Your Questions

Q:  Hi Dr. Eppley, I recently had a revison gynecomatia surgery to remove scar tissue about 3 months ago and now I have even more scar tissue buildup than I had before. I have a big lump under my left nipple and was wondering if I it was possible to get 5-FU injections to reduce the scar tissue because I heard that Kenalog can have significant side effects. My doctor does not offer 5-FU and I have heard that this needs to be injected within the first few months after surgery to have an effect so I would like to get this done if possible. I would appreciate hearing back from you and helping me out with this if possible. Thank you!

A: At this early point after your revisional surgery, it is reasonable to consider a non-surgical treatment for your recurrent scar tissue. If significant improvement was to occur, you should be seeing it by now. The standard injectable scar treatment is Kenalog. While there are potential side effects (fat and skin atrophy), these are very much dosage and location dependent. High and frequent injections of Kenalog in skin level scars can cause these problems. But low doses of Kenalog done judiciously for subcutaneous fibrosis is unlikely to create these potential problems.

5-FU scar injections are useful in scar issues that have proven resistant to Kenalog. While there is nothing wrong with using it as a first choice therapy, it may or may not be necessary. When administered it is mixed with either a small amount of Kenalog or local anesthetic since there is definite burning afterwards associated with 5-FU injections. You are correct in assuming that these injections should be done early as they work best when new scar tissue is forming as opposed to long-stand established scar tissue.

Dr. Barry Eppley

Indianapolis, Indiana

Q:   I am 52 years old and have myasthenia gravis. I had a thymectomy 23 years ago and currently have very minimal symptoms. I am interested in reducing the appearance of aging, especially in the neck and jowls. Is the IGuide or another minimally invasive procedure recommended for patients who have myasthenis gravis? If not, what are my options to improve my appearance?

A: Having the condition of myasthenis gravis (MG) poses potential issues for anesthesia for surgery but not for the surgery itself. You are likely interested in minimally invasive facial surgery because of its often association with local anesthesia and potential avoidance of general anesthesia. What you want to avoid with any form of anesthesia is a myasthenic crisis. This occurs when the muscles that control breathing weaken to the point that ventilation is inadequate, creating a medical emergency and requiring a respirator for assisted ventilation. This is most likely to occur in those MG individuals whose respiratory muscles are weak. This does not appear to an issue for you whose has minimal symptoms. Nonetheless, it is best to avoid any form of general anesthesia particularly for elective cosmetic surgery.

The IGuide neck procedure, a more limited type of necklift (e.g., Lifestyle Lift) or both done together are procedures which are effective in individuals with early to moderate neck aging issues. Whether any of these are good procedures for your neck and jowl concerns can only be determined by doing an assessment of some photographs.  They can be very successfully performed under local anesthesia supplemented by either oral or light intravenous sedation.

Dr. Barry Eppley

Indianapolis, Indiana

Q:   I have a scar tissue under my cheek bone caused by injecting an Artefill or Sculptra filler.  It’s been there since the filler was done 6 years ago. Now I’m been treated with 5-FU and Kenalog injections. I have done only 3 treatments so far but with no results. Do you think that the treatment can help to rescue the size of the scar or is there no hope?

A: Most likely your residual cheek mass is the result of an Artefill treatment and not Sculptra. Artefill is a filler that has a significant component of non-resorbable acrylic beads which settle into place by scar tissue forming through and around them. The beads are permanent. Sculptra is composed of resorbable poly-lactic crystals which causes temporary scar formation to occur which eventually goes away as the crystals eventually dissolve. After 6 years you have a residual mass that is, at least partly, due to the acrylic beads. While I think the 5-FU/kenalog scar injections are reasonable to try, I suspect they will ultimately prove unsuccessful as they are not going to make plastic beads disappear. Furthermore, this injectable scar treatment works best on scar that is newly forming not on established scar tissue.

That being said, 5-FU/kenalog scar injections often take a full course of treatment to know to be maximally effective. You have had only 3 injection treatments and the complete protocol is up to 10 injection sessions so it is too early to rule out completely that they will not work at all.

Depending upon the cheek mass/scar location, it may be more efficient to have it excised if it can be approached favorably through an intraoral (inside the mouth) incision.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I will be having nose surgery soon and one thing my doctor recommended was to cut the muscle that makes my nose tip droop when I smile. While this has been told to me as a simple step in the surgery, I am worried that my smile or, more specifically, the way my upper lip moves will be abnormal after the procedure. From your nose surgery experience have you ever seen this to be a problem?

A: For some patients, they have a hyperactive or large depressor septi muscle that pulls the tip of the nose downward when they smile. This is often resolved during rhinoplasty surgery when the tip of the nose is made stiffer through cartilage grafts and sutures,  a secondary benefit from the primary objective of nose tip reshaping.  One simple way to ensure that this result happens is to also release the bony attachment of a tiny muscle that runs from the tip of the down to the upper jaw bone, the depressor septi muscle. This muscle is not one of the smile muscles and has no role to play in how one’s mouth or lips moves. However, because the dissection to get to the muscle goes through a portion of the upper lip (either underneath the lip through the frenulum or from inside the nose), there will be some swelling of the lip for several weeks afterward. This swelling will temporarily affect the shape of the upper lip and may make the smile more ‘stiff’ until it goes away. But releasing this muscle will in no way affect how one smiles once it is healed.

