Your Questions

Q: Hello! I’d love to schedule an initial consultation with Dr. Eppley. I’m also interested in the program Dr. Eppley offers for military families as my husband is an active duty soldier who’s been in the Army for over 10 years. After two deployments and a new baby, we are ready to try and normalize our lives again. For me, feeling normal and happy is critical and in order to achieve my dreams, I must address my post-baby body! Although I’m nervous about heading down this road; I’m ready and I look forward to hearing from you. Thank you very much.

A: When you consider the post-partum body changes and being in the military, what you need is the Military Mommy Makeover! (M cubed so to speak) All mommy makeovers involve contour changes on the abdomen and breasts. While there are many variations and combinations of these procedures, it could be as simple as abdominal and waistline liposuction and breast augmentation to a full tummy tuck with flank liposuction and breast implants with a lift. More times than not, it is the latter as pregnancies usually leave extra skin on the stomach and sagging skin on the breasts partticularly if one has had more than one child. My Patriot Plastic Surgery program offers military members and their direct family a discount for surgical procedures. This will hopefully enable them to have some desired physical changes done, and as you have described, normalize your life again.

Dr. Barry Eppley

Indianapolis Indiana

Over 30 million people in the United States have some degree of migraine headaches. While there are drug therapies that are very effective, some patients either get little to no relief or have other problems related to side effects from taking the drugs. For a small number of migraine sufferers it is very disabling and little benefit is obtained despite the best neurologic care.

Plastic surgeons have developed new procedures to “deactivate” migraine headaches…and it was learned from results seen from cosmetic treatments. Usually cosmetic surgery benefits from what is learned in reconstructive surgery but this is one of the rare instances where the reverse has occurred. Based on Botox injections and browlift surgery, both which temporarily paralyze or remove certain brow muscles,  significant improvements or actual cures occur in migraines that start in the forehead. This has led to understanding the cause of migraines in some patients known as the peripheral trigger.

The peripheral trigger theory of migraines is based on certain sensory nerves being squeezed or compressed by a surrounding muscle or contact point. Due to the nerve being irritated, this leads to a cascade of events that becomes a migraine. To date, four trigger areas have been identified. Three of these are where a nerve passes through a muscle and many with migraines can actually put their finger on these exact spots; the greater occipital nerve in the back of the head, the zygomaticotemporal nerve in the temple area, and the supraorbital nerve at the inner half of the eyebrows. The fourth trigger point has been identified in the nose where a significant septal deviation makes contact with an enlarged turbinate.

Surgical migraine deactivation is done by removing the source of irritation, the muscle from around the nerves or straightening the nasal septum. This is done through small incisions inside the scalp hair or from inside the nose. Studies have now been reported that such surgery produces good results that last, with nearly 90 percent of patients having at least partial relief at five years after surgery. Migraine attacks were less in number, not as severe, and lasted for a shorter period of time.  In about one-third of patients studied their migraine headaches were completely eliminated.

While migraine surgery is for just a minority of sufferers, it is not a procedure that is associated with any significant complications or side effects. The procedures are comparatively minor surgery, have quick recovery, results are immediate and no patient yet has reported that they have gotten worse afterwards.

How does one know they may get improvement in their migraines with surgery? Before surgery, one needs to be tested with Botox injections to confirm the correct trigger site. If Botox works to temporarily improve migraine symptoms, then the peripheral trigger is confirmed and surgery will likely be successful. But before one considers Botox injections and even surgery, they should be initially evaluated and treated by a neurologist. Only after failure of traditional medical treatments should one consider this new plastic surgery treatment.

Dr. Barry Eppley

Indianapolis, Indiana

Breast augmentation continues to be one of the most popular and successful body contouring procedures in plastic surgery. While it may seem hard to make the association of breast enhancement with confections and desserts, they are more closely related than one would think. This is because of two recent technological advances in the type of breast implants that are available and how they are implanted at the time of surgery.

One important, but often overlooked, aspect of the surgical implantation of breast devices is getting them placed into the breast pocket. When only saline implants were available this was never a concern as they were inflated after they were placed. This meant that very small incisions could be used for their introduction that were not even on the breast. Rolled up like a burrito, a saline implant is inserted through a one inch incision and then inflated to the desired size. With the re-introduction of silicone breast implants in 2006, larger incisions are needed as they are pre-filled and must be inserted as such.

This makes the issue of larger scars with silicone breast implants a concern for some patients. Plastic surgeons will frequently push and cram the breast implant through a small incision because of this concern. Needless to say, this technique is not good for the implant and undoubtably weakens its shell and leads to premature rupture and the early need for replacement. That has all changed with the introduction of an improved delivery method.

