Your Questions

Q:    Dr. Eppley I’m a 30 year old single mother of two and I need a breast lift badly to improve my self-esteem.  I got pregnant with my first child at 19 and I gained over a hundred pounds.  I’m now back down to 150 and still need to lose more but I’ve lost 56 lbs.  My body just isn’t the same after two children and I just need some self esteem back. I already have a very nice size to my breast and am just looking to put them back where they belong.  Could you please give me information on what needs to be done to get my breasts back in shape and looking good again. Thank you for your help.

A: Between children and your significant weight loss, your breasts have undoubtably take a turn to the south. Breast sagging, known as ptosis, is defined by how low the nipples sit relative to the lower breast fold. When a large amount of weight has been lost (greater than 50 lbs), breast ptosis is usually severe and the amount of skin exceeds how much breast tissue exists to fill it. This usually requires a full breast lift which will result in the typical anchor scar pattern that is more commonly seen in a breast reduction procedure. This will move the nipple up to the center of the breast mound and will tighten the skin on the bottom side of the breast. While this lifts the breast, it will not usually result in permanent fullness of the upper pole of the breast. This is why a small implant may needed with the lift to get the fuller breast shape that many women desire from a breast reshaping operation.

Dr. Barry Eppley

Indianapolis, Indiana

Q:   I have a lipoma on my upper back that I would like removed. I would like to do so with minimal scarring as my wedding is coming up. Does your office perform any type of procedure that can remove it without noticeable scarring? What would the procedure cost? I am not sure if insurance would cover the procedure. Thank you for letting me know.

A: The benign fatty tumor, known as a lipoma, is a common mass that many people develop. The traditional method of removal is to have it cut out or excised. While effective and offering the best chance of a cure (no recurrence), it can leave a noticeable scar and even an indentation afterwards if it is of any size. I have found that scar concerns from open excision of lipomas are of a particular worry in women when they are about the shoulder, neck and back. Scars in these areas, no matter how well they are sutured together never end up as just a fine line…they always widen and often remain red for a long time.

Given that lipomas are benign growths and may or may not continue to grow, the trade-off of a wide scar may not be acceptable. An alternative method of lipoma removal is with liposuction. Using a very small cannula, the lipoma may be reduced or debulked by aspiration. Notice that I did not use the word, excise, or completely remove. Removing every last fat cell in the lipoma is not possible with liposuction so there is an increased risk of regrowth over time. That is the potential trade-off for a minimal scar procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  I had a liposuction operatoion to get rid of the fat in my saddle bag areas. It was done over aggressively as now I am left with indentations where the sasddle bags used to be. It looks like I have traded off one problem for another. I am looking for a plastic surgeon who has experience in fat grafting to correct these overly aggressive liposuction results in the saddlebags. I no longer have saddlebags, now I just have big dents!

A: The saddle bag or lateral thigh is not an uncommon area where irregularities and indentations can occur. Unlile surface contour problems in other liposuction-treated areas, the cause of such saddlebag problems is usually not the quality of the skin. It more often than not is the position in which the procedure is performed. It is usually done with the patient in the side or decubitus position. This is a good position to do the procedure but one has to be careful that the leg is lifted when liposuction is performed. In the side position, part of the saddlebag prominence is the greater trochanter process of the femur of the hip joint. When the leg is down, this bony prominence makes the saddle bag area look bigger than it is.  Liposuction is then done to make the area flat (removing too much fat over the bony prominence), which looks good laying down and one one’s side, only to reveal an indentation from over-resection later when one is standing. This is why the leg is elevated as the liposuction procedure is done to havge a better idea what is fat and what is bone.

That issue aside, fat injections is the only method available for treatment of liposuction irregularities. It works best for specific defects, such as indentations, and less successfully for more generalized skin rippling and irregularities. It would be beneficial to see some pictures of the saddlebag area to determine if this would be beneficial for your thigh contour problems.

Dr. Barry Eppley

Indianapolis Indiana

Q: Doctor Eppley I am a 22 years old man who would like to undergo the forehead augmentation procedure for a small change in the shape of the forehead. I believe that I am a good candidate for an endoscopic forehead augmentation because the building of the forehead I desire is small. What procedure is right for me(endoscopic or coronal incision augmentation) is something you know better and you will decide when you will meet me in person. However I would like you to inform me about the endoscopic augmentation, about the cost and the position of the small incisions. The building up I desire is small and it is for a small area of the forehead. How much does it cost a traditional endoscopic  forehead augmentation?

