Your Questions

Q: I am 38 years old, have breast fed two children and definitely sag some. While I never had big breasts, they have now completely gone away! My bra size is 34A. In addition, I have a wide sternum and my breasts appear to be fairly far apart. I think a good breast implant size for me is around 350cc. In order to get cleavage, should the implant be placed above or under the muscle?

A: While implants do a wonderful job of making breasts larger, they do not usually result in cleavage on their own. With widely separated breasts, cleavage will definitely not result from the placement of any reasonably-sized breast implants whether they are placed above or below the muscle. At 350cc, a moderately-sized implant for your chest, cleavage is not a realistic possibility. Trying to make cleavage by going above muscle with your small breast volume is a mistake in my opinion. The implant is at much great risk of hardening over time (capsular contracture) and runs the risk of resulting in synmastia (the joinging of the two breast pockets in the middle, a uni-breast so to speak), which is a very difficult problem to correct. Settle for the better long-term breast augmentation result of under the muscle and accept that cleavage without a bra is not a possibility with your breast/chest anatomy.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am interested in making my forehead more vertical and round. I also want to have more height and width of the top of the skull. Do you think this is possible using the injectable Kryptonite method? I have attached some pictures for you to see the shape of my forehead. Let me know what you think.

A: Thank you for sending your pictures. I think I understand completely your forehead shaping objectives which would involve a cranioplasty fill of the forehead to make it more vertical from the brows up in profile (increased convexity) and to add width in the frontal view.  This fill, in essence, is really to camouflage the slight brow bone prominence you have and will make the entire forehead more smooth and confluent. I have attached some imaging which is limited by the quality of the images you sent but I think it conveys the objectives.

In achieving this result, I do not think the injectable approach is best. It will take a prohibitive amount of material (cost wise) and the shaping must be perfect to have a happy end result. The evolution of the injectable cranioplasty approach is not quite far along  in terms of experience to reliably give the best result for this more complex reshaping of a very visible facial area.Therefore, an open approach is best using PMMA (acrylic). That will allow an adequate amount of material to be used at a reasonable cost and get the best shape and smoothness of the forehead augmentation. The open cranioplasty approach in a male, however, is limited by the willingness of the patient to accept a scalp scar.

Dr. Barry Eppley

Indianapolis Indiana

Q: How much would the injectable Kryptonite bone cement option cost. A ballpark figure would suffice, thank you.

A: The cost of injectable cranioplasty varies greatly based on the size area of the skull being treated and the amount of Kryptonite material that is being used. The actual cost of the Kryptonite material from the manufacturer is tremendously expensive and can potentially make up to 25% to 50% of the total procedure cost. The best ballpark that I can can give you is anywhere between $ 6,500 up to $12,500. The best way to get a more accurate answer is to send me some pictures of your skull or forehead concerns so I can see the size area involved.

Dr. Barry Eppley

Indianapolis Indiana

Q: I have a question about reducing a bulge on the side of my head. I have cranial/skull assymetry and wanted to know if I can get the side of my skull shaved down/reduction a bit so I can get a more even look on both sides. The right side of my head sticks out more then my left, it’s noticible expecially because of the close cut haircuts I love to get. Is shaving down or skull/cranial reduction possible or an option?  I have attached some pictures of my head from the front so you can see it. It is fairly obvious I think. Thanks, hope to hear from you soon.

A: What is you have is skull asymmetry caused by a bulge in the temporo-occipital bulge region or side of the skull. It is actually a combination of fullness of the back end of the temporalis muscle and the front edge of the occipital bone where the two actually come together. Both are easy to reduce, and need to be reduced to get the narrowing effect, and about 5 to 7mms of reduction/narrowing can easily be obtained, maybe more. There is no danger to the procedure nor is there any risk to any nerves in so doing. The issue of whether this is a good procedure for you or not is completely about the vertical scar running over the bulge to do it. The scar is the only risk in doing what is otherwise a fairly simple procedure. Given your close haircuts, it is a question of the trade-off of a more symmetrical skull versus that of a fine line scar when considering a skull reduction procedure.

