Your Questions

Q: Dr. Eppley, I am interested in injectable skull augmentation. I heard there is a different technique to fixing a flat head with an injection and without the need of scarring. Is this true?

A: The simple answer is that there is really no effective method of injectable skull augmentation that really works. Injectable synthetic fillers and even fat can be injected but they are not permanent, can not add significant volume and can not make a smooth contour or shape. Injected fat has received some notoriety recently as a forehead augmentation technique but the tissues in the scalp are very dense and do not provide a good injection plane to get the same volumetric changes that can be achieved in other places like the face, breasts or buttocks.

They are injectable methods (really minimal incision) of cranioplasty where the scalp tissues are lifted and the pocket above the bone made for the augmentation material. Then through a small incision, a bone cement material can be injected through a tube in the pocket over the skull bone deficiency and molded into shape from the outside. While this allows a cranioplasty to be done in an essentially scarless manner, this technique is plagued by the potential for irregularities and palpable edges. I have used this injectable                                                                                           cranioplasty method numerous times and I still consider it a technique in evolution. Its use at this time should be reserved for select skull deficiencies and a motivated patient who is willing to accept the aesthetic risks associated with it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in facial scar revision for my son. My son will be five years old this year. About 2 years ago, he hit his head on an end table and got a cut above his eye. We took him to the local emergency room and they glued it back together. He has a terrible scar now. About a year ago, I took him to a few local plastic surgeons and they all said there was anything they could do for him. I am desperate to find some way of improving how this looks. I am attaching a photo for reference. Is there anything that can be done to improve how the scar looks? I realize there is no way of eliminating the scar, but I hope there is at least some ways of making it not as noticeable. I was very impressed by the examples of your work shown on your website.

A: When considering facial scar revision, the most important question is what are the physical characteristics of the scar and how mature is the scar. Scar revision is most effective in scars that have altered surface contours (wide, depressed, raised) or are in poor orientation to the relaxed skin tension lines of the face. Your son’s scar is very wide and slightly depressed above his eyebrow. I would certainly not agree that there is no improvement that is possible for it. The scar can be excised and closed in a fine narrow line with a smoother skin surface. While this will not eliminate or erase the scar, some definite improvement can be obtained. The reluctance to offer scar revision in your son may have been because he is so young. But a young age does not preclude scar revision surgery nor foretell of a poor outcome should it be done.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Can a mini arm lift tighten loose skin on the front of the arms? I have neither lost or gained weight as I have weighted between 95 and 98 lbs for years and have worked with weights to try to keep toned arms. However, aging has caused loose skin on side and front of arms. One plastic surgeon said the surgery wouldn’t help the front area; another said I only needed a mini arm lift and it would work. What is your opinion?

A: While a formal arm lift is the most effective procedure for tightening the arms and reducing its circumferential size, many women who do not have extreme amounts of loose skin (usually due to weight loss) do not want the trade-off of a long inner arm scar just for skin tightening alone. The mini-arm lift is a smaller version of its longer cousin that can be done in two ways. The traditional mini arm lift is a crescent-shaped excision of skin in the armpit that only achieves some tightening in the inner aspect of the upper half of the arm. Another version of a mini arm lift takes out a small ellipse of skin in the central aspect of the inner arm, which more effectively provides some tightening in the front and outside of the upper arm.

I have seen many thin older women who have developed some overall skin looseness and wrinkling of their arms and elbows due to age. If you would look like any version of this form of arm skin looseness, I would not be optimistic that any mini arm lift type would provide an effective improvement for your concerns.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in gummy bear breast augmentation.  I’m a mother of three and have breastfed each baby for about a year. (currently breastfeeding my six month old). Once I’m done, I’d like to have breast augmentation with gummy bear implants. After breastfeeding, I have been left with very small breasts (embarrassing!). Can you possibly just shoot me a ballpark figure so I know what I’m able/not able to do? I’ll be probably a small B and will want a natural looking D.  Thanks in advance!

A: Pregnancy and breastfeeding always cause some degree of breast involution or loss of one’s breast tissue. The breast skin is stretched out and then there is less volume inside to support the skin. This often, but not always, leads to some degree of breast sagging. How significant that is depends on what size breasts one had before the pregnancies. The bigger breasts one had to start with the greater the sagging will be afterwards.

