Your Questions

Q: Hello Doctor, I just had juverderm ultra injected into my lips several weeks ago. But I am not happy with the amount of lip size that I got from it. I am interested in having more filler put in and want to change to Aquamid.  Is it safe to use Aquamid a few weeks after having a Juvederm treatment ? What are the potential problems that could happen?

A: There are no studies that provide comfort that the mixing of different injectable fillers is safe. In fact, a recent report that looked at multiple different injectable fillers used in the same patient indicates that complications do arise from doing so. It may be one thing to mix and match different hyaluronic-acid based fillers (such as Juvaderm and Restylane, for example), but putting two completely different chemical compounds into the same facial site is unknown in terms of their compatibility and asks for problems. No facial area is more sensitive to  inflammation and granulomatous reactions from injectable materials than the lips.

I would highly recommend that you want at least 6 months before considering injecting another filler into your lips because of these concerns.

I would also not recommend the use of any semi-permanent or particulated injectable filler be placed into the lips. Fillers, such as Radiesse, Artefill and Aquamid, are comprised of a mixture of polymer beads suspended in some form of a more liquid carrier vehicle. In the lips, these particles have been shown to have a higher incidence of foreign-body reactions, lumps, and even infection. The injectable fillers with the best track record of safety in the lips are of hyaluronic-acid derivation. Do not risk long-lasting results at the price of soft tissue problems. This is a particularly poor trade-off in the lips. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Hello, I am a 28-year old male with very prominent brow bones and I would like to have them reduced to a normal size and shape.  What is involved in doing this kind of plastic surgery? Are there any significant risks and do you think the results will be worth it? Thank you very much and I look forward to your reply.

A: Brow bone reduction is more than just burring down thick brow bone ridges. It actually involves removes the outer plate of the frontal sinus, reshaping it, and putting it back on. A prominent brow bone is really not bone, it is an overgrowth of the frontal sinus. Brow bone reduction is really about reducing the size of the air space of the frontal sinus, in essence making a room smaller by lower ing the height of the roof.

Brow bone reduction must be done through a scalp incision. While the operation is not complex or dangerous for those trained in craniofacial plastic surgery, it requires that expertise and training to be very comfortable doing it. The key aspect in the decision to have the operation, in my opinion, is the acceptance of a scalp scar. One should have a good density of scalp hair and some confidence that all hair on the top of the scalp may not be eventually lost.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I’m interested in customized mandibular angle implants for enhancement and to camoflage asymmetry and a contour defect from previous corrective jaw surgeries. I’ve had several jaw surgeries in the past. I had corrective jaw surgery which involved moving the lower jaw and chin forward. This surgery did not go very well. Due to an impacted wisdom tooth on the left side, I suffered a substantial amount of bone loss and was wired shut for several weeks. I also suffered nerve damage on the left side from the nerve be badly stretched. I had a revision surgery with another surgeon who repositioned the chin to correct asymmetry and placed a lateral onlay medpor jaw implant on the left side. I would like to have the implant removed and different style implants placed on both sides of my jaw. I would like to camoflage my defect and at the same time enhance the lower angle.

A: It appears you had orthognathic surgery and suffered what we call a ‘bad split’ on one of the mandibular osteotomy sides. (this is why it is a good idea to take out the wisdom teeth six months in advance of the procedure so the bone can heal and have better bone to work with. (I have been there before) I am assuming that the left side eventually healed but it resulted in the jaw being more posteriorly positioned on that side, resulting in chin asymmetry. Then you went on to have a chin osteotomy for anterior asymmetry correction and an onlay implant over the healed but deficient side of the lateral mandible where the sagittal split went bad.

I don’t necessarily think you need a custom implant on the left side. While it certainly can be done, the cost difference to do so may not be the effort. A careful analysis of your facial photos and x-rays is first needed to determine of that is necessary. Most of the time the problems can be improved with implants that are available off-the-shelf. You will likely need a different style and size of implant for the left side than the right. One option is the Medpor Ramus jaw angle implant with an inferior ridge on the left side. That type of implant would cover both the angle and the ramus and inferior border where the old bone defect site is. That would provide 7mms of angle width with the choice of either 5mm or 10mm lowering of the inferior ridge. The best way for me to make that determination is to look at a panorex film, which I suspect you have had at least one since your last surgery.

The other issue on the left side is the removal of the old onlay implant. That is usually not very easy with these Medpor implants but possible. You just don’t want to undergo a lot of ‘destruction’ trying to remove it unless it is really necessary. Sometimes it is better to leave it and implant over top of it. But that would depend on the size and location of the current implant in place. Again, a panorex film would be critical as the implant outline will usually show on that type of x-ray.

As for the opposite right side, I think either the smaller Medpor Ramus angle implant with the inferior ridge may suffice or a Medpor RZ angle with 7mms width. I would have a better feel for that based on an x-ray analysis.

What I would recommend is to get, or find if there are old ones, a panorex and a lateral cephalometric x-ray. With these I can trace out the mandibular shape and get a better 3-D for your unique anatomy. Then we can decide whether off-the-shelf or custom jaw angle implants are needed.

Dr. Barry Eppley
Indianapolis, Indiana

Q: My daughter had a breast reduction at the age of 14. She is now 19 and would like to have implants to bring some shape and fullness back to her breasts. Can you explain what happened? It seems like we are going in reverse. Once her breasts were too big, now they are too small.

A: While breast reduction reduces breast size by removing tissue volume and skin, the long-term results of the operation are not always stable. In fact, if you look at a woman’s breasts over a lifetime, they do change throughout her life for a variety of reasons.  The younger a breast reduction is done, the more likely the breasts will eventually undergo shape and size changes.

