Your Questions

Q: My chin is too big and I need it reduced. What is the cost of chin shaving surgery?

A: Thank you for your inquiry. When one mentions ‘chin shaving’, they may really need a submentoplasty with chin burring reduction or they may really need a chin reduction via an osteotomy. It depends on their chin problem as the approach for chin reduction can differ based on the size and shape of their chin bone and the surrounding chin and submental soft tissues. Each method of chin reduction also differs in cost. Therefore, before providing a surgical fee quote please forward to me some photographs of your chin and what specific dimensional changes you want to see.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Hello Dr. Eppley, is it possible since you’ve had experience with silicone injections running out before during your surgeries for you to do a surgery and just let as much of the oil as possible run out?? I had the same injections but I don’t know if they were done in my tissue of my gluteus muscle. What happens to the gluteus muscle if it is injected?? Does the muscle absorb the silicone oil??

A: The injection of silicone oil for buttock augmentation is almost always done in the subcutaneous fat and not the gluteal muscle. It is taught to be placed as a ‘microdroplet’ approach, meaning to try and disperse the silicone oil into many small pockets and not just one big one. In the buttock, it is not really a microdroplet approach but more like smaller island or pockets of silicone oil placewd through the buttock. Silicone oil is not absorbed no matter whether it is injected into fat or muscle. It is an inert material thaty can not be metabolized by the human body.

Because it is dispersed out through the fat, it is nit really possible to perform a surgery to ‘drain it out’. This would only be possible if there was one large pocket of silicone oil confirmed by an MRI or if there were some problematic areas or pockets that would bebnefit by some drainage. But because multiple incisions would be needed to drain small pockets, this would end up causing significant buttock deformation. Unless certains areas are causing problems such as swelling and pain, it is best to leave them alone.

I have run across silicone oil pockets inadvertently during buttock lifts and any drainage that was achieved was coincidental not intentional.

Dr. Barry Eppley

Indianapolis Indiana

Q: I underwent suprapubic liposuction one week ago. I was surprised and concerned about how much swelling and bruising I have on my penis, scrotum and inner thighs. There is also a lump at the base of my penis which makes it look shorter than before the surgery. Will this go away and will my penis now be deformed? Will look a long when the swelling and bruising goes away as it did before? Is what I am seeing normal or am I understandably freaking out about what I am seeing? How long will it be before it looks normal again? Will I still be able to get an erection?

A: What you are experiencing is absolutely normal after suprapubic liposuction. Either you have forgotten all therse details of how things will look after for a period of time or you were never properly educated before the procedure. What I tell all males that receive liposuction in the pubic area is that they will have a tremendous amount of bruising and swelling of the penile shaft and scrotum afterwards…usually shockingly so. This will be striking to the man that has not seen it before but normal from my standpoint. When you see your scotum twice as large than normal and bruising at the base of your penis, you will freak out…unless you know that this is completyely normal. Gravity and the scotal pouch drives most bruising and swelling south. It may get so swollen that the penis may become almost completely buried.This will take about 3 weeks to completely go away. From an erection standpoint, it will work just fine as liposuction does not damage (nor is close to) any of the nerves that are responsible for this important function.

Dr. Barry Eppley

Indianapolis Indiana

Q: I have a major issue with my face that has effected me my entire life. I was born with a skeletal deformity which caused my entire right side of my face to be noticeably bigger then my left side. My bite pattern is off due to this problem which in turn has prevented me from getting any adult teeth on my left side because of the lack of bone to support the teeth. I was also born with glaucoma which has been said to be the result of a tiny unseen eye ball in my left socket which caused the orbit to grow different then my right side. I have attached some pictures. As you may notice, I need some serious help. I have dealt with it all my life but I dream of the day I can look in the mirror and see the same person on both sides. If you can help me in my time of need it would be greatly appreciated. God bless.

A: Thank you for sending your pictures and sharng your story, You were born with microphthalmia which has caused the left side of your face (orbit and maxilla in particular) to develop differently than the right. (the growing eyeball has a major influence on the surriounding maxillofacial bones). This means the the left side of your face is vertically shorter than that of your right, known as facial hypoplasia on the side with only an eyeball remnant. There is much that can be done but a good place to start would be with a 3-D craniofacial CT scan to clearly show the extent of the anatomic deformity. Treatment planning could then be done and could go in two different directions, major bone repositioning through osteotomies and/or bone grafts or a camouflage approach using facial implants. It would also be extremely helpful to have a good view of your existing teeth, even starting with a simple panorex x-ray and a view of your current bite relationship.

Dr. Barry Eppley

Indianapolis Indiana

Getting rid of the jelly belly and having a flat stomach is the desire of most women.  Many women can remember that belly of their youth with fond nostalgia when they good eat whatever they want and still look good in a swimsuit. However the combination of pregnancy, weight gain and gravity conspires against this goal.

