Your Questions

Q: I would like to get a breast reduction on just my right breast. It is a couple of cup sizes bigger than the left and its very painful. I think people notice and I can’t find a bra that fits right and looks good without one of my breast falling out. Also, I can’t wear any cute shirts I like and I’m very self consious when my husband sees it. I know I would be so much happier in life if they were both the same size. How much would it cost to get tissue removed from one breast so that they are the same size and that is all? Also what do I need to do to to get started? Please help!

A: Breast reduction can equally be done on just one breast as it is on two. It just takes half the time and close to half the cost of a two-sided breast reduction. When reducing just one breast, you have the ‘advantage’ of the other breast as the cosmetic goal. While perfect size and symmetry cam never be absolutely achieved, they can be made very close. The trade-off you make is that for better size and symmetry, the reduced breast will have fine line scars that the other breast does not. The best way to get started is to visit a plastic surgeon and discuss the specifics of your breast goals. On average, the cost of one breast reduction done as an outpatinet procedure will run in the range of $ 3500 to $4500.

Dr. Barry Eppley

Indianapolis Indiana

Q:   Hello, I have had three very large children (all between 9 pounds and 10 pounds) and have had a very large weight gain/loss after each child. I am getting closer to my goal weight at this time from my youngest child. (Currently 165 pounds-my highest weight was 214 pounds) and my goal weight is around 150. Because of the large multiple pregnancies and weight gains/losses, I am in the need of some body contouring. I have multiple areas that need addressed, my loose tummy,  excessive skin in my upper arms, sagging breasts and excess skin and resistant fat deposits in my legs. I am interested in a consultation to start the process of repairing some of the damage to my body that my healthy diet and daily exercise will not fix. I plan to have the surgeries over a few years, rather than all at once, due to cost and my schedule.

A: Body changes that have occurred either from bariatric surgery, extreme weight loss or the impact of multiple pregnancies requires thoughtful consideration about the type and timing of surgical corrections. Sitting down with a plastic surgeon and going over all the surgical options is an obvious first place to start. Having had many of these discussions in my Indianapolis plastic surgery practice, most women will focus first on their tummy and waistline often combining it with another procedure such as an armlift.

These more substantative body problems are more substantial that the more traditional Mommy Makeover which is directly to two combined procedures, breast enhancement (implant with or without a lift) and some form of a tummy tuck.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am interested in getting my upper lip made bigger. It is very thin and it barely shows at all. It is very embarrassing to have such a thin upper lip when so many women have nice full lips. I think a bigger lip would make me look better and more attractive. I want to get injectable fillers into it because that seems to work well for most people. But I don’t want to look like I have a big fat upper lip or have duck lips. How can I get injectable fillers without causing that problem?l

A: Most lip augmentation patients want a natural look. Very few want their lips too look like they have had something done, although some people do end up looking that way.The success of having a natural looking result in the upper lip with injectable fillers is based on how much native vermilion tissue (pink part of the lips) you have. The most common reason one ends up with the infamous duck lips is that too much filler has been placed into the lips. A more full upper lip can take more filler and still loko natural. But a thin upper lip can take very little without creating a pufffy look.  This is because in the thin upper lip the injectable filler does more pushing out rathe than up because there is not enough tissue. When it comes to injectable fillers in athin lip like yours, you have to realize that you can never really end up with a nice full lip look that many women desire. You just don’t have enough vermilion to do it.

What you would more ideally benefit from is an upper lip advancement which directly treats the actual problem and is permanent. But because that involves a fine line scar, I would recommend that you first do an injectable filler treatment and see of you like the results. If you do, then just continue with periodic filler treatments. If you don’t, then you know that there is another option which can give a much fuller lip that is permanent.

Dr. Barry Eppley

Indianapolis Indiana

Q:  I have HIV and have been on antiviral medication for the past 15 years. I am now trying to decide if liposuction to remove the fatty deposits under my chin, lower face and around my ears would be beneficial. I read your article and feel that you are someone who is compassionate and could help me wth this issue. I am just tired of being stared at out in public because of the way I look. I don’t want to look like a freak because of my years living with HIV and taking the medications to live a productive life. I want to find out how much this would help and what the recovery time would be.

A:  Retroviral medications in the HIV patient can cause very unique fibrofatty deposition about the cervicofacial area. Most commonly a buffalo hump can appear at the back of the neck. But extensive tissue collections can occur around the neck from one side to the other including around the ears. This makes the face look like it is sitting on a tire, so to speak, if they are significant enough. Most of these fibrofatty deposits, however, are more than simple fat that is easily suctioned out. While liposuction can be done under the chin and into the sides of the neck, the deposits around the ears and into the side of the face are best treated by open removal through a facelift approach rather than just liposuction alone. Better debulking results are obtained with this combined approach. Recovery is very similar to that of a facelift with about a 50% reduction in the bulk of the cervicaofacial tissues.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am 28 years old and have had 2 kids. I only gained about 25 to 30 lbs with each pregnancy but I still ended up with stretch marks on my lower stomach and loose skin around my belly button. I know that liposuction alone is not the solution for my stretch marks and loose skin. I am at a fairly good weight for me being 5’ 3” and weighing 130 lbs. Which type of tummy tuck do you think would be best for me?

