Your Questions
Your Questions
Q: My goal is to make my jawline more defined as well as give it a more square shape. I am hoping to widen my chin in the front and make it protrude more. I am especially unsatisfied with the way my chin looks from a 45 degree angle. Do you think you can design a one piece custom implant for this? I am looking for something similar to the mandibular matrix system. I have attached pictures for you to see what I mean.
A: Thank you for sending your pictures. I am very familiar with the mandibular matrix system and use it fairly frequently when needed. In looking at your pictures and seeing your goals, I am curious as to why you do not use the matrix system instead of a custom implant. I don’t see in your case the advantages of a custom implant. It will not provide any better aesthetic outcome and, even though made as a single piece, can not be put in as a single piece. For that style of wrap around jaw implant, it would need to be sectioned into at least two separate pieces to be inserted…maybe even three. So if your thought is that a one-piece implant would be better than three separate pieces, that is erroneous. A custom one-piece jaw implant works best, and should only be used, when it is used for vertical lengthening of the jaw mainly…something that no off-the-shelf mandibular implant can do.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am very self conscious about my forehead. I have a strong square jaw and a square forehead as well. I like it that way but my forehead has two bumps on either side (genes) below my hair line and I have two bumps (kind of an eyebrow ridge) over the beginning of the eyebrow above my nose. Can these two bumps near my hairline be chiseled as well as the eyebrow ridge? You can especially see the unevenness under a light directly on top and overall it makes me look way too rough or mean.
A: Forehead irregularities and prominences can be either those that exist in the brow area (prominent brows) near the eyes or those that exist above the brows up to the hairline. They represent different types of bone problems and are treated differently. Forehead bumps are simple raised areas of excess bone that can be simply burred down. Prominent brows, however, are not bone thickenings but are expanded frontal sinuses. They may appear as prominent thick bone but it is largely air with very thin bone. They are treated through an osteotomy approach with bone reshaping and recontouring.
While both of these forehead type surgeries can be done, the rate-limiting step as to whether they should be done by the patient is the need for access to do the surgery. This requires some type of scalp incision. Whether this trade-off of a scar is worth it to the patient must be decided on an individual basis.
Indianapolis Indiana
Q: I have been unhappy with my lower abdomen area so I had Smartlipo done three years ago. So I went and asked another plastic surgeon in my area what he could do and he said either try Thermage to tighten the skin. Then if I was still unhappy I could go for a revision and do a fat transfer. I went ahead and did the Thermage and now I’m waiting o see whart the results will be. But I don’t think that it is going to even out the areas. It seems that when Smartlipo was done some fat was left behind and formed these bump and lumps. Since I’m almost 40 years old I thought the Thermage would help. I wasn’t over weight I was just trying to get a little help in sculpting since I routinely workout. And it is very apparent that the surgeon overdid it. And since then I’ve been trying to get used to seeing myself like this. But haven’t really gave up hope yet. What are your suggestions?
A: Abdominal irregularities after liposuction is unfortunately not rare. They appear as lumps and bump as you have described. While the concept of non-surgical skin tightening sounds theoretically appealing, I would not be optimistic that would be a solution to the problem. The problem is differential thickness of the underlying subcutaneous fat layer.
When considering treatment of theses lumps and bumps, you must first decide whether they are problems of fat excess or fat deficiencies. In other words, are these lumps and bumps high spots or is the area between them low spots. That decision is critical because the treatment is radically different. If the lumps and bumps are areas of fat excess, they can be treated by Lipodissolve or dilute steroid injections to cause fat atrophy. Depending upon their topography, they may also benefit by spot liposuction reduction. If the problem is that the lumps and bumps are normal and the areas between them are deficient, then fat injection grafting is the treatment of choice.
Dr. Barry Eppley
Indianapolis Indiana
Q: I tried to do some computer imaging of my face on some programs that some plastic surgeons have but it didn’t seem to work. I just couldn’t make it look right. I am interested in jawline enhancement and facial implants and was looking for some advice. I have attached some pictures for you to review and image.
A: An increasing number of websites, plastic surgeons and otherwise, and smartphone apps have interactive programs in which to do some of your own computer imaging of your face and body. By simply uploading a picture or two, you can do a little ‘Photoshop‘ plastic surgery. While these programs are certainly cool and fun, they are not particularly accurate. That is because of the simple fact that the ‘driver‘ has no realistic appreciation of what can really be done and what actually will happen if certain procedures are done. Only a plastic surgeon can add that missing element if one wants to make the transition from fooling around to seriously considering becoming more than just manipulated pixels.
But there are a few patients in which even the simplest change just don’t seem to look right. That is because their facial anatomy is different and the basic rules of changes do not work well for them. That happens to be the case with you. Your underlying problem is that your lower face is too short for the rest of your face. This shortness affects both your lower and upper jaw. So when you try and just move the chin forward, it doesn’t look right. It makes the midface (upper jaw and upper lip) look retruded or back too far. That relationship would be impossible for you as a patient to figure out. What you really need is a treatment that can move both the middle and lower third of your forward. That could be either chin and paranasal implants or orthognathic surgery that moves both the upper and lower jaws forward.
Dr. Barry Eppley
Indianapolis Indiana
Q: Nearly 15 years ago I was assaulted and punched repeatedly while unconscious. This resulted in broken bones in my face which were never fixed at the time. I have a sunken cheek and I believe my eye has dropped slightly with it. Can my cheek be repaired being that it was so long ago?
