Your Questions

Q: Dr. Eppley, I am interested in having a lip scar revision for my daughter. But I have a couple of questions,. I am really worried about administering anesthesia to her.  Is it safe to do on a child who weighs just 35 pounds?  Since this is a common type of lip scar revision, do you perform this type of scar revision frequently and on children?  Is it better to have the revision now or in a few years after her mouth grows more or when her permanent tooth comes in?  Will it create more internal scar tissue? When I put my fingers in her mouth to massage her scar, I can feel the lump, but sometimes it feels soft.  I try to keep her lips moisturized with aloe and creams.  Also would the revision take place inside her mouth or reopen her scar just above her lip and on her lip? Is it worth putting Claire through this at all?  I really do not want to see any scar or lump if she has this done.

A: In answer to your questions:

1) It is impossible to operative on a child’s face (or body for that matter) without them being under anesthesia. To get a good result, they must be perfectly still to work on them. This is never possible on their face until closer to age 12 if not older.

2) Lip scar revisions are vert common in my plastic surgery practice. As part of the Riley Hospital for Children Cleft-Craniofacial team, I have performed many hundreds of cleft lip repairs and revisions as well as traumatic lip laceration injuries.

3) This is an elective scar revision in which the timing is solely based on when you as the parent think it is appropriate or when she, as teenager, deems it a problem. Age or the state of tooth eruption makes no difference in the timing of the lip revision.

4) No topical therapy is going to alter the scar or help make it better. The firmness of the scar can only be altered by scar maturation which requires time which is several years in children.

5) The scar revision would consist of a vertical elliptical excision staying within the confines of the lip.

6) While no scar revision surgery can guarantee any specific result, it is fair to say with your daughter’s scar that substantial improvement will be seen. Whether it will be perfect with no signs of scar at all is impossible to guarantee and maybe even ti expect.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, would the following make me a favorable candidate for migraine surgery? I have a history of chronic migraines for over 15 years. It is well controlled for the past 5 years with Botox injections in four areas (forehead, above ears, back of head, and around eyes) and manual therapy. I have noted a reduction in the effectiveness of Botox injections in the last 18 months.

A: On the surface, a positive response to Botox suggests that migraine surgery can be effective. However it is important to know exactly where the Botox was injected and whether those sites corroborate with the exact anatomic sites of peripheral nerve compression. Where in the forehead and the back of the head exactly? The above the ear and around the eyes are not sites where nerve compression can occur so these may be completely incidental to whatever improvement you may have been seeing to the forehead and back of the head injection sites. (if in fact they were near the course of the nerves) These injections sites sound suspiciously like a very typical ‘wrap around’ the head injection pattern that I have seen done many times by neurologists. Such a random approach is not necessarily indicative that migraine surgery would be effective.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am inquiring about lip scar revision for my child. She suffered a fall a year ago and had a laceration of the upper lip. It went on to heal  but has done so with a noticeable bump on the lip. I would like an opinion if this could be fixed or do more harm than good if it got fixed..or create more internal scar tissue. Thank you.

A: The upper lip scar that your child has is extremely classic for lip lacerations through the vermilion. They often heal with a redundancy of vermilion scar that appears as a lump along the lip line. Such lip scars commonly undergo scar revision by a vertical elliptical excision of the scar and a smoothing out of the lip line. There is no question improvement can be obtained without the risk of doing more harm than good.

While a teenager or an adult would have a lip scar revision done in the office under local, that is not going to work in a five year-old. This would have to be done under anesthesia for patient comfort and anxiety as well as to obtain the best scar revision result and vermilion alignment.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am extremely concerned about sagging after cheekbone reduction surgery. The doctor reduced a large amount of my zygoma, about 6 to 8mms. Would this increase my chance of cheek sagging? I had previous buccal fat and facial liposuction. I am worried that I have a higher chance of sagging now. Also, I am 3 weeks after surgery. There is still quite a bit of swelling in my cheeks although a lot of the swelling has gone down. Could you give some rough guidelines as to when the swelling subsides? E.g,  2 to 3 weeks major swelling, 2 months 80% swelling goes down etc.? I greatly appreciate your input. Many thanks!

A: The proper time to asssess the result after any type of facial skeletal surgery, such as cheekbone reduction, is three months. My general guidelines is that 50% of the swelling goes down in 10 days, 70% by 3 weeks, 80% to 90% by 6 weeks and 100% by three months after surgery. Reducing your zygoma width by 6 to 8mms has a high chance of having some cheek sagging afterwards. Done bilaterally that is removing a lot of the cheek tissue support for the middle of the face. But time will tell. No one can say now whether it will or won’t.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in jaw angle implants. I’v attached some photos of my face. As you can see my jawline narrows inward as it comes down from my cheekbones. With that being said, I do not want the big, thick, extra wide looking jawline. I would like slight width and definition. I would ideally want more of a masculine, defined, bony look with hollowness between the corner of my lips to my cheekbones, kind of like a male model. I don’t want a big change, I would rather have a more inconspicuous outcome. I do understand; however, that there will be a difference in my look. From what I have seen online, the normal outcome is a thicker/ widened look. I don’t necessarily want that. I have attached images of Tom Cruise and a photo of Johnny Depp to show you examples of my desired outcome.

