Your Questions
Your Questions
Q: I have 5 lipomas in my stomach area and would love to have their size reduced, if not completely gone. I’ve been looking into having them treated by deoxycholate injections. What has been your success in getting rid of them (all of them are less than 4 cm in diameter) and how many injections sessions does it usually take?
A: The traditional method for lipoma removal is excision. These are encapsulated benign fat tumors that actually pop out of small incisions made directly over them fairly easily with a little pressure. But in an effort to avoid surgery, the use of fat-dissolving injections has been done for them as well. Known chemically as deoxycholate or phosphatidylcholine deoxycholate (often called Lipodissolve), this solution has been well described for the cosmetic reduction of small body fat collections. Working through an inflammatory process, this solution is known to break down the cell walls of fat allowing their fatty acid content to be released. It is less well described and known for fatty tumors (lipomas) treatment but it works through a similar inflammatory process. The fat in a lipoma is more densely packed and , in theory, is a little more resistant.
I have treated a series of lipoma patients with these Lipodissolve injections in my Indianapolis plastic surgery practice and do find it to be effective. It does take more than one injection session to get maximal reduction in most patients. How many injections sessions that would be depends on the size of the lipoma. As a general rule, expect about a 50% reduction with each injection session.
Indianapolis Indiana
Q: Hi I was wondering what you think of Bioplasty or have you ever heard of it. Doctors in Brazil does the whole face with pmma called Newplastique, injecting it into the jaw, cheeks, chin, eyes, brow anywhere. I saw a doctor in Mexico who uses this new plastic pmma and he quoted me $2400 for jaw jawline cheeks chin and said second touch up treatment would be half the price. What do you think?
A: What you are referring to are ‘permanent’ injectable fillers for facial fillers and volume enhancement. They are permanent based on that they contain a percent of non-resorbable particles (usually about 30% or less in volume) mixed in with fluids which allow them to be injectable. (flow through a relatively small needle) The percent of particles in any given size syringe is always less than the amount of fluid otherwise they would clog up the needle and not be injectable. There are a variety of these type injectable fillers that exist in the world using different plastic particles and different fluids. The concept, however, is the same and the potential complications are similarly the same.
Quite frankly, I am not a proponent of these type of injectable fillers for widespread facial use. I would be concerned about the potential for long-term problems from the particles such as granulomas and lumpiness. They would be difficult to remove and may have to be cut out should these types of problems arise. Advocates of their use feel that these problems can be minimized by good injection technique, which I am sure is true, but how do you know who does it well and who does it poorly? Around the world, where the medico-legal implications are not as severe, these fillers are more widely used. In the United States, however, their use and many of these type of fillers are not widely done and are not even FDA-approved for use. Nonetheless, It is not an injectable procedure that I feel comfortable doing to patients. That doesn’t make it wrong, just that I have a different practice philosophy.
I feel more comfortable doing enhanced fat injections for facial volume and reshaping. While their permanency is variable, they also are not associated with any long-term complications since it is the patients own tissues. While it is more effort and expense, and may have to be repeated sometimes as well, safety is more important than a lower cost.
Dr. Barry Eppley
Indianapolis Indiana
Q: Hello, I have several questions regarding cosmetic surgery. First off I want to say I am a single mom of four wonderful children but they have destroyed my once nice looking tummy. But I HATE how I look. I have suffered an eating disorder since my first child being born, to the point I was approx. 90 lbs and I am 5′ 5″. I still do not eat right as I am petrified that I am going to gain weight and make my stomach even bigger. I am also a full time student so I know I cannot afford surgery. There is simply no way. Is there ANYTHING I can do? I hate the way I look, I hate to take showers, I hate to be seen by my fiance naked!!! I literally HATE my body. I currently weigh 135 lbs. So I have done very well maintaining weight. I am at a loss as to how can I rid myself of this awful belly? Please help!!
A: Unfortunately, the short answer is that only surgery can offer any help. After multiple pregnancies, your abdominal wall has been irreversibly changed. The abdominal muscles are no doubt separated along the midline and are lax which accounts for the protruding appearance of your belly despite being at a good body weight. In addition, the overlying skin has been stretched beyond its elastic limit as evidenced by stretch marks. All you can do with your weight is keep the fat layer thin but that will not change your skin and muscle of the abdominal wall. Perhaps one day you will be able to have the tummy tuck surgery that can provide the solution that you are looking for.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I feel like I am ready for a facelift and want to get the best result that I can. In doing my research on the internet, I have come across several recent articles on a procedure called the Stem Cell Facelift. In reading them, they make it seem like it is the best way to go with the best results. But I don’t understand what stem cells have to do with a facelift. Do they help lift the droopy skin or do they make what is already there better. I would like to go to a doctor that does them but I am also worried about whether this is so new that maybe it doesn’t really work that well or it is just some sort of a scam. What is your opinion?
A: The concept of the Stem Cell Facelift is based on two simultaneous techniques, a traditional facelift to lift and tighten loose neck and jowl skin and fat/stem cell injections to add facial volume. The injections are not responsible for any type of skin lifting. They add volume to areas of fat absorption that have happened with age and are purported to help make the skin look better. (which remains far from proven) They may be done together but the fat and the stem cells they contain can not make for any tightening effect on the skin
Is this facelift concept hype or hope. At this point, a little of both in my opinion. The concept is very appealing and the technique uses all natural products from each patient, thus there are no risks involved in doing it. Conversely, whether this facelift approach is better than the traditional proven methods has yet to be adequately studied over the long-term. It may well prove to be an improved method with better results but at this point the promotion of it is ahead of the actual science.