A: It sounds like your original facial fracture was of the zygomatic-orbital complex variety which displaced in its classic manner, downward and into the maxillary sinus. When this ‘cheekbone complex’ falls down like this it creates a depressed or sunken cheek (lack of cheek projection/prominence) as well as moving the floor of the eye down with it. (eyeball moves downward)
Just because it has been allowed to heal and needs secondary correction does not preclude that it can be treated. But the type of treatment changes when the injury is old like yours as opposed to when it was a freshly broken. Depending upon the degree of bone displacement, there are two options. If the cheek displaccement is fairly mild, it can be treated with a cheek implant and possibly an orbital floor implant and repositioning of the corner of the eye tendon. (lateral canthoplasty) If the bone displacement is more severe, however, it is better to cut the cheekbone complex (osteotomy) and do bone grafting. Simply trying to build up bone with implants that is way out of position does not produce a result that looks very natural.
Dr. Barry Eppley
Indianapolis Indiana
The past few years have been part of an economic recession that we are told is the most serious since the Depression. Economists take a daily pulse on whether we are in some form of a recovery yet. As we enter the Christmas season, this economic ‘dip sticking’ is particularly keen. The flurry of buying, or lack thereof, at this time of year is one gauge of the state of the economy.
But, if you really want to know how the economy is doing this holiday season, don’t bother listening to pundits and endless boring numbers, such as the consumer price index, or even most of the more dry economists that have created them. They are about an accurate as the local football handicapper. I propose focusing on just one indicator and a very simple one at that – one that nearly any consumer can understand. In one word…bras…more specifically that of bra sales.
The sales of this one single clothing item is a lot more tangible for me to grasp than any cadre of numbers, fractions or percentages. If women are buying themselves new lingerie, this surely must be a sign of economic recovery. I would like to hear from Victoria’s Secret how their sales of push-up bras are going this season. According to the expert I consulted on this topic (my wife is a bra connoisseur and can spot a LaPerla knockoff in a room chock full of underwire, lace and padding) bras can sell for up to hundreds of dollars. In my mind, such purchases are a sure sign of consumer confidence. When the largest buying segment of the population is willing to indulge themselves (men may buy underwear but they are not about to splurge on an expensive item that no one ever sees), this suggests they may be willing to spend freely in other ways as well.
Paralleling the bra sales economic indicator is that of cosmetic surgery. Major cosmetic surgeries, such as breast augmentation, tummy tucks and many facial procedures, took a serious nose dive the last two years. Some plastic surgeons reported decreases of 40% or more in numbers of elective cosmetic surgeries performed. The national pulse now indicates that patients are returning for nips and tucks and some remodeling and overhauls. From Botox injections to facelifts, patients are returning to the ‘table’ in substantial numbers and spending on ‘personal image’ is gradually returning to its previous levels. Either consumer confidence is improving or the reflection in the mirror is heading in the wrong direction.
Does this mean the recession is over? No one seems to know for certain, but on a recent trip through the local Victoria’s Secret there were encouraging signs that the economy may be pushing back up.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have a bump in the middle of my forehead the size of a nickel and seems to be slightly growing. . . saw a plastic surgeon yesterday and we are going to watch it. He mentioned a hematoma. . . I haven’t had any head injuries. Is hematoma common with this type of immovable hard lump?
A: I do not have the advantage of actually looking at your forehead lump. So anything I would say is speculative and without the advantage of the plastic surgeon who has seen it.
However, without a specific history of any head trauma, the most likely diagnosis is an osteoma, a benign bony growth down at the bone surface. Sometimes they appear as a result of forehead trauma but many times they do not. They can develop from any bleeding that occurs underneath the periosteum which is a great stimulus for bone growth. They almost always are associated with a perforating blood vessel where it exits the bone. They are hard and very slow growing. They are like a small circular disk or small mountain sitting right on top of the forehead bone. They can be removed through an endoscopic technique if they get big enough to cause a noticeable forehead bump. This is done through small scalp incisions where they are chiseled off of the bone under direct vision of the endoscopic camera. If there is a prominent foreheasd wrinkle nearby, they can also be removed through an incision in the wrinkle.
Indianapolis Indiana
Q: I would like to know the differences between slim lipo and smart lipo. I have read its more the Doc, than the process. I would like to get cost estimates, and a list of good Docs near my location. Thank you.
A: You have asked three very good questions about liposuction of which all three are understandably misunderstood.
The names, Smartlipo and SlimLipo, are brand names from different manufacturers of laser liposuction equipment. Smartlipo was the original company that introduced a laser liposuction device to the market back in the mid-2000s. Since then they have undergone numerous technologic developments with better and more powerful laser liposuction machines. Along the way numerous manufacturing competitors have arisen with their own branded names of which SlimLipo is one but there at least a half dozen others. Both companies and their docs can argue all day about which one is better but, in the end, it really comes down to the skill and experience of who is driving them so to speak…as you have already pointed out.
Cost estimates in liposuction can not really be accurately done without knowing the specifics areas that one wants to treat. It is all about the time and effort that it takes to do the procedure. There is a big difference in cost, for example, from a simple neck liposuction which takes 30 minutes to total abdomen, flank and thigh treatments which could take around 2 to 2 1/2 hours to surgically complete. One would have to be specific as to the areas involved to even get a cost estimate without being evaluated in the office.