Dr. Barry Eppley

Indianapolis Indiana

Q: This is in regards to an unusual form of craniofacial surgery which I have been hoping to obtain for many years.  I have a slender jawline and forehead, somewhat prominent browline, and both wide and prominent cheekbones.  I was wondering if it were possible to have the cheekbones (by which I mean the zygomatic bone itself, the temporal process, and then the zygomatic process of the temporal bone) replaced entirely by synthetic implants so as to make my face more slender and these features, in particular, well-proportioned to the other features of my face.

A: The slimming effect to which you refer is known as cheek or midface reduction. To do so by conventional craniofacial surgery is well known and the techniques well established. It is a more common request in the Asian poopulation due to their facial shape. Complete cheek reduction is done by osteotomizing the front (zygomatic process) and back part (temporal process) of the cheek, removing bone, and allowing the enture zygomatic bone and arch (which creates the facial width) to move inward. The new bone positions are then secured with small plates and screws. This is done through an incision inside the mouth and a small incision in the temporal hairline. One can usually get a bifacial narrwoing of around 1 to 1.5 cms.

While any type of implants can be fabricated off of 3-D C scans and models, it is not practical to replace the entire zygomatic complex and arch to obtain midfacial narrowing. This would require extensive surgery, a large scalp incision, the removal of masticatory muscles which are attached to the bones, and the significnt risk of facial nerve injury. While this is done for extensive traumatic bone injuries and tumor resections, those risks for a cosmetic concern are not reasonable. This is particularly true when you consider that the same if not better result can be obtained by less invasive and ‘simpler’ surgical techniques.

Dr. Barry Eppley

Indianapolis, Indiana

Q: With all of the jaw angle implants that you have placed, what are the most common complications? What problems have you see long-term? Are they permanent or would I need another in future?

A: Jaw angle implants, in my experience, are uniquely different than all other types of facial implant locations. Because they are put under the biggest muscle in your face (masseter muscle), and the only facial muscle that actually moves a bone (mandible, lower jaw), there is more discomfort and recovery from the procedure than any other facial implant procedure. The sides of the jaws are fairly swollen and the mouth will not open normally for a few weeks. (trismus) This is due to the stretching and trauma to the masseter muscle. Because it is a large implant that is put in through the mouth, the risk of infection seems to be higher than any other facial implant.  Despite doing  every infection precaution available, I have found that the infection rate is about 5% of all patients implanted, necessitating removal and/or replacement. The other complication risk is asymmetry. Because the implants are on opposite sides of the face, it is challenging to always have a perfectly symmetric result. (many patients don’t have jawbone/angle symmetry to start with) This leads to a revision rate for symmetry correction in jaw angle implants of around 5% also. Collectively, this means that one out of every ten jaw angle implant patients will need some sort of revisional surgery. These complications are seen early within the first few weeks to several months.

On the good news side, jaw angle implants are permanent and will not change over one’s lifetime once successfully implanted amd healed into place.

Dr. Barry Eppley

Indianapolis Indiana

Q: I had a tummy tuck recently and as part of it my muscles were sewn back together. I was told there were several inches apart.  My tummy now is very flat in the lower half but the upepr half still has somewhat of a bulge. Do you think that is because the muscles weren’t sewn up togethere this high. I am confused as I thought the whole tummy would be flat from top to bottom. What are your thoughts?

A: The purpose of sewing the vertically-oriented rectus muscles in a tummy tuck together is to help correct one part of the tummy bulging problem. How much tummy skin and fat you have makes up the other components of the bulge. This muscle sewing is usually done from just under the rib cage in the middle (top of the inverted V) the whole way down to the just above the pubic bone. But it is up to the plastic surgeon’s discretion as to whether it is beneficial to cover this entire vertical length or not. More pain after surgery comes from more muscle sewing so there is no reason to do more  than is really needed. Not every patient needs the entire vertical length of the muscles swen together as tight as possible.

It is extremely common to see a different amount of improvement in the tummy bulge from that above the belly button to that below it.. The best result is seen between the belly button and the pubis because this is where the skin and fat have been completely removed and replaced with skin and fat from above. Between the rib cage and the belly button, there still may be some remaining bulge as this skin has just been pulled down and stretched but not removed. That is likely the reason you have some bulge remaining in this area, not because the muscle hasn’t been sewn back together. In thin women, this issue may not appear. But in those patients that had thicker amounts of fat under the skin in the upper abdominal area to begin with, the upper tummy area will not be as flat as the lower. This can be improved later with some liposuction to thin out the tissue thickness in this upper tummy area.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am a 35 year-old man with a facial condition known as Binder’s syndrome, you may be familiar with it as a craniofacial plastic surgeon. My whole midface is back and I think I need a combined LeFort III and LeFort I osteotomy. My upper teeth are a bit forward of my lower teeth so it is a bit of an overbite. My thought is that the LeFort III would bring out all the backset midface bones and then at the same time a LeFort I could be done to bring my teeth back into place. I am not contemplating having any orthodontic treatment before surgery. I have attached some pictures of my face for you to see. What do you think of this plan?

