Your Questions

Q: Dr. Eppley, I am interested in getting my nose built up. I think it is too small. I really don’t want to have a rib graft taken so I am looking at synthetic implants. I am trying to decide between a Voloshin and a Shirakabe nasal implant. Does a Voloshin or Shirakabe implant give a more streamlined appearance? Which implant enhances the nasal tip more? Is the Shirakabe Nasal tip too narrow? Secondly,what is the purpose behind using the Brink Peri-Pyriform Implant in rhinoplasty?

A: The fundamental difference in the Shirakabe nasal implant from that of the Voloshin is that it provides some augmentation to the base of the nose. But that is irrelevant if one is going to have a peri-pyriform (premaxillary) implant. The Shirakabe tip is a morenarrow, particularly across the tip, compared to the Voloshin. One thing you have to be very careful of is to not make the entire nasal tip cartilages (dome) completely covered by the implant. While one can get away with big sizes in facial implants that are covered by muscle, the risk for implant problems (infection, extrusion) that are covered just by skin (such as the nose) is not so foregiving. So I would not get hung up in trying to give the nasal tip too much projection with an implant. That places the skin under tension and is a setup for the aforementioned problems. If one wants to push the envelope of size and tissue tension in the nose, it is far better and less risky to do this with a rib graft. 

The purpose of the peri-pyriform (premaxillary) implant in rhinoplasty is to build out the base of the nose in cases of midface deficiency and a smaller nose. This opens up the nasolabial angle, increases the fullness of the upper lip and pushes out the base of the nostrils. This in effect creates a pulling out of the nasal base.

Dr. Barry Eppley

Indianapolis, Indiana

Botox is commonly recognized as an injection treatment to either turn back or slow down the hands of time. By reducing the wrinkle lines of the forehead and around the eyes, a more relaxed and often a less scowling appearance is achieved. But the use of Botox continues to find new medical problems for which it is effective. Allergan, Botox’a manufacturer, is already a multibillion company which continues to experience record revenue and earnings growth.

The newest FDA-approved indication is in the treatment of migraines. Approved last year it works for migraines just like it does for wrinkles, by relaxing muscles. But it is injected around those nerves in the head which are being squeezed by muscles and thus serve as the trigger for the migraine headache. These are commonly in the eyebrow, temple and at the base of the skull in the back of the head. For some patients the temporary relief is a near-miracle which will last about four months. Botox in migraines is also a test which proves that doing surgery by removing this muscle around the nerve can have a more permanent effect.

Botox has long been approved for halting severe underarm sweating, an embarrassing condition known as hyperhidrosis. This disorder causes so much perspiration that some sufferers are forced to carry several changes of clothing to make it through the day. The excessive sweating is caused by over stimulation of the sweat glands by the nerves of the autonomic system. Botox interferes with the nerves responsible for this drenching. It has a similar benefit to those who also suffer excessive sweating in the palm of their hands. (palmar hidrosis)

Botox is effective for cervical dystonia, a condition that causes the neck to twitch, twist, and go though repetitive movements and carry the head in abnormal postures. This happens because of involuntary muscle contractions which the injections directly weaken. It is similarly effective in cerebral palsy in which patients have stiff spastic arms and legs caused by abnormal signals from the brain to the muscles. Botox interrupts this communication between the nerves and the spinal cord which then causes the muscles to relax.

Overactive bladders are also benefiting by these injections. Caused by muscle spasms of the bladder muscles, urinary incontinence can make it difficult for some patients to undergo even short car trips. Some patients end up wearing  adult diapers. Botox overcomes bladder incontinence by weakening or paralyzing those muscles which contract inappropriately and squeeze out the urine involuntarily.

Botox can also stop chronic pelvic pain which can make it difficult to have sexual intercourse or undergo an examination or a pap smear test. This type of pelvic pain is caused by tight over-contracted pelvic muscles.

While often perceived as a drug of beauty, the many medical benefits of Botox makes its few precious drops life-changing for more just a better look in the mirror.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to have a chin implant to add length to the lower half of my face. However, I am 21 years old and have partially erupted wisdom teeth that I have neglected to have removed for several years. Is it necessary to have them removed before getting a chin implant?

A: The only thing that a chin implant and wisdom teeth have in common is that both occur on the mandible or the lower jaw. But beyond being on the same bone, there is no correlation between the two. The wisdom teeth or third molars are located at the junction of the body and ramus of the mandible at the back. A chin implant is done on the symphysis or front part of the lower jaw. One does not affect the other. However, if you need both done it would be most convenient that they are done during the same surgery. I have done that combination numerous times. The key to this surgical ‘opportunity’ is to find a surgeon who is qualified to perform both procedures.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have suffered an accident to my lip. I cut my lip pretty deep and it resulted in the need for stitches. The cut is not that big, however, it’s been 3 weeks and its healed fine apart from a little bumpy scar tissue. It’s the same color as my lip and slightly raised. Do you think this is a scar or is it still healing? I have been applying Vitamin E twice a day and massaging it. It’s quite a new scar so is there anything I can do to minimize the appearance and do you think I’ll be permanently scarred? Please help Thank you.