Lastly, the concept of what constitutes a ‘good Doc’ is a matter of perspective. There are no lists of good or bad docs anywhere. What you want to find is the right doctor for you. That requires doing your research online of various websites and eventually getting yourself in front of some actual doctors and gathering more information.
Dr. Barry Eppley
Indianapolis Indiana
Q: Can lipodissolve be used to eliminate lumps of fat left on the abdomen after liposuction?
A: Irregularities of the abdomen after liposuction is not a rare outcome. The abdomen is the most common body region for noticeable irregularities to occur after liposuction. This has to do with several factors including its flat surface and easy visibility (the entire surface can easily be seen and scrutinized), the unpredictability of how the abdominal skin will tighten particularly if there is any loose skin present, and the relative imprecise nature of the liposuction procedure when it comes to evenness of fat removal under the skin. While such words as ‘sculpting’ are often throw about in liposuction marketing and promotion, these are often an overstatement of what can actually be achieved in many body areas. Liposuction, of any type and technology, is best thought of as fat reduction, recontouring or reshaping. But the combination of the concepts of liposuction and sculpting is more fanciful than reality in most cases.
Lipodissolve injections, using a phosphatidycholine and deoxycholic acid mixture, can be used for any ‘high’ spots that remain after liposuction. While once conceived as possible for more major areas of fat reduction, time has not borne out that out for its utility. But for very small ‘lumps and bumps’ after liposuction, it can be very effective. The prior experience with Lipodissolve for larger fat areas showed that it has some results but just not enough. But for small fat collections, it can offer a non-surgical solution. Two things are important for patients to realize with Lipodissolve, it may take more than one injection session to get the best result and it is not an FDA-approved treatment.
Dr. Barry Eppley
Indianapolis Indiana
Q: Hi Dr. Eppley. I have seen four different plastic surgeons seeking improvement in my facial profile and, so far, nobody can show me or even tell me that by doing “this” or “that” I would get the end result I’m looking for. I’m so scared to have the wrong procedure(s) done, or to chose the wrong size of chin implant, you can’t imagine. I have attached some pictures of myself so you can see my chin and neck problem. After reviewing them s there a way we could communicate by phone? I really need to ask you some questions. I would like to thank you for doing this for me. You are my last hope!!! Please reply, thank you.
A: Quite frankly, I am not sure what the mystery is when it comes to making the facial improvements that you want. Yours is a very straightforward and common problem that I see all the time. It is the classic ‘ying and yang’ problem. The chin must come forward and the neck angle must go back. And how to do that is similarly not a mystery. The chin implant should bring the chin no further forward in a woman than a vertical line dropped down from the edge of the lower lip. In the frontal view, it must be a tapered chin implant so as the chin comes forward it remains with a more feminine shape and not becomes more square or too masculine. From the neck standpoint, liposuction is certainly needed. The only unknown, and I can not tell this from photographs or computer imaging, is what the neck and jowl skin will do. Is it good enough quality skin to tighten up on its own or does it need a little help via a jowl-neck tuck-up from incisions around the ears?
I have attached some predictive computer imaging so you can have an approximation of what the outcome from a combined chin implant and neck liposuction and recontouring procedure would be. It is unfortunate that after four plastic surgery consults, this ‘mystery’ has not become unveiled to you.
I am happy to talk to you by phone or Skype any time. Just let me know your availability and we can work out a time.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am a 21 year old male who was involved in a car accident when I was 16 years old. As a result, I have a depressed area on my forehead. I would like to know if Kryptonite Bone Cement could be injected to fill the depression?
A: The reconstruction of frontal bone defects or contour issues is often done using onlay cranioplasty techniques. It can be a highly successful procedure as synthetic material is added onto the bone defect area. Various materials have been used over the years, most commonly acrylic (PMMA, polymethylmethacrylate) and hydroxyapatite. (HA) While there may be advocates and some minor advantages and disadvantages with them, both will do the job equally well from a bone reshaping standpoint. Both materials require, however, an open approach for placement. For men in the forehead area, a scalp incision may not be worth the trade-off depending upon the size of the forehead problem. If an existing scalp scar is present from a prior neurosurgery procedure, then that is a different matter and an open cranioplasty would be the best approach.
Kryptonite bone cement is the first cranioplasty material that has physical properties to make it injectable. This means it still requires an incision but it can be as small as less than an inch through which scalp tissue elevation is done around the bone defect area. The material is then mixed and injection through a long flexible introducer tube into the defect site. Shaping of the injected material is done from the outside by external pressure.
Indianapolis, Indiana
Q: I am interested in getting a breast augmentation but also have concerns about my nose. I think a rhinoplasty would almost help me as much as the breast augmentation in both appearance and my self-confidence. My questions is can I do them at the same time and is there any discount on getting more than one surgery at the same time?
A: Multiple operations during a single plastic surgery encounter is very common. Since one is going to be asleep under general anesthesia, it just makes sense to do as much as is medically safe and reasonable from a recovery standpoint. I have seen all sorts of different types of plastic surgery procedures put together and there really is no limitation as to what can be combined. The only limitation is whether the plastic surgeon feels comfortable doing all that the patient needs…and that the patient is healthy and can tolerate the surgery.
Breast augmentation is a relatively short operation, generally an hour or so, while rhinoplasty can take two or three hours to do depending on what type of rhinoplasty it is. These two operations combined are well within a safe operative time period of 3 or 4 hours and can even be done as an outpatient. I have performed these two plastic surgery procedures together more than one time. Younger women are exactly the type of patient who would commonly have one or both of these cosmetic concerns.
