Your Questions

Q:  Dr. Eppley, I am interested in a subnasal lip lift. I have had other minor plastic surgery procedures which were done with very good results, little scarring and very little down time. My upper lip is my greatest area of facial concern due to the length of my upper lip. It actually seems to be getting longer as I get older. It was always a little long even when I was younger but time is not making it shorter! I can send you pictures if you like. I live out of the states so please let me know if  this procedure is something that could be accomplished with an out of town surgery visit. Thanks so much!

A: Thank you for your inquiry. A subnasal lip lift is a relatively simple procedure that can be performed in an office setting under local anesthesia. It is a delicate and precise lip procedure but the process to do it and the recovery is the simple part. It is a common procedure that patients from far away come into Indianapolis for me to perform. There is no physical recovery required with minimal swelling and virtually no bruising. One could have it done and leave for home whenever they want. There is no reason to stay here afterwards. I always use tiny dissolveable for the skin closure so the patient has no need to return for their removal. Please send me a picture of your lips for my assessment to determine if a subnasal lip lift procedure is for you.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I have a minor case of pectus excavatum on the bottom of my sternum, although I do not believe it is causing me any physical problems such as breathing. I find its indentation to be very disturbing and affects my self-image. I was reading about the case study: Injectable Sternoplasty with Kryptonite Cone Cement on one of your websites and was wondering if this is the treatment would be good for me as I have about the same level of severity as shown in that person. I have had quite a difficult time researching any relevant plastic surgery options for treating this problem.

A: It is no surprise that you have had a difficult time finding any treatment options for minor to moderate sternal contour deformities as they really don’t exist. Short of treatment for more significant cases of pectus excavatum with the Nuss procedure or the older radical method of rib resection, there is no reported methods for sternal ‘augmentation’. In the past, plastic surgeons have occasionally used custom or carved implants for sternal augmentation but these required large incisions to place and were often associated with postoperatuve problems of seromas, infection or implant mobility. Whatever is placed on the sternum, it must be fixed and adhere to the bone to prevent these problems. This is why I have applied a cranioplasty approach to the sternum, specifically a Kryptonite injection approach. This material bonds to the bone and can flow through a very small tube for placement. In my experience with it I have learned that it takes less material than one thinks to fill a lower sternal indentation, usually less than 5 grams due to the expansion of the material

Dr. Barry Eppley

Indianapolis Indiana

Q: Dr. Eppley, I am interested in improving the shape of my forehead. It slants backward rather significantly and I would like it to be more vertical as it goes upward from my brows into my hairline. Can this be done with Kryptonite foreheasd augmentation? How much filler would be needed and what would be the cost?

A: I have done a side view imaging prediction to show that forehead augmentation can make a real difference in eliminating the backwards slope of your forehead by incrementally increasing adding volume from above the brows to the top of the skull. While there is no question this procedure can be done very effectively and get your desired aesthetic result, there are several important issues about the technique to do it. While an injectable or endoscopic Kryptonite procedure is very desireable due to its minimal scar approach, this would not be the best method to do it for several reasons. The volume of material needed is likely 40 grams or more to add the necessary amount of augmentation. That makes the use of Kryptonite prohibitively expensive, making the cost of the material alone for the procedure in excess of $12,000. When it comes to this volume of material needed for forehead augmentation, acrylic or PMMA is far more cost effective with a material cost that is about 1/10 that of Kryptonite. Secondly, and of equal importance, is that a smooth contour of the forehead augmentation is absolutely essential. It is often assumed that the thickness of the forehead and scalp tissues makes slight asymmetries or unevenness aesthetically tolerable, but this is only true when the augmentation is in the hair-bearing scalp. On the forehead, every irregularity will eventually be seen and most certainly felt when the swelling goes down and the overlying tissues adapt to the new forehead contour. With the current use if injectable Kryptonite, it is not possible to get as smooth of a result as that with an open PMMA frontal cranioplasty or forehead augmentation.

Dr. Barry Eppley

Indianapolis Indiana

Q: Dr Eppley, I am in need of help. I had upper and lower lip lift surgery about three months ago for my very thin lips. I am not happy with the result. It looked very off-center and cock-eyed from the beginning. I could see right after the surgery that it was not even or symmetric. My doctor told me that it was just swelling but I knew it wasn’t right. Now that the swelling has long gone down, it looks the same just not swollen. My doctor keep saying it will even out but I don’t see how this is possible. I think his drawings were off from the beginning. He didn’t measure anything and just eye-balled with a drawing pen. Can any type of revision improve the way the lips look? I have attached a picture for your review.

A: For the sake of proper terminology, you had a lip or vermiliona advancemeent, not a lip lift which is just a central upper lip procedure done from under the nose. Beyond those semantics, however, your picture shows unnatural-looking lips for a variety of reasons. This would include the following; upper and lower lip asymmetry due to the cupid’s bow of the upper lip being off center and the left lower lip vermilion being vertically shorter than the left, the peaks of the cupid’s bow are too sharp (pointed), the tail ends of the lower lip vermilion into the mouth corners tails off too sharply (not enough vermilion exposure) and the arch of the upper lip vermilion in mid-portion (between the corner of the mouth and the cupid’s bow) is a little too high. I believe the lips could be improved by making some vermilion and skin adjustments to all of these areas. This is precision work so precise markings with calipers under loupe magnification is essential. These lip advancement revisions could be done as an office procedure under local anesthesia.

