Your Questions
Your Questions
Q: I’ve done Botox injections on my frown line and crow’s feet. Thinking about having Botox to treat TMJ pain and maybe some on my face. Please let me know if he accepts insurance for the Botox treatments.
A: The use of Botox to treat “TMJ’ problems is done by numerous practitioners with variable degrees of success. Botox is a very specific treatment for muscle spasms and tightness or overactive muscles. The term TMJ, however, is a broad term that actually is a collection of different pain sites that is not really a unified diagnosis. For this reason, so called TMJ patients are being injected who may not be ideal candidates for a muscle treatment.
The best orofacial pain patients, in my experience, to get relief from Botox injections are the bruxism or clenching patient. This is a very specific masseter muscle problem that can be localized in most cases to the part of the masseter that is near the bony jaw angle. This is also a perfectly safe area to treat without causing any complications. The tight and painful muscle can be easily felt and the most painful part of the muscle specifically injected. These are also patients that have either been through or are currently undergoing some form of traditional mouth splint therapy. Often this treatment has failed or its effectiveness has decreased…as this is why they are seeking Botox injections.
Because the use of Botox for bruxism or as any part of TMJ problems is not FDA-approved, it is not eligible for insurance coverage.
Dr. Barry Eppley
Indianapolis Indiana
Q: Do you offer chemical peels? What is available to forehead and brow wrinkles?
A: Assuming that these two questions are linked, so to speak, points out a basic misunderstanding of what certain procedures can do. Chemical peels, of which there are many types which penetrate from superficial to deep, are good for improving skin texture problems which does include very fine wrinkles. But they will not work on any skin problem which lies deeper, such as scars or deep wrinkles, folds, or furrows. Almost all commonly used chemical peels treat more superficial skin problems. It is best to think of chemical peels as an outer skin treatment.
Forehead and brow wrinkles are not superficial skin concerns. While they may appear on the surface as a skin change, the primary problem is deep. It is the excessive muscle action that eventually causes the outer skin layers to become etched or permanently wrinkled. Since the problem lies deep, no superficial treatment can provide any visible improvement. This is why the initial treatment for forehead and brow wrinkles is Botox injections. As a muscle-weakening agent, it can lessen or stop their movement creating an immediate improvement in the depth of the wrinkles seen. In more severe cases, a browlift may be a better answer. This procedure treats the muscles at fault through their selective removal. With less muscle action, which is combined with skin tightening through a lift, there can be a dramatic reduction in the forehead and brow wrinkling problem.
Dr. Barry Eppley
Indianapolis Indiana
Q: Hello, I went to see a plastic surgeon about repairing my one stretched ear ring hole. I pretty much made it clear why I was in the office. The office workers did not pay attention to my needs and instead pointed out all my other flaws and pushed selling other procedures on me. I wish I could afford to correct all flaws, however at this time, I just want my little ear repaired. After they had me under the bright light and made me feel awful about myself, they finally told me the cost of the ear repair… $800. Just because the way they treated me, I would rather stitch it myself then give that office the money. Can you please tell me how much the procedure would be? Thank you.
A: Earlobe deformities from the use of ear rings creates two basic correctable problems, an enlarged or elongated hole and a complete split or tear. Both can be easily and quickly treated in the office under local anesthesia in less than 30 minutes. There is no pain afterwards or significant swelling or bruising. Tiny dissolveable sutures are used so there is no suture removal afterwards either. One can shower and get it wet the very next day. Once it is healed, re-piercing can be done six weeks later.
From an office standpoint, every plastic surgery practice has differences in philosophy. Some promote and sell harder than others which often, understandably, turns some patients off. That doesn’t make them a bad practice, just one who may not be a good fit for you. From a pricing perspective, fees will vary around the country for any elective cosmetic surgery procedure based on geographic location and the size of the practice. There are no standard fees for cosmetic surgery nationally. It is a simple matter of what value the practice puts on their time and expense to do the procedure and what a patient is willing to pay. Here in Indianapolis, the prices for earlobe repairs is more typically in the range of $300 to $450 per earlobe.
Dr. Barry Eppley
Indianapolis Indiana
Q: Hi Dr. Eppley, I have a question regarding my face since it has gotten thinner after a facelift. I had a facelift last summer after losing 45 pounds. My plastic surgeon said he took four inches of skin out of my neck. However I did lose my round face because my cheeks are more sculpted now due to loss of volume. While I like the change it is a weird look for me because I have always had a round face since I was just a kid. I never had sculpted cheeks even at a normal weight. I used to get carded well in my 30’s because of my baby face. So there is some merit to having volume. It is weird for me to see my cheekbones as opposed to my puffy cheeks. I almost feel like I look older without my round face. So my question to you is it possible to add some volume in my lower cheeks BELOW the cheek bone to get my “baby face” back. What would you suggest? I can send pix if you want me to. Thanks for your advice.
A: There is no doubt that between having a facelift and undergoing considerable weight loss, one can end up with less facial volume. This is usually most manifest around the cheek areas when it occurs, specifically in the area below the cheeks known as the submalar area. I prefer to call this area the submalar triangle as it is a soft tissue area that has the configuration of an inverted triangle and has no underlying bony support. That is why it suffers the greatest indentation or hollowing on the face with fat loss…it has no underlying bony support so it sinks in.