Dr. Barry Eppley
Indianapolis, Indiana
Q: There seems to be a multitude of people out there with chin/lip problems arising from intraoral surgery who don’t know where to turn or what to rely on to remedy their situation. Mostly their problems are attributed to mentalis detachment/loosening and scar tissue, particularly in the labiomental fold region. Chin/lip deformity poses a significant quality of life issues and must be taken seriously. A case study of scar revision in this instance, with before and after photos and details of the surgery, would be of great assistance. Mentalis resuspension seems straight forward enough if its loosened or detached from its origins. The question in my mind with regards to scar tissue excision, is how much mentalis muscle in the labiomental fold or chin pad region, can be safely excised before the mentalis can no longer function properly?
A: Ptosis, or sagging, of the soft tissues of the chin can occur after any form of chin surgery done through an intraoral (inside the mouth) approach. When it occurs, one surgical method to put the soft tissues back onto the chin bone is mentalis resuspension. This is fairly way to do and the most important technique for the procedure is how the muscle is secured back to the bone.
Generally speaking, the only scar tissue that ever needs to be removed during any chin revisional surgery is the scar capsule around an existing chin implant. (if the implant is being removed) This needs to be removed because it will not allow the overlying muscle to heal back onto the bone.
Dr. Barry Eppley
Indianapolis Indiana
Q: I’ve done Botox injections on my frown line and crow’s feet. Thinking about having Botox to treat TMJ pain and maybe some on my face. Please let me know if he accepts insurance for the Botox treatments.
A: The use of Botox to treat “TMJ’ problems is done by numerous practitioners with variable degrees of success. Botox is a very specific treatment for muscle spasms and tightness or overactive muscles. The term TMJ, however, is a broad term that actually is a collection of different pain sites that is not really a unified diagnosis. For this reason, so called TMJ patients are being injected who may not be ideal candidates for a muscle treatment.
The best orofacial pain patients, in my experience, to get relief from Botox injections are the bruxism or clenching patient. This is a very specific masseter muscle problem that can be localized in most cases to the part of the masseter that is near the bony jaw angle. This is also a perfectly safe area to treat without causing any complications. The tight and painful muscle can be easily felt and the most painful part of the muscle specifically injected. These are also patients that have either been through or are currently undergoing some form of traditional mouth splint therapy. Often this treatment has failed or its effectiveness has decreased…as this is why they are seeking Botox injections.
Because the use of Botox for bruxism or as any part of TMJ problems is not FDA-approved, it is not eligible for insurance coverage.
Dr. Barry Eppley
Indianapolis Indiana
Q: Do you offer chemical peels? What is available to forehead and brow wrinkles?
A: Assuming that these two questions are linked, so to speak, points out a basic misunderstanding of what certain procedures can do. Chemical peels, of which there are many types which penetrate from superficial to deep, are good for improving skin texture problems which does include very fine wrinkles. But they will not work on any skin problem which lies deeper, such as scars or deep wrinkles, folds, or furrows. Almost all commonly used chemical peels treat more superficial skin problems. It is best to think of chemical peels as an outer skin treatment.
Forehead and brow wrinkles are not superficial skin concerns. While they may appear on the surface as a skin change, the primary problem is deep. It is the excessive muscle action that eventually causes the outer skin layers to become etched or permanently wrinkled. Since the problem lies deep, no superficial treatment can provide any visible improvement. This is why the initial treatment for forehead and brow wrinkles is Botox injections. As a muscle-weakening agent, it can lessen or stop their movement creating an immediate improvement in the depth of the wrinkles seen. In more severe cases, a browlift may be a better answer. This procedure treats the muscles at fault through their selective removal. With less muscle action, which is combined with skin tightening through a lift, there can be a dramatic reduction in the forehead and brow wrinkling problem.
Dr. Barry Eppley
Indianapolis Indiana
Q: Hello, I went to see a plastic surgeon about repairing my one stretched ear ring hole. I pretty much made it clear why I was in the office. The office workers did not pay attention to my needs and instead pointed out all my other flaws and pushed selling other procedures on me. I wish I could afford to correct all flaws, however at this time, I just want my little ear repaired. After they had me under the bright light and made me feel awful about myself, they finally told me the cost of the ear repair… $800. Just because the way they treated me, I would rather stitch it myself then give that office the money. Can you please tell me how much the procedure would be? Thank you.
A: Earlobe deformities from the use of ear rings creates two basic correctable problems, an enlarged or elongated hole and a complete split or tear. Both can be easily and quickly treated in the office under local anesthesia in less than 30 minutes. There is no pain afterwards or significant swelling or bruising. Tiny dissolveable sutures are used so there is no suture removal afterwards either. One can shower and get it wet the very next day. Once it is healed, re-piercing can be done six weeks later.
From an office standpoint, every plastic surgery practice has differences in philosophy. Some promote and sell harder than others which often, understandably, turns some patients off. That doesn’t make them a bad practice, just one who may not be a good fit for you. From a pricing perspective, fees will vary around the country for any elective cosmetic surgery procedure based on geographic location and the size of the practice. There are no standard fees for cosmetic surgery nationally. It is a simple matter of what value the practice puts on their time and expense to do the procedure and what a patient is willing to pay. Here in Indianapolis, the prices for earlobe repairs is more typically in the range of $300 to $450 per earlobe.