The first explanation is that the initial breast reduction may have been overly done. While it may have initially looked good, once the breast swelling went away the amount of reduction may have been too much. Years later, the breasts will bottom out and look deflated and flat.

Breast reduction results are affected by a variety of bodily changes long after the surgery has healed. The two biggest are weight loss and pregnancy. Both cause breast involution or tissue shrinking, resulting in a decreased breast size and more loose breast skin.

Since her breast reduction was done early at age 14, she was barely through puberty. Often breasts can ‘regrow’ when done this early but I have never seen in my Indianapolis plastic surgery practice significant breast shrinkage after just five years by age 19. If she has become pregnant and delivered, this would explain what has happened. More likely, however, is that the initial breast reduction may have been too aggressive.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I had a facelift last year but am unhappy with some ‘dogears’ in my scar under my chin. Can this be improved by extending the scar?

A: Most full or more complete facelifts involve an incision under the chin. (submental incision) This is done to access the central neck area for fat removal and neck muscle tightening. Usually this is a very small incision and does not involve the removal of skin. It is simply a point of access. It is closed and there is very rarely any scar issues with it. Dog ears, a redundancy or bunching of skin at the ends of a scar, do not usually occur with this submental incision as no skin is removed. In short, this inicision is not there to do some sort of ‘neck tuck-up’.

There is a neck procedure done known as a submental tuck-up which is done for chin ptosis or sagging. But this is not done to create a neck lift. That is a fundamentally flawed approach as the neck can not really be lifted by this limited incision. To do so would require a much longer incision which would usually be cosmetically unacceptable. I have seen a few patients over the years who have had this type of procedure done elsewhere and the results have not been good for this very reason. You can not lift and remove enough neck skin with a cosmetically acceptable submental incision.

If you have dogears in your submental scar, I am wondering if this might be the operation that you had. The dogears can be removed but it will require extending the scar length as you have surmised.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am interested in a brow lift or botox treatment…maybe a facelift. I am 43 years old and I believe I look ten years older. Do you know if I could try one procedure now and then gradually work up to a progressive series of surgeries?

A: The wonderful thing about the many procedures for facial rejuvenation is that both small and big changes can be done. And the procedures can be customized to how much one wants to do, how much one wants to spend, and how much recovery one can allow. Since facial aging is a progressive phenomenon, younger patients will need smaller procedures while bigger changes are reserved for those with more loose skin and wrinkles.

Since you have never had any of these cosmetic procedures before, it is understandable that one often does not know where to start. To ‘put your toe in the water’ so to speak, doing something non-surgical like Botox or injectable fillers is a good way to start. One can venture ‘further into the pool’ with laser treatments  and even facelift surgery at a later date. A progressive approach to facial aging treatments is both reasonable and prudent.

Always start with the facial concerns that bothers you the most. To get started, it is helpful to meet with a plastic surgeon and have an educational session about what is appropriate now and what may be beneficial in the future.    

Dr. Barry Eppley

Indianapolis, Indiana

The mixing of religion and plastic surgery are an unlikely pair that on the surface go together like oil and water. The current Gulf oil leak brings vivid images of how such things don’t go well even though they are closely aligned by proximity. Those considering plastic surgery with deep personal convictions undoubtedly feel like those contrasting mixtures. While no Christian religions of which I am aware specifically forbid having cosmetic surgery, it is with a certain amount of guilt that one of such beliefs ponders such a seemingly self-aggrandizing act.

I recently saw a mother on whose son I had operated many years ago to repair a birth defect. To leave a child’s face deformed is, of course, unimaginable in our society. But there are many third-world  countries where, due to lack of medical care,  such facial birth defects are not routinely repaired.  Even those persons with the deepest and strongest of personal convictions against ‘plastic’ surgery would not quibble about a parent’s decision to seek reconstruction of a birth defect. The same could be said for a church secretary that I saw who had breast cancer and wanted immediate breast reconstruction. But what about my former pediatric patient’s mother who now wanted a tummy tuck?  Or what about the individual who has body issues so serious after a 100 lb. weight loss that their mobility is affected?

For some, plastic surgery seems like a selfish and indulgent pursuit. While this response is often a knee jerk reaction on the part of some who see it that way, those with religious convictions are forced to look even  deeper and confront their beliefs and sometimes even question their spiritual integrity. But in a modern consumer-driven society, the awareness of such personal improvements is all around and are as readily available as the office across the street or in the next biggest town.

Over the years, I have performed cosmetic surgery on many more than a handful of patients with deeply held personal convictions who have undergo everything from breast augmentations to facelifts.  I know of their personal convictions because they told me so. While most patients offer an explanation (although not needed) as to why they want cosmetic surgery, those of religious persuasions are upfront about their struggle with this decision. There are few others that they can turn to for this discussion for fear of judgment in their community as well as to avoid the criticisms they would feel even if such words were unspoken. Most of us are quite quick to judge the motives of others without any real knowledge of their story.

 
A baby with the cleft lip and a mother who wants a tummy tuck seem worlds apart. But are they really? My observation is that both situations are wholly about the need to look and feel ‘normal’.  No parent corrects a birth defect with aspirations their child will one day become a supermodel, and a mother of four kids whose body has borne the brunt of repeated pregnancies are very similar.  These surgeries are about normalcy; and about feeling confident.   Few cosmetic patients that I have ever met really want to be special,  most only want to feel better about themselves- they want confidence. Whether that desire conflicts with the integrity of one’s religious beliefs, or are mutually exclusive, is not for me to say.

