Your Questions

Q: I had cheek implants 3 yrs ago which I am looking at having revised. I am tall and athletic and they are just giving me a bony gaunt look to my face which also makes my eyes appear too far apart. What I really wanted in the beginning were midface implants, but wasn’t able to make this clear with the doctor. They are screwed in and I am wondering if they can simply be reduced or shaven down? Also I have jaw implants and am not happy with the square shape that has resulted from their outcome .

A: Facial implants today come in a wide variety of styles and sizes. They are far more versatile than just augmenting the chin, cheeks or jaw angle in a single way. Frequently, I have patients come to my Indianapolis plastic surgery practice that have existing facial implants but did not end up with the result that they wanted. Communication and computer imaging is key in facial bone augmentation with implants.

Both cheek and jaw angle implants can certainly be modified, exchanged, or simply removed. The question for both areas is what is the best strategy to achieve your goals. From a cheek standpoint, you may have been more interested in submalar implants (on the underside of the cheek bone) rather than malar implants which sit on top. They create different looks. With the objective of improving a gaunt looking face, submalar augmentation is preferred. Malar implants will actually make that appearance worse. In jaw angle implants, the size may be too big or their position on the bone may be too high or too low. The style and shape of the implant can also affect how square or sharp the mandibular angle is.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Hi Dr. Eppley, I am 3 weeks post SMAS facelift and necklift.  I had a friend who had her facelift months before me.  She was very thin and her face looked too tight to me (really pulled along the jaw line).  I have a round face despite losing 50 pounds with very sagging neck and jowls. I read where you wrote that a facelift will not get rid of a round face.  I know know you were right.  My dilemma is that it almost appears that I had nothing done.  My round face is still….round. 

My plastic surgeon says my neck looks like an 18 year olds neck.  I am extremely pleased with that and it is tight as a drum.  I feel like my face is tight and a little lifted only on the sides near the ears.  I still have loose skin around my mouth.  Is this normal? Does the SMAS facelift not address the nasolabial folds?  I am very disappointed after spending 11k.  What should I do now? Should I address this with  my plastic surgeon?  He proclaims a “natural” facelift is one that is not too  tight or pulled.  It may be too natural for me.

A: My first comment is that it is only three weeks from your facelift. When you are living it that seems like an eternity. However, when it comes to facial swelling you still have a ways to go. I would not pass final judgment until three months after your surgery.

That being said, you appear to have a mismatch between expectations and the anatomy of a facelift. You actually have exactly what a facelift can achieve…a nice tight neck and jawline. That is all that an isolated facelift can achieve, no more and no less. It does very little to nothing around the mouth area (nasolabial folds and mouth corners) as they are too far away from the point of pull. (which is around the ears) This is a frequent point of expectation and subsequent disappointment if patients are not properly educated from the beginning. In reality, a facelift is a neck procedure and does little for what most patients believe in their ‘face’.

This also explains why a round face can never be changed from a facelift. The source of the round face is not what is treated by a facelift. The round face is largely a function of the size and thickness of the facial bones, muscles and fat layers.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I have been suffering from angular cheilitis subsequently leading to cutaneous candidiasis and sometimes even a secondary bacterial infection for the past 18 months.  If my face starts to sweat I immediately dry off my face but am mortified when I awake to realize saliva has pooled in the little cracks in the corner of my mouth. Despite my best efforts, I cannot always keep this area dry. 

My dentist told me that it was due to a parafunctional habit and anatomical variation. So I changed the one thing I could control and stopped licking my lips.  However, since then my best efforts barely keep this at bay and last week I had a tiny pimple in that area, the skin broke open, and you know the rest, the lovely normal flora became and opportunistic pathogen eating my face away, looking unsightly, and cracking my skin open if I accidentally open my mouth too far.

People think I am crazy for wanting surgery and I fear the opinion of female family members due to the new age stigma of getting plastic surgery too young.  This is not for vanity unless you count wanting to be kissed vain, and when I have this crap on my face even I do not want to kiss me!  Or look at me for that matter, not to mention how painful and itchy this can be and how long it takes to heal!

I have read that there is a possible surgical treatment for angular cheilitis. What is it and do you think it will be helpful for me. I am just looking for a permanent solution to this nasty mouth problem.

A: Angular cheilitis, also called perleche, is an inflammatory mucositis at the corner of the mouth and usually affects both sides. It presents as deep cracks or splits which may bleed when the mouth is opened widely. Why it occurs is not known precisely. Chronic wetness at the corners is the incipient event and that is most understandable in the elderly edentulous population who experience a loss of vertical dimension due to loss of teeth, thus allowing for over-closure of the mouth. This creates a spillway for saliva and chromic wetness in the mouth corners. Yet I have seen it just as often in younger patient who have a normal angulation of the corner of the mouth.