Dr. Barry Eppley
Indianapolis Indiana
Q: Hi Dr. Eppley, I have a question regarding my face since it has gotten thinner after a facelift. I had a facelift last summer after losing 45 pounds. My plastic surgeon said he took four inches of skin out of my neck. However I did lose my round face because my cheeks are more sculpted now due to loss of volume. While I like the change it is a weird look for me because I have always had a round face since I was just a kid. I never had sculpted cheeks even at a normal weight. I used to get carded well in my 30’s because of my baby face. So there is some merit to having volume. It is weird for me to see my cheekbones as opposed to my puffy cheeks. I almost feel like I look older without my round face. So my question to you is it possible to add some volume in my lower cheeks BELOW the cheek bone to get my “baby face” back. What would you suggest? I can send pix if you want me to. Thanks for your advice.
A: There is no doubt that between having a facelift and undergoing considerable weight loss, one can end up with less facial volume. This is usually most manifest around the cheek areas when it occurs, specifically in the area below the cheeks known as the submalar area. I prefer to call this area the submalar triangle as it is a soft tissue area that has the configuration of an inverted triangle and has no underlying bony support. That is why it suffers the greatest indentation or hollowing on the face with fat loss…it has no underlying bony support so it sinks in.
There are several ways to build out the submalar triangle. The simplest is to replace what is lost through fat injections. Fat is both natural and easy to harvest through liposuction and its injection is not ‘invasive surgery’. Its downside is that its survival is not always predictable. The other is to use a specific submalar implant which sits on the underside of the cheek bone. This will build out the upper part of the submalar triangle but not the lower area near the corner of the mouth. The total submalar area can also be built out by the insertion of onlay dermal grafts. Using part of your old facelift incision, allogeneic dermal grafts (human dermis out of a box) can be cut and laid underneath the skin to add a soft natural volumetric fill. The dermal grafts will integrate and become part of your natural tissues.
As you can see there are a variety of submalar augmentation options. Which one is right for you depends on which approach offers the simplest, most natural, and predictable outcome.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am very interested in learning more about the Kryptonite Bone Cement for injectable cranioplasty. I am a 36 year old female with a very unusual shaped head in which I have always hid behind various hairstyles for shame of the overall appearance of my head. I strongly believe that the shape of my skull may be the result of some form of untreated craniosynostosis or other undiagnosed craniofacial disorder. Or maybe it might just be plain old bad genes.
My skull is very narrow and somewhat small. The shape of my forehead slopes back at such an undesirable angle and is very flat and narrow in width. The resulting slope of my forehead extends up into the top of my skull of which I can only describe as a point. There is somewhat of a flatness in the center of my skull and the back of my skull is very flat and extremely narrow in width as well. I am also very hollow in the frontal view at my temple area around my eyes with very wide cheekbones and a deficient jaw and chin. I have always wondered if there were any such cosmetic procedure that could help in this kind of skull case.
My questions are: 1) What are the biggest benefits of using the older PMMA and HA methods over the new Kryptonite Cement method? How long has Kryptonite Bone Cement been used? 2) Can it be used for adding volume to reshape an entire skull like mine, making it more rounded and add mass in largely deficient areas? 3) Can it be done with scalp hair in place or does the hair need to be shaved for a better view of the entire head? 4) Is there any chance that the material will become detached from the skull and slide out of position? 5) Will the scalp expand and conform to the newly added volume comfortably? 6) Can it be used in place of such procedures as chin and jaw implants?
A: Thank for your insightful questions in regards to your craniofacial concerns. My answers would be as follows. 1) All three cranioplasty materials will work in an open scalp approach. Only Kryptonite can be injected. There are substantial cost differences between the material cost of HA and Kryptonite being over 10X the price of PMMA. For very large scalp areas, the issue of cost makes PMMA the only practical choice for most patients. 2) All the materials can be used over large skull areas. In larger areas, the cost of PMMA makes it the material of choice. 3) For large skull areas, the hair would have to be shaved to see what one is doing. For an isolated forehead cranioplasty, the hair is not shaved. 4) No, all cranioplasty materials stick quite well to the underlying bone. 5) The scalp can expand to a large degree but the skull must not be expanded (built out) greater than what can be closed over it. 6) No as yet. Kryptonite has not been yet tested for use in this way. For now, standard facial implants are more predictable and far less expensive.
Dr. Barry Eppley
Indianapolis Indiana
Q:I am looking at having a revision surgery on my chin for what I believe is a partial non-attachment of the soft tissue to the hydroxyapatite implant. Some of my chin hang independently from the rest and looks aged. My surgery was two years ago. I am contacting you because I see you have specific knowledge of the intricacies of chin surgery. Could you give me some information about what I should do now and whether you have dealt with this problem before?
A: Thank you for your inquiry. Before I can answer your questions specifically, let me get some details as to your chin surgery from two years ago. You refer to having a hydroxyapatite implant placed. Since there are no off-the-shelf hydroxypatite implants of which I am aware, I assume that this was an intraoperatively carved one that was done from a block of material. Furthermore, I am assuming that it was placed intraorally (through the mouth) as opposed to under the chin through the skin.
Your description of your concern’s sounds like what is known as a ‘witch’s chin deformity’, otherwise known as soft tissue chin ptosis. There is where the chin soft tissues sag off of the end of the bone/implant. Because any type of chin implant augmentation must detach the muscles, there is that risk after surgery although it almost exclusively occurs from an intraoral approach.
