Your Questions

 Q: I am a male who is considering having a browlift procedure. I am not sure how it is needs to be done but I do have one concern. Will a browlift make my hairline recede?

A: Browlifting in men poses unique concerns because of the varied and often absent frontal hairlines. Even in a male with a reasonably good hairline, it is impossible to predict what the hairline may do in the future. For this reason, the typical open browlift operations (either at the edge of the frontal hairline or behind the hairline) should be avoided. The endoscopic browlift remains the only ‘safe’ option even in a male with good hair density and frontal edge pattern.

The question of whether hairline recession make occur after a browlift is probably not directed towards actual hair loss from the procedure. This question likely relates to whether the hairline will move backwards as the brow is lifted. This is an excellent question and is a particularly relevant one in the endoscopic browlift.

This non-excisional (skin or scalp) type of browlift employs tissue shifting, or an epicranial shift, to create the effect of brow elevation. In other words, the entire forehead and scalp skin is shifted backwards, moving the excess tissue up and back where it sticks back down in a new position. As a result, the frontal hairline will move back to some degree. This creates some small amount of forehead lengthening, an increased distance between the brows and the frontal hairline. This is not hairline recession per se, just hairline repositioning.

Male patients in particular considering an endoscopic browlift should be aware of this hairline change. If the hairline is already fairly far back, this operation may not be a good choice or should be considered carefully.

Dr. Barry Eppley

Indianapolis Indiana

Q: I have a wide circular scar in the middle of my lower forehead from removal of basal cell cancer in the fall of 2009. It measures 5 mm wide by 10mm long and is depressed. (atrophic) The dermotologist used the ‘scraping method’ the remove the skin cancer. As the scar is in a very prominent place,  I am strongly considering scar revision to make  the scar is long and narrow. What are your thoughts?

A: Whether scar revision will be helpful is determined by two primary features of the scar in question. First, what does the scar look like? Scars that have width and height issues (raised, depressed and/or wide) are prime candidates for a positive outcome from scar revision. Narrowing and leveling a scar is one of the main changes that scar revision does well. Second, what is the age of the scar? Most scars must be mature enough to allow for good tissue handling and manipulation. In general, scars should be at least 6 months old if not longer. But the most important feature, not just time, is how pliable or flexible the surrounding skin is. Soft flexible skin is important to make most scar revisions successful.

Because the scar is located on the forehead, it is also likely that simple straightforward excision and closure, while better than what currently exists, is not ideal. Most likely, some form of geometric scar line rearrangement is needed to optimize its ultimate visibility. Scar revision using non-linear closure is best for any forehead scar that is not parallel to one’s natural wrinkle lines.  

Dr. Barry Eppley

Indianapolis Indiana

Q:I had a breast reduction about 5 years ago. I was left with scars on both sides left and right by the clevage area. The length of each is about 2 inches and they use to be raised scars. However I did go see a doctor and he injected it with some solution which did work and flatten the scar, but you can still see it. It is unsightly and I can’t wear low cut tops because its visible. What are my options? Will a scar revision make it worse? The scar skin feels and looks like nuckle skin its thin and soft. Please advise, Thank you.

A: The breast reduction operation works well but at the price of significant length of scarring. While the scars are extensive, most of them are in more natural locations being around the areola and along the length of the lower breast fold or crease. The only part of the scar that is ‘unnaturally placed’ is the vertical one which runs between the nipple and the lower breast fold. Most breast reduction scars turn out well but there is an occasional patient that is not happy with some of the scar and some scars which become wider or even raised.

While steroid injections will help soften and lower a raised scar, they will not make it more narrow. Narrower scars are less visible than wide ones. Scar revision usually works better because it gets rid of the wide scar in exchange for a more narrow one. Your breast scar problem is the medial tail of the lower breast fold scar. While it can not magically be erased, scar revision can most likely cause an improvement in its appearance. These small scars could be done in the office under local anesthesia.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I would like to schedule a consult with Dr. Eppley. I have migraines and have found that Botox was a big help to me making it at least 50-60% better. I also have neck pain badly. I think his decompression Surgery may be beneficial. I would like to speak to him about this.

A: The debilitating nature of many migraines begs for more effective solutions. In the past, the only approaches to the treatment of migraines has been pharmaceutical, obtaining some symptomatic relief. The most recent pharmaceutical treatment has been the use of Botox injections. For a very specific subset of migraine sufferers, Botox has been shown to be effective if the focus or trigger has been associated with the exit of sensory nerves from the skull base. This is usually the supraorbital/supratrochlear nerves in the brow area and the greater occipital nerve at the back of the head.

Botox works by relieving the spasms of the enveloping muscles as the nerve exits close to or at some distance from the bone. If Botox produces a profound response, this strongly indicates that surgical decompression (removal of muscle around the nerve) could be equally effective and offer better long-term results. In some cases, even a cure might be achieved.  Plastic surgeons have long recognized this surgical approach coincidentally with endoscopic browlift procedures where muscle removal around the nerve is done to help decrease wrinkling after surgery and some cosmetic patients comment that their headaches are better.