A: Thank you for your inquiry. One of the biggest drivers of the cost of endoscopic forehead augmentation is for the material, Kryptonite. Since you said the build-up is small, I will assume that you will need only 5 grams or less. That would put the cost right around $6500 to $ 7500. Like traditional endoscopic forehead surgery, two scalp incisions are used for making the dissection and placing the material. They are very small, being less than one inch each and are located behind the frontal hairline and to the sides if possible. Please send me pictures of your forehead concerns for my assessment and recommendations.

Dr. Barry Eppley

Indianapolis Indiana

Q:   Dear Dr. Eppley, I have some asymmetry on the right side of my face due to orthognathic surgery.  I consulted with a Craniofacial surgeon specialist to correct this deformity.  I also asked about getting implants on both sides because of my small mandible.  The surgical plan was to correct the asymmetry on the right side and put in jaw implants on both sides.   The same size jaw implants were used on both sides without correcting the asymmetry.  The drop down on these implants is too much for my face.  I have Medpor implants which were put in about a month ago.  I want to get these removed and just have the deformity corrected.   When is the best time to remove these implants?  Thank you and I looking forward to your reply.

A: The swelling after jaw angle implant surgery can be considerable and it takes longer than a month to really see the final results. At only a month after surgery, I am not sure you can be absolutely certain they are too vertically long. Ideally, one should wait a full 2 to 3 months to be certain you really want to reverse your initial efforts. However, if you are very certain at even this early postoperative time, then you should get the implants out as soon as possible. It is always easier to remove porous implants like Medpor sooner rather than later before extensive tissue ingrowth has occurred.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a couple of questions for you. I had breast augmentation about 10 days ago. I am still a little swollen which I have expected. However, I can’t quite put my finger on it to describe it, but after wearing a bra for a while, I get the feeling like I am rubbed raw. But you don’t really see anything and it was mainly around the bottom of the bra.  I even bought a bigger size around thinking that was the problem, but it didn’t seem to matter and again, you don’t really see anything so I couldn’t figure it out.

Over the past two days not only is it around where the bottom of the bra hits but on the sides of my breasts as well.  I realized last night its like they are extra sensitive.  I have worn a silky night shirt throughout the weekend up to last night.  It didn’t bother me before but last night it was bothering me a lot.  I had to buy a new one since my other ones no longer fit.  Since it is bigger, it moves around when I walk etc. and moves over my breasts.  It was very irritating to the point I was holding the nightie each time I walked so it wouldn’t move.  So I realized, its like my breast are very senstive to anything moving against them like that…if this even makes sense.  Its not like that if I touch them myself, but clothing.  Is that normal and will it stop?

Also, I think I read I am not supposed to wear underwire bras.  Is that only during healing time or never?  All the bras I find in department stores look like my grandma would wear them and of course all the pretty ones are underwire.  A friend suggested Victoria Secrets, so I plan to try there I just didn’t want to invest in a lot of bras until swelling, etc. is all gone so I buy what I really need, etc.

Thanks for your help.

A: You have inquired about two very typical issues after breast augmentation. The skin feelings that you are having are the tiny skin nerves, which have been temporaily disconnected or stretched, trying to recover. Think of it as the pins and needsl feeling you get when your foot falls asleep. That will typically subside around four to six weeks after surgery. That is different than some longer lasting numbness which may remain on the skin on the bottom part of the breast.

Not wearing an underwire bra for 6 weeks after surgery is to relieve any pressure on the healing inframmary incision It is also to make sure the breast implant and its lower pocket is not pushed upward as it is healing so the implant sits down in a more natural position.

Dr. Barry Eppley

Indianapolis Indiana

Q:  Hi! I have been searching for this kind of procedure for cheekbone surgery or reduction. I am glad to have found this site. I come from a family which we have strong cheekbones, but in my case I have been in a violent incident where I was injured and I think I broke or deformed a bit of my jaw. Now I have some asymmetry in my cheekbone as it seems to have become more prominent after this injury. I would really like to know if it would be possible to reduce them. I used to have a lot of charisma when I was young before my violent incident. Since then it has totally changed me. I would like to know more details in this procedure, time of recovery, possible complications, etc. Thank you.

A:  Cheekbone reduction is about narrowing the width of the body of the zygoma and the zygomatic arch. It is a common procedure for those whose face is naturally a little flatter and more wide as exists in certain ethnicities. It can also be used to treat a cheekbone fracture where the body of the zygoma has been pushed back which wides the zygomatic arch, making the cheek area have less prominence and more width.

