Your Questions
Your Questions
Q: My daughter was in a MVA in October 2010. She has an Y-shaped scar on her forehead and 2 smaller scars on her left cheek and left ear. We have consulted with a pediatric plastic surgeon, but would like a second opinion on how soon can scar revision begin and the best treatment for the best long-term outcome.
A: Scars on a face are always very emotionally disturbing. Those concerns are only magnified exponentially when those scars are now on your own child’s face. Many parents, and teenagers, are very interested to get started on a scar revision/treatment program as soon as possible for very understandable reasons.
When and whether scar revision is of benefit is going to vary based on multiple factors including the type of scar, its location and what skin texture issues it has. The classic teaching in plastic surgery is that scar revision should wait at least one year after the injury. While this can be true for some scars, it certainly is not true for all of them. The rule of thumb that I use is…will time be of benefit or not to the scar’s visibility problems. If a scar is thin and red, time will eventually make the redness disappear as the scar matures. One may want to try and hasten that up with some pulsed light therapies (IPL, BBL) and this is perfectly appropriate as it is harmless to the scar and quick and easy to do. If the scar edges are mismatched, wide, or uneven, these features will not be improved with time and earlier scar intervention is then justified.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am the mother of 3 children and am soon to be age 35. After going through 3 pregnancies my breasts are definitely not what they used to be. They not only have gotten smaller but they seem to sag more now than before. With each pregnancy they have gotten progressively worse. I know that I need an augmentation but am uncertain if I need a lift also. How do you know if you need a breast lift when getting an implant?
A: An implant will do a great job of adding volume to a deflated breast but it will not lift up a sagging breast. This is contrary to what most women think an implant can do. When the position of the nipple is close to, at, or below the lower breast crease/fold, some type of breast lift will be needed. This is regardless of whether one is getting an implant at the same time. Without a breast lift, the implanted bigger breasts will merely drive down the position if the nipple and may even make it look worse. This can be predicted before surgery by carefully looking at the nipple position and the amount of loose breast skin. When lifts are done at the time of breast implants, the procedure is known as augmentation mastopexy.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am interested in and desparately need a tummy tuck. I have checked with insurance and they will cover this procedure if a doctor states that it is medically related. I had a Dr. tell me since I delivered my baby that my stomach muscles have torn and will not grow back. Do you guys have someone that you can refer me to look at my stomach muscles so I can receive my tummy tuck with my insurance or help with your doctors in your office?
A: Unfortunately, much of your perception about insurance coverage for tummy tucks is inaccurate. No health insurance will pay for a tummy tuck, unless one has a large apron of skin (pannus) that hangs down onto one’s thighs after bariatric surgery. (and even then they deny it most of the time) There is no medical justification or reason for a tummy tuck, it is viewed by insurance as a cosmetic procedure. Despite the fact that your tummy may look the way it does from pregnancy, weight gain or loss, or even surgery, insurance views tummy tucks as having no medical benefit. That can be proven by submitting a pre-determination letter (what anyone says on the phone from an insurance company is worthless about whether they will or will not pay) to seek approval.
Pregnancy does not cause stomach muscles to tear. Rather they cause the vertically-oriented rectus muscles to separate and stay apart, particularly around the belly button area. Sometimes this may be associated with a hernia which insurance usually does cover to repair. But having a rectus diastasis (separation) is not eligible for insurance-covered reconstruction.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I had an abdominal etching procedure with liposuction of the love handles one month ago. I also had a lower buttock lift. But I still have not seen abdominal muscles. I want to have abdominal etching again. Is it possible? How long will I have to wait? I also want to have a buttock augmentation using fat cells. My butt looks too small and I want to make them lifted rounder and fuller. Is that possible?
A: Abdominal etching is essentially a linear form of superficial liposuction. While the swelling from this surgery is not completely gone from this operation, you should be seeing some of the etching at one month after surgery. If you are not seeing any signs of the etching pattern by now, that would indicate that it may not been done aggressively enough or with inadequate technique. The etching can be redone but I would wait at least 3 months after the first procedure before doing a revision. That will give you adequate time to be sure that the etching result is insufficient.
