Your Questions

Q: I am interested in having small cheek implants and was wondering who you would recommend I see in the Washington-Baltimore metropolitan area. I have spoken to several plastic surgeons who say they remove more cheek implants than they put in. I am wondering who has had good results with this procedure?

A: I wish I could answer your question in regards to plastic surgery referral in your geographic area. But, unfortunately, I could not tell you with any assurance who gets good results with cheek implants. While I am certain all plastic surgeons say that they do them, who would be better than other is impossible for me to know. (just like you)

What I can tell you about cheek implants is that what you have heard about them are true. Even though it is a very simple operation, they are the most revised and/or removed implant of all the facial implants. The reason that exists, in my experience, is that they are often oversized for the patient. Cheek implants are much better to be done in moderation or ‘underdone’. Cheek augmentation should be subtle, not dramatic. It is not like a breast implant, where many times bigger may be better. That is never true with a cheek implant. The second reason they are revised is that the cheek implant is unique in its position. It is the only facial implant that is literally ‘hanging on the side of the cliff’ in where it is placed on the cheek bone. So they are prone to movement and asymmetry between the two sides afterwards. That is why I prefer to secure them with a screw to the underlying bone to prevent that problem. Lastly, there are at least 5 different styles (not to mention sizes) of the implants, so matching the unique anatomy and patient desires with the right style and size of cheek implant is certainly more art than it is science.

Dr. Barry Eppley

Q: I have a problem with my profile. I wish it would look normal or see my jaw line. I always wished to see it. I think this is because I used to sleep with my mouth open when I was a child. I also a rhinoplasty by a bad doctor who made my nostrils asymmetric.:(  This was 4 to 5 years ago. I went to someone who offered the lowest fees since I wasn’t earning much at the time. I would like to come to the states from Egypt for corrective surgery.

A: When most people talk about happiness with their profile, they are almost universally referring to the position of their chin. Based on how the lower jaw (mandible) grows and the bite (occlusion) comes together, the horizontal or forward position of the chin will be affected. For most it is an issue of being too short or not ‘strong’ enough particularly in men. Too much chin is far less of a problem although it does exist and it is more of a concern in women rather than men.

Correction of chin shortness can be done with either an implant or osteotomy. (moving just the chin bone forward) Which is better is determined by multiple factors including the amount of chin shortness, age of the patient, and the position of other chin dimensions. (e.g., vertical height) How much or far forward the chin position should be moved can be determined prior to surgery with computer imaging.

Nostril asymmetry after rhinoplasty is not rare and does not necessarily occur because of a ‘bad’ surgeon or that the operation was performed incorrectly. Even a rhinoplasty executed perfectly can still cause some differences in the shape of the nostrils after all is healed. The nostril shape is influenced by the support of the lower alar cartilages and the overlying skin. Both of these can be altered by the healing forces after rhinoplasty, particularly in the soft triangle area of the nostril where there is no cartilage support to resist the contractile forces of scarring. Secondary correction of nostril asymmetry is possible through cartilage or chondrocutaneous grafting of the nostril rim.

Dr. Barry Eppley

For most Americans, the war in Iraq is far away and none of us can really comprehend what it must be like to live there. Living and working in an environment where uncertainty, the military presence from any side, and the potential to not be here tomorrow is an everyday reality that can not be fathomed from afar. More germaine to us is the trivial problems of do I have time to make it to Starbucks today, should I get an iPad or not, and searching for the best travel deal on the internet.

But as some form of normalcy tries to return to war-torn Iraq, there is a phenomenon they we as Americans can recognize. According to a CNN report, beauty salons are beginning to reappear and some people are even looking to cosmetic surgery for personal improvement. Even in Baghdad where buildings are pockmarked and scarred, billboards have appeared advertising for beautification procedures.