Known as the funnel, and looking exactly like what is used to decorate a cake, the breast implant is now easily propeled into the implant pocket….all without ever touching the implant or squeezing it too hard in one place. This incredibly simple but highly effective delivery method now makes it possible to use very small incisions again and even do silicone gel breast augmentation from a remote armpit incision.

As silicone gel has returned as an implant option to saline, it has again become a sought after breast implant material. With no risk of ever spontaneously deflating like a saline implant can (and eventually will), its more natural feel makes it a very popular choice. While the health concerns from the early 1990s with silicone has long been dispelled, the concern about rupture and what happens to the material persist. This has lead to the development of advanced silicone materials that hold together more like a solid, resulting in what is known as the gummy bear breast implant.

The gummy bear breast implant is more than just a cute nickname. It is a reflection how the silicone filling looks and feels…soft and spongy. And just like those cute little red, green and yellow bears, you can push and pull on it and even cut the material and it won’t lose its shape. The physical similarity between this new implant and the candy are striking and it is no wonder how it got tagged with this name.

Breast augmentation continues to get better and more safe as the materials and techniques to deliver them improve. This gives women more options to choose what they feel best fits their bodies.

Dr. Barry Eppley
Indianapolis, Indiana

Q:  I need to have my brow bones/forehead contoured by you. I must let you know that I have had my brow bone shaved down 3 years ago and I have been having problems with air leakage into my forehead. I am thinking that maybe the dr. shaved down the bone a little too much. My forehead has a “flat” surface above my nose. I would like to have my forehead rounded out and possible have my eyebrow bone made a little bigger? Do you think that would fix or help the air leakage problem?

A: Brow bone reduction is about taking down the outer table of the frontal sinus. That bone is actually very thin and is not a solid block of bone as many people think. The brow bone can be reduced by burring or actually an osteotomy with plate fixation. It sounds like you had the brow bones reduced and have an area where the bone is too thin. This can happen in burring reduction by removing too much bone or in an osteotomy with plate fixation where there is an uncovered hole area. Either way, it is clear that you have a frontal sinus fistula as a result of a hole acting as a source for an air leak. This air leak should be pushing outward into the forehead tissues as it escapes from the frontal sinus which connects to the air cavities of the nose. You would do well with an hydroxyapatite cement brow bone augmentation which would build your brow out and close off the air leak as well.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  I want to make numerous changes to my chin as I think it will make my face look better. I am looking to decrease the horizontal dimension of my chin as well as increase the vertical dimension. I think this will create a more angular jawline as my lower face is very rounded. My chin feels like it pushing my bottom lip upwards so I wanted the lower lip to be brought down slightly, would this be at all a possible? I would also be wanting a rhinoplasty, however at the moment, I will be focusing on the chin. Would these chin changes be best done with an implant or an osteotomy? I really hope you can help Dr. Eppley. Thank you for time.

A: That type of chin change can only be done by an osteotomy. With the chin pushing up on the lower lip, this suggests that it is too vertically short. A chin osteotomy can easily increase its vertical length by making an opening wedge that is held apart by a special chin plate and four screws. Lengthening the bony chin will always make it look thinner, but its bony width can also be narrowed by a midline ostectomy of the  downfractured segment at the same time.

As the chin is lengthened, it can create a slight lower lip lowering effect as the mentalis muscle is also lengthened. As the upper attachment of the mentalis muscle does extend to just below the lower lip, its lengthening as it is carried down with the bone should make the lower lip less pushed up.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  It has been 2 months since my rhinoplasty. Everything is going down very nicely. I had my bump removed and narrowed and my tip raised a little. I had a droopy profile. Sometimes when I look at my profile I see a slight hump still when I smile. That is driving me crazy, not so much on my right side but my left side. When it gets down to the tip, it goes in slightly and goes up the tip very little. My question is I was very swollen when cast was taken off. My nose was taped right away and the tip of my nose is still swollen. Could it be that this slight hump is still swollen and when the swelling comes down so will the hump and the swelling in the tip the swelling on both sides of my nose went down dramatically but I’m just concerned about the profile.  Thank you.

A: One of the hardest things in undergoing rhinoplasty is to have patience. The shape and appearance of the nose can take months to fully appear after surgery. Final results in most cases can not be fully judged for up to one year after surgery. I believe you have answered your own question already. While some swelling has gone down, it is far from being completely resolved. Whether your dorsum and the pre-existing hump will be completely gone is not yet known. If you feel that there is still some tip swelling (which there undoubtably is), then there is still some dorsal swelling which may account for a pseudohump appearance. Don’t get out the critical eye until 6 months after surgery. If the hump is still there, then it is no longer just swelling and revisional rhinoplasty may be considered.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I fell and now have a depressed scar on my forehead that I think (but what do I know) should probably be cut open and resutured so it results in just a fine line. It’s about 2″ long. I have attached a picture of it for you to see what it looks like. What do you think?