A: Jaw angle implants can produce a variety of jawline changes based on the style and size of the implant but the facial shape and tissue composition also has a major influence on the outcome. While many men do not have the facial shape to come close to those jawline goals, you actually do because you do not have a lot of subcutaneous fat. You have to have a pretty thin face to pull that off.  So while I think you can achieve it, it is not going to be able to be done with any of the standard shaped jaw angle implants. You need a special shaped jaw angle implant that just sits on the back half of the jaw angle and has a significant lateral flare to it that is concave as it flares out. This way it gives no thickness to the jawline and only adds the angle accent. That could be done by either a semi-custom or custom implant approach. A semi-custom approach is where standard jaw angle implants are hard carved before surgery to create the desired shape. A custom approach is where the jaw angle implants are computer-designed off of the patient’s 3D CT scan.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in migraine surgery. I have been suffering from disabling, chronic migraines since 1991. However, I have been suffering from migraines daily since 2011. My neurologist prescribed different types of medicines, but nothing helped. The neurologist also performed several tests including MRIs and CTs but could not find the cause of my migraines. In 2012, I began seeing a headache specialist but that too was unsuccessful. In 2013, I began seeing an acupuncturist/chiropractor. This helped very little in that I still suffer from migraines daily and the pain is even worse during my menstrual cycles. I can no longer depend on pharmaceutical short term fixes that do not and the harm it has done on my body. I’ll try to explain the location of my migraines the best I can. I usually feel my migraines right underneath my eyebrows and between them. During a migraine, I press whatever tissue that is inside my eye sockets (the area closest to the middle of my eyebrows). Doing this can take pressure off but only while I continue to press. Also I can feel a difference in the amount of swelling in the tissues of that area when my migraines are at a ten plus. There are also some rare times when my migraines are in the temple location. I hope I explained in a way that was not confusing to you.

A: Your migraine history/story is fairly classic from my perspective as patients often seek surgery as the last measure. The place to start is to define a patient’s migraines by location…where do they start and spread to. What makes some migraines improveable by surgery is if they come from a point of peripheral nerve compression. Your description sounds similar to what migraine patient’s experience when they have peripheral nerve compression of the supraorbital/supratrochlear nerves as their trigger point. This strongly suggests that migraine surgery consisting of nerve release/decompression through an open hairline approach could be effective for migraine relief.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a custom jawline implant (done by Implantech) placed last year, but there are some areas that haven’t been addressed adequately. Assuming that the design file is still available, can I just check if it would be possible to modify the previous implant design? Also, would it end up costing as much as getting a brand new custom implant made, or will the cost of modification be lower?

Additionally, I’m looking to get my philtrum augmented. Would any existing implant work (Peri-pyriform?), or should I consider fat grafting?

A: This is not the first time I have had a patient inquiry about changing a custom jawline implant to a new or tweaked design. I can assure you that your original design file is still available and the previous jawline implant design can be modified. There is some reduction in a new implant design cost fee which is about 15% from the original pricing. (as per the manufacturer) The other good news is that replacing an existing jawline implant with a new one is substantially easier than the first time with a very quick recovery.

I believe when you refer to philtral augmentation, you mean paranasal/upper lip augmentation. That is what is illustrated in the link you have provided. True philtral augmentation is philtral column augmentation done by placing cartilage grafts or small implants in the philtral columns of the upper lip right under the skin to give enhanced ridge lines. There are advantages and disadvantages to either injected fat or placing implants along the nasal base. (paranasal-premaxillary region) In general, implants are going to give a more assured and permanent augmentation effect.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in forehead augmentation as well as temporal and back of the head augmentation. I like the way I look when I have hair, but sadly my hairline has began to recede. My forehead slopes back and I feel my head lacks the mass to balance my face (forehead and all) out. I’m interested both widening my temporal region (starting at about the ear back) with custom formed implants AND correcting relatively flat back. Can one incision be used for all three adjustments (left and right temporal and the back of the head)? And if so how large of incision would be needed and where would it be located? 

