Your Questions

Q: Dr. Eppley, I have a question regarding revising a sliding genioplasty. About a year ago, I had a sliding genioplasty that moved my chin forward by 8mm. The recovery has been uneventful, and all numbness and swelling is gone. One problem, however, is that my upper chin/below my lower lip feels pretty tight. It takes a bit of effort to close my mouth completely and sometimes bothers my speech.  Is there any way to fix that?

A: What you have is tightness of the mentalis muscle and shortening of the anterior mandibular vestibule. Because a sliding genioplasty is done through an intraoral approach and must take down the superior mentalis muscle attachments, the combination of stretching them (from the advancement) and scarring will cause the muscles to be short or adhered. This can likely be improved through a mentalis muscle release and resuspension with a V-Y mucosal inner lip advancement. I have seen this problem numerous times and successful improved it through this soft tissue repositioning approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am writing because I am concerned about my mother having a facelift. She is 57 years old and I am her 24 year-old daughter. I know lots of people have facelifts but that is them and this is my mother. I am concerned about its safety and I don’t want anything to happen to her. Like me, my brother and sister don’t understand why she wants this surgery. She is a beautiful women who may be aging but still looks good to us. My father just shakes his head but is going along with it. What can I say to talk her out of it?

A: While I obviously don’t know your mother or you, I can share some general comments about ‘older’ people having plastic surgery. Children’s concerns about their parents undergoing some form of face or body rejuvenation is actually very common. Many parents have told me that their children don’t understand or approve of them having elective surgery over something they view as unnecessary. While there may be some understandable medical concerns, most of the apprehension comes from what I often say…’when you don’t have the problem, you don’t see the need’. When one is young and invincible, it is hard to imagine that one day aging and body changes will come knocking. When you develop that sagging neck and jowls or those love handles and stomach that won’t go away no matter what you do, you may have a different perspective on the merits of plastic surgery. I would respect your mother’s desire to look and feel good again for herself. A good self-image knows no age limits. Facelift surgery is very safe and most patients look remarkably recovered in just a few weeks. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 28 year-old woman who doesn’t like the shape of her breasts. They are very saggy and not even. One is smaller and hangs lower than the other. In addition, my areolas are huge and way out of proportion to the size of my breasts. I am young and these breasts like old lady breasts. I have attached pictures for you to see. What type of breast reshaping procedure do I need and will there be scars?

A: Thank you for sending your pictures and expressing your interest in breast reshaping/rejuvenation. Breasts like yours pose real challenges in getting uplifted fuller symmetric breasts while minimzing scars. There are two fundamental approaches that can be done. The first would be a periaroelar mastopexy (breast lift) with implants. This approach would make the breasts larger and would have have scars limited to around the smaller areolas. Its downside is that only a minimal lift and an improvement in symmetry would be achieved, so you would have larger breasts that still hang. The second approach would be vertical breast lifts combined with implants. This would be infinitely more effective an uplifting your breasts, improving their symmetry, making the areolas smaller, and providing improved fullness. The one downside is that there would be scars around the smaller areola and then vertically down to the lower breast fold. (and perhaps some scar along the breast fold crease as well)

As you can see, neither approach is perfect and one has to accept either low hanging breasts with minimal scar or uplifted fuller breasts with more scar.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 26 year-old Middle Eastern male and I want to change the shape of my face. I think the problem is my lower jaw. My bite is good but my chin seems to be short. I have a very long and thin face with a real narrow nose. If my jaw is bigger in some way I think my face would look less long. I have attached some pictures so you can tell what you think I need.

A: Thank you for sending your photos. I can see your concern about jaw enhancement. You have a very long and thin face with a slightly retrusive chin. Enhancing your jawline will help make your face look not so long. There are three highlight areas of the jaw to change, the chin and the two jaw angles. Bringng your chin forward is needed but it is also important to not have it become more narrow as its horizontal prominence increases. That will only continue to make your face look long and narrow. The chin shape should get wider or more square as it comes forward to help increase lower facial width. That will counteract the current longer face width. Jaw angle width needs to be increased but the jaw angles should not be made vertically longer. Again, the importance of increasing lower facial width.