A: All incisions and lacerations will leave a permanent scar, it is just a question of how significant it will be. Any laceration that is deep enough to require stitches has entered or passed the dermis of the skin. That is going to evoke an inflammatory response and collagen production to heal the wound. Collagen production equates to the formation of scar tissue. Many factors affect whether that scar will be particularly noticeable or not. Fortunately on the lip, most lacerations run parallel to or along one of the visible lines or grooves of the vermilion of the lip. This is the most favorable location for the least amount of scarring on the lip.

Because collagen and scar production is in full swing during the first month after the injury, the lip scar will become both firm and usually raised. It will require many months until this scar tissue relaxes so one can not predict what you are currently seeing will be like that six months from now. While there is nothing wrong with applying Vitamin E and massaging it, you are trying to treat a natural healing process. Quite frankly, these maneuvers are more psychotherapy than making any real difference in the scar outcome. Time is the best scar therapy on the lip. If it seems to be a persistent problem after six months, then I would consult with a plastic surgeon about possible scar revision.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m trying to remove my cauliflower ear in which I been having for years. Can it really be improved in the way the ear looks and how is it done?

A: The well known cauliflower ear, in appearance much like the vegetable plant, is the result of ear trauma. Specifically it is the production of cartilage as a response to its covering, known as the perichondium, being sheared off from its underlying cartilage. Ear cartilage is an avascular tissue that receives its blood supply and nutrition from its enveloping perichondrium. When it gets torn away from the cartilage, it bleeds and creates a blood clot between the two. This serves as a stimulus for the cartilage to grow and eventually replace the space where the blood was. Since the ear’s shape (with the exception of the earlobe) is determined by the shape of the cartilage, the traumatized ear becomes deformed in appearance.

Surgical treatment of the cauliflower ear is done by removing a flap of skin over the deformed area, shaving down and reshaping the cartilage, and then putting the skin flap back in place. The key to the success of the procedure us two-fold. First the skin flap over the deformed ear part must be raised in such a way that its blood supply is not destroyed and skin necrosis results afterwards. Secondly, the skin must be held into place with intimate contact to the cartilage after it is reshaped so blood does not form between the two and re-create the original problem. This form of ear reconstruction is done as an outpatient procedure under anesthesia.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would love to know how to book appointments for people outside the U.S. I plan to come to the U.S. and have some work done. Can a consult be done without actually having to visit you first? I obviously want to minimize my travel due to the cost and my work schedule. Thanks.

A: Thank you for your inquiry. I have many patients that come from all over the world so plastic surgery consultations are done by numerous convenient methods. Usually we start by having the patient send some photos of their concerns. Then we can consult by phone or Skype video to discuss their concerns and treatment options. Much can be accomplished by this form of  indirect consultation as almost everything in plastic surgery is visible to the eye. If one develops confidence and is comfortable, a surgery date and all the details involved can be done from afar. The patient then arrives the day before surgery where an actual hands on consultation is done to review and/or modify the next day’s surgical plan. Surgery is done (e.g., sutures and any dressings) to try and ensure that the patient does not have to return for any regular follow-up care. Any postoperative concerns or questions can be handled similarly by sending photos and discussing by phone or Skype.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting rid of my sagging jowls and neck. Do you think Thermage or radiofrequency treatments would work? If not, would you recommend a lifestyle lift or a mini lift? What about laser tightening for face & neck vs these lifts?

A: While I have never seen what you look like, I can only speculate about your neck and jowl concerns. However, almost any patient that I have ever seen with a sagging jawline and neck rarely would benefit significantly by any non-surgical or non-invasive treatment method. By and large, the use of non-surgical methods of neck and jowl improvement produce very minimal benefits and most patients would consider them unsatisfactory. They are best used when the patient has a very minimal problem or when the patient is fairly young with just the very beginning of any sagging. Most certainly, what often is paid for the hope of some of these non-surgical methods would have been better invested in a surgical solution. In short, any non-surgical method of jowl and neck tightening does not compare to the results achieved by more conventional surgical techniques.

There is no difference between a Lifestyle Lift, minilift or any other branded and marketing name for an operation that has been around for decades…a reduced version of a facelift. 

It is understandable why patients seek anything but surgery for their aging concerns of their lower face, but they often end up chasing a solution that does not exist…and waste money along the way.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am a former patient of Dr. Eppley. I had buccal fat removal and love my results… however, I am still interested in having facial liposuction to sculpt my cheeks out a bit. I am wondering if he can do this and this is possible.