Please send me some photos of your chin and provide answers to my questions, then I will be able to confirm this diagnosis. I have seen this numerous times and the appropriate correction (implant notwithstanding) in most cases is a mentalis muscle resuspension procedure.
Dr. Barry Eppley
Indianapolis Indiana
The internet continues to redefine our existence on a daily basis. From how we shop for everything from clothes to cars, to how we shop for information, it now influences and controls our culture. Even our English language is being affected.
This is best reflected in the Urban Dictionary. This is a web-based dictionary of slang words and phrases. The definitions on the website are meant to be those of slang or subculture words, phrasing phenomena not found in standard dictionaries. Most words have multiple definitions, often quite different than you think. It contains over five million definitions and is expanding rapidly with an average of over 2,000 new submissions per day. While it has tremendous web traffic, most of its users are younger than 25. For this reason you may not have heard about it…but eventually you probably will.
When it comes to ‘urban’ terminology, plastic surgery has many such terms. Used everyday with patients or in the operating room, these thinly veiled innuendos instantly describe the cosmetic problem. Let me share with you a few of the most common ones- some which you will know, and others which you may find enlightening.
Elevens– Not a number but a type of facial wrinkle. Popularized by the manufacturer of Botox in their advertisements, these vertical lines appear between the eyebrows when a person is scowling or frowning. Because they most commonly appear as paired lines, they are appropriately described as this number. The elevens are exactly what Botox injections were initially FDA-approved to treat.
Crow’s Feet – Long recognized as the wrinkles that radiate out from the corners of the eyes as we smile, a crow would probably be delighted to have its feet so described. Since wrinkles on our face always form perpendicular to the direction that the underlying muscles move, these naturally occur from eye squinting. Botox works well to reducing these also.
Dog Ears- Having nothing to do with a dog’s ear or anyone’s ear for that matter, this is the bunching of skin at the tail end of a scar. They commonly appear when skin areas are ellipitically removed, like the shape of a football, and the closure results in a straight-line scar. From procedures such as tummy tucks and breast reductions, dog ears may develop at the ends of the scars. They are a frequent source of minor scar revision.
Turkeyneck – Who doesn’t recognized this one, particularly if you are middle-aged or older. It needs no description and it often drives the desire for a necklift procedure.
Saddlebags – An older, urban plastic surgery term that many women recognize. That fat collection at the side of the thighs that resists every form of diet and exercise, but which liposuction can treat so well. If only they were as simple to get rid off as pulling their historic corollary off a horse.
Parentheses – Not an English quotation mark but those classic lines that develop from the sides of the nose down past the sides of the mouth. They are one of the major places for the use of the very popular injectable fillers (such as Juvederm) to make them look less deep and obvious.
Muffin Tops – While a tasty and crunchy part of a muffin, eating enough of those will put them on your waistline. These are the classic fat rolls that stick out from the side and back of your pants…and which are nearly impossible to get rid of. Liposuction machines love this part of the muffin, too.
Puff Daddy – Men won’t recognize this problem, but most women will. It is the fullness or puffiness of the pubic area just below the waistline. It can become evident after a tummy tuck when the waistline becomes narrower than what lies below. It can be an embarrassing bulge in pants that no slimwear can flatten.
If you recognize more than five of these terms, you can consider yourself to be both hip and plastic surgery savvy.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have a very square jaw with a lot of fullness towards the front which has always bothered me and made me self conscious. I try to keep myself thin because any weight gain will make it even fuller. I am currently 43 and it seems to be feeling fuller, where I always felt when I got older the baby fat would decrease. My mother and father both had full faces with fairly square jaw lines as well. I am hoping the buccal fat procedure and would help my profile and thin my face from the front and side…like when I bring in my cheeks by sucking them in…it seems to show the angles more rather than looking chubby.
A: A square facial architecture is strongly influenced by the shape of the lower jaw and the cheek bones. To make a square face less full, the only area that can be changed is an inward movement of the submalar triangle facial zone. That is the area beneath the cheek bone done past the corner of the mouth in an inverted triangle shape. This is an area that is not supported by bone or muscle which is why you can suck it inward. Fat removal of this area is the only way to create some tapering in of this zone. The buccal fat pad occupies the upper region of the submalar triangle but not the area down by the mouth, known as the lower submalar triangle area. So a buccal lipectomy will help but needs another method of fat removal of the lower area also known as the perioral mounds. Microliposuction should be done from inside of the mouth to help this area in conjunction with the buccal lipectomies. The combination of both has the best chance to help achieve the look you are after.
Indianapolis Indiana
Q: I have a cyst like lump right in between the eyebrow. In stead of cutting the cyst off with the knife vertical to the skin, is it possible to make a cut right underneath the frown lines and slice the lump off from the cut? Is it possible to transfer some fat to that area if the area is dented after the lump is sliced off?
A: Those are two very good insights into how to remove your forehead (glabellar) cyst while leaving the most aesthetic outcome. Using a close wrinkle or frown line would be preferable to making an incision directly over the cyst. That would make for a far better scar. Even if the scar turned out less than ideal, it is more favorable area in which to perform scar revision. It may also be possible to remove it by an endoscopic technique, although I would have to see pictures of it to be sure that is a possibility.
