Your Questions

Q: I have had severe migraines for years. My migraines start in the back of my head and shoot up into my scalp and down into my shoulders. It usually feels like there is a vise on the back of my head. I have been to a lot of doctors and have tried everything from every drug out there to chiropractors, acupuncturists, massage therapists and even Chinese oriental practitioners. A few things worked for several days or a week but nothing lasts. I went to the local university and saw a neurologist there who did an MRI and other blood tests and came up with nothing. His drugs didn’t work any better. I have read recently on the internet about some type of migraine surgery. While I am desparate to try anything, the thought of going through surgery and then not have it work would be disappointing to say the least. What is the success of this new migraine surgery?

A: Migraine surgery is based on the concept that there is a peripheral trigger or site of nerve compression which is the stimulus for the attack. One of the four recognized trigger zones is at the greater occipital nerve at the back of the head at the base of the skull which causes occipital migraines. Whether surgery would be effective can be predicted beforehand through the use of Botox injections into the area. A positive response to Botox, which includes a significant and sustained relief of the migraines, correlates highly with surgical success. While about 1/3 of patients will have a near complete elimination of their migraines, 2/3 s will have reduced frequency, intensity and duration of attacks. A recent clinical study reported that 90% of patients treated maintained good relief out to five years after surgery which as the time limit of the study.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I would love to have breast augmentation before my 21th birthday which is later this spring. My preferred approach would be breast augmentation with an incision through armpit area But  I also considering the option of an inframammary incision using Memory gel breast implants. Which do you think would be better for me? Thank you.

A: Breast augmentation poses multiple choices for prospective patients to consider. These options are driven by implant choice which can secondarily control the placement of the necessary incision. Saline breast implants are often placed through a small armpit incision because they are inserted deflated and then inflated once into position. Silicone gel breast implants, unless they are very small, can not be placed through the ampit because they are inserted pre-filled or fully inflated. Thus, they are usually placed through a lower breast crease or inframammary fold incision.

But the incision is not the most important part of the breast augmentation procedure, the implant is. All incisions heal really well and are rarely of any secondary cosmetic consequence. Therefore, it is important to understand fully the differences between saline and silicone gel implants. While both work well and do an equally good job at making a larger breast, there are some important minor differences in them that are relevant in the long-term. This is especially pertinent to you at your young age since you will live to see them. These include such risks as implant deflation (saline) and silent rupture.  (silicone) You will be replacing these implants at least once on your long remaining lifetime so understanding these differences is important to you.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am going to get a facelift and want the scars to heal to that no one will know that it was done. I have read about a Laser-Erase procedure that can get rid of the scars almost immediately. Does this really work? What are your thoughts?

A: Over 100,000 facelifts and an equal if not greater number of eyelid tucks (blepharoplasty) are performed each year in the United States.  While the incisions in the eyelids and around the ears generally scar imperceptibly, patients are understandably  motivated to get the best scar result as possible. Getting a more youthful appearance at the expense of poor scarring would not be a good trade-off.

Concerns about the possibility of less than ideal scarring, numerous plastic surgeons have touted an early laser scar treatment program. Laser-Erase is just one ‘branded’ name of this treatment approach. The concept is that about two weeks after facial surgery including facelifts, eyelid surgery or any other facial procedure that requires an incision, the incision line is then treated with a light laser resurfacing procedure. Some use high intensity light or IPL treatments as opposed to an actual laser. It is touted that the ‘incision is then erased with the laser’. The theory is that the laser disrupts a scar from forming in the very early stages of the healing process, thus to quote one treatment provider, ‘the incision line is banished from sight with a zap of the light.

While this early treatment of a scar sounds very appealing, there is no science to back up its touted benefits. Plus it goes directly contrary to how wounds heal in general. No scar can be prevented from occurring between two closed edges of skin. Scar formation is inevitable, and a little burning or heating of the upper part of the wound edges, will not make it disappear. Any scar benefits that subsequently occur are a result of a natural healing and scar fading process. Such early scar treatments are more about marketing and sales than they are about any form of a new revolutionary scar treatment approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q: For my bulgy forehead, is it possible to burr down the forehead and then do a forehead/eyebrow lift at the same time, just removing the extra skin? The reason I ask is because my head is misshappen and my hairline is too high. I want my hairline to be lower so burring down some of the forehead and then making and eyebrow lift would help alot.  After that is done I was going to get a hair transplant on my hairline to cover up the scar.  Does this sound like it will work? Will it work if I get a hair transplant over the scar and can I do the eyebrow/forehead lift thing?

A: Your approach to a forehead or frontal contouring is conceptually correct. While I don’t know exactly where your exact hairline is now or what its shape is, making a scalp or coronal incision there allows one to access the forehead area. Probably about 5mms across the forehead bulge can be taken down. A browlift can then be performed and the redundant skin removed at the scalp incision line. This will shorten the perceived length or height of the forehead skin. Thereafter, no more than 3 to 6 months later, a hair transplant can then be done to put a camouflage to the scar. Such a scar in the scalp can often heal remarkably well due to the uniqueness of hair-bearing (or past hair-bearing) scalp skin.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: I was wondering if it is possible to shave down certain parts of the skull. My forehead isn’t the way I want it to be shaped. I am trying to get my forehead to stick out a little less. Is it possible to shave the skull down? And if so how much can be taken off?

