote for surgery, I would first need to see some pictures of your arm scars to determine the best approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have been debating about getting a Brazilian Butt Lift for the past two years and I’m finally ready to do it. I have waited so long out of fear that I will pay all this money and then the fat will just resorb. Is there any further encouragement that you can give me?

A: All surgery has risks and there is no doubt that the biggest one in the Brazilian Butt Lift is the unpredictability of how much of the fat will survive later. Fat survival rates vary widely but my observation is that up to 50% of the injected fat is retained after six weeks. There is a lot of variables that go into a successful fat injection transfer from the harvest method, to fat preparation and to the injection technique. You, of course, have no control over how the surgery is performed so make sure you choose your surgeon wisely and one that has a proven history of successful patient outcomes with fat grafting. The one benefit that you will absolutely be assured, however, is the contouring that will come from the fat harvest. Most commonly, fat is taken by liposuction from the stomach and flanks as these areas offer the greatest amount of available donor material. Other sites can be used as well but usually only contribute small amounts of fat. Regardless of the harvest sites, you can be assured of the contouring benefits of the procedure. That is the one guarantee result that comes with every Brazilian Butt Lift.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, what can be done to fix my muffin tops after a tummy tuck? Six months ago I had a full tummy tuck and and a new belly button made. Right after surgery I noticed  these bulges above my hips. My surgeon say it was swelling and it would go away but that has not been the case. They look terrible with my now flatter tummy. When I asked what he could do about them at my last check up, he told me to exercise and do abdominal twists and they would go down. I feel like he is just avoiding my concerns and doesn’t want to deal with me anymore now that she has my money. What are your thoughts on my dilemma?

A:  Abdominal contouring for many patients is not just a 180 degree proposition. The excess fat can wrap around the whole way to the back. Thus abdominal and waistline contouring should be thought of as at least a 270 degree or greater approach. A tummy tuck, even a full one, however only affects the front of the trunk and its benefits stop at the front of the hip bones. This is why flank liposuction is a part of many tummy tucks in my Indianapolis practice. If not noted before surgery and left out of the operation, one could be left with very visible muffin tops after a tummy tuck. The goods news is that it is an easily solveable problem with liposuction and those bulgy muffin tops can be turned into a very pleasing inward curve to the waistline. The bad news is that it does require further surgery but it is a much smaller operation with a very quick recovery.  

Dr.  Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a chin implant and buccal fat removal several years ago to make my face less round. While that has provided some significant improvement, I still feel my cheeks are too fat. The fullness that bothers me is the fat pad below the buccal fat area. I have had several consultations with differing opinions. One surgeon suggested liposuction with a mini face lift while another recommended a deep plane facelift with removal of fat under the cheek muscle. I am confused.

A: The specific cheek area to which you refer is below the buccal fat pad and is known as the perioral mounds. This is a fat layer that is separate from the buccal fat pads and will not be affected by their reduction/removal. It is a common misconception that buccal fat removal will thin out this area as well. Perioral mounds can be reduced by small cannula liposuction done through a small incision inside the corners of the mouth. I have found that ‘chubby cheek reduction’ usually needs a combination of buccal fat pad reduction and perioral mound liposuction to get the best reduction possible. In some cases, small cannula liposuction also needs to be done above the level of the nasolabial fold at the subcutaneous level. While a mini-facelift may help with tightening loose jowl and neck skin, it will not make a significant effect on the thinning of your cheeks. Skin tightening will not make a dent in the thinning of full cheeks.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in skull reshaping if that´s possible. I´m a 45 year-old male and I wish to know if there is any procedure to implant some type of  material at the occipital area in order to increase that part of my skull and make it a little more aesthetic, because I have that part very flat. I would also like to know if that would leave me with very visible scars?  I would like my skull elongated in the anteroposterior axis. Thanking you in advance. 

