Your Questions

Q: Over 10 years ago, I was involved in a car accident and ended up getting a craniotomy and evacuation of a subdural blood clot. Afterward, the craniotomy flap got infected and had to be removed. Because I was a child at the time, some bone actually grew back over the upper forehead defect. But it was not of the same thickness or amount and I have been left with a flat and irregular upper forehead area around my hairline and into the very visible part of my forehead. It is quite noticeable and embarrassing for me and I have always wanted to get it fixed. I have read recently through your writings that it can be repaired with some types of materials that are applied to the outside of the bone. That has given me great hope that there is a solution to this embarrassing problem. I am tired of people staring it! Please tell me about this procedure and how it is done.

A: Based on your description alone, it sounds like you would be an excellent candidate for an onlay cranioplasty procedure. Compared to what you have been through previously, this is a relatively simple operation that produces immediate results. Since you had a craniotomy previously, you have an existing scalp scar. The scalp ius lifted up again and a synthetic cranioplasty mixture is used to apply to the defect and make it perfectly smooth with the rest of the forehead. The available mixtures are a powder and liquid, which when combined, turns hard after it is shaped within a few minutes. There are three specific cranioplasty materials. I would choose hydroxyapatite, specifically Mimix, for your cranioplasty as it is the most like bone and has excellent working charcteristics. I have worked with it for over 15 years, including through its research and development phase, so I know its working properties very well. This is an outpatient procedure under general anesthesia that would take about 90 minutes to do.

Dr. Barry Eppley

Indianapolis Indiana

Q: Dr. Eppley. I went online and looked at your breast implant pictures. As I can tell it looks GREAT. I have been looking at different work from different doctors. I am a very small A. What do you suggest? What type of implant do you recommend for me? What is the total price? Do you have any financing available for people like me? I really want this bad! For a very long time. I feel unsure about my body and the way I look. I am going to be 32 and I have 2 kids. I have always wanted larger breasts ever since I was in school. Can you help me?

A:  What would make you look like a full B cup would depend on numerous factors including the base width diameter of your breast, tightness of your overlying breast skin, and your envisionment of what a full B cup is. Since I have no images of you, I will have to assume your base breast width is likely in the 11 to 13 cms. range. This would make an implant in the range of 250cc to 350cc a likely possibility. That would have to be determined by an examination and some images of breast augmentations that you like. Given your described financial situation, you would be best served by a saline breast implant which can be done at a lower cost than silicone breast implants. Total costs are in the range of around $ 4,700.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I’m a 6 year old male looking to remove a bump on my skull bone on the back of my head. I believe this skull bump resulted from a forceps delivery during my birth. I had an MRI of my head done and it came back normal. This is something that has plagued me psychologically all my life and I’m looking for any options to improve the appearance of the back of my head. I’ve provided photos of the back of my head. As you can see from the pictures, aside from the bump, there is also a ridge that leads to the more protrusive bump. I look forward to your assessment.

A: Thank you for making the effort to take the pictures. They are more than sufficient. What you have are two specific occipital bony uprisings, one ‘abnormal’ and the other a natural part of the occiptal skull bone. One is a small round bump at the top of the occiput which is a small osteoma or benign bony ‘tumor’ That can be burred down through a small vertically-oriented incision over the bump measuring about 3 cms. or just slightly bigger than an inch. Incisions in the hair-bearing scalp in men heal remarkably well and would eventually be such a fine line scar that it would be virtually undetectable. The horizontally-oriented bony ridge across the bottom of the occiptal skull bone is known as the nuchal ridge. It is where the top of the neck muscles attach to the lower edge of the occipital skull bone. It is raised and visible, as it is for some people, for unknown reasons. It may be raised because of the need for a strong bony attachment for the neck muscles. That can actually be reduced by burring down the ridge but the issue is incisional access. It requires a linear horizontal incision across the back of the head along the nuchal line, probably of a width of about 5 cms. Either skull reshaping procedure can be performed alone or in combination. Either way it is an outpatient procedure under general anesthesia that would have a minimal recovery. The incisions would be closed with tiny dissolveable sutures and one could shower and wash their hair after two days. There would be some temporary swelling which would go away in two or three weeks. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  Can you tell me how close a surgical result will be compared to the computer imaging that has been shown to me? Since it is done on the computer I assume that it is fairly accurate and representative of the result. I am desiring to get a rhinoplasty and chin and jaw angle implants and want to see if the result wiould be worth the effort and the expense.

A: A very important consideration when looking at predictive computer imaging is to realize how it is done and that it is not an exact science. The only thing ‘computer’ about it is that it is done on a computer. The computer does not create the images nor portray them on some one-to-one basis from the nose or jaw implant to the patient. In other words, the computer does not take the dimensions of the implant(s) or the amount of nose structure  that is removed and directly transfer that onto the patient so the changes will identically match. Rather, computer predictive imaging is done on Photoshop by the plastic surgeon with their best guess of what the changes may be. It is an art form not an exact science. Thus, computer imaging can easily overpredict or underpredict what the final result may be. Since patients view computer imaging as a more exact science than what it is, I always slightly underpredict what I think will happen. It is important for the plastic surgeon to not overpredict as this may easily overpromise or oversell the surgical procedure. This can lead to postoperative disappointment in the result if these expectations are not met.

The very valuable feature of computer imaging in rhinoplasty and jawline implants is that it can be a very good predictor compared to many other facial plastic surgery procedures. Because these are silhouette or profile facial structures, they are easy to morph and see the potential changes.