Your description of your cheekbone problem is a it confusing to me. On the one hand, you state you have naturally strong cheekbones (forward prominence) but, after an injury, they have become more prominent. That would be very unusual given how the cheekbone fractures. For this reason, it would be best to send me some photos of your face for my assessment before I could provide any recommendations, specifically whether cheekbone reduction surgery would be benefical to you.

Dr. Barry Eppley

Indianapolis Indiana

Q:  I am an Asian American wanting to ask question to Dr. Eppley about a procedure. Is it possible to add material to the orbital rim to make it more deep? If so, what material and risks are involved?

A: When asking about building up the orbital rims, this is known as brow bone augmentation. By building out the brow bones, the globe or eyeball, will appear deeper. This is essentially a masculinizing procedure. Any of the cranioplasty materials can be used for brow bone augmentation and some plastic surgeons even use preformed or hand-carved synthetic implants. (which is not a technique that I use) The issue is not the type of material that can be used, since they all can work well, but the approach in which to do it. An incision is needed and the options include a scalp incision (for complete brow bone augmentation) or an upper eyelid incision. (for lateral brow bone augmentation) In a male with a high or variable hairline, a scalp incision is not usually cosmetically acceptable. This is less of an issue for a female.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  I am going to undergo Zerona body contouring treatments. I wanted to check with you first to make sure it is safe to do Zerona treatments with my inguinal hernia that protudes over my belly button area. I know the hernia is made up of fat, and I want to know if I should cover it with something to keep the Zerona from affecting it. Thanks so much for the help.

A: Zerona is a body contouring device that uses cold laser technology. This a low frequency low power laser light that should not be thought in the conventional laser sense. It is not a focused high energy beam which would normally burn anything in its path including skin and eventually fat. Rather it works by a different light principle known as a photochemical effect which will not injure or burn any tissues. This photochemical effect makes fat cells temporarily leaky by opening up channels or pores on the cell walls. This is not harmful to the fat cell per se, it just makes it lose some of its lipid volume. Thus, it is perfectly safe even if it would coincidentally be directed onto an abdominal area in which a hernia would be present. It would also be unlikely that the penetration of the Zerona energy would pass more than 5 cms below the skin, which is too superficial for many hernia locations.  

Dr. Barry Eppley

Indianapolis, Indiana

Q:  I have been left with a dog ear on my face after a nose reconstruction due to skin cancer. The nasal ala was reconstructed but the end result looked like a further growth. (like a pin cushion of skin stuck on to the side of my nose) It underwent a revision about two months later. I am still not totally satisfied as I now have a further deep scar on the side of my nose and an awful obvious dog ear that looks very unsightly. I went for a follow-up and they suggested giving it a year before considering any further surgery. I am desperate to have something done but if we did operate on the dog ear, I fear it might end up worse!! How can this be and why should I live with my face like it is? What can be done now?

A: Reconstruction of the nose after cancer is one of the biggest challenges in plastic surgery. This is particularly true of the nasal ala which is a small but delicate area. Having had two surgeries and now some degree of scar contraction or dogear, it is very important to let the tissues heal and settle down. The healing must progress to the point that it is not only complete but the scar tissues have relaxed. Operating on tissues that are not soft and supple will only lead to further scar contracture problems. It is certainly frustrating to have to wait a whole year with less than an optimal result sitting on your face, but the best result from an effort at scar revision depends on good quality of tissues to manipulate.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  I read an article on jaw implants in which you wrote “In some cases, no available off-the-shelf chin or jaw angle implant can create the desired effect due to a patient’s unique anatomy or aesthetic needs. In this situation, a customized ‘wrap-around’ jawline implant can be made from a 3-D CT scan of the patient. These can be made as a single implant or in multiple units that can be inserted in pieces and assembled when next to the bone. This approach is particularly useful when the jawline needs to be vertically lengthened. (implant sitting on the bottom edge of the bone)” Can you go into detail about the process of the custom mandibular implant with the 3-D CT scan? And from that how that fits into someone who travels for the surgery?

A: While standard chin and jaw implants will work most of the time, there are some patients whose jaw problem is beyond conventional implant designs. There are also patients who have been successfully implanted but do not like the aesthetic outcome that has resulted. These ‘implant-deficient’ patients have either vertical jawline deficiency, extreme chin deformities or the desire to have a more exaggerated jaw angle prominence. In these cases, only a custom jaw implant will suffice.