To achieve these objectives, I have done some imaging (attached) showing a square chin implant and width expanding  jaw angle implants.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have read and is interested in your procedures concerning temporal implants, I have  read that if placed on top the fascia the temporal branch that moves the forehead can be damaged, now I know there is also another nerve in that area which controls the upper eyelid muscles, so can this nerve also be injured if the implant is placed on top the deep fascia?

A: You are correct in assuming that the frontal branch of the facial nerve has the potential to be injured with placement of an implant on top of the deep temporal fascia. This small singular nerve branch is known to course through the tissue layer just above the deep temporalis fascia. While that tissue is easily raised off of the deep temporalis fascia, it can still be potentially injured during this dissection or even from the pressure of an implant beneath it. With frontal branch nerve injury, movement of the forehead (frontalis muscle) will be affected. If this nerve should be injured, recovery may or may not occur as this nerve branch has no cross-innervation from other nerve branches. For this reason, I generally place temporal implants deep to the fascia. But in some cases to get the desired aesthetic result, the implant must be placed on top of the deep fascia. and the potential risk of nerve injury must be accepted.

Frontal branch nerve injury, as might occur with a temporal implant placed above the deep temporal fascia,  does not usually affect the eyelids. Sensory innervation of the eyelids is through terminal branches of the ophthalmic nerve (cranial nerve 1) and maxillary divisions of the trigeminal nerve. (cranial nerve 5) The levator palpebra superioris (upper eyelid levator nuscle) is innervated by the superior branch of the oculomotor nerve. (cranial nerve 3) This is why when one looks upward, the eyelid moves upward as well.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have been using Botox for 10 years now and I have found that this last year it is lasting half the time it used to. I do my entire forehead and around the eyes. My esthetician suggested using a different product but same limited result occurred. Is there anything permanant that can paralyze the muscles in those areas? I forgot to mention I have used the same nurse in a board certified plastic surgeons office the entire 10 years so I know she knows what she is doing.

A: While uncommon, there is definite resistance to the effects of Botox over time that has been described by numerous anectodal experiences. It does not seem to occur in the vast majority of patients but I suspect we will see more of it in the next ten years as the number of people who have received it over a long time is increasing. The mechanism of resistance is not yet known. Once it occurs, there is no known reversal or alternative treatment other than trying the other approved botulinum toxins that are available which have slightly different molecular structures. (Dysport, Xeomin) There is no method of permanently paralyzing facial muscles, injectable or otherwise.

 
Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I had submalar implants (Binder silicone submalar implants) done one year ago, large size. I could not smile fully, corners of my upper lip did not go high enough, so I had them removed 3 months ago. Now, everything is fine with my smile, and I would like to have submalar implants again, may be smaller size.I would like to ask few questions: Is it common that patients which use submalar implants have difficulties with smiling or that smile looks different that before? Can it be due to too large size used in my case or…?

A:  While this is not a problem that I have ever seen from submalar implants, it is theoretically possible. Unlike malar implants, a significant portion of the submalar implant hangs down off of the bone. Given that the levator anguli oris muscle runs from the corner of the mouth up to the cheek bone and its contraction is responsible for lip elevation, it is easy to see how a large submalar implant could interfere with its action. It is either that or the sheer size of the implant simply interfered with mass tissue movement. (more likely) Either way, your experience demonstrates that it happened as proven by a return to a normal smile with their removal. While I have no idea what size submalar implant you had or exactly where on the bone it was placed, I suspect that a smaller size implant would be less likely for this problem to recur.

 
Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in having botox injections in my armpits to prevent sweating.  I have had sweating issues for years and have tried perscription deodorants and pills but haven’t had any luck.  I have Anthem insurance and wonder if this would be covered.  What would I need to do to get my insurance company to approve this?  What is the cost of the procedure?  Thanks!

