Your Questions

Q: I am in the very early stages of looking into treatment for the area under my eyes.  I believe the problem could be easily fixed by the right Dr. and this is my first attempt to find out what is involved and how much it would cost.  The skin directly under each eye is all wrinkled and takes completely away from my appearance and has caused me to be completely self conscious for many years now and if I can do something about it, I would like to.

A:  Aging around the eyes is often one of the first signs that many people notice as they get older. Changes in the lower eyelid are usually more obvious than that of the upper eyelids since they are not hidden or distracted by the eyebrow and are larger by surface area. Since so much of human conversation involves direct eye contact, how our eyes look is seen by all. It is no wonder then that many people seek plastic surgery for an improved and more youthful eye appearance.

While there are many topical creams out there, and they do have some anti-aging merits, they are no replacement for more invasive eyelid skin treatment methods. Depending upon the amount of loose skin that exists on the lower eyelid, some version of a lower blepharoplasty or eyelid tuck can be very helpful. Through a fine line incision along the lower eyelash line which extends slightly out from the corner of the eye, loose skin is removed and the lower eyelid is tightened.

Lower blepharoplasty will definitely help remove some but not all of the eyelid wrinkles. You never want to risk removing too much skin from the lower eyelid in an effort to work out every sinle wrinkle and then end up with a pulling down of the eyelid after. (ectropion) Lower blepharoplasty is an excellent wrinkle reducer but should not be thought of as a complete wrinkle remover.  

Dr. Barry Eppley

Q : Hello Doctor, I had a chin implant in November 2008. It got infected and had to be removed two weeks later. Now after one and a half years later my chin is still loose and stretched, making my chin look like it is hanging and looks weirdly different. I like to find out if there is a way of fixing this by shrinking and tightening my chin that will hold my face together the way it was before. Thank you for your time and help, hope to hear from you very soon.

A: In placing a chin implant, it is necessary to lift the mentalis muscle off of the bone. Like placing a breast implant, this stretchs the overlying tissues out. As a result, if chin implants are ever removed there is a risk of the tissues not shrinking back down and become ptotic. (sagging off the bone) This is a well recognized chin problem whose occurrence is more likely the larger the chin implant that was used. The risk of chin sagging is also greater if the pathway in which the chin implant was originally placed and removed was done from inside the mouth. (this method separates a greater amount of mentalis muscle)

Chin ptosis, also known as a ‘witch’s chin’ deformity, can be corrected through two different methods. If you want to get the effect of greater chin prominence that you were originally after, replacement of a new chin implant or moving the chin bone forward (chin osteotomy) can be done. This will give more chin projection and pick up the sagging chin tissues. If you are not interested in any further chin projection, then the mentalis muscle must be shortened and tightened to readapt the soft tissues back on the chin bone. This can be done either from inside the mouth using resorbable bone anchors or from an incision on the underside of the chin. (submental tuckup)   

Dr. Barry Eppley

Q : Dr. Eppley, I have had silicone gel implants for 31 years and am still very pleased with them.  I am presently 65 years old and in good health.  I regularly had mammograms every two years until five years ago.  At that time, the place where  got my mammograms asked me to sign a disclosure form stating that I would not hold the clinic or technicians responsible if one or both of my implants as a result of the test. This was alarming to me and I walked away without the mammogram and have not had one since! 

I realize that foregoing mammograms is foolish.  My doctor encourages me to have it done even though I have shared my fear.  Is there a better way to examine the breast with silicone implants other than a mammogram?  My breasts are small and when the paddle compresses them, it does feel like the implants could burst especially since they are such old implants. How do we know that the bag that encloses the silicone will not leak or burst? I’ve also had an ultrasound but they said that is not a good substitute and will not detect cancer cells.

Dr. Eppley, if you have any suggestions or answers to these concerns, I would certainly appreciate hearing from you.

A: Your fears about rupture of breast implants with mammograms is understandable, particularly in light of their age. While today’s breast implants have improved shells (the bag containing the implant filler) that are known to be resistant to the compressive forces of mammograms, the physical characteristics of implants thirty years ago are undoubtably less so.

I have seen breast implants of this age before on removal and most of them are either ruptured or no longer have any identifiable shell remaining. (meaning it has completely disintegrated)At thirty-one years of age, it is very likely that your breast implants are already ruptured or the shell is no longer intact. Even in asymptomatic, capsular contracture-free breasts, old breast implants will often, if not usually, not be intact.

That being said, I think your concern about breast implant rupture should not outweigh the potential benefits of mammography. Mammograms are still the simplest and most cost-effective screening tool that exists for breast cancer detection. An MRI of the breast can be done but it is more sensitive to look at whether breast implant rupture exists than to detect breast cancer.  

Dr. Barry Eppley

Q : I am scheduled for facelift surgery and want to do everything to shorten my recovery and have a good result. I have read about the medication Arnica which is supposed to reduce swelling and bruising. I bought some Arnica montana to take 2 weeks before surgery and 2 weeks after and what I found was pills that dissolved on your tongue and should be taken every 30 minutes.   Is that how I should take them? 

A: Arnica, known more formally as Arnica Montana, is a herb extract from the mountain lily flower. It has been used for medicinal purposes for hundreds of years and remains popular today. It is used in the non-drug treatment of muscle aches and to reduce inflammation. In plastic surgery, it is used with the primary intent to reduce bruising. It can be applied topically as a cream or ointment to a bruise or can be taken orally to either prevent or treat bruising. Its effectiveness is more than a medical myth and clinical studies have shown its value. It has not known harmful effects when taken in homeopathic doses.

Oral arnica is what is recommended for elective cosmetic surgery. Because of the visibility of the face, I always recommend to my facial surgery patients that they take it several weeks before and after surgery. It comes in homeopathic doses which are usually given in C units rather than milligrams like prescription drugs. Arnica tablets can usually be gotten in doses of 15C, 30C and 60C. There are no proven differences in  anti-bruising benefits to any of these doses. They are to be taken by placing several tablets under the tongue (sublingual) and letting them dissolve at a frequency of four times per day.