A: The thickness of one’s skull can be taken done by burring. How much it can be reduced is determined primarily by the thickness of one’s outer cortex. The skull has three bony layers, an outer hard cortex, an inner spongy marrow space and and an inner hard cortex.  While the burring reduction can be taken down past the outer cortex into and through the marrow space, that causes a lot of bleeding and can make for an irregular surface. Therefore for practical reasons, the outer cortex is usually the only skull thickness reduced when done for cosmetic purposes. That can vary in different skull areas but in the forehead in a man, that may be up to 5mms or so.

The more significant rate-limiting step for male forehead reduction is the incision needed for access to do the procedure. A scalp incision is needed to turn down the scalp so the bony forehead is exposed for reduction. Given the unstable frontal hairlines and hair densities of most men, forehead surgery of any kind may not be worth the trade-off of a scalp scar.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  I had a chin reduction a couple of years ago and although I am happy with the new shape of the bone, I now have hanging soft tissue. Needless to say I am not happy with these results. I have visited five plastic surgeons and none of them wanted to fix this problem saying that it was dangerous to cut or reattach the muscles and the ending results could be worse. I am very dissapointed and have attached some before and after pictures for your review. I hope you can help.

A: Your pictures show quite clearly some soft tissue sag or ptosis off of the chin bone. It is most pronounced centrally which is what one would expect given that your chin reduction was most likely an intraoral burring approach done to the central button.  To improve this problem there are two approaches, intraoral muscle resuspension or a submental tuckup. The intraoral approach uses a suture anchor to the bone to reattach the muscle and tighten it back done. This is a scarless approach. The submental tuckup  uses an incision under the chin where the loose skin and muscle is removed and tucked or tightened to the bone. Each has its own advantages and disadvantages. The intraoral approach avoids a scar under the chin but the submental tuckup is a more reliable method.

There is no danger to performing this procedure and there is no chance of making the problem worse. Whoever has said has either never treated the problem or is completely unaware that such surgical correction exists.

Dr. Barry Eppley

Indianapolis Indiana

Q: I wrote you a couple of months ago about the possibility of undergoing a forehead contouring surgery to address my possible forehead bulging, to which you asked me to provide you with pictures. This is want I would like to do now and i have attached some forehead pictures for you to review. I don’t know whether the bulge is created by my high hairline or if it is just the way my forehead is. Basically, as previously stated, I would like to know if the problem is a high hairline or a protruding forehead, or both. At any rate, I would like to hear your surgical recommendations, or lack thereof!

A: Thank you for sending your pictures. I think there is some degree of a mild amount of forehead bulging that is accentuated by a higher hairline. Given the mild problem and the resultant scalp scar to improve it, I would not recommend any surgical modification. While it can certainly be done, the scalp scar in a male is a major limiting factor. This would not be such a rate-limiting step for surgical treatment in a female.  I have looked at hundreds of male candidates over the years for cosmetic forehead contouring and brow bone reductions and could only ever justify surgery on about 2% to 3% of them.The magnitude of the forehead problem has to justify the trade-off of the scar to do it.

Dr. Barry Eppley

Indianapolis Indiana

Q: I have a long and wide forehead scar that I would like to be made to look better. I have attached some pictures of it for you to review. I was wondering if you think that laser resurfacing will help. I have read that it can make scars go away. What is your opinion of it?

A: The origin of your question is will any form of laser resurfacing make your forehead scar disappear. The simple answer to your question is no, no matter what type of laser resurfacing technique is used. And let me explain to you why. Your forehead scar is composed of abnormal tissue which is why it does not feel or look like normal skin. It is in fact abnormal tissue or scar but, most relevantly, that scar involves the entire thickness of your skin. In other words, the skin has been replaced by full-thickness scar. You can smooth of the surface of the scar out all you want with any form of laser resurfacing but it will always appear just as wide, just as discolored and just as obvious. Laser resurfacing only smooths out the surface of the scar, which is helpful if the scar’s main problem is surface irregularities, but it will get rid of the actual full-thickness of the scar. Only cutting it out (excision) can do that. When excision is combined with a geometric broken-line closure, the scar will become more narrow and less obvious. Secondary touch-up with laser resurfacing may be helpful but it is an ineffective treatment to do first. I realize that grasping out the hope of laser resurfacing seem appealing but it is but a treatment mirage. Formal surgical scar revision is what would benefit you the most.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am interested in learning about the cosmetic effectiveness of doing both zygomatic osteotomies with orthognathic surgery. I have seen some plastic and oral surgeons and I am told I have what they call a class 2 malocclusion with a restrusive mandible and maxilla, low sunken zygomas and mid-face with the outer edges of my eyes drooping. I am going to have orthognathic surgery in near future for functional reasons, sleep apnea, tmj problems, snoring, and to improve breathing while I am awake by enlarging the air ways. But cosmetically my cheeks and drooping eyes I would also like to improve. There are multiple modified LeFort osteotomies that help with filling in the face, but I am looking for something that will address the drooping outer edges of the eyes. What are the risks involved for a zygomatic osteotomy? (like double vision) How do you feel about the procedure being performed with orthognathic surgery? How cosmeticly effective is it when both done together? (other opinions suggesting best done separately) Can you achieve symmetric cosmetic pleasing effect? Not too interested in implants due to risks of dislodging and erosion, very active lifestyle, feel it would get in the way.

