Your Questions
Your Questions
Q: My problem is that one side of my actual jawline is naturally lower than the other. I had jaw angle implants placed and now it looks worse. The look, now with the implants, is even more asymmetric and unbalanced. The shorter side needed to be lengthened but, with the conventional Porex implant selection, obviously that was not possible. It looks like I will need to pursue the CT scan and customized implant option, yet my concern is not only the price, but also when this will need to be dealt with. I know these types of implants unite with the bone tissue quite strongly and as years go by, it becomes even more difficult to remove them from the face. I know it causes a great deal of trauma and involves a lot of risk on both the part of the patient and surgeon. I would appreciate your thoughts and help.
A: While the custom approach is certainly a possibililty (it adds about $5000 onto the procedure to get the final implants in hand and sterile), I am not certain that may be exactly what you need based on your description.
It sounds like asymmetry was the original issue and that is now exaggerated because of the implants used. Contrary to your perception, there are six different styles of jaw angle implants from Porex some of which are lateral augmentation and others which are inferolateral augmentation types.Choosing a different style of implant for each side may well have made for a better result. When asymmetry exists, it is important to first get a panorex film to look at the height and shape of the jaw angles. Then one can decide if the existing off-the-shelf implants may suffice.
As for secondary surgery on Porex implants, I have not found that it is unduly difficult to remove or that it has ever grown to the bone. Much is talked about that concern, but it is largely overblown in my experience. Yes it is much more ‘difficult’ than removing silicone implants, which by comparison slide right in and out, but it is not impossible or causes significantly more tissue trauma than that of the original implant surgery. All synthetic implants get a scar capsule around them. That capsule with Porex implants is more adherent due to some tissue ingrowth. But they do not unite with the bone or become part of them as an onlay implant.
Dr. Barry Eppley
Indianapolis Indiana
Q: Dear Dr. Eppley, I wonder whether you could give me some advice about forehead recontouring. I have a very prominent brow and two bony protusions on my forehead. I look fine straight on but at 45 degrees I look extremely hollow-cheeked and my eyes look abnormally deep-set. I tried cheek implants about 15 years ago (they have since reabsorbed) but of course these only made my eyes look even deeper-set. I also have a very strong chin and nose but can’t reduce these either because they go some way to balancing out my brow line. Would you be able to provide me with some idea as to my suitability for surgery? Thank you very much.
A: Occupying the upper one third of one’s face, the shape and size of the forehead can impact significantly one’s facial balance and appearance. Your description illustrates that quite clearly. The brow bone area, known medically as the supraorbital rims, is a bony prominence like the cheeks and chin in the lower two-thirds of the face that has cosmetic significance. When it is normal (not protruding) one does not give it a second thought. When the brow bones are excessive, however, it can change the look of one’s entire face…and changing other parts of the face will not really ‘hide’ the brow protrusion or its impact on how one’s eye area looks.
While the shape of the forehead and brows is significant, it is not commonly surgically changed. This is not because the possible forehead recontouring procedures are difficult, have high risks, or involve a long recovery, as they do not. It is because it requires an open approach with a scalp incision and a resultant scar in the scalp. For women this is not usually a major stumbling block, but for most men it is. Since many more men have forehead concerns than women, this makes the number of cosmetic forehead contouring procedures that are done fairly small.
Indianapolis Indiana
Q: I recently came across an article written by you regarding jaw angle implants for male patients. I went through this particular surgery and I am saddened to say I am not exactly happy with the results. It is a tough situation to be in, but now I realize I should have pursued a CT scan and customized implants, though it was not an option for me or the doctor who treated me at the time. What do you recommend for me now?
A: There are multiple reasons why dissatisfaction can occur after jaw angle implant surgery. The two main reasons are implant size and implant style. Like any implants placed anywhere in the body, they can end up being too big or too small. But that is not the impression that I am getting about your dissatisfaction. Implant style, or how the implant actually changes the shape of the jaw angle, is actually the most common problem. One type of jaw angle implant merely makes the existing jaw angle wider, known as lateral angle augmentation. Most men interested in improving their jaw angle definition, however, don’t suffer from an exclusive width problem. They are interested in a wider and more defined angle which means extending the angle lower as well. That is a different jaw angle implant style, known as inferolateral angle augmentation, and is more difficult to surgically place. Getting lateral jaw angle augmentation when you really need or want inferolateral jaw angle augmentation will only make your jaw look puffy and wide and not get that more sharply defined angle that many men are seeking.
The other jaw implant problem is when one really needs vertical lengthening of the entire lower jaw line but they end up getting lateral jaw angle implants. Vertical jaw implants are ideally made on custom basis for each patient off of a 3-D model from a CT scan. But a combination of an inferolateral jaw angle implant combined with a prejowl chin implant may suffice in some cases. Since you mentioned a CT scan and custom implants, this may be the problem to which you refer.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am interested in having a dimple put into my chin. I do modeling and I feel it would add more definition to my face. What do you think? Will it be easy to tell I have had it done? How long does it take to heal? Will I need bandages on it?
I have attached a few images of myself to show you what I look like. I have also added a picture of a gorgeous girl I know who has a dimple that I really like. Will it look anything like hers?
A: Creating some form of a concavity in the chin, whether it be a dimple or a cleft, is about providing some character and uniqueness to a facial feature. I don’t think it necessarily creates more definition to the face but it provides a highlight feature that many people find attractive. In creating this chin feature it is important to differentiate between a chin dimple and a chin cleft. They look different and are surgically created with different nuances of the same basic procedure. You have stated your interest in a chin dimple which is a rounded indentation in the middle portion of the soft tissue chin pad. The picture of the model whose chin you like, however, appears more like a chin cleft which is more a vertical indentation from the middle of the soft tissue chin pad down to the edge of the bone. Both can be created, it is just important to know exactly what you want.