What I tell any patient, of strong religious convictions or not, is that plastic surgery is a tool. It is a method for personal improvement. The decision to have surgery or not is only part of the personal enrichment process.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I had cheek implants placed over10years ago and an oral and maxillofacial surgeon told me one of them is infected. It started with a visit to the dentist.I had 2 fillings done in my upper molars.The freezing was in the same area the implants are and this somehow caused one of them to get infected. It is swollen and I am upset it happened and worried about the infection. I have been  on antibiotics for about a month.I know infection is rare but I got unlucky and I was wondering how many times you’ve had to take one or both implants out?

A:  You are correct in that infections with cheek implants are rare, but they are not unheard of. It has been reported that cheek implants can get infected with local anesthetic injections during dental treatment. An upper vestibular or intraoral nerve block puts the needle very close to a cheek implant and could very easily, unknowing to the dentist, touch or penetrate into the implant. This would be a source of bacteria brought into the implant capsule from the needle track.

Once a cheek implant, or any facial implant for that matter, gets infected, it is likely that it will eventually require surgical treatment. An implant is an avascular surface, that once contaminated, can not easily get rid of an infection. Antibiotics are a logical first choice but they will tend to only suppress it for the duration that you are them. Once off, the swelling and infection usually returns. If this does not work after a month or so, I would re-operate, remove and clean off the existing implant and either replant it or replace it with a new one. This approach will work. The opposite cheek implant is at no risk from the infection of the other one.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am 53 yrs. old and have very deep nasolabial folds (more so on one side than the other).  I don’t know why they are so deep at my age but they are. I was interested in the “Cutting out” of the fold, however, my question is what happens to the cheek? Would the skin not sag? This is a problem I have and am very self conscious about it.

A: The development of nasolabial folds occurs in everyone as they age, some are more pronounced than others. How deep and early nasolabial folds appear is a function of numerous factors including thickness of one’s facial skin, thinness or fullness of one’s face, cheek bone support and how much cheek soft tissue sagging or ptosis develops. The nasolabial fold develops as the cheek tissues sag down over the more fixed and stable upper lip region. They are really tissue that is ‘falling over the fence’ so to speak.

By far, the most common treatment for softening the nasolabial folds are injectable fillers. But in advanced stages of nasolabial folds, an inverted-V deformity exists in the skin and injectable fillers do not produce  a significant or worthwhile reduction. Usually inverted nasolabial folds are seen in older patients. (> 60 years of age)

In the inverted V or deep nasolabial fold, excision is a treatment option. Because this technique cuts out the fold, it is very effective at restoring a smooth transition between the lip and the cheek again. However, there is a trade-off of a scar which make proper patient selection critical. While this fine line scar does quite well, it is a scar nonetheless and that deformity trade-off is not right for everyone.

Another treatment option for the deep nasolabial fold is a ‘release and fill’ technique. A fine surgical wire is used to release the dermal attachments of the fold and an interface of injectable fat placed under the release. While this sounds like it would be theoretically successful, long-term follow-up has not borne out this theory.

Before considering nasolabial fold excision, one may want to try injectable fillers to be certain that their effect is not sufficient since they are reversible. Nasolabial fold excision is a one-way commitment.

Dr Barry Eppley

Indianapolis, Indiana

Q: I was just wondering if Dr. Eppley could do scar revision on old keloid acne scars. I went to a Dermatologist over 7 years ago and he told me that plastic surgeons could remove the scars with great success. I am very self conscious and I love to swim, but I haven’t really done it because I know people are staring and want to know why I have these ugly scars. I wish I could tell them to mind their own business but obviously I can’t. I have them on my shoulders, top of my biceps, and a couple on my chest area. I was just wondering if you had done this kind of surgery before and what was the outcome from the surgery?

A: The success of scar revision is measured by how much the scar appearance is improved. Improvement in problematic pathologioc scars as you decribe  is ultimately measured by whether hypertrophy or keloiding reappears. There is no question that scar revision is successful early because the previous scar is cut out and temporarily eliminated, trading off a thick raised scar for a more narrow scar line. But what does the scar look like three or six months later?

How successful scar revision is depends on many factors, including skin type, anatomic location of the scar, and what caused the scar. Hypertrophic or keloid scars in thicker skin with darker pigmentation over stretch out areas such as the sternum and shoulders can be very difficult scar problems with a high rate of recurrence. They remain a plastic surgery problem where a better understanding of the science of scar formation is needed before more effective treatments are developed.

Until that day arrives, we must consider traditional scar excision and see what happens. I would recommend to do just one of the scars and see what happens, using it as a ‘test’. Based on that outcome one can determine if the other scars are worth the surgical effort.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Hello Dr. Eppley. I’m a 25 yr old male who is dissatisfied with my cheeks. They are very round and full, and give me a infantile or boyish look, rather than a more angular, defined, masculine one. I’m pretty thin so weight loss is not an option.  I’m wondering what my surgical options are. Apparently plastic surgeons don’t think buccal fat reductions are a good idea. Would creating a cheek dimple help? What do you think?

A: Full cheeks do contribute to a more round facial shape although they are just one factor in creating that appearance. Depending upon how one defines the cheek area, a full cheek can be due to a prominent cheek bone, a large buccal fat pad, a thicker subcutaneous fat layer across the cheeks and face, or some combination of all three. It is obviously important to know what in the cheek area is creating that look when one tries to figure out how to change it.

From a practical standpoint, the only reliable method of ‘cheek’ fullness reduction is partial or complete buccal fat pad removal. While this is a very simple procedure, one has to appreciate what type of facial slimming effect that it will create. Buccal fat removal will create a soft tissue indentation below the cheek bone prominence. If you put your finger under the prominence of the cheek bone, this submalar or under the cheek location will be the area effect. The slimming effect will not go down or past the corner of the mouth.