A: There are numerous methods of skull augmentation or expansion. They all rely on adding synthetic materials to the deficient skull area in the desired shape. The two basic methods are cranioplasty materials, such as PMMA (acrylic) and hydroxyapatites, and a custom-fabricated silicone or silastic skull cap or prosthesis. There are advantages or disadvantages to each approach which fundamentally comes down to cost and the ability to get a smooth contour and the maximal amount of expansion. The limiting factor in how much expansion can be obtained is how much the scalp can expand and to get a relatively tension-free scalp closure over the augmentation material. In my experience, a safe amount of skull augmentation is about 10mm in thickness. That may not sound like a lot but it creates an effect more significant than the number suggests. All of these methods require an open approach with a scalp incision to place them. This results in a fine line scar across the upper back of the head, somewhat similar to the location of a hair transplant harvest scar.

Dr. Barry Eppley

Q: Dr. Eppley, I’m interested in having Smart Lipo to remove some fat on my chin.  However, I have a chin implant that I got 16 years ago. One doctor told me that the risk of infection would be higher and the heat from the laser could move or melt the implant.  He advised me to get another opinion and to ask the doctor before I make the appointment because some doctors’ immediate answer may be no.  Can you please tell me about the risks and whether this is a good idea or not. Thanks very much.

A: My question to you  is what you mean by ‘chin liposuction’. Do you mean having liposuction on the chin pad proper (which is highly unusual and associated with risks of irregularities) or do you mean liposuction under the chin area, formally known as the submental region?

Either way, I would see no negative effect of the laser probe on a chin implant. The location of a chin implant is deep and against the bone and is beneath the fat layer of the chin. There is also the mentalis muscle which exists between the chin fat pad and the implant. In addition, the melting temperature of polymerized silicone is quite high (over 350 degrees F) and the heat generated by a fiberoptic laser probe does not create or should not create field temperatures higher than 145 degrees F. In addition, inadvertent touching of the end of the laser probe to the implant (which should not happen based on the previous description of where the implant is located) will still not cause it to melt.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a breast reduction  done when I was a teenager (now age 30)and now, if you can believe it, am thinking about getting breast implants. I am currently a 34B and was thinking of getting 350cc silicone gel implants if this will not make me too big. I am trying to get some fullness not necessarily be really big again. My main concern is am I more likely to have something go wrong or it is more difficult since I already have had breast surgery?

A: Surprisingly it is not rare that a former breast reduction patient will one day later desire a breast augmentation. This is a testament to the fact that a woman’s breasts are not stable throughout life. Their size and shape are affected by many factors. Teenage breast reduction has the potential for this to happen in particular as the reduced breast will be exposed to pregnancies which cause breast involution or breast tissue shrinkage. When coupled with the prior breast reduction, a woman can eventually end up with almost no breast tissue at all. The desire for augmentation after reduction may also occur if the amount of breast tissue removed was excessive.

Prior breast reduction surgery has no negative influence on the subsequent placing of breast implants. Reduction surgery occurs above the muscle, implants are generally placed below the muscle.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a few wrinkles and extra skin on my lower eyelids that I would like to get rid of.  I don’t think I need any blepharoplasty surgery and have read about lasers and chemical peels. Which of these two lasts the longest or do they both last a comparable amount of time? Which is most natural looking result or is there no difference? Which is least likely to excessively tighten skin? I am curious as to why laser resurfacing is so popular over chemical peels. Which has the least downtime?

A: There is no evidence that either method,  laser vs TCA chemical peel, is more effective or long-lasting on lower eyelid skin rejuvenation. Laser do have a higher risk of hypopigmentation. Both are commonly used and it is a matter of comfort and experience as to which method plastic surgeons use.

It is likely you may also benefit by a pinch lower blepharoplasty with a TCA peel but I would have to look at your lids to answer that question. This is a favorite method of mine for the lower eyelids because it works very well with a very small amount down time. It is also the most minimalist method to guarantee that lower lid skin would be tightened to some degree.

Lasers are more popular than peels today for a variety of reasons. First they are more ‘high-tech’ and with that comes the assumption that they produce better results. In addition, their high cost and the need for the manufacturers to sell them drives a lot of more visible marketing efforts.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, What is the cost of the brow bone procedure on average and what would the consequences of this procedure be if they were to occur?