A: I am very familiar with Binder’s syndrome, also known as nasomaxillary hypoplasia. You definitely have a rather severe manifestation of it with the entire midface quite retruded. Your basic thoughts on the need for midface advancement is correct but what it is not obvious to you is how one’s bite relationship controls whether and how any type of orthognathic surgery is done.

Let me give you some clarification on your LeFort concepts as they are understandably not accurate. You can’t separate or differentiate different levels of a LeFort osteotomy regardless of  type. You either have to do a LeFort III or do a LeFort I, you can’t do both at the same time. That make look like it would work on drawings or on paper, but it does not work that way in practical application. The bottom line is while your facial deformity would ideally benefit from a LeFort III advancement, your bite does not support that facial skeletal change. That would put your upper teeth (provided that the bone would actually move that far which I doubt without external distraction) greater than 10 mms in front of your lower teeth. (and no you can’t do a LeFort I setback later as a secondary procedure) The irony is that your bite, for whatever reason, is simply too close to normal to support any of these LeFort procedures even though your facial skeleton could use it.Your bite with the amount of midfacial deficiency that you have should show a severe Class III malocclusion (underbite) which it does not. I have never seen such a combination of severe midfacial hypoplasia with a relatively normal bite before.

This leaves your only practical treatment solution as an augmentative or camouflage approach, which is actually much easier on you. The midface can be brought forward through infraorbital rim-malar and paranasal implants combined with a rib graft rhinoplasty. This concept builds on top of the existing midfacial skeleton rather than trying to move it forward. As an additional benefit, the brow bones/supraorbital rims can be set back as they have a large amount of bossing. The combination of all these facial procedures does a pretty good job of improving your facial balance. I have attached some imaging which shows those changes.

Dr. Barry Eppley

Indianapolis Indiana

Q:  I am a fit 24 year-old guy but I don’t like the look of my cheeks. They are definitely chubby and they don’t fit my face or the rest of my body. I would to get rid of my chubby cheeks, All my family have chubby cheeks and they don’t look good on them either. I have read on the internet about different cheek procedures such as excision of the bichat fat pad, liposuction and smartlipo? Can you please tell me what to do?

A: Chubby cheeks or fullness in the cheeks is caused by excess fat in two different areas not just one. The upper submalar area (right below the prominence of the cheekbone) is where the buccal fat pad (formally known as Bichat’s fat pad)  lives. The lower submalar area, unlike the buccal fat pad, is not one large piece of localized fat but is composed of diffuse subcutaneous fat. (fat layer between the skin and the buccinator muscle) A buccal lipectomy which is done from a small incision inside the mouth will help reduce the size of the area right under the cheek. But a buccal lipectomy will not change the fullness below that in the lower submalar area closer to the level of the mouth. These are perioral mounds which can be reduced by very small cannula liposuction done from inside the corners of the mouth. Both locations of fat removal are needed to get the best reduction of chubby cheeks.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am a 35 year-old mother of four who is tired of my stomach hanging over my pants. I need some type of surgery to help shape up my stomach area. I don’t know whether it should be just liposuction or some form of a tummy tuck. The main reason I want this surgery is that no matter how hard I work out or diet, it just won’t go away. I’ve got a very persistent pooch and it really needs to just go away! Which do you think is better, liposuction or a tummy tuck?

A: While an actual examination with a plastic surgeon is the only way to know for sure, there are several key statements in your inquiry that give it away. The mixture of having had four children and a stomach that hangs over your pants indicates one key thing…you have too much stomach skin.While there no doubt is some fat under there as well, the key indicator of the choice between liposuction and a tummy tuck is how much extra skin is there. Liposuction can effectively remove fat but it has little skin tightening capability. A tummy tuck very specifically addresses the excess skin issue that exists from one hip to the other. Liposuction is quite often part of many tummy tucks in a complementary role as it helps reduce the muffin tops that most people have off to the sides of the tummy tuck. The combination of a tummy tuck and hip/flank liposuction creates a better waistline result that wraps around to the back.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am interested in shortening my upper lip. It is way too long. It is big enough that you could land a plane in that part of my face! I have read about the subnasal or bullhorn upper lip lift and that seems like a good solution to my problem. However, I am Hispanic and am concerned about the car under my nose. I have read about the Italian upper lip lift which does not create the scar under the middle part of the nose. Do you think this is a good option for me?