A: The removal of the buccal fat pads is the largest fat depot that can be surgically removed on the face aside from the neck. Its removal creates a slimming change in but one region of the face, the submalar region or the area right below the cheek bones. There are no other distinct or encapsulated fat areas to remove on the face. The rest and majority of facial fat is located in the subcutaneous level or right under the skin. This is much more difficult to remove and can only be addressed by small cannula liposuction. Many such facial fat areas are not even treatable by liposuction.

When patients seek a slimming effect of the face, they often are referring to the side of the face from the cheeks down to the jaw line. This leaves a lot of facial areas beyond the submalar or buccal fat region. Most of these areas can be treated by liposuction if done carefully and not done too deep. The buccal branches of the facial nerve lie on top of the muscle layer just underneath and injury to them should obviously be avodied. The question is not whether it can be done, but whether any significant change can be achieved. In general you can not make a wholesale facial slimming change by facial liposuction but small discrete areas may be able to be improved.    

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have chin scar which is still new and is about 3 months old. I got it falling off a skateboard falling onto asphalt. It is in the central and lower area of my chin and is slightly indented I am uncertain as to exactly what to do. I hope it does not stay this way as it heals further. I have attached some pictures of it for your advice? Is there going to be a substantial improvement in the way it looks in the next few months? I am worried about the indentation and the whitish color of the scar line. I appreciate any advice you can give.

A:  Thank you for sending your pictures which show the chin scar well. As scars heal there are certain features which will improve with time and others that won’t. Scar redness and a feeling of firmness are the main features that will improve with time. A raised scar is also a scar feature that can settle down and get flat as it matures. The two features that won’t improve significantly with time are scar width and depression or indentation. Scars over bony facial prominences, such as the chin and cheeks, often end up indented as fatty tissue is lost underneath it from the trauma of the injury. When combined with scar contracture/tightening as it heals, the scar can seem like it is being pulled inward. 

In looking at your scar, although it is still early, the width of the scar and its indentation suggest that it may not improve greatly as it heals. I would give it the benefit of some more time. But if you see no substantial change in the next few months, then I would consider early scar revision. The good news is that the scar width and indentation can be significantly improved by scar revision techniques.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dear Dr. Eppley, I am interested in getting jaw surgery for my sleep apnea. My lower jaw is short and my doctor tells me it is a likely cause of my sleep problems. I had a chin implant put in several years ago which made it look so much better but now I am interested in getting the whole jaw moved forward. I know that orthodontics will be be needed before the surgery. The orthodontist said a year of braces would be required and that he estimated 5 mm of advancement would be possible. He also said it was uncertain whether the advancement would open my airway, but the first surgeon I meet with seemed more optimistic. I was going to attempt the surgery anyway because it would be nice to fix the malocclusion even if the apneas do not completely disappear. Do you ever advance the upper jaw along with the lower to increase the total advancement? Breaking my upper jaw along with the lower does not sound pleasant, but I obviously want the surgery to work.

A: The causes of sleep apnea are numerous and a short lower jaw is but one of them. In cases of a really significant mandibular deficiency, such as 8 or 10mms, it would be fair to say that jaw advancement has a very high probability of reducing some of the symptoms of sleep apnea. Since yours is only about 5mms, I would not be as optimistic. It is true that upper and lower jaw advancements (bimaxillary surgery) would allow the lower jaw to be moved forward much further. (probably 10mms in your case) But you have to look at the impact of that procedure on your facial aesthetics as you don’t want to trade off one problem for another, even if it just is an aesthetic one. Another option with your mandibular advancement is to remove the chin implant and do a bony genioplasty advancement at the same time. This would not only maintain your jawline and facial profile aesthetics but doubles your changes of just lower jaw surgery alone helping your sleep apnea. As the chin comes forward, it brings the genioglossus muscle and tongue forward as well. As the jaw advancement has a similar effect, the synergism of the two procedures might just be what would significantly improve your sleep apnea.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a very short forehead and really want it to be longer. (more skin) But I have been told that a browlift will also make my brows lift up as well as lengthen my forehead which I don’t want. I have read about the use of tissue expanders to make more skin. Do you think the use of tissue expansion is too invasive for someone with a  short forehead?

A:  The issue with forehead tissue expansion is not whether it is more invasive as it does not involve much more tissue dissection than any form of a browlift. The question is whether it is worth the effort. It is a two stage process with the first procedure being the placement of a tissue expander and a second stage about 6 to 8 weeks later for removal and the retropositioning of the frontal hairline. So it becomes two operations…neither are very complex or extensive nor is recovery difficult or extended. Then there is the intervening interval between the two when the inflation of the tissue expander occurs. Once a week saline injections are done to gradually stretch out the upper forehead. Patients often do this on their own. Through this tissue expansion phase, it will become obvious that there is a bulge in the forehead, so this is a socially awkward period. As you can see from this description, one has to be fairly motivated to be willing to go with this effort. But tissue expansion works really well anywhere on the skull or forehead because it is pushing off of a solid platform underneath. (bone)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to see if it is possible to improve 3 areas around my chin. The areas I want to improve are my jawline. I would like it better defined. I would also like to create a better angle on neck underneath the chin for better profile. I would also like to create better balance and harmony on my chin. Maybe lengthen it to try and release some of the mental crease. I’m not quite sure what will work. It’s a pretty deep crease. I was born with it. Feels like a huge step below my lower lip. I have attached a front and side view of me for you to see what I mean.