While being bikini clad may not be possible for some as the warm weather approaches, at least looking good in a one-piece without that bulge would be great. This brings many to consider that a tummy tuck would be the answer. There is no question that the fullest version of a tummy tuck can make one the flattest but with that comes a fine line scar from hip to hip as well as a scar around the new belly button. That may be a good trade-off for the bigger hanging midruff but is not for everyone.

An alternative to this scarring is the mini-abdominoplasty, also known as the bikini line tummy tuck. Like the Lifestyle Lift is to the facelift, the bikini line tuck results in less  scar (shorter low scar with no belly button scar) and puts it in a better location…as low as possible. I often find that the length of the full tummy tuck scar is not what is usually the most offensive. It is that is very difficult to keep it really low, within the bikini line, due to the amount of skin removed and the tension that is placed upon it when it is closed.

Bikini Tucks are best for women who do not have tons of excess skin and fat. They are most ideal for the average build to more trim individual that just can’t get rid of that small belly issue and is driving them crazy. No amount of diet and exercise can get rid of it and one has reached the wall in terms of effort in trying to do so. This is understandable as loose skin is not a calorie sensitive tissue, it can’t be exercised off no matter how many situps you do or miles that you walk or run.

Some skin will tighten back up after weight loss or pregnancy but if it hasn’t done within 6 months to a year, it is not going to happen.  If there are stretch marks over the skin you want to get rid off, forget about any tightening at all. Stretch marks means the skin has been permanently damaged and has little to no elasticity at all left, it has been permanently expanded.

Liposuction can be part of any tummy tuck but it is most extensively used and often needed in the bikini line tummy tuck. Thinning out any fat above the belly button and along the sides of the waistline and hip at the same time adds to whatever skin and fat is  removed in the front.

Are you bikini ready? Maybe not and you may not even wanna be. But the Bikini Line tummy tuck can take your stomach and waistline to a place that you can’t get to…without a lot of visible scarring.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  I am developing deep folds on the sides of my mouth and my eyelids have extra skin that make me look tired. I have attached a picture so you can see my concerns. What type of plastic surgery will get rid of these problems?

A: Thank you for your inquiry and picture. There are two comments that I can make based on your pictures. First, you have a thin and lean type of fat. As a Caucasian, this makes your skin thin and extremely prone to wrinkles particularly around the mouth area. Such wrinkles around the mouth, known as smile lines outside the corners of the mouth, are virtually resistant to any treatment other than temporary injectable fillers. There is no surgery that can provide a cure or any long-lasting treatment for that resistant wrinkle problem. It is resistant because the one thing that would help in not making them continue to develop is to stop smiling or moving your mouth…not only an impossible but not a good social habit to develop.

From an eyelid standpoint, you have deep set eyes (again due loss of fat around the eyeball area or, in your case, you may have never had it to start with) with some moderate skin redundancy of both upper and lower eyelid skin. The real issue is whether the skin on your upper eyelids needs to be removed (eyelid tuck or blepharoplasty) or whether lifting of the eyebrows is better. You can determine that by doing a simple lift test on your eyebrows and see what it does to the skin on your upper eyelids and the new brow position.

For all of these reasons, I don’t think computer imaging is helpful in making these facial aging treatment decisions. It would be better to come in and sit down and go over the options that are available…and see what they can and cannot do.

Dr. Barry Eppley

Indianapolis Indiana

Q:  I have had 3 c-sections, hysterectomy, and my gall bladder removed that left a large scar. I have a lot of scar tissue that causes me sever pain in my stomach plus I know the muscles in my stomach have separated because you can feel it by feeling my stomach. The scar tissue is attached to my bladder which causes me problems in urination. I also have a large cyst on my left ovary that has added to the pain for the last year. I have a severe amount of skin that hangs from my lower stomach also. My question is since the scar tissue is causing my so much pain in my lower stomach, would it be possible that it would be a surgery that might be covered by my insurance and have the skin removed also.

A: Unfortunately, the simple answer to your question of insurance coverage for a tummy tuck is no. Insurance may cover adhesion release from your bladder and ovarian cyst removal which need to be evaluated and predetermined by your Gynecologist and/or a Urogynecologist. But the skin overhang and its skin removal (tummy tuck or abdominoplasty) will be deemed cosmetic by your insurance company. Similarly, the separation of the muscles (known as rectus diastasis) and bringing them surgically back together is not a medically necessary issue as would be determined by any insurance company that I have ever worked with. This is not to be confusd with a hernia which is a defect in the abdominal wall where bowel may be protruding through, which is a covered procedure.