There are several ways to build out the submalar triangle. The simplest is to replace what is lost through fat injections. Fat is both natural and easy to harvest through liposuction and its injection is not ‘invasive surgery’. Its downside is that its survival is not always predictable. The other is to use a specific submalar implant which sits on the underside of the cheek bone. This will build out the upper part of the submalar triangle but not the lower area near the corner of the mouth. The total submalar area can also be built out by the insertion of onlay dermal grafts. Using part of your old facelift incision, allogeneic dermal grafts (human dermis out of a box) can be cut and laid underneath the skin to add a soft natural volumetric fill. The dermal grafts will integrate and become part of your natural tissues.
As you can see there are a variety of submalar augmentation options. Which one is right for you depends on which approach offers the simplest, most natural, and predictable outcome.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am very interested in learning more about the Kryptonite Bone Cement for injectable cranioplasty. I am a 36 year old female with a very unusual shaped head in which I have always hid behind various hairstyles for shame of the overall appearance of my head. I strongly believe that the shape of my skull may be the result of some form of untreated craniosynostosis or other undiagnosed craniofacial disorder. Or maybe it might just be plain old bad genes.
My skull is very narrow and somewhat small. The shape of my forehead slopes back at such an undesirable angle and is very flat and narrow in width. The resulting slope of my forehead extends up into the top of my skull of which I can only describe as a point. There is somewhat of a flatness in the center of my skull and the back of my skull is very flat and extremely narrow in width as well. I am also very hollow in the frontal view at my temple area around my eyes with very wide cheekbones and a deficient jaw and chin. I have always wondered if there were any such cosmetic procedure that could help in this kind of skull case.
My questions are: 1) What are the biggest benefits of using the older PMMA and HA methods over the new Kryptonite Cement method? How long has Kryptonite Bone Cement been used? 2) Can it be used for adding volume to reshape an entire skull like mine, making it more rounded and add mass in largely deficient areas? 3) Can it be done with scalp hair in place or does the hair need to be shaved for a better view of the entire head? 4) Is there any chance that the material will become detached from the skull and slide out of position? 5) Will the scalp expand and conform to the newly added volume comfortably? 6) Can it be used in place of such procedures as chin and jaw implants?
A: Thank for your insightful questions in regards to your craniofacial concerns. My answers would be as follows. 1) All three cranioplasty materials will work in an open scalp approach. Only Kryptonite can be injected. There are substantial cost differences between the material cost of HA and Kryptonite being over 10X the price of PMMA. For very large scalp areas, the issue of cost makes PMMA the only practical choice for most patients. 2) All the materials can be used over large skull areas. In larger areas, the cost of PMMA makes it the material of choice. 3) For large skull areas, the hair would have to be shaved to see what one is doing. For an isolated forehead cranioplasty, the hair is not shaved. 4) No, all cranioplasty materials stick quite well to the underlying bone. 5) The scalp can expand to a large degree but the skull must not be expanded (built out) greater than what can be closed over it. 6) No as yet. Kryptonite has not been yet tested for use in this way. For now, standard facial implants are more predictable and far less expensive.
Dr. Barry Eppley
Indianapolis Indiana
Q:I am looking at having a revision surgery on my chin for what I believe is a partial non-attachment of the soft tissue to the hydroxyapatite implant. Some of my chin hang independently from the rest and looks aged. My surgery was two years ago. I am contacting you because I see you have specific knowledge of the intricacies of chin surgery. Could you give me some information about what I should do now and whether you have dealt with this problem before?
A: Thank you for your inquiry. Before I can answer your questions specifically, let me get some details as to your chin surgery from two years ago. You refer to having a hydroxyapatite implant placed. Since there are no off-the-shelf hydroxypatite implants of which I am aware, I assume that this was an intraoperatively carved one that was done from a block of material. Furthermore, I am assuming that it was placed intraorally (through the mouth) as opposed to under the chin through the skin.
Your description of your concern’s sounds like what is known as a ‘witch’s chin deformity’, otherwise known as soft tissue chin ptosis. There is where the chin soft tissues sag off of the end of the bone/implant. Because any type of chin implant augmentation must detach the muscles, there is that risk after surgery although it almost exclusively occurs from an intraoral approach.
Please send me some photos of your chin and provide answers to my questions, then I will be able to confirm this diagnosis. I have seen this numerous times and the appropriate correction (implant notwithstanding) in most cases is a mentalis muscle resuspension procedure.
Dr. Barry Eppley
Indianapolis Indiana
Q: I have a very square jaw with a lot of fullness towards the front which has always bothered me and made me self conscious. I try to keep myself thin because any weight gain will make it even fuller. I am currently 43 and it seems to be feeling fuller, where I always felt when I got older the baby fat would decrease. My mother and father both had full faces with fairly square jaw lines as well. I am hoping the buccal fat procedure and would help my profile and thin my face from the front and side…like when I bring in my cheeks by sucking them in…it seems to show the angles more rather than looking chubby.