Dr. Barry Eppley

Indianapolis Indiana

Q: I had saline breast implants placed two months ago. Today I felt the implant at the bottom of my breasts. When i touch the bottom of my breast I feel the implant itself. I don’t know if this is normal or not?? Please advice.

A: The feeling of saline implants at the bottom of your breasts could be one of two phenomenon. First, it is likely it is completely normal if it is present on both sides. Initially breast implants can be initially high and then they eventually settle lower. Because the implant is only partially covered by the pectoralis muscle (the upper half), the bottom pole of the breast has the implant covered by just skin and whatever breast tissue you had to start with. Since saline implants will usually develop a little rippling in the implant shell, this is most palpable at the bottom and the sides of the breast. This is initially not able to be felt because of the tissue swelling and skin stretching which takes several months to go away. Since you are two months out from surgery, you are exactly in the time frame when this will occur. The other possibility, particularly if it has happened on just one side, is that one of the implants has bottomed out. (dropped too low) You would know this because the breasts would be asymmetric. (unless it has occurred on both sides)  But either way, it would be apparent because the implants look too low. That is a surgical (revisional surgery) problem.

Dr. Barry Eppley

Indianapolis Indiana

Q: I want to get breast implants but am concerned about the scar. I really don’t want  a scar on my breasts anywhere as I think that would look bad. Who would care how big my breasts were if they were badly scarred? I have read about the belly button insertion of breast implants and there seems to be a lot of negative comments about it from other plastic surgeons. Do you agree with these feelings? What are the problems with putting in breast implants this way? It just seems to make sense to me that it is the best way to go.

A: When considering breast augmentation, the size and location of the incision is one important consideration to most patients. But one must remember that the incision is not the operation, the breast implant and its proper positioning is. Going through the belly button does provide a hidden scar but does so at the expense of several significant disadvantages for the final breast implant result. Besides being only able to use saline breast implants, there are potential problems with getting them in the right pocket and having good symmetry afterwards. At the least, these risks are higher when going through the belly button as opposed to any of the other three options. If one wants a hidden scar, a transaxillary (through the armpit) incision can be used without incurring a higher risk of other potential implant-related problems. This approach is more direct and gets the implant immediately underneath the muscle. The belly button incision offers no advantages at all over the armpit incision.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am interested in getting a Vi Peel to improve my skin’s texture and appearance. I am specifically trying to get rid of some wrinkles, get a collagen boost and take away brown spots on my face. Can you do some computer imaging on my attached pictures to show me what I would look like after this chemical peel treatment?

A: Thank you for sending your pictures. Unfortunately computer imaging is not ideal for skin texturing predictions. With imaging tools it can be made to look completely smooth and flawless (like airbrushing of the models in magazines)  but that is not what the purpose of computer imaging is. It is intended to help a patient understand the improvement so they can see whether the changes are worth the investment. By making your skin look perfect, you will not doubt be motivated to do the peel…but that doesn’t mean the chemical peel can create that same result. In this context, computer imaging can be deceiving. Computer imaging is best reserved for facial  structural change predictions…where a patient is taking their face to a place where it has never been…as opposed to trying to return to a place that they were once more familiar.

By the way, a Vi Peel is a great facial skin treatment and will definitely help you achieve many of your stated goals

Dr. Barry Eppley

Indianapolis Indiana

Q:  Hi I would like to inquire about information for the correction of facial asymmetry. I have been irritated by the clear tilt in my cheeks and jaw for sometime. My head just doesn’t appear to sit on my neck correctly. After reading your artilesl very carefully I feel I may be a candidate for this. I must stress I understand perfection is unobtainable, however, this has bothered me for sometime. I hope someone can get back to me.

A: The origin of many facial asymmetries is developmental, the facial skeleton is rotated based on a skull growth issue. In craniofacial biology, it is well recognized that how the skull forms through plate expansion and underlying brain growth has a major inflence on how the facial bones develop. If the skull is twisted to any degree so will be the face. This can affect everything resulting in asymmetries of the forehead, brow bones, orbits, cheeks, nose, and jaw.