This may all sound very unfair to you but that is the stark reality of insurance coverages today. There was a day long ago when insurance coverage was more broad and less discriminating but those days have gone the way of the Walkman and the eight track tape. You may even contact your insurance company and they may even say they will provide coverage if the doctor gives a medical reason. (they say anything on the phone but don’t confuse that with what they will really do later…since the person you are talking to will not even be in the section of the insurance company that actually makes the coverage decisions) The only way to know for sure is to send in an actual pre-determination letter which has to be done by the examining plastic surgeon.

Dr. Barry Eppley

Indianapolis Indiana

Q: I would like to know more about the transconjunctival approach referring to orbital rim augmentation with medpor implants and subperiostal midface lifts. Because you are both a plastic surgeon and an oral an maxillofacial surgeon I´am sure you are very familiar with this kind of approach. Once I have read that the infection rate of medpor implants placed through an intraoral approach is a little bit higher, because the mouth can´t be completely disinfected. Is it the same with the transconjunctival approach or is the mucosa in the lower eyelid an area in the face that is usually very clean due to its special purpose? What are the common risks of a tranconjunctival approach? Is there any chance of getting blind after such an operation? If performed right, has the transconjunctival approach any risk of ectropion or entropion or an increase of scleral show? Thank you in advance for your reply.

A: Unfortunately, you have been misinformed about placing any type of orbital rim implant through a transconjunctival approach, regardless of the material type. That is simply not physically possible given the size of the implant and the very size of this inner eyelid incision. All orbital rim implants have to be done through an external or subciliary lowere eyelid incision. This is the only way to insert them and have them properly secured into place.

You are correct about the higher rate of infections with porous implants like Medpor when placed through an inside the mouth or mucosal incision. That has been my experience as well.

Dr. Barry Eppley

Indianapolis Indiana

Q: I have suffered from severe disabling migraines for years. I have seen two different neurologists and none of the medications seem to work or are causing severe side effects. I’ve been doing research and came across the migraine surgery. I am willing to try anything to do away with or at least ease my migraines. As I am a single mother of three small children and it is crippling my income because I miss so much work due to these awful migraines.

A: Certain types of migraines can be cured or significantly improved by migraine surgery. Such surgery is based on release or decompression of sensory cranial nerves as they pass through muscles as they emerge from the bone. This has been shown to be effective for migraines that originate from the occipital, temporal, or supraorbital (brow bone) areas. A physical examination and the history of the migraine headache pattern can determine if one is a potential candidate. The definitive presurgical test is a Botox injection treatment into the identified nerve area. If significant relief occurs with the Botox injection, then this is a very good indicator that surgical decompression will be effective. I have yet to see a positive Botox test in which the patient did not get significant and sustained relief from the surgery.

Long-term studies out to five years has shown that about one-third of patients who undergo migraine surgery are cured. The majority of migraine surgery patients (about half) are not cured but have reduction in the number and severity of their headaches. A small number of patients (about 10%) failed to get benefit from the surgery.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: Will a LeFort osteotomy for short face syndrome tend to increase upper lip length (vertical height of upper lip)? If not is there a surgery to increase upper lip height (distance between columella and mouth)?

A: A LeFort I (maxillary) osteotomy for a short face is either being horizontally brought forward or being vertically lengthened. Either way, that facial bony movement will not make the upper lip longer. In fact, it is more likely to make it shorter due to the new bone position and the facial muscles which have been detached from the vestibular incisional access. During incisional closure of a LeFort I osteotomy, it is important to do an alar cinch suture and a v-y mucosal closure to prevent the nostrils from widening and the upper lip becoming shorter and more thin.

While there are multiple plastic surgery procedures for shortening the long upper lip, there are no operations that can truly lengthen the outside skin of the upper lip. Injectable fillers to the vermilion of the upper lip and internal V-Y mucosal advancements can provide the illusion of longer length or maybe even add a millimeter or two. But significant upper lip lengthening is not surgically possible.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I have scleroderma which over time has caused atrophy and asymmetry to my face. I’m interested in plastic surgery to help fill my face out and not make it look so narrow. So if you could please just send me some more information about this that would be great. Thank you.

A: Scleroderma that affects just one side of the face (most commonly) is known as linear scleroderma or Romberg’s disease. It is a rare facial condition that often does not start until late childhood or early adolescence and then burns itself out by early adulthood. It is not known what causes it or why it stops. It is currently thought there is a neurogenic basis for it. It results in soft tissue atrophy, with loss of subcutaneous fat, thinning of the overlying skin, and occasionally loss of some of the underlying bone. (most notably the mandible with loss of the jaw angle and shortening of the jaw line) This creates one-half of the face that is thinned and asymmetric. The forehead may have just a vertical line atrophy. Romberg’s disease comes in all variations from just a single area of atrophy to an entire facial half that is severely withered.

