Your Questions

Q: Hello Dr. Eppley, I would like to know anything you can offer to tell me about plastic surgery! I would love to be a plastic surgeon as a career in the near future! (: Right now i’m going into my senior year in high school. So any advice of how I can reach my dreams would be great! Thank you!!

A:  Few things can be achieved in life without a dream or goals. So it is good that you have a focus at this early age in your life. I have no idea what has captured your attention of plastic surgery as a career. While plastic surgery may seem glamorous, it is far cry from what you may have seen on TV or other mediums. It is hard work and a long arduous process with the foundation of becoming a physician first. This not only requires the traditional effort with college and then medical school but, equally importantly, some exposure to medicine and health care in some capacity along the way. Whether it be volunteer or part-time employed work at a hospital, emergency clinic or a doctor’s office, you need to see what being a physician is like up close. You need to discover if you have the interest and ultimately the passion for it. For it is these attractions to the field that will keep you going when you have to outstudy many others in the eight years of preparatory academic work (while others are at the football game, frat party or on that ski trip) or those six to eight years with many long nights on call during general and plastic surgery training.

It is never too early to begin your research into medicine as a career and I encourage you to begin now in any way you can. Plastic surgeons in many commnunities are always willing to allow observers either in the office or the operating room…and can give you a lot of good insights and information about the field.   

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr Eppley, I had Juvederm injected into my upper and lower lips yesterday. My lips are very swollen now and my lower left lip is noticeably larger than the others. What can be done to make this better as they are much larger than with what I left the doctor’s office yesterday. Could this be an infection? I am quite concerned. Please advise. I’m freaking out!

A:  Most lip injection patients do experience some mild swelling for the first day or two after the treatment. The lips are exquisitely sensitive to any type of trauma so swelling may occur. Some patients experience it more than others. This would be particularly true if all the lip injected areas seem swollen. As long as the lips are not hot, red and swollen, then this is the likely reason for their appearance.

Of the thousands of lip injections that I have done, I have only ever seen three adverse reactions. One was an actual infection of the lower lip that eventually required antibiotics and drainage. Both upper and lower lips had been injected and the upper lip was fine. An infection would be more likely to affect just one of the lips or even just one side of a lip than the entire area. Suspected infections are initially treated with oral antibiotics. Infections often don’t occur for days as it takes time for bacteria to multiply.  The other two were inflammatory reactions to the injected material which is known to occur as the Juvederm material, while a known and fairly natural substance to the body, is nevertheless synthetically manufactured. By the manufacturer’s package inserts, these inflammatory reactions can occur in about 1% of all injected patients. My experience has been much more uncommon than that. If both the upper and lower lips are swollen (all injected areas) then this is the likely explanation. This is treated by oral steriods.

Lip asymmetries are much more common issues after injectable fillers that often don’t become evident for hours or days after the treatment. If one area feels lumpy or a little bigger, it is perfectly fine to massage or “strip’ the lip (between your fingers) to attempt to smooth it out. Injectable fillers are very much like clay after they are injected and they can be molded and moved slightly by such manipulations for a few days after the treatment.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, can a lower jaw setback be combined with a lower gfacelift during the same procedure? Have you yourself done this before?

A:  The technical capability of performing a combined orthognathic procedure, like a mandibular setback, with a facelift is certainly possible. The need for it is so rare, however, that it would be hard to a surgeon that had ever done it together. There are several reasons for its rarity. By definition, a facelift would be done in an older patient while orthognathic surgery is usually done in a younger patient. Thus, the mainstream population of each procedure are at diametric ages. There is also the consideration that the  type of surgeon that performs these procedures are quite different. Most maxillofacial surgeons have little or no training for facelift surgery and most plastic surgeons have little or no training in orthognathic surgery. While plastic and maxillofacial surgeons certainly can work together and coordinate these surgeries, most plastic surgeons would probably prefer to defer the facelift to a later date due to swelling considerations.

With all of that being said, a mandibular setback and a facelift can be done together. The question is not whether they can be done together but whether they should. While each operation poses a ‘surgical opportunity’ to do additional procedures, you want to make sure that the patient can still get a result that would be comparable if either procedure was done alone. Surgical opportunity should not be more important than an outcome. In that regard, I would have to know more about how much mandibular setback is needed and the proposed technique (sagittal split ramus osteotomy vs vertical oblique osteotomies) and the degree of neck and jowl sagging that exists. Then I could answer the question better about whether such a combination is a good idea.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Over 10 years ago, I was involved in a car accident and ended up getting a craniotomy and evacuation of a subdural blood clot. Afterward, the craniotomy flap got infected and had to be removed. Because I was a child at the time, some bone actually grew back over the upper forehead defect. But it was not of the same thickness or amount and I have been left with a flat and irregular upper forehead area around my hairline and into the very visible part of my forehead. It is quite noticeable and embarrassing for me and I have always wanted to get it fixed. I have read recently through your writings that it can be repaired with some types of materials that are applied to the outside of the bone. That has given me great hope that there is a solution to this embarrassing problem. I am tired of people staring it! Please tell me about this procedure and how it is done.