Whether it is a chin dimple or a chin cleft, the operation is done from the inside of the mouth. It is a very simple procedure from the perspective of what it is like to go through and recover. It is usually done under local anesthesia or IV sedation. There are no external bandages after surgery. The sutures inside the mouth are dissolveable so their removal is not necessary. There are no restrictions after surgery in terms of eating or activities. There is some chin swelling but no bruising. The chin dimple or cleft can be seen immediately after and it may initially be a little more indented or clefted that it will be when the swelling goes down. It will take about two to three weeks until the chin feels completely normal again.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I recently had a buccal fat extraction procedure 6 weeks ago. I had minimal discomfort and recovered quickly. I am concerned now, however, about the symmetry in the final result. I initially thought that the swelling on one side may go down more quickly than the other and I wanted to give it time to see if it was indeed the swelling or not. I did have slightly more removed out of one side than than the other because when I smiled it seemed to be bigger. I didn’t consider that it may it could end up being more sculpted on that side at rest (not smiling) than the other. At this point the one side is definitely “chubbier” than the other. So, I am wondering if think that it may even out a bit more if I wait longer?
A: A buccal lipectomy, or buccal fat extraction, is a simple procedure. But despite its ease of doing it, the final result does take some time to see. Because swelling goes away fairly quickly, within a few weeks, most patients understandably think that will be the final result. But the second phase of healing from this procedure is the contracture or scarring down of the space where the buccal fat was removed. This takes much longer, at least 3 to 4 months, before one can appreciate the fine details of the ultimate result. Whether your submalar areas will eventually even out and stay asymmetric can not be predicted. But I can say that it is too early to make a final judgment. Time is your friend at this point.
Indianapolis Indiana
Q: I have developed a half grape-sized keloid from a piercing behind my ear. It has completely crippled my self esteem to the point where I have become reclusive. I can’t live like this anymore, so I was wondering if you could tell me how I could best get rid of it and what it would cost to do so. I lost my job, and my family might be willing to pay for it if I can gather information. You seem to be the leading plastic surgeon in the area, so I hope to hear back from you soon. Thank you for your time.
A: Keloids of the earlobe are particularly difficult scar revision problems. This is so for two diametric reasons. When removing keloid scars it is critical to get it out completely, not leaving even a miniscule amount of keloid behind. If one does, it will surely come back. The earlobe, however, is a small piece of ear real estate and wide excision of the earlobe can make it nearly disappear or at least distort it when putting it back together. This is balancing act that can make for a difficult decision if the earlobe keloid is of any appreciable size.
The other concept to grasp about its removal is the high propensity for keloids to recur. This recurrent rate can be reduced if all of the keloid is removed and someone is not genetically prone to them. (in other words, not have developed them in other areas of the body) Yours is a primary keloid problem and was caused by an inciting event. (ear piercing) These may be favorable for a lower risk of recurrence but the risk remains nonetheless.
Because the plastic surgery techniques for ear keloid removal can be different, it would be important to see the keloid problem before you could get a cost estimate.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am a transgender person with HIV. I am healthy and on medication. I am really having a hard time finding a cosmetic surgeon that is willing to do surgery on me, perhaps because they feel uncomfortable about my HIV or are unsure if I am more prone to infection afterwards. I have read that you have performed plastic surgery uneventfully with people who have HIV. I hope you can help me with my questions:
1. Any advice with the anesthesia ( I read a few stories that it could interfere with medication and that could lead to coma). I am on a medication called Atripla.
2. What is the best CD4 count I would be reasonable to continue with surgery?
3. Any suggestions with antibiotics and anti inflammatory medication to avoid infection and promote good healing?
Dr, your advice and help would be much more appreciated. I hope to hear from you very soon.
A: There is a growing body of evidence that HIV patients are not at increased risk for infection or wound healing problems from surgery in general and plastic surgery in particular. Recent published studies in plastic surgery dispel this myth, provided that the patient has good CD4 counts and is not an immunosuppressive medication. One study has shown that there may be an increased risk when plastic surgery is done through the mouth as opposed to the skin. But it can also be said that such may apply to the general population as well. In my Indianapolis plastic surgery experience, I have not seen any increased problems operating on HIV patients for either cosmetic or reconstructive plastic surgery. To answer your specific questions:
1) Atripla is a multiclass retroviral drug commonly used in the treatment of HIV. It has no known adverse effects on wound healing which is the most important consideration in surgical outcome. From an anesthesia standpoint, there is a drug interaction with Versed, a common drug in the anesthesiologist’s pharmaceutical cornucopia. This drug is mainly used to treat anxiety immediately before surgery done on an intravenous basis. It is not absolutely necessary to use it for general anesthesia as other drug options exist.
2) Patients with CD4 counts greater than 200 and low viral loads have surgical risks that are similar to the general population. There is no evidence to support the historic contention that they have poor or compromised wound healing. Increased surgical risks are in those patients whose CD4 counts are less than 200 or have viral loads greater than 10,000.
3) The usual use of antibiotics and pain medications, as is usually done on any other patient, is all that is needed. No extra dosing of antibiotics or prolonged duration of antibiotic use has any proven benefit on reduced infection risk.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am a 30 year old African-American female. I have had three breast augmentations and the scar from the first augmentation was too high leaving me with visible scars. My last augmentation left me with even longer and more hypertrophic scars. I have tried laser in the past and I am considering deep resurfacing and then using the ACell micronized particles (Matristem powder) as this may help smooth the skin out. What do you think? The alternative will be to open the scars and redo them but that would not help as I have done 3 boob jobs and still scarred. I would like to give the laser a go and use the particles as I believe that if it can heal a finger without scars it should at least prevent the skin fromover healing and it will heal to a more even tone. Please email me your thoughts.
A: Hypertrophic scars from breast augmentation, even in an African-American female, is not common. But when it does occur, as yours obviously has, it can be a real problem to improve. Searching for another solution than what you tried (scar excision and re-closure) is understandable.