A: I commonly have performed combined forehead augmentation and occipital augmentation. Dual access to both the back of the head, temporal and forehead regions can be done through a single scalp incision. It is known as a coronal scalp incision and runs across the top of the head from ear to ear. It effectively allows a ‘clamshell’ approach to be taken to skull rehabbing surgery and provides a 360 degree access and view of the entire head above the eye and ears. While it sounds and looks dramatic, it heals very well and quickly When looking at the patient the very next day when the dressing comes off, it is hard to image that type of surgical exposure that was done just the day previously. Patients also have a surprisingly minimal amount of discomfort afterward.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am wondering if I am a candidate for custom chin implant as I want both vertical and lateral projection (as opposed to simply lateral with most implants) Also if I decided to go ahead with a large chin implant would jaw angle implants be needed to add balance?

A: There is now available a type of chin implant that produces a combined vertical and horizontal lengthening to the chin so a custom chin implant may not absolutely be needed. This is a new type of chin implant that provides a vertical length increase to the chin that has never before been part of any chin implant. What size of vertical lengthening chin implant you would need depends on how much of a chin change you were looking for. The largest vertical lengthening chin implant creates a 7mm horizontal advancement with a 7mm vertical lengthening effect, creating a 45 degree angulation to the chin.

If you lengthen the chin to any degree, I would suspect that jaw angle implants would be needed to balance out the new jaw length. That could be confirmed by computer imaging.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am looking for some insight as to what to do with my undereye hollows. I am 50 years old and starting to show a little hollowing under eyes.  I think the fat has shifted and there is less volume. I’m looking for ideas as to the best and least invasive way to improve it. I had a lower blepharoplasty about six years ago. I have heard conflicting views on using temporary synthetic fillers (Radiesse, Juvaderm, etc) vs. fat injections. If I did something, I would prefer permanent, rather than a touch up every 6 months or so. Perhaps you could comment on fat injections and whether its a reliable way to correct this. I do have some creepy skin underneath and would like to know about skin resurfacing, laser, etc… No knives and cutting for me. 

A: When it comes to under eye hollowing, it is an issue of volume addition. But there is no under eye filler approach that can guarantee smoothness or permanency. Fat is the only injectable option that may achieve some permanency but it has the risk of unevenness or small lumps. While they would likely not be seen, they may be felt. It is just the nature of a filler that does not have linear flow coming out of the end of the injection cannula. If you particulate the fat into a liquid that will have linear flow, then there will likely be 100% absorption of the injectate.

The best approach to undereye skin tightening is fractional laser resurfacing which can be done in the office under topical anesthesia. Because of the very thin skin of the lower eyelid, one has to be careful to be too aggressive to avoid a burn injury. Thus it may require more than one fractional laser treatment to get the best result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a very deep labiomental fold that I seek improved.  That is what I am seeking your opinion about. What labiomental fold reduction procedure do you recommend? If so do you believe this procedure would bring long term improvement for me. Also, have you successfully performed this procedure in the past?  Your credentials speak for themselves and I value and will follow your lead.

A: Even though it is a small area, labiomental fold  reduction is challenging. Having tried synthetic fillers, injectable fat and Gore-tex, silicone and allogeneic dermal implants for the severely inverted V shaped labiomental fold, they simply can not lift the retracted skin edges. Internally the labiomental fold sits over the lower lip vestibule so it is not a bone influenced soft tissue structure of the upper chin. It requires release by making an incision along the depth of the crease (there is a skin fold there anyway), undermining and lifting up the skin edges, placing a dermal-fat graft and then closing the skin edges over it. A dermal-fat graft will completely survive and provide a permanent solution to the inverted labiomental fold.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am currently 21 years old, and wear around a size 36 H.  I am 5’1 and weight roughly around 210 pounds. The women in both sides of my family have large breasts. Both my aunt and my mother had breast reduction surgery. I do have discomfort while sitting which has caused me to have really bad posture. The bad posture has caused a pretty decent size hump on my lower neck/back. Would I be a good candidate for a breast reduction?

A: By your description I could not imagine a better candidate for breast reduction surgery. Your musculoskeletal symptoms and posture indicate that your breasts are too heavy and hung too low for your body frame to support it. You have already seen the benefits (and the scars) from breast reduction in your relatives so you are well aware of both the benefits and the trade-offs of the procedure. You age is not a limiting factor for having the surgery. While you are overweight for your height, that is also not an excluding factor in having successful breast reduction surgery. Weight loss will most likely make your breasts smaller but will not correct the sag which is often as much a culprit as their weight.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am inquiring about how to get rid of some injectable filler I had placed. I had two rounds of Sulptra to my cheeks and upper face last year that produced a subtle but pleasant change. I then went in a third time for lines around my mouth and was injected with a 1/2 vial of Sculptra into my lower cheeks and in front of my ears. The creation of volume started at just three weeks and has continued into this 6th week. I just wanted a couple lines filled near my mouth and specifically told her no more volume, but I realize there was either a miscommunication or she hasn’t had someone react so strongly on the 3rd vial. I know that most doctors say that Sculptra is irreversible and I might just have to wait two years, but a few others have suggested collagenase, 5FU and Kenalog injections to reduce it. One even suggested Ulthera therapy. I’m confused, but if there is something I can safely try, I really don’t want to go two years waiting for it to wear off.

