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As we begin a new year, it is time to once again throw out some fearless predictions about what we will see in 2011. There are endless lists of predictions this time of year, so why not one for plastic and cosmetic surgery as well.

1) As the economy improves, albeit slowly, expect to see the number of people undergoing plastic surgery to increase this year. The past two years has seen the numbers of most major cosmetic surgeries decline by anywhere from 10% to 25%. If the economists are right (?), this will be the a turnaround year to reverse this downturn. Nips and tucks that people have put off in the recession will account for this increased demand.

2) The demand for non-surgical procedures will continue to increase. Between the number of new injectable fillers, competitive products to Botox, laser and light therapies for skin tightening, and different methods to zap unwanted fat, science and technology continue to expand the non-surgical market. The irrepressible human hope that one can look five or ten years younger in just one office visit assures a surging public interest.

3) The need for body contouring after massive weight loss will rise this year. As more and more people undergo bariatric surgery with weight losses in excess of 100lbs, the burgeoning amount of flabby skin will parallel that of the national debt. The subspecialty of Bariatric Plastic Surgery grows as fast as the number of contestants lining up to vie for the next The Biggest Loser show.

4) Incredulous cosmetic procedure disaster stories will continue. While the internet can account for anything becoming instant international news, poorly trained and unqualified practitioners will keep the complications coming. From discount injectable products to surgeries performed in a hotel room or people’s homes, those searching to gather quick cash off of naive patients will keep contributing to this type of plastic surgery news.

5) The number of reality plastic surgery TV shows will reach new lows. The list of cringe-inducing reality TV shows continues to grow. Just when I thought it couldn’t possibly get any worse than with the debut of Bridalplasty last fall, next up will be Mistress Makeover… a show for women who have had alleged illicit affairs with celebrities. I think I could have stomached a show on Pet Makeovers better.

6) The hottest body fashion trend this year will be the one you sit on. With the influences of celebrities like Kim Kardashian, Beyonce, and Jennifer Lopez, women are increasingly seeking a more shapely rear-end. Buttock lifts and fat injection buttock augmentations will become more mainstream. This is also influenced by an ever growing and diverse ethnic population that often places as much emphasis on this area as has historically been focused on the breasts.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Can injectable fillers adequately fill the buccal facial area?  I have heard that Sculptra is used for that but because the product is synthetic I have read a lot of online complaints about problems with the material causing granulomas and lumps. Could Perlane be used instead? Does Perlane work in the buccal area? I previously had spent about $5000 worth of fillers of Restylane and Voluma and it couldn’t adequately fill the buccal area.

A: I think you have hit on a key issue. There is no question you can eventually place enough injectable fillers into the buccal area to see an effect but the sheer volume required makes the use of injectable synthetic fillers financially impractical for some patients  Your past injectable history indicates exactly that issue. Although I have not seen any pictures of you, I would guess that the volume deficiency of your buccal areas is in the range of at least 10 to 15mls per side if not more. At such volume deficiency, it takes a lot of fillers to make an appreciable change.

This is why if you are thinking of injectable fillers, it is probably better to think of fat injections. While the fate of injected fat is never guaranteed, at least you know for certain you could get more than an adequate volume fill at a set price. With facial fat injections, I mix in Matristem powder to theoretically create more of a collagenous response as well.

Dr. Barry Eppley

Indianapolis Indiana

Q: Dr. Eppley, My droopy eyelids are driving me crazy. While I have always had very fleshy and heavy eyelids, they have gotten worse as I age. After my 40s (I am 55 now), they began to sag badly. Putting on makeup has become very difficult. What’s even worse is that it is making my forehead wrinkle. My eyelids are heavy and they seem to be in the way of me seeing. Without realizing it, I tense my forehead muscles to lift my brows up. This lifts up some of the eyelid skin and makes me see better. All of this forehead muscle tensing has given me permanent creases in my forehead. Should I just have my eyelids done or both my eyelids and my forehead?

A: Droopy and heavy eyelids, besides interfering with you seeing, can make you look sad and tired. Blepharoplasty (eyelid lift or tuck) can open them up dramatically and give you a fresher and more alert appearance. (some call it a youthful change) That is certainly what you would benefit from as you have realized.

A browlift is a good complementary procedure to blepharoplasties if your brows have dropped with age. Lifting one’s brows up can signify that it is either a reaction to drooping eyelid skin or that the brows are too low as well. That is an important distinction to make. I suspect that it is more of a reaction to your eyelid skin issue. Therefore a browlift is not what you really need. More likely you would benefit from Botox injections to ‘detrain’ your forehead muscles from the muscular responses they have now learned to do.  

Dr. Barry Eppley

Indianapolis Indiana

Q: I am suffering from some hyperpigmentation from Fractional CO2. I had a few courses of Medlite (At both 532 and 1064 wavelengths) but have noted little improvement. I am also using bleaching creams – hydroquinone and Retin-A. What in your practice has helped with laser induced PIH? I am Asian and probably have skin type III.

A: Post-inflammatory Hyperpigmentation (PIH) can be a sequelae of any form of facial laser resurfacing. However, it is most common in patients with intermediate skin pigments such as Asians. Once it occurs, it can be very difficult to treat. Bleaching creams, steroids, and Retin-A are common topical treatment methods. The use of combination hydroquinone and kojic acid creams are the best topical agents. Laser and light therapies that target brown pigment may also be helpful.

