Your Questions
Your Questions
Q: Please tell me the procedure for the neck lift that is natural looking, no downtime and no bandages. I’ve done a lot of research into plastic surgery, worked with plastic surgery patients, so just want to know about the procedure and cost. I don’t want to make an appt to ask questions until I know what it is about and have done my research. Thanks so much.
A: Thank you for your inquiry. As you may know, there are a variety of limited neck and facial procedures for improving the signs of jowl and neck ptosis that occurs with age. In reality, these are all forms of more limited facelift type procedures although they are usually referred to by patients as ‘necklifts’. Many of these have branded and marketed names that imply rapid recoveries and minimal downtime. They are all based on the same structural premise which is neck liposuction (maybe with a little submental platysmal plication) and a preauricular-jowl skin flap with SMAS plication.
When the necklift procedure is done this way, there is virtually no downtime (very mild swelling and little bruising usually), no sutures to remove (all dissolveable sutures), no drains used, and no dressing. (sometimes only a head wrap for the first night only) This is quite a different early postoperative look than what one would be familiar with in the more traditional full facelift approach. The procedure generally takes about 90 minutes to do as an outpatient.
The success of this type of facial rejuvenation procedure is based on patient selection. It is not the best procedure for patients with substantial neck and jowl sagging where a fuller facelift version would be more appropriate. But for mild to moderate jowl and neck issues, and as a secondary tuck-up to freshen up an old facelift result, this approach can be very useful. Generally, the total costs of the procedure is going to be in the $4500 to $5500 range.
Dr. Barry Eppley
Indianapolis Indiana
Q: I had an accident about a year ago in 2009 and got a stitch on my right chin to fix it. The scar is about 1 inch long. I got my real color and texture for the scar. But the skin above the scar had a slight swelling which is making the scar more evident. Is there any way to reduce this swelling? I would like to know the technique and cost of the treatment, which would help to improve the appearance of the scar.
A: The slight swelling to which you refer in your scar is no longer swelling. That would have resolved a long time ago given that this injury is more than a year old. What you undoubtably have is a residual mismatch in the skin edges with the upper edge being slightly higher than the lower one. This gives the illusion of swelling when it is really differences in tissue thickness between the two sides. This is a result of the original repair.
The best and only solution to improve this scar is excisional scar revision. The edges of the scar are opened up and the skin edges are realigned so they lay more flush and can heal back in a smoother fashion.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am interested in removing acne scars. I am trying to decide between punch excision and dermabrasion. As I understand it with dermabrasion I will get minimal results on old and deep scars (however I am not sure what is meant by deep), but with punch excision I will be left with a small scar. As dermabrasion works best on newer scars, would a good option be to start with punch excision and then use dermabrasion to remove the resulting scar? or would dermabrasion or punch excision alone be the best option? or would there be another, better option. I am looking for the most promising option here, I have spend a lot of time and money on snake oil treatments and empty promises with no real results. Thank you for your time.
A: Thank you for your inquiry on acne scar revision. Punch excision is the only thing that will work for ice pick or deep acne scars. Dermabrasion works best on moderate-depth acne scars particularly of the saucer-shape variety. Laser resurfacing works best on more superficial or fine acne scars. The age of an acne scar is really irrelevant unless it is fairly new. The logic would be to work on the deepest scars first with punch excision and then use the skin resurfacing methods (dermabrasion or laser resurfacing) after.
Dr. Barry Eppley
Indianapolis Indiana
Q: Can my eyes be made more narrow with an outer tilt to them? How is that done and what is the downtime to do it?
A: One’s eye shape can usually be changed. Depending on your anatomy, that change can be very subtle or more obvious. The first thing I like to know is exactly what a patient’s means when they say ‘more narrow with an outer tilt’. I know what it means to me as a plastic surgeon but I have to be sure what it means to each patient so the changes are what the patient really wanted.
The concept of uptilted eyes, from a plastic surgery perspective, usually means that the outer corner is turned up. In other words, the outer corner of the eye is above the level of the inner corner of the eye. This gives the eyes an inward slant which is often described as being more exotic looking. Giving the eyes such a shape is done commonly with a procedure called a lateral canthoplasty or tendon repositioning. The corners of the eye are held in their position by a tendon that attaches to the bone inside the rim of the eye socket. There is both an inner (medial) tendon and an outer (lateral) tendon. This procedure repositions the lateral canthal tendon at the outer aspect of the eye. By turning up the outer corners this gives the eyes a more upward tilted appearance. Besides some temporary swelling, and some occasional bruising, there are no bandages or restrictions after surgery. The swelling and bruising will go away in a week or two. The result is immediately apparent.
Dr. Barry Eppley
Indianapolis Indiana
Q: Hi, I am 25 and have a really flat area at the back of my head. I’m very self-conscious about this since I was 15. Is there any way that I can fix this for a cosmetic purpose. Can something be implanted at the back of my head? You are my only hope I have. I almost cried of joy after reading your articles that it is possible to reshape the back of my head by some materials and that you have done this so many times. This really means so much to me if I can get a new round back of the head, I will also get a new life with your help. I have attached some opictures of my head taken on the side. Whenever I look at it, i just want to cry. And I’ve mentally suffered from this flat head shape since I was a teenager. What needs to be done, and how long does it take to recover after the operation? I would appreciate your help and time so much.