A: Let me give you some general thoughts about your questions with the caveat that I have never seen your photographs or x-rays and am only working off of your description of your face.

Your orbitozygomatic facial skeletal arrangement is such that the cheek bones are flat and recessed and the lateral orbits may have a little downslanting orientation. (tilted horizontal orbital axis) That problem alone, which occurs commonly in more severe deformities such as Treacher-Collins, requires a combination of  a C-shaped orbitozygomatic osteotomy with bone grafts to improve the total three-dimensional bone problem. Yours may not be as severe but the 3-D problem is likely the same. Beyond the fact that this requires a coronal (scalp) incision to do the bone cuts properly, it would be very difficult to do this simultaneously with any form of a LeFort I osteotomy. Between the scalp scar and the type of osteotonies needed, this treatment is likely too severe for correcting a more mild orbitozygomatic bone problem.

While there are some high modifications of a LeFort I osteotomy, they are restricted in how the zygoma moves and will only bring it forward but not out. (no width improvement) These are interesting operations on paper and in surgical diagrams but have never proven very practical or effective. That is why they simply are not done or rarely attempted.

The conclusion is that any form of an orbitozygomatic osteotomy is too big of an operation, will leaves palpable (able to be felt) bone edges, and also requires bone grafts. This is why the best approach, even if you don’t desire it, is to do some form of a cheek implant with lateral canthal repositioning of the eye. These are far simpler, much more cosmetic effective, have less complications (both short and long term) and can be combined with orthognathic surgery.

Dr. Barry Eppley

Indianapolis Indiana

Q:  I am considering scar revision but need some direction. I basically have two small scars on my butt. They are small and they look like chicken pox scars However they are perfectly centered on each cheek. They are from a liposuction surgery I had many years ago. What is the best way to correct them? I hope you can help.

A:  The three-dimensional shape or geometry of these scars is an important consideration. Are these scars wide and flat like chicken pox scars as you havhe described or are they wide and indented, having a central depressed component to them? Since they are old liposuction entrance scars, they are probably wide but the key question is are they indented or flat? That distinction is critical in choosing what type of scar revision to perform.

Excising small scars on the buttocks is easy to do and the intent of such an excision is to make the scar ultimately more narrow. While at the time of the procedure, they will be but in the long run they will likely widen again. The pressure of sitting on the buttocks will defeat most attempts at scar narrowing in this area if the scars are anywhere on the rounded portion of the buttocks. If they are around the perimeter or in the buttock crease, then such desired narrowing is more likely to be achieved.

If the scars are indented, however, cutting them and out and closing them make not make them smooth or flat. For this type of scar revision in this area, I would place small fat graft underneath them to prevent recurrent tethering or indentation.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am interested in getting a chin implant to make my weaker chin look better. It seems like a fairly simple procedure but this bone resorption underneath the implant sort of scares me. Why does this happen? Is there any way to avoid this bone reorption if I get a chin implant?

A: The phenomenon of bone resorption under a chin implant is a much talked about finding for many decades. One of the reasons that it occurs is due to a pressure issue with the implant sandwiched between the soft tissues and the bone. While the implant pushes the soft tissue out, causing more visible chin projection, the soft tissues do apply a small amount of pressure or recoil back over time. Since the implant is not going to resorb because it is an inorganic synthetic material, that leaves the underlying bone to accomodate and relieve this pressure.

This pressure situation is really magnified with implants that are placed too high on the chin bone. This happens when chin implants are placed from inside the mouth and are not secured down to the lower edge of the bone. It can also happen from a submental chin incision approach but is much less common because it it easer to keep the pocket of the implant low. The observation that it does not occur with more contemporary anatomical chin implants is because the wings of the implant keep them from riding up higher, acting like lateral stabilizing bars. From either approach, if the implant ends above the basal bone of the chin (which is thick cortical bone) it rests on bone with a much thinner cortex. This is where bone resorption will be seen with chin implants. It is a function of bone position and is not an actual feature or result of the implant or its material composition per se. This bone resorption phenomenon (which is largely benign and not of any great signfiicance) can be completely avoided by proper implant position on the lower edge of the chin bone. This will also maximize the benefits of the horizontal projection that the chin implant provides, some of which is lost if it gets malpositioned higher as it slides up and back.