A: Scar revision is ideal for those scars that have healed with a contour depression or indentation. No other method, such as injectable fillers or lasr resurfacing, can change the level of the line of original injury as well as excision and reclosure. By cutting out the scar edges and recruiting normal unscarred skin and subcutaneous tissues, the lack of volume which represents the original scar indentation is replaced. You are correct in assuming that you are trading off an indentation for a smoother fine line scar. Your scar is small enough that it can be done in the office under local anesthesia, saving the expense of the operating room and other supplies. The new scar will be finer and mor even with the surrounding skin. It will take months for its redness to go away but, in the end, its appearance will be much improved.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am interested in rhinoplasty and jawline enhancement. My nose is too big and my jaw is weak in my opinion. I am hoping to achieve a more masculine and symmetrical appearence to my face. I would greatly appreciate any suggestions as to how to best go about achieving my goals. I have considered possibly just opting for rhinoplasty and not having any jawline augmentation at all. I have pulled my hair back in the photos to give you a better idea of the overall shape of my face. P.S sorry if the photos are not crystal clear, but this is the best camera I have. Thank you for your time.

A: Thank you for sending your pictures. I have done some imaging using a combination of rhinoplasty and chin augmentation. When you have a larger nose, even when the chin is not overly weak, a chin augmentation provides better facial balance by counteracting the appearance of the nose. This is particularly true in a man where a stronger chin can be better facially tolerated. No rhinoplasty can truly make a large nose small but it can reshape it so that its size is better balanced. The chin augmentation really enhances the facial effect of the rhinoplasty and is really the only jaw enhancement procedure that you need in my opinion. For the best effect, both rhinoplasty and chin augmentation should be done at the same time.

Dr. Barry Eppley

Indianapolis Indiana

Q: Hello, I know I’ve contacted you before I would just like to go a little more in depth. I searched the web and you seem to be the most qualified surgeon in terms of facial/skull surgery. I had contacted you about taking hgh pills at 16 (now 18) and seeing an increase in head size. My head is not extremely big but I don’t feel comfortable with it from how my head size should be and also I have concerns of possible frontal bossing in the forehead area. I understand costs can be high for this kind of extensive work but I’m very interested in finding out how you could help me. I have attached some photos of me and I also am planning to have the necessary x-rays done in order to understand how much between the skull and actual brain.Thank you.

A: Thank you for sending your pictures. I am seeing some mild frontal bossing (brow reduction), a smaller chin (chin augmentation) and a larger nose (rhinoplasty), all of which could be surgically modified. But I am not seeing reason for any other skull modification or skull problems. The x-ray would be helpful to know how thick the frontal bone is over the frontal sinus which helps choosing the surgical technique for brow reduction should that be a desired change.

Dr. Barry Eppley

Indianapolis Indiana

Q: Dr. Eppley, I have a scar in the middle of my eyebrows that has bad indents from stitches that look like a train track. Can scar revision fix these indents?

A: When referring to indents, it appears you are talking about the stitch marks which are often called ‘train tracks’ or ‘train-tracking’. These are the result of using sutures that are too big for the face, leaving sutures in too long, or a combination of both. What they are is the healed indentations from where the sutures went into the skin and the skin healed around them. While all sutures have the potential to develop these dots or indentations, large sutures leave little round white holes and sutures that have been left in way too long can have these hole which are indented.

These train track scar marks can be difficult to remove since they lie outide of the existing scar, making wide scar revision often not possible. This leaves the option of removing the track marks iindividually through small punch excisions. This may make it possible to improve the indented nature of theae marks but there will always be a small white scar from the original or new hole. I wowuld have to see a picture of how bad these marks to determine of there is any worthwhile treatment option.

Dr. Barry Eppley

Indianapolis Indiana

Q:I have a light brown birthmark on my left hand. It is the shape of a thumb print. I am very self concious about this, and I would like it removed. Is this possible? If so, could I please receive information about the consultation & cost.

