Your Questions

Q: Dr. Eppley,  about three months ago my plastic surgeon cut out a chunk of skin out from the center of my forehead that had pock-like scarring and sutured it together. He told me that once the line heals, it would barely be noticeable and flow in into the creases of my forehead. He did a v-shaped straight line which looks anything at this point but a natural horizontal forehead crease. Is it normal right now for the closure line to appear indented and red and would you recommend Fraxel lasers and silicon strips at this point in time. Is all that i’m seeing pretty normal or did this doctor jack up my face?

A: I do not know what you looked like before and was not involved in how the decision for that approach was decided. I can make no educated comment on the decision for that particular approach to your problem. This is not an approach that I have ever used for pock scarring issues in the forehead. Most certainly if I would have done that large forehead excision I would not have made it v-shaped. There is nothing natural about that scar orientation in the forehead. What I can say is that for three months out in thick pigmented skin, the scar is what I would antiipate…very red and noticeable. It is going to take considerable time for any amount of fading that may occur. Given the way it was done, your scar appearance does not surprise me at this point. I do envision the eventual need for some additional work, whether it is scar revision or fractional laser resurfacing remains to be seen with more time.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 30 years old and have had one child. Last year, I had liposuction to get rid of some ugly fat deposits on my stomach and thighs. It turned out very well and I am overall very pleased with the contour reduction of the treated areas. But I have noticed a little loose skin on my stmach and there are a few small uneven areas. My skin doesn’t look quite as tight as it did before the procedure.  Is this normal? Is there anything that can be done to help tighten and smooth out the skin any further?

A: It is very common after liposuction to have less than perfectly smooth skin. That is often the trade-off for the volume reduction. Simply put, when you have less fat you need a little less skin. That accounts for what you perceive as skin that is just not as tight as before.  This particularly occurs in the abdominal region in women who have lost a little skin elasticity after pregnancy. There certainly is no harm in trying any of the numerous skin tightening devices that are available, such as  Exilis. The only question will be how effective it may be.

In addition, liposuction is about fat removal but it is a blind procedure. There is no way for the treating doctor to see what they are removing and how even that removal is underneath the skin. This is the art form of liposuction and it takes a lot of experience and attention to detail to get the smoothest result possible. Eventually the healing will reveal how close to even that fat removal was.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in complete removal of the fatty tissue located in my chest area. I don’t know why I have developed actual breasts but it is very embarrassing. I am a 32 year-old male and I have to wear loose fitting shirts to hide my jiggling breast mounds. I am not really much overweight, no more so than some of the pro golfers that I have seen. I wanted to know the average recovery time. Also how long does the procedure usually last as well.

A: Thank you for your inquiry. Gynecomastia deformities the size of yours, where there exists a real breast mound, is a difficult challenge to get the flattest result with the least amount of scarring. It may likely require a two-stage approach. The first stage would be a circumareolar approach with nipple lift/reduction with open excision of underlying gland tissue and surrounding contouring liposuction. Depending upon how it looks and heals, this may be all that is needed. But I like to prepare patients for the high probability of the need for a revision based on how the circumareolar scar heals and contour of the chest looks. This would be known as the second stage if needed. (areolar scar revision, touch-up liposuction) It is difficult, although not impossible, to get a good symmetrical chest result with good-looking scars in one procedure.

This type of gynecomastia reduction procedure is done under general anesthesia as an outpatient. Drains would be needed for up to 5 days after surgery. Recovery time would depend on what type of work/activities you do. For a more physical job, it would be two to three weeks before one should actively stress the chest area. This restriction is done primarily to affect fluid build-up after the removal of the drains. The results of gynecomastia are fairly long-lasting and in many cases would be considered permanent…provided one does not gain a lot of weight.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I found your website while looking for other penises like my husbands. He is an overweight man of 37 and his penis is slightly hidden. referring to this article– http://exploreplasticsurgery.com/category/buried-penis/ I found you can do surgery to help his “show size”. He basically looks like the pictures within this article. He would not let me take pictures of his body. I hope you can still give me a price idea. Thanks!

A: Thank you for your inquiry. Without seeing some pictures of the problem, I can not even tell if it is improveable. As a plastic surgeon, what I can do for buried penises is to decrease the size of the surrounding suprapubic mound through liposuction or lift away overhanging skin that is contributing to penile concealment. Often times both have to be done to get the best result. But many concealed or hidden penises also have penile contraction due to tissue fibrosis which requires the use of an experienced Urologist to diagnose and treat. In this cases, a combination Urologic-Plastic Surgery approach is needed.