When it comes to gummy bear breast augmentation using highly cohesive silicone implants, knowing whether any breast sagging has to be dealt with is critical in determining whether a breast lift is needed with the implants and that impact on cost. But for general numbers expect the total cost for gummy bear breast augmentation to be $5,500 and the addition of a lift can increase the to total costs to around $8,000.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in facial mole removal. I was born with a mole on the side of my nose. I spoke with a dermatologist in my teens and he said he couldn’t remove it because the mole was too deep and there would be a crater. Now I’m 22 years old and looking for a second opinion and, from what I’ve read, it’s better to talk to a plastic surgeon. From my attached photos, what do you think would be possible for me? Do you think there would be too big of a crater? 

A: Facial mole removal must always take into consideration where on the face it is located and what size itis. The mole on your nose appears to be about 6 x 6mms and can be removed without leaving a crater deformity. Since the skin on the alar rim of the nose is so tight where it is located, the key to removing it is to do it in two stages. In the first stage, the central 2/3s of the mole is removed and closed. Then six weeks later the remainder can be removed. By doing it in two stages, this allows the surrounding skin to stretch so that after the second completion stage the scar does not widen and leave an indentation or notch on the rim of the nose. This is a procedure that be simply performed in the office under local anesthesia.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am seeking a testicular implant. I had hernia surgery over ten years ago that subsequently developed complications. As a result, it left one testicle which got atrophied. It has since basically disappeared. I would like more information on the procedure. I am not sure of a testicular implant would be covered under insurance or not.

A: A testicular implant is a fairly simple procedure done through a small incision in the scrotum. The original testicular sac would be identified and a soft silicone testicular implant that matches the normal testicle in size would be implanted into it. Other than some swelling there is no much recovery from it. It would be be similar to the recovery from a vasectomy surgery. Testicular implants are not usually covered by insurance since it does not provide or restore any medical function.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want to know if I just need breast implants or whether I need to get a breast lift. I don’t want an increase in size as I currently am a 36D cup size now, but I would like my breasts back up where they should be  and I don’t want the skin to stretch again as time goes on. I’m 5′ 4” and about 142 lbs. I have had three children, the last one being just over three months ago. I am planning to lose a little more weight (15 lbs) to shed the last of the baby fat. But with the breast sag that I now have, I am wondering if an implant will create enough of a lifting effect that I can avoid the need for a breast lift and its scars. I have attached pictures so you can see the shape of my breasts.

A: Your breast situation is very common and your desire to avoid a breast lift is also common and understandable. However, with breasts that sag to the point that the nipples are below the lower breast fold, the option of avoiding a breast lift no longer exists. This is particularly so when the amount of breast sagging will be aggravated by further weight loss. It is common misconception that breast implants have a lifting effect. While this is actually true when there is a slight breast sag and the nipple is close to but still above the lower breast fold, an implant will actually have a worsening effect on breast sag when there is the amount of drooping that your breasts have.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am very interested in getting cheek implants. I have some questions and infection concerns that I need answers to.

1) Will using Rogaine(Minoxidil) on my head twice a day increase the chance of my implants becoming infected? Minoxidil is absorbed through the skin, thats why I ask.

2) If I opt to have Micro Scalp Pigmentation (MSP), This is a procedure where they basically tattoo your scalp with little black dots , to make it look like you shave your head.  Do you think tattooing your scalp can cause your cheek implants to become infected? 

3) I have had numerous dental problems. If I were to have cheek implants, how can I avoid the risk of infection? Should I take an antibiotic before and after the dentist for a couple days?

4) Can I use acne medication on my face after I’ve healed? Can this cause infection?

A: In answer to your questions about cheek implants and their infection risk:

1) There is no correlation between Minoxidil on the scalp and an increased risk of cheek implant infection.

2) The issue is the same with scalp tattoos as that of topical Minoxidil for cheek implant infection.

3) The real risk of getting cheek implants infected with dental treatments is the risk of the dentist inadvertently sticking a needle into the implant while injecting local anesthetic for maxillary vestibular infiltration. It would be important to tell your dentist that you have cheek implants should any upper teeth (premolar and molar) dental work be needed. This would be particularly important should any root canal work be done on these same teeth.

4) Topical acne medication does not increase the risk of cheek implant infection.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, One thing I did notice in brow bone augmentation before and after pictures was that the eyebrows seem more raised. This was most apparent to me in brow bone augmentations that were done with bone cement but this also seemed to occur in those that got fat grafts too, albeit to a much lesser extent. Is such an outcome a given? Or can it be avoided in any way? What causes this in the first place?