A: Based on your description alone, it sounds like you would be an excellent candidate for an onlay cranioplasty procedure. Compared to what you have been through previously, this is a relatively simple operation that produces immediate results. Since you had a craniotomy previously, you have an existing scalp scar. The scalp ius lifted up again and a synthetic cranioplasty mixture is used to apply to the defect and make it perfectly smooth with the rest of the forehead. The available mixtures are a powder and liquid, which when combined, turns hard after it is shaped within a few minutes. There are three specific cranioplasty materials. I would choose hydroxyapatite, specifically Mimix, for your cranioplasty as it is the most like bone and has excellent working charcteristics. I have worked with it for over 15 years, including through its research and development phase, so I know its working properties very well. This is an outpatient procedure under general anesthesia that would take about 90 minutes to do.

Dr. Barry Eppley

Indianapolis Indiana

Q: Dr. Eppley. I went online and looked at your breast implant pictures. As I can tell it looks GREAT. I have been looking at different work from different doctors. I am a very small A. What do you suggest? What type of implant do you recommend for me? What is the total price? Do you have any financing available for people like me? I really want this bad! For a very long time. I feel unsure about my body and the way I look. I am going to be 32 and I have 2 kids. I have always wanted larger breasts ever since I was in school. Can you help me?

A:  What would make you look like a full B cup would depend on numerous factors including the base width diameter of your breast, tightness of your overlying breast skin, and your envisionment of what a full B cup is. Since I have no images of you, I will have to assume your base breast width is likely in the 11 to 13 cms. range. This would make an implant in the range of 250cc to 350cc a likely possibility. That would have to be determined by an examination and some images of breast augmentations that you like. Given your described financial situation, you would be best served by a saline breast implant which can be done at a lower cost than silicone breast implants. Total costs are in the range of around $ 4,700.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I’m a 6 year old male looking to remove a bump on my skull bone on the back of my head. I believe this skull bump resulted from a forceps delivery during my birth. I had an MRI of my head done and it came back normal. This is something that has plagued me psychologically all my life and I’m looking for any options to improve the appearance of the back of my head. I’ve provided photos of the back of my head. As you can see from the pictures, aside from the bump, there is also a ridge that leads to the more protrusive bump. I look forward to your assessment.

A: Thank you for making the effort to take the pictures. They are more than sufficient. What you have are two specific occipital bony uprisings, one ‘abnormal’ and the other a natural part of the occiptal skull bone. One is a small round bump at the top of the occiput which is a small osteoma or benign bony ‘tumor’ That can be burred down through a small vertically-oriented incision over the bump measuring about 3 cms. or just slightly bigger than an inch. Incisions in the hair-bearing scalp in men heal remarkably well and would eventually be such a fine line scar that it would be virtually undetectable. The horizontally-oriented bony ridge across the bottom of the occiptal skull bone is known as the nuchal ridge. It is where the top of the neck muscles attach to the lower edge of the occipital skull bone. It is raised and visible, as it is for some people, for unknown reasons. It may be raised because of the need for a strong bony attachment for the neck muscles. That can actually be reduced by burring down the ridge but the issue is incisional access. It requires a linear horizontal incision across the back of the head along the nuchal line, probably of a width of about 5 cms. Either skull reshaping procedure can be performed alone or in combination. Either way it is an outpatient procedure under general anesthesia that would have a minimal recovery. The incisions would be closed with tiny dissolveable sutures and one could shower and wash their hair after two days. There would be some temporary swelling which would go away in two or three weeks. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  Can you tell me how close a surgical result will be compared to the computer imaging that has been shown to me? Since it is done on the computer I assume that it is fairly accurate and representative of the result. I am desiring to get a rhinoplasty and chin and jaw angle implants and want to see if the result wiould be worth the effort and the expense.

A: A very important consideration when looking at predictive computer imaging is to realize how it is done and that it is not an exact science. The only thing ‘computer’ about it is that it is done on a computer. The computer does not create the images nor portray them on some one-to-one basis from the nose or jaw implant to the patient. In other words, the computer does not take the dimensions of the implant(s) or the amount of nose structure  that is removed and directly transfer that onto the patient so the changes will identically match. Rather, computer predictive imaging is done on Photoshop by the plastic surgeon with their best guess of what the changes may be. It is an art form not an exact science. Thus, computer imaging can easily overpredict or underpredict what the final result may be. Since patients view computer imaging as a more exact science than what it is, I always slightly underpredict what I think will happen. It is important for the plastic surgeon to not overpredict as this may easily overpromise or oversell the surgical procedure. This can lead to postoperative disappointment in the result if these expectations are not met.