But as a general guideline, I will have my assistant contact you to give you a cost for the combined procedure of a suprapubic lift with mound liposuction, which was what was discussed in that article.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 38 year-old female that has chubby cheeks. They make me look ten years older than I am and I just hate them. I have been to several plastic surgeons and they have uniformly said there is nothing to do about them. I have tried injectable fillers around them but that just makes me look puffy and is not an improvement. What do you recommend? I have attached pictures so you can see what they look like in different lighting.

A: Thank you for sending your pictures. I can clearly see your concerns of the ‘fatty or chubby cheeks’. The first question is always what is the diagnosis. Why do your cheeks look chubby? Is it because they are chubby or is what is around has become indented or atrophic? I am going to assume that they did not look like this originally ten or fifteen years ago. Many people with aging will develop malar festoons. These occur because the cheek pad falls off of the bone (ptosis) and in much later years can even become chronically swollen. While your cheek problem initially may appear as festoons, on close examination of the pictures they are not. Your cheek tissues are up high on the bone as would be commensurate with your still young age. It is easy to see that you have little aging around the eyelid area. In short, I do not feel that your chubby cheeks are from soft tissue laxity or ptosis. You clearly have tear troughs and a descending infraorbital groove which goes below the cheek area. This is what I think makes your cheeks look chubby, it is what is around them either from the early signs of aging or genetic predisposition that makes them look fat.

In theory, the correct treatment would not be cheek reduction but augmentation of the tear troughs and infraorbital groove. Having had this done through injectable fillers with an unsatisfactory result, this appears to not be a good option for you. It may be that the injectable fillers were not placed correctly or overdone, but I will assume for now they were and the look from that approach was not an improvement.

This raises the next question of what can be done with the cheek pad tissue. Simple ‘removal’ is not a realistic treatment as you can not liposuction the cheek pads or perform direct excision. Even if that was technically possible, it would leave the cheek skin deflated, possibly wrinkled, and thus create an alternative problem that would not be viewed as an improvement. Treatment possibilities include some higher malar suspension through a transcutaneous lower eyelid incision, possibly combined with a small cheek implant that would augment the lower cheek groove. Even though you don’t have true malar ptosis, lifting and repositioning this cheek tissue slightly higher would help to efface the lower malar groove. One way you can get a feel if this approach might be effective is to push up on the skin by the corner of the eye and see what happens to the appearance of the chubby cheeks.

Another option to consider before surgery is non-invasive skin tightening and fat shrinking devices. There are numerous device options out there. My current favorite is that of Exilis. It is a radiofrequency device that has the ability to perform some small amounts of fat reduction and skin tightening. It always takes a series of treatments, usually four, to get the final result. But I would be very interested in seeing you have this done before any surgical efforts are made. Whether it would solve your cheek issues is unknown, but it would be more reassuring that you tried every less invasive option before you came to the conclusion that surgery was warranted.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Can stem cells be used for buttock augmentation practically? I mean can we use stem cells to culture enough volume to be used in buttock augmentation ? I am trying to avoid fat harvest .

A:  Fat injections have a certain percentage of stem cells in them so they are used routinuely in the procedure. But stem cells can not be used alone. The sheer quantity of stem cells that would be needed in volume is beyond what can be practically done if used alone. But it would be possible, and maybe even ideal, if cutured stem cells were added in increased numbers to what naturally occurs in fat to get improved volume take and preservation.

On a practical basis, however, stem cells can not be used for buttock augmentation for numerous reasons. It would take 200cc to 300cc of stem cell volume per buttock to be able to do it. This can be done by numerous companies but at around $1500 to $2000 per 3cc to 5cc aliquot, it would be prohibitively expensive. In addition, the FDA has recently clamped down on stem cells being harvested, grown and then returned even to the same patient. So it is now not even allowed by federal regulations.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am wondering if getting Botox injected into the masseter muscles will cause a slack in the skin on the cheek/loose skin/jowls.  I’d like to try the Botox in that location but am hesitant because I already have some pre-nasolabial folds developing.  I am 27 years old. Thank you for your time!