This facial asymmetry can be camouflaged, or made less apparent, by making adjustments to any of the facial prominences/flattenings. This could include bony reductions or shavings or augmentation through the use of implants. It takes a careful analysis to choose a balance of bony reductions and augmentations to achieve the look of improved facial asymmetry. What procedures would be of most benefit to any particular patient would depend on their individual anatomic issues. Common procedures include forehead augmentation, brow bone reduction, cheek implants, chin osteotomies and jaw angle implants.

Dr. Barry Eppley

Indianapolis Indiana

Q: Hi Doctor Eppley. I’m a 19 years of age male and I have a mild flat spot on the back of my head. It’s not that bad but I would still like to know if it’s possible to treat it and be able to achieve good aesthetic results and shape it to be more round. Also, I have read some questions and answers of people that have have a similar problem, and you responded by saying that this problem can be treated by using regular cranioplasty making a large incision, or by injecting Kryptonite with a much smaller incision. What is the difference between the two, in terms of healing process, reliability, aesthetics? etc. Is the surgery going to leave any visible permanent scars? I’m really looking forward for your response.

A: By your own description, you have a mild depression on the back of your head. That would indicate that an open form of cranioplasty with causes a long scar would not be an appropriate solution. With that approach, the treatment may cause a worse aaesthetic problem (scar) than the area of skull flattening. That leaves you with the option of the injectable Kryptonite approach. That uses a very minimal incision and the resultant scar is never an issue. It is a minimalist procedure with very little reovery. The material sets up with the consistency of bone so it is very stable and impact resistant. The only potential issue with this approach is trying to get a nice smooth round profile which for just one side of skull flattening is very achievable.

Dr. Barry Eppley

Indianapolis Indiana

Q: I read with interest your article about upper lip lifting in the case of a retracted columella.  I’m a 35 year old trangendered male who’s already undergone a feminizing forehead procedure elsewhere.  My upper lip is VERY long and unattractive, but I’ve been told that, because of my nose, to shorted it I’d have to have grafts taken from elsewhere or even have my upper jaw moved, which needless to say I’m not crazy about.  I have a short, upturned nose that I really rather like, but the long upper lip is a big issue and I’m curious if anything can be done without rib grafts or the like.

A: A subnasal lip lift can be done whether you have a retracted columella or not. The ability to do that fairly simple lip lifting procedure is not restricted by a retracted columella or decreased nasolabial angle. It may be aesthetically better to deal with the retracted columella at the same time however. That could be done in a variety of ways, all of which involve the insertion of some supporting graft behind the nasolabial angle. Instead of a rib graft, I would consider a dermal graft which does not need to be harvested from the patient. That could be inserted directly down to the columellar base from the a small opening after the bullhorn lip skin is removed and before final lip closure. But whether you even need that is unclear to me at this point. I would need to see see some lip photos to answer that question.

Dr. Barry Eppley

Indianapolis Indiana

Q: I have 6 lines of self harm on my right wrist. They are white clear lines, which I would like them removed due to constantly being cautious to cover up when around people. I have recently found out that I am pregnant and would like them removed even more now, before the birth of my child. I’m so confused as to what I should do and which is the safest option. I’m so desperate to have them removed. I have had them for two years now and would like them removed by September of this year. What dio you recommend?

A: What you are referring to are many numerous fine white scar lines that often criss-cross each other on the volar aspect of the wrist. As self-mutilation/suicide attempt scars go, this pattern is fairly common and I have seen it numerous times in scar revision consultations. The reality is that there is no magic eraser and any technique for their removal. They are as narrow as scars can get due to their creation by a sharp instrument and their white color is unchangeable due to the scar in them. No form of laser resurfacing can ‘wipe them off’ or erase them, that simply is not going to work.

Since the stigmata of these scars are its classic pattern, an alternative approach is to create one larger scar which is more amorphous. A more confluent non-descript scar will at least not look like a pattern of knife cuts. In effect, this is creating a bigger burn scar which will look like a burn injury not a knife injury. Deep laser resurfacing can be done to create this effect. While this is not as desirous as erasing the scars, it is a more achievable goal.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am interested in having a cleft put into my chin. Can you tell me how this is done, how successful it is, and is there any visible scarring as a result. Thank you for your time.