Buttock augmentation is commonly done with fat injections, often called a Brazilian Butt Lift. The only limiting factor in this non-implant buttock augmentation is whether you have enough fat to harvest. It is usually taken from the abdomen and flanks but those donor sites may have already been liposuctioned in your first procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dear Doctor Eppley, I came across your name after reading article by you. You described the use of a custom designed titanium mesh cage and plate made off of a 3-D model fabricated from a CT scan and using bone marrow from the hip to form bone along the mesh. The reason I’m writing you is that my wife had a mandibulectomy in 2009 and had a titanium plate used to replace the removed part of her mandible. Last week the plate broke so now we are looking for other reconstruction options. We have an appointment with an oral surgeon next week but preliminarily we have been told that his reconstruction options are the use of her fibula or part of her hip bone. Do you think she would be done with a specially designed mandible reconstruction plate alone. I hate the thought of her having to have another big operation. I have attached a panorex which shows her jaw and the broken plate. Any help would be appreciated. Thank you for your time.
A: Thank you for sending your wife’s panorex. The jaw image is quite clear and is a mirror image match of the patient I did about 6 months ago….same exact mandibulectomy defect and location of plate fracture. I am assuming she has not had radiation?? The standard approach, if she has had radiation, would be a fibular free flap. But if she has not, and the long-term goal is not to try and place dental implants into the reconstruction, a metallic reconstruction with iliac marrow graft would be appropriate. It requires a specially designed titanium reconstruction that is much stouter than this simple now fractured reconstruction place which is really just intended to be a temporary stopgap measure. They all will fracture within a year or two due to the stresses that are placed by jaw opening at the angle of the mandible. This is why a custom-designed one is needed to be made off of a 3-D CT model.
Indianapolis, Indiana
Q: I am interested in breast augmentation and want silicone implants. But I am Hispanic and am very worried about any scars on my breasts. I have been to several plastic surgeons and they all have said that silicone implants need to be put in through an incision on the bottom of my breasts. They say only saline implants can be put through an armpit incision which is what I want. I have had numerous cuts on my body since I was a child and the scars all get dark and don’t go away. So even though the doctors say the scar under my breast will heal and look good, I know better based on my own body’s experience. Is there any way silicone implants can be put in through my armpit?
A: While once very difficult to get any size silicone implant in through the small armpit incision, that problem has now been solved. A brand new insertion or delivery device is now available for silicone breast augmentation. Known as the Keller Funnel, this funnel-shaped wrap allows the implant to be gently squirted into the breast through very small incisions, including the armpit one. Looking like a pastry chef applying icing to a cake, the breast implant is placed into the funnel and then squeezed out of its smaller end. This means not only can even large silicone breast implants be put in through smaller lower breast crease and nipple incisions, but they can now routinuely be inserted through an armpit incision as well. This will be of great interest to non-Caucasian breast augmentation patients, particularly those of Hispanic ethnicity who tend to get scar hyperpigmentation. The other great benefit of Funnel Breast Augmentation is that the implant is not touched from the product packaging to the breast pocket. This also reduces the risk of infection after breast augmentation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I had a chin reduction by bone burring 2 months ago. Not only do I see no change in the size of my chin, but I now have a witch’s chin/double chin due to the scar under my chin. I feel like I should wait to address this, but I am in a very public position and need to fix this as soon as possible. It is affecting my work and my self-esteem. Is it too soon to do a revision?
A: With the story of a recent chin reduction by burring, you almost certainly had an intraoral (inside the mouth) approach to your chin procedure. When this is attempted, two results happen after surgery. First, little to no change is ever seen in the amount of chin projection as just the very edge of bone has been work on which is inadequate. Secondly, and a much worse problem, is the chin ptosis or sagging that can occur due to the disinsertion of the mentalis muscle and the degloving of the chin soft tissues. The intraoral approach requires a very careful reapproximation and resuspension of the muscle if this is to be prevented.
The best time to correct a chin ptosis/witch’s chin is earlier rather than later. The more time that passes allows more scar tissue to form and can make a good correction more difficult. There are several different methods of correction depending upon the end goal and tolerance to an external scar. The chin soft tissues can be resuspended from an intraoral approach which will leave no visible scar but will not make for any chin reduction. The other approach for chin ptosis repair is from under the chin where both bone and soft tissues can be reduced, solving two problems, but leaving a submental skin scar.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am interested in having a rhinoplasty for my big nose but don’t want it to make my already large brow bones to look even bigger. I have attached a couple photos (front and side) of myself to give you a better idea and possibly even hear any other suggestions you may have to maybe give my face a better balance. I did have a rhinoplasty when I was younger but it didn’t make much of a difference. I was going to have a second rhinoplasty, but I didn’t want a smaller, well-proportioned nose to create my brow bone to appear larger than it already is. In other words I thought my nose being somewhat larger now balances out my brow bone.