Any time multiple cosmetic procedures are combined, there is some economy to be had in both recovery and costs.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have drooling from the corners of my mouth and its embarrassing. I am 73 years old and have not had a stroke and I am still working everyday. What can be done for this corner of the mouth drooling problem. It was also occasionally get red and sore and painful. When this happens, it takes a fair while until it finally gets better. I have tried all sorts of antibiotic creams and salves but nothing seems to be that effective. I have read about a procedure called the corner of the mouth lift that removes the overhanging skin. Do you think this will help?
A: Downturning of the corners of the mouth, combined with aging which creates a skin overhang, creates a gutter effect at the corner of the mouth. This is the perfect setup for a runway for saliva. This problem can be further magnified with one has overclosure of their lower jaw due to a loss of teeth or ill-fitting dentures. This overclosure causes a lower lip inversion which makes the drool problem at the corner of the mouth worse. Localized infection at the mouth corners can happen due to the chronic wetness of skin that is not normally so like the lining inside the mouth. This is known as angular cheilitis. Topical steroids and antifungals can help but a change of the anatomy is more effective.
The corner of the mouth lift can be really helpful for this problem as it removes the skin overhang and lifts the mouth corner. This eliminates much of the spillway problem. There is a trade-off of a small scar that tails away from the mouth corner but this is not usually a significant cosmetic concern.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am bothered by my puffy cheek look. I feel that the area under my cheekbones is full and, as a result, does not give good definition to my cheek area. I had cheek implants placed but they didn’t give me that more sculpted look that I was looking for. I think the problem isin the full area below the cheek. I have read this is called the submalar area. Is it possible to have a tightening of the submalar soft tissues area. Is there such a procedure? I have simulated this concept in front of the mirror many times without knowing it was possible outside of a full facelift and really liked the improvement it makes in highlighting the cheekbone. How would such a procedure be done? Is there any external scarring or is it done completely intraorally? I would like to pursue this procedure seriously so any information you can provide would be much appreciated. Thanks again.
A: The submalar area of the face is a non-bone supported area beneath the cheek bone (malar eminence) that is influenced exclusively by the volume of soft tissue that it contains. Thinning, or creating an indentation, in the submalar area is commonly done by buccal fat removal. While this simple procedure can be helpful in the right patient, it does not work well for every fuller face. And can even create too much of an indentation later in life when one gets older as natural fat atrophy occurs in most people.
An alternative procedure is submalar tightening. It is not nearly as well known but can also create a narrowing of the submalar triangle. Using the same intraoral incision and approach as one does for a buccal lipectomy, the underlying soft tissues are cinched down with a suture anchor placed into the underside of the zygoma. This can be done in conjunction with buccal fat removal for a combined submalar indentation effect.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dear Dr Eppley, I underwent a chin reduction with a jaw contouring operation about one year ago. As for the result, have always found that it looked odd. My chin was reduced by 1cm and now my mouth does not close properly at rest and there is a ‘balling’ shape to the muscle and a wrinkled look. I recently had a MACS lift as my jaw muscles also looked slack after the op. However my chin is unchanged and still feels loose, unattached and ‘balled up’. I have come across your writing online and think your expertise may help resolve this. What do you suggest?
A: If your chin reduction was done through an intraoral vertical osteotomy reduction technique, then you would likely end up with soft tissue excess over the chin area when a large amount (1 cm) is vertically reduced.. (mentalis muscle and skin) These excess soft tissues could very well end up looking like a ‘ball’ over the chin area. This could really be predicted beforehand as where is all of the soft tissue that covered the 1 cm that was removed supposed to go?
No form of a facelift would solve the excess tissue problems in the chin area nor should it be expected to. A MACS lift, like any form of a limited facelift, is a lateral or side of the face operation based on soft tissue pull. So it will tighten up any loose skin over the side of the jaw/jaw angle area/jowls, but will do nothing for the chin area. The chin area excess is a central problem that requires direct excision and tightening, most commonly done through a submental incisional technique.
Dr. Barry Eppley
Indianapolis Indiana
Q: Dr. Eppley, I had a Medpor Lateral Augmentation Onlay Mandible Angle Implant for mandibular augmentation about nine months ago. While I am satisfied with the results, I desire more lateral augmentation of his mandible. I know from reading that it is possible to reduce Medpor Implants in a second operation if the patient feels the implant provides too much augmentation. Is it also possible to enhance an implanted Medpor implant, by placing some further Medpor material on top of the implant surface in a second operation? I thought it could be useful to place smaller pieces from Medpor sheets and place and secure (screw) them over the existing mandibular implants in order to increase their lateral projection. Would you advise to place additional Medpor over an incorporated Medpor implant? Do you know if Medpor is designed for this or are there any problems that might occur by enhancing an existing Medpor implant with further Medpor material? Thank you in advance for your efforts.
A: I see no problem why you can’t add more material on top of an existing Medpor implant. The important issue would be good security (screw fixation) to the underlying implant. I would be concerned about shifting or palpability of a multi-implant reconstruction not any interactive material problem or reaction.
It would be far better and easier, I think, to remove the existing implant and add to it on the back table…to assemble a good solid construct and then re-insert during the surgery. This may make it surgically easier to do. Or why not change just to a whole new bigger implant and be assured you have a solid one-piece construction?