For most patients, buccal lipectomies will create a mild reduction in cheek fullness in the submalar area, but never dramatic. It is a good procedure, in my opinion, in the properly selected patient. It has gotten a bad reputation because of poor patient selection and over aggressive fat removal. In patients with thin or lean body types, the short-term facial sculpting effect may not be worth the potential for a long-term facial atrophy look with aging.

In trying to create a more sculpted face, it is also important to look at other potentially useful procedures such as chin augmentation, neck liposuction, and maybe even mild cheek augmentation. When put together with buccal lipectomies in the right face, a signficant more defined facial look can be obtained.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am writing to you because I have a very troublesome scar on one of my cheeks.  The scar has been there for a long time since I was 5 years old. At that time I had some type of cyst removed which left a bad scar. It has bothered me for over 20 years and has very negatively affected how I see myself.  I have tried the best that laser resurfacing (Fraxel) has to offer as well as Botox and filler injections, all with no visible improvement. I have paid good money for these treatments and I was really disappointed to see that they did not make a difference. What do you recommend?

A: Your question has me at a disadvantage as I can not see your facial scar. Having seen and operated on children for facial nevi and other tumors, however, it is like that your scar is plagued by multiple adverse scar factors including being wide, is deeper or more depressed than the surrounding skin, and is positioned over a prominent facial area. I can say that with some confidence because you were still young when the scar occurred and your face has grown much since that time.  Facial growth always causes scars to stretch and be thinner than the surrounding skin.

The only hope of any improvement is actual scar excision. Cutting all or part of the scar out and then re-closing it can narrow it. Often this takes two stages to get the scar narrowed as much as possible. Thereafter laser resurfacing may be beneficial but may not be needed at all. When one considers serial scar revision, including healing and scar fading time, this is a process that easily can take a year or longer to get to where you want to be. A patient must be prepared to make such a time commitment. You are still young so such lengthy efforts will still have a long lifetime of benefits.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am writing to inquiry about a calf implant for my daughter. She has developed a  rather significant difference in the size of her calfs now that she is a teenager. While it was slightly apparent as a child, it has become real obvious as a 15 year-old teenager. It bothers her to the point that she will not wear shorts or go to the pool with other teenagers. She walks fine and as no disability from the calf size difference. I know that calf implants can be done for body builders and others who want both calfs to look bigger, but can just one calf implant be done? I could not find anywhere where just one was done.

A: Calf augmentation with implants is an uncommon body contouring procedure. While it has been done for decades, it is far less common than breast or buttock implants. While most people think that only body builder types do the procedure, it may surprise you to know that their use for ‘reconstruction’ of congenital calf deformities makes up about half of all calf augmentation procedures.

Calf implants are made of specially-shaped soft flexible silicone rubber. They are surgically placed through a small incision behind the knee. They can not really be put inside the calf muscle but are placed on top under its fascial covering. They can be placed on either the inside, outside of the calf, or both. Most commonly, they are placed on the inside half (medial) which is where most of the calf’s definition can be visually seen.

For calf asymmetry, placing a calf implant on the smaller side can help make their size discrepancy less apparent. If your teenager is that bothered by it, I would seriously consider the procedure. It is really the only good plastic surgery option for such a calf problem.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I have a strange question for you Dr. Eppley but I am very curious. I am going to get breast augmentation in the near future and am an avid swimmer. My friend told me that it might interfere with me swimming. She said she heard that breast implants will act like floats and slow me down or could weigh me down and make it harder to stay afloat. Is what she is saying true?

A: Your question/concern about the impact of breast implants in the water is neither strange nor new. Women have asked me about that numerous times in my Indianapolis plastic surgery practice. One the one hand, millions of women over the past thirty years have had breast implants and such potential problems have never surfaced or been reported. This would strongly suggest that what your friend is telling you is nothing more than an urban myth.

From a scientific standpoint, the question is one of the buoyancy of breast implants. Depending upon the type of breast implant, the answer differs slightly. Saline implants are neutrally buoyant, meaning that they will neither float nor sink. This makes perfect sense since they are essentially the same density as the water in which they are immersed. The two fluids are only separated by the thin containment shell of the implant. Silicone implants, however, are a little more dense than water and  will have a slight sinking effect.But they will not completely sink and essentially float as well. This can be easily demonstrated by placing both type of implants in a sink filled with water.

When placed in the body, however, the buoyancy of breast implants demonstrated by benchtop testing becomes irrelevant. Their impact will be the same as any other enclosed body part. Their only potential impact on swimming is on the aerodynamics of the body shape, which is only relevant if one is an Olympic or competitive swimmer.

Dr. Barry Eppley

Indianapolis, Indiana

Q : I had a facelift right after this past Christmas. While it turned out great and I wouldn’t change a thing, I forgot to ask my plastic surgeon how long it would last. What is your take on the longevity of facelift surgery? What can I expect to look like five years from  now? Will I eventually look like I did right before the facelift?

A: The simple answer is…you will eventually outlive the results of your facelift. In fact, I would argue that is your goal, to be able to live long enough to need some type of tuck-up or secondary facelift. In that answer lies an important truth…facelift surgery is not permanent. Its lack of permanency is because the surgery treats the symptoms of the problem but not the problem itself which is unstoppable aging.

The complex answer is that it is very difficult to predict how long the results of a facelift will last. The rate at which people age is highly variable and depends on the interplay of numerous factors including heredity, sun exposure, stress, smoke and environmental poison exposures and nutrition. The quality of one’s skin, its thickness and elasticity, and the shape and support of the underlying facial bones play a major role in the stability of a facelift result.

The age at which a facelift is done is also an important factor as aging accelerates at different stages of life. As an example, the results of a facelift performed at age 50 can be expected to last longer than the results of a facelift done in a 65 year-old.