A: The effects of Sculptra are magnified each time you use it as the body is reacting to the polymer crystals that are being implanted. So much like an immune response, each exposure to it (as well as the volume placed) can create an even more profound effect. Its effects are created by the scar/collagen reaction to the implanted material. The volume effect goes away when the polymer crystals finally dissolve and the scar tissue created by them eventually wears off…a period of between 18 and 24 months. In very rare cases, the volume effect does not go away.

Since it is very likely that time will solve the problem, you don’t want to do anything that may have its own adverse effects. For this reason, injectable steroids (Kenalog) would be excluded no matter how dilute. Collagenase is an option but is a small percentage of patients they can develop a reaction to the enzyme. 5FU has really known side effects although it is less effective than either steroids or collagenase. External skin tightening therapies such as Ulthera or Exilis can have some facial slimming effects because of the radiofrequency heat they produce which could cause the reactive subcutaneous scar tissue to dissipate. They are well known to cause fat absorption at high energies or repeated treatments.

The safest options in my opinion would be 5FU injections combined with Exilis. It may require more one treatment but conservative improvement with no downsides would be a prudent approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, If I had you take out my chin implant, would I get my original chin back, or will it look somewhat deformed from all the carving you have to do and all the ingrown tissue that has been produced since it was put it one year ago.

A: What happens to the chin with chin implant removal depends on numerous factors. What is the size of the implant, what is the composition of the implant (silicone vs Medpor) how long has it been in place, and what is the nature of the soft tissue pad sitting on top of it. By far the most important of these issues is the size of the implant and the material. Small sized chin implants composed of silicone material are the most likely to have a chin return to its original shape. Large implants, particularly those composed of Medpor which are more ‘destructive’ to remove, are less likely to have the chin return to its original shape. Usually it is not a bone change issue, but the stretch of the overlying soft tissues that poses the potential issue. In many cases managing the soft tissue by tightening or suspension helps solve any soft tissue deformity that may have been caused by the implant.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I came across your website and am very impressed with your blogs on cheek bone reduction and jawlione shaving surgery. I underwent zygoma and jaw shaving both a month ago and am very worried regarding my decision. I have some questions to ask you, which I hope you can help me.

1) Is facial sagging more common with my surgeries of both zygoma shaving and jaw shaving? Two years previously, I had buccal fat removal and facial liposuction. I am worried that this increased my chances of facial sagging?

2) The right side of my mouth is harder and more painful to open. Is this normal for slightly over one month post-op?

3) My facial swelling changes daily. Some days are more swollen and chubbier than other days. Is this normal?

4) Is zygoma and jaw shaving supposed to give a narrower face? A friend of mine is post op three months and she is chubby at the bottom cheeks. I have heard many stories of young girls having chubby bottom cheeks. Will it go away?

5) I have read that it takes 2 to 3 weeks for majority of the swelling to subside, I still feel I have a large amount of swelling. When would you say the majority of swelling will subside?

6) My doctor says that nothing can be fixed in the following months if facial sagging occurs on the cheeks, is this true?

A: In answer to your questions about cheek bone reduction and jawline shaving:

1) Soft tissue sagging is a more common problem with cheek bone reduction, not so much for jawline shaving. Having had a previous buccal lipectomy and facial liposuction did not increase your risk of soft tissue sagging with these procedures.

2) It would be perfectly normal to have stiffness and soreness of mouth opening and stiffness at the is early point after surgery. Expect full recovery to take 3 months.

3) Facial swelling is very cyclical after surgery due to positional changes of the face and resolving lymphedema.

4) You should not judge the final results from any facial bone surgery until a minimum of 3 and preferably 6 months after surgery. She may be chubby due to swelling and resolving lymphedema or may also perceptual enhanced lower facial fullness due to the now more narrow midface.

5) A few weeks after surgery is way too premature to expect most of the facial swelling to have gone away.

6) You need to wait 6 months to both judge the results and before embarking on any corrective procedures.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a question about cheek bone reduction. I hope you can help me because I am very afraid. I had a zygoma reduction with the L-osteotomy. Now my cheeks are sagging. I can see it because of the swelling look around my mouth. Now my surgeon told me that he will do a midface lift and Medpor implants. Will that help or not? I am afraid because I read on some pages that it is very difficult to fix this problem. Is that right? Please help me, I don’t know what to do.

A: One of the well known risks of cheek bone reduction is loss of soft tissue support or cheek soft tissue sagging. Since the cheek bones act as attachments and support for the midface tissues, it is no surprise that in some cases with some cheek bone techniques that the cheek tissues may sag afterwards. It is not a universal complication of every cheek bone reduction but it definitely can occur. It is for this reason that I like to perform cheek tissue suspension at the same time as the cheek bone reduction.