The process of making a custom jaw implant begins with the patient getting a 3-D CT scan at a local hospital or x-ray facility. That 3-D mandibular data is then sent to a custom model manufacturer. (I use Medical Modeling, Golden, CO) That model is then sent to me where I will hand carve out of wax or acrylic the desired implant(s) shape. Once approved by the patient, it is then sent to an implant manufacturer who will manufacture and sterilize the final implant(s). It will then be shipped to me for surgical implantation. This entire process takes about 4 to 6 weeks to complete. For someone traveling from afar, they only have to make one visit for the actual surgery. All preparations can be done from afar.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  I have my ears gauged to about 1 inch and I have a really bad tear in my left ear. My right ear isn’t too bad but is blown out in the back. Can these ears be fixed? But I don’t want my ears closed all the way! Just the scar tissue removed and my left ear thickened a little bit so it doesn’t tear off.

A: The repair of the gauged earlobe, while looking intimidating, is actually easier than one would think. The reason is the normal earlobe is small but the gauged earlobe, despite its big hole, has actually created extra earlobe tissue. Through a basic plastic surgery concept of tissue expansion, the earlobe edges may have gotten thinner but the actual amount of earlobe tissue has increased. It is always easier to reconstruct a body part where there is too much tissue than when there is a deficiency.

In reconstruction of the gauged earlobe, it can be done two different ways. The most common method is to remove the excess tissue and put it back together as a complete earlobe. After 3 months of healing, the ear can then be pierced. An alternative method is to do the reconstruction leaving a smaller but complete hole in the middle. The hole can be made very small for a piercing or left larger to wear a smaller gauge. Either 3 months of healing again are needed before anything is inserted.  

Dr. Barry Eppley

Indianapolis, Indiana

Q:  For most of my life I have considered myself ugly. I avoid having pictures taken and I most certainly don’t look at them if they have to be taken. I have a total lack of confidence and this has definitely poses problems in my personal relationships. I don’t know what it is about my face but it just doesn’t look right. I am only 29 but I look much older. My eye area looks droopy and old and may face looks thin and distorted. I have attached some pictures for you to see and review. What would you recommend to help me look better ?

A: When someone doesn’t like their face, particularly at a young age, this indicates that the problems are with how it is put together (structural components) not that it is has early aging. This means the underlying structures that make up the shape and highlights of the face which are largely bone and cartilage. In reviewing your pictures, I can see that your face has unbalanced structures which include low hanging brows, a broad and prominent nose, hollow cheeks, and a wide and long chin. The combination of these features creates an overall facial look that you do not like. Procedures such as an endoscopic browlift, rhinoplasty, cheek implants and chin reduction collectively would make a major change in how your face looks. It would lend a softer and more youthful due to a better balance of your facial features. Computer imaging with these changes would demonstrate their potential benefit in changing the shape of your face.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  I had a wart removed from my lip about a month ago. It has left scar tissue that really bothers me. It feels lumpy. People tell me they can barely tell but I know it’s there and was wondering what might be the best option for me?

A: To provide a really accurate answer, it would be helpful to know exactly how this lip lesion was removed and where exactly on the upper or lower lip it was removed. I am assuming that it was cut out and involved part of the wet and dry vermilion. (pink part of the lips) Excisions that involve the lip will frequently leave a bump or hard knot behind for a period of time. This is a normal reaction to injury and is a combined inflammatory and scar tissue reaction. This is usually very noticeable due to the sensitivity of the lips and the natural tendency for one to constantly run one’s tongue over it. In most cases, this reactive lump will eventually subside as it heals. It will usually take about 3 to 6 months for it to soften up and feel more natural. In those few cases where this lip knot does not eventually go away, a scar revision would be needed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Hi, I have hated my nose for a long time and I have finally decided to get a nose job. I am African-American and I don’t like the lower third of my nose. My nose is too wide and big when I smile. My nostrils flare really wide. I just want to get rid of some of the wideness but don’t want to change the whole nose. Is that possible?

A: One of the many distinguishing features of the African-American nose can be its unique tip and nostril shape. The tip is often more flat and less well-defined and the nasal base is wide, often with nostrils that have a larger size that also flare. Many African-American rhinoplasties involves reduction of the wide and flaring nostrils. This can be done by removing skin from the inside of the nostrils for some minor reduction or by repositioning the entire nostril base for a more major change. Nostril and nasal base reduction can be done by itself but it is important to see how this may change the overall look to the nose. This is where computer imaging is absolutely essential. Most likely changing the size of the nostrils will affect how the tip of the nose looks and will make it look even more flat and shorter. Some tip changes through columellar strut grafting may be needed with nostril reduction to keep the lower third of the nose in balance. Dr. Barry Eppley Indianapolis, Indiana

Q: I was born with a club foot. I had my first surgery when I was a few months old. I would love to have matching legs. Does insurance cover this since it is a bitth defect?