Dr. Barry Eppley

Q: I am wanting to get liposuction and a tummy tuck and I have learned that it is quite expensive. Do people generally pay cash, out right? What financing options are available?

A:  Elective cosmetic plastic surgery is not inexpensive and many people considering it do require some financial assistance. While the concept of financing plastic surgery was once rare, it is not quite common. I have read estimates that in 2000 the number of patients that financed surgery was 5%. Today that number is closer to 40% and growing. For these patients, financing could be the only means to afford their desired plastic surgery procedures.

Most, if not all, plastic surgeons are very familiar with a patient’s request to finance their surgery. This is an everyday event in any busy plastic surgeon’s practice. While the plastic surgeon’s office can assist and guide you through the financing process, plastic surgeons do not directly loan money for surgery. Nor  do they work out a payment plan so that one can have surgery and then pay out off the plastic surgeon over time.  That requires a financing company or back (not usually the best) to work with you to develop the loan amount, interest, and a repayment schedule. Most plastic surgeons are signed up with financing programs that allow you to directly apply to and get very quick responses.  Like a car or appliance purchase, you need to think about making monthly payments over a given period of time 

There are a large number of companies offering plastic surgery financing. In my Indianapolis plastic surgery practice, we use Care Credit and My Surgery Loans, for example. But there are many other options out there that offer medical loans. Simply google the term ‘plastic surgery finiancing’ and a plethora of them will appear. These medical loans are not necessarily based on the procedure you are considering but on a dollar amount. You can then select the procedure you want to have, and depending on your credit ratings, you could be granted different interest terms.

When considering financing plastic surgery, there are three (and potentially four) costs that you need to be aware of. These include the surgeon’s fee, operating room charges, the anesthesiologist’s fee (if general anesthesia is used), and implant charges. (if some form of an implant is being used) Make sure you know all of the fees that will be required of your procedure so you don’t inadvertently get a loan that is not adequate. Your plastic surgeon should give you an estimate (quote) for all the costs of your procedure. Get a consultation and written quote before you ever finance. Do not take the estimated costs off of a website or some verbal exchange.

 Lastly, like all financial and legal documents,  double check the agreement terms, interest rates and re-payment time before signing at the dotted line.

Dr. Barry Eppley

Q: Dr Eppley I have had my lower eye bags and lids done and also had a MAC facelift with liposuction to my neck all at the same time. I now have two eyelids that are different and am not pleased with the result of my lower neck. I went back to see the surgeons yesterday and they said they would have to do the two eyelids again but can’t do the neck any better. I am 65 years old and after reading your article about a low horizontal neck lift I wonder if this is would nto work for me. That procedure has given me hope but I can’t trust my previous surgeons to do it.

A: The MAC facelift, like all forms of limited facelifting, is a great procedure for the right patient. The right patient for it is one that doesn’t have a significant neck problem or a lot of loose neck skin. These limited facelifts are primarily jowl reducing/smoothing procedures with some minor improvements in the neck area. Those improvements are helped through the use of neck liposuction, but the key to getting a good result is that the neck skin must not be too loose.

When one has a more significant neck issue, a full or more traditional facelift procedure is more appriopriate. This is a much more powerful neck procedure. One of the problems with these limited facelifts is that they get used in patients that really should have had a more complete necklifting procedure. As a result, they can often be disappointed with the neck result. I suspect this is what has occurred in your case.

Once can always have a secondary more complete facelift done to improve your neck result. Having had a MAC facelift does not preclude that. Saying that ‘no more can be done’ suggests to me that they are either unwilling or incapable of doing a more complete facelift procedure.

A low horizontal neck lift is always an option and certainly is simpler and easier than reverting to a complete facelift. As long as one can accept a fine line scar in a low neck crease, this could be an option worth considering. That could even be done local anesthesia.  

Dr. Barry Eppley

Q : I had my lower eyelids tucked (blepharoplasty) over 6 months ago. While my lower lids look much better, I have had  a problem with dry eyes and tearing since the surgery. It was really bad right after and has gotten somewhat better. It is almost painful to be out in direct sunlight and my eyes really tear if there is any wind. My lower eyelid also doesn’t look right. I think I show more whites of the eye than before and it looks pulled down. My doctor keeps saying to give it more time and it will get better. But it has been some time now since surgery and I just don’t see it happening. What do you suggest? By the way I am a women who is 58 and I still have to work!

A: One of the potential, although fortunately uncommon, risks of lower blepharoplasty surgery is ectropion. This sounds like exactly what you have.

The lower eyelid, unlike the upper, is like a clothesline strung out between the inner and outer eye socket bones. The eyelid is attached to the bone by tendons called the canthal tendons.  This clothesline effect keeps the lower eyelid snugged up against the eyeball just at the lower edge of the iris. By being tight up against the eyeball, it is protected from drying out and being irritated. Any slight change, even one millimeter, between the eyelid and the eyeball (out or down) will cause eye symptoms of dryness, irritation, and tearing. Manipulation of the lower eyelid through surgery can disrupt this relationship if the eyelid and the lateral canthal tendon are snugged back up properly as part of the operation.

While small amounts of ectropion may correct itself with the passage of time and upward massage, six months with this degree of symptoms indicates another approach is necessary. Performing a canthopexy or canthoplasty  (tendon tightening and eyelid re-suspension) and retightening of the outside eye corner can provide an immediate solution to this very irritating problem. Once the lower eyelid is back tight against the eyeball, it will not only look better and more natural but the eye is protected once again.