Now that you have it, and I presume you are at least 3 or 6 months from the procedure, the treatment would be the reverse of what caused the problem. At the least the cheek soft tissues need to be elevated and this could be done through a combination temporal and intraoral suspension approach. While adding bony projection with a cheek implant can be an adjunctive procedure to a cheeklift, it seems counterproductive to add back cheek prominences when you went through the original operation to get rid of them.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have some more questions based on our previous discussions with skull implants.

1) What is your protocol, or what can I do, in the unlikely event (post op) , I develop an infection?

2) What if I’m unhappy with the outcome or placement? Do I have to pay for the corrections or revisions?

3) Is this something that will last the rest of my life? Is it likely for my body to reject the implant? I have read up on a lot of cases of people developing infections from implants.

4) Who can i go to in the event that something goes wrong with the implant when im older, (or if its damaged or detached) in the event that you have retired or no longer practicing?

5) Is there any way at all for me to feel confident that the implant will fit correct, look right, and feel right for me the first time around, without you actually evaluating me in person, aside from the CT scan?

6) Is the incision and scar guaranteed to be no more than 4-5 inches? Is it possible to make it smaller? ( this is one of the biggest factors in my decision)… I’d love to see what a scar on the scalp will look like on me, from previous surgeries you performed… I really don’t know what the scar will look like when it heals.

7) Also I seen you mention online that there may we unexpected expenses once you meet the patient? Obviously I know what I can afford to spend and what I cannot, so if there are additional unexpected costs, that has to be factored into my budget of what I can or cannot pay.

A: In answer to your questions on skull implants:

1) Fortunately, I only seen an infection in one case. Initially antibiotics are used. However, if that fails to resolve it it is very likely the implant will end up being removed to cure the infection.

2) There is a very specific revisional policy on all aesthetic surgeries. While I try very hard to get the optimal outcome in every patient, that is not always achieved. Should a revision be necessary, the patient is responsible for the OR and anesthesia fees for the time to do it.

3) Infection is always possible with an implant placed in the body, that is very different than rejection which basically is very rare to non-existant. People always confuse infection for rejection. Barring an infection or some aesthetic issue, this is a permanent procedure. The implant will never degrade, break down or need to be changed.

4) That is an impossible question to answer right now. Any craniofacial plastic surgeon will suffice.

5) This is a 3D computer designed implant, it will fit like a glove to your bone.

6) I do not believe the incision will be smaller than 4 or 5 inches. See attached image of various scalp scars from these procedures.

7) In your case, you have been given the quote which is what it will be. That is a statement made to general inquiries who many just ask for a general cost number.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting injectable fillers into my tear troughs (tear trough injections) but am very nervous about it. I have read numerous horror stories of significant bruising and clumps and irregularities in this area. What is the best way to inject the tear troughs and not have these problems?

A:  Injections for tear trough (nasojugal) effacement is the most technique sensitive of all injectable filler treatments of the face. I used to use a 1/2 inch 30 gauge needle and injected down to the level of the periosteum along the medial orbital rim. But the periosteum over the orbital rim is quite adherent and recent studies have shown that the periosteum and the retaining ligaments in this area are very difficult to elevate and are prone to bleeding and external bruising.

I have subsequently changed my tear trough filler technique to using a microcannula rather than a needle. Coming though the thicker cheek skin rather than the thinner eyelid skin, I enter the submuscular plane above the periosteum to inject. This approach puts the microcannula directly into the tear trough and has no risk of causing bleeding or bruising afterwards. This more superficial submuscular deposition of filler has improved my results dramatically. In addition, the entire tear trough can be filled from a single puncture in the upper cheek. The microcannula can reach the most medial part of the tear trough.

It is important when filling the tear trough to only use hyaluronic acid-based fillers to avoid clumping and to not overfill. Less is more when it comes to filling the tear troughs.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I am interested in getting a rhinoplasty to reshape the tip of my nose. I have attached two pictures one picture being how my nose looks now (bulbous tip, very bulky in appearance) and a second picture of how I want it to be like. ( slim and straight) Would the result I hope to achieve be possible? What would need to be done to produce the desired result in the picture?

A: What you initially have is a bulbous tip that makes it fuller and stick above the rest of your otherwise straight dorsal line. This bulbous tip is composed of the union of the paired lower alar cartilages which are both wide (cephalic to caudal direction) and long. (anteroposterior direction) A tip rhinoplasty can reshape these cartilages by a cephalic trim, cartilage length reduction by medial footplate resection and dome narrowing by suture plication. Together these nasal tip changes are very likely to achieve the desired result that you have illustrated.

