Your Questions
Your Questions
Q: I had a rhinoplasty several years ago. One of my reasons for having the operation was to get a large hump on my nose removed. Since the surgery I have had trouble breathing through my nose. What can be done to correct the breathing problem resulting after hump removal? Is the cause of these breathing difficulties the enlarged inferior turbinates?
A: In removing a large nasal hump, several structures are taken down. While most people think a hump is made up of bone, it is really as much cartilage as it is bone. This cartilage includes the upper half of the septum and portions of the upper lateral cartilages. The merging of the upper lateral cartilages and the septum make up what is known as the internal nasal valve. This internal nasal valve is an important area that has great influence on how easily air moves through the nose. With larger hump reductions, the internal nasal valve may become compromised, causing postoperative breathing problems. While the size of the inferior turbinates may have an effect on your breathing, the most likely cause is internal nasal valve collapse.
Reconstruction of a collapsed middle vault (compromised internal nasal valve) is done primarily through cartilage grafts, a procedure known specifically as spreader grafting. This is done through an open rhinoplasty approach. Reduction of the inferior turbinates can be done at the same time to eliminate any other airway obstructive factor.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am asking about what to do with my under eye area. I had a lower blepharoplasty 15 years ago. My undereye area is very sunken looking and there is a little darkness in the skin but that may be due to some shadowing as well. I am wondering if I need a redo with a canthoplasty/canthopexy and some orbital rim/tear duct/cheek implants. I have attached some photos of my eyes from different angles. I assume you can tell from photos I also had a cheek lift and other work.
A: Based on your photos, you have a significant volume loss of fat/tissue of the lower eyelids and over the lower orbital rims onto the cheeks. Whether that is due to your prior lower blepharoplasty with fat removal is speculative and irrelevant at this point. Because of the loss of lower eyelid/cheek volume and support, you also have increased scleral show. (pseudoectropion)
What you need is volume replacement of the lower eyelid and cheek. There are several different options to consider for this replacement. It fundamentally comes down to synthetic vs. autogenous graft materials. The synthetic approach is one you have already mentioned, that of an orbital rim/cheek implant either as a single piece or in two different segments. There are several different styles for this area. These have the advantage of an immediate augmentation that will be permanent. They are placed through your old blepharoplasty incision and a canthopexy would be done at the same time. The other option is that of fat injections to add volume or the placement of allogeneic dermal grafts. This approach has the advantage of not using an implant but the survival of fat is not assured and it may require more than one treatment session to get the best result.
There are advocates for either approach and it is not a proven matter than one method is better than the other. The use of implants has a more proven track history of use.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hola por favor diganme si colocarse silicona solida en la parte de atras d la cabeza es bueno o malo? si mas adelnate de dañara cual es el costo y en donde puedo hacermelo,xfavor diganmee!! tengo la cabeza plana y tengo 20 años esto me ha molestado toda mi vida!! ayudaaaa xfavorrrrrr
A: A solid silicone implant is not a good idea for the back of the head for correction of flatness or asymmetry. However, an acrylic or PMMA cranioplasty is a better idea and is commonly used. This is placed through a scalp incision where the acrulic mixture is placed, shaped, and allowed to set before closure. One could anticipate a total surgical cost of around $7500 when done as an outpatient procedure.
You may feel free to send me some photos of your head for my assessment to see if this is a good procedure for you.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dear Dr Eppley, I am an Asian female. I have had an advancement chin osteotomy, 4mm forward and 2mm downward. But the result makes me have a long flat face with wider chin. As it’s not just the tip of the chin move forward but also the wide chin so it’s not good. I am guessing that the chin bone should be trimmed and I was wondering if it can be done in 2 to 3 weeks after the chin osteotomy has been done? It seems the swallow is not yet gone, is it good for immediate surgery again? Also I will do a facelift with fat transfer with other surgeon. I was wondering if I should wait and to have the chin bone trimming and facelift done at the same time, rather than do the bone trimming now? If I can’t do them together, how long should I wait before each of the steps? I look forward to hearing from you very soon.
A: Based on your description, it sounds like your chin osteotomy was just done. Your chin bone movement was very small and I doubt that amount of bone movement would make your chin ultimately look wider. I think what you are seeing is swelling, particularly if it has just been done in the past few weeks. You can not really judge the dimensional changes after a chin osteotomy, particularly width, for several months. I would advise waiting 3 months and then see what you think. There is no reason you can not do some chin reshaping if needed with a facelift and fat transfer later.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am a bit disappointed with the way that I look and I would like to fix some things. I believe a forehead augmentation would help me look a lot better. One of the changes I would like my forehead to undergo is to put the hairline at a higehr height, so my foehead would become a bit higher. That means building up the upper forehead area about 1 to 2 cms. I don’t think it is necessary to build up any area of the parietal bone. These are the changes I desire in the hairy part of my forehead. The second change I desire is in the brow bone. I have the feeling that from the side, it doesn’t look masculine enough because the brow bone doesn’t stick out as it should in a male. I think an augmentation of a few millimeters and a reshaping with nice corners would improve the way my brow bone looks. The second change I would like to do is the slope of my forehead. The slope of my forehead is very good but somewhere between the hairline and the brow bone the frontal bone has a small ‘puddle’ and I think it should be built up too. Those are the changes I want to do for my forehead and I hope that an endoscopic bone augmenttaion would help. How many grams of cranioplasty material woould be used for this? I have attached a side view of my forehead for you to see its shape.
