Your Questions

Q: Dr. Eppley, I have a question related to my paranasal implants. from Korea. Five months ago I had this augmentation but now I am disappointed with the result. I start to have awkward smile and a much longer upper lip. But because I have a sunken nose base, I do need the augmentation. In short, I am planning to remove the paranasal implant and change to a new one. I am wondering if I want to have an improved result whether I need to do these procedures separately (6months or so after removing current implant then add a new one) or can I do these two procedures together in one single surgery. It would be much easier for me to have only one surgery. But I am really worried that if I do so (removing and changing the implants at one time), that the swelling during the surgery might affect the doctor’s aesthetic decision for the new implant. Besides I am also worried that if I have only one surgery, whether it is possible the new implant would be much more likely to change its position on my face in future. Do you have any suggestion for my problem?

A:  To provide a very specific answer, it would be helpful to know what type of paranasal implants these were, what was their shape and how were they placed. (through the mouth and and on the bone around the pyriform apertures or placed through the nose in the soft tissue of the nasal base) One of the advantages of having existing implants in place is now you know the result they create. That provides valuable information as to how to change them for an improved result. The existing problems with your current paranasal implants could be their size, shape, and/or anatomic location. The change should be predictable before surgery, not during the procedure. Therefore, there should be no problem removing and replacing them during the same procedure. I see no advantage to a staged procedure. In fact, I would find that actually counterproductive. Knowing what didn’t work well is a good guide to improving it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have some additional questions about thigh liposuction. I need a fair amount of fat removed frm my thighs and during our consult you estimated that it would be about 1.5 L per thigh.  I know you are the expert but I’m wondering if I should get more removed (have you seen these thighs lately? Ha!). I believe your concern was that I have somewhat of  “cellulitic” thighs – nothing too severe but my legs aren’t perfect either (I’m 5’5, 165 lbs). How big of a factor is this when taking the amount of lipo into consideration?  Would it be risky to remove a little more per thigh?  Part of me would like more removed.  However, the other part of me worries about skin elasticity and “lumpiness” or other skin irregularities produced from the procedure.

A: The key concept for your thigh reduction to consider is that the more aggressive you are with liposuction in someone who has pre-existing thigh cellulite, the more likely you are to worsen the appearance of the cellulite and create unevenness. Contrary to a common public misconception, liposuction is not a treat for thigh cellulite but a potential exacerbation of that problem. It is a delicate balance between improvement in thigh size and not worsening the overlying skin’s contour. The ‘price’ to be paid for aggressive liposuction (maximal fat removal) is increased skin irregularities. Removing anywhere near 1 liter of fat from the saddlebag area is a lot and is certainly aggressive. But almost assuredly, increased skin irregularities will be the trade-off.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, my 14 year-old son had his foreheasd bone fractured in an accident this past April 2012 . The bone was removed by the doctor then and he now now needs reconstruction of that part. The place is between both eyes with a size of size of 7cm length and 5.5 cms width. The doctor here is saying they will take out a piece of bone from the front table of head bone and put that on. Is it safe? I need your view.

A:What are you are referring to is reconstruction of the forehead with a split calvarial bone graft. That is certainly one accepted cranioplasty method to do the reconstruction and is the only natural or autologous method. It is a well known craniofacial surgical technique and is very safe if done in experienced hands. Given that it is a full thickness frontal bone defect, the size is not too big (7 x 5 cms) and he is only 14 years of age, this is probably the best approach. His skull should be thick enough that the outer table can be removed elsewhere on the skull in a single piece and moved to cover the forehead defect. There are numerous alternative methods that are technically easier such as titanium mesh and hydroxyapatite combinations as well as custom HTR cranial implants, which are also acceptable methods, but the cranial bone graft for his size defect should work well. This is particularly important of the frontal sinuses have been exposed in the defect, which I suspect that they have.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, regarding the skull augmentation will the bone cement be set beneath the periosteum. Could that involve any risk of “osteolysis”? Could the bone cement be put on the periosteum instead? Thanks!