Dr. Barry Eppley

Q : I am interested in reshaping my forehead. When I was a child I was diagnosed with craniosynostosis of the middle forehead suture which I think is called the metopic? I had infant cranial reshaping which I am sure helped a lot but since I was so young I can’t remember what it used to look like. I have been bothered by the shape of my forehead since I was a teenager. It appears too narrow for a male and has a slight vertical ridge down the middle of the forehead. What can I do about it now? I am a male and am 24 years of age.

A: What you have is the secondary sequelae of correction of an initial metopic craniosynotosis. That initial surgery is designed to bring out the sides of the forehead (temporal area) which helps create a more normal forehead contour. While this initial surgery is often completely curative, older styles of this form of cranial reconstruction often produced suboptimal results, leaving patients with a minor form of residual metopic craniosynostosis. This is seen as a residual bitemporal narrowing and the hint of the vertical midline ridge.

Secondary forehead reshaping can be done that is infinitely simpler than the initial cranial reconstructive procedure. Rather than bone removal, material is added on the outer surface of the bone. This is known as an onlay or frontal cranioplasty. Using the initial scalp incision, the forehead skin is peeled back to expose the bone. Then using either PMMA (acrylic) or HA (hydroxyapatite, my favorite) material, the bone is reshaped through an onlay spackling method. Any irregularities are smoothed out through an additive approach. Deficient areas are built up and made confluent with the surrounding cranial contours. Emphasis for this problem is on both smoothing the forehead and building up the still deficient temporal areas. This is a relatively simple procedure for those plastic surgeons with training and experience in craniofacial surgery.

Dr. Barry Eppley

Q: I am interested in breast implants. After I lost all my weight (was originally 198 lbs), I have a muscular body but I have NO BREASTS!!! When I was heavy,  my cup size was 40D. Now I wear 32B and you can see my ribs all the way down to my stomach. I workout every other day to stay in shape.

A: One of the few negative side effects of weight loss, like pregnancy, is the loss of breast tissue and volume. The more weight that is lost, the more breast volume that disappears. This is particularly seen after bariatric surgery where the weight loss may be 100 lbs or more. Many such women end up with no breast tissue at all and just two hanging empty skin envelopes.

Breast implants will definitely provide a return of volume but the key question is how much loose skin remains. If the amount of loose skin is only moderate and the nipple position remains at or above the lower breast fold, then an implant alone will be adequate. If, however, the amount of loose and hanging skin is more significant and the nipple is below the lower breast fold or pointing downward, then a breast lift may be needed as well as a breast implant.

Breast augmentation in some weight loss patients presents challenges to the plastic surgeon  than one does not usually have in the typical small-breasted female. How much loose skin exists, and the key issue of current nipple position, can turn what appears to be a simple breast implant procedure into a more complex breast implant and lift procedure.   

Dr. Barry Eppley

Q: I have been infected with HIV for 31 years, and have seen every one of my former friends and acquaintances succumb to AIDS. For some reason meds have always become available just in time to save my life. For that I am thankful But my life feels hardly worth living with the disfigurement of facial lipoatrophy and pain of buttock lipoatrophy. My face is so gaunt it is horrible and I have not butt at all!

A: One of the very unique effects of anti-viral medications in the management of HIV/AIDS is their effects on fat wasting or lipoatrophy. While much of the body (but not all) is affected by this fat loss, the face and the buttocks are frequent areas of aesthetic concern.

Facial lipoatrophy can be treated by two potential methods. The non-surgical approach is with the use of Sculptra injections. This is an FDA-approved injectable material that is essentially the placement of crystals or ‘seeds’ of a resorbable polymer that promotes collagen formation. It requires a series of injections over time to get a sustained response. The injections are placed in the cheek and submalar areas where the hollowing is the worst. While there is the possibility of a foreign-body reaction or granulomas with its use, good technique can minimize that risk. This injection material is not permanent and must be repeated every year or so once the desired result is obtained. From a surgical standpoint, cheek or submalar implants can be used which is actually my preferred approach. The procedure is simple, is done from incisions inside the mouth, and the volume obtained is permanent. Once can then use Sculptra to further highlight and feather the result out further into the face if desired.

Unlike the face, there is no good solution for the buttocks. Fat injections are not a good idea as there is no fat to harvest in most HIV patients and it will likely be absorbed anyway even if there was. Buttock implants are a possibility but the pain of recovery and the risk of infection may this procedure unappealing.

Dr. Barry Eppley

Q: I am interested in receiving a jaw and chin augmentation. I live in Canada. I have a consultation scheduled with a local plastic surgeon in a week, however I see that Dr. Eppley is very experienced in the procedures I am interested in. My question is do your do consultations over the web? If so, I would like to schedule one. I would like to have the procedure done this summer.

A: The internet has enabled patients to access information from anywhere in the world. This is no less true in plastic surgery. Through the free internet service, Skype, phone or video discussions are easy to set up and do. While this video conversation method is not a replacement for having an actual consultation in a plastic surgeon’s office, it can be a great first step where you can actually talk directly to a plastic surgeon without leaving the comfort of your own home or city.

I have offered free Skype consultations for over a year and have interacted with people from all over the world. To take advantage of this opportunity, go to the Skype website, download the application and register under your name. Registration is free and takes but a few minutes.You will then need to add me to your contact list. My Skype contact name is dr.barry.eppley. Add my name to your contact list. I will get a message requesting me to add your contact to my list. Once I have done so, you will get a message confirming so. You can then send me a message describing what your plastic surgery needs are. We will then work out a convenient time to get together on Skype for an in-depth conversation.

Dr. Barry Eppley

Q: I had an otoplasty performed about 2 years ago. Although very pleased with the initial result, I feel the upper third part of my ears have relapsed to a more prominent position. I heard of a procedure using sutures between the root of the helix and the temporal fascia to correct this problem without going through the whole traditional otoplasty procedure again. Is this something that you are familiar with? Are the incisions well hidden? And is this a well accepted method?

