Your Questions
Your Questions
Q: Dr. Eppley, I need to have a pannciuectomy. I had weight loss surgery in November 2010. I was originally 375lbs and I lost over a hundred pounds. I have had this overhang since I was in my teens and it now hangs to touch my upper legs. Will my insurance pay for it? My out of pocket expense is met for this year so surgery should be paid in full. Please please can you help me?
A: Many overweight people have a large abdominal overhang initially that is then aggravated by their weight loss. As the weight comes off and the ‘balloon deflates’ so to speak, this skin overhangs worsens and sags lower as it has lost volume. This creates complete obliteration of the groin creases and their pubic and genital regions creating the well known hygiene and skin irritation issues. As you have described, your abdominal pannus now hangs down completely into your thighs. By definition, this is one of the criteria that insurance uses to determine coverage.
While I would agree that it sounds like your panniculectomy would be covered by insurance, my opinion is irrelevant and is meaningless from the insurance coverage perspective. This is why we always file a predetermination so the insurance company has enough information for them to make a decision. It is their decision not mine. As a plastic surgeon, I am merely a vehicle by which I can help the patient be put in a position so their insurance company can make an accurate review and determination. This predetermination involves a written letter by me describing your condition, the problems that it is causing and photographs which show the size of the abdominal pannus. That is mailed to them and then you await a written response as to their decision about coverage for your abdominal panniculectomy.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had breast augmentation about six months ago. I went from a 34B to a 34D and they are under the muscle. While the size is satisfactory, they still feel and look fake. They still feel hard, although not as hard as right after surgery. One breast is also higher than the other one and they have not dropped like my surgeon said they would. What do you recommend I do now?
A: While it is true that breast implants can initially be high due an immediate skin expansion effect, some settling or dropping of them can usually be expected as the lower breast skin relaxes. This is an effect that will occur within the first few months after surgery. I usually like to see it happen by no later than six weeks after surgery. While some settling can still occur up to several months later, you are at a point in time where no change will be seen. Besides a high position, your breast implants feel tight because the tissue pocket that contains them is somewhat too small. A small pocket around a bigger implant will feel tight or hard. What you need now is revisional surgery. The breast implant pockets need to be opened up on the lower pole, one side more than the other. This will drop down and even out the implants and, with larger pockets, make them feel softer. Breast augmentation revision is your next step.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am 38 years old and have had very noticeable nasolabial folds for the past several years. I have had injectable fillers, specifically Juvederm Ultra XC, placed into them with some improvement. I also had my cheeks injected also. Now, less than 6 months after the injections, my nasolabial folds are just about back again. I would like to something that is more permanent and may even have a greater effect. Do you think a cheek lift will work? Or should I just wait until I am older?
A: Deep nasolabial folds at a young age can be a very difficult problem. Some facial shapes and skin types are simply more prone to them and, if this is an issue at the young age of 38, it is going to continue to be a long-term facial issue. Injectable fillers for the nasolabial folds offer both advantages and disadvantages. Their advantage is that they work when properly placed. There is great debate of the many fillers as to which one is better but none has ever been shown to be really be ‘better’, they all work. Some simply last longer at a greater price. They work instantaneously and generally have no significant problems. Their disadvantage is that they are not permanent. No injectable filler is permanent, no matter what is said by some. However, a cheek lift is not the solution either…for now. You are too young to justify such surgery and it is not a permanent solution either. You would be best served to continue with injectable fillers at this point even though they have limited duration. The effectiveness of cheek or midface lifts depends on mobility of the cheek tissue across the zygoma or cheekbone. I doubt if you have much of at your age. This is why such cheek lifts are years away for you.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting fairly large breast implants. I am only 5′ 2” and 107lbs. I’m currently a 32A. I have been told that I would need multiple surgeries to get my desired size of 650cc. One plastic surgeon I consulted with suggested that I start with a 400cc implant and then have a second implant later to get to my size. My breast width is about 13cm. What is the largest implant (style and cc)that I can get based on my breast width?
A: There are some issues that you may be aware of when you place large implants in women with small breasts, primarily which is the stretching out of tissue support. This can cause some long-term problems such as tissue thinning, bottoming out and an increased risk of the need for revisional surgery. But I will assume you know these so I will answer your specific question.
Depending upon whether you are choosing a saline or silicone gel implant, there are different size consideration either of which would be a high profile style implant. I only use Mentor breast implants so I can only speak of those sizes. A 560cc high profile saline implant has a base width of 13.4 cms which can be maximally filled to 650cc. At maximal fill this will narrow its base to 13.1cm. For silicone Memory gel implants, a 650cc implant has a base width of 14.4cm.