Dr. Barry Eppley

Indianapolis Indiana

Q: I had a breast augmentation about 10 years ago. I felt that they were too big right after surgery but my doctor somehow convinced me to keep them at the time. I would them either downsized or completed removed with some type of lift done at the same time. My question is what are the chances of my insurance covering a breast reduction or at least part of it? Have you ever dealt with a situation like this?

A: The simple answer is that this is not a procedure that would be covered by one’s health insurance. While the breasts are being downsized, this does not constitute a medically necessary breast reduction as implants are being removed, not breast tissue. The premise of a true breast reduction is that there is too much breast tissue present and a certain amount must be taken out. A medically necessary procedure has at its origin a health or medical cause. Prior breast augmentation is a cosmetic cause not a medical one. Breast implant removal and any lift that may be associated with it to reshape the loose and sagging breast skin is a cosmetic procedure.

Dr. Barry Eppley

Indianapolis Indiana

Q: Dr. Eppley, about six months ago I had a medpor chin implant inserted through an intraoral incision and secured with screws. Unfortunately, the wings were too large and malpositioned. I had a revision one month ago in which the implant was removed, trimmed and re-inserted. Now the implant is the right shape and size, but my lower lip feels shorter and tighter. The top halves of my lower teeth show with the lip at rest, and I can barely raise it enough to cover them. When raised, the lip is lower in the center than at the sides. After the original surgery I had the same problem but not as bad, and the lip eventually went back to normal. This time the lip seems worse, and I’m worried it might stay this way. My Dr. said getting the medpor implant out was “very difficult” and it took twice as long as he expected. The implant actually broke when he took it out and he added 2 extra screws to hold it together when he re-inserted it. My chin and lower lip where very swollen for two weeks afterward and the center of the lip is still slightly numb. I’m worried I might have a problem with my mentalis muscle. Does my lip issue sound like something that will go back to normal on its own or like something that will require correction? Thanks for any advice.

A:  In your history you have said the key words…intraoral incision. When using this approach for chin augmentation, the superior bone attachments of the mentalis muscle are cut and have to be resutured at the end of the procedure. Besides the numbness,, it is common to have some lower lip tightening and little tethering until the tissues heal and relax again. Going through the muscle twice, particularly in a more extensive revisional procedure, traumatizes and scars the muscle again…making symptoms of tethering and lower lip retraction more significant. It is too early to tell whether this problem is temporary or permanent. If it has not significantly improved by three months after surgery then I would recommend a mentalis muscle v-y lengthening and resuspension procedure.

Dr. Barry Eppley

Indianapolis Indiana

Q: Dr. Eppley, about six months ago I had a medpor chin implant inserted through an intraoral incision and secured with screws. Unfortunately, the wings were too large and malpositioned. I had a revision one month ago in which the implant was removed, trimmed and re-inserted. Now the implant is the right shape and size, but my lower lip feels shorter and tighter. The top halves of my lower teeth show with the lip at rest, and I can barely raise it enough to cover them. When raised, the lip is lower in the center than at the sides. After the original surgery I had the same problem but not as bad, and the lip eventually went back to normal. This time the lip seems worse, and I’m worried it might stay this way. My Dr. said getting the medpor implant out was “very difficult” and it took twice as long as he expected. The implant actually broke when he took it out and he added 2 extra screws to hold it together when he re-inserted it. My chin and lower lip where very swollen for two weeks afterward and the center of the lip is still slightly numb. I’m worried I might have a problem with my mentalis muscle. Does my lip issue sound like something that will go back to normal on its own or like something that will require correction? Thanks for any advice.

A:  In your history you have said the key words…intraoral incision. When using this approach for chin augmentation, the superior bone attachments of the mentalis muscle are cut and have to be resutured at the end of the procedure. Besides the numbness,, it is common to have some lower lip tightening and little tethering until the tissues heal and relax again. Going through the muscle twice, particularly in a more extensive revisional procedure, traumatizes and scars the muscle again…making symptoms of tethering and lower lip retraction more significant. It is too early to tell whether this problem is temporary or permanent. If it has not significantly improved by three months after surgery then I would recommend a mentalis muscle v-y lengthening and resuspension procedure.

Dr. Barry Eppley

Indianapolis Indiana

Q:  Dr. Eppley, I am interested in breast augmentation but am concerned about the possibility of bad scarring. As a small child I had chicken pox and developed many of the typical pustules. While they went on to heal, I developed keloid scars scattered across my body. Although I do not feel that I still scar this way, I am concerned that I might and these would look terrible in my breasts! Do you think it will happen from the breast augmentation incisions?

A: Having had a terrible scar situation at an early age, it is understandable why you would be concerned about it occurring again from an entirely elective cosmetic procedure. However, and fortunately, these are not comparable scar circumstances. Chicken pox scars are the result of secondary healing of open wounds. They have a high propensity of resulting in hypertrophic scars which appears as wide as the original wound and are heaped up higher than the surrounding skin. This is not a keloid scar (whose growth goes beyond the boundaries of the original wound edges and often keeps growing) with which hypertrophic scars are often confused. The incision from breast augmentation ,whether it is around the nipple, along the inframammary fold, or in the armpit, is a controlled narrow skin injury which heals by primary healing. Primary healing almost always results in much better scars than from secondary healing. I have never seen a wide hypertrophic scars from any breast augmentation incision. Therefore, I would have no fear about developing the type of scars from any breast augmentation incision that would remotely be close to your existing chicken pox scars.    