A: Whether the eyebrow raises after any form of brow bone augmentation is an issue which I nor any patient have ever noticed in any significant manner. At the least no patient has ever told me it was a concern or problem after surgery. It would make sense that some elevation may occur since volume and projection is being added and the overlying skin surface area is not being increased per se. (minus the tissue expansion effect) I do know that the reverse can be true…brows can fall somewhat after brow bone reduction which is why I almost always do some minor brow lifting with most brow bone reductions.

Whatever the browlifting effect that may or may not occur wit brow bone reduction, it does not appear to be significant.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in breast augmentation and need help in breast implant sizing. I am very small in size I am not looking for something huge. I am 4’11 and weigh 100 pounds. I am a 32C Cup. What cup size would you recommend?

A: When it comes to breast implant sizing there is no question that you are small in frame but what constitutes an adequate size that is not too big depends on numerous factors…not the least of which is your perception of ‘huge’ or what looks right. Obviously you do have some breast volume given that you wear a C cup bra. Having some breast volume also plays a role in how an implant will look in size compared to someone who is flat chested. Given someone with more loose breast skin compared to tighter skin in a woman with little to no breast volume also makes a difference in how the size of the implant affects the overlying look of the breast. I would really need to see some pictures of your breasts currently and some pictures of what you think is a good size or even too big on someone else before I can really offer any meaningful input. The most assured way to choose the right breast implant size is to use volumetric sizers which is done in the office. In my experience, this is the most reliable method to give women the breast size they want with implants.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had custom facial implants placed recently and it looks like they’ve been infected and need to be removed. The initial cost for these implants was $5500. Assuming I would like the same set manufactured, would it incur the same charges? Lastly, if I wanted them slightly modified, would it be considered starting over from scratch, and would I have to pay the full fee again?

A: Fortunately, I have never had a set of custom facial implants get infected but I have had patients who want to modify their existing custom facial implants for new ones for aesthetic reasons. In these circumstances, I have had the manufacturer (Implantech) make new ones at a reduced fee over the original implants even with a few modifications of the original design. The manufacturer has no obligation to do so and whether that is a universal policy I do not know. Each case with any surgeon must be determined on an individual basis in discussion with the manufacturer.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Which is better for me, jaw advancement or a sliding genioplasty. I think my whole lower jaw is short and needs to be brought forward. I have attached some view pictures of my ideal result and an x-ray of my jaws from the side view. Can you tell me what I really need to give my face/lower jaw a better profile?

A: What you have is a classic Class malocclusion/dental relationship which accounts for the retrognathic lower facial profile and the associated soft tissues effects. A sagittal split mandibular osteotomy would be the ideal procedure which requires some preoperative orthodontic preparation. (as the amount of forward jaw movement is completely controlled by how the teeth fit together afterwards. Whether the amount of forward jaw movement would create the profile change you have shown would have to be determined by preoperative cephalometric tracings.It is possible that a small sliding genioplasty movement may be needed with it as well. But this can not yet be determined until the orthodontics have you prepared for surgery.

If orthodontics are not in the plan, then an isolated sliding genioplasty would need to be done to create the bony chin and profile change. Moving the whole mandible is skeletally better (as it moves the teeth and lower lip forward as well but that completely depends on orthodontic preparation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have some questions about facial implants.  I had a square chin implant and paranasal plus midface rim implants placed one month ago. I’m happy with the augmentation they’ve provided, but they haven’t exactly addressed the areas I really wanted augmented. I’m aware that there’s still quite a bit of swelling, but the parts of my face that were initially deficient now look worse in relation to my augmented mid-face and chin. Here are my questions:

1) It has been 4 weeks since I had these implants placed. Given your experience, what % of swelling is there still remaining?

2) The paranasal implants have given me mid-face volume, but the area that I really want augmented is the areas under the nose and above the upper lips. I’m looking to make that region more convex to obtain a ‘step off’ between the upper mouth and the mid-face. I’ve done a bit of research, and I suspect I may need premaxillary implants. 

3) I had this weird issue of there being some kind of ‘jowl lines’ from my lower lips to the sides of my chin. The chin implant does seem to have exacerbated it, and I don’t think implants are going to address the issue. I’m not sure what has caused it, but the region below my lower lips appears to be more convex relative to the areas to the side of it, which is what gives the appearance of jowl lines.