A: While brow bone reduction can be a very effective forehead reshaping procedure, the two most important issues for any patient to consider are cost (average total cost $ 8500), of course, but also that a scalp incision will be needed to do the procedure. For many men based on their hair style and density, such a scar may be a disadvantageous aesthetic trade-off. While there are many other minor considerations to be aware of from this procedure, these are the first two hurdles to get over before one can ponder the less significant issues of brow bone forehead reshaping.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have had a chin implant which was done four years ago. Now I want to get a jaw angle implants to achieve a subtle outwards projection and a slight vertical projection such that the lower 1/3rd of the face becomes ever so slightly longer in the back. I only want subtle changes and do not want a very prominent square jaw. Instead, I want to retain the V shape ending of my lower 1/3rd of the face but just slightly stronger. Am I correct to assume that this can only be achieved through custom implants?

A:You are not correct in assuming that custom jaw angle implants would be needed to achieve your goals. While they could be done in a custom fashion, it would be more cost effective to modify existing stock jaw angle implants. Custom facial implants are almost always done when the size of the facial projection needed exceeds those implants which are commercially available. You are going the opposite and more favorable direction. Based on your description, I would recommend Medpor RZ jaw angle implants, small, which could be intraoperatively modified to 3mms lateral width extension and 5mms vertical length extension. That is about the size to me that you are talking about when you mean subtle increase in jaw angle projection.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I currently have 300cc cc moderate plus silicone breast implants in place whichi were placed eight years ago. I have decided to go bigger and am going to get 650cccc high profile Mentor silicone breast implants through my old inframmary fold scar. My current implants were originally placed under the muscles with complete muscular coverage. Now that I am getting new implants I have read that most plastic surgeons now put them in a dual plane position instead of completely under the muscle. Do you think this dual plane location is better than what I have now and will it give me better results?

A: Historically breast implants were placed in a completely submuscular location. That technique today is largely passé and has been replaced by the dual plane method. What this means is that only the upper half or so of the implant is covered by muscle while the bottom half sits below it. The dual plane technique has become popular because it produces more natural looking results by not having the implants too high. This has also become necessary because the average size breast implant placed today is larger than that which was placed fifteen to twenty years ago.

This discussion for you, however, is largely irrelevant. When making a more than 100% increase in your breast implant volume, it will not be possible for the implants to remain completely under the muscle…even if you wanted it so.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to know your experience with breast augmentation revisions. Is this something that you have done often? I am considering revision from saline to silicone and believe I’d like to go smaller. My previous surgical site for the augmentation was axillary and can this be done again with a revision? Any information you can provide would be greatly appreciated.

A:Any plastic surgeon that performs a substantial number of breast augmentations will perform secondary breast implant surgery, given desires of changes in size later in life, change in breast shape due to pregnancy and weight loss and the eventual failure of most breast implants over a patient’s lifetime. So yes I have done many breast implant exchanges and revisional surgery.

I believe you are asking if your existing saline implants could be replaced with smaller silicone implants through your already present axillary scars. The answer to that question is maybe…and it depends on what size silicone implant needs to be inserted through such a small incision. In days past, I would say it would not be adviseable unless the silicone implants are fairly small (under 350ccs). But with today’s funnel insertion technique, much bigger silicone breasts implants can now be placed through much smaller incisions.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have an eye problem. My right eye is lower than my left by a few millimeters, I can tell because when I look straight in the mirror it looks lower as judged by the level of the pupil. I got punched in the face about five years around broke some bones around my eye but never had surgery. They said it wasn’t bad enough to have surgery at the time. But my eye has slowly sunk down over time. Is there a way to fix this?

A: What you have is called enophthalmos where the eyeball has dropped lower due to lack of bone support or fat support underneath. Most likely you had an orbital floor fracture which was not significantly displaced so surgery to fix it was not done at the time. But over time, fat atrophy may have occurred which is another well known cause of enophthalmos after such floor fractures. The best approach is to build the floor back up with a synthetic orbital floor implant. The question is whether you have enoughenophthalmos to justifiy the surgery. But then you likely would not be asking me about it if it was irrelevant to you. If done through a transconjunctival approach then the procedure would not create any new skin scars. The risks of such surgery would be persistent undercorrection, overcorrection, implant shifting and potential infection. The aesthetic side of these risks are more likely.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 25 years old and have a chubby face. I am slightly overweight but not as fat as my face makes me look. I am very self concious about my oversized cheeks. I also have a double chin which is very noticeable and unattractive. Do you think a buccal fat pad removal would help me? I have read on the internet that removing it may make your face look too thin down the road. However, I feel that I  will always be stuck with a fat face and chubby cheeks as both my parents look the same way. Please advise on what you think would be the best way to help reduce the fatness in my face. Also, are there any less aggressive or non-surgical ways to lessen the fullness of my cheeks and chin? I have attached some pictures of me for your review.

