Your Questions
Your Questions
Q: I had rhinoplasty surgery one week ago today. Ever since the surgery my nose has been very congested and I can only really breathe through my mouth. It runs all the time and I constantly have to wipe it. My concern is whether this is normal? What can I do to make my breathing better?
A: Such nasal congestion after a full septorhinoplasty is very common and almost the norm for the first week after surgery. Even though most plastic surgeons today don’t use nasal packing, often some form or resorbable or dissolveable packing may be used. This takes a week or two to go away. This combined with the swelling of the nasal linings, clots and reactive production of nasal secretions can make for a difficult first week. Yours sounds like a very typical one for many more complete rhinoplasties.
While time will improve the nasal congestion substantially, it make take up to 10 to 14 days until it is really better. Complete resolution of the congestion and drainage will be seen by three to four weeks after surgery.
The use of hot showers or a dehumidifier in your bedroom at night and the liberal spraying of your nose with Afrin (decongestant) and saline nasal sprays will reduce the swelling in the nose and help loosen obstructive clots. During your first postoperative visit to your plastic surgeon, those clots that are easily visible and not too painful to remove can be cleared.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am interested in getting a mini-facelift done. I would like to know some information about it and the cost.
A: The mini facelift to which you refer is also known by many marketed and highly promoted names. Its primary effect is to dramatically improve saggy jowls, smooth out the jawline and have some secondary effects in the neck. It is different from a full facelift because it is not effective for the really saggy neck. It is often combined with other facial rejuvenation procedures such as neck liposuction, chin augmentation and eyelid tucks. It takes just over an hour to perform and is usually done under IV sedation or general anesthesia. In my Indianapolis plastic surgery practice, it is not usually performed under local anesthesia. While the use of local anesthesia is an understandable attraction point for many patients, it makes the operation longer and takes an already limited operation and makes it more’limited’. The limited facelift is an outpatient procedure that uses no drains or sutures that have to be removed. One can shower and style their hair normally the next day after the overnight dressing is removed. While there is someswelling and bruising, this is more limited than what occurs in a full facelift. One can expect a complete social (how do I look?) recovery in 7 to 10 days.
The average cost for a limited facelift, all costs included, is in the range of $5,500 – $6,500
Dr. Barry Eppley
Indianapolis Indiana
Q:I would like my cranium to be more symmetrical. I didnt notice how misshapen it was until I started going bald. The shape is extremely incongruous with my handsome face. I would love to have a consult via skype. thank you for your time.
A: The true shape of one’s skull (cranium) often remains hidden under the cover of hair. For women this rarely becomes a subsequent issue as their hair pattern and density is more stable. This accounts for why I have had very few adult women requesting any skull reshaping procedures. For men, however, close-cropped hair or an eventual bald pate makes the shape of the skull very obvious. This is particularly true when it comes to the back of the head or the occipital region.
While loss of hair makes the skull shape more obvious, it also limits what can be done from a surgical reshaping standpoint. The use of scalp incisions and the subsequent scar must be considered as an aesthetic trade-off for a abetter shaped skull. For many men, this trade-off may not be a good one.
Skype is a wonderful to communicate for potential plastic surgery patients. It allows patients to ask questions and get answers from an expert from the convenience of their own home. I always ask patients to send me some pictures of their concerns beforehand so I can have a good idea during our online discussion. If one has a webcam that is even better as a video consult is the most interactive and informative.
Indianapolis, Indiana
Q:Dr. Eppley, Can you tell me how to get rid of my pesky double chin? It bothers me tremendously. I am only 43 years old and my neck looks twenty years older! I am too young to look like this. I am at a good weight and haven’t been able to shake these two chins off no matter what I do. What do you recommend?
A: The ‘double chin’ appearance comes from two upside down hump areas. The first is the chin, which everyone has, but in the double chin patient it is often short or set back. This can make it appear that it is part of the neck when it should be a more distinct forward prominence of the jaw. The second hump or sag is the soft tissue of the neck. This may be just a lot of fat but is usually mixed in with some loose skin as well. This is particularly so in older patients who may have overall neck skin laxity. Given your relatively young age, I would envision that the anatomic composition of your double chin is a bony chin shortness and a collection of fat with some mild amount of loose skin in the neck.
Therefore, correction of your jaw and neck contour could be done by a combined chin augmentation and neck liposuction. It may also be beneficial to do a little neck muscle (platysma) tightening at the same time to get the best neck angle. I doubt if you need any removal of skin at your age and we would rely on the natural skin tightening that occurs after liposuction in good quality skin.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dear Dr.Eppley, I am 27 years ol male and when I was born I had a skull deformity in which the bones of the skull were bonded together. For that reason I had a surgery at the age of 3 year s old in order to be fixed. But the surgery left me with a disfigurement on my forehead, which is a deformity which affected how people were looking at me since I was little. I was hoping after I have read an article of yours on the web that you can help me. I look forward if you can give me your opinion and the possibility to treat my forehead problem.