The very valuable feature of computer imaging in rhinoplasty and jawline implants is that it can be a very good predictor compared to many other facial plastic surgery procedures. Because these are silhouette or profile facial structures, they are easy to morph and see the potential changes.

Dr. Barry Eppley

Indianapolis Indiana

Q: Dr. Eppley,  I need to lose 145 lb and I have tried everything. Can liposuction help and how much does it cost? I also I need a tummy tucks and my breasts lifted.

A: With the need to lose a lot of weight, liposuction is absolutely not the answer that you seek. Liposuction is best used for spot fat reduction and for those patients who may need a ‘jumpstart’ for relatively small amounts of weight loss. (10 to 25 lbs) For near or over a 100 lb weight loss, you need to seek a consultation with a bariatric surgeon if everything to now has failed. That amount of weight loss can only be achieved through gastric banding or gastric bypass surgery.  Any other desired body changes, such as a tummy tuck to get rid of the skin overhang around the waistline or lifting sagging breasts, must wait until after this weight loss have occurred. Attempting to do such surgery in the face of being significantly overweight is not only ill-advised from a health standpoint but any benefits gained will be wiped out by significant weight loss. Not to mention that the amount of improvement one can achieve in the obese patient is relatively limited.

The foundation of your body reshaping begins with the need for a large amount of weight loss. The first place to start is a consultation at a Bariatric Center.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am interested in reducing the size of my adam’s apple as it sticks out like a bulge in my neck. In reading about tracheotomies, I wonder if there was an at-home method in which a man could try the look, feel and sound of having a more feminine adams apple appearance just for say a few weeks before taking surgery. Have you ever heard of anything like this?

A: For the sake of clarification, tracheal reduction and tracheotomies are two different completely different operations with diametric objectives. A tracheostomy makes a hole through the skin and down into one’s windpipe below the thyroid cartilage for the sake of breathing. A tracheal reduction, technically known as a thyrochondroplasty or adam’s apple reduction, reduces the protrusion of paired thyroid cartilages as they bulge out into the neck. If done properly and without removal of too much cartilage, it will not change the pitch or sound of one’s voice. (a tracheostomy will definitely affect one’s voice) If you wanted to see what a tracheal reduction would look like, that is what computer imaging does. You can get a good visual approximation of the final neck contour result. It can help one see what the change would look like on them and is the best way to ‘try it on’ before surgery. There are no non-surgical methods to try and simulate that change in neck appearance.

Dr. Barry Eppley

Indianapolis Indiana

Q: Dr. Eppley. I am interested in getting the large dimple removed from my chin. I am not sure where to turn to since it seems very few plastic surgeons perform this procedure. Please send me information in regards to how this surgery is done, how successful it is, and the possible cost. Thank you!

A: Thank you for your chin surgery inquiry. Chin dimple reduction/removal is usually done by an incision inside the mouth. (behind the lower lip) The key to a successful chin dimple reduction (sometimes a complete removal) is that you have to fill the muscular defect/indentation with some type of graft. This could be allogeneic dermis (off the shelf) or fat or dermal-fat grafts from the patient. In some cases, releasing the dimple and sewing the muscle together may suffice. This is done under local anesthesia or IV sedation as an outpatient procedure. Dissolveable sutures are used inside the mouth. There are no restrictions in eating or physical activity after surgery. Some mild swelling is to be expected but this will be gone in a few weeks.

The cost of chin dimple surgery is around $2500.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have an unusual question about a part of my face that was wounded by laser treatments. Several years ago I went to a family doctor in town that offered laser hair removal at  a great discount. For that great fee reduction, I ended up getting several areas of burns on my face that have scarred. These have largely gotten better. My ongoing problem is on some facual skin areas that show no visible signs of scarring. Instead, there is an issue of a constant burning sensation under the skin. There is no scar and the skin looks normal but there is a constant burning sensation that occurs. So, my question for you is what could be causing this burning
sensation under my skin? It undoubtably occurred from the laser treatments since I did not have it before. What could the laser have damaged under the skin that caused this constant burning sensation? Most importantly, what can I do to fix it?

A: This is certainly an unusual problem. The laser may well have burned the ends of the tiny sensory nerves, which are more sensitive than the overlying skin to a thermal injury. This nerve scarring may have changed how those nerves feel due to the damage. That would explain why it feels like it is burning, years later, even though it is long past the possibility of any actual skin injury.

Time initially would be the first option. Nerves can heal and recover but that would, in theory, have done it by this point years later. If there has been  no gradual improvement in that sensation lessening by now, then it may well be permanent. The next treatment option to consider is Botox. This simple injection approach will block the acetycholine transmission and the sensation may cease as long as the Botox is effective. (4 or more months) Whether it will work or not is speculative but that is exactly how it works in the treatment of hyperhidrosis for example. In addition there is nothing to lose as long as there are not muscles of facial expression nearby. If this is ineffective, then skin flap undermining in a minor surgical procedure will disrupt the nerve ends and may possibly end this dysesthesia.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I recently had jaw angle implants and it has not turned out to be a good experience. My jaw angles were high and made the back part of my face looked weak and absent. My surgeon initially placed silicone implants but all they did was make my face look more wide and fatter and did nothing to make the jaw angle change I needed. My surgeon acknowledged that these implants were not the right types. I then had a second surgery done using Medpor jaw angle implants. Even though there was a lot of swelling after surgery, I noticed that my left side was very different from the other side. This has become only more apparent as the swelling has gone away. They look and feel completely different between the two sides. My surgeon says he wants to go in and shave down one of the implants but I have lost faith in him at this point. What do you recommend?

