Your Questions

Q: I have always wanted plastic surgery but can’t afford it. I have not aged well and I think it would make me feel better about myself. Do you know where I can get it for free? I would be willing to be a guinea pig to let someone learn on me. I would be willing to let them use an extra skin removed from me for help in reconstruction of burn victims.

A: Interest in cosmetic surgery continues to increase. While there are some people who say they wouldn’t subject themselves to something as vain or as drastic as plastic surgery, most people do not feel that way. In a recent online surgery of over 2,000 people done on behalf of theWeb community RealSelf.com, they  reported that more than two-thirds (69 percent to be exact) said they would choose to undergo cosmetic surgery if they had the money. Perhaps to no surprise, a lot more people would have cosmetic surgery if money wasn’t the limiting step. I suspect in this group that some of those state opposition to plastic surgery would change their mind.

The bottom line is that there is no place where cosmetic surgery is done for free. There are costs involved, beyond the plastic surgeon’s time, that are incurred in surgery. In addition, there are medicolegal risks and exposure that one would not risk for no reimbursement. There was a time, years ago, when plastic surgery training programs did do cosmetic surgery for free for the educational experience of the residents and fellows. But that time has long passed and will not likely be seen again.

By the way, a patient can not use someone else’s skin for reconstruction. It would be rejected and cause infection. Skin can only be used from yourself.

Dr. Barry Eppley

Q: I am interested in corner-of-the-mouth lift surgery? I tried injections to turn up the corners of the mouth but that didn’t work. Then I went to a plastic surgeon who told me a facelift would make the corner of my mouth look better…and it didn’t! Since injectable fillers and a facelift didn’t work, I read about this procedure on the corner of the mouth. That seems like it would work. Can you tell me about the scars? Thanks!

A: For the downturned corner of the mouth (frowning or upside down U-shaped smile line), neither injectable fillers or a facelift will be successful. Either one may help a little but not generally for mouth corners that are more than just a little down.

The corner of the mouth lift is a simple but very effective procedure for leveling out the smile line. While it is a very small procedure, it can easily be overdone if the plastic surgeon is not careful and go the other way, up too high. (i.e., joker’s smile) By removing a small triangle or heart-shaped piece of skin just above the corners of the mouth, the tail of the smile line is brought. This does result in a small scar, about 7mms or so, off of the corner of the mouth that points up in the direction of the ear. But it is a very small scar that fades quite quickly.

A corner of the mouth lift can be done at the same time as a facelift or can be done as a stand alone procedure. When done by itself, it can be done under local anesthesia in the office. There is no recovery or any significant swelling or bruising. Tiny sutures are removed in a week or for out-of-town patients only small dissolveable sutures are used.

The corner of the mouth lift is a ‘cute’ little procedure that really can make quite a difference in one’s smile.

Dr. Barry Eppley

Q: I am interested in getting a tummy tuck. I have had two children and do not want any more. I can not get rid of this lower stomach pouch no matter what I do. A tummy tuck would do the trick but I am concerned about the scar. I am Hispanic and I am afraid I might scar badly. My c-section scar looks great so I seem to scar well. Will my tummy tuck scar look the same? I know it will be longer but will it look so fine and narrow?

A: While there are many factors that influence how a scar will ultimately look, one of the most important is that of tension. How tight is the wound on closure. A wound closed under tension will usually develop a scar that is somewhat wider  than one that is not.

The concept of wound tension is what differentiates the c-section vs an abdominoplasty scar. C-sections are closed under absolutely no tension. They literally fall together loosely because of the expanded abdominal skin. This is why they usually look so good no matter how or by whom they were closed. A tummy tuck, however, is quite a different story. It is closed under considerable tension and requires the closure skills and training of a plastic surgeon to get a scar that may approximate that of a c-section. A good c-section scar is not necessarily a good predictor of what a tummy tuck may look like.

While scar outcomes are not always predictable, darker pigmented skin may widen and hyperpigment more than skin with less pigment. This is the risk of an abdominoplasty scar in one of Hispanic origin. Always remember that a tummy tuck is a trade-off, getting rid of that loose skin and fat with a better waistline for a scar. A scar is still an imperfection but, hopefully, one that is more tolerable.

Dr. Barry Eppley

Q: I  have read numerous blogs that talk about the value of facial exercises. With so many debates on this subject, I wonder if there is any benefit to doing facial exercises to tone up the face. Plastic surgery seems so drastic.

A: Much has been written over the past fifty years about using exercise to lift up a sagging aging face…or to prevent it from happening. This concept is not new. I have an original copy of a book entitled ‘Lifting Up Your Face’ from 1951. The more recent books that I have seen today in the book stores are beautifully done, and even have their own DVDs in the cover, but they are just modern re-inventions of this original concept.

It is certainly reasonable to do anything to avoid actual surgery, if it has some benefit. The problem that I have with facial exercising is three-fold. First, most of the signs of facial aging that are bothersome to people (appearance of jowls, loose skin in the neck, dropping brows, etc) are not muscular in origin. They did not occur because the muscles were loose and sagging. Anatomically, they are the result of the skin and the subcutaneous fat becoming loose and sliding off of the deeper tissues. That is not something that muscle tightening, even if it were possible with facial exercises, can really treat or prevent. Secondly, all facial wrinkles that develop are the result of muscle movement. That is why Botox is so popular, because it decreases this wrinkle-causing muscle movement. Moving those muscles a lot more through facial exercising will likely increase, not decrease the age signs of wrinkling. Lastly, I have yet to see adequate before and after photographs of believeable results from any facial exercising program. The photographs shown are never standardized. There are always some subtle changes in angle and lighting that can make a big difference in how the result looks. We know this very well in plastic surgery. It is very easy, intentional or not, to have an after result that appears to show a facial change that does not really exist.