A: While it is impossible to give an accurate assessment without photos, your description of your abdominal concern do make for a philosphic discussion between the two types of tummy tucks.   The conceptual difference between a mini- and full tummy tuck is that the more limited procedure produces less of a result (around the belly button area) but has a smaller and lower placed horizontal scar. The key question is which trade-off can you live with better…a flatter and more complete abdominal result but with a much longer and higher horizontal scar (full) or a less long lower placed horizontal scar but with some stretch marks and loose skin still left around the belly button area. (mini-) There is also a belly button scar difference as the full tummy tuck will have one and the mini-tummy tuck will not.  It really comes down to which aesthetic trade-off  (scar vs amount of improvement) is more important to you.

Many women will less severe lower abdominal concerns (excess tissue) do opt for a mini-tummy tuck. When combined with liposuction in the upper abdomen and around the sides of the waistline, this more limited tummy tuck approach can provide for good improvement with a very acceptable low-placed scar.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am interested in making my face look thinner. Even though I am not fat (below the neck), my face make me look like I am. I have read about the buccal lipectomy procedure and that seems like it would work for me. I am most interested in getting the lower part of my face thinner. I have attached a front picture for computer imaging to see what the change would look like. Thank you for your help!

A: Thank you for sending your frontal picture. I have imaged the result doing buccal lipectomies (upper submalar triangle) and some perioral mound liposuction. (lower submalar triangle) It is important to realize that these procedures are most effective for the areas below the cheek down to about the mouth level and not for fullness at the jaw angle or in the lower part of the face. Facial defatting procedures work best in areas that are not directly supported by bone where the fullness is more the result of the thickness of the fat and not the bone. In bony-supported facial areas, thickness or projection can only be reduced by bone reduction which is often not only difficult but not that effective. There are no effective lower facial procedures (sides of the face and along the jawline) for defatting or making it look thinner.

Dr. Barry Eppley

Indianapolis Indiana

Q:   Dear Dr Eppley. I am wondering if it is possible to get a variation of genioplasty done.
I am wanting to reposition my chin bone higher up. In reduction genioplasty the chin tip is sawn off, a wedge of bone is removed and the chin repositioned back.Is it possible to saw off the end of the chin, then without removing any bone, reattach the sawn off tip at a higher position? This could help address saggying tissue as the higher position of the bone could help lift the surrounding tissue. This would leave a bony ridge on the chin, however this could be hidden with fillers.Does this type of surgery sound like something you could do? Thank you.

A: That is known in chin surgery as a ‘jumping genioplasty’. That places the cut piece of chin bone on top of/in front of the upper chin segment. However this will bring the chin forward and make it more prominent, although it would lift up sagging chin tissues and shorten its vertical length somewhat.

By your descriptions, I think you may have an erroneous concept of how chin osteotomies are done. It is important that the cut piece of chin bone remains attached to the muscles which provide it with a blood supply, otherwise it will die and resorb away. It is not just moved anywhere else one wants to put it.

Perhaps you could send me some pictures so I could see what type of chin problem you and what may or may not work.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I had a septorhinoplasty about six weeks ago. As a male, I was told that my thick oily skin will cause a lot of swelling in the tip of the nose that will take longer to settle down and go away. My concern is not the swelling in the tip of the nose but that it is drooping and the columella seems to be hanging too low. These were two key issues that I really wanted improved but right now it does not look like this has been achieved. Is it possible that my concerns are just do to swelling? Should I be considering early revisional  surgery?

A: While it is still early in the rhinoplasty healing process, some improvement in the major focus of the nose should be evident at this point. There is no doubt that swelling is still present at this point and it may be considerable. So all hope is not lost that the final result may still turn out satisfactory. Whether revisional surgery may or may not be needed can not be foretoold at this early sfter surgery point. What you don’t want to do in consideration of revisional surgery, however, is chase a ‘moving target’. Give the nose a full six months after surgery and then go back and get a more useful after surgery evaluation from your plastic surgeon. What matters most at thaty point is how is how much change has occurred from now until then. If improvemenmt has been seen, then more time may be adviseable. However, if there has been no visible significant change between 6 weeks and 6 months after surgery, then revisional surgery is going to be needed.