A: A square facial architecture is strongly influenced by the shape of the lower jaw and the cheek bones. To make a square face less full, the only area that can be changed is an inward movement of the submalar triangle facial zone. That is the area beneath the cheek bone done past the corner of the mouth in an inverted triangle shape. This is an area that is not supported by bone or muscle which is why you can suck it inward. Fat removal of this area is the only way to create some tapering in of this zone. The buccal fat pad occupies the upper region of the submalar triangle but not the area down by the mouth, known as the lower submalar triangle area. So a buccal lipectomy will help but needs another method of fat removal of the lower area also known as the perioral mounds. Microliposuction should be done from inside of the mouth to help this area in conjunction with the buccal lipectomies. The combination of both has the best chance to help achieve the look you are after.
Indianapolis Indiana
Q: I have a cyst like lump right in between the eyebrow. In stead of cutting the cyst off with the knife vertical to the skin, is it possible to make a cut right underneath the frown lines and slice the lump off from the cut? Is it possible to transfer some fat to that area if the area is dented after the lump is sliced off?
A: Those are two very good insights into how to remove your forehead (glabellar) cyst while leaving the most aesthetic outcome. Using a close wrinkle or frown line would be preferable to making an incision directly over the cyst. That would make for a far better scar. Even if the scar turned out less than ideal, it is more favorable area in which to perform scar revision. It may also be possible to remove it by an endoscopic technique, although I would have to see pictures of it to be sure that is a possibility.
Also, placing a fat graft at the time of a facial cyst removal is almost a standard technique that I do since indentations may follow later due to a mass removal effect. An indentation may now appear initially, due to fluid fill of the cyst removal space, but will appear once that fluid is absorbed weeks to months after surgery. If the cyst is more than just the size of a pea, I would recommend that at the same time rather than waiting for it to appear later. It is just as simple to do it at the time of cyst excision.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am 5’7″ and weigh 128 lbs. Even though I am relatively thin, I have always had a double chin for some reason. But I feel like it has gotten worse since I have given birth to two children and have gained over 40 lbs with each pregnancy. I am interested in knowing what could be done and how much improvement I could expect. Getting rid of this double chin would help me feel more confident. Thank you so much for your time.
A: The cause of a ‘double chin’ is a combination of three anatomic factors; neck fat, neck skin, and chin projection/prominence. Every double chin is made up of differing ratios of all three components. It is always about how much neck fat is there, how much extra neck skin there is, and how short one’s chin may be. While you didn’t state your age, that number also has an influence because it suggests how much neck skin you may have and, most importantly, how elastic it is.
Some double chins can be corrected by as simple a procedure as neck liposuction in someone who is young and with decent chin projection. On the flip side, an ‘older’ severe double chin may require everything including neck liposuction, chin augmentation, and some form of a necklift to help tighten the extra loose skin. Each patient must be assessed individually and a custom treatment plan devised as double chin correction is not a one size fits all procedure.
One surprising aspect to the ideal correction of double chin problems is that of the chin. Many people have short chins that are magnified by this problem. Lengthening the jawline with a chin implant while bringing the angle of the neck back (or making it more defined) is the classic ‘ying and yang’ approach which together makes a better result than either change alone.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am interested in getting some facial implant work done and was wondering if I can have wisdom teeth extraction done at the same time? I want to get orbital rim implants with a possible midface lift. Is there any reason why these two can not be done together? Will one potentially cause problems with the other or is it better to have them done separately, like a decreased risk of infection?
A: I see no reason why these two facial bone procedures can not be done at the same time. It is quite common to do multiple hard and soft tissue procedures of the face together. The face is tremendously well vascularized and very resistant to infection. (I didn’t say impossible just very resistant) While such a combination (facial implants and 3rd molar extraction) is unusual, it is by no means contraindicated. The hardest part is not the operation, but finding someone who is well qualified to do both at the same time.
Orbital rim augmentation and a midface lift is done from the outside through a lower blepharoplasty incision. Wisdom tooth or 3rd molar extraction is done intraorally from inside the mouth. The two areas are not anatomically contiguous and would not connect, thus ensuring no risk of oral bacterial contamination coming in contact with any implanted material. Because of this risk, the orbital/midface procedure is done first so cross-contamination from instruments does not cause any inadvertent oral bacterial inoculation on the implant.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am considering getting involved in martial art training and was wondering if having a chin implant would pose a problem with that activity. I have a porex chin implant and I’m afraid it will shift if struck. Have you ever seen a porex implant shift from blunt trauma? Is there a difference in potential shifting between porex and silicone implants. Please let me know so I will know whether or not to proceed with martial arts training.
A: I would not personally refrain from martial arts training, or any other contact-related sports activity, if I had an indwelling chin implant. The risk is always there that a good blow to the chin could cause a problem such as shifting of the implant but that risk to me seems very low. There is an equal, if not greater risk, of breaking one’s nose or having a tooth knocked out. Such are the orofacial risks of any contact sport.