Dr. Barry Eppley

Indianapolis Indiana

Q: Dr. Eppley,  I need to lose 145 lb and I have tried everything. Can liposuction help and how much does it cost? I also I need a tummy tucks and my breasts lifted.

A: With the need to lose a lot of weight, liposuction is absolutely not the answer that you seek. Liposuction is best used for spot fat reduction and for those patients who may need a ‘jumpstart’ for relatively small amounts of weight loss. (10 to 25 lbs) For near or over a 100 lb weight loss, you need to seek a consultation with a bariatric surgeon if everything to now has failed. That amount of weight loss can only be achieved through gastric banding or gastric bypass surgery.  Any other desired body changes, such as a tummy tuck to get rid of the skin overhang around the waistline or lifting sagging breasts, must wait until after this weight loss have occurred. Attempting to do such surgery in the face of being significantly overweight is not only ill-advised from a health standpoint but any benefits gained will be wiped out by significant weight loss. Not to mention that the amount of improvement one can achieve in the obese patient is relatively limited.

The foundation of your body reshaping begins with the need for a large amount of weight loss. The first place to start is a consultation at a Bariatric Center.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am interested in reducing the size of my adam’s apple as it sticks out like a bulge in my neck. In reading about tracheotomies, I wonder if there was an at-home method in which a man could try the look, feel and sound of having a more feminine adams apple appearance just for say a few weeks before taking surgery. Have you ever heard of anything like this?

A: For the sake of clarification, tracheal reduction and tracheotomies are two different completely different operations with diametric objectives. A tracheostomy makes a hole through the skin and down into one’s windpipe below the thyroid cartilage for the sake of breathing. A tracheal reduction, technically known as a thyrochondroplasty or adam’s apple reduction, reduces the protrusion of paired thyroid cartilages as they bulge out into the neck. If done properly and without removal of too much cartilage, it will not change the pitch or sound of one’s voice. (a tracheostomy will definitely affect one’s voice) If you wanted to see what a tracheal reduction would look like, that is what computer imaging does. You can get a good visual approximation of the final neck contour result. It can help one see what the change would look like on them and is the best way to ‘try it on’ before surgery. There are no non-surgical methods to try and simulate that change in neck appearance.

Dr. Barry Eppley

Indianapolis Indiana

Q: Dr. Eppley. I am interested in getting the large dimple removed from my chin. I am not sure where to turn to since it seems very few plastic surgeons perform this procedure. Please send me information in regards to how this surgery is done, how successful it is, and the possible cost. Thank you!

A: Thank you for your chin surgery inquiry. Chin dimple reduction/removal is usually done by an incision inside the mouth. (behind the lower lip) The key to a successful chin dimple reduction (sometimes a complete removal) is that you have to fill the muscular defect/indentation with some type of graft. This could be allogeneic dermis (off the shelf) or fat or dermal-fat grafts from the patient. In some cases, releasing the dimple and sewing the muscle together may suffice. This is done under local anesthesia or IV sedation as an outpatient procedure. Dissolveable sutures are used inside the mouth. There are no restrictions in eating or physical activity after surgery. Some mild swelling is to be expected but this will be gone in a few weeks.

The cost of chin dimple surgery is around $2500.

Dr. Barry Eppley

Indianapolis, Indiana

Catching a glance in the mirror or looking at a picture and seeing those sagging jowls and a droopy neck can be a troubling finding. It often seems like it came out of nowhere. I have yet to see a person find this discovery charming. While hope lies in that some magic cream or laser treatment will make it all go away, deep down inside we all know it isn’t true. (but we can dream can’t we?)

When it comes to that loose jowl and neck skin, everyone wants to avoid the dreaded word…facelift. While most people are unaware that a facelift is really just a necklift, everyone would agree that they would like as little surgery as possible. While the fears and recovery surrounding a necklift are largely overstated, one really hopes that they can get by with a ‘minimal’ procedure. This understandable apprehension has led to the nationwide branded selling of facelift surgery.

The best example is that of the Lifestyle Lift. Through their national magazine and television ads, this is a franchise approach to getting a facelift…or some version of it. I have seen many patients who know the name, but don’t really know what it is. Promising to turn the clock back at least ten years and look recovered in just a few days, its catchy name seeks to assure patients that it will fit into their ‘lifestyle’. Interestingly, and perhaps not an oversight, nowhere in their advertising does it even suggest that it is real surgery. Many prospective patients only become aware that it is surgery when they actually visit a company facility.

What is a Lifestyle Lift? While sounding new, it is really quite old and has been practiced by plastic surgeons for decades. It is a scaled-down version of a facelift, a ‘mini-facelift’ if you will.  Sometimes called a tuck-up facelift, a secondary facelift, or a jowl lift, it is a limited operation that best improves those sagging jowls with a little tightening of the neck. The operative word here is a ‘little tightening of the neck’. If you have a neck wattle or turkey neck, this is not the right procedure for you.

Because it has an appealing name, the Lifestyle Lift has created a number of name knock-offs, including the Swiftlift and even the Lunchtime Lift to name just a few. Most of these are surgeons who have jumped on the naming and marketing bandwagon and have given their version of a limited facelift its own name. There is no real difference in the procedure or in whom it is or is not most beneficial.

Because it is heavily marketed and the internet exists, the Lifestyle Lift has its share of critics.  Much of this has to do with trying to make an individualized custom operation into a factory line retail product. As an operation, however, limited types of facelifts do have a valuable role in facial rejuvenation. Not every patient needs or wants a full facelift.