 A: Sorry to hear of your surgical misfortune. Jaw angle implants are, without question, the most difficult facial implant to do well, both in implant selection and in surgical placement. They are incrementally more difficult than the more commonly used chin and cheek implants. Symmetrical placement, because you have to put in each implant independently and without view of the other one, is challenging. One has to be very attentive to every detail of the implant position and to screw it into place, if possible, to ensure the best symmetry. The most difficult jaw angle implant to place are the Medpor ones because their material surface has a high degree of frictional resistance and they don’t slide in easily. That is the only jaw angle implant, however, that can drop the jaw angle down vertically. Most of the time, these implants have to be trimmed down to fit, removing the long anterior end. I have found it very beneficial to use the implant sizers first to fully develop the pocket and only place the final implant when the sizer slides it easily to the desired location. It would be impossible for me to say what is the best approach with your current jaw angle implant situation. I don’t know what you look like now nor do I know the details of your current implants and what is making them asymmetric. Shaving down the malpositioned implant may work but, more likely, the implant needs to be repositioned.

 Dr. Barry Eppley

 Indianapolis, Indiana

Q: Dr. Eppley, I have a problem with the right side of my chest. It is smaller and looks completely different from my left side. I have noticed it since I was a small boy and it has always embarrassed me. It looks like I do not have a chest muscle on my right side. I want to know what can be done for it. I have attached some pictures including ones with my arm raised where you can really see the difference.

A: Thank you for sending your pictures. It does appear that you have Poland’s syndrome. This is an underdevelopment of the pectoralis chest muscle. It is a well known congenital chest deformity. This can clearly be seen in your pictures, particularly the one with the arms lifted. You can see the short pectoralis muscle and its abnormal attachment to the upper sternum. This accounts for your smaller right chest appearance, the high position of the right nipple, and the asymmetry between the two sides of your chest. 

In treatment of male Poland’s syndrome, several treatment options are available which primarily focus on improving the volume of the right chest. This can be done with an implant, a pedicled latissimus dorsi muscle flap or a combination of both. A pectoralis implant is the simplest approach but the lower edge of implant will not have muscular coverage so the lower edge may be palpable or visible when the arms are lifted. Other treatment options include scar release/lengthening of a tight muscle band across the armpit and possible right nipple repositioning. It is also important to look at the opposite chest to see of anything can be done there to help improve the symmetry between both sides of the chest.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have terrible sagging elbows. It is not really the upepr arms like many people but just down and around the elbows. I have lost a fair amount of weight but the extra skin seems to have settled largely in the lower part of my arms. I am very interested in correcting this problem as when I lean on them they are painful and red. Is there a surgery for saggy elbows?

A: It is very common with a lot of weight loss for women to develop the saggy upper arms in the triceps area. (aka batwing) If extensive enough, the extra skin may extend the whole down across the elbow into the forearms. This is treated by an extended armlift.

But extra skin that is largely just around the elbows, and not involving the upper arm as well,  is not common. Bur whether it is common or not, it can be treated by skin excision making it an elbow lift. Just like the armlift this does result in a longitudinal scar that crosses the elbow joint. The key to this elbow lift is to not put the scar on the back of the arm. This would make the scar come directly across the prominent angle of the elbow on bending one’s arm. That would likely cause healing problems in the short-term and scar pain in the long-term. The scar needs to be placed on the inner aspect of the elbow to both avoid the flexion of the elbow joint and to be least visible to others.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dear Dr. Eppley, what are the different techniques used in brow bone augmentation? What are the pre-operative and postoperative things to consider? Thank you so much.

A: When it comes to brow bone augmentation, the first consideration is what part of the brow does one want augmented? Most patients want the whole brow done and it must be approached through a scalpor coronal incision. There are some patients who just want the tail of the brow augmented and that can then be done through an upper eyelid incision. The next consideration is what material to use. There are four options including preformed implants and three mixtures which are applied and then harden which include acrylic (PMMA), hydroxyapatite (HA) and Kryptonite. (calcium carbonate) Because of moldability to the brow bones and that more volume can be obtained, I prefer the mixture materials. There are arguments to be made for any of them and they all will work. Considerations must be given to cost, long-term tissue acceptance and fracture resistance. From a cost standpoint, acrylic is best and is the most fracture resistant but there may be some tissue thinning over many decades of implantation. (emphasis on the word…maybe) HA and Kryptonite are very similar to bone so there will never be any problems with tissue acceptance but they are more easily fractured (theoretical concern, not one I have ever seen)  and cost more. The choice of any of these materials for brow bone augmentation must be done on an individual patient basis.