A:  What you have is a classic issue of an overall short lower jaw. Your lower jaw is short in both horizontal and vertical dimensions which is most manifest in the chin area. While I can not see your occlusion (bite), I suspect it is a Class II malocclusion where your lower teeth are somewhat behind your upper teeth and do not meet in an edge-to-edge fashion. That is also why you have a deep labiomental crease. The lower lip is not well supported by the retropositioned lower teeth so the crease deepens while the lower lip rolls forward. What you need for correction is a vertical lengthening chin osteotomy that also brings the entire chin bone forward. I would estimate that it must be vertically lengthened by 8mm and brought forward 10mms. A hydroxyapatite block needs to be added to the step-off in the osteotomy to help build out the labiomental crease or at least prevent it from becoming even deeper. Lengthening the chin will actually help soften the depth of the crease as it pulls the soft tissue of the lower chin down and forward.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hello, I was reading the article on the knee liposuction procedure that you do. I had liposuction in the knee area and now I have an actual fold of skin over the right knee. Is there anything that can be done? It is not fat but actual skin that hangs over the knee. Thank you so much for your response. I need to get something done because it is so ugly!!!

A: Liposuction in the knees can be one of the most satisfying body areas to treat. However, this is primarily in the medial or inside area of the knee. The skin retracts very well on the inside of the knee so few contour deformities arise with the elimination of the inner knee bulge. Many patients also have a fullness across the top of the knee, known as the suprapatellar region. While liposuction can be done in this area with good fat removal, it can result in an unflattering roll of skin. This is because the skin across the knee must be very flexible to allow for knee extension and, most importantly, knee flexion. (bending) This skin ‘excess’ is hidden when the knee is fuller but becomes unmasked when it’s volume is deflated. Improvement of this suprapatellar fold of skin is very difficult. The absolute cure is skin fold excision but the resulting scar is unacceptable with significant widening and an aesthetic outcome that might be worse than the original problem. The only reasonable treatment option is additional small cannula liposuction into and above the skin fold to try and get it flatter. The success of that approach is one of some improvement but no absolute cure.

Barry Eppley

Indianapolis, Indiana

Q: Dear Dr. Eppley,  I have seen on your website you are very experienced with scars and would very much appreciate your opinion please. I incurred an injury to my upper lip which caused the lip to split open and require stitches. The scar remaining, now 2 years old, is within the attached picture. It appears to have 3 elements: the line which is indented, discolouration of the red part of the lip and the bump on the lip. The bump on the lip is the element which is concerning me most in terms of my appearance. Is there anything I can do to improve this such as massage or oils? Is surgery the only remedy?

A: What you have is a classic lip vermilion scar. The edges are mismatched which creates the bump and the indentation. This is very similar to a cleft lip scar after a primary repair which I have seen many times. Given that it is two years old, it is a mature scar. Therefore, no external treatment methods will be successful like massage or even injectable steroids. To get improvement, you need a scar revision. The scar must be excised and the vermilion realigned and leveled by suturing. This can be done as a fairly simple procedure done under local or IV sedation, whichever makes you the most comfortable. I would expect good improvement as the scar is oriented parallel to the natural lip lines of the vermilion…which is always a good sign for a favorable lip scar revision outcome.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have clubfeet and even with exercise, my calfs are still smaller than my forearms. Would calf implants make a difference in their appearance? Also I have really good insurance, would I be able to use it for a procedure like this?

A: Your questions are two-fold; 1) Will calf implants improve the appearance of your calfs, and 2) will insurance pay for it? While calf implants can improve the size of one’s calfs, the person born with congenital calf hypoplasia (clubfeet) poses a unique problem. The skin over and around the calfs is very tight as the muscle never fully developed. This ‘shortness’ of skin limits the size of calf implants that can be safely placed. It also makes it very difficult, if not impossible, to get subfascial placement so the implant will lie completely in the subcutaneous fat space. Secondly, insurance will not pay for calf implants because they do not provide any functional medical benefit, such as improved range of motion, more calf strength, etc. Since only appearance is improved, the procedure will be deemed cosmetic in nature.You may feel free to send me some pictures of calfs for my assessment. Please send them directly to me at the following address:

beppley@ologymd.com

I shall look forward to receiving them and giving you my recommendations.

Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want to get implants for my saggy breasts. I want them to be at least a full C, maybe a D cup. My breasts also sag but I think implants will take care of the problem. What do you think? I have attached some photos for you to see what they look like.

