Your Questions

Q: I am a single mom and have a daughter who will soon be 12 years old. She is suffering from a lot of teasing because her ears really that stick out. I think they are adorable but she has become very self-conscious and is dreading going to middle school in the fall because of her ears. I am writing to inquire of how much ear pinning would cost. Not sure if I can afford it at all as I am a single mom and have another daughter in college. So my question is how much is it and is there a possibility of payments? Thank you.

A: When the ears excessively protrude or stick out, it is not rare that a child or teenager receives a lot of unwarranted criticism because of it. While parents have been with their children since birth, they often can fail to see how bothersome their ear position or shape can be. Children frequently will not say anything to their parents about it.  Fortunately you have perceived her distress and recognize that otoplasty surgery can make a dramatic difference. Otoplasty is a fairly simple procedure that reshapes the cartilages of the ear from an incision on their backside. In a one hour operation, the ears can be dramatically reshaped so they blend in naturally and inconspicuously to the side of the head. The average costs of an otoplasty is generally in the $4,500 to $5,000 range, all costs included. You may be able to work out a discounted fee with a plastic surgeon and I would not be afraid to have that discussion with their office. Perhaps you will be able to work a ‘single mom’s’ fee reduction for your daughter’s otoplasty surgery.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: I had a SMAS facelift earlier this year in February. I also had my eyelids done as well. I have several problems from this surgery. My eye opening is smaller than before and one of my lower eyelids is hanging down. In addition, you can not tell that I have had a facelift. It doesn’t look different or improved at all. The Dr. said he will not redo it. Will I have to get a complete facelift again? Do you do redos?

A: Anytime there is an outcome that does not meet a patient’s expectations, it is important  to determine why. There are only two fundamental reasons; there has been a complication that mars an otherwise acceptable result or there has been a fundamental miscommunication between the doctor and the patient as to what to expect afterwards. Having one lower eyelid than hangs down or is pulled away from the eyeball after surgery is known as ectropion. That is a postoperative complication that can occur after a lower blepharoplasty. If it is a small amount of ectropion and it is not that far out from surgery, then time and patience are acceptable for now. But since it is four months after surgery and there is still some noticeable lower eyelid malposition compared to the other side, revisional lower eyelid surgery may be needed. Why you see no result from your facelift is another matter. That would be an unusual outcome given the nature of how a facelift is performed. I think you need to go back and discuss your results with your original plastic surgeon. Most likely what he said was that he would not revise or redo your surgery at just 4 months after surgery. A different answer may be forthcoming with more time and if your lower eyelid ectropion persists. Only after you have given the original surgeon ample opportunity to come to a mutually acceptable decision should you pursue an outside opinion for revisional surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  I am going to get a breast augmentation next month. I am 23 years old. My plastic surgeon never mentioned or suggested about getting a mammogram before surgery. I have read that some plastic surgeons require it while others do not. What is your recommendation?

A: Whether a mammogram is needed before breast augmentation has no uniform answer. Every plastic surgeon has a different perspective on this issue.  My practice is to not get a mammogram under the age of 35 unless there is a family history of breast cancer or a history of breast problems such as cysts or fibromas. While breast cancer does rarely occur in younger patients, the statistical likelihood of a young patient having it is so low that I do not feel that the extra expense and radiation exposure justifies the effort. After age 35, I follow the recommendations of the American Cancer Society in regards to a baseline mammogram and subsequent studies. Some plastic surgeons routinuely get mammograms regardless of age before breast augmentation and this is a perfectly valid approach as well. You need to discuss this issue with your plastic surgeon and reach a mutually acceptable approach to the need for this presurgical breast screening study.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: I want a bigger butt and am interested in silicone injection buttock augmentation. How much does it cost?

A: As you may not be aware, the use of silicone injections is poor medical practice (if not illegal) in the United States..not to mention that it is a terrible procedure associated with a lot of complications. It seems to be performed only by the most nefarious of practitioners some of whom are not even physicians. I would advise you to stay well clear of this approach to buttock augmentation. Fat injections to the buttock, however, are a different matter and are an accepted method of natural buttock enhancement. This is the injectable procedure you should be considering. It has the advantage of not only being safe but gives one the secondary benefit of liposuction done elsewhere, usually on the stomach, waistline and back. Its one drawback is that how well the fat survives and takes is not always assured and only so much fat volume can be done at a single time. But that is a much better ‘problem’ and easier to recover from than infection, granulomas and skin pigmentation changes that are not infrequent problems with silicone injections into the buttocks. Not to mention that the silicone can never be removed no matter what problems it may be causing,

Dr. Barry Eppley

Indianapolis Indiana

Q: My nose is fatty from the tip area. When I smile it becomes even more broad. Should I get just the tip changed or should I go for whole nose plasty. I have attached some photos for you te see what my nose looks like.