The key to reconstruction in Linear Scleroderma is soft tissue replacement or augmentation. I have done numerous Romberg patients and have used allogeneic dermal grafts, dermal-fat grafts, fat injections and even vascularized free flaps. Since the problem is largely soft tissue loss, the focus on reconstruction should be soft tissue-based. Occasionally, I have used a synthetic implant in the jaw angle but one should generally avoid placing implants is areas of thin soft tissue coverage. Which one of these soft tissue replacements is best on based on the location and degree of the facial atrophy. Each of their own advantages and disadvantages and combinations of two or more of them are usually needed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Hello Dr. Eppley, I have many problems related to my face. Firstly, my jaw is asymmetrical. Right side of my face/jaw is smaller than the left side. Therefore, my jaw is slanted to the left. My nose is deviated. Secondly, I have prominent zygomatic arch but my cheeks are hollow. My eyes are also deep probably due to my prominent brow bone. Beside my jaw, my left and right profiles are different. Back of my head on right side is flatter and hairline in the temporal area is different. How can these problems be solved? I want a more balanced face, in fact a more balanced skull, a flatter forehead, stronger and symmetrical jaw. I also want to have strong cheekbones but maybe a narrower midface. In addition to my photos, I also added photos of the face type that I want to have. Of course it is impossible to have the exact same face but similar facial features and proportions are what I think of. To what extent it is possible?

A: In trying to achieve improved facial balance it is important to focus on those features that can be changed without causing a lot, if any, surgical scars to do. This makes the improvement of jaw and cheek asymmetries capable of being improved with jaw angle and cheek implants that can be placed through the mouth. Similarly, cheekbone reduction can be done through combined incisions inside the mouth and from the temporal hairline. A rhinoplasty, open or closed, can be reliably done for better midline nose alignment and shape changes. Brow bone reduction, while commonly requested by men, is a more difficult choice because there is no ‘scar-free’ way to do it ( a scalp incision is needed) even though the procedure is very reliable at lessening the prominence of the brows. Skull augmentations may be able to be done through an injectable cranioplasty technique depending upon the degree of skull flattening.

When it comes to the potential of face changing surgery, it is best to think of altering and improving the foundation of what you have…not facial transformation.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr.Eppley, my fiance was hit in his face with a softball. We went to the doctor and the doctor told us that a part of it had shattered and recommended us to see a specialist. Approximately how much will his cheekbone surgery be? He doesn’t have a job, or any insurance. It is only I with an income and I’m supporting a family of five will that take part in paying for it?

A:  It would be impossible for me to say exactly what needs to be done with your fiance’s facial bone fracture. I am assuming, having seen a lot of ball injuries to the face, that it is a cheekbone fracture that may or may not involve the orbital floor. Some types of cheek bone fractures can be repaired simply through a single intraoral incision. If the orbital floor is significantly displaced, the fracture is more complex and would require a combined intraoral and a lower eyelid incision. Because of these differences, it is difficult to provide an accurate cost estimate. I would need to see some x-rays of his facial fracture to provide a good estimate.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: I don’t like the appearance of my nose and want to get a rhinoplasty to fix it. The problem is that the upper part of my nose is not straight or symmetric. There is also a small bump that I want to get rid of as well. Is there any way to really just straighten out the top bone of my nose? The upper part of my nose is diagonal. That is what I believe makes the one side look bigger. Is there any way to shave just a bit off the tip of the nose as well without  tampering with the nostrils or performing open surgery? What happens if the surgery does not heal correctly? Will I need to pay to fix it again? By that I mean deformed nostrils of something of that nature. Thank you so much! Sorry for my abundance of questions.

A:  You are talking about a closed rhinoplasty versus doing an open rhinoplasty. Through a closed rhinoplasty approach, the hump can be taken down, the nasal bones straightened by osteotomies and the tip narrowed by plication with sutures . With a closed rhinoplasty, there would be limited risk of nostril asymmetry. The more major issue and the real concern is how straight and symmetric the nasal bone area (pyramid) can be made. It is also important to realize that the tip changes through a closed approach would be less significant than that of using an open approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Hi Dr. Eppley. I am considering going to you for facial surgery, but I am unsure about exactly what procedure is necessary. All I know is this: I am a male with a long, narrow face. Can jaw angle implants make my face look more wide and more square-shaped? I am interested in making my face seem less long and vertical.

A: Thank you for your inquiry. Jaw angle implants do make the lower jaw more wide and square-shaped which may, or may not, be beneficial in helping you improve your long and narrow face appearance. That question can be answered by computer imaging. By simulating the results of the surgery on your own images, you can visually get the answer to these questions. If you send me some photos (front and side of your face on a clean background such as a wall or door), I will do the computer imaging so we can see if jaw angle implants are beneficial for you. Once we see the results, we will know if jaw angle implants or other facial implant procedures may be beneficial.