Dr. Barry Eppley

Indianapolis Indiana

Q:  I have an unusual question. I’m half Chinese but my eyes are more Caucasian-looking. So I was wondering if there is a surgery to create an epicanthal fold at the medical canthus? ( the one that half covers/hides the tear duct). Some doctor once told it’s possible with a w-plasty or a jumping man flap to create a fold in the inner most part of the upper lid. And is it possible to lower the height of the eyelid? Like taking apart the previous fold and resetting it at a lower position? Many thanks and sorry for all the questions

A: The epicanthal fold area is composed of very thin and delicate skin that is prone to poor scarring, particularly in the Asian patient. Because of this scarring potential, unless the epicanthal fold is really prominent and bothersome, I generally steer away from surgical manipulation of this delicate skin.  Many of the operations described for epicanthoplasty, like the w-plasty and the jumping man flap, create a lot of tiny skin flaps and often scar poorly. They look great on paper and in diagrams, and do get rid of the epicanthal fold, but their scar result may not be a good trade-off. For this reason, I prefer a smaller z-plasty technique for epicanthoplasty which helps open up the narrowing effect that the fold has on the horizontal dimension of the eye.

Your question is one of the reverse of an epicanthoplasty or the creation of an epicanthal fold. I have never heard of that being done and certainly nothing is written about it. In my opinion that is possible through a different orientation of a z-plasty but my concern would be the scarring. As the fold of skin that would normally make up the epicanthal fold would likely have a line of scar on it, that may or may not have a natural appearance.

When you speak of lowering the height of the eyelid, are you referring to the location of the lid margin or the height of the supratarsal skin crease of the upper eyelid?

Please send me some photos of your eyes for my further assessment.

Dr. Barry Eppley

Indianapolis Indiana

Q:  I have heard of rib graft nose augmentation. Is this method better than using silicone implants? It seems that most people use silicone so why rib? Can a rib graft be carved like silicone with  a nice shape ? Can it get warped  and twisted? How many people are fixing their nose using rib grafts? How many people need to be redone because of problems with the rib graft? I want to fix my nose but am scared of using a rib graft because of what I have heard about them.

A: Rhinoplasty with dorsal nasal augmentation can be done using either a synthetic implant or an autogenous rib graft. While there are advocates for both approaches, either one can have very successful results. It is not a function that one is better than the other, they just have different advantages and disadvantages. Synthetic implants to the nose are relatively simple to do and require less operative time and surgical skill to do but they have potential long-term problems such as infection and extrusion in some patients. Rib grafts to the nose are harder to do and require greater skill and familiarity in working with this type of graft as well as requiring a donor site but they do not have long-term problems of infection or risk of graft extrusion.

In my experience, diced rib cartilages to the nose eliminate the risk of warping or twisting and mold nicely for dorsal augmentation. Solid rib grafts must be very carefully harvested, shaped and secured to avoid the problems to which you refer. I have done both techniques successfully and decide between the two rib cartilage graft techniques based on the quality and shape of the rib graft harvest.

The vast majority of patients wanting primary dorsal augmentation rhinoplasty for esthetic reasons, such as the Asian patient, is going to choose a silicone implant because of its simplicity and lack of the need for a donor site.

Dr. Barry Eppley

Indianapolis Indiana

Q:  My daughter has grown in the past two years a strange looking abdominal growth. It doesn’t look like any abdominal pannus picture I have ever seen. She is very obese but has a normal looking white abdomen which hangs down a little. However, directly under (and separate from) this normal looking abdomen is a huge purple/red hanging balloon which is ulcerated and infected. It grows out from under the abdomen right above the pubis. She is scheduled for surgery in a month and the surgeon is acting like he doesn’t know for sure what it is. It is estimated to weigh about 50 pounds. Have you ever run across anything like this in your plastic surgery practice?

A: While it is unusual, I am certain it is not a mystery per se. There are only a certain number of conditions that it could be. Possibilities include a granulomatous reaction from a ulcerated wound in the skin fold, an area of  lymphedema with resultant ulceration, ballooning subcutaneous fat necrosis or benign growths such as large lipomas, hemangiomas or even a teratoma. Whatever the final pathologic diagnosis, it will be removed by wide excision down to the underlying abdominal wall  with a modified abdominal panniculectomy. It does not sound anything like a hernia of which it is in an unlikely location and a CT scan would easily rule that out. A CT scan would also rule out any tumor growths from deeper structures, such as the ovaries.

With a weight of 50 lbs, however, it is much more likely that this is a benign tumor growth of solid tissue rather than any reactive mass.

Dr. Barry Eppley

Indianapolis Indiana

Q:  I want to have breast implants done. I am not happy with the way my breasts look. But I have lupus and am not sure that I can have this procedure with this medical condition.

A: Whether breast augmentation with the medical history of lupus is a good idea would depend on what the extent and how symptomatic this autoimmune disease is in you. Do you have any known healing problems as a result of your lupus? Have you had surgery in the past and did you have any problems with healing or infections after surgery? Are you on any steroids or other immunosuppressive medications? What symptoms do you currently have from your lupus? What are your titer levels of ANA and other blood tests from your doctor?

 Ultimately, what your doctor or rheumatologist would say about your lupus condition would have a lot to say about the adviseability of breast augmentation for you. Despite the past allegations that silicone breast implants cause autoimmune disease from the 1990s, that has now long been disproven.