A: Thank you for sending your pictures. Despite the relative poor image quality, it is clear as to your forehead concerns. I think there is no doubt you would benefit by forehead augmentation (frontal cranioplasty) but I need to clarify what is and is not possible. To achieve a good result, your forehead augmentation can not be done closed or endoscopically.There is no way to ensure a smooth and confluent result by any type of injectable approach. Your forehead reshaping is too complex for that it would have to be done through an open approach requiring a scalp incision. Secondly, the volume of augmentation material that you require makes the use of Kryptonite too expensive. You likely require about 40 grams of material. Your most economic approach would be acrylic (PMMA) where such a volume of material is economically feasible. Thirdly, it is not possible to buildup your forehead as much as 2 cms, the scalp incision could not be closed afterward.
One cm. at most is what is possible. Lastly, your frontal hairline may come up a bit with the augmentation but not substantially so. It is not possible to buildup your forehead an surgically move your hairline back at the same time.
These are some practical considerations for you to consider.
Dr. Barry Eppley
Indianapolis Indiana
One of the most significant changes in plastic surgery in the past decade has been the emergence of non-invasive cosmetic procedures. Led by the well recognized use of treatments such as Botox, injectable fillers and laser skin resurfacing, some youthful changes and anti-aging prevention can be realized. Obtaining such results without surgery represents a paradigm shift from historic invasive treatments.
From treating wrinkles to losing wanted body fat, devices using various forms of energy have become popular. (laser, high intensity light, ultrasound, radiofrequency) Their popularity is not just because they are not surgery but because they do produce visible results for most patients. Such hopes of cosmetic improvements by an external device has also been applied to loose or unwanted skin. The concept of non-surgical skin tightening has tremendous appeal, whether it is those sagging jowls, that unwanted roll of belly skin, or that floppy skin on the back of the arms.
Such devices abound and are all over the internet and popular magazines from Thermage, Ulthera or Smartlipo, to name just the most popular. They claim to produce skin tightening as one of their benefits. I regularly see patients who come in to get rid of their turkey neck, bat wings, sagging breasts or roll of skin that bulges over their beltline…with the hope and belief that such devices will avoid the need for surgery.
In reality all of these devices do produce skin tightening, with an occasional dramatic change in a few patients and more modest changes in most patients. Despite their skin tightening abilities, many patients will never be happy with the outcomes of these treatments alone. This has to do with the differences in how patients perceive skin tightening and in how much skin tightening these devices can do.
My observation is that a patient’s perception of skin tightening can be measured by centimeters and inches. Any device’s skin tightening ability can be measured in millimeters or just small fractions of an inch. It is not that these devices can not tighten skin but that most patient’s loose skin problems far exceed what can be done without surgery. No skin tightening device can replace a facelift, armlift or a tummy tuck when truly sagging skin exists. Non-surgical skin tightening works best for very modest amounts of loose skin…that one wouldn’t consider undergoing surgery to remove.
Like trying to lose fat with only taking a pill, wiping the appearance of cellulite and stretch marks clean by a skin massager, or getting rid of those dark undereye circles by just applying a cream, hope is eternal. Getting rid of loose skin, as most patients define extra skin, will almost always defy any current method of device-based skin tightening. It is not always appealing to realize that surgical removal is still the best way to get rid of unwanted loose areas of skin. Having a ‘nip and tuck’ may not be high-tech, but it continues to provide a level of improvement that will satisfy most patient’s expectations.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I had a Le Fort I osteotomy to correct my bite, which it did. Despite the upper jaw movement my midface still appears flat. I was told to look toward having cheek and paranasal implants to correct my profile.
A: A LeFort osteotomy only affects the face at the upper jaw/upper tooth level, otherwise known as the maxilla. If the maxilla is brought forward (LeFort advancement) it can change the anterior nasal spine and the base of the nose, opening up the nasolabial angle and providing some paranasal augmentation. But it takes a significant movement forward to make those changes. But it will never provide any cheek or zygomatic enhancement as the level of the bone movement is way below these bone structures.
Secondary midface augmentation will require cheek and paranasal implants to achieve increased midface fullness/projection. When the degree of midfacial fullness is recognized before the LeFort procedure, the implants can be placed at the same time. But they can also be done afterwards as a secondary procedure. This would also provide an opportunity to remove the metal plates and screws that were initially placed to hold and heal the LeFort osteotomy. Four implants are used to create both lower (paranasal) and upper (cheek) midfacial augmentation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am an Asian male and I have a retracted columella and a slightly acute nasolabial angle (I’d estimate it to be roughly 85 degrees). I have read that it is possible to use cartilage (either from the septum or the ear) and fill in the area of the columella to increase the nasolabial angle. I have also done research and found that a subnasal lip lift can correct the nasolabial angle as well. I don’t want anything else done but to have the base of the columella fixed. How do you recommend it to be done?