Matristem collagen particles, derived from porcine bladder, is a new wound healing agent that is certainly touted as having regenerative properties. But do not confuse how a fingertip will heal with that of hypertrophic breast scars. Those are two completely different types of wounds and they do not translate in terms of results. Lasering your scars is probably the worst thing that you could do. It would result not only in loss of skin pigment but creates a secondary healing event that is more prone to scar hypertrophy than your prior scar excisions. I doubt that the ‘magic’ of Matristem particles will overcome your body’s robust healing response in that setting.
I would be more enthused about re-doing your scar revision using Matristem particles placed into and between the wound edges at closure. They are then better placed to exert their beneficial effects at the site of where the active wound healing process is occurring.
Dr. Barry Eppley
Indianapolis Indiana
Q: I have a few questions on creating the male model look which I have read about in a number of forums. This will involve a number of procedures including cheek, chin, and jaw implants, facial liposuction, rhinoplasty, lipadvancement, and possibly a forehead and brow augmentation. First, is it recommended to have all these procedures performed at the same time? Second, is there a discount on the per procedure cost for having multiple procedures performed at the same time?
A: The male model look is about having a well defined or well chiseled look to the face. This specifically relates to facial features where the bony highlights of the face are prominent and ‘strong’. What it would take for any man’s face to achieve that look, or whether it is even possible, depends a lot on the anatomy and look of their face to start with. No everyone is going to need all the procedures that you have described. Some may just benefit from just a few of them in facial areas where they are deficient. Others may require a more complete number of available facial contouring procedures to get a better result. Each man’s face must be assessed on its own merits and must have a custom treatment plan. Some may just require a rhinoplasty and chin implant, others may require those as well as cheek and jaw angle implants and buccal fat extraction.
That being said, in the spirit of getting the best change possible, whatever procedures are deemed best should be done at the same time if possible. That is not only more efficient from a facial change and recovery standpoint but is more economically efficient as well. The main reason to ever stage such facial procedures is because of the cost or if one is uncertain as to whether a procedure(s) may be beneficial.
Dr. Barry Eppley
Indianapolis Indiana
Turkey and Thanksgiving go together like no other holiday and food combination. While there is no evidence that it was ever actually served at the first pilgrim’s festival, it became a mainstay shortly thereafter. While many will anxiously await for their share of the turkey this holiday, whether it is a leg, breast or stuffing, no one aspires for the turkey neck.
This fleshy fold of hanging skin, known as the neck wattle in the bird, appears in people as well. While in turkeys it occurs mainly in the male, in humans the turkey neck is not gender specific. As we age, the appearance of one’s neck often becomes a bothersome issue. The loss of a once smooth jaw line and a shapely neck shows the effects of gravity and time. Catching one’s profile in a picture can sometimes be disturbing…who is that older person with such a floppy neck?
While creams and other potions do much to alleviate’s one’s pocketbook, the turkeyneck is otherwise a surgical problem. Forget about non-invasive options or ‘lunchtime’ type procedures. These simply will not work for the dangling neck no matter how they are marketed or hopeful one is. For the full neck with good skin, and if one is young enough, good results can be had with liposuction alone. But when the skin is loose and floppy, fat removal alone with only make the neck skin more loose and floppy.
If you can grab a wad of neck skin and fat between your fingers, then some form of a facelift procedure is what is needed. Using the term facelift can be confusing as this procedure often conjures up images of extensive surgery from the forehead down to the neck. In reality, a facelift is really a neck and jowl operation and does not affect the face above the jaw line. It is a poorly named procedure and the term necklift would more accurately describe it than calling it a facelift. It is really less extensive and easier to go through than most people actually think.
When it comes to facelifts (aka necklifts), there are numerous options.Which one is best for any particular person is determined by how much loose neck skin one has. Some jowling and a little loose neck skin may only need a limited facelift. (often called the Lifestyle Lift) If there is a lot of loose neck skin, then the more complete facelift is really needed. This is a powerful neck changer and can produce some really dramatic results. For those that want the least invasive amount of surgery but with a dramatic change, the turkeyneck can be directly cut out in a procedure appropriately called the direct necklift.
The turkeyneck is not a desired culinary item on the bird and many people don’t like it on themselves either. While year round turtlenecks are always an option, a little skillful carving may be a better solution.
Dr. Barry Eppley
Indianapolis, Indiana
The association of turkey and theThanksgiving holiday goes back for over three hundred years. While there is no real evidence that it was ever served at the first pilgrim’s festival, it became a mainstay shortly thereafter. While many people will anxiously await for their share of the turkey this holiday, albeit a leg, breast or otherwise, nobody aspires to have a turkey neck.
This well recognized fleshy fold of hanging skin, known as a wattle in the bird, appears in people as well. While in turkeys it occurs mainly in the male, in humans the turkey neck is not gender specific. For some, the neck is often one of the biggest areas of concern as one ages. The loss of the once smooth jaw line and a more well-defined neck angle are telltale signs of the effects of gravity and time. The turkey neck is just an advanced stage of neck aging as it eventually flops from side to side in the older patient.
While year round turtlenecks are an option, it is otherwise a surgical problem. Forget about non-invasive options or ‘lunchtime’ type procedures. These simply will not work for the turkey neck no matter how they are marketed. If the neck and jowls are made up mainly of fat with good skin, as usually occurs in the younger patient, then good results can be had with liposuction alone. But when the skin is loose and floppy, fat removal alone with only make the neck skin more loose and floppy
If you can grab a wad of neck skin between your fingers, then some form of a facelift procedure is what is needed. Using the term facelift can be confusing as this procedure often conjures up images of extensive facial surgery throughout the whole face. In reality, a facelift only effects the neck and jowl area and will do nothing for the face above the jaw line. It is a poorly named procedure and a facelift should be called a neck-jowl lift. It is really less extensive and easier to go through than most people actually think.