It is true that one way to change the illusion of how a face appears is to change the alternative or perpendicular dimensions. Therefore, vertical facial length may be counterbalanced by increasing facial width or forward facial projection.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am wanting to get my forehead fixed. It just never grew in right and I have been made fun of since I was a kid. Photos may not look bad but I have been called horn head, hell boy, and square head all my life and I just want it to look a little better. I have two prominent ‘horns’ for lack of a better word on my forehead. I don’t know if these are just bone growths or my brain sticking out. They feel hard though. I have attached a picture so you can see them. Can these be burred down or something to make them look better?

A: Based on the one picture that I could see, it looks like you have two bulges on the sides of your forehead creating that look. These are very much like larger osteomas. The skull is thicker in these bulging areas. Reducing the bony bulges is actually fairly easy by burring them down to make the forehead less square and more round. The trick to it, however, is getting there to do it. The best approach would be a coronal (scalp) incision across the top of the scalp but that resultant scar (fine as it is) may not be a good choice for a male.The other approach is an endoscopic one where much smaller incisions are used. The access is not quite as good but I should still be able to burr down the prominent areas.

Dr. Barry Eppley

Indianapolis Indiana

Q: I had a rhinoplasty last year of which I am not too happy about. The bridge was shaved too low and I do not like the tip. It looks fat and pinched to me. I have attached a front and side view of your nose so you can see the problems. I would love to see what kind of improvements you think should be made! Thank You.

A:  I have looked at your nose and my thoughts are that you have a fundamentally over-resected nose that was done too aggressively. While it may have looked good initially, the nose is now collapsed and contracted inward at the bridge and upward at the tip. In short, you have excessive hump reduction, an inverted v deformity due to nasal bone collapse, an over-rotated and pinched tip and excessive nostril show. In days of old, this type of problem was more commonly seen. Today it is more uncommon as the emphasis on rhinoplasty has been on conservation of structures and not simply removal.

To improve this nasal deformity, the nose needs to be done through an open approach with the nasal tip de-rotated, the bridge and middle vault built back up and the nostril rims grafted. This requires cartilage grafts which, most likely, can come from the septum and ear but may require rib cartilage to get the best amount of graft material. I have attached some computer predictions which demonstrates the objectives. This is a difficult recondary rhinoplasty problem but good improvement can almost always be obtained.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  My 19 year old son has very large guaged ear lobes. I am told they are the largest people say they have ever seen. He has been living in Los Angeles and now realizes that he has made a mistake. He will be moving back home where I am living in the rural Midwest.. He is hoping to attend college and make a new start here. We are  looking for a plastic surgeon here and some information on what the cost may be. Thank you for the information provided here and any further info you could provide to us. I really appreciate it!

A: Thank you for your inquiry. I have seen all types of gauged earlobes, so they may be big, but that doesn’t change the ability to fix them. All he has done is make more earlobe tissue to work with. More earlobe tissue is always better than less. While putting the earlobes back together is a delicate and complex task, it is a lot easier when there is adequate tissue to manipulate. Thus, while gauged earlobes look bad they almost always havge an ample supply of skin. Please have him send some pictures to me of his earlobes for my assessment. As a general cost quote, reconstruction of gauged earlobes (both sides) done as an outpatient procedure, either under straight local or IV sedation, is around $3500.

Dr. Barry Eppley

Indianapolis Indiana

Q: I self harmed for many years as a young person, I haven’t done so in almost a decade and I am a different person to the one I was back then. I find it almost unbearable to see the constant reminders on my arms and stomach. They are quite bad. I never go out in short sleeves and this has lead me to detest the summer as I am always covered up, miserable and uncomfortable. I wish I was like everybody else. Is surgery a good option for me to think about? I’m desperate to live a ‘normal’ life.

A: Self-mutilation leads to many linear and cross-hatched scars, often on the patient’s arms. They usually appear as fine white lines. They are white because of the unpigmented scar that is created from the often superficial lacerations. In general, the concept of simply wiping them away by laser resurfacing is not possible because the scar depth is too deep. At best, all one can do is trade-off a different type of scar for the self-mutilation scars. I have done deeper laser resurfacing to create a burned appearance as well as have even skin-grafted arm areas. The intent of this scar trade-off is that it can be more easily explained as part of a more socially accepted injury (e.g., burn) and not look like it was from self-mutilation  or from someone who is a ‘cutter’. If one can accept this scar trade-off, such a scar revision approach may be reasonable.

Dr. Barry Eppley

Indianapolis Indiana

Q:  I would like to know if Dr. Eppley has any experience in removing free silicone oil from the butt? I had silicone injections in my butt and would like it removed and replaced with my own fat.