As one young Iraqi female was interviewed about her upcoming nosejob (rhinoplasty), she stated she never cared much for her nose and wanted her face to be prettier. When asked about the vanity of cosmetic surgery given her circumstances,  she stated that it was nothing out of the ordinary even for an Iraqi. Because of the internet, satellite channels and television, they see people having these types of cosmetic surgeries done and they look better after. Seeing such things encourages them and gives them an incentive to get cosmetic surgery. Iraqi women have always prided themselves in the Arab world for their looks and style and taking care of themselves is a matter of national pride. As a result, the women are happy to spend their hard earned money to make themselves look as good as they can.

An increasing number of Iraqis appear to be electing to undergo cosmetic surgery for the simple reason that most Americans do…because they can. Changing the face of Iraq for some appears to have a different meaning.

But the emergence of cosmetic surgery out of war is not a new phenomenon. Most people don’t know that most of the common cosmetic procedures performed today had very humbling and catastrophic origins. Plastic surgery today has been highly influenced by the world wars of the last century. Working on the war wounded leads to the development of surgical techniques that have more universal applications. The trench warfare of World War I, for example, has  led to many modern-day facial procedures. (it was generally not a good idea to stick your head up out of the trench too frequently) Rhinoplasty surgery was highly influenced in World War II by ethnic masking of the Jews through alteration of the nose. Dental implants were first used to bridge jawbone war defects. The list continues for dozens of plastic surgery procedures that we assume came out of pure imagination.  

Will anything new in plastic surgery come out of the Iraq/Afghanistan conflicts…one never knows. But the desire for people to look and feel better is universal. Even in a country like Iraq that has been ravaged by decades of war, beauty and cosmetic procedures bring hope and a feeling of self-improvement. When you have so little to say in what goes on around you, making changes in your own little world can provide some personal empowerment.

Dr. Barry Eppley

Q :  I have a stomach pouch that I just can’t stand. After my third child, I just could not get rid of this loose skin and fat that hangs below my belly button. Despite really watching what I eat and trying to exercise more, it won’t come off. It hasn’t budged at all in the past year. I think I may need some type of a tummy tuck. What is the difference between a mini- and a full tummy tuck?

A: Any form of a tummy tuck, also known as an abdominoplasty, removes skin and fat as well as tightens the rectus muscles. The removal of skin and the muscle tightening is what separates it from a liposuction procedure.

Most types of tummy tucks are horizontal full-thickness excisions of skin and fat down to the abdominal muscle wall. The difference between a mini- and a full tummy tuck is in the amount and location of this cut out. A mini-tummy tuck performs it below the belly button while a full  tummy tuck goes above the belly button. As a result, the full tummy tuck has a longer final scar as well as a circumferential scar around the ‘new’ belly button. The mini-tummy tuck just has a less long low horizontal scar only.

A patient’s decision between a mini- and full tummy tuck must consider a variety of factors. How long a scar can one tolerate? How much loose skin and fat does one have? Is there loose and creapy skin around the belly button? Are there any rolls of skin above the belly button? How flat does one want the stomach area to be?

The simplistic answer to deciding between a mini- and full tummy tuck is what the stomach looks like above the belly button. Only a full tummy tuck can smooth out loose skin and fat above that central abdominal marker.

Dr. Barry Eppley

Q: I have seen your chin osteotomy video on Youtube. I’m from Vietnam. May I have your advice? I really need it. I had my chin done about 6 weeks ago. My chin bone was cut and moved forward about 8mm and now I have 3 small pieces of stainless steel in my chin bone. (like small rings). My doctor says that it’s ok to have those stainless steel in my chin for the rest of my life. Is that right? And the sad thing is that I regret that I had my chin cut. In fact, I just wish I hadn’t had the surgery. Should I now have my chin bone moved back? Can everything be like it was before or would my chin just be weaker? Can I get rid of that stainless steel in my chin if I have my chin moved back to its place just like it was before?