But for those that like numbers, on average, most patients will get at least five to seven years of good longevity of  a facelift. Some patients make take as long as ten to twelve years to see a significant return of jowling and loose neck tissue again.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m hoping you will be able to advise based on your article on conservative vs aggressive liposuction and the trade-off with skin contouring. Would you please tell me what my options are to correct the skin irregularities on my upper arms as a result of liposuction done severalyears ago? Would weight training or weight gain or massage help? What are the odds that a second liposuction procedure on the arms would correct vs worsen the skin irregularities? Thank you!

A: The number one complication after liposuction is contour irregularities, i.e., lack of perfectly smooth skin. Certain body areas are more prone to that problem than others. The arms is one of those potential areas and that has to do with how liposuction is performed in an axially-oriented extremity…usually from one direction. It is very difficult, from an access standpoint, to treat the back of the arms from different directions. The concept of cross-tunnelling, an old liposuction concept, still has merit even with today’s advanced liposuction technologies.

Massage therapy done early after liposuction surgery can help with working out any irregularities and uneven areas. However, months to years later when the tissues have healed, make such tissue manipulation unsuccessful. Weight training or arm toning would be unsuccessful as the contour problem does not lie at the muscular level.

The only option for improvement would be another liposuction surgery. The scarred and irregular subcutaneous tissues must be released for any better contour to be achieved. Since the old motto of ‘plan B should not be the same as plan A if you want a different result’ applies, how the liposuction was done and what was done afterwards should be different. In my Indianapolis plastic surgery practice, I would use laser liposuction (Smartlipo) as a different method, access the area from both at the elbow and from behind the arms, and institute massage therapy beginning two weeks after the liposuction surgery. While no guarantee can be made that it would be better, my experience is that it would. If the same technique was used as the last time, the odds are higher that it could be worse.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am wondering about reducing an area of my upper lip. Here is the problem.  When I was younger, I had an incident that cut an area of my upper lip.  My lip healed fine and the cut mark is no longer there.  However, it appears that an excess of fat or tissue (not sure what it is) has collected in that part of my lip.  I am guessing the procedure may be something like liposuction or something like that. It looks rather simple to do and perhaps could just be fluid in there.  Please advise.

A:  The bump on your lip that you are seeing is undoubtably scar tissue. It is not fluid or fat. This is an absolutely classic case of scar formation that occurs after a significant cut or laceration on the lip occurs.

While scar forms anywhere on the body after injury (this is how things heal), the lips are uniquely different from what occurs in skin…because they are not skin. Lips are a combination of wet and dry mucosa which is much thinner and more elastic than skin. It has to be so that the lips can be flexible. There is a reason that you can pull on your lips and really stretch them out without tearing them. (up to a point) Wet mucosa is more flexible than the dry mucosa which is the part of the upper and lower lips that we externally see.

The thinness of mucosa, particularly the dry mucosa, makes it very susceptible to forming a thicker scar. This can particularly occur with many lip lacerations which are often left to heal on their own. Such secondary healing almost always leads to a thicker area which disrupts the smoothness of the horizontal lip lines.

Lip scars can easily be re-excised and closed with successful smoothing of the lip line. Lip scar revisions can usually be done under local anesthesia.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I had my face injected with fat and it was initially overfilled. The doctor that did it said it would go down and look more normal but it has not. Can anything be done to make the fat go away or at least become less full?

A: Fat injections to the face is a good and safe technique for adding soft tissue volume to specific areas. Its almost sole problem is that its volume retention (aka how much survives) is not completely predictable. Studies have shown that certain areas of the face do retain transplanted fat better than others. For example, the cheek and side of the face do much better than that of the lips. Thus, it is standard practice to overfill or add more volume than one thinks is really necessary. How much one should overfill has never been precisely defined. Some plastic surgeons may do it just a little, others may significantly overfill.

Despite overfilling, the most persistent fat injection problem is that not enough ultimately remains. It is rare, but I have seen it, that too much fat remains. One should wait at least 3 months after facial fat injections to judge the outcome. By then, one is most likely looking at how much fat volume will be maintained.

There are two basic methods for reducing overfilled fat facial areas. If the location permits, ‘micro-liposuction’ can be done if a small incision can be cosmetically tolerated. The other approach is using injection therapy. I have seen successful use of either a steroid (Kenalog or triamcinolone) or very dilute Lipodissolve solutions. (phosphatidylcholine)  The two can be combined together to create a mild fat dissolving solution that does not cause a lot of facial swelling afterwards. Injection therapy as the advantage of a non-surgical approach in which the treatment can be done in very discrete spots. It is also a more gradual process that lowers the risk of removing too much fat and causing the reverse contour problem.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Can you undo cheek dimple surgery I had done about 10 years ago? If so, how is it done?

A: The surgical making of cheek dimples is different from what causes natural cheek dimples. Anatomically, natural cheek dimples have been shown to be present from a split in the zygomaticus nuscle which runs from the upper lip to the cheek above. Because of this natural split in the muscle, the overlying soft tissues are pulled down or tethered into the split muscle, creating an overlying indentation in the cheek. Depending upon the size of the muscle split and the amount of tethering, this is why some dimples don’t appear until one is smiling or those that have them at facial rest get much deeper with smiling. The surgical creation of cheek dimples is done by going from inside the mouth, splitting between the zygomaticus muscle, and sewing the underside of the desired spot on the cheek down to the muscle.

Reversing cheek dimples is a matter of releasing the tethered skin and placing something between the skin and the muscle as a soft tissue filler or spacer. The best filler for that, in my opinion, is fat. The easiest and most convenient place to harvest fat is the buccal fat pad which is anatomically close to where one would be working for the cheek dimple release.

