Your Questions

Q: Dr. Eppley, I am interested in getting a tummy tuck but have a few questions about it. In reviewing the photos of other women whom have had the procedure, I noticed that the scars are up fairly high, is that necessary to achieve proper results? You see, in having two cesarean births, both incisions were very neat along the hairline, I really like the way it had healed. Do you cut through the muscle in this procedure? Oh, and the other thing, in viewing some post-op footage, there were these drainage apparatus, is that something always done? Sorry for all of the questions, I hope you don’t mind. 

A: A full tummy tuck always pulls the incision up higher than a mini- or more limited tummy tuck. Only a min-tummy tuck can keep the incision as low as most women have their c-sections scars at. C-section scars should almost always heal beautifully because they are closed under no tension. (loose stretched out skin) Tummy tuck scars rarely look quite that good because they are close under considerable tension. (tight taut skin) Tension is the enemy of a narrow scar line.

No muscle is ever cut though in a tummy tuck of any form.

The use of a drainage tube is a necessary evil after tummy tuck surgery that stays in for about a week.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a dermoid cyst in my forehead bone that needs to be removed. Because of its size, it will leave a significant bone defect after its removal so it will need to be reconstructed. One  plastic surgeon told me that he has to take out too many bad products from people’s head’s so he now only uses a titanium mesh covering for these repairs. My question is which is a better method for reconstruction, metal mesh or a bone filler? Also, two different incisions  have been discussed.  Since the lesion is not too far from the hairline, is it possible to do a smaller incision, one that goes from the  sideburns to the midline  of the forehead and just very slightly into the hair line? I know that a bicoronal incision can be used but it is a more difficult recovery and some  scalp numbness will result. Which incision would be better to perform the surgery with the least risk of problems?

A: It appears that you have an epideroid cyst in the diploic space of the frontal bone. I assume the reason for its removal is that it is slowly growing.

I have no picture of you to see where exactly the lesion is located in reference to your frontal hairline so it is impossible for me to comment on what incisional approach could be used. Certainly some variation of the bicoronal incision can be used. The only question is whether some other form of more limited incisionall approach could be used. Without knowing where on the forehead it is (seeing a picture with a mark on your forehead), I can comment no further.

In terms of reconstruction, I would disagree strongly with the idea that there are a lot of bad products for skull reconstruction. I have used all available materials and have never had a problem with any of them in hundreds of cases. They all work well when used with proper technique. For covering a ‘crater’ in the forehead after the cyst removal, I absolutely would go with an hydroxypatite cement. It can fill in the defect and make the forehead perfectly smooth. While covering the defect with low profile plates and screws is also acceptable, there is always the chance that you will be availble to feel the outline of the metal hardware and even some risk that it may leave a negative image on the forehead skin should it thin out after the surgery. 

Dr. Barry Eppley

Indianapolis, Indiana

While the neck is technically not part of the face, it does makes a very important contribution to one’s appearance. A sharp neckline helps highlight the jawline and makes a clear transition between the two. When the neck is too full or hangs downward, it may be the result of too much fat, loose or saggy skin or a combination of both.

How to reshape the unsightly neck requires an understanding of why it is that way. As a general rule, a younger patient’s neck has more fat than skin. Conversely, older patients usually have more loose skin than fat…and skin that may have lost much of its elasticity.

Many neck contouring treatments are touted that range from non-surgical energy therapies to  actual surgery such as liposuction and necklifts. The degree of effectiveness of any of these neck procedures depends on how well the treatment changes the amount of fat in the neck, tightens the skin or preferably does some of both. When the patient’s problem matches what the treatment does best, an improved neck shape will occur. If not, results will be poor.

One effective neck contouring treatment is liposuction. As the only known treatment method that can remove fat, it is no surprise that it is a part of almost any surgical neck procedure. A basic principle of liposuction is that the skin must contract afterwards. Part of its reshaping effects relies on the skin shrinking down to the slimmed down neck. What is unique in neck liposuction is that the skin must actually shrink upward.

While traditional liposuction does not have any direct effects on creating skin tightening, that has changed with the use of Smartlipo or laser liposuction. The heat created by the melting of fat and the ability to directly treat the underside of the skin with the laser energy creates better skin retraction and some degree of actual skin tightening.

Smartlipo has been and remains my preferred technique when liposuction of the neck is done as a stand alone procedure. When used in younger patients with fuller fatty necks, good skin retraction and reshaping can be seen. It is very common for the neck to feel very firm for weeks afterwards. This is a temporary skin effect that takes a month or two to soften and go away.

In older patients with significant skin sagging, the tightening effects of Smartlipo are limited due to the amount and quality of the skin. When requested to do it in a few patients who refused any other form of surgery, I have seen a few impressive neck reshaping results. But I do not consider it the treatment of choice in the older neck and patients should temper their expectations accordingly. Its benefits are also obviated when liposuction is done as part of a face or necklift where skin undermining and flap repositioning are far more effective methods for neck reshaping.  