Facelifting is not an operation that should performed the same on everyone. Nor does having a catchy name mean it leads to better results or a quicker recovery. Many plastic surgeons offer similar limited types of  facelifts that just don’t have a branded name, but that doesn’t make them any less effective or useful.

Dr. Barry Eppley

Indianapolis

Liposuction is a very effective procedure for removing unwanted fat. It is a well known procedure that many people want and some have concerns about its safety. There are stories every year around the U.S. about serious complications arising from liposuction so it is no wonder it can give one pause. If you dissect behind these stories, however,  there is almost always a reason these liposuction complications have occurred. This recent story caught my attention…I will get into the reason after the story.

‘Earlier this month,  an Arizona doctor was charged with murder after three patients died in 2006 and 2007 during liposuction procedures performed at his clinic. According to the prosecution, the doctor did not kill these patients with a gun, rather the murder weapon was arrogance and the motive was greed. Two of the patients overdosed on anesthesia during routine liposuction procedures and the third died of a fat embolism after undergoing buttock augmentation with fat injections. All three were improperly intubated during resuscitation, making it impossible to save them.

The doctor, who was trained in Internal Medicine and Dermatology, opened a cosmetic clinic in 2005. Initially he offered Botox, hair restoration and laser procedures before moving ‘up’ to do  liposuction and breast augmentation. He employed medical assistants with little or no medical training. According to the Arizona Medical Board Review, his medical staff included a massage therapist, a former restaurant owner, two former pre-school teachers and his mother. And when he had to surrender his medical license after the first two deaths, he hired a homeopathic doctor to perform surgery that soon killed a third patient.’

While on the surface of the story liposuction receives the blame for these complications, even the medically uneducated would perceive that the real problem was not the procedure but the doctor. The average person reading this story would say…how could this happen? Aren’t there rules and regulations that govern what doctors are allowed to do?

The simple answer is…no. Once  a doctor has a medical license, they can perform anything they want…in their office or their own clinic. The only regulations are when they try to perform procedures in a hospital where medical oversight exists. This has become a significant issue in cosmetic surgery where much can be done under local and IV sedation anesthesia. An office setting without general anesthesia is very appealing to many patients, particularly when it comes to liposuction, as they perceive a limited or virtually no recovery scenario. As this story illustrates, the office setting under local anesthesia may not be safer than an operating room under general anesthesia. Not to mention that the results between the two locations may not be remotely similar.

How could someone with no real training be allowed to perform these procedures you ask? Because in the office setting the only ‘regulations’ a doctor has is their own conscience. In today’s medical climate, whether it be for economics or ego, the appeal of an upfront fee as opposed to an insurance billable procedure is an invitation for doctors to step beyond what they are actually formally trained to do.

Prospective cosmetic surgery patients need to do their homework and look out for their own health and safety. That attractive low fee and the ‘simple’ office procedure can be a recipe for problems. Bargains are for the retail mall, not for medical procedures.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have an unusual question about a part of my face that was wounded by laser treatments. Several years ago I went to a family doctor in town that offered laser hair removal at  a great discount. For that great fee reduction, I ended up getting several areas of burns on my face that have scarred. These have largely gotten better. My ongoing problem is on some facual skin areas that show no visible signs of scarring. Instead, there is an issue of a constant burning sensation under the skin. There is no scar and the skin looks normal but there is a constant burning sensation that occurs. So, my question for you is what could be causing this burning
sensation under my skin? It undoubtably occurred from the laser treatments since I did not have it before. What could the laser have damaged under the skin that caused this constant burning sensation? Most importantly, what can I do to fix it?

A: This is certainly an unusual problem. The laser may well have burned the ends of the tiny sensory nerves, which are more sensitive than the overlying skin to a thermal injury. This nerve scarring may have changed how those nerves feel due to the damage. That would explain why it feels like it is burning, years later, even though it is long past the possibility of any actual skin injury.

Time initially would be the first option. Nerves can heal and recover but that would, in theory, have done it by this point years later. If there has been  no gradual improvement in that sensation lessening by now, then it may well be permanent. The next treatment option to consider is Botox. This simple injection approach will block the acetycholine transmission and the sensation may cease as long as the Botox is effective. (4 or more months) Whether it will work or not is speculative but that is exactly how it works in the treatment of hyperhidrosis for example. In addition there is nothing to lose as long as there are not muscles of facial expression nearby. If this is ineffective, then skin flap undermining in a minor surgical procedure will disrupt the nerve ends and may possibly end this dysesthesia.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I recently had jaw angle implants and it has not turned out to be a good experience. My jaw angles were high and made the back part of my face looked weak and absent. My surgeon initially placed silicone implants but all they did was make my face look more wide and fatter and did nothing to make the jaw angle change I needed. My surgeon acknowledged that these implants were not the right types. I then had a second surgery done using Medpor jaw angle implants. Even though there was a lot of swelling after surgery, I noticed that my left side was very different from the other side. This has become only more apparent as the swelling has gone away. They look and feel completely different between the two sides. My surgeon says he wants to go in and shave down one of the implants but I have lost faith in him at this point. What do you recommend?

