Your Questions
Your Questions
Q : I AM A 39 Y/O FEMALE. WEIGHT 155LBS, 5FT 9′ WITH A B CUP WANTING A LIFT AND C CUP AND SILICONE IMPLANTS. AFTER LOOKING OVER MANY PLASTIC SURGEONS IN INDIANA I HAVE CHOSEN DR EPPLY AS MY FAVORITE IN RELATION TO THE WORK IVE SEEN. A FEW QUESTIONS: HOW MANY YEARS HAS HE BEEN PERFORMING BREASTS LIFTS, & IMPLANTS. DO YOU HAVE AN APPROX OF HOW MANY HE HAS PERFORMED? AND WHAT WOULD BE THE APPROX. COST? ALSO, WITH ME BEING A SMOKER WOULD THIS AFFECT MY BEING ABLE TO GET THE SURGERY PERFORMED? THANK YOU i HOPE TO HEAR FROM YOU SOON
A: Thank you for your inquiry regarding breast enhancement. I have done such cosmetic breast surgery for the past 20 years and have done over 1,000 breast augmentation/lifts patients. The cost of breast augmentation with silicone implants (Mentor memory Gel) is right aorund $ 5,900 all costs included. Adding some form of a breast lift to it does increase the cost but that can not be predicted without seeing you since there are 4 different types of breast lifts which add varying amounts of time to the procedure.
Smoking does not have any significant effect on complications from a routinue breast augmentation. There is a slightly higher risk of wound problems when any form of skin lift is done such as a breast lift. How risky that would be would be based on what type of breast lift is needed…the more extensive, the more risk of wound healing problems. The best way to handle the smoking issue is to refrain 2 weeks before and 2 weeks after surgery if possible.
Dr. Barry Eppley
Indianapolis, Indiana
Q : I had a chin implant 9 years ago, when I smile its seems to be without form, like flat. And after X-rays I noticed that the implant is placed higher up where it should be (close to my teeth). A doctor told me it would be very laborious, because it would be two operations, one to remove the chin implant which would remain a hole, wait 3-6 months to heal the skin and the second to put the new implant from under the chin. Is there another solution? Thanks!
A: It is very common to have a chin implant that ends up being positioned too high on the chin bone when it is placed from inside the mouth and is not secured with a screw. When the implant is too high on the bone, it loses some of the projection or forward position of the chin that it would otherwise have.
Replacing a misplaced chin implant is fairly easy and can be routinuely done in a single operation. I have never heard of having to do it in two operations nor does that make any biologic sense to me. Going through a small submental (under the chin) incision, a new lower pocket can be made, the old implant removed, and a new chin implant placed and secured. In some cases, I have left the old chin implant where it was and just placed a new one beneath it. If someone has a deep labiomental crease, keeping a ‘spacer’ (old implant) high can help push that area out and prevent it from becoming deeper.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am a 43 year-old male who is bothered by my long upper lip. When I smile I show no teeth and this makes me look older in my opinion. In addition, I have almost no red part of my line, it is just like a thin pencil line. I have done some reading and it seems a lip lift work. My measured vertical distance between the base of my nose and the top of the red part of my lip is 23mms. I have not read anywhere or seen that a man has had this type of lip shortening. Can it be done in a male? I have attached a front photo of myself for you to see what my lip looks like.
A:Thank you for sending your facial photo. While it is not a completely closed mouth view, it does show how long your upper lip is. You are correct in assuming that the only option for shortening your upper lip is a subnasal lip lift. As a general rule, I remove about 1/3 of the natural philtral distance. Since you are at 23mms, you could remove about 6 to 7 mms without any difficulty… maybe more. Whether this will be enough to unmask your teeth in smiling is to be seen but, at the least, the upper lip will be centrally shorter. The subnasal lip lift does not shorten or reduce the sides of the lip since the width of the tissue removal is limited to between the nostril bases. The lip near the corners of the mouth will not improve from a subnasal lip lift.
Dr. Barry Eppley
Indianapolis, Indiana
Q:I have had a c section with my son and I have no feeling toward the bottom of my belly. I have lost 52 pounds but still over weight. I am so frustrated but I think the only thing that will work is plastic surgery. Based on my readings, it looks like liposuction and a tummy tuck will do the trick. What has been your experience with the amount of improvement that thees two procedures can do?
A: Your question is a bit of a loaded one but the answer is in most cases very well. In fact so well for some people that it can be considered a ‘waistline’ miracle. This may seem a bit of an overstatement but for many tummy tuck patients it is not. The sheer removal of a full-thickness piece of skin and fat (either above or below the belly button) does something that no diet and exercise program ever could for someone who has lost a lot of weight. (50 lbs count as a lot!) When this skin and fat removal is combined with liposuction around the waistline and into the back, significant mid-trunk reshaping is done.