Dr. Barry Eppley

Indianapolis Indiana

Q: Dear Dr. Eppley, I was looking at your web page description of ear lobe surgery and it made me feel hopeful. I recieved an infection/cut in my ear several years ago. Despite minor irritation, I continued to wear light earrings but the ear plug kept lowering and lowering until today. Today my earlobe has split entirely. I would like to have further information on whether and how this can be fixed. What should I do with in the interim to heap it heal?

A: Once the tissue begins to thin in the outer earlobhe skin from a piercing or a larger insert, eventually the skin will break down and a complete earlobe tear will occur. This is not uncommon and it is an easy problem to fix. It is a simple earlobe reconstruction done in the office under local anesthesia. The earlobe can be completely restored to normal size and shape, albeit with a fine line scar. The cost for this procedure is about $425. Once can re-pierce their ear 6 weeks after the procedure. (but gauging can never be done again)

In the interim you may apply antibiotic ointment until the skin edges heal in a few weeks. You may tape it together for appearance reasons during the daytime although this is not essential. Taping it together will help it heal a little faster.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am in need of getting jaw surgery and was told that I could get my nose and cheeks done at the same time. They want to do an open rhinoplasty and malar osteotomies  as well to get an improved look to my face. My question is can these be done safely all during the same surgery?

A: There are several fundamental issues with this combined surgical plan. The first would be what type of orthognathic surgery? If it is just an isolated lower jaw (mandible osteotomy) procedure, then I see no problem with a combined rhinoplasty as one does not really affect the other. (other than the need to change position of the endotracheal tube for anesthesia) If it is an orthognathic surgery procedure that involves the maxilla (alone or in conjunction with the lower jaw), then more thought need to be put into it. The advisability of those two would depend on what type of nasal deformity one has and what needs to be done to the nose. A maxillary osteotomy changes the skeletal foundation on which the nose sits and detaches the facial muscles which affects the alar base or nostril width. This can make it hard to know with any certainty how the nose will change with rhinoplastic maneuvers. A rhinoplasty procedure, on its own, is fraught with certain variables that can adversely affect the outcome even in the most experienced hands. Adding the underlying changes of maxillary position only adds another variable that may affect the final shape of the nose after its manipulation.

Most of the time, the concept of combining rhinoplasty and orthognathic surgery is an issue of ‘surgical opportunity’. You just want to be sure that the benefit of the opportunity does not over ride the more important objective of a desired result with the least risk of complications.

Lastly, I am unclear as to the need for malar osteotomies vs implants for cheek augmentation. Malar osteotomies tend to be more difficult bony movements that often do not produce as good as a cheek result as the more simple placement of implants. I have put in many a cheek implant with a LeFort 1 osteotomy and have never seen an infection.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Hello! I had gastric bypass surgery in August 2008. Since that procedure, I have lost over 135 pounds. Here is the my problem. I have worked much of my life trying to gain control of my weight and now that I have done that I have excess and sagging skin that is a constant reminder of the overweight, unhealthy person I used to be. Furthermore, I am at a dead end financially as I had to pay out of pocket the expenses for by bypass surgery which was almost $50K. I am exhausted financially between the surgery and my four kids. Are you aware of any programs, grants or clinics that are available to assist bariatric patients with the skin removal they need after their weight loss?

A: Congratulations on your weight loss success. That is a big accomplishment. While such extreme amount of weight loss is a big first step, most patients with this much weight loss will have large amounts of deflated skin that just hangs. This is managed by a range of procedures known as bariatric plastic surgery. With the exception of an abdominal panniculectomy, these procedures are cosmetic from a financial perspective. I know of no doctors or clinics that perform these extensive procedures at low to no cost. They require a large amount of surgical effort and operating room expense which is why there are no limited cost facilities or programs that perform them.

I wish you continued success in maintaining your current weight and one day being able to complete phase 2 of your body metamorphosis.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Hello, I am a 27 year-old athletic male who is bothered both my puffy nipples. Some days they don’t seem that bad. But other days they really stick out. I don’t know why they are so different on different days. I am not sure whether I need my nipple cut down or the tissue under the nipple removed. Whatever it takes to do it I don’t care as I just want it gone. What do you recommend and what is the surgery like and how quick will I recover?