A: Correction of the too acute nasolabial angle can be done by directly addressing the source of the problem. The nasolabial angle is effected by numerous anatomic factors but the angulation of the causal end of the septum and the anterior nasal spine most directly influence it. I am not aware that a subnasal lip lift can change the nasolabial angle to any great degree and that would not be an option unless one had a long upper lip concern also. Correction should be directed towards modifying the underlying osteocartilaginous foundation. Cartilage grafts can be used to buildup the base of the caudal septum. But attaching grafts in an end-to-end manner to the end of the septum has them being unstable and to wiggle back and forth. To be stable they have to be placed as a bilayer with the septum in the middle of the ‘sandwich’. A more stable method is to augment the anterior nasal spine, also known as premaxillary augmentation. Cartilage grafts and synthetic implants can be used but I find that a dermal graft is the best graft in the long-term for this area. That can be placed through an intraoral incision under the upper lip above the frenum.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr.Eppley, will you look at patients that had cheek implants performed by another surgeon? The surgery was performed a month ago and they are asymmetrical and one side is more swollen then the other. They don’t look right. I would like them revised or removed.
A: Thank you for your inquiry. The first thing to realize about cheek implants is that the swelling between the two sides is never exactly symmetrical. Even though you do exactly the same thing to both sides, they will have differential amounts of swelling. Secondly, it really takes almost three months to see the final results from the procedure. It takes this long to have almost all of the swelling gone and to see if true cheek implant asymmetry exists. Since you are only one month from surgery (which does seem like forever when you are the patient), it is too early in my opinion to yet assume that the cheek implant placements have been asymmetrical. That being said, I would be happy to assist you. Please send me some pictures and any information about your surgery (when, type of implants if you know etc) that you know. Let us assume that after three months, this cheek asymmetry persists. Since there is asymmetry, I am assuming that there is one good side and one unhappy asymmetric side. That raises the question about whether the off side should be adjusted to better symmetry, changing the styles and position of the implants on the cheeks (there was a good reason you have it done to begin with) or simply having them removed altogether. At that point, we can delve into what your original objectives were for getting the cheek implants and see if that effort can be salvaged.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr Eppley I am currently in Iraq and my wife and I have been researching breast augmentation for her upon my return. She has had two children over 4 years and, as a result, has since lost much of her perkiness. She is currently 32 yrs old and is 5′ 3″ and weighs 124lbs and is a 34C. She wanting to go to a 34DD. We are currently stationed in Texas. We do not mind traveling if the price is right. If you could let me know the prices and also how long we would have to stay. We want the procedure to be done this summer but we could also wait until fall when I am on leave.
A: Thank you for your inquiry. I will have my assistant pass along the costs for breast augmentation through our Patriot Plastic Surgery program. In general, the cost is about 20% less that that of the average cost of the procedure. Several important questions to know is whether she prefers saline vs silicone implants as that has a major influence on costs of the procedure. (up to 20% in cost differential) Also with C cup breasts, having two children and having lost her perkiness, does she have any significant ptosis? (breast sagging) If she does, implants alone will not lift a breast up or move the nipples upward. Implants add volume and will only make the way her breasts look now bigger.regards. So the potential issue of a some form of breast lift may be needed although it is impossible for me to say without at least seeing some pictures of her.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Having recently had a mini-facelift7 and eyelift, I found your sit7e very useful and explicit. I had my surgery 5 weeks ago and the scars around the ears are more pronounced that say 2 weeks ago. I was quite alarmed and decided to search the internet for answers. I came across your site and have to say it was the only one that gave me the specific answers I needed for peace of mind. Thank you so much.
A: Undoubtably you are referring to the inevitable change in the appearance of most incisions that occur several weeks after surgery. This is the typical change from what appeared as an initially great looking incision to now a more red scar. Many patients understandbly think that something is wrong or that they have an infecion. In reality this is a normal biologic process and is part of the typical cascade of events that lead to wound healing.
While incisions make look fantastic during the first week after surgry, that is largely because little to no wound healing has actually occurred. The wound is only being held together by the stitches and the fibrin glue that the body naturally makes between the skin edges. It requires before the blood vessels grow into the tissues to supply the necessary elements that cause complete wound healing. It is the ingrowth of blood vessels into the scar that makes it turn red. Think of it as soldiers being amassed before an attack can occur. Once the wound is more fully healed, there is no purpose for the extra blood vessels and they go away…leading to the fading of the redness of the scar. This scar maturation process takes many months and can last up to a year after surgery. Although in the face it occurs much faster due to the already good supply which exists in the tissues. This is also why scar revision are often not recommended to be performed until all of the redness of the scar has subsided.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am Vietnamese and want a rhinoplasty. The rhinoplasty I would like to have done is a higher nose base (i think its call dorsal augmentation), have the tip more pointy (is that call narrowing?), as well as nostril reduction. I was also wondering if I need “nasal bone osteotomies”? And for a dorsal augmentation, please can you let me know what is the difference between a cartillage and a synthetic implant. And please if you could let me know the average cost of a rhinoplasty so I could have a better idea. I have attached a fromt picture of me for you to see what my nose looks like. Thanks so much!