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dear Dr. Eppley , I had chin augmentation about two years ago with terino square chin imlpants, style 1. It looked for about two years but it has disappeared somewhat. I would like to know if it is possible to place another square chin implant,  a Terino square chin implant style 2 on the top of the existing one and have it secureed with screws to add some more definition, squarnes and some more anterior projection. I think it makes sense to place the bigger one on the the top of the smaller and according to the dimensions on the Implantech website they would fit perfectly. Would you please express your opinion on this matter? I would greatly appreciate it.

A: In regards to your existing chin implant disappearing, that impression is likely a combination of two factors. Many patients after face and body augmentations suffer what I call ‘cosmetic accomodation’. They simply have gotten used to the look and it no longer looks as good or as big as it used to. Secondly, the implant may have suffered a little settling into the underlying bone of a fedw millimeters which is not uncommon particularly if the implant is not directly over the lowest edge of the basal bone. These two issues combined have likely resulted in your implant ‘disappearing’.

In regards to placing a style 2 directly over a style 1 silicone square chin implant, your assumptions fro a chin implant revision based on measurements are correct. There is a 10mm difference in the square width of the implants so a style 2 does fit rather nicely over a style 1. That would also add an additional 8mms of anterior projection as well. They would absolutely have to be secured with at least two screws placed on their lateral edges to prevent the shifting of one smooth surface against the other. The only contour concern is on the edge of the lateral wings where a more noticeable step-off may occur as the transition back to the bone will have a double-thick edge. I would advise the wings of the overlay implant to be trimmed and feathered about 10mms short of the underlying implant to avoid this problem.

Dr. Barry Eppley

Indianapolis Indiana

Q:  Dr. Eppley, how much is the laser removal for scars for burns?

A: There are several problems with your request. There is no such thing as ‘scar removal’ by any method. Scars can be treated so that they may be less noticeable but there is no such thing as scar removal. Scars can only be improved but never are they able to be removed, hence the term ‘scar revision’.  The treatment for burn scars is variable given the very diverse presentation of burn scars. It is fair to say that laser resurfacing is often the only option for many burn scars given the large surface area that many burns have. Whether that approach would even be worthwhile or effective would require a visual inspection of the scars. Until this is done, no reasonable assessment of potential effectiveness or cost can be given.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I am going to have a breast augmentation done next month. I also wanted my right nipple to be lifted and brought up to the level of my left side. My doctor said that I didn’t need to have it done and that it would put a scar around my nipple and down the breast if I did it. In my reading of nipple lifts this doesn’t make sense to me. Why does my doctor say it can’t be done without a lot of scar and I have read that it can. Can you explain this to me?

A: In solving this discrepancy for you, there are numerous types of breast lift techniques. Which one is best for any particular patient depends on numerous factors including how much sagging the breast has (how low does the nipple hang) and how much scar can the patient tolerate. The most limited scar technique is that of a nipple lift, also known as a superior crescent mastopexy. By removing a small crescent of skin from the top of the nipple, the nipple position can be elevated about 1 cm. For very minor breast lifts with small amounts of sagging this may be all that is needed. I suspect this is what you have been reading about or are referring to. The next type of breast lifts are the circumareolar or donut lift (scar around the whole nipple) and the vertical breast lift. (scar around the nipple and down to the fold, the one to which your doctor is referring) Both of these will move the nipple up higher but with more scar.

Which type of breast lift you may need depends on the difference in the horizontal levels of your two breast nipples. Without knowing that information, I can not recommend what lifting method may be needed in your case.     

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Hello Dr. Eppley, I was reading some of the information on your site about the use of Matristem (Acell) in scar revision. I was wondering if the several scars on my face from a previous auto accident, including a small raised scar (keloid?) would benefit by this treatment. In my readings I see that it has been used on fingertips and other body areas but it is not clear to me how useful it would be in the face. I really want to do something about these scars on my face and lessen their appearance. Thanks for your time in answering my question.

A: I think it is important to understand that Matristem, nor any known agent, has magical properties in either wound healing or in preventing scar formation. It should be perceived as a potential adjunctive material that can be incorporated into other scar revision strategies. Because it comes in powder form, it can easily be used in traditional open scar revisions done by excision with or without some type of geometric arrangement. Its benefit is that it encourages healing with less scar formation than may otherwise occur. Whether it would produce a better result (scar appearance) than scar revision alone is theoretical but appealing nonetheless. I have used it in numerous types of face and body scars and some open wound problems. Since it is has no known side effects or negative issues with its use, there are no drawbacks to adding it to the scar revision approach. When it comes to problematic scars, every available advantage is needed to get the best result.

Dr. Barry Eppley

Indianapolis, Indiana

The concept of non-surgical fat reduction has been around for over a century. From belt machine devices in the early 1900s to the infomercial weight loss supplements of today, hope is eternal when it comes to getting rid of unwanted fat. Without question, the definitive way to lose spot areas of fat is liposuction. Liposuction is a proven surgical method to trim down specific body areas, but it is an operation and involves recovery.

Non-surgical fat removal, no matter what the method, will never be as effective as surgery for spot reduction. However,  newer non-surgical methods of fat melting have appeared in the past few years. One of these is Zerona, or specifically the Zerona laser treatment program. It is touted as a painless body slimming method that is proven to remove fat and inches without surgery with zero pain and downtime.  Does it really work? Is it hype or hope?

