Your Questions

Q: I have had forehead reshaping surgery about a year ago with PMMA resulting in a very unsatisfactory result. None of the areas I was concerned with have been addressed and there is significant visible irregularities as a result of the surgeons incompetence at the task. I wanted to know how long I should wait before seeking revision surgery? I would ideally like to have it nine months after the first surgery. Also how would the existing material (PMMA) affect how the surgery will be performed? Is there a greater risk of infection or is the surgery going to be significantly more difficult??

A: Sorry to hear of your unsatisfactory outcome from your cranioplasty procedure. From a technical standpoint, you could have revisional surgery at any time. There is no advantage or disadvantage to doing it now or years down the road. The material is set and stable and can be smoothed and rehaped, or added to, at any time. There is no increased risk of infection or increased difficulty in performing the procedure at any point. Revisional cranioplasty, when PMMA is the indwelling material, is actually slightly easier to do as the scalp tissues lift off of the material very easily as they do not bind or adhere to the PMMA. PMMA becomes encapsulated rather than integrated to the overlying soft tissues and the underlying bone. My observation is that patients having secondary scalp flaps raised report little to no pain afterwards although the swelling and the bruising will likely be similar.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am interested in having several plastic surgery procedures done. Do you know if I can use my health insurance for plastic surgery?

A: Your health insurance is intended to cover medically necessary procedures. From a plastic surgery standpoint, operations such as breast reduction, large abdominal panniculectomies, repair of cleft lip and palate deformities, traumatic facial injuries, removal and reconstruction of skin cancers, breast reconstruction after cancer removal, and numerous other face and body problems constitutes reconstructive plastic surgery. They are reconstructive because they are directed toward returning the body part back to what it once or should be (e.g., breast reconstruction) to relieving medical symptoms such as pain and skin rashes. (e.g., breast reduction) Cosmetic plastic surgery, conversely, changes a normal body part to have another look (e.g., breast augmentation) even though there are no medical symptoms with it. Not liking the way something looks and being bothered by it, even if that degree of bother borders on some level of impairment, does not constitute a medical necessity. Therefore, cosmetic surgery is not covered by any known medical insurance program in the world. There are a few instances where a body part can have both reconstructive and cosmetic needs. The nose would be a prime example where the internal breathing parts can be covered by insurance when they are dysfunctional (septoplasty), while changing the outside appearance of the nose (rhinoplasty) would be considered cosmetic. When done together which is common, such a procedure is known as a septorhinoplasty.

Dr. Barry Eppley

Indianapolis, Indiana

Q: My friends had fat taken from her stomach and put into her upper lip lines.  Is this a procedure you do or recommend?

A: The search for a long-lasting injectable filler to the lips has naturally led to the use of one’s own fat. Even the thinnest person has a little bit of fat which can be harvested and recycled to the lips. In injecting fat to the lips, one accepts two caveats with its use. First, it is good for bulk filling (making the lips overall bigger) but is not useful for injecting into individual lip lines. It is not like synthetic injectable fillers which are injected using very small needles and can be selectively placed into a line as thin as the width of the needle. Fat is injected with a very large needle as the material is quite thick and does not come out in a true linear flow pattern. Secondly, its take or how well it survives is unpredictable. While the theory and expectation with its use is some or complete permanency, that outcome varies amongst different patients. One can not predict whether any one specific patient will have a long-lasting result. My experience has been to overfill (which can look really overfilled with the lip swelling that happens from the procedure), taking into account that there will be some fat resorption. By three months the size of the lip, and the amount of remaining fat, will then be permanent.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: Hello! Do you perform the laser eyelid rejuvenation procedure? I am 48 and have eye hooding and really don’t want to have the surgery at this time. I have read that there is laser treatment that is quite successful. Thank you for your help!

A: I am not aware of any laser eyelid procedure that does not involve making incisions to do a blepharoplasty or eyelid tuck. The term ‘laser eyelid rejuvenation’ may suggest that there is some type of a laser which magically tightens eyelid skin without surgery, but that is not the case. When eyelid hooding exists, the only known effective treatment is actual skin removal. When upper blepharoplasties are done alone, they can be performed under local anesthesia and, in some cases, may even be done in an office setting. Mini-blepharoplasties exist using a pinch technique which is also an office procedure done under local anesthesia. Given the effectiveness of even these more limited skin removal procedures, any non-surgical approaches have never yet been developed that remotely compares.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I would like to have breast augmentation. I have never had because I feared the curvature of my spine might be a problem. I have curvature of the spine, two curves to be exact. I have NEVER really had any problems with it. However, I am not even an A cup and want to go to a D cup. Any issues I should be aware of??