The potential advantage of a porex (medpor) chin implant over a silicone one in terms of shifting in the face of trauma is theoretical. Because the porex implant has greater tissue adherence and even some amount of tissue ingrowth, one would assume that it is more resistant to movement after surgery over a purely non-ingrown encapsulated silicone implant. But blunt trauma to the jaw with enough force can easily fracture the bone so the potential for implant movement, regardless of its composition, is always a low occurrence possibility.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am interested in the Fat Injection Breast Augmentation surgery but have a few questions. What are the preop requirements and do you have to have multiple operations?
A: Breast augmentation with fat injections is in the early stage of technique development. While the appeal is enormous for some patients, it is a concept which has not been shown to be consistent in results just yet and the long-term outcome on breast health and cancer surveillance is unknown. Breast augmentation with implants remains a proven technique. Whether fat injections will one day be a comparative procedure remains to be seen.
What is known about fat injections for breast augmentation is that one has to select the patient for it very carefully. Several criteria are important. First, one has to have enough fat to transfer into the breast. If one is very thin or skinny, they will not be a candidate due to lack of adequate donor tissue. Secondly, one’s desired breast size increase must be modest. At best, only a 1/2 cup or maybe more can be gained in size. Desiring a bigger change than that is beyond what fat injections can yet achieve. Lastly, one must be prepared to accept the likely possibility that more than one fat transfer may be needed. Injecting too much fat in a single session will not work. It is better to incrementally increase the fat breast volume to ensure the best survival and decrease the risk of fat necrosis. Therefore, patients must be willing to accept, and have enough donor tissue, to do a second fat injection session in most cases.
Dr. Barry Eppley
Indianapolis Indiana
Q: Hi, I need your help. Three months ago I had a gynecomastia operation done and now I have a problem. The problem is that my nipples are folded in now and going inside. My skin is also very dry around nipples and my nipples have become cracked. This looks like a serious problem. How can I fix my nipples?
A: Gynecomastia reduction procedures can be done two fundamental ways; liposuction or open excision (removal) of excess breast tissue. Sometimes the two techniques are done together to get the best result. With the open excision technique, breast tissue is removed through an incision on the underside of the nipple. (technically the areola) Removal of this breast tissue is largely an art form. How much to remove and how to shape what is left behind is more of matter of experience than an exact science.
One of the known complications of open gynecomastia removal is over-resection, removing too much breast tissue. This make look alright in the very beginning (or not) but as the swelling subsides and scarring sets in, the nipple gets pulled into the over-resected space where breast tissue once was. This is called nipple inversion or a retracted nipple. It most commonly appears underneath the nipple since this is closest to the incision but it can appear outside the diameter of the areola if the over-resection goes beyond just that area.
Correction of the inverted nipple after gynecomastia reduction requires replacement of the missing tissue to support the projection of the nipple. This is best done by a fat graft or a dermal-fat graft using the patient’s own tissues. This requires a donor site and a scar elsewhere on the body to do it.
Dr. Barry Eppley
Indianapolis Indiana
Q: I was wondering if I could get a Botox procedure done in my masseter muscles to help with my teeth clenching. I have tried mouth guards and it doesn’t solve the problem because I’m also clenching my teeth a lot when I am awake. Please send me any information you can regarding this issue.
A: I have used Botox for masseter muscle injections for clenching and bruxism for the past five years. I have yet to see a patient who has not had some near immediate and significant improvement of their clenching afterwards. The duration of the pain relief will last as long as the Botox is effective, generally around four months or so. This makes perfect sense as the clenching is muscular in origin. While it can also involve the temporalis muscle, the large masseter muscles are certainly a major source of the clenching problem. While the simultaneous use of oral splints still has a role, particularly to prevent excessive tooth wear, the direct injection of a true ‘anti-spasm’ agent into the muscle is undoubtably more effective and immediate. (results within a week or less)
I have found that the starting dose of Botox is 25 units per side. Both sides are only done if the patient feels that the pain is on both sides. Many patients will have only a one-sided or unilateral source of masseter pain and clenching. The injections are placed in the lower half of the masseter. If a line is drawn from the earlobe to the corner of the mouth, the injections are placed in the part of the masseter muscle that lies below that imaginary line. This is a simple office procedure that is both quick and fairly painless. Compared to cosmetic Botox injections in the forehead, masseter muscle injections are surprisingly more comfortable.
Dr. Barry Eppley
Indianapolis Indiana
Q: Dr. Eppley, I have a question about the cranioplasty operation. I had some frontal bone augmentation done two weeks ago with acrylic material. I had it done to get rid of some irregular areas that were quite prominent on my forehead. I had a craniosynostosis repair when I was one year old. I know that swelling is to be expected but I thought most of it would be gone by now. It appears asymmetric between the two sides of my forehead and doesn’t look quite even. Am I being too optimistic about the swelling?
A: It is normal that patients are generally quite overoptimistic as to how long it takes to see the final result of the cranioplasty procedure. While two weeks may seem like an eternity when you are the patient, six to eight weeks is the realistic time period to see about 90% of the final result…and 3 months after surgery before one can make a final critical analysis. That’s how long it takes for the scalp tissue swelling to go completely away and all areas to settle. The thicker the tissues are, the more swelling and the longer it takes for it to go away…and the scalp tissues are quite thick.