PIH is a particularly difficult problem in Asians. It is so problematic that I have evolved to the point in my practice that we simply don’t do laser resurfacing on patients of this ethnicity and skin type. (at least not deep laser resurfacing) Once it occurs, it is virtually impossible to get rid of it. It can be most disconcerting for those patients so affected. It appears that prevention is a far better approach than any post laser resurfacing therapy for Asian PIH.

Dr. Barry Eppley

Indianapolis Indiana

Q: Hi Dr Eppley, I have been reading with interest on the extensive archive of questions that you have previously responded to pertaining to scar revision. In one of the replies posted, you wrote that the extremities presents the most difficult anatomical sites on which to perform surgical revision. I have a long fairly wide <1 cm in most places) surgical scar sustained from ankle fracture surgery. It is slightly raised in areas, and slightly depressed in certain areas. It has been 3 yrs so it is actually no longer red but pale, shiny and wrinkled in areas. The scar bothers me greatly so I’ll really wish for it to be aggressively treated. I understand that the skin is thicker and more prone to shear /mechanical forces as explained in your response. If I plan to stay at home over the course of the entire recovery period and restrict movement to an absolute minimum, will this help my recovery to a large degree? I will also want to do taping/apply pressure (perhaps in the form of a compression garment or silicone sheeting) to prevent any widening of the scar. As an adjunct, I could possibly have dermabrasion or laser early in my recovery to improve the aesthetic outcome. Do you believe this to be a reasonable approach/treatment plan for improvement of my scar? Apologies in advance for the numerous questions; I’ll be extremely grateful if you can spend a few minutes of your time addressing the points I have raised above. Many many thanks!

A: Scars over the ankle are particularly difficult to improve. Since it is a wide scar, the primary basis for its treatment would be surgical excision (scar revision by cutting it out and re-closing it) to make it a more narrow line. Since it is a mature scar and very pliable, the end result should certainly be better than the width of the scar that exists now. The best treatment to do after would be cross-taping to resist the shear and tensional forces across the healing incision. Avoiding strenuous activities, such as exercise on it, for the first 6 to 8 weeks after its revision would be helpful. I do not think that severe physical restriction, however, would make a big difference as stresses across it will continue for years. The use of dermabrasion or laser may be secondarily useful depending upon how the scar outcome.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Barry Eppley, I am a 15 year old male, and I have a excessive areola projection problem. My nipples have been pointy for about 2 years now, and I get made fun of every day for it. I saw some pictures of your surgeries, and I was wondering I you could help me out by giving me some more information about this procedure?

A: As a 15 year-old male, I regret to inform you that I am unable to communicate with you due to your age. In order to share any medical information with you, I must have a consent from your parents to do so. Even though we are just communicating on the internet, the same rules apply as if I was seeing you in the office. Patients under the age of 18 must be either accompanied by a parent or have verbal or written parental consent to talk to them.

Independent of the above e-mail inquiry, male nipple issues are fairly straightforward. Excess areolar projection signifies that there is a limited gynecomastia problem that may be restricted to just the areola. This can be treated by a direct excision of the areolar gynecomastia through a lower areolar incision.

Excessive nipple projection can be reduced through a simple wedge excision and closure. Both nipple and areolar reduction can be performed during the same procedure. This can be done under IV sedation or general anesthesia as a one hour procedure as an outpatient.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am a male who is unhappy with the result of my facelift. My plastic surgeon was way too aggressive when he performed a SMAS rhytidectomy three years ago. The outcome from this facelift looks very unnatural and I know it. I get a lot of eye popping stares from women which leaves me feeling very uncomfortable. What was supposed to be a facial rejuvenation for the better has in fact turned out to be something for the worse. When making my concerns known to my plastic surgeon he told me,” look at many other male celebrities, you don’t look like them”. I did not find these words very consoling. Is there any way now to improve the result of my facelift to make it look more natural?

A: Facelifting in men is a bit different than in women. It is easy to overdo a facelift in a man and create a very unnatural result. There are many male celebrities that exhibit this look. What is it that makes them look this way? It is actually not the facelift result per se. A facelift technically is just a neck and jowl procedure. That is not what makes the unnatural look. As part of many facelifts, other procedures are done with it such as eyelids (blepharoplasty) and browlifts. This part of the ‘facelift’ which occurs around the eyes can make for ‘eye popping stares’. Brows that are lifted too high and too much eyelid skin removed (eyes that are too ‘tight’) can make the entire periorbital area look unnatural. Since the eyes are a focal point in conversation, this is a hard area to hide.

Unfortunately, there is no surgery to undo the results of a facelift and its associated procedures. Time, however, will help with some facial skin relaxation and returning to a more natural aging look for a man.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: What are the options to put volume back to buccal area underneath the cheek bone? I am in my mid 30s.

A:  A buccal or submalar indentation or concavity can occur for a variety of reasons including a congenital facial concern  (developmental), after a buccal lipectomy (iatrogenic), or medication-induced. (retroviral drugs)  This area extends from underneath the prominence of the cheek bone down to the end of the nasolabial fold and out into the lateral face. In many patients the outline of this area resembles a triangle, hence its common referral as the submalar triangle.

The easiest approach for submalar facial augmentation is the injectable route. The most common agents used are the synthetic material Sculptra or your own fat. Sculptra was specifically developed for exactly this facial problem with its initial FDA-approval for facial lipoatrophy in the HIV patient. It is not permanent, however, and it requires a series of three injections a month apart to build up a result that may last up to 2 years. Fat injections are more of a surgical injectable method as they require a fat harvest which is then processed and injected into the submalar area. The fat of fat injections is not always consistent but the submalar does better than many other facially injected areas.