A: When considering rhinoplasty, it is important to first look at the whole nose. While it may be that just the tip area seems to bother you, the problems with the tip may extend up into the upper two-thirds of the nose as well. This would be very common in the broad or wide nose. ln reviewing your pictures, you have a rather classic ethnic nose. (Indian) The nose skin is thick, the tip is broad, the nostrils are slightly flared, there is a hump that extends up into the upper third of the nose and the nasal bridge (bone) area is wide. In essense, your broad nose is not just limited to the tip area. Rather it is an aesthetic issue that extends throughout the entire nose. Doing just a tip rhinoplasty alone may likely leave you unsatisfied with the final result. I would recommend a complete rhinoplasty in which the hump can be removed, the bones narrowed, the tip reshaped to be less broad with increased tip rotation and the nostrils narrowed. I think you will be far more satisfied with this rhinoplasty result. The differences between a tip and full rhinoplasty can be easily illustrated with computer imaging before surgery.

Dr. Barry Eppley

Indianapolis Indiana

Q: I desire a larger more prominent but one that is more sculpted. Can you do the a cleft chin implant with the y fissure? Or a chin dimple? I am looking for a square chin implant with the y fissure. I have a implant now but it is not squared and not exactly what wanted.

A: Chin implants today come in a vareity of styles and sizes. Some of those styles from different manufacturers include square chin implants and chin implants that have a central vertical groove or cleft in them. I find the square chin implants very effective for those men that need more transverse chin width. The cleft chin implants, however, look good on drawings and would theoretically appear to create an often desired chin cleft. In reality, however, the external appearance of the cleft may not always appear due to the effect of the overlying thickness of the soft tissues of the chin. That is why I also create a vertical groove in the muscle and sew the tissues into the clefted chin implant to be sure that an external effect is seen. Chin clefts in implants can be done with either a dimple or a vertical fissure or groove. When trying to place one in conjunction with a chin implant, it is more reliable to have a vertical groove or notch whether the implant has that shape or not. You can always take a squate style chin implant and cut a cleft or vertical groove in it at the time of surgery. That is a simple intraoperative manuever to do during chin implant augmentation.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am interested to find out if you could help me to reduce my facial assymetry. What would you actually perform as I am not able to even guess that, but it seems that my halves are different in jaw and forehead shape. I want to make my face more symmetrical and I want to reduce and minimize the difference of my jaw and forehead. Please advise what kind of procedure do you recommend and what would be the estimated cost. Attached is the photo so you can see and assess the treatment.

A:  In looking at your frontal view photograph, I see four isses that are making your face asymmetrical. The first is the difference in the sdie of the jaw angles between the two sides. The right is bigger than the left. That could be addressed by either a right jaw angle reduction or left jaw angle augmentation depending upon which side you like better. Secondly, there also appears to be left cheek deficiency which is less prominent than the right. That would be compatible with the left side of your face being smaller than the right. That could be improved by a left cheek implant. Thirdly, the right upper eyelid has more skin which hangs down onto the lashline. That could be removed by an upper eyelid blepharoplasty. Lastly, your nose is deviated towards the left side  with a broader tip. That could be improved by a rhinoplasty. I think the combination of these four procedures would go a long way to improving your facial asymmetry.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am interested in getting a subnasal lip lift as my upper lip is way too long and is getting worse as I age. I have several concerns about the procedure, hwoever, and wonder what could be done if undesired results happen. I had a previous rhinoplasty dne through an open rhinoplasty several years ago that I am quite happy with. Since the subnasal lip lift puts an incision at the base of the columella could that stretch or distort the space between my nose and lips and make it appear freakishly short? I know initially it may look a little short and that it does relax and stretch out somewhat later, but what if it doesn’t. Can any secondary correction be done if things didn’t resolve on their own? Thanks for your opinion.

A:  Your concerns about overcorrection in a subnasal lip lift, also known as the bullhorn lip lift, are very valid and it is something I think about every time I do this procedure. This is because of it is overcorrected, too much lip skin removed, there is no recovery from it. There is no aesthetic method of putting skin back once too much is removed. It is for this reason that it is always better to be more conservative than aggressive with this procedure. My rule of thumb on subnasal lip lifts is too never remove more than 1/3 of the vertical distance of skin as measured from the based on the columella down to the height of the cupid’s bow along the philtral column. Sometimes I may only remove 1/4 of that distance. Yes it is too true that it may relax and be undercorrected in some cases later. But it is always easy to repeat the procedure, it is impossible to reverse it if too much is removed.