Another interesting note is the concept of bilateral (two-sided) surgery. Even though the same thing is done to both sides, the swelling that occurs is never, or rarely, the same. So any asymmetry at this point I would still judge to be swelling differences and not yet proven to be some differences in the degree of forehead symmetry from the augmentation.
Indianapolis Indiana
Q: I am unhappy with the mid- and lower cheek area of my face. My cheeks are sunken in below the cheek bone causing a hollow/gaunt appearance. I have smile lines that are becoming heavier and more visible all the time. I had fat injections in the area of the smile lines about 3 months ago. I would estimate that about half remains at this point. I saw your videos on Youtube and would like your opinion on whether a submalar implant would fully correct, partially correct, or have minimal effect in this area of my face. I would like to understand your recommendations on improving this area. My objective is to create a permanent and fuller looking face in the cheek area and pull out the smile lines without creating a chubby or fat face.
A: The key to answering your question is to understand the anatomy of the submalar triangle area. This is an inverted triangle facial zone that lies below the cheek bone in which the apex of the inverted triangle goes down below the corner of the mouth. Almost all of this area is not supported by bone, but by soft tissue only. As a result, a submalar implant will only help create fullness in the upper region of the submalar triangle. The smile lines lies in the lower end of this triangle and will not be changed by a submalar implant. Soft tissue augmentation must be done in the smile line area. Fat injections is one method but is fraught with unreliable take as you have experienced. But its simplicity remains its appeal and another effort at it may produce even better results. The other option, which I currently prefer due to its better effect and longevity, is interpositional dermal grafting. By placing layers of allogeneic dermal grafts in this area, the skin and the underlying tissues are released and separated by the grafts. They add an eventual well-vascularized tissue layer that can be from 2 to 5mms thick which is not unduly bulky. They must be placed through a limited facelift (preauricular) incision. Their longevity is much more assured than injectable fat grafts in this facial area.
Dr. Barry Eppley
Indianapolis Indiana
Q: I live in New Jersey and loved reading your advice articles on injectable fillers. I am a 42 year-old female with dark circles under my eyes with hollowing, upper lip wrinkles, and horizontal forehead ceases. I would love to know if you could recommend a skilled Dr in my area who could do my eyes? Thank you for your time.
A: Injectable fillers can be used to create a variety of instantaneous facial effects by adding volume under the skin. While once limited only to lessening the depth of the nasolabial folds or increasing the size of one’s lips, their uses are being expanded. One of these newer areas is around the eyes, specifically for hollowing of the lower eyelids or treatment of the tear trough depression. This lack of volume can be one of the contributing factors to the appearance of dark circles under the eyes. Suborbital injection filling is one of the more technique sensitive (trickier) areas to inject well however. There is definitely much greater risk of bruising due to the many blood vessels in this area. Missing all of them can not always be predicted. Proper placement of the filler in the deeper tissue level down to the bone is important to not only get the best fill but to avoid lumps of the material if injected just under the skin. For those physician injectors that regularly perform blepharoplasty (eyelid) surgery, they will more likely feel comfortable placing the injectable filler into the proper tissue level. They will also be in better position to judge whether an injectable filler is the best treatment option and how it might compare to other methods of treatment such as fat grafting.
Dr. Barry Eppley
Q: I am interested in what a limited facelift or lifestyle lift might do for me or if I can get away with fillers or something like that. What is the comparative recovery time? Costs? How long do they last?
A: One of the common misconceptions in management of the aging face is that injectable fillers and some form of a facelift treat the same problems. They do not and, as a result, are not comparable treatments. They are often companions (done together or in separate stages) but are never substitutes for each other. Injectable treatment are for the central part of the face and do things that surgery generally can not either achieve or do very well. These include Botox for forehead and eye wrinkles and fillers for nasolabial fold depth reduction and lip wrinkle reduction and lip size increase. Any form of a facelift deals only with the sagging skin and excess fat in the neck and jowls, lower third of the face sagging.
There are procedures touted as ‘liquid facelifts’ but these are a bit (or maybe a lot) misleading and are associated, in my opinion, with a relatively poor value. By using injectable fillers, the sides of the face and cheeks can be puffed up which does create a mild temporary lifting effect due to the expansion of the tissues. The operative word is temporary (six months or less) and, when one compares the cost of numerous syringes of injectable fillers, one could already be more than halfway to one of the variations of a facelift. This injectable approach will also do nothing for the neck area which is the primary target of facelift surgery.
For the patient with lesser amounts of facial aging, the combination of a limited facelift (aka Lifestyle Lift) and injectable fillers can create a very dynamic effect by being able to treat the entire face more effectively. There is a very definite role and benefit to injectable fillers but their results are not comparable to facelift surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I had a chin reduction just about two months ago. I still have not seen any results. If anything I feel that my chin seems longer then before. I spoke to the doctor about it and addressed my concerns. He said it takes up to 6 months for the final results. If by then I am not happy with it, he will then try something else. What to you suggest?