For those patients that have exhausted all medical treatments for angular cheilitis, surgical treatment is possible. When the corners of the mouth are sufficiently downturned, I have found a corner of the mouth lift to be helpful to change angulation and eliminate that spillway effect. In younger patients with a normal horizontal angulation, a resection of the mouth corner mucosa with mucosal advancement can be done. Sometimes this can include skin as well. The theory here is that the tissues are chronically infected and it is removed. I have seen improvements of the condition with both approaches.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Hello, I just have a few questions about a cosmetic issue that I have been dealing with for really all of my life, but just became totally aware of within the last few years. I have a condition called Plagiocephaly. I’m sure you know what that is, so I won’t go into that. I will say, however, that I have a flat spot on the left side of my head. It has caused my left ear to protrude, and my left brow ridge(the part that the eye brow covers), also protrudes. It is very noticeable, especially to me, but others do notice it too. My question is whether or not I can have a procedure done to either A.) Reconstruct the left side of my head and brow ridge so it looks more symmetrical with the other side of my head, or B.) Just correct one of the two areas. I really would like both done and I would like to know about scarring and what would they look like, and whether they would be covered by my hair or not.

A: The physical changes that you have described are classic for occipital plagiocephaly in children and adults in which the condition was not treated early or was felt not to be severe enough for traditional skull molding therapy. On the same side, one can have a flat spot on the back of the head, a brow protrusion and an ear that sticks out more than the other side.

All three cosmetic problems can be effectively treated through known plastic surgery procedures. These include an injectable occipital cranioplasty using Kryptonite material (limited scar technique), a simple ear setback (otoplasty) , and a burring down of the tail of the eyebrow (brow bone reduction)  using an endoscopic technique. All three can be treated during a single operation or only the most bothersome can be treated alone.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley. Five years ago, I had surgery on the right upper eyelid  to reduce the size of my eye opening.  My right eye used to be larger than the left one.  Some times for a few seconds my right eyelid seems relatively normal but as I blink, it seems like the skin detaches from the muscle and the eyelid goes back to a droopy appearance. Unfortunately, it seems like the scar didn’t heal well or the stitches weren’t placed correctly.  If the inner crease or fold would stay inside it would have a normal look.  I wouldn’t want my right eye to end up larger or deformed compared to the left side again.

A: In looking at your pictures, one can see that with the eye open there is a fold of skin that hangs down onto the lashes of the upper eyelid. However, when the upper eyelid closes completely that fold of skin disappears. That dynamic piece of information is critical in selecting the right blepharoplasty procedure.

Trying to correct this problem by only removing all the extra skin may cause exactly the problem you are trying to avoid. Rather, a very conservative amount of upper eyelid skin should be removed and the dermis then sutured down to the tarsus or levator muscle. This is very similar to the classic ‘double eyelid’ operation done in Asians where they lack an upper eyelid fold. Your problem is conceptually similar.

Because it is only one one eyelid, the procedure can comfortably done under local anesthesia. This would also be helpful in that you would be awake and the dynamic action of the eyelid can be observed as the blepharoplasty repair is being performed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Can you tell me how the Zerona laser is supposed to remove fat. When I think of a laser it seems to be that it is hot and would burn the skin before it ever got to the fat underneath. I am interested in it to help me reduce my lower tummy, back and thighs. I just can’t bring myself to have liposuction as that seems too invasive and painful. I like the idea of not having surgery and not having to recover and less money is good too! but I want to know it is safe and won’t hurt me in anyway.

A: The type of laser that is used in Zerona treatments is not a ‘hot’ laser. It is a low frequency laser which makes it ‘cold’. It passes through the skin without injuring it. It can not cause a burn injury. It has a photochemical effect on the fat cells which makes them temporarily leaky. By being leaky, they ooze out some of their fatty acid content. This leakiness is only very temporary which is why treatments are needed every few days to keep them open for a period of time. Once the free fatty acids are out of the fat cells, they enter what is known as the interstitial space. In this space they are transported to the liver where they are broken down and eliminated. This is the process of fat reduction and elimination.

It is important to remember that Zerona is not a substitute for liposuction and it is a program, not just a machine. Other components of the program include water intake, niacin supplements and exercise. These help the effects of the laser treatments to be more pronounced.

Dr. Barry Eppley
Indianapolis, Indiana

Q : I recently had a rhinoplasty approximately 3 months ago.  The purpose was to make my nose more symmetrical (nose was crooked due to getting hit in the nose 10+ years ago) and smaller/narrower.  I consider the results (as I see the nose today) as somewhat of an improvement, but I believe that better results (potentially much better) are possible.  Furthermore, I am not 100% certain, but I believe that the results were better the day I got the cast off than they are today (could be my imagination though).

A: Thank you for sending your photographs. My first general comment is that the details of a rhinoplasty often don’t become revealed for several months after surgery. While all areas can look great right after the splint is removed, asymmetries may appear in the tip or bridge as the swelling subsides over the next few months. As I tell my patients, we will not have a victory parade until 3 to 6 months later when the final results will be seen.

In looking at the pictures and reading your comments, the issue is that of the asymmetry of the upper part of your nose from the position of the nasal bones. There is an asymmetry of the nasal bones after osteotomies, the right is more infractured (and perhaps more thoroughly osteotomized) than that of the left. The asymmetry is probably a combination of positional issues on both sides, the right nasal bone is in too much and the left nasal bone is out a little far.