For the sake of discussion, however, let’s us assume that there is some minor benefit to facial execising. In most patient cases, it is likely that the result would not be adequate…a lot of effort for a minor improvement. With todays’ minimally invasive and limited downtime facial procedures, they quickly surpass what exercising could do and require less effort. Plastic surgery does not have to be so drastic, one can get a few ‘tweakments’ that can make a real visible difference.

Dr. Barry Eppley

Q: I had breast implants done about 8 to 9 years ago and am looking to have them redone. Thr original size was 600cc implants. I am between D and DD cup size I think…but it depends 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 as a hobby. I think it would balance my shape better.

A: Breast implant size is a personal choice and no one can really say what size someone should or should not be. Breast implants of 600cc size can be big or not so big depending upon whose chest they are on. For a small person this could be fairly large, for a bigger and broader-chested woman this may only be average looking in size. Most women are interested in having breasts that are in proportion to the size of their body but a few women want more than that.

Within reason, just about any breast implant size can be put in any patient. Whether that final size is in or out of proportion, or what someone really desires, is up to the patient to judge. In my Indianapolis plastic surgery practice, I try and accomodate a woman’s breast implant size desires. That being said, women should know that there are potential long-term consequences for having large breast implants. (i.e., extreme breast augmentation) Over time, the weight and size of the implant may cause tissues to stretch out and a ‘bottoming out’ of the implant may occur as the implant falls on the chest wall. This is known as loss of tissue support. This is why as a general rule it is wise to keep the base width size of the implant within the natural breast base width. Also remember, it is easy to go up in size without significant scar consequences. Should one day the desire arises to go smaller, there will be significant breast scars to remove and tighten the loose skin that the implant has created.

Dr. Barry Eppley

Q : I have one ear that sticks out more than the other. My right ear is just fine and looks good. But the top of my left ear sticks out further than the right and it bothers me. This seems like it would be a simple thing to fix. How is it done? Does it require surgery to fix it?

A: The position of the ear and its angular relationship to the side of the head is the result of the shape of the ear cartilage. The ear cartilage has many folds and grooves. If one of these folds is not quite bent or shaped symmetrically, the ear will stick out further from the side of the head.

Otoplasty, or ear cartilage reshaping, is done but rebending the ear with sutures from an incision on the backside of the ear. With this technique, much of the ear can be brought back and made less prominent. When only one part of the ear is protruding out, a single suture can usually solve the problem. ‘Mini-otoplasties’ can be done under local anesthesia in the office in a short period of time. There are no dressings to wear afterwards. One does have to be careful not to pull on the ear or traumatize it in the first months after surgery to prevent dislodging the retaining suture as the ear heals.  

Dr. Barry Eppley

Q: I am really curious about brow bone shaping. I am wondering if it is possible to lower the brow bone. My concern is that the distance between my eyes and brow bone is very large and therefore my mid face looks very long. I want to shorten this and I think one of the most effective ways would be to lower the brow bone. Is this possible? How is it done, etc?

A: The brow bone is traditionally reshaped because it is too prominent. The so-called Neanderthal look occurs due to excessive growth of the frontal sinus which causes the outer table of the brow bone to stick out. This can be reduced by setting back this outer table of brow bone.

The brow bone can also be built up by various materials should it be underdeveloped or deformed from a traumatic injury.

Lowering the brow bone is a very unusual request as the need to do it is very rare. But the lower edge of the brow bone, however, can be brought lower. This is not done by moving the bone though. The lower edge of the brow bone can be built up with an implant material that is secured to the bone with very tiny screws. The implant is custom-carved during surgery to make an exact as fit as possible. This would be done through an upper eyelid (blepharoplasty) incision. Whether this would actually make the eyebrows look lower or create the effect that one wants is uncertain.

Besides considering a build-up of the lower brow bone, there are other considerations such as dermal-fat grafting to the upper eyelid sulcus which may create the same desired effect. I would have to see photos to make a more educated opinion on what is possible.

Dr. Barry Eppley

Q : Hi Dr Eppley, I am inquiring about how to reduce a long forehead. My forehead is so long it is ridiculous. I have good hair but my hairline is so far back I can’t wear my hair pulled back. My forehead also has a bulge in it near the hairline which makes it look like it is even back further. I have heard that a plastic surgery procedure exists that can pull my hairline forward. Is this possible?

A: The typical distance for most people between their eyebrows and their hairline (forehead length) is up to 7 cms. When that distance is greater than that, most people would consider it to be a long forehead. In actuality, however, if one thinks that they have too much forehead skin then they do.

One’s forehead can be shortened through a skin excision procedure. The skin is removed in front of the hairline and the scalp hair brought forward in its place. In essence, this is a reverse browlift. The amount of scalp advancement can be up to 2 cms to 2.5 cms without any problem. More can sometimes be obtained by a very posterior scalp elevation at the subgaleal level the whole back to the occiput. Even more than that can be obtained by a two-stage procedure using a tissue expander although this is reserved only for the most severe cases.

The trade-off for a forehead reduction is a fine line scar along the hairline. As long as one has reasonable hair density and hair quality this is not a concern. With the forehead bone exposed, any bony contouring or reduction can be done at the same time.

Dr. Barry Eppley

Q : I would like perky and fuller breasts. I have had three children and my breasts have just lost everything. They are so saggy and droopy they are disgusting. I am so embarrassed about them I won’t even let my husband see them. My right breast is also different than the left. It is bigger and more saggy and the nipple is much bigger. I know I want implants but I think I may some sort of lift too. Can you tell me how bad the scars will be?