A: The simple answer is no. The masseter muscles have no impact on the tone or position of the overlying soft tissues. They are rigidly fixed to the mandible, pterygoid plates of the maxilla and the zygoma and never get lax with Botox injections. They may get smaller with some muscle atrophy but will never lose their fixation points or become like a loose rubber band. Any looseness or descent of the overlying soft tissues with time and gravity is due to laxity developing in the osseo-muscular and osteocutaneous ligaments, not the masster muscle proper. Therefore, getting Botox injections into the masseter should not pose any concern in that regard.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  Approximately 15 years ago, I fell over and knocked my front two teeth out. Today, I suffer from cross-bite and a deviated chin during occlusion. It is quite apparent to me that my jaw has been shunted ever so slightly to one side posteriorly, and slightly superiorly also, this is the side to which my chin deviates. I believe that I could have had a unilateral condylar fracture which has subsequently healed in a dislocated position. Could you advise me as to what diagnostic modality could be used to evaluate a historical condylar fracture, or what factors may suggest a condylar fracture that has thus gone undetected. What methods can be used to correct this issue? Many thanks.

A: The best way to diagnose condylar position is a 3-D CT scan of the face. That will clearly show you the position of the condyles and the entire shape of the lower jaw. At this point you want to only correct the asymmetry through a chin osteotomy and midline realignment. The condylar position, regardless of where it is, is beyond changing at this point as lpng as one has a functional and good interdigitating occlusion.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have had 3 C-sections, bowel obstruction surgery, hernia surgery and hysterectomy. I was wondering if getting a tummy tuck would be possible for me and would this be a feasible avenue to take? Also, would I be a viable candidate for the insurance to cover this procedure? Thanks for your assistance.

A: Thank you for your inquiry. It would be impossible for me to say whether you are a good candidate for a tummy tuck based on your complex abdominal surgical history alone. I have seen many patients with similar histories and they all were perfectly good candidates for tummy tuck surgery. So based on your information alone, I would assume until proven otherwise by actually seeing you that you would be a reasonable candidate. One of the very good benefits of a tummy tuck in patients with complex abdominal surgeries is that many of the abdominal scars as well as the loose skin and fat can be removed and traded off into one single horizontal scar placed low on the abdomen. Often, one gets a simultaneous pubic lift as well. Insurance does not cover nor do we attempt to process it for elective cosmetic tummy tucks. While you have a complex abdominal history and likely numerous contour deformities from them, these are still cosmetic and not functional issues.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a dorsal hump on my nose. I had a consult with another doctor who mentioned using fillers or if electing surgery breaking my nose. I do have breathing problems in my nasal area which we discussed also. But, I am concerned about dramatically breaking my nose. I am African American. I do not want a slender Jackson Family nose. I want to look like myself, just better 🙂

A: While the African-American nose typically has a low and wide nasal bridge, it can still have a dorsal hump. Or in the low nasal bridge a pseudo dorsal hump, a dorsal hump that appears to be there because of a low nasofrontal junction or radix area. There are two approaches to your dorsal hump removal , augmentation or reduction, which has already been discussed with you. Augmentation may be a better approach for you since you already have a breathing problem and you fear too slender of a nose. The only role that fillers would play in my hands for your nose is to determine whether augmentation above the hump produces the desired effect. This is a good simple and reversible test using the non-surgical rhinoplasty concept. If filling above the hump produces a good look, then you can proceed with a rhinoplasty doing dorsal augmentation using either a cartilage graft or an implant. Each has their own advantages and disadvantages which needs to be discussed in detail.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have had frontal headaches for about 10 years.  I don’ t like getting toxins, but a low dose Botox injection cut my usual debilitating headache from a 9/10 to about a 5 for seven weeks and then about a month later last week, I am back to a 9/10 again. Can you do a surgical procedure to get me more permanent relief? If so, do you think insurance will cover it?

A: You may have had more significant migraine relief if the dose of Botox was higher than just ‘low dose’. The wearing off of the Botox effects after three months or so is a fairly standard period of time for the duration of its effects. If Botox is effective in the supraorbital area for migraine reduction, then surgical decompression of the supraorbital  and supratrochlear nerves should provide similar (and hopefully greater) and more sustained relief than the injections. The general quoted numbers is 70% of patients will get a noticeable and sustained reduction in the frequency and severity of their headaches with surgical nerve decompression. The remaining 30% is a mixture between ‘cures’ and those with limited to no  benefit.

Insurance is very unequivocal about not covering migraine decompression surgery. They have a hardline stance that it is still ‘experimental’ at this time.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I googled “skull reduction” and found out that you are the only one in the world who does skull reduction. I see you need a bicoronal incision for this, which is not a problem. I have a big head and can’t wear hats and I am always teased. I read that reduction is achieved throught a rotatory instrument that shaves done the external layer. You said to think about an oreo cookie. When do you reduce the skull, do you only use this instrument or you do osteotomies as well? If you burr the bone doesn’t the skull become weaker and more susceptible to fractures or soft to the touch? Do you perform a lot of these procedures?