A: The congenital skull deformity to which you refer is generally known as craniosynostosis. The skull bones are connected by fibrous connections known as sutures. If one or more of these is fused, the skull can not grow (expand) properly and a variety of craniofacial deformities results, depending upon which cranial sutures were affected.
I suspect that your form of crasniosyntosis was either trigonocephaly (metopic suture) or plagiocephaly (coronal sutures). While early surgical intervention (frontal and orbital bone reshaping) is very helpful, it often leaves some residual forehead contour issues. I would have to see pictures of you to determine exactly what the forehead shape issue.
In men, forehead reshaping is complicated by the need to use a scalp incision for access to do the surgery. In patient’s that have had a prior craniofacial surgery in infancy or as a young child, an incision (scar) would already exist making this surgery obstacle irrelevant.
Indianapolis Indiana
Q:How difficult would it be to remove a dorsal onlay graft composed of a continuous piece of septal cartilage? The underlying structure of the nose was not changed.
A: Cartilage grafting in rhinoplasty is commonly done for a variety of structural enhancement reasons. Building up the bridge of the nose, widening the middle vault, and supporting and expanding the tip of the nose are common reasons for the use of cartilage grafts in rhinoplasty. Raising up a low dorsum, also known as the bridge of the nose or dorsal augmentation, can be done with cartilage grafts or synthetic materials. When possible, the use of your own natural cartilage is always best as it poses no long-term problems in terms of infection or tissue reaction. The most common problems with cartilage dorsal augmentation is shifting or asymmetry of the graft, underprojection (not enough height) or overprojection. (too much height which is rare)
Cartilage grafts to the nose heal with a surrounding capsule or scar. Inside this envelope sits the cartilage graft. Much like the original mucoperichondrial lining from which it was harvested (septum), this lining can be raised up and the cartilage graft exposed and removed. The cartilage grafts do not heal and become one with the surrounding cartilage like a bone graft would do in other areas of the face. There remains a clear demarcation between graft and the surrounding tissues. It should not be a problem to remove it in one-piece although it is best done through an open rhinoplasty approach.
Because it is a septal graft, it is unlikely that enough volume has been placed to make the graft too big or too high. I would be curious to know what about the graft makes you want to remove it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: What is the name of the computer program application which allows a plastic surgeon to show anticipated changes prior to surgery?
A: Computer imaging, or predictive surgical outcomes, is a very useful tool in elective cosmetic plastic surgery. Its value is not in that the predictions are a guarantee of what the final results will be, but as a communication tool between plastic surgeon and patient. Through the exchange of predictive images, it is far more likely that the plastic surgeon will have a good idea as to exactly what the patient does, and does not, want to achieve by the proposed surgery. Some unhappy outcomes from plastic surgery are the direct result of a misunderstanding of what the procedure(s) could do. This type of complication can be avoided by good communication before surgery and computer imaging can help that important process.
While it can be used all over the body, computer imaging is most effective and predictive for the face. It is particularly good in profile changes, such as rhinoplasty, chin and neck changes and forehead contouring. Because it is morphing anatomy that is contrasted with a different color background, the changes can be very accurate in many cases. They are also quite easy to see and appreciate. Frontal face imaging is also very useful but it is less accurate as one is pushing around and changing colors of pixels that are more similar. It is very easy to overpredict outcomes (looks better than what can really be achieved) in frontal views and the experienced and artistic hand of the plastic surgeon is really needed here to avoid an exaggerated prediction.
There are numerous software programs out there for computer imaging of the plastic surgery patient. The most common and widely available one is that of Photoshop Elements.
Dr. Barry Eppley
Indianapolis, Indiana
Q : My son is 5 years old and he has three scars on his face that we would like to have improved. The first scar is a laceration scar that is located above his eyebrow that happened about 2 years ago. The other two scars are minor scars that just never went away. We are just looking to see what options we have for scar revision and if he is even old enough to receive surgical treatment for his scars.
A: Age of the patient is rarely a reason that scar revision can not be done. The most important issue regarding age is how old is the scar? Scars that are immature, usually less than 6 months old, are often too ‘young’ for treatment as their appearance is still evolving. Scars that are raised, red or have initially appearing uneven skin edges will usually have improvement in these features as healing progresses.
Time is a scar’s best friend unless the scar has physical characteristics that time does not improve. One of the time-resistant features of a scar is width. As scars heal they will not get more narrow. Often the opposite will occur, they will get wider due to the effects of skin tension on them. For this reason, I may do scar revision early in very wide scars as waiting further only loses time in getting to a point of a better appearing scar.
On a different scar note, one of the most frequent misconceptions about what makes scars look better is that of laser resurfacing. It is commonly believed that the laser is the primary tool used in scar revision. This is completely false. It rarely can make a significant difference in how a scar looks. It’s role is often as an adjunctive tool after surgical scar revision is done.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I want to know if my protruding nipples can be reduced on size and made to lay flat. I am a 23 year-old guy that has gotten big nipples just in the past several years. I never noticed them before but now that really bug me. I am very conscious of them and have to be careful as to what type of shirt that I wear or they will be sticking out and obvious. I want them to be flat and smooth with the rest of my chest. I have read that women can have their nipples reduced but can’t find that it is done in men.