A: Thanks for sending the picture. While its clarity is satisfactory, it is not a good image to judge the effects of a rhinoplasty. At the minimum, two facial views are needed…a front and a side view. A non-smiling front view is needed as smiling distorts the nostrils and makes them even wider. The effects of dorsal augmentation can not be seen at all in a front view and requires a side view to see that part of the result.
There is no question that what you are looking for in your rhinoplasty is dorsal augmentation, tip narrowing amd nostril reduction. These are very typical changes that are requested in rhinoplasties of your ethnicity.
The biggest decisiion to make in your rhinoplasty is that of the augmentation material for the dorsum. This is a classic debate between a synthetic implant and your own cartilage. Cartilage for your dorsal augmentation, due to the volume needed, would have to come from the rib. Your septum is inadequate for your dorsal augmentation needs. While there is no question that a small piece of rib cartilage is much better for you over your lifetime and will not give you any healing, infection or rejection problems, it is not appealing in a primary rhinoplasty to harvest it. This is why many such Asian rhinoplasty patients choose a synthetic implant even though there are higher rates of long-term problems with them.
Nasal osteotomies means cutting the base of the nasal bones to try and narrow the broad width of the upper part of the nose. With an adequate dorsal augmentation, this would not be necessary as when the dorsum is built up it makes the base of the nasal bones look more narrow.
The average cost of a full or more complete rhinoplasty, all fees included, is in the range of $ 6500 to $ 8500.
Dr. Barry Eppley
Indianapolis Indiana
Zerona is a relatively new body contouring device that uses cold laser technology to help with spot fat reduction. This can be particularly helpful for those troublesome stomach, waistline and thigh areas. Through its photochemical effect, fat cells in the path of the light energy become temporarily leaky and lose some of their contents. Through a series of painless and comfortable laser sessions over a few weeks, we have seen most patients lose a collective number of inches based on circumferential measurements taken before and after the treatments.
In weight loss management, there are numerous medications and supplements that have variable amounts of effectiveness. Adding a weight loss component to a Zerona treatment series is a logical application of combining light technology and modern pharmacology. Patients should get an enhanced result by attacking the problem simultaneously from different angles.. One of the intriguing hormonal supplements with a long history in weight loss is HCG. Once popular in the 1970s it fell into disuse until recently. It has now resurfaced as a weight loss medication and is gaining renewed use.
HCG or Human Chorionic Gonadotropin is a hormone produced in pregnancy that is made initially by the developing embryo after conception (hence the positive pregnancy test) and later by the placenta. Its primary role in pregnancy is to help nourish the growing fetus by releasing the nutrients in fat from the mother’s body. This hormonal role has lead to a lot of research that has looked at its potential role in adult weight loss and obesity. While its exact role in fat metabolism can be debated, it is currently thought that it likely exerts its effect by stimulating testosterone, an anabolic hormone that causes weight loss in both men and women.
Taking small daily doses of HCG (approx. 125 IU to 200 IU) can help in the weight loss process, particularly when combined with other treatments such as Zerona and a calorie-restricted diet. When accompanied by a low calorie diet of approximately 1500 calories, HCG has emerged as a very useful adjunct. People fear dietary restriction because they know they will feel hungry or deprived. However, on HCG people do not feel the same as with the usual diets. This occurs because the HCG instructs the body to utilize fat reserves through the hypothalamus. Thus the body becomes flooded with 2000 to 3000 calories from these reserves, which along with the calorie intake, is more than sufficient to take care of one’s daily nourishment. As a result, not only do patients not feel as hungry but their energy levels stay high.
The combination of HCG with Zerona treatments creates a combination fat reducing effect. Zerona targets problem areas with its cold laser technology for spot reduction, HCG helps the body with overall fat and weight reduction. The Zerona treatments will last only several weeks but the HCG supplement and keeping your calories low is to be done for 40 days.
While liposuction surgery offers an immediate and sometimes dramatic body change, many people would prefer a less traumatic approach. Zerona HCG offers a less painful and costly approach that some people may find provides enough improvement that the thought of surgery is just that…a thought.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have a deficient jawbone on my right jaw. I had braces in my teens, but I never had the underlying jaw issue corrected (there is lack of bone on the entire side). My teeth are somewhat slanted to compensate for this (deficient ramus included), and I have a bit shorter jaw on one side. I saw your comment on the custom jaw implant. I have a CT scan and am curious as to the cost of the custom implant. This of course is a cosmetic procedure, and I don’t think I want to suffer another 2 years in braces and jaw surgery when potentially an implant will work out for what I want (especially since my teeth fit very well right now). It does not bother me much, but I could definitely benefit from having more structure to one side of my face, as my chin gives a pointy appearance due to the lack of jawline. What is the estimated cost of a full length jaw implant underneath the bone? I take it this is screwed in? If something goes wrong, can it be removed without damage to the nerves/muscles? Any risks 20 years down the line? Thanks.