The issue is are you more prone to breast implant complications from your lupus? Infection risk in the short term and capsular contracture in the longer term are the issues. If you have skin problems, such as banding and contractures, than you would be likely to get problematic breast implant capsules. If not and your lupus is stable and relatively asymptomatic, then breast augmentation may be a satisfactory procedure for you.

Dr. Barry Eppley

Indianapolis Indiana

Q:  What do you think of hyaluronic acid for buttock augmentation? It seems like it would be  a lot easier to do than using your own fat or putting a synthetic implant in your body.

A: While the family of hyaluronic acid fillers are commonly used for very small volume facial augmentation, they are very rarely or never used to try and fill other body areas which require much larger volumes. While it may be a biologically sound concept, it is an economically terrible idea. The volume of hyaluronic acid needed, if we use fat as an analogy, would be around 350cc per buttock or 700cc per procedure. If we use the cost factor in the U.S. of $375/1cc syringe for Restylane that would be a buttock augmentation at a cost of $262,500…all for a result that would last 3 to 4 months. Using Juvederm, which would last twice that long but at a cost of $550/1cc syringe, the procedure would cost $385,000.

While your own fat make not always be reliable in terms of volume survival, it is easy to see that it is a far more economical approach for buttock augmentation.

Dr. Barry Eppley

Indianapolis Indiana

Q: I would like to get my eyelids done as they are very heavy looking and make me look bad. People tell me all the time that I look tired even though I am not. I am sick of hearing that! My only real concern about the surgery is recovery. How long is the recovery and what will I look like?

A: Thank your for your inquiry. Recovery after blepharoplasty surgery is largely social…meaning how do I look? (how much bruising and swelling will you get) That would depend on whether one is doing only upper eyelids, only lower eyelids, or all four eyelids.. When all four eyelids are done, most people will have noticeable bruising and swelling for up to 10 to 14 days after surgery. If only one set of eyelids is done, it will be less than that. Lower eyelids develop more welling and bruising than the upper eyelids after surgery. There are also different types of blepharoplasties done in which the overall swelling and bruising may well be less, what we call limited blepharoplasties which are either of the pinch type or lower eyelid which use only a transconjunctival (inside the eyelid incision) approach.

There are numerous strategies for keeping the amount of swelling and bruising as limited as possible. This includes pre-and postoperative oral Arnica, keeping one’s head elevated above one’s heart for the first few days and a good icing of the eyes the night after surgery. I also use gentle surgical technique with delicate amounts of cautery to keep down the amount of bruising that can develop.

Dr. Barry Eppley

Indianapolis Indiana

Q:  I am interested in getting pec implants. I have always had a very flat chest with little muscle definition at all. I have done a lot of chest exercises but I have not seen a lot of improvement or at least the amount that I want. I have tried protein supplements, testosterone and even some human growth hormone but I just can’t get the size of pecs that I want. This has brought me to the conclusion that the only way I am going to get there is with an implant. Do you think pec implants will finally help me get what I want?

A: There is no question that pectoral implants will increase the perceived size of your pectoral muscles. Increasing the bulk of the muscle is what they do best from their subpectoral or under the muscle position as they push the muscle forward. Implants are not quite as good as improving pectoral muscle definition with the exception of the lower lateral pectoral border. The question you are really asking probably relates more to implant projection…or how big can the pectoral muscles be made to look.

Pectoral implants have, at most, up to 3 cms. of projection or forward push of the muscle. How significant that is depends on how thick the muscle is to start with. In other words, a flat chest with a thinner pectoralis muscle will show more but it will not be a ‘bodybuilder-like’ result. An already thicker pectoralis muscle in someone who is fairly developed will have a much more prominent result.

Dr. Barry Eppley

Indianapolis Indiana

Q:  I currently have silicone breast implants that became hard and encapsulated. This was treated by having the scar tissue removed and new implants placed. Unfortunately, my implants became encapsulated again. In searching for what to do now, I have several consults with different plastic surgeons and have gotten differing opinions as to my options. One plastic surgeon suggested that I try the scar removal again with the use of dermal grafts and PRP. (??, not sure what this is) Another plastic surgeon suggested that I remove the implants and replace them with fat injections. Is this a reliable method? What would you recommend?

A: Recurrent capsular contracture, although uncommon, can be a difficult breast implant problem. The conventional approach is total scar removal, with or without replacing the implants with those that have a textured surface. If the implant was originally above the muscle, relocating it to a submuscular position can also be tremendously helpful. These combined techniques are probably effective about half the time, maybe more. But when they fail, different strategies need to be explored.

One alternative approach is to wrap the new implant partially in a dermal graft after the repeat capsulectomy. This ‘out-of-the-box’ graft is intended to heal around the implant lessening the risk of new scar formation, essentially serving as a part of the new capsule rather than fresh new scar tissue which has a high propensity for contracture. PRP, also known as platelet-rich plasma, is a concentrate from the patient’s blood which can be sprayed onto the internal breast tissue surfaces. Its theoretical benefit is that it causes less scar tissue to form. The addition of a dermal graft is a more proven capsular contracture approach but the use of PRP has no downside and is simple to apply.