A: Thank you for sending your pictures. I can see how flat the back of your head. The best and most economical way to augment and expand the back of your skull is through an onlay cranioplasty method. This involves putting a material on top of the bone to build it out. Given the amount of material needed, I would recommend acrylic or PMMA. Other materials exist but they are exponentially more expensive. There is even an injectable technique using Kryptonite Bone Cement, and that would be a good option for you, but that would be a cost issue.
Recovery from this type of surgery is fairly quick, particularly if an injectable method was used. (since there is only a one inch incision to do it)
Indianapolis Indiana
Q: I am a healthy 55 yo female. Over the past year, I have lost 40lbs in an attempt to become healthier. After the weight loss, I had a bilateral breast reduction perfomed. The surgeon removed approximately 3lbs from each breast. The original surgery went very well, the drains were removed on post op day 3, and I thought I was on my way to complete healing. By day 10, the wounds started to separate and open, and subsequently, all the suture lines were involved. The surgeon treated my with prophylactic ATBs with no resolution. I was never sick and never ran a fever. I saw an Infectious Disease specialist who treated with with IV antibiotics but the cultures were negative. I was then referred to an allergist who patch tested me for the two types of suture material (Monocryl and Vicry) and the chemical coating (Triclosan); all of which were negative. I am going on 5 months post op and still have some areas of non-healing and draining. The drainage is sometimes a creamy, bloody fluid and is mainly from the areolar areas and the horizontal area. Could you please offer any insight into what may be causing this delay and how long this may last. The breast surgeon claims he has never seen a case like this and offers no answers to my questions. I will get hard nodules under the suture lines, which then pustule up, opens, and then drains.This has been an extremely frustrating experience, expecially since not one of the specialists can tell me exactly what caused this and how long to expect it to continue.
A: Your postoperative breast reduction course has been complicated, and is not a common experience, but it is not rare or unheard of. While I have never seen your wounds, your exact course and the time sequence by which it occurred is something that I have seen more than once from breast reduction surgery. It is not the result of an infection nor is it a reaction to the suture material. The origin lies in the nature and skin perfusion of how a breast reduction is done.
A breast reduction, and even a full breast lift, raises skin flaps whose blood supply is separated from the underlying breast tissue. Its perfusion largely relies on coming in through the skin along the sides. In addition to this vascular compromise, it is then put togther under considerable tension in the inverted T or anchor area on the lower pole of the breast. All of this stresses how well the incisions heal. While the vast majority of time healing is uneventful, the balance can occasionally tip and the wound comes apart. And it never comes apart until between 10 to 21 days after surgery when inflammation and healing really start. Before then the incisions are not really healing but just held together by the sutures. This begins by opening of the invert T and stop in that area for most patients. But rarely it will extend up the vertical incision to the nipple area and open up the whole way. When this occurs, one has to wait for secondary healing which can take several months if not longer until the wounds fill with granulation, contract, and then re-epitheliaze. As the wound is largely open in this process, suture spitting and extrusions become common even in those areas of the incisions that have remain closed.
This is a skin perfusion/vascular injury, not an infection or allergy. I assume you have closed downk considerably and are getting closer to closed wounds. It may take another month or so for the healing to be complete.
Dr. Barry Eppley
Indianapolis Indiana
Q: Please I need a second opinion. I have breast implants (saline) since August of last year and the left is still resting high. A few hours after surgery, my left breast implant moved all the way up close to my clavicle. It was a crazy experience. It seems like only after a month it stopped moving downward to settle in its right place. It feels and look stuck like if implant is glued or my skin is too tight to allow it to move naturally on its own. I fear and strongly believe that another surgery in my case is necessary. Please is there a non surgical way or is it mandatory for another surgery? Please need advice and thanks for your time.
A: What you have is a classic case of a highly-positioned implant that is reflective of an implant pocket that was not made low enough on that side or one that scarred down on the bottom too quickly. I suspect that your saline implants were placed through an armpit incision since you describe the pocket on the left side as being as high as your clavicle. It is not that the implant or skin is glued, there is just no pocket for it to settle down lower into. It is being restricted by tissue attachments from being lower.
There is no non-surgical solution. You will need a fairly simple surgery to make the pocket lower so the implant can settle down to match the other one. This can be done either through a nipple incision or a small incision in the lower breast fold. The implant pocket has now healed so additional time will not change its position. If you don’t make this implant adjustment, then the left-sided breast implant will always be where it is right now with an asymmetrical breast augmentation result.
Dr. Barry Eppley
Indianapolis Indiana
Q: I have read on the internet an articlce that stated that Botox can cause permanent muscle weakening over time. Since I get Botox fairly regularly should I be concerned that it might eventually affect other facial muscles as well?
A: I think the article that you are referring to and has been reported in different internet venues was the one in the Journal of Biomechanics that appeared last year. I am familiar with that study and have read it. In this animal study, they examined the effects of Botox on not only the muscles that were injected but on the surrounding muscles as well. They found that Botox did lead to local muscle wasting as well as weakness of other untreated muscles in the region.
This study has caused a little bit of hullaboo about Botox but, in my opinion, it has no relevance to the cosmetic use of Botox. Beyond the fact that this was done in animals (rabbits), the doses were very high compared to what we use in humans. By my calculation, they were giving the equivalent of 200 to 300 units of Botox every six months. Given that the normal cosmetic dose of Botox is around 24 to 36 units, their dosing was nearly 10X that of a cosmetic facial treatment. The muscles that they injecting were voluntary motor muscles as opposed to involuntary muscles of facial expression. These are quite different types of muscles. Motor muscle are well known to atrophy from simple disuse, muscles of facial expression do not display this atrophy phenomenon. Most of our cosmetic patients would welcome that if it happened but there has been no evidence that it occurs.