 A: Sorry to hear of your surgical misfortune. Jaw angle implants are, without question, the most difficult facial implant to do well, both in implant selection and in surgical placement. They are incrementally more difficult than the more commonly used chin and cheek implants. Symmetrical placement, because you have to put in each implant independently and without view of the other one, is challenging. One has to be very attentive to every detail of the implant position and to screw it into place, if possible, to ensure the best symmetry. The most difficult jaw angle implant to place are the Medpor ones because their material surface has a high degree of frictional resistance and they don’t slide in easily. That is the only jaw angle implant, however, that can drop the jaw angle down vertically. Most of the time, these implants have to be trimmed down to fit, removing the long anterior end. I have found it very beneficial to use the implant sizers first to fully develop the pocket and only place the final implant when the sizer slides it easily to the desired location. It would be impossible for me to say what is the best approach with your current jaw angle implant situation. I don’t know what you look like now nor do I know the details of your current implants and what is making them asymmetric. Shaving down the malpositioned implant may work but, more likely, the implant needs to be repositioned.

 Dr. Barry Eppley

 Indianapolis, Indiana

Q: Dr. Eppley, I have a problem with the right side of my chest. It is smaller and looks completely different from my left side. I have noticed it since I was a small boy and it has always embarrassed me. It looks like I do not have a chest muscle on my right side. I want to know what can be done for it. I have attached some pictures including ones with my arm raised where you can really see the difference.

A: Thank you for sending your pictures. It does appear that you have Poland’s syndrome. This is an underdevelopment of the pectoralis chest muscle. It is a well known congenital chest deformity. This can clearly be seen in your pictures, particularly the one with the arms lifted. You can see the short pectoralis muscle and its abnormal attachment to the upper sternum. This accounts for your smaller right chest appearance, the high position of the right nipple, and the asymmetry between the two sides of your chest. 

In treatment of male Poland’s syndrome, several treatment options are available which primarily focus on improving the volume of the right chest. This can be done with an implant, a pedicled latissimus dorsi muscle flap or a combination of both. A pectoralis implant is the simplest approach but the lower edge of implant will not have muscular coverage so the lower edge may be palpable or visible when the arms are lifted. Other treatment options include scar release/lengthening of a tight muscle band across the armpit and possible right nipple repositioning. It is also important to look at the opposite chest to see of anything can be done there to help improve the symmetry between both sides of the chest.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have terrible sagging elbows. It is not really the upepr arms like many people but just down and around the elbows. I have lost a fair amount of weight but the extra skin seems to have settled largely in the lower part of my arms. I am very interested in correcting this problem as when I lean on them they are painful and red. Is there a surgery for saggy elbows?

A: It is very common with a lot of weight loss for women to develop the saggy upper arms in the triceps area. (aka batwing) If extensive enough, the extra skin may extend the whole down across the elbow into the forearms. This is treated by an extended armlift.

But extra skin that is largely just around the elbows, and not involving the upper arm as well,  is not common. Bur whether it is common or not, it can be treated by skin excision making it an elbow lift. Just like the armlift this does result in a longitudinal scar that crosses the elbow joint. The key to this elbow lift is to not put the scar on the back of the arm. This would make the scar come directly across the prominent angle of the elbow on bending one’s arm. That would likely cause healing problems in the short-term and scar pain in the long-term. The scar needs to be placed on the inner aspect of the elbow to both avoid the flexion of the elbow joint and to be least visible to others.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dear Dr. Eppley, what are the different techniques used in brow bone augmentation? What are the pre-operative and postoperative things to consider? Thank you so much.

A: When it comes to brow bone augmentation, the first consideration is what part of the brow does one want augmented? Most patients want the whole brow done and it must be approached through a scalpor coronal incision. There are some patients who just want the tail of the brow augmented and that can then be done through an upper eyelid incision. The next consideration is what material to use. There are four options including preformed implants and three mixtures which are applied and then harden which include acrylic (PMMA), hydroxyapatite (HA) and Kryptonite. (calcium carbonate) Because of moldability to the brow bones and that more volume can be obtained, I prefer the mixture materials. There are arguments to be made for any of them and they all will work. Considerations must be given to cost, long-term tissue acceptance and fracture resistance. From a cost standpoint, acrylic is best and is the most fracture resistant but there may be some tissue thinning over many decades of implantation. (emphasis on the word…maybe) HA and Kryptonite are very similar to bone so there will never be any problems with tissue acceptance but they are more easily fractured (theoretical concern, not one I have ever seen)  and cost more. The choice of any of these materials for brow bone augmentation must be done on an individual patient basis.

Dr. Barry Eppley

Indianapolis Indiana

Q: Dear Dr. Eppley, I was looking at your web page description of ear lobe surgery and it made me feel hopeful. I recieved an infection/cut in my ear several years ago. Despite minor irritation, I continued to wear light earrings but the ear plug kept lowering and lowering until today. Today my earlobe has split entirely. I would like to have further information on whether and how this can be fixed. What should I do with in the interim to heap it heal?

A: Once the tissue begins to thin in the outer earlobhe skin from a piercing or a larger insert, eventually the skin will break down and a complete earlobe tear will occur. This is not uncommon and it is an easy problem to fix. It is a simple earlobe reconstruction done in the office under local anesthesia. The earlobe can be completely restored to normal size and shape, albeit with a fine line scar. The cost for this procedure is about $425. Once can re-pierce their ear 6 weeks after the procedure. (but gauging can never be done again)

In the interim you may apply antibiotic ointment until the skin edges heal in a few weeks. You may tape it together for appearance reasons during the daytime although this is not essential. Taping it together will help it heal a little faster.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am in need of getting jaw surgery and was told that I could get my nose and cheeks done at the same time. They want to do an open rhinoplasty and malar osteotomies  as well to get an improved look to my face. My question is can these be done safely all during the same surgery?