A: Thank you for sending your pictures. I have done some computer imaging to demonstrate several points. Your first rhinoplasty result is not very impressive and probably shows little change. I suspect it was done as a closed rhinoplasty by someone with little experience in doing the procedure. But doing your secondary rhinoplasty would actually make little difference in how prominent the brow appears as demonstrated in the attached imaging. Making your nose bette balanced does not make the brow bone prominence look worse and that is well demonstrated in the computer imaging. The reverse is, however, quite different. Reducing the prominent brow bones would definitely make the nose look even bigger. I have demonstrated the combination of a rhinoplasty and brow bone reduction to see the total change. Therefore, you could feel quite comfortable doing a secondary or revisional rhinoplasty without fear of making any part of the rest of your face look more out of balance.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have very prominent brow bones and want to get them reduced. What would cause the frontal sinus space to become so prominent? I have an older brother who has a nice flat brow bone and forehead. Conversely, my father has somewhat of a prominent brow but not quite as large as mine So could it be just genetics? Or could it be from falling on my forehead when I was younger? As far as brow bone reduction surgery goes, I have read that it involves a scar across the top of my head. Given my hairline this is not very appealing. Is there a way of going between the very top bridge area of the nose and bottom of the brow to contour it that way and bypass the hairline all together?
A: There is no known reason that the frontal sinus expands to such a large degree, short of the presence of a sinus tumor. It has nothing to do with trauma and is just purely a genetic blueprint issue.
There is an alternative to a scalp or coronal incision which is done directly as you have indicated. It is an incision done directly across the brow bone area, being just at the brow hairline margin and then coming across the middle by stepping done into a horizontal skin crease between the top of the nose and the forehead area. This is known as the ‘open sky’ approach and has an historic use for the treatment of fronal sinus fractures and tumors. For most men, it is a better option for brow bone reduction than a scalp incision and would be less noticeable. It would also make the surgery less traumatic and involve a quicker recovery. It does heal as a very fine line scar. If one’s brow is big enough and disconcerting enough, this is a reasonable approach.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I need breast implants to make my breasts more even. I think insurance should pay for them because I think my genes didn’t have them grow right. They are quite uneven. My left breast is about a C cup and my right breast is just a small B cup. I think two different sized breast implants would work to make them both D cups. What do you think are the odds my breast implant surgery will get covered by my health insurance?
A: Quite frankly, I think those odds are as close to zero as you can get. Despite your wanting breast augmentation to be a reconstructive procedure, it is not. Breast asymmetry, despite it causing some understandable anguish and embarrassment, is not viewed as a congenital deformity. (caused by ‘poor genes’) It is viewed by health insurance companies as both cosmetic and elective. There was a day many years ago when they may have in some severe cases prior to 2000, but those days have long passed now.) For insurance to cover breast implants, it would have to be done for reconstructive purposes which insurance views as due to cancer resection or a traumatic injury. Breast reconstruction is viewed as a medically necessary surgery in cases of lumpectomies and mastectomies. Incredulously, I have numerous cases today where insurance even fights covering it when cancer is involved!
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am interested in getting an endoscopic forehead augmentation done with the Kryptonite material. For the past few years from your website, I read that you believe endoscopic forehead augmentation leads often to a poor result. But since the Kryptonite material came out you sound more optimistic for the endoscopic forehead augmentation. Do you believe that this new material makes the endoscopic augmentation safer and widely useful for augmentation of larger areas of the forehead that before? Are complications possible?
A: With traditional cranioplasty materials, a true endoscopic or injectable forehead augmentation procedure is not really possible. The materials (acrylic and hydroxyapatite) are too thick and can not even be inserted through the small access provided by a few limited incisions. The emergence of Kryptonite cranioplasty material has made a small incision or injectable approach technically possible. Kryptonite has now made the procedure possible but it is not completely free of potential complications. The biggest issue with this injectable forehead cranioplasty is making sure the final result is smooth and confluent across the forehead. That is the trick to making this procedure truly successful and satisfying.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hello Dr. Eppley I am a 28 year old male with an extreme prominent brow ridge. I have been doing research on this and understand the male vs female forehead anatomy. It seems my brow is quite larger than a typical caucasian male and was wondering if I went through a surgery for this what would be the result. I’m certainly not looking to become “feminine” by any means. I am a heterosexual male, but the size of my brow makes me feel uncomfortable and self-concious. I have a cephlometric x-ray of my profile view so you can see the size of the brow and maybe show me how much of a change is possible. Thanks for taking the time to read this, it’s a great website you have which is very informative.