A: Thank you for sending your photos for review. While it is clear that you have had near complete breast involution (breast tissue shrinking) and would benefit by the substantial addition of volume (implants), you also have a significant breast sagging issue. You can not achieve your desired results unless a vertical breast lift is done at the same time as implant placement. Contrary to the perception of many patients, breast implants will not cause any significant lifting effect. Rather they will take the breast tissue the way it lies and make the breast much bigger but have the nipple and the existing breast tissue hanging off of the bottom of the implant. This is not likely the look you are after.

The key to knowing whether a breast lift is needed at the time of augmentation is the determination of where the nipple and any breast tissue hang relative to the level of the lower breast crease. (inframammary fold) If the nipple and any breast tissue is at or below the lower breast crease, some type of breast lift will be needed. Your photos show that, not only the nipple, but at least half of your breast tissue and skin is at or below the breast crease.

There are different types of breast lifts but I think you would do well with one in which the scar goes around the nipple and down to the lower breast crease. (hence the name, vertical breast lift) Your nipple needs to move up several inches so that it can be centered around a substantially enlarged breast mound.

Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am serious about getting a bullhorn lip lift. I am a model and, although I am considered very attractive, I do not feel my mouth area looks the best. My lips are reasonably full but my upper lip is too long and I don’t show any teeth even when I smile. That is why I think a lip lift would enhance my appearance. I have attached some modeling photos for you to see what I mean. What do you think?

A: Thank you for sending your excellent photos. While you do have a very nice shape to your upper lip, I can see your concerns that it is vertically too long between the base of the nose and the upper lip vermilion. I think you would be a good candidate for the subnasal lip lift as it would decrease this vertical skin distance, give more pout to the central cupid’s bow portion of the upper lip, and has a chance of increasing some tooth exposure between the canines.

This is an office procedure done under local anesthesia. (infraorbital nerve blocks and direct infiltration into the base of the nose) The key is to have a wavy excisional pattern for the lift so the scar blends in along the base of the nose. As an out of town patient, I would use tiny dissolveable sutures for the final skin closure so no postoperative visit is necessary. There is always about a 20% to 30% relapse of the lip lift over the first six months after the procedure so it is a little ‘over-corrected’ in the beginning to compensate for that event. However, it is very important to never remove too much lip skin as there is no way to reverse that problem. You can always take more if needed so undercorrection is always better than overcorrection.

Barry Eppley

Indianapolis, Indiana

Q: I read your blog on plastic surgery after a large amount of weight loss. I’m pretty sure that you broke my heart, but I’m glad you wrote the reality. I am so completely disappointed. I joined a sight that said men donate to women like me for breast lift and breast augmentation surgeries. I now know that it’s hopeless. I am on disability and have no way to pay for these procedures. It would take me many years to save for the procedures I need desperately. I only wish that if medicaid or medicare could understand that these procedures are needed and not just for cosmetic reasons. Having low self esteem, a feeling of complete hopelessness, depression, and anxiety are all factors they should consider too. I really hoped that when I lost most of my weight that I would once again be nice looking. I used to weigh almost 280 pounds and I am now 145 pounds. It did not make one bit of difference because now I have sags and hanging skin. I would do anything to look good and feel confident again. Thank you for sharing your wisdom. Please remind people who can and do succeed with their procedures that they are lucky and truely blessed.

A: The unfortunate reality is that cosmetic surgery is not free nor are any health insurances going to pay for elective body contouring surgeries. This is of great disappointment to many massive weight loss patients that understandably feel that their loose hanging skin poses many physical as well as psychological problems. Even in the few body contouring procedures that some insurances may cover, such as a panniculectomy, plastic surgeons are very hesitant to do them because the reimbursements are so low, they take a lot of work with potential complications and there are always medico-legal risks and exposure.   

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dear Dr. Eppley, I have a question about cheek and orbital rim implants. I have fairly wide cheek bones that I am considering reducing via osteotomy, but the frontal cheek area directly beneath my eyes seems deficient. Are there cheek implants (or fillers) that can push out this area under the eye (a slightly near the transition of the nose)? Can the results of such cheekbone implants make a wide/flat face look less wide and more defined? Also, does cheekbone reduction cause sagging skin/prejowl?

I have fairly large eyebrow ridges, which I am generally happy about, but the ridge area close to my radix is deficient compared to the prominent ridge area near my temples (I think it pushes my eyebrows up vertically near the side of the temples). Is there a way to augment the area near the radix so that it more smoothly matches the rest of my eyebrow ridge? Would the only way to do this be to have an open-scalp incision? What would be the complications of such a procedure?

A: It is common in wide cheek or zygomatic widths to have anterior infraorbital rim deficiency. This is part of the wide midface look. There are specific infraorbital-malar implants that augment this area exclusively. They come in a variety of styles and sizes although my preference is to custom carve implants out of a Gore-tex block at the time of surgery, particularly when the amount of rim/tear trough augmentation is small.