Indianapolis Indiana
Q: I have been developing droopy jowls over the past few years and it is getting worse. I am 50 years and I don’t want a facelift or surgery. Is there anything that may help them go away that doesn’t involve any cutting and scars? I have read about some fat dissolving injections which they say can make jowls get better. Is this true?
A: The development of jowls or jowling will occur in everyone eventually. These classic aging signs are when the skin and fat that used to be up on the side of the face comes sliding down due to time, gravity, and weakening of the skin’s attachments. There is no question that the preferred as well as superb treatment for isolated jowling is some form of a facelift. If jowling and not the neck is the main issue, then a more limited type of facelift will work quite well. These smaller facelifts (jowl lifts or tuckups) go by many different names, most popularly known as a MAC Lift or a short scar facelift. Regardless of the branded name, they are all essentially the same type of limited facelift operation.
Short of surgery, fat dissolving injections have been used for mild jowling. Known as Lipodissolve injections, these chemical concoctions do have the ability to break down small areas of fat and tighten just a little bit of skin. I have used them very rarely in the jowl area but, in the handful of cases that I have done, there was a definite amount of improvement and several of those patients were absolutely thrilled. The key is in patient selection. They must not have too much loose skin or too much jowling or these injections will have no benefit.
There are also other device-driven methods of jowl tightening such as Thermage, Skin Tyte and others. The concept is to treat the deeper skin and underlying tissues with heat, ultrasound or radiofrequency energy to create the tightening. These device approaches to jowling would be more mainstream and accepted as opposed to Lipodissolve injections.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am considering breast augmentation but am just insure about what size to go to. I have been an A cup all my life and have no real idea what would like right on me. Do you have any suggestions to offer in choosing size?
A: When it comes to breast size, beauty is truly in the eyes of the beholder. While there are certainly trends in each culture that reflect the ‘average breast size’, that has little to do quite frankly with what you want for yourself and how you want to look.
Breasts should be proportionate to a woman’s body frame and build. The historic concept of 36-24-36 inches, though quite exaggerated, basically refers to breast size being equal to the hips, with a significant narrower waist in between. This creates that classic hourglass figure but that may not be right for everyone and probably is more uncommon than common.
It is important to consider a woman’s body build in determining the most suitable breast size because if one’s arms or tummy is bulky then the breasts will have to be bigger to give the right profile. In thinner women smaller sized breasts will give the same look of fullness in the breasts.
With all of that being said, the one single parameter that seems to work for most patients is to choose a breast size (implant) whose base width matches the natural base width of your breast. This is a simple horizontal measurement. As breast implants increase in diameter as they get bigger, having an implant that is no wider than your natural breast will never give one a final breast size that is too big. (which is the most common fear of most breast augmentation patients before surgery.
Dr. Barry Eppley
Indianapolis Indiana
Q: I have a burn scar on my leg from several years ago. I am sending a picture of my burnt leg, which I can stretch and bend easily meaning I can move it freely. I would like to know what you can suggest for getting the best scar result. I have heard about scars and that its impossible to make them disappear. Thanks in advance.
A:Thank you for sending your picture of your leg burn scar. Burn scars (deep 2nd and degree burns) create the worst outcomes in terms of eventually doing much with the scar because they have changed the entire thickness of the skin into one complete scar. The tissues are just never normal and do not have the ability for much normal tissue regeneration.
The good news is that you can move your leg freely without scar contracture or restriction. The bad news is that I don’t believe there is anything that will provide a substantial improvement in its appearance by any form of scar revision. Hypertrophic burn scars have changed the entire thickness of the remaining skin into one large white scar. It may be possible to get some improvement with combined fractional and CO2 laser resurfacing but the improvement may not be significant enough to justify the effort. That form of laser treatment may make it a little flatter but it will not make the scar disappear nor make it look like normal skin. Those goals are not possible. If the objective is some level of improvement then such effort may be worth it. But if the objective is to make it look like there is no scar there then any form of treatment should not be pursued as disappointment will surely follow.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am 36 years old and have had fairly deep forehead lines for quite a few years now, which appear to be getting worse. Is there something other than plastic surgery or Botox that I can do to help my problem? I am desperate!
A: The simple answer is…no. But let me explain why. Wrinkles on the face form perpendicular to the direction that the underlying muscles move with facial expression. The well known horizontal lines on the forehead are a result of the large frontalis forehead muscle that attaches to our eyebrows and goes across our forehead the whole way to the back of our head. As you move your forehead with expression, the muscle lifts the eyebrows and creates the horizontal lines. The only way to stop them from forming, therefore, is to stop moving your forehead. Notice the difference in the depth of the forehead wrinkles when your forehead is still and not moving versus when you are lifting your eyebrows. (that difference is important for treatment considerations below)
There are only two non-Botox and non-plastic surgery options that can reduce your forehead wrinkles. A state of permanent facial paralysis is one option, otherwise known as death. Very effective but not appealing. The other option is to retrain your facial expressions so you don’t move your forehead anymore. Theoretically possible but if you are successful you will be the first human to have successfully done so.
I tell you this so in your desparate state so you don’t chase worthless treatment options and throw away money…or actually transfer your assets to the benefit of someone else. So do not chase the illusion of innumerable skin lotions, potions and facial exercises that promises a miracle wrinkle cure.