Already having a C-section scar (with numbness) and the extra skin created by your weight loss makes the consideration of a tummy tuck a fairly easy one as there are no viable alternatives. It is hard to predict how many inches may be lost around your waistline but it is fair to say at least 2 to 3 inches and maybe more. As impressive as the frontal change may be, I am always excited to help create the narrowing of the waistline by aggressive flank and back liposuction.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have read about fat injections to the breast but am concerned that it won’t give me enough of a cup increase. In my reading it says that the average increase in volume is around 100cc. Is that only a 1/2 cup increase. I have also read that an external suction device can be used with fat injections to get a better result, is this a hoax?
A: A 100 to 200 ml improvement in breast size for most women (depends on what they have to start with and how wide their breast base diameter is) will only be a 1/2 cup to 3/4 cup at best. You have to remember that much of fat breast augmentation work currently comes from Japan where small breasts (B cup) is the desired size by their cultural standards. That is why fat injections may be more ‘successful’ in this population. In the American population, such small breast size increases would not be considered enough. I have never placed a breast implant that was 200ml or smaller. Occasionally a 250ml to 275ml breast implant may be used but this is very uncommon. Most American breast augmentations are in the 300 to 375cc range.
The concept of external suction on the breasts to increase breast size is not a hoax. It is an actual device known as the Brava system. It has been shown to increase breast in the range of a 1/2 cup or more. The theoretical science is that pulling on the breast tissue stimulates fat or stem cell replication or growth. It is currently being studied in combination with fat injections to the breast. Combining the two makes biologic sense and I would suspect that their combined use is better than either one alone.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I would like to know more about laser liposuction. I had two C-Section deliveries and abundance of skin because of it.
A: While laser liposuction does have the ability to tighten some skin, it is not a replacement for a tummy tuck. Your description of having had two pregnancies with C-sections and now an ‘abundance of skin’ suggests that your skin excess problem is not slight. In addition, the skin that is there has lost its elasticity (which is why there is an abundance) and does not have the ability to respond to the tightening caused by the heating effect of the laser. Such loose abdominal skin is always more effectively removed by an excisional procedure, aka a tummy tuck.
Laser liposuction, often called Smartlipo, is an improved method of fat removal than traditional liposuction. By using a laser probe to create an elevated temperature in a zone of fat, the fat cells break apart and loose their lipid content. This not only makes it easier to suction out, but fat cell damage continues beyond the surgical period much like the progression of a burn injury on the skin. Even some fat cells which were not directly injured by the laser probe at the time for surgery may go on to die later from the laser injury. This produces more fat loss in the days ahead. Whether that amount of fat loss is significant or not depends on how high and uniform the temperatures were at the time of the laser liposuction procedure.
The skin tightening effect of laser liposuction is similarly caused by the heat created. The temperatures must be high enough and close enough to the underside of the skin for this effect to be created however. Whether that occurs is dependent on the skill and the expertise of the physician driving the laser probe.
Dr. Barry Eppley
Indianapolis Indiana
Q: I have read that there is a cosmetic procedure that cures migraine headaches. I have had migraines for years and sometimes they are so bad I can’t leave the house. If there is an operation to cure this migraine problem, I would sign up for it in a minute! Can you tell what they are talking about?
A: The use of Botox for the treatment of glabellar furrows (wrinkles between the eyes) has been done for decades. One of the very interesting findings from that cosmetic treatment was that plastic surgeons discovered that some patients with frontal migraines got a temporary cure, as long as the Botox lasted. The now proven theory is that in those patients with a focus of their migraines that starts above their eyes in the brow area are caused by the muscles squeezing the sensory nerves that exit from the bone there. This is why Botox relieves those migraines…it stops those muscles from working.
If you take that one step further, a browlift (of any type) can create the same effect as Botox except that its results will last much longer and maybe even permanently. That is because during a browlift some of the muscles are removed to prevent that type of wrinkling action. Recent studies and publications in the journal Plastic and Reconstructive Surgery has shown that certain types of migraines can be cured by performing a modified forehead/brow lift. Therefore, the type of forehead lift used to cure migraines could also lead to one looking younger as well. This type of cosmetic operation has been shown to be safe, effective and can lead to a tremendous improvement in the quality of some migraine patient’s lives.
Dr. Barry Eppley
Indianapolis Indiana
Q: Hello Doctor, I am 18 years of age, an Asian Chinese and I have big cheekbones. It was almost twice the size of the other people and that makes my face looking round and unpleasant big. I’ve read articles about cheek implants but I was wondering if there is a surgery that reduce the cheeks size, the best case scenario, to make it look flatter? Thanks in advance for helping me.
A: When you are referring to big cheekbones, you are undoubtably referring to them being too wide. Big in cheekbones invariably refers to how far they stand out from the side of one’s face. Wide and prominent cheekbones are most common in Asians as their genetic face tends to be less projected forward (horizontally) and more projected to the side. (wide)
Cheekbone reduction surgery can be done and understanding how it is done requires a knowledge of the bony anatomy of the face. The front part of the cheekbone is a fairly solid bone that is partially made up of bone from the side of the eye socket. This is the location, for example, where cheek implants are placed to make the cheek more full. But the part of the cheek that makes it wide is known as the zygomatic arch which acts as a span of thin bone that arcs out from the cheekbone in front to the temple bone in back. How much this piece of bone arcs determines how wide the cheek bones appears. Cutting the attachments of the cheekbone from the side of the eye socket and the back part where it attached to the temporal bone allows it to fall in. It falls inward (less wide) because not only are the bone attachments cut but there are muscles attached to it that help to pull it in also.