This article is an interesting piece of science but its findings do not hold a candle to the 25 years of human Botox use in which this permanent muscle weakening effect has never been seen in a low-dose cosmetic application.
Dr. Barry Eppley
Indianapolis Indiana
Q: After having four children and breast feeding them all I am not happy with the way my breasts look. I am interested in getting breast implants. Do you think I will need a breast lift as well?
A: The combination of four children and breast feeding would take a toll on any women’s breasts. The effects of that repetitive expansion and then subsequent deflations will cause both skin excess and loss of breast tissue, known as breast involution. Undoubtably breast implants would be of great help in restoring breast volume and size.
The key issue is whether breast implants alone will be enough. If there is any significant sagging or ptosis, then some form of a breast lift may be needed. That can be determined by where the nipple now sits relative to the lower breast fold. If the nipple is above the breast fold, then implants alone will suffice. If the nipple is just at the lower breast fold, then a combination of breast implants and a small nipple lift will be needed. If the nipple sits below the lower breast fold, then implants with a more formal breast lift will be necessary.
What you don’t want are larger breasts with the nipples pointing downward or towards the floor. The nipples should be relatively centered on the implanted breast mound. Whether a breast lift is needed can be determined before surgery based on your nipple position on the deflated breast mound.
Dr. Barry Eppley
Indianapolis Indiana
Q: I read your very interesting article about lip lifts. I was wondering if it would be possible to do the same but on the inner side of the lip? My upper lip is quite thick and juts out a bit. The outward rotation and protrusion of the lip which he conventional procedure causes would not be a good thing for me. Would that be possible?
A: A subnasal lip lift is designed to shorten the skin distance between the base of the nose and the lip vermilion and lift the central portion of the upper lip giving it more of a pout. Doing the reverse, or the procedure on the inside of the lip, has another name known as a lip reduction.
In a lip reduction, a wedge of mucosa is taken internally to derotate the lip and give it less of a pout or fullness. Unlike the lip lift which is done high on the outer lip, a lip reduction is done closer to the vermilion or low on the inside of the upper lip. This is because the outer skin is different than the inner mucosa. Mucosa is more loose and stretches more than skin. Therefore, doing the resection way away from the lip margin in a lip reduction would cause no change in the visible lip shape.
Basically, you are talking about a lip reduction procedure which is well known, successful, and fairly easy to do.
Dr. Barry Eppley
Indianapolis Indiana
Q: Hi, After I was born, a hematoma appeared on the back top right corner of my skull (either trauma on the way out of my mom, or trauma suffered after being born…we’re not sure.). It ended up calcifying after being left untreated (at least that’s what doctors have said in the past), and to this day, the lump is still there. It’s about 1.5 inches in diameter and sticks up about 1/2 inch from my skull. This wasn’t necessarily a problem growing up, because hair could cover it up. But unfortunately, genetics have brought on the beginning stages of male pattern baldness. I’m thinning quickly, and a hair transplant seems unlikely at my age of just 23. Therefore, I would like to get used to shaving my hair down, but as we all know, people need a good head shape to pull it off properly. Another side note, but not necessarily as important: I have a prominent forehead that sticks out a bit further than the ridge of my browbone, and my temples are a bit hollowed out. I wear bangs to cover this stuff up as well, but with hair loss, this isn’t feasible in the long run. I’m not sure if these things are fixable, but hopefully I can begin to get some information on what should be done. This stuff is killing my self esteem! I’m a good lookin’ guy! I’m in college! This shouldn’t be happening right now! Looking forward to your response.
A: What you had an birth was a cephalohematoma, a blood collection under the skin and more pertinently under the periosteum of the bone. This is a well known stimulant to bone formation and they are well know to calcify. It can certainly be rather easily burred down which is a simple procedure. The key is to be able to do it with a fairly minimal resultant scar. (incisional access) Given its relatively small size, that should be able to be done with a very minimal scar of about an inch placed vertically on the back of the head at its lower end.
The forehead issues can be similarly treated through burring reduction but the problem is one of hidden surgical access. In the forehead with an unstable hair pattern in a male this is not very feasible. A long scar placed across the top of the head is not a good trade-off. Having a smoother and less bulgy forehead at the expense of a long scalp scar may not be a good aesthetic alternative.
Your temporal hollowing, however, can rather easily be improved through a temporal augmentation procedure. Dermal grafts can be placed under the muscle fascia through small vertical incisions in the temporal scalp. Rounding out the temporal area will help blend in with the forehead shape better.
Indianapolis Indiana
Q: Hi Dr Eppley, I read a article that you have used a long-lasting injectable filler to lessen the deepness of the chin lip fold? I had a sliding genioplasty and there is a mild stepoff and a bit of a deeper sulcus afetr surgery. I was wondering if you would be able to blend the chin into the jawline like the stepoffs and also lessen the labiomental chin lip sulcus? How long after genioplasty am I able to have the injectabale treatment? Also what complications have you seen with such injectable treatments? Thanks.