A: Curvature of one’s spine could pose two potential problems for breast augmentation, although neither is preventative from having the operation. The first issue is the potential impact of any significant curvature might have on the lungs or pulmonary capacity. If severe one would have some obvious pulmonary restrictions and this could be a problem for general anesthesia. But your curvature does not sound that severe since you have never had any known problems with it. The second issue is an aesthetic one. Curvature of the spine may give the chest some asymmetry when standing which could give the breasts small differences in size or horizontal position. Any breast asymmetry from spine curvature could be magnified when the breasts become enlarged, particularly up to a D cup size. While all breast augmentation patients must accept the risk of implant asymmetry, that risk may be increased in patients with visible spine curvatures. Short of these potential issues, I see no other issues that would not be standard  in you having breast augmentation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I was just curious about whether I am a good candidate for liposuction on the buttocks and my abdominal oblique areas.  I am pretty small as it is but I have always had stubborn fat no matter what I do. I work out and eat right, I only weigh 105lbs and I am only 5 ft tall. My buttocks is a lot bigger than my size and that is what I consider my worst problem.  I have been trying to get sculpted for a couple of years, but nothing has worked. I have thought about getting this procedure done, but never had the nerve to get it started. If you could e-mail me back your thoughts that would be great.

A: Small discrete areas of fat on someone who is absolutely weight appropriate for their height, despite working out and eating right, is a common problem that I see in many patients. As such a slight frame and build you can be assured that these fat collections are genetic in nature and not metabolically responsive, which is why you can’t get rid of them by your own efforts. Such small areas I would refer to as liposculpture (shaping) more so than liposuction. (significant volume reduction) Small areas such as these respond quite well to small cannula liposuction.

One caveat about any type of liposuction is in the buttocks area. You have careful to not be too aggressive with the fat removal in this area as one can end up with a ‘deflated’ or sagging buttocks after volume is removed. Fat removal in the buttocks should be more conservative and carefully done to avoid this potential problem. Most likely in a small frame such as yours that is not a significant concern.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I have been attempting to learn the pros and cons of chin surgery. I really want my chin longer and want to know in your opinion if it would stretch my lower lip and expose too much of my lower teeth when I smile? In addition, if I had a chin implant could a widening chin implant be used to square my jaw and length it?

A:  Lengthening of the chin usually means increasing the vertical height of the bony chin. Some may use lengthening in terms of a horizontal increase or projection. I am assuming by your question that you mean a vertical increase. Whether the vertical height is increased by an osteotomy with an interpositional graft or an implant, neither approach will stretch your lower lip and expose any more tooth show. That simply doesn’t happen with vertical chin lengthening and is not a concern. But there are differences, however,  in how much vertical lengthening can be achieved by the two techniques. An implant can only lengthen the chin by being placed on the edge of the bone, creating a lengthening of maybe 2 or 3 mms. In contrast, an osteotomy can lengthen a chin up to 10 or 12mms which is a significant difference.

Square chin implant styles do exist but they will have only a minimal, if any, vertical lengthening effect.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: I have read that paranasal implants can be done in local anesthesia. Is this right? Is local anesthesia possible also with malar implants which are placed right next to paranasal implants? Does not the lifting of the periosteum from the bone hurt in spite of the local anesthesia? Thank you very much for your information.

A:  Cheek and paranasal implants are placed from an incision inside the upper lip. Besides the mucosal incision, muscles and the periosteum covering the maxillary and zygomatic bone must be lifted up and a pocket made to place the implants. Given the proximity of the paranasal area to the upper lip compared to the cheek area, it would be ‘easier’ to position paranasal implants under local anesthesia as opposed to cheek implants where greater dissection is needed and the feeling in this area has more contributing nerve endings. You are correct in that it is the periosteum that is the most sensitive part of the surgical dissection. I also prefer to us screw fixation for the implants that I place in the midface which can cause more discomfort from the bone drilling.

 While just about any surgery can be done under local anesthesia, I am not sure if I was a patient that I would ever do it that way. (particularly cheek implants) Unless there is some compelling medical reason why IV or general anesthesia could not be used, it would be more comfortable and slightly less costly to use some form of anesthesia for this type of facial implant surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I have sleep apnea and a very thick fat neck. I was wondering if liposuction of the neck would help my sleep apnea? My thought is that if the fat was removed from my neck it would not be so heavy when I laid down. That way it would not push down on my neck and obstruct my throat as much when I was sleeping/ Does this make any sense? What are your thoughts?