Correction could consist of further infracture of the left nasal bone and onlay augmentation of the right nasal bone. Outfracture of a nasal bone is unpredictable in stability.Ideally, cartilage is the best onlay material but an adequate piece in size may not be obtainable from the septum. (based on your previous surgery) An alternative onlay option is a thick piece of allogeneic dermal graft.( available in 2 and 3mms thickness) 

Since it has been three months, I suspect that what you see now is the way it will be. A revisional rhinoplasty could be done in the next few months, about six months after your initial surgery. 

Dr. Barry Eppley

Indianapolis, Indiana

The desire to eliminate excess fat is both universal and historic. The sheer number of diet books, meal programs, and fat burning medications and supplements are a testament to what the majority of the American population would like to do. If one of these approaches was universally effective, there would not need to be so many treatment choices.

Liposuction is a proven surgical method to reduce spot areas of fat and trim down specific body areas, but it is surgery and involves expense and recovery. Lipodissolve injections are a non-surgical method of spot fat reduction but it is a slow and somewhat uncomfortable process that really works for the smallest areas of fat.

Along now comes ZERONA. Imagine a painless body slimming method that is medically proven to remove fat and inches without surgery with zero pain and downtime.  Seem too good to be true? As a weight loss method…yes. As an effective body slimming method that can shrink your tummy, hips and thighs without surgery…no.

ZERONA is uniquely different from liposuction and other body slimming methods. How does it work? Using a low frequency ‘cold’ laser that uses the 635nm wavelength, the energy passes through the skin without injury and penetrates up to 5 centimeters.  The laser energy causes the fat to emulsify through a photochemical process. Not to be confused with a photothermal (heat) or photoacoustic (vibration) method, this non-heat generating process makes the fat cells ‘leaky’. The fat cells shed their liquid fat content, now known as free-fatty acids,  which is subsequently absorbed through your lymphatic system. The lymphatic system transports it to the liver where it is processed and broken down, and most importantly, not re-circulated and stored again as fat.

ZERONA is more than just a machine, it is a process. Through a typical series of 9 treatments, up to 5  inches off of the hips, waist and thigh in two to three weeks can be achieved. But, to aid the lymphatic process, the patient must significantly increase their water intake,  and take a twice-daily niacin supplement during the treatment process. The treatment sessions require a commitment and must be done every two to three days to really be effective. Once the fat cells get leaky, you can’t let them heal themselves by missing treatments or having them too far apart. Each treatment session takes just under an hour, and is painless. Some have described them as almost ‘zen-like’ which I interpret as relaxing and non-stressful. Equally important, the patient can get up,  go and return to all regular activities without any restrictions. There is no pain, bruising, or need for restrictions,  but daily exercise (such as brisk walking, light running, or other cardio training) can increase the final results by aiding in lymph mobility.

If  you are looking for a quick, safe, and affordable way to lose some fat areas, ZERONA may be a good option. For some people, it will be an effective alternative to liposuction and may eliminate the need for liposuction procedures altogether.  For others it may not be a magic pill, but does offer a jump start to a healthier lifestyle…and along the way you may be able get back into that favorite pair of jeans.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I’m interested in a facial fat graft.  You’ve mentioned in one your Explore Plastic Surgery blogs about the use of growth factors with fat grafting. My understanding is that these can be derived from the patient’s blood . How is that done and how does it work?

A: Fat grafting to the face through injection techniques become popular because it is both natural (organic you might say) can be placed fairly precisely. Its one drawback is that the survival of the fat is not predictable. There are numerous steps with fat grafting that will influence survival from the way it is harvested to how and where it is injected. One historic variable in this pathway has been the addition of agents to the fat graft that may help it survive. Insulin is the best example of this approach. A contemporary agent to add to fat grafts is growth factors. This is done by adding the patient’s own concentrated platelets. Known as platelit-rixh plasma (PRP), this is an extract from the patient’s own blood that is drawn during surgery. The blood is processed in such a way so that several ccs. of platelet concentrate is obtained. This is then mixed in with the fat graft.

While the use of platelets with fat graft injection is a natural agent, it has yet to be proven to be conclusively beneficial to an improved survival volume. Its concomitant use is currently based on more of an alchemy approach with the hope that the potent growth factors which the platelets contain will help the stem cells in the fat graft survive, differentiate into fat cells, and help main graft volume.

Dr. Barry Eppley

Indianapolis, indiana

Q: I’m 29, very healthy and I weigh 128 lbs. I have always wanted a more rounder shapely butt for years but never could get enough money for the procedure and was afraid of the risks associated with the procedure. My self-esteem is very low because of my small buttocks. I just want to feel good and feel secure about myself and my looks.

A: While buttock augmentation can be done with either an implant or fat injections, your small frame and low weight leave you with only the implant option. The good thing about buttock implants is that they produce a very nice result in a single operation and  the augmentation is stable over one’s lifetime. Because it is an implant, however, there is a longer recovery and there are potential implant risks of infection or seroma formation.

The key, in my opinion, to your buttock augmentation is to place the implant into the gluteal muscle and not to place too big of an implant. Going above the muscle in the subfascial plane is not advised with low buttock soft tissue coverage. Getting good closure of the muscle over the implant during the surgery is important as it helps reduce the risk of any problems.