A: The first thing to appreciate is the anatomy of the labiomental sulcus (chin-lip groove) and how that has been changed from your bony genioplasty. The depth of the labiomental sulcus is a reflection of your anterior mandibular vestibule. If you put your thumb in the labiomental sulcus and your index finger inside your mouth, you will see the correlation between the two. The fold represents the level of the vestibule but, more pertinently, it is the upper or superior attachments of the mentalis muscle. Once the chin bone has been slide forward, the labiomental sulcus deepens because the chin point moves forward with the bulk of the mentalis muscle with it. That will deepen thue sulcus because the vestibule has not moved but the chin bone has.
How to treat the deep labiomental sulcus can be done several ways. If one is looking for a permanent solution to the depth of the fold, treat the exact anatomic problem and place a dermal graft and build it up from underneath in the bony step-off. That would be my preferred approach. The other option is to use injectable fillers but understand that they will onlu be temporary and are not long-term solutions.
Dr. Barry Eppley
Indianapolis Indiana
Q: Hello Dr Eppley. I wonder if there is a way to remove bumps on the temporal area just above my ears. They aren’t related to any medical problem but I want to have flat temporal sides. So is there a procedure to remove them or make them flatter? The other thing I want to learn is whether it is possible to increase length of lips. I’m not talking about lip augmentation, is there a way to increase horizontal length of lips? Thank you.
A: Temporal bulging above the ears, in most cases, is a reflection of the combined muscle and bone mass. The tail or back end of the temporalis muscle is what lies above the ear. I have done temporal narrowing (bitemporal reduction) through muscle resection and superficial cranial bone burring. That has worked quite well and is fairly easy to go through. You don’t really need the posterior attachments of the temporalis so it can be removed. The amount of temporal narrowing would be about 7 to 8mms per side.
The horizontal distance of the mouth (commssiure to commissure) can be surgical increased. It is done by a Y-V lengthening of the corners of the mouth. In essence, it is a lateral vermilion advancement through skin excision. While it can be technically done and is virtually painless afterwards, it does leave fine line scars at the edge of the vermilion. Whether that is an acceptable trade-off would depend on the nature of your skin and the amount of mouth widening that one would desire.
Dr. Barry Eppley
Indianapolis Indiana
Q: Dr. Eppley, I am interested in getting my nose done. My main reason is that I don’t like this bump on my nose. The rest of my nose I am really fine with. What I want to know is how can this bump be taken down. Can it be shaved or does it have be cut off? Will I need to have my nose broken? What type of rhinoplasty needs to be done? Will this in any way affect my breathing?
A: A bump or hump on the nose is one of the most common reasons one seeks a rhinoplasty procedure. Reducing a hump and having a smoother bridge of the nose makes it appear more pleasing. A hump on the nose is not just bone but a combination of bone and cartilage most of the time. Very small bumps may be bone only but the midportion of larger humps, known as the rhinion, is at the junction of bone and cartilage. Reducing the nasal hump, therefore, must take down bone and cartilage in the vast majority of cases.
If a patient only needs a hump to be taken down for their rhinoplasty, I will do it through what is known as a closed approach. (incisions on the inside of the nose only) Most rhinoplasties, however, involve hump and other changes as well so an open approach with degloving of the nasal skin provides a much better view and more predictable results.
Breaking of the nasal bones is often a part of hump reduction but frequently not understood. When large humps of the nose are taken down, removal of that hump or ‘roofline’ (bone and cartilage) leaves a flat and open bridge area. The nasal bones are no longer attached to the apex of the roofline but are standing ‘open’. This is one reason why the nasal bones are broken (nasal osteotomies) so that they will fall back in towards the center, recreating the roofline and making the bridge of the nose smooth and more rounded. This may also make the upper part of the nose more narrow which is often desireable.
Small hump reductions do not require breaking the bones of the nose, but larger hump reductions almost always do. That is why some patients will get black and blue under the eyes after rhinoplasty while others do not.
The trend today, not only for aesthetic reasons but to preserve good breathing through the nose, is to keep a high dorsal nasal profile. Taking down the bridge of the nose too much, as was commonly done in the past with ‘scooped out’ or ‘ski-jump’ noses, is not acceptable today as it leads to breathing problems. Keep a high but smooth dorsal line helps not only to protect breathing through the nose but to prevent further collapse (known as a saddle nose deformity) later in life.
Dr. Barry Eppley
Indianapolis Indiana
A bump or hump on the nose is one of the most common reasons someone doesn’t like the way their nose looks. Removing a hump on the nose and having a smoother bridge down its length will make it appear more pleasing. That feeling about a nose hump is universal as people seem to intuitively know when the upper part of the nose is out of balance to the lower part of the nose…humps make the nose look too big and thick and sometimes even ages a face. Large nose humps can make one look older. (just like a downturned tip of the nose)
Hump reduction of the nose is one of the main reasons many people want nose-changing surgery or rhinoplasty. But removing a nasal hump is usually more than just simple shaving of the bone. What makes up most humps is a combination of bone and cartilage as the hump occurs where the bone of the nose stops and the cartilage of the nose begins. This means that both bone and cartilage must be taken down for a successful hump removal.
How big a nose hump is changes how it is done and what the recovery would be. Small hump reductions can be done by shaving or rasping and do not require breaking the bones of the nose, but larger hump reductions almost always do. That is why some patients will get black and blue under the eyes after a rhinoplasty while others do not.