A: Nipple reduction can be done just as easily and simply in men as it is done in women. In fact, it is actually easier in men because there is no effort needed to preserve nipple sensation or any height of the nipple. Also, men rarely have the degree of protrusion of the nipple that many women have making it, by comparison, an easier problem to cure.
In men, nipple reduction is done by a wedge-excision approach. This will completely eliminate the nipple and will make a seamless color transition into the areola as it is that tissue which is actually closed over where the nipple was. This will always make the nipple completely flat and eliminate any chance that it will ever protrude again. While nipple sensation will be lost that is rarely a concern for most men. It is a simple procedure done in the offiec under local anesthesia. There is no recovery or restrictions any activities afterward. Tiny dissolveable sutures are used and one can shower the very next day.
Indianapolis, Indiana
Q : I have a deformity of the skull known as plagiocephaly. I stumbled across your site a few days ago and a sudden feeling of relief came over me. For the first time in my life I feel as if there is hope for me. I would like to know what can be done to correct the condition that I have. I know that nothing is perfect in this life, I am a living example of that but I would sure love to give your treatment a try. I have lived my life in the shadows, hiding away from the world. I think that Dr. Eppley will help me live for once.
A: Plagiocephaly, meaning crooked or twisted skull, affects more than just the shape of the cranium. Since the face is attached to the cranial base, it also is affected by how the skull develops. Untreated plagiocephaly can affect the front or back of the skull. When untreated as an infant, if severe, it can lead to a variety of predictable face, ear and skull deformities.
The first question is whether your plagiocephaly is frontal or occipital in origin. Facial photographs will make that fairly clear. Either way, the key in providing some cosmetic improvement to the craniofacial deformities is to understand what can and cannot be done. While much can be done to improve facial asymmetries, less can be done with adult skull deformities. Forehead recontouring can be done but changes in the back or side of the skull are more difficult and much less can be done.
What I ask every patient is to make a list of what bothers you from most significant to least significant. Then we go over the list, look at what can be done, and come up with a practical and value-oriented plan for improvement. Such improvements as forehead and brow reshaping, rhinoplasty, cheek, chin and jaw angle augmentations, and otoplasty are common procedures that can be very helpful in attaining improved facial symmetry. Augmentation procedures on the back and sides of the skull can also be done but very little can be gained by any form of reduction cranioplasty.
Dr. Barry Eppley
Indianapolis, Indiana
Q : I am trying to research plastic surgery on nipples but am having trouble. What I am looking for is a remedy for droopy nipples. I am 49 and breast fed my son for 3 and 1/2 years when I was about 30. As he fell asleep he tended to grit his teeth. Because of this and some some loss of size of my breasts there seems to be extra skin around the nipple area and my nipples lay down rather than remain perky (unless it is quite cold). Also, if I raise my arms, they can look like the skin around an elephants ankle. Is there a surgery for this. If so, what is it called. I would like to research it before jumping into things.
A: The extra skin around your nipples is the result of pregnancy and breast feeding. (the gritting of your baby’s teeth had nothing to do with it) Both conditions result is loose breast skin which is most noticeable around the center area of the breast mound where the nipple happens to be located. Depending upon the amount of loose breast skin, there are a variety of breast lift or breast tightening procedures to consider.
If the breast is not too saggy (the nipple still lies at or above the lower breast skin), a periareolar mastopexy may be all that is needed. Sometimes called a ‘donut mastopexy’, a ring of skin taken from around the nipple and the breast skin circumferentially tightened back up against the nipple. This results in a fine line scar around the outside of the nipple.
If the breast is very saggy (nipple lies below the lower breast skin), then breast lifting techniques are needed to remove and tighten skin that will leave scars that run down from the nipple and into the lower breast crease.
Dr. Barry Eppley
Indianapolis, Indiana
Q : I had a sliding genioplasty surgery with bone graft on my jaw angle on the 17th of august, before the surgery when i smile my chin tissue protudes downward (chin ptosis) the oral maxilofacila surgeon told me he can fix it during the sliding genioplasty surgery, its been 3 weeks now, and when i smile my chin tissue still protudes downward, i told him about it and he said my mental labial fold has not heal completely thats why it protrudes downward, i think is cos he didnt move my chin forward enough. i wan to send photo to you so you can see what i mean, i really want to get this fixed asap.
A: Generally, a sliding genioplasty will pick up loose chin tissues as it comes forward. Thus correcting a pre-existing chin ptosis. It is not so much that the bone is advanced, but the mentalis muscle and the chin skin are pulled back over a longer bone surface. This is essentially the reverse of what happens when the bony chin is set back (not a good idea) as there is too much chin soft tissue that has less bone surface to be suspended and it will then droop.