I don’t know if you would call a combined cheekbone reduction with infraorbital rim implants making the face more defined. But it will change its shape and proportions acroos the midface area to look less wide. Calling it increased facial definition is a stretch.

Building up the radic of the nose can be done with either injectable fillers or fat for a minimal or non-invasive approach or can it be bult up with either a very small implant or cartilage from an intranasal approach. A scalp incision would never be needed.

Dr. Barry Eppley

Indianapolis, Indiana

Q:I had a combined breast augmentation with a lift about 3 weeks ago. It seems like my implant on the left side is below my breast. It has been like that from the beginning so I should have asked the doctor aboutthat when I last saw him. I was just wondering if it is like that because of swelling still or is it going to stay like that. I know it has only been 3 weeks and my doctor said you really can’t critique it for 3 months, so I’m not overly concerned just wondering about it. Maybe my left one required more work, it’s still a little bruised. I didn’t know if I should try to do something to push it up? I guess I was wondering if this is normal. I probably wouldn’t think as much about it if both of my breasts did the same thing. I have attached some pictures for you to see.

A: Based on the pictures, the left breast implant is below your original inframmary fold of which some of that crease still exists. It is often necessary to lower an inframammary crease, particularly in cases where there is breast asymmetry. I would suspect that your original left breast was smaller with a higher imframammary fold prior to surgery. This made it necessary to achieve better symmetry during surgery by lowering the crease on that side so the implant will match better with the original larger right breast. This is an issue in which more time is going to be needed to see how the whole breast shapes out over time. Combined breast augmentation with lifts are always more complicated than when implants are placed alone, particularly when there is significant prior differences between the the breast mounds and the level of the inframammary folds. I think it would be alright now to begin wearing an underwire to give that left breast better support as healing progresses.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in breast augmentation. I want to get bigger fuller breasts, preferably a full C cup. I am attaching some pictures of my breasts for imaging to see how I would look.

A: Thank you for sending your pictures. While I can see why you desire breast augmentation, you appear also to have some significant breast sagging. That is partially camouflaged because you have your arms raised. That makes the breasts look less saggy than they actually are. You need to send me some additional pictures with your arms down at your side with a view from not only the front but also from the side. This is important because I suspect you will need some form of a breast lift with your implants, even if it is just a nipple or circumareolar type lift.

Trying to computer image breasts in an effort to see what final size a patient wants is interesting and even entertaining, but not really valuable from a surgical planning standpoint. It is fraught with distortion problems and ideally requires a small breast with a centrally located nipple with no breast sagging. In trying to help your plastic surgeon choose your desired breast size, it is just as helpful if not more so to show images of other breast augmentation results that have the desired breast size look. Choosing breast size is really about getting a look, not necessarily a specific cup size or implant volume.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley. I have a rhinoplasty with a silicone implant several years ago. It has had to undergo several subsequent revisions where it was shaved down to get it to look right. I am now at the point with it that I just want to get rid of it. Iwas told that it would be very difficult if not impossible to remove now by surgery because it would be ingrown into the surrounding nasal tissues. Is it possible to remove the remaining silicone implant by melting it?

A: The answer to your question is no…nor would you want to. As a chemical element at 14 on the periodic table, it has a very high melting point at around 1400 C. That number is when it is in a very solid form. As a facial implant, silicone is not as well polymerized so its melting point is lower. But regardless of its melting temperature, it is far too high and your own tissues would be burned long before the silicone melted. I do not believe there is any validity to the idea that it can not be surgically removed if it is a solid implant, regardless of how much whittling had been done to it. However, if it was a ‘rhinoplasty’ done by injected silicone, that is a different story. There is no way to remove silicone oil particles, short of wide excision of tissues which on the nose would cause a lot of scarring and deformity.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Hi, Dr. Eppley. I have a really flat head. I can hide it by blow drying my hair, using gels and any volumizing products to make my head look not so flat. My hair is very short  and has lots of layers at the back of my head so it hide it pretty well.. Is there a surgery for flat heads to make it not flat? If so, what’s it called?  Have you done any surgeries for flat heads before?

A: When most people refer to having a flat head, there are talking about the back part. Sometimes it is one side but, most of the time, it is both sides. This is called occipital plagiocephaly, either unilateral (one-sided) or bilateral. (both sides) This flatness is always at the upper part of the back of the head, which is the bony or skull part. Down low, it become more neck muscle and less bone. Building this area ouot (augmentation) is done the same way as it is in the forehead through an onlay cranioplasty technique. This is done by adding a bone-like material onto the top of the bone in the amount that will satisfactorily expand out the bony contour and make it more rounded. The critical decisions about occipital cranioplasty is what type of incision to place and what type of cranioplasty material to use. The type of cranioplasty material influences the incisional approach. A vertical incision is used down the back of head (open technique) where either acrylic or hydroxyapatite materials can be placed. This offers the best and smoothest shape. A smaller vertical incision can also be used (endoscopic or injection technique) in which only Kryptonite material can be used. While offering a smaller incision, the trade-off is in the difficulty in getting a perfectly smooth shape.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley. I am interested in getting liposuction to make my upper arms smaller. They are so big I can not get shirts over them and it has been an annoyance for a long time. They flop around and it is so embarrassing. I only wear long sleeve shirts so they stay hidden. I think liposuction will help make them smaller but I am confused as to what method of liposuction is best. Should I get Smartlipo, Cool Lipo, Vaser Lipo or Lipotherme?