Think of the bridge of the nose like the roof line on your house. Trimming off a little bit of the rooftop will not significantly change the inverted-V shape of the roof. (small hump) But taking more than just the very top of the roof line will leave the sides of the roof standing where they originally were….with an open top. To change that open roof back to an inverted-V shape requires moving the sides of the roof inward. To make them fall back to the middle, the base of the roof must be cut so they will fall back in together. This is what breaking or cutting the nose bones does. It is also the rhinoplasty maneuver that will leave you with black eyes afterward. The nasal bones are cut down low and then pushed in to close the open roof. This will also make the upper part of the nose more narrow and less thick.
Taking off a nasal hump, however, must not be done too far. Taking down the bridge of the nose too much, as was commonly done in the past, results in ‘scooped out’ or ‘ski-jump’ noses and leads to breathing problems. Keep a high but smooth and non-humped bridge of the nose helps to protect from breathing problems after rhinoplasty surgery.
Interestingly, taking down a hump also makes the nose look smaller and less long, an optical illusion that can easily be demonstrated by computer imaging.
The shape of one’s nose is said to reflect on one’s personality. I have no idea whether that is true but a well-shaped nose without a hump can definitely improve one’s facial balance and appearance.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am HIV positive as well as a diabetic with deflated cheeks. Do you think transferring fat from my own body to my face will work?
A: Facial lipoatrophy is a common sequelae from the antiviral medications used in the treatment of HIV. Often this loss of fat is quite severe with the skin literally be right down on the bone with loss not only of the buccal fat but loss of the subcutaneous fat as well. When the condition is this severe, the concept of injectable fillers must be looked at very carefully. While fat injection transfer can clearly be done, the question is will it work long-term. How much of the injected fat will survive? The HIV patient on antivirals poses an additional variable to the biology of injected fat which is already challenged in the variability of its survival. Will the same medications that caused the fat atrophy to begin with do the same to the injected fat? No one knows with absolute certainity.
For these reasons, I prefer an additional approach to just injected fat for this cheek lipoatrophy. I like to place a submalar implant on the lower edge of the cheekbone and then cover this with an internally placed dermal-fat graft. Then injected fat can be placed subcutaneously throughout the cheek and lateral facial areas as an additional outer layer. This is a good way to hedge your bet so to speak by at least having some type of cheek augmentation that you can be assured will have stable volume preservation.
Dr. Barry Eppley
Indianapolis Indiana
Fat is one of those topics that we hear too much about and want as little to do with as possible. Most people feel like they have a little or maybe a lot too much. For some, fat is a definite the enemy that makes the choice between what tastes good and one’s waistline a difficult one.
When thinking of fat, it is almost always perceived as this blob of yellow jelly-like stuff that just sits there without much purpose. This collection of extraneous lipids and carbohydrates appears as nothing more than a piggybank of kitchen and restaurant memories. The reality is quite the contrary, however, as fat is really a dynamic body tissue that is a lot more active than it looks. And it has different bodily functions than just being an annoyance.
Seeing patients daily who have chosen to finally battle their fat with plastic surgery, I get to hear a lot of personal stories and insights into how fat is perceived and what is believed to get rid of it. Such experiences have prompted me to write a little mini-tutorial on one aspect of the biology of fat and body contouring.While fat may look the same throughout the body, it is actually quite different in structure. The size of fat globules, for instance, is quite different from that of the abdomen (big) versus that of the face or neck. (small) This is clearly evident when performing a tummy tuck versus a facelift. Because structure follows function in nature, it should be not surprise that the role of fat in the two places is different. Fat in the abdomen and waistline (men and women) and in the buttocks and thighs (just women) is depot fat. These are the primary storage areas and they offer a good central location with a lot of storage capacity. Fat in the extremities and the face and neck is largely insulating fat. Yes you can accumulate there but it is harder than storing it in your trunk regions.
This may be interesting biology but how is it relevant? While diet and exercise is a great first line of fat defense, it will not spot reduce any single area. And it does not work well on peripheral insulating fat areas. You can reduce tummy fat but it is virtually impossible to do the same with arm, neck or knee fat for example. And that flank or back fat is just about as stubborn. (it has smaller fat globules as well even though it is a trunk area) You can do all the crunches and twists that you want (and it is worth giving it a try first) but core fat reduction comes from overall weight loss. Spot or resistant fat reduction is most effectively reduced by liposuction, a focused fat removal method.
Will fat return after liposuction? The parallel question is will fat return after weight loss? Yes but the difference lies in what body areas are being treated. Depot fat site removal can return just like that of weight loss. But peripheral or insulating fat site removal is much more difficult (not a primary depot site) and those results are more likely to persist over time.
Dr. Barry Eppley
Indianapolis Indiana
Q: I broke my cheekbone when I was 16 years old in a car accident. After it healed, I was left with a dimple on the left side of my face that is prominent when I smile. I have been receiving botox injections in the dimple and the results are minimal, although the dimple does appear about 50% less noticeable. I would like the dimple to be completely gone. What can I do? I read about fat transfers?
A: While I don’t know exactly where this facial dimple is, I suspect it is over the mid-portion of your zygomatic arch. This is likely because of your history of a car accident and facial injuries. You likely had a zygomatic arch fracture which, when left untreated, results in a classic facial dimple which appears over the midportion of the cheek. This occurs because the zygomatic arch, which is originally a thin arch of bone between the front of the cheek below the eye which extends back to the temporal bone, is fractured at its weakest point at the height of the arch. This creates a V-shaped bone indentation which is then seen as a facial dimple from the outside.
While fat injections are one treatment option, the survival of fat is not assured. I have found that a better solution is to place a small implant or dermal graft on top of the indented bone. This will push out the dimple and be permanent. This is a simple procedure done from inside the mouth and directly treats the actual problem.