A: I have never had the experience in my Indianapolis plastic surgery practice of a patient ever regretting having their chin bone moved forward. This is a completely avoidable concern by using computer imaging prior to surgery. The chin is one of the two (the nose is the other) most easily and accurately computer imaged areas of the face. You can know precisely before surgery what it will likely look like afterwards. I am assuming that the regret from this patient is that they do not like the ‘new look’. Maybe it is moved too far forward or maybe it shouldn’t have been done at all. This is clearly a preventable case of surgical remorse.

While today’s facial bone surgery uses very small titanium plates and screws, the use of stainless steel wire (rings) is historic and perfectly safe. The use of bone wiring is still done in many parts of the world due to its lower cost. There is no concern with them there nor should they ever need to be removed.

Just as the chin can be cut and brought forward, it can be brought back to where it once was. This is much easier and quicker than the original surgery. If that is what one wants to do, I would do it within three months of the original surgery since there is minimal bone healing at this point. Chin osteotomies usually take at least six months to become completely healed back together. The use of wires or plates does have to be done to hold the bone together so it heals properly. The key to moving the chin back is to tighten the mentalis muscle back together well. Since it has been stretched out and expanded, it needs to be shortened and tightened once the bone is moved back and set. If not, you will end up with soft tissue sag known as a witch’s chin deformity.

Dr. Barry Eppley

Q: I would like to know what the rate of satisfaction is amongst patients that have had chin osteotomies or chin implants when actually they should have had lower advancement jaw surgery? Are they happy with their appearance or do they feel their top teeth extend out too much when they smile?

A: The short answer is yes. But that answer needs a more detailed explanation. The key is proper patient selection and understanding that a chin implant or osteotomy for a mandibular deficient patient is a compromise operation. It is treating the symptoms of the problem and not the primary problem. In other words, one is camouflaging the real defect and accepting whatever (if any) functional problems that may exist.

The idea treatment for a mandibular deficient patient with a malocclusion (Class bite relationship where the lower teeth are behind the upper…an overbite) is orthognathic surgery. Specifically, a mandibular advancement osteotomy with preparatory and postoperative orthodontics. While this is a very effective operation, it requires a commitment of several years of orthodontics, an operation, and the risks of damage to the inferior alveolar nerve. (some permanent change in the feeling of the lip and chin) The decision for mandibular advancement surgery, therefore, should be based on one’s age and the degree of malocclusion. You must balance the risks vs the benefits like any surgery. If one is young with more than several millimeters of overbite, this should seriously be considered and even done. In patients who are older, often with even more significant overbites, the enthusiasm for this surgical effort is often not there. Camouflaging the jaw defect and getting a better profile and improved facial proportions through a simpler chin implant or osteotomy has a lot more appeal.

In my Indianapolis plastic surgery experience, I have never had any unhappiness amongst patients who has chosen the isolated chin route. Nor has it been reported to me that their upper teeth stick out too far when they smile.

Dr. Barry Eppley

Q :  Which is better for my laugh lines, Botox or fillers?

A: It is very common that Botox and injectable fillers are confused as to what they do. Because both are administered by a needle and are used in the face, many assume that they do similar things. In fact, they are quite different both in chemical composition and the effects that they create and in how they are used.

Botox works its magic by being a muscle weakening or paralyzing agent. It is primarily used in the forehead and around the eyes to decrease unwanted expressions caused by overactive muscles. As a result, Botox (and now Dysport) is really a ‘northern facial’ procedure. It effectively reduces horizontal forehead lines, furrows between the eyebrows, and crow’s feet around the eyes.

Injectable fillers (there are now over a dozen commercially available brands) work by adding instant volume to deep wrinkles and folds as well as enhancing the size of the lips. By adding a material under the skin or into the lips, the outer skin and lips is pushed outward. Injectable fillers are primarily used around the mouth making it a ‘southern facial’ procedure.

While there are crossover areas in the face where Botox and fillers are otherwise used, they are largely separated in application to these northern and southern hemispheres.