A: In looking at your pictures, I can assure you that nothing short of surgery will help reduce the fullness in your face. I would recommend buccal fat  removal, submental/neck liposuction and maybe even a small chin implant. These are some standard techniques in faces such as yours to make a visible difference. While these will not necessarily make your face, they will go a long way to reducing some fullness. It is also important to realize that buccal fat removal does not address all areas of the cheek region in reducing fullness. You will also benefit from liposuction of the perioral mounds and above the nasolabial fold, two areas that are full but lie outside  any effects of buccal fat pad removal.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have previously had breast implants placed below the muscle and donut lift around the nipple. While I thought that would be the best way to get my breasts uplifted and have a batter shape and avoid skin scars, it did not turn out like I thought it would. My breasts are too big and the nipples point slightly downward. I have read that the nipple can die in these more aggressive or full breast lift surgeries. Obviously I don’t want that to happen. What can I do or how should the surgery be done that would afford me the least chance of blood supply problems and loss of the nipple?

A:  When it comes to getting the sagging breast really uplifted, I have rarely found the donut breast lift very satisfactory. So I am not surprised that you have had a similar experience. The one important thing that you can do with any type of breast lift or reduction surgery is to not smoke before or after surgery. If you are not a smoker, great. If you do smoke, you should quite one month before and continue cease smoking for one month after surgery. Fortunately, your breast implants are below the muscle so the blood supply to the nipple has not been previously disrupted. This makes the potential problem with nipple healing after more extensive breast lift surgery unlikely.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I don’t like the idea of losing consciousness under general anesthesia or IV sedation. Would it be possible to undergo cheek augmentation with malar cheek implants with only local anesthesia? I am very tough and I am not afraid of surgery or the sounds of surgical instruments at all, but I don’t want to feel any pain during the procedure. Is it possible to numb the midface area completely? Would you do cheek augmentation under local anesthesia if the patient is aware of the fact that this might be very uncomfortable?

A: While any type of procedure can theoretically be done under local anesthesia, that does not mean it is always a good idea. I have never done cheek implants under straight local anesthesia since it is a bone-based operation. I am sure one could get through it, but I could not promise that it would be completely pain-free. In addition, the most important aspect of the procedure is to get the implants into the correct position. You would not want anything to limit that objective. Always remember the purpose of the operation is about getting the best surgical result, not about how little anesthesia is needed. There are no rewards for seeing one ‘tough;’ one can be. In short, this would not be something I would advise or do… as I know well how this story would play out. To quote an anesthesiologist whose skill and experience I admire…‘the patient who states that will be just just fine under local anesthesia is exactly the patient who won’t be’. I would recommend that you do not have this operation unless you can come to the acceptance of doing it under sedation or general anesthesia.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want to get a flatter tummy, actually very flat. My hips may be a little big, which I can not change, but I know I can do something about my stomach. I have thought about a tummy tuck but wanted to know if a flat tummy is possible with just liposuction? If not am I a good candidate for a mini tummy tuck with less scar or do I just need a regular tummy tuck? I originally just wanted a regular tummy tuck to get rid of stretchmarks around my belly button. However, I think that if my tummy was flat by liposuction then the appearance of the stretch marks would be reduced. Does this make sense? I have attached some pictures for you to see what I look like.