A: Your question is an interesting one and is only relevant based on the type of cranioplasty material that may be used. When using any of the hydroxyapatite (HA) formulations, you definitely want to be under the periosteum for two good reasons. First, the material does bond directly to bone with no risk of osteolysis and you want to take advantage of this biologic benefit. Secondly, if HA materials do not bond to the bone they will ultimately be unstable and may likely shift position afterwards and develop fractures or fragmentation of the materials at their feather edges. When it comes to poly methylmethacrylate (PMMA) cranioplasty material, this can be placed on top of the periosteum and will set up and will likely not shift or fragment afterwards particularly if microscrew anchorage is used. PMMA materials, unlike HA, do have a known and low risk of settling into the bone a little bit and are what you refer to as ‘osteolysis’. But this is not a particularly progressive process and is self-limiting. Conversely, I have greater concerns for its effects on the overlying scalp and tissue thinning. Therefore I think it more important to provide as much barrier between the material and the overlying scalp tissues as possible and would recommend staying beneath the periosteum for this important long-term reason.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I really need your advice, I have a problems with my eyes. There are very round, there are always dry and the corner of my eyes there is no fullness. (no arch shape) . My questions is are infraorbital rim implants right for me? Should a midface lift be done with the infraorbital implants? Please send info to my email please get back to me if you can.

A: To best answer your questions, I would need to see some pictures of your orbital/facial area. Round eyes with too much scleral show can be improved by tightening  procedures at the corners (canthopexy) which may alone offer an improvement. In some cases of round eyes, there is laxity and/or a lower eyelid malposition contributed to by a lack of underlying skeletal support. That is where infraorbital rim implants can be helpful. By providing skeletal augmentation and a push upward to the lower eyelids, lower eyelid tightening procedures can be more effective and the lower eyelid position better maintained in its new position. This is also the role of a midface lift, to provide soft tissue support to the lower eyelid. By definition, infraorbital-malar implants produce a midface lift by the displacement of the soft tissues.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have been researching doctors for breast augmentation this fall. I  am interested in breast augmentation and was wondering what your philosophy is about going big enough but not too big for your body. I am an A cup and would like to be a D cup. Another doctor told me a DD would put my body at significant risk for re-operation. My biggest fear is a doctor not letting me go as big and I would like or not setting the limits for too big and my body being injured. Thank you for your time!

A: Selecting breast implant size is, by far, the most discussed patient issue in the breast augmentation procedure for understandable reasons. The whole purpose of the operation is to get a larger breast size. I do not choose what size implant any patient should have, I merely help the patient select a volume that matches their desires. There is no absolute science to selecting breast implant size but through experience and the use of shaped sizers, I found that the desired result is obtained in just about every patient. I personally have never had a patient who has undergone a reoperation to get a larger breast implant size because they didn’t get what they wanted the first time. Conversely, I have had a few patients that opted for bigger implants but it was because they chose a smaller size initially.

When it comes to size selection, here is definitely a growing trend and philosophy amongst many plastic surgeons to place implants whose size stays within the existing breast base diameter and does not exceed the ability of the breast  tissues to support it long-term. When you look at the relatively high rate of breast implant revisions (nationally around 30% in the first three years after augmentation…my practice revision rate is less than 10%) it is understandable why a more conservative size approach has become popular. While the need for revisions comes from a lot of different reasons (infection, hematoma, implant failure, etc), very large implants potentially contribute to these causes. ( e.g., due to bottoming out, asymmetry, symmastia, breast tissue thinning ,etc)

What defines a large breast implant size or too large of a breast implant for the patient is going to be different based on each patient’s breast anatomy and chest/body size. For most patients, I would not think that going from an A to a D cup would constitute in my mind an implant that is too large or, more relevantly, places the patient at a substantially increased risk of subsequent breast tissue support problems. But that would have to be determined by an actual physical examination of the patient.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 44 year-old male interested in a direct neck lift but I think a modified version. My saggy neck skin is caused after neck liposuction when skin did not fully re-attach firmly and/or shrink, so the underlying muscle is fine. I just need the excess sagging skin removed and the neck tightened up. I do NOT want a behind the ear neck lift and like the direct neck lift. Also I like the fact it can be done under local anesthesia.