While cheekbone reduction surgery sounds drastic, it is done from inside the mouth with small bone-cutting instruments.
Dr. Barry Eppley
Indianapolis, Indiana
Q : I am a 55 year-old male and am bothered by low hanging brows. It makes me look angry all the time and I am actually a good-natured and upbeat person. It seems my eyebrows are falling off of the brow bone and they look so heavy. My mother had a facelift and browlift several years ago and I am wondering if this would work for me.
A: While a man can aesthetically tolerate a lower brow position than a woman, there is a point when the brow descent is too excessive. When the eyebrow is below the brow bone, the look that is created is a perpetual scowl or frowning. At the least, it makes the size of the eye look small and the forehead look very long.
Browlifting in men poses unique challenges that are not present in most women. The lack of a well-defined and permanent hairline with good hair density makes the options for a browlift more limited and less effective. Browlift scars are not easily hidden and the risk of visible scarring is beyond just a theoretical possibility. None of the hairline or scalp approaches that are most commonly used for lifting the brows are worthy of that scar trade-off. In some cases, an endoscopic approach can be used but it stills creates small scars that can be visible through most men’s hair patterns.
There is a mid-forehead incision approach to a browlift but it requires a man to have a deep and prominent horizontal wrinkle in which to use. The scar with this approach takes a long time to settle and the redness to fade. While effective, this central forehead scar should be reserved for a few select patients.
This leaves the eyelid or transpalpebral approach as the only browlift option without the risk of adverse scarring. The eyebrow is lifted and sewn back up to the bone through an upper eyelid or traditional upper blepharoplasty incision. It is not as effective as a ‘superior-based’ browlift but the risk of adverse scarring is eliminated.
Dr. Barry Eppley
Indianapolis, Indiana
Q : We have a potential new hire for our company that has about a ¾ inch insert gauged in both ears. This person regrets having this done and wants to abide by company requirements and have them removed. How is this done and what does the earlobe look like afterwards. Also, what would the potential cost be to have both earlobes repaired?
A: Gauging of the earlobes creates a central hole surrounded by a thinned out or thin ring of earlobe skin. The size of the gauge determines how thin the ring of earlobe skin is. As long as the gauge is not too big (greater than one inch), the expanded earlobe can be put back together and have about the same size as it was before having the insert. When the insert becomes much bigger, it not only stretches out the earlobe but the tissue becomes much thinner as well. (pressure atrophy) When put back together, the final size of the earlobe will likely be smaller than before.
Earlobe reconstruction is done by cutting out the skin along the central hole, including some of the rim, and putting it back together in the shape of a more normal earlobe.
Like the split earlobe deformity, reconstruction of the gauged earlobe can be done under local anesthesia. This can usually be done in the office which saves a lot of expense when the cost of an operating room and anesthesia is not used. The typical cost of such earlobe surgery is in the range of $750 to $1,000 per ear.
Dr. Barry Eppley
Indianapolis, Indiana
Q : Hi, I read online that other girls have the same problem as me. I had a jaw reduction and the doctor shaved too much bone and side of the jaw, is uneven to the other side. You gave advice to them to have jaw implant. My question is that since the jaw is now uneven, how can you make it even by putting jaw implant? Will the implant be different since it is not the same? How much does it cost for chin augmentation? Not the implant but the moving if the chin. Thank you.
A: It sounds like you had a jaw angle reduction. Often times, too much bone is removed and the sides are uneven as more bone is taken from one side than the other. The only way to improve that problem is to replace the lost bone with an implant. The size and shape of the jaw angle implant is taken from tracings off of a panorex x-ray as both implants can not obviously be the same when asymmetry is involved.
Jaw angle reduction must be carefully done as it is easy to remove a large bone segment from this intersection of the posterior and inferior border of the jaw. This not only makes the jaw angle blunt but can make one look more aged as well.
A chin osteotomy is done much less frequently than an implant for chin augmentation. But in the right patient, it can offer some different dimensional changes that may be more ideal for facial balance. (e.g., chin lengthening) The average cost for a chin osteotomy is around $6500 when done as a one hour outpatient procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q : Last year I had a facelift which made my sagging neck and jowls look so much better. I love the result but have developed some raised and mildly painful scars behind my ear. My plastic surgeon said they would eventually go away but I am not so sure. They have not changed in size and they feel like small ropes along the backside of my ears. What do you suggest?
A: Nearly one-half of the incisions that are used in a facelift are behind the ears. Going along the grooves where the ear connects to the side of the head, these scars run along this groove where they go back into the scalp near the top of the ear. The skin behind these scars is used to pull up loose skin from the neck where it is trimmed off.