If the origin of the migraine and Botox injection relief is from the back of the head (occipital area) then decompression of the greater occipital nerve and release of the fascial attachments frm the back of the skull may work quite well. This is done through two small incisions in the hairline where the neck muscle meets the bottom of the skull bone in the back of the head. It is a fairly simple procedure that is done as an outpatient. Migraine relief should be seen quite early after surgery. There is only very mild discomfort after the operation which passes ina  week or so.

Dr. Barry Eppley

Indianapolis Indiana

Q : Hi, I found you in reading an article you wrote. This situation applies to me as I very recently had a subnasal lip lift done and I am still in recovery. I can see that my upper lip is crooked and way over corrected so much that my upper lip may be unfunctional. The worse part is however I had no idea I would not be able to smile, and appear deformed should I try to smile!!! I was told to expect some tightness but this is beyond tightness. What are my options? Can I get my smile back?

A: In the subnasal lip lift procedure, a wavy amount of skin (thicker in the middle) is taken directly beneath the nose with advancement of the lower edge of the incision to the area directly beneath the nose. The final closure is tucked in along the base of the nose from one side of the nostril to the other. This procedure shortens the distance between the top  of the upper lip vermilion and the base of the nose allowing for more upper tooth show when the lips are slightly parted. It also everts more of the upper lip vermilion, therefore creating an increased amount of a central pout of the upper lip. It is always slightly overcorrected as there will be some relaxation (mild re-lengthening) of the upper lip afterwards.

While this is a fairly simple procedure, I have seen and read of some problems associated with it. One complication appears to be from manipulating the underlying orbicularis oris muscle besides the skin while doing the upper lip lift. In theory, sewing the orbicularis oris muscle to the periosteum underneath the nose may make for a more stable long-term result. However,such a maneuver creates an unnatural stiffness and deformity of the upper lip when can be evident during smiling. This is not a good trade-off for the theoretical benefits of this manuever.  It is far better to run the inconsequential risk of doing a secondary tuck-up the procedure if there has been some relapse. Correction of this stiff lip problem can be done with re-opening the incision and releasing the abnormal attachments, with the possible insertion of a dermal or dermal-fat graft to prevent recurrence. The sooner this is done the better.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I want to have a breast lift, liposuction on my stomach,thighs,buttocks,under the arms,between my chin and lower neck line, an eyebrow lift, and some under the eye work. (dark and somewhat deep and little wrinkles) I am a mother that is curious of amount of the cost. I’m not even sure that I can afford this but I truly have self esteem issues. My weight topped out at 202 lbs but I i am now down to 178 lbs. I have always been one to want to look and feel good about myself and I do not feel that way at 35 yrs old. I am too young to feel this bad about myself!

A: How we feel about ourselves is one of the most important characteristics of a person. While inner beauty and well-being is all that really counts, there is no doubt that how we look on the outside affects how we feel on the inside. Your plastic surgery wish list is comprehensive and, affordability aside, all of that could and probably should not be done in  a single surgery. Therefore, it is important to prioritize this face and body plastic surgery wish list. The best way to approach that, and is what I discuss with all my patients who want an extreme body makeover, is to ask yourself this question. If I could only do one plastic surgery operation and could never return to the operating room, what procedures would you do on this list? I say pick just three and even put those in order of importance to you. Whether you would ever get to phase 2 or not is unknown, but if you don’t, then you will have accomplished the most important changes anyway.

Looking at your list, I can divide it into body and face work. While I am not you, most likely the body work is of greatest importance to you because you have listed/described it that way. It appears that a breast lift (with or without implants) and some abdominal and waistline contouring are your prime targets for change. It may also be possible to do so thigh and arm liposuction at the same time if your budget allows for it.

Dr. Barry Eppley

Indianapolis, Indiana

Q:I was wanting to know if Dr. Eppley has any experience in the repair of stretched (gauged) earlobes and how much a consultation would cost?

A: Repair or reconstruction of earlobe deformities are common in-office plastic surgery procedures. Short of congenital microtia or earlobe loss from injury, the gauged earlobe deformity is of greater complexity that simple earlobe split repairs. Gauging the ear is a form of earlobe expansion. When the gauge size is not too big (not bigger than the original size of one’s natural earlobe) the expanded earlobe has a generous amount of tissue. This enables it to be put back together in a normal size because there is adequate soft tissue. When the gauge becomes much bigger, the earlobe tissues become stretched and actually thinner. (tissue atrophy) When putting this type of gauged earlobe back together, the final appearance of the earlobe will be smaller than it originally was.

I have done lots of ear and earlobe reconstructions over the years of many different causes. The gauged earlobe is but a newer type of deformity but its reconstruction still uses the same basic plastic surgery principles. In many cases it can still be done in the office under local anesthesia.