Fat injections as an alternative to the use of a breast implant for the treatment of capsular contracture may be novel but is both unproven and biologically flawed in my opinion. The survival of fat injections in breast augmentation is based on the graft being injected into the midst of healthy tissue where it can survive by revascularization. Injecting fat into a large empty open space would not only have it not survive but would likely become a liquefied pool of oil and fat that is prone to infection.    

Dr. Barry Eppley

Indianapolis Indiana

Q: I would like a normal chin size without cutting or moving bone. Just with a chin implant or injectables. is it possible? I´m not interested in a major surgery such a sliding genioplasty. It seems that I have overbite but my dentist says that my bite is ok and I don’t need any orthognatic procedure. I ´d like to have neck liposuction too. I have a little extra fat below my chin and round the neck. The truth is that I don´t want to go under a major surgery but I also want a stronger chin. Can I achieve this result? I want it to look like a good male chin and not weaker or like a girls´s chin. I have looked at different projections of chin implants and I think that an 8 mm implant would work. I think that an implant with some little liposuction would be ok. I want it to be bigger but maybe more than 8mms kwill make my chin to look like very big. Please tell me what you think?

A: When it comes to chin implant size, there is a fine balance between too much vs too little. For a male, the chin position should ideally be even with the most protrusive part of the lips when see in a side view. While this is a classic anthropometric measurement, and one that is historically espoused in the concept of male beauty, that does not mean it is the most ideal aesthetically for any individual. Some men prefer their chin to be stronger than this measurement suggests while others prefer it to be a little shorter. When trying to decide between two chin implants sizes of a few millimeters difference ask yourself this question…would I prefer to ‘error’ on the side of having the chin turn out to be a little too strong or a little too weak? Obviously you want it perfect but knowing that choice will help make the decision between those two implant sizes.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am a 52 year old female that weighs 127 pounds. Several years ago I was down to 117 pounds and the lower belly pouch didn’t get much better. At that time I was exercising 4 days a week and doing everything I could to lose that belly. This seems to be a family trait as both my mom and her sisters had it. Do you think liposuction can remove this lower belly pouch?

A: There is no question, even without seeing most patients, that the description of a lower belly pouch signifies that they have some excess fat there. So the use of liposuction for abdominal fat reduction is going to be useful. Whether liposuction would be of benefit, therefore, is not really in question. The issue is how much lower abdominal skin do you have and what will happen to it when the lower belly is deflated so to speak. In other words, do you need some type of a tummy tuck with the liposuction? The aesthetic outcome of liposuction is predicated, partially, on how well the skin contracts down once there is less volume. If there are a lot of stretch marks and you can pinch  more than an inch or two of skin, then it is likely than some skin removal (mini-tummy tuck) may be helpful also. If there is a question as to whether skin removal is really needed, you can always do the liposuction first and let that outcome make that decision for you. I would use Smartlipo (laser liposuction) for your abdominal liposuction as that has the best chance of shrinking down the skin you have the best.

Dr. Barry Eppley

Indianapolis Indiana

Q:  Dr. Eppley I need your help with my cheek. Several years ago I was involved in a fight and got struck on the left side of my face. At the hospital they diagnosed me with a cheekbone fracture but I never got it fixed since I didn’t have insurance at the time. The left side of my face is asymmetric now to the other side and I want to get it fixed. I will describe the problem as I see it. If you look at about an inch down from my left eye, that area from the middle of the top portion of the cheek toward the edge of my nose is flattened. It has no definition like my other cheek. The flatness extends down toward the middle portion of my ceek also. It appears to me as the complete area is shaped like a sideways triangle toward the rear. Also in the same area about an inch under my left eye, right on top of the upper portion of my cheek, it appears as if that area has dropped down. Do you think the bone needs to be rebroken to be fixed or can some type of implant be used to fix it? Thanks for your time.

A: Your description of the left cheek/midface deformity is exactly what one would anticipate from an incomplete zygomatic or cheekbone fracture. As the zygomatic complex, when fractured, can only rotate downward and inward toward and into the maxillary sinus you will lose some cheek and underlying anterior maxillary projection. Because you have described no changes in the eye area or numbness of the cheek and teeth (infraorbital nerve impingement) your original zygomatic fracture is incomplete and less severe than a fully displaced fracture. Given the age of the injury and the now healed bone, a modified cheek implant placed across the anterior maxillary wall and up onto the anterior zygoma should do nicely to restore the bone fullness lost. Given the modified position of such a cheek implant, it would need to be secured by multiple screw fixation.

Dr. Barry Eppley

Indianapolis Indiana

Q: I have had two babies in three years and have lost nearly 50 lbs through an aggressive diet and execise program. While I have defnitely seen some body changes, I am not happy with the way my breasts and stomach look. I thought with all of this working out that my stomach would look better. I have loose skin and stretch amrks around my belly buttonm and my breasts droop and are floppy. I have read about a plastic surgery procedure called the Mommy Makeover.  What is sone in this procedure and can it be done all in one surgery. I am worried about recovery time and getting back into the gym for my workouts. Thanks!