In actuality, there are only two types of facelifts… limited and full. Which one is best for any particular6 person is determined by the amount of loose neck skin that one has. If the loose neck skin is not extensive, a limited facelift may be enough as this lifts the loose jowl skin a lot and the loose neck skin a little. If there is a lot of loose neck skin, then a full facelift is really needed. This is the most powerful neck procedure and can produce some really dramatic results. The differences between the two are how much of an incision is needed around the ear and the number of days of recovery needed. (even though the recovery is really about how you look or a social issue, there is next to pain at all for either)
Dr. Barry Eppley
Indianapolis, Indiana
Q: I would like to ask if you do use fillers for augmentation in the temple zone, where I have sufffered fat loss. If it is possible, what filers would you use? I look forward to hearing from you.
A: Temporal hollowing is a result of fat loss which occurs for a variety of reasons. Some people have it at birth, some develop it with aging, and others develop it from certain medications and surgical procedures. Either way, it is a deflation of the temporal muscle as the fat is lost underneath and around it. While synthetic injectable fillers can be used to fill it, it is not my first preference. This is because it takes a lot of filler to augment the area and, given that they are not permanent, is not a good value in the long run.
My choices would be either injectable fat, a synthetic implant, or a dermal graft implant. Any of these are surgically placed beneath the deep temporal fascia on top of or underneath the muscle. I have used them all and find that for most cosmetic augmentations (not caused by a craniotomy or temporal muscle detachment) the use of a subfascial dermal graft woks well. It is simple to do, is a natural collagen material that is soft and flexible, and appears to have good long-term retention. Some would argue that fat injections are best, and I do like them, but their volume retention is not as assured. Through a very small vertical temporal incision, sheets of dermal graft can be placed which fill out the hollowing very nicely.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I want to investigate the use of botox to help with my jaw clenching and teeth grinding. I currently wear an appliance to help protect my teeth, but still clench and have jaw pain.
A: Clenching and the sequelae from it, pain and excessive tooth wear, is the result of overactive masseter muscles. (and sometimes the temporalis muscle as well) No one knows why this muscle hyperactivity occurs although it is blamed on personality types and stress. The exact reason why, however, is unknown. The traditional treatment of clenching uses non-muscular therapies such as dental appliances and anti-inflammatory or anti-spasm drugs. The purpose of a dental appliance (i.e., splint or mouthguard) is primarily to protect the teeth from excessive wear. It does an excellent job of that and there is no better substitute. The other objective of some dental appliances is to break the cycle of muscle spasm through jaw opening (increasing the interdental space and stretching the muscle out) and changing how one’s teeth interdigitate. (bite or occlusion) Their effectiveness in this regard is quite variable. Great claims are made by some as to how beneficial they are. But, in the end, they will work well for some and not for others.
Botox takes a different strategy to the muscle problem in clenching. By directly injecting the muscle into the most spastic and painful areas, these zones of paralysis or muscle weakening that Botox causes can very effectively reduce the muscle spasm and pain. For some patients, it can be a near miracle. For others the relief is still significant. I have yet to see any clenching patient who does not get noticeable relief. Sometimes additional or supplemental injections are needed to get the right dose of Botox after the initial treatment. The relief will last as long as the Botox works, for 3 to 4 months.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have one ear that sticks out further than the other. I think the good ear, the one that doesn’t stick out as far as the other, looks pretty good and may be normal. But my bad ear on the other side is definitely different. The bottom part where the earlobe is ok, it is the upper part of the ear that sticks out. My question is…can you just fix only one ear? And can you just fix a part of one ear only? Thanks and look forward to hearing back from you.
A: Otoplasty, or ear reshaping surgery, can be done on just one ear or just a part of one ear. In fact, in my Indianapolis plastic surgery practice, about half of the otoplasties I do are on just one ear or some part of it. Otoplasty, like rhinoplasty or nose reshaping, is not an all or none procedure. The ear is composed of a number of different cartilage convolutions and indentations which can be selectively shaped.
Cartilage shaping in otoplasty is done through either suture shaping or bending combined with weakening the cartilage at specific points through cartilage cuts or actual cartilage removal. It does take a bit of artistic sense and experience to know how to cut and suture the ear cartilages to get just the right shape.
While otoplasties on both ears is usually done under general anesthesia, single ear otoplasties can often be done under local anesthesia in the office in adults. This is particularly true if the only a simple stitch or two for cartilage bending needs to be done to get the right shape.
Dr. Barry Eppley
Indianapolis Indiana
Q: Who is the best Indianapolis plastic surgeon?
A: This is not an uncommon question as there seems to be many purported ‘bests’ of about anything. However, there is no such thing as Indianapolis’ Best Plastic Surgeon. While magazine and websites may create these ratings, and doctors may so anoit themselves as such, there is no real rating method to make this determination. There is not one single plastic surgeon in Indianapolis who is the best….many are quite good…..but not one that is the best at everything…and maybe not even the best at even one single procedure. I can tell you that there are many fine plastic surgeons in Indianapolis who do excellent work. It is your task to find the plastic surgeon that is the best suited for you and your concerns!
But let me give you a few pointers to help you find your Best Indianapolis Plastic Surgeon.
One of the first questions that patients should ask is about board-certification. Despite knowing to ask this question, most patients have no idea what it means or what to do with the answer. If the answer is no, keep moving on to another doctor. But if the answer is yes, don’t just stop there. That answer needs some qualifying…are they board- certified in plastic surgery. And you don’t even have to ask that question to the doctor directly…. go to their practice website and get that answer. But it may be misleading and here are some signs that it might be. Stating that one is board-certified, but not specifically saying in what specialty. Being board-certified in Dermatology or Family Practice, for example, is obviously not the same as being board-certified in Plastic Surgery. A weekend course or seminar does confer the same experience and skill set as years of actual training. Stating that one is board-certified in Cosmetic Surgery. This is the one that is the most misleading because it conveys equivalency. Being board-certified in cosmetic surgery is not the same as being board-certified in Plastic Surgery. Plastic Surgery is one of the 22 recognized medical specialties by the American Board of Medical Specialties and has been training plastic surgeons through organized medicine and its own recognized board (American Board of Plastic Surgery) since 1937. The American Board of Cosmetic Surgery is not a recognized specialty by the American Board of Medical Specialities. Rather it is a more recent invention created by physicians and dentists from many other medical and dental specialties to provide a forum for education as well as a method to bestow some level of qualification. It is not a certificate that indicates that a residency training program was done by the individual in plastic surgery. Most doctors certified by the Cosmetic Surgery Board have their residencies in other disciplines such as Ob-Gyn, Dermatology, and Oral Surgery. This statement is not to imply that board-certified Cosmetic Surgeons perform less quality work than that of board-certified Plastic Surgeons…just that their training is substantially different. One does not equal the other.