A:  In answer to your questions:

1) Cosmetic skull reduction is done by burring down the bone,, not by osteotomies. Osteotomies are major cranial bone flaps are not indicated for cosmetic improvement.

2) The skull does not get appreciably weaker with outer cranial table reduction as there remains an inner diploic layer as well as an inner cortical bone layer as well to the skull.

3) Various forms of skull reduction/reshaping are done in my practice. Whether anyone is a reasonable candidate depends on many factors and I would have to seem some pictures of one’s head to determine if they are a reasonable candidate.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in breast implants. I am 19 years old and currently an A-cup, I would like to go up to a B or maybe even C-cup. Am I too young for this procedure? And what is the average overall cost?

A: You are not too young for breast augmentation. As long as you are 18 years of age and can make an informed and educated decision, you may get breast implants. The one cavest is that you must get saline implants and not silicone gel implants. As of 2006, a patient has to be 22 years of age to be eligible for any type of silicone gel breast implants per the Food and Drug Administration (FDA) and the manufacturers. What size you should increase your breasts to is a personal one. While you think about breast size in cups, plastic surgeons think about breast size in volume. (ccs) Trying to figure out volume:cup size is an art form in any patient and not an exact science. This is why I prefer to use an anatomical breast implant volume sizer system which is very accurate in terms of helping you get the breast size you desire.

The total cost for saline breast augmentation is in the range of $3800 to $4000.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  Can you answer a few questions about eyebrow transplants? I hardly have any right now since they fell out when I was 21 due to taking birth control pill. They never came back.  Does the transplant last forever or do you have to keep having the transplant? Are the eyebrow hairs normal looking? How is the procedure done?

A:  Eyebrow hair transplants are like any other form of hair transplantation. The goal is to create living hair that is permanent. How much of the hair transplant survives is likely what you are referring to as ‘having to keep having the transplant’.  Normally 100% of the hair transplant does not survive so an additional procedure may be needed to fill in any areas in which the grafts have not taken. Once a hair has taken, it will be permanent because the bulb or follicle has taken. Technically, hair transplantation is about tranferring the hair follicle (the growing portion of the hair) and the actual hair is nothing more than a handle to manipulate and carry the follicle to the recipient site. Once the hair has taken, it will grow faster than normal eyebrow hairs and will require more frequent trimming.

Eyebrow hair transplantation can be done under local or IV sedation anesthesia. The donor site is the scalp, usually taken from the finer hairs behind the ear. It requires at least 50 to 75 hairs per eyebrow or a total of 150 to 200 hairs for both eyebrows.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want to improve the look of my jawline and my lips. I am enclosing a youtube link to a male model whose lips and jawline seem to match the look I see for myself.  If you have a chance to review model Chad White’s lower face and let me know if that is possible for me based upon your imaging my photo, I would be interested to hear your thoughts. I understand that the end results won’t be an exact replica, but how closely can his lower features be matched.

A: I have taken a look at the video link and you are just one of many who have sent me Chad White’s images as their desired goal. While I think having a defined aesthetic goal is always good, it usually sets up unrealistic expectations. You nor anyone can look like he does. You can only become a better you working with the anatomy you have to get a more defined jawline and larger lips. Will your jawline and lips be better with surgery…yes. Will they look like Chad White’s….no. You and he are quite different ages with different tissues and different faces. That may sound negative but I have yet to have a male patient who comes in with model photos to ever really achieve the look they ideally want.  Using them to illustrate a point is one thing, but having them as the aesthetic target is not realistic. Using model pictures in my extensive experience is often a red flag for what will come after surgery…disappointment and subsequent (and sometimes endless) revisions of the procedure.

It is more important to focus on what can be done with your face and its anatomy rather than a model’s whose face you can never become.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, here is a some photos of my face from both side angles and front on.  Any suggestions you have on improving my chin / side profile will be appreciated.  I’ve already have a very low fat content in my body, but my jawline is still ill-defined.  I’ve been considering a sliding genioplasty to move my chin forward.  I play a lot of contact sports (boxing, wrestling, soccer), so I imagine a chin implant isn’t a great option as it could shift.  Let me know what you think. Thanks a lot for your time.