Folds around the mouth are commonly referred to as laugh lines. When one smiles, indentations or wrinkles are created beyond the sides of the mouth. They are different than the nasolabial folds which run from the side of the nose  to outside of the corners of the mouth which are situated above the laugh lines. Injectable fillers can be effective at softening one’s laugh lines.

Dr. Barry Eppley

Q: What is best way to build up an African-American nose that is short and small?

A: The overall shape of the African-American nose is often that of being broader and less projecting than that of a more Roman or aquiline nose shape. As a result, one of the key considerations in the rhinoplasty management of this nasal shape is to build up the bridge or dorsal line of the nose and improve tip projection and definition. Such an approach is most likely what is meant by having a nose that is ‘short and small’.

An type of augmentative rhinoplasty requires the addition of some form of graft or internal support structure to lift up the roof (skin) and reshape it. How much graft volume is needed determines the best way to do it. Each patient will be different in this regard. But this discussion always comes down to whether one wants to use a synthetic implant vs. cartilage.

The historic debate between allograft vs. autograft in rhinoplasty is an old one. Each has their own advantages and disadvantages with surgeon advocates on both sides. But the differences between the two are always the same. An implant is a lot easier to do (off-the-shelf) for both patient and surgeon and comes in a variety of ready-made shapes to create small or big ghraft needs. The price that is paid for this ease is the increased risks of infection and long-term implant extrusion and problems. Cartilage grafting is much harder to do, necessitates a donor site and require more surgical skill and experience to do well. But the risk of infection is much lower and there is no risk of any long-term extrusion or rejection problems.

Which is best must be determined with the patient through a thorough consultation and educational session. Both methods can be successful but the patient with the plastic surgeon must weigh the benefits and risks of each approach. When possible and acceptable, I prefer cartilage grafting because of its long-term benefits.

Dr. Barry Eppley

Q: I am interested in getting liposuction done on my stomach and flanks but am confused about the different types that I have read about. There appears to be regular liposuction, ultrasonic, laser, water jet…and and even something like ultrasonic done from the outside without surgery. Which type of liposuction is the best?

A: Liposuction has come a long way since its first introduction in the United States in 1981. It is a two-part process during surgery that involves the first phase of breaking up the fat and a second phase of removing or suctioning it out. All of the advancements in liposuction have come forth for the first phase, different methods to help loosen up the fat for evacuation.

One highly touted liposuction method that is neither new or novel is that of tumescence. This is an original advance in liposuction that began to be used in the mid-1980s and is part of every liposuction procedure today. Prior to doing phase one particulation, a special solution is first instilled that provides numbness to the treated area and helps cut down the extreme bleeding that would otherwise occur. This does make it possible for small areas of liposuction to be done under local anesthesia, but is also used even when you are going to sleep for the procedure.

Most of the advancements in liposuction that are highly marketed and promoted on the internet are relatively new. Whether one method really offers any improvement over the other has yet to be proven no matter what the endorsement and advertisement says. My current preference is for laser liposuction, branded as Smartlipo. We all know that fat is very sensitive to heat and can be melted as is observed during cooking. So the concept of heating up a treated area makes sense and is something that can really be felt during surgery. It is usually touted as also having skin tightening capabilities, and while I have observed that some of that does occur, it will not solve skin laxity problems where more than an inch of excess skin is present.

No matter what the tool that is being used, the most important element in getting good liposuction results is the experience and skill of the one holding the instrument or device. One of the real negatives to technology (and probably the only one) is that it enables those surgeons of lesser skill or training (and sometimes not a surgeon at all) to look equal to others of extraordinary experience and expertise.

At this time, I would be leary of any device that offers significant fat reduction through some method of external application. While the concept is harmless and certainly appealing, what you really risk is your money. If you are prepared to be dieting and exercising and doing everything to help lose weight anyway, then these device approaches may be reasonable. I suspect they do offer some benefit in the very weight loss conscious patient who is even more motivated by their economic investment. It is probably the ‘coach potatoes’ who make up the greatest percent of failed results with these devices.