The American Board of Plastic Surgery is the most prestigous distinction that any plastic surgeon can achieve in the world. To be certified, one has to complete a two to three year residency training program in plastic surgery after completing prerequisite training in another surgical discipline, most commonly general surgery. After training is completed, a combination of written and oral examinations are required to attain the status of board-certification in plastic surgery. Every ten years one must re-certify by taking a repeat examination, assuring that one has maintained an adequate knowledge base in the areas of plastic surgery that one primarily practices.
It is easy to find out if your doctor is board-certified in plastic surgery. Simply go to the website of the American Board of Plastic Surgery and see if you doctor is listed as a member.
Once beyond assessing qualifications, education and board-certification, only an actual consultation can provide the following important insights. The consultation is really about finding out if the surgeon you are seeing is right for you. It is as much about a personality match and an emotional connection than anything else. Yes, getting good and accurate information is important. Hopefully, every plastic surgery consultation provides that transference of information. But the feel of the consult will tell you about your level of comfort and connectivity with the plastic surgeon. Ask yourself these questions afterwards. Did the consultation feel like an educational experience or a sales presentation? Where treatment options presented and reviewed…or was only one treatment approach offered? Did you understand why the surgery proposed was right for you? Was time given to answer all your questions….and a way to answer questions that may arise after? Did the plastic surgeon provide you with a way to see before and after photographs, either during the consult or a referral to a website? Do they have a website where more than one before and after photo set of the procedure is shown? Was talking to actual patients whom have had the procedures offered as an option? Were these patients who have had surgery in the past three months? (recent experiences are better than someone from a long time ago) Finally, once home, did the plastic surgeon and his office feel right? Did the consultation make you feel more comfortable and secure in your decision?
In the end, The Best Indianapolis Plastic Surgeon is the one that has the training, education and experience to effectively treat your problem…and the one right demeanor and personality that makes you feel comfortable.
Good luck on your search for…..Your Best Indianapolis Plastic Surgeon!
Dr. Barry Eppley
Indianapolis, Indiana
Q: Just had a question about the pubic lift…Can I still have children after the surgery is done or is it something that needs to be done after having children? Thank you so much for your time.
A: The pubic lift is a modified form of a tummy tuck or abdominoplasty. It is very much like the reverse of a mini-tummy tuck or an upside down mini-tummy tuck. During the procedure, the suprapubic area is first thinned out or reduced by liposuction since there is usually a lot of fat within it. (which is one reason it is so puffy) Then skin is removed and the pubic area is lifted up to a predetermined line. The combination of the two creates the pubic lift.
Pubic lifts are often done concurrently at the time of an abdominal panniculectomy or a large tummy tuck as large pubic mounds are usually present in patients that need these procediures. More often, however, a pubic lift is done as a secondary procedure after a large tummy tuck or panniculectomy as they are hard to optimally treat at the same time. The pubic lift is then done using the scar line from the first stage tummy tuck or panniculectomy.
There is no problem having children after any pubic procedure, albeit pubic liposuction or a formal pubic lift. Pregnancy, however, will not help the result and from an aesthetic standpoint one could argue that it is best to wait until one has a more stable abdominal area before investing in that effort.
Dr. Barry Eppley
Indianapolis Indiana
Q: Is it possible to reduce the size of my forehead? I do not mean lowering the hairline, because my hairline is already low. My forehead is vertical and almost seems as if I do not even have a forehead to begin with. The shape of my head is very strange. As most people’s head is round or square. My head is like the roof of a house, being pointed at the top making a sort of 60 degree angle. I can feel and hear my head always cracking as if its not stable or solid. I am also not sure it bone can be molded or change shape but I have been able to compress my head through pressure. Very very painful but I was desperate. With a 30 minute span however, it would return back to its original shape. I most know if there is some way to mold my cranium to a rounded shape?
A: First of all, you should now that it is not possible to reshape your skull bone by any form of external pressure, except in newborns where the skull plates are not yet fused. All you are doing by external compression is squeezing the fluid out of your soft tissues overlying the bone. Once released, the fluid returns and your ‘skull’ reverts back to its original shape. I can assure you that your skull is solid and is not ‘cracking’.
It is possible to do some forehead reshaping through an open scalp approach. The bone can be reduced and shaped by about 5 to 6mms, maybe more, in some patients depending upon the thickness of their outer cortical table. This may be enough of a change for some patients to notice a visible difference.
Indianapolis Indiana
Smartphones have undoubtedly taken over our lives. Spend time in any crowd or shopping mall and notice how many people are doing something on their phones at that instant. Whether it be reading e-mail, downloading, playing a game, taking a picture…and yes even talking… so loud that we all must know that their dog is safely at the groomer getting a blowdry…or how insufferable it is to wait a few extra minutes on the tarmac. (pardon me; I digressed for a moment..but I’m sure that you too, are familiar with this phenomenon).
Plastic surgery is no different in being swept up in the smartphone craze. There are now numerous iPhone and Droid apps that are designed to give your body a total makeover. People contemplating some type of surgical metamorphosis can now get to know what their post-procedure look may be thanks to these apps.