A: The direct neck lift has the advantage of treating loose neck skin by direct excision and is very effective as a result. But it does so at the price of a scar. This is usually not a big concern in the older male (> 65 years old) who has a classic turkey neck problem but may be more of a potential aesthetic issue in the younger male with less loose neck skin. For this reason I might consider an alternative to a vertical neck skin excision to that of a horizontal excision right under the chin. This is more formally known as a submentoplasty. It removes much less skin than the direct neck lift but has a much better scar camouflage. At your young age, I question the wisdom of vertical neck skin removal and the subsequent scar when the problem is loose neck skin after liposuction. This tells me that the skin redundancy issue is mild and much less than a drooping neck wattle.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a pretty big scar which runs down the middle of my forehead. It is from an accident I was in last October. It was cut down to the skull and they did plastic surgery but my doctor said its all healed now. I want it to blend in more and not look so scary. What type of scar revision would help me the most?

A: As your scar is now nine months old, it is likely close to maturity. This is confirmed by your doctor saying that it is ‘all healed now’. In looking at your pictures, your scar could be improved through further manipulations. It is not tremendously wide but it is visually obvious because it is a vertical scar in the forehead where the relaxed skin tension lines (RSTL) run horizontal, completely perpendicular to your scar’s orientation. I think you would benefit by a two-staged scar revision approach. A first-stage running w-plasty scar revision done under local anesthesia in the office. This would help change the straight line vertical scar appearance to a more of a broken line closure. That would achieve two things. First it will help redistribute the tension better by the interdigitation of the wound edges so it will likely end up as a more narrow scar. Secondly, an irregular line is a better camouflage when the scar runs adversely to the RSTL of the forehead. If needed, a second-stage fractional laser resurfacing of the scar several months later for optimal blending into the surrounding skin.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have an weird forehead. It has that I mainly have a brow as a man and it also has horns (exotosis) I was wondering if you do such surgery to fix this/shave down my skull to get me a desired smooth forehead as a female should have. I also have a high hairline so I’m wondering if you can pull it down. How old do you have to be? I know 18+ but the skull doesn’t finish developing until what age? I am 20 so I don’t know if I am old enough yet. Also, can both surgeries be performed at the same time?

A: The skull is largely finished developing by one’s early teens, it is the facial bones below it that continue to develop until the late teens with the mandible finishing complete growth around age 21. Therefore, at age 20 you can have frontal/brow bone reduction without any concerns about growth implications. The only issue is how much the brow bones can be reduced given the frontal sinus which lies underneath it. That could be determined before surgery by a simple lateral skull film. The hairline advancement/vertical forehead skin reduction is done through a pretrichial incision. This also provides the exposure needed for the forehead and brow reduction so, by necessity, these two procedures would be performed at the same time.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am just enquiring about getting my head wider. I have a fairly thin head and want it wider. Is that possible?

A: When it comes to widening faces, most of the narrowing that I see is in the temporal regions from the lateral orbital wall  back into the temporal muscle above and behind the ear. Augmentation of the narrowed temporal region can be done one of two ways. The first method would be to use off-the-shelf silicone temporal implants. They are designed to fill out temporal hollows and are placed under the temporalis fascia just above the muscle. While they are primarily intended to be used to fill out the temporal hollows between the side of the eye and the temporal hairline, an additional implant can also be placed above the ear level also. This does not give the ideal augmentation because of the shape of the implant, but it is the most economical approach because it uses ready-made implants. The second approach is to use custom-fabricated implants made out of either Gore-Tex (carved out blocks during surgery) or silicone (pre-made off of a skull model) materials. They would provide the most ideal augmentation because the implants cover the optimal surface area of the temporal regions.

The other narrowed area is more of the head and is in the upper temporal region back to the occiput. This is a more challenging because the temporalis fascia gets very thin the higher it goes up the skull/forehead. This makes it difficult to have a subfascial implant which helps camouflage the contours of the implant.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting some volume back in my face. I lost a fair amount of weight over the past two years and my face has become quite gaunt. After doing a lot of reading, I know that there are the options of either some type of injectable filler or using your own fat. There doesn’t seem to be any consensus as to which is best. What is your opinion?