A: What is have sounds very similar to a variation of hemifacial microsomia where the one side of the face is shorter than the other, particularly the lower jaw. This cases the bite (occlusion) to be canted upward, the chin deviates to the shorter side and the jawline/jaw angle is less full on that side. The first important question is whether a custom implant is really needed at all for improvement of the right jaw. A common approach is a chin osteotomy to move the chin point to the midline and an extended off-the-shelf jaw angle implant. This may well work fine for you and would obviate the added expense ($7500) for custom implant fabrication. Custom implants are invaluable when nothing else will work well, but more standard techniques with your jaw asymmetry problem may offer similar results.
Dr. Barry Eppley
Indianapolis Indiana
Q:I would like to ask you some advise. I have a high natural hairline that makes my forehead look bigger. I don’t have problem of losing hair. I would like to have a hairline lowering, but I don’t know how to choose between a forehead reduction and a hair transplant. With the forehead reduction I will have a quick result and after seeing some pictures on internet the result looks great. The bad point is the scar and I would like to know if this procedure can have a bad consequence for the future. For the hair transplant I would like to know if the result can be natural, I have long and dense hair. I have attached some pictures for you to see.
A: Thank you for sending your pictures. I don’t know if that is the standard way you wear your hair or whether you were doing that just for the pictures. (I’ll assume you were doing that just for the pictures) You have a very good hair density and a relatively full hairline pattern. I really think you could go either way with a hairline advancement or hair transplants. each has their own advantages and disadvantages for you. Hair transplants will have no hairline scar but I doubt you can get the density of your natural hair down to 2 cms from your existing hairline. You certainly won’t be able to do it in one session. If for whatever reason you don’t like the transplants then that effort will be wasted by doing a hairline advancement after. With the hairline advancement, you will get a well matched hairline density and pattern but at the expense of a very fine line scar.
My thoughts are that the hairline advancement is the best initial approach. Because…if the scar is too prominent it can be easily covered up with some hair transplants later. The reverse is definitely not true.
Dr. Barry Eppley
Indianapolis Indiana
Q: I’ve been considering a couple of procedures for several years. While googling plastic surgery procedures I saw several patient results that I liked and I noticed you had performed the surgeries.You really made an impression on me with what I seen in the before and after results. This year might be a good possibility for me to follow through with my hopes of doing some plastic surgery. I look forward to hearing from your assistant or even more so – would like a pamphlet mailed out to me so I can have some literature to review. Thanks!
A: Before and after photographs of a plastic surgeon’s work is one of several methods to determine whom a patient may visit for a consultation. While any single set of before and after photographs of a procedure does not mean that the same result will happen for you, it is one piece of the puzzle in the plastic surgeon evaluation process.
In today’s internet world, there is no longer a need for generic pamphlets. Pamphlets provide just a cursory overview and often are more sales or promotional than they are educational. In my Indianapolis plastic surgery practice, I have replaced pamphlets with an educational blog. My blog, http://www.exploreplasticsurgery.com/, has nearly 2,000 articles about every conceivable cosmetic plastic surgery procedure. Written from my own personal experience and with the intent of explaining how things work and what it is really like to go through, there is an infinite greater amount of useful information there. All you have to do is go to the site and use the search to pull up articles for your procedures of interest.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I had a chin implant done on 2/1/2011. It was a 7mm projection Mettleman style. The right side looks wonderful and I cannot feel the implant really at all. On the left side, however, the implant traces nicely along the edge of the jawbone until aproximately the last 8mm of the wing. At that point it swings upward at about a 40 degree angle. The wing can be felt intraorally with my finger near the bottom of my mouth on that side. Aesthetically, on that same side, there is a jowling effect. I do not know if this is due to the free floating wing or if the wing has pushed other tissue upward and created a lump or ball. My surgeon has suggested that we wait 6 weeks and then go in intraorally and either “tuck” the wing back under the periosteum or simply snip it off IF it is beyond the point of the pre-jowl sulcus, thus accomplishing the pre-op goal of filling in that area. He described it by saying that that what is now the “floor” of the pocket where the wing is malpositioned will be the “ceiling” if we tuck it back under the periostium. I believe he would suture the ceiling so as to ensure the wing doesn’t communicate with the previous pocket and again migrate north. Does this sound like a reasonable plan to you?
A: With today’s extended chin implants, exclusively those made out of silicone, the most common complication is wing malposition. The ends of the silicone implant wings are very thin and easily bent or folded onto themselves if the pocket made during surgery is not fully developed and extended enough to accommodate the full length of the implant. Because you can feel the end of the implant in the vestibule at the side of your mouth,it is bent up in that direction which also causes an implant to create a bulge in the jowl area. There are several approaches to fixing the malpositioned implant wing. The intraoral approach is one and is the easiest. The implant can also be removed, the pocket extended and replaced but involves ‘more surgery’.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hi, I live in the UK and am interested in a gull wing lip lift. I have a few questions. How bad can the scar be? Do you have any photos of ‘worst case scenario’ ? Also can there be tightness or loss of feeling afterwards? Why do so few plastic surgeons do this operation? If I have a lower lip increase as well as upper would I have increase bottom tooth show? (which I don’t want). Lastly, how soon after can I fly back to the UK? I could get a surgeon here to remove stitches if necessary.