Dr. Barry Eppley

Indianapolis, Indiana

When the subject of breast implants or breast enlargement surgery comes up, many people immediately think about size. Large breasts that create eye-catching cleavage are what comes to many minds, a concept that has not been helped over the past two decades from celebrities ranging from Pamela Anderson to Heidi Montag of more recent note.

The reality of breast implant surgery, however, is far from this image. There are certainly a minority of women who do want this look. But the  vast majority of women who choose to have breast implants are much more interested in finding the right size for their body and not to have overpowering breasts that become the focal point of their appearance.

Most breast augmentation patients are average women who simply want to look good in clothes and sport attire. I have seen many women who have told me that they are embarrassed to wear a bathing and won’t go to the pool or beach with their family. While breast underdevelopment is the most common motivation for getting implants, there are numerous other reasons. These include such breast conditions as postpregnancy sagging, asymmetrical breasts, body proportioning, breast asymmetry and reconstruction after mastectomies.

Pregnancy and nursing can have an adverse effect on a woman’s breast shape and size causing sagging and, almost always, a change in the amount of breast tissue. Many women are unaware that it is completely normal to lose breast tissue after pregnancy, a phenomenon known as involution. For some women who have had multiple pregnancies, they lose all of the breast tissue they originally had. When combined with stretched out skin, the change in a woman’s breasts can be deflating for their self-image as well. These are women who simply want to return to their pre-baby size and shape.

There are many women who have breast asymmetry where one breast is larger or different in shape than the other. In some cases the breast size difference can be as much as a cup size, sometimes even more. For women so afflicted, finding a bra to fit comfortably and properly is not as easy as going to Victoria Secret’s and pulling a good fit off the rack. Often they are forced to add padding to create a more even look in their clothing.

One of the most recognized and easily understandable reasons for implants is in breast reconstruction. The physical and emotional devastation of going through any form of a lumpectomy or mastectomy procedure can be softened knowing that an immediate or even a delayed reconstruction can be done. While numerous forms of breast reconstruction exist, including flaps that form the breast mound out of your tissues, implants remain the backbone of how most breasts are recreated.

Dr. Barry Eppley

Indianapolis, Indiana

Rhinoplasty surgery can make many changes to the nose, from taking down a bump on the bridge to narrowing the tip. But in the end, the result that will be seen depends how the skin of the nose redrapes and adapts to the new changes that have occurred in the supporting framework underneath it. Given that removing skin from the nose or tightening it through incisions and creating external scars would be unacceptable, the wildcard in any rhinoplasty outcome is ultimately the patient’s nasal skin.

Thus, unlike any other piece of nasal anatomy, the skin is really a fixed and not a variable component of rhinoplasty. It is the one piece of nasal anatomy in which its surface area can not be reduced. It is a common principle in rhinoplasty teaching that the skin will shrink down and adapt to show the changes that have occurred in the bone and cartilage framework. But this is not always so and is not necessarily even always predictable.

How well the skin of the nose can shrink down is influenced by many variables. The two most important are the thickness of the skin and where on the nose it is located. Skin in the upper half of the nose seems to be better at adapting than the lower half of the skin. But that may be just a reflection of the complexity of the anatomy underneath it. The upper nose is like a saddle while the lower nose has a much more complex shape and is more similar to wrapping paper around one side of a ball. Thin skin is believed to shrink better than thick skin and probably reflects that it has less overall mass. In theory, thick skin should shrink more than thin skin due to a higher number of elastic fibers. But its thickness provides 50% more mass given any  surface area so significant skin contraction does not occur.

When one has thick skin on the nose and is undergoing a rhinoplasty, it is important to temper one’s expectations and to have extreme patience in awaiting the final result. This is particularly relevant to many ethnic rhinoplasties including Africa-American, Hispanic, and Middle Eastern. Since one of the main objectives of these rhinoplasties is to have a more slim and refined nose, thick skin will have an influence on how achieveable that goal is. It is also important when performing these rhinoplasties to not attempt to slim the nose by  removing too much underlying structure. That will cause the skin to ‘ball up’ particularly in the tip area since the now ‘excessive’ skin has nowhere to go but to contract onto itself.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting a browlift and an upper blepharoplasty fro my hooded eyes and low brows. I am now 54 years old. Three years ago I had a facelift done and, although I am happy with the neck and jowl results, the scars around my ears have significantly widened. This has made me afraid of doing any type of browlift as I don’t want a wide scar in my scalp. I wear my hair with bangs and I also have a high forehead. What are your thoughts on the transpalpebral approach to browlift surgery?