A: One of the aesthetic sequelae of a club foot deformity, which is one of the most common birth defects, is that of calf asymmetry. Due to the foot deformity, the calf muscle of the involved leg does not develop to the size of that of the normal opposite leg. This results in one calf being smaller than the other which causes an aesthetic imbalance of the lower legs.  This can be improved with a calf implant which is placed from an incision on the backside of the knee. While the small calf size can be improved, it rarely can become exactly as big as the opposite side as the calf skin is very tight and will only expand so far. This is done as simple outpatient procedure that takes about an hour to perform. Calf implant surgery for club foot is not covered by insurance even though it is being done to correct a congenital deformity. This is because the implant is not improving the function of the leg (medically necessary) but is being done to improve how it looks. (cosmetic) The lower leg will not work any better as a result of the implant but it will look more symmetric to the opposite side.

Dr. Barry Eppley

Indianapolis Indiana

Q: I had liposuction done on my neck  when I weighted 185 lbs with about 15% to 16% body fat. I had a good immediate change in the shape of my neck from that procedure. I am now 170 lbs and about 12% to 13% body fat. The great results from the liposuction have persisted as I would have suspected. What I am wondering is what will happen if I gain weight back to where I originally was around 185 lbs. I am not planning to but I am curious as you never know what the future holds. Does it matter if my weight fluctuates  between 170lbs and 185lbs? Will the fat return in my neck if I gain weight back?

A: The long-term results of liposuction on most areas of the body are highly dependent on the stability of one’s weight. The neck may be a slightly more privileged site (resist fat re-accumulation) than the stomach or flanks for example, but fat can definitely return there if one gains enough weight back. I think as long as you stay under your weight at the time of your original surgery, then your neck liposuction result should be unchanged. The percent body fat and weight ranges that you are talking about are not significantly large (170 to 185 lbs) so that change will likely not make much if any difference in the neck. However, it behooves you to keep the weight off as the amount of fat that was originally in your neck was there for a reason…so don’t give it a second chance to come back to an area that it once enjoyed.

Dr. Barry Eppley

Indianapolis Indiana

Q: I had a sliding genioplasty just one month ago in January 2011. It was advanced 8mm and I feel it was too much. I do not like how my chin looks. It is not a natural look. I also lost almost 2/3 of my lower lip which make the chin even bigger. It really has changed me a lot. I was wondering what can be done to recover the fullness of my lip. I am even considering a reverse genioplasty to bring it back to 5mm even though the cephalometric analysis says that I am short 9 mms. How long should I wait for a revision and any further interventions?

A: Now that you are roughly 6 weeks out from your initial chin surgery, most (but not all) of the swelling should have subsided. While there is some final swelling and stiffness of the chin that needs to go away in the next few months, that will only change the chin projection by maybe 1 to 1.5mms. Therefore if you feel the chin is too strong at this point, then it is and your decision to set it back some more is reasonable. A change from 8mm to 5mm is reasonable since it takes at 2 to 3mms to really see any difference. The time to make that change is NOW. The bone is not yet healed and it is a relatively easy plate and screw exchange to do the revision.

When you say you have lost ‘2/3s of my lower lip’, I am assuming you mean that you have a drooping lower lip otherwise known as lip incompetence or sag. Unlike chin swelling where time will make some of it go away, time will not lift up a sagging lower lip. This is a function of the mentalis muscle position/resuspension on the chin bone. To imrpove that situation, the muscle need to be lifted up higher in the bone and secured. This will help the lower lip get back to a more normal position. The sooner this is done the better as muscle scarring is occurring. So again, NOW is the time to revisit this with your surgeon and have these discussions.

Reversing/revising the effects of a sliding genioplasty are best done early before complete bone and soft tissue healing has occurred.

Dr. Barry Eppley

Indianapolis Indiana

Q: I would like to get a breast reduction on just my right breast. It is a couple of cup sizes bigger than the left and its very painful. I think people notice and I can’t find a bra that fits right and looks good without one of my breast falling out. Also, I can’t wear any cute shirts I like and I’m very self consious when my husband sees it. I know I would be so much happier in life if they were both the same size. How much would it cost to get tissue removed from one breast so that they are the same size and that is all? Also what do I need to do to to get started? Please help!