A: Once silicone oil is injected into any tissue it can not be removed, from a practical standpoint, from the recipient site. The oil is dispersed throughout the tissues in many islands or droplets (really pools of oil) so it is not just one large collection which can be evacuated. It is not like an implant where it is in just one location as a congealed or formed mass. During buttock lifts I have run across injected silicone oil several times and it just runs out as you hit every subcutaneous pocket that it is in. The only way the silicone oil can be removed would be to completely cut off one’s entire buttocks. Therefore, it is best left alone.

The good news is that the silicone oil is not in the deep muscle but in the fat or subcutaneous tissues under the skin. Buttock fat injections can still be placed with the silicone oil in place as they are placed deeper into the gluteal muscle and deeper fat. I am not aware that the presence of silicone oil causes any problems with doing fat injections to the buttocks or necessarily causes greater problems because it is there.

Dr. Barry Eppley

Indianapolis Indiana

Q: I recently had small cheek implants but they don’t seem to have  made much of a difference. No one has really noticed. In addition, I have pain on my left side, it is more swollen, and my teeth and upper lip are numb. I think they should just be removed. Do you think implants should be removed sooner rather than later? What sort of time frame would you suggest -one week, two weeks etc?  At this point I am taking Oxycodone just to get through work due to the pain.  My plastic surgeon does not seem overly helpful at this point.  I cannot get in to see him until the end of this month.  The pain was so great over the weekend I was thinking of going to the ER but I did not think an ER doc could do a whole lot to help.  Also, if the implants are removed will there be any permanent structural change to my cheeks, from the pockets that were created for the implants?

A: I would only suggest getting them removed sooner rather than later given your pain issues. If they weren’t  painful, then there would be as much urgency to it. Such pain after cheek implants is uncommon…plus if the implant on the numb side is sitting up against the nerve (don’t know whether it is or isn’t but the numbness on just one side is a concern) the sooner it is removed the better for nerve recovery. With such small implants, there should not be any residual effects from having them in there. The pockets will just shrink down and go away and will leave no residual structural or scar issues.

Dr. Barry Eppley

Indianapolis Indiana

Q:   I’m considering a breast reduction with the hope of going from a 36DD to a C cup. The surgeon is anticipating approx 300 cc reduction on each breast.  Will that leave me with a C cup or less?

A: I would have to say that this is a question that your surgeon should answer for you since he/she has actually seen you and is in a better position to answer.

That being said, a 300cc reduction in breast volume for most women will not take a DD cup down to C, let alone less than a C cup. A 300cc reduction is quite small and would not qualify for an insurance-covered breast reduction because of the small amount of breast tissue being removed. Unless you are quite a small person, this will not cause a significant reduction in your breast size. I would go back and revisit this issue with your surgeon as there appears to be different levels of expectations in the end result. Breast reduction is a significant operation that is changing breast size at the expense of permanent scars. You want to make sure that in accepting this trade-off you are getting the breast size reduction that you desire.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  I had a rhinoplasty several years ago. One of my reasons for having the operation was to get a large hump on my nose removed. Since the surgery I have had trouble breathing through my nose. What can be done to correct the breathing problem resulting after hump removal? Is the cause of these breathing difficulties the enlarged inferior turbinates?

A: In removing a large nasal hump, several structures are taken down. While most people think a hump is made up of bone, it is really as much cartilage as it is bone. This cartilage includes the upper half of the septum and portions of the upper lateral cartilages. The merging of the upper lateral cartilages and the septum make up what is known as the internal nasal valve. This internal nasal valve is an important area that has great influence on how easily air moves through the nose. With larger hump reductions, the internal nasal valve may become compromised, causing postoperative breathing problems. While the size of the inferior turbinates may have an effect on your breathing, the most likely cause is internal nasal valve collapse.

Reconstruction of a collapsed middle vault (compromised internal nasal valve) is done primarily through cartilage grafts, a procedure known specifically as spreader grafting. This is done through an open rhinoplasty approach. Reduction of the inferior turbinates can be done at the same time to eliminate any other airway obstructive factor.  

Dr. Barry Eppley

Indianapolis, Indiana

Q:  I am asking about what to do with my under eye area.  I had a lower blepharoplasty 15 years ago. My undereye area is very sunken looking and there is a little darkness in the skin but that may be due to some shadowing as well. I am wondering if I need a redo with a canthoplasty/canthopexy and some orbital rim/tear duct/cheek implants. I have attached some photos of my eyes from different angles. I assume you can tell from photos I also had a cheek lift and other work.