These skin flaps behind the ears are very thin and often are the slowest to heal after a facelift…even though they are not easily seen. Because these incisions behind the ears are stitched back together under some tension, a few patients can develop hypertrophic or raised scars because of it. Once the scar thickens it will become and stay sensitive.
Sometimes these raised behind the ear scars will settle down on their own with just time and scar maturation. If these raised scars persist beyond a few months, I recommend steroid injections. I repeat these injections every month for up to three injection sessions. They will usually cause the raised scars to settle. If they have not gone away by then, cutting out the scars is needed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am getting saline breast implants in the next several months. I am getting them because they are less expensive and the size of the cut to put them in is much smaller. What I want to know is where is the best place to put them through…my armpit, nipple, or under my breast in the crease?
A: One of the two advantages to saline breast augmentation, besides a lower cost, is that they can be inserted through very small incisions. Because they are put in deflated, they are rolled up to about the size of a small burrito. This enables them to pass through incisions as small as one inch or 2.5 cms. Once in place, they are the inflated to their desired size.
While all three incision locations will work (armpit, nipple, lower crease), choosing one of them is based on the patient’s preference for scar location and how soon they must return to work and what type of work they do. If one has darker skin color (e.g., Asian or Hispanic), they I would definite choose the armpit or axillary approach. This is because this puts the scar away from the breast and women of these ethnic backgrounds are very sensitive about any visible scarring. Conversely, if one needed to return to work quickly and their job involved lifting, then I would choose the lower breast crease. Becasue the entire pectoralis muscle does not need to be elevated (only the lower half is), one will have less pain and a quicker recovery due to the more limited muscle trauma.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am interested in getting breast implants but only want to go up maybe one cup size. I don’t want anything drastic just a little change. I want the result to be completely natural looking and not fake. How can I be sure that will happen?
A: The concept of natural breasts can mean different things to different women. In general, however, what most women are referring to is a breast that is not disproportionate to their body and chest size and one that does not have a completely round shape. (too much upper pole fullness)
The most assured way to avoid an unnatural breast augmentation result is to have properly sized breast implants. In short, don’t get too big of an implant for your chest or the amount of breast skin that you have. The single best way to avoid that problem is to keep the diameter of the implant at or less than your own breast base diameter. Implants that are wider than your breast base will always look unnatural or too big. This may also mean to avoid a high profile implant which can have a tendency to look rounder after surgery, particularly if you have small breasts with tight skin to start.
Natural breasts are also those that don’t have palpable (able to feel) implant rippling. This is more of a concern with saline implants who have a greater tendency to develop implant rippling, which may also be able to be seen as well.
In summary, natural breast augmentation is best done by choosing a silicone gel implant that is slightly narrower than your breast base width. For many women this means that implants sizes will run between 250cc to 350cc.
Dr. Barry Eppley
Indianapolis, Indiana
Q: How do you do mouth widening? I have a relative that is scheduled for that procedure and we are hesitant to do it. We have never heard of such a thing. How safe is the procedure? Thank you for any information that you can share with me.
A: The concept of making one’s mouth wider is possible but very rarely done. I can only assume that your relative has a small horizontal width to their mouth (small mouth) and wants it to be extended further horizontally.
Such an operation is possible by using the principles of commissure creation or modification. Known in plastic surgery as a commussuroplasty, the corners of the mouth can be either shortened (closed down) or opened up. (made wider). To make the mouth wider, a modified isoceles triangle of skin is removed out to the distance you want and the inner lining of the lip (mucosa/vermilion) is advanced out and sewn to it. (a Y-V advancement) This relatively simple procedure will make the mouth wider but does so by leaving small scars at the corners of the mouth at the junction of the skin and the lip tissue. If not overdone too much, it can definitely make a difference and look fairlu natural. Such a technique is used in the more commonly done corner of the mouth lift, where downturned corners are turned up and made more horizontal to get rid of frowning or a downturned smile.
Conversely, the reverse can be done to make a wide mouth small. (a V-Y advancement) This leaves a more noticeable scar in its wake as the lip lining is moved further inward.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I want to know more about a procedure that will lower my upper lip. I show a lot of gum when I smile and this bothers me. I have read about a ‘mucosal roll-out’ operation that brings down the upper lip. Please tell me more about it.
A: An upper lip mucosal roll-out will have only a very minimal effect on actual upper lip lowering. That is used more to make the upper lip fuller but, in and of itself, will only lower it maybe a millimeter or two at best. To lower an upper lip for the purposes of a gummy smile treatment, the upper lip must be treated by levator myotomies (release of one of the main lip elevators) , an upper lip spacer insert (to keep the muscles from healing back together and to help push it down) and a V-Y mucosal release (frenulectomy, although technically it is a frenulotomy) and advancement. Moving the inner lining of the upper lip (mucosa) only will not be effective.
Lowering an upper lip is even more difficult to achieve than raising a depressed lower lip. While bone shortening (maxillary impaction) is the most effective way to bring the horizontal lip level down closer to the teeth during smiling, most patients do not want that much surgery to achieve that goal. Soft tissue surgery to lower the upper lip can be expected to achieve about 3 to 5mms of actual lip lowering. This can be combined with other dental procedures (crown lengthening) to get an even greater amount of gummy smile reduction.