That leaves you with exactly what you want to avoid, Botox and forehead surgery, Unappealing but actually the only things that will work. Back to the depth of your forehead wrinkles when they are still versus moving. If the depth of the forehead wrinkles is acceptable when your forehead is still, then Botox would be the preferred treatment. If the depth of the forehead wrinkles at rest is still not acceptable, then a forehead lift with muscle removal would be the better treatment.
Dr. Barry Eppley
Indianapolis Indiana
Q: Is it possible to have a vertical chin that points downward as a result of fleshy tissue and not bone? My chin is vertically too long for my face and projects downward especially when I smile. I’d hate to have complications from having the bone burred down on the tip but would also hate to have titanium plates & screws in my chin from a wedge of bone being cut out to reduce the chin. I live in Texas and I don’t’ know any surgeons here that are properly certified and experienced in chin reductions. Please let me know. Thanks.
A: A long vertical chin can be the result of too much bone, too much soft tissue, or a combination of both. In most cases, vertical chin excess is a combination of both. By definition, a chin that is too long because of bone must have extra soft tissue to go with it. Making the proper diagnosis helps one correct the right chin reduction procedure. Not properly addressing the right problem, or inadequately treating it, is the reason so many chin reductions have unsatisfactory results.
A physical exam can usually tell which component make up the vertically excessive chin. In some cases, a simple panorex dental x-ray can also be helpful. The observation that your chin soft tissues pull downward when you smile is common and indicates that it a combined bone and soft tissue problem.
Chin reductions can be done by bone only reductions (intraoral horizontal reduction osteotomy) and bone and soft tissue reductions. (extraoral submental bone burring reduction and soft tissue resection and tightening) Because these two procedures are so different, one can see the importance of making the correct diagnosis of excessive tissues.
Dr. Barry Eppley
Indianapolis Indiana
Q: Does Dr. Eppley perform non-surgical rhinoplasty? If so, how many has he done and what does it cost?
A: I have performed non-surgical rhinoplasty, otherwise known as using an injectable rhinoplasty. It is about using an injectable filler most commonly in the upper part of the nose (radix) to treat (hide) a hump. I have done that office procedure numerous times. It is only good to fill the bridge area above a hump to make it smooth. In a few other cases, I have used injectable fillers for small areas of fill-in for dents and asymmetries in other parts of the nose. But you can’t do a complete rhinoplasty or even a partial rhinoplasty in a non-surgical fashion. So the concept of an injectable rhinoplasty is for filling in small defects in the nose. It is also important to realize that these effect are temporary (one year or less) and not permanent.
I would have to see pictures of your nose to determine if this procedure is for you. If so, the usual injectable filler used is Radiesse because it lasts the longest although other fillers can be used. (e.g., Juvederm)The cost of the procedure is based on how much filler is used and what type. It could range anywhere from $350 to $850 depending on those factors.
Another form of injectable rhinoplasty is that using diced cartilage. While it does require a septal graft harvest, the cartilage is diced and injected through small syringes from an incision inside the nose. This injectable rhinoplasty procedure does require an anesthetic to perform and so it is better called a minimally-invasive rhinoplasty.
Dr. Barry Eppley
Indianapolis Indiana
Q: Several of my friends have had breast augmentation with you and have loved their results. I am 41 years old and have always wanted larger breasts. My problem is my doctor has informed me that it would not be a good idea go under general anesthesia. The reason being is my mother at age 45, my brother at age 29, and a sister at age 22, all passed away all while under general anesthesia. They never identified a specific cause although my doctor said it is genetic and has told me if I want to do any sort of plastic surgery it would need to be done under a local. Is there any hope for me finding a plastic surgeon who would do my breast augmentation under a local, epidural or something while I am conscious. This is something I have longed for over 15 years. Please respond as soon as possible. I don’t want to go to a cosmetic surgeon and have this done. I want a reputable plastic surgeon such as yourself to perform this. Thank you so much for your time.
A: That family history is the most tragic that I have ever heard in all of my surgical experience. One family member dying under this general anesthesia is rare enough, but three is beyond comprehension. While their diagnoses may not have been known at the time, it is highly likely that your family has the gene for Malignant Hyperthermia. (MH) While not recognized decades ago, it now is and every operating room that does general anesthesia has an emergency kit for its treatment. There is no blood or genetic test for MH. Family history is the only ‘test’ for its presence. Your family history is more than suspicious for this diagnosis.
While you have a likely family history for MH, this does not mean you can not have general anesthesia. The known anesthetic drugs that trigger MH is the muscle paralyzer, succinylcholine, and all of the inhalation agents. General anesthesia without these drugs can be done using narcotics and a propofol infusion, a common combination used in many plastic surgery procedures.
But given your family history, it is also understandable that no matter how a general anesthetic is done you would never feel completely comfortable. Therefore, having a breast augmentation under local anesthesia is possible. (with some oral sedation drugs beforehand) The key to this approach is to place the implant above the muscle (subglandular) and infiltrate the breast first with a tumescent solution for local anesthesia. (much like what is done for liposuction surgery)
Dr. Barry Eppley
Indianapolis Indiana
Our skin is the largest body organ that we have and has more medications and treatments per surface area than any body part. The skin care world is chocked full of thousands of products that claim to either protect it or make it look younger. The sheer cacophany of skin care products clamoring for our attention leaves most women (and a few men) completely confused about what to use.
One newer type of skin care technology is that of antioxidants. Besides the obvious psychological appeal of not wanting to be ‘oxidized’, products containing antioxidant ingredients are popping up everywhere. While the scientific benefits of antioxidants and how they work are better reserved for a classroom or as a replacement for melatonin before retiring, it strikes me that we are seeing what’s old becoming new again…through the wonders of modern chemistry.