A tip rhinoplasty, what I call a Type 1 rhinoplasty, is done through an open approach and is  associated with a fairly quick recovery. Some prolonged nasal tip swelling can be expected.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, How should I take care of my incisions and sutures after surgery? I had eyelid surgery yesterday and my doctor did not give my any directions as to how to take care of them. My friend told me I should clean them every day with hydrogen peroxide and then apply ointment. Is this correct?

A: After surgery wound care is frequently misunderstood. Hydrogen peroxide has been historically used and is still recommended as a wound agent for sutures lines. However, it is important to recognize when and how to use it to avoid adverse healing and scarring effects. Hydrogen peroxide can help remove small clots on suture lines which develop right after surgery due to its effervescent bubbling action. (the effect of catalase) Using a Q-tip several times a day right after surgery to get the blood clots off suture lines is beneficial as these blood clots are a potential breeding ground for bacteria.  However once there are no more clots on the suture lines (as they should all be gone in a day or two after surgery) hydrogen peroxide should not be used. It has been shown hydrogen peroxide applied to wounds can actually impede their healing and lead to increased scarring as it destroys newly formed skin cells.  Once the clots are gone only topical ointments should be used to aid in the healing and protection of new skin cells so that complete re-epitheliazation across the wound can occur.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to have liposuction on my calfs, but,I have been told by several doctors not to do it? Is it safe? I see on your website you do calf and ankle liposuction.

A: Liposuction can be done safely on the lower extremities, including calf and ankle liposuction. It is not a question of safety but effectiveness. Can enough fat be taken from the right places to make a visible difference. While most people that seek liposuction below the knees would like a large circumferential reduction, such changes are not usually possible. However, selective small cannula liposuction done in the right areas (high inner calf, lower inner calf, low posterior calf and inner and outer ankles) can give the calfs and ankles some shape so that they don’t look like ‘cankles’ and straight tubed calfs.

The issue with liposuction below the knees is that there will be some prolonged swelling due to the high venous pressures that naturally are present in the ankle and feet. It usually takes about 3 months for the full effects of the procedure to be seen.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am very interested in the head widening procedure displayed on your website.  ( http://www.exploreplasticsurgery.com/tag/head-widening/ )

I have a couple of questions:

1. Can this overall head widening procedure also widen the temporal hollows? Can one implant be used to widen both the front temples going all the way behind the ear?

2. You describe this procedure as increasing bitemporal diameter. But am I correct in saying that it also widens the biparietal diameter?

3. How much does this procedure cost, and how much would a CT scan for it cost?

4. Can I please see the patients before/after pictures?

A: Thank you for your inquiry. In answer to your questions about custom temporal implants:

1) The temporal hollows can also be widened (filled in) but I would just use an additional set of standard small temporal implants to augment that area. That is too far forward and would make the implant too big to get in.

2) Yes, expansion occurs in both the bitemporal and biparietal diameters

3) Some of the total cost would depend on whether we used semi-custom or true custom implants. You can get a CT scan in your local commnunity for just a few hundred dollars in most cases.

4) Those can be sent to you by a specific e-mail request to: inquiry@eppleyplasticsurgery.com.

Please feel free to send me some pictures of your temporal/head narrowing concerns.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting a custom skull implant made for the back of head to correct its flatness. But I have some basic questions if you don’t mind about the process and how it all works as well as some question about the surgery itself.

1) How many times do we physically have to meet? How many trips will I have to take to your office?

2) My biggest concern is that the implant has be made exactly to the specifications and contours of my sKull so that there are no “pockets” between my skull or the implant (no matter how small or microscopic, i don’t want to risk complications) I want it to fit “like a glove.” Will the implant be custom made at the time me meet? After? Will I have time to see and try the implant, (meaning see how it fits on the back of my head by actually applying it on my head externally?)  How will I know what the final result will look like? How accurate are the computer models?

3) How are the implants designed? Can you tell me more about the process and steps? I.e: we meet, you take measurements of my head, look at CT scans, and send info out to the lab where its made? What is the actual process from the moment I agree to surgery 

4) What complications (if any) have you had in the past with surgery of this nature? How many patients needed revision or had complications? 

5) What are the risks or side effects post op? What should I expect? How long is recovery and healing time? How long does it take for the scar to heal, or for any swelling to go down? Is there a high risk of infection?

A: In answer to your questions about a custom skull implant:

1) The only times we really have to meet is the day before surgery when you come for your surgery. Any followups are done by phone or Skype.

2) The implant will be made off of your 3D CT scan (which you can get in your local community). It is made by a computer design process to the dimensions that I provide. This way it will fit perfectly, like a cap on a prepared tooth. This is all done before surgery and does not require you to be seen. During the design process I will provide with the PDF files so you can see exactly what the implant looks like and its size. This process takes about 3 weeks to make once they (Medical Modeling, Golden Colorado) get the CT scan.