As can be seen by these numbers, I do not know why you can not reach your desired breast implant size in a single breast augmentation surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was wondering if you performed jaw augmentation using bone grafts.What do you think about using bone grafts to increase the mandibular angle? Would you recommend it? And if you prefer other materials, why is that? I was browsing the web for some before and after photos of jaw augmentation using bone grafts, but to no avail. If you perform this procedure, and have done so in the past, would it be possible to see some of your work? Thank you!
A: There is a good reason why you can not find jaw angle augmentation using bone grafts…it is not done. It would be a very poor procedure for cosmetic jawline augmentation for the following reasons. First, onlay bone grafts to the face undergo partial or complete resorption. For the purposes of volume augmentation, much of the grafts would likely be lost or they would lose shape. Secondly, the amount of bone graft material that could be obtained and its thickness is very limited. Even using skull, hip or rib bones, it would be difficult to get enough material to adequately do both sides. This is not to mention the pain, discomfort and scars that would result from their harvest. Thirdly, most jaw angle augmentations require vertical lengthening which would mean placing part of the bone graft out into space. This would completely resorb.
For these three major reasons, and a few minor ones that I didn’t mention, synthetic implants are far superior to bone grafts for jaw angle augmentation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am 35 year old man and I have always been heavy since I was a teenager. Last year I decided to do something about my weight and I worked out alot at the gym and started eating better and I lost 120 lbs. Doing this made me feel great while I am fully clothed. However when I am naked I look terrible and am not confident whatsoever. I have the classic excess skin around the tummy area and the back and the breast area. Also I have excess skin between my Scrotum and my Bottom cheeks between my legs. I would really appreciate some advice on what procedures I can have done for this excess skin. It is for me that I want to do this not for other people I want to be able to feel as good naked as I do fully clothed. What can I do? Any help you can give me would be gratefully appreciated.
A: The loss of a lot of weight, whether it be by bariatric surgery or non-surgical methods, creates a very classic pattern of excess skin. For men, the primary skin excesses are around the waistline, the chest and the inner thighs. These require a surgical approach which usually consists of a waistline tummy tuck with a low horizontal scar, chest lifts, and inner thigh lifts. These are the three primary targets of male body contouring after weight loss. They often can all be done at the same time. The key concept to grasp is that there are scar trade-offs for removal of this excess skin.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting breast implants. I am fairly small framed, some call me petite, at ‘m 5’0” and 102lbs. I’m currently a 32A cup size. I have had one consultation and tried on sizers and it seems like 550cc implants seem to be the best fit for me for the size I am after. I have been told that this is a large implant for my type of body but this is the look I really want. My goal is a 34 DD. With implants of this size would it be possible for me to get a teardrop breast shape despites the large implant size on my small chest? Two other questions, will my areola stay the same size and what is the best implant and incision to use?
A: There is no doubt that you are interested in a very large implant for your frame. While it is every women’s right to choice any size implant they want, there are many plastic surgeons who will not accommodate an implant size that they feel may lead to loss of breast tissue support in the long run. That being said, whether it is a saline vs a silicone implant, you need a high profile implant to accommodate that volume with the most narrow implant base diameter so it does not end up too far to the side getting in the way of the swing of your arm. I would lean towards a saline high profile implant because it can be placed through a small armpit incision and gives the most projection with the narrowest implant width. As the skin expands to accommodate the breast implant underneath, your areolar size will get bigger.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, My teenage daughter was born with a hairy giant nevus in her scalp. It required three procedures of subtotal removals before it was completely gone between the ages of two to four years of age. While the scars from the removal procedu Smart Sales Blueprint res are largely hidden in her scalp, it has resulted in one of her eyebrows being much higher than the other. She is now a teenager and her eyebrow asymmetry is of understandable source of concern and embarrassment for her. I am looking into seeing if some plastic surgery procedure can be done getting her left eyebrow lowered to match her right eyebrow. Do you have any suggestions for how this may be done?
A: Eyebrow over-elevation can be a common sequelae from nevus excision of the scalp or forehead. It is obviously the result of either the scalp resection or actual forehead skin removed as part of the nevus excision. Thus the eyebrow malposition is because there is a forehead tissue deficiency. It is unlikely therefore that the eyebrow can be lowered by a ‘simple’ forehead and scalp tissue loosening, a reverse endoscopic browlift so to speak. The most successful and likely only effective procedure is to create more forehead skin or loosening through tissue expansion, thus allowing the eyebrow to move downward. Unlike eyebrow elevation through standard browlift techniques, eyebrow lowering is a much bigger challenge.