A: The only way to really shorten an upper lip is to remove a strip of skin, either across the subnasal base (under the nose) or across the top of the cupid’s bow. in the ‘Italian’ version, the select removal of skin from just under the nostrils will not significantly shorten the upper lip. That published article, which I have read and reviewed in the past, is quite frankly flawed. All of the patient results shown have the after photos with the head tilted upward which makes it look like the lip is shorter. (or the before photos have the head tilted slightly downward to make the lip appear longer than the afters) While I don’t think the authors deliberately meant to deceive the readers, the results do not support that it actually works. While having less scar under the nose is certainly appealing, the upper lip is not going to get shorter if the central part under the columella is not removed. That is the cornerstone of upper lip lifting. With your ethnicity and skin pigment, a scar anywhere is always a concern more of a concern than it would be in a Caucasian patient. It may be for that very concern that the Italian upper lip lift was devised.

Dr. Barry Eppley

Indianapolis Indiana

Q: As a 59 year-old female, I am interested in the corner of the mouth lift. I had a facelift four years ago which did help the corners of my mouth to some degree but they need more attention. They are still downturned to some degree. Any info or photos would be appreciated.

A: Contrary to popular perception, a facelift has little effect on the corners of the mouth. In general, a facelift will not turn up corners of the mouth that are drooping down. It will have a very mild effect but nothing significant. This runs contrary to the fear that the corners of the mouth can be pulled way to the side and distorted if a facelift is ‘overdone’. Such is not the case. The mouth is a long way from the point of pull which is by the ears in a facelift. By the time the pull force reaches the mouth, it has little power left to much of anything. The downturned corner of the mouth must be attacked directly with a procedure right at where the problem is located.

The corner of the mouth lift is a simple office procedure done under local anesthesia. It involves the removal of a small triangle of skinjust above the downturned corner. In its replacement, the mouth corner is moved upward. It can be done conservatively or more aggressive depending upon the degree of downturning of the corners of the mouth. There is virtually no recovery other than some persistent redness at the corner of the mouth for a few weeks. This simple mouth procedure is powerfully effective.

Dr. Barry Eppley

Indianapolis Indiana

One of the images highly associated with Valentine’s Day are lips…big, red and full lips. They are as synonymous with this day as much as chocolate and flowers. While big lips may be highly visible on this one day, they are actually sought out every other day of the year as well. Lip enhancement has been one of the popular office procedures in plastic surgery for nearly a decade and there is no sign of the demand slowing down.

Many women want fuller lips, some motivated by the look of Hollywood stars like Angelina Jolie which is more of an extreme look. But women of all ages seek lips that are larger, even if it just a little bit more. They want to add volume to their lips or improve the shape of their lips so that they can have more of an attractive pout. There are numerous injectable fillers that can make an instantaneous change, albeit temporary, and even some more surgical procedures and implants that offer a permanent result.

But plastic surgery technology aside, why is it that women want fuller lips? What is the deep-seated reason for this facial enhancement? Men do not ask for it and I have never had a single male request compared to thousands of female lip enlargements performed.

Some, of course, would say that bigger lips are an enticement to be kissed and therefore makes one more attractive. Kissing in not an exact science, although there is some interesting factoids about it. When you give your loved one a smooch, the majority of people tilt their head to the right. It requires six major muscles around the mouth to pucker up for a kiss. Our pupils dilate while we kiss, which is why we often close our eyes. A good sloppy wet kiss can transfer up to 100 million bacteria (not very romantic, but scientific fact nonetheless).

There is no question that lips are an erogenous zone for women in both appearance and function. Anthropologists tell us that a woman’s lips are a visible expression of her fertility. Studies have shown that a woman’s facial and sexual attractiveness is closely linked to her hormonal makeup during puberty and development. A woman’s estrogen levels helps maintain a youthful facial appearance in which the lips are fuller. Full lips are therefore attractive to men because they serve as marker of a woman’s health and fertility. They certainly seem to make women feel more attractive and sexy.

With this understanding, putting injectable fillers into the lips (or the more common application of lipstick) takes advantage of this innate biology. Bigger lips ‘fool’ men into thinking that a woman has more estrogen than she actually has and thus is more fertile and attractive. I have always said men are easy creatures to motivate…and this is one time again we don’t mind being fooled. Pucker up !

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dear Dr. Eppley, I read your article where you speak about chin implants and you say: “Lateral or wing malpositioning is actually the most common problem and is a result of the newer styles having thin and more floppy wing extensions which can easily fold onto themselves” . I would be most grateful if you could advise on the best way to correct misplaced wings on the side of the jaw.

A: Unlike chin implants of old, most contemporary chin implant styles are more anatomic in design and shape. This means that rather than having a simplistic button or oval shape that just sits on the very end of the chin bone, they are longer and wrap around the bone to flow more confluently into the body of the mandible. This gives them long wings or lateral extensions along their sides. With silicone chin implants, these wings have thinner material thicknesses that end in minute paper-thin extensions. Because silicone is flexible, this makes them prone to fold upon themselves or buckle if the implant pocket is not dissected far enough back. Also they can ride upward or downward based on the angulation of the pocket dissection. Either way, these implant wing malpositions will be felt or seen as a lump or bump along the jawline. With Medpor chin implants, these wing malformations do not occur as the material is much stiffer and not flexible so the ends do not bend.