A: There are chin clefts and chin dimples. I assume you are very specific about a vertical chin cleft. They can be created anywhere from a hint of a cleft to a very prominent one but the techniques to do so are different. A subtle to moderate chin cleft (most natural) is done by notching the bone internally, removing a wedge of mentalis muscle and fat, and then sewing the underside of the skin down towards the bone with suture anchors. Very deep chin clefts can be created but that requires a vertical incision in the outer chin skin which would only be acceptable in those desiring a very deep cleft almost down to the bone. This is more unnatural looking in my experience. The most commonly done chin cleft surgery is performed from inside the mouth where no external scarring is created. It is a highly successful procedure which will initially look a little deep or overdone but some relaxation of the depth of the cleft will occur to create a more natural look.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I had considering having a revisional PMMA cranioplasty as I am dissatisfied with the results of my first one.  There are bumps and irregularities across my forehead. I have been advised before that getting a flush integration of the material to the bone, with respect to the edge of the material and the surrounding bone, is difficult to accomplish. This is evident in my current implant where I can really feel the edge of the material especially around the top part of my head where there is very visible indention where the material is raised from the rest of my head and also on the right lateral portion of my forehead where there is a large visible lump. Without considering the presence of the scar, this visible raised portion makes wearing my hair short impossible. If you were to perform secondary cranioplastic surgery can you achieve a smooth finish with the implant and surrounding bone and how would you address the problem of tapering the existing PMMA material. Would you shave it down? Remove it and re-apply? Add more material to surrounding bone and then feather it off???

A: The key to getting a good edge and smoothness of PMMA in a revisional cranioplasty is to add it, allow it to set, and then using a handpiece and burr to carefully feather and smooth all edges. While it is tedious to do and causes a lot of shave debris, it is essential to do this step. You must have perfectly smooth edges that blend perfectly in all directions or you will have visible edges later when the swelling goes down. Even though the scalp is thick and seems like it would hide any bumps or edges, it will not once the swelling goes away and the skin contracts down to the implanted material. One has to remember that the skull is smooth for a reason, even if one doesn’t like its original shape.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am a 35 year-old female and I exercise but not as much as I could because I just don’t seem to be able to lose weight. For years I would exercise for months, 5 days a week for 2 to 3 months and not lose weight that people can see, then I’d stop for lack of results. I start up again for a couple of months then the same results occur. With my history, is liposuction or SmartLipo not right for me? I thank you for your response.

A: As a general concept, any form of liposuction should not be viewed or undergone if the primary objective is weight loss. Liposuction is a body shaping or spot reduction method, not a weight loss technique. There is no doubt that many patients do lose weight after liposuction which is usually in the range of double (at 6 to 8 weeks after surgery) of the fat weight that is taken off surgery. This is the result of a combination of immediate fat removal followed by a metabolic weight loss due to a negative caloric balance from healing and reduced intake. Liposuction’s primary objective, which it can do very successfully, is to remove fat areas that are resistant to diet and exercise efforts. Any weight loss is a secondary benefit. This surgically-induced weight loss can be just short-term, however, if lifestyle changes do not support the new weight. It doesn’t take very long (at 3500 extra calories = a lb of weight gain) to regain the weight removed after liposuction if one is not vigilant over the long-term.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I have a problem with the whole upper back of my skull, it is quite flat. It is not hereditary because my other brothers and sisters have normal skulls. I wonder if my mother had me always lying on my back on a pillow during my infancy.  Thus far I have always been able to camouflage it by back-combing my hair and using spray to add volume but now, with age, it isn’t very easy anymore.  It is constantly on my mind and I was considering the purchase of a wig.  I will and never have gone with my head under water at a pool or ocean. Could enough material during a cranioplasty be added to make a difference given that there isn’t that much loose skin back there?available. Have you had much experience in that particular field?  From what I read on the internet, most women are rather more interested in a derriere augmentation. 

A: While the scalp does feel fairly adherent, it does move more freely than you would think once mobilized in the subgaleal plane. With wide undermining (the entire scalp can be easily undermined) and scoring of the galea, some laxity of it can be obtained. For the back of the head, you can probably build out the bone by cranioplasty but about 1 to 1.5cms at the center  (tapering to the sides of the skull) and still get good scalp coverage.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: Hi I actually live a few hours away and before I set up a consultation, there are a few questions I have. I am currently a small A cup and am wanting to go to a C cup. I was wondering how much that would be, just an estimate is fine. I know you can’t tell me exactly and also I was wondering how the payments work and what kind of insurance you take. I have Medicaid. i hope to hear from you soon. Thank you!