Why your chin ptosis did not at least get some correction with the advanced bony chin is not clear. The one possibility is that the mentalis muscle was not put back or resuspended as well as it could be, thus negating the effects of better bony support. This is easily corrected at this early point after surgery as little actual tissue healing has occurred. More time and having the swelling go down further will not likely show an improvement. I would recommend re-entry and better muscle suspension.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have a very strong square-shaped masculine jawline. I am not dissatisfied with my chin, but I would like to reduce the sides of my jawline, to make my face appear more oval and feminine. Does Dr Eppley do this kind of surgery? I have heard of it referred to as jaw shaving, and it seems to be popular among Asian women. I am Caucasian and I would like to reduce my jawline, not my chin. My jawline makes me look too masculine and I don’t like it.
A: One of the main reasons a jawline can look too square is at the jaw angle prominences. How much the jaw angles flare and how square the angle is has a big impact on the arched shape of the lower jaw which frames the entire lower face.
Jaw angle reduction is a procedure where the shape of the jaw angle is changed. By removing the end of the jaw angle, this area becomes more blunted or rounded. This is done through incisions inside the mouth behind the molar teeth. Using the same surgical access and instruments used to cut the lower jaw and bring it forward, jaw angle reduction is simpler and quicker to perform. There is also no risk to injury of the mandibular nerve or risk of bone healing problems as the bone is not actually split or fractured. Rather a piece of the edge of the bone is removed.
While jaw angle reduction is fairly easy to perform, one must avoid taking away too much of the jaw angle. Over resection of the jaw angle can lead to an unflattering ‘deflation’ of the angle and potential soft tissue sag. The other focus during the procedure is to make both sides evenly reduced. That seems easy but when you are working in the restricted space inside the mouth, asymmetry in resection can easily occur.
Indianapolis Indiana
Q: I have these indented areas to the sides of my eyes that bother me tremendously. My temples are sunken in and I have to style my hair to keep them covered. I read in one your blogs that a temporal augmentation procedure can be done to built these areas out. I would do just about anything so I could wear my hair back and not have to spend some time making a styling effort to keep them hidden. I have attached some pictures which show the areas of the temples that bother me. Tell me what you think can be done. Do you think the temporal augmentation procedure will work for me?
A: Thank you for send these very well illustrated photos. I could not have drawn the problem or photographed it any better myself. In studying these different angles, your temporal issues are fairly unique in terms of location. They are located not primarily in the hairline (or substantially there) but anterior to the temporal hairline extending right up against the lateral orbital rim of bone of the eye. They are not large (but skull defect standards) but are deep and very apparent. I can certainly see your esthetic concerns with them.
Indianapolis, Indiana
Q: I have a forehead scar from falling as a child many years ago. It has bothered me all of my life and have always wondered if some form of scar revision could improve it. I went to one doctor and he told me it wasn’t worth it and would probably not work. That really depressed me so I have since thought that nothing could be done. Then I saw online some forehead scar revisions that you ha done and that gave me hope again. I have attached some photographs of the scar for your review. I am hoping to hear good news this time!
A: Thank you for sending your photos. I think your scar could definitely be improved. I do not know why you were ever told that improvement was not possible. Quite frankly, your scar pattern is one of the easiest in which to see improvement.
Given its vertical location near a glabellar furrow, it should be excised as a straight line (possibly a step pattern though) That is a simple office procedure done under local anesthesia. Becasue of the tightness of forehead skin, you need to think about that it may require two stages. Vertical forehead scars have a notorious propensity to widen. So the first stage may end up with it being 50 – 75% less wide as the scar matures. (hopefully not) Then a second stage could for sure get it as narrow as a pencil line. The goal, of course, with your scar revision is to get it as narrow as possible in one-stage.
Dr. Barry Eppley
Indianapolis Indiana
Q: Ever since my chin osteotomy was done over a year ago, the muscle in my chin does not seem to be working right. It feels tighter on the right side and dimples in when I smile or make a pout or blowfish face. It feels tight all the time and twitches often. Can muscle work be done on the chin without having to do anything with the chin bone? I do not want to go through another chin osteotomy. I have attached some photographs, at rest and in animation, for your review.
A: Thank you for sending those very illustrative photographs. I couldn’t have asked or instructed you to take those animated views any better. The one observation that seems to be consistent is that there is mentalis muscle asymmetry, both at rest and in animation. With your history and photographs this suggests to me that the right mentalis muscle has been tightened, lifted more or otherwise sewn donw tighter to the bone. This would explain why the right side has better lip competence (elevation at rest) but moves and feels abnormal.
Given that you are over one year months from surgery, I would expect to see no improvements or changes. You certainly could have some muscle done on that side. That would require no bone work or secondary chin osteotomy. Your chin bone position and overall facial appearance look very good to me, very balanced. That is a very simple procedure that could be done under local anesthesia or IV sedation. It is nothing like what you have experienced with the original chin osteotomy. I would go intraoral on that side and release part of the mentalis muscle in the area where the greatest dimpling is/loss of labiomental fold. I would then place a small dermal graft so the muscle in that area stays released.