Zerona works by using a low frequency ‘cold’ laser that passes through the skin without injury and targets the fat cells. The laser energy targets the fat cells through a photochemical process. Not to be confused with a photothermal (heat) or photoacoustic (vibration) method, this non-heat generating process makes the fat cells ‘leaky’. The fat cells shed their liquid fat content, now known as free-fatty acids,  which is then absorbed through your lymphatic system. The lymphatic system transports it to the liver where it is processed and broken down, and most importantly, not re-circulated and stored again as fat.

Zerona is more than just a machine, it is a process. Treatment sessions number six to nine and have been shown to be able to take off three to five inches in the hips, waist and thigh in two to three weeks. But to aid the lymphatic clearing process, one must significantly increase their water intake and take a twice-daily niacin supplement (Curva) or HCG (human chorionic gonadotropin) during the treatment process. The treatment sessions require a commitment and must be done every two to three days to really be effective. Once the fat cells get leaky, you can’t let them heal themselves by missing treatments or having them too far apart. Each treatment session takes just under an hour and is painless. You literally get up and go afterwards. Daily exercise (such as brisk walking, light running, or other cardio training) can increase the final results by aiding in lymphatic clearance and an increased metabolism.

Is Zerona fat reduction too good to be true? It depends on your expectations and how much fat you have from the beginning. We do screen our patients and select those that we think, based on our experience, have the best chance for success. That has resulted in about a 70% satisfaction rating from our treated patients. This means that those patients saw enough of a difference, both visually and by measurements, that they rated the treatment a worthwhile investment. Thus, as part of a jumpstart on the front end of some body slimming or as part of an overall weight loss program, Zerona can make for very visible body changs.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dear Dr. Eppley, I would like to have those chiseled high cheekbones. I have looked at some implant styles online and it seems that the Medpor extended malar implant may work for me. The picture on the website product catalog shows the implant in a high and lateral position and the implant is described to augment the malar region. My surgeon told me that this kind of implant can only be placed under the cheekbone (submalar) and more towards the nose than towards the zygomatic arch and that the picture on this website shows the wrong placement of this implant design. I really don´t want submalar augmentation! Is it true that this implant design is actually a submalar implant and therefore not used for malar augmentation or can it be used for both malar and submalar augmentation? What is your experience with this kind of implant design?

A:  Choosing the correct implant design and size is obviously critical for any type of facial implant procedure. This is particularly true in the cheek or malar region as this area has the most complex three-dimensional anatomy to it. It contains five zones of potential augmentation including anterior, lateral, oblique, orbital rim and submalar. Any cheek implant will affect at least three of these zones in any single design. For those interested in more ‘chiseled’ cheeks, by definition this means that the oblique and lateral zones are most important. The submalar zone should absolutely not be augmented as part of this type of cheek implant because it will create more of a rounded full cheek look rather than making higher and more ‘chiseled’ cheekbones. The type of cheek implant to which you refer will not help create the look you are after. That type of cheek implant design creates fullness on the lower or submalar cheek zone and will not achieve that higher angular cheek look.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley I had a chin implant placed over a year ago. While I like the amount of projection the implant gave me, I feel that my chin would look better if it was also longer. I suggested to my doctor that a chin osteotomy would be a good idea so that the chin is angled downward as well as brought forward. He felt that it would make my face too long and discouraged me from it. While I respect his opinion, my artistic sense of my own face disagrees with that assessment and I strongly feel that my small and round face would look better with some lengthening. I have attached a side picture for you to give me your opinion.

A:  The debate of whether one facial change or another is better can be largely answered by computer imaging. This is particularly true in a profile facial structure such as the chin which is one of the most accurate areas for predicting facial bone to soft tissue alterations.

There are two ways to get create vertical lengthening of the chin. One way is to position or reposition a chin implant lower on the bone so that it is just not sitting exclusively on the front edge. If the implant is moved down to be between the front and lower edge of the bone, some mild vertical lengthening of chin and lower face can be achieved. (2 – 4 mms) The implant has to be secured in this position by screws for stability as you can’t rely on the containment of the soft tissue envelope only. The other option which you have already mentioned is a chin osteotomy which can make for more significant vertical lengthening of 6 to 8mms.

By making these chin changes on the computer, you can visually determine whether your belief for more vertical chin lengthening is correct.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Hello Dr. Eppley, I would like to know anything you can offer to tell me about plastic surgery! I would love to be a plastic surgeon as a career in the near future! (: Right now i’m going into my senior year in high school. So any advice of how I can reach my dreams would be great! Thank you!!

A:  Few things can be achieved in life without a dream or goals. So it is good that you have a focus at this early age in your life. I have no idea what has captured your attention of plastic surgery as a career. While plastic surgery may seem glamorous, it is far cry from what you may have seen on TV or other mediums. It is hard work and a long arduous process with the foundation of becoming a physician first. This not only requires the traditional effort with college and then medical school but, equally importantly, some exposure to medicine and health care in some capacity along the way. Whether it be volunteer or part-time employed work at a hospital, emergency clinic or a doctor’s office, you need to see what being a physician is like up close. You need to discover if you have the interest and ultimately the passion for it. For it is these attractions to the field that will keep you going when you have to outstudy many others in the eight years of preparatory academic work (while others are at the football game, frat party or on that ski trip) or those six to eight years with many long nights on call during general and plastic surgery training.

It is never too early to begin your research into medicine as a career and I encourage you to begin now in any way you can. Plastic surgeons in many commnunities are always willing to allow observers either in the office or the operating room…and can give you a lot of good insights and information about the field.   