A: While it is understandable why you are considering liposuction for your upper arms, it will not produce the result you are looking for not matter what the liposuction technique. Based on your description of your arms, it sounds like you simply have too much skin to get the arm reduction you desire. Ideally you need liposuction combined with an armlift or arm skin reduction procedure. This does result in an upper arm scar so you have to consider that carefully as a trade-off. There is nothing wrong with doing liposuction alone but your expectation of the arm reduction results should be appropriately tempered. As liposuction removes fat, it makes the skin of the arm like the belly of a pregnant women who has just delivered…deflated and more loose. This is why consideration must be given to the resultant skin excess after arm liposuction alone.

Dr. Barry Eppley

Indianapolis, Indiana

When a product or manufacturer calls itself ‘smart’, there should be a good reason. Such is the case with the plastic surgery method known as Smartlipo. Highly touted as a better and more efficient method of liposuction, its name clearly suggests that it is better than traditional or ‘dumb’ liposuction. Grandiose claims are made all over the internet, most of which by doctors who use this liposuction technique. The manufacturer of the liposuction device, Cynosure, focuses on the established science behind it.

Smartlipo is a laser technique for melting fat to make it easier to extract. By first heating up the fat to a specific temperature, like oil in a cooking pan, it is turned from a solid into a liquid. This is done by using a laser probe that is passed through the fat area until the right temperature is reached. Then a liposuction cannula is used to remove by vacuum the oily liquid and any other fatty chunks in the area.

But what makes this liposuction so smart and why is it better? First, what it isn’t. Because a laser is involved, many potential patients think it is not invasive surgery. It is just as invasive as traditional liposuction which means there will be a recovery. This is not some magical approach that works from outside the body. Just because it is a laser, it doesn’t really zap the fat like a video game. It is about raising the temperature of the fatty zone until the fat begins to melt. The laser is just a way to heat the fat like the burner on the stove.

What makes Smartlipo better is that it creates a global melting effect which removes more fat than suction alone. Because of the heat damage, more fat is lost later than just what comes out at the time of surgery. Fat continues to die days to weeks later, thus the full effect of the fat removed is not really seen for months even though the early results are apparent within weeks after the procedure. This heating effect also accounts for its skin tightening capability. Such an effect, however, is almost always overstated and over expected. Do not expect Smartlipo to replace what a tummy tuck or armlift can do.

While many doctors tout Smartlipo as being done under local anesthesia with little recovery, this is often not so. Because there is considerable heat generated during the procedure, it is not hard to see that local anesthesia is often not enough for a comfortable operative experience. One can only remove enough fat if the patient is comfortable and will allow it. It is not a test to see who is the toughest. This is why I recommend a general anesthetic. The best result in the shortest period of time can be done when the maximal amount of fat can be comfortably removed.

Recovery from Smartlipo is not much different than traditional liposuction. While the amount of fat removed can be better, this does not mean there is less recovery. The laser does result in less pain and bruising but the amount of swelling is about the same, requiring months to eventually see the final body contouring effect.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dear Dr. Eppley, I had a revision chin surgery to correct chin ptosis. Ever since, I am unable to protrude my lower lip when speaking. I also noticed that when I smile, the right side of my lower lip remains elevated while the left side goes down into a natural smile position. My ENT stated that the sulcus is unusually high, and the speech pathologist stated that they can not help me improve my speech as it a mechanical issue. My question is…Can the sulcus be lowered to my natural state and can the mentalis or the depressor labi inferior muscle (whichever was suspended..not sure) be released to enable me to speak, smile, etc..normally once again? I greatly appreciate your time.

A:With a high or scar contracted vestibular sulcus of the anterior mandible, the lower lip may well be restricted in movement. The role of the vestibule between the lip and the teeth is a valuable one and allows independent lip movement from that of the jaw. The key to successful vestibular lengthening is to appreciate that this represents a loss of mucosal tissue. Simply releasing scar or moving tissues around in an attempt to deepen or lengthen the vestibule will not work. It will simply be negated by scar contracture. What is needed is a vestibular release combined with a small skin or mucosal graft. Buccal mucosa is my preference for small amounts of vestibular deepening. The graft must be held in place for 7 to 10 days with a specially-designed small intraoral bolster.  