A: The development of synthetic fillers has created a whole new field of aesthetic medicine, mainly for facial rejuvenation. They are understandably hugely popular because of their instantaneous effects. While some last longer than others, in the end they are all temporary fillers. This issue only becomes truly relevant with major facial volumization is desired. The issue is simply one of cost. Given the volume of synthetic filler needed and the time that they last is the cost worth it? That, of course, is an individual question but the cost:benefit ratio does come into play for most patients.

Fat injections do not suffer from volume concerns and are more cost effective when considering the volume that is capable of being injected. Fat also has the added benefit of providing some stem cells as well although what their role is and how much they contribute to fat graft survival and overall tissue rejuvenation is still a matter of some debate. While fat grafts have the potential for long-term survival, their retention is not completely assured. Fat grafting procedures are a surgical procedure, however, and need to be performed under either local anesthesia or IV sedation depending upon the volume needed.

In the end, both synthetic fillers and fat grafts have their advantages and disadvantages. When it comes to substantial facial filling as in the gaunt face, fat grafting has more advantages as long one is willing to commit to more than an office procedure with some downtime.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I took a look at the computer imaging that you did for me for my jawline. I like what you did to the chin but don’t like the jaw angle result. I saw a case of a guy onlione who had custom made jaw angle implants done and he did not had that square look. Is that possible to be done to me like that as well?

A: Let me explain the purpose of facial computer imaging. Initially it is to create a dialogue or communication as to what the patient wants. No knowing what anyone really wants when they say a stronger jawline, I have to have a starting point for discussion. I made those angles square to see if this is the tyhe of jaw angle look you prefer. They do not reflect any particular implant selection as of yet. Therefore, looking at other jawline examples is helpful only for the standpoint of giving me guidance as to what look someone prefers…it means nothing about the implant style. So custom jaw angle implants are not what you need. Custom facial implants are usually used when the final look is more extreme or when stock off-the-shelf implants can achieve the desired look if they are intraoperatively modified. When going for less than a square or flared jaw angle look, stock jaw angle implants will work just fine…and they are far less expensive.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I weighed around 95 pounds before I had ovarian cancer.  After my cancer treatments, I gained 130 pounds.  I ended up have gastric bypass surgery and now have lose skin that needs to be taken off. Had a tummy tuck in 2001 so, don’t have too much loose skin in the tummy area. I am interested in my butt, arms and legs…can you help me with this?

A: Thank you for your inquiry. I am going to assume that you need a traditional arm lift (brachioplasty) and an extended inner thigh lift, which would be standard for many extreme weight loss patients after gastric bypass surgery. While every patient is different, I will assume these issues as a starting point. Your butt concern is harder to figure as I am uncertain whether an upper buttock lift or a lower buttock tuck tuck needs to be done. I will assume for now that an upper buttock lift (lower back lift) need to be done as this would be most common in the bariatric surgery patient. It is also a way to finish off a circumferential lower body lift as a second stage procedure to your initial tummy tuck done previously.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in the lipodissolve or liposmart for underneath my chin and abdomen area. I have excess skin and fat due to having a child. I am still a thin female, but have insecurity in these areas and feel these procedures would benefit me the most in regards to my weight and issues I am having. Please email me with more info and pricing estimates if possible.

A: The best way to get an accurate price quote is to come in for a consultation so I can see what you really need. or send me some pictures. The under the chin area (submental) fat is going to need to be treated by liposuction (Smartlpo) not lipodissolve for a variety of good reasons, mainly a much better result in a single treatment session.  The abdominal issue is less clear given that I have no idea what it looks like. When you use the words ‘excess skin and fat’, that may imply that liposuction may not be a good treatment approach because of the skin excess. No form of liposuction is going to shrink much loose skin, not even Smartlipo. If you have any stretch marks at all on this loose abdominal skin, there is no chance of shrinkage due to complete loss of elastic fibers/elasticity in the skin. Depending upon how much loose skin there is, this may put you more in need of some form of a tummy tuck.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I have concerns about my nose and I focus on it all the time. I think (know) my nose is too pointy at the tip and people confuse me as if I am Native American. I could see why. What can be done to make my nose less pointy?