A: While a transpalpebral browlift avoids any hairline scars, the ‘price’ to be paid for that decision is that it does a relatively poor job of lifting the brow. At best, it can only make a minor elevation of the tail of the eyebrow. It illustrates a basic principle that you can’t really lift much when all you are doing is pushing up from below. It can not elevate at all the inner half of the eyebrow because the supraorbital and supratrochlear neurovascular bundles are in the way. With your already high forehead, I would strongly consider a hairline or trichophytic browlift technique. That would achieve the dual effect of lifting the brows and shortening the vertical length of the forehead at the same time. Provided you have a good frontal hairline density, the resultant fine scar at the edge of the hairline is one that is usually not associated with any significant scar widening. I would not equate what can happen along the ears from a facelift to that of the effects of a browlift on the hairline. Excellent scars can be obtained, however, from each with good surgical technique.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a rhinoplasty several years ago that changed the angle of my nose from convex to acute. I would like to have this corrected with a premaxillary implant. Do you prefer silicone, mersilene mesh or hydroxyapatite?

A: Thank you for your inquiry and good question. While arguments can be made for any of the materials you have mentioned, and I have used them all, I prefer mersilene mesh in the premaxillary/pyriform aperture area. While I don’t use this material for most other facial areas, it has several advantages under the base of the nose including easy shaping and fabrication, no need for implant fixation, rapid tissue ingrowth with firm fixation and minimal palpability to the touch. Silicone implants tend to be a little firm and placing them under the thin mucosa of the maxillary vestibule makes them prone to future problems of tissue thinning, exposure as well as palpability. Hydroxyapatite granules is another reasonable alternative as a good long-term facial implant material. Its only problem is that one does not have ideal control over the placement of the material and the granules do settle out so the amount of premaxillary augmentation may not be enough or may be uneven or irregular.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am very interested in a knee lift.  I have had liposculpture around the front of my knee and thigh with the hope it would remove the wrinkly look I have around my knees.  I am 48 yrs old therefore the loss of skin elasticity has effected the look of my knees.  I am desperate for some advice of where I can go to improve  this part of my body. I have considered a thigh lift but have been advised that it is not possible to lift my problem area because there is a long distance between my knees and upper thighs.

A: The loose skin and wrinkles above and around the knee area is a difficult problem. As you have discovered, deflating thin older skin by liposuction will usually just create more loose skin. Like anywhere else on the body where there is loose skin, it is possible to do some form of a lift. Essentially a knee lift is the direct removal of skin above the knee cap area. This is actually a fairly simple procedure in concept but is flawed by the creation of a scar. While lifts are done in many areas of the body and they all create scars, the knee lift is unusual in its location. It is placed in an area that is directly exposed to high degree of motion and a high angle of potential flexion…which puts stretching forces on the scar in a perpendicular direction. This will likely result in noticeable scar widening. Whether such a scar is a better aesthetic result than the wrinkly skin around the knee is a critical question. While I would have to see how ‘bad’ your knees look now, I would be suspicious that this may not be a good aesthetic trade-off.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, How long does it take to heal from a tummy tuck? What is the success rate to keep the contour? How much does the procedure cost?

A:  Recovery from a tummy tuck depends on how you want to view the concept of recovery. To be 100% full recovered (feeling like before the surgery and doing all normal and strenuous activities), it will take a full 6 weeks. If you are talking about returning to work in a sitdown job, it will be closer to 10 days. Returning to a more strenuous job will be closer to three weeks. Up and about after surgery around the house will be a few days.

The success of tummy tucks in terms of long-term contour preservation is actually pretty good. The excess or loose skin is never going to return provided one does not get pregnant again, which is the primary skin-stretching mechanism for most women. (extreme weight loss is the other) One can thicken up the fat layer around the trunk and waistline based on one’s weight and diet. I have seen that in a few patients over the years. It all depends on the stability of one’s weight and the type of body build one has.

There are different forms of tummy tucks that may or may not include liposuction. For the sake of simplicity, I would look at the concept of a full tummy tuck with flank liposuction which is the most commonly performed one. As an out patient procedure this more complete tummy tuck is in the range of $6500 to $7500, all costs included. This is an approximation and may change based on an actual examination of the patient.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 25 year old man and I want to fix the sunken look I have in my midface area. Below my cheeks it is very hollow. In addition, there are indented lines which I call railroad track lines in my midface? I have read about filler injections but I know they are only temporary and may leave a plump, round shape which I don’t want. I would like to have a more narrow/angular look. Do you think cheek implants will work?