Dr. Barry Eppley

Q :  I had gastric bypass surgery about six months ago and have already lost 65 lbs. At the pace I am going, I will reach my goal of 100 lbs within one year after surgery. While the weight loss is fantastic, the amount of loose hanging skin that has developed is disgusting. I want to get this loose skin removed as soon as I can. How soon once I reach my weight loss goal can I have plastic surgery?

A: It is understandable that most extreme weight loss patients want to enjoy the benefits from their efforts as soon as possible. While the weight loss is the first step, most patients will require some skin removal through a second stage body contouring surgery to really see the body that they had hoped for.

Despite the enthusiasm of pressing forward as soon as possible, it is important to wait until some point after you have reached your weight loss goal. Your body needs time to recover and adjust to the new weight. This also allows you to learn new eating habits that will help keep the weight off but also have you become more nutritionally sound.

Body contouring surgery places major stress on one’s body and requires a lot of nutrients and energy to heal properly. You also want your immune function to be functioning as best as possible. In short, you don’t want to be malnourished going into major surgery. It has been that many post-bariatric surgery patients have protein-calorie malnutrition as well as various vitamins and mineral deficiencies.

While there is no standard waiting period after bariatric surgery, it is best that one have a stable weight for at least three months before considering elective body contouring surgery. Patients who have had gastric bypass, due to intestinal absorption changes, aren’t usually ready for body contouring surgery for six months or more afterwards. Lapband patients lose weight at a much slower rate and it may be much longer than a year after their procedure before they are ready. Extreme weight loss patients who have done it on their own without surgery can be done sooner because their intestinal absorption of nutrients has not been altered.

Dr. Barry Eppley

Q: I have one breast that is quite a bit larger than the other one. I am way too embarrassed to wear a bathing suit or even go out with men for more than a couple of weeks. (I don’t let my relationships, go to the next level so to speak, in fear that the guy will totally freak out and embarrass me even more if that is possible because I already feel pretty bad about myself!) Anyway I was wondering if you could enlarge just one of my breasts?

A: While few women have breasts that are perfectly symmetric, congenital or developmental breast asymmetry is another matter. In this condition, one breast is significantly larger than the other often by several cup sizes. In its most severe form, there is a medical condition known as Poland’s syndrome where the breast and the underlying chest muscles on one side fail to develop much at all.

All forms of breast asymmetry can be significantly improved through modern breast surgery methods. In some cases, the smaller breast may be merely enlarged by the placement of a breast implant. In other cases, differential enlargement of the breasts will different implants sizes may be better.

Often times, however, the differences between the breasts is more than just that of volume. The larger or more normal breast will have more skin and a different size and position of the nipple on the breast mound. Optimal correction may require adjustment of the more normal breast as well through a lift or nipple elevation.

 Dr. Barry Eppley

Q :  I am interested in getting breast implants. I have been saving for years and am so excited to be close to actually getting it done. One worry I have is about the time to recover.  I can’t be out of work too long. I have read from some doctor’s advertisements that it can be done with no recovery whatsoever. Is that true? How can that be possible since it is surgery?

A: Breast augmentation is definitely real surgery. While it is a cosmetic operation, it does involve lifting up your main chest muscle (pectoralis) to insert the implant underneath it. Lifting up any muscle in the body is not pain-free and does involve some recovery.

There has been a general change amongst many plastic surgeons over the past decade about what to do after breast implant surgery. In the past, there was the belief that restricting any motion of the arms and chest muscles improves healing around the implant and helps control discomfort. There has been a 180 degree change in recovery philosophy with the recognition that the fastest way to recover from a ‘pulled muscle’ is to use it rather than restrict it.

As a result, contemporary recovery techniques after breast augmentation use an aggressive physical therapy approach. Early and frequent arm range of motion and a ‘get up and go’ approach is now used. Pain medications are either not used or restricted and one begins immediate use of non-narcotic anti-inflammatory medications. From a marketing standpoint, these have become known as ‘no recovery’, ‘rapid recovery’ or ‘easy aug’ breast augmentation methods. Suggesting that there is no recovery is a bit overstated but it is certainly much easier than it used to be.