In natural cheek dimples, or in surgically created ones of long-standing, the result will be a softening or less prominent depth of the dimple. This is because some of the dimple presence is due to inverted or indented  skin, which an intraoral approach alone will not solve. The skin also could be completely leveled but this would require a skin incision to do so. This creates a small scar in the skin as a replacement for the dimple which may or may not be a good trade-off.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I am unhappy with what was done to my jaw angles. The procedure was done using a saw-like tool that was used to cut off bone from my jaw angles. I think they took too much bone. I don’t want to go back to exactly the way my jaw angle was before, however, I would like to get some prominence back. I think too much was shaved down and it looks too weak now. Also, both sides are uneven so my left and right  profiles do not match which just shows how much my last surgeon was lacking in skill and technique. What can be done now to fix it?

A:  Jaw angle reduction is done for prominent or flaring jaw angles which make the lower face too square. This is most commonly done in Asian populations due to their ethnically more square facial shapes. From inside the mouth, am oscillating saw is used to remove the tip of the jaw angle in an angulated bone. How much bone to remove and how steep to make the angle of the cut is a matter of intraoperative  judgment and experience.

Restoring a now too obtuse and short jaw angle can be done with jaw angle implants. Placed from inside the mouth, the implants are inserted under the muscle back over where the bone had been cut out. The implant’s size and shape, like the original bone cut, is a matter of aesthetic judgment. While the jaw angle implant’s size should be small, positioning them to correct jaw angle asymmetry requires precise and secure placement. Using a panorex x-ray before surgery, measurements can be taken to get a good idea about the differences in bone shape around the jaw angle. This can be useful to appreciate when placing the implants as both sides can not be seen at the same time.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I don’t have a butt and my tail bone sticks out further then my butt. I have an pronounced tail bone and don’t have a butt. It hurts to sit long periods of time because of my tail bone and having no butt. My butt is really small and has no outside fat or butt to it. I can never find pants to fit because of having no butt to hold them up. I don’t wear bathing suits because of what little butt I have. I am 26 years old and would like to have a butt and not be embarrassed to wear tight jeans and/or a nice bathing suit in the summer time. I would like to see if you can help me with this. I had Ricket’s as a child and that is why I didn’t grow a butt. That is what the doctor’s told me and I would like to finally have a nice butt. Please help me if you can.

A: Buttock augmentation can be done by either injecting your own fat or using synthetic implants. While I usually prefer fat injections for buttock enlargement in my Indianapolis plastic surgery practice, there are certain limitations to its use. You have to have enough fat to harvest for transfer and there has to be some subcutaneous fat in your buttocks to put fat into. Fat grafts need an adequate fat bed to be implanted and grow. With absolutely no buttock substance at all (completely flat), fat injections are not a viable option. With such lack of buttock volume, the body habitus of such patients is that they would not have adequate fat to harvest anyway.

Buttock implants are the only option with such severe buttock hypoplasia. While the recovery and risks of buttock implants are important to consider, their submuscular placement is necessary if any significant buttock enlargement is to be obtained in a very thin patient. 

Dr. Barry Eppley

Indianapolis, Indiana

Q:  I am a 31yr old mother of two kids. I got out of a five year relationship where I got too comfortable and gained a lot of weight. About six months ago I started working out and lost over 30lbs along with a strict diet. I still have about 25lbs to go to reach my goal weight but I know that dieting alone will not give me the final results I want. I am interested in a tummy tuck, a monsplasty, and breast augmentation. I was born with one breast about 1 cup size bigger. I would like them to be equal in size along with a lift. Can all of these procedures be done in a single operation?

A: Congratulations on the results you have obtained so far. It is always surprising what effort and discipline can do for one’s weight. You should be proud that you have gotten this far. In pursuit of your goal weight, think of the plastic surgery as an incentive to get there.

The first step in body contouring is weight loss but this alone is often not enough to get the shape that one wants. There is no better combination than a combined breast and abdominal procedure to change a woman’s appearance between the shoulders and the waistline. In a few hours of surgery, some dramatic changes can be obtained. Putting these two operations together is very common and I have done it many times in my Indianapolis plastic surgery practice.  Breast enhancement and tummy tucks together can still be done as  an outpatient procedure.

Many larger tummy tucks require reduction of a large mons at the same time. It is done as part of the tummy tuck by modifying the location and orientation of the lower incision. Complete mons reduction may still require a secondary liposuction procedure for optimal flattening. Breast enhancement in most significant weight loss patients requires a combined lift with an implant, known as an augmentation mastopexy.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Where to start? I had a chin reduction at a hospital overseas in 1992. I have never been happy with it. I have always been so self conscious that it looks odd to people when they see me from certain angles. I also felt that it was too extreme and not what I had pictured the result would look like. I also have a metalplate in my chin and too much fatty tissue in the front chin area. Is it possible to have the chin operation redone so it looks better? Or is a chin implant the answer for me?

A:  Chin reductions can create unhappy results if not done properly. When you reduce bony support, you have to account for the overlying soft tissue. Reducing bone requires stripping off all of the chin pad tissues, there must be a way to satisfactorily reattach it and reduce or tighten these soft tissues. If not done, the chin bag will sag down and look like a lump of fatty tissue. Doing a chin reduction without simultaneous soft tissue management is akin to doing a breast reduction but without reducing and tightening the loose overlying skin.

There are three approaches to managing a sagging or ptotic chin pad. They include an intraoral muscle resuspension, a submental chin tuck-up, and the placement of a chin implant. Which approach is best depends on how on much the chin pad sags and one’s facial profile and appearance.  If one is happy with their profile (chin not deficient), then either a muscle suspension or a submental tuck-up will work. The difference between the two depends on much tissue there is to tighten and whether one can accept a scar under the chin. If one feels that their horizontal chin position is short, then a chin implant would be preferable.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I want to get my outie turned into an inne bellybutton. I don’t care for how it looks now, I think it looks weird. I have always wanted to get it fixed so I could look like everyone else. Can you tell me about how this is done and what is involved?