A: Otoplasty, or ear pinning surgery, involves the use of sutures on the backside of the ear to reshape it. These sutures are used to create or make more pronounced the antihelical fold, whose absence is often the primary cause of an ear that sticks out too far. These antihelical fold sutures are known as Mustarde or horizontal mattress ear sutures.  Another contributing cause to the protruding ear is a large concha. The conchal prominence of the ear can be reduced by sutures between it and the mastoid known as concha-mastoid suturing. Often many otoplasties require a combination of both types of sutures to get the best result.

Many otoplasties experience a mild degree of relapse months to years after surgery. This can be due to slipping of the sutures but is most commonly the result of cartilage relaxation over time. This is usually very mild and not bothersome to the patient as the change has been so dramatic that even some relapse still leaves one with a pleasing change.

In a few cases, the relapse is most noticeable in the upper ear area. This region has the  least suture support and is above the level of the concha where both types of sutures may have been used. This is an easy problem to fix by placing an additional horizontal mattress suture or two in the upper area. This can be done by reusing just the upper portion of the original incision on the back of the ear. It can be done under local or IV anesthesia and without the need for a head or ear dressing afterwards.

Dr. Barry Eppley

Q: I am interested in forehead reshaping. I have a very large forehead which I know takes away from my appearance and I’ve been teased about it alot. How is this procedure done?

A: The forehead makes up one-third of the total face and is frequently overlooked as having a major contribution to one’s appearance. Only when something about the forehead is ‘wrong’ does one take notice of its facial significance.

When a patient feels that they have a forehead problem, they are usually referring to two potential concerns or problems. The issues are usually its shape, which is a reflection of the underlying shape of the bone, or of its length or height, which is a the result of the amount of skin between the frontal hairline and the brows.

Forehead bone problems could be irregularities, bumps or high spots, prominent brow bones, or the narrowness or width of the forehead from one temple to the other. Such forehead problems are treated with frontal cranioplasty procedures where the bone can be reduced or added by different materials. This does require an open approach with a scalp scar needed for access. But with this wide open visibility, a wide array of bone reshaping and contouring can be relatively easily done to the frontal and brow bones.

Too high a forehead or too long of a forehead is a matter of skin reduction. This procedure is essentially a ‘reverse browlift’ where the skin is removed through an incision at the frontal hairline. Instead of the brows coming up, the frontal hairline comes down thus shortening the visible forehead skin to 7cms or less in vertical length.

Dr. Barry Eppley

Q: I am interested in having small cheek implants and was wondering who you would recommend I see in the Washington-Baltimore metropolitan area. I have spoken to several plastic surgeons who say they remove more cheek implants than they put in. I am wondering who has had good results with this procedure?

A: I wish I could answer your question in regards to plastic surgery referral in your geographic area. But, unfortunately, I could not tell you with any assurance who gets good results with cheek implants. While I am certain all plastic surgeons say that they do them, who would be better than other is impossible for me to know. (just like you)

What I can tell you about cheek implants is that what you have heard about them are true. Even though it is a very simple operation, they are the most revised and/or removed implant of all the facial implants. The reason that exists, in my experience, is that they are often oversized for the patient. Cheek implants are much better to be done in moderation or ‘underdone’. Cheek augmentation should be subtle, not dramatic. It is not like a breast implant, where many times bigger may be better. That is never true with a cheek implant. The second reason they are revised is that the cheek implant is unique in its position. It is the only facial implant that is literally ‘hanging on the side of the cliff’ in where it is placed on the cheek bone. So they are prone to movement and asymmetry between the two sides afterwards. That is why I prefer to secure them with a screw to the underlying bone to prevent that problem. Lastly, there are at least 5 different styles (not to mention sizes) of the implants, so matching the unique anatomy and patient desires with the right style and size of cheek implant is certainly more art than it is science.

Dr. Barry Eppley

Q: I have a problem with my profile. I wish it would look normal or see my jaw line. I always wished to see it. I think this is because I used to sleep with my mouth open when I was a child. I also a rhinoplasty by a bad doctor who made my nostrils asymmetric.:(  This was 4 to 5 years ago. I went to someone who offered the lowest fees since I wasn’t earning much at the time. I would like to come to the states from Egypt for corrective surgery.

A: When most people talk about happiness with their profile, they are almost universally referring to the position of their chin. Based on how the lower jaw (mandible) grows and the bite (occlusion) comes together, the horizontal or forward position of the chin will be affected. For most it is an issue of being too short or not ‘strong’ enough particularly in men. Too much chin is far less of a problem although it does exist and it is more of a concern in women rather than men.

Correction of chin shortness can be done with either an implant or osteotomy. (moving just the chin bone forward) Which is better is determined by multiple factors including the amount of chin shortness, age of the patient, and the position of other chin dimensions. (e.g., vertical height) How much or far forward the chin position should be moved can be determined prior to surgery with computer imaging.

Nostril asymmetry after rhinoplasty is not rare and does not necessarily occur because of a ‘bad’ surgeon or that the operation was performed incorrectly. Even a rhinoplasty executed perfectly can still cause some differences in the shape of the nostrils after all is healed. The nostril shape is influenced by the support of the lower alar cartilages and the overlying skin. Both of these can be altered by the healing forces after rhinoplasty, particularly in the soft triangle area of the nostril where there is no cartilage support to resist the contractile forces of scarring. Secondary correction of nostril asymmetry is possible through cartilage or chondrocutaneous grafting of the nostril rim.

Dr. Barry Eppley

Q: I am currently a nurse in the US Marines stationed in Afghanistan and will be visiting home for a month in September later this year. I’m interested in breast augmentation surgery and have thought having this done for some time. Do I get a discount because of the Patriot Program? I am also interested in having a Skype consultation which would be  great for me given the distance. That way I could get everything arranged so when I return I can have my surgery within a day or two after my arrival.