A: Thank you for your inquiry. Whether the brown mark on your hand can be removed is a function of whether it is an acquired skin discoloration or whether it is a congenital or birthmark skin lesion. That difference is significant as it indicates at what the level the excessive brown pigment exists in the skin. An acquired brown lesion develops because of chronic sun exposure and the excessive pigment is in the superficial layer of the skin. (epithelium and upper dermis) That can be treated quite successfully by pulsed light therapy such as BBL (broad band light) or IPL. (intense pulsed light) Brown birthmarks, however, usually have pigment that goes all the way through the thickness of the skin and involves the deeper dermis. These do not respond to any type of light or laser treatments because the discoloration is too deep to reach without burning the skin. In some cases, removal by excision can be done by that leaves the trade-off of a scar which is often not a better cosmetic result.

I would need to see a picture of your hand ‘birthmark’ before I could comment on whether any removal treatment is possible.

Dr. Barry Eppley

Indianapolis Indiana

Q:  Hello, my name is Mary. I am currently a 36DD and hate them. I have back pain and my ribs hurt. I have trouble finding comfortable bras, and I would much rather be a large B cup or small C cup. I had a baby 6 months ago and wanted to know how soon I could have a breast reduction. Thanks.

A: It is clear from your writing that a breast reduction would be beneficial. The timing of any breast reshaping surgery after pregnancy depends on several factors. First consideration is that one has to have stopped breastfeeding. Second and most importantly, one’s breast size and shape should be stable. The breasts should have maximally involuted (shrunk) and sagged from the effects of pregnancy. This makes the breast tissue removal (reduction) and the accompanying lift to be best done without having the uncontrolled effects of these ongoing breast changes. Lastly and ideally, one should be certain that they are done with having children as this will have a negative effect on the long-term breast size and shape.

Breast reduction provides a consistent  improvement in the back, shoulder, and neck pain that frequently accompanies large breasts. Its improvement is a function of the weight reduction but can also be attributed to the repositioning of the breast tissue back and higher on the chest wall.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: My 5 year old daughter fell on a metal fireplace about 3 months ago and has been left with an oblong dimple across her right cheek that turns in significantly when she smiles.  We have seen a plastic surgeon who thinks we are best to do nothing for say ten years.  I am assuming this is because as she grows her face will change and also by the time she is 15 she will be able to make her own mind up about surgery.  What would be your opnion on operating on young children and are there benefits to waiting?

A: Given that injury is only a few months old and she is five years of age, there is still a chance that time and healing will make the cheek dimple better or it may go away completely. That is still to be determined and you will know how permanent the dimple is by one year after the injury. If there has been no change or significant improvement by then, then one can consider corrective plastic surgery. My philosophy on the timing of ‘cosmetic’ plastic surgery procedures in children is that it is a parental decision until the child is a teenager. Once puberty hits, it then becomes a patient-driven decision. Either way the treatment would be concentrated fat injections into the depressed cheek area. The only advantage to waiting is in the first year after the injury to see how much improvement is obtained naturally so surgery might be avoided.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  I am interested in getting my nose fixed and have my upper lip shortened at the same time. I have been some research on lip lifts and it seems wonderful and the results are exactly what I want. But you have written that a rhinoplasty can not be done at the same time. That bothers me because I did not want to recover twice. But I have been doing some searching and som,e doctors do both at the same time but some don’t. Is there a possible reason/ I really want to have my surgery with you because you have the best before and after pictures I’ve ever seen for noses that are similar to mine.

A: The reason that I don’t combine an open rhinoplasty and a subnasal lip lift is because of the potential risk of skin necrosis. When done together, there will remain a small area of columellar skin between the two incisions, that of the open rhinoplasty and about 6 to 8mms below that of the subnasal lip lift. The survival of that skin depends on having an adequate blood supply coming into it. Part, and may be most, of the blood supply to that skin is cut off by making those two incisions at the same time. While it is likely that it would be fine with some blood supply coming from the septal mucosa, there is some risk that it might not be and that skin would then die. That would be a cosmetic disaster and my concern is more then theroetical…I have taken care of a patient who had that exactly happen when those two procedures were done together by another surgeon. Given that the lip lift can be done as a simple office procedure later under local anesthesia with very little recovery, I don’t think the risk is worth it for an elective cosmetic operation.

If one was doing a closed rhinoplasty, in which a columellar incision is not used, then a subnasal lip lift could be done at the same time. It is likely that is the type of rhinoplasty the doctors who say they do it at the same time are performing.

Dr. Barry Eppley

Indianapolis Indiana

Q:  Dear Dr. Eppley, I am having a bilateral sagittal split mandibular osteotomy with upward rotation as well as a sliding genioplasty done by a maxillofacial surgeon in a few months. I still want to get jaw implants. Is it still possible to get jaw implants even after all these surgeries I am getting? Wouldn’t all the screws and metal plates they are putting into me cancel out the ability to get jaw implants? Thank you.