If you send me pictures of your ear, we can consult for free by e-mail. This is an easily visualized problem that allows photographs to suffice in lieu of an actual office visit. That way, you can schedule a repair and get it done by only having to make one visit. (although a second visit will be needed for suture removal)

Dr. Barry Eppley

Indianapolis, Indiana

Q:I had a genioplasty to move the chin forward and now i want to do another surgery that doesn’t involve implants to make the chin wider. Is that possible and will the chin resorb after awhile because of splitting the chin and expanding it in the horizontal direction?

A: As you have discovered, moving the chin forward by an osteotomy will usually make it appear more narrow or tapered. This is because of simple geometry. If you move the front part of an arc forward (think of the lower jaw as u-shaped or an arc), it will make the overall shape of the total arc longer but more narrow in front. For this reason in male patients, I evaluate the front shape of the chin very carefully so if an osteotomy is performed for advancement, and the patient wants the chin to end up wider, I factor that into the osteotomy design and plan a central osteotomy with expansion.

Certainly a second chin osteotomy can be done and the downfractured chin segment split and expanded. It will be held apart by the necessary plates and screws needed to fix the overall osteotomy into position. This should not cause the bone segment later to undergo any resorption. A simpler method to get chin width expansion is to place a chin implant in front of or on top of the bone. There are chin implant styles that provide lateral fullness without any significant horizontal advancement and they would be a good choice here also.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I read in Dr. Eppley’s blog about using Kryptonite Bone Cement for pectus excavatum. I had the Nuss procedure done 5 years ago and breast implants done 4 years ago. I got very good results with the procedure and implants with the lower part of my ribs; however, the upper area (below the collarbone) is still indented. I would like to inquire about this procedure and whether or not I would be a viable candidate.

A: Kryptonite bone cement is a new type of bone filler/replacement that works well as an onlay, meaning to build out a bone surface to create a better contour. Currently it is approved in the United States for cranioplasty, the filling in or building out of skull bone contours. While it has never been formally tested for use on the sternum, there is no reason to think that it would not work just as well there as on the skull. What makes Kryptonite a possibility in the sternum is that it can be injected after it is mixed before it sets up into a hard mass. This is a very unique characteristic of a bone cement and no prior ones have ever had this physical property. As valuable as that material property is in the skull, it becomes a critical material characteristic in the sternum as incisions of any size are easily seen there.

For an upper sternal problem, a small incision inside the sternal notch can be used to develop the subperiosteal/supraperiosteal pocket. It is into this pocket that the material is injected and molded. The critical step in injectable sternoplasty, like injectable cranioplasty, is to make a good recipient pocket that matches the external outline of the contour defect.

Dr. Barry Eppley

Indianapolis, Indiana

Q : I AM A 39 Y/O FEMALE. WEIGHT 155LBS, 5FT 9′ WITH A B CUP WANTING A LIFT AND C CUP AND SILICONE IMPLANTS. AFTER LOOKING OVER MANY PLASTIC SURGEONS IN INDIANA I HAVE CHOSEN DR EPPLY AS MY FAVORITE IN RELATION TO THE WORK IVE SEEN. A FEW QUESTIONS: HOW MANY YEARS HAS HE BEEN PERFORMING BREASTS LIFTS, & IMPLANTS. DO YOU HAVE AN APPROX OF HOW MANY HE HAS PERFORMED? AND WHAT WOULD BE THE APPROX. COST? ALSO, WITH ME BEING A SMOKER WOULD THIS AFFECT MY BEING ABLE TO GET THE SURGERY PERFORMED? THANK YOU i HOPE TO HEAR FROM YOU SOON

A: Thank you for your inquiry regarding breast enhancement. I have done such cosmetic breast surgery for the past 20 years and have done over 1,000 breast augmentation/lifts patients. The cost of breast augmentation with silicone implants (Mentor memory Gel) is right aorund $ 5,900 all costs included. Adding some form of a breast lift to it does increase the cost but that can not be predicted without seeing you since there are 4 different types of breast lifts which add varying amounts of time to the procedure.

Smoking does not have any significant effect on complications from a routinue breast augmentation. There is a slightly higher risk of wound problems when any form of skin lift is done such as a breast lift. How risky that would be would be based on what type of breast lift is needed…the more extensive, the more risk of wound healing problems. The best way to handle the smoking issue is to refrain 2 weeks before and 2 weeks after surgery if possible.

Dr. Barry Eppley

Indianapolis, Indiana

Q : I had a chin implant 9 years ago, when I smile its seems to be without form, like flat. And after X-rays I noticed that the implant is placed higher up where it should be (close to my teeth). A doctor told me it would be very laborious, because it would be two operations, one to remove the chin implant which would remain a hole, wait 3-6 months to heal the skin and the second to put the new implant from under the chin. Is there another solution? Thanks!

A: It is very common to have a chin implant that ends up being positioned too high on the chin bone when it is placed from inside the mouth and is not secured with a screw. When the implant is too high on the bone, it loses some of the projection or forward position of the chin that it would otherwise have.