A: In looking at your pictures, the pointiness  of your nose is the direct result of the alar cartilages which make up the tip. Your alar cartilages show rim retraction (an acute alar angle backwards) and a narrow dome area. Together this makes your nose tip come to a point. Since the overlying skin just follows the underlying cartilages, this gives you a sharp and pointy nose appearance. This could be improved through a tip rhinoplasty with cartilage grafting. In some cases of a pointy nose, the tip is both narrow and very long. This requires tip cartilage shortening. But your tip is not too long, it is just too narrow. Cartilage grafts would be harvested from your septum and used to augment the alar rims combined with a tip shield and dome spreading grafts. The objective is to change the shape of the dome and lower alar cartilages to make the tip more round and drop the rim of the nostrils down. This should help make a substantial change in the way the tip of your nose looks.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to reshape my chin. My chin doesn’t stick out, it just looks boxed look especially when I started losing weight. Also my ears don’t stick out, I feel they look big as in length for my small head. What do you recommend? I have a front and side picture for you to see.

A: Thank you for sending your excellent pictures. Your square chin can be contoured fairly simply through an intraoral approach where the square corners are removed (chin ostectomy) and the chin made more rounder as a result. The vertical height of your ears is a more challenging issue. It can be seen that what makes your ears long is that the upper half of the ear is big compared to the lower half.  While they can be reduced substantially in height, this necessitates a scar which would run across the outer helix in the upper ear area. I am not so sure this is a good aesthetic trade-off. There is an alternative approach for ear height reduction that is done from behind the ear, which leaves no scar on the outside, but it would only reduce the height of the ear a minor amount. So you can see neither approach is ideal, substantial reduction with a scar or minimal reduction with no scar.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, about 4 years ago upon a surgeons recommendation, I got infraorbital implants. Shortly afterward, I noticed a “bulge” underneath my eyes. I am not sure if the implants need to be removed or if this is a case of my cheeks dropping and my own bones would have produced the same appearance. I believe the implants were placed close to the lower lid. (I have attached  a picture of where they are placed ) I am not sure exactly what they are made out of.  When I went to the web-site, it just said a porous material. I believe that they were placed from inside the mouth.

A: Based on that information, you have Medpor implants placed through the mouth. This means they are actually a combined infraorbital rim/malar type implant. The bulge to which you refer, given that it appeared shortly after surgery, is undoubtably that of the implant and not your natural bone. As the tissues eventually contract and shrink around the implants, their outline and placement become fully evident.

The good question now is what to do with them. The only way to get rid of the bulge is to remove the implants. The interesting question is what will happen to the soft tissues that have been expanded because of them. It may be that is largely a non-issue or it may be that it will cause some soft tissue sagging over the cheek afterwards. It is hard for me to tell the likelihood of either just based on one single photo. However, knowing their location, size (bulge) and that they are a Medpor material (which means they will be harder to remove), that all suggests that there may be some additional cheek sagging afterwards. An alternative approach to removal is to feather the edges of the implant so that a bulge no longer is seen, but keeping the implant volume in place.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Is it possible to place the wing of a chin implant separately from the front part of the implant by cutting it loose? On one side of the jawline my implant wing crosses the bone and sticks out. My jawline is asymmetric and is higher on one side. On the higher side the wing sticks out. My doctor told me the implant wing can’t be placed upward and inserted on line with the jawline because the shape of the implant doesnt allow it. The wings on the implant don’t have the right angle to match my higher jawline. Placing it on line with the jawline would stress the implant and eventually lead to malposition. Is it possible to cut the wing loose from the implant and place it separately from the rest of the implant on line with the jawline?

A: The simple answer to your question is yes. You are referring to a chin implant revision due to a wing malposition. Although the malposition in your case is a direct result of your own anatomy which is not symmetric. During your revision, the wing can be separated from front or main bofy of the implant. But that alone will not make the wing move into the desired position. The implant pocket must be modified as well to accommodate the desired position of the implant wing.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a facelift about six weeks ago. This was a very traumatic experience for me. While my jowls and neck got better, my nasal folds and turned down corners of the mouth did not. They initially looked good while I was still swollen but that has now all gone away. This is very disappointing since this was one of the main reasons I had the operation. I feel like a wasted my money as my jowls and neck were not that bad.