A: Botox can be remarkably effective at significant sweating reduction for up to one year after an injection treatment. Typically, I like to start at a dose of about 35 units per armpit (70 units total) and see the response. More units is obviously better but we want to find the minimum effective dose to keep the cost down. At this dose range, the cost of a single treatment is around $950. I can not answer the insurance coverage question as we do not process insurance for these treatments. Some physicians may provide such treatments through insurance but insurance reimbursement , even if approved, is slow and does not usually even cover the cost of the Botox to the physician.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was reviewing your Patriotic Program for plastic surgery. Honestly, I never in my wildest dreams thought I could receive a military discount for cosmetic surgery. I’m interested in having a consultation for an Tummy Tuck and liposuction around my knees. I have been waiting for close to 10 years to do this surgery. I think now is the time. My husband of almost 20 years  is now serving in Afghanistan.
He should be home in the next two months. That being mentioned, I would like to be healed buy the time he comes home and look fantastic or at least as good as it gets. My husband has been telling me to go ahead and do it but I never do. I always find other ways to spend the money. I know I will feel so much better when my clothes fit nice and I don’t have to wear spanks…especially in a formal gown. Yep, I know I have at least 4 more formals to attend before retirement because of my four children. Thank you so much for taking your professional time to support our troops and their families using your gift.

A: Tummy tuck surgery can make a dramatic difference in your body shape and how you fit in clothes. Since you are done having children the results of a tummy tuck can last a lifetime and is one investment that cap pay dividends for decades.

We have offered military discounts for years for a wide variety of cosmetic surgery procedures. We are happy to do so and  try to make a small contribution to those that serve or have served to protect the freedoms for what we have the opportunity
to choose to do every day.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I had an otoplasty for protruding ears one year ago. From the beginning my left ear has not been symmetrical to my right ear. The top part sticks out a little bit more and it bothers me. I want to have revisional surgery for it. I am assuming that a revision otoplasty is simpler with less recovery than the first one? Also, how likely is it that the ears will end up the same? It would seem like it is easier now that only one is being changed as opposed to two ears. Lastly, since the left ear will have had two surgeries will it end up being weaker than the right? If it gets hit is it more likely to spring back out again if it is weaker?

A: You are correct in assuming that only one ear is less invasive and easier than operating on both ears. Also a revision of an otoplasty in any one ear is less invasive than the original since usually only an additional plication suture or two has to be placed. Given that yours is just the top part of the ear, only the upper half of the incision has to be re-opened for suture placement. This also means that such a revision can usually be done under local anesthesia. Certainly a revision is going to get your ears closer in symmetry but I would not expect perfection. It is unlikely that your ears were perfectly the same before surgery so you should not expect perfect ears after surgery either. The revised ear will not end up being weaker since no cartilage is removed, it is just folded back further.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My nose has a lot of things about that I don’t like and want to change. It has never been broken or anything so I think I was just born with this shape of a nose. What bothers me about it are several things. First, I don’t like the thick broad tip that I have. It needs to be thinned and made more narrow. I also think the tip is too long. Second, I don’t like the nasal bump that I have. My nose is not smooth from between the eyes down to the tip due to this bump. I also think that the bump makes the nose broader up top. I guess when you put these two things together, I pretty much want a whole new nose. I am wondering if a lot of these changes are possible.

A: Essentially your redo of your whole nose is known as a complete septorhinoplasty. Through an open approach all segments of the nose are addressed. The hump is taken down, the upper nasal bones are narrowed, the tip is reduced and narrowed and the dorsal line of the nose is made smooth. If needed the septum is also straightened, or at the least, used for cartilages grafts which are almost always needed. This is a complete overhaul of the nose and substantial changes can be obtained. All of what you are describing is both possible and also common im rhinoplasty surgery. Make sure you get some computer imaging done before surgery so you will be prepared for what these structural changes will potentially look like.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 34 year old woman who has had two children. I am done having children and now want to address the damage done to my breasts by pregnancy and breast feeding. I have lost all of my breast volume and they sag. I want breast implants but I don’t want a breast lift. I don’t want the scars from the lift. I would be ok with small hidden scars but nothing that goes beyond the border of the nipple and the skin. I have attached some pictures of my breasts. Can you tell me if what I am asking is reasonable?