A:  Thank you for sending your pictures. It is a little hard to see precisely your chin position due to the amount of facial hair, but I have some projected imaging based on much chin advancement I think you would need. I would estimate from 7 to 9mms forward increase. In addition, I have opened up the osteotomy to give some vertical chin lengthening as well of about 3mms. You are correct in assuming that moving your own chin bone long term is better than using an implant if you do participate in a lot of contact sports. Chin implants can be used and screwed into place so shifting with trauma is not a big concern. But it only makes sense to not unnecessarily expose a protruding chin implant to trauma. Your bone is much better designed to withstand that than an implant.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 42 year-old female and have always had a touch of bags on my lower eyelids.  Due to aging no doubt and some weight loss, these bags seem to have become bigger and at least they seem that way to me. I saw one doctor recently and she told me that I should have injectable fillers put in to puff out the indented areas around them. Then I saw another doctor and he  told that the fat should be removed through an eyelid procedure. These two different opinions have me confused. What do you think?

A: Most undereye bags consist primarily of fat that has escaped from under the eyeball. Our eyeballs are encased in a bed of fat inside the eye socket bones. This allows the eye to be padded so it can move around inside its encasement without risk of being ruptured. This fat is held back by a ligament that runs from the lower eyelid down to the bone. With age that supporting ligament is naturally weak or weakens allowing the fat to come out from under the eye. Much like an abdominal hernia and protruding bowel, the lower eyelid develops bags of herniated fat. Some people have a natural weakness of this ligament and develop lower eyebags very early in life. (I suspect this is you) With aging they become much worse. Removal of this fat can be done from inside the eyelid without any external incisions. (transconjunctival lower blepharoplasty) This would make for a far superior result in your case. Adding more volume around the herniated fat is only going to make your lower eyelids even more puffy.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, One year ago I decided to do laser skin resurfacing in order to get rid of small scars on my leg. They were scars after ingrown hair. I did the last procedure one month ago and the result just scares me. I think that they burned me. It was Cutera Fraxel Laser.They also made a cortisone shot to my scars and didn’t tell me about the possible side effects. Now my skin is a little bit recessed. Now I’m so scared. I do not know what to do. Is that possible for skin to recover after cortisone shot? Is that possible to do a scar revision? Thank you in advance and kind regards.

A: While fractional laser resurfacing can offer improvement for some scars, legs scars from ingrown hairs would not be one of them in my experience. All laser resurfacing  methods basically create a superficial burn, allowing secondary healing and re-epitheliazation to take place. In essence, ‘burning you’ is how the laser works. Fractional laser resurfacing simply burns less of you, hence the term of a fraction of the skin’s surface. But each laser column goes deeper, actually creates a deeper burn injury (but less of it) in the hope of promoting improved collaguen remodeling. While this frequently offers scar appearance improvement in the face, it is less successful below the neck. The thicker and less forgiving leg skin is always risky when it comes to any type of scar revision. It is easier to burn and heals more slowly. It is more prone to hyperpigmentation even after  it is healed.

Another misconception is that of ‘getting rid of scars’ with laser resurfacing. It simply does not work that way. It is not as simple as using the laser like a blackboard eraser. At best, it is about some level of scar improvement. When comparing the risks vs benefits in laser resurfacing of leg scars, you are unfortunately experiencing the very narrow margin between improvement and the risk of further s potential scarring.

Depending upon the dose, steroid injections can cause subcutaneous fat atrophy and even skin thinning, thus the indentation that you are seeing. If this was a single dose, and it appears that it was, then there is a good chance of rebound fat restoration over the next few months. You will not know fully until six months after this injection. No further steroid injections should be done. They do not help the healing of any burn injury and can actually cause other potential problems as you have now know. Patience and further healing is the key to now allowing this scar area to settle and judge the final result.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, a month ago I underwent jaw advancement surgery as well as open rhinoplasty. My surgeon harvested bone from my skull and used it for both the nose and the jaw. Immediately after the surgery I realized that I had a hump, which I never had. I had a droopy nose and flared nostrils, but I had a really nice bridge, no hump. As the inflammation subsided, it became more and more apparent that the bone implant was very visible and crooked. I consulted my surgeon and he said it was just swelling. I saw several other surgeons and they all said it was not swelling, that it will not resolve, and that the bone was poorly shaped and implanted. I now must find a doctor to correct this deformity and I would like your professional opinion as to how long I should wait for a revision.