The other submalar augmentation method is the use of implants. A synthetic implant, known as a submalar implant, can be placed on the underside of the cheekbone to provide fullness to the upper submalar area. The other implant option is the use of a dermal-fat graft which can be placed into the buccal space. In a few cases, I have done a combination of a submalar implant with a dermal-fat graft to get a more complete submalar augmentation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Hi Dr. Eppley, I am interested in nose and neck surgery. In the front view the tip of my nose is too fat. My nose profile shows that my bridge projects too much and the line from my top of forehead down through the bottom of my nose is too straight. I wish to have these things changed by a closed rhinoplasty. Also my neck and jowls is sagging and I would like liposuction to tighten them up, I am 49 years old. Additionly I don’t wear face makeup so I wish for no visible scars to show. Thank you for your time and I really enjoying reading all your info on the web and hoping you can improve my nose and neck. I have attached some pictures for you to review.

A: Thank you for sending your pictures. I have some computer imaging on them and those are attached. Here are my comments based on your stated desires and what is realistic.

Your rhinoplasty would be best done open. You have thick nasal bones and cartilages and to effect those changes you would get a better result through an open visual approach. (less chance of need for revision) You have thick nasal skin so there is no risk of having your nose ‘overdone’ or looking like it is too small or has an operated look. Thick nasal skin always make a rhinoplasty result less rather than more in appearance.

You have too much loose jowl and neck skin to just do liposuction  alone. That will just make the skin look loose and have more sag. You need a tuck-up neck-jowl lift with liposuction to get the result that you are after. Again, the thickness of your skin and it looseness work against a fat removal only procedure. Your skin quality and amount in the jowl and neck area makes it necessary for a more aggressive approach to get a good result.

One additional thought is that of your chin. It is horizontally short and that works against you getting an improved jaw line and neck appearance. A chin augmentation would really complement the neck-jowl lift.

Dr. Barry Eppley

Indianapolis Indiana

Q: I had a breast reduction in October 2010, and I am thinking about getting pregnant again. I was a DDD before, and now am a B. Surgery went well, but if I gain roughly 20 lbs during pregnancy, how big do you think that the breasts will get? I had a free nipple graft, so no breast feeding. I just don’t want to go back to the “bigger” me. I love being smaller. Thanks so much!

A: The changes that will occur after pregancy from a breast reduction are fairly predictable for many patients. The breasts will, of course, enlarge during the course of your pregnancy. They will not likely become a DDD again but they will certainly get bigger than a B cup. After delivery, your breasts will almost certainly shrink back down. There are a few patients in which they do not shrink back down considerably but this is fairly rare. What will also happen in this shrinking process is that they may potentially end up even smaller than before, perhaps going all the way down to an A. This is known as breast involution (loss of breast tissue after pregnancy), and is common, but in the breast reduction patient may become more pronounced. I have seen more than one breast reduction patient who lost all of their remaining breast tissue after pregnancy and actually later went on to a have a breast augmentation to get back some breast volume and shape. What will actually happen to you, of course, can not be precisely predicted but I think the fear of ending up bigger again is unlikely.

Dr. Barry Eppley

Indianapolis Indiana

Q: I would like an opinion by a plastic surgeon. I would like to get rid of the hump on my nose and for it to be smaller and not so wide. My nose is especially wide underneath my eyes. I would like a chin implant to help with my side profile. These are the two procedures that I’m for sure ready to have done immediately. I eventually would like enhance the size of my lips. I had Juvaderm administered to my upper lip about two years ago and did not have good results. My primary focus right now is my nose and chin and would really like to see what I would generally look like after a Rhinoplasty with a chin implant. Thank you so much!

A: The combination of a rhinoplasty and chin augmentation is very common and highly successful. This is particularly true in one’s s profile view even though that is not how one usually sees themselves. (even though most of the world knows you more this way) In this what I call the ‘ying and the yang’ procedure, reducing prominent areas on the nose (hump reduction, shortening or de-lengthening the nose) and bringing a recessed chin forward can make for a significant change in one’s side view. And because two areas are being changed in different directions, it does not take large changes in either the nose or the chin to make a real visible difference. This can be demonstrated before surgery (and always should be) by computer imaging. Rhinoplasty and chin augmentation are two procedures that can be both easily and accurately demonstrated by computer imaging manipulation.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am in the beginning stages of considering the possibility of rhinoplasty procedure.  A large nose runs in my family, but what I’m most unhappy with is that my nose is slightly crooked.  I also wouldn’t mind some size adjustment, both length and width.  I am truly unsure of what potential costs for something like this may be.  I am 30, single and have limited income.  Can you provide me with more information that may be helpful to me at this point in my process?  I would certainly consider a consultation, and would be extremely interested in seeing photos of what you could do with me, if possible.

A: Rhinoplasty for the crooked nose is one of the more challenging nose operations. This is because a very crooked nose is the result of more than one part of the structural anatomy that accounts for why the nose is not straight. It usually involves a deviated septum, middle vault asymmetry and right down to a twisted tip. It is not usually possible to just fix a deviated septum and have the whole nose.then become straight. Crooked noses involve every cartilaginous element and often the bone as well. For these reasons, correction of a crooked nose involves a full septorhinoplasty.

While computer imaging can make a crooked nose perfectly straight, rhinoplasty surgery is not like Photoshop. It is best to think of a straighter but not perfect crooked nose result than to undergo surgery with the expectation that it will be perfectly straight. While that is the goal, there is a reason (bent and deformed cartilages) that the nose was crooked to start with. And cartilage does have memory so some relapse or recoil may occur even out to 6 months after surgery.