Also, placing a fat graft at the time of a facial cyst removal is almost a standard technique that I do since indentations may follow later due to a mass removal effect. An indentation may now appear initially, due to fluid fill of the cyst removal space, but will appear once that fluid is absorbed weeks to months after surgery. If the cyst is more than just the size of a pea, I would recommend that at the same time rather than waiting for it to appear later. It is just as simple to do it at the time of cyst excision.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am 5’7″ and weigh 128 lbs. Even though I am relatively thin, I have always had a double chin for some reason. But I feel like it has gotten worse since I have given birth to two children and have gained over 40 lbs with each pregnancy. I am interested in knowing what could be done and how much improvement I could expect. Getting rid of this double chin would help me feel more confident. Thank you so much for your time.
A: The cause of a ‘double chin’ is a combination of three anatomic factors; neck fat, neck skin, and chin projection/prominence. Every double chin is made up of differing ratios of all three components. It is always about how much neck fat is there, how much extra neck skin there is, and how short one’s chin may be. While you didn’t state your age, that number also has an influence because it suggests how much neck skin you may have and, most importantly, how elastic it is.
Some double chins can be corrected by as simple a procedure as neck liposuction in someone who is young and with decent chin projection. On the flip side, an ‘older’ severe double chin may require everything including neck liposuction, chin augmentation, and some form of a necklift to help tighten the extra loose skin. Each patient must be assessed individually and a custom treatment plan devised as double chin correction is not a one size fits all procedure.
One surprising aspect to the ideal correction of double chin problems is that of the chin. Many people have short chins that are magnified by this problem. Lengthening the jawline with a chin implant while bringing the angle of the neck back (or making it more defined) is the classic ‘ying and yang’ approach which together makes a better result than either change alone.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am interested in getting some facial implant work done and was wondering if I can have wisdom teeth extraction done at the same time? I want to get orbital rim implants with a possible midface lift. Is there any reason why these two can not be done together? Will one potentially cause problems with the other or is it better to have them done separately, like a decreased risk of infection?
A: I see no reason why these two facial bone procedures can not be done at the same time. It is quite common to do multiple hard and soft tissue procedures of the face together. The face is tremendously well vascularized and very resistant to infection. (I didn’t say impossible just very resistant) While such a combination (facial implants and 3rd molar extraction) is unusual, it is by no means contraindicated. The hardest part is not the operation, but finding someone who is well qualified to do both at the same time.
Orbital rim augmentation and a midface lift is done from the outside through a lower blepharoplasty incision. Wisdom tooth or 3rd molar extraction is done intraorally from inside the mouth. The two areas are not anatomically contiguous and would not connect, thus ensuring no risk of oral bacterial contamination coming in contact with any implanted material. Because of this risk, the orbital/midface procedure is done first so cross-contamination from instruments does not cause any inadvertent oral bacterial inoculation on the implant.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am considering getting involved in martial art training and was wondering if having a chin implant would pose a problem with that activity. I have a porex chin implant and I’m afraid it will shift if struck. Have you ever seen a porex implant shift from blunt trauma? Is there a difference in potential shifting between porex and silicone implants. Please let me know so I will know whether or not to proceed with martial arts training.
A: I would not personally refrain from martial arts training, or any other contact-related sports activity, if I had an indwelling chin implant. The risk is always there that a good blow to the chin could cause a problem such as shifting of the implant but that risk to me seems very low. There is an equal, if not greater risk, of breaking one’s nose or having a tooth knocked out. Such are the orofacial risks of any contact sport.
The potential advantage of a porex (medpor) chin implant over a silicone one in terms of shifting in the face of trauma is theoretical. Because the porex implant has greater tissue adherence and even some amount of tissue ingrowth, one would assume that it is more resistant to movement after surgery over a purely non-ingrown encapsulated silicone implant. But blunt trauma to the jaw with enough force can easily fracture the bone so the potential for implant movement, regardless of its composition, is always a low occurrence possibility.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am interested in the Fat Injection Breast Augmentation surgery but have a few questions. What are the preop requirements and do you have to have multiple operations?
A: Breast augmentation with fat injections is in the early stage of technique development. While the appeal is enormous for some patients, it is a concept which has not been shown to be consistent in results just yet and the long-term outcome on breast health and cancer surveillance is unknown. Breast augmentation with implants remains a proven technique. Whether fat injections will one day be a comparative procedure remains to be seen.
What is known about fat injections for breast augmentation is that one has to select the patient for it very carefully. Several criteria are important. First, one has to have enough fat to transfer into the breast. If one is very thin or skinny, they will not be a candidate due to lack of adequate donor tissue. Secondly, one’s desired breast size increase must be modest. At best, only a 1/2 cup or maybe more can be gained in size. Desiring a bigger change than that is beyond what fat injections can yet achieve. Lastly, one must be prepared to accept the likely possibility that more than one fat transfer may be needed. Injecting too much fat in a single session will not work. It is better to incrementally increase the fat breast volume to ensure the best survival and decrease the risk of fat necrosis. Therefore, patients must be willing to accept, and have enough donor tissue, to do a second fat injection session in most cases.
Dr. Barry Eppley
Indianapolis Indiana
Q: Hi, I need your help. Three months ago I had a gynecomastia operation done and now I have a problem. The problem is that my nipples are folded in now and going inside. My skin is also very dry around nipples and my nipples have become cracked. This looks like a serious problem. How can I fix my nipples?
A: Gynecomastia reduction procedures can be done two fundamental ways; liposuction or open excision (removal) of excess breast tissue. Sometimes the two techniques are done together to get the best result. With the open excision technique, breast tissue is removed through an incision on the underside of the nipple. (technically the areola) Removal of this breast tissue is largely an art form. How much to remove and how to shape what is left behind is more of matter of experience than an exact science.