A: Belly buttons are nothing more the formation of scar and is actually the body’s first scar. The umbilical cord, which supplied precious nutrients to the unborn baby, is clamped off shortly after birth. It is clamped off an inch or two from where it exits from the baby’s stomach and the placenta and much of the cord is removed. The remaining stalk of the umbilical cord goes on to die and fall off, leaving a small scar we know as the belly button. For most people (90%), the scar is concave and is an innie. For the remaining 10%, the scar tissue protrudes slightly from the body creating an outie.

An outie can be changed to an innie with an umbilicoplasty procedure. This is a small outpatient operation done under IV sedation or local anesthesia. A small incision is made on the inside of the belly button. Scar tissue between the underside of the bellybutton and the abdominal wall is removed. The underside of the outie is then swen down to the abdominal wall, changing its appearance to an innie. Dissolveable sutures are used and the only dressing is a band-aid. One can shower the next day and not worry about getting the area wet. One should avoid strenuous exercise for one week and no sit-ups or crunches for one month after the procedure.

In women who have had children, their outie could be an umbilical hernia particularly if it did not exist prior to pregnancies. This is a common finding during tummy tuck surgery. Since you are a male, your outie is unlikely to be a hernia.

Dr. Barry Eppley

Indianapolis, Indiana

Watching the crowd today at the Indy 500 in 90 degree heat with open skies, many no doubt wished that they had a better sunscreen. Perhaps some wished they had some sunscreen, any sunscreen for that matter. But for those who had the forethought to pull some sunscreen out of the closet or buy some on the way to the race, they probably couldn’t tell the difference between the numerous brands. The usual public mindset is that they are pretty much all the same and slathering on something is better than nothing at all.

What most people don’t know is that most sunscreens only protect against ultraviolet B rays. Most sunscreens don’t provide sufficient protection against skin damage that is caused by a much larger percent of the ultraviolet spectrum, ultraviolet A rays. (UVA) It is these UVA rays that contribute to wrinkling, freckling, brown spots and skin cancer since they are the same strength all year, all day long. They penetrate glass and is why your left face and left arm frequently develop greater skin damage from the sun exposure gotten during decades of driving.

While some sunscreen manufacturers now carry combined UVA and UVB protection ingredients, the lack of FDA regulation makes their claims confusing and often misleading. One would think that the same federal agency that regulates medical drugs would have long ago set standards for sunscreen performance and ingredients. But that is not the case. This is particularly peculiar given that every other industrialized nation uses UVA protection with specific guidelines. The FDA has stated that they will be releasing sunscreen recommendations in the fall. But until then another summer will pass with most people not knowing what they are actually putting on their skin.

If you are a teenager or in your 20s, the thought of skin cancer is as remote as the need for Botox or developing an unflattering neck wattle. But recent statistics show that more than 2 million people in the United States are diagnosed with skin cancer per year. This is an almost shocking two to three times increase from just twenty years ago. And most of these are directly related to sun exposure. The seeds of these skin cancers are sewn at the very age when one thinks the least about it.

The myths of sunscreen claims are numerous. Besides not knowing whether they really are as effective at blocking the sun rays as they state, many other label claims are more than just misleading. Such proclamations as ‘all day protection’, ‘waterproof’ and ‘sweatproof’ have no scientific basis and are simply not true.

The only reliable sunscreen claim is SPF (sun protection factor) which  blocks UVB rays. But manufacturers use this well recognized sunblock factor to sell more sunscreen. With common SPF numbers of 15, 30, 45 and greater, one would logically think that the sunburn protection would be substantially better as the number gets higher. But the truth is that SPF 15 blocks 94% UVB and  SPF 30 blocks 97% UVB. Beyond that there is no real improvement in sun ray blocking effect.

Until the FDA regulates sunscreen, the best approach is to use a dual protection UVB/UVA combination that is SPF 30 rated. UVA blockers avobenzene and meroxyl are becoming more widely used now in these broader spectrum sunscreens and they may last up to five hours. Reapplication should be done if the one sweats heavily or goes swimming. They are certainly pricier than what most are used to paying for it but is worth it for not getting skin cancer. 

 Dr. Barry Eppley

Indianapolis, Indiana

Q: I am 65 years old and am extremely bothered by my turkey wattle. I do not look my age except this makes me very self conscious. I want to get rid of it with some type of neck procedure. What do you recommend?

A: Sagging or drooping of one’s neck is one of the most bothersome features of facial aging. While some people would never consider undergoing a ‘facelift’, they want some type of neck procedure to deal with their most troublesome age-related issue.

Aging necks are referred to many uncomplimentary names such as turkey neck and neck wattle. Some people become initially aware of it when they see themselves in profile in a photograph. Others notice it, particularly men, when wearing certain shirts and certainly in a shirt and tie. Others do not like, understandably, that it can be felt to move or flop when turning their head. (in more advanced aging)

Interestingly, some people would consider a necklift but wouldn’t dare undergo a facelift. This comes from a misunderstanding of the two procedures, not realizing that they are largely one and the same.  I have found only a handful of patients in my Indianapolis plastic surgery practice who actually knew what a facelift really was.

A facelift is primarily a necklift. The type of facelift determines how much improvement in the neck is obtained. A limited facelift (aka Lifestyle Lift) has a minor effect on neck sagging and is best for just minor neck problems. It is primarily a jowl changing procedure. A full facelift is a powperful changer of the aging neck. The differerence between the two is the location and extent of the incisions around the ears. To really change the neck in more significant wattles and sagging, the facelift must have an incision that goes up behind the ear and back into the occipital scalp. It is the pull from behind the ear that changes the neck. You can demonstrate this quite simply with your fingers in front of a mirror. A manuever that many patients with aging faces have done regularly.