A: The need for a lift with the use of breast implants can be determined by one simple anatomic measurement…where does the nipple sit relative to the lower breast fold. (inframammary crease) If the nipple is above this level, an implant alone will give the breast a good shape with the nipple reasonably centered on the new larger mound. If the nipple sits at or below the fold, then an implant will make the breast bigger but the nipple will be on the ‘southside’ of the mound. (i.e., pointing downward)

There are essentially four types of breast lifts based on how much the nipple needs to move upward. They are with their resultant scars; type 1 superior nipple lift (scar on top part of nipple), type 2 circumareolar lift (scar 360 degrees around the nipple), type 3 vertical breast lift (scar around the nipple and vertically down to the fold) and type 4 full breast lift. (around the nipple and vertically down into the fold and then horizontally along the fold, an anchor scar pattern)

In general, breast lift scars usually turn out pretty well. The scars around the nipple and along the inframammary fold do the best. If a vertical breast scar is needed between the nipple and the fold, this is the one that has the most potential to widen due to the constant pulling by the weight of the breast against the scar. Most breast lift scars revisions involve that scar if needed.

Dr. Barry Eppley

Q : I would love to sign up for some free plastic surgery. I have never been happy with the way I look. My ex-boyfriends always told me I’m not good enough for them and they could do better. I always wanted plastic surgery but with no money and no time to work extra hours. I’m a single parent of three and try to give them the best. My time and money is for them, they are my life. I’m unable to save for surgery. Please contact me and let me know what I need to do.

A: The possibility of free plastic surgery is certainly appealing. Like a winning lottery ticket, the opportunity to be able to ‘afford’ something you could not previously is intriguing to say the least. But unfortunately, real life is not like a television show. Extreme makeovers for free really only do exist on the television screen. It simply is not provided by any plastic surgeon in any community.

There are a variety of reasons plastic surgeon do not provide cosmetic surgery for free. First and foremost, cosmetic surgery does not usually improve any medical function. Yes it is true it will make one feel a whole lot better about themselves but that is different than reconstructive surgery where the origin of the problem is from a birth defect, cancer, or a traumatic injury. Patients in need of reconstructive surgery are more in need than that of any cosmetic concern. Plastic surgeons have a long history of being very benevolent with their services for reconstructive surgery. Secondly, there are more costs involved than just the plastic surgeon’s time or expertise. The use of the operating room and an anesthesiologist (if needed) must be accounted for.  Those providing these costs do not feel or have any obligation to give away their materials and labor. Lastly, free cosmetic surgery does not waive the plastic surgeon from medicolegal liability and exposure. Why should a plastic surgeon assume those financial and professional risks without compensation?

Board-certified plastic surgeons also cannot provide cosmetic surgery as a prize from a contest or giveaway. This is an ethical violation as a member of the American Society of Plastic Surgeons. While many cosmetic surgeons from different specialities freely do promote such contest prizes, board-certified plastic surgeons can not do so.

Dr. Barry Eppley

As people age, two of the most noteworthy and bothersome facial changes is what occurs along the jaw line and neck. These two changes are usually progressive, first comes the jowls then goes the neck.  Like wax melting off of a candle, cheek skin and fat begins to slide off of the face creating those fleshy droopy folds at the jaw line known as the jowls. Recent research also indicates that it is more than just gravity that causes jowls, it is the shrinking of facial fat as well.

The appearance of jowls will eventually occur in everyone with enough time. Jowling creates an undesireable change in facial shape, making it wider and more rectangular in the lower face which is characteristic of  an older person. It also causes a distinct disruption of a smooth jaw line from the chin on back, which is characteristic of a more youthful appearance.

Jowl correction is generally part of a facelift procedure. This is done during a facelift by either trimming the jowl fat, suturing the jowl fat back up to a higher level,  or some combination of both of these manuevers. Facelifting is a relatively common procedure as evidenced by the 95,000 performed in the U.S. in 2009 according to the American Society of Plastic Surgery.

When only jowls are present and the neck has minimal loose skin, a different variation of a facelift can be done. Scaling back the ‘size’ of the facelift procedure can very effectively eliminate those troublesome jowls. Known by a wide variety of different names, the limited or downsized facelift tucks up the hanging loose jowls with very minimal recovery. Unlike a traditional facelift where incisions are made in front of and on the back of the ears, the jowl facelift only uses a fine incision in the front. The lack of any significant recovery is noted by the different names that are used to describe it, such as Lifestyle Lift, Swiftlift and EZ Lift. Expect one week for the significant recovery period of some mild swelling and bruising.

One of the great advantages of a jowl lift or ‘short scar facelift’ is that it also addresses a common facelift fear, that of looking unnatural. Few patients that I have ever met want to look like they have had  a facelift.  These procedures have no risk of that ever happening as they deliver a more subtle and less dramatic result. One will never look have that windwept or overdone look as, by definition, the procedure is more limited.

Q: Hi Dr. Eppley. I am a 56 yr old female and I am interested in liposuction for my arms. I am currently losing weight and have lost just about 25 pounds. My current weight is 186 and my question is… do I need to wait till I have lost all the weight I want to lose or could I have liposuction on my arms now? I am exercising on a regular basis, but I am seeing very little if any progress on my arms. I am having to cover my arms as much as possible and I so want to wear sleeveless tops. I have researched this subject and have read where liposuction of the arms produces  “only modest improvement”. Would I even benefit from such a procedure?

A: Like all liposuction, but particularly in the arms, patient selection is key for a satisfactory result. The real question is what is making your arms big? Is it fat alone, extra skin or a combination of both? Conversely, a good question is how much improvement is needed to make a visible difference? How much change is necessary to be able for you to comfortably wear sleeveless tops again? That is the bottom line question and objective.