A: Based on your photos, you have a significant volume loss of fat/tissue of the lower eyelids and over the lower orbital rims onto the cheeks. Whether that is due to your prior lower blepharoplasty with fat removal is speculative and irrelevant at this point. Because of the loss of lower eyelid/cheek volume and support, you also have increased scleral show. (pseudoectropion)

What you need is volume replacement of the lower eyelid and cheek. There are several different options to consider for this replacement. It fundamentally comes down to synthetic vs. autogenous graft materials. The synthetic approach is one you have already mentioned, that of an orbital rim/cheek implant either as a single piece or in two different segments. There are several different styles for this area. These have the advantage of an immediate augmentation that will be permanent. They are placed through your old blepharoplasty incision and a canthopexy would be done at the same time. The other option is that of fat injections to add volume or the placement of allogeneic dermal grafts. This approach has the advantage of not using an implant but the survival of fat is not assured and it may require more than one treatment session to get the best result.

There are advocates for either approach and it is not a proven matter than one method is better than the other. The use of implants has a more proven track history of use.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Hola por favor diganme si colocarse silicona solida en la parte de atras d la cabeza es bueno o malo? si mas adelnate de dañara cual es el costo y en donde puedo hacermelo,xfavor diganmee!! tengo la cabeza plana y tengo 20 años esto me ha molestado toda mi vida!! ayudaaaa xfavorrrrrr

A: A solid silicone implant is not a good idea for the back of the head for correction of flatness or asymmetry. However, an acrylic or PMMA cranioplasty is a better idea and is commonly used. This is placed through a scalp incision where the acrulic mixture is placed, shaped, and allowed to set before closure. One could anticipate a total surgical cost of around $7500 when done as an outpatient procedure.

You may feel free to send me some photos of your head for my assessment to see if this is a good procedure for you.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dear Dr Eppley, I am an Asian female. I have had an advancement chin osteotomy, 4mm forward and 2mm downward. But the result makes me  have a long flat face with wider chin. As it’s not just the tip of the chin move forward but also the wide chin so it’s not good. I am guessing that the chin bone should be trimmed and I was wondering if it can be done in 2 to 3 weeks after the chin osteotomy has been done? It seems the swallow is not yet gone, is it good for immediate surgery again? Also I will do a facelift with fat transfer with other surgeon. I was wondering if I should wait and to have the chin bone trimming and facelift done at the same time, rather than do the bone trimming now?  If I can’t do them together, how long should I wait before each of the steps?  I look forward to hearing from you very soon.

A: Based on your description, it sounds like your chin osteotomy was just done. Your chin bone movement was very small and I doubt that amount of bone movement would make your chin ultimately look wider. I think what you are seeing is swelling, particularly if it has just been done in the past few weeks. You can not really judge the dimensional changes after a chin osteotomy, particularly width, for several months. I would advise waiting 3 months and then see what you think. There is no reason you can not do some chin reshaping if needed with a facelift and fat transfer later.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am a bit disappointed with the way that I look and I would like to fix some things. I believe a forehead augmentation would help me look a lot better. One of the changes I would like my forehead to undergo is to put the hairline at a higehr height, so my foehead would become a bit higher. That means building up the upper forehead area about 1 to 2 cms. I don’t think it is necessary to build up any area of the parietal bone. These are the changes I desire in the hairy part of my forehead. The second change I desire is in the brow bone. I have the feeling that from the side, it doesn’t look masculine enough because the brow bone doesn’t stick out as it should in a male. I think an augmentation of a few millimeters and a reshaping with nice corners would improve the way my brow bone looks. The second change I would like to do is the slope of my forehead. The slope of my forehead is very good but somewhere between the hairline and the brow bone the frontal bone has a small ‘puddle’ and I think it should be built up too. Those are the changes I want to do for my forehead and I hope that an endoscopic bone augmenttaion would help. How many grams of cranioplasty material woould be used for this? I have attached a side view of my forehead for you to see its shape.

A: Thank you for sending your pictures. Despite the relative poor image quality, it is clear as to your forehead concerns. I think there is no doubt you would benefit by forehead augmentation (frontal cranioplasty) but I need to clarify what is and is not possible. To achieve a good result, your forehead augmentation can not be done closed or endoscopically.There is no way to ensure a smooth and confluent result by any type of injectable approach. Your forehead reshaping is too complex for that it would have to be done through an open approach requiring a scalp incision. Secondly, the volume of augmentation material that you require makes the use of Kryptonite too expensive. You likely require about 40 grams of material. Your most economic approach would be acrylic (PMMA) where such a volume of material is economically feasible. Thirdly, it is not possible to buildup your forehead as much as 2 cms, the scalp incision could not be closed afterward.

One cm. at most is what is possible. Lastly, your frontal hairline may come up a bit with the augmentation but not substantially so. It is not possible to buildup your forehead an surgically move your hairline back at the same time.

These are some practical considerations for you to consider.