Anyway, do you think that fat grafting to the perioral and upper chin region will address it? Further, if I’m getting fat grafting done, should I consider getting fat grafts placed in the premaxillary region too? Could you kindly give me your professional advice on my options to augment these areas?

A: At just four weeks after facial implant surgery, you probably have about 75% of facial swelling reduction. But the remaining 25% of facial swelling and soft tissue adaptation to the new facial contours will take several months to resolve.

Facial implants are generally designed to provide augmentation of facial skeletal areas that are flat or convex in nature. They are not effective for concave facial areas that are not supported by bone. Thus, premaxillary augmentation is best done by an implant while the jowl areas above the jawline are better augmented by fat injections.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I had my buccal fat pad extracted a few years back when I was younger. I liked the look initially, but it has now made me look a little too gaunt.

Anyway, I’m looking to add more volume back to the buccal region. I’m not sure how to describe it, but imagine pressing a couple of fingers diagonally up below the cheek bones.

The question is, I’m not sure what route to go for volume restoration to the region. Personally, it seems the more logical choice would be to replace like with like and to use fat injections to the region. However, I’ve read some doctors advocate the use of submalar implants.

In your opinion, which would present with the better result?

A: By far and away, the best approach is the submalar implant combined with a little fat injection around it. The submalar implant covers the upper half of the buccal space but not the lower half. So depending upon the extent of the buccal deficiency, fat injections may or may not be needed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am looking to do something for my lower lip asymmetry. My bottom right lip pulls down. It is worse appearing when I smile. What type of lower lip symmetry surgery may solve my problem? Would a corner lift help this? I have had Botox injections, which definitely made it look better but I am seeking something more permanent.

A: Your lower lip asymmetry is caused by a weakness in the marginal mandibular nerve which works the anguli depressor muscle. (which pulls the lower lip down) This is why the left side of the lower lip is higher than the right which becomes magnified when you smile. You said that you were getting Botox to make it more even which I assume is done on below the right lip to weaken the depressor anguli muscle to better match that of the left side?

This leaves you with three options to improve your lower lip asymmetry:

1) Augmentation of the right lip vermilion to raise the lip edge

2) A partial depressor anguli muscle resection (done intraorally) to weaken the stronger right side so it elevates higher

3) left lower lip vermilion resection to lower the left

There are also combinations of any and all of these three.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am looking to achieve more definition and masculine features. I want a more defined jawline, neck and cheekbones. I actually am even more dissatisfied with how my face looks from the side or profile view. Do you think that liposuction of any area of the neck or cheeks would be beneficial? Or just all implants? I’m slightly hesitant to do implants other than the chin and wondering if you yourself would be able to use fillers instead of something permanent. I have attached some front and side pictures for your assessment.

A: Your side picture clearly shows a more recessed chin that would benefit from a chin augmentation. I think this combined with small jaw angle and cheek implants would provide much better facial definition. But it is clear that you are only comfortable with a chin implant at this time.

When it comes to fat removal, many chin/jawline enhancement patients will benefit from sub mental/neck/liposuction as a complementary procedure. For the cheeks, fat removal is done by a buccal lipectomy procedure which help define or skeletonize the cheek bones better. There is certainly nothing wrong with using injected fat for cheek augmentation. It does not create a sharper or mored defined cheek augmentation effect because it is a soft material and its survival is anything but assured. But for those patients who are a bit skiddish about cheek implants and want to do an initial trial with something more natural (albeit with its own drawbacks), injected fat for cheek augmentation is a good treatment approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I recently had a bilateral sagittal split ramus mandibular osteotomy with a sliding genioplasty. My bottom lip (and perhaps top) have thinned considerably. It seems the bottom lip flips in somewhat. It was always very full and pouty. Can something be done? In addition, my jaw angles used to be much more prominent and I had a longer ramus. What can be done? Will reversing the genioplasty help?

A: Reversing the genioplasty is not the solution for an inward inversion of the lower lip after the procedure. That is caused by disruption of the origin of the mentalis muscle on the bone and it being resutured back together. This can be a source of lower lip tightness, lower lip thinning, and some inward inversion/contracture of the lower lip. Unless you terribly dislike the position of the chin, moving the chin back is not going to solve these soft tissue problems. Rather some soft tissue augmentation is a better approach. This could include the placement of a dermal-fat graft below the vestibule in the lower lip after it is released. (all done through your existing intraoral incision) Fat injections can also be done at the same time into the lips. The take of fat injections is variable but that of the dermal-fat graft assured.