Dr. Barry Eppley
Indianapolis Indiana
Q: Hello Dr Eppley. I am now 23 years old and up until the age of 18 I had a flat brow bone. Now it bulges out unevenly and hangs over my eyes. I look completely different now. It may have happened after I scrubbed my brows with a scourer to remove hair dye 5 years ago. It really is since then that it has happened. My brow bone was not meant to be like this, I look quite wierd now. My eyes were allways my best feature. I dont understand how this happened apart from the metal scourer incident. I really need some advice on how to rectify the problem if possible. I also have problems with my sinuses that may have something to do with it. Thank you for your time, I hope you can help.
A: This is not the first time that a patient has contacted me about having ‘brow bone growth’ in their early adult years. It is certainly possible that the brow bones can grow beyond the teenage years, although technically it is the growth or ongoing pneumatization of the underlying frontal sinuses. All I can say for sure is that the metal scourer event is not the cause. It is not possible to stimulate craniofacial bone growth by stimulating the overlying skin. It may or may not have sonmething to do with sinusitis or it could even be a sinus tumor. I would recommend getting a CT scan of the frontal sinuses/forehead to determine if this is just an overexpansion of the frontal sinus space or whether there may be an underlying sinus tumor. If it is just growth of the frontal sinus, then brow bone reduction can be considered.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am interested in getting Smartlipo for my love handles. I am a 42 year old healthy HIV positive male since 2005. My CD4 count is 435 and my viral load is undetectable. I am 5′ 9 and weigh 170lbs. I am on HIV medications with no signs and symptoms. I have been recently diagnosed with Hepatitis C but am not on any medications for it. My liver enzymes are close to being normal and my liver ultrasound is normal. Would I be a candidate for Smartlipo?
A: Having these two viral infectious diseases does not preclude you from having any form of liposuction surgery. The key is that your medical conditions are stable with good counts that would not make your risk of infection significantly increased and that you could safely go through a short surgical procedure without any adverse effects on your health. You would need medical clearance from your physicians as they are most familiar with the details of your current condition and laboratory values.
Smartlipo of the flanks is a fairly small liposuction procedure that can have a dramatic effect on the waistline and the flanks. It is a common treatment for men that reduces a fat problem that is otherwise impossible to exercise and diet off. Done as an outpatient procedure, it is completed in under an hour with minimal recovery and restriction of activities.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I had inferior orbital rim implants done with a midface lift about 6 weeks ago. It has left me with upper lips on the right side that I cannot purse and numbness in my top front teeth and extending up my nose to my eyes. I am also numb above the implant on the right side. I also had a blepharoplasty. My muscles of my lip don’t function right so my lip hangs down a bit and I have to be careful not to bite it. I can’t spit or whistle right. The muscles that lift the right side of my nose and face don’t work right so one side goes up higher than the other. The implant was put in so that part of it sticks up like the screw wasn’t seated well so i can feel the edge and see its edge in the mirror. The surgeon says he’ll fix it but there is still so much trauma in my face that I don’t know if it will ever resolve and I don’t want to make it worse! I know you don’t know me but I need advice on how to proceed and if this teeth numbness, etc. is normal. Should I wait until my face settles down?
A: The combination of a midface lift, lower blepharoplasties, and orbital rim implants does impose a fair amount of trauma to the midfacial area. It does take more than a few weeks for the feeling and lip and nose movement to return to normal. If this was done in the usual fashion, the lower blepharoplasties was the route through which the orbital rim implants were placed and incisions were done inside the mouth under the upper lip to assist with the midface lift.
The combination of orbital rim implants and the intraoral dissection works around the infraorbital nerves which comes out just under the lower orbital rim. This nerve supplies the feeling to your lip, nose and cheek. It is normal for some temporary numbness to occur afterwards due to the trauma around it. It should be gradually improving and I would expect less numbness each and every week at this point. It should take no longer than three months or so to completely return. If the numbness is not improving by the week, there is the possibility that the implant may be impinging on the nerve. If the other side is completely different in the recovery and much further along, this becomes a real possibility.
Feeling the edge of the implant or the screw is not likely to become less noticeable with time. I believe this is the implant on the same side as the lip and nose numbness and movement concerns. The combination of the above suggests that orbital rim implant adjustment may be needed. Since this is done through the lower blepharoplasty incision, there would be no added trauma to the recovering area below the implant.
As a general philosophy, you wait on a revision when it appears that time is continuing to make progress. When time no longer is making any difference, and the operated area still has problems, then revisional surgery can proceed.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am a 59 year old male that has developed breasts from my cancer medication. I have prostrate cancer and am on Casodex. I am told by my doctor that I can not go off this medication for the rest of my life. I want to do something with my breast enlargement not only because of the way it looks but also because they hurt all the time. I have been told by one doctor that I can’t have the surgery unless I stop the medication as it will just come back. What do you think?
A: Gynecomastia is a known complication of the prostate cancer medication, Casodex. Bicalutamide (Casodex) is usually used with a luteinizing hormone-releasing hormone to treat metastatic prostate cancer (cancer that started in the prostate and has spread to other parts of the body). This medication is in a class of drugs known as nonsteroidal antiandrogens. It works by blocking the effect of androgen (a male hormone) to stop the growth and spread of cancer cells. Because of its antimale hormone effects, it is no surprise that male breast enlargement can occur with its use.