A: While liposuction of the neck may help improve the shape and profile of it, I doubt very highly if it would make any improvement in your sleep apnea. Your logic seemingly makes sense but the flaws in it are that fat doesn’t weigh very much, the thyroid cartilage protects the voice box and lower area with a stout shield of protecive armour and the usual sites of anatomic obstruction are usually higher and are closer to the base of the tongue. While I don’t think liposuction of the neck will have any negative effects, it is not an acknowledged procedure in the surgical treatment of sleep apnea. Procedures such as septorhinoplasty and turbinate reductions to open the nasal airway, maxillary and mandibular advancements to open up the entire posterior oropharyngeal airway, shortening of the soft palate (fading in popularity) and bony chin advancement and genioglossus procedures to bring the base of the tongue forward are well recognized sleep apnea operations. Other non-surgical efforts include weight loss and various dental appliances. Before considering any of these options, one should be fully worked up by a sleep apnea specialist to search for the most effective solution.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am interested in trying to get my face to look less fat. I want to make my face slimmer if possible. I have a small double chin and fatter cheeks and jowls. I have read about Lipodissolve injections and this seems like a good and easy solution for my small areas of facial fat as I know these injections are for small areas and not big ones. Do you think this will work for me?

A: While Lipodissolve injections can provide some minor benefit in fat reduction in the neck and jowl areas, they require three or more injection sessions (spaced 4 to 6 weeks apart) to get the best result. After each injection session, the treated areas will double or triple in size for one week as part of the inflammatory by which it breaks down the fat. . Because of this socially visible recovery, most patients will opt for a more effective set of procedures that actually has less total recovery even though it is surgery. I would recommend a combination of submental, jowl and lateral face liposuction and buccal lipectomies. This reduces all available fat compartments in the face that can easily and safely be treated. This is is the best way to get a slimmer face through fat reduction. It has less recovery than Lipodissolve injections because the swelling is only one time and is largely over after a few weeks. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am 30 yrs old and am tried of people telling me that I am in my mid to late 40s. Ugghhh! I usually just walk away and cry and I am tried of crying over this and want to get something done about it. I have had a brow lift and a neck liposuction about 2 yrs ago. I would like to see what it would look like with eyelid lift and filler. Would you also recommend something else? Maybe a chemical peel? Thank you for your help! I really appreciate it!

A: Thank you for sending your pictures. Unfortunately computer imaging is good at changing structures of the face but not very good at soft tissue manipulations such as those that you have asked for. An eye lift can not be done as it distorts the whole eyelid. However, I think there is no question you have upper eyelid hooding and you would clearly benefit by an upper blepharoplasty or eyelid lift. Putting in fillers along the nasolabial fold and lips is also not very accurate and often just distorts the lips in trying to image it. You have reasonable lip size so injectable fillers will make them nicely bigger. As you have suggested, a chemical peel is good for skin texture and brightening the glow of the skin and for fine wrinkles as well.

As for other recommendations, I have done some other changes just to look at how to soften your facial features and make your face more ‘youthful’. These have included the following:revisional browlift to lower hairline (reduce long forehead) and correct existing brow asymmetry, rhinoplasty to make nose look slimmer and more narrow and chin reduction to soften chin point and make softer looking.These are structural facial changes which are different than just anti-aging procedures.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I have had severe migraines for years. My migraines start in the back of my head and shoot up into my scalp and down into my shoulders. It usually feels like there is a vise on the back of my head. I have been to a lot of doctors and have tried everything from every drug out there to chiropractors, acupuncturists, massage therapists and even Chinese oriental practitioners. A few things worked for several days or a week but nothing lasts. I went to the local university and saw a neurologist there who did an MRI and other blood tests and came up with nothing. His drugs didn’t work any better. I have read recently on the internet about some type of migraine surgery. While I am desparate to try anything, the thought of going through surgery and then not have it work would be disappointing to say the least. What is the success of this new migraine surgery?

A: Migraine surgery is based on the concept that there is a peripheral trigger or site of nerve compression which is the stimulus for the attack. One of the four recognized trigger zones is at the greater occipital nerve at the back of the head at the base of the skull which causes occipital migraines. Whether surgery would be effective can be predicted beforehand through the use of Botox injections into the area. A positive response to Botox, which includes a significant and sustained relief of the migraines, correlates highly with surgical success. While about 1/3 of patients will have a near complete elimination of their migraines, 2/3 s will have reduced frequency, intensity and duration of attacks. A recent clinical study reported that 90% of patients treated maintained good relief out to five years after surgery which as the time limit of the study.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I would love to have breast augmentation before my 21th birthday which is later this spring. My preferred approach would be breast augmentation with an incision through armpit area But  I also considering the option of an inframammary incision using Memory gel breast implants. Which do you think would be better for me? Thank you.

A: Breast augmentation poses multiple choices for prospective patients to consider. These options are driven by implant choice which can secondarily control the placement of the necessary incision. Saline breast implants are often placed through a small armpit incision because they are inserted deflated and then inflated once into position. Silicone gel breast implants, unless they are very small, can not be placed through the ampit because they are inserted pre-filled or fully inflated. Thus, they are usually placed through a lower breast crease or inframammary fold incision.