Many BSSO procedures change the shape of the jaw angles, often losing their distinct shape. They often appear less pronounced and higher afterwards when the bone has healed. In some patients, jaw angle implants can restore a more distinct shape and the addition of a little angular width as well.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting a body lift. I have had bariatric surgery two years ago and I need to get rid of excess skin. This excess skin around my waistline is causing severe chafing. My insurance won’t cover ‘cosmetic’ surgery. My question is this: can we get insurance to cover it if it is a medical necessity?

A: Insurance in some cases will cover an abdominal panniculectomy but it depends if the abdominal pannus meets several criteria established by the insurance industry. for such coverage. The abdominal pannus must of a certain size as seen in multiple view pictures (hangs down onto the upper thighs), have a medically documented history by a physician of skin rashes/infections that failed to be resolved by topical therapies and one must be of appropriate weight based on their height. (within 20% of their ideal body weight) Fulfilling these criteria is what constitutes ‘medically necessary’ and such information must be submitted to the insurance company for them to pass judgment on whether it is covered or not.

Even if determined medically necessary, insurance will only cover the front half of the trunk (abdominal panniculectomy) and to the back half or the full body lift.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 38 years old and have horrible bags under my eyes despite good sleep and a healthy diet. Can you tell me what the best option would be to get rid of them and down time for the surgery?

A: Despite the fact that you are relatively young, your lower eyelids are a contradiction to your age. They show herniated infraorbital fat pads and some excessive skin. Because your pictures show you smiling (which always makes everyone’s lower eyelids have a lot of wrinkles) I can not fully appreciate how much skin laxity is there or to what degree you may have tear troughs present. Thus it is not a question of whether you would benefit by lower blepharoplasties but what type of lower blepharoplasty. Would it be a fat sparing and transpositional one or should the protruding infraorbital fat merely be excised with the skin tightening? I would need to see a picture of you not smiling to make that determination. Regardless of the type of lower blepharoplasty, the recovery is the same. There will be some swelling and bruising and it will take about 10 days or so to become very presentable in public again. It is not painful nor physically limiting just visibly noticeable for this period of time after surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had an operation on my lips in order to have bigger ones. I had the operation about six months ago. I did not like the result of the operation and two months later I had a second operation. I had scar and asymmetric shape so I did not like the result again. I am regretting my decision for surgery and am missing my previous lips. My problems are the philtrum height is very short, my teeth does not appear because of mucosa and the lips have been stretched too much. I hope you can help in this regard.  I am very unhappy indeed. I want you to remedy this situation soon. I really miss my old thin lips. I have attached some pictures of my lips before and after the procedures.

A: Thank you for sending your lip pictures. You did not say what procedure was done but it appears to have been a lip or vermilion advancement on the upper and lower lips. Unfortunately there is no turning back, so to speak, when it comes to a lip advancement. Once the skin is removed to do the procedure, it can not be replaced later. In essence, you can not reverse a lip advancement procedure. There is no operation to return your lips to their once thinner appearance. The only potential improvement that I can envision is lip edge mucosal resection to achieve a bit of an inner lip roll in and expose more of the teeth.

Your case illustrates why it is always best ti be conservative in a lip advancement. You can always do more but can never do less.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I honestly need an abdominal panniculectomy and need a price. I do have Medicare and Medicaid. I live in Indiana. How much do they cover and how much would it cost out of pocket. I get rashes and yeast infections because of it. It hangs down to lower pelvic area.

A: There are two options to consider regarding an abdominal panniculectomy. It can be done through my private practice on a self pay basis as an outpatient procedure. This is the most efficient method to have the procedure performed, as surgery could be done in a matter of weeks at an outpatient facility. All follow up care is done at one of my private offices. The other route is to use Medicare for the procedure. Medicare is primary over Medicaid so it needs to be approved through Medicare. This would need to be done at my downtown Indianapolis office, where you would be evaluated, photographs would be taken and medical records obtained to document the time and number of treatments done to treat the skin infections. To qualify for Medicare coverage the abdominal pannus must be of a certain size (hanging down onto the thighs), rashes must be present underneath it and there must have been a course of at least 3 months of care provided for the skin infections/rash from your doctor. It would take a few months to determine if you qualify.