A: When it comes to the expense of breast augmentation, there are numerous misconceptions about that aspect of the surgery. The cost of getting breast implants is the same regardless of the size of the implant used. Cost differences in implants do exist, but it is based on the type of breast implant selected not its size. Saline implants will cost less than silicone gel as the cost of the devices from the manufacturer is different. Many patients do finance their breast surgery through outside companies such as Care Credit. Plastic surgeons do not finance the cost of the surgery for patients nor can patients make monthly payments until their breast implant surgery is paid off. Payment for the surgery must be all paid up front which is why patients acquire the necessary funds from a financing company and pay them back over time with interest. No health insurance covers breast augmentation or any breast implant surgery unless it is associated with reconstruction from breast cancer.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I just have a question about tummy tucks. I have wondered whether it is important to have the stomach muscles tightened. I met a surgeon and he said it is not necessary for me, as I am young (23) and have not had any children. He did assess me. In your opinion (without examining me), could you agree with his statement?

A: Tummy tuck surgery has the capability to address all three components of the abdominal wall, skin, fat and muscle. While it may be fairly routinue to perform muscle tightening as part of tummy tuck surgery, it is not always necessary. The important question is whether muscle laxity or midline rectus separation is making any significant contribution to the protruding shape of the stomach area…or whether an umbilical or ventral hernia is present. If a woman has never been pregnant and does not a hernia then it is unlikely that  muscle plication will be of any benefit. Interestingly, tummy tucks done in men do not usually involve muscle tightening as those muscles have never been stretched out due to pregnancy. Muscle manipulation is what causes the greatest amount of pain in a tummy tuck and should only be done if there is a compelling reason to do so. Skin and fat removal is always done and is the backbone of tummy tuck surgery. At 23 years of age and having never been pregnant, I would agree with your plastic surgeon that it is not necessary for your tummy tuck to include muscle manipulation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Thank you for reviewing my photos and my desire to make some facial changes, particularly that of my jaw line. In looking at your computer imaging predictions, the jaw angle implants seemed to have lengthened my jaw angles quite a bit in the side view. I like the shape of my jaw for the most part and was looking mainly to add width from the front view.  I know there’s only certain jaw angle implants available so would that be possible or even advisable?  Also, do you think I’m a candidate for chin implants?  I’m now thinking those may help as well.

A: Thank you for your comments on the computer imaging as that clearly tells me what the right style of jaw angle implant/change that you desire. The one I depicted was the style known as an inferolateral jaw angle implant which does just what you have described and seen, it makes the jaw angle longer and wider simultaneously. Having seen that you have described and preferred what is known as the other jaw angle implant style which exists known as a lateral projection or width only style. That is a very distinct jaw angle implant style and is easier and less traumatic to place as the tissues at the lower border of the jaw do not have to be stripped off to place the implant.

 As for chin implants, there are a half dozen styles that make different chin dimensional changes. What type of chin change do you think you would like? That helps in selecting the best type of chin implant style for you.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Hello! Dr. Eppley performed an open brow lift for me several years ago before I moved out of state. The results are fabulous! I have a question regarding the procedure however. What material are the screws made of? I am asking as I might consider Thermage in the future, and I am not sure if this is advisable with the metal screws. Thank you!

A: When I perform an open browlift, also known as a pretrichial browlift, the uplifted side of the forehead flap is secured to the bone. This not only provides an anchoring point for the upper end of the forehead flap but also takes tension off of the hairline incision closure to prevent scar widening in what could be a visible area. With the fixation technique that I use, drill holes are made on the outer cranial cortex through which slowly resorbable sutures are passed and tied to the forehead flap. No screws, metal or resorbable, are used although this is a perfectly acceptable method of browlift flap fixation. Therefore, you should have no problem or concerns with any method of skin tightening through any device that heats the underside of the skin in the forehead after an open browlift.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I have had forehead reshaping surgery about a year ago with PMMA resulting in a very unsatisfactory result. None of the areas I was concerned with have been addressed and there is significant visible irregularities as a result of the surgeons incompetence at the task. I wanted to know how long I should wait before seeking revision surgery? I would ideally like to have it nine months after the first surgery. Also how would the existing material (PMMA) affect how the surgery will be performed? Is there a greater risk of infection or is the surgery going to be significantly more difficult??