Dr. Barry Eppley

Indianapolis Indiana

Q: I’m a little self-concious about my lower face.  I am now 48 years old and feel lilke the sides of my jaw are lacking. When I was a teenager, I had orthodontics which included removal of four permanent teeth to make room for other teeth. This moved by front teeth and my back teeth forward to close the space. Now that I’m older, I’ve come to believe that I have a shallow jaw because of this earlier orthodontic treatment.  I would like some jaw angles as I think my jawline is too steep. From my chin, my jawline just goes straight back and up towards my ears without any definition to the back part of my jawline.

A: For what it is worth, your prior orthodontic treatment (which was and still is standard in many patients) is not the source of a steep jawline. A steep jawline is when the angulation from the jaw angle down along the inferior border of the mandible to the chin is greater than 15 to 20 degrees, often approximating 35 to 40 degrees. As long as the teeth satisfactorily come together, this is an aesthetic issue that is the result of high or underdeveloped jaw angles.

Jaw angle implants can make a big difference in the aesthetics of the jaw angle and jawline. but it has to be the right type of jaw angle implant. It needs to be the type that will lower the jaw angle and not just simply make it wider.  In general, jaw angle implants can lower the prominence of the jaw angle by 1 to 2cms with standard off-the-shelf implants.

Dr. Barry Eppley

Indianapolis Indiana

Q: Is there no way to bringing out the midface with dermal fillers? Are the results not so good as with implants? What is the material of which midface implants are made of? What the advantages and disadvantages of injectable fillers vs implants for midface deficiencies?

A: For midfacial deficiency, albeit of the cheeks, maxilla, or paranasal region, synthetic implants are the preferred treatment. They are far superior to injectable fillers in both results and cost effectiveness. Injectable fillers are intended to treat small soft tissue deficiencies of the facial skin such as wrinkles or folds. They were never intended to be used for more significant bone-based facial deficiencies but rather to be placed into or just under the skin. The sheer cost of placing large volumes of injectable fillers down at the bone level would quickly equal or come close to the cost of implant surgery. When you factor in that they are all temporary, the value proposition of injectable treatments for facial skeletal deficiencies becomes quite poor.

Most facial implants, including those of the midface region, are primarily composed of solid silicone. Silicone is one of the most biocompatible of all implant materials and also offers the largest array of facial implant designs. All midfacial implants are introduced and placed through incisions inside the mouth so there is no external scarring with their use.

Dr. Barry Eppley

Indianapolis Indiana

Q:  Hi, it was so interesting reading your thoughts on cheekbone reduction surgery after a facial injury. I have some questions about almost the same problem. My right cheekbone is bigger than the left one and it is growing bigger. When I look at two year old photos you can see a big difference. I was in a car accident about 15 years ago and hit the right side of face on the dashboard of the car. Is it possible to have some sort of surgery?

A: While cheek bone injuries are common from many types of trauma, they are largely that of fractures and displacement. Secondary reconstruction is often needed to bring out a cheek bone that is too flat or has inadequate projection. The reverse problem, overgrowth or too much projection of a cheek bone is very rare. The presumed cause is that a hematoma has developed above or around the bone, stimulating some bone deposition or ‘growth’. Depending upon the dimension of the cheek bone overgrowth, surgery can be done to reduce. Shaving of the cheekbone is always possible but is not usually my preferred technique unless the overgrowth area can be precisely identified. It is far more common to do a cheek osteotomy and remove a vertical wedge of bone to allow it to move inward. A very helpful diagnostic tool is a 3-D CT scan. This allows one to study the shape of the cheekbones on both sides and determine the exact location of what is making the bigger cheek bone look the way it does. This allows for a precise surgical procedure for bone reduction to be planned.

Dr. Barry Eppley

Indianapolis Indiana

Q: Dr. Eppley, I want to get your opinion. I want to get rid of some body fat. I am not obese but need some help getting rid of some fat areas. I really don’t want to get liposuction and am interested in trying the Zerona. What has been your experience with its use? Do you think it is worthwhile to do? Or should I just go ahead and get liposuction?

A:  As you have read about it and probably seen it in magazines or on TV, Zerona is a non-surgical device for circumferential fat reduction most commonly used for the waist, hips, and thighs. (although it can be used anywhere) It works by emitting a low-level laser energy that targets fat cells through a photochemical process. This causes the fat cells to temporarily open up and release fat which is then safely removed and broken down without side effects or downtime. 

Its manufacturer has done a considerable amount of marketing largely based on his clinical study that was used to get FDA approval. In this study, they showed an average inch loss reduction of 3.65 inches across patient’s waist, hips, and thighs in as little as two weeks.

While this sounds great, I decided in my Indianapolis plastic surgery practice to do my own study. We studied our first 10 patients who underwent a full series of Zerona body slimming treatments. Our results were an average circumferential measurement reduction of over 6 inches. On a patient satisfaction scale, seven (70%) were extremely satisfied and saw significant improvement, two (20%) were satisfied as they saw improvement but had hoped for more, and one (10%) saw little change or improvement and was not satisfied.

Our first Indianapolis results were better than expected. When it comes to the measurements, know how they are derived. When you have an average of 6 inches lost, this does not mean it comes from the waistline or from one single body area measurement. Rather it is the collective number of inches lost from a combined number of cirumcumferential measurements including the waist, hips and thighs.