With chin implant wing malformations, the only way to correct them is to do an open revision. The implant is removed, the pocket checked and dissected further if needed and the implant then re-inserted. In some cases, the fine ends of the wings are removed as they serve no volume or contour purposes.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  I have a ruptured implant and am in need of a breast augmentation revision. I have always thought they were a little too large.  I’m wanting to downsize 25cc; they are different sizes, 275cc on the left and 250cc on the right. When downsized, I would then have 225 and 250. I’m worried about the 275 to 250 because the diameter is so much different. Is this going to look change the look dramatically?

A: In answer to your question, I would have no concern about such a small implant volume change on the breast look. A change of 25cc in a 250cc implant is only a 10% change in volume and would be less than .5cm in base diameter of the implant. In a 275cc implant that volume changes drops to only 9%, a change that is hardly visible. With either implant, that would likely have a minimalistic change in the outer breast appearance. In the case of saline breast implants, there are a lot of variables in implant selection such as their base size and what they are filled to as well as the projection or profile that they have. Such variables can make a visible external difference and all must be considered. With silicone implants, they are prefilled and their only variable is the different projections. (low, medium, and high) As a general rule, visible changes in the size of the external breast when it comes to a breast implant exchange should be in the percent volume change of 20%. Therefore, if one wants to have a smaller breast size with an existing 250cc implant, the downsized implant should be 200cc.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I had bariatic surgery four years ago. This has left me a lot of loose hanging skin as well as a prominent and painful bulge around my belly button. I have been told that it is a hernia and it certainly feels like it is. Are you qualified to fix a hernia and do tummy tuck? What is the normal price for this type of procedure as I currently have no insurance?

A: Thank you for your inquiry. It is extremely common to have to do a hernia repair with any type of abdominal contouring procedure for the bariatric patient, whether it is a simple abdominal panniculectomy, a fleur-de-lis abdominoplasty, or a circumferential body lift. Hernias are now less frequently found with the newer laparoscopic bypass surgeries than with the older open approaches but they are still relatively common. As a plastic surgeon, we routinuely fix hernias using a muscle repair technique rather than the placement of any type of synthetic mesh. This is easy to do with the wide open exposure that occurs with the tummy tuck procedure.

The cost of a ‘bariatric’ tummy tuck can be quite variable based on what type of abdominal procedure is really needed. There are three basic options for the extreme weight loss patient, whether they have lost the weight by bariatric surgery or not. There are two types of frontal cutouts (panniculectomy, fleur-de-lis tummy tuck) and the circumferential body lift. (360 degree tummy tuck or tummy tuck combined with a hip and buttock lift) To get an accurate quote, one has to know exactly what is going to be done. This being said, as an outpatient procedure done under general anesthesia, the total costs can range from $ 6,500 to $ 9,500.

Dr. Barry Eppley

Indianapolis, Indiana

Q: The back of my head is very flat. As a child in school, they used to make fun of me  because the back of my head was so flat. While I want to wear my hair short, I can’t because it becomes really apparent. I have attached some pictures showing how flat it is. Because of my longer hair, I have drawn a line indicating the actual shape of my head beneath my hair. I want to add up to an inch to the whole backside of my head to give a more rounded shape. Do you think it is possible with the Kryptonite material and not having to make a big incision across the back of my head?

A: Thank you for sending your pictures. It is easy to see, even with your hair, how flat the back of your head is. Yes it is possible to build out the back of your head with a minimally invasive cranioplasty technique using Kryptonite. However there are several caveats about the outcome with this cranioplasty method. The build-out of your skull can not go below the lowest level of the occipital bones which is about at the mid-level of the ear. (you can feel how high the end of the occipital bone sits with your fingers. Most people think that the bone goes much lower than it does. Any cranioplasty material can only be put on bone not muscle. A skull build-out of as much as an inch may be too extreme due to scalp expansion issues, a more likely result is 1/2″ to 3/4″ at the very center. (midline)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Hello Dr Eppley, I am a boxer and wanted to get a sliding genioplasty. I am recessed by about 10mm’s and was wondering if I would be able to box after this chin surgery. If so, how long after surgery can I do so? Thanks for your time.