A: This is a common misconception and occurs either as a result of inadequate education during the consultation or a failure to understand what a facelift does best on your part. Because the tissue pull of a facelift occurs from around the ears, it has the least effect on anything far away. The mouth area is the furtherest point from the ears on the face, thus deep nasolabial folds or a downturned corner of the mouth will ultimately remain unchanged. It is just biomechanically impossible to substantially change the center of the face from back in the hairline. This is an issue that has frustrated facelift surgeons for years and many techniques have been tried, few with much success. This is why adjunctive techniques are often done with facelift that address the mouth area directly, like fat injections and a corner of the mouth lift. These can be at the time of a facelift or afterwards as may be desired in your case.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have deep nasolabial folds and a mouth whose corners turn down. I have read about a way to improve them by using your own tissue through grafting. I had a facelift already which got rid of my jowls and helped my neck but didn’t do a thing for the area around my mouth. I don’t want to treat them with injectable fillers because that will only be temporary. Are you familiar with this tissue grafting technique?

A: What you are talking about is an old plastic surgery technique, dermal-fat grafts, that has been applied to a cosmetic problem. A dermal-fat graft is a piece or strip of skin that has a thin layer of fat on its underside. The overlying epithelium or skin layer is removed, leaving just the dermal skin layer with the attached fat. Provided that the graft size is not too big, it survives quite well as the blood vessels of the recipient site attach quickly to the vessel ends in the dermis. This allows a quick return of blood flow to the fat thus enabling it to survive.

For use in the face for nasolabial folds,  it must be taken from the lower buttock crease or any other large scar site and must be at least 6 to 7 cms in length for each nasolabial fold. From inside the nose, a tunnel is made under the nasolabial fold curving down to the corner of the mouth. The dermal-fat graft (dermis side up) is then placed through tunnel and fixed to the corner of the mouth through a small incision from inside the corner. It is then lifted and tightened from inside the nose and the excess graft trimmed and closed. The graft simultaneously augments the nasolabial fold and lifts the corner of the mouth. I have done this procedure numerous times and it does have its merits. But the issue is that it requires a harvest site and the buttock crease is almost always the best choice because of the thicker dermis. The discarded skin from a pretrichial browlift can be used as well. There are also other simpler ways to achieve both of these facial objectives. Fat graft injections combined with a corner of the mouth lift is another approach. But for the right patient who does not mind a buttock scar, the dermal-fat graft approach can be used.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hello, I’m a 19 year old male. I recently cut my hair short and to my surprise, I have a very Neanderthal-esque brow ridge. It doesn’t stick out as far as some people from pictures I’ve seen, just a couple of millimeters probably. I was wondering if there was any alternatives to plastic surgery for this? Can small amounts of pressure be applied to the area over an amount of time to reduce the appearance, or anything similar? Obviously at such a young age I don’t want to resort to plastic surgery, but I dislike the appearance that my brow ridge gives my face. Thanks in advance.

A: The pneumatization or expansion of the frontal sinus cavity creates the prominence of the brow bones. This is not bone growth but bone stretching due to underlying air expansion. This is why the brow bones, the bigger they are, are very thin often only being a few millimeters in thickness. The development of a brow bone prominence or bossing is genetic and can not be modified once established by any external pressure or molding. If it is too aesthetically excessive, it requires surgery for brow bone reduction.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 32 year old and about six months ago an ENT specialist diagnosed me with having a deviated septum. I have not had good sleep in about 15 years, because I have extremely restricted breathing. I do have insurance to cover the surgery but would prefer a plastic surgeon to perform the procedure, so that I may also correct a very large bump on my nose that I have extreme insecurities about. Do you know if your services would be covered by the insurance company? Also, is this a procedure that can be done if I am in my first trimester of pregnancy?

A: Your inquiry has two fundamental misconceptions. First, no elective surgery or procedure is ever performed on any patient who is pregnant. Pregnancy is an absolute exclusion for surgery and anesthesia because unknown and potentially deleterious effects on the developing fetus. Secondly, insurance does not pay for any external change to the nose such as removing a large nasal hump. That is cosmetic surgery and must be paid for as an out of pocket fee. Insurance will usually cover septoplasty and other functional nasal airway surgery but not for any rhinoplasty procedure. The two most certainly, and commonly, are done together but you will have to pay additional surgeon, OR and anesthesia fees for the cosmetic portion.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a mastopexy/abdominoplasty (mommy makeover) in future years. So that I have an idea about cost, I would love to know the extend of the incisions that I would need, i.e., anchor incision and full vs crescent incision with partial tummy tuck. I am 5 pounds from my ideal weight and still carry quite a bit of weight in my torso. My ptosis is moderate to severe in my mind, but would love an expert’s opinion. Thanks!