A: There is no question that any form of chin surgery takes time for the swelling to go down. In my experience in chin reduction, this is particularly true as swelling will mask a reduction longer than it will an augmentation. (the result from a chin augmentation will be seen immediately, the issue is that it initially looks too big due to the swelling) The initial soft tissue swelling from most forms of chin reduction will make it look longer or bigger initially and this is normal. Generally, however, the results start to become apparent within three to four weeks at most. By six weeks, patients should be able to say that they see a difference if not significantly so. It will take three to six months, however, for the true final result to be appreciated.
One important factor that controls the amount and duration of swelling is what type of chin reduction procedure was performed. There are two different types of chin bone reduction procedures, an osteotomy and a burring or shaving. One is done from inside the mouth (osteotomy) and the other is done from an incision underneath the chin. Knowing which one was done can help determine how long it may take to see the final results from the chin modification.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am exploring cheek implants as a solution to my flat cheekbones which i was born with.sunken cheeks (genetic). I live in Pennsylvania and wanted to find out if Dr. Eppley would initially review emailed photos before making an appointment.
A: The concept of ‘consults from afar’ in plastic surgery was once inconceivable and impractical. But the internet and the ease of photographic acquisition and transfer has changed that perception. Since almost all of plastic is external and very visible, physical and cosmetic issues can now be seen from great distances by simply sending pictures. In fact, the reach of the internet and its virtual no cost has made it possible to connect any two places in the world, at the very least by e-mail.
I regularly (daily ) do internet plastic surgery consultations. Many are from various U.S. states and provinces of Canada but some are from countries around the world ranging from the United Kingdom to China. There are two types of internet consultations. The first type is of an e-mail nature only. Inquiries are initially done by e-mail from which I request photographs for review and possible computer imaging. That may then proceed onto an actual phone call for the next level of more indepth discussion. The other type is a Skype video consultation. Its origin may be from an initial e-mail or from Skype itself. If a video Skype consultation is arranged, then photographs may be bypassed due to actually seeing the patient. However, due to the poorer resolution of many Skype video connections, photographs are recommended to be sent first.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hi. I know I might be young to ask, age 19, but I was wondering what you called a plastic surgery that takes care of love handles. But I am not talking about the hip handles. I have some pretty good handles right under my breasts that wrap to my back. I believe it is some loose skin as I have managed to loose 25 pounds this past year. I am just wondering what you would call that specific body part and maybe an average of how much it would cost to fix it. Thanking you in advance for replying. From a discouraged yound girl.
A: The important question is whether the rolls underneath your breast that extend into your back are skin, fat or a combination of both. With weight loss, most loose skin is going to develop and be seen lower due to gravity. That being said, I would have no doubt that it is a combination of loose skin and fat. Whether one is more predominant over the other would require an actual physical examination to make that distinction. But given your young age, I would recommend a liposuction procedure for fat reduction first and see how the skin adapts. The fat in the upper abdomen and the back is more fibrous in nature than lower abdominal fat and a liposuction technique, such as Smartlipo, will be more effective than traditional liposuction. There are methods of skin and fat removal by excision in the upper abdomen, which do leave lower breast fold scars, but they are usually reserved for more extreme cases of weight loss where the sagging skin is the predominant problem.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hey! I have large indentation on the right side of my frontal bone. It is becoming noticeable since I have started losing my hair. I am wondering if it is possible to correct it without any visible scars. Thanks and.hope to hear from you soon.
A: For select cranial defects, the use of the new Kryptonite bone cement may make it possible to fill out or augment deficient bony areas. Because of its flow characteristics, it can be injected through long small plastic catheters into cranial areas from a small incision placed in the most inconspicuous location as possible. Studies have shown that it is injectable through catheters as as small as a 12 or 14 French size. (roughly 4 to 5mms internal diameter) Once injected it can be molded through the skin from the outside until it steps up into a firm consistency.
When defects are present on the frontal bone, it is important to recognize the exact location if this injectable technique is to be used. Defects that exist between the anterior temporal lines are bone-based and can be augmented by onlay bone materials. If the forehead defect extends beyond the anterior temporal line, this area is covered by the upper edge of the temporalis muscle. While the temporal muscle can be lifted up and material added onto the bone, this is not possible with a limited incision injectable treatment method. Defects that extend into the temporal area require the more traditional open scalp incision for access and wider exposure.
Indianapolis Indiana
Q: I am a male and would be interested in receiving a surgery in order to correct my bulging forehead. Do you perform that kind on procedure on men?
A: Forehead surgery or forehead reshaping can mean different things to various patient, both male and female. The two most common procedures performed on the forehead are brow bone reduction in the male and brow bone reduction/tapering in the transgender patient. (male to female) There are also a variety of other forehead reshaping procedures from defects and asymmetry caused by craniofacial birth defects and trauma and prior neurosurgical/craniotomy operations. Bu, by far, regardless of the diagnosis the vast majority of forehead surgeries are done in men.