Recovery is the biggest short-term concern for buttock implants and one should really allow about three weeks before returning to work and most more normal activities. More physical activities like working out, running, and cycling will take up to 6 weeks until one is more confortable to do them.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am seeking information regarding some sort of procedure I could have done and if you either know about it or can do it. I am unhappy with my forehead. My forehead slopes down perfectly then rounds out. Its bone from my eye socketes in my skull that stick out. Basically Im assuming my skin would need to be pulled back off and the bone chipped down to be even with the top of my forehead. Do you know what im talking about and can you help me?

A:  Your description of your forehead shape is classic for brow bone protrusion, medically known as brow bone hypertrophy. Technically, it is not thickening of the brow bones per se but expansion of the underlying frontal air sinus. The frontal sinus has become too aerated or big and that pushes out the thin overlying layer of bone. Brow bone reduction surgery is a very effective plastic surgery procedure for bringing this bone area back into a more pleasing shape with the rest of the upper forehead. This thin outer table of frontal bone is removed, reshaped and put back with tiny metal plates and screws so that it is less protrusive. In essence, the size of the frontal sinus is reduced. This does not affect how the frontal sinus functions nor create the potential for future sinus infections.

While this type of surgery sounds scary, it is really similar to an open browlift which is a common cosmetic surgery. The only difference is the bone is removed and reshaped. The access to get there are the recovery from the surgery is pretty much the same.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I have an old indented fracture of my left cheekbone. I fell several years ago on my face and was diagnosed with an ‘infracture of my zygoma’.  It didn’t seem to bad at the time but maybe the swelling made it look better than it was. Now that side of my cheek is flatter and asymmetric to the opposite cheek. Can it be repaired?

A: Zygomatic, or cheekbone fractures, are common facial injuries. When fractured, the cheekbone rotates downward and inward, causing loss of prominence of the cheek. While the swelling may camouflage the ultimate degree of cheek flattening, eventually an asymmetric cheek will result if not repaired as the swelling goes away and the overlying soft tissue contracts.

Secondary correction of the cheek flattening can be done by one of two approaches. A cheek implant can be placed through the mouth to build the depressed part of the cheek back out. With some many different styles and sizes of cheek implants available today, a lot of cheek reshaping can be done with an implant alone. The other more extensive alternative is to re-fracture the cheekbone and move it back into its original position. (cheek osteotomy) Generally, a cheek osteotomy is reserved for those cheek deformities where the amount of cheek flattening is severe, the position of the corner of the eye is pulled down, and/or there is numbness of the lip and nose from the infraorbital nerve being impinged from the bone displacement.

I suspect your cheek deformity is more modest, since it was not initially repaired, and an implant would be the simplest and less complicated treatment approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q:I’m 20 years old and I had a direct brow lift a year ago and now i have very obvious and wide depressed scars over each brow. I started out getting Botox and liked the effects that it had on lifting my brows. My doctor then told me that if I had a direct browlift I would not have to get Botox again. I’d love to know if scar revision will help. I have attached some pictures for you to see the scars.

A: Your case is most unusual for two reasons. First, the need or indication for doing a direct browlift on someone who is  20 years old is hard to fathom. Short of some form of severe congenital brow ptosis, I could see no reason what that procedure was ever done on you. It was ill-conceived and inappropriate at your young age. If some form of a browlift had to be done, it certainly should have been an endoscopic technique to both limit the scars and keep them back in the hairline.

Your scars are exceptionally wide and I have never seen such direct browlift scar results. The good news is that they can be made much better through scar revision. They can be cut out and closed into a narrow fine line. While there will always be a scar along the upper eyebrow line, it will be much narrower.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dear Doctor: I’m a 47 yr. old white male in good health. A few years ago I went to India to have a jaw augmentation that was done by lipo injection which was absorbed in a short period of time. I’m looking for a better and lasting result. I would like to know if you think implants would produce a better and more permanent result?

A: The use of fat injections in the past decade has gained in popularity and effectiveness for many plastic surgery problems. The appeal of using your own tissue to create a ‘redistribution effect’ is undeniable. Since most people have some (or a lot) of fat to give, it is not surprising that the technique is being widely used. As part of that widening use effect, it is inevitable that some will use it for uses that are not biologically sound. Fat as a tissue graft has real value for soft tissue augmentation but it is ill-conceived to use it as a bone-based graft. It will fare very poorly as a replacement for chin, cheek or jaw angle implants. The reason is in understanding how implants actually work. They function as a spacer on top of the bone to provide a push to the overlying soft tissues. It takes a fair amount of sustained pressure to hold the overlying soft tissues outward. A non-resorbable synthetic implant can maintain that effect. A soft tissue graft, like fat, will resorb under that kind of pressure.

Advocates may argue that the fat graft is put into the soft tissue and not the bone and therefore has a basis for being effective. Results like you have obtained provide all the evidence you need to counter those claims. Bone-based synthetic implants are simple and effective for facial bone augmentation even if they are not your own tissue.

Dr. Barry Eppley

Indianapolis, Indiana

Q : I had a birthmark removed, and I went back to the plastic surgeon for him to cut out the remaining area he missed. He ended up cutting out more than he should have and left me a huge scar on my face, with dog ears at the ends. The scar is already twice the size it was, and I don’t want to cut the scar any bigger. Isn’t there any other way to get rid of dos ears on your face?