A: Hollowing below the cheeks, known as submalar hollowing, is the result of the cheek soft tissue not being supported by bone. Without a large buccal fat pad or thick subcutaneous fat being there, this area will become a concavity and not a convexity. Injectable fillers can certainly be used as a temporary augmentation method but I would agree that it lacks the ability to create sharp definition. Cheek implants are the only other options and they do provide a permanent change. But there are numerous types of cheek implants and it would be very important to get the right implant shape to achieve the desired result. Submalar cheek implants would theoretically be the best choice but they do add some cheek width and lateral fullness.. It may be better to use a combined malar and submalar implant, known as a malar shell, and modify the submalar edge to create medial augmentation of the submalar hollow but not lateral fullness.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was wondering if forehead reduction was possible. I have a high forehead and it makes my head look rather large. I also feel like my forehead comes outward too much like bossing. Can anything be done to fix these problems?

A: Forehead reduction is done by loosening and advancing the frontal hairline forward and removing the forehead skin that it overlaps. Since this is an open procedure, the bulging upper forehead (frontal) bone can be shaved down four to five millimeters for some mild bossing reduction. The key to doing this procedure is that the one must have a stable and fairly dense frontal hairline as this is where a fine line scar will result. This means that it is a procedure that can be done for many women but only in a very limited number of men. I actually have never performed a forehead reduction in a male for this very reason.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: Hi Dr. Eppley, I was wondering whether trauma to the brow bone early in life could have caused it to grow differently than it should have. I was on a trampoline as a child  and fell onto the left side of my face and had large swelling there for about a week before it went away.  Now that I am older I have noticed that the side of my brow seems to be lower, giving my left eye a perpetual sad look that I do not like. While I could be mistaken, and it could be scar tissue causing this asymmetry, I am wondering if this is due more to bone. If so, is there a cosmetic procedure to fix this and if the childhood trauma could have been the cause. Thank you.

A: Most certainly trauma to the brow bones can be a source of brow asymmetry. The trauma could have caused an actual deformation of the bone by infracturing the thin bone over the frontal sinus in an adult or causing a compression fracture in children that changes how the shape of the bone grows and expands. Such asymmetry is the result of the edge of the brow bone being lower than the unaffected side. This can usually be corrected by a brow bone reshaping procedure by shaving ‘up’ the lowered edge of the brow bone. This can be done through an upper eyelid incision. It usually takes about two to three weeks until all the swelling and bruising is gone.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 72 years old and in excellent health… exercise, good diet, etc.  When I was around age 45 I had a blepharoplasty operation as I had developed large bags under my eyes. The surgery was to remove fatty tissue from my eyelids.  It did me a world of good, as I was quite self-conscious of my appearance.  Those bags have gradually come back and I am, again, very self-conscious of them.  I look relatively young except for this excess fatty tissue.  I can hardly imagine how I would look now had I not had the first operation! My question is how could this fat come back since I haven’t really gained any significant weight. Can they be removed again and do you think that it would be covered by Medicare? Thank you for your help.

A:  Bags that develop from the lower eyelids is a common problem that occurs largely in aging eyes and occasionally in younger people due to genetics. The bags are due to fat which is sticking out from underneath the eyeball. One can think of it as a hernia. Our eyeballs are surrounded for their protection by fat. This fat is held in place underneath the eyeball by a special tissue that runs from below the lashline (tarsus) of the lower eyelid down to the rim of the lower eye socket. As we age this tissue becomes weak and the fat is no longer held back and begins to stick out. (bags) For some people, they have a congenital weakness of this tissue and they may have bags as early as their teen years. Once this protruding fat is removed, it is still possible later in life for it to ‘return’. This is really just more fat that is coming out from around the eyeball as the supporting tissues become weaker. Like the first surgery, further fat can be removed by additional lower blepharoplasty surgery.

Lower eyelid surgery is never covered by insurance because it does not interfere with one’s vision. Only the upper eyelid can create that medical problem.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I need advice as to whether I should have a mini- or full tummy tuck. I have attached some pictures of my stomach so you can see. I have been to two plastic surgeons and have gotten two different opinions. In listening to them, both make sense for what they want to do so I am confused.

A: When considering the type of tummy tuck one may need, it is important to look at the components of the excess tissue problem. The most important consideration in choosing between a mini- vs a full tummy tuck is how much skin is present. While you don’t have a large amount above your belly button, there is enough there that a mini-tummy tuck will not fully get rid of it.  The other tissue consideration is the amount of muscle laxity or protrusion. You appear to have a protuberance of your abdomen starts way above your belly button.  Like the skin excess, this muscle protrusion indicates that you will get a much better result from a full tummy tuck. One issue to consider in doing a fully tummy tuck is the vertical level of the horizontal scar. If the belly button cut out in the skin needs to stretch down to meet the lower incision, the horizontal scar will likely end up a little high. Therefpre, I would recommend that you end up with a small vertical scar in the lower part of your abdomen.  That way the scar can stay low and the belly button hole can be closed vertically. I think this would be better given how jeans and underwear are cut and designed today for women.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting breast implants but am having a hard time figuring out the right size. There does not seem to be any specific method about how to select the size. know I should not focus on the cup size but more on what I want it to look like. I do want want them to be large though.  I am 5′ 6″, weigh 135 lbs and am athletically built. I want them to be large, but not so large that they will cause me problems down the road. One plastic surgeon I consulted with recommended 500cc implants. But in trying them on inside my bra, they seemed too small. What would you recommend?