A: Thank you for sending your ceph x-ray. There is no question that you have a very large pneumatized frontal sinus air space which is the cause of the prominent brow bones. The size of those brow bones are very good candidates for significant reduction through a brow bone reduction osteotomy technique. This is done by removing the outer table of frontal sinus bone, reshaping it, and then putting it back in a much flatter shape and secured with tiny titanium plates and screws. I have attached the ceph x-ray computer imaged as to how much flatter it can be.
The biggest issue for a male brow bone reduction is the scalp incision/scar required to do it. That often is the rate-limiting step for most men and is highly influenced by the man’s hair density and hairline pattern.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley I’m a 30 year old single mother of two and I need a breast lift badly to improve my self-esteem. I got pregnant with my first child at 19 and I gained over a hundred pounds. I’m now back down to 150 and still need to lose more but I’ve lost 56 lbs. My body just isn’t the same after two children and I just need some self esteem back. I already have a very nice size to my breast and am just looking to put them back where they belong. Could you please give me information on what needs to be done to get my breasts back in shape and looking good again. Thank you for your help.
A: Between children and your significant weight loss, your breasts have undoubtably take a turn to the south. Breast sagging, known as ptosis, is defined by how low the nipples sit relative to the lower breast fold. When a large amount of weight has been lost (greater than 50 lbs), breast ptosis is usually severe and the amount of skin exceeds how much breast tissue exists to fill it. This usually requires a full breast lift which will result in the typical anchor scar pattern that is more commonly seen in a breast reduction procedure. This will move the nipple up to the center of the breast mound and will tighten the skin on the bottom side of the breast. While this lifts the breast, it will not usually result in permanent fullness of the upper pole of the breast. This is why a small implant may needed with the lift to get the fuller breast shape that many women desire from a breast reshaping operation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have a lipoma on my upper back that I would like removed. I would like to do so with minimal scarring as my wedding is coming up. Does your office perform any type of procedure that can remove it without noticeable scarring? What would the procedure cost? I am not sure if insurance would cover the procedure. Thank you for letting me know.
A: The benign fatty tumor, known as a lipoma, is a common mass that many people develop. The traditional method of removal is to have it cut out or excised. While effective and offering the best chance of a cure (no recurrence), it can leave a noticeable scar and even an indentation afterwards if it is of any size. I have found that scar concerns from open excision of lipomas are of a particular worry in women when they are about the shoulder, neck and back. Scars in these areas, no matter how well they are sutured together never end up as just a fine line…they always widen and often remain red for a long time.
Given that lipomas are benign growths and may or may not continue to grow, the trade-off of a wide scar may not be acceptable. An alternative method of lipoma removal is with liposuction. Using a very small cannula, the lipoma may be reduced or debulked by aspiration. Notice that I did not use the word, excise, or completely remove. Removing every last fat cell in the lipoma is not possible with liposuction so there is an increased risk of regrowth over time. That is the potential trade-off for a minimal scar procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I had a liposuction operatoion to get rid of the fat in my saddle bag areas. It was done over aggressively as now I am left with indentations where the sasddle bags used to be. It looks like I have traded off one problem for another. I am looking for a plastic surgeon who has experience in fat grafting to correct these overly aggressive liposuction results in the saddlebags. I no longer have saddlebags, now I just have big dents!
A: The saddle bag or lateral thigh is not an uncommon area where irregularities and indentations can occur. Unlile surface contour problems in other liposuction-treated areas, the cause of such saddlebag problems is usually not the quality of the skin. It more often than not is the position in which the procedure is performed. It is usually done with the patient in the side or decubitus position. This is a good position to do the procedure but one has to be careful that the leg is lifted when liposuction is performed. In the side position, part of the saddlebag prominence is the greater trochanter process of the femur of the hip joint. When the leg is down, this bony prominence makes the saddle bag area look bigger than it is. Liposuction is then done to make the area flat (removing too much fat over the bony prominence), which looks good laying down and one one’s side, only to reveal an indentation from over-resection later when one is standing. This is why the leg is elevated as the liposuction procedure is done to havge a better idea what is fat and what is bone.
That issue aside, fat injections is the only method available for treatment of liposuction irregularities. It works best for specific defects, such as indentations, and less successfully for more generalized skin rippling and irregularities. It would be beneficial to see some pictures of the saddlebag area to determine if this would be beneficial for your thigh contour problems.