The typical cosmetic reason for male forehead surgery is brow bone reduction. Large brow bones, caused by overgrowth of the underlying frontal sinus, can create very prominent bulges in the forehead bone above the eye. (supraorbital rims) While most patients think it is a thickening of the bone and a simple burring down will suffice, this is not so. Rather the frontal table of the frontal sinus (visible brow bone) must be removed, reshaped, and then put back in a more flatter or recessed position. While tremendously effective, the access to perform that procedure requires a long scalp incision. This cosmetic trade-off is a serious one to consider and is usually an issue which prevents most men from having the procedure. Until a more minimally invasive approach to brow bone reduction is developed, most men with prominent brow bones will have to live with them.
Q: I have a noticeable cleft in my chin and I was wondering what procedures can be done to remove the cleft and how invasive are they?
A: Soft tissue indentations of the chin can appear as either clefts or dimples. While both involve the chin soft tissues, they are anatomically different. Chin dimples are round depressions in the middle portion of the soft tissue pad of the chin and occur because of a central muscular and fat deficiency. There is no underlying bony abnormality. Chin clefts are vertical indentations that run from the middle part of the soft tissue pad down to the lower border of the chin. While they also have a muscle and fat deficiency (cleft of the soft tissues), they almost always have some notching of the lower border of the chin bone as well. (symphysis) Embryologically, it is easy to understand how a chin cleft occurs because of the union of the mandibular arches in the midline during development. It is harder to understand the origin of the central dimple although this likely represents an area of lack of epidermal cell adhesion during the final phase of merging.
Chin cleft surgery is best thought of as a reduction rather than a complete removal. There are two fundamental ways to perform the procedure based on the depth of the cleft and the tolerance for any outward scarring. An intraoral approach can be done where the the tissues under the skin are released from the bone, the cleft of the chin bone is filled in (if deep enough) and the muscles put back together to create more of an outward pout of the muscle. This works well for modest to moderate deep chin clefts. In very deeply grooved chin clefts, this will only provide partial depth reduction. Outward skin excision is more effective in these deeply grooved clefts but the creation of a vertical scar, even if the surrounding skin edges are smooth, may not be cosmetically acceptable.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hi, I am trying to find an expert z plasty surgeon and I was wondering if you could help? Thank you.
A: Z-plasty is a common plastic surgery technique that is used to improve the functional and cosmetic appearance of scars. It has a long history of use in plastic surgery and is one of the original scar revision procedures. It can lengthen a contracted scar or change the direction of a scar’s tension line. It is conceptually done by initially drawing the he middle line of the Z-shaped incision along the line of greatest tension or contraction. Triangular-shaped flaps are then raised on opposite sides of the two ends and then switched or transposed. The transposition of these two triangular skin flaps creates the classic Z shape of the final scar lines. The angles at which the triangular flaps are cut will determine how much the scar is really lengthened. The traditional 60° angle Z-plasty will give a theoretical lengthening of the central limb of 75%. Different angles of the flaps will give variable amounts of lengthening. While the mathematics of these flap angles are interesting, the most important thing is that the z-plasty will always lengthen a scar. Single or multiple z-plasties can also be used in a variety of clever ways for longer scar problems.
The use of z-plasty scar revision and contracture releases is very common and every plastic surgeon is trained and knows how to use them. Therefore, ‘expert z-plasty’ surgeons would be any board-certified plastic surgeon in your local or regional community.
Dr. Barry Eppley
Indianapolis Indiana
Q: Dear Dr. Eppley, I am about to undergo a third surgery for my short mandible. My first surgery consisted of bone grafts to the jaw angles with a sliding genioplasty for my chin. I then had a second surgery in which silastic jaw angle implants were placed as the bone grafts had resorbed. For my upcoming third surgery, a medpor chin implant is going to be used which will extend back to the jaw angle. My doctor is concerned, however, about placing the medpor implants over the indwelling silastic implants (to improve the angle still) because of issues with bonding medpor to silastic. I assume it will take some method to secure the two implants together. He is concerned with slippage of the two implants placed on top of each other. Do you have any suggestions as to how to fix these two implants together? Your comments will be very appreciated. Thanks.
A: Commenting on another surgeon’s operative plan or method of surgery is not really appropriate from my perspective. I am certain that your surgeon would not really appreciate it and, if he needed help in the planning, he would have his own reference sources to ask. In addition, the details of exactly what has been previously done and the specifics of this next proposed surgery are lacking in your brief description of the issues. I wish you the best in this upcoming surgery and hope that your desired final aesthetic goals from your jaw reconstruction will be successfully met.
Dr. Barry Eppley
Indianapolis Indiana
Q: Hello, I had a hair transplantation done about 6 years ago which left me with a terrible strip Scar on the back of my head. Because of the failure of the hair transplant, I now shave my head smooth and this scar is particularly noticeable. Getting the hair transplant was the worst decision I ever made in my life. I am trying to get to a scar revision to reduce the size and appearance of the scar.Is it possible to get good results? I have attached pictures of my scar. What is the best procedure available?
A: Thank you for sending pictures of your hair harvest scar. Admittedly it is not a good looking scar from this procedure as it is very long and wide and the suture or staple marks are quite evident. It is also unusual in that is obliquely oriented which was undoubtably done to get the most follicles for the transplant but poor orientation for good scar formation.