A: For your chin deficiency, a sliding genioplasty is probably a more wise decision than an implant given your boxing avocation/occupation. A chin implant may have also worked as long as it would be secured with 3 to 5 screws. It would have a quicker recovery and return to boxing (1 month if contact to face may occur, training part doesn’t matter) but there is always the potential for some implant related problem long-term if struck on the chin. (which I assume is common on boxing) For a chin osteotomy, the return to contact boxing should be 3 months at least although training could occur at any time one felt comfortable. You could argue that the bone is not really healed in a big advancement (10mms) for up to 6 months so this is a more conservative estimate. With the osteotomy in your case, I would secure it with more than the traditional chin plate (step plate) and 4 screws. I would probably add a small plate on each side of the sliding genioplasty for the extra security of the bone position.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am 38 years old, have breast fed two children and definitely sag some. While I never had big breasts, they have now completely gone away! My bra size is 34A. In addition, I have a wide sternum and my breasts appear to be fairly far apart. I think a good breast implant size for me is around 350cc. In order to get cleavage, should the implant be placed above or under the muscle?

A: While implants do a wonderful job of making breasts larger, they do not usually result in cleavage on their own. With widely separated breasts, cleavage will definitely not result from the placement of any reasonably-sized breast implants whether they are placed above or below the muscle. At 350cc, a moderately-sized implant for your chest, cleavage is not a realistic possibility. Trying to make cleavage by going above muscle with your small breast volume is a mistake in my opinion. The implant is at much great risk of hardening over time (capsular contracture) and runs the risk of resulting in synmastia (the joinging of the two breast pockets in the middle, a uni-breast so to speak), which is a very difficult problem to correct. Settle for the better long-term breast augmentation result of under the muscle and accept that cleavage without a bra is not a possibility with your breast/chest anatomy.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am interested in making my forehead more vertical and round. I also want to have more height and width of the top of the skull. Do you think this is possible using the injectable Kryptonite method? I have attached some pictures for you to see the shape of my forehead. Let me know what you think.

A: Thank you for sending your pictures. I think I understand completely your forehead shaping objectives which would involve a cranioplasty fill of the forehead to make it more vertical from the brows up in profile (increased convexity) and to add width in the frontal view.  This fill, in essence, is really to camouflage the slight brow bone prominence you have and will make the entire forehead more smooth and confluent. I have attached some imaging which is limited by the quality of the images you sent but I think it conveys the objectives.

In achieving this result, I do not think the injectable approach is best. It will take a prohibitive amount of material (cost wise) and the shaping must be perfect to have a happy end result. The evolution of the injectable cranioplasty approach is not quite far along  in terms of experience to reliably give the best result for this more complex reshaping of a very visible facial area.Therefore, an open approach is best using PMMA (acrylic). That will allow an adequate amount of material to be used at a reasonable cost and get the best shape and smoothness of the forehead augmentation. The open cranioplasty approach in a male, however, is limited by the willingness of the patient to accept a scalp scar.

Dr. Barry Eppley

Indianapolis Indiana

Q: How much would the injectable Kryptonite bone cement option cost. A ballpark figure would suffice, thank you.

A: The cost of injectable cranioplasty varies greatly based on the size area of the skull being treated and the amount of Kryptonite material that is being used. The actual cost of the Kryptonite material from the manufacturer is tremendously expensive and can potentially make up to 25% to 50% of the total procedure cost. The best ballpark that I can can give you is anywhere between $ 6,500 up to $12,500. The best way to get a more accurate answer is to send me some pictures of your skull or forehead concerns so I can see the size area involved.

Dr. Barry Eppley

Indianapolis Indiana

Q: I have a question about reducing a bulge on the side of my head. I have cranial/skull assymetry and wanted to know if I can get the side of my skull shaved down/reduction a bit so I can get a more even look on both sides. The right side of my head sticks out more then my left, it’s noticible expecially because of the close cut haircuts I love to get. Is shaving down or skull/cranial reduction possible or an option?  I have attached some pictures of my head from the front so you can see it. It is fairly obvious I think. Thanks, hope to hear from you soon.

A: What is you have is skull asymmetry caused by a bulge in the temporo-occipital bulge region or side of the skull. It is actually a combination of fullness of the back end of the temporalis muscle and the front edge of the occipital bone where the two actually come together. Both are easy to reduce, and need to be reduced to get the narrowing effect, and about 5 to 7mms of reduction/narrowing can easily be obtained, maybe more. There is no danger to the procedure nor is there any risk to any nerves in so doing. The issue of whether this is a good procedure for you or not is completely about the vertical scar running over the bulge to do it. The scar is the only risk in doing what is otherwise a fairly simple procedure. Given your close haircuts, it is a question of the trade-off of a more symmetrical skull versus that of a fine line scar when considering a skull reduction procedure.

Dr. Barry Eppley

Indianapolis Indiana

Q: I had saline breast implants placed two months ago. Today I felt the implant at the bottom of my breasts. When i touch the bottom of my breast I feel the implant itself. I don’t know if this is normal or not?? Please advice.