A: While there is no exact science to selecting breast implant size for any patient, there are some guidelines to follow. Remember, however, the goal is in how the breast loko after surgery not necessarily what cup size they fit into or what volume of implant it is. It is all about the look. There are two criteria that I use.  The first is how wide is your natural breasts, known as the base breast width. Select an implant whose base width does not exceed that of your own breasts. That will keep them from getting too fat to the side or into the swing of the arm. Secondly, what breast look is the patient after. This requires the patient to s look at and select some after breast augmentation photos of sizes (look) they like. When putting the two together, a good breast implant size can usually be chosen that satisfies most patients. If the breast look appears bigger than what one’s breast width can accomodate, then select a bigegr implant that has a high profile. This will allow for more volume while keeping the implant diameter within the boundaries of the side of your breast.

Q:  Dr. Eppley, I was surfing the web when I came across your blog. As I was reading I got excited in hopes that you could be help for me. I am 35 yrs of age and all my life I have avoided anyone touching my head or getting my hair wet in public places such as a pool. The reason is that one side of the back of my head is flat. I think the medical term for it is deformational plagiocepahly. The back of my head is flat, my left side to be exact. In addition, my forehead is somewhat flat as well. This condition has severely bothered me. Growing up as a child was difficult, I had plenty jokes directed at me for the shape of my head. I have used a blow-dryer most of my adult life to camouflage this area as best I can. I would hope that you can help me. What can be done for it?

A:  You are describing deformational plagiocephaly to a tee… a twisting of the skull during growth that creates a flattening on the back of one side of the head and a similar but more modest flattening on the opposite forehead. In severe occipital flattening in adults,  I have performed cosmetic skull reshaping through an onlay cranioplasty technique. Most cases of a flat back of the heads have their locations up high above the ear level. Through a small vertical incision, the bone can be built up using either hydroxyapatite or acrylic. (PMMA) There are some advantages and disadvantages to either material and they need to be reviewed carefully with the patient. But the surgery is fairly easy to go through, one’s recovery is very quick, and the results are immediate.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, My upper jaw (maxilla) seems to be slightly recessed and the natural outward projection of maxilla is not present creating an unusually flatter profile in mid-face. My chin is also recessed but interestingly don’t have any bite problem. After extraction orthodontics(to treat crowding) the problem seems to have aggravated and now the upper teeth show way behind the upper lip and now the dental arch provides minimal support to the lip. This makes the upper lip to hang without proper base support resulting in speech problems. (lisp) I also had an unsuccessful chin surgery (implant removed 1 yr back) creating awkward tensions in chin fold area and trickier lower lip movement. Combined with above, my face is in pretty bad shape and preventing me to achieve a good speech. Kindly suggest what are the options.

A: By your description, it sounds like the fundamental problem is that of maxillary horizontal retrusion. That has been magnified by the teeth extractions for orthodontics which have pulled the anterior maxillary teeth (and the lip support) further back. It would be important to have a full facial skeletal workup on you (photographs, x-rays and dental models) to determine the viability of orthognathic surgery. (maxillary and mandibular advancement combined) That would treat the fundamental underlying problem of a deficient skeletal base. Onlay implant facial augmentation is another option (midface and chin implants) but should only be considered if the orthognathic surgical approach was either not possible to do or was too extreme an approach to go through.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve found a website that can do plastic surgery to change your appearance by making your ears pointed. And can put implant horns/antlers on your forehead or the top of your head. I was wondering if you can do something like that but if not, do you know any surgeons who can do something like that? The website  I saw  is made from a surgeon/doctor.

A:  The procedures that you have requested are both unusual and dysmorphic in nature. While plastic surgery can create an enormous number of facial changes, the goals of such procedures are to reconstruct one to a more normal appearance or to enhance one’s normal physical features. Altering one’s ears to a ‘spocklike’appearance or putting forehead and skull implants in to create horn-like protrusions are a poor use of plastic surgery techniques and implant materials. While I am certain there are some ‘surgeons’ out there that perform these procedure, I would know of no board-certified plastic surgeons that would perform these disfiguring procedures that, no doubt, one day the patient will ask to reverse and restore a more normal appearance.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My cheek bones come down just past the nostril base of my nose and from what I’ve read, that is supposed to be ideal. However, to me, it appears that I am lacking some volume and “flatness” in the submalar region. My chin is also slightly weak but the idea of a chin implant concerns me since it can be easily overdone and too prominent. If possible, I’d like the chin not to look wider from the front or longer from the profile…just creating outward volume. My goal is to maintain a feminine look with naturally done contours.