Antioxidants in skin care is actually a bit nostalgic and reminds us that our great grandmothers had the right concept all along. Most of today’s antioxidant skin care potions derive their properties from the naturally available fruits, vegetables, and whole grains that were once the main ingredients of age-old facials and historic healing compounds. They may not have known why it worked, and may not have had the right proportions of ingredients, but their organic approach was rooted in science after all.The fruit acid facials of today (also known as alpha hydroxy acids, or AHAs) derive their ingredients from extracts of grapefruit (procyanidin), lemon (vitamin C) or apple cores (vitamin C and phenols), are actually quite old. I have had more than one older patient who has told me they used to rub lemon juice or the cut edge of an orange on their face to reduce wrinkles or on their scars to make them look better. The ancient use of green tea facials (and you thought it was only for drinking) has been found to contain catechin which has potent antioxidant properties.
Old vegetable masks contained tomatoes, which are rich in lycopenes and carotenoids, to help control oily skin and reduce wrinkles. Oatmeal powder and other grains contain ferulic acid which has an antioxidant effect…not to mention the skin calming benefits of the well known oatmeal bath. Curd contains lactic acid which is a chemical peel. Cucumber and pumpkin have high levels of the potent antioxidant vitamin C. (the benefits of reducing eye puffiness from sliced cucumbers is not because they have a magic ingredient, it is that they are cold…a cool washcloth works just as well) Honey and egg yolk have been used in facials dating back to ancient Egypt. Honey contains flavinoids and vitamin C while egg yolks have the antioxidant carotenoid in them.
Before we wax romantically and start rubbing lemons and green teas leaves on our face, it is important to realize that science has several advantages over nature. Through purified and concentrated extracts from these natural sources and using technologically advanced delivery systems, what does come out of that expensive bottle is easier to use and does work better.
Indianapolis, Indiana
Q: I am currently faced with several problems. My face looks wide because I have prominent cheekbones. I have deep set eyes because of very prominent and bulgy orbital rims. It’s not so much the width of my face that bothers me but it brings everything out of place. Because of the small eyes and the rest of my face is pretty crowded together. When looked from the side, the orbital rim covers nearly everything of my eye while other people still have a part of the eye visible. My cheekbones are bulgy both in the front and the side. Is there any procedure to help me?
A: What you are referring to is prominent orbital rims which make up 3/4s of the orbital ‘box’ that encases the eye. When this outer circle of bone is prominent, it makes the eye seem deep or hidden. It is possible to reshape the orbital rims, particularly the brow bone (upper orbital rim) and the side. (lateral orbital rim) It is not so much whether it can be done but whether the trade-off for doing so is worth it. To surgically access this area, a scalp or coronal incision is needed. This allows the skin to be lifted to get to the area for reshaping. For many women this is not a rate-limiting consideration. But for many men it understandably is.
The width of the cheek bone can be narrowed by a vertical wedge bone removal right below the eye bone which is done from inside the mouth.
Indianapolis Indiana
Q: I have an extremely deep acne scar on my cheek from cystic acne that has tunneled under the skin. Subsequent healing has resulted in some type of contracture and folding of the skin so that an indentation extends under the skin itself. The indentation extends for about 15 millimeters and seems to follow the track of a hair follicle. The opening is broad, about 9 millimeters and regular. I would happily trade this scar for an excision scar. Can you tell me if this can be done and is it a good idea?
A: Acne scarring can be quite severe and deep. This is particularly true on the cheek area which shows such scarring prominently due to the tighter skin stretched across the bone. I have seen this exact cheek acne scar situation that you have described several times before. What it really represents is the loss of subcutaneous fat underneath the skin due to the infection with the skin edges healing inward. You have described it quite accurately as a scar contracture.
As a result, the problem with this type of cheek scar is that it is not only indented but is missing tissue underneath. So while cutting it out is an important step (scar excision), replacement of deeper fat at the same time is also important. If not replaced, there is a chance of the wound edges pulling downward as it heals to a space with less fill underneath. For this reason, I would do a scar revision with the simultaneous placement of a fat graft underneath the skin edge closure. This would be particularly important in the tight skin that overlies the cheek.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am looking to have what I think is called a Mommy Makeover. I have it on TV shows and read about it on the internet. For the breast implants, I am looking to have saline implants done. I would like them placed behind the muscle if possible. I am not sure what my ‘true’ cup size is. I know it is between an A and B. I would like to be a full C to a small D. I do need a slight lift but I am concerned about scarring. I would like the incisions to be as discreet as possible. As for the tummy tuck, I think I only need a mini-tuck. I have a little bit of fat in my lower stomach that stays and I cannot get rid of it. I also have a little bit of stretched skin that needs to be removed. I am looking to have the problem fat suctioned out and the muscles to be sutured back together and the little bit of stretched out belly skin removed. After looking at pictures and watching animated videos on tummy tuck; I realize that my tummy problem is quite small compared to majority of the pictures I have viewed. I am a small frame as it is. I am about 5’2” and weight about 115 pounds.
The issues I have may not seem like anything to someone else; but they are BIG to me. I look at myself each day and do not see a young beautiful woman. I wonder each day how in the world is my husband still attracted to me. I am wanting to do this for my self. I would love to love myself again! Does this sound like it can be all done in a single operation?