Dr. Barry Eppley

Indianapolis Indiana

Q:  I am trying to make my face symmetrical. My jaw is not aligned, making my mouth and smile crooked and my nose is wide with a pronounced bump. I have attached some pictures for you to evaluate, image, and give me recommendations as to what to do. Thanks!

A: An analysis of your pictures shows that you do have a deviated nose with a hump and a wide tip. But in addition, you have left facial hypertrophy. This is the origin of why you feel that your jaw and smile is crooked. The left side of your face, from the orbit down to the jaw angle is bigger and wider. This creates your facial imbalance/crookedness. I have done some imaging of your rhinoplasty, with and with adjustment of the left facial enlargement. In facial asymmetry it is always a question as to whether to build up the smaller side or reduce the bigger side. In your case, I think it is better to try and make the larger side smaller through cheekbone and jaw angle reduction. This is shown in your rhinoplasty front view imaging, both with and without it being done. From a side view, I have also added a small chin augmentation as your profile shows some mild horizontal chin deficiency.

I think the combination of rhinoplasty, cheekbone and jaw angle reduction and chin augmentation can make for a more symmetrical and balanced face. This will not change the asymmetry in your smile as that is soft tissue-based and can not be adjusted like the underlying harder facial structures.

Dr. Barry Eppley

Indianapolis Indiana

Q: I have lipoatrophy and would like to perhaps have my face lifted and cheeks implants placed in order to achieve a fuller, rounder appearance so I am able to appear the age that I am which is age18. I sent in earlier pictures and I was smiling in them and was told they were unusable so I sent these.

A: Thank you for sending your additional pctures. You probably have the most severe case of facial lipoatrophy that I have ever seen in someone your age. Facial lipoatrophy is classified on a scale of 1 to 5 based on its severity. You are clearly at least a 4 if not a 5. You face is completely skeletonized with essentially no fat, thus resulting in hollowing of the temporal, submalar, maxillary and lateral facial areas. This problem is not treated by any form of facelifting. Rather it requires volume addition, most of whcih must be fat not implant. Submalar implants would be helpful in the cheek area but most of the volume addition must come from fat injections due to the size and location of the hollowed areas. The important question is….do you have enough fat to harvest and transfer? Most medically-sound people with severe facial lipoatrophy are also thin in their bodies, thus having little fat to harvest for the procedure. At a minimum, you need about 30 to 35 cc of concentrated fat per facial side (in addition to the submalar implants), which means that 150cc to 200cc needs to be harvested from somewhere, usually the abdomen or thighs. While that is not much and easy to get from most people, your body may be a different matter.

The pictures you sent are not easy to show the results of volume addition, which is virtually impossible to image from the side view. The front view imaging is not great but it demonstrates what happens when your facial hollows are filled in or expanded. Just think of your concave facial regions becoming more even with the surrounding bone structure.

Dr. Barry Eppley

Indianapolis Indiana

Q: I have been researching how to make my cheek area look better as it seems to be kind of flat and has no cheek highlights, plus my face is a little round. It seems I have two choices, cheek implants, buccal fat removal or some combination. In my research I have reading that cheek augmentation would be better than the buccal fat removal as far as years down the road as I may not like it and it may look like I am older than I really am. Just doing some research on this subject. What is your opinion? Thanks for your help.

A: Both cheek implants and biccal lipectomies do impact on the appearance of the midface. While they are in close proximity, they create different midface effects. Buccal fat removal decreases the fullness below the cheekbone area. If the complete buccal fat pad is removed then a gaunt look may eventually appear is some patients. The key is subtotal reduction, particularly in someone who does not have a ‘fat’ or round face. Cheek implants create a different effect as it brings out the prominence of the bone above the buccal fat area. These can be not so subtle differences and you have to look and play with your own face to see whether more cheek or less fullness below it is better. They are not necessarily interchangeable procedures. Whether one is better than the other, or whether a combination of both is best, is determined by one’s facial shape and must be decided on an individual basis

Dr. Barry Eppley

Indianapolis Indiana

Liposuction remains the most rapid way to lose unwanted fat albeit a surgical one. While it is ideally for those people who have made every effort to lose fat areas on their own through diet and exercise, not every fat area responds the same. Some fat areas are more difficult to lose than others and certain fat areas can not be reduced at all except in the face of extreme weight loss. It is these non-metabolically responsive fat areas that justify liposuction intervention.

One of the very good questions any prospective patient should ask about liposuction is will my fat return? Will I keep this fat off years from now or is this just a short-term fix? Economically does this procedure have a good ROI? (return on investment) There are many urban myths about whether fat can or can not return after liposuction. Where some of these purported claims come from I do not know, but science and a lot of patient experience provides the following insights.