A: Thank you for your inquiry. Having done a lot of subnasal lip lifts, I have never seen a bad scar and not a single patient has ever complained about any scar issue. While there may be some temporary upper lip tightness, it passes quickly and no patient has ever told me that it is a long-term problem. Patients do say that they have some upper lip numbness for a period of time which has always surprised me but it is a consistent finding. No sutures are placed that need to be removed as they are all dissolveable. One can return home the very next day. There are no restrictions after surgery.
While you will have some increase upper tooth show (1 to 3 mms), which is desired, there is no increase in lower tooth show. That is controlled by the lower lip position not the upper lip.
I don’t know why so few plastic surgeons do lip lift or advancement procedures. In the right patient they are extremely successful with no significant problems.
Dr. Barry Eppley
Indianapolis, Indiana
Q: My daughter was in a MVA in October 2010. She has an Y-shaped scar on her forehead and 2 smaller scars on her left cheek and left ear. We have consulted with a pediatric plastic surgeon, but would like a second opinion on how soon can scar revision begin and the best treatment for the best long-term outcome.
A: Scars on a face are always very emotionally disturbing. Those concerns are only magnified exponentially when those scars are now on your own child’s face. Many parents, and teenagers, are very interested to get started on a scar revision/treatment program as soon as possible for very understandable reasons.
When and whether scar revision is of benefit is going to vary based on multiple factors including the type of scar, its location and what skin texture issues it has. The classic teaching in plastic surgery is that scar revision should wait at least one year after the injury. While this can be true for some scars, it certainly is not true for all of them. The rule of thumb that I use is…will time be of benefit or not to the scar’s visibility problems. If a scar is thin and red, time will eventually make the redness disappear as the scar matures. One may want to try and hasten that up with some pulsed light therapies (IPL, BBL) and this is perfectly appropriate as it is harmless to the scar and quick and easy to do. If the scar edges are mismatched, wide, or uneven, these features will not be improved with time and earlier scar intervention is then justified.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am the mother of 3 children and am soon to be age 35. After going through 3 pregnancies my breasts are definitely not what they used to be. They not only have gotten smaller but they seem to sag more now than before. With each pregnancy they have gotten progressively worse. I know that I need an augmentation but am uncertain if I need a lift also. How do you know if you need a breast lift when getting an implant?
A: An implant will do a great job of adding volume to a deflated breast but it will not lift up a sagging breast. This is contrary to what most women think an implant can do. When the position of the nipple is close to, at, or below the lower breast crease/fold, some type of breast lift will be needed. This is regardless of whether one is getting an implant at the same time. Without a breast lift, the implanted bigger breasts will merely drive down the position if the nipple and may even make it look worse. This can be predicted before surgery by carefully looking at the nipple position and the amount of loose breast skin. When lifts are done at the time of breast implants, the procedure is known as augmentation mastopexy.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am interested in and desparately need a tummy tuck. I have checked with insurance and they will cover this procedure if a doctor states that it is medically related. I had a Dr. tell me since I delivered my baby that my stomach muscles have torn and will not grow back. Do you guys have someone that you can refer me to look at my stomach muscles so I can receive my tummy tuck with my insurance or help with your doctors in your office?
A: Unfortunately, much of your perception about insurance coverage for tummy tucks is inaccurate. No health insurance will pay for a tummy tuck, unless one has a large apron of skin (pannus) that hangs down onto one’s thighs after bariatric surgery. (and even then they deny it most of the time) There is no medical justification or reason for a tummy tuck, it is viewed by insurance as a cosmetic procedure. Despite the fact that your tummy may look the way it does from pregnancy, weight gain or loss, or even surgery, insurance views tummy tucks as having no medical benefit. That can be proven by submitting a pre-determination letter (what anyone says on the phone from an insurance company is worthless about whether they will or will not pay) to seek approval.
Pregnancy does not cause stomach muscles to tear. Rather they cause the vertically-oriented rectus muscles to separate and stay apart, particularly around the belly button area. Sometimes this may be associated with a hernia which insurance usually does cover to repair. But having a rectus diastasis (separation) is not eligible for insurance-covered reconstruction.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I had an abdominal etching procedure with liposuction of the love handles one month ago. I also had a lower buttock lift. But I still have not seen abdominal muscles. I want to have abdominal etching again. Is it possible? How long will I have to wait? I also want to have a buttock augmentation using fat cells. My butt looks too small and I want to make them lifted rounder and fuller. Is that possible?
A: Abdominal etching is essentially a linear form of superficial liposuction. While the swelling from this surgery is not completely gone from this operation, you should be seeing some of the etching at one month after surgery. If you are not seeing any signs of the etching pattern by now, that would indicate that it may not been done aggressively enough or with inadequate technique. The etching can be redone but I would wait at least 3 months after the first procedure before doing a revision. That will give you adequate time to be sure that the etching result is insufficient.