I would need to see a picture of eyebrows and forehead to determine what may be possible.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have some questions about chin augmentation for me.Here is a picture that I myself adjusted (I included the original). I actually like my front but as you can tell from my profile, my chin is weak. If you adjust my chin, it really doesn’t do anything to make me look better. My question is after a chin augmentation what can I do to achieve better symmetry in my profile and make me look better from the front (cheek reduction?). It’s quite odd because I look good from the front and correcting my chin doesn’t seem to make me any better looking. In before and afters online you can clearly see how it makes people look remarkably better. Perhaps this is as good as it will get for my chin. Do you think it will dramatically change the way I look from the front? I am interested to hear your professional opinion because I’m puzzled, I was thinking this procedure would make me better looking.
A: Thank you for sending your pictures. What you are perceiving is absolutely correct. While from a profile view, bringing your chin forward increases its prominence and is better by facial proportions measurements, it does not necessarily improve your overall appearance. The reason that more chin prominence does not fit in ‘better’ with the rest of the shape of your face is due your ethnicity in which your facial shape is broader, wider and flatter. You do not have an angular thinner face in which more chin prominence helps make the rest of the face look better as well. (balance) You have to be careful in your facial type that increasing your lower facial prominence does not make it look heavier and too prominent. The only way that chin augmentation would be a benefit is that from the frontal view the chin becomes more tapered rather than wider. This requires more of a central button implant and not the typical anatomic chin implant with long wrap-around wings.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have had breast augmentation with saline implants filled to 450ccs. This gave me a 36 D bra size. I had it done five years ago and have been very happy until recently. I have noticed that my breasts seem to be getting lower and my neck and back is hurting more. I am wondering if you think this is because of their weight? I am considering having them replaced with smaller implants that would take me down to a C cup which I assume is around 3255cc to 350ccs. My question is if I do have them reduced will one cup size smaller help them sit higher and reduce my back pain?
A: Your question is an interesting one but I doubt if your breast implants are a primary culprit of your neck and back pain. Contrary to the perception of many, the most common reason why large breasts cause musculoskeletal pain is because of their severe sagging and not just their weight. In most women with breast implants, the implant makes up a large percent of their breast size and the ‘sagging’ they may get with time is more skin relaxation and not true breast tissue ptosis. While I don’t know what your breasts look like, you would have to have a lot of breast tissue sagging off of the implant to cause these problems. Therefore downsizing your implants, short of complete removal, does not seem like it would prove beneficial for pain relief.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a chin implant placed six months ago. The implant was fairly small (4mm) and didn’t seem to make much of a difference. I then had the implant replaced about a months ago for a larger one because I wanted to see an actual difference. Now my chin is huge! The surgeon who redid it didn’t show me my any pictures of what the result would look like or did he show me the size of implant that he would use. I was just told the measurements and didn’t see it. So needless to say I am not happy and am looking for a really good surgeon who would be able to go in and replace the implant for a more aesthetically pleasing one for a small petite female. I have a slender face but the new implant just makes it look longer and because of how large it now is, I can’t smile right, etc. Please let me know if this is something that could be considered. Thank you.
A: I can appreciate your dilemma. A 4mm implant is not really visible in just about anyone. But it is also easy to go too big and wide in a female. Too wide an implant in a female is a common problem that I see. Chin implants in women have to take into account different size and shape considerations. What you would use in a women can be different than that of a man. I would need to see some pictures of where you were when you started and what you look like now if that is possible. I am certain you can get a much better result than you have now just based on your description alone. I suspect it is the wings of the implant that are as much of a culprit as that of the actual horizontal projection.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, if eyebrow loss is due to disease process like alopecia and not to behavioral issues such as trichotillomania or over plucking, would it still be considered cosmetic or might insurance cover part of the procedure(s)? I realize cost may vary, but since I would be traveling a fair distance for a consultation, can you provide ballpark estimate of cost? Thank you.