One of the known complications of open gynecomastia removal is over-resection, removing too much breast tissue. This make look alright in the very beginning (or not) but as the swelling subsides and scarring sets in, the nipple gets pulled into the over-resected space where breast tissue once was. This is called nipple inversion or a retracted nipple. It most commonly appears underneath the nipple since this is closest to the incision but it can appear outside the diameter of the areola if the over-resection goes beyond just that area.
Correction of the inverted nipple after gynecomastia reduction requires replacement of the missing tissue to support the projection of the nipple. This is best done by a fat graft or a dermal-fat graft using the patient’s own tissues. This requires a donor site and a scar elsewhere on the body to do it.
Dr. Barry Eppley
Indianapolis Indiana
Q: I was wondering if I could get a Botox procedure done in my masseter muscles to help with my teeth clenching. I have tried mouth guards and it doesn’t solve the problem because I’m also clenching my teeth a lot when I am awake. Please send me any information you can regarding this issue.
A: I have used Botox for masseter muscle injections for clenching and bruxism for the past five years. I have yet to see a patient who has not had some near immediate and significant improvement of their clenching afterwards. The duration of the pain relief will last as long as the Botox is effective, generally around four months or so. This makes perfect sense as the clenching is muscular in origin. While it can also involve the temporalis muscle, the large masseter muscles are certainly a major source of the clenching problem. While the simultaneous use of oral splints still has a role, particularly to prevent excessive tooth wear, the direct injection of a true ‘anti-spasm’ agent into the muscle is undoubtably more effective and immediate. (results within a week or less)
I have found that the starting dose of Botox is 25 units per side. Both sides are only done if the patient feels that the pain is on both sides. Many patients will have only a one-sided or unilateral source of masseter pain and clenching. The injections are placed in the lower half of the masseter. If a line is drawn from the earlobe to the corner of the mouth, the injections are placed in the part of the masseter muscle that lies below that imaginary line. This is a simple office procedure that is both quick and fairly painless. Compared to cosmetic Botox injections in the forehead, masseter muscle injections are surprisingly more comfortable.
Dr. Barry Eppley
Indianapolis Indiana
Q: Dr. Eppley, I have a question about the cranioplasty operation. I had some frontal bone augmentation done two weeks ago with acrylic material. I had it done to get rid of some irregular areas that were quite prominent on my forehead. I had a craniosynostosis repair when I was one year old. I know that swelling is to be expected but I thought most of it would be gone by now. It appears asymmetric between the two sides of my forehead and doesn’t look quite even. Am I being too optimistic about the swelling?
A: It is normal that patients are generally quite overoptimistic as to how long it takes to see the final result of the cranioplasty procedure. While two weeks may seem like an eternity when you are the patient, six to eight weeks is the realistic time period to see about 90% of the final result…and 3 months after surgery before one can make a final critical analysis. That’s how long it takes for the scalp tissue swelling to go completely away and all areas to settle. The thicker the tissues are, the more swelling and the longer it takes for it to go away…and the scalp tissues are quite thick.
Another interesting note is the concept of bilateral (two-sided) surgery. Even though the same thing is done to both sides, the swelling that occurs is never, or rarely, the same. So any asymmetry at this point I would still judge to be swelling differences and not yet proven to be some differences in the degree of forehead symmetry from the augmentation.
Indianapolis Indiana
Q: I am unhappy with the mid- and lower cheek area of my face. My cheeks are sunken in below the cheek bone causing a hollow/gaunt appearance. I have smile lines that are becoming heavier and more visible all the time. I had fat injections in the area of the smile lines about 3 months ago. I would estimate that about half remains at this point. I saw your videos on Youtube and would like your opinion on whether a submalar implant would fully correct, partially correct, or have minimal effect in this area of my face. I would like to understand your recommendations on improving this area. My objective is to create a permanent and fuller looking face in the cheek area and pull out the smile lines without creating a chubby or fat face.
A: The key to answering your question is to understand the anatomy of the submalar triangle area. This is an inverted triangle facial zone that lies below the cheek bone in which the apex of the inverted triangle goes down below the corner of the mouth. Almost all of this area is not supported by bone, but by soft tissue only. As a result, a submalar implant will only help create fullness in the upper region of the submalar triangle. The smile lines lies in the lower end of this triangle and will not be changed by a submalar implant. Soft tissue augmentation must be done in the smile line area. Fat injections is one method but is fraught with unreliable take as you have experienced. But its simplicity remains its appeal and another effort at it may produce even better results. The other option, which I currently prefer due to its better effect and longevity, is interpositional dermal grafting. By placing layers of allogeneic dermal grafts in this area, the skin and the underlying tissues are released and separated by the grafts. They add an eventual well-vascularized tissue layer that can be from 2 to 5mms thick which is not unduly bulky. They must be placed through a limited facelift (preauricular) incision. Their longevity is much more assured than injectable fat grafts in this facial area.
Dr. Barry Eppley
Indianapolis Indiana
Q: I live in New Jersey and loved reading your advice articles on injectable fillers. I am a 42 year-old female with dark circles under my eyes with hollowing, upper lip wrinkles, and horizontal forehead ceases. I would love to know if you could recommend a skilled Dr in my area who could do my eyes? Thank you for your time.