I would need to see some pictures of your abdominal pannus to determine if Medicare is even an option and I also need some information about your general medical history.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, How feasible would it be for a healthy 70-year-old female to undergo a “turkey neck, jowl, eyelid” lift?  I’m on Medicare and a fixed income. 

A: Feasibility for any type of facial rejuvenation procedure(s) (such as a lower facelift and eyelid lifts) is determined by two factors. First, age is really an irrevelant issue as long as one has good health. There are many 70 year old and older patients that very successfully undergo these procedures without any problems. The oldest patient I have ever done for a facial procedure (necklift) was a 92 year-old man! So as long as you are healthy and have laboratory studies which are normal, your age is not a limiting factor for the surgery. Secondly, there is the affordability of the procedure. These are plastic surgery operations not covered by Medicare. As such, they must be paid for as an out of pocket expense up front before the surgery. These costs would be affected by what type of lower necklift and how many eyelids are being done. For most patients at any age, the cost of the surgery is usually the determining factor of feasibility. I would need to see some pictures of your face to determine what the feasibility numbers would be for you.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Two years ago I got lateral supraorbital rim implants made of Medpor.There is only one design of supraorbital rim implants available from this company (Porex/Stryker). They were placed through the upper lid crease. About 4 weeks after surgery the implant on the left side got infected. The pus was drained through a small incision in the lid crease, the wound has been daily cleansed and I have been on Rifampicin and Ciprofloxacin for two months. Because of the incision for the draining, about 2 mm oft the implant surface became visible, but the hole closed soon after the infection subsided. Although since then I have never got any symptoms of infection like swelling, discharge, pus, warming or pain, there is still a quite visible red patch where the pus had been drained. This patch is 7 mm long and 3 mm broad and very adherent to the underlying implant surface… that means it doesn´t move with the upper eyelid. Fortunately it is no problem to close my eyelids. From time to time a thick layer of keratin forms on this patch. Do you think this could still be some kind of infection or could this be a chronic inflammation due to the mechanical friction? What would you advise me to do?

A: What you have is a healed sinus or fistula tract and the local sequelae when that occurs in thin tissue. When the implant was infected, the accumulated pus had to go somewhere and it usually goes to the path of least resistance. (along the incision line) This draining tract was a ‘hole’ in the tissues that, once the infection was resolved, collapsed and healed with scar tissue. This scar tissue is thinner and less stable than the normal eyelid tissues. This is why it is adherent, red and undergoes intermittent effort sat re-epithelization. (thick keratin patch)In short, this is not normal skin.

If this is bothersome what I would do is excise the scar, place a small fat graft underneath (to fill in the missing tissue and prevent recontracture of the skin down to the implant) and close the skin over it. This is a scar contracture issue not a chronic implant infection.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am scheduled to have a sliding genioplasty next month and I just wanted to clarify some things. Is there some sort of guarantee I get that this procedure it would improve or completelyy resolve my sleep apnea? Otherwise I don’t see any other benefit other than the profile improvement which would not be worth the surgery risk.

A: The simple general answer to your question is no. There are no guarantees in plastic surgery of any specific outcome. Any surgery is an educated guess that doing a certain maneuver will cause a specific effect. In some surgeries, experience may show that a certain outcome is very likely if not highly predictable. In other types of plastic surgery, the outcomes are less predictable and may, in some cases, be more hopeful than completely predictable.