A: There are four basic types of breast lifts that vary based on much lifting is needed and the scars that they produce. Without seeing pictures of your breasts, it is impossible for me to say what exact breast lift operation you need. But since you used the term ‘moderate to severe’ ptosis, and patients almost always underestimate what they really need, I will assume that you need a full breast lift. (anchor scars) Also know that few women actually ever have just a breast lift alone unless they already have substantial volume. Breast lifts in general do not create persistent upper pole fullness which most women want when undergoing any breast enhancement procedure. This is why most breast lifts also incorporate the use of an implant at the same time. (augmentation mastopexy) Even if it is a small implant, it provides that retained upper pole fullness that merely lifting up and resuspending the breast tissue on the chest wall that does not.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 32 year-female with a chin issue. My chin doesn’t look too bad when I’m not smiling because I have a large nose so it is somewhat in balance.  However when I smile, I have excess soft tissue that almost looks like cellulite on my chin and it then sticks out more.  It is an appearance that is very similar to what I understand is witch’s chin deformity or chin ptosis.  I would like to know what you recommend for this problem and what the cost would be.  From reading your blog, I would presume that you would suggest some chin burring using the underneath the chin approach and soft tissue excision.  My concern of course is the length and visibility of the scar and I wondered what your experience with that has been. What is the average size of the scar? Is it visible from a frontal view and does it fade significantly over time? Also, do you think you can effect significant improvement in my problem or would the change be only minor?

A: In looking at your pictures, I suspect most of your chin issue is a soft tissue problem with a small bone component to it. That makes the submental approach the most effective treatment. The submental chin reduction scar is about 4 cm long and is curved to match the border of the lower jawline. Quite frankly, the effectiveness of the procedure is a balance of how much soft tissue tightening/removal can be done vs keeping the scar as short as possible. The scar is not visible from the front view and the redness of the scar does fade with time. I suspect the final result would be somewhere between a minor change vs a significant improvement. That is probably the best way to think about it. It is going to change, it is just a question of how much.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a healthy 65 year-old women with a large turkey-like hanging directly under my chin as well a bit of jowls. When I pull the skin back at the jaw angle/ear area, I see a great change and I look like myself again…like I did 20 years ago. What type of necklift is this? I do not feel like a need a facelift but just a necklift.

A: The turkeyneck is a common problem and there are many people who have this pessky aging issues but are happy with the rest of the face…or at least it does not look as bad as the neck and jowl area. This hanging neck skin must be treated by moving it up and backward to hidden incisions around your ears where it can be removed and invisible scars left in its wake. Your perception of a facelift is common with the belief that it is a top of the scalp down to the neck procedure, which it is not. A true isolated facelift only treats the lower 1/3 of the face, exactly where your concerns are. As a result, it is a much simpler and easier procedure to go through than most patients envision. Your proof that this is the correct procedure is evident by the presurgical facelift ‘test’, pulling up and back around the ears and jaw angles creates the desired neck and jowl changes.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want to have my buffalo hump liposuction along with my neck done at the same time. As I have gotten older the buffalo hump and bad posture have made my spine curve a bit. The hump is really visible when I straighten my back and when you feel it you can feel tissue but you can also feel my bone. My concern is does this put me at a risk for injury to my spine? is it possible to hit my bone while performing the liposuction and paralyze or injury my spinal cord in any way?

A: The buffalo hump is a collection of fat that appears above the fascial covering of the muscle. It is a subcutaneous collection that is far away from the deeply located spinal cord which is under the muscle. Also remember that the spinal cord is encased by protective bony vertebrae besides being deep to the muscle. Therefore, there is no chance of vertebral or spinal cord injury with liposuction surgery to the buffalo hump fatty deformity. The type of fat that is in the buffalo hump is also a more firm or fibrofatty tissue that can be more difficult to extract than softer fat like that in the stomach. For this reason, the use of advanced technology, like Smartlipo, may be more effective in the loosening or melting of the fat prior to suction extraction.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 45 year-old female and I have concerns about my jaw line. I have attached some pictures and we would like to have your opinion on what would be some treatment options. I would like to have a return of firmness to my jawline.