A: Dog ears, or redundant skin edges, are a common problem with elliptical or fusiform excisions. They appear as mounds of tissue at the end of the scar or may actually have visible overlapping skin edges. Their removal is fairly simple by performing a smaller elliptical excision around the dog ear or opening the incision and raising and trimming one of the skin edges.

Such dog ear treatments will always make the scar line longer to some degree. In a tummy tuck, for example, extending the scar line is not a big issue given the location and already long scar line which exists. On the face, however, every extra millimeter of scar is burdensome and keeping the scar line as small as possible is paramount.

Facial dog ear scar revisions can be kept limited by defatting of the bunched scar ends and a minimal extension of the scar line of just a few millimeters for excision of redundant skin. Careful technique can make this minimal scar extension of little consequence for the elimination of the dog ears.

Dr. Barry Eppley

Indianapolis, Indiana

Q: i am interested in changing the bottom front part of my nose. i believe it is called the columella. I think this is where the skin between the nostrils meets the upper lip. In my case, that angle is too small. It should be more open. I have read that an implant can create that effect. If an implant is placed there will it also lift up the tip of my nose? I have attached pictures which show what changes I want.

A: In doing assessment of the ‘columellar implant’ in your desired image look, there are three changes I see that you have made: 1) opening up/fullness of the nasolabial angle, 2) change in the angulation of the columella to the lip, and 3) nasal tip narrowing and lifting. It is important to note that to really achieve these changes an open tip rhinoplasty with an implant needs to be done. I would use cartilage for an implant in the columella rather than a synthetic implant. The columellar skin is not very thick and less potential problems will occur from a graft from your own body.  That is so for the following reasons:

1) a premaxillary implant will push out the columellar base (open up the nasolabial angle) but will not push up the tip of the nose.

2) A true columellar implant will push out the columellar skin but will not, in and out itself, narrow and lift the lip of the nose.

The concept here is that a columellar implant or strut is an adjunct to a tip rhinoplasty but not a substitute for it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, one of my earlobes is split.  This is a result of earrings.  Discoloration has taken place at the opening of the split earlobe.  Is there any hope for my situation?

A: A torn or split earlobe is a very common ear problem. In fact, it may be the single most common reason for plastic surgery performed on the ear. The earlobe frequently separates from the long-term use of heavy ear rings or the inadvertent pulling on a dangling ear ring from a child. The earlobe is easily torn because there is no cartilage in it, unlike the rest of the ear. The two layers of skin and the intervening fat poses little resistance to the rounded edge of a metal object.

The split or enlarged ear ring hole can be easily repaired. It is a simple office procedure done under local anesthesia. The edges of the healed split earlobe are made fresh and put back together as a vertical line. Any discolored skin is removed at the same time. This does heal with a very fine line scar but it is often very hard to see. It will usually be obscured by future ear ring wear or the insertion of a new ear post. Re-piercing of the repaired split earlobe can be done six weeks after the procedure. Usually the new hole is made at the top of the healed scar line which is usually at the center of the earlobe.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am considering getting jaw angle implants and have some basic questions. I want the Medpor RZ angle implants but don’t know if 3mms or 7mms width is the best for me. How can I decide? Will looking at patients with each size implant in help? Also, what is the recovery from this surgery like? I am having a hard time finding helpful information on the internet. Thanks!

A: It is tough to say which size is really best for any patient when you are looking at a 4mm difference in lateral projection. (0.15 inches) In different people with varying anatomies, the look can be quite variable. The best way to approach this question in your mind is…would you rather error on being a little too small or a little too big. While I obviously want a perfectly sized result, sizing is still an art form and not completely scientific.

I would order a 7mm implant and cut it done if need be during surgery. An 11 mm wide implant, which is the third and final size, is quite big and is only reserved for those men who want the most extreme jaw angle accentuation.

The best way to think about recovery from jaw angle implants is that it will be tougher and longer than you think. In general, most patients underestimate recovery from any type of plastic surgery and jaw angle implants are no exception. The issues are prolonged swelling and stiffness/soreness of mouth opening and chewing. One really doesn’t start to feel and look more normal for about 3 weeks after surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q : I am 49 years old and at least 30 lbs over weight. I am in the process of losing this weight. I want a facelift and liposuction under my chin to help my neck. My second question is about burn scars on the bottom of both of my large toes. These scars cover my toe pad and are up under my toe nails making it very difficult to trim my nails. I have never had a pedicure because I’m too embarassed and scared the clinician will cut into the tissue causing pain and bleeding. What procedure would be used to reduce these scars?

A: One should ideally be within 20% of your weight target before undergoing any facelift/necklift procedure. Most people will lose some weight in the neck with their weight loss, creating more loose skin. You don’t want to do the procedure on the front end of the weight loss as you will end up with more rebound skin relaxation once the weight loss occurs negating some of the hard-earned benefit of the operation. Plus, having the procedure as a ‘reward’ after the weight loss may be more motivating. When it comes to weight loss it is always best to have a definitive but realistic weight target.