A: Mommy makeovers are typically a combination of breast and abdominal reshaping. Improving the very problems that being a mommy has created. Saline breast implants can be placed from a remote incision high up in the armpit that will never be seen. The most limited incision breast lift is that of the superior crescent mastopexy, also known as a nipple lift. It puts a fine line scar at the top of the nipple only right at the junction of the areola and skin. Given your body frame size, you are describing perfectly what a limited or mini-tummy tuck accomplishes.
Both breast augmentation with a lift and a mini-tummy tuck can be done in a single outpatient procedures. The combination of the two truly makes for a new body for Mommy!
Dr. Barry Eppley
Indianapolis Indiana
Q: I need a chin augmentation because my chin is definitely short. I know there are two ways to do it, either with an implant or an osteotomy. I would ultimately prefer the implant over an osteotomy. Is it possible to get some vertical lengthening with an implant, maybe in the range of 2 or 3 mms? Is it possible to get an implant without making the labiomental indentation deeper?
A: When significant vertical lengthening of the chin is needed, an osteotomy is really needed. But when the vertical height increase needed is small, a chin implant can achieve that dimensional change. It is necessary to place the implant as low as possible on the chin bone, almost as if it was on the edge of the bone. To maintain that position, I prefer to place a single metal screw into the bone to secure it. That way there is no risk that it can move upward even a single millimeter.
The labiomental sulcus or groove is located below the lip and really represents the location of the mandibular vestibule inside the mouth where the mentalis muscle attaches to the bone. Because of its superior fixed location, it will usually become a little deeper after chin implant augmentation. This is because it doesn’t change but the soft tissue of the chin moves forward, making it look a little deeper. When the amount of chin advancement is significant (8 to 10mms), the labiomental fold will get deeper in most patients. That effect will be lessened when the implant is placed on the lower end of the chin bone with vertical lengthening as the push underneath the labiomenal fold is less due to the lower position of the implant.
Dr. Barry Eppley
Indianapolis Indiana
Q: I came across your website, while doing research on cosmetic surgery. I currently have depression. After three pregnancies, I feel like my body is mangled. I know that my self-image is what brings on most of my depression. I know that depression alone is not a reason to have surgery. I have been treated for depression for about three years now. I have thought about cosmetic surgery just as long. After the pregnancies and losing weight, gaining weight, and losing weight, my belly definitely needs a tuck. I breastfed all of my children. I breastfed only for about 2 months with the first child but about a year with the last child. With breastfeeding and losing weight; I barely have any breasts at all.
I am only 28 years old. I want to feel young and beautiful again! I know I deserve to and my husband deserves to have a wife who feels good about herself again. My kids deserve a mother that feels comfortable enough to take them swimming. I would love to be able to eventually wear a bikini.
I know that some people may get depressed after they have surgery; whose to know how I will be after surgery. Seeing that a lot of the causes of my depression are due to the way I feel about myself or view my body. I know surgery could not make my depression worse; if anything it will help improve the way I see myself and think about my body. The only way surgery would worsen my depression is if I had surgery by a surgeon who did a lousy job.
I am not interested in looking fake. I just want to look normal again. I would like to either be a full C or small D regarding my breast.
I suppose a ‘Mommy Makeover’ is what I am really looking for. What are your thoughts?
A: Of your situation and feelings, I understand completely and could not be more emphatic. Pregnancies can definitely take a toll on your body, and between the skin stretching and shrinking and the inevitable breast involution (loss of breast tissue), some women can not even recognize the current skin and body that they now have.
As you have correctly pointed out, surgery is not a cure for depression. But at least it can improve one recognizeable and understandable cause of it…the way one looks. The body problems can definitely be improved and, hopefully with that, one’s self-image elevates. In my experience with women and these type of popular ‘Mommy Makeovers’, patient do report a dramatic improvement in their self-confidence and clothing options.
The classic ‘Mommy Makeover’ is some form of combined abdominal and breast rehaping plastic surgery procedures. This is usually a tummy tuck with or without liposuction and breast implants with or without a lift. In about a four hour surgery (or less), a dramatic body transformation can occur.
Dr. Barry Eppley
Indianapolis Indiana
Q: I have had a beard for years and now I have a job that will not allow facial hair. This has made my insecurities over my chin to resurface. I am especially interested in a chin implant. After review a lot of before and afters you have seemed to me to do the best work. What is the best type of chin implant ti use?
A: Facial hair on men provides uniqueness to one’s facial appearance and is often a fashion statement. Many times, however, facial hair serves as either a distraction or camouflage technique. This is especially true for upper lip and chin concerns in men. A beard or a goutee adds at least 5 to 8mm of pseudoprojection of the chin depending upon how long the hair is allowed to grow.
When it comes to chin implants, there is no one single style or type of material used that is the best. There are over a dozen chin implant styles, which initially seems confusing, but that allows for a chin implant style that goes best with a wide variety of chin concerns and objectives. Chin implants should be looked at as more than just providing horizontal projection. The frontal view of the chin and jawline should also be taken into consideration in term of vertical height and width of the chin area. It is important to go over all chin dimensions with your plastic surgeon so the best chin implant style is chosen for you. When it comes to different materials of chin implants, there are certainly advocates for each type. I personally find the material composition of chin implants largely irrelevant and am more interested in making sure the style and the patients desires match the best.
Dr. Barry Eppley
Indianapolis Indiana