A: The Patriot Plastic Surgery program has had a good response since we have offered it over the past year. I have gotten numerous inquiries from around the world, particularly from overseas in Europe and Afghanistan. I am happy to offer what we can to a very deserving group of men and women who are doing far more for our country that I ever could.

Because of the age group (ages 18 to 35) that make up a significant percent of the military, most requests have been for body procedures such as breast augmentation and liposuction and face procedures such as rhinoplasty, otoplasty, and chin augmentation.

Many of these military patients come in for surgery during their leave back to the United States or from where they are stationed here in the United States. The use of Skype as a free internet method of discussions and consultations makes the consideration and coordination of surgery possible from afar. By using the video feature of Skype, one can have a good conversation about potential surgery almost as if one was in the office. I often review pictures that are sent to me before these Skype discussions to help focus the conversation. Patients can then have surgery arranged and come in and see me the day before for a real hands-on evaluation and final discussion prior to surgery the next day.  

Dr. Barry Eppley

Q :  I have a stomach pouch that I just can’t stand. After my third child, I just could not get rid of this loose skin and fat that hangs below my belly button. Despite really watching what I eat and trying to exercise more, it won’t come off. It hasn’t budged at all in the past year. I think I may need some type of a tummy tuck. What is the difference between a mini- and a full tummy tuck?

A: Any form of a tummy tuck, also known as an abdominoplasty, removes skin and fat as well as tightens the rectus muscles. The removal of skin and the muscle tightening is what separates it from a liposuction procedure.

Most types of tummy tucks are horizontal full-thickness excisions of skin and fat down to the abdominal muscle wall. The difference between a mini- and a full tummy tuck is in the amount and location of this cut out. A mini-tummy tuck performs it below the belly button while a full  tummy tuck goes above the belly button. As a result, the full tummy tuck has a longer final scar as well as a circumferential scar around the ‘new’ belly button. The mini-tummy tuck just has a less long low horizontal scar only.

A patient’s decision between a mini- and full tummy tuck must consider a variety of factors. How long a scar can one tolerate? How much loose skin and fat does one have? Is there loose and creapy skin around the belly button? Are there any rolls of skin above the belly button? How flat does one want the stomach area to be?

The simplistic answer to deciding between a mini- and full tummy tuck is what the stomach looks like above the belly button. Only a full tummy tuck can smooth out loose skin and fat above that central abdominal marker.

Dr. Barry Eppley

Q: I have seen your chin osteotomy video on Youtube. I’m from Vietnam. May I have your advice? I really need it. I had my chin done about 6 weeks ago. My chin bone was cut and moved forward about 8mm and now I have 3 small pieces of stainless steel in my chin bone. (like small rings). My doctor says that it’s ok to have those stainless steel in my chin for the rest of my life. Is that right? And the sad thing is that I regret that I had my chin cut. In fact, I just wish I hadn’t had the surgery. Should I now have my chin bone moved back? Can everything be like it was before or would my chin just be weaker? Can I get rid of that stainless steel in my chin if I have my chin moved back to its place just like it was before?

A: I have never had the experience in my Indianapolis plastic surgery practice of a patient ever regretting having their chin bone moved forward. This is a completely avoidable concern by using computer imaging prior to surgery. The chin is one of the two (the nose is the other) most easily and accurately computer imaged areas of the face. You can know precisely before surgery what it will likely look like afterwards. I am assuming that the regret from this patient is that they do not like the ‘new look’. Maybe it is moved too far forward or maybe it shouldn’t have been done at all. This is clearly a preventable case of surgical remorse.

While today’s facial bone surgery uses very small titanium plates and screws, the use of stainless steel wire (rings) is historic and perfectly safe. The use of bone wiring is still done in many parts of the world due to its lower cost. There is no concern with them there nor should they ever need to be removed.

Just as the chin can be cut and brought forward, it can be brought back to where it once was. This is much easier and quicker than the original surgery. If that is what one wants to do, I would do it within three months of the original surgery since there is minimal bone healing at this point. Chin osteotomies usually take at least six months to become completely healed back together. The use of wires or plates does have to be done to hold the bone together so it heals properly. The key to moving the chin back is to tighten the mentalis muscle back together well. Since it has been stretched out and expanded, it needs to be shortened and tightened once the bone is moved back and set. If not, you will end up with soft tissue sag known as a witch’s chin deformity.

Dr. Barry Eppley

Q: I have numerous small lipomas on my forearms and legs. How effective is lipossolve on these?

A: Lipomas are benign fat tumors that develop for unknown reasons. It is common that one may eventually develop one or two lipomas over their lifetime. Usually they are small and can develop anywhere from the scalp down to the legs. I have never seen them in the hands or feet, probably because there is very little fat there. They are harmless but sometimes they can be uncomfortable. Rarely, a patient may present with multiple and newly developing lipomas at several different areas of the body. This is known as a condition of familial lipomatosis in which the patient will continue to develop many (dozens to hundreds of lipomas) throughout their lifetime.

Lipomas are easy to remove surgically and they can literally ‘pop out’ through a small incision. But they will leave a small scar from the incision and, at the least, require a local anesthetic for removal. Depending on where they are located and how big they are, they may require more than just a local anesthetic. If there is only one or two, then surgical removal is reasonable. When one has many, surgery becomes more arduous and less appealing. Liposuction is not an option for lipomas.

There is no proven or FDA-approved method of injectable lipoma treatment. The chemical concoction, known as Lipodissolve, has had widespread use for injectable fat reduction for cosmetic purposes over the past decade. Because it is intended for fat lipolysis (dissolving), it is no surprise that it has been reported to be used for the non-surgical treatment of lipomas. It is simple and quick to do and, in my limited experience of a handful of patients, has been effective. It may require more than one injection to make the lipoma go away but most of the time it will work. There will be the typical swelling of the injection site for a week or so after treatment.