A: Puffy nipples are different than pointy nipples as patients often describe these two male chest problems. A pointy nipple is when the centrally located nipple within the areola sticks out like a small sharp point. It is small protrusion and is managed by a simple nipple reduction which is an office procedure done under local anesthesia. There is no real recovery as small dissolveable sutures at placed and one goes about their activities as normal immediately afterward. A puffy nipple refers to the development of a small mass of breast tissue underneath the nipple-areolar complex that makes it stick out or be puffy. This is known as areolar gynecomastia and is a limited gynecomastic reduction. It is treated by an outpatient procedure in which the enlarged breast tissue is removed from under the nipple by a small lower areolar incision. Patients wear a chest wrap for a week or so and show refrain from exercise or strenuous exercise for a few weeks to avoid a fluid collection or excessive scar tissue formation which will wipe out the benefits of having the puffy breast tissue removed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I need to have my chin brought forward as it is very weak. I know that the bone hs to be moved given how short it is. I want to have this surgery but I have a lot of questions. I am hoping you can answer them for me. Will I need to put braces or get some teeth removed to do this? How long will I have to stay in the hospital and how long will it take me to recover completely? In case I meet with an accident in the future and hit the chin, what would be the consequences? In case I meet with an accident in just a few weeks/months after the surgery and hit the chin, what would be the consequences? What are the risks of this surgery? In case the results are not what I desire, what kind of measures do you use to fix it? Any long term side effects? How painful will it be, and for how long can the pain last. Are there any breathing problems? How different is this from a complete jaw surgery? Are there any visible scars after the surgery? If yes, where exactly on the face? Thank you in advance for taking your time to answer my many questions.

A: If one is having the whole jaw advanced, braces are needed. I have not seen your bite nor do I know if you have any interest in changing it. If so, then presurgical orthodontics are needed. However, I am assuming that this is a chin osteotomy advancement and not the whole jaw so the answer would be that no braces are needed. All the remaining answers are based on a chin osteotomy procedure. This is an outpatient procedure and is done in a surgery center not a hospital. The chin bone will heal normally and will be no different than your normal chin bone is now once full healed. The chin would not move after the surgery since plates and screws are holding it together as it heals. The biggest risk of surgery is some temporary numbness of the lip and chin. If the look is not adequate or the chin not advanced far enough, the bone can always be readjusted or an implant placed to augment it further. I have never seen this so it is unlikely. There is no risk of breathing problems from chin surgery. Most patients report that the chin area is sore and mildly uncomforatble but not  severe pain. In a chin osteotomy, only the deficient chin bone is moved and does not involve movement of the rest of the jaw and the teeth. Everything is done inside the mouth. There are no external scars.

Dr. Barry Eppley

Indianapolis Indiana

Q: I have a weak jawline and would like to do something about it. I have previously had a chin implant but it did not appear to have made much of a difference. The implant didn’t address my weak jawline. I would like to find out more about the wrap around jaw implant. How many days do I have to wait between 3D CT scan and the actual surgery? I have attached a side view picture of myswlf for you to see what I mean.

A: Thank you for sending your picture. Based on this one view, I am seeing the need for chin augmentation and possible jaw angle imlants. But it is not clear to me why a custom-made implant would be necessary. Such wrap around implants are most beneficial when the entire jawline needs to be augmented from one angle to the other It is especially useful when the entire jawline is vertically deficient for which there is no off-the-shelf implants available. Horizontal or minor vertical jaw angle deficiences can be managed by non-custom made implants. I would be curious to know why has interested you in the custom wrap-around jaw implant. Perhaps it is because you have had no success with a chin implant already. But that may be because the size and style of implant chosen was too small. I would need to know what type and size of chin implant was used to determine whether to go with a stock or custom implant for better correction.

To answer your other question, the usual turn around time from the patient getting a 3-D CT scan and then the jawline implant being ready for surgery is about 6 weeks.

Dr. Barry Eppley

Indianapolis Indiana

Q: Dr. Eppley, several weeks ago I had surgery to repair a cheekbone fracture. However, I am not satisfied with the results. The cheek bone fracture was repaired through an incision in my temple hair. I was told by the surgeon the fracture couldn’t be accurately aligned and fixed together without significant scarring so this was the best way to do it.  Is this possible for you to do?  Is it too late? I have attached a picture of how I look now so you can see that my cheek is flat but the side of my face is wider than before.

A: Your history and picture are very helpful in understanding what type of zygomatic fracture that you have.It appears you have a classic ZMC fracture with inward rotation of the cheekbone complex into the maxillary sinus. This is the classic direction that it rotates when displaced, down and in. That explains the orbital rim-zygomatic flattening with the lateral facial widening (bowing out of the zygomatic arch) that you have.

I wonder why a Gilles approach as used for your repair that as that would never work. The Gilles approach is for an isolated zygoimatic ARCH fracture not a body fracture. Your cheekbone fracture repair could be fixed by either an intraoral incision alone or combined with a lower eyelid approach. The bones could be realigned and then secured by plate and screw fixation. That would not result in any significant scarring. That is the classic and best approach with hat appears to be your zygomatic fracture.

Dr. Barry Eppley

Indianapolis Indiana

Q: Dr. Eppley, I am curious about nipple reduction. I am an athlete with only about 10-12% body fat but I have nipples that stick out. I have always been self-conscious about the kind of shirts I wear or even taking my shirt off. I would like more information on what is best for my situation.