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr Eppley, I had Juvederm injected into my upper and lower lips yesterday. My lips are very swollen now and my lower left lip is noticeably larger than the others. What can be done to make this better as they are much larger than with what I left the doctor’s office yesterday. Could this be an infection? I am quite concerned. Please advise. I’m freaking out!

A:  Most lip injection patients do experience some mild swelling for the first day or two after the treatment. The lips are exquisitely sensitive to any type of trauma so swelling may occur. Some patients experience it more than others. This would be particularly true if all the lip injected areas seem swollen. As long as the lips are not hot, red and swollen, then this is the likely reason for their appearance.

Of the thousands of lip injections that I have done, I have only ever seen three adverse reactions. One was an actual infection of the lower lip that eventually required antibiotics and drainage. Both upper and lower lips had been injected and the upper lip was fine. An infection would be more likely to affect just one of the lips or even just one side of a lip than the entire area. Suspected infections are initially treated with oral antibiotics. Infections often don’t occur for days as it takes time for bacteria to multiply.  The other two were inflammatory reactions to the injected material which is known to occur as the Juvederm material, while a known and fairly natural substance to the body, is nevertheless synthetically manufactured. By the manufacturer’s package inserts, these inflammatory reactions can occur in about 1% of all injected patients. My experience has been much more uncommon than that. If both the upper and lower lips are swollen (all injected areas) then this is the likely explanation. This is treated by oral steriods.

Lip asymmetries are much more common issues after injectable fillers that often don’t become evident for hours or days after the treatment. If one area feels lumpy or a little bigger, it is perfectly fine to massage or “strip’ the lip (between your fingers) to attempt to smooth it out. Injectable fillers are very much like clay after they are injected and they can be molded and moved slightly by such manipulations for a few days after the treatment.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, can a lower jaw setback be combined with a lower gfacelift during the same procedure? Have you yourself done this before?

A:  The technical capability of performing a combined orthognathic procedure, like a mandibular setback, with a facelift is certainly possible. The need for it is so rare, however, that it would be hard to a surgeon that had ever done it together. There are several reasons for its rarity. By definition, a facelift would be done in an older patient while orthognathic surgery is usually done in a younger patient. Thus, the mainstream population of each procedure are at diametric ages. There is also the consideration that the  type of surgeon that performs these procedures are quite different. Most maxillofacial surgeons have little or no training for facelift surgery and most plastic surgeons have little or no training in orthognathic surgery. While plastic and maxillofacial surgeons certainly can work together and coordinate these surgeries, most plastic surgeons would probably prefer to defer the facelift to a later date due to swelling considerations.

With all of that being said, a mandibular setback and a facelift can be done together. The question is not whether they can be done together but whether they should. While each operation poses a ‘surgical opportunity’ to do additional procedures, you want to make sure that the patient can still get a result that would be comparable if either procedure was done alone. Surgical opportunity should not be more important than an outcome. In that regard, I would have to know more about how much mandibular setback is needed and the proposed technique (sagittal split ramus osteotomy vs vertical oblique osteotomies) and the degree of neck and jowl sagging that exists. Then I could answer the question better about whether such a combination is a good idea.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Over 10 years ago, I was involved in a car accident and ended up getting a craniotomy and evacuation of a subdural blood clot. Afterward, the craniotomy flap got infected and had to be removed. Because I was a child at the time, some bone actually grew back over the upper forehead defect. But it was not of the same thickness or amount and I have been left with a flat and irregular upper forehead area around my hairline and into the very visible part of my forehead. It is quite noticeable and embarrassing for me and I have always wanted to get it fixed. I have read recently through your writings that it can be repaired with some types of materials that are applied to the outside of the bone. That has given me great hope that there is a solution to this embarrassing problem. I am tired of people staring it! Please tell me about this procedure and how it is done.

A: Based on your description alone, it sounds like you would be an excellent candidate for an onlay cranioplasty procedure. Compared to what you have been through previously, this is a relatively simple operation that produces immediate results. Since you had a craniotomy previously, you have an existing scalp scar. The scalp ius lifted up again and a synthetic cranioplasty mixture is used to apply to the defect and make it perfectly smooth with the rest of the forehead. The available mixtures are a powder and liquid, which when combined, turns hard after it is shaped within a few minutes. There are three specific cranioplasty materials. I would choose hydroxyapatite, specifically Mimix, for your cranioplasty as it is the most like bone and has excellent working charcteristics. I have worked with it for over 15 years, including through its research and development phase, so I know its working properties very well. This is an outpatient procedure under general anesthesia that would take about 90 minutes to do.

Dr. Barry Eppley

Indianapolis Indiana

Q: Dr. Eppley. I went online and looked at your breast implant pictures. As I can tell it looks GREAT. I have been looking at different work from different doctors. I am a very small A. What do you suggest? What type of implant do you recommend for me? What is the total price? Do you have any financing available for people like me? I really want this bad! For a very long time. I feel unsure about my body and the way I look. I am going to be 32 and I have 2 kids. I have always wanted larger breasts ever since I was in school. Can you help me?