One of my favorites is called the iSurgeon Game. It combines a game mode that enables users to try their hand at surgery (sounds pretty accurate, doesn’t it?). People can modify images ranging from lip enhancements, breast augmentations and many other improvements. Users can quickly simulate plastic surgery by easily modifying face and body features on their phone including such operations as rhinoplasty, breast augmentation, brazilian buttlifts and tummy tucks.With clever and unusual names like BodyPlastika, Modiface and FaceTouchUp, morphing a body part is becoming as easy as nuking a frozen dinner. With some of the apps, you can even turn your phone around, take your own photo and email them to the doctor with your questions.
There is a lot to be said for seeing the potential outcomes of cosmetic procedures. This is common practice in plastic surgery during a consultation and is of the greatest value in understanding what changes will occur in one’s own face. The public’s interest in this kind of personal ‘modification’ is great even if one is never going to embark on a surgical journey. While some plastic surgeons may criticize the concept of allowing patients to make changes to their own body parts- which may be wildly unrealistic and usually are- it is certainly a fun ‘test drive’. Having patients simulate what they want creates an informative dialogue in the vein of a picture is worth a thousand words.
While the smartphone and electronic manipulation can make plastic surgery like a fun game, it is largely just that. If only surgery was as simple and predictive as morphing a few thousand pixels around. What one can do on the computer and what can actually be done in the operating room is often quite different and certainly far less precise. Let us never confuse Photoshop plastic surgery with real plastic surgery. While most people would quickly acknowledge that, a few do forget during the recovery process.
In the spirit of continual smartphone distraction, I must run now to answer an inquiry that just came in on my own iphone app, Ask My Cosmetic Surgeon.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dear Dr Eppley I have two deep scars (they are red and has slight dent) )on my legs due to an accident three months ago. I know scar revision can remove the redness, but can it treat the dent too? How long will it take and how much will it cost( just give myself some mental preparation)? Thank you.
A: Contrary to your perception, scar revision can do exactly the opposite of what you think. Scar revision can improve the indentation of the scars by removing the depressed portion and bringing skin in from the sides to make it more level. The redness of scars is not something that traditional scar revision will help. Redness of scars fades mainly a a function of time. As the scar matures, the blood vessels in it recede as the nutrients are no longer needed to heal. That makes the scar redness go away.
The more significant question is the timing of your scar revision…when is a good time to undergo scar revision? That will depend on the appearance and location of your leg scars. Each scar must be assessed on its own qualities. Scars on the legs are particularly difficult to improve due to the tightness of the leg skin and the pressure and stresses to which the leg is exposed. I would have to see pictures of your scars to determine the best approach as well as timing and the costs. Relaxation of the surrounding skin is particularly important. So being only three months after your injury is undoubtably too soon.
Dr. Barry Eppley
Indianapolis Indiana
Q: Hi, I’m interested in getting a buttocks lift with the fat injection procedure. I am currently a student and therefore do not have a lot of money, I’ d like to know if you offer payment plan options and, if so, what would be an approximate monthly payment. Thank you.
A: Fat injections are one of the two options for buttock augmentation. Often referred to as a buttock lift or the Brazilian buttock lift, it ‘lifts’ the buttocks by adding volume and expanding the buttock skin. Probably calling it a lift is a bit of an exaggeration. It is really a buttock augmentation, any lifting is purely coincidental.
As for financing of any cosmetic procedure, there are few if any plastic surgeon’s and their practices that would directly do the financing. Many patient’s ask about whether we finance and it is an understandable question. But plastic surgeon’s are not experts in banking or lending and therefore do not do it directly. It is also not prudent to provide a non-returnable service upfront and then hope to be paid until completion later. For this reason, plastic surgeons use outside financing companies to which they refer their cosmetic patients. There are numerous ones and each plastic surgery practice has one or two that they have had good experience using. In my Indianapolis plastic surgery practice, we have used many over the years and currently use Care Credit. Once patients have the quote for surgery, they can go online and see if they qualify. They have many different financing options which allows patients to choose the length of the loan and their monthly payment.
Dr. Barry Eppley
Indianapolis, Indiana
Q:Hello, I am 58 years old and I had a full hysterectomy in May and then another surgery a few weeks later when all my stitches ripped out and I totally opened up. My son is in Afganistan (fourth time) as well as my daughter in law. I also served in the Navy years ago. Anyway, as I cannot afford the smart lipo on my abdomen (upper and lower) presently, I was wondering how much of a discount the patriot plan saves on this procedure and how long will this promotion go on? Also, does the skin actually tighten up and not sag? This email is just a question about the future possibilities and any information you can give me would be appreciated. I really want to get rid of my stomach and maybe next year I would be able to afford it. Thanks for your time – I appreciate it.
A: Thank you for your inquiry. The general discount in the Patriot program averages around 25% off the full procedure and the program continues without any deadline. What type of procedure is best for your stomach area, however, remains unclear based on your description. My concern is that the description of your problem sounds more like some form of a tummy tuck than that of Smartlipo. If there is any substantial skin excess, then no form of stomach liposuction is the way to go. One of the great misconceptions about Smartlipo is that it is a great skin tightening method. It is not and is highly overpromoted that way. While it does have some skin tightening ability, it will tighten inches of loose abdominal skin which many people that come in for it have. Between a hysterectomy and its after surgery problem, multiple pregnancies and your age, I suspect that the skin issue is beyond what Smartlipo can improve. A tummy tuck in some form is likely more appropriate for your problem.
Feel free to send me a picture of your stomach and I can answer that question very quickly.
Dr. Barry Eppley
Indianapolis Indiana
Q: Hello. Does Dr. Eppley do cosmetic hip implant surgery? I saw this on the website, but I couldn’t find the surgery listed on the drop down menu.
A:I have performed implant procedures all over the body including the rarely done hip implant. It is very infrequently requested (you are only the second inquiry that I have ever had) and I have only performed the procedure one time, on one side, for a traumatic injury problem to get better hip symmetry and provide a ‘ledge’ to hold up their pants better on that side.