When it comes to a sliding genioplasty, both sides of these potential outcomes are seen. It is a predictable fact that moving the chin bone forward will change one’s profile and give a stronger chin appearance. Once can debate whether the chin changes net a patient’s expectation but there is no debating that the chin position will change. When performing a sliding genioplasty to help improve sleep apnea, the results are less assured. In theory, when moving the chin forward the tongue is likewise brought forward somewhat due to the attachment genioglossus muscle between the tongue and the back of the chin bone. This is actually the basis of the historic genioglossus advancement procedure done for sleep apnea when a sliding genioplasty is not being performed. To be successful for sleep apnea improvement, the sliding genioplasty movement must usually be significant (greater than 10mms) and one should have a very short or horizontally deficient chin. (indicating there may be posterior tongue prolapse)  Often a lateral cephalometric x-rays will show the position of the base of the tongue to the posterior pharyngeal wall with a narrow airway space. But because the sliding genioplasty moves the front position of the tongue more forward than the back (closer to the point of pull), the amount of chin bone movement does not translate in a 1:1 ratio to what occurs further back at the base of the tongue and the posterior airway opening. This is the anatomic variable in whether a sliding genioplasty will help improve sleep apnea symptoms.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a chin reduction. have always had a unique chin with over-protruding bone, an excessive soft tissue pad and deep labiomental crease. It almost looks like I have a bottle cap lodged onto my chin. I am very curious as to what you feel would the best approach here. I have had a couple consults with other docs who have suggested a sliding genioplasty and was even shown some pictures of expected results, which I loved, but I am worried about a sagging chin pad after the procedure as they confirmed that they would not do anything to the soft tissue. So I am pessimistic of the accuracy of the pictures they offered. I would definitely prefer an intraoral approach if possible, though I know this could be a complicated procedure that could benefit from an approach via under the chin. Your thoughts?

A: Chin reduction is a much different procedure than chin augmentation due to soft tissue consierations. From a chin reduction standpoint, I would agree that the accuracy of those imaging results is suspect. There is no doubt that the bony chin can be moved back that far, but the question and issue that has to be dealt with in every chin reduction is where is the ‘excess’ soft tissue going to go. With a setback sliding genioplasty, it is not sagging of the chin pad that is the concern as the chin pad soft tissues are not overly detached. It is the tissue under the chin, the submental area, that often can become bunchy or redundant. As the chin moves back, the skin under the neck can bunch up. This is why a submental approach to chin reduction is usually more successful as it deals with the soft tissue redundancies. But I can certainly understand why one would want to try and avoid a submental scar. The good news is that you are fairly thin with no substantive subcutaneous fat so perhaps the soft tissue redundancy concern may be overstated. Therefore one could undergo a setback genioplasty with the understanding that the sub mental tissue issue is unpredictable and may have to be dealt with secondarily if it is an issue. It just depends on how one wants to ‘gamble’…risk a scar revision with the sub mental approach or risk the potential need for a secondary submental tuck up with the sliding genioplasty setback.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am seeking a revision rhinoplasty. I had an open rhinoplasty about five years ago and I am unhappy with the results. It was a very conservative rhinoplasty little to no changes were noticed. Even my friends and family see no difference. I would love to have the tip refined (made thinner and lifted, if possible), a possible reduction of nostrils and even some bony adjustments.

A: In regards to a revision rhinoplasty, the first question is always what was done in the original procedure. That is not something you would ever know but if you could get a copy of your original operative note from your surgeon that information is always helpful. It is instructive to know from where you started and what was done to know what may be more beneficial in the next procedure. A revision rhinoplasty usually has to do things differently than the first time if a different result is to be expected.

Otherwise, although not uncommon, one just has to await what surprises one may find in there during the revision. (where grafts done?, where was the cartilage harvested? etc)  But in just looking at your photographs, I see room for improvement from the tip standpoint and in nostril narrowing. It is always easier to make a thinner tip when it is being lifted as opposed to being deprojected in thicker male nose skin.

Dr. Barry Eppley

Indianaolis, Indiana

Q: Dr. Eppley, I have facial tics from Tourette’s syndrome. The facial signs that I have are that I blink frequently and occasionally will wrinkle my nose. I have researched Botox for facial tics and would like to know what you’re experience is with this. I can get past the social awkwardness the tics cause at times, but there are flare ups and I would like to stop them. I do not like the long term side effects of medication so I’m looking at this option.

A: Botox can be effective for facial tics as facial tics come from the muscles of facial expression. However, Botox injections for facial tics are done somewhat differently than when it is used to treated overactive muscles from undesired facial expressions and the wrinkles and folds that result.

The location of the facial tics must be precisely located and a superb understanding of the facial musculature is needed. However, many patients with facial tics can not always reproduce them in the office and a description alone is not sufficient for accurate muscular placement. What I like patients to do is to take pictures, or even better a video, of their facial tics in action and bring it into the office. That is the best way to see where the injections should be placed.