Indianapolis, Indiana
Q: Dear Dr Eppley, I am contacting you with interest in stem cell-enriched breast augmentation. I think it is an interesting new technique and it has raised many questions in my mind. Here is my list of questions.
1) First of all, how is the surgery done and how much fat do you need to do it?
2) Specifically, I would like to know whether it is possible to transform my small A-cup to a preferred C/D cup. Is this possible with the procedure. What is the average gain in ml when you have an A-cup?
3) What are the risks? From other plastic surgeons I hear that the long-term effects are very uncertain.
4) I am kinda slim, so I am wondering if I have enough fat on my body to do the procedure?
I am looking froward to our answers.
A: In answer to your questions about breast augmentation with fat injections and stem cells, here is some current realities with it:
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am interested in having a jawline tuck procedure. The only part of my face that bothers me as I have aged is along the jowls. That is the only place where I have some excess skin that affects my appearance. Please tell me where the incisions area and what part of the face this operation does, and does not, affect. Thank you!
A: Basically, a jawline tuck is a simple modification of a limited or mini-facelift. It is similar to the advertised and marketed ‘Lifestyle Lift’ which is a franchise approach that offers a very similar procedure. As the name would imply, it is a facial rejuvenation procedure that has very little downtime hence the branded name. The fine line incision starts at the top of the front of the ear, goes inside the ear behind the tragus, and then around the back of the earlobe. Through this hidden incision, any loose skin along the jawline (jowls) is lifted smoothing this area out. There is some benefit in the neck area but not as significant as that of the jowls. This procedure is as described….a tuck for the jawline or jowls. It does not affect any other part of your face.
Many times other facial procedures are done with this ‘little’ facelift such as neck liposuction, laser resurfacing or chemical peels, and eyelid tuck procedures. But when done alone, there is less than a week of any visible swelling and bruising so recovery is quite rapid.
The key concept to grasp is that a facelift is an isolated jowl and neck procedure. A limited facelift or jawline tuck is just a smaller version of it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I had breast reduction surgery last year and , while those results were great, my stomach area is now the problem. What is the best way to get rid of some (or a lot of!) stomach fat? I have read about Zerona. Is it better than liposuction or does it just depend on the person?
A: It is not uncommon after breast reduction that one notices that they now have ( or have had) a larger stomach than they knew. Since the breasts hung down on the stomach, the size of the stomach is usually obscured. After breast reduction, where the breasts are lifted and reduced, these ‘new’ stomach problem appears.
While fat reduction can be done both surgically (liposuction) and non-surgically (Zerona), the results and the process are not the same. Do not equate Zerona and liposuction as providing the same results. Liposuction is a much more effective and rapid way of eliminating unwanted fat, albeit with surgery. Zerona is best considered as a non-surgical step before one considers liposuction. In the right patient (5 to 20 lbs overweight), Zerona may provide enough of a result that liposuction may never be needed. In larger fat collections, liposuction may ultimately be needed.
Therefore, patient selection is critical when deciding what approach to take for abdominal fat reduction. For small to modest abdominal fat fullness, Zerona is probably worthwhile as enough of a result can usually be obtained without surgery. But if you have a large abdominal girth or any excess overhanging abdominal skin, some form of surgery will be more effective whether it is liposuction, a tummy tuck or some combination thereof.
Dr. Barry Eppley
Indianapolis, Indiana
Q : When I was 20 and in the service I had a breast reduction. I went from a 44DD down to a C cup. I am now 50 and my breasts have slowly over the years grown back. I have been so uncomfortable physically and mentally from their size. I didn’t know breasts could grow back after they were reduced. Can I have another breast reduction at my age?
A: Breast reduction is a very successful operation at reducing one’s breast size as well as lifting it back up onto a better position on the chest wall. (where it once was) In most cases, once the breast is reduced it does not return to its original size. But breast regrowth has been reported and it does occasionally occur. This is almost always in the young female population when the operation is done during the teenage years. When done under the age of 18, exposure to continued bodily growth, weight gain and pregnancy can all be hormonal signals for breast tissue growth. But even in these circumstances it is still rare. Having it happen after one is developed is rare but not unheard of as you illustrate.
There is no age limit when breast reduction can not be performed. It is not an operation that is stressful to one’s bodily systems. It can be done using your existing breast scars as the operative pattern. It would be fair to say that there is no chance your breasts would regrow after being reduced at age 50.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I wanted to get some information as far as migraines and Botox. I have suffered with migraines for many, many years and have read that Botox can help. My headaches usually start around the eyebrow area. Thank you.