A: The simple answer is no. Most of the titanium plates and screws that are used in orthognathic surgery ends up inside the bone. The outer screwheads and plate profiles are very thin, generally only sitting up 1 to 2 mms above the bone. Furthermore the location of the metal fixation devices lies in front of where jaw angle implants are placed or behind where a chin implant would be positioned. While there would be some scar from the prior surgery, it only makes the path of dissection a little more difficult than normal. This in so way precludes the placement of any type of jaw augmentation implant.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Hello! I’m a young girl who has very puffy and big cheeks. From my cheekbones down to my jawline it is very full. I really love my face otherwise, but it’s too much fat there. I am a very thin girl and no one in my family has these big cheeks. Is there any way to reduce the chubbiness of my face? Do you think liposuction would make it thinner? Or is there something else to make my face thinner? I’m willing to do anything for this, because I’m depressed and desperate. Thanks.

A: Chubby cheeks are part of many person’s facial makeup, particularly when they are young. You did not provide your age other than to say you are young. But if you are under the age of 16, your chubby cheeks may become less so as you mature further. If you are over the age of 18 and at a good body weight then the fullness of your cheeks is built into your genetic code so to speak. Some reduction in the fullness of one’s cheeks can be done by buccal lipectomies and small cannula liposuction of selective facial areas. Potential liposuction areas include the perioral mounds (below the cheeks) and lateral facial areas around and in front of the parotid glands. These facial fat reduction methods will not make a chubby face thin but they will help provide some more shape and contours to an otherwise amorphous round face.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I am a 30 year old male and I have a flattened skull at back, which I understand to be plagiocephaly. This has until now been fairly well-covered with hair, but I am beginning to recede at the temples, and so I am becoming increasingly concerned about it, should I go bald. I am therefore interested in exploring possible treatments- I hear you offer a cranioplasty procedure involving injectable kryptonite? I would be very interested in hearing more about this- in terms of how successful/established the procedure is, likely cost and potential risks. Any information you could provide would be really useful. I appreciate it may be difficult to provide a concrete answer without a full consultation, but any general information would be really useful.

A: I would seek out any postings that I have written using Kryptonite cement for skull reshaping which would appear on a Google search. I have written extensively about it and all of your questions would probably be answered there. In summary, it is a developing technique that is far from perfected with the biggest complication being irregularities and the potential need for a smoothing revision. But it is a simple one hour procedure that involves minimal recovery using only a one inch incision. The cost of this cranioplasty procedure is largely driven by the volume of the material that is used. The cost of the material will easily make up more than half of the cost of the surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  I am interested in getting a six-pack look to my stomach. I work out all the time and do a lot of abdominal crunches but it is just not appearing. I am a man who is fairly lean and have only 9% body fat at 34 years of age. I have read about a liposuction method called ‘etching’ which can make the six-pack look in one surgery. Can you tell me how it is done and what makes it work? Are there any long-term problems with having it done?

A: The abdominal etching surgery to which you refer is a modified liposuction method for producing abdominal highlights. Using fine liposuction cannulas, fat is removed along predetermined highlight lines in a linear array of a central vertical line and multiple (usually three) horizontal lines. By removing linear lines of fat lines, this causes the stomach skin to selectively indent inward which then appears like the underlying abdominal muscles lines, creating the ‘six-pack’ look. Interestingly, abdominal etching is done in exactly the opposite way that traditional liposuction is done. Rather than trying to remove an even amount of fat over a broad surface area of the abdomen to avoid any irregularities, etching deliberately aims to create indentations through an uneven (but precise) amount of fat removal. Abdominal etching is really best done on someone who already has a near flat abdomen and wishes for a more liposculpture approach rather than a large amount of fat removal. It is not a good idea for someone who has a large protuberant abdomen or is significantly overweight. The only long-term issue is what would happen if you gain abdominal weight. The etch lines may look peculiar on a bigger belly.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, does zerona help with belly fat and gynecomastia. Not sure why it wouldn’t help gynecomastia if it’s all adipose tissue.

A: The first thing to realize about fat is that it is not all the same throughout the body. It is both structurally and biochemically different as it actually serves different physiologic roles depending upon its anatomic location. It is present in our bodies for very functional purposes other than being a source of annoying collections of unwanted bulges. It also has some differences between males and females as well. This is illustrated in your question about male gynecomastia and belly fat. Male breast enlargement is composed of fibrofatty tissue. Some of this is fat but it also has a significant component of gritty fibrous tissue. This makes it unresponsive to an external treatment like Zerona. Gynecomastia can only really be effectively treated by liposuction, particularly Smartlipo, or open excision. Belly fat is distributed differently in men than women. Most of belly fat in women is external to the abdominal muscles (subcutaneous) and can be reached by Zerona (up to 5 cms. penetration) or liposuction. Male belly fat has a greater percent hat lies underneath the abdominal muscles (intraperitoneal) and does not respond as well to such fat treatments.