Dr. Barry Eppley

Indianapolis Indiana

Q: Hello, I am looking the best procedure for diminishing marionette lines, over lips, and most importantly, droopy skin on the neck. What do you recommend?

A: In reading your question, I am going to assume that you mean marionette lines that start at the corner of the mouth and hangs over the corners. (hence the phrase ‘over lips’) When you combine those aging facial features with droopy neck skin, you are talking about a combined neck-jowl problem. Heavy marionette lines that hang over the mouth corners indicates that there is likely some jowling and skin that is falling forward and down…the reason thaty most marionette lines exist. While I obviously have not seen any pictures of you nor have examined you, all of these aging facial issues point to one and only one effective treatment option…some version of a neck-jowl lift. The key issue is the droopy neck skin. Nothing short of this type of a tuck or lift can change a loose neck skin issue. This is often combined with a corner of the mouth lift to get rid of the overhang, a small little procedure done at the corner of the mouth. This will most effectively get rid of the loose neck skin, ‘over lips’ and decrease the depth of the marionette lines.

It would be helpful to see some facial photographs or come in for an evaluation to confirm this potential recommendation. These are common facial aging problems where patients are often searching for some ‘simple’ or non-surgical approach where such treatments do not really exist. You want to avoid wasting money on any non-surgical treatments that really have no hope of making a substantive difference…and there are lots out there that sound good but don’t work very well.

Dr. Barry Eppley

Indianapolis Indiana

Q:  I am interested in making my existing breast implants bigger. I am unsure as to whether it is better to just add more saline to my existing implants or to get new implants altogether. I currently have Mentor smooth round moderate plus saline implants which are 325cc. I am fairly small being 5’ 3” and weigh 108 lbs. I started out as an A cup and am now a C cup. Would adding 50cc to my implant make enough of a difference?

A: The answer to your question can be partially deduced by analyzing the percent change by ratio assessment. With existing 325cc implants, an additional fill of 50cc will make a 15% change in their volume. This will make a noticeable size difference with your small frame but don’t expect it to make a 1/2 or full cup size difference. Also, further saline fill will make the implants feel a little firmer. Assuming that the base size of your implants was 325cc, an additional 50cc will not make them feel abnormally firm. This is a good approach to enhance what you already have for a little ‘perk-up”. But if you are looking for a significant difference in breast size like a D cup, you will need to redo your breast augmentation with new implants that have a larger base size.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  I am 24 years old, 5′ 4” tall, weigh 135lbs, and have 38DD breasts. Am I a good candidate for breast reduction and could it be covered by insurance? My back, shoulders and neck are always sore and I get migraines in the back of my head all the time. I wear loose clothes to hide my hideously large breasts and I would never even think of wearing a swimsuit for fear that I might fall of it! I just want to be physically and emotionally happy, but its hard with my unproportioned body due to my large breasts. Insurance is the only way possible for this surgery to happen if I qualify.

A: Based on the size of your breasts and your height and weight, it would seem likely you’re your breast reduction would qualify for insurance coverage based on my experience. But whether one’s medical insurance will provide can not be determined by your plastic surgeon. Insurance coverage for breast reduction requires a predetermination letter to be sent by your plastic surgeon with specific qualifying information. Your height, weight, breast cup size, history of medical symptoms associated with your large breasts, what non-surgical treatments have been attempted, and how much breast tissue in grams is to be removed is the needed information. This letter, complete with photographs of your breasts, will be submitted for their review. They will then determine if you qualify and their decision with be returned by letter to you in about 4 to 6 weeks after submission.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr Eppley, I was involved in a car accident several years ago which left me with a big ugly scar on my upper lip. The scar connects with a scar on my nose. It seems like I don’t have that line (margin) of the lip as it is flat. The scar has been revised several times but there has been no improvement. I was wondering if anything can be done to make that line/margin of the upper lip? I know the scar won’t disappear but at least just to have some improvement. Your help will be greatly appreciated.

A: While I would have to see pictures of the lip scar to be certain, it sounds like you are talking about loss of the philtral height or the philtral ridge. When a scar crosses it, it will likely lose its height or prominence. A skin scar revision alone will not restore the height of a philtral ridge. I have found that an allogeneic dermal graft placed under and along the philtral column underneath the scar area is necessary to resist scar contracture. Please send me some photographs of the scar for my assessment.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Hello, I had submental chin implant revision surgery and lipo under the chin. The incision was made in my natural crease and is extremely apparent. Also, it seems as though after the surgery, I have jowls that I have never had before. People think I lost a lot of weight. Is there anything that can be done to correct either situation reasonably? Thank you for your time.