Replacing a misplaced chin implant is fairly easy and can be routinuely done in a single operation. I have never heard of having to do it in two operations nor does that make any biologic sense to me. Going through a small submental (under the chin) incision, a new lower pocket can be made, the old implant removed, and a new chin implant placed and secured. In some cases, I have left the old chin implant where it was and just placed a new one beneath it. If someone has a deep labiomental crease, keeping a ‘spacer’ (old implant) high can help push that area out and prevent it from becoming deeper.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am a 43 year-old male who is bothered by my long upper lip. When I smile I show no teeth and this makes me look older in my opinion. In addition, I have almost no red part of my line, it is just like a thin pencil line. I have done some reading and it seems a lip lift work. My measured vertical distance between the base of my nose and the top of the red part of my lip is 23mms. I have not read anywhere or seen that a man has had this type of lip shortening. Can it be done in a male? I have attached a front photo of myself for you to see what my lip looks like.

A:Thank you for sending your facial photo. While it is not a completely closed mouth view, it does show how long your upper lip is. You are correct in assuming that the only option for shortening your upper lip is a subnasal lip lift. As a general rule, I remove about 1/3 of the natural philtral distance. Since you are at 23mms, you could remove about 6 to 7 mms without any difficulty… maybe more. Whether this will be enough to unmask your teeth in smiling is to be seen but, at the least, the upper lip will be centrally shorter. The subnasal lip lift does not shorten or reduce the sides of the lip since the width of the tissue removal is limited to between the nostril bases. The lip near the corners of the mouth will not improve from a subnasal lip lift.

Dr. Barry Eppley

Indianapolis, Indiana

Q:I have had a c section with my son and I have no feeling toward the bottom of my belly. I have lost 52 pounds but still over weight. I am so frustrated but I think the only thing that will work is plastic surgery. Based on my readings, it looks like liposuction and a tummy tuck will do the trick. What has been your experience with the amount of improvement that thees two procedures can do?

A: Your question is a bit of a loaded one but the answer is in most cases very well. In fact so well for some people that it can be considered a ‘waistline’ miracle. This may seem a bit of an overstatement but for many tummy tuck patients it is not. The sheer removal of a full-thickness piece of skin and fat (either above or below the belly button) does something that no diet and exercise program ever could for someone who has lost a lot of weight. (50 lbs count as a lot!) When this skin and fat removal is combined with liposuction around the waistline and into the back, significant mid-trunk reshaping is done.

Already having  a C-section scar (with numbness) and the extra skin created by your weight loss makes the consideration of a tummy tuck a fairly easy one as there are no viable alternatives. It is hard to predict how many inches may be lost around your waistline but it is fair to say at least 2 to 3 inches and maybe more. As impressive as the frontal change may be, I am always excited to help create the narrowing of the waistline by aggressive flank and back liposuction.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I have read about fat injections to the breast but am concerned that it won’t give me enough of a cup increase. In my reading it says that the average increase in volume is around 100cc. Is that only a 1/2 cup increase. I have also read that an external suction device can be used with fat injections to get a better result, is this a hoax?

A: A 100 to 200 ml improvement in breast size for most women (depends on what they have to start with and how wide their breast base diameter is) will only be a 1/2 cup to 3/4 cup at best. You have to remember that much of fat breast augmentation work currently comes from Japan where small breasts (B cup) is the desired size by their cultural standards. That is why fat injections may be more ‘successful’ in this population. In the American population, such small breast size increases would not be considered enough. I have never placed a breast implant that was 200ml or smaller. Occasionally a 250ml to 275ml breast implant may be used but this is very uncommon. Most American breast augmentations are in the 300 to 375cc range.

The concept of external suction on the breasts to increase breast size is not a hoax. It is an actual device known as the Brava system. It has been shown to increase breast in the range of a 1/2 cup or more. The theoretical science is that pulling on the breast tissue stimulates fat or stem cell replication or growth. It is currently being studied in combination with fat injections to the breast. Combining the two makes biologic sense and I would suspect that their combined use is better than either one alone.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I would like to know more about laser liposuction. I had two C-Section deliveries and abundance of skin because of it.

A: While laser liposuction does  have the ability to tighten some skin, it is not a replacement for a tummy tuck. Your description of having had two pregnancies with C-sections and now an ‘abundance of skin’ suggests that your skin excess problem is not slight. In addition, the skin that is there has lost its elasticity (which is why there is an abundance) and does not have the ability to respond to the tightening caused by the heating effect of the laser. Such loose abdominal skin is always more effectively removed by an excisional procedure, aka a tummy tuck.

Laser liposuction, often called Smartlipo, is an improved method of fat removal than traditional liposuction. By using a laser probe to create an elevated temperature in a zone of fat, the fat cells break apart and loose their lipid content. This not only makes it easier to suction out, but fat cell damage continues beyond the surgical period much like the progression of a burn injury on the skin. Even some fat cells which were not directly injured by the laser probe at the time for surgery may go on to die later from the laser injury. This produces more fat loss in the days ahead. Whether that amount of fat loss is significant or not depends on how high and uniform the temperatures were at the time of the laser liposuction procedure.