That being said, Zerona is not a good treatment for Gynecomastia and tends to be less effective for some men than women for the reduction of belly fat.  

Dr. Barry Eppley

Indianapolis, Indiana

Q:  I am interested in forehead augmentation to make the slope of my forehead less so and longer. I was hoping to retain my brow ridge prominence somewhat as that is a family trait…and in fact I’d like to keep the forehead looking sloped and straight as opposed to rounded and convex….keep it similar to how it is now, except for perhaps slightly raising the hair-line and moving it out a bit, while making the slope of the forehead greater, but certainly no where near convex.  In other words, just as the brow ridges end moving toward the hair line, all of that forehead area I was hoping to making steeper, but still straight and non convex, and at the very top where the hair line is i was hoping to making higher and more in line with the rest of the forehead.  Is that not possible? I don’t know how these surgeries work… in other words, I don’t know what the limitations are for the shape of the molds and their complexity…but I certainly didn’t want a drastic change in the forehead. How “complex” can the moulds be made that fit into the forehead region?  What is the potential for tweaking certain aspects? 

A: Forehead augmentation is not done by a preformed implant or a mold. It is done by cranioplasty onlay materials. These are mixed together at the time of surgery and applied like plaster of paris. It is then shaped by hand until the desired form is obtained and then allowed to set or cure. The average working time is about 10 minutes for this process. It is a very artistic technique which is why one has to have a very good idea what type of forehead shape the patient wants. You have been quite explicit as to your forehead shape desires which is good. Given the volume of material needed (at least 40 grams), PMMA (acrylic) is best for you because of the cost issue with that volume of material. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Would Acell Matrsitem be helpful in forehead reshaping to minimize the scalp scar in the hairline? I have a crooked forehead as a result of the way I slept as a child and I know surgeons are generally reluctant to perform this procedure in maklkes due to the scalp scar in the hairline showing as it recedes.

Also, I was wondering of you have ever heard of or used Resobone (custom fit degradable implants to correct bone defects and what are your thoughts on this technology?

A: I think when it comes to optimizing a scalp scar in any patient, but particularly a male, anything that may help would be useful. In that regard, Acell Matristem may provide some healing advantage and it is certainly easy to apply into the wound during closure. While it is not magical and can not make it heal without any scar, anything benefit it can provide to making the scar as narrow and inconspicuous as possible is a bonus.

Resobone is a mixture of two resorbable materials, poly-lactic acid polymers and tricalcium phosphatre. Its intent is to act as a matrix to encourage bone to heal a defect. For bone reconstruction of bone defects, it is an option although I do not see a big advantage over many of the hydroxyapatite cements that exist today or even a computer-generated custom HTR-PMI implant. It does have one disadvantage and that is it is resorbable, so if bone doesn’t replace it the reconstruction will be gone. It should not be used, however, as an onlay or building up material. Since bone will never grow into and replace that of an onlayed resorbable scaffold no matter what its composition. If your thoughts are to use Resobone as a forehead cranioplasty implant it will eventually resorb away and be left with very little if any augmented result.

Dr. Barry Eppley

Indianapolis Indiana

Q: I was recently burned on my chin and left with pitted scars.  I am interested in ACell to repair and restore the skin.  I believe it can facilitate new skin to grow if the scar tissue is removed.  If you believe this too can you help me.  I am a 34 year old mother of three.

A: The treatment of acute burns versus the chronic scarring that it creates after it has healed is different. During the healing of a partial-thickness burn, the application of Acell particles may well have an accelerated healing effect that may result in less scarring than would otherwise occur with its healing on its own. Once the burn wound has healed and scar is formed, however, there is no role for any form of topical therapy. Removing the old burn scar and then reapplying Acell would be unlikely to create a better scar result in my opinion. This is because you are no longer working with a fresh wound that does not yet have a lot of scar tissue formed. In a healed wound, substantial scar tissue exists and removing the topical layer alone is not sufficient to change the final scar appearance. To have its best effect, Acell would have to be applied close to the time of the original injury to work with the wounded tissues before a lot of scar (unnatural tissue) has already been formed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I’m 46 years old. I have a spare tire around my middle. I don’t want to lose weight because I end up losing my breast and butt. What procedure do you recommend?