Buttock augmentation is commonly done with fat injections, often called a Brazilian Butt Lift. The only limiting factor in this non-implant buttock augmentation is whether you have enough fat to harvest. It is usually taken from the abdomen and flanks but those donor sites may have already been liposuctioned in your first procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dear Doctor Eppley, I came across your name after reading article by you. You described the use of a custom designed titanium mesh cage and plate made off of a 3-D model fabricated from a CT scan and using bone marrow from the hip to form bone along the mesh. The reason I’m writing you is that my wife had a mandibulectomy in 2009 and had a titanium plate used to replace the removed part of her mandible. Last week the plate broke so now we are looking for other reconstruction options. We have an appointment with an oral surgeon next week but preliminarily we have been told that his reconstruction options are the use of her fibula or part of her hip bone. Do you think she would be done with a specially designed mandible reconstruction plate alone. I hate the thought of her having to have another big operation. I have attached a panorex which shows her jaw and the broken plate. Any help would be appreciated. Thank you for your time.
A: Thank you for sending your wife’s panorex. The jaw image is quite clear and is a mirror image match of the patient I did about 6 months ago….same exact mandibulectomy defect and location of plate fracture. I am assuming she has not had radiation?? The standard approach, if she has had radiation, would be a fibular free flap. But if she has not, and the long-term goal is not to try and place dental implants into the reconstruction, a metallic reconstruction with iliac marrow graft would be appropriate. It requires a specially designed titanium reconstruction that is much stouter than this simple now fractured reconstruction place which is really just intended to be a temporary stopgap measure. They all will fracture within a year or two due to the stresses that are placed by jaw opening at the angle of the mandible. This is why a custom-designed one is needed to be made off of a 3-D CT model.
Indianapolis, Indiana
Q: I am interested in breast augmentation and want silicone implants. But I am Hispanic and am very worried about any scars on my breasts. I have been to several plastic surgeons and they all have said that silicone implants need to be put in through an incision on the bottom of my breasts. They say only saline implants can be put through an armpit incision which is what I want. I have had numerous cuts on my body since I was a child and the scars all get dark and don’t go away. So even though the doctors say the scar under my breast will heal and look good, I know better based on my own body’s experience. Is there any way silicone implants can be put in through my armpit?
A: While once very difficult to get any size silicone implant in through the small armpit incision, that problem has now been solved. A brand new insertion or delivery device is now available for silicone breast augmentation. Known as the Keller Funnel, this funnel-shaped wrap allows the implant to be gently squirted into the breast through very small incisions, including the armpit one. Looking like a pastry chef applying icing to a cake, the breast implant is placed into the funnel and then squeezed out of its smaller end. This means not only can even large silicone breast implants be put in through smaller lower breast crease and nipple incisions, but they can now routinuely be inserted through an armpit incision as well. This will be of great interest to non-Caucasian breast augmentation patients, particularly those of Hispanic ethnicity who tend to get scar hyperpigmentation. The other great benefit of Funnel Breast Augmentation is that the implant is not touched from the product packaging to the breast pocket. This also reduces the risk of infection after breast augmentation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I had a chin reduction by bone burring 2 months ago. Not only do I see no change in the size of my chin, but I now have a witch’s chin/double chin due to the scar under my chin. I feel like I should wait to address this, but I am in a very public position and need to fix this as soon as possible. It is affecting my work and my self-esteem. Is it too soon to do a revision?
A: With the story of a recent chin reduction by burring, you almost certainly had an intraoral (inside the mouth) approach to your chin procedure. When this is attempted, two results happen after surgery. First, little to no change is ever seen in the amount of chin projection as just the very edge of bone has been work on which is inadequate. Secondly, and a much worse problem, is the chin ptosis or sagging that can occur due to the disinsertion of the mentalis muscle and the degloving of the chin soft tissues. The intraoral approach requires a very careful reapproximation and resuspension of the muscle if this is to be prevented.
The best time to correct a chin ptosis/witch’s chin is earlier rather than later. The more time that passes allows more scar tissue to form and can make a good correction more difficult. There are several different methods of correction depending upon the end goal and tolerance to an external scar. The chin soft tissues can be resuspended from an intraoral approach which will leave no visible scar but will not make for any chin reduction. The other approach for chin ptosis repair is from under the chin where both bone and soft tissues can be reduced, solving two problems, but leaving a submental skin scar.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am interested in having a rhinoplasty for my big nose but don’t want it to make my already large brow bones to look even bigger. I have attached a couple photos (front and side) of myself to give you a better idea and possibly even hear any other suggestions you may have to maybe give my face a better balance. I did have a rhinoplasty when I was younger but it didn’t make much of a difference. I was going to have a second rhinoplasty, but I didn’t want a smaller, well-proportioned nose to create my brow bone to appear larger than it already is. In other words I thought my nose being somewhat larger now balances out my brow bone.