A:  What would make you look like a full B cup would depend on numerous factors including the base width diameter of your breast, tightness of your overlying breast skin, and your envisionment of what a full B cup is. Since I have no images of you, I will have to assume your base breast width is likely in the 11 to 13 cms. range. This would make an implant in the range of 250cc to 350cc a likely possibility. That would have to be determined by an examination and some images of breast augmentations that you like. Given your described financial situation, you would be best served by a saline breast implant which can be done at a lower cost than silicone breast implants. Total costs are in the range of around $ 4,700.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I’m a 6 year old male looking to remove a bump on my skull bone on the back of my head. I believe this skull bump resulted from a forceps delivery during my birth. I had an MRI of my head done and it came back normal. This is something that has plagued me psychologically all my life and I’m looking for any options to improve the appearance of the back of my head. I’ve provided photos of the back of my head. As you can see from the pictures, aside from the bump, there is also a ridge that leads to the more protrusive bump. I look forward to your assessment.

A: Thank you for making the effort to take the pictures. They are more than sufficient. What you have are two specific occipital bony uprisings, one ‘abnormal’ and the other a natural part of the occiptal skull bone. One is a small round bump at the top of the occiput which is a small osteoma or benign bony ‘tumor’ That can be burred down through a small vertically-oriented incision over the bump measuring about 3 cms. or just slightly bigger than an inch. Incisions in the hair-bearing scalp in men heal remarkably well and would eventually be such a fine line scar that it would be virtually undetectable. The horizontally-oriented bony ridge across the bottom of the occiptal skull bone is known as the nuchal ridge. It is where the top of the neck muscles attach to the lower edge of the occipital skull bone. It is raised and visible, as it is for some people, for unknown reasons. It may be raised because of the need for a strong bony attachment for the neck muscles. That can actually be reduced by burring down the ridge but the issue is incisional access. It requires a linear horizontal incision across the back of the head along the nuchal line, probably of a width of about 5 cms. Either skull reshaping procedure can be performed alone or in combination. Either way it is an outpatient procedure under general anesthesia that would have a minimal recovery. The incisions would be closed with tiny dissolveable sutures and one could shower and wash their hair after two days. There would be some temporary swelling which would go away in two or three weeks. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  Can you tell me how close a surgical result will be compared to the computer imaging that has been shown to me? Since it is done on the computer I assume that it is fairly accurate and representative of the result. I am desiring to get a rhinoplasty and chin and jaw angle implants and want to see if the result wiould be worth the effort and the expense.

A: A very important consideration when looking at predictive computer imaging is to realize how it is done and that it is not an exact science. The only thing ‘computer’ about it is that it is done on a computer. The computer does not create the images nor portray them on some one-to-one basis from the nose or jaw implant to the patient. In other words, the computer does not take the dimensions of the implant(s) or the amount of nose structure  that is removed and directly transfer that onto the patient so the changes will identically match. Rather, computer predictive imaging is done on Photoshop by the plastic surgeon with their best guess of what the changes may be. It is an art form not an exact science. Thus, computer imaging can easily overpredict or underpredict what the final result may be. Since patients view computer imaging as a more exact science than what it is, I always slightly underpredict what I think will happen. It is important for the plastic surgeon to not overpredict as this may easily overpromise or oversell the surgical procedure. This can lead to postoperative disappointment in the result if these expectations are not met.

The very valuable feature of computer imaging in rhinoplasty and jawline implants is that it can be a very good predictor compared to many other facial plastic surgery procedures. Because these are silhouette or profile facial structures, they are easy to morph and see the potential changes.

Dr. Barry Eppley

Indianapolis Indiana

Q: Dr. Eppley,  I need to lose 145 lb and I have tried everything. Can liposuction help and how much does it cost? I also I need a tummy tucks and my breasts lifted.

A: With the need to lose a lot of weight, liposuction is absolutely not the answer that you seek. Liposuction is best used for spot fat reduction and for those patients who may need a ‘jumpstart’ for relatively small amounts of weight loss. (10 to 25 lbs) For near or over a 100 lb weight loss, you need to seek a consultation with a bariatric surgeon if everything to now has failed. That amount of weight loss can only be achieved through gastric banding or gastric bypass surgery.  Any other desired body changes, such as a tummy tuck to get rid of the skin overhang around the waistline or lifting sagging breasts, must wait until after this weight loss have occurred. Attempting to do such surgery in the face of being significantly overweight is not only ill-advised from a health standpoint but any benefits gained will be wiped out by significant weight loss. Not to mention that the amount of improvement one can achieve in the obese patient is relatively limited.

The foundation of your body reshaping begins with the need for a large amount of weight loss. The first place to start is a consultation at a Bariatric Center.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am interested in reducing the size of my adam’s apple as it sticks out like a bulge in my neck. In reading about tracheotomies, I wonder if there was an at-home method in which a man could try the look, feel and sound of having a more feminine adams apple appearance just for say a few weeks before taking surgery. Have you ever heard of anything like this?

A: For the sake of clarification, tracheal reduction and tracheotomies are two different completely different operations with diametric objectives. A tracheostomy makes a hole through the skin and down into one’s windpipe below the thyroid cartilage for the sake of breathing. A tracheal reduction, technically known as a thyrochondroplasty or adam’s apple reduction, reduces the protrusion of paired thyroid cartilages as they bulge out into the neck. If done properly and without removal of too much cartilage, it will not change the pitch or sound of one’s voice. (a tracheostomy will definitely affect one’s voice) If you wanted to see what a tracheal reduction would look like, that is what computer imaging does. You can get a good visual approximation of the final neck contour result. It can help one see what the change would look like on them and is the best way to ‘try it on’ before surgery. There are no non-surgical methods to try and simulate that change in neck appearance.