A: There are several fundamental issues with this combined surgical plan. The first would be what type of orthognathic surgery? If it is just an isolated lower jaw (mandible osteotomy) procedure, then I see no problem with a combined rhinoplasty as one does not really affect the other. (other than the need to change position of the endotracheal tube for anesthesia) If it is an orthognathic surgery procedure that involves the maxilla (alone or in conjunction with the lower jaw), then more thought need to be put into it. The advisability of those two would depend on what type of nasal deformity one has and what needs to be done to the nose. A maxillary osteotomy changes the skeletal foundation on which the nose sits and detaches the facial muscles which affects the alar base or nostril width. This can make it hard to know with any certainty how the nose will change with rhinoplastic maneuvers. A rhinoplasty procedure, on its own, is fraught with certain variables that can adversely affect the outcome even in the most experienced hands. Adding the underlying changes of maxillary position only adds another variable that may affect the final shape of the nose after its manipulation.

Most of the time, the concept of combining rhinoplasty and orthognathic surgery is an issue of ‘surgical opportunity’. You just want to be sure that the benefit of the opportunity does not over ride the more important objective of a desired result with the least risk of complications.

Lastly, I am unclear as to the need for malar osteotomies vs implants for cheek augmentation. Malar osteotomies tend to be more difficult bony movements that often do not produce as good as a cheek result as the more simple placement of implants. I have put in many a cheek implant with a LeFort 1 osteotomy and have never seen an infection.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Hello! I had gastric bypass surgery in August 2008. Since that procedure, I have lost over 135 pounds. Here is the my problem. I have worked much of my life trying to gain control of my weight and now that I have done that I have excess and sagging skin that is a constant reminder of the overweight, unhealthy person I used to be. Furthermore, I am at a dead end financially as I had to pay out of pocket the expenses for by bypass surgery which was almost $50K. I am exhausted financially between the surgery and my four kids. Are you aware of any programs, grants or clinics that are available to assist bariatric patients with the skin removal they need after their weight loss?

A: Congratulations on your weight loss success. That is a big accomplishment. While such extreme amount of weight loss is a big first step, most patients with this much weight loss will have large amounts of deflated skin that just hangs. This is managed by a range of procedures known as bariatric plastic surgery. With the exception of an abdominal panniculectomy, these procedures are cosmetic from a financial perspective. I know of no doctors or clinics that perform these extensive procedures at low to no cost. They require a large amount of surgical effort and operating room expense which is why there are no limited cost facilities or programs that perform them.

I wish you continued success in maintaining your current weight and one day being able to complete phase 2 of your body metamorphosis.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Hello, I am a 27 year-old athletic male who is bothered both my puffy nipples. Some days they don’t seem that bad. But other days they really stick out. I don’t know why they are so different on different days. I am not sure whether I need my nipple cut down or the tissue under the nipple removed. Whatever it takes to do it I don’t care as I just want it gone. What do you recommend and what is the surgery like and how quick will I recover?

A: Puffy nipples are different than pointy nipples as patients often describe these two male chest problems. A pointy nipple is when the centrally located nipple within the areola sticks out like a small sharp point. It is small protrusion and is managed by a simple nipple reduction which is an office procedure done under local anesthesia. There is no real recovery as small dissolveable sutures at placed and one goes about their activities as normal immediately afterward. A puffy nipple refers to the development of a small mass of breast tissue underneath the nipple-areolar complex that makes it stick out or be puffy. This is known as areolar gynecomastia and is a limited gynecomastic reduction. It is treated by an outpatient procedure in which the enlarged breast tissue is removed from under the nipple by a small lower areolar incision. Patients wear a chest wrap for a week or so and show refrain from exercise or strenuous exercise for a few weeks to avoid a fluid collection or excessive scar tissue formation which will wipe out the benefits of having the puffy breast tissue removed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I need to have my chin brought forward as it is very weak. I know that the bone hs to be moved given how short it is. I want to have this surgery but I have a lot of questions. I am hoping you can answer them for me. Will I need to put braces or get some teeth removed to do this? How long will I have to stay in the hospital and how long will it take me to recover completely? In case I meet with an accident in the future and hit the chin, what would be the consequences? In case I meet with an accident in just a few weeks/months after the surgery and hit the chin, what would be the consequences? What are the risks of this surgery? In case the results are not what I desire, what kind of measures do you use to fix it? Any long term side effects? How painful will it be, and for how long can the pain last. Are there any breathing problems? How different is this from a complete jaw surgery? Are there any visible scars after the surgery? If yes, where exactly on the face? Thank you in advance for taking your time to answer my many questions.

A: If one is having the whole jaw advanced, braces are needed. I have not seen your bite nor do I know if you have any interest in changing it. If so, then presurgical orthodontics are needed. However, I am assuming that this is a chin osteotomy advancement and not the whole jaw so the answer would be that no braces are needed. All the remaining answers are based on a chin osteotomy procedure. This is an outpatient procedure and is done in a surgery center not a hospital. The chin bone will heal normally and will be no different than your normal chin bone is now once full healed. The chin would not move after the surgery since plates and screws are holding it together as it heals. The biggest risk of surgery is some temporary numbness of the lip and chin. If the look is not adequate or the chin not advanced far enough, the bone can always be readjusted or an implant placed to augment it further. I have never seen this so it is unlikely. There is no risk of breathing problems from chin surgery. Most patients report that the chin area is sore and mildly uncomforatble but not  severe pain. In a chin osteotomy, only the deficient chin bone is moved and does not involve movement of the rest of the jaw and the teeth. Everything is done inside the mouth. There are no external scars.