Should you get Zerona treatments? It is reasonable to do of you understand that Zerona is not magic nor is it equivalent to liposuction surgery. And it may not work well for everyone. But most patients do end up see some visible body changes and were happy that they had the treatments. Because I want to have happy and satisfied patients, and do not want to see patients waste money if avoidable, we credit much of what patients pay for Zerona towards the cost of liposuction surgery should they decide to go that route after a Zerona treatment program.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am considering liposuction of my stomach. I am not fat but just want to thin it out further than I can do on my own. What is the best liposuction method to avoid any uneven or irregular areas on my stomach area afterwards. Since I am thinner to begin with I think it is more likely on someone like me. Would Smartlipo be best?

A: While highly effective at removing abdominal fat, irregularities after abdominal liposuction are not rare. Since the outer contour of an abdominal liposuction result is a direct reflection of the evenness of fat removal underneath the skin, it is important to have as even removal of fat as possible. While many new technologies have emerged for performing liposuction, they have not necessarily resulted in a lower incidence of contour problems. This is because the technique for performing liposuction is more important than the device.

No matter what liposuction method is used, the tracks or tunnels that are made under the skin by different types of cannulas in the fat layer is ultimately important for the final contour. This has lead to the use of smaller cannulas for fat removal and this has definitely decreased irregularity problems. But small cannula size alone is not enough to guarantee no contour irregularities…and it is probably not the most important.

Superceding cannula size is the precision of the underlying tunnels that are made. This is the in and out pattern of the liposuction cannula that most people associate with the procedure. While this movement may look random, it is not. Rather it should be a deliberate  and evenly distributed method of cross-tunneling.

Cross-tunneling, when possible, during liposuction is still one of the most important concepts in liposuction to avoid abdominal irregularities. By cutting tunnels in the fat from multiple directions in any given area, fat is removed in a more even fashion. This is especially important in the abdomen where the cross-tunneling method can be most effectively used.

In short, the operator and not the device is the most important consideration when performing liposuction and avoiding postoperative irregularities.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  I have consulted Dr. Eppley before about jaw implants and noticed in a recent article that he is using Kryptonite Bone Cement that is injectable. Could this be used to augment the jaw or cheeks and chin instead of having a full blown surgery? Just curious if it can’t because if it can be used in skull recontouring the use for facial recontouring seems like a logical extension of its use. After all, bone is bone and why would it not adhere to the jaw/cheeks/chin as well?

A: Currently, the use of Kryptonite Bone Cement as an injectable method is for skull recontouring only. While in theory it could be used for facial augmentation (cheek and chin implants) as well, there are two major problems with this application. First, the material must be injected and then shaped by external molding. Making a flat shape on a skull by using external digital molding can easily be done, trying to make a more complex shape like a cheek or a chin is another material.Whatever shape you get after four minutes after injection is what it will permanently be. To adhere to bone the periosteum must first be raised just like an implant. Injecting onto the bone does not make go under the periosteum alone. If he material does not completely go under the persiosteum and adhere to the bone, it will rock and be mobile. Secondly, the cost of Kryptionite is 10 to 20X what a facial implant will cost. For the skull, all competitive materials cost thousands of dollars in material cost as well. For the face, however, facial implants are far less expensive and have established shapes that work. It simply is not cost effective for the patient to use Kryptonite for facial bone augmentation, even if it worked just as well.  

Dr. Barry Eppley

Indianapolis Indiana

Q:  Hello Dr. Eppley I am a 25 year old male who has been through several extensive surgeries due to craniosynostosis as a child. The last reconstruction surgery done was when I was 18. Unfortunately my Dr. wasn’t as concerned with the cosmetic outcome as I was. I feel that my head is to narrow both from ear to ear and back to the forehead. Additionally my forehead has irregularities and is not proportional. I feel that I need to widen my entire skull, giving it more girth. Augmenting the back of my skull, as well as the sides, starting in my temple regions, then along the front of the forehead so that my eyebrow line is defined rather than flat.
Also during surgery they left me with a 1.5″ wide scar from ear to ear. Towards the top of my head it actually creates a deep groove. Last but not least, I feel that my hairline is extremely close to my eyebrow line, and my left temple area of hair grows too far in towards the middle of my forehead. What would need to be done to improve all my skull imperfections and correct the proportions of it? Is there a way to make my scar smaller or vanish possibly by cutting along onside and folding my scalp over it? Finally, can I bring back my hairline and fix the side area as well? Since these are all things cause by a brith defect/disease what if any could possibly be covered under insurance?

A: Based on your concerns and objectives, I think it is possible to provide improvement for some but not all of them. Nor could whatever can be maximally done occur all in one surgery. Adding material to your skull (cranioplasty) is often best done for the forehead and front of the skull which is the most aesthetically visible. This should be your primary focus. While material can be added to the back of your skull, you can do not both front and back at the same time. Your coronal scalp scar may be able to be reduced depending upon how tight your scalp tissues are. It can certainly be narrowed, it is just a question of how much. Your concept of de-epithelization of the scar and advancing the other portions of the scalp over it for closure is the correct approach. Changing the position of your frontal and temporal hairlines, however, is not realistic as there is no procedure to really make that happen other than how the hairline may change slightly with the scalp scar excision and closure may cause.

Whether insurance will cover such a procedure must be determined by a process known as pre-determination.

Dr. Barry Eppley

Indianapolis Indiana

Q:  Hi Dr. Eppley I just had a combined breast lift with implants less than three days ago. I have several concerns at this point and want your opinion. My left breast seems to currently have a different shape than my right (more fullness to the top and more stiff on the top).  I don’t know if it’s usual for them to have different shapes at the beginning of recovery if they were different sizes to begin with (my right was bigger than my left before surgery).   