A: When one is concerned about nipples that stick out, it is very important to differentiate between true nipple protrusion and areolar gynecomastia. Both can cause protrusion from the nipple area but they appear quite differently on close inspection anad are treated with different techniques.

The commonly called nipple is really better understood as the nipple-areolar complex. There is a central protruding nipple surrounded by a flat pigmented areola. In men, the nipples are smaller because the size (diameter) of the areola is very small. In nipple protrusion or hypertrophy, the small central nipple sticks out while the surrounding areola is flat. This makes for a small point that sticks out in shirts. It is treated by a simple nipple reduction done under local anesthesia in the office. Most of the nipple is removed so it lays flat and will never protrude again. In areolar gynecomastia, there is a mass of breast tissue that pushes out the whole nipple-areolar complex. This is better called a ‘puffy nipple’. It is treated by removing this mass of breast tissue through a small areolar incision. This is done as an outpatient procedure under IV sedation or general anesthesia.

Dr. Barry Eppley

Indianapolis Indiana

Q: Hello, I’m writing because I am in need of a tummy tuck. I have had four c-sections and I would like to know if I will be able to get a tummy tuck. I have a very large stomach pouch that I dislike and would like for it to be removed before I get too old. If not, it will be sitting in my lap. Will having these c-section scars interfere with having a tummy tuck? Can the entire stomach pouch be removed or can only some of it come off? Thanks for answering my questions!

A: The large stomach pouch to which you refer is a pannus, otherwise known as an apron of skin. (and fat) Between multiple children, c-sections and weight gain, the excessive abdominal skin and fat falls over the waistline. The scarred and indented c-section location accentuates this pannus by pulling in tightly underneath it. The solution to this pannus problem is a modification of a traditional tummy tuck known as an abdominal panniculectomy. It differs from the tummy tuck because the amount of tissue that is removed is larger. This makes for a longer low horizontal incision, often extending into the back area. The final result is often not as refined as that of a tummy tuck given the type of body on which it is performed. In its simplest form, an abdominal panniculectomy is an amputation of the pannus from along the waistline.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I have previously had a tummy tuck and liposuction of my waistline and thighs last year. That went well and the results are really good. My remaining body issue is my lower legs. They are still so thick and they have no shape. I guess they are called ‘cankles’. I am embarrassed by them so I always wear pants. I wold love to be able to wear shorts and even a low hanging skirt. I have read that liposuction can be done for the lower legs. Do you think it will make enough of a difference? Will I be as satisfied with it as my tummy tuck and other liposuction?

A: Calf and ankle liposuction can be very gratifying and make a big difference in the shape (not the size) of the lower leg between the knees and the ankles. By selecting removing small fatty areas and making curves in the favorable silhouette areas of the inner knee, upper and lower calfs and ankles, the shape of the lower legs from the front can be made more pleasing. This is done with small cannulas and is really a form of liposculpture rather than volume reduction liposuction. The biggest issue with lower leg liposuction (cankle liposuction) is that there will be prolonged swelling in the lower leg. The changes may not even be apparent in the first few weeks after surgery adn your lower legs may even look fatter initially. It will take several months to really appreciate the final result. It always appears but it does take time. In my experience, patients have been happy with the results even though they do not end up with skinny legs, just more shapely thicker ones.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am interested in getting a complete mandibular implant and would like to know an approximate cost.

A: When people use the term, complete mandibular implant, their objective is to enhance along their jawline from the angles to the chin. To achieve that look, there are two different approaches. These different methods affect how the procedure is done and the cost. The first approach, and the most common, is to use three separate implants. This includes off-the-shelf chin and jaw angle implants placed through a submental and intraoral incisions. That total cost averages around $8500 to $9500. The other approach is a custom one-piece implant that is made off of a 3-D CT scan taken from the patient. It may or may not be put in as a one-piece implant but it is completely customized to the patient’s jaw anatomy and aesthetic desires. That total cost is in the range of about $15,000.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am interested in getting cheek implants as I think they would help my facial appearance. But I don’t really know if that is true. If it is, what type of cheek implant would be best? I know there are different types, like malar, submalar and shell styles, so which would be best for me? I have attached some pictures of my face for your opinion. Thanks and looking forward to your recommendations.

A: When looking at cheek augmentation, you must first determine whether and where any cheek bone (zygomatic or malar) deficiency exists. This requires looking for obvious bony deficiences of the midface, the relationship of the eye to the brow and cheek bones and the thickness of the overlying soft tissues. This must all be taken in context of the overall facial shape as well.