A: The placement of a submental (under the chin) incision for chin augmentation is a fairly simple and straightforward consideration. Most people have a skin crease on the underside of their chin and this is a logical incision location. But depending on the location of this crease and the size of chin implant to be placed, this may not always be a good location. The chin skin stretched forward due to the push of the implant and what was once a hidden location may become more visible. For this reason, I often move the incision location slightly behind the submental skin crease to avoid any potential that it may become visible. Once the incisional scar location is set, there is no way to relocate the scar.

The development of jowls after chin augmentation may be the result of the wings or sides of the chin implant. Chin implants today are more anatomic in design and often will have long extensions that go back from the sides of the chin into the body of the jaw. If these wings get folded unto themselves and are not fully extended due to a pocket dissection that was short, the folding of the implant’s wings could create the look of jowls. If this is the problem, it can only be resolved by revisional chin implant surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Hi Dr. Eppley, I recently had a revison gynecomatia surgery to remove scar tissue about 3 months ago and now I have even more scar tissue buildup than I had before. I have a big lump under my left nipple and was wondering if I it was possible to get 5-FU injections to reduce the scar tissue because I heard that Kenalog can have significant side effects. My doctor does not offer 5-FU and I have heard that this needs to be injected within the first few months after surgery to have an effect so I would like to get this done if possible. I would appreciate hearing back from you and helping me out with this if possible. Thank you!

A: At this early point after your revisional surgery, it is reasonable to consider a non-surgical treatment for your recurrent scar tissue. If significant improvement was to occur, you should be seeing it by now. The standard injectable scar treatment is Kenalog. While there are potential side effects (fat and skin atrophy), these are very much dosage and location dependent. High and frequent injections of Kenalog in skin level scars can cause these problems. But low doses of Kenalog done judiciously for subcutaneous fibrosis is unlikely to create these potential problems.

5-FU scar injections are useful in scar issues that have proven resistant to Kenalog. While there is nothing wrong with using it as a first choice therapy, it may or may not be necessary. When administered it is mixed with either a small amount of Kenalog or local anesthetic since there is definite burning afterwards associated with 5-FU injections. You are correct in assuming that these injections should be done early as they work best when new scar tissue is forming as opposed to long-stand established scar tissue.

Dr. Barry Eppley

Indianapolis, Indiana

Q:   I am 52 years old and have myasthenia gravis. I had a thymectomy 23 years ago and currently have very minimal symptoms. I am interested in reducing the appearance of aging, especially in the neck and jowls. Is the IGuide or another minimally invasive procedure recommended for patients who have myasthenis gravis? If not, what are my options to improve my appearance?

A: Having the condition of myasthenis gravis (MG) poses potential issues for anesthesia for surgery but not for the surgery itself. You are likely interested in minimally invasive facial surgery because of its often association with local anesthesia and potential avoidance of general anesthesia. What you want to avoid with any form of anesthesia is a myasthenic crisis. This occurs when the muscles that control breathing weaken to the point that ventilation is inadequate, creating a medical emergency and requiring a respirator for assisted ventilation. This is most likely to occur in those MG individuals whose respiratory muscles are weak. This does not appear to an issue for you whose has minimal symptoms. Nonetheless, it is best to avoid any form of general anesthesia particularly for elective cosmetic surgery.

The IGuide neck procedure, a more limited type of necklift (e.g., Lifestyle Lift) or both done together are procedures which are effective in individuals with early to moderate neck aging issues. Whether any of these are good procedures for your neck and jowl concerns can only be determined by doing an assessment of some photographs.  They can be very successfully performed under local anesthesia supplemented by either oral or light intravenous sedation.

Dr. Barry Eppley

Indianapolis, Indiana

Q:   I have a scar tissue under my cheek bone caused by injecting an Artefill or Sculptra filler.  It’s been there since the filler was done 6 years ago. Now I’m been treated with 5-FU and Kenalog injections. I have done only 3 treatments so far but with no results. Do you think that the treatment can help to rescue the size of the scar or is there no hope?

A: Most likely your residual cheek mass is the result of an Artefill treatment and not Sculptra. Artefill is a filler that has a significant component of non-resorbable acrylic beads which settle into place by scar tissue forming through and around them. The beads are permanent. Sculptra is composed of resorbable poly-lactic crystals which causes temporary scar formation to occur which eventually goes away as the crystals eventually dissolve. After 6 years you have a residual mass that is, at least partly, due to the acrylic beads. While I think the 5-FU/kenalog scar injections are reasonable to try, I suspect they will ultimately prove unsuccessful as they are not going to make plastic beads disappear. Furthermore, this injectable scar treatment works best on scar that is newly forming not on established scar tissue.

That being said, 5-FU/kenalog scar injections often take a full course of treatment to know to be maximally effective. You have had only 3 injection treatments and the complete protocol is up to 10 injection sessions so it is too early to rule out completely that they will not work at all.