A: The fact that your migraines have a focal area of initiation at the eyebrows strongly suggests that their origin is compression of the supraobital/supratrochlear nerves. Contraction of these muscles squeezes the nerves that they surround and causes a painfuol migraine to start. Botox has a good chance of having a positive effect since it weakens the muscles around those nerves as they exit from the brow bone. This is a simple treatment that looks like it may work well for you. For a few hundred dollars, you can easily prove this migraine theory. While the effect of Botox is not permanent, many responsive patients find it to be a temporary miracle that provides a level of relief that no other medication does. In select migraine patients, plastic surgeons have learned many years ago that Botox around the brow area reliefs headaches. The key to whether Botox will be a successful migraine treatment is to have a very specific point of headache origin at one of the major cranial sensory exit sites from the skull. Botox is not effective for many types of migraines, just ones that have a very specific focus or loci.
If Botox is effective, that would mean that endoscopic supraorbital/supratrochlear nerve decompression may provide some long-term reduction in your migraine symptoms.
Dr. Barry Eppley
Indianapolis, Indiana
Q: i am going to have my chin shortened by cutting the bone, a procedure known as a vertical chin reduction. But I wanted to know something that is very important to me. After the surgery, the people that know me which i see everyday, will they see the difference in my face without me telling them? Will they know I have had some type of surgery? I am worried that they might say something like ‘Hey, what happened to your face?’ or something like that.
A: It is perfectly normal to assume that everyone that sees you after surgery will know exactly what you have had done. In reality, we give other people too much credit when it comes to perception. Most people, other than those who know us closely, see our faces in a more overall impression but not a lot of detail. Known as a facial gestalt, it is the image of our face people know, not the specific details. Therefore, after surgery people make see some difference (hopefully positive) but can not usually put their fingers on what was done. They will perceive that you look better, more refreshed, etc but they rarely can tell what part of the face was changed.
This is particularly true in anti-aging facial surgery (facelifts, eyelid tucks etc) but is also true in structural facial surgery. (rhinoplasty, otoplasty, facial implants, etc) Just because you know it doesn’t mean everyone else will. This is also because of another basic human characteristic….we are all more focused on ourselves than anyone else. Almost every human is more interested in how they look as opposed to how other people look.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have a prominent ‘apron’ and it’s getting difficult to navigate. I had twin girls last year and would just like to have a lap to hold them in. I am not expecting to be a size six overnite but I just need to get rid of this extra baggage. I have read about the operation ‘abdominal panniculectomy’ and it sounds exactly like what I need. I would like to have that operation but just want to be sure it it safe since I have a young set of twins. What complications have you seen with this operation and how quickly does one recover?
A: The abdominal panniculectomy is essentially an amputation operation of the overhanging apron. It should not be confused with its cousin, an abdominoplasty or tummy tuck. While they are seemingly similar procedures as they do recontour the abdominal wall, how it is done and what the final result looks like is different. The goal of a panniculectomy is to get rid of the overhang, not to create a slim waist or flat stomach. That simply is not possible given the large anatomy of the abdominal pannus. Getting rid of the pannus will improve back and knee pain as well as skin hygiene underneath the skin flap. In most panniculectomies, it is best to eliminate the belly button (umbilicus) so there is less potential for wound healing problems after surgery.
The most common complications after abdominal panniculectomies are fluid collections (seromas) and wound healing problems of the incision. They are so common it is fair to say that 100% of panniculectomy patients will experience them. Most of them they don’t require further surgery to solve but sometimes they do. Major medical problems, such as blood clots, pneumonia or heart problems, are not common. But most panniculectomy patients are often overweight and may have other accompanying medical problems. This is why a good medical work-up before surgery with approved clearance by your doctor is very important.
It is best to think of complete recovery after a panniculectomy as taking up to four to six weeks.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I had cheek implants 3 yrs ago which I am looking at having revised. I am tall and athletic and they are just giving me a bony gaunt look to my face which also makes my eyes appear too far apart. What I really wanted in the beginning were midface implants, but wasn’t able to make this clear with the doctor. They are screwed in and I am wondering if they can simply be reduced or shaven down? Also I have jaw implants and am not happy with the square shape that has resulted from their outcome .
A: Facial implants today come in a wide variety of styles and sizes. They are far more versatile than just augmenting the chin, cheeks or jaw angle in a single way. Frequently, I have patients come to my Indianapolis plastic surgery practice that have existing facial implants but did not end up with the result that they wanted. Communication and computer imaging is key in facial bone augmentation with implants.
Both cheek and jaw angle implants can certainly be modified, exchanged, or simply removed. The question for both areas is what is the best strategy to achieve your goals. From a cheek standpoint, you may have been more interested in submalar implants (on the underside of the cheek bone) rather than malar implants which sit on top. They create different looks. With the objective of improving a gaunt looking face, submalar augmentation is preferred. Malar implants will actually make that appearance worse. In jaw angle implants, the size may be too big or their position on the bone may be too high or too low. The style and shape of the implant can also affect how square or sharp the mandibular angle is.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dear Dr. Eppley, I’m 20 yrs old and currently in my junior year at college. I just found out earlier this year I have a breast deformity called ‘Constricted Breasts”. I knew something was wrong growing up when I wasn’t developing as I should. So I asked my doctors, at 18, about that, and he told me that when I get 20, my breasts should be fully developed. Well I’m 20 now, and they still look the same as they did in 7th grade. I have already tried to see if my insurance would cover a breast augmentation procedure, but they won’t, and my heart just sunk. It hurts so bad. It causes me mental, physical, and emotional pain. Just talking about it I burst into tears. My self-esteem is low, and I am not happy with the way they look and I also find myself cringing when I look down at them. I’m contacting you because I’ve seen your work here and I’m very impressed. I don’t want to seem as if I’m begging, but please, would you grant me with a free procedure? Being in a low-middle class family and in college, at times it’s really hard to make ends meet. I really don’t have anybody around me that understands the way I feel, or where I’m coming from, but you would make me smile from the inside out if you did this. I will be so blessed, and you can possibly change my life forever. From my heart, please consider this procedure for me. I can’t explain how happy I will be if you did this for me.