Most certainly, this scar should be able to be substantially improved with scar revision. The length and orientation of it can not be changed but it can be made much thinner. In that regard, scar revision can offer improvement. The scar must be cut out completely but the key to a narrower result is what is done underneath. The galea deep to the follicles must be released and undermined so the scalp can come together without much if any tension. Tension is the enemy of any scar narrowing effort. The deep layers are put together to take tension off of the skin. The sutures to close the skin are merely put in help it heal quickly but will not ward off tension on the closure line. The skin must also be handed gently to avoid injuring any hair follicles. Loss of hair in the scalp equates to a wide and noticeable scar.
Dr. Barry Eppley
Indianapolis Indiana
Q: I have a very noticeable buffalo hump and I have tried the traditional liposuction and it didn’t work. I just recently tried smart lipo and the Doctor said the area was too fibrous and he could not get the laser probe in. He said that there was too much scar tissue. My neck is still swollen since this procedure was just attempted several weeks ago. Are there any other solutions to get this buffalo hump off of me?
A: When neither liposuction option will work, there is always the traditional method of excision for the buffalo hump neck deformity. This is actually more effective than liposuction in terms of the amount of reduction because the buffalo hump is a different form of fat that is not as easily removed due to its natural more fibrous composition. But there is the trade-off of a midline scar from the nape of the neck down into the upper back to do the procedure. The length of the scar would be no longer than the vertical height (length) of the buffalo hump. There will also be a need for a drain after surgery as the tendency to form fluid collections (seromas) after open excision is quite high.
While this approach may leave a scar, this may now be a good alternative given that two attempts at ‘non-scar’ liposuction has not worked. It is a matter of trading off one deformity for the other. You have to decide whether the scar is a better ‘problem’ than the buffalo hump.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am in need of a septoplasty and turbinate reduction for nasal obstruction and snoring. I am considering rhinoplasty at the same time as I have a larger nose which I want to make smaller. Do you perform turbinate reduction with radiofrequency ablation? Do you have an idea how much my insurance may cover due to breathing problems and what part I would have to pay for the rhinoplasty?
A: Contemporary turbinate reduction can be done by a variety of methods, all intended to shrink the size of the turbinates rather than by just cutting them out. Several methods exist including radiofrequency ablation. That is not a technique that I use. I use diathermy or cautery ablation and have done so for years. Whether one method over the other provides a better result is unknown as both approaches cause shrinking of the inferior turbinate by devascularization and some degree of mucosal necrosis.
Insurance almost always covers any form of internal functional nasal airway surgery and their willingness to do so has actually improved over the years unlike many elective medical procedures. Such allowed coverage is determined beforehand through the typical insurance pre-determination process.
Doing rhinoplasty at the same time as nasal airway surgery is obviously common and efficient from a nasal perspective. While insurance does not cover rhinoplasty, there is no question that it does help to lessen the cost of rhinoplasty as opposed to it being done as a stand alone procedure due to time efficiencies and many surgeon’s willingness to accept some reduced cosmetic fee for doing it.
The answer of the cost of rhinoplasty with internal nasal surgery would be based on what type of rhinoplasty is needed (partial vs. full) and what facility the procedure may be performed in. (different facilities have varying fees for operating room use and anesthesia charges) As a result of these variabilities, definitive cost estimates would require knowing what type of rhinoplasty you need and where it would be performed.
Dr. Barry Eppley
Indianapolis Indiana
Q: I have a deviated septum. I am pretty sure my insurance covers surgery to fix a deviated septum. I was wondering whether would there be anyway of sliding in a rhinoplasty while fixing the deviated septum to cover majority of the costs. How would that work, thanks so much.
A: The premise of your question is…can I get insurance to pay for part or all of a cosmetic procedure? While the answer to that seems obvious, it is actually an understandable and common question that has historic precedence. In the past, many cosmetic procedures were done at the same time as medical or insurance-covered procedures…and the patient was never charged for the associated expenses of operating room charges and the anesthesiologist’s time. They were just ‘rolled into’ and considered part of what was billed to insurance. The hospital or surgery center never really knew or just looked the other way.
But such surgical behavior is now long gone and is viewed for exactly what it is…insurance fraud. Getting the insurance company to pay for part of a cosmetic procedure, just because a medical procedure is being done, is not what any patient’s health insurance is intended to cover. Nor are they obligated to do so. And the insurance companies understandably take a very dim view of such actions. As a result of such past behaviors, health insurance companies have gotten very vigilant of such behavior as well as hospitals and surgery centers. There are substantial fines and even criminal sanctions if such actions are discovered on the providing facility. Therefore, any operating facility is fully aware of whether a cosmetic procedure is going to be done and expects to be paid in advance for the time involved in performing the cosmetic part of the operation.
Similarly, expecting or asking your treating plastic surgeon to make an operation appears as if it were medically necessary, when it isn’t, is just a different form of fraud. Septoplasty, or internal nasal surgery, provides functional breathing benefits and is medically necessary. A rhinoplasty, unless done as a result of a birth defect (e.g., cleft lip and palate), accident, or as a result of tumor removal, is a cosmetic change that is not eligible for medical coverage.
Dr. Barry Eppley
Indianapolis Indiana