The skin tightening effect of laser liposuction is similarly caused by the heat created. The temperatures must be high enough and close enough to the underside of the skin for this effect to be created however. Whether that occurs is dependent on the skill and the expertise of the physician driving the laser probe.

Dr. Barry Eppley

Indianapolis Indiana

Q: I have read that there is a cosmetic procedure that cures migraine headaches. I have had migraines for years and sometimes they are so bad I can’t leave the house. If there is an operation to cure this migraine problem, I would sign up for it in a minute! Can you tell what they are talking about?

A: The use of Botox for the treatment of  glabellar furrows (wrinkles between the eyes) has been done for decades. One of the very interesting findings from that cosmetic treatment was that plastic surgeons discovered that some patients with frontal migraines got a temporary cure, as long as the Botox lasted. The now proven theory is that in those patients with a focus of their migraines that starts above their eyes in the brow area are caused by the muscles squeezing the sensory nerves that exit from the bone there. This is why Botox relieves those migraines…it stops those muscles from working.

If you take that one step further, a browlift (of any type) can create the same effect as Botox except that its results will last much longer and maybe even permanently. That is because during a browlift some of the muscles are removed to prevent that type of wrinkling action. Recent studies and publications in the journal Plastic and Reconstructive Surgery has shown that certain types of migraines can be cured by performing a modified forehead/brow lift. Therefore, the type of forehead lift used to cure migraines could also lead to one looking younger as well. This type of cosmetic operation has been shown to be safe, effective and can lead to a tremendous improvement in the quality of some migraine patient’s lives.

Dr. Barry Eppley

Indianapolis Indiana

Q: Hello Doctor, I am 18 years of age, an Asian Chinese and I have big cheekbones. It was almost twice the size of the other people and that makes my face looking round and unpleasant big. I’ve read articles about cheek implants but I was wondering if there is a surgery that reduce the cheeks size, the best case scenario, to make it look flatter? Thanks in advance for helping me.

A: When you are referring to big cheekbones, you are undoubtably referring to them being too wide. Big in cheekbones invariably refers to how far they stand out from the side of one’s face. Wide and prominent cheekbones are most common in Asians as their genetic face tends to be less projected forward (horizontally) and more projected to the side. (wide)

Cheekbone reduction surgery can be done and understanding how it is done requires a knowledge of the bony anatomy of the face. The front part of the cheekbone is a fairly solid bone that is partially made up of bone from the side of the eye socket. This is the location, for example, where cheek implants are placed to make the cheek more full. But the part of the cheek that makes it wide is known as the zygomatic arch which acts as a span of thin bone that arcs out from the cheekbone in front to the temple bone in back. How much this piece of bone arcs determines how wide the cheek bones appears. Cutting the attachments of the cheekbone from the side of the eye socket and the back part where it attached to the temporal bone allows it to fall in. It falls inward (less wide) because not only are the bone attachments cut but there are muscles attached to it that help to pull it in also.

While cheekbone reduction surgery sounds drastic, it is done from inside the mouth with small bone-cutting instruments.

Dr. Barry Eppley

Indianapolis, Indiana

This is one of those headlines that attract a lot of attention as the concepts of Free and Plastic Surgery go as much together as Peyton Manning and quarterback sacks. One of the not infrequent requests that I get as a plastic surgeon, however, is about this very concept. On my practice website and numerous blog sites, requests come in every week for some form of plastic surgery ‘donation’. Many of the requests go into great detail about why they want a certain procedure and they are often quite moving. While the idea of performing surgery for free seems fairly simple, it actually is not.

This can best be explained by my response to a recent request for a free breast augmentation with a heart-felt plea for an improved perception of herself.

‘I have great empathy for the concerns you have about your breasts, and wish that providing you with a free procedure were an easy choice.  Given the number of women who come into my office with similar concerns about their bodies, I can understand how connected self-esteem and a positive self-image are.   Providing surgery for free may seem like a simple and straightforward thing to do,  but there are many factors involved that make the concept of ‘donated’ surgery not exactly free. While any plastic surgeon can give away his time to perform the operation, a surgeon’s fee represents just a fraction of the total costs of surgery. The cost of the breast implants, use of the operating room, and the fee for the anesthesiologist expertise are other cost factors that must be accounted for and paid. The surgery center or hospital, implant company and anesthesiologist are under no obligation, and usually are unwilling, to provide services and materials at their expense for an elective procedure. Often times, these costs make up more than that of the plastic surgeon’s normal fee.’

One of the hidden costs of any donated surgery in this country is the potential medical-legal responsibility. Unfortunately, donating surgery does not waive any responsibility on the plastic surgeon for the outcome. Should any untoward events happen, such as a rare but possible complication,  the surgeon is still liable and responsible.  The possibility also exists for the need for revisional surgery after the initial procedure should the result not be ‘perfect’ and the question then arises is the surgeon again expected to waive his or her fees?   While many patients say they will sign anything to get the procedure for free, the legal reality is that there are no forms or waivers that a patient can sign that will legally hold harmless the physician for the services that he or she has provided.