But the incision is not the most important part of the breast augmentation procedure, the implant is. All incisions heal really well and are rarely of any secondary cosmetic consequence. Therefore, it is important to understand fully the differences between saline and silicone gel implants. While both work well and do an equally good job at making a larger breast, there are some important minor differences in them that are relevant in the long-term. This is especially pertinent to you at your young age since you will live to see them. These include such risks as implant deflation (saline) and silent rupture.  (silicone) You will be replacing these implants at least once on your long remaining lifetime so understanding these differences is important to you.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am going to get a facelift and want the scars to heal to that no one will know that it was done. I have read about a Laser-Erase procedure that can get rid of the scars almost immediately. Does this really work? What are your thoughts?

A: Over 100,000 facelifts and an equal if not greater number of eyelid tucks (blepharoplasty) are performed each year in the United States.  While the incisions in the eyelids and around the ears generally scar imperceptibly, patients are understandably  motivated to get the best scar result as possible. Getting a more youthful appearance at the expense of poor scarring would not be a good trade-off.

Concerns about the possibility of less than ideal scarring, numerous plastic surgeons have touted an early laser scar treatment program. Laser-Erase is just one ‘branded’ name of this treatment approach. The concept is that about two weeks after facial surgery including facelifts, eyelid surgery or any other facial procedure that requires an incision, the incision line is then treated with a light laser resurfacing procedure. Some use high intensity light or IPL treatments as opposed to an actual laser. It is touted that the ‘incision is then erased with the laser’. The theory is that the laser disrupts a scar from forming in the very early stages of the healing process, thus to quote one treatment provider, ‘the incision line is banished from sight with a zap of the light.

While this early treatment of a scar sounds very appealing, there is no science to back up its touted benefits. Plus it goes directly contrary to how wounds heal in general. No scar can be prevented from occurring between two closed edges of skin. Scar formation is inevitable, and a little burning or heating of the upper part of the wound edges, will not make it disappear. Any scar benefits that subsequently occur are a result of a natural healing and scar fading process. Such early scar treatments are more about marketing and sales than they are about any form of a new revolutionary scar treatment approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q: For my bulgy forehead, is it possible to burr down the forehead and then do a forehead/eyebrow lift at the same time, just removing the extra skin? The reason I ask is because my head is misshappen and my hairline is too high. I want my hairline to be lower so burring down some of the forehead and then making and eyebrow lift would help alot.  After that is done I was going to get a hair transplant on my hairline to cover up the scar.  Does this sound like it will work? Will it work if I get a hair transplant over the scar and can I do the eyebrow/forehead lift thing?

A: Your approach to a forehead or frontal contouring is conceptually correct. While I don’t know exactly where your exact hairline is now or what its shape is, making a scalp or coronal incision there allows one to access the forehead area. Probably about 5mms across the forehead bulge can be taken down. A browlift can then be performed and the redundant skin removed at the scalp incision line. This will shorten the perceived length or height of the forehead skin. Thereafter, no more than 3 to 6 months later, a hair transplant can then be done to put a camouflage to the scar. Such a scar in the scalp can often heal remarkably well due to the uniqueness of hair-bearing (or past hair-bearing) scalp skin.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: I was wondering if it is possible to shave down certain parts of the skull. My forehead isn’t the way I want it to be shaped. I am trying to get my forehead to stick out a little less. Is it possible to shave the skull down? And if so how much can be taken off?

A: The thickness of one’s skull can be taken done by burring. How much it can be reduced is determined primarily by the thickness of one’s outer cortex. The skull has three bony layers, an outer hard cortex, an inner spongy marrow space and and an inner hard cortex.  While the burring reduction can be taken down past the outer cortex into and through the marrow space, that causes a lot of bleeding and can make for an irregular surface. Therefore for practical reasons, the outer cortex is usually the only skull thickness reduced when done for cosmetic purposes. That can vary in different skull areas but in the forehead in a man, that may be up to 5mms or so.

The more significant rate-limiting step for male forehead reduction is the incision needed for access to do the procedure. A scalp incision is needed to turn down the scalp so the bony forehead is exposed for reduction. Given the unstable frontal hairlines and hair densities of most men, forehead surgery of any kind may not be worth the trade-off of a scalp scar.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  I had a chin reduction a couple of years ago and although I am happy with the new shape of the bone, I now have hanging soft tissue. Needless to say I am not happy with these results. I have visited five plastic surgeons and none of them wanted to fix this problem saying that it was dangerous to cut or reattach the muscles and the ending results could be worse. I am very dissapointed and have attached some before and after pictures for your review. I hope you can help.