A:  Unfortunately, there is a significant difference between what you need for a good breast result and what you want.  You are not alone in this position as many women need a breast lift but don’t want the scars. You have too much sagging to get a good result using breast implants alone. In fact, implants without a lift is going to make your breasts look worse not better. They will create a mound above the current level of your hanging breast tissue and will merely end up placing your nipple on the bottom half of the implants. This will create a breast appearance that you will likely not find better.  It will just be trading into a different type of breast deformity.

If you are not ready to accept scars as of yet, you can always have breast implants first and let the result prove to you whether that look may be acceptable.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am entertaining the thought of a breast lift only. So I am researching a little bit. I am 50 yrs old and have always had nice naturally large breasts but with age they are hanging low but not flat yet. I’m a Size D now. My question is with a lift only does the procedure reduce the size when they are lifted? I’m sure some liposuction etc is needed so that seems to me it would take them down at least one size naturally. Is that correct? I’m thinking it would not be so bad as with age our backs take a toll carrying them around our whole lives, so smaller could be a good thing. Thank you for your time.

A: A breast lift, in its purest form, does not reduce the size of the breast. It lifts it, tightens the skin envelope and moves the nipple position into a more central position on the breast mound, but it removes no breast tissue. This is what separates it from a breast reduction procedure which also removes a significant amount of breast tissue. But variations can be done to a breast lift procedure to provide both a lift and a small amount of breast reduction. It is this procedure that you appear to be seeking by description. This combination breast lift-reduction procedure involves the removal of between 100 to 200 grams of breast tissue which will reduce the size of the breast by a ½ cup or so. Liposuction can also be done on the side of the breast into the back, an area which is outside the direct effect of any breast reshaping procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have finally decided  as an adult to have my cleft lip scar and nose asymmetry repaired. What I don’t like about my face is that I have a prominent lip scar, a downturned and twisted nose and an overall flatter face. I have attached some pictures so you can clearly see what I mean. What specific procedures do you think I will need and how are they done?

A: Thank you for sending your pictures. You have many of the very typical lip/nose/midface cleft-induced deformities that many so affected patients have. In analyzing how to make a significant improvement, I would recommend the following approach. A full septoprhinoplasty is needed to straighten out the whole nose and give the tip more projection and some narrowing. You would need a cartilage rib graft to build up the base of the nose (pyriform aperture/paranasal regions) by onlay grafting and as a columellar strut to improve tip projection and support. Your cleft lip repair is pretty good at the cupid’s bow area but I would excise the philtral scar and re-unite the underlying orbicularis muscle better.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have one calf that is extremely lager than the other, I always had nice legs and nice calves, I dont have bulging veins, but because I am very fair in complexion, my veins were very visible, so i had the vein injected by a podiatrist . ever since that my left calf has progressively gotten bigger. Please let me know if I can get plastic surgery to reduce this calf as to me it is unsightly, so much i dont want to wear a dress. Help!!!!

A: The first question is how long ago was the vein injected and why did it become bigger after. Calf enlargement is not an expected outcome from sclerotherapy, unless has developed a deep vein thrombosis. If the injection was done recently and you have pain in that calf, then I would recommend that you have it evaluated with an ultrasound to make sure you have not developed a DVT.

From a calf reduction standpoint, there are only two approaches. Either reduce the fat around the calf via small cannula liposuction or muscle reduction. Muscle reduction can be done by Botox injections or denervation but there are considerable costs and some surgical risks with either approach. Liposuction contouring is the simplest and whether that would be effective depends on how much subcutaneous fat exists around the calf area. At a minimum I at least need to see a picture of calfs to determine if that is possible.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I currently have mandibular angle implants but they are just slightly too large and I would like to get them shaved or switched for a slightly smaller pair. 1.) How difficult is the process of shaving them down? 2.) Is the recovery time just as bad as when they were first placed? 3.) Do you recommend shaving them down or switching them out for a smaller pair? Thank you in advance for your response.