One may wonder then how do they do these free makeover surgery contests, either done locally or even on TV? The answer is whoever is doing it most likely is not a board-certified plastic surgeon. The American Society of Plastic Surgery strictly forbids providing any free surgery as a result of a contest, promotion, or any other method of inducement which encourages a patient to undergo surgery based on an economic incentive. Doing so is an ethical violation of its membership and could be grounds for dismissal from the Society. Those non-plastic surgeons who do offer such free surgery are not bound by these ethical guidelines and merely see the risk as a marketing expense.

While a plastic surgeon may choose to donate his or her skill and experience for free, the rest of the costs of surgery remain, and are usually out of the surgeon’s control. The legal and ethical issues, that are completing unaware to most patients, makes donating an invasive operative procedure not quite the same as giving away a more traditional retail product.

Dr. Barry Eppley

Indianapolis, Indiana

Q : I am a 55 year-old male and am bothered by low hanging brows. It makes me look angry all the time and I am actually a good-natured and upbeat person. It seems my eyebrows are falling off of the brow bone and they look so heavy. My mother had a facelift and browlift several years ago and I am wondering if this would work for me.  

A: While a man can aesthetically tolerate a lower brow position than a woman, there is a point when the brow descent is too excessive. When the eyebrow is below the brow bone, the look that is created is a perpetual scowl or frowning. At the least, it makes the size of the eye look small and the forehead look very long.

Browlifting in men poses unique challenges that are not present in most women. The lack of a well-defined and permanent hairline with good hair density makes the options for a browlift more limited and less effective.  Browlift scars are not easily hidden and the risk of visible scarring is beyond just a theoretical possibility. None of the hairline or scalp approaches that are most commonly used for lifting the brows are worthy of that scar trade-off. In some cases, an endoscopic approach can be used but it stills creates small scars that can be visible through most men’s hair patterns.

There is a mid-forehead incision approach to a browlift but it requires a man to have a deep and prominent horizontal wrinkle in which to use. The scar with this approach takes a long time to settle and the redness to fade. While effective, this central forehead scar should be reserved for a few select patients.

This leaves the eyelid or transpalpebral approach as the only browlift option without the risk of adverse scarring. The eyebrow is lifted and sewn back up to the bone through an upper eyelid or traditional upper blepharoplasty incision. It is not as effective as a ‘superior-based’ browlift but the risk of adverse scarring is eliminated.

Dr. Barry Eppley

Indianapolis, Indiana

Q : We have a potential new hire for our company that has about a ¾ inch insert gauged in both ears.  This person regrets having this done and wants to abide by company requirements and have them removed.  How is this done and what does the earlobe look like afterwards. Also, what would the potential cost be to have both earlobes repaired?

A: Gauging of the earlobes creates a central hole surrounded by a thinned out or thin ring of earlobe skin. The size of the gauge determines how thin the ring of earlobe skin is. As long as the gauge is not too big (greater than one inch), the expanded earlobe can be put back together and have about the same size as it was before having the insert. When the insert becomes much bigger, it not only stretches out the earlobe but the tissue becomes much thinner as well. (pressure atrophy) When put back together, the final size of the earlobe will likely be smaller than before.

Earlobe reconstruction is done by cutting out the skin along the central hole, including some of the rim, and putting it back together in the shape of a more normal earlobe.

Like the split earlobe deformity, reconstruction of the gauged earlobe can be done under local anesthesia. This can usually be done in the office which saves a lot of expense when the cost of an operating room and anesthesia is not used. The typical cost of such earlobe surgery is in the range of $750 to $1,000 per ear.

Dr. Barry Eppley

Indianapolis, Indiana

Q : Hi, I read online that other girls have the same problem as me. I had a jaw reduction and the doctor shaved too much bone and side of the jaw, is uneven to the other side. You gave advice to them to have jaw implant. My question is that since the jaw is now uneven, how can you make it even by putting jaw implant? Will the implant be different since it is not the same? How much does it cost for chin augmentation? Not the implant but the moving if the chin. Thank you. 

A: It sounds like you had a jaw angle reduction. Often times, too much bone is removed and the sides are uneven as more bone is taken from one side than the other. The only way to improve that problem is to replace the lost bone with an implant. The size and shape of the jaw angle implant is taken from tracings off of a panorex x-ray as both implants can not obviously be the same when asymmetry is involved.

Jaw angle reduction must be carefully done as it is easy to remove a large bone segment from this intersection of the posterior and inferior border of the jaw. This not only makes the jaw angle blunt but can make one look more aged as well.

A chin osteotomy is done much less frequently than an implant for chin augmentation. But in the right patient, it can offer some different dimensional changes that may be more ideal for facial balance. (e.g., chin lengthening) The average cost for a chin osteotomy is around $6500 when done as a one hour outpatient procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q : Last year I had a facelift which made my sagging neck and jowls look so much better. I love the result but have developed some raised and mildly painful scars behind my ear. My plastic surgeon said they would eventually go away but I am not so sure. They have not changed in size and they feel like small ropes along the backside of my ears. What do you suggest?