Your toe scars are unusual in that they seem by your description to come right up under the nail. (eponychium) I am assuming that your toenails have no problem growing. It is just the thickness of the scar right under the nail edge. I would suggest that dermabrasion  (not microdermabrasion) be done to reduce the thickness of the scar. This could remove a few millimeters and reduce the scar hypertrophy.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I have always been bothered by these fat collections on the lower part of my stomach and around into my back. Despite working out regularly and really focusing on these araes, I have been unable to lose them. Several years ago I tried fat-dissolving injections (I can’t remember their name) but they were very painful so I never did it more than one time. I have been hearing about the Zerona laser and it seems that these fat treatments do not cause any pain or swelling afterwards. This sounds almost too good to be true. Do you think as a plastic surgeon that it really works?

A: Zerona is the newest and most popular method of non-invasive fat removal. Using cold laser technology, it has the ability to pass through the skin and disrupt the membranes of the fats cells. This causes release of fat when the cell membranes breaks open. This released fat is absorbed  and eliminated through the lympatic system. This is proven science and is significant enough that its clinical data passed through and was approved by the FDA. Through the concomitant use of exercise, increased water intake, and oral supplements, the effects of the laser are enhanced.  

Is Zer0na a replacement for liposuction….no. It is effective but not that dramatically effective and effiicient as actual surgery. I think it is a proven method that for the right patient can be very effective at making visible fat reduction.  Its success is patient-specific and better results are undoubtably obtained when the patient follows all of the adjunctive recommendations.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: Hello, I am 27  years old and thin but have always had these little fat pouches that are positioned below the corners of my mouth. It’s hard to explain but it makes my cheeks look like they’re sagging (but they aren’t). If I put one finger in the inside of my mouth, and one on the outside and pinch that area, I can feel the distinct fat pocket. I have two questions. What is this fat called? I can’t find any similar cases online, and I’ve done lots of searches. And secondly, what can I do to remove this??  Thank you in advance.

A: It sounds like you may have a unique facial condition known as pseudoherniation of the buccal fat pad. This is where the normal buccal fat pockets, which lie right under the cheek bone, fall or prolapse through their containing fascia and create a low fullness opposite the corners of the mouth or even lower. While rare, this problem has been described in the plastic surgery literature before. Undoubtably the ‘ball of fat’ that you feel is a part of the buccal fat pad.

Q: I had breast implants originally done about 8 or 9 years ago and am looking to have them redone. My existing breast implants are saline 600cc and I think I am between D and DD depending on the bra. I want them increased but not sure if that is something you do? I know i would like to be DDD cup. I am a body builder and I think it would balance my shape better. Any information back would be great!!

A: Ideally, the size of a breast implant should stay within the base diameter of one’s breast. This produces the most natural looking result and also avoids the potential of the implants bottoming out over time due to loss of tissue support. That being said, some women prefer to go larger than these parameters. While some plastic surgeons have objections to that desire, my feeling is that as long as one realizes there may be a price to be paid long-term with bigger sizes (eventual removal and downsizing with breast skin reduction), then I have no objection.

Since you already have 600cc implants in place, the largest available implants are 800cc, either saline or silicone. At this size increase, that represents a 33% size increase. Saline implants can be further filled up to 960cc, representing an approximate 50% increase over your current size. At these size increases, one should definitely go with a high profile implant to get the base diameter as narrow as possible. Whether these sizes are appropriate are based on your height and chest width and breast augmentation size desires.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Hi doctor, I have a big forehead and I need a scalp advancement to make it smaller. To do this surgery do you needs to shave my hair? What is the maximum of centimeters that you can reduce? How much does this surgery cost? Thank you.

A: A long forehead can be reduced by moving the scalp forward (hairline advancement) and removing upper forehead non-hairbearing skin. While this does leave a fine line scar along the frontal hairline, that is usually nto a problem for most women. As long as the hairline is distinct with reasonable density, the scar is usually a good trade-off. One of the keys to a scalp advancement is to secure it to the underlying frontal bone in its new position. This will not only prevent relapse but will also take the tension off of the scarline so it heals as narrow as possible.

In answer to your specific questions:

1) No hair is ever shaved for the procedure.

2) Usually at least 2 to 2.5 cms of scalp can be advanced with the same vertical reduction in forehead skin. That tapers off into the temple areas. The greatest amount of advancement is in the center.

3) The overall costs are about $ 7500 – $ 8500

For those women afflicted with a very high hairline, a forehead reduction procedure through a scalpadvancement can be life-changing. One can think of it as a ‘reverse browlift’ so it is an outpatient procedure that takes about 2 hours to perform. The very next day one can wash and style their hair.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  What is Dr. Eppley’s experience in fixing breast implants that have bottomed out? What is the success rate in it staying fixed?

A: Bottoming out in breast augmentation is when the implant falls below the level of the lower breast crease. There are numerous factors which contribute to this problem, but the main one is when the size of the implant exceeds the ability of the tissues to hold it up. This is a problem that is usually seen long-term, not immediately after surgery. The implants may have initially been in good position but have dropped over time. Sometimes this may not occur for years.

When this problem is seen right after surgery it is the result of the pocket dissection going below the attachments of the lower breast fold. This is acute fold attachment disruption not its weakening over time.