Depending upon the cheek mass/scar location, it may be more efficient to have it excised if it can be approached favorably through an intraoral (inside the mouth) incision.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I will be having nose surgery soon and one thing my doctor recommended was to cut the muscle that makes my nose tip droop when I smile. While this has been told to me as a simple step in the surgery, I am worried that my smile or, more specifically, the way my upper lip moves will be abnormal after the procedure. From your nose surgery experience have you ever seen this to be a problem?

A: For some patients, they have a hyperactive or large depressor septi muscle that pulls the tip of the nose downward when they smile. This is often resolved during rhinoplasty surgery when the tip of the nose is made stiffer through cartilage grafts and sutures,  a secondary benefit from the primary objective of nose tip reshaping.  One simple way to ensure that this result happens is to also release the bony attachment of a tiny muscle that runs from the tip of the down to the upper jaw bone, the depressor septi muscle. This muscle is not one of the smile muscles and has no role to play in how one’s mouth or lips moves. However, because the dissection to get to the muscle goes through a portion of the upper lip (either underneath the lip through the frenulum or from inside the nose), there will be some swelling of the lip for several weeks afterward. This swelling will temporarily affect the shape of the upper lip and may make the smile more ‘stiff’ until it goes away. But releasing this muscle will in no way affect how one smiles once it is healed.

Dr. Barry Eppley

Indianapolis Indiana

Q: This is in regards to an unusual form of craniofacial surgery which I have been hoping to obtain for many years.  I have a slender jawline and forehead, somewhat prominent browline, and both wide and prominent cheekbones.  I was wondering if it were possible to have the cheekbones (by which I mean the zygomatic bone itself, the temporal process, and then the zygomatic process of the temporal bone) replaced entirely by synthetic implants so as to make my face more slender and these features, in particular, well-proportioned to the other features of my face.

A: The slimming effect to which you refer is known as cheek or midface reduction. To do so by conventional craniofacial surgery is well known and the techniques well established. It is a more common request in the Asian poopulation due to their facial shape. Complete cheek reduction is done by osteotomizing the front (zygomatic process) and back part (temporal process) of the cheek, removing bone, and allowing the enture zygomatic bone and arch (which creates the facial width) to move inward. The new bone positions are then secured with small plates and screws. This is done through an incision inside the mouth and a small incision in the temporal hairline. One can usually get a bifacial narrwoing of around 1 to 1.5 cms.

While any type of implants can be fabricated off of 3-D C scans and models, it is not practical to replace the entire zygomatic complex and arch to obtain midfacial narrowing. This would require extensive surgery, a large scalp incision, the removal of masticatory muscles which are attached to the bones, and the significnt risk of facial nerve injury. While this is done for extensive traumatic bone injuries and tumor resections, those risks for a cosmetic concern are not reasonable. This is particularly true when you consider that the same if not better result can be obtained by less invasive and ‘simpler’ surgical techniques.

Dr. Barry Eppley

Indianapolis, Indiana

Q: With all of the jaw angle implants that you have placed, what are the most common complications? What problems have you see long-term? Are they permanent or would I need another in future?

A: Jaw angle implants, in my experience, are uniquely different than all other types of facial implant locations. Because they are put under the biggest muscle in your face (masseter muscle), and the only facial muscle that actually moves a bone (mandible, lower jaw), there is more discomfort and recovery from the procedure than any other facial implant procedure. The sides of the jaws are fairly swollen and the mouth will not open normally for a few weeks. (trismus) This is due to the stretching and trauma to the masseter muscle. Because it is a large implant that is put in through the mouth, the risk of infection seems to be higher than any other facial implant.  Despite doing  every infection precaution available, I have found that the infection rate is about 5% of all patients implanted, necessitating removal and/or replacement. The other complication risk is asymmetry. Because the implants are on opposite sides of the face, it is challenging to always have a perfectly symmetric result. (many patients don’t have jawbone/angle symmetry to start with) This leads to a revision rate for symmetry correction in jaw angle implants of around 5% also. Collectively, this means that one out of every ten jaw angle implant patients will need some sort of revisional surgery. These complications are seen early within the first few weeks to several months.

On the good news side, jaw angle implants are permanent and will not change over one’s lifetime once successfully implanted amd healed into place.

Dr. Barry Eppley

Indianapolis Indiana

Q: I had a tummy tuck recently and as part of it my muscles were sewn back together. I was told there were several inches apart.  My tummy now is very flat in the lower half but the upepr half still has somewhat of a bulge. Do you think that is because the muscles weren’t sewn up togethere this high. I am confused as I thought the whole tummy would be flat from top to bottom. What are your thoughts?