Potential patients needs to understand that neither the solution or treatment method have ever been through formal FDA testing and evaluation. Reports of its use and effectiveness for lipomas are anectodal, not scientifically proven.

Dr. Barry Eppley

Q: I would like to know what the rate of satisfaction is amongst patients that have had chin osteotomies or chin implants when actually they should have had lower advancement jaw surgery? Are they happy with their appearance or do they feel their top teeth extend out too much when they smile?

A: The short answer is yes. But that answer needs a more detailed explanation. The key is proper patient selection and understanding that a chin implant or osteotomy for a mandibular deficient patient is a compromise operation. It is treating the symptoms of the problem and not the primary problem. In other words, one is camouflaging the real defect and accepting whatever (if any) functional problems that may exist.

The idea treatment for a mandibular deficient patient with a malocclusion (Class bite relationship where the lower teeth are behind the upper…an overbite) is orthognathic surgery. Specifically, a mandibular advancement osteotomy with preparatory and postoperative orthodontics. While this is a very effective operation, it requires a commitment of several years of orthodontics, an operation, and the risks of damage to the inferior alveolar nerve. (some permanent change in the feeling of the lip and chin) The decision for mandibular advancement surgery, therefore, should be based on one’s age and the degree of malocclusion. You must balance the risks vs the benefits like any surgery. If one is young with more than several millimeters of overbite, this should seriously be considered and even done. In patients who are older, often with even more significant overbites, the enthusiasm for this surgical effort is often not there. Camouflaging the jaw defect and getting a better profile and improved facial proportions through a simpler chin implant or osteotomy has a lot more appeal.

In my Indianapolis plastic surgery experience, I have never had any unhappiness amongst patients who has chosen the isolated chin route. Nor has it been reported to me that their upper teeth stick out too far when they smile.

Dr. Barry Eppley

Q :  Which is better for my laugh lines, Botox or fillers?

A: It is very common that Botox and injectable fillers are confused as to what they do. Because both are administered by a needle and are used in the face, many assume that they do similar things. In fact, they are quite different both in chemical composition and the effects that they create and in how they are used.

Botox works its magic by being a muscle weakening or paralyzing agent. It is primarily used in the forehead and around the eyes to decrease unwanted expressions caused by overactive muscles. As a result, Botox (and now Dysport) is really a ‘northern facial’ procedure. It effectively reduces horizontal forehead lines, furrows between the eyebrows, and crow’s feet around the eyes.

Injectable fillers (there are now over a dozen commercially available brands) work by adding instant volume to deep wrinkles and folds as well as enhancing the size of the lips. By adding a material under the skin or into the lips, the outer skin and lips is pushed outward. Injectable fillers are primarily used around the mouth making it a ‘southern facial’ procedure.

While there are crossover areas in the face where Botox and fillers are otherwise used, they are largely separated in application to these northern and southern hemispheres.

Folds around the mouth are commonly referred to as laugh lines. When one smiles, indentations or wrinkles are created beyond the sides of the mouth. They are different than the nasolabial folds which run from the side of the nose  to outside of the corners of the mouth which are situated above the laugh lines. Injectable fillers can be effective at softening one’s laugh lines.

Dr. Barry Eppley

Q: What is best way to build up an African-American nose that is short and small?

A: The overall shape of the African-American nose is often that of being broader and less projecting than that of a more Roman or aquiline nose shape. As a result, one of the key considerations in the rhinoplasty management of this nasal shape is to build up the bridge or dorsal line of the nose and improve tip projection and definition. Such an approach is most likely what is meant by having a nose that is ‘short and small’.

An type of augmentative rhinoplasty requires the addition of some form of graft or internal support structure to lift up the roof (skin) and reshape it. How much graft volume is needed determines the best way to do it. Each patient will be different in this regard. But this discussion always comes down to whether one wants to use a synthetic implant vs. cartilage.

The historic debate between allograft vs. autograft in rhinoplasty is an old one. Each has their own advantages and disadvantages with surgeon advocates on both sides. But the differences between the two are always the same. An implant is a lot easier to do (off-the-shelf) for both patient and surgeon and comes in a variety of ready-made shapes to create small or big ghraft needs. The price that is paid for this ease is the increased risks of infection and long-term implant extrusion and problems. Cartilage grafting is much harder to do, necessitates a donor site and require more surgical skill and experience to do well. But the risk of infection is much lower and there is no risk of any long-term extrusion or rejection problems.

Which is best must be determined with the patient through a thorough consultation and educational session. Both methods can be successful but the patient with the plastic surgeon must weigh the benefits and risks of each approach. When possible and acceptable, I prefer cartilage grafting because of its long-term benefits.

Dr. Barry Eppley

Q: I am interested in getting liposuction done on my stomach and flanks but am confused about the different types that I have read about. There appears to be regular liposuction, ultrasonic, laser, water jet…and and even something like ultrasonic done from the outside without surgery. Which type of liposuction is the best?

A: Liposuction has come a long way since its first introduction in the United States in 1981. It is a two-part process during surgery that involves the first phase of breaking up the fat and a second phase of removing or suctioning it out. All of the advancements in liposuction have come forth for the first phase, different methods to help loosen up the fat for evacuation.

One highly touted liposuction method that is neither new or novel is that of tumescence. This is an original advance in liposuction that began to be used in the mid-1980s and is part of every liposuction procedure today. Prior to doing phase one particulation, a special solution is first instilled that provides numbness to the treated area and helps cut down the extreme bleeding that would otherwise occur. This does make it possible for small areas of liposuction to be done under local anesthesia, but is also used even when you are going to sleep for the procedure.