A: It is very common with any type of cosmetic breast surgery at this early postoperative period (48 hours) to have breasts that have some differences. This is a function of many factors including peak swelling that occurs 48 to 72 hours after surgery, the fact that no two breasts swell the same afterwards even if they had the identical operation, the fact that they are heavily taped which distorts them, and your pre-existing asymmetry (which will be improved but not cured). 

For all of these reasons, I would not even try to look at them and come away with any assessment. It simply is way too early and substantial changes will take place over the next 4 to 6 weeks in both breasts as swelling subsides and the breast implants and tissues settles.The time to get more critical is 6 to 8 weeks after surgery but certainly not now.

In the end, I believe there will be some mild asymmetry in shape and the nipple position as this always occurs after major breast recontouring. (combined breast augmentation and breast lifts)  But there is no way to get idea about that at this point. I know it is hard but my best advice is to stop looking at them for now.

Dr. Barry Eppley

Indianapolis Indiana

It has been over a decade since a landmark study was published on identical twins and how their appearance changed as they aged. It showed how you live your life impacts how fast you age, and how old you look, more than the genes that are flowing through your bloodstream or camped out in your skin.

In this plastic surgery research that studied twins, it was observed that often one twin would look considerably older then the other. Since their gene make-up was obviously identical, how does one account for these differences? After studying hundreds of adult identical twins, the researchers discovered that how we nurture our skin has a huge influence on how well or poorly our skin ages. Three lifestyle factors came up consistently as accelerants of wrinkles and droopy skin; sun, smoking and stress.

So for this New Year if you want to slow down the clock on how you look as you age, here is another set of resolutions to consider. Limit the number of S’s in your lifestyle, adopt an S-free lifestyle as possible. Limit sun exposure, quit smoking and reduce the stress in your life as much as possible.

Everyone knows of the damaging effects caused by too much sun exposure on your skin. There are great examples that are not more than a person or two away most of the time. But not getting as burnt as toast at the beach is not what ages most people, it is the daily innocuous exposure that we don’t even feel. Lack of adequate daily UV protection in your moisturizer will add a few years and wrinkles than might otherwise have occurred.

The horrific effect of smoking on our heart and lungs is well chronicled since C Everett Koop was our Surgeon General.  And most people recognize that it is not good for the skin either. Its impact is more than just those pesky lip lines from embracing that cylinder (and we have yet in plastic surgery come up with a good way to get rid of them), but it causes more and deeper wrinkles to occur, thins the skin, and creates a lot of dark spots and pigmentation irregularities. By reducing the blood supply to the skin, proper nutrients can not be delivered creating a state of skin malnutrition. A significant smoking habit can easily make a person look five to ten years older.

Stress is the wild card. It is bad for your skin and definitely causes more wrinkles. But treating stress is not as easy as applying a topical cream or not flicking a match or lighter. Maybe don’t sweat the small stuff (and it is all small stuff) approach is one antidote to adopt.

So if you’ve got wrinkled skin, age spots or a turkey neck, don’t blame your family tree. Blame those Ss in your life and make this the year you resolve to reduce them.

Dr. Barry Eppley

Indianapolis, Indiana

It has been over a decade since a landmark study was published on identical twins and how their appearance changed as they aged. It showed how you live your life impacts how fast you age, and how old you look, more than the genes that are flowing through your bloodstream or camped out in your skin.

In this plastic surgery research that studied twins, it was observed that often one twin would look considerably older then the other. Since their gene make-up was obviously identical, how does one account for these differences? After studying hundreds of adult identical twins, the researchers discovered that how we nurture our skin has a huge influence on how well or poorly our skin ages. Three lifestyle factors came up consistently as accelerants of wrinkles and droopy skin; sun, smoking and stress.

So for this New Year if you want to slow down the clock on how you look as you age, here is another set of resolutions to consider. Limit the number of S’s in your lifestyle, adopt an S-free lifestyle as possible. Limit sun exposure, quit smoking and reduce the stress in your life as much as possible.

Everyone knows of the damaging effects caused by too much sun exposure on your skin. There are great examples that are not more than a person or two away most of the time. But not getting as burnt as toast at the beach is not what ages most people, it is the daily innocuous exposure that we don’t even feel. Lack of adequate daily UV protection in your moisturizer will add a few years and wrinkles than might otherwise have occurred.

The horrific effect of smoking on our heart and lungs is well chronicled since C Everett Koop was our Surgeon General.  And most people recognize that it is not good for the skin either. Its impact is more than just those pesky lip lines from embracing that cylinder (and we have yet in plastic surgery come up with a good way to get rid of them), but it causes more and deeper wrinkles to occur, thins the skin, and creates a lot of dark spots and pigmentation irregularities. By reducing the blood supply to the skin, proper nutrients can not be delivered creating a state of skin malnutrition. A significant smoking habit can easily make a person look five to ten years older.

Stress is the wild card. It is bad for your skin and definitely causes more wrinkles. But treating stress is not as easy as applying a topical cream or not flicking a match or lighter. Maybe don’t sweat the small stuff (and it is all small stuff) approach is one antidote to adopt.

So if you’ve got wrinkled skin, age spots or a turkey neck, don’t blame your family tree. Blame those Ss in your life and make this the year you resolve to reduce them.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  I’m writing to you from after reading your article on temporal hollowing. I’ve been trying to find a recommendation on how to treat the temporal hollowing on the left side of my face that developed several years ago. I have yet to be satisfied that any surgeon I have seen truly understands the problem and how to treat it. Those that have seen it recommended some form of fat injection to mask it. Most of the surgeons wouldn’t speculate what might have happened that caused the hollowing, but I recently found out what it was. One surgeon asked for a CT scan and it was quite obvious that the temporalis muscle and the fat pad behind it was sitting around 1 inch lower, at the temple, on the left side than the right. In addition, the collapsed fat was bunching up behind the zygomatic arch causing the soft tissue to bulge above the zygomatic arch.