A: When someone has a ‘spare tire’ around their middle, they could be referring to two basic types of waistline problems. The first would be fat only. They have thickness around the middle and waistline due to a fat collection but there is no loose or overhanging skin. The other problem is one in which there is both too much fat but with excess skin as well. Each requires a different solution. The fat only problem is treated by liposuction of which Smartlipo (laser liposuction) is my current choice. For a fat and skin problem, a tummy tuck or an abdominoplasty is needed. Often liposuction must be added to the tummy tuck to get those muffin tops which wrap around the sides of the waistline into the back.

You are correct in assuming that some surgical intervention is needed if you are not willing to try some weight loss efforts. Such ’spot’ body contouring changes require surgical treatrment.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Hello, I am 22 years old and am currently on my journey to lose at least 80 lbs which would put me at 5’4 and 115 lbs. That being said I realize mine is an ambitious goal and I also know that a lot of skin will be leftover when I get there. So i am interested in abdominoplasty, mini or full depending on what is decided at consultation and also breast implants and butt implants might be of interest too. But we’ll talk about that particular idea when I get where I am going. I have a couple questions:
* how much will a high profile gel, hopefully via armpit run me?
* do you accept payment through www.myfreeimplants.com
* would there be a small discount because i will at least be combining the breast and abdomnial surgeries,
* how much is abdominoplasty,
* and finally, if I added up all three abdominoplasty, breast augmentation and gluteal implants, what about would be my total?

A: I applaud you setting an ambitious but achieveable weight loss goal. Going from near 200 lbs down to 115 lbs would be a good achievement and, as you have predicted, will result in some significant loose extra skin from the arms down to the thighs. While it is impossible to accurately predict what you may need, there are some relative certainties. Your abdominoplasty would not be a mini- but would be a full. A breast lift will likely be needed in addition to getting breast implants. An implant alone will not lift a breast. Butt implants are not a solution for a sagging butt anymore than a breast implant alone solves a sagging breast.

In your search for plastic surgery costs, look for some general pricing from plastic surgeon’s websites for a full or complete abdominoplasty ($6500 to $8500) and breast lifts with implants. ($ 7,000 to $ 9,000) This will help you think about setting some financial goals as well.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I’m 25 years old and I just had my 4th daughter in February of this year. I am still breastfeeding and I am going to stop breastfeeding in two more weeks. How soon can I do my breast augmentation after I stop breastfeeding?

A: This is a common question as many women want to quickly improve the size and shape of their breasts after childbirthing. Obviously breast enhancement can not be done while actively breastfeeding so how soon after?  Breast augmentation, because it involves the placement of a synthetic implant, needs to be done as sterile as possible to avoid infection. Milk actively coming from a nipple with breast manipulation during surgery does pose an increased infection risk. You also want to be sure that the breast is adequately deflated and is still not engorged so one is working with a stable breast size that is not subject to further tissue changes after surgery. Most plastic surgeons would  recommend waiting at least 3 months after you have finished breast feeding before undergoing surgery. I would also recommend getting a consultation once you have finished breastfeeding to begin the consideration of implant options. It is also likely that after having four children that breast augmentation alone is not the only solution to better breasts. If there is any sagging (nipples at or below the lower breast crease), then a breast lift will need to be done at the same time as the implant placements. (mastopexy-augmentation)

Dr. Barry Eppley

Indianapolis, Indiana

Q: I was wondering if an intraoral chin reduction could be successful if I don’t have much soft tissue. I know if the mentalis muscle is disturbed it can cause sagging but if it is properly tightened back together could this still happen? What is the likelihood?

A: When the chin bone is shortened from inside the mouth, the muscle is not only detached but now an excess amount of soft tissue results. In other words, there is too much soft tissue for the amount of bone left. That is what creates a chin soft tissue sag or witch’s chin. While tightening up the muscle back to the bone is effective for very small chin reductions (that aren’t noticeable), such muscle tightening will not work for more visible chin bone reductions. The extra amount of soft tissue must be shortened (removed) as well as tightened. So the answer to your question is that intraoral chin reduction is usually a bad idea no matter how well the muscle is retightened. Only a submental (under the chin) approach can adequately remove and tighten the loose soft tissue that is created from chin bone reduction.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, what is the chance of any type of nerve damage from chin, jaw and cheek augmentations. Also, what is the rate of infection from facial implants? Mostly though I am concerned about nerve damage from these facial implants.