A: Short of traumatic loss of part or all of the eyebrows due to trauma( burn, avulsions), insurance is not going to cover eyebrow hair transplants. Thin or thinning eyebrows are viewed by insurance as a cosmetic problem not a medical one. Generally speaking, most eyebrow hair transplants need about 150 to 200 hair on each side. (more may be needed) At $10 per each indivudal hair transplant that would bring the cost to about $ 4,000 for the procedure which is done in an office setting under local anesthesia.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have an horizontal scar split my eyebrow. from1mm in the middle of the eyebrow to 6 mm at the end of the eyebrow. I have 6 hairs growing in the scar and i wouldn’t like thm to be lost in a scar revision. I don’t want to lose even one eyebrow hair in a scar revision. It is possible?
A: The simple answer is I couldn’t tell you without seeing a picture of the scar. But by definition, a scar revision removes scarred skin and anything that lies within that scarred skin. When dealing with noticeable scars inside the eyebrow, what makes them visible is their lack of hair or very scant hair within them. This scar needs to be removed, and any free-standing hairs included, to bring the edges of the eyebrow skin that has good density of hair together to minimize the scar’s appearance. This concept of eyebrow scar revision is limited by the size of the scar and would not work well if the scar is very large. (greater than 1 cm.) In these cases to prevent eyebrow distortion, one would need to consider eyebrow hair transplants instead.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a better chin and jawline. I am a 28 year-old female and I have always thought my chin was too short. I am fairly tall (5’ 9”) and my short chin gives me somewhat of a short-faced look that becomes particularly apparent when I smile. I know chin augmentations in women are not that common but I think I really need it. I have attached some pictures for you to review and tell me what you think.
A: Thank you for sending your pictures. While the pictures you have sent show you smiling (which distorts the chin area somewhat), I can still see your concerns about a small chin. I have done imaging showing a 5 to 7mm horizontal advancement in side view and a central or button style chin implant in frontal view to give it more of a tapered look which is more aesthetically pleasing in a female’s chin. I think this size and style of chin implant gives your lower face better balance and shape.
Actually chin augmentation in women, while less common in numbers than in men, is not that rare in my experience. How chin augmentation in done in women, however, is different in the amounts and shape of the augmentations as what defines an attractive female chin is different than that of men. It is more than just a simple horizontal measurement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have underwent a lower jaw advancement plus a genioplasty few months ago. I think my chin could have been advanced a lot more and would appreciate feedback if such can be procedure can be performed once again. What would be a cost of such procedure given it would be a repeated genioplasty. Thank you.
A: Thank you for your inquiry and sending your pictures. Your chin certainly still appears short despite the recent combination of mandibular advancement and osseous genioplasty. Your chin needs to be brought forward at least 7mms if not more to bring your lower face into better balance. Whether that can or should be done by a repeat osteotomy or simply putting an implant in front of the osteotomy needs to be determined by a lateral cephalometric x-ray. That would show how far the chin as been brought forward by the first osteotomy and how thick the chin bone is to see how much further advancement can be done. It is not a problem technically to do the genioplasty again, you just want to know precisely how much advancement can be gained. It certainly appears that the original genioplasty was fairly conservative.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, The picture used on the December 28, 2008 article written by Dr. Eppley looks like my body. I have lost some weight but am still a large women. I am very curious about this procedure. Do I have to be at normal weight to have a pubic lift done? Does insurance ever cover this type of procedure. My Gyn says that she thinks I may have some sort of a “prolapse” and suggested I go see a plastic surgeon. I am so embarassed by how I look I haven’t done so. Your website gives me hope that I am not the only person who has this problem. I look forward to hearing from you. Thank you.
A: A large overhanging suprapubic mound is a common problem for men and women that either have a large abdominal pannus or who have lost a lot of weight. The difference between the two is in the amount of fat that either contains. Either way, this overhanging mound can interfere with urinary outflow, sexual function as well as pose hygiene issues. Its removal can be done through a procedure known as a suprapubic reduction/lift (mons reduction) which consists of liposuction debulking of its fat volume if needed and reduction and lifting of the excess skin that it contains. Based on the above or overlying abdominal anatomy, it may be necessary in some cases to remove any overhanging abdominal pannus or extra skin first before proceeding with a pubic lift procedure. (e.g., abdominal panniculectomy or extended tummy tuck) This is usually not a procedure that medical insurance will cover.
Dr. Barry Eppley
Indianapolis, Indiana
Stem cells have caught the imagination of medical specialists and researchers over the past decade. The idea that your body holds within it the ability to regenerate and heal itself through these wonder cells has an irresistible appeal. Stem cells show good promise for numerous d How Do You If Your Ex Boyfriend Wants You Back ifficult diseases for which modern medicine has few good answers. Clinical trials for some neurologic and degenerative disease therapies have been encouraging.