Fat will not return after liposuction. This is patently false and perhaps was started and propogated by what one would hope will happen. The reality is fat can return. The results from liposuction are closely aligned with your weight. If your weight stays the same years from now then so should the result. Fat after liposuction can return just as easily as after weight loss…and then weight gain. Some body areas are more resistant to fat return than others (knees or arms vs stomach and waistline), but no body area or fat cell is completely immune to the allure of extra calories.

If fat comes back after liposuction it will go to other body areas. This is sort of true but not to the extent of what was originally removed. A recent published study showed that fat suctioned from the stomach and thighs from women had some slight increase in measurements in the arms and upper back a year after surgery. But not to the extent that the women noticed or was bothered by it…or that they regretted having the procedure. If fat returns it must go somewhere and it is logical that it may have more trouble going back to a treated area that is now embedded with scar tissue.

Fat cells are permanently destroyed by liposuction. This is not true. Those fat cells that have been suctioned out are permanently removed. But there are always lots of fat cells left behind as you can not or would you want to remove them all. (otherwise your skin would be stuck down to your muscles and wouldn’t move) While the fat cells that are left behind may be damaged, they have a great ability to heal and regrow. Since it has been discovered that fat sites have the highest amounts of stem cells in the body, and stem cells can be easily stimulated to grow and transform into fat cells, liposuctioned fat sites are not immune to  recur. This may be different with the current use of Smartlipo (laser liposuction) where the heat from the laser energy can cause more fat and stem cell damage.

Despite the effectiveness of liposuction to reduce unwanted fat, the long-term success of the procedure is highly dependent on the lifestyle habits on whom it is performed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I had cheek and jaw angle implants last year. While I think I look better, I still feel my face does not have enough definition and is still a little too round. What do you recommend that will help my facial aesthetics? I have attached some before and after pictures from my previous surgery.

A: Thank you for sending your pictures. I think you have achieved some facial highlights from your previous procedures but implants also add width and volume. In certain faces this can make one’s face look a little ‘fatter’ or fuller and not always provide the definition that one wants. This can be particularly true with jaw angle and cheek implants. To create some further facial refinement, I would recommend buccal lipectomies to slightly narrow the area below the cheek implants, a chin implant with a prejowl extension to smooth out the jawline better (your chin is slightly deficient and there is a notch in the jawline at the prejowl area) and possible a jowl tuck-up to remove some skin along the jawline an give it better highlights and a possible thinning rhinoplasty. The goal now is to create more definition in your face and help better highlight the facial features that you now have.

Dr. Barry Eppley

Indianapolis Indiana

Q:  I need to do something with my stomach to make me feel better about myself. I have had two children and the last one really did my stomach in. I didn’t have any stretch marks or loose skin after my first child. But I gained 45 lbs with my second and obviously my skin didn’t like that and now I am left with some loose skin and stretch marks particularly around my belly button. I did have a plastic surgery consult about six months ago and was told that I needed a mini-tummy tuck with a ‘free floating umbilicus’. I didn’t understand what that was and I was worried that my belly button would move around so I never had the surgery. Can you tell me what that is and should I be concerned about it?

A: The fundamental difference between a full or complete tummy tuck and a mini-tummy tuck is in how much skin and fat is cut out and where this occurs. In a mini-tummy tuck this tissue removal is done below the belly button as opposed to a full tummy tuck where it is done above and includes the skin around the belly button. Thus in a mini-tummy tuck, the underlying attachment of the belly button to the abdominal muscles (technically the fascia covering of the muscles) must be released so the upper abdominal skin can stretch down and close to the lower abdominal incision. Before closure the base of the bellybutton is reattached in a new lower position, usually about an inch or so lower than where it was originally. It is only ‘free floating’ for a very short period of time during surgery and is not an issue after surgery. The term free floating is both an historic and poor name which is why it is better known as umbilical transposition or relocation.  

Dr. Barry Eppley

Indianapolis, Indiana

Q:  I am 62 years old and I am thinking about getting breast augmentation. I got divorced recently after 35 years of marriage and want to start dating again. I think breast implants will make me feel and look better, not to mention more appealing. My breasts have shrunk and have gotten quite floppy over the years. Do you think I am nuts for considering this cosmetic procedure at my age?

A: I don’t think there is an upper age for breast augmentation or any other cosmetic procedure. If one is healthy and in good physical condition, then there should be no problem with undergoing this surgery. The more important question is whether breast implants alone will create the result you want. With advancing age, the breasts not only lose volume but develop more sagging or ptosis. If the nipple is pointed south or hangs at or below the lower breast crease, then some form of a breast lift will definitely be needed in addition to an implant.  If the nipple sits above the lower breast crease then breast implants alone will create the look you want.