A: Sorry to hear of your unsatisfactory outcome from your cranioplasty procedure. From a technical standpoint, you could have revisional surgery at any time. There is no advantage or disadvantage to doing it now or years down the road. The material is set and stable and can be smoothed and rehaped, or added to, at any time. There is no increased risk of infection or increased difficulty in performing the procedure at any point. Revisional cranioplasty, when PMMA is the indwelling material, is actually slightly easier to do as the scalp tissues lift off of the material very easily as they do not bind or adhere to the PMMA. PMMA becomes encapsulated rather than integrated to the overlying soft tissues and the underlying bone. My observation is that patients having secondary scalp flaps raised report little to no pain afterwards although the swelling and the bruising will likely be similar.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am interested in having several plastic surgery procedures done. Do you know if I can use my health insurance for plastic surgery?

A: Your health insurance is intended to cover medically necessary procedures. From a plastic surgery standpoint, operations such as breast reduction, large abdominal panniculectomies, repair of cleft lip and palate deformities, traumatic facial injuries, removal and reconstruction of skin cancers, breast reconstruction after cancer removal, and numerous other face and body problems constitutes reconstructive plastic surgery. They are reconstructive because they are directed toward returning the body part back to what it once or should be (e.g., breast reconstruction) to relieving medical symptoms such as pain and skin rashes. (e.g., breast reduction) Cosmetic plastic surgery, conversely, changes a normal body part to have another look (e.g., breast augmentation) even though there are no medical symptoms with it. Not liking the way something looks and being bothered by it, even if that degree of bother borders on some level of impairment, does not constitute a medical necessity. Therefore, cosmetic surgery is not covered by any known medical insurance program in the world. There are a few instances where a body part can have both reconstructive and cosmetic needs. The nose would be a prime example where the internal breathing parts can be covered by insurance when they are dysfunctional (septoplasty), while changing the outside appearance of the nose (rhinoplasty) would be considered cosmetic. When done together which is common, such a procedure is known as a septorhinoplasty.

Dr. Barry Eppley

Indianapolis, Indiana

Q: My friends had fat taken from her stomach and put into her upper lip lines.  Is this a procedure you do or recommend?

A: The search for a long-lasting injectable filler to the lips has naturally led to the use of one’s own fat. Even the thinnest person has a little bit of fat which can be harvested and recycled to the lips. In injecting fat to the lips, one accepts two caveats with its use. First, it is good for bulk filling (making the lips overall bigger) but is not useful for injecting into individual lip lines. It is not like synthetic injectable fillers which are injected using very small needles and can be selectively placed into a line as thin as the width of the needle. Fat is injected with a very large needle as the material is quite thick and does not come out in a true linear flow pattern. Secondly, its take or how well it survives is unpredictable. While the theory and expectation with its use is some or complete permanency, that outcome varies amongst different patients. One can not predict whether any one specific patient will have a long-lasting result. My experience has been to overfill (which can look really overfilled with the lip swelling that happens from the procedure), taking into account that there will be some fat resorption. By three months the size of the lip, and the amount of remaining fat, will then be permanent.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: Hello! Do you perform the laser eyelid rejuvenation procedure? I am 48 and have eye hooding and really don’t want to have the surgery at this time. I have read that there is laser treatment that is quite successful. Thank you for your help!