Because of the uncomitted nature of stem cells, it is no surprise that it has been touted for the most common of all human conditions…that of aging. As an anti-aging treatment, stem cells have become the magic pixie dust allegedly contained in numerous topical skin therapies and cosmetic surgeries. A topical potion that may contain stem cells is surely as close to the fountain of youth as we have ever been. Their use has spilled over into cosmetic surgeries which are now being advertised for such procedures as stem cell facelifts and stem-cell-enhanced fat injection breast augmentations. These are being promoted as not only cutting edge operations but promising results that are far better than traditional methods of plastic surgery used.
When you factor in that everyone has plenty of stem cells throughout their body, many of whom lie in great numbers in our fat, their benefits seem obvious. How could they not make any cosmetic surgery better?
While stem cells are a part of the future of some medical therapies, they currently represent a potential case of a ‘truism.’ Truisms are common beliefs in which something just seems to be so true that we assume that it is…only later on closer scrutiny to be proven to not be so. Currently stem cells, at least in anti-aging therapies and plastic surgery, has many of the makings of a truism.
Those that advertise and market them are making claims that are far ahead of proven science. There has yet to be a single piece of medical evidence or research that has shown that stem cells can make your skin younger or your facelift last longer or look better. While we would like it to be true, and it seems that it should be true, the reality is that stem cells and anti-aging effects are still courting but there is no signs yet that they are to be married.
Because fat is resplendid with stem cells and fat injections are a common part of many plastic surgery procedures today, it is tempting to call them ‘stem-cell enhanced’ or even a stem cell therapy. This is false advertising at the least and deceptive at the worst. While stem cells may be part of our fat, we don’t yet even know how to make them work or what they would do if they could be turned on.
If you drawn to some type of cosmetic stem cell treatment, whether it be a cream or surgery, remember that nothing sells better than hope.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have loose skin on elbows and I only want the elbows done, I have had a quote but unsure how and when I can drive, and I am not sure about visible scar will be which worries me. It’s just coming into summer and not sure if that would matter to have it done now or wait. Can you advise me Thanking you in advance.
A: The biggest issue with elbow lifts, very similar to armlifts, is that there will be a visible scar as the trade-off for the loose skin. Whether this is a good trade-off will differ for each patient. If you have a scar concern, then this may not be a good procedure for you. That aside, my patients can drive the very next day. This would not be a procedure that most people would want to do in the summertime due to early scar visibility due to short sleeves being worn.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hello Dr. Eppley, I have reviewed your website qned found that you have run across silicone oil pockets and were able to induce drainage during a lift surgery. I have had buttock injections done. I do not have any lumps and I wanted to know that if found by MRI is there a way for a large pocket of silicone in my buttock to be drained? I really want to know if you can help me by performing this procedure, since you have seen and had experience with silicone oil. I really need your care. Thank you for emailing me in advance.
A: The traditional method by which silicone oil injections are done is supposed to be a small or ‘microdroplet’ approach for soft tissue augmentation. This is taught this way to avoid a large collection of isolated oil which can cause tissue reactions and fibrosis. While this may be the way it is done in the face, I suspect that most buttock augmentations with silicone oil involves much larger deposits than small drops. Since you have no lumps in your buttocks, you may not have any large oil collections that are capable of being drained. Certainly an MRI would reveal if such collections exist. If they do, drainage may certainly be possible. The one question I would ask then is, if you are having no problems, why do you want it removed? This is particularly relevant given that a surgery and an incision may be needed to do so.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a flat spot on the back of my head that I would like corrected. It is at the back of the crown of my head and it gives me a funny looking head. I have attached pictures and have drawn on them the shape that I would like to have. Can you tell me I how this can be corrected? What material and how would it be placed? What is the recovery after this type of operation?
A: Having done quite a few occipital cranioplasty procedures for skull flattening that looks just like yours, I would recommend PMMA. This is because it will take about 40 to 60 grams of material to create the desired effect. PMMA offers the most cost effective material when it comes to this amount of cranioplasty augmentation. Other material options include HA (hydroxyapatite) and Kryptonite but they will cost anywhere from 3x to 5X more in terms of material cost, that can add thousands of dollars to operative costs. The procedure would be done through an open approach through a low horizontal incision on the back of the head, where hair loss is not likely to ever occur. This is done as an outpatient procedure done under general anesthesia with an operating time of approximately 90 minutes. There is actually very minimal recovery afterwards other than some non-visible swelling on the back of the head. Occipital cranioplasty is a much simpler procedure to go through than most people envision.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, what can you tell me about this new procedure of making cheek dimples?