Today’s 60 is yesteryear’s 45 or 50 so your request, while not common, is both reasonable and medically safe.  The oldest breast augmentation patient I have performed was 64. It is also important to remember that breast reconstruction is regularly done on patients your age. So the desire to look normal and or even be enhanced is not limited by age.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  I am interested in getting breast augmentation but am confused about what size of implant I should get. I am 5’ 4’ and weight 115 lbs with a small A cup and I mean really small. I wear a 32A bra. I want to be a small to medium C cup but don’t want to look like I obviously have breast implants or a look like some entertainer. What is the best way to go about selecting the size of the breast implant that looks best on me?

A: For any woman undergoing breast augmentation, size is the number one issue they understandably think the most about. Plastic surgeons have numerous methods of how they size patients and there is no uniform method for doing so. The ‘safest’ method of breast implant sizing is matching the base diameter of one’s breast to the base diameter of an implant. Each size of breast implant has an increasing base diameter as the size or volume of the implant gets bigger. With this approach there is no fear of the implant being too far to the side (in the way of the swing of the arm) as it is matched to one’s natural breast dimensions. There is also no fear that the implant will ever be too big. Conversely it is more likely that for some women the final result may not be big enough with width dimension alone so it shouldn’t be the only criteria used. But it is the one that can  be specifically measured and is unique to each patient.  

Dr. Barry Eppley

Indianapolis, Indiana

Q:  I have 3/4 inch gauges in my earlobes which were taken out 6 months ago. I would like the holes sewn up so I have normal looking earlobes again. I want this done asap, please contact me soon. Thanx!

A: Thank you for your inquiry. Please send me a picture of your ears so I can see how big the residual holes are. The good news is that gauged earlobes create an excess amount of lobe tissue, making a good reconstruction possible albeit with a few fine line scars. This procedure is very common for me so all arrangements can be made to do the repair as an office procedure under local anesthesia in advance to save you a separate consultation trip.

The earlobe reconstruction takes about an hour to do for both ears. Sutures are placed on both the front and back of the earlobe. Only those on the front of the earlobe need to be removed 7 to 10 days later. (if one is from out of town dissolveable sutures are used on both sides of the earlobe so removal is not necessary) There is no dressing applied and no special wound care other than to apply a little antibiotic ointment. You may shower and wash your hair the very next day. There are no after surgery activity restrictions. Within a few months the earlobe scars fade to a near indiscernible appearance.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I would like to know if there is any procedure that can be done to reshape or reduce the muscle on the tip of my chin. I had a sliding genioplasty in 2005 but I still have this round fleshy muscle on the end. I know the muscle is functional but can it be reduced at all or reshaped? I can send pictures if you would like. Thanks so much.

A: What you are referring to is the size or thickness of the mentalis muscle. That certainly makes up some of the chin thickness but there is also some contribution by fat also. Some debulking of the mentalis muscle can be done but you have to be careful not to take too much. That can cause  scar tissue and lead to irregulrities and muscular fasciculations when the chin moves. But it may benefit by some debulking and repositioning on the chin bone since you have had a prior sliding genioplasty. I would have to see some pictures to have a better idea as to whether that is a reasonable option.

Dr. Barry Eppley

Indianapolis Indiana

Q: Hi Dr Eppley, I had chin implant taken out before the doctor tried to sew the intraoral incision under the lower lip 3 times to fix numbness and droppy lower lip before taking the medium silicone chin implant out which was put intraorally. Now after 6 months the pain and numbness is gone but the chin is droppy due to all these surgeries. Do you think a sliding genioplasty will make the chin look less droopy and, if it is possible, to also slide it forward and bit upward? Where I live the surgeons are not advanced as you Dr Eppley. I tried to call the manufacturer who supplies dissolvable bone anchors but they did not know anything about this treatment. Please advice me something as I have lost all hope.

A: The concept to grasp about the placement of a chin implant is that it stretches or expands the existing chin tissues. In essence, it creates more soft tissue than was originally present. This combined with disruption of the mentalis muscles off of the bone over a  projecting prominence make for a potential problem if the implant is ever removed. Without implant support, the chin soft tissues will sag or become ptotic. There are multiple strategies to deal with this chin problem but a sliding genioplasty can be a very effective solution. As the chin bone is advanced, it not only increases chin prominence but adds underlying volume to support the sagging expanded soft tissues. While I would have to see pictures of you to be sure, this sounds llike an excellent solution to your chin problem.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am 45 years old and have been frustrated with the appearance of my jowl area.  I  am interested in improving that part of my face.  I want to learn more.  What is the recovery/healing time?   Can anything go wrong during procedure? Thanks

A: Sagging of the jowl area is a natural part of aging and is often the first area of the face to fall. Provided that the neck is not also sagging, and it often isn’t early on, a modified or limited type of facelifting procedure is used. Known by a variety of branded and marketed names, which imply rapid recoveries and minimal interruption in your lifestyle, it is a jowlift or a mini-facelift. Because it is a scaled down version of a facelift, it is a much shorter procedure to undergo and the recovery is likewise much quicker…like in the one week range. Recovery in this limited type of facelift is largely social in how one appears. (bruising, swelling) Other than the typical surgical risks of bleeding, infection and adverse scarring, there is nothing else that can go wrong of any significance. None of these risks have I ever seen in this jowl lift procedure.