It is certainly possible today to be sufficiently recovered after breast implants to be back at a non-physical job within a few days. A heavier labor position may take a one week or two to have sufficient recovery to work unrestricted and relatively pain-free.

Dr. Barry Eppley

Q : I would like my brow bones reduced. I am now 20 and until about 12 years old my brow areas looked normal as best as I can remember. Since then they have continued to grow, or at least seemed to, to the point that I look like a Cro-Magnon man. My parents took me to get evaluated by an endocrinologist around age 14 or 15 to see if there was some reason and to make sure I did not have acromegaly or some other hormone problem. Those tests were normal. I feel like a freak with the way I look. How is this surgery done?

A: Prominent brows are not due to excessive bone growth of the forehead per se. Rather it is due to the overdevelopment or pneumatization of the frontal sinuses. The frontal sinus is an air-filled space between the inner and outer bone surfaces of the forehead brow bone. They empty into the lower portion of the nose through long ducts. Sometimes they exist as two separate cavities above each brow. Other  times, they connect across the middle and are just one big frontal sinus.

The frontal sinuses do not even begin to develop until age 8 or older. They do not stop forming until well after puberty. When the airspace gets too big, it causes the bone on the outer side of the sinus to bulge out. Why some people’s brows remain flat and others ’overdevelop’ is not known. While there can be a medical reason, such as a pituitary tumor, most cases are idiopathic. (they just happen for no apparent reason)

Brow bone reduction surgery involves taking off the bulging outer plate of bone and reshaping it. During the operation, the cavity of the frontal sinus is widely exposed and the reshaped outer plate of bone is put back with tiny plates and screws. While this sounds like a gruesome operation, it is not. In many ways, it is a glorified brow lift using the same scalp incisional approach. It is the same operation as a frontal sinus fracture repair.

The sticky issue for men is the need to create a fine line scalp scar behind the frontal hairline. Based on hairlines and density, this may be a concern for some men.

Dr. Barry Eppley

Q : I am interested in scar revision. I have had three hair restoration procedures and this has now left me with a very wide donor scar that is quite noticeable on the back of my head.

A: Hair restoration, also known as hair transplantation, is a true ‘robbing Peter to pay Paul’ type of surgery. Hair grafts are harvested in a horizontal excision pattern in the lower portion of the occipital scalp. (back of the head) The donor site is brought back together so that the scar, hopefully, is just a fine line that can not be easily found in the remaining scalp hair.

Harvesting scalp skin (and hair) is quite easy and the donor scar usually looks quite good since the scalp is very flexible and comes together without much tension. Since most hair transplants require more than one session to get the maximal hair density, this same donor site must be used consecutively. The scar will usually stay quite narrow even after the second time of graft harvesting but the scalp closure is definitely tighter.

The third scalp harvest, which is often not advised and even done, will likely run into a wider donor scar problem. One of the most important contributors to how all scars will eventually look is tension. The tighter the closure, the more likely the scar will end up being wide. Tension wins over time and it relieves itself through widening of what is an initially narrow-looking scar. Also contributing to the scar widening is the inavoidable horizontal orientation of the scar which is repeatedly pulled downward with neck flexion.

Wide occipital scalp scars can almost always be improved by excisional scar revision. Unlike the donor harvests, however, the skin is closed with the aid of significant tissue undermining at the galeal plane level. This helps reduce the tension on what would otherwise be a very tight skin closure. In addition, I have occasionally incorporated a geometric skin closure pattern with a running w-plasty series. The interdigitating limbs of skin closure are another method to change the tension lines on the skin closure.   

Dr. Barry Eppley

Q: Can facial implants help to fill in a cheek region, where collagen injections have been beneficial? I have a large depressed scar from dermabrasion and laser treatments on an acne scarred region of my face. I would be glad to email pictures of the region to assist in the answer. 