A: There have been media reports recently that talk about a ‘new’ plastic surgery procedure known as dimpleplasty. While this has been touted as being new, it really is not. The actual procedure of making dimples dates back several decades.
Cheek dimples are actually anatomic defects in the zygomatic muscles which run between the lips and the cheeks. This is an important muscle for smiling as it helps lift up and out the upper lip. In someone with cheek dimples, this muscle has a split in it. When someone smiles and the zygomatic muscle contracts, the split in the muscle separates which allows the skin overlying the split to be pulled inward. Thus a cheek dimple is really a hernia in the muscle. How big and where it is located determines the location and the size of the dimple.
In cheek dimpleplasty, a small incision is made inside the cheek where a split in the muscle is created. This allows the underside of the cheek skin at the desired dimple location to be sewn or attached to the inside of the cheek lining. This creates a scar or attachment that will lead to dimples when one smiles. This is a simple outpatient procedure done under local anesthesia so the dynamics of smiling and the dimple effect can be seen. There really is not recovery other than some mild cheek swelling. The biggest risk of the surgery is that the cheek dimples may be less or even more noticeable than desired. (depth of the dimple)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in using PRP for lip augmentation. I am looking for something more natural and longer-lasting other than the typical injectable fillers. Can PRP be put into the lips and how well does it work?
A: PRP can be injected into the lips just like anywhere else. It is not a question as to whether it can be done but whether it should be done. Will it create a lasting augmentative effect beyond that of a short-term fluid distention is the question. There is no medical evidence that it would nor would I biologically understand why it would. PRP is not a filler material per se but rather an adjunctive healing agent. It has no primary effect on its own such as creating more collagen than would normally exist in an otherwise healthy tissue site. The PRP I have put into the lips has been combined with fat to offer a higher probability of a sustained effect. It is the fat that is the filler and the PRP is added for its theoretical benefit on helping fat cells to survive or in helping stem cells to convert to fat cells. This is the most natural lip augmentation injection treatment but it is unproven as to how sustained or permanent the lip enhancement effect is.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like to start by saying your website and blog have been so helpful as both a research tool and making me feel so much more comfortable in approaching this issue. It is one of the few sources I have found that really takes the time to properly explain things, that most people in plastic surgery don’t understand. I would like to have more balanced facial features and to improve my asymmetries to improve my facial appearance. I feel that I have a long lower face and chin compared to my forehead, which is very low and slopping. I can’t wear hats and have to spike up my hair all the time so I don’t get teased. I recently lost a lot of weight and with it my cheeks, with used to be very full. But I guess what bothers me the most is my nose – I have a deviated septum which makes me look crooked and my nose is very romanesque in appearance. I think that a rhinoplasty and cheek augmentation would help me best but I’m open to suggestions. I just want to be the most attractive me I can be. From my photos can cosmetic surgery help me?
A: Facial symmetry and proportion are the two most important components of facial attractiveness. In looking at your photos, I would agree that the deviated and dorsal convexity of the nose combined with flat cheeks are the two main areas to try and improve. I would propose a rhinoplasty whose objectives are to straighten the nose in the frontal view and bring down the dorsal line to one that is straight between the frontal-nasal junction and the nasal tip. The tip could also tolerate a bit of thinning as well. For your cheeks, anatomical style cheek implants secured high up along the flat malar prominence will bring some highlights to your midface and more angularity to your face.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a son whose ears stick out. When he was little, he was sometimes called dumbo which was cute at the time. Now that he is in school, he is called dumbo and it is no longer funny. I can tell that it bothers him considerably and he is very self-conscious about his big ears. I want to get him an ear pinning procedure, which I know is the right thing to do, but I need some more information about the operation. Please give me an overview of some of the specifics about this type of ear plastic surgery.
A: Ear deformities can be emotionally traumatic to anyone but it is particularly bothersome to young school-aged children and teenagers during their very important formative years of their self-image. The good news is that an ear pinning, known as otoplasty, is a relatively easy and highly successful procedure. As the ear is about 90% complete in its growth by age 5 or 6, an otpoplasty can be done before a child enters school.