Dr. Barry Eppley

Indianapolis Indiana

Q: I have a weak jawline and would like to do something about it. I have previously had a chin implant but it did not appear to have made much of a difference. The implant didn’t address my weak jawline. I would like to find out more about the wrap around jaw implant. How many days do I have to wait between 3D CT scan and the actual surgery? I have attached a side view picture of myswlf for you to see what I mean.

A: Thank you for sending your picture. Based on this one view, I am seeing the need for chin augmentation and possible jaw angle imlants. But it is not clear to me why a custom-made implant would be necessary. Such wrap around implants are most beneficial when the entire jawline needs to be augmented from one angle to the other It is especially useful when the entire jawline is vertically deficient for which there is no off-the-shelf implants available. Horizontal or minor vertical jaw angle deficiences can be managed by non-custom made implants. I would be curious to know why has interested you in the custom wrap-around jaw implant. Perhaps it is because you have had no success with a chin implant already. But that may be because the size and style of implant chosen was too small. I would need to know what type and size of chin implant was used to determine whether to go with a stock or custom implant for better correction.

To answer your other question, the usual turn around time from the patient getting a 3-D CT scan and then the jawline implant being ready for surgery is about 6 weeks.

Dr. Barry Eppley

Indianapolis Indiana

Q: Dr. Eppley, several weeks ago I had surgery to repair a cheekbone fracture. However, I am not satisfied with the results. The cheek bone fracture was repaired through an incision in my temple hair. I was told by the surgeon the fracture couldn’t be accurately aligned and fixed together without significant scarring so this was the best way to do it.  Is this possible for you to do?  Is it too late? I have attached a picture of how I look now so you can see that my cheek is flat but the side of my face is wider than before.

A: Your history and picture are very helpful in understanding what type of zygomatic fracture that you have.It appears you have a classic ZMC fracture with inward rotation of the cheekbone complex into the maxillary sinus. This is the classic direction that it rotates when displaced, down and in. That explains the orbital rim-zygomatic flattening with the lateral facial widening (bowing out of the zygomatic arch) that you have.

I wonder why a Gilles approach as used for your repair that as that would never work. The Gilles approach is for an isolated zygoimatic ARCH fracture not a body fracture. Your cheekbone fracture repair could be fixed by either an intraoral incision alone or combined with a lower eyelid approach. The bones could be realigned and then secured by plate and screw fixation. That would not result in any significant scarring. That is the classic and best approach with hat appears to be your zygomatic fracture.

Dr. Barry Eppley

Indianapolis Indiana

Q: Dr. Eppley, I am curious about nipple reduction. I am an athlete with only about 10-12% body fat but I have nipples that stick out. I have always been self-conscious about the kind of shirts I wear or even taking my shirt off. I would like more information on what is best for my situation.

A: When one is concerned about nipples that stick out, it is very important to differentiate between true nipple protrusion and areolar gynecomastia. Both can cause protrusion from the nipple area but they appear quite differently on close inspection anad are treated with different techniques.

The commonly called nipple is really better understood as the nipple-areolar complex. There is a central protruding nipple surrounded by a flat pigmented areola. In men, the nipples are smaller because the size (diameter) of the areola is very small. In nipple protrusion or hypertrophy, the small central nipple sticks out while the surrounding areola is flat. This makes for a small point that sticks out in shirts. It is treated by a simple nipple reduction done under local anesthesia in the office. Most of the nipple is removed so it lays flat and will never protrude again. In areolar gynecomastia, there is a mass of breast tissue that pushes out the whole nipple-areolar complex. This is better called a ‘puffy nipple’. It is treated by removing this mass of breast tissue through a small areolar incision. This is done as an outpatient procedure under IV sedation or general anesthesia.

Dr. Barry Eppley

Indianapolis Indiana

Q: Hello, I’m writing because I am in need of a tummy tuck. I have had four c-sections and I would like to know if I will be able to get a tummy tuck. I have a very large stomach pouch that I dislike and would like for it to be removed before I get too old. If not, it will be sitting in my lap. Will having these c-section scars interfere with having a tummy tuck? Can the entire stomach pouch be removed or can only some of it come off? Thanks for answering my questions!

A: The large stomach pouch to which you refer is a pannus, otherwise known as an apron of skin. (and fat) Between multiple children, c-sections and weight gain, the excessive abdominal skin and fat falls over the waistline. The scarred and indented c-section location accentuates this pannus by pulling in tightly underneath it. The solution to this pannus problem is a modification of a traditional tummy tuck known as an abdominal panniculectomy. It differs from the tummy tuck because the amount of tissue that is removed is larger. This makes for a longer low horizontal incision, often extending into the back area. The final result is often not as refined as that of a tummy tuck given the type of body on which it is performed. In its simplest form, an abdominal panniculectomy is an amputation of the pannus from along the waistline.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I have previously had a tummy tuck and liposuction of my waistline and thighs last year. That went well and the results are really good. My remaining body issue is my lower legs. They are still so thick and they have no shape. I guess they are called ‘cankles’. I am embarrassed by them so I always wear pants. I wold love to be able to wear shorts and even a low hanging skirt. I have read that liposuction can be done for the lower legs. Do you think it will make enough of a difference? Will I be as satisfied with it as my tummy tuck and other liposuction?