A: Your pictures show quite clearly some soft tissue sag or ptosis off of the chin bone. It is most pronounced centrally which is what one would expect given that your chin reduction was most likely an intraoral burring approach done to the central button.  To improve this problem there are two approaches, intraoral muscle resuspension or a submental tuckup. The intraoral approach uses a suture anchor to the bone to reattach the muscle and tighten it back done. This is a scarless approach. The submental tuckup  uses an incision under the chin where the loose skin and muscle is removed and tucked or tightened to the bone. Each has its own advantages and disadvantages. The intraoral approach avoids a scar under the chin but the submental tuckup is a more reliable method.

There is no danger to performing this procedure and there is no chance of making the problem worse. Whoever has said has either never treated the problem or is completely unaware that such surgical correction exists.

Dr. Barry Eppley

Indianapolis Indiana

Q: I wrote you a couple of months ago about the possibility of undergoing a forehead contouring surgery to address my possible forehead bulging, to which you asked me to provide you with pictures. This is want I would like to do now and i have attached some forehead pictures for you to review. I don’t know whether the bulge is created by my high hairline or if it is just the way my forehead is. Basically, as previously stated, I would like to know if the problem is a high hairline or a protruding forehead, or both. At any rate, I would like to hear your surgical recommendations, or lack thereof!

A: Thank you for sending your pictures. I think there is some degree of a mild amount of forehead bulging that is accentuated by a higher hairline. Given the mild problem and the resultant scalp scar to improve it, I would not recommend any surgical modification. While it can certainly be done, the scalp scar in a male is a major limiting factor. This would not be such a rate-limiting step for surgical treatment in a female.  I have looked at hundreds of male candidates over the years for cosmetic forehead contouring and brow bone reductions and could only ever justify surgery on about 2% to 3% of them.The magnitude of the forehead problem has to justify the trade-off of the scar to do it.

Dr. Barry Eppley

Indianapolis Indiana

Q: I have a long and wide forehead scar that I would like to be made to look better. I have attached some pictures of it for you to review. I was wondering if you think that laser resurfacing will help. I have read that it can make scars go away. What is your opinion of it?

A: The origin of your question is will any form of laser resurfacing make your forehead scar disappear. The simple answer to your question is no, no matter what type of laser resurfacing technique is used. And let me explain to you why. Your forehead scar is composed of abnormal tissue which is why it does not feel or look like normal skin. It is in fact abnormal tissue or scar but, most relevantly, that scar involves the entire thickness of your skin. In other words, the skin has been replaced by full-thickness scar. You can smooth of the surface of the scar out all you want with any form of laser resurfacing but it will always appear just as wide, just as discolored and just as obvious. Laser resurfacing only smooths out the surface of the scar, which is helpful if the scar’s main problem is surface irregularities, but it will get rid of the actual full-thickness of the scar. Only cutting it out (excision) can do that. When excision is combined with a geometric broken-line closure, the scar will become more narrow and less obvious. Secondary touch-up with laser resurfacing may be helpful but it is an ineffective treatment to do first. I realize that grasping out the hope of laser resurfacing seem appealing but it is but a treatment mirage. Formal surgical scar revision is what would benefit you the most.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am interested in learning about the cosmetic effectiveness of doing both zygomatic osteotomies with orthognathic surgery. I have seen some plastic and oral surgeons and I am told I have what they call a class 2 malocclusion with a restrusive mandible and maxilla, low sunken zygomas and mid-face with the outer edges of my eyes drooping. I am going to have orthognathic surgery in near future for functional reasons, sleep apnea, tmj problems, snoring, and to improve breathing while I am awake by enlarging the air ways. But cosmetically my cheeks and drooping eyes I would also like to improve. There are multiple modified LeFort osteotomies that help with filling in the face, but I am looking for something that will address the drooping outer edges of the eyes. What are the risks involved for a zygomatic osteotomy? (like double vision) How do you feel about the procedure being performed with orthognathic surgery? How cosmeticly effective is it when both done together? (other opinions suggesting best done separately) Can you achieve symmetric cosmetic pleasing effect? Not too interested in implants due to risks of dislodging and erosion, very active lifestyle, feel it would get in the way.

A: Let me give you some general thoughts about your questions with the caveat that I have never seen your photographs or x-rays and am only working off of your description of your face.

Your orbitozygomatic facial skeletal arrangement is such that the cheek bones are flat and recessed and the lateral orbits may have a little downslanting orientation. (tilted horizontal orbital axis) That problem alone, which occurs commonly in more severe deformities such as Treacher-Collins, requires a combination of  a C-shaped orbitozygomatic osteotomy with bone grafts to improve the total three-dimensional bone problem. Yours may not be as severe but the 3-D problem is likely the same. Beyond the fact that this requires a coronal (scalp) incision to do the bone cuts properly, it would be very difficult to do this simultaneously with any form of a LeFort I osteotomy. Between the scalp scar and the type of osteotonies needed, this treatment is likely too severe for correcting a more mild orbitozygomatic bone problem.