A: In regards to early onset jowling/laxity, there are two basic options depending upon how one wants to approach the problem. From a non-surgical standpoint, there is a slew of energy-based devices out there that do create some degree of skin tightening/fat reduction for minor degrees of jowling. Devices such as Exilis, Ulthera and Thermage all drive energy into the dermis of the skin to heat it up creating some new collagen production and a tightening effect. Given Melinda’s good skin thickness and minor amount of jowl softening, you could argue that she is an ideal candidate for this non-surgical device approach. Its negatives are that it requires a series of treatments to get the desired effect, usually four separated by a week or two between them, and it is indeterminate how much improvement can be obtained. While I find these devices effective, it is best to view these treatments as a delaying manuever or bridging step to an eventual  surgical treatment. For some patients, it may put off the ‘inevitable’ for years. Remember that you don’t cure aging, you just temporarily improve it. As a surgical approach, a very simple and easy jowl tuck-up can provide an immediate improvement that will surpass what any device can do. This one-hour tuck-up with less than a week social (appearance) recovery is a common facial rejuvenation procedure today as people seek earlier treatment for their jowls and neck issues than ever before. It is really just a miniature or microform version of a lower facelift.

In conclusion, either jowl tightening approach is perfectly valid and the choice depends on what result someone wants and what they want to do to get it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I had fracture of my cheekbone and eyesocket and four plates with eight screw were implant in my face…………..I want to ask can I remove these plates once if my fracture got healed??……Will there be any problem of refracture or any another problem after plate removal??

A: It sounds like you have a very typical zygomatico-orbital complex fracture which required three/four point fixation for anatomic realignment.There should be no problem with removing your fixation hardware 6 to 12 months after your original facial fracture repair. Facial bones generally heal completely by 6 months after surgery so removing them should not be a problem. Barring any future facial trauma, removing your plates and screws will cause the bones to collapse or refracture. Given the re-entry operative trauma to remove your hardware, there should be compelling reasons to do so such as uncomfortable palpability, cold temperature transmission or plate and screw loosening.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Has you ever successfully micropigmented a donor strip scar from a hair transplant?

A: In my experience, it is virtually impossible to match skin colors with micropigmentation tattoos. There is always going to be some color mismatch. But your specific situation in the scalp is unique. There are two approaches you could use, all based on the concept of if you don’t like it you can also just excise the micropigmented area and be right back where you started or maybe even with a better looking scar. You could try and match the skin colors by micropigmenting the skin. Or you could place micropigmented dots to represent hair shafts.  Which approach may be better would require me to see some pictures of your scalp scar. But I would imagine that trying to create ‘shaved’ hair dots would be more a more effective camouflage.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 27 year-old Asian female who would like to change the shape of my nose. I have a low nasal bridge and a flat tip of my nose with low projection. I would like to get my nose more Westernized with a higher bridge and more tip projection. I have read that this takes cartilages grafts that either come from my nose or from my rib. I definitely do not want a rib graft done so I am considering implants instead. I know about the implant used to build up the bridge but how does the tip get more projection as well? Is cartilage used to do that or can implants be used for it?

A: In changing the tip and columella of the Asian nose, a septal extension graft as well as a columellar strut graft is used. The septal extension graft is placed along the caudal edge of the septum and out onto the anterior nasal spine. This graft not only helps tip projection but also improves a retracted columella and opens up the nasolabial angle. When combined with a columellar strut, these two tip grafts together give more tip support for the weaker lower alar cartilages and is a standard technique in my practice. It is entirely possible, and very likely, that the septum of the nose may not provide an adequate donor source for the amount of grafts needed. If the septum is inadequate, one can use synthetic implants instead. The best choice of implants would be Medpor or porous polyethylene sheeting from which to fabricate these grafts. Usually a combination can be used, using the septum or the columellar strut and Medpor for the septal extension graft for an Asian rhinoplasty.

Dr. Barry Eppley

Indianapolis, Indiana