Several years ago, I was involved in a cycling accident that left me with facial fractures on the left. One bicoronal scalp incision and multple plates and screws later I was quite well put back together. Within a year though, I had developed a droop in my brow, one of the plates was loose along my left orbit and I had developed a minor protrusion on the zygomatic arch. The surgeon I saw opened the bicoronal scar up, lifted the brow a bit, remove the loose plate and burred the left zygomatic arch a bit. When I saw him a month later with hollowing in the temporal fascia, he had no idea what might have caused it.

You’re the first surgeon anywhere in the world that I’ve found who has experience in treating this problem. As you’ve mentioned that different filler materials may be used depending on the case, I’d be really interested from hearing from you about what you believe to be the best treatment in my case. Also I am interested in reducing the bulge over the zygomatic arch. To date, only the surgeon has made any recommendation in that regard. He suggested that a small amount of Lipodissolve might be used along the top of the arch in order to reduce the fat along it prior to applying the filler treatment. The same doctor suggested Aquamid as the filler, but after researching this, I have decided against it as there are a large number of reports on the Internet referring to negative side effects.

A: Thank you for sending me your photos and providing your history. I think it is quite clear as to what the origin of the temporal hollowing is. In your first bicoronal craniofacial fracture repair, little or no temporalis muscle was lifted up to do the primary fracture fixation. But in the second procedure, the zygomatic arch was burred down. The only way to safely approach the zygomatic arch to do any burring, without risking injury to the frontal branch of the facial nerve, would be to do some elevation of the temporalis fascia near the zygomatic arch and come at it from underneath the fascia. With this approach, some temporalis atrophy (aka temporal hollowing) can be one of the side effects to doing so. Your temporal hollowing is not major compared to many other patients, but it is noticeable.

The correction of your temporal hollowing could be done by subfascial implant placement. While there are a variety of materials to use, I would place a allogeneic dermal graft if it was an isolated procedure. However, that approach MAY change if you are trying to get the arch prominence reduced. I do not think (until proven otherwise) that the prominent area over the zygomatic arch is fat. More likely, it is bowing of the zygomatic arch bone. Fat does not cause that bulge unless the zygomatic arch is no longer present. If it is indeed the arch, burring will not work for it. The bone is too thin. A more effective approach would be to osteotomize the arch’s front and posterior attachments and let the entire arch complex settle in a bit. This is a modification of a technique that I use for cheekbone reduction.

The combination of temporal augmentation and arch reduction should get you close to your intended aesthetic temporal/cheek goals.

Dr. Barry Eppley

Indianapolis Indiana

Q:  Please help me out.  I’m so tired of being called Mrs Leno and hiding my lower face.  I have been married for 6 years to a great man but to this day I cover my face when sleeping so he can’t see me and hide my face when we are in a car or at home.  I can’t take this anymore.  I just want to feel beautiful for once.  Can my big chin be made smaller and more proportionate to the rest of my face? I have attached some photos for you to see my chin concerns.

A: Thank you for sending your photos. I can quite clearly see your concerns. You do indeed have a very large lower jaw which is most manifest in the strong chin protrusion. In studying your photos, I think the best method of chin reduction would be an intraoral vertical reduction osteotomy. That would give the greatest amount of vertical reduction and some horizontal reduction as well. There is always some concern about what will happen to the ‘extra’ skin under the chin area when the bone is reduced by this approach. Which is why I would think about doing a simultaneous submentoplasty (skin removal and tightening of the skin) at the same time. Normally this would not be necessary but your very large chin area poses an uncommon problem even in those who seek chin reduction.

Dr. Barry Eppley

Indianapolis Indiana

Q: Hi Dr. I have a large adam’s apple that I want reduced…I am not a transgender, just a regular guy who doesn’t want a big adams apple sticking out, I get tired of people mentioning it too. I was wondering what the approximate cost would be for this procedure! Thanks!

A: A prominent adam’s apple, medically known as a thyroid cartilage or voice box, causes a protrusion in the very visible central part of one’s neck. its size and shape can be very effectively changed through a procedure known as a reduction thyrochondroplasty or adam’s apple reduction. Using a small (one inch) incision overlying the thyroid prominence, the u-shaped protruberance can be shaved down. There is a limit as to how far it can be reduced because of the vocal cords that lie on the inside of the voice box. Most patients will not get a completely flat side neck profile but it is safe to say it can usually be reduced 50% to 75% in profile which is a significant difference.

Contrary to popular opinion, the majority of people whom I have performed this procedure on in my Indianapolis plastic surgery practice are not transgender patients. Most are men who just want their neck bulge reduced. At one time the transgender patient may have made up the bulk of whom was requesting this procedure but not of recent times. More men are becoming increasingly sensitive to a large thyroid cartilage and want it reduced for cosmetic neck contouring purposes.

The typical overall cost estimate, all fees included, is in the range of $5,000 to $ 5,500. It is a one hour procedure that can be done under Iv sedation or general anesthesia.