While there are some high modifications of a LeFort I osteotomy, they are restricted in how the zygoma moves and will only bring it forward but not out. (no width improvement) These are interesting operations on paper and in surgical diagrams but have never proven very practical or effective. That is why they simply are not done or rarely attempted.

The conclusion is that any form of an orbitozygomatic osteotomy is too big of an operation, will leaves palpable (able to be felt) bone edges, and also requires bone grafts. This is why the best approach, even if you don’t desire it, is to do some form of a cheek implant with lateral canthal repositioning of the eye. These are far simpler, much more cosmetic effective, have less complications (both short and long term) and can be combined with orthognathic surgery.

Dr. Barry Eppley

Indianapolis Indiana

Q:  I am considering scar revision but need some direction. I basically have two small scars on my butt. They are small and they look like chicken pox scars However they are perfectly centered on each cheek. They are from a liposuction surgery I had many years ago. What is the best way to correct them? I hope you can help.

A:  The three-dimensional shape or geometry of these scars is an important consideration. Are these scars wide and flat like chicken pox scars as you havhe described or are they wide and indented, having a central depressed component to them? Since they are old liposuction entrance scars, they are probably wide but the key question is are they indented or flat? That distinction is critical in choosing what type of scar revision to perform.

Excising small scars on the buttocks is easy to do and the intent of such an excision is to make the scar ultimately more narrow. While at the time of the procedure, they will be but in the long run they will likely widen again. The pressure of sitting on the buttocks will defeat most attempts at scar narrowing in this area if the scars are anywhere on the rounded portion of the buttocks. If they are around the perimeter or in the buttock crease, then such desired narrowing is more likely to be achieved.

If the scars are indented, however, cutting them and out and closing them make not make them smooth or flat. For this type of scar revision in this area, I would place small fat graft underneath them to prevent recurrent tethering or indentation.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am interested in getting a chin implant to make my weaker chin look better. It seems like a fairly simple procedure but this bone resorption underneath the implant sort of scares me. Why does this happen? Is there any way to avoid this bone reorption if I get a chin implant?

A: The phenomenon of bone resorption under a chin implant is a much talked about finding for many decades. One of the reasons that it occurs is due to a pressure issue with the implant sandwiched between the soft tissues and the bone. While the implant pushes the soft tissue out, causing more visible chin projection, the soft tissues do apply a small amount of pressure or recoil back over time. Since the implant is not going to resorb because it is an inorganic synthetic material, that leaves the underlying bone to accomodate and relieve this pressure.

This pressure situation is really magnified with implants that are placed too high on the chin bone. This happens when chin implants are placed from inside the mouth and are not secured down to the lower edge of the bone. It can also happen from a submental chin incision approach but is much less common because it it easer to keep the pocket of the implant low. The observation that it does not occur with more contemporary anatomical chin implants is because the wings of the implant keep them from riding up higher, acting like lateral stabilizing bars. From either approach, if the implant ends above the basal bone of the chin (which is thick cortical bone) it rests on bone with a much thinner cortex. This is where bone resorption will be seen with chin implants. It is a function of bone position and is not an actual feature or result of the implant or its material composition per se. This bone resorption phenomenon (which is largely benign and not of any great signfiicance) can be completely avoided by proper implant position on the lower edge of the chin bone. This will also maximize the benefits of the horizontal projection that the chin implant provides, some of which is lost if it gets malpositioned higher as it slides up and back.

Dr. Barry Eppley

Indianapolis Indiana

Q:  I have an unusual question. I’m half Chinese but my eyes are more Caucasian-looking. So I was wondering if there is a surgery to create an epicanthal fold at the medical canthus? ( the one that half covers/hides the tear duct). Some doctor once told it’s possible with a w-plasty or a jumping man flap to create a fold in the inner most part of the upper lid. And is it possible to lower the height of the eyelid? Like taking apart the previous fold and resetting it at a lower position? Many thanks and sorry for all the questions

A: The epicanthal fold area is composed of very thin and delicate skin that is prone to poor scarring, particularly in the Asian patient. Because of this scarring potential, unless the epicanthal fold is really prominent and bothersome, I generally steer away from surgical manipulation of this delicate skin.  Many of the operations described for epicanthoplasty, like the w-plasty and the jumping man flap, create a lot of tiny skin flaps and often scar poorly. They look great on paper and in diagrams, and do get rid of the epicanthal fold, but their scar result may not be a good trade-off. For this reason, I prefer a smaller z-plasty technique for epicanthoplasty which helps open up the narrowing effect that the fold has on the horizontal dimension of the eye.