A: I don’t know the other details of your open rhinoplasty, other than you clearly have had a cranial bone graft augmentation. While cranial bone would not be my first choice for dorsal nasal augmentation, the logic of using it if bone was being harvested anyway for your mandibular osteotomy is logical. While you are only one month out from surgery and there still is persistent swelling, I would agree that the bone graft is oversized. While cranial bone will undergo some remodeling and even potential loss of volume, there is no assurance that this will happen in an even and regular fashion. Most certainly, you can not count on it remodeling into the desired amount and shape of dorsal augmentation that is desired. So the question is not whether a revision rhinoplasty will be needed but when and what exactly to do at the revision. There are arguments to be made for early vs delayed revision and, in my mind, it depends on what else was done to the nose and what the end goals were. If everything is fine and headed in the right direction with the rest of the nose and only the bone graft is the problem, then an earlier revision at 2 to 3 months could be done. If other aspects of the nose are undesired or unknown yet due to swelling, then it may be better to let the whole nose settle down and delay a revision until six months after the original procedure so any other adjustments can be done at the same time. One also has to factor in how much this new hump bothers you now, as if it is causing some distress, a revision can be done quite soon using a closed approach to remove, reshape and reinsert the bone graft so it has a better profile.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, my Asian wife and I found your article entitled ‘Asian Breast Augmentation’ very informative and helpful.  Obviously choosing the right implant size depends on many factors that are unique to each woman. But we were both curious to know what implant propfile you used in that particular case as we both thought the results were excellent and very natural looking.

A:  Thank you for your kind comments. Choosing the correct implant size and profile to get any woman’s desired breast look is as much art as it is science. There is no precise scientific or measurement method that can assure any patient as to how it will look afterwards. But there are some general guidelines. The first is to choose an implant’s size  in which the base width of the implant does not exceed the woman’s natural breast base width. Many Asian women tend to be smaller in size with more narrow breast widths. This is very compatible with the general smaller breast size enlargements that most Asian women desire. Breast implant sizes of 300cc to 350cc are very common in this patient population. Smaller perkier breasts are a desired look and for this reason I will almost always a high profile implant, keeping the implant’s width more narrow with greater upper pole fullness. Incision location is also an important consideration due to potential hyperpigmentation from scars. Therefore, I use a transaxillary approach for saline implants and a small (3.5cm) inframmary fold incision aided by the use of a Funnel insertion device for silicone gel implants.   

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a  circumferential body lift performed in late 2008 during which my navel was also removed. Approximately a year later I noticed a sharp protrusion from my navel. I at first thought it was a bit of suture too close to the surface of the skin to snip off. About the middle of 2011 I noticed that there were small blood clots around the area. It progressed until I needed to clean the area daily, during which smears of blood were found. Approximately 3 days ago what appeared to be a knotted loop of green dental floss protruded from my navel. I made an appointment with the plastic surgeon, and the nurse told me that this was an extrusion. She said this was highly unusual this far after the original surgery date, but the doctor would look at it. I notice no pain, but the site is still numb. Is this unusual or dangerous? Each day more of the suture comes out, and now there is about 3-4″ clearly visible. I am concerned about what can be done and how much of this material is yet to protrude. Please advise as I am concerned about the consequences.

A: What you undoubtably have is extrusion of some of the abdominal fascial plication suture used for rectus muscle tightening in your tummy tuck. The knots often are around the navel area. Because the suture is permanent (non-resorbable) there is always the risk of lifelong issues with the embedded suture. (although they are uncommon) The fact that it appeared years later after surgery is not unusual and it just as easily could have occurred ten years later as opposed to three. It is a foreign body reaction that has appeared due to its close proximity to the skin and scar around the navel area. The suture merely needs to be cut back to where it lies deep under the tissues again. This may require opening up a small area of the incision to permit it to be ‘chased’ and removed until it is far from the incision line.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a question concerning my “puppet” lines around my mouth  that get infected often.  Are some type of injections a reasonable answer to this problem?   Thank you.

A: What you refer to as puppet lines are technically known as marionette lines. That is the groove area that develops as the face and jowls fall forward with aging against the fixed skin of the chin. They extend downward from the corner of the mouth to the jaw line. There are multiple treatment options for marionette lines, depending upon how severe they are. For mild to moderate depth marionette lines, injectable fillers may be a reasonable option albeit a temporary one. For moderate to deeper marionette lines, injectable fillers are not very effective at effacing them. Options include a jowl lift (mini-facelift) which really treats the cause of the problem or direct excision of them which may be a reasonable option in the older patient who does not want to undergo any form of a jowl lift. I would need to see a picture of your mouth or face to give you a more definitive answer.