Either way, the treatment of breast implant ptosis (bottoming out) can be done by two different methods. The most common approach is to suture the attachment of the breast fold back onto the chest wall, which pushes the implant back up. This is the simplest approach but loosening of the sutures can happen and dropping of the implants can happen again. If this were to happen it would usually occur within the first six weeks after surgery.

The other approach, which is newer, is to insert a lower sling of allograft dermis between the pectoralis muscle and the chest wall. Like an internal bra, this tissue supports the bottom part of the breast better. It is more reliable in terms of success but is much more expensive due to the cost of the dermal graft.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  What can I have done to make my breasts look fuller but still feel as natural as possible?

A: Breast implants are the only reliable method for increasing the size of one’s breasts currently. Many women have breast implants that look quite natural while others have a breast look after augmentation that some perceive as unnatural or fake. What is the difference between the two?

There are many element that contribute to the appearance of a breast augmentation. How loose or tight is the overlying breast skin and the size of the implant are the major contributing anatomic factors. A large implant with an initial tight breast skin will create a more rounded look with a full upper pole. A smaller implant with loose pre-existing breast skin will end up as more of a tear-drop shape.

The feel of a breast implant, however, is slightly different. Regardless of implant size, either saline or silicone gel implants can feel quite natural. Outside of the body, most people would agree that silicone implants feel more like natural breast tissue. But inside the body that difference is not as obvious. Saline breast implants can feel unnatural if rippling is present on the bottom or sides of the breast or if the implant is significantly overfilled so that it feels too hard.

In general, most breast augmentation patients are quite pleased with the feel of their implants. Unhappiness with implants that are too hard or too soft is a rare reason for revisional surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Hopefully someone there can fill me in even though I have no insurance! I want to know the approximate cost for an abdominal panniculectomy. I am very obese, weigh 360 lbs and am 5′ 2″. The majority of my weight is in my abdomen. This apron is like a catch 22, It is getting harder to walk and then I don’t so I eat and don’t walk and gain weight. I fell and hurt my knees 4 years ago, gained 100 lbs since then.  Thanks for providing an outlet for me to vent. I liked the idea that you have had experience with this surgery for obese people. I still want to know what the surgery would cost. I maintained a weight of 250 to 260 lbs for over 25 years before the knee injury that never got fixed. Fat never stopped me before and it won’t now. My health history is otherwise remarkably good. My blood pressure is 115/60,   fasting blood sugar 70 to 80 and the rest of my blood work is normal.

A: The abdominal panniculectomy procedure provides great physical benefits to those patients such as yourself. By the removal of overhanging weights that often approximate 30 to 40 bs, if not more, the strain on one’s back and knees is significantly reduced. This is in addition to the improvement in groin and genital hygiene.Most medical insurances will cover this procedure as ythey should given the medical benefits that it provides. The abdominal panniculectomy can not really be compared to the more common tummy tuck which is performed in more weight appropriate patients and is smaller in surgical magnitude and recovery.

Unlike a tummy tuck, the cost of an abdominal panniculectomy is out of reach for most patients. Costs could easily approach $10,000 to $15,000. It takes longer to do and will almost always require an overnight stay and often several days in the hospital. Complications rates are high and secondary problems such as fluid collections and wound breakdowns are common. Secondary surgical revision for wound closure is not rare ane exposes one to even greater expense. For these reasons, one should attempt this procedure under insurance for the really large type pannuses that you appear to have.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I have a few questions that I have been wondering about for a long time. First, what causes frontal brow bone growth? The reason I am asking is because since I turned 21 it seems that my frontal brow bones have grown outward. When I look at the side of my face, there is not that smooth appearance that there once was when I was a teenager and this is because of my frontal brow bones poking out. I have always been considered a good looking guy but since this has started happening, I have gotten to be very self conscious of my looks.

One more question…. and this may seem like a very odd question. Does sleep deprivation or a very weird sleeping pattern have any thing to do with frontal brow bone growth? The reason I am asking this is because just before I turned 21, I developed a sleeping disorder. Not long after this sleeping disorder started, it seems like I started noticing my frontal brow bones getting a little bigger. I am 24 today and I still have a sleeping disorder. I have helped it quit a bit by taking medications to help with sleep. Anyway, my brow bones are bigger than I think they should be and I am just wondering if sleep deprivation has anything to do with frontal brow bone growth.

I have really want to know the answers to these questions for a long time and it would be greatly appreciated if you could please answer them for me. Thank you.

A: The development of the frontal sinuses does not begin until after age 6 and often will nolt be evident on an x-ray until age 9 or 10. The frontal sinuses are air-filled cavities that drain into the nose. Their growth should be consistent with that of the skull which is usually complete no later than age 18. Prominent brow bone often do not become apparent until after puberty for many young males and they seemingly ‘grow’ up until the late teenage years.

Sleep deprivation or any form of sleeping disorder is not a known case for the development of prominent brow bones.

Prominent brow bones can be reduced through skull reshaping surgery. I perform this by taking off the frontal later of bone over the sinuses, reshaping the forehead, and putting it back on. While very effective, a male must consider the trade-off of a fine scar in the hairline which is needed to gain access to the bone to do the procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I was wondering if liposuction can be done on the calfs?  Ever since I was little my calfs have always been disproportionate compared to the rest of my body.  I have been teased my whole life because of them, even now at 24 I still am teased, and I have tried everything short of surgery to reduce their size. I am 5’7″ and 145 lbs and my calves are 16.5″ around, but if I workout or am on my feet all day, which I usually am, they can be 17″ to 17.5″.