A: While liposuction will reduce fat, it does not get rid of loose skin or stretch marks. It sounds like you intuitively know that a tummy tuck is a better choice but are hoping that you could get by with liposuction alone. Your gut instincts are correct. You will be happier with the results from a tummy tuck as excess skin is as much your stomach problem as fat. The debate between a full vs a mini tummy tuck is a classic one for many patients. The reality is that a full tummy tuck provides the best stomach contouring and is usually worth the extra scar length. Mini- tummy tucks are usually best in thinner women where a large skin excision would leave a very high scar placement.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a scar in on my abdomen (from surgery on my pancreas and spleen) running from my diaphragm to just below the belly button. It goes through my belly button, and thus my previously “innie” belly button is now a bloated mess, let alone the “train tracks” on the scar running through my abbs. I wish to remove the train tracks, fix my belly button (make it an innie again) and fade the scar as much as possible. I’m mainly looking if it can be done and how effective would it be?

A: I would like to see a picture of your abdominal scar to determine what is possible. But having seen many such scars before, I would imagine that it can be completely excised including the suture tracks if there is enough lateral abdominal skin laxity. At the least, the scar can be narrowed considerably. The convex shape of the belly button can be converted back into a concave or inverted form at the same time. Given that the vertical abdominal scar runs completely vertical and perpendicular to the relaxed skin lines of the trunk, a subcuticular skin closure needs to be done with a secure suture such as that offered by the Quill line of barbed resorbable sutures. This can produce a very nice improvement from abdominal scar revision.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in reduction rhinoplasty, alar base reduction, cheek bone reduction, and jaw reduction. I have diamond face jaw bones and cheek bones which are prominent and also have a big nose with an asymmetric alar region. I need a beautiful symmetric face with small nose and beautiful cheeks. Do you think this is possible? I have attached some pictures for your review and imaging.

A: Thank you for sending your pictures. I have taken a careful look at them and have imaged an open reductive rhinoplasty.  Your nose, as you know, is the largest feature on your face and is disproportionate in size to every other facial feature. While there is a limit as to how refined your nose can become given the thickness of the overlying skin, you most certainly can obtain significant improvement. When it comes to cheek bone or jaw angle reduction, however, I fail to see how those procedures will make any significant improvement. Your facial skin and tissues are too thick to reveal any bone reduction underneath. You are better off leaving the bone structure as it is to support the thick heavy overlying soft tissues. Your soft tissues will simply not permit a delicate and more refined facial structure that you desire.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have read about nipple reduction surgery and think that it is what I want to have. I am 45 years old but have long had nipples that stick out too far. There is barely any type of shirt that I can wear that hides them. My teenage son who is 15 years old has the identical problem (bad gene!) and I don’t want to see him suffer as I have over the years when there appears to a good solution. Would he qualify for this surgery? Also since we are from out of town can we have a consult and the surgery the same day? Thanks!

A: With parental consent, your son would qualify so there is no concern with that issue. Consults can be done by phone, Skype or e-mail so there is no reason to come for in for ani nitial evaluation when the problem is so visually obvious. I would just send me a picture or two of your and your son’s nipples for my assessment. Obviously they are too long and protruding but it would be nice to see them anyway in advance.

Usually nipple reductions are done under local anesthesia as a simple outpatient procedure. They should not be confused with more complex procedures like gynecomastia reductions.Whether a 15 year-old could handle that or not under local anesthesia I do not know although I suspect so. The toal cost of the procedure is $1500. You would just book the procedure(s) through our office after I have evaluated the pictures so it would be a one-time visit. Dissolveable sutures are used so there is no return follow-up needed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have had injectable fillers placed along the back side of my jaw to give me more of a sharper angle appearance. It was Radiesse and it took two full syringes to get a modest effect. The result was good but I wished it was stronger and more pronounced. I have heard that if you keep getting the fillers they will build up overtime and you will get a permanent effect. Is this true? If it is not, then do you think jaw angle implants will give me what I want?

A: There are no synthetic injectable fillers currently approved in the U.S. that are permanent. So it is not true that repeat treatments of any injectable filler will lead to a long-lasting build up of any facial bone site. Most certainly injectable fillers are not a substitute for the volume and permanency that can be provided by jaw angle implants. What your injectable filler treatment has done is to demonstrate that augmentation of the jaw angle region is aesthetically beneficial for you. That can be very helpful when uncertain if such a facial change is worthwhile. This should give you the confidence of proceeding forward with this implant surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am very unhappy with the result of a rhinoplasty that I had done two years ago. It was a closed rhinoplasty and I wanted to have a more refined and pretty nasal tip. It has ended up, however, being just a balled up fat tip with nostrils that now look bigger. What type of rhinoplasty do I need now to fix it? And can it be fixed?