While I can not obviously see your arms, I have never seen any patient at a weight of 186 lbs where fat removal alone with liposuction will produce a significant arm contour change, particularly in someone losing weight. Significant arm changes at this size require both skin and fat removal, otherwise known as an armlift or brachioplasty. That procedure can make a dramatic arm change at the price of a scar running down the backside of the arms. More likely your decision is whether an arm scar is a good trade-off for a noticeable arm improvement.

Dr. Barry Eppley

There are many reasons why people undergo plastic surgery. The desire for self-improvement is the most compelling but the underlying motivation for such an emotional decision is never quite that simple. In a recent study in a prestigious plastic surgery journal,  it was reported that nearly 80 percent of patients surveyed said that part of their decision to have plastic surgery was triggered by television and other media exposures. One television influence prominently noted was that of reality programming. The influence in the last decade of the reality TV concept is undeniable and has focused on everything from cake baking to child rearing..

The early success of ‘Doctor 90210’ and the now defunct   ‘Extreme Makeover’ has fueled many copycats and there does not appear to be an end to the public’s desire for this form of reality plastic surgery. Whether the appeal is similar to the transformations seen on ‘Yard Crashers’ and ‘Rock Solid’ or the fascination of watching others subject themselves to an extensive makeover  is undoubtedly part of it.  I am all for increasing the public’s awareness of the benefits of plastic surgery but the ‘reality’ shown in the little bit of these programs that I have seen doesn’t really reflect the real life experience of the plastic surgery process. 

Just like the entertaining but tragically distorted plastic surgery show, ‘Nip/Tuck’, television is all about entertainment and getting you to watch and rarely about truth. Only the highlighted moments of excitement and results is portrayed, leaving out all of what the producers consider dull filler material. This unshown filler, however, is really what plastic surgery is about. Boring accurate information, such as risks and complications and realistic outcomes, are never portrayed.  What may happen when the plastic surgery doesn’t turn out so well is rarely if ever shown. In fact, some of these shows focus almost exclusively on the eccentricities of the plastic surgeons or their patients. While Dr. Ray may be entertaining, it is never revealed that he has never taken the effort to be board-certified.

Not all plastic surgery programs on TV, however, are badly done.  There are some that are especially informative and insightful. This is the case with the Discovery Channel’s “Plastic Surgery: Before and After.”  It is clear in this type of programming that their intent was educational, not a festive diversion to keep your eyes glued. Rather its intent is to teach, educate, and give us a greater explanation of what cosmetic surgery is all about. That is meaningful time spent about a serious TV subject.

In reality, most patients are not primarily driven to get plastic surgery because of these reality TV programs.  They do it because they have physical imperfections that are bothersome to them. These TV programs are an extension of the often distorted Hollywood world where the pursuit of physical perfection and the fighting of father time is taken to sometimes ridiculous levels.  They promote unhealthy desires such as teenage girls possessed about enlarging their breasts or changing their nose in the hope that this make them famous or get them noticed. Most people may be able to see through the façade of these shows and see them for the trivial entertainment that they are. But impressionable teenagers and insecure adults may not be so discerning. Just like the recently passed Health Care Reform bill, the devil is in the details. The real reality of plastic surgery is in that boring stuff that is hardly worth watching…but is really worth knowing.

Dr. Barry Eppley

Q: I have an inherited double chin that makes me look twice my 46 years of age. Can you make it disappear so I can look younger ??

A: A  ‘disappearing’ act is what we do a lot of in plastic surgery. Whether it be liposuction, chin implant, facelift…or some combination….it certainly can be made to ‘vanish.’ I know that your double chin makes you look older….but I doubt if it makes you look 92!

When patients refer to a ‘double chin’, this means there are at least two and sometimes three rolls of skin if you include the chin as one of the rolls. The double chin is often the result of the combination problem of a full neck and a short chin. In the younger patient, this can be improved by doing chin augmentation and neck liposuction at the same time. When you move two different things in opposite directions, the result becomes greater than when only one is done alone. In an older patient with more loose skin, this diametric action may require chin augmentation and a facelift to get the neck going back and up as the chin comes forward.

If the forward position of the chin is adequate, then the neck alone can be treated. Again, age and the amount of loose skin determines whether liposuction (good skin) or some version of facelift (bad skin) is needed.

Correction of a double chin is highly effective plastic surgery adventure and can make for a dramatic difference in one’s appearance.

Dr. Barry Eppley

Q : I am bothered by the size of my nipples. They stick out too far. It is embarrassing in shirts. They are even noticeable in bras unless they are padded. I often wear nipple pads or ‘dimmers’ so they are not so obvious. I am interested in having them reduced but am afraid of losing all my feeling in them. Can you tell me how this procedure is done?

A: There is no standard size or length for what a nipple should be. But when its length becomes a socially embarrassing issue, then nipple reduction should be considered. Reducing the length of the nipple is a simple procedure that can be done under local anesthesia. It can be done alone or in combination with most forms of breast surgery, most commonly breast implant augmentation.

The nipple can be reduced two different ways depending upon its size, how much reduction one wants to achieve, and if as much feeling as possible wants to be maintained. A wedge excision of the nipple can be done which will reduce its length by at least half if not more. (depends on the size of the wedge) This will eliminate the possibility of breast feeding and some feeling will definitely be lost. (how much can not be predicted) The other option is a circular or donut reduction where a ring of nipple tissue is removed at its base. Breast feeding will still be possible and the least potential for feeling loss is the benefit of this approach.

Either method uses dissolveable sutures with only a band-aid for a dressing. One can shower the next day. There are no restrictions after nipple reduction surgery.   

Dr. Barry Eppley

Q : What kind of headband or sweatband do you have your patients wear after otoplasty? Thanks! How long do you have them wear this?