I am tired of not being comfortable in a skirt, or swimsuit, and not being able to find boots that will fit around my calves. I have attached pictures of them so you can see what I mean.  They are muscular, but they do have fat, when I flex I can grab a handful of fat from my ankle all the way up to just under my knee. I don’t know if it is possible to remove this. I have contacted a few other clinics, and they said they do not perform the procedure. I have attached some pictures so you can see what I mean.

A: Thank you for sending those excellent pictures. I can clearly see your calf size concerns as they do not seem to fit the rest of youor body frame. Liposuction of the calfs can be done and definitely make a contour improvement. Think of calf liposuction not as completely circumferential but done is select areas that will provide more shape to the calf. Fat removal on the inside of the lower calf, at the outside of the ankle, and in the inside of the upper calf be low the knee are all good shaping areas. Circumferential liposuction of the calf causes a lot of swelling that takes a long time to go away. It is better to think of calf reshaping rather than calf size reduction.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Four years ago I had a rhinoplasty for a tip deformity. After the surgery my nose looked extremely nice and I was receiving excellent comments. However, about one year later a dimple appeared on the tip of my nose. I asked my plastic surgeon about it and he referred me to a dermatologist.  I have spent a year going from one dermatologist to another and no one was able to help me. One of the dermatologists took a biopsy but the biopsy revealed nothing. After being exhausted I went back to my plastic surgeon  and he diagnosed that the cause of this dimple may be some stitches that did not go away after the surgery. He operated on my nose again and told me after the surgery that his diagnosis was correct and he removed all the stitches from my nose. However, the dimple was not removed. He asked me to be patient. I went to him several weeks later as my situation didn’t change so he did a minor surgery in his clinic and again with no success.  I then went to another plastic surgeon who was able to remove the dimple and he said there was some white cheesy stuff behind it that he completely removed. However the surgery resulted a scar in my nose. What do I do now?

A: Your rhinoplasty problem is rare but not unheard of. Your explanation of the events is perfectly understandable and it paints a very clear picture to me. Undoubtably what has happened are sutures reactions to internal sutures used to reshape the nose cartilages. This is common practice. I use dissolveable sutures for this purpose but other surgeons do not always do so. While rare, they can cause a delayed inflammatory reaction which is the initial culprit in your case. Now because of the biopsy and subsequent excision, there is an indented scar.

Cosmetic plastic surgery has long been unintentionally gender-biased. Since the field began, the vast majority of patients who seek cosmetic enhancements, albeit it surgery or office-based treatments, have been women. Men have always made up less than 10% of most plastic surgery practices.  Hollywood would lead you to believe otherwise but it just isn’t so. The only rare exception to that has been the more recent popular treatment of laser hair reduction. When it comes to hair removal, men make up about half of the patients seen with the hairy back and shoulders being the prime targets.

But more men are finding their way into the plastic surgeon’s office in the past few years. Besides a steady increase in male numbers, what is noteworthy is the change in what what men are requesting. While there remains some traditional procedures that have always been of interest, technology, societal trends, and younger men have opened up new areas of the face and body for change and improvement. Here are four of the most popular younger male (teenage to early 40s) procedures today.

Liposuction still remains the most requested male procedure.  The culprits are always the same, the stomach and love handle areas. But most men that want liposuction are not fat and many are not even overweight. To the contrary, they are lean but have fat collections at the side of the waist and flanks. Even in men that work out regularly, those love handles can be impossible to work off. Today’s liposuction techniques can even give that ‘six-pack’ look for those leaner men that are not opposed to a little surgical cheating.

Chest recontouring is the one male plastic surgery procedure that is really on the rise. Male breast enlargement, known as gynecomastia, has always been an issue. But with increasing teenage weights and the present young male aesthetic for a completely flat and smooth chest, improvement in the male chest is sought out like never before. Even small nipple protrusions can be bothersome for the teenage male. Obvious man boobs are not desireable at any age.

Nose reshaping (rhinoplasty) has always been a popular male operation and that has not changed. It is the one procedure of the face that young men are not afraid to change. Noses that are big with prominent humps and wide nasal tips are bothersome and distracting to an otherwise balanced face. Sports and recreational activities make the young male nose a good target for injury causing twisted and deviated noses that often pose problems for breathing as well.

One set of procedures that is really new and undoubtably influenced by movies and models is structural facial reshaping. Creating that chiseled and angular face is what some young men aspire to achieve. A good jawline in particular is associated with enhanced masculinity. While one perceived just as making a strong chin with an  implant, modern plastic surgery implants can be extended all the way to the back of the jaw. With the development of jaw angle implants, the jaw line can become more defined than just with a chin implant alone.  

A new generation is redefining male plastic surgery. Have a lean body, flat chest, and a nose and jaw line that creates a well defined face has probably never been out of style. But modern surgical developments make them more attainable than ever before.

Dr. Barry Eppley

Indianapolis, Indiana