A: I am not aware of any laser eyelid procedure that does not involve making incisions to do a blepharoplasty or eyelid tuck. The term ‘laser eyelid rejuvenation’ may suggest that there is some type of a laser which magically tightens eyelid skin without surgery, but that is not the case. When eyelid hooding exists, the only known effective treatment is actual skin removal. When upper blepharoplasties are done alone, they can be performed under local anesthesia and, in some cases, may even be done in an office setting. Mini-blepharoplasties exist using a pinch technique which is also an office procedure done under local anesthesia. Given the effectiveness of even these more limited skin removal procedures, any non-surgical approaches have never yet been developed that remotely compares.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I would like to have breast augmentation. I have never had because I feared the curvature of my spine might be a problem. I have curvature of the spine, two curves to be exact. I have NEVER really had any problems with it. However, I am not even an A cup and want to go to a D cup. Any issues I should be aware of??

A: Curvature of one’s spine could pose two potential problems for breast augmentation, although neither is preventative from having the operation. The first issue is the potential impact of any significant curvature might have on the lungs or pulmonary capacity. If severe one would have some obvious pulmonary restrictions and this could be a problem for general anesthesia. But your curvature does not sound that severe since you have never had any known problems with it. The second issue is an aesthetic one. Curvature of the spine may give the chest some asymmetry when standing which could give the breasts small differences in size or horizontal position. Any breast asymmetry from spine curvature could be magnified when the breasts become enlarged, particularly up to a D cup size. While all breast augmentation patients must accept the risk of implant asymmetry, that risk may be increased in patients with visible spine curvatures. Short of these potential issues, I see no other issues that would not be standard  in you having breast augmentation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I was just curious about whether I am a good candidate for liposuction on the buttocks and my abdominal oblique areas.  I am pretty small as it is but I have always had stubborn fat no matter what I do. I work out and eat right, I only weigh 105lbs and I am only 5 ft tall. My buttocks is a lot bigger than my size and that is what I consider my worst problem.  I have been trying to get sculpted for a couple of years, but nothing has worked. I have thought about getting this procedure done, but never had the nerve to get it started. If you could e-mail me back your thoughts that would be great.

A: Small discrete areas of fat on someone who is absolutely weight appropriate for their height, despite working out and eating right, is a common problem that I see in many patients. As such a slight frame and build you can be assured that these fat collections are genetic in nature and not metabolically responsive, which is why you can’t get rid of them by your own efforts. Such small areas I would refer to as liposculpture (shaping) more so than liposuction. (significant volume reduction) Small areas such as these respond quite well to small cannula liposuction.

One caveat about any type of liposuction is in the buttocks area. You have careful to not be too aggressive with the fat removal in this area as one can end up with a ‘deflated’ or sagging buttocks after volume is removed. Fat removal in the buttocks should be more conservative and carefully done to avoid this potential problem. Most likely in a small frame such as yours that is not a significant concern.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I have been attempting to learn the pros and cons of chin surgery. I really want my chin longer and want to know in your opinion if it would stretch my lower lip and expose too much of my lower teeth when I smile? In addition, if I had a chin implant could a widening chin implant be used to square my jaw and length it?

A:  Lengthening of the chin usually means increasing the vertical height of the bony chin. Some may use lengthening in terms of a horizontal increase or projection. I am assuming by your question that you mean a vertical increase. Whether the vertical height is increased by an osteotomy with an interpositional graft or an implant, neither approach will stretch your lower lip and expose any more tooth show. That simply doesn’t happen with vertical chin lengthening and is not a concern. But there are differences, however,  in how much vertical lengthening can be achieved by the two techniques. An implant can only lengthen the chin by being placed on the edge of the bone, creating a lengthening of maybe 2 or 3 mms. In contrast, an osteotomy can lengthen a chin up to 10 or 12mms which is a significant difference.

Square chin implant styles do exist but they will have only a minimal, if any, vertical lengthening effect.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: I have read that paranasal implants can be done in local anesthesia. Is this right? Is local anesthesia possible also with malar implants which are placed right next to paranasal implants? Does not the lifting of the periosteum from the bone hurt in spite of the local anesthesia? Thank you very much for your information.

A:  Cheek and paranasal implants are placed from an incision inside the upper lip. Besides the mucosal incision, muscles and the periosteum covering the maxillary and zygomatic bone must be lifted up and a pocket made to place the implants. Given the proximity of the paranasal area to the upper lip compared to the cheek area, it would be ‘easier’ to position paranasal implants under local anesthesia as opposed to cheek implants where greater dissection is needed and the feeling in this area has more contributing nerve endings. You are correct in that it is the periosteum that is the most sensitive part of the surgical dissection. I also prefer to us screw fixation for the implants that I place in the midface which can cause more discomfort from the bone drilling.