The good thing about this jowl lift operation is that it is a solution that is well matched to the size of the problem. Jowling is a relatively minor facial aging issue and therefore it does not need a major operation  for its improvement.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Hi Dr. Eppley, I would like to inquiry which scar removal procedure (besides laser treatment which I have tried – result is not so great) will you advise for the alar rim of the nose area? I had my alar size reduced through a surgery a few years back, the cutting was almost around the whole alar (sides). Unlike other scarring on other flat areas, the alar somehow retracts due to different expressions like laughing. Hope to hear from you, much appreciated thanks.

A: From your description you appear to have had alar rim narrowing, presumably as part of a rhinoplasty procedure. Usually that scar is intended to be placed in the ‘hidden’ skin groove between the attachment of the alar rim (nostril) and the skin of the upper lip. Most of the time this area heals very well although on close inspection in some patients the fine white line may be slightly perceptible. What you are describing as a scar problem does not sound exactly like a scar problem per se. Rather it sounds like it is a nostril retraction problem that becomes evident when smiling or other expressions that push the lip up against the nostril. I suspect that the problem is that the nostril shape has been changed (shortened in circumference) that now allows it to move unnaturally. The scar tissue from the prior procedure may also tether the nostril down creating the same problem. Whether it can be improved by any form of scar revision would depend on my assessment of pictures of the scar, both smiling and non-smiling.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am a 25 y.o male with a substantial overbite that has remained after a long orthondontic treatment at a too late of an age and a recessed chin, altogether creating that “neanderthal” ethnic look to my bottom face.

Rather than living with it or going through a massive jaw surgery, I was wondering since a significant part of the protrusion is actually caused by a fat philtrum – wether there is a procedure that can reduce the philtrum thickness (with an internal stitch in the upper mouth). From  a short online enquiry I am starting to think it isn’t possible, and even if that is the case – would still like to know why – is it because it has muscles and not only fat?

I would also like to know why are lip reductions usually very subtle (only about 10%?), and whether there is a vertical reduction in the circumfrance of the lips (I have enough excess lips to go around two mouths…)?

Thanks for your time.

A: Philtral upper lip reductions are not possible because the lip is largely muscle and would cause a lot of lip dysfunction. PLus whatever little bit of thinning could be obtained is not enough to make a visible difference to compensate for maxillary protrusion.

I can explain to you why your perception of lip reduction results is only ‘about 10%’. That has not been my experience where it is more typically a 20% to 30% improvement in my lip reduction surgery efforts. Perhaps, some surgeons are understandably more conservative since you can always take more but you can”t put any back.

Dr. Barry Eppley

Indianapolis Indiana

Q:  Hi, I wanted to ask you about lipolysis injection treatment in lipomas. I want to ask whether the method of lipolysis is effective over the lipoma. How many sessions are needed? Will I have the desired effect? I want your opinion on this matter… thank you.

A: There is no doubt that the excision of lipomas is standard treeatment because it is more effective and a one-time surgery for that specific lipoma. While there is a trade-off of a scar, it usually is less in size than that of the diameter of the lipoma. But for those who are opposed to excision, injection therapy can be done. But it will take multiple sessions whose number depends on how big the lipoma is. For each cm in lipoma size, there is usually 2 injection sessions. So measure yours and you can do the math to see how many injections sessions might be needed. There is also a higher risk of recurrence with injection therapy because not all of the lipoma, or its attached blood supply, may be completely eradicated.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am thinking about getting numerous facial procedures and I have a few questions. I am wondering if getting a chin implant will stop hair growth on my chin? Whatever I have done I want a natural look, will too much facial surgery ruin this or make me look unnatural? Last question,what are some alternatives to cheek implants?

A: A chin implant will not stop beard growth on the chin. It is put in through an incision under the chin so it is very far away from the hair follicles of the chin skin.

Getting a natural result in facial surgery is based on doing whatever procedures are done in balance with the rest of the face and not overdoing any one procedure. Facial surgery, whether it is a rhinoplasty, chin implant or forehead recontouring, is making the structural change to look ike it belongs to the rest of the face.