A: The purpose of sewing the vertically-oriented rectus muscles in a tummy tuck together is to help correct one part of the tummy bulging problem. How much tummy skin and fat you have makes up the other components of the bulge. This muscle sewing is usually done from just under the rib cage in the middle (top of the inverted V) the whole way down to the just above the pubic bone. But it is up to the plastic surgeon’s discretion as to whether it is beneficial to cover this entire vertical length or not. More pain after surgery comes from more muscle sewing so there is no reason to do more  than is really needed. Not every patient needs the entire vertical length of the muscles swen together as tight as possible.

It is extremely common to see a different amount of improvement in the tummy bulge from that above the belly button to that below it.. The best result is seen between the belly button and the pubis because this is where the skin and fat have been completely removed and replaced with skin and fat from above. Between the rib cage and the belly button, there still may be some remaining bulge as this skin has just been pulled down and stretched but not removed. That is likely the reason you have some bulge remaining in this area, not because the muscle hasn’t been sewn back together. In thin women, this issue may not appear. But in those patients that had thicker amounts of fat under the skin in the upper abdominal area to begin with, the upper tummy area will not be as flat as the lower. This can be improved later with some liposuction to thin out the tissue thickness in this upper tummy area.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am a 35 year-old man with a facial condition known as Binder’s syndrome, you may be familiar with it as a craniofacial plastic surgeon. My whole midface is back and I think I need a combined LeFort III and LeFort I osteotomy. My upper teeth are a bit forward of my lower teeth so it is a bit of an overbite. My thought is that the LeFort III would bring out all the backset midface bones and then at the same time a LeFort I could be done to bring my teeth back into place. I am not contemplating having any orthodontic treatment before surgery. I have attached some pictures of my face for you to see. What do you think of this plan?

A: I am very familiar with Binder’s syndrome, also known as nasomaxillary hypoplasia. You definitely have a rather severe manifestation of it with the entire midface quite retruded. Your basic thoughts on the need for midface advancement is correct but what it is not obvious to you is how one’s bite relationship controls whether and how any type of orthognathic surgery is done.

Let me give you some clarification on your LeFort concepts as they are understandably not accurate. You can’t separate or differentiate different levels of a LeFort osteotomy regardless of  type. You either have to do a LeFort III or do a LeFort I, you can’t do both at the same time. That make look like it would work on drawings or on paper, but it does not work that way in practical application. The bottom line is while your facial deformity would ideally benefit from a LeFort III advancement, your bite does not support that facial skeletal change. That would put your upper teeth (provided that the bone would actually move that far which I doubt without external distraction) greater than 10 mms in front of your lower teeth. (and no you can’t do a LeFort I setback later as a secondary procedure) The irony is that your bite, for whatever reason, is simply too close to normal to support any of these LeFort procedures even though your facial skeleton could use it.Your bite with the amount of midfacial deficiency that you have should show a severe Class III malocclusion (underbite) which it does not. I have never seen such a combination of severe midfacial hypoplasia with a relatively normal bite before.

This leaves your only practical treatment solution as an augmentative or camouflage approach, which is actually much easier on you. The midface can be brought forward through infraorbital rim-malar and paranasal implants combined with a rib graft rhinoplasty. This concept builds on top of the existing midfacial skeleton rather than trying to move it forward. As an additional benefit, the brow bones/supraorbital rims can be set back as they have a large amount of bossing. The combination of all these facial procedures does a pretty good job of improving your facial balance. I have attached some imaging which shows those changes.

Dr. Barry Eppley

Indianapolis Indiana

Q:  I am a fit 24 year-old guy but I don’t like the look of my cheeks. They are definitely chubby and they don’t fit my face or the rest of my body. I would to get rid of my chubby cheeks, All my family have chubby cheeks and they don’t look good on them either. I have read on the internet about different cheek procedures such as excision of the bichat fat pad, liposuction and smartlipo? Can you please tell me what to do?

A: Chubby cheeks or fullness in the cheeks is caused by excess fat in two different areas not just one. The upper submalar area (right below the prominence of the cheekbone) is where the buccal fat pad (formally known as Bichat’s fat pad)  lives. The lower submalar area, unlike the buccal fat pad, is not one large piece of localized fat but is composed of diffuse subcutaneous fat. (fat layer between the skin and the buccinator muscle) A buccal lipectomy which is done from a small incision inside the mouth will help reduce the size of the area right under the cheek. But a buccal lipectomy will not change the fullness below that in the lower submalar area closer to the level of the mouth. These are perioral mounds which can be reduced by very small cannula liposuction done from inside the corners of the mouth. Both locations of fat removal are needed to get the best reduction of chubby cheeks.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am a 35 year-old mother of four who is tired of my stomach hanging over my pants. I need some type of surgery to help shape up my stomach area. I don’t know whether it should be just liposuction or some form of a tummy tuck. The main reason I want this surgery is that no matter how hard I work out or diet, it just won’t go away. I’ve got a very persistent pooch and it really needs to just go away! Which do you think is better, liposuction or a tummy tuck?