You can always try injectable fillers first as they are easy to do in a few minutes in the office setting. An injectable treatment will prove, one way or the other, if it is effective. Whether that is ‘reasonable’ ultimately comes down to an issue of cost. Is the depth of the marionette lines worth that gamble? That is where seeing a picture of it will help.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a severe skull shape problem that has been with me all my life. My skull is weirdly shaped like an alien. I am tired of being made fun of because of my head shape. I have seen a few doctors by they all say that nothing can be done and I should just live with it. I know you are an expert in this area so I thought I would ask you as no one else seems able to help. Attached are some pictures from different angles.

A: Thank you for sending your pictures. The shape of your skull appears to be the result of a congenital sagittal craniosynostosis condition that has been undiagnosed and untreated. This explains the very long, higher and narrow head shape that you have. Unlike the surgery done as an infant for this condition (take the bone apart, some of it completely off and put it back reshaped), that approach can not be done as an adult. The best that can be done now is to reshape the skull somewhat from manipulations on the outside. This would entail some reduction of the prominent midline ridge and some reduction contouring of the forehead. The sides would then be built up to make it wider. This type of cranioplasty requires being done through an open scalp incision for access to all of the skull areas. This would provide some definite improvement although it can never be an ideal or perfectly normal shaped skull.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m interested in essentially reducing my mandible to a more “V” shape, and the only place I could find that does this procedure is in Thailand (which, is alright, I have the resources to get there. But I’d feel more comfortable with surgery in America). I wanted to know if you knew anything about this surgery and if it would be possible for you to do? My second question would be how far you can go with a chin reduction. I have a really prominent chin and it’s completely destroyed my self-confidence, it’s hard not to be when you’re called Jay Leno as a young teenager and being told you have look like a man. I’d love to get a more feminine, small chin that is in proportion with the rest of my features. I do have example pictures of chins I love and I have to wonder if it’s even possible for me to get that type.

A: These are procedures that I do all the time so I am quite familiar with what can be done and can’t be done with them. You can not achieve your desired chin reduction based on where you are right now. You may be able to get about halfway there between what you have now and those images. The fundamental problem is the soft tissue excess, that is the major limited factor. I can reduce the bone all I want but the overlying soft tissues have to adapt to it to be seen. Too much reduction and the soft tissues will just hang or sag, a worse problem than where you are now. There are two fundamental approaches, intraoral osteotomy reduction with muscle tightening or submental extraoral ostectomies with a soft tissue tuck-up. Each has their own advantages and disadvantages. I would recommend a phone or Skype consultation to discuss further.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want to have a normal shaped-head. I have neurosurgery two years ago and the bone flap had to be taken out and frozen due to brain swelling afterwards. It was put back in at a second operation but as it healed it became very uneven. I have dents and visible screwheads throughout my entire forehead. One of the screws also became loose and had to be removed later. Also my forehead is so narrow and looks like an alien. I just want to look close to what I used to before the accident, a more normal shape head with noindents and bumps sticking out. You can see in my forehead photos how unusual my forehead looks.

A: The re-implantation of skull bone flaps, while necessary, is often fraught with bony resorption and irregularities. In addition, the metal hardware used to place it often become visible or loose as you have experienced. The good news is that vast improvement can be obtained by an onlay cranioplasty. Using your original scalp incision, the bone can be re-exposed, all existing metal hardware removed and the entire forehead and skull area covered and built up in a smooth and symmetrical fashion using any of the several available cranioplasty materials. This is a highly successful procedure that is not associated with any of your prior problems with bone flap replacement surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a recent consultation with another plastic surgeon and that surgeon believes I only need augmentation, no lift necessary. I am somewhat asymmetrical so I need about 50cc more on the right side. I want silicone implants placed under the muscle. I am a paramedic so I have recovery time concerns, but think I will have no problem recovering since I am very fit. The size I had looked at were around 420cc/480cc, but think I might go just a little bit smaller. I am basically a B-cup on the right and a C-cup on the left, but lost size and volume after breast-feeding three children. Fortunately, my nipples are in a good position still and I am not too droopy, just lost my size and fullness. I am 34 years old and weight 145 lbs, but I am an extremely fit size 6. Thanks.