The question with doing gynecomastia reduction on a patient taking this medication is will it come back? That would depend on several factors including the type of gynecomastia reduction (extent) and the dose of the medication. But all those issues aside, the bottom line is there is definitely some risk that recurrent gynecomastia could develop after surgery. However, as long as you are aware of this possibility, the benefits of reduced pain and a more comfortable chest contour would seem to outweigh that potential risk. If it returns the surgery can always be repeated. But there is also the possibility that it may not come back as no one can predict with absolute certainty what may happen after your gynecomastia surgery.
Dr. Barry Eppley
Indianapolis Indiana
Q: I have cheek implants that I would like to have taken out. What can I expect after they are taken out? Also, my right side of my face is a little higher then my left. Is their anything that can be done about that?
A: While cheek implants can certainly be removed, is it important to look and consider several factors before doing so. First and foremost, why did you have them put in in the first place? Was it a primary procedure (the only one done) or where the implants a secondary procedure or a throw-in? (while we are there….why not?) Second, what is it about them that you do not like? Too big, creating an unusual look, not the look you wanted? Lastly, what size can style are these cheek implants?
The amalgamation of all of these factors can help one determine whether removal or replacement/adjusting the cheek implants is the best choice. Usually when someone wants their cheek implants removed, it is because they are creating a look that they do not like….and often they were put in not as a primary procedure. Whether the undesired look is a result of cheek implant style or size must be determined on an individual patient basis.
All of that being said, the removal of any facial implant will likely leave behind the potential of soft tissue sag as a result of soft tissue expansion. Whether the soft tissue expansion will be significant depends on the size of the implant used. A small cheek implant will likely not cause this potential problem. But a bigger cheek implant might. If this is a real potential problem with removal, one may consider some form of a cheek or midface soft tissue lift at the time of their removal.
Dr. Barry Eppley
Indianapolis Indiana
Q: Hello, I have some severe lumps from a previous liposuction therapy on my upper and lower abdomen. I have since attempted corrective surgery, but it has actually made the issue worse. Is it possible to better the results?
A: Waviness or unevenness is the most significant risk in liposuction of the abdomen. While it is not a common postoperative problem, it is a particularly difficult one to improve once it occurs. It may develop for a variety of reasons including poor quality abdominal skin, an aggressive liposuction approach, and a liposuction technique that only uses a unidirectional point of access. This results from an inconsistent fat layer that is left behind underneath the skin.
While not just unique to abdominal liposuction, contour irregularities are most commonly seen on the abdomen because it is the only truly flat surface of the body that is so treated.
Small abdominal irregularities can be rather easily improved by select or spot liposuction touch-ups. Severe or extensive lumpiness, however, is a much different story. Your efforts at corrective surgery, and the resultant lack of any improvement, reflect the difficulty of the problem.
If further invasive corrections have not worked, one last option would be to consider injection therapy. I have used a mixture of lipodissolve and steroid injections to treat the high spots of abdominal irregularities with some success. It usually takes several injection sessions spaced about 6 weeks apart to get the maximal improvement. This approach will never get the abdomen to be perfectly smooth again but it can help lessen the magnitude of a ‘cratered‘ abdominal wall.
Dr. Barry Eppley
Indianapolis Indiana
Q: I had a face lift a few years ago and now looking into a procedure for the aging, saggy skin on my neck to be tightened. I’m hoping it will not be as invasive as the face lift. A consultation would be great so that I could learn more about the procedure, expense, recovery and an approximate number of years it would be expected to last. I’m not very good at understanding how to put pictures on the computer but would be willing to attempt a virtual consultation using the website.
A: It sounds like what you have is some rebound relaxation after a facelift procedure. This is very common and expected for many facelift patients. While patients appreciate that any facial tightenng procedure is not permanent (treating the symptoms of the problem, not curing the actual problem which is aging), they are not usually asware of the phenomenon of rebound relaxation. Just like stretching out a rubber band and hold it there, there will be some eventual relaxation or loss of the stretch. From a biomechanical perspective, this is elastic deformation. The once tight skin flaps, after all the swelling goes down, relaxes a little from being stretched. (tissue accomodation) How much this occurs will vary based on skin type (thickness) and how much direct tightening was actually done. This is always most evident in the neck which is the most distant point from the origin of the pull. (ears)
What you need is a little touch-up or tuck-up facelift. This is a much more limited procedure than your first initial facelift. These little neck-jowl tuckups are also known as a variety of branded and franchised mini-facelifts which promote the rapid recovery from the procedure.
Dr. Barry Eppley
Indianapolis Indiana
Q: I have a son who is 5 almost 6. He has a flat spot on the back of his head due to sleeping in the same position as an infant. We were oblivious to the fact that our child’s head wasn’t perfect. Anyway we never got him a helmet and now he has a small flat spot on the back of his head. His pediatrition said that we were lucky because his flat spot is directly in the back of his skull so his head is still pretty symmetrical. His hair covers it for the most part–but I would love to be able to fix this flat spot for him. That way he can shave his head if he wants without fear of ridicule. Since he is only 6, and I have read that the skull continues to grow until you are 8, would it be best to wait until he is atleast 8 years old? Your advice please. Thank you!