A: Otoplasty, or pinning back ears, uses internal permanent sutures to reshape the cartilage. This is done from an incision on the backside of the ear. The security of the sutures are very critical until enough scar tissue between the folded ear cartilages forms to act as a ‘cement’ to hold them permanently together. This is usually about six to eight weeks after surgery.

Accidental folding of the ear forward could loosen the sutures or pull them through the cartilage, thus allowing the recoil of the ear cartilages to cause relapse. This risk is largely age and activity dependent and determines whether and how long any form of ear protection should be used. In teenagers and adults, I recommend such ear protection only at night for two weeks where inadvertent turning on one’s side could pop a stitch. In children, ear protection should be used more liberally given their propensity to accidental events. For two weeks after surgery, ear protection is worn round the clock and then only at night for another two weeks.

While plastic surgeons may use a variety of ear protection methods after otoplasty, the simplest and most comfortable is a sweatband or athletic headband. Its soft elastic is comfortable and it is inexpensive. Multiple headbands can be purchased for a few dollars. In addition, its width is only an inch or two which makes it not too hot to wear.

Dr. Barry Eppley

Q: I have been contemplating rhinoplasty for many years.  Only now that I’m approaching my thirties have I decided it’s time to take that step.  Please provide any information you can at your convenience and hopefully we will be in touch.  Thanks.

A: Considering rhinoplasty is a big step given the very significant changes that it can make on your face. When beginning the initial step in the process, you must first consider what plastic surgeon you are going to see and prepare yourself for the initial consultation.

In choosing a plastic surgeon for rhinoplasty, first use the internet as a resource. Look in your geographic area for those plastic surgeons that offer it and do it with regularity. That can usually be gleaned from their practice website. Look for specific photos of their patients and there should be a good number of them showing different types of noses and results. Also look for any articles (blogs) that they may have written about rhinoplasty. Between photos and writings you can gather how concerned and focused they are on rhinoplasty surgery and patients.

In preparation for the consult, write down exactly what you want to achieve from surgery. Saying that you want a better looking nose is obvious, be more specific. What parts of the nose do you not like and how would you like it changed. A written list is always good to see. You may bring pictures of noses that you like but remember those are just suggestions and ideas and can not be reproduced in surgery.You are not the person in the magazine, your face and nose is different. Anything else you do not like about your face can also be brought up as this is an opportune time for that discussion. Also, do you have any trouble breathing through your nose? Functional (internal) nasal surgery is commonly done with changing the appearance of the outside of the nose.

Expect during the consult to have photos taken for computer imaging. This assessment is critical and a review of the suggested changes and results may require a second consult to be sure everyone is on the same page so to speak.

For more detailed information on rhinoplasty, go to my blog, www.exploreplasticsurgery.com and search under rhinoplasty. You will find dozens of helpful articles there.

Dr. Barry Eppley

Q : I had liposuction in December and still have pain in my stomach. Also I have an ugly lump under my chin after my liposuction and facelift. Have you seen such chin lumps before?

A: While liposuction doesn’t look like much from the outside, what goes on inside is quite extensive and traumatic to the fatty tissues. While liposuction can be very effective at fat removal and contouring, full recovery is not quick and really takes time often as long as three months to four months.

As part of this prolonged recovery process, there are some very typical aches, pains, and irregularities which one will experience. While liposuction is not acutely painful, soreness and discomfort persist at different intensities over time. As one gets more active and moves about more, twinges of shooting pain and tightness will occur. This is the stretching out and breaking loose of scar tissue  that has formed as a result of the procedure. The skin over any liposuction-treated area will also be numb. Full feeling will return but again will take months. Some of the those shooting pains may also be nerves that are healing and re-establishing feeling.

One of the very common sequealae of liposuction is the temporary areas of lumpiness or irregularities that will be felt. These are collections of dead fat, scar and blood that have accumulated in an area. These feel very firm and painful to manipulate or massage. They are extremely common in the neck area because of the thinner neck skin and being an easy place to accumulate in the center of the neck. With time, they will get softer and eventually go away. The neck can get quite indurated after liposuction  and will create fullness that temporarily distorts the good result that was seen at the end of surgery. One can massage the neck area several times a day which will help soften it faster.

The recovery after liposuction is a prolonged process and patience is definitely needed. I would not judge the final outcome until you are six months out after your surgery.

Dr. Barry Eppley

Q: I am in the very early stages of looking into treatment for the area under my eyes.  I believe the problem could be easily fixed by the right Dr. and this is my first attempt to find out what is involved and how much it would cost.  The skin directly under each eye is all wrinkled and takes completely away from my appearance and has caused me to be completely self conscious for many years now and if I can do something about it, I would like to.

A:  Aging around the eyes is often one of the first signs that many people notice as they get older. Changes in the lower eyelid are usually more obvious than that of the upper eyelids since they are not hidden or distracted by the eyebrow and are larger by surface area. Since so much of human conversation involves direct eye contact, how our eyes look is seen by all. It is no wonder then that many people seek plastic surgery for an improved and more youthful eye appearance.

While there are many topical creams out there, and they do have some anti-aging merits, they are no replacement for more invasive eyelid skin treatment methods. Depending upon the amount of loose skin that exists on the lower eyelid, some version of a lower blepharoplasty or eyelid tuck can be very helpful. Through a fine line incision along the lower eyelash line which extends slightly out from the corner of the eye, loose skin is removed and the lower eyelid is tightened.

Lower blepharoplasty will definitely help remove some but not all of the eyelid wrinkles. You never want to risk removing too much skin from the lower eyelid in an effort to work out every sinle wrinkle and then end up with a pulling down of the eyelid after. (ectropion) Lower blepharoplasty is an excellent wrinkle reducer but should not be thought of as a complete wrinkle remover.  