Dr. Barry Eppley

Indianapolis Indiana

One of the most significant changes in plastic surgery in the past decade has been the emergence of non-invasive cosmetic procedures. Led by the well recognized use of treatments such as Botox, injectable fillers and laser skin resurfacing, some youthful changes and anti-aging prevention can be realized. Obtaining such results without surgery represents a paradigm shift from historic invasive treatments.

From treating wrinkles to losing wanted body fat, devices using various forms of energy have become popular. (laser, high intensity light, ultrasound, radiofrequency) Their popularity is not just because they are not surgery but because they do produce visible results for most patients. Such hopes of cosmetic improvements by an external device has also been applied to loose or unwanted skin. The concept of non-surgical skin tightening has tremendous appeal, whether it is those sagging jowls, that unwanted roll of  belly skin, or that floppy skin on the back of the arms.

Such devices abound and are all over the internet and popular magazines from Thermage, Ulthera or Smartlipo, to name just the most popular. They claim to produce skin tightening as one of their benefits. I regularly see patients who come in to get rid of their turkey neck, bat wings, sagging breasts or roll of skin that bulges over their beltline…with the hope and belief that such devices will avoid the need for surgery.

In reality all of these devices do produce skin tightening, with an occasional dramatic change in a few patients and more modest changes in most patients. Despite their skin tightening abilities, many patients will never be happy with the outcomes of these treatments alone. This has to do with the differences in how patients perceive skin tightening and in how much skin tightening these devices can do.

My observation is that a patient’s perception of skin tightening can be measured by centimeters and inches. Any device’s skin tightening ability can be measured in millimeters or just small fractions of an inch. It is not that these devices can not tighten skin but that most patient’s loose skin problems far exceed what can be done without surgery. No skin tightening device can replace a facelift, armlift or a tummy tuck when truly sagging skin exists. Non-surgical skin tightening works best for very modest amounts of loose skin…that one wouldn’t consider undergoing surgery to remove.

Like trying to lose fat with only taking a pill, wiping the appearance of cellulite and stretch marks clean by a skin massager, or getting rid of those dark undereye circles by just applying a cream, hope is eternal. Getting rid of loose skin, as most patients define extra skin, will almost always defy any current method of device-based skin tightening. It is not always appealing to realize that surgical removal is still the best way to get rid of unwanted loose areas of skin. Having a ‘nip and tuck’ may not be high-tech, but it continues to provide a level of improvement that will satisfy most patient’s expectations.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  I had a Le Fort I osteotomy to correct my bite, which it did. Despite the upper jaw movement my midface still appears flat. I was told to look toward having cheek and paranasal implants to correct my profile.

A: A LeFort osteotomy only affects the face at the upper jaw/upper tooth level, otherwise known as the maxilla. If the maxilla is brought forward (LeFort advancement) it can change the anterior nasal spine and the base of the nose, opening up the nasolabial angle and providing some paranasal augmentation. But it takes a significant movement forward to make those changes. But it will never provide any cheek or zygomatic enhancement as the level of the bone movement is way below these bone structures.

Secondary midface augmentation will require cheek and paranasal implants to achieve increased midface fullness/projection. When the degree of midfacial fullness is recognized before the LeFort procedure, the implants can be placed at the same time. But they can also be done afterwards as a secondary procedure. This would also provide an opportunity to remove the metal plates and screws that were initially placed to hold and heal the LeFort osteotomy. Four implants are used to create both lower (paranasal) and upper (cheek) midfacial augmentation.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  I am an Asian male and I have a retracted columella and a slightly acute nasolabial angle (I’d estimate it to be roughly 85 degrees).  I have read that it is possible to use cartilage (either from the septum or the ear) and fill in the area of the columella to increase the nasolabial angle.  I have also done research and found that a subnasal lip lift can correct the nasolabial angle as well.  I don’t want anything else done but to have the base of the columella fixed. How do you recommend it to be done?

A: Correction of the too acute nasolabial angle can be done by directly addressing the source of the problem. The nasolabial angle is effected by numerous anatomic factors but the angulation of the causal end of the septum and the anterior nasal spine most directly influence it. I am not aware that a subnasal lip lift can change the nasolabial angle to any great degree and that would not be an option unless one had a long upper lip concern also. Correction should be directed towards modifying the underlying osteocartilaginous foundation. Cartilage grafts can be used to buildup the base of the caudal septum. But attaching grafts in an end-to-end manner to the end of the septum has them being unstable and to wiggle back and forth. To be stable they have to be placed as a bilayer with the septum in the middle of the ‘sandwich’. A  more stable method is to  augment the anterior nasal spine, also known as premaxillary augmentation. Cartilage grafts and synthetic implants can be used but I find that a dermal graft is the best graft in the long-term for this area. That can be placed through an intraoral incision under the upper lip above the frenum.

Dr. Barry Eppley

Indianapolis, Indiana