3) As above. It all starts with you getting a 3D CT Skull scan.

4) I have done many custom implants and skull augmentation with implants and bone cements. The only problems that I have seen are aesthetic…was it big enough? was it smooth and symmetric? My experience shows about a 10% risk of a revisional surgery for some aesthetic adjustment. In the case of a computer-generated skull implant, the computer design process helps avoid most of these aesthetic issues. I have yet to see an infection or any significant wound healing problem.

5) Other than some swelling, most patients do not have much pain. There are no restrictions after surgery and one can return to any activity as soon as they feel like they can. The incision heals very quickly and, even with swelling, most people don’t even notice it since the head shape just becomes more normal. In rare cases, some swelling may go forward to the eyes but that depends on how much scalp dissection is needed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in thigh lifts. My inner thighs run together and there are several rolls of skin that meet and rub when I walk. Sometimes this causes irritation of the skin. I would like them reduced and lifted so there is a gap between them. I also have a pubic area that hangs a bit low so combining thigh lifts with some type of tummy tuck would be ideal. Can these two procedures be done at the same time?

A: Inner thigh lifts can be very effective at improving the shape of the inner thighs near the pubic region. In most women, however, getting an actual thigh gap from the procedure is expecting too much. There is a limit as to how much skin can be removed in a thigh lift and how much fat can be suctioned from the area at the same time. The more skin that is removed, the higher the risk of scar widening and scar migration below the groin crease, making the scar more visible. While improvement is always seen in inner thigh lifts, it is a balance between the improvement in shape and the length and location of the scar.

Thigh lifts and tummy tick surgery can be combined without any vascular compromise issues between the intervening skin. (although this would depend on how long and close together the two incision lines will be) It does make one’s recovery more difficult with tightness of both the abdominal wall and bending at the thighs, but it can be successfully done as a combined procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am considering facial implants to rejuvenate my young but old-looking face. I am 37 years old and underwent gastric bypass surgery two years ago and it seems all the volume in my face went away. I hate the excess skin under and above the eye and the deep grove under the eye. I use to have chubby cheeks that went away after the surgery. I tried Radiesse a year ago that didn’t give me the cheek volume I desired and didn’t address the hollow grove under the eye and my face went back flat in about eight months. I have always hated my nose. I hate that the bridge is flat but have a big round tip and my nostrils are huge. I always wanted a small nose that lined up with my eyebrows .I shaved my eyebrows and draw them on until I find the perfect surgeon for a forehead/brow lift to address the hanging/excess skin. I am aware that some people want a subtle change…not me… I want a drastic change. I lost over 1090 pounds so I feel like a new person but I look like a old person. I have searched high and low for the perfect facial surgeon please let me know if you can help.

A: Facial implants can be beneficial for all three areas that you have mentioned, tear trough, cheeks and the nose. But in applying facial implants to these areas, it is important to realize what they can and can not do. Tear trough implants, which have to be placed through a lower eyelid incision, will help fill in the depressions along the infraorbital rim but they will not get rid of loose skin on the lower eyelids. In many cases skin removal may be simultaneously done but you seem to have little room for loose skin removal even though you are demonstrating the laxity of the skin by pulling on it. Cheek implants, which are placed through the mouth, can be used to build up overall cheek area although your cheeks already seem full. (but then I have no idea what you looked like before your weight loss) Nasal implants are commonly used in rhinoplasty to build up the bridge of the nose. When combined with tip narrowing and elevation and nostril narrowing, significant changes can be achieved in the shape of the nose. Although the thickness of one’s skin will control how much narrowing of the tip can be obtained so one has to be realistic with these type of rhinoplasty outcomes.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had custom chin and jaw angle implants placed four months ago and then I had them revised with new implants two months ago. While it is much improved and is almost what I want, I think I need another surgery. How soon should I have another jawline implant surgery again, I am ready right now?

A: While I am not your plastic surgeon, I do not agree with any patient changing their facial implants repeatedly over very short times. Making facial structural changes before 9 to 12 months short of some major aesthetic problem is often premature. You have been through two surgeries over a short postoperative period of time and now you want to change the look again…before you have ever truly seen the final result and before you have had time to psychologically adjust to your new look. Perhaps you have learned that, despite all the preoperative predictions and planning, that it really isn’t the look you want or maybe achieving that look isn’t even possible. I am not looking for an explanation nor do I want one from you as to the logic of the desire for another surgery, it is just this decision just seems very hasty sitting from my perspective.