Dr. Barry Eppley
Indianapolis Indiana
Q: Doctor Eppley I am a 22 years old man who would like to undergo the forehead augmentation procedure for a small change in the shape of the forehead. I believe that I am a good candidate for an endoscopic forehead augmentation because the building of the forehead I desire is small. What procedure is right for me(endoscopic or coronal incision augmentation) is something you know better and you will decide when you will meet me in person. However I would like you to inform me about the endoscopic augmentation, about the cost and the position of the small incisions. The building up I desire is small and it is for a small area of the forehead. How much does it cost a traditional endoscopic forehead augmentation?
A: Thank you for your inquiry. One of the biggest drivers of the cost of endoscopic forehead augmentation is for the material, Kryptonite. Since you said the build-up is small, I will assume that you will need only 5 grams or less. That would put the cost right around $6500 to $ 7500. Like traditional endoscopic forehead surgery, two scalp incisions are used for making the dissection and placing the material. They are very small, being less than one inch each and are located behind the frontal hairline and to the sides if possible. Please send me pictures of your forehead concerns for my assessment and recommendations.
Dr. Barry Eppley
Indianapolis Indiana
Q: Dear Dr. Eppley, I have some asymmetry on the right side of my face due to orthognathic surgery. I consulted with a Craniofacial surgeon specialist to correct this deformity. I also asked about getting implants on both sides because of my small mandible. The surgical plan was to correct the asymmetry on the right side and put in jaw implants on both sides. The same size jaw implants were used on both sides without correcting the asymmetry. The drop down on these implants is too much for my face. I have Medpor implants which were put in about a month ago. I want to get these removed and just have the deformity corrected. When is the best time to remove these implants? Thank you and I looking forward to your reply.
A: The swelling after jaw angle implant surgery can be considerable and it takes longer than a month to really see the final results. At only a month after surgery, I am not sure you can be absolutely certain they are too vertically long. Ideally, one should wait a full 2 to 3 months to be certain you really want to reverse your initial efforts. However, if you are very certain at even this early postoperative time, then you should get the implants out as soon as possible. It is always easier to remove porous implants like Medpor sooner rather than later before extensive tissue ingrowth has occurred.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a couple of questions for you. I had breast augmentation about 10 days ago. I am still a little swollen which I have expected. However, I can’t quite put my finger on it to describe it, but after wearing a bra for a while, I get the feeling like I am rubbed raw. But you don’t really see anything and it was mainly around the bottom of the bra. I even bought a bigger size around thinking that was the problem, but it didn’t seem to matter and again, you don’t really see anything so I couldn’t figure it out.
Over the past two days not only is it around where the bottom of the bra hits but on the sides of my breasts as well. I realized last night its like they are extra sensitive. I have worn a silky night shirt throughout the weekend up to last night. It didn’t bother me before but last night it was bothering me a lot. I had to buy a new one since my other ones no longer fit. Since it is bigger, it moves around when I walk etc. and moves over my breasts. It was very irritating to the point I was holding the nightie each time I walked so it wouldn’t move. So I realized, its like my breast are very senstive to anything moving against them like that…if this even makes sense. Its not like that if I touch them myself, but clothing. Is that normal and will it stop?
Also, I think I read I am not supposed to wear underwire bras. Is that only during healing time or never? All the bras I find in department stores look like my grandma would wear them and of course all the pretty ones are underwire. A friend suggested Victoria Secrets, so I plan to try there I just didn’t want to invest in a lot of bras until swelling, etc. is all gone so I buy what I really need, etc.
Thanks for your help.
A: You have inquired about two very typical issues after breast augmentation. The skin feelings that you are having are the tiny skin nerves, which have been temporaily disconnected or stretched, trying to recover. Think of it as the pins and needsl feeling you get when your foot falls asleep. That will typically subside around four to six weeks after surgery. That is different than some longer lasting numbness which may remain on the skin on the bottom part of the breast.
Not wearing an underwire bra for 6 weeks after surgery is to relieve any pressure on the healing inframmary incision It is also to make sure the breast implant and its lower pocket is not pushed upward as it is healing so the implant sits down in a more natural position.
Dr. Barry Eppley
Indianapolis Indiana
Q: Hi! I have been searching for this kind of procedure for cheekbone surgery or reduction. I am glad to have found this site. I come from a family which we have strong cheekbones, but in my case I have been in a violent incident where I was injured and I think I broke or deformed a bit of my jaw. Now I have some asymmetry in my cheekbone as it seems to have become more prominent after this injury. I would really like to know if it would be possible to reduce them. I used to have a lot of charisma when I was young before my violent incident. Since then it has totally changed me. I would like to know more details in this procedure, time of recovery, possible complications, etc. Thank you.