Hip implants are almost exclusively done for cosmetic augmentation and, in rare cases as described above, for reconstructive purposes. For those women who feel that their hips are too narrow and want more of an hourglass figure, hip implants can give them more curvature.
Hip augmentation can be done through either an implant placement or fat injections. each has their advantages and disadvantages. Hip implants require an incision to be placed and are a foreign material in a very palpable and prominent area. They are placed down on top of the fascia or aponeurosis covering the iliac crest. They are not placed directly on the bone surface as this requires stripping of attachments off of the crest which is painful. (like an iliac bone graft harvest) Fat injections use your own tissue (which gets a cosmetic benefit also from the harvest site) and are soft with little risk of infection. But their reliability in terms of volume retention is not always assured.
Indianapolis Indiana
Q: I’m a male in my thirties and I would like to have surgery to give my orbital rim and forehead a more masculine (protruding) appearance. I had a craniotomy 3 years ago which has left a dent on my forehead which I would like to eliminate. I understand that solid HA is more porous than the moldeable putty type which would allow tissue growth and ossification. I would like to know answers to the following questions. 1) In order to make my forehead more prominent would it be possible to use 3-D CT scan technology to customize a solid HA implant instead of using moldable HA paste? 2) Could the customized HA implant be made with an interior mesh to make it less brittle? 3) Would a customized HA implant in solid form be easier to work with than HA in paste? 4) Could using a solid HA implant present problems such as fluid accumulation, visible borders, migration or extrusion. I thank you for your time.
A: Thank you for your excellent and thoughtful cranioplasty questions. I can answer of your HA cranioplasty questions by saying that I really don’t use the HA pastes anymore. In their day they were state of the art and they were wonderfully moldeable, but they are brittle. This is no different that HA blocks or HA custom implants which actually are just as brittle and much harder to work with. The newest and more improved cranioplasty material is Kryptonite Bone Cement. It offers easy molding and shaping into the defect, sets up and gets just as hard as bone, and is truly porous (unlike most HAs which are not except the blocks) which allows tissue ingrowth. This is clearly the superior cranioplasty material and eliminates all of your stated concerns and questions.
Therefore, based on these working properties of Kryptonite, HA is no longer used and a 3-D CT scan model is not necessary beforehand since there is no advantage to making a pre-formed implant. (which is now a disadvantage and very costly)
I see no problems at all doing forehead and orbital rim augmentation and any contouring of a forehead indentation with Kryptonite Bone Cement through your existing scalp scar and open approach.
Indianapolis, Indiana
Q: My ears have always stuck out. One definitely sticks out further than the other. Growing up I have been always self-conscious about them and I have never worn my hair in a ponytail as a result of how my ears look. It was awful when I went swimming because with my hair wet my ears stuck out even further. I have finally decided to do something about it with otoplasty surgery. My question is at age 43 am I too old to get a good result? Are the ear cartilages too stiff (too old) at this point to be changed? Also, will changing the shape of my ears affect my hearing?
A: External ear reshaping, known as otoplasty, can be done at any age. While it is true that cartilage does stiffen with age throughout the body due to loss of water content and even calcification, this cartilage ‘aging’ does not affect the ear cartilages very much. I have done otoplasty in patients in their 60s and 70s (rare as they are at this age) without any noticeable change in the ability to reshape the cartilages.
A change in your ear shape will not affect your hearing. Although the ear’s folds and convolutions do serve to concentrate and localize sound waves, pinning back or reshaping the outer aspect of the ears will not produce a noticeable change in your hearing. The inner bowl of the ear (concha) is what does most of the gathering of sound waves and this is not changed significantly in otoplasty surgery.
Dr. Barry Eppley
Indianapolis Indiana
Q: Hi Dr. Eppley I want to get your opinion on what to do with scars after surgery. Specifically, in regards to the use of a taping method. I know there are a lot of creams out there but the use of tape just makes more sense to me. I have read about two different taping materials, silicone sheeting or strips and something called micropore tape. Which one do you think is better?
A: Yours is not the first such question that I have ever heard about the use of different taping methods. Specifically, can micropore tape or any other similar adhesive tape be just as effective as silicone sheets or tapes in helping scars look better? From a proven standpoint, I should say that silicone scar sheets are the only FDA-approved methods for the treatment of scars. This means that enough evidence and documentation has been provided by certain manufacturers that has clinically shown that it works. Silicone has a long clinical history of success in the management of surgery scars The molecular composition of silicone has a parallel position as one of the most inert biological materials known to man. This allows it to have minimal irritation to the skin with long-term use. As silicone also has a semi-occlusive property, it allows for scar hydration which has been shown to be helpful in minimizing undesired collagen production.
Micropore tape is appealing, however, because it is an easy taping that may be less expensive and more convenient. Manufactures of silicone-based tapes would no doubt tell you that there is no proven effectiveness of micropore tape and that it may, in fact, lead to skin reactions because it is too constrictive and does not permit hydration of the skin. The lack of FDA-approval is true but I have yet to have a patient that has developed a skin reaction problem with micropore tape, which is my preferred method of scar taping.
The debate between these two taping methods may continue but doing some form of scar management, if possible, is probably better than no method in many cases. In select cases, it could be beneficial to avoid the need for a later scar revision and is very helpful as a postoperative scar revision topical treatment.
Dr. Barry Eppley
Indianapolis Indiana
Q: Does Dr. Eppley have experience with lip reduction procedures (making lips smaller instead of fuller? How is the surgery done and how successful is it?