A: The key factor in determining the need for a breast lift is where the nipples are positioned. If they are above the lower breast fold still, then an implant alone will suffice and no lift will be needed. With asymmetrical breast sizes before surgery, placing different implant volumes is common. But be aware that this may improve the asymmetry but it is unlikely they will be perfectly matched after surgery since they are other tissue factors that affect breast size other than just breast tissue volume. (e.g., skin envelope) Most breasts are asymmetric for multiple reasons and a breast implant only addresses one of them.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Here you will find attached some crude pictures of myself on the webcam. They are not the highest resolution but it might give you a first impression. I personally think that the overall look of my eyes and eyebrows is a bit sad or tired. I thought of rim implants to push forward and fill a bit the depression  and also maybe reduce the scleral show? Not really sure if  its possible or if I will go for a tilt of my eyelids as I think that a simple narrowing will do. I was also curious about what a jaw angle implant could do for me even though some how I’m not so concerned about it overall. Please feel free to comment. For me this is more of a structural improvement rather than an anti aging procedure I am seeking as look younger than my actual age. Any procedure that you think could be beneficial to make me look more handsome without obvious work being done is welcome. Thank you for your advice and time.

A: Thank you for sending the detailed pictures. It shows that you have a recessive infraorbital rim-malar region which you already know. This is why you have undereye hollowing and weak lower eyelid support with some mild scleral show. Orbital rim implants do add volume in this area and can provide a bit of an upward push to improve lower eyelid support and position. This may provide a bit of decreased scleral show in which  a lateral canthal tightening or adjustment is a good combination with them.

While jaw angle implants can provide some significant lower facial changes, you do not consider them on a casual basis. They are the most difficult of all facial implants to undergo and recover from so you have to be really motivated to undergo their placement. Since you are not concerned about the jaw angle at all, this is not a procedure to consider for you.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had silicone placed in my upper lip and now I want it reduced a little. Is this possible? I have attached a picture of my lips.

A: Thank you for sending your pictures. I am assuming that your are referring to silicone oil droplets for your lip augmentation as opposed to silicone formed cylinder implants. Silicone oil droplets can not be easily removed from the lip tissues (without a lot of tissue destruction) because they are spread out in many small droplets through the lip tissues. This is the same whether it is in the lips or anywhere else in the body. Depending upon the lip problem (size vs lumps or granulomas), the treatment would be different. Lip size concerns is best dealt with by a lip reduction procedure based on some vermilion excision at the wet-dry line. Lumps or granulomas have to be treated by individual excision or drainage based on where they are located. I am assuming that your lip concerns are that of size.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, approximately six weeks ago I had a medium chin implant and super petite malar implants placed by anoral surgeon. All of the implants were Medpor material. In my initial consultation the doctor told me that such implants were completely reversible if I did not like them, or if something happened to the implant. In addition, he told me that they were of a silicone type material. Two weeks after surgery when I was expressing that I didn’t think I like the chin implant he told me that it was Medpor of which my understanding is it is more difficult to remove. Now I am six weeks after surgery, and while I think the chin implant has improved slightly, I still do not think I will end up with the result I wanted. I think the chin is too big. The doctor keeps telling me it looks great do not worry about it. I went to see another surgeon, (a facial plastic surgeon) he said that he believes that he can take out the chin implant and has done a few before. He said he is unsure if the chin will assume its original appearance and that the risk of permanent nerve damage to the chin for removal is quite substantial. The original implant was placed via a submental incision and I had loss of sensation for a month or so the first time. In your experience how often is the nerve damage permanent after removing this type of implant? Should I learn to live with the chin implant that is making me self-conscious?

A: Three comments based on my experience with a wide variety of chin implants:

1) You need to wait a full three months after any type of facial implant to get an accurate assessment of the final shape. It takes that long for all tissues to settle.

2) Medpor implants can be removed fairly easily in my experience. The risk of nerve damage is not much greater with its removal than with its placement in most cases. But it depends on the size of the implant and how long it has been in place.

3) Whether the chin will resume its normal shape depends on the size of the implant placed and how much the tissue has been stretched. If in doubt at its removal, the expanded soft tissue should be tucked and tightened to avoid any soft tissue ptosis.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I wanted to have a well defined face shape, so I am thinking of doing buccal fat removal but at the same time I want high cheek bones. Is it possible for me to do buccal fat removal and at the same time still put Juvederm fillers in right under my eyes? Does that make sense?

A: That does make sense with the exception of it is unclear how that will give you high cheek bones. Buccal fat reduction provides some submalar ccontouring which helps in some small amount of facial thinning in that area but will not, by itself, give you high cheek bones. The Juvederm filler will help with tear trough filling but also will give not give you any cheek bone augmentation effect. Those two procedures make sense for what they are intended to improve but neither one will create the illusion of high cheek bones. For that result, you should consider a small cheek implant which can be placed through the same incision as tha of buccal fat removal. That combination will create a more shapely cheek look.

Dr. Barry Eppley

Indianapolis, Indiana