In looking at your face, you have a longer face that is fairly skeletonized. Your eyes do not have a lot of fat around them which makes them more deep-set. This is magnified by prominent brow bones and heavy eyebrow hair density. Your malar area shows good width but there is anterior malar and infraorbital rim deficiency. This is why your cheeks appear flat to you in a side or three-quarter view. When considering cheek implants, therefore, it is important that you avoid submalar and any malar implant that adds much zygomatic arch width. Augmenting these areas are not helpful to your face. Malar implants that add some anterior fullness along the suborbital groove and front end of the cheek is where your augmentation needs to be. This cold be done with either a modified malar shell implant or an extended tear trough style. Either way the volume should not be much greater than about 5mms. Too big of a cheek implant size will make the eyes even more deep-set or hollow in appearance.

Dr. Barry Eppley

Indianapolis Indiana

Q:  Dr. Eppley, I had a rhinoplasty done three years of which I am very unhappy from the results. I am of Middle eastern ethnicity and initially had a big hump on my nose that I wanted to get rid of. I just wanted my nose to look more proportionate and not be so big. Right after ther surgery it did look better but as the swelling went down after a few months it didn’t look as good. While the hump is gone, my nose is now twisted and somewhat deformed. My breathing got worse after surgery too. It seem like it is getting worse with each passing year, is that possible? i have attached some pictures so you can see what I mean. I know I need a redo rhinoplasty but what do you recommend to make it better?

A: Your nose has some of the classic problems from an over-resected or radical reductive rhinoplasty. I suspect this was done through a closed technique and you may have initially had a large dorsal hump. Your nose shows middle vault collapse, indentations at the osseo-cartilaginous junctions, a pollybeak tip deformity and alar rim retraction. The upper nose deformity can happen when a large dorsal hump is taken down and the resultant open roof is closed with osteotomies that get infractured too far. This causes disruption of the upper lateral cartilages from the nasal bones creating an ‘hourglass’ deformity where the hump used to be. The middle vault constriction (pinched middle third of the nose) is the result of too much of the height of the upper lateral cartilages being removed causing collapse and possible breathing difficulties from pinching of the internal nasal valves. The tip deformity is marked by a hump in the supratip area and alar rim retraction with excessive nostril show. This occurs when too much cartilage is taken away and the tip is no longer supported. It then collapses and retracts so that the upper end of caudal end of the septum (septal angle) is now more prominent than the tip.

Your revisional rhinoplasty would be done through an open technique using spreader grafts for the middle vault, rasping of the dorsum, lowering of the lower end of the septal height, and columellar and alar rim grafts to the tip. In essence, cartilage support need to be put back into your nose to improve its appearance as well as your breathing.

Dr. Barry Eppley

Indianapolis Indiana

Q:  Dr. Eppley, I was involved in a car accident in 2009 and sustained what is called a subcondylar jaw fracture. I was told by the doctors that it was not bad enough to fix so they let it heal without surgery. After a few months when I could open my jaw better, I noticed an obvious difference between the two sides of my jaw. My left jaw angle appears to have disappeared. It now makes my face appear crooked. I was wondering if some type of implant may help cover up this lost part of my jaw. What do you suggest?

A: When the neck of the jaw is broken, the thin connecting bone between the condylar head and the big ramus of the back part of the jaw, the vertical length or height of the jaw can shorten. A subcondylar fracture, if unrepaired, can make for a shorter posterior jaw height and apparent ‘loss’ of the distinctive jaw angle. This is because the jaw angle moves upward as the jaw height shortens. Provided that you have good jaw function and the only issue is a cosmetic one of the jaw angle, that could be camouflaged and made more symmetric by a jaw angle implant. It would be important that the right jaw angle implant be used. It needs to be one that doesn’t just widen the jaw angle (lateral augmentation) but rather provides a lengthening to the jaw angle. (inferolateral augmentation). These type of jaw angle implant can provide up to a centimeter of vertical length increase.

Dr. Barry Eppley

Indianapolis Indiana

Q: Hello Dr. Eppley, I am an Asian male and want to know if alar plasty can reduce the size my nostrils and reshape my nose? It kind of looks like Eddie Murphy as it is really flared.  I want my nose to look like Justin Biebers nose , straight and pointed and not very flared. Can rhinoplasty make this happen?

A: When I hear these type of goals from a rhinoplasty, it brings me to a discussion of expectations and reality of what can be achieved from surgery. The simple answer to the question of whether you can have a nose like Justin Biebers is no. That is not surgically possible. Justin Biebers is Caucasian, you are Asian. The underlying anatomy of the nose stucture is different and, of equal importance, the overlying skin thickness and texture is not the same. This makes it impossible to achieve what is essentially transracial changes. Even if you were Caucasian, you still could not have his nose. Rhinoplasty can not make you look like someone else or give you someone else’s nose. Pictures of famous or other people faces are helpful, as they help to convey what one’s nose shape goals are, but they can not be surgically duplicated. One of the most challenging aspects of rhinoplasty surgery is to meet a patient’s expectations. When patients bring out celebrity or model photos to say what they want, it is always is a concern that their expectations may not be able to be realized.

Dr. Barry Eppley

Indianapolis Indiana