Otoplasty is done under general anesthesia in children. The incision and resultant scar is placed on the back of the ear and will heal so that it is never seen. The ears are reshaped by giving the ear cartilages a new shape through the use of permanent sutures which folds the ears back. The operation takes about one hour. Dissolveable sutures are used to close the incision and a head dressing is applied for few days. There is some slight discomfort but it is not a painful experience afterwards. Once the dressing is removed, the results are immediately seen. While there is some slight ear swelling, there is usually no bruising.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am curious about the use of hydroxyapatite or kryptonite bone cement for the use of building up areas of the cranium that are asymmetrical. Is hair loss something that occurs over the area where either of those two materials would be applied or is hair growth unaffected by having those materials placed onto the cranium?
A: Hair loss is not a potential complication of any cranioplasty procedure. I have been asked this question many times and it is an understandable concern.The blood supply to the scalp is extensive as the scalp is one of, if not the most, vascularized skin structures on the body. More pertinently, the scalp is tremendously thick often being 1.5 to 2 cms in tissue thickness. The hair follicles reside just under the skin in the top layer of the scalp, being in the upper 10% to 20% of its thickness. When raising a scalp flap for any cranioplasty procedure, the entire thickness of the scalp is raised off of the bone. Thus the plane of dissection and flap elevation is far away from where the hair follicles may be injuried. The only risk to hair follicles is in the making of the scalp incision not in the raising of the scalp flap or from the cranioplasty material underneath it. Such limited damage can be avoided by careful angulation of the incision, not using cautery in the upper level of the scalp and in careful scalp incision closure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had implants for submalar augmentation placed through mouth on September 2nd and then had them removed one month later. I also had a small premaxillary implant put in through the nose. I removed them because they were too big and the premaxillary implant changed the way my nose looked. The implants have been out for one week. I know that some of the undesirable effects were swelling and that I didn’t give them a real chance. But the anxiety they were causing me on a daily basis was too much. I can’t find any information as to why my nose looks different still after removal, it is wider and the nostrils look rounder and slightly more upturned. Is it possible it won’t go back to pre op look? Could scar tissue have formed that quickly or is it just swelling and if so when should I expect it to truly resolve. The cheeks and lower face are still very swollen also, will this eventually return to pre op look also given that they were in and out so quickly? When can I expect to look like me again? My muscles are a bit tight but overall seem to be functioning without any issues to the nerves and I can smile. Thanks and I look forward to your response.
A: Certainly one week after implant removal, there will be residual swelling and facial distortions. By your own admission you know this and it will take several months before you can judge the final outcome. I would have no doubt that the cheeks area will return completely to normal. Whether the nasal base will is unknown. In placing premaxillary implants the attachments to the nose around the pyriform aperture and the anterior nasals spine are disrupted. This may cause the nostrils to end up slightly wide than before but this is a possibility not a certainty.You must wait three months after facial implant surgery, either after their placement or removal, before seeing the final results.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am in need of some breast help! I have had three children, all whom I have nursed. I have also lost 45 lbs over the past year through diet and exercise. This has left my breasts saggy. I know that I need a breast, that is without question. The only question I really have is whether I can get by with out breast implants.Do you think that’s possible with how my breasts look? I’m happy with the size of my breasts when I wear a good bra (currently 40D) but unhappy with how deflated and saggy they are without a bra.
A: Breast lifts do an excellent job of lifting and tightening the shape of the breast mound. By keeping the same amount of breast tissue and lifting and tightening the ‘bag’ which contains them, this does create a less saggy and more round breast. This is particularly true in the bottom pole of the breast and less so in the upper pole of the breast. In the beginning right after breast lift surgery, the upper pole of the breast is quite round and full. But as the tissues relax and settle, much of the upper pole fullness will be lost. If one doesn’t ming some rebound flattening of the upper breast pole, then I think you would be fine with a breast lift alone. However, if your goal is to have a rounder and more full upper breast pole long-term, then a small implant will be needed to accomplish that breast shape goal.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had Botox for the first time a year and a half ago for free. A local doctor was training a woman on it and he did one side and instructed her on the other side. It was just okay, one side felt heavier than the other and one eye brow was higher than the other.
Then an anesthesiologist friend offered to give me Botox injections as she does a small group of women from time to time and I wanted to try again. This was like eight months after my first try. Long story short, I had a furrowed left brow for a while which was not cool. Plus she diluted it big time which in hindsight was a blessing because of the furrowed brow. I was starting to think that there is definitely an “art” to this injection thing.