A: Cheekbone reduction is about narrowing the width of the body of the zygoma and the zygomatic arch. It is a common procedure for those whose face is naturally a little flatter and more wide as exists in certain ethnicities. It can also be used to treat a cheekbone fracture where the body of the zygoma has been pushed back which wides the zygomatic arch, making the cheek area have less prominence and more width.
Your description of your cheekbone problem is a it confusing to me. On the one hand, you state you have naturally strong cheekbones (forward prominence) but, after an injury, they have become more prominent. That would be very unusual given how the cheekbone fractures. For this reason, it would be best to send me some photos of your face for my assessment before I could provide any recommendations, specifically whether cheekbone reduction surgery would be benefical to you.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am an Asian American wanting to ask question to Dr. Eppley about a procedure. Is it possible to add material to the orbital rim to make it more deep? If so, what material and risks are involved?
A: When asking about building up the orbital rims, this is known as brow bone augmentation. By building out the brow bones, the globe or eyeball, will appear deeper. This is essentially a masculinizing procedure. Any of the cranioplasty materials can be used for brow bone augmentation and some plastic surgeons even use preformed or hand-carved synthetic implants. (which is not a technique that I use) The issue is not the type of material that can be used, since they all can work well, but the approach in which to do it. An incision is needed and the options include a scalp incision (for complete brow bone augmentation) or an upper eyelid incision. (for lateral brow bone augmentation) In a male with a high or variable hairline, a scalp incision is not usually cosmetically acceptable. This is less of an issue for a female.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am going to undergo Zerona body contouring treatments. I wanted to check with you first to make sure it is safe to do Zerona treatments with my inguinal hernia that protudes over my belly button area. I know the hernia is made up of fat, and I want to know if I should cover it with something to keep the Zerona from affecting it. Thanks so much for the help.
A: Zerona is a body contouring device that uses cold laser technology. This a low frequency low power laser light that should not be thought in the conventional laser sense. It is not a focused high energy beam which would normally burn anything in its path including skin and eventually fat. Rather it works by a different light principle known as a photochemical effect which will not injure or burn any tissues. This photochemical effect makes fat cells temporarily leaky by opening up channels or pores on the cell walls. This is not harmful to the fat cell per se, it just makes it lose some of its lipid volume. Thus, it is perfectly safe even if it would coincidentally be directed onto an abdominal area in which a hernia would be present. It would also be unlikely that the penetration of the Zerona energy would pass more than 5 cms below the skin, which is too superficial for many hernia locations.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have been left with a dog ear on my face after a nose reconstruction due to skin cancer. The nasal ala was reconstructed but the end result looked like a further growth. (like a pin cushion of skin stuck on to the side of my nose) It underwent a revision about two months later. I am still not totally satisfied as I now have a further deep scar on the side of my nose and an awful obvious dog ear that looks very unsightly. I went for a follow-up and they suggested giving it a year before considering any further surgery. I am desperate to have something done but if we did operate on the dog ear, I fear it might end up worse!! How can this be and why should I live with my face like it is? What can be done now?
A: Reconstruction of the nose after cancer is one of the biggest challenges in plastic surgery. This is particularly true of the nasal ala which is a small but delicate area. Having had two surgeries and now some degree of scar contraction or dogear, it is very important to let the tissues heal and settle down. The healing must progress to the point that it is not only complete but the scar tissues have relaxed. Operating on tissues that are not soft and supple will only lead to further scar contracture problems. It is certainly frustrating to have to wait a whole year with less than an optimal result sitting on your face, but the best result from an effort at scar revision depends on good quality of tissues to manipulate.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I read an article on jaw implants in which you wrote “In some cases, no available off-the-shelf chin or jaw angle implant can create the desired effect due to a patient’s unique anatomy or aesthetic needs. In this situation, a customized ‘wrap-around’ jawline implant can be made from a 3-D CT scan of the patient. These can be made as a single implant or in multiple units that can be inserted in pieces and assembled when next to the bone. This approach is particularly useful when the jawline needs to be vertically lengthened. (implant sitting on the bottom edge of the bone)” Can you go into detail about the process of the custom mandibular implant with the 3-D CT scan? And from that how that fits into someone who travels for the surgery?