A: Breast reduction can equally be done on just one breast as it is on two. It just takes half the time and close to half the cost of a two-sided breast reduction. When reducing just one breast, you have the ‘advantage’ of the other breast as the cosmetic goal. While perfect size and symmetry cam never be absolutely achieved, they can be made very close. The trade-off you make is that for better size and symmetry, the reduced breast will have fine line scars that the other breast does not. The best way to get started is to visit a plastic surgeon and discuss the specifics of your breast goals. On average, the cost of one breast reduction done as an outpatinet procedure will run in the range of $ 3500 to $4500.

Dr. Barry Eppley

Indianapolis Indiana

Q:   Hello, I have had three very large children (all between 9 pounds and 10 pounds) and have had a very large weight gain/loss after each child. I am getting closer to my goal weight at this time from my youngest child. (Currently 165 pounds-my highest weight was 214 pounds) and my goal weight is around 150. Because of the large multiple pregnancies and weight gains/losses, I am in the need of some body contouring. I have multiple areas that need addressed, my loose tummy,  excessive skin in my upper arms, sagging breasts and excess skin and resistant fat deposits in my legs. I am interested in a consultation to start the process of repairing some of the damage to my body that my healthy diet and daily exercise will not fix. I plan to have the surgeries over a few years, rather than all at once, due to cost and my schedule.

A: Body changes that have occurred either from bariatric surgery, extreme weight loss or the impact of multiple pregnancies requires thoughtful consideration about the type and timing of surgical corrections. Sitting down with a plastic surgeon and going over all the surgical options is an obvious first place to start. Having had many of these discussions in my Indianapolis plastic surgery practice, most women will focus first on their tummy and waistline often combining it with another procedure such as an armlift.

These more substantative body problems are more substantial that the more traditional Mommy Makeover which is directly to two combined procedures, breast enhancement (implant with or without a lift) and some form of a tummy tuck.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am interested in getting my upper lip made bigger. It is very thin and it barely shows at all. It is very embarrassing to have such a thin upper lip when so many women have nice full lips. I think a bigger lip would make me look better and more attractive. I want to get injectable fillers into it because that seems to work well for most people. But I don’t want to look like I have a big fat upper lip or have duck lips. How can I get injectable fillers without causing that problem?l

A: Most lip augmentation patients want a natural look. Very few want their lips too look like they have had something done, although some people do end up looking that way.The success of having a natural looking result in the upper lip with injectable fillers is based on how much native vermilion tissue (pink part of the lips) you have. The most common reason one ends up with the infamous duck lips is that too much filler has been placed into the lips. A more full upper lip can take more filler and still loko natural. But a thin upper lip can take very little without creating a pufffy look.  This is because in the thin upper lip the injectable filler does more pushing out rathe than up because there is not enough tissue. When it comes to injectable fillers in athin lip like yours, you have to realize that you can never really end up with a nice full lip look that many women desire. You just don’t have enough vermilion to do it.

What you would more ideally benefit from is an upper lip advancement which directly treats the actual problem and is permanent. But because that involves a fine line scar, I would recommend that you first do an injectable filler treatment and see of you like the results. If you do, then just continue with periodic filler treatments. If you don’t, then you know that there is another option which can give a much fuller lip that is permanent.

Dr. Barry Eppley

Indianapolis Indiana

Q:  I have HIV and have been on antiviral medication for the past 15 years. I am now trying to decide if liposuction to remove the fatty deposits under my chin, lower face and around my ears would be beneficial. I read your article and feel that you are someone who is compassionate and could help me wth this issue. I am just tired of being stared at out in public because of the way I look. I don’t want to look like a freak because of my years living with HIV and taking the medications to live a productive life. I want to find out how much this would help and what the recovery time would be.

A:  Retroviral medications in the HIV patient can cause very unique fibrofatty deposition about the cervicofacial area. Most commonly a buffalo hump can appear at the back of the neck. But extensive tissue collections can occur around the neck from one side to the other including around the ears. This makes the face look like it is sitting on a tire, so to speak, if they are significant enough. Most of these fibrofatty deposits, however, are more than simple fat that is easily suctioned out. While liposuction can be done under the chin and into the sides of the neck, the deposits around the ears and into the side of the face are best treated by open removal through a facelift approach rather than just liposuction alone. Better debulking results are obtained with this combined approach. Recovery is very similar to that of a facelift with about a 50% reduction in the bulk of the cervicaofacial tissues.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am interested in making my face look thinner. Even though I am not fat (below the neck), my face make me look like I am. I have read about the buccal lipectomy procedure and that seems like it would work for me. I am most interested in getting the lower part of my face thinner. I have attached a front picture for computer imaging to see what the change would look like. Thank you for your help!