Then I was out of town visiting friends and a local doctor introduced me to Dysport. At the time I was totally feeling ugly and wanting to try anything to reduce the fine wrinkles in my forehead, just look fresh. Well he did a first rate job so I loved it! No heavy feeling in the forehead and it took almost immediately and looked great! I’m sold on Dysport for no other reason than it was my best experience to date. You will have to educate me on the cost vs Botox as I have no idea.
So here I am today, looking online for a reputable guy to help me out…I’m due for something, but will not go the route of using anybody but a professional ever again!
A: The apparent simplicity of facial injections does belie that there is actually some art to it. There is also an obvious benefit to knowing the underlying facial muscles and how their movement contributes to facial expression. It is slightly more sophisticated that just throwing darts at the side of the wall so to speak.
The actual differences between Botox and Dysport are very slight and there is no real evidence that one is more effective than another. Dysport may ‘kick in’ a day or two earlier than Botox but otherwise lasts and costs about the same as Botox. The differences you have had with two negative experiences with Botox and the favorable one with Dysport undoubtably reflects technique (injection location) and doses used. I have not seen any differences in my experience with either one. There is some evidence that Dysport may be slightly more effective than Dysport (because it spreads out better) but in the forehead there is no appreciable difference in effect.
All of that being said, you should continue with Dysport because you have had a good experience and there is no change what isn’t broken.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 36 year-old and I have a very thick and prominent brow ridge bone. A few years ago I suddenly lost my hair because of alopecia and now my forehead looks very unpleasant. I was wondering if you can offer bone reduction and reshaping solution for me. I have taken some photos of my facial profile which would be available if you required. I am serious to perform the procedure and at the same time have some concerns regarding the techniques to approach this procedure .
A: Brow bone reduction in a male, who is the most common type of patient who develops prominent brow bones, must always take into account the surgical approach. The only way to do brow bone reduction in any patient, male or female, is through a scalp incision. There is simply no other incisional method, even an endoscopic technique, that can provide the exposure for the instrumentation to do the procedure. In the male patient with no hair or a very sparse hair pattern the trade-off of a scalp scar must be considered very carefully. Essentially one is trading off one problem (prominent brow bones) for another. (scalp scar) This may be a reasonable trade-off but the magnitude of the brow bone protrusion has to be fairly significant and really deform the shape of the forehead to justify brow bone reduction in men.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, one year ago I underwent surgery for a medium chin implant and neck liposuction. Though I was initially pleased with the result due to the way the swelling made my chin look, after the swelling had subsided I was very disappointed with the outcome. I feel that my chin and jaw line are vertically short and that my chin is still a little bit horizontally short. Additionally, my jaw line lacks solidity and I think that my chin could stand to be a little wider/fuller. I have attached two photos of what my face currently looks like.
I would like to add roughly a 1/2 inch to my chin/jaw line vertically, as well as 3-5 mm horizontally (from where the current implant ends). I would like my jaw to angle down to my chin, so that the chin is lower than the rest of the jaw. As I previously mentioned, I would also like my chin to be a little bit wider and to add solidity to my jaw line as it gains fat easily.
In order to obtain the results that I desire and keep them long-term, what would be the best procedure for me? The three that I have been looking at are a sliding genioplasty, a geniomandibular implant with Gore-Tex strips or a custom jaw implant. Money is a little bit tight for me, so I’m hoping to avoid the custom jaw implant.
I appreciate your help and eagerly await your response,
A: I have taken a careful look at your photos and your desired aesthetic chin changes. While a custom implant is one method to achieve those changes, it is not the only way as you have pointed out and the cost of it eliminates it from consideration by your own admission.
Between a chin osteotomy and geniomandibular implants, each has its own advantages and disadvantages. A chin osteotomy (keeping the chin implant in front of it) would easily create 10mms of vertical lengthening, about 5mms of additional horizontal advancement and could be sectioned to create 5mms of horizontal expansion as well. It is done from the inside of the mouth and would actually be my preference in your case even over a custom chin implant. Geniomandibular groove implants could also provide up to 10mms of vertical lengthening and 5 to 7mms of horizontal widening as the implants can be placed with separation between the two sides. The problem with these implants is that you would only get about 2 to 3mms of additional horizontal advancement and your existing chin implant would have to be placed on top and in front of it to keep and enhance the horizontal projection that you already have. That is not a big problem, just that you have two implants stacked together. This procedure would need to be done from a submental skin incision from below the chin with a resultant scar.
Dr. Barry Eppley
Indianapolis, Indiana