A: Injectable fillers can be used to create a variety of instantaneous facial effects by adding volume under the skin. While once limited only to lessening the depth of the nasolabial folds or increasing the size of one’s lips, their uses are being expanded. One of these newer areas is around the eyes, specifically for hollowing of the lower eyelids or treatment of the tear trough depression. This lack of volume can be one of the contributing factors to the appearance of dark circles under the eyes. Suborbital injection filling is one of the more technique sensitive (trickier) areas to inject well however. There is definitely much greater risk of bruising due to the many blood vessels in this area. Missing all of them can not always be predicted. Proper placement of the filler in the deeper tissue level down to the bone is important to not only get the best fill but to avoid lumps of the material if injected just under the skin. For those physician injectors that regularly perform blepharoplasty (eyelid) surgery, they will more likely feel comfortable placing the injectable filler into the proper tissue level. They will also be in better position to judge whether an injectable filler is the best treatment option and how it might compare to other methods of treatment such as fat grafting.
Dr. Barry Eppley
Q: I am interested in what a limited facelift or lifestyle lift might do for me or if I can get away with fillers or something like that. What is the comparative recovery time? Costs? How long do they last?
A: One of the common misconceptions in management of the aging face is that injectable fillers and some form of a facelift treat the same problems. They do not and, as a result, are not comparable treatments. They are often companions (done together or in separate stages) but are never substitutes for each other. Injectable treatment are for the central part of the face and do things that surgery generally can not either achieve or do very well. These include Botox for forehead and eye wrinkles and fillers for nasolabial fold depth reduction and lip wrinkle reduction and lip size increase. Any form of a facelift deals only with the sagging skin and excess fat in the neck and jowls, lower third of the face sagging.
There are procedures touted as ‘liquid facelifts’ but these are a bit (or maybe a lot) misleading and are associated, in my opinion, with a relatively poor value. By using injectable fillers, the sides of the face and cheeks can be puffed up which does create a mild temporary lifting effect due to the expansion of the tissues. The operative word is temporary (six months or less) and, when one compares the cost of numerous syringes of injectable fillers, one could already be more than halfway to one of the variations of a facelift. This injectable approach will also do nothing for the neck area which is the primary target of facelift surgery.
For the patient with lesser amounts of facial aging, the combination of a limited facelift (aka Lifestyle Lift) and injectable fillers can create a very dynamic effect by being able to treat the entire face more effectively. There is a very definite role and benefit to injectable fillers but their results are not comparable to facelift surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I had a chin reduction just about two months ago. I still have not seen any results. If anything I feel that my chin seems longer then before. I spoke to the doctor about it and addressed my concerns. He said it takes up to 6 months for the final results. If by then I am not happy with it, he will then try something else. What to you suggest?
A: There is no question that any form of chin surgery takes time for the swelling to go down. In my experience in chin reduction, this is particularly true as swelling will mask a reduction longer than it will an augmentation. (the result from a chin augmentation will be seen immediately, the issue is that it initially looks too big due to the swelling) The initial soft tissue swelling from most forms of chin reduction will make it look longer or bigger initially and this is normal. Generally, however, the results start to become apparent within three to four weeks at most. By six weeks, patients should be able to say that they see a difference if not significantly so. It will take three to six months, however, for the true final result to be appreciated.
One important factor that controls the amount and duration of swelling is what type of chin reduction procedure was performed. There are two different types of chin bone reduction procedures, an osteotomy and a burring or shaving. One is done from inside the mouth (osteotomy) and the other is done from an incision underneath the chin. Knowing which one was done can help determine how long it may take to see the final results from the chin modification.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am exploring cheek implants as a solution to my flat cheekbones which i was born with.sunken cheeks (genetic). I live in Pennsylvania and wanted to find out if Dr. Eppley would initially review emailed photos before making an appointment.
A: The concept of ‘consults from afar’ in plastic surgery was once inconceivable and impractical. But the internet and the ease of photographic acquisition and transfer has changed that perception. Since almost all of plastic is external and very visible, physical and cosmetic issues can now be seen from great distances by simply sending pictures. In fact, the reach of the internet and its virtual no cost has made it possible to connect any two places in the world, at the very least by e-mail.
I regularly (daily ) do internet plastic surgery consultations. Many are from various U.S. states and provinces of Canada but some are from countries around the world ranging from the United Kingdom to China. There are two types of internet consultations. The first type is of an e-mail nature only. Inquiries are initially done by e-mail from which I request photographs for review and possible computer imaging. That may then proceed onto an actual phone call for the next level of more indepth discussion. The other type is a Skype video consultation. Its origin may be from an initial e-mail or from Skype itself. If a video Skype consultation is arranged, then photographs may be bypassed due to actually seeing the patient. However, due to the poorer resolution of many Skype video connections, photographs are recommended to be sent first.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hi. I know I might be young to ask, age 19, but I was wondering what you called a plastic surgery that takes care of love handles. But I am not talking about the hip handles. I have some pretty good handles right under my breasts that wrap to my back. I believe it is some loose skin as I have managed to loose 25 pounds this past year. I am just wondering what you would call that specific body part and maybe an average of how much it would cost to fix it. Thanking you in advance for replying. From a discouraged yound girl.