A: In looking at your face and in conjunction with your stated goals, I would recommend a small submalar implant and a small central chin implant style. Your cheekbones actually are quite nice and ideally positioned and full. The submalar area could stand a little volume as you have surmised but the key is subtle or small. This is why I suggest one of the smallest submalar implants. The malar and submalar areas are very easy to overdo and too large a size is a common problem in implant selection. From a chin standpoint, females needs a more central chin implant with very limited lateral wings. Women need a more tapered chin appearance, more pointy if you will, which is more feminine as opposed to a more square chin look for men. The combination of small submalar and chin implants should provide highlights and natural contours to your already good facial bone structure rather than overpowering it or being obvious.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I am interested in a rhinoplasty which builds up the bridge of my nose.I would definitely want to use a rib cartilage tissue for it due to good long term results and safety which are my main concerns. However, I still have some questions about the operation. How will the rib operation affect my ability to function? I go to gym and exercise a lot and I wondered if there might be some long term problems with the operated rib?

A: There will be no long-term sequelae/dysfunction from taking a portion of a lower rib for rhinoplasty. Not only is the rib harvest not bone but cartilage but it is a small portion of it and not the whole rib. Th function of ribs is to provide structural support to the chest wall but it would take many whole ribs being removed to destabilize that function. This is just a portion of one of the lower ribs ( 8, 9 or 10) which actually have no real function for chest wall support and pulmonary function as they lie below the level of the bottom portion of the lung.  What is associated with some rib removal is pain and discomfort. To manage this immediately after surgery I inject a 24 hour local anesthetic into the surrounding rib tissues from the harvest so one does not wake up in severe pain. While this does wear off, it gives one time to acclimate to the soreness. One can usually return comfortably in 3 to 4 weeks to exercise and more strenuous activities.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Hi Doctor Eppley, can the type of cheekbone and jaw angle advancement be done without implants but with the patients own bone? Such as with a cheekbone osteotomy? Also, do you have any before and after pics of this kind of procedure. I would like the male model look, but I have relatively flat and narrow cheekbones and a weak chin. I am currently undergoing orthodontic treatment and will eventually have a rotational advancement of my jaw, but this will not necessarily improve my cheekbones –do you perform cheekbone advancement widening? And could you send me some before/after pics of such results? Thank you very much for any help! I would certainly be willing to travel to consult with you.

A: Most facial bone augmentations can only be done using synthetic implants on top of the bone. The one exception to that is the chin where the option exists of either a chin osteotomy or chin implant. This is because there is enough bone to cut and move and the direction needed is a favorable one from a bone movement and blood supply concern. Such is not the case with the cheek. While the cheekbone can be cut and moved, it will only produce a widening effect and not a forward or anterolateral effect which is what most patients need and want when they undergo cheek augmentation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I have poor elasticity and a pannus that is causing problems sitting and walking. However I’m not that obese at 175. My skin is just weird after years of battling anorexia and bulimia. I’m in recovery now and off weight causing meds (depakote and seroquel). I don’t like liposuction outcomes and want to avoid that. I am hoping you can tell me that this is just from atrophy and break down of muscle from my disorders, and healthy work with weights and aerobic exercise and good meal plan can get rid of my thin skinned pannus covering mainly groin and hips (not over pubis). It’s causing pinching pain when I walk or sit and sweat related problems like chaffing. It’s  getting worse even though I’m losing weight to hopefully go back to my previous set-point of about 133. I should add that I’m an apple with a lot of adipose fat in relation to my hips. Also, I am wondering if my insurance might cover a panniculectomy, and if that is an option for me. Thanks for you time.

A: No abdominal pannus can ever be removed short of excisional surgery. Skin excess will not disappear with exercise, diet or even any form laser or ‘skin-tightening’ liposuction. Only a panniculectomy or amputational abdominoplasty will work. This is a surgical problem. When it comes to potential insurance coverage, your description of your pannus sounds like it would not qualify. One of the clear insurance coverage criteria for an abdominal panniculectomy is that the pannus hangs over the groin crease onto the thighs.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, There are several parts of my face that I wanted to improve, but I feel like the nose is the most significant feature that I want to change. I attached some pictures which show the amount that I want my nose to be built up. I would like to know if this is realistic. What is the best way to accomplish this, implants or your own tissues. I have heard implants can get infected and that rib cartilage is known for warping. I am uncertain as to which choice to make. What do you recommend?

A: What you are demonstrating is nasal dorsal augmentation from the frontonasal junction down to the supratip area below and behind the lower alar cartilages. The greatest amount of dorsal augmentation is in the radix because it is also the lowest. I think the kind of result you have imaged is realistic.