A: Thank you for sending your pictures. I have done some computer imaging to demonstrate several points. Your first rhinoplasty result is not very impressive and probably shows little change. I suspect it was done as a closed rhinoplasty by someone with little experience in doing the procedure. But doing your secondary rhinoplasty would actually make little difference in how prominent the brow appears as demonstrated in the attached imaging. Making your nose bette balanced does not make the brow bone prominence look worse and that is well demonstrated in the computer imaging. The reverse is, however, quite different. Reducing the prominent brow bones would definitely make the nose look even bigger. I have demonstrated the combination of a rhinoplasty and brow bone reduction to see the total change. Therefore, you could feel quite comfortable doing a secondary or revisional rhinoplasty without fear of making any part of the rest of your face look more out of balance.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have very prominent brow bones and want to get them reduced. What would cause the frontal sinus space to become so prominent? I have an older brother who has a nice flat brow bone and forehead. Conversely, my father has somewhat of a prominent brow but not quite as large as mine So could it be just genetics? Or could it be from falling on my forehead when I was younger? As far as brow bone reduction surgery goes, I have read that it involves a scar across the top of my head. Given my hairline this is not very appealing. Is there a way of going between the very top bridge area of the nose and bottom of the brow to contour it that way and bypass the hairline all together?
A: There is no known reason that the frontal sinus expands to such a large degree, short of the presence of a sinus tumor. It has nothing to do with trauma and is just purely a genetic blueprint issue.
There is an alternative to a scalp or coronal incision which is done directly as you have indicated. It is an incision done directly across the brow bone area, being just at the brow hairline margin and then coming across the middle by stepping done into a horizontal skin crease between the top of the nose and the forehead area. This is known as the ‘open sky’ approach and has an historic use for the treatment of fronal sinus fractures and tumors. For most men, it is a better option for brow bone reduction than a scalp incision and would be less noticeable. It would also make the surgery less traumatic and involve a quicker recovery. It does heal as a very fine line scar. If one’s brow is big enough and disconcerting enough, this is a reasonable approach.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I need breast implants to make my breasts more even. I think insurance should pay for them because I think my genes didn’t have them grow right. They are quite uneven. My left breast is about a C cup and my right breast is just a small B cup. I think two different sized breast implants would work to make them both D cups. What do you think are the odds my breast implant surgery will get covered by my health insurance?
A: Quite frankly, I think those odds are as close to zero as you can get. Despite your wanting breast augmentation to be a reconstructive procedure, it is not. Breast asymmetry, despite it causing some understandable anguish and embarrassment, is not viewed as a congenital deformity. (caused by ‘poor genes’) It is viewed by health insurance companies as both cosmetic and elective. There was a day many years ago when they may have in some severe cases prior to 2000, but those days have long passed now.) For insurance to cover breast implants, it would have to be done for reconstructive purposes which insurance views as due to cancer resection or a traumatic injury. Breast reconstruction is viewed as a medically necessary surgery in cases of lumpectomies and mastectomies. Incredulously, I have numerous cases today where insurance even fights covering it when cancer is involved!
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am interested in getting an endoscopic forehead augmentation done with the Kryptonite material. For the past few years from your website, I read that you believe endoscopic forehead augmentation leads often to a poor result. But since the Kryptonite material came out you sound more optimistic for the endoscopic forehead augmentation. Do you believe that this new material makes the endoscopic augmentation safer and widely useful for augmentation of larger areas of the forehead that before? Are complications possible?
A: With traditional cranioplasty materials, a true endoscopic or injectable forehead augmentation procedure is not really possible. The materials (acrylic and hydroxyapatite) are too thick and can not even be inserted through the small access provided by a few limited incisions. The emergence of Kryptonite cranioplasty material has made a small incision or injectable approach technically possible. Kryptonite has now made the procedure possible but it is not completely free of potential complications. The biggest issue with this injectable forehead cranioplasty is making sure the final result is smooth and confluent across the forehead. That is the trick to making this procedure truly successful and satisfying.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hello Dr. Eppley I am a 28 year old male with an extreme prominent brow ridge. I have been doing research on this and understand the male vs female forehead anatomy. It seems my brow is quite larger than a typical caucasian male and was wondering if I went through a surgery for this what would be the result. I’m certainly not looking to become “feminine” by any means. I am a heterosexual male, but the size of my brow makes me feel uncomfortable and self-concious. I have a cephlometric x-ray of my profile view so you can see the size of the brow and maybe show me how much of a change is possible. Thanks for taking the time to read this, it’s a great website you have which is very informative.
A: Thank you for sending your ceph x-ray. There is no question that you have a very large pneumatized frontal sinus air space which is the cause of the prominent brow bones. The size of those brow bones are very good candidates for significant reduction through a brow bone reduction osteotomy technique. This is done by removing the outer table of frontal sinus bone, reshaping it, and then putting it back in a much flatter shape and secured with tiny titanium plates and screws. I have attached the ceph x-ray computer imaged as to how much flatter it can be.
The biggest issue for a male brow bone reduction is the scalp incision/scar required to do it. That often is the rate-limiting step for most men and is highly influenced by the man’s hair density and hairline pattern.
Dr. Barry Eppley
Indianapolis, Indiana