I couldn’t guarantee that that would be a complete cure but there is no downside (can’t make it worse) and it is fairly simple to do with no real recovery.
Dr. Barry Eppley
Indianapolis Indiana
Q: It’s been 9 months since I underwent a sliding genioplasty (to move my chin forward and decrease vertical height). It seems like the bony portion of my chin is symmetrical but the soft tissue is not. My lip line is uneven at rest and looks more pronounced when I smile. This is very bothersome to me since my smile and lip line were even before the surgery. My doctor repositioned my mentalis muscles to help with lip incompetence and it seems like the right side is higher than the left. I think the muscles are working properly, it just seems that their origins or insertions are just not even. It has not gotten any better with time. I have an awkward dimpling on the right side of my chin also (the right side definately feels abnormal compared to the left). Wondering if the soft tissue can be corrected to give me an even lip line and smile. I’m not interested in redoing the osteotomy but really would like your opinion on the soft tissue aspect. I’m very uncomfortable with how I look right now which is really making me regret having the genioplasty done in the first place. Thank you for you time Dr. Eppley!
A: While the bone in chin osteotomies understandably gets the most attention, there is also associated soft tissues that are carried with it. Since these soft tissues, particularly the mentalis muscle, must be cut through to perform the procedure it must be put back together in the final phase of the wound closure after the osteotomy is completed. While it is not common to have mentalis muscle problems, they can happen.
The most common mentalis muscle problem relates to how it was resuspended. Inadequate suspension or suspension that has loosened during the healing phase can cause lip and chin asymmetries, dimpling in the chin, and an uneven lower lip during smiling. When these occur, they can be corrected but one must have a very clear understanding as to the location and type of muscle problem. Sometimes it may just be a matter of soft tissue release and the interposition of a fat graft. Other times it may require muscle tightening or shortening. Careful analysis of at rest and smiling photographs in front and side views will help make the correct diagnosis.
Dr. Barry Eppley
Indianapolis Indiana
Q: I have a fracture in my right cheek bone from a fall. There is a dent in bone. Is there anything that could be done to fix it. I’d like to send a picture of me to you.
A: Thank you for sending your picture. What it shows is the sequelae of a a cheek or zygomatic infracture. When the cheek bone is struck with enough force it will fracture the ‘legs’ of bone which support it. When the cheek bone loses this support, it will always fall down and inward impacting into the maxillary sinus. This is known as a rotation fracture. When this happens the prominence of the cheek is lost, causing an indentation of the cheek. That indentation will appear just below and to the side of the eye. It is the prominence of the cheekbone which is lost.
Secondary of uncomplicated cheek fractures can take two approaches depending upon the degree of displacement and if there are other associated symptoms. Rebreaking the bone (cheek osteotomy) is only indicated when the amount of displacement is severe and there may be some nerve pain or numbness and alteration of the corner of the eye. If the indentation is the only problem, however, a cheek implant will usually suffice.
Through an intraoral (inside the mouth) incision, a cheek implant can be easily placed. It is important to have the right shape of cheek implant and that it is accurately positioned over the loss of prominence for the best correction.
Dr. Barry Eppley
Indianapolis Indiana
Q: Four years ago, I was injured and sustained a fractured zygomatic arch from a blow to the side of my face from a punch. I did not get it treated at the time because I had no medical insurance. After the swelling went down, I noticed an indentation over the side of my face which has remained ever since. Recently I visited a local plastic surgeon and he suggested to inject Artefill into the cheek area to lift up the dent. It is about the size of a dime or larger in diameter, a little less than an inch maybe. I had a CT scan which showed the zygomatic arch in the form of a U shape and it goes impressed in towards my skull. Please give me your opinion about his idea and yours.
A: The zygomatic arch is a very thin piece of bone that runs between the cheek bone (zygoma) in the front of the face back to the temple bone near the temporomandibular joint. It has a true arch shape as the large temporalis muscle runs underneath it. This arch shape provides fullness to the transition zone of the temple above to the rest of the face below.
Because of its thinness, it can be easily fractured with a direct blow. Once fractured, it changes from a convex arch to a V-shape as the fractured ends bow inward. This will create an indentation in the overly cheek skin. While easily repaired near the time of injury, it is very difficult to fix once it has healed in this position. If one has difficulty with opening one’s mouth because of the bone edges impinging on the masseter muscle, then some form of bony repair should be attempted.
If the zygomatic arch fracture is causing an external cosmetic deformity (indentation), there are multiple ways to fill out this bony deformity. Using an injectable filler is a simple and very reasonable method. While Artefill is a long-lasting filler, it is not permanent. Repeated injections may make it so however. Another method is to place a custom-shaped arch implant over the bone from an intraoral (inside the mouth) approach. This is easily done and would provide a permanent solution with a single procedure.
Dr. Barry Eppley
Indianapolis Indiana
Q: I used to use liner on my lips to make them look bigger. Now I use injectable fillers to make them bigger. But after so many years of injectable fillers, I am now looking for a different procedure that will last longer and may even be permanent.