A: The Mommy Makeover has become a popular plastic surgery procedure amongst mothers between the ages of around 25 to 45, although it can be done at any age. It has gotten this catchy name because the procedures involved help reverse the effects that pregnancy has ravaged on a woman’s body. These procedures have been commonly done for many decades so they are not new. They have just been put together and ‘packaged’ for this specific set of female body problems, that being the breasts and the stomach areas. Breasts frequently have lost volume (deflated) and sag and the tummy has loose skin and stretch marks. The combination of breast reshaping (implants with or without a lift) and some form of a tummy tuck (with or without liposuction) is the backbone of a Mommy Makeover. They are almost always done together if a patient’s economics permits. While this combination of a breast augmentation and tummy tuck will have a dramatic change on one’s body, you must tone down the concern about getting back to working out as soon as possible. This is a setup for after surgery problems. It is understandable that you have an addiction to working out as you would not have gotten this far without doing so.  But that same addiction, which you think is good, is not so good after this kind of surgery. You must mentally plan on 6 weeks before getting back to working out like you are now. Remember that in a span of a few hours you are going to make changes that you can’t do by working out for the rest of your life. The risk is not worth it for a few extra workouts that, in the big picture, will gain you nothing.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am going to get cheek implants but am concerned about them moving around afterwards. I am an extremely athletic person who works out a lot. This involves running and jumping around a lot. I do participate in conatct sports such as basketball and flag football. However, I don’t do boxing and am not planning to get punched in the face. (who does really?)  My cheek implants will be the Conform malar shell type so they are not small. Do you think just suturing them in is enough or should they be secured with screws. Which method is best for me?

A: What makes cheek implants different from other facial implants is their bony position. Sitting on the side of the cheek bone, with no bone support underneath them, makes them more prone than many other facial implants to shifting or malpositioning. This risk is magnified by their path of insertion from inside the mouth which opens up the southern avenue for shifting. While most cheek implants do not experience these problems, the risk is not zero. Because of this concern, it is my preference to almost always screw fixation for cheek implants. This makes me feel the most comfortable that the postoperative risk of implant shifting is virtually eliminated. the appeal to me of screw fixation is that it is also easy to do, involves no risk, is done at minimal extra cost, and adds essentially no extra time to complete the procedure.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am interested in Female Feminization Surgery which would encompass brow bossing reduction, hairline lowering, rhinoplasty, chin and jaw shaving and breast augmentation. I am considering doing the FFS either all at once or in two parts. I am male to female transgender. Can you provide me some details or specifics about what I need to consider for each of these procedures.

A: All of those Facial Feminization Surgery (FFS) procedures certainly can all be done as a single procedure and are not too excessive for one operation. If you were to do them in stages, I would separate them into the facial procedures as one set of procedure and the breast augmentation as a separate procedure.

A few comments about your proposed FFS procedures:

Hairline lowering – Whether that is possible would depend on your hairline now and where it is located. Some FFS patients have to consider hair transplants instead if their hair density is very thin or too far back.

Brow Bone Bossing – There are two methods based on the degree of bossing, burring reduction (tail of brow only) or frontal sinus wall setback (if the whole brow is very prominent) It is impossible to know which is best for you without seeing a picture. The relevance to this difference is prinarily a cost issue. Frontal sinus wall setback requires some tiny plates and screws to hold the reshaped bone and takes a little longer to do.

Rhinoplasty – There are two different types of rhinoplasty, limited and full. The full rhinoplasty requires more work and is almost always needed when there is a hump reduction needed. Limited rhinoplasty is where only the tip is manipulated/changed.

Chin and Jaw Shaving – For most FFS patients, this is largely burring reduction or saw shaving of the inferior border although sometimes the chin bone may need to be shortened vertically as well as setback.

Adam’s Apple – Any issues here? I am supposing not since you didn’t mention it.

Breast Augmentation – The only issue here is saline vs silicone gel breast implants. That is just a cost difference issue

Dr. Barry Eppley

Indianapolis Indiana

Q:  Hi, I’m 25 and have a really flat area at the back of my head. I’m very self-conscious about this since I was 15. Is there any way that I can fix this for a cosmetic purpose. Can something be implanted at the back of my head? You are my only hope now. If I can get the new round back of the head, I will also get a new life with your help. I have attached some of the pictures of my head taken on the side. Whenever I look at it, i just want to cry. And I’ve mentally suffered from this flat head shape since I was a teenager. If you could possibly please tell me, what needs to be done, and how long does it take to recover after the operation, I would appreciate your help and time so much.

A: Thank you for sending your pictures. I can see how flat the back of your head. The best and most economical way to augment and expand the back of your skull is through an onlay cranioplasty method. This involves putting a material on top of the bone to build it out. Given the amount of material needed, I would recommend acrylic or PMMA. Other materials exist but they are exponentially more expensive. There is even an injectable technique using Kryptonite Bone Cement, and that would be a good option for you, but that would be a cost issue.