A: Nearly one-half of the incisions that are used in a facelift are behind the ears. Going along the grooves where the ear connects to the side of the head, these scars run along this groove where they go back into the scalp near the top of the ear. The skin behind these scars is used to pull up loose skin from the neck where it is trimmed off.

These skin flaps behind the ears are very thin and often are the slowest to heal after a facelift…even though they are not easily seen. Because these incisions behind the ears are stitched back together under some tension, a few patients can develop hypertrophic or raised scars because of it. Once the scar thickens it will become and stay sensitive.

Sometimes these raised behind the ear scars will settle down on their own with just time and scar maturation. If these raised scars persist beyond a few months, I recommend steroid injections. I repeat these injections every month for up to three injection sessions. They will usually cause the raised scars to settle. If they have not gone away by then, cutting out the scars is needed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am getting saline breast implants in the next several months. I am getting them because they are less expensive and the size of the cut to put them in is much smaller. What I want to know is where is the best place to put them through…my armpit, nipple, or under my breast in the crease?

A: One of the two advantages to saline breast augmentation, besides a lower cost, is that they can be inserted through very small incisions. Because they are put in deflated, they are rolled up to about the size of a small burrito. This enables them to pass through incisions as small as one inch or 2.5 cms. Once in place, they are the inflated to their desired size.

While all three incision locations will work (armpit, nipple, lower crease), choosing one of them is based on the patient’s preference for scar location and how soon they must return to work and what type of work they do. If one has darker skin color (e.g., Asian or Hispanic), they I would definite choose the armpit or axillary approach. This is because this puts the scar away from the breast and women of these ethnic backgrounds are very sensitive about any visible scarring. Conversely, if one needed to return to work quickly and their job involved lifting, then I would choose the lower breast crease. Becasue the entire pectoralis muscle does not need to be elevated (only the lower half is), one will have less pain and a quicker recovery due to the more limited muscle trauma.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am interested in getting breast implants but only want to go up maybe one cup size. I don’t want anything drastic just a little change. I want the result to be completely natural looking and not fake. How can I be sure that will happen?

A: The concept of natural breasts can mean different things to different women. In general, however, what most women are referring to is a breast that is not disproportionate to their body and chest size and one that does not have a completely round shape. (too much upper pole fullness)

The most assured way to avoid an unnatural breast augmentation result is to have properly sized breast implants. In short, don’t get too big of an implant for your chest or the amount of breast skin that you have. The single best way to avoid that problem is to keep the diameter of the implant at or less than your own breast base diameter. Implants that are wider than your breast base will always look unnatural or too big. This may also mean to avoid a high profile implant which can have a tendency to look rounder after surgery, particularly if you have small breasts with tight skin to start.

Natural breasts are also those that don’t have palpable (able to feel) implant rippling. This is more of a concern with saline implants who have a greater tendency to develop implant rippling, which may also be able to be seen as well.

In summary, natural breast augmentation is best done by choosing a silicone gel implant that is slightly narrower than your breast base width. For many women this means that implants sizes will run between 250cc to 350cc.

Dr. Barry Eppley

Indianapolis, Indiana

Q: How do you do mouth widening? I have a relative that is scheduled for that procedure and we are hesitant to do it. We have never heard of such a thing. How safe is the procedure? Thank you for any information that you can share with me.

A: The concept of making one’s mouth wider is possible but very rarely done. I can only assume that your relative has a small horizontal width to their mouth (small mouth) and wants it to be extended further horizontally.

Such an operation is possible by using the principles of commissure creation or modification. Known in plastic surgery as a commussuroplasty, the corners of the mouth can be either shortened (closed down) or opened up. (made wider). To make the mouth wider, a modified isoceles triangle of skin is removed out to the distance you want and the inner lining of the lip (mucosa/vermilion) is advanced out and sewn to it. (a Y-V advancement) This relatively simple procedure will make the  mouth wider but does so by leaving small scars at the corners of the mouth at the junction of the skin and the lip tissue. If not overdone too much, it can definitely make a difference and look fairlu natural. Such a technique is used in the more commonly done corner of the mouth lift, where downturned corners are turned up and made more horizontal to get rid of frowning or a downturned smile.

Conversely, the reverse can be done to make a wide mouth small. (a V-Y advancement) This leaves a more noticeable scar in its wake as the lip lining is moved further inward.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I want to know more about a procedure that will lower my upper lip. I show a lot of gum when I smile and this bothers me. I have read about a ‘mucosal roll-out’ operation that brings down the upper lip. Please tell me more about it.

A: An upper lip mucosal roll-out will have only a very minimal effect on actual upper lip lowering. That is used more to make the upper lip fuller but, in and of itself, will only lower it maybe a millimeter or two at best.  To lower an upper lip for the purposes of a gummy smile treatment, the upper lip must be treated by levator myotomies (release of one of the main lip elevators) , an upper lip spacer insert (to keep the muscles from healing back together and to help push it down)  and a V-Y mucosal release (frenulectomy, although technically it is a frenulotomy) and advancement. Moving the inner lining of the upper lip (mucosa) only will not be effective.