A: Thank you for sending your frontal picture. I have imaged the result doing buccal lipectomies (upper submalar triangle) and some perioral mound liposuction. (lower submalar triangle) It is important to realize that these procedures are most effective for the areas below the cheek down to about the mouth level and not for fullness at the jaw angle or in the lower part of the face. Facial defatting procedures work best in areas that are not directly supported by bone where the fullness is more the result of the thickness of the fat and not the bone. In bony-supported facial areas, thickness or projection can only be reduced by bone reduction which is often not only difficult but not that effective. There are no effective lower facial procedures (sides of the face and along the jawline) for defatting or making it look thinner.

Dr. Barry Eppley

Indianapolis Indiana

Q:   Dear Dr Eppley. I am wondering if it is possible to get a variation of genioplasty done.
I am wanting to reposition my chin bone higher up. In reduction genioplasty the chin tip is sawn off, a wedge of bone is removed and the chin repositioned back.Is it possible to saw off the end of the chin, then without removing any bone, reattach the sawn off tip at a higher position? This could help address saggying tissue as the higher position of the bone could help lift the surrounding tissue. This would leave a bony ridge on the chin, however this could be hidden with fillers.Does this type of surgery sound like something you could do? Thank you.

A: That is known in chin surgery as a ‘jumping genioplasty’. That places the cut piece of chin bone on top of/in front of the upper chin segment. However this will bring the chin forward and make it more prominent, although it would lift up sagging chin tissues and shorten its vertical length somewhat.

By your descriptions, I think you may have an erroneous concept of how chin osteotomies are done. It is important that the cut piece of chin bone remains attached to the muscles which provide it with a blood supply, otherwise it will die and resorb away. It is not just moved anywhere else one wants to put it.

Perhaps you could send me some pictures so I could see what type of chin problem you and what may or may not work.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I had a septorhinoplasty about six weeks ago. As a male, I was told that my thick oily skin will cause a lot of swelling in the tip of the nose that will take longer to settle down and go away. My concern is not the swelling in the tip of the nose but that it is drooping and the columella seems to be hanging too low. These were two key issues that I really wanted improved but right now it does not look like this has been achieved. Is it possible that my concerns are just do to swelling? Should I be considering early revisional  surgery?

A: While it is still early in the rhinoplasty healing process, some improvement in the major focus of the nose should be evident at this point. There is no doubt that swelling is still present at this point and it may be considerable. So all hope is not lost that the final result may still turn out satisfactory. Whether revisional surgery may or may not be needed can not be foretoold at this early sfter surgery point. What you don’t want to do in consideration of revisional surgery, however, is chase a ‘moving target’. Give the nose a full six months after surgery and then go back and get a more useful after surgery evaluation from your plastic surgeon. What matters most at thaty point is how is how much change has occurred from now until then. If improvemenmt has been seen, then more time may be adviseable. However, if there has been no visible significant change between 6 weeks and 6 months after surgery, then revisional surgery is going to be needed.

Dr. Barry Eppley

Indianapolis Indiana

Q: Hello, I am looking the best procedure for diminishing marionette lines, over lips, and most importantly, droopy skin on the neck. What do you recommend?

A: In reading your question, I am going to assume that you mean marionette lines that start at the corner of the mouth and hangs over the corners. (hence the phrase ‘over lips’) When you combine those aging facial features with droopy neck skin, you are talking about a combined neck-jowl problem. Heavy marionette lines that hang over the mouth corners indicates that there is likely some jowling and skin that is falling forward and down…the reason thaty most marionette lines exist. While I obviously have not seen any pictures of you nor have examined you, all of these aging facial issues point to one and only one effective treatment option…some version of a neck-jowl lift. The key issue is the droopy neck skin. Nothing short of this type of a tuck or lift can change a loose neck skin issue. This is often combined with a corner of the mouth lift to get rid of the overhang, a small little procedure done at the corner of the mouth. This will most effectively get rid of the loose neck skin, ‘over lips’ and decrease the depth of the marionette lines.