Unlike cosmetic use of Botox, injecting for facial tics is a fine balance in getting just the right amount of Botox to control the tic but not causing too much surrounding facial weakness. There is always a trial and error period to find the exact injection location and the right number of units (dose) for the facial tic problem. It is always best to start conservatively with a few injection locations and a small number of units in the first treatment.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, you have written that the collagen stimulated by the Sculptra injections disappears once the Sculptra crystals are all gone. Since the effects of Sculptra last on average 2 years, your implication is that the crystals remain on the face for up to 2 years. However, in almost every piece of literature/opinions, I have read that the actual Sculptra dissolves entirely within a few months, leaving behind new collagen. If this is true, then logically this collagen would dissipate no quicker than regular (non-Sculptra stimulated) collagen. Is what I have read incorrect? Are you saying that Sculptra stimulated collagen dissipates faster than our natural collagen? I hope that your theory is correct because I received 2 treatments 2 years ago. I am 26 and underweight and my face is fuller than ever. It’s very upsetting to me. I’m hoping that it’s true that there are still crystals inside my face and that’s why it’s still overstuffed.

A: Any discussion I have ever had on Sculptra is based on the known chemistry of its poly-lactic acid (PLA) particles…which are the crystals to which we both refer. PLA is a very slowly resorbing polymer that often can take up to a year or longer. Most commonly they persist for 9 to 15 months based on the variable resorption patterns amongst different patients although particle resorption may take longer than that in some individuals. The effect of Sculptra comes from the laying down of scar (collagen) around the particles. As the particles are eventually resorbed, the collagen produced will eventually go away as well in most patients. This collagen resorption follows by months after the particles are resorbed. It may also be possible in a few patients that the collagen scar effect may not dissipate although this is very uncommon.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a custom jawline implant placed three months ago and I think it is a fine result. However, I would like to make just a few changes to the size and shape of the chin implant portion. Can this be done? Is it a complicated surgery? Recovery time? Can these modifications be made to the original implants or do you believe we need to design a new chin/jaw implant? Thank you and I appreciate all your help.

A: Even with perfect placement and an uncomplicated surgery and recovery, I find that it is not rare that patient’s want to change slightly or modify their custom jawline implant. The good news is that this is a very simple surgery and so much easier than the first time. With an established pocket it is very easy to remove and replace it with very little swelling and no pain. If the initial recovery was a 10, this one will be a 1 or 2. The key question is how to change the implant. It is choice between using the existing one and simply carving it down in the selected areas or making a new one with the new dimensions. Each way has its own advantages and disadvantages being hand carving down the existing one eliminates any new implant cost but requires a good artistic eye to do the changes and keep it smooth. A new implant absolutely ensures smoothness and the exact changes in the right location but incurs the cost of the implant. The difference in the two options is that of the implant cost only.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have severe breast sagging/ptosis I believe. I would like a breast reduction or lift without implants if possible. I have udnergone a 150lb weight loss which has ruined my breasts! I’m 33 years old with 90 year old bags for breasts. They are heavy,ugly sagging breasts. I currently weigh 220lbs with a weight goal of 180lbs. I have read that some surgeons will not preform the surgery on someone with a certain weight or BMI, so I’m working on dropping further weight. I obviously need other areas worked on but right now my breasts bother me the most. Do I qualify for the Lollipop procedure or the one that follows after that? Have you worked on breast this large or severe? Can you help me?

A: There is no question that you have extreme breast sagging and near total breast involution. (loss of breast tissue) Breast sagging or ptosis is classified by where the nipple sits relative to the lower breast fold. When the nipple and the breast mound hangs way below the lower breast fold that is known as a Type 4 breast sagging. (on a scale of 1 to 4) Given how your breast sags I would have to classify yours as a Type 5 sagging which is off the scale!

I have seen breasts just like yours and successfully operated on them. The question that relates to your breast surgery is what type of reduction/lift is needed and the timing of the surgery as it relates to your weight. Understand that every breast reduction incorporates a breast lift. (although not every breast lift is a breast reduction) Your breast lift is way beyond that of the lollipop lift, rather you will end up with a anchor scar pattern due to extreme amount of lifting needed and the amount of breast skin removal. Another consideration would be a partial breast amputation and free nipple grafting technique. This will get you the greatest amount of lift and reduction although your young age and the desire to maintain some volume probably precludes against this more simplest approach. If you were a smoker thisn would have to be the technique of choice. As it relates to your weight, you should be within 25 lbs or less of your weight loss goal to have the procedure.

Dr. Barry Eppley

Indianapolis, Indiana