The other equally important reason that I advise against prematurely jumping in and changing facial implants is that each surgery carries risk and the more surgery you have the greater likelihood that one of those risks will occur.  Every surgery always involves some form of a trade-off and each new surgery creates the opportunity for a new problem to appear. The dreaded one, of course, is infection. Just because it has not occurred before, each new surgery involves a new spin of the wheel so to speak, and repeated surgeries increases that risk.

I say all of this because a patient’s decision to undergo any revision should be based on the severity of the problem versus the degree of risk involved. There does come a time when the balance between those two should give one pause for reflection.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had gynecomastia reduction surgery for what a plastic surgeon told me was a minimal grade 1. He said he would first try with liposuction and excision would be considered during surgery. After surgery, he told me he took 200cc fat from each side (totally 400cc) and there was no need for excision. He then advised to wear garment for six months. I wore the garment for two weeks full time 24×7, now wearing it during day time. Now its exactly 3 months after surgery and I feel not satisfied with the result. Please advise will I need revision or is it ok? I am still wearing garment. How long should I continue ? Shall I do some light weight exercise to maintain weight or will the exercise cause chest to bulge out?

A: If you are not happy with your gynecomastia reduction at three months after surgery, it is unlikely that further time is going to change that perception. At this point, there is no benefit to continuing to wear your garment. You should resume all physical activities including exercise as this will not adversely affect the result at this point. I would wait until you are six months after your surgery and then purse a gynecomastia reduction revision which will likely involve an open excision as part of it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Looking into the mommy makeover. I am 35 years old and I have five kids. Exercise is not gonna get it done, I can see that now. I wanna be ready for this summer. I have attached some pictures of my body so you can determine what needs to be done.

A: Thank you for sending your pictures. They give me a clear idea as to the exact Mommy Makeover procedures you need. From an abdominal standpoint, you need a full tummy tuck with flank liposuction. You have excess abdominal skin that is loose and hanging over your waistline. Full ness from fat extends around your waistline into your back. From a breast standpoint, you need implants with a vertical breast lift. Your breasts have lost substantial volume and are saggy (ptois) with the nipples hanging below the lower breast crease.

Both breast and abdominal reshaping procedures can be done during the same surgery, hence the derivation of the Mommy Makeover name. In a single operation, often lasting 3 to 5 hours depending on what is being exactly done, a women’s body can be very positively changed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I definitely want to remove my acne scars, but other than that, I’ve been given so many different suggestions, I’m not even sure anymore. For the acne scar laser resurfacing, I was told my skin type has a high chance of pigmentation. What are safe options? I do want a rhinoplasty, but I want it to be very subtle, and I’m mainly interested in fixing the tip that sort of goes down like a beak. How is this usually corrected? Also, you mentioned that it appears my buccal lobe was removed. Does this mean the maximum amount was taken out?  I am now 2.5 weeks post op. Do you think my final results will give me the skeletonized appearance I desire? I still feel 2 grape sized bumps, hard as rock, when I push down on my cheeks.

A: What would structurally benefit your face is not a mystery and is very straightforward…it lies with your nose and chin. Your chin is very deficient, by at least 9mms, and is one feature that will keep your face from ever having a very defined and angular appearance., By using a sliding genioplasty to bring it forward it will improve your facial profile and help create a more defined appearance in the front view.

You have a very classic ethnic nose with a broad flat tip that has little support and no projection, hence a rounded tip that droops down. An open tip rhinoplasty will reshape the tip and give it a better profile and a more narrow appearance in the frontal view. You would also need some upper dorsal/radix augmentation.

Fractional laser resurfacing is the only type of acne laser resurfacing that you should have as this has a very low risk of any hypopigmentation problems. It will take more than one treatment and the best result you can hope for is about a 50% improvement in the appearance of your facial acne scarring.

It takes a full 3 months for the buccal space where the fat pads were removed to become soft and not feel as hard lumps, this is perfectly normal to feel what you are feeling at just 3 weeks after surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I know I want infraorbital rim implants but an additional concern is the changes in the skin under my eyes that I have noticed in the last three to four years.  I have attached a PDF of some of my eye pictures.  They shows the bunching up and “crepey” skin that tends to exacerbate my undereye issues and tired appearance.  Even though the lower photos are the effect with an extreme smile, this tends to occur even with a mild smile, and really affects my self-esteem.  I was wondering how infraorbital implants and/or fat relocation will ameliorate these folds.  Though I had a series of three micro laser peels this last year, they did little to address this issue.  I just would like to be realistic as possible in terms of the outcome of this procedure.

A: The smile animation ‘deformity’ around the lower eyelids (under eye wrinkles) is a tough one since it is a muscular action effect and not a structural problem. No amount of static skin resurfacing will help a dynamic movement issue. The  infraorbital rim implants will make some improvement in it due to volume expansion and some diminution of muscular excursion but ultimately animation wrinkle deformities respond best to Botox injections.

Dr. Barry Eppley

Indianapolis, Indiana