A: Modification of jaw angle implant size is certainly easier than the first procedure. This is because the submuscular/subperiosteal pockets have already been made. This is what causes the real trauma and swelling from their original placement. While there will be some swelling the second time around, it will not be as bad as the first. Whether you modify in size or get new jaw angle implants depends on what type of implant was placed (silicone vs medpor) and what is the dimension that you want changed. If it is a silicone implant, I would just replace it with a smaller size as their cost is very low. If they are porous polyethylene (Medpor), I would shave down the existing implants because their cost replacement is substantially higher and they are easy to shave down after they have been implanted for awhile. (get softer with hydration)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,I would like to know if I am a candidate for short scar upper arm lift. I had liposuction of the upper arms done 1 1/2 years ago. Since then, my upper arms sag moderately. Thank you

A: Without seeing pictures of your arms, I can only conjecture as to the utility of a short scar armlift in your case. But having had liposuction previously with ‘moderate’ sagging now present, you may well be a candiddate. It depends on exactly where the greatest amount of sagging skin is. The closer it is to your armpit or upper half of the arm, the more likely a limited armlift may be of benefit. It will result in no improvement near the elbow or lower half of the arm.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have what I would consider a significant amount of lipoatrophy in my face (and I’m HIV positive for almost 4 years).  I also unfortunately had a small amount of buccal fat removed when I was younger.  That, combined with the lipoatrophy, has left my cheeks, buccal, and temporal areas looking quite thin (and in my view, gaunt).  What do you feel is the best way of treating this fat loss?  I’m not really interested in an implant due to cost and I really am interested in restoring volume.  I have had Sculptra treatments previously, but the results were not long lasting and did not restore an adequate amount of volume in my view.  I have considered facial fat grafting, but am concerned about the reliability of whether that fat would survive (especially in someone with HIV).  I am interested in your thoughts as to what the best course of treatment may be for something that is not short lasting and not outrageously expensive.

A: The only reliable permanent method of restoring volume in the malar, submalar and temporal regions are with implants. Malr shell and temporal implants will do well in those areas. Injectable fat grafting is another alternative, and the least costly one, but its reliability on someone on antiviral medication is very suspect. Even in a patient not on such medication, fat grafting is not always reliable anyway. Unfortunately, there are no treatment options that combine the concepts of ‘not short lasting and not expensive’ when it comes to facial volume restoration. Your best choice under these circumstances is fat grafting and one has to accept that it is unknown what will happen with volume persistence. Another option is to combine temporal implants with malar/submalar fat grafting. Temporal implants are the easiest and least costly of all facial implants to put in and can easily be done under IV sedation as can fat grafting.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want to change the look of my breasts. I don’t mind having small breasts but I just don’t like the sag. Do you think a  breast lift alone will give me a good result? What are the benefits of implants with a lift? Is the combination better than a lift alone?

A: Your breast sagging and your questions about how to improve them are fairly classic. Your dilemma is not new and it can be hard to figure out what exactly to do. So let me break down into the structural problems. In sagging breasts, there are three elements to them that bother women. First is the lack of upper pole fullness. While a lift may make some immediate improvement, it will not be sustained. This is what implants are used for to create some permanent upper pole fullness. The next issue is the low nipple position that is either pointing forward but low on the breast mound or is pointing downward to the floor. This is what a lift does best, reposition the nipple back up higher and in a more centric position on the breast mound. Lastly, is the bottoming out of the lower breast tissue that hands over the lower breast fold. This also is what a lift helps with by removing skin and tightening the tissues on the lower pole.