Most of the advancements in liposuction that are highly marketed and promoted on the internet are relatively new. Whether one method really offers any improvement over the other has yet to be proven no matter what the endorsement and advertisement says. My current preference is for laser liposuction, branded as Smartlipo. We all know that fat is very sensitive to heat and can be melted as is observed during cooking. So the concept of heating up a treated area makes sense and is something that can really be felt during surgery. It is usually touted as also having skin tightening capabilities, and while I have observed that some of that does occur, it will not solve skin laxity problems where more than an inch of excess skin is present.

No matter what the tool that is being used, the most important element in getting good liposuction results is the experience and skill of the one holding the instrument or device. One of the real negatives to technology (and probably the only one) is that it enables those surgeons of lesser skill or training (and sometimes not a surgeon at all) to look equal to others of extraordinary experience and expertise.

At this time, I would be leary of any device that offers significant fat reduction through some method of external application. While the concept is harmless and certainly appealing, what you really risk is your money. If you are prepared to be dieting and exercising and doing everything to help lose weight anyway, then these device approaches may be reasonable. I suspect they do offer some benefit in the very weight loss conscious patient who is even more motivated by their economic investment. It is probably the ‘coach potatoes’ who make up the greatest percent of failed results with these devices.

Dr. Barry Eppley

Q :  I had gastric bypass surgery about six months ago and have already lost 65 lbs. At the pace I am going, I will reach my goal of 100 lbs within one year after surgery. While the weight loss is fantastic, the amount of loose hanging skin that has developed is disgusting. I want to get this loose skin removed as soon as I can. How soon once I reach my weight loss goal can I have plastic surgery?

A: It is understandable that most extreme weight loss patients want to enjoy the benefits from their efforts as soon as possible. While the weight loss is the first step, most patients will require some skin removal through a second stage body contouring surgery to really see the body that they had hoped for.

Despite the enthusiasm of pressing forward as soon as possible, it is important to wait until some point after you have reached your weight loss goal. Your body needs time to recover and adjust to the new weight. This also allows you to learn new eating habits that will help keep the weight off but also have you become more nutritionally sound.

Body contouring surgery places major stress on one’s body and requires a lot of nutrients and energy to heal properly. You also want your immune function to be functioning as best as possible. In short, you don’t want to be malnourished going into major surgery. It has been that many post-bariatric surgery patients have protein-calorie malnutrition as well as various vitamins and mineral deficiencies.

While there is no standard waiting period after bariatric surgery, it is best that one have a stable weight for at least three months before considering elective body contouring surgery. Patients who have had gastric bypass, due to intestinal absorption changes, aren’t usually ready for body contouring surgery for six months or more afterwards. Lapband patients lose weight at a much slower rate and it may be much longer than a year after their procedure before they are ready. Extreme weight loss patients who have done it on their own without surgery can be done sooner because their intestinal absorption of nutrients has not been altered.

Dr. Barry Eppley

Q: I have one breast that is quite a bit larger than the other one. I am way too embarrassed to wear a bathing suit or even go out with men for more than a couple of weeks. (I don’t let my relationships, go to the next level so to speak, in fear that the guy will totally freak out and embarrass me even more if that is possible because I already feel pretty bad about myself!) Anyway I was wondering if you could enlarge just one of my breasts?

A: While few women have breasts that are perfectly symmetric, congenital or developmental breast asymmetry is another matter. In this condition, one breast is significantly larger than the other often by several cup sizes. In its most severe form, there is a medical condition known as Poland’s syndrome where the breast and the underlying chest muscles on one side fail to develop much at all.

All forms of breast asymmetry can be significantly improved through modern breast surgery methods. In some cases, the smaller breast may be merely enlarged by the placement of a breast implant. In other cases, differential enlargement of the breasts will different implants sizes may be better.

Often times, however, the differences between the breasts is more than just that of volume. The larger or more normal breast will have more skin and a different size and position of the nipple on the breast mound. Optimal correction may require adjustment of the more normal breast as well through a lift or nipple elevation.

 Dr. Barry Eppley

Q :  I am interested in getting breast implants. I have been saving for years and am so excited to be close to actually getting it done. One worry I have is about the time to recover.  I can’t be out of work too long. I have read from some doctor’s advertisements that it can be done with no recovery whatsoever. Is that true? How can that be possible since it is surgery?

A: Breast augmentation is definitely real surgery. While it is a cosmetic operation, it does involve lifting up your main chest muscle (pectoralis) to insert the implant underneath it. Lifting up any muscle in the body is not pain-free and does involve some recovery.

There has been a general change amongst many plastic surgeons over the past decade about what to do after breast implant surgery. In the past, there was the belief that restricting any motion of the arms and chest muscles improves healing around the implant and helps control discomfort. There has been a 180 degree change in recovery philosophy with the recognition that the fastest way to recover from a ‘pulled muscle’ is to use it rather than restrict it.

As a result, contemporary recovery techniques after breast augmentation use an aggressive physical therapy approach. Early and frequent arm range of motion and a ‘get up and go’ approach is now used. Pain medications are either not used or restricted and one begins immediate use of non-narcotic anti-inflammatory medications. From a marketing standpoint, these have become known as ‘no recovery’, ‘rapid recovery’ or ‘easy aug’ breast augmentation methods. Suggesting that there is no recovery is a bit overstated but it is certainly much easier than it used to be.

It is certainly possible today to be sufficiently recovered after breast implants to be back at a non-physical job within a few days. A heavier labor position may take a one week or two to have sufficient recovery to work unrestricted and relatively pain-free.

Dr. Barry Eppley

Q : I would like my brow bones reduced. I am now 20 and until about 12 years old my brow areas looked normal as best as I can remember. Since then they have continued to grow, or at least seemed to, to the point that I look like a Cro-Magnon man. My parents took me to get evaluated by an endocrinologist around age 14 or 15 to see if there was some reason and to make sure I did not have acromegaly or some other hormone problem. Those tests were normal. I feel like a freak with the way I look. How is this surgery done?