Thanks for your time, and I hope that for your kindness of your heart, you will make me happy.
A: I have great empathy for the concerns you have about your breasts, and wish that providing you with a free procedure were an easy choice. Given the number of women who come into our office with similar concerns about their bodies, I can understand how connected self-esteem and a positive self-image are. Providing surgery for free may seem like a simple and straightforward thing to do, but there are many factors involved that make the concept of ‘donated’ surgery not exactly free. While any plastic surgeon can give away his time at no cost, a surgeon’s fee represents just a fraction of the total costs of surgery. The cost of the breast implants, use of the operating room, and the fee for the anesthesiologist expertise are other cost factors that must be accounted for and paid. The surgery center, implant company and anesthesiologist are under no obligation to provide services and materials at their expense for a cosmetic procedure. Often times, these costs make up more than that of the surgeon’s normal fee.
One obscure but significant cost of any surgery is the potential medical-legal responsibility that exists in every state. Unfortunately, donating surgery does not equal any waiver of responsibility on the surgeon’s part. Should any untoward events happen, such as a rare but possible complication, the surgeon is still liable and responsible. The possibility exists too, for the need for revisional surgery after the initial procedure and the question then becomes is the surgeon again expected to waive his or her fees? There are no forms or waivers that a patient can sign that can legally hold harmless the physician for the services that he or she has provided.
While a plastic surgeon may choose to donate his or her skill and experience for free, the rest of the costs of surgery remain, and are usually out of the surgeon’s control.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hi Dr. Eppley, I am 3 weeks post SMAS facelift and necklift. I had a friend who had her facelift months before me. She was very thin and her face looked too tight to me (really pulled along the jaw line). I have a round face despite losing 50 pounds with very sagging neck and jowls. I read where you wrote that a facelift will not get rid of a round face. I know know you were right. My dilemma is that it almost appears that I had nothing done. My round face is still….round.
My plastic surgeon says my neck looks like an 18 year olds neck. I am extremely pleased with that and it is tight as a drum. I feel like my face is tight and a little lifted only on the sides near the ears. I still have loose skin around my mouth. Is this normal? Does the SMAS facelift not address the nasolabial folds? I am very disappointed after spending 11k. What should I do now? Should I address this with my plastic surgeon? He proclaims a “natural” facelift is one that is not too tight or pulled. It may be too natural for me.
A: My first comment is that it is only three weeks from your facelift. When you are living it that seems like an eternity. However, when it comes to facial swelling you still have a ways to go. I would not pass final judgment until three months after your surgery.
That being said, you appear to have a mismatch between expectations and the anatomy of a facelift. You actually have exactly what a facelift can achieve…a nice tight neck and jawline. That is all that an isolated facelift can achieve, no more and no less. It does very little to nothing around the mouth area (nasolabial folds and mouth corners) as they are too far away from the point of pull. (which is around the ears) This is a frequent point of expectation and subsequent disappointment if patients are not properly educated from the beginning. In reality, a facelift is a neck procedure and does little for what most patients believe in their ‘face’.
This also explains why a round face can never be changed from a facelift. The source of the round face is not what is treated by a facelift. The round face is largely a function of the size and thickness of the facial bones, muscles and fat layers.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have been suffering from angular cheilitis subsequently leading to cutaneous candidiasis and sometimes even a secondary bacterial infection for the past 18 months. If my face starts to sweat I immediately dry off my face but am mortified when I awake to realize saliva has pooled in the little cracks in the corner of my mouth. Despite my best efforts, I cannot always keep this area dry.
My dentist told me that it was due to a parafunctional habit and anatomical variation. So I changed the one thing I could control and stopped licking my lips. However, since then my best efforts barely keep this at bay and last week I had a tiny pimple in that area, the skin broke open, and you know the rest, the lovely normal flora became and opportunistic pathogen eating my face away, looking unsightly, and cracking my skin open if I accidentally open my mouth too far.
People think I am crazy for wanting surgery and I fear the opinion of female family members due to the new age stigma of getting plastic surgery too young. This is not for vanity unless you count wanting to be kissed vain, and when I have this crap on my face even I do not want to kiss me! Or look at me for that matter, not to mention how painful and itchy this can be and how long it takes to heal!