A: Injectable fillers, of different chemical compositions, are the primary method of lip enhancement (enlargement) today. They are so popular because they are successful at creating an instant effect that most patients find very satisfying.
But because they are not permanent, injectable fillers to the lips must be repeated. Besides having to be injected with needles, there is also the long-term costs of these repeated treatments. As a result, some patients desire for a lip enlargement procedure that can done once and for all.
There are just a few limited options for permanent lip augmentation. The use of fat injections has promise but is very inconsistent in terms of permanent volume retention. Fat injections often have to be repeated to get a volume that is maintained. The use of dermal grafts (allogeneic cadaveric dermis) has been used for over a decade for lip implantation. Because it is a product out of a box, it is easy to use and insert. But it is often prone to complete resorption. Newer types of human dermis may offer a more permanent result but this has yet to be proven.
The only certain permanent method is that of lip implants. One implant product exists which is that of Advanta. These are soft spongy tubes of Gore-tex of various diameters. These are easily threaded into the lips under local anesthesia. There is no question of their permanent retention. But like all implants, they do have the risks and can usually be felt with one’s tongue or fingers. In my Indianapolis plastic surgery practice, I used them quite frequently and have found few complications with them.
Dr. Barry Eppley
Indianapolis Indiana
Q: I had a severe case of cystic acne which after treatments of accutane left me with severe crater like facial ice pick scars on both my jaws. I am an african american male and have heard due to my color I can worsen the scars with laser surgery. I am at my wits end with this. I need help.
A: Icepick acne facial scars, even in a Caucasian, would not be treated with laser surgery as it could not go that deep. Your skin color is a reason the laser should not be used but is not the main reason.
Icepick scars are treated by excision, sometimes called punch excision, for their removal. This is a technique where they are cut out by small instruments and then closed, trading off a fine line scar that is level as opposed to a deep pitted scar.
This method can be helpful for scar improvement and is usually done in the office under local anesthesia. Based on the number of pitted scars you have, this can be done in a single session or may require multiple sessions.
The concept of performing these small acne scar excisions can be unsettling as one may not be certain that sufficient improvement in scar appearance may be obtained. The best way to answer that concern is to just do a few of the worst ones and judge the results. That will tell you whether this method is helpful and can give one the confidence to do more. (or stop if one is not satisfied with the improvement)
Dr. Barry Eppley
Indianapolis Indiana
Q: I am a male who is considering having a browlift procedure. I am not sure how it is needs to be done but I do have one concern. Will a browlift make my hairline recede?
A: Browlifting in men poses unique concerns because of the varied and often absent frontal hairlines. Even in a male with a reasonably good hairline, it is impossible to predict what the hairline may do in the future. For this reason, the typical open browlift operations (either at the edge of the frontal hairline or behind the hairline) should be avoided. The endoscopic browlift remains the only ‘safe’ option even in a male with good hair density and frontal edge pattern.
The question of whether hairline recession make occur after a browlift is probably not directed towards actual hair loss from the procedure. This question likely relates to whether the hairline will move backwards as the brow is lifted. This is an excellent question and is a particularly relevant one in the endoscopic browlift.
This non-excisional (skin or scalp) type of browlift employs tissue shifting, or an epicranial shift, to create the effect of brow elevation. In other words, the entire forehead and scalp skin is shifted backwards, moving the excess tissue up and back where it sticks back down in a new position. As a result, the frontal hairline will move back to some degree. This creates some small amount of forehead lengthening, an increased distance between the brows and the frontal hairline. This is not hairline recession per se, just hairline repositioning.
Male patients in particular considering an endoscopic browlift should be aware of this hairline change. If the hairline is already fairly far back, this operation may not be a good choice or should be considered carefully.
Dr. Barry Eppley
Indianapolis Indiana
Q: I have a wide circular scar in the middle of my lower forehead from removal of basal cell cancer in the fall of 2009. It measures 5 mm wide by 10mm long and is depressed. (atrophic) The dermotologist used the ‘scraping method’ the remove the skin cancer. As the scar is in a very prominent place, I am strongly considering scar revision to make the scar is long and narrow. What are your thoughts?
A: Whether scar revision will be helpful is determined by two primary features of the scar in question. First, what does the scar look like? Scars that have width and height issues (raised, depressed and/or wide) are prime candidates for a positive outcome from scar revision. Narrowing and leveling a scar is one of the main changes that scar revision does well. Second, what is the age of the scar? Most scars must be mature enough to allow for good tissue handling and manipulation. In general, scars should be at least 6 months old if not longer. But the most important feature, not just time, is how pliable or flexible the surrounding skin is. Soft flexible skin is important to make most scar revisions successful.
Because the scar is located on the forehead, it is also likely that simple straightforward excision and closure, while better than what currently exists, is not ideal. Most likely, some form of geometric scar line rearrangement is needed to optimize its ultimate visibility. Scar revision using non-linear closure is best for any forehead scar that is not parallel to one’s natural wrinkle lines.