It would be helpful to see some facial photographs or come in for an evaluation to confirm this potential recommendation. These are common facial aging problems where patients are often searching for some ‘simple’ or non-surgical approach where such treatments do not really exist. You want to avoid wasting money on any non-surgical treatments that really have no hope of making a substantive difference…and there are lots out there that sound good but don’t work very well.

Dr. Barry Eppley

Indianapolis Indiana

Q:  I am interested in making my existing breast implants bigger. I am unsure as to whether it is better to just add more saline to my existing implants or to get new implants altogether. I currently have Mentor smooth round moderate plus saline implants which are 325cc. I am fairly small being 5’ 3” and weigh 108 lbs. I started out as an A cup and am now a C cup. Would adding 50cc to my implant make enough of a difference?

A: The answer to your question can be partially deduced by analyzing the percent change by ratio assessment. With existing 325cc implants, an additional fill of 50cc will make a 15% change in their volume. This will make a noticeable size difference with your small frame but don’t expect it to make a 1/2 or full cup size difference. Also, further saline fill will make the implants feel a little firmer. Assuming that the base size of your implants was 325cc, an additional 50cc will not make them feel abnormally firm. This is a good approach to enhance what you already have for a little ‘perk-up”. But if you are looking for a significant difference in breast size like a D cup, you will need to redo your breast augmentation with new implants that have a larger base size.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  I am 24 years old, 5′ 4” tall, weigh 135lbs, and have 38DD breasts. Am I a good candidate for breast reduction and could it be covered by insurance? My back, shoulders and neck are always sore and I get migraines in the back of my head all the time. I wear loose clothes to hide my hideously large breasts and I would never even think of wearing a swimsuit for fear that I might fall of it! I just want to be physically and emotionally happy, but its hard with my unproportioned body due to my large breasts. Insurance is the only way possible for this surgery to happen if I qualify.

A: Based on the size of your breasts and your height and weight, it would seem likely you’re your breast reduction would qualify for insurance coverage based on my experience. But whether one’s medical insurance will provide can not be determined by your plastic surgeon. Insurance coverage for breast reduction requires a predetermination letter to be sent by your plastic surgeon with specific qualifying information. Your height, weight, breast cup size, history of medical symptoms associated with your large breasts, what non-surgical treatments have been attempted, and how much breast tissue in grams is to be removed is the needed information. This letter, complete with photographs of your breasts, will be submitted for their review. They will then determine if you qualify and their decision with be returned by letter to you in about 4 to 6 weeks after submission.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr Eppley, I was involved in a car accident several years ago which left me with a big ugly scar on my upper lip. The scar connects with a scar on my nose. It seems like I don’t have that line (margin) of the lip as it is flat. The scar has been revised several times but there has been no improvement. I was wondering if anything can be done to make that line/margin of the upper lip? I know the scar won’t disappear but at least just to have some improvement. Your help will be greatly appreciated.

A: While I would have to see pictures of the lip scar to be certain, it sounds like you are talking about loss of the philtral height or the philtral ridge. When a scar crosses it, it will likely lose its height or prominence. A skin scar revision alone will not restore the height of a philtral ridge. I have found that an allogeneic dermal graft placed under and along the philtral column underneath the scar area is necessary to resist scar contracture. Please send me some photographs of the scar for my assessment.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Hello, I had submental chin implant revision surgery and lipo under the chin. The incision was made in my natural crease and is extremely apparent. Also, it seems as though after the surgery, I have jowls that I have never had before. People think I lost a lot of weight. Is there anything that can be done to correct either situation reasonably? Thank you for your time.

A: The placement of a submental (under the chin) incision for chin augmentation is a fairly simple and straightforward consideration. Most people have a skin crease on the underside of their chin and this is a logical incision location. But depending on the location of this crease and the size of chin implant to be placed, this may not always be a good location. The chin skin stretched forward due to the push of the implant and what was once a hidden location may become more visible. For this reason, I often move the incision location slightly behind the submental skin crease to avoid any potential that it may become visible. Once the incisional scar location is set, there is no way to relocate the scar.

The development of jowls after chin augmentation may be the result of the wings or sides of the chin implant. Chin implants today are more anatomic in design and often will have long extensions that go back from the sides of the chin into the body of the jaw. If these wings get folded unto themselves and are not fully extended due to a pocket dissection that was short, the folding of the implant’s wings could create the look of jowls. If this is the problem, it can only be resolved by revisional chin implant surgery.

Dr. Barry Eppley

Indianapolis, Indiana