A: The important question is whether the rolls underneath your breast that extend into your back are skin, fat or a combination of both. With weight loss, most loose skin is going to develop and be seen lower due to gravity. That being said, I would have no doubt that it is a combination of loose skin and fat. Whether one is more predominant over the other would require an actual physical examination to make that distinction. But given your young age, I would recommend a liposuction procedure for fat reduction first and see how the skin adapts. The fat in the upper abdomen and the back is more fibrous in nature than lower abdominal fat and a liposuction technique, such as Smartlipo, will be more effective than traditional liposuction. There are methods of skin and fat removal by excision in the upper abdomen, which do leave lower breast fold scars, but they are usually reserved for more extreme cases of weight loss where the sagging skin is the predominant problem.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hey! I have large indentation on the right side of my frontal bone. It is becoming noticeable since I have started losing my hair. I am wondering if it is possible to correct it without any visible scars. Thanks and.hope to hear from you soon.
A: For select cranial defects, the use of the new Kryptonite bone cement may make it possible to fill out or augment deficient bony areas. Because of its flow characteristics, it can be injected through long small plastic catheters into cranial areas from a small incision placed in the most inconspicuous location as possible. Studies have shown that it is injectable through catheters as as small as a 12 or 14 French size. (roughly 4 to 5mms internal diameter) Once injected it can be molded through the skin from the outside until it steps up into a firm consistency.
When defects are present on the frontal bone, it is important to recognize the exact location if this injectable technique is to be used. Defects that exist between the anterior temporal lines are bone-based and can be augmented by onlay bone materials. If the forehead defect extends beyond the anterior temporal line, this area is covered by the upper edge of the temporalis muscle. While the temporal muscle can be lifted up and material added onto the bone, this is not possible with a limited incision injectable treatment method. Defects that extend into the temporal area require the more traditional open scalp incision for access and wider exposure.
Indianapolis Indiana
Advertising and marketing permeates our existence at every turn. It is so omnipresent that it takes outlandish claims and often near unbelieveable stories to even catch most people’s attention anymore. Nowhere is this more true than in anything connected to the pursuit of beauty and youth. From magical skin care creams that purport to make one look 10 years younger in just a fraction of that time to amazing non-prescription supplements that claim to grow body parts, it is hard to separate reality from just another pitch into your pocketbook.
The world of cosmetic surgery, even though it is done by medical doctors which should be more credible, frequently falls into these same marketing shenanigans. This has become rampant in the unregulated sphere of cyberspace where the only monitor is whomever is doing the posting. But when it comes to board-certified plastic surgeons, it is a completely different story. The American Society of Plastic Surgery provides it members with a clear set of ethical regulations and rules which clearly provides what can and cannot be marketed and claimed. Violation of these rules can result in Society expulsion. Here are a few of these highlights.
Plastic surgeons are not allowed to claim to be the ‘best’ without indicating where that claim comes from. No claim of superiority of skills or results of those skills can be stated compared to physicians of similar training unless it can be factually verified by the public. There are no rating methods provided by any legitimate plastic surgery society. Patients may have different experiences with various surgeons, and the internet provides countless means by which to report them (unregulated and one-sided), but plastic surgeons and their results are not something that can be quantitatively evaluated like a product by Consumer Reports.
The use of before and after photographs must be of the same patient and unaltered. Photographs that have been digitally altered, are of different people, or show results that are not typical for the average patient is forbidden. Before and after surgery pictures that use different lighting, angles and poses that misrepresent results from any plastic surgery procedure is prohibited.
American Society of Plastic Surgery members cannot participate in a raffle, fund raising event, contest or promotion in which the prize is free surgery. No method of inducement to encourage patients to undergo surgery for a financial reason can be done. When you see such a contest or someone who has won a free makeover, you can be assured it is not a board-certified plastic surgeon that is involved.
Claims can not be made of guaranteed surgical results. Predictions of any outcomes of surgery, including satisfaction or any degree of improvement, is likewise prohibited.
Procedure description or outcomes that are placed next to a picture (usually a model) whom has never had the procedure is another ethical violation. This would suggest that the accompanying picture is representative of results that the plastic surgeon can produce. While models in advertisements may be used, they must clearly state next to them that the person in the picture has not received the advertised procedures.
The need for such rules in advertising and marketing in plastic surgery runs counter to what is happening in the ever expanding world of the internet and social media. On the one hand, such rules seem both fair and obvious. But in the pursuit of the cash paying patient for elective surgery, it should be no surprise that the temptation for anything goes can be a powerful one. Plastic surgery is taking the high road in ‘truth in advertising’ and is holding its member’s feet to the fire.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am a male and would be interested in receiving a surgery in order to correct my bulging forehead. Do you perform that kind on procedure on men?
A: Forehead surgery or forehead reshaping can mean different things to various patient, both male and female. The two most common procedures performed on the forehead are brow bone reduction in the male and brow bone reduction/tapering in the transgender patient. (male to female) There are also a variety of other forehead reshaping procedures from defects and asymmetry caused by craniofacial birth defects and trauma and prior neurosurgical/craniotomy operations. Bu, by far, regardless of the diagnosis the vast majority of forehead surgeries are done in men.
The typical cosmetic reason for male forehead surgery is brow bone reduction. Large brow bones, caused by overgrowth of the underlying frontal sinus, can create very prominent bulges in the forehead bone above the eye. (supraorbital rims) While most patients think it is a thickening of the bone and a simple burring down will suffice, this is not so. Rather the frontal table of the frontal sinus (visible brow bone) must be removed, reshaped, and then put back in a more flatter or recessed position. While tremendously effective, the access to perform that procedure requires a long scalp incision. This cosmetic trade-off is a serious one to consider and is usually an issue which prevents most men from having the procedure. Until a more minimally invasive approach to brow bone reduction is developed, most men with prominent brow bones will have to live with them.