 While just about any surgery can be done under local anesthesia, I am not sure if I was a patient that I would ever do it that way. (particularly cheek implants) Unless there is some compelling medical reason why IV or general anesthesia could not be used, it would be more comfortable and slightly less costly to use some form of anesthesia for this type of facial implant surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I have sleep apnea and a very thick fat neck. I was wondering if liposuction of the neck would help my sleep apnea? My thought is that if the fat was removed from my neck it would not be so heavy when I laid down. That way it would not push down on my neck and obstruct my throat as much when I was sleeping/ Does this make any sense? What are your thoughts?

A: While liposuction of the neck may help improve the shape and profile of it, I doubt very highly if it would make any improvement in your sleep apnea. Your logic seemingly makes sense but the flaws in it are that fat doesn’t weigh very much, the thyroid cartilage protects the voice box and lower area with a stout shield of protecive armour and the usual sites of anatomic obstruction are usually higher and are closer to the base of the tongue. While I don’t think liposuction of the neck will have any negative effects, it is not an acknowledged procedure in the surgical treatment of sleep apnea. Procedures such as septorhinoplasty and turbinate reductions to open the nasal airway, maxillary and mandibular advancements to open up the entire posterior oropharyngeal airway, shortening of the soft palate (fading in popularity) and bony chin advancement and genioglossus procedures to bring the base of the tongue forward are well recognized sleep apnea operations. Other non-surgical efforts include weight loss and various dental appliances. Before considering any of these options, one should be fully worked up by a sleep apnea specialist to search for the most effective solution.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am interested in trying to get my face to look less fat. I want to make my face slimmer if possible. I have a small double chin and fatter cheeks and jowls. I have read about Lipodissolve injections and this seems like a good and easy solution for my small areas of facial fat as I know these injections are for small areas and not big ones. Do you think this will work for me?

A: While Lipodissolve injections can provide some minor benefit in fat reduction in the neck and jowl areas, they require three or more injection sessions (spaced 4 to 6 weeks apart) to get the best result. After each injection session, the treated areas will double or triple in size for one week as part of the inflammatory by which it breaks down the fat. . Because of this socially visible recovery, most patients will opt for a more effective set of procedures that actually has less total recovery even though it is surgery. I would recommend a combination of submental, jowl and lateral face liposuction and buccal lipectomies. This reduces all available fat compartments in the face that can easily and safely be treated. This is is the best way to get a slimmer face through fat reduction. It has less recovery than Lipodissolve injections because the swelling is only one time and is largely over after a few weeks. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am 30 yrs old and am tried of people telling me that I am in my mid to late 40s. Ugghhh! I usually just walk away and cry and I am tried of crying over this and want to get something done about it. I have had a brow lift and a neck liposuction about 2 yrs ago. I would like to see what it would look like with eyelid lift and filler. Would you also recommend something else? Maybe a chemical peel? Thank you for your help! I really appreciate it!

A: Thank you for sending your pictures. Unfortunately computer imaging is good at changing structures of the face but not very good at soft tissue manipulations such as those that you have asked for. An eye lift can not be done as it distorts the whole eyelid. However, I think there is no question you have upper eyelid hooding and you would clearly benefit by an upper blepharoplasty or eyelid lift. Putting in fillers along the nasolabial fold and lips is also not very accurate and often just distorts the lips in trying to image it. You have reasonable lip size so injectable fillers will make them nicely bigger. As you have suggested, a chemical peel is good for skin texture and brightening the glow of the skin and for fine wrinkles as well.

As for other recommendations, I have done some other changes just to look at how to soften your facial features and make your face more ‘youthful’. These have included the following:revisional browlift to lower hairline (reduce long forehead) and correct existing brow asymmetry, rhinoplasty to make nose look slimmer and more narrow and chin reduction to soften chin point and make softer looking.These are structural facial changes which are different than just anti-aging procedures.

Dr. Barry Eppley

Indianapolis, Indiana