A: While an actual examination with a plastic surgeon is the only way to know for sure, there are several key statements in your inquiry that give it away. The mixture of having had four children and a stomach that hangs over your pants indicates one key thing…you have too much stomach skin.While there no doubt is some fat under there as well, the key indicator of the choice between liposuction and a tummy tuck is how much extra skin is there. Liposuction can effectively remove fat but it has little skin tightening capability. A tummy tuck very specifically addresses the excess skin issue that exists from one hip to the other. Liposuction is quite often part of many tummy tucks in a complementary role as it helps reduce the muffin tops that most people have off to the sides of the tummy tuck. The combination of a tummy tuck and hip/flank liposuction creates a better waistline result that wraps around to the back.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am interested in shortening my upper lip. It is way too long. It is big enough that you could land a plane in that part of my face! I have read about the subnasal or bullhorn upper lip lift and that seems like a good solution to my problem. However, I am Hispanic and am concerned about the car under my nose. I have read about the Italian upper lip lift which does not create the scar under the middle part of the nose. Do you think this is a good option for me?

A: The only way to really shorten an upper lip is to remove a strip of skin, either across the subnasal base (under the nose) or across the top of the cupid’s bow. in the ‘Italian’ version, the select removal of skin from just under the nostrils will not significantly shorten the upper lip. That published article, which I have read and reviewed in the past, is quite frankly flawed. All of the patient results shown have the after photos with the head tilted upward which makes it look like the lip is shorter. (or the before photos have the head tilted slightly downward to make the lip appear longer than the afters) While I don’t think the authors deliberately meant to deceive the readers, the results do not support that it actually works. While having less scar under the nose is certainly appealing, the upper lip is not going to get shorter if the central part under the columella is not removed. That is the cornerstone of upper lip lifting. With your ethnicity and skin pigment, a scar anywhere is always a concern more of a concern than it would be in a Caucasian patient. It may be for that very concern that the Italian upper lip lift was devised.

Dr. Barry Eppley

Indianapolis Indiana

Q: As a 59 year-old female, I am interested in the corner of the mouth lift. I had a facelift four years ago which did help the corners of my mouth to some degree but they need more attention. They are still downturned to some degree. Any info or photos would be appreciated.

A: Contrary to popular perception, a facelift has little effect on the corners of the mouth. In general, a facelift will not turn up corners of the mouth that are drooping down. It will have a very mild effect but nothing significant. This runs contrary to the fear that the corners of the mouth can be pulled way to the side and distorted if a facelift is ‘overdone’. Such is not the case. The mouth is a long way from the point of pull which is by the ears in a facelift. By the time the pull force reaches the mouth, it has little power left to much of anything. The downturned corner of the mouth must be attacked directly with a procedure right at where the problem is located.

The corner of the mouth lift is a simple office procedure done under local anesthesia. It involves the removal of a small triangle of skinjust above the downturned corner. In its replacement, the mouth corner is moved upward. It can be done conservatively or more aggressive depending upon the degree of downturning of the corners of the mouth. There is virtually no recovery other than some persistent redness at the corner of the mouth for a few weeks. This simple mouth procedure is powerfully effective.

Dr. Barry Eppley

Indianapolis Indiana

Q: Dear Dr. Eppley, I read your article where you speak about chin implants and you say: “Lateral or wing malpositioning is actually the most common problem and is a result of the newer styles having thin and more floppy wing extensions which can easily fold onto themselves” . I would be most grateful if you could advise on the best way to correct misplaced wings on the side of the jaw.

A: Unlike chin implants of old, most contemporary chin implant styles are more anatomic in design and shape. This means that rather than having a simplistic button or oval shape that just sits on the very end of the chin bone, they are longer and wrap around the bone to flow more confluently into the body of the mandible. This gives them long wings or lateral extensions along their sides. With silicone chin implants, these wings have thinner material thicknesses that end in minute paper-thin extensions. Because silicone is flexible, this makes them prone to fold upon themselves or buckle if the implant pocket is not dissected far enough back. Also they can ride upward or downward based on the angulation of the pocket dissection. Either way, these implant wing malpositions will be felt or seen as a lump or bump along the jawline. With Medpor chin implants, these wing malformations do not occur as the material is much stiffer and not flexible so the ends do not bend.