Dr. Barry Eppley

Indianapolis Indiana

Q: I have a large bump on my nose and a long pointy nose to boot. My girlfriend tells me it looks ‘birdlike’. I also have trouble breathing through the right side of my nose. Can you help me get my health insurance to pay for my nose surgery?

A: Nose surgery can be divided into two areas, internal and external. Internal nasal surgery, often called septoplasty, is done to try and improve one’s breathing through the nose. This usually involves straightening of a crooked septum (septoplasty) and reduction of the size of the inferior turbinate bones. (turbinectomy) External nasal surgery, known as rhinoplasty, is done to change the shape of the visible external nose. When internal and external nasal surgery is done together, which is common, is called septorhinoplasty.

Internal nasal surgery is almost always covered by health insurance because its purpose is to improve a medical function, breathing through the nose. External or rhinoplasty surgery is not covered by insurance because it is changing appearance which is a cosmetic objective…unless the shape of the nose is the result of a traumatic injury, a birth defect (such as cleft lip and palate) or from removal of cancer.

Many patients are under the false belief that they can get their rhinoplasty covered by insurance because they have trouble breathing through their nose. While the breathing part may be covered, the rhinoplasty portion is the responsibility of the patient.  The costs of that portion of the nose operation is given to patients in advance of the surgery date as it has to be paid prior to surgery being performed.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  have a older button style chin implant and would like to replace it with a new one. I want a chin implant that creates a more masculine look with lateral fullness in the mandible area and a more squared off appearance to the chin. I would also like to have a lip reduction to rebalance my facial proportions so that the jaw line is more prominent and the lips less so. Let me know if this is something you can do all at the same time.

A: Older style chin implants were much smaller in size and ‘non-anatomic’ in shape. They usually just fit over the central part or button of the chin, providing only central horizontal augmentation. While such chin augmentation shape can be acceptable in some patients (usually females), it does not provide the best chin shape in most males. It makes the frontal chin shape too triangular. In men, squaring of the chin shape produces a much more pleasing facial change. While profile views shows good horizontal advancement, patients do not usually see themselves that way and using that view as a judgment of the final result can be deceiving.

Today, chin implants come in a wide variety of styles and shapes that can achieve more than just a simple gain in profile lengthening. Men, in particular, often want a more masculine chin look which means a more square frontal shape and one that blends into the side of the jaw without an obvious transition. In addition, some increase in vertical length is often aesthetically desireable.

Chin implants can easily be exchanged in styles and size, regardless of whether they were placed from under the chin (my preference) or through the mouth. Pocket size and positioning may need to be altered but this does not usually involve the extent of dissection and postoperative discomfort that occurred from the first chin implant placement procedure.

Lip procedures can easily be done at the time of chin augmentation, particularly if the path of implant insertion is done from under the chin. (submental incision)

Dr. Barry Eppley

Indianapolis, Indiana

Q: I was in a car accident several years ago and had some bad lacerations to my face. While they were sutured up by a plastic surgeon thaty same day, they have turned into some bad-looking scars. I would really like them to look a lot better. I know they can not be made to go completely away but do you think laser surgery would help? Thanks for your time.

A: The use of lasers in scar revision is useful but largely over rated. Lasers are not a magic tool for erasing scars or other skin imperfections. The public’s perception of that highly desirous quality is a function of adventurous marketing and the ‘Star Wars’ effect which still persists even today.

Most scars are a full-thickness skin injury, meaning what you see on the outside exists the whole way through the skin. Lasers are a partial-thickness skin removing tool. As a result, it is easy to see why a laser can not remove a scar. The problem and the solution are not well-matched.

Lasers have a role is scar revision but it is more for creating a smoothing effect and often is used after other scar treatments are done. The most common scar treatment is surgical excision, cutting out the scar (full-thickness) and making the scar line thinner or changing the way the scar line runs.

Because of their more superficial effect, lasers are better at removing or lessening wrinkles and other more minor skin imperfections.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am tired of looking older. My jowls are getting bigger and my neck is starting to really sag. I hate to consider the thought of a plastic surgery procedure like a necklift but I am going to have to do something in the near future. I don’t mind getting old per se, I just don’t want to look old! I have read that there are different types of facelifting procedures. How do I know which one will work for me?

A: A facelift is a plastic surgery operation that changes the lower third of the face, the neck and jowls only. So it is a good match for the jowl and neck issues which bother you. Like many plastic surgery procedures, there are different ways to do them and they come in different ‘varieties’. No one type of facelift is right for everyone. Your plastic surgeon must ‘match the solution to the problem.’

Fundamentally, a full facelift changes both the neck and jowls and is best for someone whose primary problem is their neck. The jowls get improved as well and get swept alone in the changes that occur far away in the neck. The mini-facelift, aka Lifestyle Lift as called by some, changes the jowls primarily and a little bit of the neck. Any limited improvement in the neck is the result of the changes that have occurred in the jowls. The mini- or limited facelift is best for someone whose primary concern is in their jowls. Since jowling proceeds any significant changes in the neck, one can appreciate why a limited facelift is for younger people who have less signs of facial aging.

Another way to think about it is by looking at the incisional pattern around the ears. Mini-facelifts have use an incision that runs into and around the front the ear. Pulling upward from there only impacts the jowls primarily. A full facelift uses incisions in front of and behind the ear. By moving tissue upward from behind the ear, excess neck skin can be worked out to be cut off behind the ear. 

Dr. Barry Eppley

Indianapolis Indiana