A: Calf and ankle liposuction can be very gratifying and make a big difference in the shape (not the size) of the lower leg between the knees and the ankles. By selecting removing small fatty areas and making curves in the favorable silhouette areas of the inner knee, upper and lower calfs and ankles, the shape of the lower legs from the front can be made more pleasing. This is done with small cannulas and is really a form of liposculpture rather than volume reduction liposuction. The biggest issue with lower leg liposuction (cankle liposuction) is that there will be prolonged swelling in the lower leg. The changes may not even be apparent in the first few weeks after surgery adn your lower legs may even look fatter initially. It will take several months to really appreciate the final result. It always appears but it does take time. In my experience, patients have been happy with the results even though they do not end up with skinny legs, just more shapely thicker ones.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am interested in getting a complete mandibular implant and would like to know an approximate cost.

A: When people use the term, complete mandibular implant, their objective is to enhance along their jawline from the angles to the chin. To achieve that look, there are two different approaches. These different methods affect how the procedure is done and the cost. The first approach, and the most common, is to use three separate implants. This includes off-the-shelf chin and jaw angle implants placed through a submental and intraoral incisions. That total cost averages around $8500 to $9500. The other approach is a custom one-piece implant that is made off of a 3-D CT scan taken from the patient. It may or may not be put in as a one-piece implant but it is completely customized to the patient’s jaw anatomy and aesthetic desires. That total cost is in the range of about $15,000.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am interested in getting cheek implants as I think they would help my facial appearance. But I don’t really know if that is true. If it is, what type of cheek implant would be best? I know there are different types, like malar, submalar and shell styles, so which would be best for me? I have attached some pictures of my face for your opinion. Thanks and looking forward to your recommendations.

A: When looking at cheek augmentation, you must first determine whether and where any cheek bone (zygomatic or malar) deficiency exists. This requires looking for obvious bony deficiences of the midface, the relationship of the eye to the brow and cheek bones and the thickness of the overlying soft tissues. This must all be taken in context of the overall facial shape as well.

In looking at your face, you have a longer face that is fairly skeletonized. Your eyes do not have a lot of fat around them which makes them more deep-set. This is magnified by prominent brow bones and heavy eyebrow hair density. Your malar area shows good width but there is anterior malar and infraorbital rim deficiency. This is why your cheeks appear flat to you in a side or three-quarter view. When considering cheek implants, therefore, it is important that you avoid submalar and any malar implant that adds much zygomatic arch width. Augmenting these areas are not helpful to your face. Malar implants that add some anterior fullness along the suborbital groove and front end of the cheek is where your augmentation needs to be. This cold be done with either a modified malar shell implant or an extended tear trough style. Either way the volume should not be much greater than about 5mms. Too big of a cheek implant size will make the eyes even more deep-set or hollow in appearance.

Dr. Barry Eppley

Indianapolis Indiana

Q:  Dr. Eppley, I had a rhinoplasty done three years of which I am very unhappy from the results. I am of Middle eastern ethnicity and initially had a big hump on my nose that I wanted to get rid of. I just wanted my nose to look more proportionate and not be so big. Right after ther surgery it did look better but as the swelling went down after a few months it didn’t look as good. While the hump is gone, my nose is now twisted and somewhat deformed. My breathing got worse after surgery too. It seem like it is getting worse with each passing year, is that possible? i have attached some pictures so you can see what I mean. I know I need a redo rhinoplasty but what do you recommend to make it better?

A: Your nose has some of the classic problems from an over-resected or radical reductive rhinoplasty. I suspect this was done through a closed technique and you may have initially had a large dorsal hump. Your nose shows middle vault collapse, indentations at the osseo-cartilaginous junctions, a pollybeak tip deformity and alar rim retraction. The upper nose deformity can happen when a large dorsal hump is taken down and the resultant open roof is closed with osteotomies that get infractured too far. This causes disruption of the upper lateral cartilages from the nasal bones creating an ‘hourglass’ deformity where the hump used to be. The middle vault constriction (pinched middle third of the nose) is the result of too much of the height of the upper lateral cartilages being removed causing collapse and possible breathing difficulties from pinching of the internal nasal valves. The tip deformity is marked by a hump in the supratip area and alar rim retraction with excessive nostril show. This occurs when too much cartilage is taken away and the tip is no longer supported. It then collapses and retracts so that the upper end of caudal end of the septum (septal angle) is now more prominent than the tip.

Your revisional rhinoplasty would be done through an open technique using spreader grafts for the middle vault, rasping of the dorsum, lowering of the lower end of the septal height, and columellar and alar rim grafts to the tip. In essence, cartilage support need to be put back into your nose to improve its appearance as well as your breathing.

Dr. Barry Eppley

Indianapolis Indiana

If you ever consider having plastic surgery, qualifying the doctor is an important first step. Are they the right doctor for you and what you need? Many magazine articles and other sources will give you a list of good questions to ask when you have an in-office consultation such as  (1) are they board-certified, (2) how many years have them been in practice, and (3) how many procedures of your interest have they done?

While these are certainly good questions and the answers are extremely relevant, such questions today can be answered long before you ever pull into the parking lot of the doctor’s office. If you walk in with these types of questions for your consultation, you must not have a computer in your house or have never done a Google search. It is hard to imagine that such a person exists today, except maybe my 95 year-old grandmother.

While these were once good questions for prospective patients to ask during an office visit, they have gone the way of the bag phone. Such answers are relatively easy to find at the click of a mouse from home. Whether we as plastic surgeon’s like it or not, our websites and the information that they provide is a lot more relevant to patients than any number of diplomas hanging on the wall. If a plastic surgeon doesn’t have an up-to-date website that easily provides this basic information, patients will quickly move on to another surgeon that does.  Today’s internet-based society makes it essential that these once basic qualifying questions are easily answered with minimal research effort.