With chin implant wing malformations, the only way to correct them is to do an open revision. The implant is removed, the pocket checked and dissected further if needed and the implant then re-inserted. In some cases, the fine ends of the wings are removed as they serve no volume or contour purposes.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  I have a ruptured implant and am in need of a breast augmentation revision. I have always thought they were a little too large.  I’m wanting to downsize 25cc; they are different sizes, 275cc on the left and 250cc on the right. When downsized, I would then have 225 and 250. I’m worried about the 275 to 250 because the diameter is so much different. Is this going to look change the look dramatically?

A: In answer to your question, I would have no concern about such a small implant volume change on the breast look. A change of 25cc in a 250cc implant is only a 10% change in volume and would be less than .5cm in base diameter of the implant. In a 275cc implant that volume changes drops to only 9%, a change that is hardly visible. With either implant, that would likely have a minimalistic change in the outer breast appearance. In the case of saline breast implants, there are a lot of variables in implant selection such as their base size and what they are filled to as well as the projection or profile that they have. Such variables can make a visible external difference and all must be considered. With silicone implants, they are prefilled and their only variable is the different projections. (low, medium, and high) As a general rule, visible changes in the size of the external breast when it comes to a breast implant exchange should be in the percent volume change of 20%. Therefore, if one wants to have a smaller breast size with an existing 250cc implant, the downsized implant should be 200cc.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I had bariatic surgery four years ago. This has left me a lot of loose hanging skin as well as a prominent and painful bulge around my belly button. I have been told that it is a hernia and it certainly feels like it is. Are you qualified to fix a hernia and do tummy tuck? What is the normal price for this type of procedure as I currently have no insurance?

A: Thank you for your inquiry. It is extremely common to have to do a hernia repair with any type of abdominal contouring procedure for the bariatric patient, whether it is a simple abdominal panniculectomy, a fleur-de-lis abdominoplasty, or a circumferential body lift. Hernias are now less frequently found with the newer laparoscopic bypass surgeries than with the older open approaches but they are still relatively common. As a plastic surgeon, we routinuely fix hernias using a muscle repair technique rather than the placement of any type of synthetic mesh. This is easy to do with the wide open exposure that occurs with the tummy tuck procedure.

The cost of a ‘bariatric’ tummy tuck can be quite variable based on what type of abdominal procedure is really needed. There are three basic options for the extreme weight loss patient, whether they have lost the weight by bariatric surgery or not. There are two types of frontal cutouts (panniculectomy, fleur-de-lis tummy tuck) and the circumferential body lift. (360 degree tummy tuck or tummy tuck combined with a hip and buttock lift) To get an accurate quote, one has to know exactly what is going to be done. This being said, as an outpatient procedure done under general anesthesia, the total costs can range from $ 6,500 to $ 9,500.

Dr. Barry Eppley

Indianapolis, Indiana

Q: The back of my head is very flat. As a child in school, they used to make fun of me  because the back of my head was so flat. While I want to wear my hair short, I can’t because it becomes really apparent. I have attached some pictures showing how flat it is. Because of my longer hair, I have drawn a line indicating the actual shape of my head beneath my hair. I want to add up to an inch to the whole backside of my head to give a more rounded shape. Do you think it is possible with the Kryptonite material and not having to make a big incision across the back of my head?

A: Thank you for sending your pictures. It is easy to see, even with your hair, how flat the back of your head is. Yes it is possible to build out the back of your head with a minimally invasive cranioplasty technique using Kryptonite. However there are several caveats about the outcome with this cranioplasty method. The build-out of your skull can not go below the lowest level of the occipital bones which is about at the mid-level of the ear. (you can feel how high the end of the occipital bone sits with your fingers. Most people think that the bone goes much lower than it does. Any cranioplasty material can only be put on bone not muscle. A skull build-out of as much as an inch may be too extreme due to scalp expansion issues, a more likely result is 1/2″ to 3/4″ at the very center. (midline)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Hello Dr Eppley, I am a boxer and wanted to get a sliding genioplasty. I am recessed by about 10mm’s and was wondering if I would be able to box after this chin surgery. If so, how long after surgery can I do so? Thanks for your time.

A: For your chin deficiency, a sliding genioplasty is probably a more wise decision than an implant given your boxing avocation/occupation. A chin implant may have also worked as long as it would be secured with 3 to 5 screws. It would have a quicker recovery and return to boxing (1 month if contact to face may occur, training part doesn’t matter) but there is always the potential for some implant related problem long-term if struck on the chin. (which I assume is common on boxing) For a chin osteotomy, the return to contact boxing should be 3 months at least although training could occur at any time one felt comfortable. You could argue that the bone is not really healed in a big advancement (10mms) for up to 6 months so this is a more conservative estimate. With the osteotomy in your case, I would secure it with more than the traditional chin plate (step plate) and 4 screws. I would probably add a small plate on each side of the sliding genioplasty for the extra security of the bone position.

Dr. Barry Eppley

Indianapolis, Indiana