Dr. Barry Eppley
Indianapolis Indiana
Q:I had a breast reduction about 5 years ago. I was left with scars on both sides left and right by the clevage area. The length of each is about 2 inches and they use to be raised scars. However I did go see a doctor and he injected it with some solution which did work and flatten the scar, but you can still see it. It is unsightly and I can’t wear low cut tops because its visible. What are my options? Will a scar revision make it worse? The scar skin feels and looks like nuckle skin its thin and soft. Please advise, Thank you.
A: The breast reduction operation works well but at the price of significant length of scarring. While the scars are extensive, most of them are in more natural locations being around the areola and along the length of the lower breast fold or crease. The only part of the scar that is ‘unnaturally placed’ is the vertical one which runs between the nipple and the lower breast fold. Most breast reduction scars turn out well but there is an occasional patient that is not happy with some of the scar and some scars which become wider or even raised.
While steroid injections will help soften and lower a raised scar, they will not make it more narrow. Narrower scars are less visible than wide ones. Scar revision usually works better because it gets rid of the wide scar in exchange for a more narrow one. Your breast scar problem is the medial tail of the lower breast fold scar. While it can not magically be erased, scar revision can most likely cause an improvement in its appearance. These small scars could be done in the office under local anesthesia.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I would like to schedule a consult with Dr. Eppley. I have migraines and have found that Botox was a big help to me making it at least 50-60% better. I also have neck pain badly. I think his decompression Surgery may be beneficial. I would like to speak to him about this.
A: The debilitating nature of many migraines begs for more effective solutions. In the past, the only approaches to the treatment of migraines has been pharmaceutical, obtaining some symptomatic relief. The most recent pharmaceutical treatment has been the use of Botox injections. For a very specific subset of migraine sufferers, Botox has been shown to be effective if the focus or trigger has been associated with the exit of sensory nerves from the skull base. This is usually the supraorbital/supratrochlear nerves in the brow area and the greater occipital nerve at the back of the head.
Botox works by relieving the spasms of the enveloping muscles as the nerve exits close to or at some distance from the bone. If Botox produces a profound response, this strongly indicates that surgical decompression (removal of muscle around the nerve) could be equally effective and offer better long-term results. In some cases, even a cure might be achieved. Plastic surgeons have long recognized this surgical approach coincidentally with endoscopic browlift procedures where muscle removal around the nerve is done to help decrease wrinkling after surgery and some cosmetic patients comment that their headaches are better.
If the origin of the migraine and Botox injection relief is from the back of the head (occipital area) then decompression of the greater occipital nerve and release of the fascial attachments frm the back of the skull may work quite well. This is done through two small incisions in the hairline where the neck muscle meets the bottom of the skull bone in the back of the head. It is a fairly simple procedure that is done as an outpatient. Migraine relief should be seen quite early after surgery. There is only very mild discomfort after the operation which passes ina week or so.
Dr. Barry Eppley
Indianapolis Indiana
Q : Hi, I found you in reading an article you wrote. This situation applies to me as I very recently had a subnasal lip lift done and I am still in recovery. I can see that my upper lip is crooked and way over corrected so much that my upper lip may be unfunctional. The worse part is however I had no idea I would not be able to smile, and appear deformed should I try to smile!!! I was told to expect some tightness but this is beyond tightness. What are my options? Can I get my smile back?
A: In the subnasal lip lift procedure, a wavy amount of skin (thicker in the middle) is taken directly beneath the nose with advancement of the lower edge of the incision to the area directly beneath the nose. The final closure is tucked in along the base of the nose from one side of the nostril to the other. This procedure shortens the distance between the top of the upper lip vermilion and the base of the nose allowing for more upper tooth show when the lips are slightly parted. It also everts more of the upper lip vermilion, therefore creating an increased amount of a central pout of the upper lip. It is always slightly overcorrected as there will be some relaxation (mild re-lengthening) of the upper lip afterwards.
While this is a fairly simple procedure, I have seen and read of some problems associated with it. One complication appears to be from manipulating the underlying orbicularis oris muscle besides the skin while doing the upper lip lift. In theory, sewing the orbicularis oris muscle to the periosteum underneath the nose may make for a more stable long-term result. However,such a maneuver creates an unnatural stiffness and deformity of the upper lip when can be evident during smiling. This is not a good trade-off for the theoretical benefits of this manuever. It is far better to run the inconsequential risk of doing a secondary tuck-up the procedure if there has been some relapse. Correction of this stiff lip problem can be done with re-opening the incision and releasing the abnormal attachments, with the possible insertion of a dermal or dermal-fat graft to prevent recurrence. The sooner this is done the better.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I want to have a breast lift, liposuction on my stomach,thighs,buttocks,under the arms,between my chin and lower neck line, an eyebrow lift, and some under the eye work. (dark and somewhat deep and little wrinkles) I am a mother that is curious of amount of the cost. I’m not even sure that I can afford this but I truly have self esteem issues. My weight topped out at 202 lbs but I i am now down to 178 lbs. I have always been one to want to look and feel good about myself and I do not feel that way at 35 yrs old. I am too young to feel this bad about myself!