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I don’t like the deep vertical lines on my upper lip. Those lines are really the only thing I don’t like on my face. I have a read that there is a three-step process to get rid of them. An injectable filler, like Restylane or Juvederm, is first placed into the upper lip to fill them. Then a small amount of Botox is injected into the sides of the mouth to weaken the muscles that cause them to pucker and make those lines. Lastly, one treatment with a fractional CO2 laser is used to wipe them away. There is only  up to a week of redness and swelling after the procedure. According to what I read this combined treatment can last up to 10 years. This sounds wonderful but is it really true?

A: When it comes to any facial anti-aging treatment, there are few things that can last years let alone a decade. This is no where more evident than in the upper lip line problem. This is a particularly pesky facial aging problem that largely affects Caucasian women with fair complexions, thin skin, and often a thin to moderately-sized upper lip. The three treatment strategies described are all useful for decreasing upper lip lines and, when combined in a single treatment, are particularly effective. But they in no way will last a decade, at best the result will last a year. The reason is simple…Botox last 4 months and fillers less than a year. With loss of upper lip volume and the muscle action returning, there is nothing to resist the lip lines from returning. This combined treatment strategy, while effective, must be repeated every year or so to maintain the initial excellent results.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley,  I had a chin implant placed about 4 months ago. After I got my implant I was delighted as I thought the chin projection made my face look more defined and also gave a nice strength to it both from the front and the side. As the initial swelling decreased over time it still looked acceptable. Now it has gotten to the point where I almost hate it because it makes me look too much like I used to earlier especially from the front. I have always hated how my mouth would be so overprojected and my chin slightly receded. While this problem had gone away after I got the implant is, it has now come back and I couldn’t be more dissapointed. I also hate how round my chin appears now. I was talking to my Dr about it and he just said its just how swelling goes down but I hate this final result. I want my final result to be what it looked like around a month and a half ago. I have asked my Dr  how to recapture that and he mentioned maybe a square chin but he didn’t seem convinced at all. As a patient I cannot figure out what is it I need. That is why I wanted your opinion on this but I have also been skeptical of a larger implant cause I don’t want to add unnecessary length to my face.

A: The time to judge the final outcome from most facial implants, and particularly a chin implant, is around 3 to 4 months after surgery. That is when all of the visible swelling is gone and, most importantly, the chin tissues have adapted and settled around the implant so you can see the final shape and size change. Since you are at this time period, you are now looking at the final effects of the chin implant that is in place. Based on the way you feel about the result, it appears that you feel it does not have adequate horizontal projection and it provides too round of a chin contour. A new implant with more horizontal projection and a more square-shaped or non-anatomic shaped (less lateral wings) implant style is needed. It would be helpful to know exactly what type of implant and its dimensions that you currently have to make more specific new chin implant recommendations.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley,  Hello I live in Europe and would like to do the lip advancement as an alternative to injectable fillers for permanent lip enhancement. But I would like to know where you do it and how much it costs?

A: Most lip (vermilion) advancements are done in the office under local anesthesia. Using initial infraorbital nerve blocks (like going to the dentist) and then followed by direct infiltration into the lips, the procedure thereafter is painless. If a patient prefers it can also be done supplemented by oral valium or Xanax or even IV sedation for a completely comfortable experience. It takes about 90 minutes to perform. The amount of vermilion advancement is determined by the patient prior to the numbing by making marks using calipers and a fine marking pen…and then having the patient approve the amount of lip increase with a mirror. There is some mild lip swelling afterwards and very minimal discomfort. Patients generally do not take any pain medication afterwards. For patients that are geographically close to me, I place tiny 7-0 size sutures that are removed 10 days after surgery. For my far away patients, I use a fine 6-0 dissolveable sutures and skin glue so no return is necessary for suture removal. 

For the properly selected patient, lip advancements are a powerful lip enlargement procedure that produces a permanent result.

The total costs of the procedure are around $ 3,500.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I had a medpor chin implant placed in me about 18 months ago.  I would like this removed and replaced with a smaller implant for several reasons (mechanical problems and aesthetic reasons).  Can you remove the implant given the time frame I have had it? Thank you for your time.

A: Despite the fact that the Medpor material does allow for some superficial tissue ingrowth, it is by no means impossible or even that difficult to remove. The material gets the reputation for being difficult to remove as it is compared to silicone, which has a smooth and slippery surface which slides in and out of tissue pockets quite easily. But Medpor facial implants can be removed, it just requires a little more surgical effort and sometimes removing the old implant in pieces. The chin implant being in place 18 months does not impact the removal process anymore than if it was there 18 weeks or 18 years. Tissue ingrowth into the material occurs rapidly and very early after implantation. It does not get worse with longer times of implantation and, contrary to many opinions, does not get any bony ingrowth into it either. Since the tissue ingrowth just occurs into the outer layers of material, it does not get deeper or penetrate further beyojd a certain point.

Dr. Barry Eppley

Indianapolis, Indiana