A: The number of requests for lip augmentations exceeds the number for lip reductions by about 1000:1. Every request that I have ever had for a lip reduction is almost always in an ethnic patient, most commonly African-Americans although not exclusively so. I usually perform about six or eight cosmetic lip reductions per year, if you are counting lips and not patients. Lip reduction is done by removing a wedge of lip tissue at the junction of what is known as the wet-dry vermilion. This is a very distinct line of demarcation between your dry vermilion (pink part of the lip that is seen on the outside) and where the wet mucosa begins on the inside of your lip. That area is easy to see when you roll your lip outward. The dry vs wet part of the lip is quote obvious. This is where the incision line is placed most of the time. The actual part of the lip that is reduced is the dry vermilion. Usually about 5 to 7mms is removed in the central area of the lip and then it tapers outward towards the corner of the mouth. (commissure) The lip is then rolled back and closed so that the visible part is reduced and the scar remains behind in a more inconspicuous area. The key in lip reduction is not to overdo it or remove too much. There is no way to put back lip tissue. One can always remove more later if quite not enough has been removed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have just read a few artcles from Dr Eppley and I would value his opinion on my scars. I had fractional laser treatment for three scars on my right cheek. Afterwards, unfortunately, I developed an infection as my skin would not heal and there was bleeding underneath. I could not get the area to heal so I ended up contacting a specialist out of the country who diagnosed it s fungal. I was treated with antifungal medications and it healed within a few weeks. While it healed, it developed a lumpy shiny texture. I then underwent intense pulsed light therapy and topical steroids to help the skin recover. This did help. After a while I was recommended to have more fractional laser treatment for further improvement. Despite having good results so far, I thought I could get even better. Unfortunately the settings may have been too strong and things became ten times worse. My right cheek has every imaginable scar and the texture is horrible, just like a burn. I am now having PDL and smoothbeam for one year with very mimimal improvement and I more recently had a PDT treatment which I am not sure if it helped as I am still very red. I seem to have exhausted everything and am now without any hope of looking normal again. Do you have any suggestions.
A: While I have not seen what your cheek looks like, it would be fair to say that the numerous laser and light treatments have ended up making the skin area act more like a scar than normal skin. All of these therapies, laser or light, produce a thermal insult on the skin. And just like burn skin, it will be more sensitive to just about anything you do. Unless…you give the skin area an adequate time to recover without doing anything including topical steroids. An adequate time is at least a year with leaving it alone. While that will understandably seem like an eternity, particularly when it is on your face, it is the best thing to do if ever you are going to do any more therapy that might ultimately be effective. Sometimes patients keep searching for the next light or laser treatment that will be the ‘magic’, when the real magic in some scars is time. I think it time to sit back and let the area fully recover and then re-evaluate.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Do you use screw fixation for your silicone chin implants? I have a silicone chin implant that moved upward off the inferior part of my chin. I am looking to do a revision but I want some type of screw fixation this time.
A: If a chin implant has slide too far upward for optimal chin projection, it was likely placed through an intraoral (inside the mouth) incision. This is a common problem with this approach as the dissection and the pocket created allows the implant to slide up towards the incision after surgery…unless it is secured in a low position on the chin bone by a screw. This problem does not usually arise when the incisional approach is from a skin incision under the chin as the undisturbed mentalis muscle keeps a firm ‘roof’ over the implant.
In any type of chin implant revision, where the problem is shifting from the ideal position, some method of implant fixation is needed. The easiest and most economical approach is to use a single midline screw to the bone. If side-to-side shifting is the problem (rotation), then double screw fixation may be needed.
While screw fixation of chin implants can be very helpful, it is not always needed in a primary or initial surgery. Many chin implants can be secured in the midline with a simple resorbable suture to the periosteum covering of the bone. But implants placed from inside the mouth or those that need to be kept positioned very low on the bone for optimizing vertical height need screw fixation.
Dr. Barry Eppley
Indianapolis Indiana
Q: I went in for a rhinoplasty consultation and, during the course of discussion, the plastic surgeon brought up the idea of combining it with a premaxillary implant. I had never heard of that type of facial implant before. I can understand that it pushes out the base of the nose but I am concerned as to what it may due to my upper lip. Does a premaxillary implant change the appearance of the upper lip in any way?
A: The premaxillary implant is one of the uncommonly used of all the facial implants. The benefit of its use comes when one’s facial profile or midface is a little recessed or retruded. With this facial skeletal pattern, the nasolabial angle is usually too acute (less than 90 degrees) and contributes to a hanging or downturned nasal tip appearance. Bringing out the nasal base can be aesthetically helpful in midfacial hypoplasia whether one is having a rhinoplasty or not. The premaxillary implant builds out the paranasal and the anterior nasal spine area using an implant which spans across the entire lower pyriform aperture region. (nasal base) This will usually result in a very mild vertical lip lengthening although that will not occur in everyone based on their anatomy. At the least, it will cause the upper part of the lip to be more full/protrusive. This will also change the nasolabial angle, the angle between the columella of the nose and the upper lip, which is the primary objective of this type of facial implant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dear Dr.Eppley, I am interested in having surgery to better my breathing through my nose. In my younger days I was hit in the nose several times and suffered much damage which makes it hard to breath through my nose. I have suffered with this for years and would like to do something soon.I do have several questions and would like to be very educated on the procedure. I was wondering how long you have been doing these types of operations and how much they would cost. Also what can I expect after the operation. As of now you can see my nose has caved in on the sides and it is extremely hard to breath through my right nostril. I look forward to hearing from you. Thank you.
A: Injury is a common cause of nasal breathing difficulties. External forces can displace both the nasal bones and the septum, causing obstruction through one’s nasal passages. While septal deviation is the most common sequelae of traumatic injury, changes in the external skeleton through nasal bone fractures and upper and lower cartilage derangements (middle vault collapse) can also be sources of the breathing problem. Such changes are also a source for visible nasal asymmetries and crookedness of the nose. Traumatic nasal injuries almost always require a full septorhinoplasty to get a complete correction. This sounds like what you need by your description. If you could send me some pictures, I can take a look at them and do some computer imaging as well if needed.
Typically, insurance will cover some of the costs of a septorhinoplasty but may not cover everything depending upon what is needed and done. This would have to be initially pre-determined through the insurance company with a letter and photos to get an answer from them in regards to coverage.
Dr. Barry Eppley
Indianapolis, Indiana