I have read that there is a possible surgical treatment for angular cheilitis. What is it and do you think it will be helpful for me. I am just looking for a permanent solution to this nasty mouth problem.
A: Angular cheilitis, also called perleche, is an inflammatory mucositis at the corner of the mouth and usually affects both sides. It presents as deep cracks or splits which may bleed when the mouth is opened widely. Why it occurs is not known precisely. Chronic wetness at the corners is the incipient event and that is most understandable in the elderly edentulous population who experience a loss of vertical dimension due to loss of teeth, thus allowing for over-closure of the mouth. This creates a spillway for saliva and chromic wetness in the mouth corners. Yet I have seen it just as often in younger patient who have a normal angulation of the corner of the mouth.
For those patients that have exhausted all medical treatments for angular cheilitis, surgical treatment is possible. When the corners of the mouth are sufficiently downturned, I have found a corner of the mouth lift to be helpful to change angulation and eliminate that spillway effect. In younger patients with a normal horizontal angulation, a resection of the mouth corner mucosa with mucosal advancement can be done. Sometimes this can include skin as well. The theory here is that the tissues are chronically infected and it is removed. I have seen improvements of the condition with both approaches.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hello, I just have a few questions about a cosmetic issue that I have been dealing with for really all of my life, but just became totally aware of within the last few years. I have a condition called Plagiocephaly. I’m sure you know what that is, so I won’t go into that. I will say, however, that I have a flat spot on the left side of my head. It has caused my left ear to protrude, and my left brow ridge(the part that the eye brow covers), also protrudes. It is very noticeable, especially to me, but others do notice it too. My question is whether or not I can have a procedure done to either A.) Reconstruct the left side of my head and brow ridge so it looks more symmetrical with the other side of my head, or B.) Just correct one of the two areas. I really would like both done and I would like to know about scarring and what would they look like, and whether they would be covered by my hair or not.
A: The physical changes that you have described are classic for occipital plagiocephaly in children and adults in which the condition was not treated early or was felt not to be severe enough for traditional skull molding therapy. On the same side, one can have a flat spot on the back of the head, a brow protrusion and an ear that sticks out more than the other side.
All three cosmetic problems can be effectively treated through known plastic surgery procedures. These include an injectable occipital cranioplasty using Kryptonite material (limited scar technique), a simple ear setback (otoplasty) , and a burring down of the tail of the eyebrow (brow bone reduction) using an endoscopic technique. All three can be treated during a single operation or only the most bothersome can be treated alone.
Indianapolis, Indiana
Q: Dr. Eppley. Five years ago, I had surgery on the right upper eyelid to reduce the size of my eye opening. My right eye used to be larger than the left one. Some times for a few seconds my right eyelid seems relatively normal but as I blink, it seems like the skin detaches from the muscle and the eyelid goes back to a droopy appearance. Unfortunately, it seems like the scar didn’t heal well or the stitches weren’t placed correctly. If the inner crease or fold would stay inside it would have a normal look. I wouldn’t want my right eye to end up larger or deformed compared to the left side again.
A: In looking at your pictures, one can see that with the eye open there is a fold of skin that hangs down onto the lashes of the upper eyelid. However, when the upper eyelid closes completely that fold of skin disappears. That dynamic piece of information is critical in selecting the right blepharoplasty procedure.
Trying to correct this problem by only removing all the extra skin may cause exactly the problem you are trying to avoid. Rather, a very conservative amount of upper eyelid skin should be removed and the dermis then sutured down to the tarsus or levator muscle. This is very similar to the classic ‘double eyelid’ operation done in Asians where they lack an upper eyelid fold. Your problem is conceptually similar.
Because it is only one one eyelid, the procedure can comfortably done under local anesthesia. This would also be helpful in that you would be awake and the dynamic action of the eyelid can be observed as the blepharoplasty repair is being performed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Can you tell me how the Zerona laser is supposed to remove fat. When I think of a laser it seems to be that it is hot and would burn the skin before it ever got to the fat underneath. I am interested in it to help me reduce my lower tummy, back and thighs. I just can’t bring myself to have liposuction as that seems too invasive and painful. I like the idea of not having surgery and not having to recover and less money is good too! but I want to know it is safe and won’t hurt me in anyway.
A: The type of laser that is used in Zerona treatments is not a ‘hot’ laser. It is a low frequency laser which makes it ‘cold’. It passes through the skin without injuring it. It can not cause a burn injury. It has a photochemical effect on the fat cells which makes them temporarily leaky. By being leaky, they ooze out some of their fatty acid content. This leakiness is only very temporary which is why treatments are needed every few days to keep them open for a period of time. Once the free fatty acids are out of the fat cells, they enter what is known as the interstitial space. In this space they are transported to the liver where they are broken down and eliminated. This is the process of fat reduction and elimination.
It is important to remember that Zerona is not a substitute for liposuction and it is a program, not just a machine. Other components of the program include water intake, niacin supplements and exercise. These help the effects of the laser treatments to be more pronounced.
Dr. Barry Eppley
Indianapolis, Indiana