Your question is one of the reverse of an epicanthoplasty or the creation of an epicanthal fold. I have never heard of that being done and certainly nothing is written about it. In my opinion that is possible through a different orientation of a z-plasty but my concern would be the scarring. As the fold of skin that would normally make up the epicanthal fold would likely have a line of scar on it, that may or may not have a natural appearance.

When you speak of lowering the height of the eyelid, are you referring to the location of the lid margin or the height of the supratarsal skin crease of the upper eyelid?

Please send me some photos of your eyes for my further assessment.

Dr. Barry Eppley

Indianapolis Indiana

Q:  I have heard of rib graft nose augmentation. Is this method better than using silicone implants? It seems that most people use silicone so why rib? Can a rib graft be carved like silicone with  a nice shape ? Can it get warped  and twisted? How many people are fixing their nose using rib grafts? How many people need to be redone because of problems with the rib graft? I want to fix my nose but am scared of using a rib graft because of what I have heard about them.

A: Rhinoplasty with dorsal nasal augmentation can be done using either a synthetic implant or an autogenous rib graft. While there are advocates for both approaches, either one can have very successful results. It is not a function that one is better than the other, they just have different advantages and disadvantages. Synthetic implants to the nose are relatively simple to do and require less operative time and surgical skill to do but they have potential long-term problems such as infection and extrusion in some patients. Rib grafts to the nose are harder to do and require greater skill and familiarity in working with this type of graft as well as requiring a donor site but they do not have long-term problems of infection or risk of graft extrusion.

In my experience, diced rib cartilages to the nose eliminate the risk of warping or twisting and mold nicely for dorsal augmentation. Solid rib grafts must be very carefully harvested, shaped and secured to avoid the problems to which you refer. I have done both techniques successfully and decide between the two rib cartilage graft techniques based on the quality and shape of the rib graft harvest.

The vast majority of patients wanting primary dorsal augmentation rhinoplasty for esthetic reasons, such as the Asian patient, is going to choose a silicone implant because of its simplicity and lack of the need for a donor site.

Dr. Barry Eppley

Indianapolis Indiana

Q:  My daughter has grown in the past two years a strange looking abdominal growth. It doesn’t look like any abdominal pannus picture I have ever seen. She is very obese but has a normal looking white abdomen which hangs down a little. However, directly under (and separate from) this normal looking abdomen is a huge purple/red hanging balloon which is ulcerated and infected. It grows out from under the abdomen right above the pubis. She is scheduled for surgery in a month and the surgeon is acting like he doesn’t know for sure what it is. It is estimated to weigh about 50 pounds. Have you ever run across anything like this in your plastic surgery practice?

A: While it is unusual, I am certain it is not a mystery per se. There are only a certain number of conditions that it could be. Possibilities include a granulomatous reaction from a ulcerated wound in the skin fold, an area of  lymphedema with resultant ulceration, ballooning subcutaneous fat necrosis or benign growths such as large lipomas, hemangiomas or even a teratoma. Whatever the final pathologic diagnosis, it will be removed by wide excision down to the underlying abdominal wall  with a modified abdominal panniculectomy. It does not sound anything like a hernia of which it is in an unlikely location and a CT scan would easily rule that out. A CT scan would also rule out any tumor growths from deeper structures, such as the ovaries.

With a weight of 50 lbs, however, it is much more likely that this is a benign tumor growth of solid tissue rather than any reactive mass.

Dr. Barry Eppley

Indianapolis Indiana

Q:  I want to have breast implants done. I am not happy with the way my breasts look. But I have lupus and am not sure that I can have this procedure with this medical condition.

A: Whether breast augmentation with the medical history of lupus is a good idea would depend on what the extent and how symptomatic this autoimmune disease is in you. Do you have any known healing problems as a result of your lupus? Have you had surgery in the past and did you have any problems with healing or infections after surgery? Are you on any steroids or other immunosuppressive medications? What symptoms do you currently have from your lupus? What are your titer levels of ANA and other blood tests from your doctor?

 Ultimately, what your doctor or rheumatologist would say about your lupus condition would have a lot to say about the adviseability of breast augmentation for you. Despite the past allegations that silicone breast implants cause autoimmune disease from the 1990s, that has now long been disproven.

The issue is are you more prone to breast implant complications from your lupus? Infection risk in the short term and capsular contracture in the longer term are the issues. If you have skin problems, such as banding and contractures, than you would be likely to get problematic breast implant capsules. If not and your lupus is stable and relatively asymptomatic, then breast augmentation may be a satisfactory procedure for you.

Dr. Barry Eppley

Indianapolis Indiana

Q:  What do you think of hyaluronic acid for buttock augmentation? It seems like it would be  a lot easier to do than using your own fat or putting a synthetic implant in your body.