A: The feeling of saline implants at the bottom of your breasts could be one of two phenomenon. First, it is likely it is completely normal if it is present on both sides. Initially breast implants can be initially high and then they eventually settle lower. Because the implant is only partially covered by the pectoralis muscle (the upper half), the bottom pole of the breast has the implant covered by just skin and whatever breast tissue you had to start with. Since saline implants will usually develop a little rippling in the implant shell, this is most palpable at the bottom and the sides of the breast. This is initially not able to be felt because of the tissue swelling and skin stretching which takes several months to go away. Since you are two months out from surgery, you are exactly in the time frame when this will occur. The other possibility, particularly if it has happened on just one side, is that one of the implants has bottomed out. (dropped too low) You would know this because the breasts would be asymmetric. (unless it has occurred on both sides)  But either way, it would be apparent because the implants look too low. That is a surgical (revisional surgery) problem.

Dr. Barry Eppley

Indianapolis Indiana

The shape and profile of the neck, even though it is not on the face per se, imparts an impression as to one’s appearance. Whether one is young with a fat neck or older with loose skin or a turkeyneck, a poorly defined neck angle results. While liposuction can remove fat and a necklift can tighten skin, an ideal neck angle is not always achieved.

What is missing from any cosmetic neck operation is a method to tighten the underlying muscles and tissues. By making a more firm ‘hammock’ that extends from ear to ear, the neck angle can be changed significantly.  A new device, called the iGuide, has now become available to help create a firmer and more youthful neckline.

The iGuide is an FDA-approved device that is for tightening and lifting of neck tissues. It provides a less invasive technique to improve the neck and jawline with minimal incisions (unlike a traditional facelift) while at the same time shortening recovery time. By not doing wide undermining and elevation of neck skin, the swelling and bruising is much less and one’s recovery is quicker.

The iGuide allows the deeper tissue in the neck to be tightened by essentially creating a ‘neck hammock’ using a permanent suture. Through a series of needle punctures placed along the jawline, a suture is weaved back and forth from side to side to create a trampoline-like structure. This suture weave creates a low-tension support which elevates the tissues below the neck skin, a missing element from current necklifting procedures. This type of suture is not to be confused with the infamous barbed sutures (Threadlift operation) of the past.

From a neck recontouring standpoint, the iGuide has multiple potential uses. For the younger patient with a fuller neck where liposuction alone is not completely satisfactory, a suture weave can provide additional neck angle improvement. For the early signs of neck and jowl aging, a short scar facelift is great for the jowl area but may not always optimally treat the neck angle. The trampoline effect of the suture weave makes for a better neck angle result. Older patients with a turkeyneck may still require a more traditional necklift however.

The iGuide neck contouring system, in some cases, may be able to be done under local anesthesia without going to sleep.  If all one’s neck needs is some liposuction and a suture weave, this would certainly be possible. Neither the tiny incisions nor the weaving of the suture requires the use of any sharp needles. But when other facial procedures are being done with it, then more than local anesthesia would be needed.

The iGuide provides a clever minimally invasive approach to redefining one’s neckline and is a great adjunct to liposuction and any form of a necklift.  As its tagline states, it is ‘The Neck’s Big Thing‘.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I want to get breast implants but am concerned about the scar. I really don’t want  a scar on my breasts anywhere as I think that would look bad. Who would care how big my breasts were if they were badly scarred? I have read about the belly button insertion of breast implants and there seems to be a lot of negative comments about it from other plastic surgeons. Do you agree with these feelings? What are the problems with putting in breast implants this way? It just seems to make sense to me that it is the best way to go.

A: When considering breast augmentation, the size and location of the incision is one important consideration to most patients. But one must remember that the incision is not the operation, the breast implant and its proper positioning is. Going through the belly button does provide a hidden scar but does so at the expense of several significant disadvantages for the final breast implant result. Besides being only able to use saline breast implants, there are potential problems with getting them in the right pocket and having good symmetry afterwards. At the least, these risks are higher when going through the belly button as opposed to any of the other three options. If one wants a hidden scar, a transaxillary (through the armpit) incision can be used without incurring a higher risk of other potential implant-related problems. This approach is more direct and gets the implant immediately underneath the muscle. The belly button incision offers no advantages at all over the armpit incision.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am interested in getting a Vi Peel to improve my skin’s texture and appearance. I am specifically trying to get rid of some wrinkles, get a collagen boost and take away brown spots on my face. Can you do some computer imaging on my attached pictures to show me what I would look like after this chemical peel treatment?

A: Thank you for sending your pictures. Unfortunately computer imaging is not ideal for skin texturing predictions. With imaging tools it can be made to look completely smooth and flawless (like airbrushing of the models in magazines)  but that is not what the purpose of computer imaging is. It is intended to help a patient understand the improvement so they can see whether the changes are worth the investment. By making your skin look perfect, you will not doubt be motivated to do the peel…but that doesn’t mean the chemical peel can create that same result. In this context, computer imaging can be deceiving. Computer imaging is best reserved for facial  structural change predictions…where a patient is taking their face to a place where it has never been…as opposed to trying to return to a place that they were once more familiar.