To summarize, you can do an occipital cranioplasty by either:

1) An open cranioplasty approach with acrylic or PMMA, PMMA is a very firm material, is the least costly and must be put in through an open approach. (meaning a long fine line scar in the hairline) It would be a two hour procedure under general anesthesia.

2) The other option would be an injectable approach using Kryptonite cement. This would only need about a 2 inch incision. This procedure would take about an hour to do.

The fundamental difference between the two procedures, besides the incision/scar, is the cost of using the material.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am 23 years old and am interested in breast augmentation. I know that there are different types of implants but I am most intrigued by the gummy bear implants that I have read about. They sound like the best type of breast implant to get but are there any real downsides to them? What do you think of them?

A: The term, gummy bear breast implant, is a layman’s term and not an actual name of a breast implant. I am not sure of the history of this name but I have heard the term was coined by a plastic surgeon. It is a new generationand innovation of a silicone breast implant, technically a third-generation gel filler material. Think of the original silicone filler material as a Type I which is more runny like thinner molasses syrup and existed up until 1991 when it was removed from the market, A type II gel implant filler is in newer and current breast implants, released commercially again in 2006, and is more cohesive like very thick molasses syrup. A gummy bear implant would be a Type III gel filler and is much more cohesive or stiffer like the gummy bear candy. (hence the name)

From a manufacturer’s standpoint, they have been known as the 410 implant (Allergan) and the CPG implant (Mentor) and have been in clinical trials for years. All manufacturer’s clinical trials with these implants are now closed and under FDA evaluation. It is possible that they may be commercially released by the FDA in 2011 but that is not a certainty.

The biggest advantage to the gummy bear implant is that the gel filler material is more cohesive and has no risk of leaking. It does feel more firm which some patients may feel is an advantage. It will be introduced initially as an anatomically-shaped (tear drop) shape with a textured surface. Because of these features, it must be placed through a lower breast fold incision to ensure proper positioning of the shaped breast implant.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I had saline breast implants placed in 2003. Last week I developed some mild discomfort in my right breast which was just sort of achy. I thought my right breast was getting smaller right after but now I know for sure. My right breast looks much smaller than my left now so I think I have developed the dreaded deflation. I remember something about a warranty program in case this happens. What do I have to do now to get my breast implant replaced for free?

A: The risk of saline breast implant deflation is always a lifelong possibility. While most patients will enjoy the benefits of their saline breast implants for an average of 10 to 15 years, deflation can certainly occur much earlier. Since breast implant failure is one of the known complications of breast augmentation, patients need to be aware of the manufacturer’s warranties. There are two levels of implant manufacturer warranties; implant replacement and monetary contribution to the cost of replacement surgery. Over the years these two warranties have changed and it is important to contact the manufacturer (Mentor or Allergan) and find out what was in effect from that manufacturer in 2003.

In general, replacement of a failed breast implant is usually lifelong and never goes away. Money to be provided to help defray the cost of replacement surgery is usually time limited at 10 years currently. (less in 2003) That amount was $3500 in 2010 but likely was only $1200 in 2003. That money is not given up front to the patient but only months after the surgery is completed so patients have to wait to get their partial reimbursement. (the failed implant must be returned and evaluated first to determine the cause of failure)

One important point of confusion in replacement surgery is that the warranty is given by the breast implant manufacturer as it is a medical device. These warranties do not apply to the implanting plastic surgeon, operative facility or the anesthesiologist.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting my fatter face and neck thinned out if possible. I am sending pictures for your review (frontal and profile) so you can see what I mean. I am interested in a buccal lipectomy procedure and submental lipectomy. I have always thought my face has made me look, in pictures, 30-40 lbs heavier than I actually am. I have also looked at people that are obese or considerably heavier than I am in pictures, comparatively, and noticed that my face make me looks extremely heavy which I am not. I would like to have the procedures done if the changes are significant. I would also like to know if the procedures can be done under local anesthesia. Please advise.

A: Thank you for sending the pictures. I can see your concerns with the fuller tissues around the jawline and into the neck. Certainly fat reduction by neck liposuction and buccal lipectomy is all that is appropriate or should be done. The good question is how much improvement will be seen. That is a tough one to answer as the final result is determined by how well the skin adapts and shrinks down. The limiting factor in your result, and in other male patients who look just like you, would be controlled by the subplatysmal fat at the cervicomental angle (it is not all just above the platysma in the neck angle area) and the subcutaneous fat layer around the jaw angle and over the parotid. Subplatysmal neck fat can be removed by direct excision but the jaw angle fullness is more limited because it can not be treated neither by liposuction or direct excision because of the marginal mandibular branch of the facial nerve. While changes will clearly be seen, I would use the term moderate improvement rather than a dramatic change. Because of the variabiity of the result, you should only undergo the procedure if you can accept modest to moderate improvement. If it turns out to be significant or dramatic in your view then that would be a bonus.

To get the best result possible, doing the liposuction and lipectomy procedure under local anesthesia would not be my approach. That limits how much can be done as patient comfort then takes precedence over the extent of the result.

Dr. Barry Eppley

Indianapolis Indiana