Dr. Barry Eppley

Q : Hello Doctor, I had a chin implant in November 2008. It got infected and had to be removed two weeks later. Now after one and a half years later my chin is still loose and stretched, making my chin look like it is hanging and looks weirdly different. I like to find out if there is a way of fixing this by shrinking and tightening my chin that will hold my face together the way it was before. Thank you for your time and help, hope to hear from you very soon.

A: In placing a chin implant, it is necessary to lift the mentalis muscle off of the bone. Like placing a breast implant, this stretchs the overlying tissues out. As a result, if chin implants are ever removed there is a risk of the tissues not shrinking back down and become ptotic. (sagging off the bone) This is a well recognized chin problem whose occurrence is more likely the larger the chin implant that was used. The risk of chin sagging is also greater if the pathway in which the chin implant was originally placed and removed was done from inside the mouth. (this method separates a greater amount of mentalis muscle)

Chin ptosis, also known as a ‘witch’s chin’ deformity, can be corrected through two different methods. If you want to get the effect of greater chin prominence that you were originally after, replacement of a new chin implant or moving the chin bone forward (chin osteotomy) can be done. This will give more chin projection and pick up the sagging chin tissues. If you are not interested in any further chin projection, then the mentalis muscle must be shortened and tightened to readapt the soft tissues back on the chin bone. This can be done either from inside the mouth using resorbable bone anchors or from an incision on the underside of the chin. (submental tuckup)   

Dr. Barry Eppley

Q : Dr. Eppley, I have had silicone gel implants for 31 years and am still very pleased with them.  I am presently 65 years old and in good health.  I regularly had mammograms every two years until five years ago.  At that time, the place where  got my mammograms asked me to sign a disclosure form stating that I would not hold the clinic or technicians responsible if one or both of my implants as a result of the test. This was alarming to me and I walked away without the mammogram and have not had one since! 

I realize that foregoing mammograms is foolish.  My doctor encourages me to have it done even though I have shared my fear.  Is there a better way to examine the breast with silicone implants other than a mammogram?  My breasts are small and when the paddle compresses them, it does feel like the implants could burst especially since they are such old implants. How do we know that the bag that encloses the silicone will not leak or burst? I’ve also had an ultrasound but they said that is not a good substitute and will not detect cancer cells.

Dr. Eppley, if you have any suggestions or answers to these concerns, I would certainly appreciate hearing from you.

A: Your fears about rupture of breast implants with mammograms is understandable, particularly in light of their age. While today’s breast implants have improved shells (the bag containing the implant filler) that are known to be resistant to the compressive forces of mammograms, the physical characteristics of implants thirty years ago are undoubtably less so.

I have seen breast implants of this age before on removal and most of them are either ruptured or no longer have any identifiable shell remaining. (meaning it has completely disintegrated)At thirty-one years of age, it is very likely that your breast implants are already ruptured or the shell is no longer intact. Even in asymptomatic, capsular contracture-free breasts, old breast implants will often, if not usually, not be intact.

That being said, I think your concern about breast implant rupture should not outweigh the potential benefits of mammography. Mammograms are still the simplest and most cost-effective screening tool that exists for breast cancer detection. An MRI of the breast can be done but it is more sensitive to look at whether breast implant rupture exists than to detect breast cancer.  

Dr. Barry Eppley

Q : I am scheduled for facelift surgery and want to do everything to shorten my recovery and have a good result. I have read about the medication Arnica which is supposed to reduce swelling and bruising. I bought some Arnica montana to take 2 weeks before surgery and 2 weeks after and what I found was pills that dissolved on your tongue and should be taken every 30 minutes.   Is that how I should take them? 

A: Arnica, known more formally as Arnica Montana, is a herb extract from the mountain lily flower. It has been used for medicinal purposes for hundreds of years and remains popular today. It is used in the non-drug treatment of muscle aches and to reduce inflammation. In plastic surgery, it is used with the primary intent to reduce bruising. It can be applied topically as a cream or ointment to a bruise or can be taken orally to either prevent or treat bruising. Its effectiveness is more than a medical myth and clinical studies have shown its value. It has not known harmful effects when taken in homeopathic doses.

Oral arnica is what is recommended for elective cosmetic surgery. Because of the visibility of the face, I always recommend to my facial surgery patients that they take it several weeks before and after surgery. It comes in homeopathic doses which are usually given in C units rather than milligrams like prescription drugs. Arnica tablets can usually be gotten in doses of 15C, 30C and 60C. There are no proven differences in  anti-bruising benefits to any of these doses. They are to be taken by placing several tablets under the tongue (sublingual) and letting them dissolve at a frequency of four times per day.

Dr. Barry Eppley

Q: I am wanting to get liposuction and a tummy tuck and I have learned that it is quite expensive. Do people generally pay cash, out right? What financing options are available?

A:  Elective cosmetic plastic surgery is not inexpensive and many people considering it do require some financial assistance. While the concept of financing plastic surgery was once rare, it is not quite common. I have read estimates that in 2000 the number of patients that financed surgery was 5%. Today that number is closer to 40% and growing. For these patients, financing could be the only means to afford their desired plastic surgery procedures.

Most, if not all, plastic surgeons are very familiar with a patient’s request to finance their surgery. This is an everyday event in any busy plastic surgeon’s practice. While the plastic surgeon’s office can assist and guide you through the financing process, plastic surgeons do not directly loan money for surgery. Nor  do they work out a payment plan so that one can have surgery and then pay out off the plastic surgeon over time.  That requires a financing company or back (not usually the best) to work with you to develop the loan amount, interest, and a repayment schedule. Most plastic surgeons are signed up with financing programs that allow you to directly apply to and get very quick responses.  Like a car or appliance purchase, you need to think about making monthly payments over a given period of time 

There are a large number of companies offering plastic surgery financing. In my Indianapolis plastic surgery practice, we use Care Credit and My Surgery Loans, for example. But there are many other options out there that offer medical loans. Simply google the term ‘plastic surgery finiancing’ and a plethora of them will appear. These medical loans are not necessarily based on the procedure you are considering but on a dollar amount. You can then select the procedure you want to have, and depending on your credit ratings, you could be granted different interest terms.