A: Thank you for sending your pictures. What appears to have happened is that you have lost cartilaginous support of the tip due to overresection of the lower alar cartilages and the caudal end of the septum. The thick overlying tip skin has now just contracted inward without adequate support, resulting in a ball-like tip with excessive nostril show. Your nasal problem most definitely can not be fixed by any closed rhinoplasty method. It will need a rhinoplasty revision using an open approach and cartilage grafting to restore support for the tip to create a more natural shape and decrease nostril show. You will need a columellar strut graft and alar rim grafts to help correct the retraction as well as tip reshaping. These type grafts are best placed through an open rhinoplasty, particularly in the face of a nose that has scar from prior surgery. Presumably these cartilages grafts can be harvested from the septum and the ear.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a chin implant, neck liposuction and a submentoplasty with fat removed under the platysma muscle one month ago. I am 32 years old and had a double chin that could not be improved by any other method.  I wore a neck compression garment faithfully for three weeks after surgery. Despite this, I have very visible lumps and creases which did not exist prior to surgery. Will this resolve? What else can I do to help?

A: A submentoplasty combined with liposuction is a very good but aggressive procedure for neck recontouring. There is no question that it can do a good job of removing fat and tightening muscle, significant anatomic changes to improve a neck profile, but it does not remove skin. Thus it relies on the elasticity of skin to shrink down and produce the final shape. It is not uncommon for this procedure in some patients to end up with skin redraping issues. (irregularities, indentations, creases) That is the one knock on the procedure in my experience. It is still early so some of these skin issues will definitely get better with time. Whether they will completely go away remains to be seen and I doubt if there will be 100% resolution. But this is an issue of time and you will know more by six months after surgery. You would probably benefit by neck treatments such as massage or Exilis treatments which can help with skin smoothing and now is the time to do them before a lot of scar sets in.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a question about Kryptonite bone cement. Can it be used to build up the jawline. I was born with hemifacial microsomia and my jaw on one side is short not very full. My bite has been corrected by a jaw osteotomy previously but the overall side of the jaw is still small and too thin. Would this be a good use for this type of bone cement material? Also what would happen it is got infected after surgery?

A: Kryptonite bone cement is FDA-approved for all craniomaxillofacial bone applications whether it is as an inlay, onlay or any combination thereof. Therefore, it is appropriate  to use it as an onlay augmentative material for the mandible or any other facial bone for either reconstructive or cosmetic indications. So it could be safely used for jaw onlay augmentation.

Having 20 years experience as a craniofacial plastic surgeon with a lot of experience in biomaterials in the craniofacial region, Kryptonite has a very steep learning curve with its use. It handles completely different than every other bone cement material used in craniomaxillofacial surgery.  It would also be a challenge in getting into a site with difficult access such as the jawline. What I have learned in complex cases like yours is to first get a 3-D craniofacial model made from a CT scan. Then use that either to premake the desired implant for other synthetic materials or use it sterilized during surgery to custom make an implant intraoperatively out of Kryptonite. This will help tremendously in getting the best contour shape and in its placement.

Once  an implanted material gets infected, Kryptonite or otherwise, antibiotics will not usually solve it. The material must be removed to cure the infection. The material is simply inoculated, particularly a porous material, and you can’t get rid of the bacteria with drugs alone. They will only provide a temporary amelioration of the infection which will return as soon as the antibiotics are stopped. Clearly this is a problem to be avoided which is why I always mix in antibiotic powder with any bone cement material in the preparation process.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 22 years old and am bothered by my small lower jaw. It is small with about a 1/2 inch discrepancy between my upper and lower teeth. I really dislike my profile.  I had an appointment with an orthodontist last week and he recommended getting braces and then having a lower jaw advancement. This sounds too extreme to me. I was wondering if I can just get a chin implant if I’m that unhappy with my looks. If you were me what would you do?