A: While standard chin and jaw implants will work most of the time, there are some patients whose jaw problem is beyond conventional implant designs. There are also patients who have been successfully implanted but do not like the aesthetic outcome that has resulted. These ‘implant-deficient’ patients have either vertical jawline deficiency, extreme chin deformities or the desire to have a more exaggerated jaw angle prominence. In these cases, only a custom jaw implant will suffice.
The process of making a custom jaw implant begins with the patient getting a 3-D CT scan at a local hospital or x-ray facility. That 3-D mandibular data is then sent to a custom model manufacturer. (I use Medical Modeling, Golden, CO) That model is then sent to me where I will hand carve out of wax or acrylic the desired implant(s) shape. Once approved by the patient, it is then sent to an implant manufacturer who will manufacture and sterilize the final implant(s). It will then be shipped to me for surgical implantation. This entire process takes about 4 to 6 weeks to complete. For someone traveling from afar, they only have to make one visit for the actual surgery. All preparations can be done from afar.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have my ears gauged to about 1 inch and I have a really bad tear in my left ear. My right ear isn’t too bad but is blown out in the back. Can these ears be fixed? But I don’t want my ears closed all the way! Just the scar tissue removed and my left ear thickened a little bit so it doesn’t tear off.
A: The repair of the gauged earlobe, while looking intimidating, is actually easier than one would think. The reason is the normal earlobe is small but the gauged earlobe, despite its big hole, has actually created extra earlobe tissue. Through a basic plastic surgery concept of tissue expansion, the earlobe edges may have gotten thinner but the actual amount of earlobe tissue has increased. It is always easier to reconstruct a body part where there is too much tissue than when there is a deficiency.
In reconstruction of the gauged earlobe, it can be done two different ways. The most common method is to remove the excess tissue and put it back together as a complete earlobe. After 3 months of healing, the ear can then be pierced. An alternative method is to do the reconstruction leaving a smaller but complete hole in the middle. The hole can be made very small for a piercing or left larger to wear a smaller gauge. Either 3 months of healing again are needed before anything is inserted.
Dr. Barry Eppley
Indianapolis, Indiana
Q: For most of my life I have considered myself ugly. I avoid having pictures taken and I most certainly don’t look at them if they have to be taken. I have a total lack of confidence and this has definitely poses problems in my personal relationships. I don’t know what it is about my face but it just doesn’t look right. I am only 29 but I look much older. My eye area looks droopy and old and may face looks thin and distorted. I have attached some pictures for you to see and review. What would you recommend to help me look better ?
A: When someone doesn’t like their face, particularly at a young age, this indicates that the problems are with how it is put together (structural components) not that it is has early aging. This means the underlying structures that make up the shape and highlights of the face which are largely bone and cartilage. In reviewing your pictures, I can see that your face has unbalanced structures which include low hanging brows, a broad and prominent nose, hollow cheeks, and a wide and long chin. The combination of these features creates an overall facial look that you do not like. Procedures such as an endoscopic browlift, rhinoplasty, cheek implants and chin reduction collectively would make a major change in how your face looks. It would lend a softer and more youthful due to a better balance of your facial features. Computer imaging with these changes would demonstrate their potential benefit in changing the shape of your face.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I had a wart removed from my lip about a month ago. It has left scar tissue that really bothers me. It feels lumpy. People tell me they can barely tell but I know it’s there and was wondering what might be the best option for me?
A: To provide a really accurate answer, it would be helpful to know exactly how this lip lesion was removed and where exactly on the upper or lower lip it was removed. I am assuming that it was cut out and involved part of the wet and dry vermilion. (pink part of the lips) Excisions that involve the lip will frequently leave a bump or hard knot behind for a period of time. This is a normal reaction to injury and is a combined inflammatory and scar tissue reaction. This is usually very noticeable due to the sensitivity of the lips and the natural tendency for one to constantly run one’s tongue over it. In most cases, this reactive lump will eventually subside as it heals. It will usually take about 3 to 6 months for it to soften up and feel more natural. In those few cases where this lip knot does not eventually go away, a scar revision would be needed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hi, I have hated my nose for a long time and I have finally decided to get a nose job. I am African-American and I don’t like the lower third of my nose. My nose is too wide and big when I smile. My nostrils flare really wide. I just want to get rid of some of the wideness but don’t want to change the whole nose. Is that possible?