The major question is what material to use for nasal dorsal augmentation. There are two main choices; synthetic implants and rib cartilage of which I have used both. (although many more rib cartilage grafts than implants) While there are advocates for each, I would heavily lean towards the use of rib cartilage given your young age and skin type and quality. While it requires a greater investment of time and recovery up front, the use of your own tissues will not give you any infection, extrusion or tissue thinning problems for the remainder of your long life. In using rib cartilage, it can be done as a whole piece or as a fabricated diced roll construct. Which one is better is based on the quality of the rib tissue harvested and surgeon’s preference. Because most rib cartilages have some curve to them, it requires good surgical technique in how to harvest and shape them to avoid the potential for warping concerns.  I always use the cartilages from either the 8^th or 9^th rib. Sometimes a very straight piece can be obtained and shaped and then I use it as a solid graft. If the rib is very curved and a very straight piece can not be fashioned out of it, then it is cut into very small pieces (1mm) and packed into a surgical wrap to create a very moldable long implant like a piece of sausage. Once in place it is easy to shape and the splint after surgery holds it into place. It becomes very solid in a short period of time as the small pieces of cartilage allow very rapid fibrovascular ingrowth. As a young man, you should have very good rib tissue and I suspect the solid rib graft for your rhinoplasty will work just fine. That has been my experience in younger male patients.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, my jaw grew asymmetrically from birth. I had a surgery when I was 18 years old where they shaved off part of the chin, and added implants around much of my jaw. However, when it was done I thought my face looked too full. I had a second surgery to remove some of the implants. The result was better, but I am still not satisfied. I don’t need to look perfect, but I don’t enjoy having one side of my face be fuller than the other. Would it be possible to do surgery and simply shave off a little of the implant? I don’t want it out, because it needed to be in there, it is just too large.

A: Onlay augmentation of the jaw with implants is a common method to improve jaw asymmetry. This is a good treatment option when an osteotomy and occlusal adjustment is not needed or desired. There are numerous types of implants used in the jaw including silicone, Medpor (porous polyethylene) and Gore-Tex. (polytetrafluoroethylene) Each has their own advantages and disadvantages but they all share one similarity…they are relatively easy to carve and shape with a scalpel. Even though you did not say and may not even know what type of material that was implanted, it should be able to be pared down to a smaller size without the need to remove it first. Jaw implants are usually fairly easy to modify once in place.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I am a Mexican-American and want to get my nose fixed. My nose is flat in the middle while the tip is wide and droopy. Do you think a non-surgical nose job can lift my nose? I am afraid of surgery since I have never had any and because it would take time to heal.

A: The concept of a non-surgical rhinoplasty is understandably appealing but it is a far overblown treatment method in terms of what it can really achieve. It is the use of injectable fillers to augment or plump out certain areas of the nose. For the right problem, such as an indentation or depression in the nose, it can be very effective. It can also raise up part or all of the dorsal line of the nose or even push out a retracted columella. But it can not create an overall global change in the nose such as what you appear to need by your description. An injectable filler will help fix the ‘flat area in the middle of your nose’ because that is an augmentation issue. But the technique can not make a ‘tip less wide and droopy’ as that is a reduction issue. In trying to lift your nose with a filler you would merely make it more wide and fat with little lifting effect. A non-surgical injectable approach has its best use in correction of some postoperative irregularities after a rhinoplasty and is the most common usage in my plastic surgery practice.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve just recently had upper and lower jaw surgery to correct an underbite. I also had a sliding genioplasty (4 mm vertical reduction).   All of this was just done 5 weeks ago, so I realize I need to give it more time before know what the final results will be; it seems I still have some swelling. My questions/issues: 1) I’m wondering if the chin should have been reduced more. 2) I’m wondering if a have a bit of ptosis. I don’t notice it so much normally, but when I smile big, my chin gets flatter and seems to project out more. There seems to be a little loose/excess skin. The bottom half of my chin (maybe my chin pad?) seems a bit puffy and fatty, but maybe some of this is swelling.  I’m not sure if a lipo of the chin area would fix this, or if the mentalis needs to be resuspended, etc.  Or maybe it’s just in my head and it’s normal. Or maybe it’s swelling. I should note though that in 2002, I had a chin reduction that was done with a burr, and I’ve since learned that that can cause soft tissue issues. 3) The right side of my chin is a little longer than the left side, so it kind of makes my chin look a little slanted and the right side looks a little pointy.  I’d prefer for the bottom of the chin to just be straight across (square-ish jaw line maybe?)

A: The first thing I would say, of which you already know, is that it is way too early to judge the final results of your recent bimaxillary jaw surgery even in the chin area. Quite frankly, you still have an ‘orthognathic’ facial appearance which means there is still swelling and the tissues havge not settled over the new skeletal base. I would not critique the results until a minimum of 3 months and preferably 6 months after the date of your orthognathic surgery. When the tissues feel soft, move normally, and most of the feeling has returned, then you can focus on the aesthetic outcome.