By the way, a Vi Peel is a great facial skin treatment and will definitely help you achieve many of your stated goals

Dr. Barry Eppley

Indianapolis Indiana

Q:  Hi I would like to inquire about information for the correction of facial asymmetry. I have been irritated by the clear tilt in my cheeks and jaw for sometime. My head just doesn’t appear to sit on my neck correctly. After reading your artilesl very carefully I feel I may be a candidate for this. I must stress I understand perfection is unobtainable, however, this has bothered me for sometime. I hope someone can get back to me.

A: The origin of many facial asymmetries is developmental, the facial skeleton is rotated based on a skull growth issue. In craniofacial biology, it is well recognized that how the skull forms through plate expansion and underlying brain growth has a major inflence on how the facial bones develop. If the skull is twisted to any degree so will be the face. This can affect everything resulting in asymmetries of the forehead, brow bones, orbits, cheeks, nose, and jaw.

This facial asymmetry can be camouflaged, or made less apparent, by making adjustments to any of the facial prominences/flattenings. This could include bony reductions or shavings or augmentation through the use of implants. It takes a careful analysis to choose a balance of bony reductions and augmentations to achieve the look of improved facial asymmetry. What procedures would be of most benefit to any particular patient would depend on their individual anatomic issues. Common procedures include forehead augmentation, brow bone reduction, cheek implants, chin osteotomies and jaw angle implants.

Dr. Barry Eppley

Indianapolis Indiana

Q: Hi Doctor Eppley. I’m a 19 years of age male and I have a mild flat spot on the back of my head. It’s not that bad but I would still like to know if it’s possible to treat it and be able to achieve good aesthetic results and shape it to be more round. Also, I have read some questions and answers of people that have have a similar problem, and you responded by saying that this problem can be treated by using regular cranioplasty making a large incision, or by injecting Kryptonite with a much smaller incision. What is the difference between the two, in terms of healing process, reliability, aesthetics? etc. Is the surgery going to leave any visible permanent scars? I’m really looking forward for your response.

A: By your own description, you have a mild depression on the back of your head. That would indicate that an open form of cranioplasty with causes a long scar would not be an appropriate solution. With that approach, the treatment may cause a worse aaesthetic problem (scar) than the area of skull flattening. That leaves you with the option of the injectable Kryptonite approach. That uses a very minimal incision and the resultant scar is never an issue. It is a minimalist procedure with very little reovery. The material sets up with the consistency of bone so it is very stable and impact resistant. The only potential issue with this approach is trying to get a nice smooth round profile which for just one side of skull flattening is very achievable.

Dr. Barry Eppley

Indianapolis Indiana

Q: I read with interest your article about upper lip lifting in the case of a retracted columella.  I’m a 35 year old trangendered male who’s already undergone a feminizing forehead procedure elsewhere.  My upper lip is VERY long and unattractive, but I’ve been told that, because of my nose, to shorted it I’d have to have grafts taken from elsewhere or even have my upper jaw moved, which needless to say I’m not crazy about.  I have a short, upturned nose that I really rather like, but the long upper lip is a big issue and I’m curious if anything can be done without rib grafts or the like.

A: A subnasal lip lift can be done whether you have a retracted columella or not. The ability to do that fairly simple lip lifting procedure is not restricted by a retracted columella or decreased nasolabial angle. It may be aesthetically better to deal with the retracted columella at the same time however. That could be done in a variety of ways, all of which involve the insertion of some supporting graft behind the nasolabial angle. Instead of a rib graft, I would consider a dermal graft which does not need to be harvested from the patient. That could be inserted directly down to the columellar base from the a small opening after the bullhorn lip skin is removed and before final lip closure. But whether you even need that is unclear to me at this point. I would need to see see some lip photos to answer that question.

Dr. Barry Eppley

Indianapolis Indiana

Q: I have 6 lines of self harm on my right wrist. They are white clear lines, which I would like them removed due to constantly being cautious to cover up when around people. I have recently found out that I am pregnant and would like them removed even more now, before the birth of my child. I’m so confused as to what I should do and which is the safest option. I’m so desperate to have them removed. I have had them for two years now and would like them removed by September of this year. What dio you recommend?

A: What you are referring to are many numerous fine white scar lines that often criss-cross each other on the volar aspect of the wrist. As self-mutilation/suicide attempt scars go, this pattern is fairly common and I have seen it numerous times in scar revision consultations. The reality is that there is no magic eraser and any technique for their removal. They are as narrow as scars can get due to their creation by a sharp instrument and their white color is unchangeable due to the scar in them. No form of laser resurfacing can ‘wipe them off’ or erase them, that simply is not going to work.

Since the stigmata of these scars are its classic pattern, an alternative approach is to create one larger scar which is more amorphous. A more confluent non-descript scar will at least not look like a pattern of knife cuts. In effect, this is creating a bigger burn scar which will look like a burn injury not a knife injury. Deep laser resurfacing can be done to create this effect. While this is not as desirous as erasing the scars, it is a more achievable goal.

Dr. Barry Eppley

Indianapolis Indiana