When considering financing plastic surgery, there are three (and potentially four) costs that you need to be aware of. These include the surgeon’s fee, operating room charges, the anesthesiologist’s fee (if general anesthesia is used), and implant charges. (if some form of an implant is being used) Make sure you know all of the fees that will be required of your procedure so you don’t inadvertently get a loan that is not adequate. Your plastic surgeon should give you an estimate (quote) for all the costs of your procedure. Get a consultation and written quote before you ever finance. Do not take the estimated costs off of a website or some verbal exchange.

 Lastly, like all financial and legal documents,  double check the agreement terms, interest rates and re-payment time before signing at the dotted line.

Dr. Barry Eppley

Q: Dr Eppley I have had my lower eye bags and lids done and also had a MAC facelift with liposuction to my neck all at the same time. I now have two eyelids that are different and am not pleased with the result of my lower neck. I went back to see the surgeons yesterday and they said they would have to do the two eyelids again but can’t do the neck any better. I am 65 years old and after reading your article about a low horizontal neck lift I wonder if this is would nto work for me. That procedure has given me hope but I can’t trust my previous surgeons to do it.

A: The MAC facelift, like all forms of limited facelifting, is a great procedure for the right patient. The right patient for it is one that doesn’t have a significant neck problem or a lot of loose neck skin. These limited facelifts are primarily jowl reducing/smoothing procedures with some minor improvements in the neck area. Those improvements are helped through the use of neck liposuction, but the key to getting a good result is that the neck skin must not be too loose.

When one has a more significant neck issue, a full or more traditional facelift procedure is more appriopriate. This is a much more powerful neck procedure. One of the problems with these limited facelifts is that they get used in patients that really should have had a more complete necklifting procedure. As a result, they can often be disappointed with the neck result. I suspect this is what has occurred in your case.

Once can always have a secondary more complete facelift done to improve your neck result. Having had a MAC facelift does not preclude that. Saying that ‘no more can be done’ suggests to me that they are either unwilling or incapable of doing a more complete facelift procedure.

A low horizontal neck lift is always an option and certainly is simpler and easier than reverting to a complete facelift. As long as one can accept a fine line scar in a low neck crease, this could be an option worth considering. That could even be done local anesthesia.  

Dr. Barry Eppley

Q : I had my lower eyelids tucked (blepharoplasty) over 6 months ago. While my lower lids look much better, I have had  a problem with dry eyes and tearing since the surgery. It was really bad right after and has gotten somewhat better. It is almost painful to be out in direct sunlight and my eyes really tear if there is any wind. My lower eyelid also doesn’t look right. I think I show more whites of the eye than before and it looks pulled down. My doctor keeps saying to give it more time and it will get better. But it has been some time now since surgery and I just don’t see it happening. What do you suggest? By the way I am a women who is 58 and I still have to work!

A: One of the potential, although fortunately uncommon, risks of lower blepharoplasty surgery is ectropion. This sounds like exactly what you have.

The lower eyelid, unlike the upper, is like a clothesline strung out between the inner and outer eye socket bones. The eyelid is attached to the bone by tendons called the canthal tendons.  This clothesline effect keeps the lower eyelid snugged up against the eyeball just at the lower edge of the iris. By being tight up against the eyeball, it is protected from drying out and being irritated. Any slight change, even one millimeter, between the eyelid and the eyeball (out or down) will cause eye symptoms of dryness, irritation, and tearing. Manipulation of the lower eyelid through surgery can disrupt this relationship if the eyelid and the lateral canthal tendon are snugged back up properly as part of the operation.

While small amounts of ectropion may correct itself with the passage of time and upward massage, six months with this degree of symptoms indicates another approach is necessary. Performing a canthopexy or canthoplasty  (tendon tightening and eyelid re-suspension) and retightening of the outside eye corner can provide an immediate solution to this very irritating problem. Once the lower eyelid is back tight against the eyeball, it will not only look better and more natural but the eye is protected once again.

Dr. Barry Eppley

Q : I am interested in reshaping my forehead. When I was a child I was diagnosed with craniosynostosis of the middle forehead suture which I think is called the metopic? I had infant cranial reshaping which I am sure helped a lot but since I was so young I can’t remember what it used to look like. I have been bothered by the shape of my forehead since I was a teenager. It appears too narrow for a male and has a slight vertical ridge down the middle of the forehead. What can I do about it now? I am a male and am 24 years of age.

A: What you have is the secondary sequelae of correction of an initial metopic craniosynotosis. That initial surgery is designed to bring out the sides of the forehead (temporal area) which helps create a more normal forehead contour. While this initial surgery is often completely curative, older styles of this form of cranial reconstruction often produced suboptimal results, leaving patients with a minor form of residual metopic craniosynostosis. This is seen as a residual bitemporal narrowing and the hint of the vertical midline ridge.

Secondary forehead reshaping can be done that is infinitely simpler than the initial cranial reconstructive procedure. Rather than bone removal, material is added on the outer surface of the bone. This is known as an onlay or frontal cranioplasty. Using the initial scalp incision, the forehead skin is peeled back to expose the bone. Then using either PMMA (acrylic) or HA (hydroxyapatite, my favorite) material, the bone is reshaped through an onlay spackling method. Any irregularities are smoothed out through an additive approach. Deficient areas are built up and made confluent with the surrounding cranial contours. Emphasis for this problem is on both smoothing the forehead and building up the still deficient temporal areas. This is a relatively simple procedure for those plastic surgeons with training and experience in craniofacial surgery.