This being said, I find in many cases that a breast lift alone can be disappointing particularly in the thin-skinned small breasted patient. It really requires an implant to create sustained upper pole fullness and some upward movement of the breast

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a jaw angle augmentation surgery done over a week ago and now that major swelling has subsided I’m noticing that my implants are way too big, they make my face look round, like a watermelon, and not long and squared like I wanted them to. My question is: can the implant be taken out, reshaped and placed back in? Do you recommend this or should new implants be ordered? Will the revision surgery have the same amount of swelling/downtime as the intial one? Thank you so much for taking the time to answer my questions.

A: Quite frankly, if I have heard these same concerns from one male patient who has had jaw angle implants, I have heard it from the last fifty. You are jumping the gun in trying to determine just one week out form surgery what the results will be. Jaw angle implants cause, by far, the largest amount of swelling of any of the facial implants. Patients generally swell up like a balloon and don’t even start to look human again until three weeks after surgery when maybe 50% of the swelling has subsided. I would not even try to judge the results obtained by these implants until at least six weeks after surgery…three months is even better. Swelling aside, there are numerous other factors which control the shape of the jaw angle afterwards including the original jaw angle deformity and what style of jaw angle implants were used. Size of the implants is one issue but style of the implant and where on the bone they were placed and how they were  secured is even more important. Patience is the key for now. It is just as ‘easy’ later to adjust or switch out the implants at six weeks or three months as it is now. You will only benefit by patient and more healing time to make the right decision.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have been fighting my insurance company since last year due to a yeast infection under the pannus of my stomach. The insurance denied the surgery, saying it was cosmetic, but recently these huge purple marks have appeared and are very thin. A nurse friend said they feel like a blister about to pop and are concave. However, these marks keep spreading across the pannus. My question to you, is, would you, or do you know of a surgeon that would be willing to use me as a teaching subject and take me on as a case study and do the surgery as pro bono? I have had this yeast infection for 7 years and now I am at a standstill. Any advice you could offer would be more then generous. Thank you so much for your time.

A: Battling insurance companies to get coverage for abdominal panniculectomies is standard and the denials and appeals can go on for years. But this is fight you must continue and eventually you should win because you have a real medical necessity condition that justifies an abdominal panniculectomy. It is also a fight you must continue because you are not going to find a plastic surgeon to do it at their own expense. There are also numerous other expenses of surgery (OR, anesthesia, etc) that must be paid that go way beyond whatever a surgeon’s fee is.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have decided that I would like to have my cleft lip scar and nose asymmetry repaired. Besides the surgeries for primary repair as a child, I have never considered surgery, so I have no experience in what to look for, how to choose the right surgeon, etc. I was very impressed by your website and the way it explains things. I am very serious about having this procedure done, I just need to figure out the logistics with scheduling, recovery time, costs involved, etc. Please let me know what my next steps should be. Thank you very much.

A: Even with the best primary cleft lip and nose repair as an infant, growth and ongoing facial development of the scarred area will result in lip and nose asymmetries. Most of these secondary deformities are quite classic and include vermilion notching, a vermilion-cutaneous mismatch, wide philtral scarring of the lip and tip asymmetry with nostril slumping and widening of the nose. As an adult, the best nose repair comes from a complete septorhinoplasty with cartilage grafting and a cleft lip revision. These usually can be done during the same surgery. Recovery largely revolves around the nose and includes the wearing of a nasal splint for a week after surgery. You should be back to work within 10 days after surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want to remove excess fat in the pubic and labia area in order to wear pants and bathing suit more comfortably. It is terribly embarrassing when you have  this puffiness sticking out in your clothes. I am not overly fat but my pubic area sticks out further than my stomach. What can be done to reduce this area? I have attached a front and side picture for you to see how big it is. Also I would like to know if I qualify for military discount since my husband is a retired Air Force veteran of Gulf War I and my son is active duty Air Force currently.