A: Your dilemma is a classic one and the decision is ultimately affected by a patient’s age, whether they have any masticatory functional symptoms, the magnitude of the jaw discrepancy and what they are willing to go through. From a long-term standpoint at your young age, both functionally and aesthetically, you should have the combined orthodontic and jaw advancement surgery. It is most certainly not extreme and is a routinue maxillofacial surgical procedure. A chin implant, while comparatively simple and providing an immediate aesthetic benefit, would offer no functional improvement for your bite, jaw function and TMJ health.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I have a problem from a previous closed rhinoplasty. I am very unhappy with the tip of my nose. It has been lifted too high and this has exposed my nostrils unfavorably. It also makes my face look flat. What I want is correction through a closed rhinoplasty. Will that work for me and my nose problem?

A: When the nasal tip becomes too shortened after a rhinoplasty,  it will produce a set of classic aesthetic issues including an obstuse nasolabial angle with excessive nostril exposure. It can be corrected through tip lengthening/de-rotation through cartilage grafting. This is not best done through a closed rhinoplasty. The grafts would be hard to place and secure through such limited visualization. An open rhinoplasty would provide much better exposure to accurate place tip grafts and/or septal extension grafts to create a de-rotation effect. The one exception to this approach is if the amount of tip lengthening needed is small. Then the placement of limited tip grafting could be done through a closed approach. I would need to see photos of your nose to determine which rhinoplasty approach may work for your revisional surgery. The only question I would ask is what is the basis for your deference to an open rhinoplasty? The scar is inconsequential and the results are more consistent and superior.

Dr.  Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I am a 27 year old man and I’m thinking to have a surgery to reduce the size of my brow bone. My question is if the look of my eyes would change. Because I have read in other forums that such surgery might change the deep of my eyes of which I love their appearance. I would appreciate very much your esteemed opinion to my concern. Is it justified or not? Thank you very much.

A: It has not been my experience that the depth of one’s eyes appears any different after brow bone reduction surgery. This is because brow bone reduction in men, in particular, is about changing the bulge or convexity of the anterior table bone of the frontal sinus. It does not change very much the lowest edge of the brow bone or reduce it posteriorly which would make the eyes look less deep. I would have to see some pictures of you, particularly from the side view, to make that determination more specifically however. 

Dr.  Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I am having a tummy tuck later this spring and look forward to a beach vacation this summer with my new body! My question is how soon after surgery can I begin tanning? If I have my surgery in May could I get into the ocean by July? How much time should I allow between surgery and these activities? I don’t want to do them too soon and affect my results but I know I will be anxious to do them.

A: The answer to both questions resolves around the tummy tuck scar and making sure it is healed enough to not be affected by these activities. Getting into ocean water, which will have organisms in it that do not occur in chlorinated water,  should be deferred until 6 to 8 weeks after tummy tuck surgery. At this point, you should be well healed including any small areas of potential suture extrusions. The effects of tanning and sun exposure on your tummy tuck incision, however, is a much different concern.  Both tanning bed and sun rays can adversely effect how the scar may eventually look so such exposure should be deferred until it is well healed for at least three months after surgery. If you must use the tanning bed, I would cover the tummy tuck scar with tape until then to block these undesired rays. 

Dr.  Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I have saline breast implants placed under the muscle now 11 years ago. I have been very happy with them and have had no problems at all. I was originally told by my plastic surgeon that they will last anywhere from ten to twenty years. Now that I am past the ten year mark, I am wondering if I should just have them replaced now since a deflation could happen anytime now.

A: It is important to realize that breast implants are not life-long devices. They will eventually fail, which means the containment bag will develop a leak. With saline this means the fluid is coming out and the implant will deflate with an external flattening of the involved breast. How long saline breast implants will last and when they will deflate can not be accurately determined. While your breast implants are living on borrowed time, I see no reason to preemptively just replace them. You might as well get the value out of them for as long as you can. While this will someday result in a breast implant ‘emergency’, it can be replaced within a matter of days with no significant recovery. (unlike the first time)  

Dr.  Barry Eppley

Indianapolis, Indiana