The only alternative to cheek implants is fat injections. While I think cheek implants and their numerous styles and sizes offer more versatility for cheek changes, fat injections can definitely add volume to the cheek and submalar (below the cheek) areas. With today’s more concentrated methods of fat preparation, fat injections to the face also work better in terms of maintaining volume to the injected facial area.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am interested in getting either a new chin implant or modifying the one I have. I had a Medpor contoured two-piece chin implant with 7mm (medium) projection placed about one year ago. While I like how much projection it has given and its front shape, I feel it is not adequate as it goes around the side of my mouth below the corners. I would like it fuller in this area but I don’t want a square chin implant shape either. I still want it contoured. What do you recommend?

A:I have taken a careful look at your existing chin implant’s dimensions and your desire for more lateral fullness as the implant crosses a vertical line below the corner of the mouth. In most patients that is going to be about 30 to 35mms from the midpoint of the chin back along the jawline. Your current implant has a thickness of about 4.9 mms (.7 of total 50mm wing length x 7mm central thickness) in this area as it tapers posteriorly. Switching to a larger projecting implant (9mms) will only make about a 1mm difference (5.7mm) in this prejowl area. A different style chin implant of the same central projection will not produce any larger fullness in this area. (4.5mms) Therefore, it is my advice to not consider changing the implant as no current chin implants styles make for increased fullness in this area without adding more horizontal projection. One option to consider, which is actually easier, is to keep the existing chin implant and place ‘shims’ underneath the implant in these areas. Shims are wedges of cut material that are slid underneath the indwelling implant that can provide more fullness to the implant in this area than it otherwise has. Since you have a Medpor implant, I would use double-stacked 1.5mm shims to accomplish this implant modification.

Dr. Barry Eppley

Indianapolis Indiana

Q: I would like to know your opinion about mandibular implants for woman. I am 53 and I was told that an angle implant would improve my features, as I have a steep mandibular plane; it would also be better to do it prior to face lift. Thank you for your opinion and advice.

A: Jaw angle implants are not that common in women as a well defined and angular back of the jaw has not been an historic aesthetic feature for women. That has changed in more recent times as more celebrities and recognized women with fairly angular jaw structures are seen regularly. While too strong of a jaw is obviously not desireable for women, a weak jawline and shape does not age well either. More recently I have done jaw angle implants for women, either to get a stronger jaw angle in younger women or to enhance the appearance of an aging jawline in middle-aged women who have a weak jaw angle or steep mandibuar plane angle.

While I obviously can not answer whether jaw angle implants are a good choice for you without seeing pictures, it can be determined before surgery whether they would be advantageous with computer imaging. That can show you quite clearly whether they are of benefit. When done as part of a more complete hard and soft tissue facial rejuvenation, I would recommend having it done at the same time as a facelift. While there is an argument to be made for separating the procedures (swelling), there is the inconvenience of two separate procedures.

Dr. Barry Eppley

Indianapolis Indiana

Q: Dear Dr. Eppley, I am a 19 year old male. I am having a 5 mm lower jaw advancement (BSSO). I know that the human jaw and chin and other facial bones continue to grow until around age 25. I also know that after surgery, the doctors screw and bolt your jaw into a new position. Would this mean that since my jaw would be screwed and bolted in its new position that my jaw will not be able to grow anymore? Will I have my 19 year old jaw all my life? The reason I ask this is because I have a small jaw, and I want it to keep growing as much as it can, but I am afraid that this surgery I am having in a few months will stop the growth of my jaw.

A: Jaw (mandible) growth in a male is known to not stop growing until at least age 21 or so. That is the reason any form of jaw surgery, mandibular advancement or mandibular setback, is not usually done until age 17 or 18. At this age, one is unlikely to outgrow their surgical result. This is much more of a potential concern when the jaw is set back than when it is moved forward. I have never seen a jaw advancement done where it becomes ‘too short‘ later in life. But I have seen jaw setbacks where the underbite recurs with ongoing jaw growth. This indicates that surgery of the ramus does not really affect jaw growth and I think this is not a concern that you should have.

Dr. Barry Eppley

Indianapolis Indiana

Q:  My 17 year old son has pectus excavatum which is more pronounced on his left side. It is slight according to the pediatric surgeon we saw and he felt that any sterna reshaping surgery wasn’t justified. He was fitted for a chest brace which was ineffective. Is there anything that can be done that doesn’t involve cutting the bone like some type of implant?