A: Based on your pictures, you are an excellent candidate for suprapubic mound liposuction. Fat removal in this area can make it quite flat and is a simple and highly successful contouring procedure of a small area. It can be performed under IV sedation as an outpatient procedure. There will be some mild swelling and bruising and it will take about 3 weeks before all goes down and you are in the benefits phase of the procedure. Because of your husband and son, you most certainly would qualify for a discount for the procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a very small upper lip which is substantially smaller than my lower lip. I have had several consultations and the recommendations have ranged from injectable fillers, implants to a lip lift.  I am confused by these different recommendations as there doesn’t appear to be a consensus as to the best thing to do. I have attached a picture of my lips for you to see  and give me your recommendation.

A:  As you have discovered there is a variety of lip enhancement procedures that approach making the lips more attractive in a variety of ways. In the end, they all have the same objective, making the vermilion of the lips more pronounced. (increased vertical height and fuller) Think of these procedures as minimally-invasive (non-surgical) to surgical. As a general rule, most patients should always start with injectable fillers because this treatment is the simplest and is completely reversible. What this tells you is whether the existing size of your vermilion can be adequately inflated to achieve the look you want. If it does, then you can ponder whether fat injections or implants may be a better long-term solution. If expanding the existing vermilion is inadequate or produces an undesired look (duck lips), then the location of the vermilion needs to be removed. This is where vermilion advancements and lip lifts have a role to change the vermilion-cutaneous junction and the amount of lip skin.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, First I must say I’m very impressed with your forehead contouring method and I think I come to the right place for my procedure. I am an Asian male who had goretex custom implants placed for brow bone augmentation via a bicoronal incision and fixed with screws. From beginning I was unsatisfied with the result. It gave me extreme brow ptosis with a paralyzed left eyebrow that interferes with my vision. I can not raise my left eyebrow at all. The paralyzed left eyebrow seems like it is caused by implant placement which is placed slightly higher than the right eyebrow. I know because I can feel it. The brow ptosis dramatically changed my youthful eyes shape and made me like an old tired man. I have to keep raising my eyebrow muscles constantly everytime I meet people to make my face look ‘normal’. It has been three years since this surgery and I don’t want to look this way anymore. Now I’m considering brow lift to help my issue. Am I good candidate? What is the best brow lift method to address my complex issue? I tried to avoid bicoronal incision again because it left me with 1 cm width scar ear to ear with no hair growth at all in that area. I even want this ‘bald’ scar removed if possible. Can this brow lift method change my youthful eyes shape back like before?

A:  To lift your brows now, the only option would be to re-use your bicoronal incision. The good news is that the scar needs to be excised anyway to obtain a substantial narrowing of it.  That scar is unacceptable. That would work in helping with the browlift since the amount of brow movement upward should be roughly the same amount as the width of the scar that needs to be removed. I believe this will be successful. Whether it will get the brows elevated as much as you demonstrate with your hands may be overly optimistic but much improvement should be obtained.

As an aside, I suspect your left eyebrow paralysis is the result of an injury to the frontal nerve branch of the facial nerve on that side from the raising of the bicoronal forehead flap. It would be unlikely that the eyebrow doesn’t elevate because it is ‘stuck’ on the brow bone implant.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 26 years old and have a very flat midface. I would like to do something that will give my midface more projection but I don’t know what is the best thing to do. I read that some doctors use implants while other recommend injectable fillers. I have been through orthodontics to correct my crossbite and it is now perfect. But my face is still pushed in and unattractive with deep nasolabial folds. What do you recommend?

A: By description and as evidenced by your orthodontic treatment, you likely have some amount of natural midface retrusion with a corrected Class III malocclusion. This would indicate a more panfacial or significant midface deficiency of which injectable fillers would be a poor treatment choice. It would take a fair amount of filler volume to achieve a visible improvement not to mention the need for repeated treatments, provided a good aesthetic change could be achieved. There are a variety of facial implant options which can provide both improved midface projection and a permanent result. Malar, submalar, paranasal, premaxillary and infraorbital rim implants are all potential options for augmentation depending upon the amount and location of the midface retrusion. Most patients do well with combined malar and paranasal implants. However the malar deficicency usually has an infraorbital component as well. Similarly, the nasal base deficiency may include a more extensive premaxillary retrusion and not just the lateral pyriform aperture areas. A good eye is needed to determine the type of implant styles that would best treat any patient’s specific concave facial shape.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a condition known as facial lipoatrophy. From what I have read it is type III or IV based on how my face looks. I am 24  years old and have had this look since I was a teenager. It makes me look older than I really am and I am concerned if I look this way now what I will look like in 10 or 20 years. I have high cheekbones but they are very skeletal-looking with indentations beneath them with loose skin sitting atop them. What type of surgery will make my face look more normal?