A: While the family of hyaluronic acid fillers are commonly used for very small volume facial augmentation, they are very rarely or never used to try and fill other body areas which require much larger volumes. While it may be a biologically sound concept, it is an economically terrible idea. The volume of hyaluronic acid needed, if we use fat as an analogy, would be around 350cc per buttock or 700cc per procedure. If we use the cost factor in the U.S. of $375/1cc syringe for Restylane that would be a buttock augmentation at a cost of $262,500…all for a result that would last 3 to 4 months. Using Juvederm, which would last twice that long but at a cost of $550/1cc syringe, the procedure would cost $385,000.

While your own fat make not always be reliable in terms of volume survival, it is easy to see that it is a far more economical approach for buttock augmentation.

Dr. Barry Eppley

Indianapolis Indiana

Plastic surgery, unlike some medical specialties, seems to always find its way into the news. 2010 was no exception in this regard. As a plastic surgeon, most of the items that become newsworthy were an incredible mix of the freaky, incredulous and even fantastic events.

Breasts always seem to make the news and the more freaky seems to be better. Whether it is basketball-size implants of quadruple FFFF proportions, dancers subject to IRS scrutiny trying to write off their surgery, or breast augmentation as part of a marathon makeover (aka Heidi Montag), women who seek their ten minutes of fame marr the perception of an otherwise highly successful body contouring surgery. While the real breast augmentation news this coming year will be the introduction of a new form-stable (gummy bear) implants, this will likely be overshadowed by the media’s never-ending focus on celebrities, their breasts and Hollywood’s version of silicone valley.

There is always the continued incredulous news of patients suffering complications and even death at the hands of so-called cosmetic surgeons. This seems to be most evidenced with liposuction, largely due to its popularity and the larger body surface areas that it treats. There is an obvious difference in the size of the trauma to the body from abdominal and thigh liposuction from that of a nosejob or eyelid surgery for example. Liposuction attracts a large number of inexperienced and often unscrupulous practitioners because of the relative ‘simplicity’ of the procedure and easy access to new liposuction devices. It only takes a medical license and a credit card to buy the newer laser liposuction machines. Equipment manufacturers are more interested in sales than safety as evidenced by their marketing and selling behavior. Patients died last year from one coast to the other at the hands of doctors with dubious credentials. The public would think that better regulations would exist but they would be wrong. Doing your homework is your best protection.

Botox continues to show its fantastic benefits and those are not only in those worried about their frown lines or crow’s feet. Last year Botox was approved by the FDA for the treatment of migraines. For some migraine sufferers, Botox injections can be a miracle even if its effects are only temporary. The benefits of Botox have translated into an actual migraine surgery procedure developed by plastic surgeons. If Botox injections relieve one’s migraines, a relatively simple muscular decompression around the nerve trigger points can provide a more permanent amelioration of one’s migraine pain and frequency of attacks. It’s a rare example of a cosmetic treatment turning into a really useful medical or reconstructive surgery, usually that works in reverse.

One other piece of fantastic plastic surgery news from last year has been the emergence of face transplants. While once thought impossible and something more akin to a movie or science fiction, more and more partial or complete face transplants are being done around the world. While the patients who need them are last resort problems of massive facial deformities and tissue loss, that is the history also of all organ transplants which are commonplace today. From the extreme technical advances of today come spinoffs that will benefit many more facial reconstruction patients in the future.

No telling what this coming year will bring, but if past history is any predictor of future events, plastic surgery will continue to make the headlines…let us hope it is largely in the fantastic category.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I would like to get my eyelids done as they are very heavy looking and make me look bad. People tell me all the time that I look tired even though I am not. I am sick of hearing that! My only real concern about the surgery is recovery. How long is the recovery and what will I look like?

A: Thank your for your inquiry. Recovery after blepharoplasty surgery is largely social…meaning how do I look? (how much bruising and swelling will you get) That would depend on whether one is doing only upper eyelids, only lower eyelids, or all four eyelids.. When all four eyelids are done, most people will have noticeable bruising and swelling for up to 10 to 14 days after surgery. If only one set of eyelids is done, it will be less than that. Lower eyelids develop more welling and bruising than the upper eyelids after surgery. There are also different types of blepharoplasties done in which the overall swelling and bruising may well be less, what we call limited blepharoplasties which are either of the pinch type or lower eyelid which use only a transconjunctival (inside the eyelid incision) approach.

There are numerous strategies for keeping the amount of swelling and bruising as limited as possible. This includes pre-and postoperative oral Arnica, keeping one’s head elevated above one’s heart for the first few days and a good icing of the eyes the night after surgery. I also use gentle surgical technique with delicate amounts of cautery to keep down the amount of bruising that can develop.

Dr. Barry Eppley

Indianapolis Indiana