Dr. Barry Eppley

Indianapolis Indiana

Q: Dr. Eppley. I am interested in getting the large dimple removed from my chin. I am not sure where to turn to since it seems very few plastic surgeons perform this procedure. Please send me information in regards to how this surgery is done, how successful it is, and the possible cost. Thank you!

A: Thank you for your chin surgery inquiry. Chin dimple reduction/removal is usually done by an incision inside the mouth. (behind the lower lip) The key to a successful chin dimple reduction (sometimes a complete removal) is that you have to fill the muscular defect/indentation with some type of graft. This could be allogeneic dermis (off the shelf) or fat or dermal-fat grafts from the patient. In some cases, releasing the dimple and sewing the muscle together may suffice. This is done under local anesthesia or IV sedation as an outpatient procedure. Dissolveable sutures are used inside the mouth. There are no restrictions in eating or physical activity after surgery. Some mild swelling is to be expected but this will be gone in a few weeks.

The cost of chin dimple surgery is around $2500.

Dr. Barry Eppley

Indianapolis, Indiana

Catching a glance in the mirror or looking at a picture and seeing those sagging jowls and a droopy neck can be a troubling finding. It often seems like it came out of nowhere. I have yet to see a person find this discovery charming. While hope lies in that some magic cream or laser treatment will make it all go away, deep down inside we all know it isn’t true. (but we can dream can’t we?)

When it comes to that loose jowl and neck skin, everyone wants to avoid the dreaded word…facelift. While most people are unaware that a facelift is really just a necklift, everyone would agree that they would like as little surgery as possible. While the fears and recovery surrounding a necklift are largely overstated, one really hopes that they can get by with a ‘minimal’ procedure. This understandable apprehension has led to the nationwide branded selling of facelift surgery.

The best example is that of the Lifestyle Lift. Through their national magazine and television ads, this is a franchise approach to getting a facelift…or some version of it. I have seen many patients who know the name, but don’t really know what it is. Promising to turn the clock back at least ten years and look recovered in just a few days, its catchy name seeks to assure patients that it will fit into their ‘lifestyle’. Interestingly, and perhaps not an oversight, nowhere in their advertising does it even suggest that it is real surgery. Many prospective patients only become aware that it is surgery when they actually visit a company facility.

What is a Lifestyle Lift? While sounding new, it is really quite old and has been practiced by plastic surgeons for decades. It is a scaled-down version of a facelift, a ‘mini-facelift’ if you will.  Sometimes called a tuck-up facelift, a secondary facelift, or a jowl lift, it is a limited operation that best improves those sagging jowls with a little tightening of the neck. The operative word here is a ‘little tightening of the neck’. If you have a neck wattle or turkey neck, this is not the right procedure for you.

Because it has an appealing name, the Lifestyle Lift has created a number of name knock-offs, including the Swiftlift and even the Lunchtime Lift to name just a few. Most of these are surgeons who have jumped on the naming and marketing bandwagon and have given their version of a limited facelift its own name. There is no real difference in the procedure or in whom it is or is not most beneficial.

Because it is heavily marketed and the internet exists, the Lifestyle Lift has its share of critics.  Much of this has to do with trying to make an individualized custom operation into a factory line retail product. As an operation, however, limited types of facelifts do have a valuable role in facial rejuvenation. Not every patient needs or wants a full facelift.

Facelifting is not an operation that should performed the same on everyone. Nor does having a catchy name mean it leads to better results or a quicker recovery. Many plastic surgeons offer similar limited types of  facelifts that just don’t have a branded name, but that doesn’t make them any less effective or useful.

Dr. Barry Eppley

Indianapolis

Liposuction is a very effective procedure for removing unwanted fat. It is a well known procedure that many people want and some have concerns about its safety. There are stories every year around the U.S. about serious complications arising from liposuction so it is no wonder it can give one pause. If you dissect behind these stories, however,  there is almost always a reason these liposuction complications have occurred. This recent story caught my attention…I will get into the reason after the story.

‘Earlier this month,  an Arizona doctor was charged with murder after three patients died in 2006 and 2007 during liposuction procedures performed at his clinic. According to the prosecution, the doctor did not kill these patients with a gun, rather the murder weapon was arrogance and the motive was greed. Two of the patients overdosed on anesthesia during routine liposuction procedures and the third died of a fat embolism after undergoing buttock augmentation with fat injections. All three were improperly intubated during resuscitation, making it impossible to save them.

The doctor, who was trained in Internal Medicine and Dermatology, opened a cosmetic clinic in 2005. Initially he offered Botox, hair restoration and laser procedures before moving ‘up’ to do  liposuction and breast augmentation. He employed medical assistants with little or no medical training. According to the Arizona Medical Board Review, his medical staff included a massage therapist, a former restaurant owner, two former pre-school teachers and his mother. And when he had to surrender his medical license after the first two deaths, he hired a homeopathic doctor to perform surgery that soon killed a third patient.’

While on the surface of the story liposuction receives the blame for these complications, even the medically uneducated would perceive that the real problem was not the procedure but the doctor. The average person reading this story would say…how could this happen? Aren’t there rules and regulations that govern what doctors are allowed to do?