A: How we feel about ourselves is one of the most important characteristics of a person. While inner beauty and well-being is all that really counts, there is no doubt that how we look on the outside affects how we feel on the inside. Your plastic surgery wish list is comprehensive and, affordability aside, all of that could and probably should not be done in a single surgery. Therefore, it is important to prioritize this face and body plastic surgery wish list. The best way to approach that, and is what I discuss with all my patients who want an extreme body makeover, is to ask yourself this question. If I could only do one plastic surgery operation and could never return to the operating room, what procedures would you do on this list? I say pick just three and even put those in order of importance to you. Whether you would ever get to phase 2 or not is unknown, but if you don’t, then you will have accomplished the most important changes anyway.
Looking at your list, I can divide it into body and face work. While I am not you, most likely the body work is of greatest importance to you because you have listed/described it that way. It appears that a breast lift (with or without implants) and some abdominal and waistline contouring are your prime targets for change. It may also be possible to do so thigh and arm liposuction at the same time if your budget allows for it.
Dr. Barry Eppley
Indianapolis, Indiana
Q:I was wanting to know if Dr. Eppley has any experience in the repair of stretched (gauged) earlobes and how much a consultation would cost?
A: Repair or reconstruction of earlobe deformities are common in-office plastic surgery procedures. Short of congenital microtia or earlobe loss from injury, the gauged earlobe deformity is of greater complexity that simple earlobe split repairs. Gauging the ear is a form of earlobe expansion. When the gauge size is not too big (not bigger than the original size of one’s natural earlobe) the expanded earlobe has a generous amount of tissue. This enables it to be put back together in a normal size because there is adequate soft tissue. When the gauge becomes much bigger, the earlobe tissues become stretched and actually thinner. (tissue atrophy) When putting this type of gauged earlobe back together, the final appearance of the earlobe will be smaller than it originally was.
I have done lots of ear and earlobe reconstructions over the years of many different causes. The gauged earlobe is but a newer type of deformity but its reconstruction still uses the same basic plastic surgery principles. In many cases it can still be done in the office under local anesthesia.
If you send me pictures of your ear, we can consult for free by e-mail. This is an easily visualized problem that allows photographs to suffice in lieu of an actual office visit. That way, you can schedule a repair and get it done by only having to make one visit. (although a second visit will be needed for suture removal)
Dr. Barry Eppley
Indianapolis, Indiana
Q:I had a genioplasty to move the chin forward and now i want to do another surgery that doesn’t involve implants to make the chin wider. Is that possible and will the chin resorb after awhile because of splitting the chin and expanding it in the horizontal direction?
A: As you have discovered, moving the chin forward by an osteotomy will usually make it appear more narrow or tapered. This is because of simple geometry. If you move the front part of an arc forward (think of the lower jaw as u-shaped or an arc), it will make the overall shape of the total arc longer but more narrow in front. For this reason in male patients, I evaluate the front shape of the chin very carefully so if an osteotomy is performed for advancement, and the patient wants the chin to end up wider, I factor that into the osteotomy design and plan a central osteotomy with expansion.
Certainly a second chin osteotomy can be done and the downfractured chin segment split and expanded. It will be held apart by the necessary plates and screws needed to fix the overall osteotomy into position. This should not cause the bone segment later to undergo any resorption. A simpler method to get chin width expansion is to place a chin implant in front of or on top of the bone. There are chin implant styles that provide lateral fullness without any significant horizontal advancement and they would be a good choice here also.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I read in Dr. Eppley’s blog about using Kryptonite Bone Cement for pectus excavatum. I had the Nuss procedure done 5 years ago and breast implants done 4 years ago. I got very good results with the procedure and implants with the lower part of my ribs; however, the upper area (below the collarbone) is still indented. I would like to inquire about this procedure and whether or not I would be a viable candidate.
A: Kryptonite bone cement is a new type of bone filler/replacement that works well as an onlay, meaning to build out a bone surface to create a better contour. Currently it is approved in the United States for cranioplasty, the filling in or building out of skull bone contours. While it has never been formally tested for use on the sternum, there is no reason to think that it would not work just as well there as on the skull. What makes Kryptonite a possibility in the sternum is that it can be injected after it is mixed before it sets up into a hard mass. This is a very unique characteristic of a bone cement and no prior ones have ever had this physical property. As valuable as that material property is in the skull, it becomes a critical material characteristic in the sternum as incisions of any size are easily seen there.
For an upper sternal problem, a small incision inside the sternal notch can be used to develop the subperiosteal/supraperiosteal pocket. It is into this pocket that the material is injected and molded. The critical step in injectable sternoplasty, like injectable cranioplasty, is to make a good recipient pocket that matches the external outline of the contour defect.
Indianapolis, Indiana