A: A simple injectable cranioplasty approach is certainly appealing for cosmetic flat spots on a child’s head. (occipital plagiocephaly) While I haven’t seen any photos of your son’s head, he seems like a reasonable candidate. The age at which to do it beyond 6 years of age is solely driven, in my opinion, by parental/patient desires. The skull’s growth cycle slows down appreciably by this age so whatever contour is obtained should simply grow with his remaining head growth without change. Remember that the implant material is sitting on top of the bone, not in it, so it is just being pushed out with the remaining skull growth.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am impressed with the results I saw of yours on a patient that I ran accross on the internet while doing plastic surgery research. The patient had cheek implants and I think removal of buccal pads. I am 57 years old and have a lean face. I think this procedure is what I would need to achieve the results I am looking for. My buccal pads are more prominent with age and above the buccal pad area my cheeks are flat. I am not interested in filler because the buccal pad area, I believe, still needs to be addressed. Did you remove the buccal pads in this patient and insert cheek implants? I am thin so I do not think liposuction would be in order. I once asked a plastic surgeon about removing the buccal pads and he told me that would make me look dreadful. Please advise. Thank you for your time.
A: Cheek or midface augmentation can include several procedures depending upon the make-up of the anatomic problem. Implants for cheek and submalar augmentation, submalar or buccal fat removal OR augmentation, and cheek or midface lifts for sagging skin are all potential options. These procedures can be done alone or some combination thereof may be more ideal. But it all depends on an appreciation of the cheek bone anatomy and the soft tissue make-up around the cheek bones. Only through a pictorial analysis could I provide you with what may be beneficial for you.
That being said, a thin face almost never aesthetically benefits from a buccal lipectomy. I have a suspicion that what you may be seeing as buccal fat may be cheek tissue ptosis or sag. Rather than a buccal lipectomy, you may need a midface lift which resuspends the sagging cheek tissues which have fallen into the buccal triangle up back onto the bone. A midface lift may or may not be complemented by small cheek implants.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am a 19 y/o male with a receded lower jaw along with a very small chin. I am very unhappy with my profile and unable to afford corrective jaw surgery nor do I wish to deal with orthodontics for over a year. I have had braces before when I was younger and do not want them again. I want my chin to look masculine and large but not abnormal. At the moment my mouth and nose stick out farther than my chin. I would like my chin to go out farther than, or at least in line with my mouth. Any advice or help you can offer is very much appreciated.
A: Thank you for sending your pictures. Your chin deficiency is significant enough (at least 12 to 15mms) that a chin implant alone will not suffice. No chin implant is made that can bring the chin far enough forward. Rather than an implant, you need a chin osteotomy (not a jaw osteotomy) which is to cut and move the chin bone forward. That will bring the chin forward about 12mms. In addition, it also has the advantage of vertically lengthening the chin which an implant alone can not do. If you then add a chin implant in front of or on top of the chin osteotomy, you can then get the more ideal result that you are after from a horizontal projection standpoint in a profile view.
Dr. Barry Eppley
Indianapolis Indiana
Q: I have some severe lumps from a previous liposuction therapy on my upper and lower abdomen. I have since attempted corrective surgery, but it has actually made the issue worse. Is it possible to better the results? I have attached some pictures of my abdomen so you can see how bad it is.
A: A very lumpy and irregular abdomen after liposuction is a difficult problem indeed. This is doubly so considering you have had two attempts to correct it. Lumpiness after abdominal liposuction is the result of uneven fat removal, leaving behind a surface of high and low spots. The most common reason this occurs in the abdomen is from the use of a non-cross tunneling technique. In an effort to eliminate any visible entry points, many inexperienced practitioners perform the liposuction exclusively from inside the centrally-located belly button in a 360 degree radiating pattern. This can result in unevenness in fat removal due to the radiating linear pattern. It is always better to use to two waistline entry points (one on each side of the waistline) in addition to the belly button location to ‘cross’ the linear liposuction strokes. This creates a cross-hatching pattern throughout the entire abdomen and helps lessen the risk of leaving flat surface irregularities.
Can your lumpy abdomen be secondarily improved by using this liposuction technique? That would depend on knowing how your original procedures and the subsequent revisions were performed. If no cross-tunneling has ever been performed, then this revisional liposuction approach may be considered. But the hope of having a perfectly smooth abdomen is not a realistic outcome when one has this liposuction complication. The best result at this point is some degree of less abdominal unevenness.
Dr. Barry Eppley
Indianapolis Indiana
Q: Hi Dr. Eppley, I have a chin scar that I would like improved. I have lived with it for three years but it has not gotten any better. I fell over my bicycle handlebars and ran my chin into the ground. (ouch!) While it was stitched up in an emergency room, it did not turn out as well as I would have liked. It is on the left side of my lower chin and it turns inward. Do you think scar revision will help? I have attached some pictures for you to see what it looks like.
A: Thank you for sending your photos. The origin of your poor chin scar has to do with its geometry. It is essentially a Y-shaped scar pattern so that when it healed, scar contracture pulled downward towards the V portion of the scar. This is a classic scar healing process. Given that the Y is angulated in an unnatural position on the chin (there is no natural position for a Y-shaped scar on the chin), the resultant scar deformity that you have is fairly predictable.
Essentially you have an indented and downward pulling of the chin scar. This could definitely be improved by scar revision. In doing your scar revision, the scar lines would be opened up and a dermal or fat graft placed underneath to add volume. Then the Y pattern of the scar would be closed in a ‘shorter’ Y (V-Y advancement) so that the skin edges would be more level and the downward pull eliminated. While you would still end up with a scar, the goal is to have it smoother and not indented as it appears now.
Dr. Barry Eppley
Indianapolis Indiana