The simple answer is…no. Once  a doctor has a medical license, they can perform anything they want…in their office or their own clinic. The only regulations are when they try to perform procedures in a hospital where medical oversight exists. This has become a significant issue in cosmetic surgery where much can be done under local and IV sedation anesthesia. An office setting without general anesthesia is very appealing to many patients, particularly when it comes to liposuction, as they perceive a limited or virtually no recovery scenario. As this story illustrates, the office setting under local anesthesia may not be safer than an operating room under general anesthesia. Not to mention that the results between the two locations may not be remotely similar.

How could someone with no real training be allowed to perform these procedures you ask? Because in the office setting the only ‘regulations’ a doctor has is their own conscience. In today’s medical climate, whether it be for economics or ego, the appeal of an upfront fee as opposed to an insurance billable procedure is an invitation for doctors to step beyond what they are actually formally trained to do.

Prospective cosmetic surgery patients need to do their homework and look out for their own health and safety. That attractive low fee and the ‘simple’ office procedure can be a recipe for problems. Bargains are for the retail mall, not for medical procedures.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have an unusual question about a part of my face that was wounded by laser treatments. Several years ago I went to a family doctor in town that offered laser hair removal at  a great discount. For that great fee reduction, I ended up getting several areas of burns on my face that have scarred. These have largely gotten better. My ongoing problem is on some facual skin areas that show no visible signs of scarring. Instead, there is an issue of a constant burning sensation under the skin. There is no scar and the skin looks normal but there is a constant burning sensation that occurs. So, my question for you is what could be causing this burning
sensation under my skin? It undoubtably occurred from the laser treatments since I did not have it before. What could the laser have damaged under the skin that caused this constant burning sensation? Most importantly, what can I do to fix it?

A: This is certainly an unusual problem. The laser may well have burned the ends of the tiny sensory nerves, which are more sensitive than the overlying skin to a thermal injury. This nerve scarring may have changed how those nerves feel due to the damage. That would explain why it feels like it is burning, years later, even though it is long past the possibility of any actual skin injury.

Time initially would be the first option. Nerves can heal and recover but that would, in theory, have done it by this point years later. If there has been  no gradual improvement in that sensation lessening by now, then it may well be permanent. The next treatment option to consider is Botox. This simple injection approach will block the acetycholine transmission and the sensation may cease as long as the Botox is effective. (4 or more months) Whether it will work or not is speculative but that is exactly how it works in the treatment of hyperhidrosis for example. In addition there is nothing to lose as long as there are not muscles of facial expression nearby. If this is ineffective, then skin flap undermining in a minor surgical procedure will disrupt the nerve ends and may possibly end this dysesthesia.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I recently had jaw angle implants and it has not turned out to be a good experience. My jaw angles were high and made the back part of my face looked weak and absent. My surgeon initially placed silicone implants but all they did was make my face look more wide and fatter and did nothing to make the jaw angle change I needed. My surgeon acknowledged that these implants were not the right types. I then had a second surgery done using Medpor jaw angle implants. Even though there was a lot of swelling after surgery, I noticed that my left side was very different from the other side. This has become only more apparent as the swelling has gone away. They look and feel completely different between the two sides. My surgeon says he wants to go in and shave down one of the implants but I have lost faith in him at this point. What do you recommend?

 A: Sorry to hear of your surgical misfortune. Jaw angle implants are, without question, the most difficult facial implant to do well, both in implant selection and in surgical placement. They are incrementally more difficult than the more commonly used chin and cheek implants. Symmetrical placement, because you have to put in each implant independently and without view of the other one, is challenging. One has to be very attentive to every detail of the implant position and to screw it into place, if possible, to ensure the best symmetry. The most difficult jaw angle implant to place are the Medpor ones because their material surface has a high degree of frictional resistance and they don’t slide in easily. That is the only jaw angle implant, however, that can drop the jaw angle down vertically. Most of the time, these implants have to be trimmed down to fit, removing the long anterior end. I have found it very beneficial to use the implant sizers first to fully develop the pocket and only place the final implant when the sizer slides it easily to the desired location. It would be impossible for me to say what is the best approach with your current jaw angle implant situation. I don’t know what you look like now nor do I know the details of your current implants and what is making them asymmetric. Shaving down the malpositioned implant may work but, more likely, the implant needs to be repositioned.

 Dr. Barry Eppley

 Indianapolis, Indiana

Q: Dr. Eppley, I have a problem with the right side of my chest. It is smaller and looks completely different from my left side. I have noticed it since I was a small boy and it has always embarrassed me. It looks like I do not have a chest muscle on my right side. I want to know what can be done for it. I have attached some pictures including ones with my arm raised where you can really see the difference.

A: Thank you for sending your pictures. It does appear that you have Poland’s syndrome. This is an underdevelopment of the pectoralis chest muscle. It is a well known congenital chest deformity. This can clearly be seen in your pictures, particularly the one with the arms lifted. You can see the short pectoralis muscle and its abnormal attachment to the upper sternum. This accounts for your smaller right chest appearance, the high position of the right nipple, and the asymmetry between the two sides of your chest. 

In treatment of male Poland’s syndrome, several treatment options are available which primarily focus on improving the volume of the right chest. This can be done with an implant, a pedicled latissimus dorsi muscle flap or a combination of both. A pectoralis implant is the simplest approach but the lower edge of implant will not have muscular coverage so the lower edge may be palpable or visible when the arms are lifted. Other treatment options include scar release/lengthening of a tight muscle band across the armpit and possible right nipple repositioning. It is also important to look at the opposite chest to see of anything can be done there to help improve the symmetry between both sides of the chest.

Dr. Barry Eppley

Indianapolis, Indiana