A: One of the many distinguishing features of the African-American nose can be its unique tip and nostril shape. The tip is often more flat and less well-defined and the nasal base is wide, often with nostrils that have a larger size that also flare. Many African-American rhinoplasties involves reduction of the wide and flaring nostrils. This can be done by removing skin from the inside of the nostrils for some minor reduction or by repositioning the entire nostril base for a more major change. Nostril and nasal base reduction can be done by itself but it is important to see how this may change the overall look to the nose. This is where computer imaging is absolutely essential. Most likely changing the size of the nostrils will affect how the tip of the nose looks and will make it look even more flat and shorter. Some tip changes through columellar strut grafting may be needed with nostril reduction to keep the lower third of the nose in balance. Dr. Barry Eppley Indianapolis, Indiana
Q: I was born with a club foot. I had my first surgery when I was a few months old. I would love to have matching legs. Does insurance cover this since it is a bitth defect?
A: One of the aesthetic sequelae of a club foot deformity, which is one of the most common birth defects, is that of calf asymmetry. Due to the foot deformity, the calf muscle of the involved leg does not develop to the size of that of the normal opposite leg. This results in one calf being smaller than the other which causes an aesthetic imbalance of the lower legs. This can be improved with a calf implant which is placed from an incision on the backside of the knee. While the small calf size can be improved, it rarely can become exactly as big as the opposite side as the calf skin is very tight and will only expand so far. This is done as simple outpatient procedure that takes about an hour to perform. Calf implant surgery for club foot is not covered by insurance even though it is being done to correct a congenital deformity. This is because the implant is not improving the function of the leg (medically necessary) but is being done to improve how it looks. (cosmetic) The lower leg will not work any better as a result of the implant but it will look more symmetric to the opposite side.
Dr. Barry Eppley
Indianapolis Indiana
Q: I had liposuction done on my neck when I weighted 185 lbs with about 15% to 16% body fat. I had a good immediate change in the shape of my neck from that procedure. I am now 170 lbs and about 12% to 13% body fat. The great results from the liposuction have persisted as I would have suspected. What I am wondering is what will happen if I gain weight back to where I originally was around 185 lbs. I am not planning to but I am curious as you never know what the future holds. Does it matter if my weight fluctuates between 170lbs and 185lbs? Will the fat return in my neck if I gain weight back?
A: The long-term results of liposuction on most areas of the body are highly dependent on the stability of one’s weight. The neck may be a slightly more privileged site (resist fat re-accumulation) than the stomach or flanks for example, but fat can definitely return there if one gains enough weight back. I think as long as you stay under your weight at the time of your original surgery, then your neck liposuction result should be unchanged. The percent body fat and weight ranges that you are talking about are not significantly large (170 to 185 lbs) so that change will likely not make much if any difference in the neck. However, it behooves you to keep the weight off as the amount of fat that was originally in your neck was there for a reason…so don’t give it a second chance to come back to an area that it once enjoyed.
Dr. Barry Eppley
Indianapolis Indiana
Q: I had a sliding genioplasty just one month ago in January 2011. It was advanced 8mm and I feel it was too much. I do not like how my chin looks. It is not a natural look. I also lost almost 2/3 of my lower lip which make the chin even bigger. It really has changed me a lot. I was wondering what can be done to recover the fullness of my lip. I am even considering a reverse genioplasty to bring it back to 5mm even though the cephalometric analysis says that I am short 9 mms. How long should I wait for a revision and any further interventions?
A: Now that you are roughly 6 weeks out from your initial chin surgery, most (but not all) of the swelling should have subsided. While there is some final swelling and stiffness of the chin that needs to go away in the next few months, that will only change the chin projection by maybe 1 to 1.5mms. Therefore if you feel the chin is too strong at this point, then it is and your decision to set it back some more is reasonable. A change from 8mm to 5mm is reasonable since it takes at 2 to 3mms to really see any difference. The time to make that change is NOW. The bone is not yet healed and it is a relatively easy plate and screw exchange to do the revision.
When you say you have lost ‘2/3s of my lower lip’, I am assuming you mean that you have a drooping lower lip otherwise known as lip incompetence or sag. Unlike chin swelling where time will make some of it go away, time will not lift up a sagging lower lip. This is a function of the mentalis muscle position/resuspension on the chin bone. To imrpove that situation, the muscle need to be lifted up higher in the bone and secured. This will help the lower lip get back to a more normal position. The sooner this is done the better as muscle scarring is occurring. So again, NOW is the time to revisit this with your surgeon and have these discussions.
Reversing/revising the effects of a sliding genioplasty are best done early before complete bone and soft tissue healing has occurred.
Dr. Barry Eppley
Indianapolis Indiana