With today’s electronic informational access, photo and video acquisition, and numerous locations for postings, contemporary plastic surgery qualifiers are different and more meaningful. Today, the more relevant checklist in finding the right plastic surgeon for your needs is procedure education, photographic examples and patient testimonials.

Traditional office print pieces, such as brochures and flyers, are historic methods of education in every plastic surgery practice. While they are still useful, so many are tempate-derived that they provide generic and virtually useless information…other than to say this service is provided. You want to know what this specific plastic surgeon does, not what most plastic surgeons do. This has spilled over now into websites as well. They all look pretty but what about their content? Is it meaningly and relevant to your needs? Look for brochure and website information that provides current and updated procedure information. This also suggests an interest in ongoing patient education which is most manifest in some type of website blog.

We have image overload everyday. Whether it is on Facebook or on your cell phone, we are surrounded by pictures. Plastic surgeons are without question the most advanced and proficient of all medical specialities in taking pictures. Therefore, patients should expect a good demonstration of a plastic surgeon’s most valued asset, their before and after patient photographs. While it is true that the best results will be posted, at the least you need to see a handful of actual patient before and after photographs. The more, the better.

Patient testimonials carry a lot of weight. Who doesn’t want to hear about a happy patient when you are considering going to that plastic surgery practice. But don’t just rely on what is posted, ask to talk to at least one patient who has had your similar procedure. But a patient who had surgery a long time ago is not as useful as one who has had surgery in the past weeks to months. Fresh experiences are what you need as these patients have the best recall of what it was like right after surgery.. Having a  recent patient also suggests that the procedure is performed more than just a few times a year.

Dr. Barry Eppley

Indianapolis, Indiana

Liposuction is a very popular body contouring surgery largely because it works. It is an immediate method to remove certain areas of unwanted fat that you just haven’t been able to budge by your best efforts. With this fat removal method, may people expect to lose weight as well. It is no wonder many people think this when you see such advertisements such as ‘Lose 10 lbs In A Few Hours’ or ‘Get The Body You Always Wanted’.  I have seen many such liposuction promotions in magazines and on the internet and it begs the question of aggressive advertising vs . medical fact.

Can you lose weight by liposuction? The simple answer is yes…in the short term. When advertisements promote how much weight is removed with liposuction, they are referring to what is suctioned out at the time of surgery. This is known as the fat aspirate and and is collected in a canister. It can be both measured in cubic centimeters or millimeters (always is) and weighed. (sometimes is) The weight of the aspirate can be closely approximated by its measured volume. Since a gallon of water weights 8 lbs and a gallon contains 2.2 liters (2200cc), then a liter (1000cc) of fat will approximately weigh 3 1/2lbs. Therefore if you have had liposuction surgery and had 2000ccs removed, for example, then you would have had a surgical weight loss of about 7lbs.

While this seems impressive, and one did have this 7lb weight loss in a hour or two, it is actually a bit misleading. The reason is that prior to the actual liposuction being done, a large amount of fluid is first put into the fat known as tumescent fluid. This is essential to liposuction to not only lessen the pain after surgery but, of equal importance, to reduce any bleeding that the procedure will cause. This fluid has both volume and weight and the actual fat aspirate will contain up to 1/3 of this by content. So the actual amount of fat removed and weight that has come off has to be toned down a bit. When you see large weight loss claims from liposuction, it is because large amounts of tumescent fluid have been initially placed….and then removed as well.

While liposuction may cause some weight loss immediately (surgical weight loss), a more significant drop may actually occur afterwards. In the healing phase for several weeks after surgery, most people are not motivated to eat normally. When combined with the increased caloric demands of healing, a metabolic weight loss often happens. This will usually equal the surgical weight loss by four to six weeks after surgery. So if 5lbs of fat aspirate has been removed during surgery, one can usually expect to be down 10lbs in another month or so. Whether one sustain this weight loss over time is affected by many factors, not the least of which is one’s lifestyle habits.

While liposuction and weight loss will be forever linked, one should view the association as incidental and a side benefit. Weight loss is not the reason to have liposuction…spot body contouring is. Some weight loss will happen for almost all patients. The amount varies on one’s body and how much fat was removed. Some view liposuction as a jump start method for their weight loss approach and, in the short term, that is what will happen.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I was involved in a car accident in 2009 and sustained what is called a subcondylar jaw fracture. I was told by the doctors that it was not bad enough to fix so they let it heal without surgery. After a few months when I could open my jaw better, I noticed an obvious difference between the two sides of my jaw. My left jaw angle appears to have disappeared. It now makes my face appear crooked. I was wondering if some type of implant may help cover up this lost part of my jaw. What do you suggest?

A: When the neck of the jaw is broken, the thin connecting bone between the condylar head and the big ramus of the back part of the jaw, the vertical length or height of the jaw can shorten. A subcondylar fracture, if unrepaired, can make for a shorter posterior jaw height and apparent ‘loss’ of the distinctive jaw angle. This is because the jaw angle moves upward as the jaw height shortens. Provided that you have good jaw function and the only issue is a cosmetic one of the jaw angle, that could be camouflaged and made more symmetric by a jaw angle implant. It would be important that the right jaw angle implant be used. It needs to be one that doesn’t just widen the jaw angle (lateral augmentation) but rather provides a lengthening to the jaw angle. (inferolateral augmentation). These type of jaw angle implant can provide up to a centimeter of vertical length increase.

Dr. Barry Eppley

Indianapolis Indiana