A: Minor cases of pectus excavatum can be cosmetically treated by onlay implant augmentation. There are no specific sternal implants that are available off-the-shelf. In addition, it is desireable to limit the need or size of an incision to minimize scarring.  A noticeable scar would make for a poor aesthetic trade-off  despite the sternal contour improvement. Therefore, I have found that the use of Kryptonite bone cement currently offers the best treatment option. It can be injected through a small tube, making for a very small incision of just a few millilmeters. Once injected, it can be molded and contoured to smooth out the sterna depression. Another potential option is fat injections. With today’s improved fat concentration techniques, the survival and volume retention of fat is much improved. In small areas like the lower end of the sternum, I would expect fat volume survival to be good. The only negative is that it would be soft rather than firm like a normal underlying sterna bone. Whether this is significant is a matter of debate.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Hello, my problem is that I have a lower anterior face height deficiency. Because of that my total face looks very small. First I didn’t know what the problem was. After examining my face very well I came to see that the lower anterior face height is very small. I have a very little chin and small jawline. I have read your article entitled ‘Case Study: Vertical Jawline Lengthening for a Short Lower Face’, and I think I have the same problem as this girl that is mentioned in the article but a bit worse than that. I have attached some pictures of my face so that you can take a closer look. When I look at the photos I think my lower anterior face height should be longer. Can I do this with a chin and a jaw implant or some kind of other implants? Because I’m not sure what kind of implants the girl in the article had. I think I have the same problem as her but more extreme. I would like to know your professional opinion. I went to a local plastic surgeon but they didn’t understand what I mean or maybe they just don’t have the techniques. They kept saying my chin had the right position. (apart from that  my chin). Because my lower anterior height is small my forehead looks a bit big. But it is a normal size forehead, it’s just compared to the lower face it looks big. So I think my face needs to be lengthened vertically and a bit horizontal at the jaw (because when it is only vertically lengthened my face will look long, because I don’t have a wide face). I hope you see what I’m trying to say because I know something is not right.

A: I can see perfectly what your facial concerns are and you have stated them quite accurately. Your lower facial height is proportionately short compared to the upper two-thirds of your face. Your chin needs to be vertically lengthened by 7mms and horizontally advanced 5mms. That can not be done with an implant but requires an osteotomy. There is where the chin bone (not the main jaw bone) is cut and moved down and forward. It is held into its new position by a small plate and screws as it heals. This is done from inside your mouth through a small incision in the vestibule below your front teeth. This is a common chin surgery that I regularly perform which is highly successful at improving your lower facial lengthening.

Dr. Barry Eppley

Indianapolis, Indiana

If a picture is worth a thousand words, then a story is worth at least five hundred words. Many mothers may find this story of interest.

‘When 34 year-old Kathy opted to get breast implants and a lift one year after having her third child, she didn’t really think of herself as having any type of makeover. She just wanted back what she had before children and to regain the confidence and clothing options that she once had. Before three pregnancies, she was a nice full C cup. But between breastfeeding and the repeated stretching and shrinking that occurs from the pregnancy process, she was now done to nearly an A cup. She knew it was bad when her sister said she really need some plastic surgery.

Two years later, she returned for a tummy tuck. She wouldn’t be seen in a swimsuit or any tightly fitting clothes, lest her stomach bulge be seen complete with all of its stretch marks and an unusually-shaped belllybutton. Despite of years of steady dieting and numerous weekly workouts, no stomach cure had been achieved. She wasn’t fat but had a lot of loose skin of which no amount of exercise is magically going to burn off. She finally realized that she was trying to get rid of something over which she had no control. ‘

Between the two plastic surgery procedures she had undergone a Mommy Makeover, a popular term used for multiple plastic surgery procedures that restore, or improve, one’s post-pregnancy bodies. Unlike the extreme plastic surgery makeovers seen on TV, mommy makeovers are extremely common and the breast and stomach procedures are both done at the same time. Unlike the previous generation, mothers of today want to return to their old body and, in many cases, even have a better one than before the pregnancies.

One interesting thing about Mommy Makeovers is some psychology behind them. Many women feel guilty and little selfish about such ‘self-indulgence’. They may also be worried about taking time away from their children’s and husband’s hectic schedules to undergo surgery. Some may argue that how you feel as a mom is important to one’s family as well. It is not really all that self-centered to feel youthful and more confident. Having an improved body image may also improve one’s interactions with their own family. I am not a women nor have ever been pregnant so I can’t speak for whether this is psychological double talk or fact. But I do know what many women have told me… they may be a mommy but they are still their own person as well.

One very common Mommy Makeover questions I get asked is, how soon after my last pregnancy can I have surgery? How long to wait differs on whether it is the breasts or the stomach that is being addressed. Breast augmentation and/or lifts can be done as soon as six months afterwards as time never improves breast shape. One only awaits the completion of breast feeding or the maximal amount of breast deflation. Liposuction and/or tummy tucks should wait until you have put forth your best effort at diet and exercise or have come to the realization that the loose skin is the main problem. This may be six months for some and for other women it may be years later.