A:  The look of facial lipoatrophy is easily identifiable with loss of some or nearly all subcutaneous and buccal fat over the central portion of the face. Surgery must incorporate both hard and soft tissue augmentation since the problem extends over both bone-supported and non-bone supported facial areas. One successful treatment strategy is a combination of submalar implants to fill out the upper submalar triangle and fat injections for the lower submalar triangle and the sides of the face. Temporal implants can also be used for the always present temporal hollowing which is often overlooked in the treatment of facial lipoatrophy.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Could my prominent, asymmetrical eyes be corrected with fillers? A nurse told me that the bones in one eye socket are further apart causing that eye to be able to stick out further. Could they be made even and the bulging eliminated? They are quite “bug eyed” to me which is just genetic. All the women in my family have these eyes. Also, the wrinkles beneath my lower lid when I smile– will the increased volume in that area from the filler eliminate them? Will it also correct the dark skin/shadow under my eye?  I think they really age my face. But I think it’s lack of volume that causes it.  How much would something like this cost in total? Do u use Restylane for this? I really appreciate your time.

A: In looking at your pictures, injectable fillers under the eyes is NOT going to correct you eye concerns. What you have is what is known as pseudoptosis. The eyes bulge out, not because they are too far forward, but because the bone around them (orbital rims) is recessive or deficient. You are not going to lift up the lower eyelid by placing injectable fillers underneath it, that simply will not work. What you need is to have the orbital rims built up with an implant material. For the lower eyelids this would be infraorbital rim implants. For the upper eye area, this would be brow bone augmentation. Understand that the problem is a bone deficiency of which it requires surgical augmentation not injectable fillers.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have lost weight and have an apron of loose skin that hangs over, plus some fat at my waist that I would love to not have to look at anymore. I have looked at your gallery and have seen a couple of pictures that are very close to my condition, and like the after photos. I would be very happy to look like that. I am 60 years young and still have a lot of living to do. I am very healthy with only a thyroid condition that I take a small dosage of synthroid to correct.

A: Your age of 60 is certainly not a limiting factor in having tummy tuck surgery. As long as you are healthy and have no restrictive medical conditions, which it appears you are, there is no reason not to enjoy the outcome of removal of an overhanging abdominal pannus. Such a removal can be very liberating and improves not only your clothing options and hygiene but your self-image as well. Tummy tuck surgery is performed as an outpatient surgery under general anesthesia. The biggest issue in after surgery recovery is that you will have a drain for 7 to 10 days afterwards. This is more of a nuisance than anything else as you can move about and shower normally.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have some questions concerning adding implants to the top of the head. How thick can the implant be at most in your opinion? How is PMMA implants fixed to the top of the skull? Is there any risk of getting loose later and cause infection? Will it thin the skin?Thanks in advance.

A: The thickness of any skull augmentation that can be achieved is directly related to how much the scalp can expand over it. Short of a first-stage tissue expansion procedure, most scalps can stretch 5 to 7mms and have a tension free skin closure. Once you get anything over 10mm, a tension-free scalp closure may become more difficult. Anything cranial implant is secured by small titanium screws through a ‘rebar method’ when it comes to cranioplasty materials that are applied initially as liquid-powder or putty mixtures that then set up. Looseness or infection are two potential complications that I have not seen. There is always some slight tissue thinning around any body implant that expands the overlying tissue. But the scalp is very thick and any tissue thinning over a long time does not affect the skin or the hair follicles.

Dr. Barry Eppley

Indianapolis, Indiana