A: Prominent brows are not due to excessive bone growth of the forehead per se. Rather it is due to the overdevelopment or pneumatization of the frontal sinuses. The frontal sinus is an air-filled space between the inner and outer bone surfaces of the forehead brow bone. They empty into the lower portion of the nose through long ducts. Sometimes they exist as two separate cavities above each brow. Other  times, they connect across the middle and are just one big frontal sinus.

The frontal sinuses do not even begin to develop until age 8 or older. They do not stop forming until well after puberty. When the airspace gets too big, it causes the bone on the outer side of the sinus to bulge out. Why some people’s brows remain flat and others ’overdevelop’ is not known. While there can be a medical reason, such as a pituitary tumor, most cases are idiopathic. (they just happen for no apparent reason)

Brow bone reduction surgery involves taking off the bulging outer plate of bone and reshaping it. During the operation, the cavity of the frontal sinus is widely exposed and the reshaped outer plate of bone is put back with tiny plates and screws. While this sounds like a gruesome operation, it is not. In many ways, it is a glorified brow lift using the same scalp incisional approach. It is the same operation as a frontal sinus fracture repair.

The sticky issue for men is the need to create a fine line scalp scar behind the frontal hairline. Based on hairlines and density, this may be a concern for some men.

Dr. Barry Eppley

Q : I am interested in scar revision. I have had three hair restoration procedures and this has now left me with a very wide donor scar that is quite noticeable on the back of my head.

A: Hair restoration, also known as hair transplantation, is a true ‘robbing Peter to pay Paul’ type of surgery. Hair grafts are harvested in a horizontal excision pattern in the lower portion of the occipital scalp. (back of the head) The donor site is brought back together so that the scar, hopefully, is just a fine line that can not be easily found in the remaining scalp hair.

Harvesting scalp skin (and hair) is quite easy and the donor scar usually looks quite good since the scalp is very flexible and comes together without much tension. Since most hair transplants require more than one session to get the maximal hair density, this same donor site must be used consecutively. The scar will usually stay quite narrow even after the second time of graft harvesting but the scalp closure is definitely tighter.

The third scalp harvest, which is often not advised and even done, will likely run into a wider donor scar problem. One of the most important contributors to how all scars will eventually look is tension. The tighter the closure, the more likely the scar will end up being wide. Tension wins over time and it relieves itself through widening of what is an initially narrow-looking scar. Also contributing to the scar widening is the inavoidable horizontal orientation of the scar which is repeatedly pulled downward with neck flexion.

Wide occipital scalp scars can almost always be improved by excisional scar revision. Unlike the donor harvests, however, the skin is closed with the aid of significant tissue undermining at the galeal plane level. This helps reduce the tension on what would otherwise be a very tight skin closure. In addition, I have occasionally incorporated a geometric skin closure pattern with a running w-plasty series. The interdigitating limbs of skin closure are another method to change the tension lines on the skin closure.   

Dr. Barry Eppley

Q: Can facial implants help to fill in a cheek region, where collagen injections have been beneficial? I have a large depressed scar from dermabrasion and laser treatments on an acne scarred region of my face. I would be glad to email pictures of the region to assist in the answer. 

A: Facial implants work by pushing out from the underlying bone on the overlying soft tissue. This how they create more highlights or volume to specific facial bony prominences. While a facial implant can be placed anywhere on the facial bones, they work best on convex or flat surfaces such as the chin, cheeks, and jaw angles.

The treatment of most depressed scars would be either some form of surgical scar revision (cut out and re-closure) or skin resurfacing. In some select cases, such as yours, actually filling in the underlying soft tissue helps flatten the outer appearance of the scarred area. Injectable fillers can work well for that type of depressed scar but they are not permanent and must be repeated.

You have correctly pointed a very uncommon but potentially beneficial approach to depressed cheek scars. Having proven that soft tissue expansion makes the scar look better, it is insightful to ask about whether a cheek implant can create the same effect. Since the cheek bone is convex, an implant will definitely push outward on the skin, helping flatten a depressed scar. I have done such an approach twice in my Indianapolis plastic surgery practice and it can work well as you have surmised.

The key to the successful use of an implant for a depressed cheek scar is two-fold. The acne or traumatic scars must be directly over the prominence of the cheekbone to get the most benefit from the underlying push of the implant. And you must consider the opposite cheek prominence as well from the perspective of balance. (one-sided or both sides for cheek augmentation)

Dr. Barry Eppley

Q: When I was younger, around 14 years old, I was punched on the left side of my cheek which caused my left side (cheekbone) to be larger than my right side. I did not notice this until my ex-g/f, then current, informed me of this. It’s maybe 4 to 6mms bigger than the right side. I didn’t get it fixed since I didn’t realize there was a problem until the bones had already repaired itself. I suspect a lot of it is bone growth making my cheekbone larger. Could you tell me if this is possible to fix?

A: This is an unusual reaction to a traumatic facial injury. Usually the cheekbone would have gotten fractured causing the opposite problem long-term, cheek indentation or flattening. The observation that it got bigger would indicate that an actual fracture of the bone did not occur.

It is more likely that you sustained a traumatic hematoma (blood collection) to the tissues. This could result in either extra bone being deposited on the outer surface of the cheekbone (appositional bone development with blood as the stimulant which could happen in a growing bone such as a teenager) or scar tissue which has thickened the soft tissue.

The question is how do you make that determination as to which it is? A plain x-ray (Water’s view) would be a simple and useful diagnostic test. Or you could just treat the problem the only way you can which is cheekbone reduction. Even if it is soft tissue thickening, bone reduction would still be the treatment method. Through an incision inside the mouth, the outer surface of the cheekbone would be burred down. If the difference was greater, a cheekbone reduction osteotomy could be done. But for 5mms or less, simple outer cortical burring of the cheekbone is the best way to go. Because it is done through the mouth, there would be no scarring and just a temporary period (four to six weeks) before you would see the final result,.

Dr. Barry Eppley