Dr. Barry Eppley

Q: I am interested in breast implants. After I lost all my weight (was originally 198 lbs), I have a muscular body but I have NO BREASTS!!! When I was heavy,  my cup size was 40D. Now I wear 32B and you can see my ribs all the way down to my stomach. I workout every other day to stay in shape.

A: One of the few negative side effects of weight loss, like pregnancy, is the loss of breast tissue and volume. The more weight that is lost, the more breast volume that disappears. This is particularly seen after bariatric surgery where the weight loss may be 100 lbs or more. Many such women end up with no breast tissue at all and just two hanging empty skin envelopes.

Breast implants will definitely provide a return of volume but the key question is how much loose skin remains. If the amount of loose skin is only moderate and the nipple position remains at or above the lower breast fold, then an implant alone will be adequate. If, however, the amount of loose and hanging skin is more significant and the nipple is below the lower breast fold or pointing downward, then a breast lift may be needed as well as a breast implant.

Breast augmentation in some weight loss patients presents challenges to the plastic surgeon  than one does not usually have in the typical small-breasted female. How much loose skin exists, and the key issue of current nipple position, can turn what appears to be a simple breast implant procedure into a more complex breast implant and lift procedure.   

Dr. Barry Eppley

Q: I have been infected with HIV for 31 years, and have seen every one of my former friends and acquaintances succumb to AIDS. For some reason meds have always become available just in time to save my life. For that I am thankful But my life feels hardly worth living with the disfigurement of facial lipoatrophy and pain of buttock lipoatrophy. My face is so gaunt it is horrible and I have not butt at all!

A: One of the very unique effects of anti-viral medications in the management of HIV/AIDS is their effects on fat wasting or lipoatrophy. While much of the body (but not all) is affected by this fat loss, the face and the buttocks are frequent areas of aesthetic concern.

Facial lipoatrophy can be treated by two potential methods. The non-surgical approach is with the use of Sculptra injections. This is an FDA-approved injectable material that is essentially the placement of crystals or ‘seeds’ of a resorbable polymer that promotes collagen formation. It requires a series of injections over time to get a sustained response. The injections are placed in the cheek and submalar areas where the hollowing is the worst. While there is the possibility of a foreign-body reaction or granulomas with its use, good technique can minimize that risk. This injection material is not permanent and must be repeated every year or so once the desired result is obtained. From a surgical standpoint, cheek or submalar implants can be used which is actually my preferred approach. The procedure is simple, is done from incisions inside the mouth, and the volume obtained is permanent. Once can then use Sculptra to further highlight and feather the result out further into the face if desired.

Unlike the face, there is no good solution for the buttocks. Fat injections are not a good idea as there is no fat to harvest in most HIV patients and it will likely be absorbed anyway even if there was. Buttock implants are a possibility but the pain of recovery and the risk of infection may this procedure unappealing.

Dr. Barry Eppley

Q: I had an otoplasty performed about 2 years ago. Although very pleased with the initial result, I feel the upper third part of my ears have relapsed to a more prominent position. I heard of a procedure using sutures between the root of the helix and the temporal fascia to correct this problem without going through the whole traditional otoplasty procedure again. Is this something that you are familiar with? Are the incisions well hidden? And is this a well accepted method?

A: Otoplasty, or ear pinning surgery, involves the use of sutures on the backside of the ear to reshape it. These sutures are used to create or make more pronounced the antihelical fold, whose absence is often the primary cause of an ear that sticks out too far. These antihelical fold sutures are known as Mustarde or horizontal mattress ear sutures.  Another contributing cause to the protruding ear is a large concha. The conchal prominence of the ear can be reduced by sutures between it and the mastoid known as concha-mastoid suturing. Often many otoplasties require a combination of both types of sutures to get the best result.

Many otoplasties experience a mild degree of relapse months to years after surgery. This can be due to slipping of the sutures but is most commonly the result of cartilage relaxation over time. This is usually very mild and not bothersome to the patient as the change has been so dramatic that even some relapse still leaves one with a pleasing change.

In a few cases, the relapse is most noticeable in the upper ear area. This region has the  least suture support and is above the level of the concha where both types of sutures may have been used. This is an easy problem to fix by placing an additional horizontal mattress suture or two in the upper area. This can be done by reusing just the upper portion of the original incision on the back of the ear. It can be done under local or IV anesthesia and without the need for a head or ear dressing afterwards.

Dr. Barry Eppley

Q: I am interested in forehead reshaping. I have a very large forehead which I know takes away from my appearance and I’ve been teased about it alot. How is this procedure done?

A: The forehead makes up one-third of the total face and is frequently overlooked as having a major contribution to one’s appearance. Only when something about the forehead is ‘wrong’ does one take notice of its facial significance.

When a patient feels that they have a forehead problem, they are usually referring to two potential concerns or problems. The issues are usually its shape, which is a reflection of the underlying shape of the bone, or of its length or height, which is a the result of the amount of skin between the frontal hairline and the brows.

Forehead bone problems could be irregularities, bumps or high spots, prominent brow bones, or the narrowness or width of the forehead from one temple to the other. Such forehead problems are treated with frontal cranioplasty procedures where the bone can be reduced or added by different materials. This does require an open approach with a scalp scar needed for access. But with this wide open visibility, a wide array of bone reshaping and contouring can be relatively easily done to the frontal and brow bones.

Too high a forehead or too long of a forehead is a matter of skin reduction. This procedure is essentially a ‘reverse browlift’ where the skin is removed through an incision at the frontal hairline. Instead of the brows coming up, the frontal hairline comes down thus shortening the visible forehead skin to 7cms or less in vertical length.

Dr. Barry Eppley