For the sake of discussion, if all of these chin asymmetry/shape issues persist, they can be further improved by a chin revision. Whether this is done by a submental or intraoral approach remains to be seen based on exactly what the issues are. The key is what the overlying soft tissues do and how they settle out.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, what I would like to know is would liposuction and laser treatment to tighten abdomen area help with my problem area?  I seem to have small area over belly button that has always been there even when I lose and get almost too skinny for frame.  My skin on lower abdomen seems to be fine its tight when I stand but when I sit it gets kind of mushy with the rest of stomach.  I just have a hard time fathoming the fact that I would need a tummy tuck it’s not huge like some peoples I have seen.  I have had two pregnancies but no C-sections. Thank you so much!

A: In looking at our pictures, I can appreciate the slight quandry you have being uncertain whether liposuction alone or a mini-tummy tuck is needed. As a general rule, when you see a roll of skin above the bellybutton that is a sign of skin excess that can really only be flattened by a mini-tummy tuck. Since a mini-tummy tuck loosens and repositions the belly button from underneath, the roll of skin above is stretched out and moved lower which is how it gets ‘removed’. However, when your lower abdomen is in good shape (no excess skin) and the roll of tissue above the bellybutton is as much fat as skin, then liposuction alone is a viable treatment. In your case, I would have laser liposuction alone accepting that the postoperative flatness will be much improved even if it is not ‘washboard’ tight.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  My question is what is your opinion on fat transfers? I¹ve heard that there is some disagreement about it. Would that be an option instead of using Radiesse every six months which I have been getting for my depressed scars on the top of my nose and forehead?

A: The ‘disagreement’ on fat injections revolves completely around how they survive after injection. In the face and in small amounts, fat injections have the best chance for optimal survival but it can never be guaranteed. I do think that fat injection grafting is a very viable option for your facial scars and there is no real downside or risk of complications by doing so. The issue with fat injections for small facial scars, however, is about the hassle of doing it. Synthetic injectable fillers, despite their short-lived effects, have their appeal because they are quick and easy to do being an off-the -shelf product and treatment. Fat injections require a harvest site, preparation and then injection under very clean conditions like in the OR. I think if you were having some other surgery then fat injections would really be worth a try. But as a stand alone procedure, it is not very cost effective and the risk of complete resorption may not justify that effort for such a small amount of fat.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, our son is in need of some revision of scars about his face and lips. he is only 4 years old. I have some questions about the procedure if you wouldn’t mind answering them for me.

1. Would it be necessary for you to remove any stitching afterwards? And if so, how long would it be before they would be removed.?
2. One concern I have is that he is so young that he might damage or pick at any stitches if he had the operation now.
3. Is the operation done under a local?  He may also be a little too young to sit still for a long time. If the operation is under local how long would the procedure take?
4. Do you perform the procedure?

A: In answer to your questions of facial scar revision in children:

1. I never use stitches that have to be removed in children under the age of around 8 years old. Children are understandably fearful and uncooperative when you approach their face with instruments, as you might imagine. Therefore, I use very tiny dissolveable sutures that go away on their own. For lip scar revision, there are no restrictions afterward in regards to eating and oral hygiene practices.
2. I have never children picking or manipulating their stitches to be a problem. I have done many hundreds of cleft lip and nose repairs in children, for example, and have never seen that to be an issue.  The only issue with children, particularly boys, is their tendency to get inadvertent trauma such as falls and collisions while playing.
3. I would never perform facial surgery on a child under the age of about 10 unless they were asleep. Just like stitches that they won’t let you take out, they most assuredly are not going to allow the process to get them in.
4. There is only me to perform the procedure. I have no assistants or trainees. And even if I did, they would still not be performing the surgery. That is what people pay for me to do.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I am ready to change the look of my face and am willing to spend whatever money it takes to do it. First I want to make my nose smaller as it is too big for my face I think. Second, I want to reduce my jaw size and I want to shift it little back and narrow it from the front view. If these are possible, please get back to me. I have attached some pictures of me for you to see my problems.

A: Based on your pictures, your nose is wide and broad from the front and has a low dorsal profile from the side. Your nose could be made to look smaller by a rhinoplasty which includes dorsal augmentation, nasal bone osteotomies, tip narrowing and nostril reduction. How much smaller it would appear would ultimately be controlled, particularly in the tip area, by the thickness of your nasal skin. From a jaw standpoint, I am a little perplexed that you want your jaw smaller when it already has a horizontal chin deficiency when view from the side. But in applying your request, it could be made slightly smaller by chin reduction by burring through a submental approach and jaw angle reduction by oblique osteotomies. I have attached some predictive imaging with those nose and jaw changes in mind.

Dr. Barry Eppley

Indianapolis, Indiana