Dr. Barry Eppley

Indianapolis Indiana

Q: I have been thinking about getting a rhinoplasty. I have never had any nose surgery before. I am filipino and my nose is short and too small for my face. What I would like to achieve is the following in my rhinoplasty; augment the dorsum, lengthen the columella, improve tip projection and definition, alar base reduction and show less nostril. I would like costal cartilage rhinoplasty, definitely no silicone or GoreTex implant for dorsum augmentation. Been thinking of rhinoplasty for a long time. I have attached some pictures for your review and imaging.

A: Thank you for sending the picture and your detailed analysis and goals. Given your smaller and short nose, you are absolutely correct in determining that only a rib graft rhinoplasty could achieve your goals. What you need is a combined dorso-columellar augmentation or the geometry of a L-strut configuration. Only a rib graft or a synthetic implant can possibly achieve that degree of augmentation. You have stated you want to avoid an implant and I assume you feel so because of their potential long-term problems, even though they are the ‘easiest’ to do. A rib graft would provide the best long-term graft retention without problems even though it has the short-term ‘problem’ of a donor site and resultant scar. I have attached some predictive imaging for your review. Please note that the increased columellar show in the side vie does not appear as it is not present at all in the original photo. (you can’t morph what is not there!)

Dr. Barry Eppley

Indianapolis Indiana

Q:  I am looking to get my nose fixed after it has been traumatized in the past. I believe the problem is what is called the tip of the right-dorsal horn has separated or fractured from the left cartilage. In doing so, it is no longer held to symmetry as it extends away from the cartilage it separated from. Because of this it has created an appearance of a hook on the right side of my nose as well as a bumpy tip. I noticed that by pushing the cartilage in toward the fracture point the hook is no longer significant and the tip looks less bumpy. This is what my nose use to look like before the separation of the right cartilage from the left side. Is it possible to have a closed procedure where you stitch the right tip back to its natural foundation with the left tip. I am hoping to remedy this permanently with a less invasive procedure; hopefully removing the hook and smoothing out the tip of my nose. Thank you very much for your help.

A: Thank you for sending the pictures and clarifying exactly where the problem is. The problem is in the tip of the nose which is created by the union of two pieces of cartilage. It is a difference in the shape of the two domes or lower alar cartilages. They are separated and apparently the right dome or alar cartilage has been displaced to the right. You were correct in assuming that it can be fixed by a simple closed rhinoplasty using suture techniques. That is a relatively simple fix that is as close as it gets to minimally invasive for the nose.

Dr. Barry Eppley

Indianapolis Indiana

Q: My main questions are in regards to the permanent lip options available to me.  I could send you my picture so you can get a better idea.  I have tried a few injectables and am not really happy with results in terms of size and longevity.  I understand there are also options for implants vs. v-y surgery. (most permanent?) What are the complications, risks and costs of these options.  Also, do you use Alloderm or Gortex implants, or is it based on cases by case basis. What is the longevity of Allodem?

A: I choose which permanent lip enhancement option on a case to case basis. That could include lip advancement,lip lift, v-y advancement or Advanta lip implants. There are different reasons for using any of these based on the existing size and shape of one’s lip. Pictures would be of great help in determining what may be best for you. Alloderm has not proven to be a permanent lip implant material so it is no longer used.

If you have not had good success with injectable fillers, then the concept of putting in any permanent material will likewise be unsuccessful. Your lips are not big enough or have the right shape to merely be ‘inflated’. This would indicate that you need more vermilion exposure through some form of excisional procedure such as a lip advancement or possibly a tissue shifting approach with an internal V-Y advancement.

Dr. Barry Eppley

Indianapolis Indiana

Q:   I am a 33 year old adult who was born with a cleft lip and palate. I have had two rhinoplasties since the original surgeries I had as an infant. One nose surgery was at the age of 14 and the other one was at the age of 23. My nose is still not straight at all. I know that I do not normal tissue and the cartilage is very stubborn, but I want to know if there is any hope for a more symmetrical nose.

A: One of the most difficult of all rhinoplasties in which to get a good result is that of the cleft nose. As you have pointed out, the tissues on the side of the cleft (if it is unilateral) are not normal. This means that the lower alar cartilages are deficient and there is scar from the lip repair into the base of the nose as well as the scar tissue that you would have from your prior two rhinoplasties. But the most limiting factor, above all of that, is the skin at the tip of the nose and around the nostril. It is not only thicker than normal but it is both deficient and scarred. This is particularly true inside the nostril and in the soft triangle area near the tip. Having done many hundreds of cleft rhinoplasties, I find this issue to be the really problematic one that limits how good a cleft rhinoplasty result can be. To answer your question specifically, please send me some photos of your nose and I can provide a good answer if any further efforts at rhinoplasty are worth it.

Dr. Barry Eppley

Indianapolis Indiana

Q:  Hello Dr Eppley,  I’m just writing to thank you for the great information you have posted on vertical chin reduction. I’ve always had a long chin and had liposuction on my neck 3 years ago. Afterwards it made my chin longer. I don’t know if it just looks that way or something was done to actually make my chin longer if that makes sense. In any event I’m too afraid to do anything about it, but thank you so very much for providing the great information on your site.

A: The neck liposuction did its job by making the neck less full and improving the neck-chin (cervicomental) angle. But having a long chin to start with by your admission, the improved neck shape has unmasked the chin area and made it look longer. That is actually an optical illusion. But an illusion that aesthetically does not work in your favor. When considering neck changes, it is always important to not overlook the chin area as the two work together to contribute significantly to one’s facial profile. Doing computer imaging would have revealed what neck liposuction alone would look like. It likely would have shown that vertical chin reduction was just as important to an improved facial profile as was the neck fat removal.

Dr. Barry Eppley

Indianapolis Indiana