Lowering an upper lip is even more difficult to achieve than raising a depressed lower lip. While bone shortening (maxillary impaction) is the most effective way to bring the horizontal lip level down closer to the teeth during smiling, most patients do not want that much surgery to achieve that goal. Soft tissue surgery to lower the upper lip can be expected to achieve about 3 to 5mms of actual lip lowering. This can be combined with other dental procedures (crown lengthening) to get an even greater amount of gummy smile reduction.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dear Dr Eppley, I am contacting you with interest in stem cell-enriched breast augmentation. I think it is an interesting new technique and it has raised many questions in my mind. Here is my list of questions.

1) First of all, how is the surgery done and how much fat do you need to do it?

2)  Specifically, I would like to know whether it is possible to transform my small A-cup to a preferred C/D cup. Is this possible with the procedure. What is the average gain in ml when you have an A-cup?

3) What are the risks? From other plastic surgeons I hear that the long-term effects are very uncertain.

4) I am kinda slim, so I am wondering if I have enough fat on my body to do the procedure?

I am looking froward to our answers.

A: In answer to your questions about breast augmentation with fat injections and stem cells, here is some current realities with it:

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am interested in having a jawline tuck procedure. The only part of my face that bothers me as I have aged is along the jowls. That is the only place where I have some excess skin that affects my appearance. Please tell me where the incisions area and what part of the face this operation does, and does not, affect. Thank you!

A: Basically, a jawline tuck is a simple modification of a limited or mini-facelift. It is similar to the advertised and marketed ‘Lifestyle Lift’ which is a franchise approach that offers a very similar procedure. As the name would imply, it is a facial rejuvenation procedure that has very little downtime hence the branded name. The fine line incision starts at the top of the front of the ear, goes inside the ear behind the tragus, and then around the back of the earlobe. Through this hidden incision, any loose skin along the jawline (jowls) is lifted smoothing this area out. There is some benefit in the neck area but not as significant as that of the jowls. This procedure is as described….a tuck for the jawline or jowls. It does not affect any other part of your face.

Many times other facial procedures are done with this ‘little’ facelift such as neck liposuction, laser resurfacing or chemical peels, and eyelid tuck procedures. But when done alone, there is less than a week of any visible swelling and bruising so recovery is quite rapid.

The key concept to grasp is that a facelift is an isolated jowl and neck procedure. A limited facelift or jawline tuck is just a smaller version of it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I had breast reduction surgery last year and , while those results were great, my stomach area is now the problem. What is the best way to get rid of some (or a lot of!) stomach fat? I have read about Zerona. Is it better than liposuction or does it just depend on the person?

A: It is not uncommon after breast reduction that one notices that they now have ( or have had) a larger stomach than they knew. Since the breasts hung down on the stomach, the size of the stomach is usually obscured. After breast reduction, where the breasts are lifted and reduced, these ‘new’ stomach problem appears.

While fat reduction can be done both surgically (liposuction) and non-surgically (Zerona), the results and the process are not the same. Do not equate Zerona and liposuction as providing the same results. Liposuction is a much more effective and rapid way of eliminating unwanted fat, albeit with surgery. Zerona is best considered as a  non-surgical step before one considers liposuction. In the right patient (5 to 20 lbs overweight), Zerona may provide enough of a result that liposuction may never be needed. In larger fat collections, liposuction may ultimately be needed.

Therefore, patient selection is critical when deciding what approach to take for abdominal fat reduction. For small to modest abdominal fat fullness, Zerona is probably worthwhile as enough of a result can usually be obtained without surgery. But if you have a large abdominal girth or any excess overhanging abdominal skin, some form of surgery will be more effective whether it is liposuction, a tummy tuck or some combination thereof.

Dr. Barry Eppley

Indianapolis, Indiana

Q : When I was 20 and in the service I had a breast reduction. I went from a 44DD down to a C cup.  I am now 50 and my breasts have slowly over the years grown back. I have been so uncomfortable physically and mentally from their size. I didn’t know breasts could grow back after they were reduced. Can I have another breast reduction at my age?

A: Breast reduction is a very successful operation at reducing one’s breast size as well as lifting it back up onto a better position on the chest wall. (where it once was) In most cases, once the breast is reduced it does not return to its original size. But breast regrowth has been reported and it does occasionally occur. This is almost always in the young female population when the operation is done during the teenage years. When done under the age of 18, exposure to continued bodily growth, weight gain and pregnancy can all be hormonal signals for breast tissue growth. But even in these circumstances it is still rare. Having it happen after one is developed is rare but not unheard of as you illustrate.

There is no age limit when breast reduction can not be performed.  It is not an operation that is stressful to one’s bodily systems. It can be done using your existing breast scars as the operative pattern. It would be fair to say that there is no chance your breasts would regrow after being reduced at age 50.

Dr. Barry Eppley

Indianapolis, Indiana