A:  When considering nerve damage from chin, cheek or jaw angle implants, you must separate the two types of facial nerves which are motor (risk of muscle paralysis) and sensory. (risk of numbness) There is no risk of facial paralysis from any of these facial implants. Where they are inserted from, which is usually from inside the mouth (with the exception of a chin implant), does not come near any branch of the facial nerve. Risk of some numbness, temporary or permanent, is the more common nerve risk of facial implant surgery. Branches of the trigeminal nerve at risk are the mental (chin implants), infraorbital (cheek implants) and the long buccal nerve. (jaw angle implants) It is rare that permanent numbness would result from these surgeries.

Infection is always a risk from the placement of any type of synthetic material into the face. While the face is exceedingly well-vascularized, it is still possible for infection to occur from bacterial contamination during their placement. The infection risk is about 1% to 3% and is slightly higher when the implants are placed from inside the mouth vs. through the outside of the skin. A chin implant is most commonly placed through an incision under the chin through the skin.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am concerned about the way my face has started to look. I am only 45 years old but I look much older. I don’t think there is anything in my medical history that could explain this change in my appearance. I’m otherwise quite healthy; I eat well, exercise regularly, and have not had any recent weight loss or gain. I had a hormone panel done and they are all normal. The only other possibility I can come up with–although I highly doubt medical data could back-up my hypothesis–is that over the past few years I lost both of my parents. I feel that perhaps stress and anxiety have taken their toll on my face. I have attached pictures so you can see what I mean. I also have an indentation below my left cheek that has appeared without any explanation. I wonder if a submalar implant would work to build out that area. Otherwise, I would welcome any other suggestions you would have for my aging face.

A: Thank you for your inquiry and sending your pictures. Based on a review of your pictures, I can make the following comments.

 1) The area of left facial indentation/depression is not over a bony prominence or the submalar area. It is actually over the concave portion of the underlying maxilla and is in the area of the infraorbital nerve exit/distribution into the tissues. I do not know why it has selectively become that way.

2) You also have more generalized facial lipoatrophy which is apparent when looking at your younger facial photographs. While you have no sagging skin that would require something like a facelift, your face has undergone more deflation or loss of volume.

3) A submalar or any other type of synthetic or bone-based implant is not what will work for the soft tissue indentation.

4) I think that concentrated fat injections, not only into the left maxillary indentation, but through your cheeks, orbital and lateral facial areas would be a good treatment for you. You need restoration of facial volume through injectable fat grafting.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Hi Dr. Eppley I’ve been suffering with TMJ pain for a long time. And I’d like to know how well does Botox work for TMJ and also do you use Xeomin as well for TMJ?

A:  Thank you for your inquiry. Botox is an anti-muscle spasm/pain injectable drug so it is good for masseteric muscle pain and hypertrophy but not specifically true TMJ dysfunction. Although many people think that they have ‘TMJ’, they actually do not have a true intracapsular joint problem which is a dysfunction between their condylar head and the moveable meniscus. (disc) Rather most ‘TMJ’ patients actually have myofascial pain (muscle pain) which may or may not be responsive to Botox. I would need to know more about your ‘TMJ history’ to determine if this is a treatment option for you. Knowing if you have specific trigger points for your pain would suggest that Botox injections could be beneficial.

Xeomin is the second competitive drug to Botox that has come out in the past two years. I do not currently use it as it does not offer any significant clinical advantages over Botox such as longer duration of action or a stronger effect. It works identical to Botox other than how its units are measured. One has to be very careful in trying to compare Botox, Dysport and Xeomin as they all have different unit dosages. Their units are not comparable terms of strength and price. Usually the unit dosing is different but the cost works out to be about the same, or very similar, for all of them.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I would like to know what you recommend to make my nose smaller and my upper lip bigger. I have attached some pictures of myself for you to see and do computer imaging as well as some pictures of my goals. I understand the results are not going to be identical. The pictures are just an “inspiration” of what i want to achieve. I’am very excited to see the computer imaging!

A:  Thank you for sending your pictures. I have done somecomputer imaging on your nose and lips. The side view is not a good quality image but I did the best I could. The refinement in your nasal tip will be somewhat limited by the thickness of your nasal skin which is always the limiting factor in tip definition from a rhinoplasty. But the tip area can definitely be improved. I also did some cartilage buildup of the dorsal line and bridge area. This will help make the rest of the nose higher and slimmer which will also help the appearance of the tip.

From an upper lip standpoint, you have nice contours and definition but just need some more volume. I would recommend concentrated fat/stem cell injections into the upper lip. That could be done at the same time as the rhinoplasty. An alternative is a subnasal (bullhorn) lip lift but this can not be done at the same time as an open rhinoplasty. Therefore, I would do the fat injections at the time of the rhinoplasty and see how that turns out. The subnasal lip lift can always be done later as an office procedure under local anesthesia.

Dr. Barry Eppley

Indianapolis, Indiana