A: Facial implants work by pushing out from the underlying bone on the overlying soft tissue. This how they create more highlights or volume to specific facial bony prominences. While a facial implant can be placed anywhere on the facial bones, they work best on convex or flat surfaces such as the chin, cheeks, and jaw angles.

The treatment of most depressed scars would be either some form of surgical scar revision (cut out and re-closure) or skin resurfacing. In some select cases, such as yours, actually filling in the underlying soft tissue helps flatten the outer appearance of the scarred area. Injectable fillers can work well for that type of depressed scar but they are not permanent and must be repeated.

You have correctly pointed a very uncommon but potentially beneficial approach to depressed cheek scars. Having proven that soft tissue expansion makes the scar look better, it is insightful to ask about whether a cheek implant can create the same effect. Since the cheek bone is convex, an implant will definitely push outward on the skin, helping flatten a depressed scar. I have done such an approach twice in my Indianapolis plastic surgery practice and it can work well as you have surmised.

The key to the successful use of an implant for a depressed cheek scar is two-fold. The acne or traumatic scars must be directly over the prominence of the cheekbone to get the most benefit from the underlying push of the implant. And you must consider the opposite cheek prominence as well from the perspective of balance. (one-sided or both sides for cheek augmentation)

Dr. Barry Eppley

Q: I am 42 years old. I have always had large breasts. I have permanent indentations on my shoulders from bra straps. I currently wear a 40F bra. I have had back and neck pain for as long as I can remember as well as rashes under my breasts which become unbearable in the summer. I had an MRI to rule out spine problems as a cause for my back pain and it was normal. I am extremely uncomfortable in a bathing suit (in fact, last summer I wore a bra under my suit) and I have a difficult time finding clothes that fit properly. I am unporportioned. I wear a size 18 pants, but a 3x top. I would love to be able to run. I currently weight 190lbs and am uncomfortable exercising but want desperately to lose weight. Please help me.

A: One of the real benefits to breast reduction surgery is how consistently it improves, or alleviates, the musculoskeletal pain from large breasts. While the size and weight of large breasts is often believed to be the sole reason for musculoskeletal pain, the sag of the breasts is just as important in contributing to the pain. Like a rope around the neck attached to several lbs of sugar in bags, this creates a downward pull on the neck and shoulders. Breast reduction surgery works because of weight reduction and resuspension of the remaining breast tissue back up on the chest wall. (thus eliminating that rope around the neck effect)

In a patient with these symptoms, breast reduction will reduce the back and shoulder pain, eliminate completely the rashes, and will enable her to exercise and run better. For many patients so afflicted, breast reduction surgery can be life-changing.

Dr. Barry Eppley

Q : I am writing because I am bothered by bags under my eyes. Since I was a teenager these bags have been there but are now much more prominent as I have gotten older. I don’t expect my eyes to be perfect but I shouldn’t look this way at only 38. I have tried every cream out there and nothing seems to make them better. Is there a plastic surgery for this problem?

A: Lower eye bags are the result of herniated eye fat. Most of the time they appear as a result of aging. But some people have it appear much sooner in life, even during their teenage years. One occurs as a result of weakening of a lower eyelid membrane with age, teenage eyebags are the result of a congenital weakness in the same membrane.

To understand lower eye bags, one must know that our eyeball sits in a bed of surrounding fat for padding and protection. The lower eyelid is like a gate in which fat underneath the eye is held back by a membrane between the lower eyelid margin down to the lower edge of the eye socket bone. When this membrane is weak, eye fat can protrude through like a hernia through an abdominal wall defect. This is easy to demonstrate by closing your eye and pressing on the eyeball. You will see that the tissues underneath the eye bulge out as you press in. This is eye fat being pushing out.

Lower eyebags can only be removed by lower blepharoplasty surgery. No topical treatments or other external treatments will cause the fat to go away. If there is no significant extra skin which is common in younger patients, the fat can be removed through an incision from inside the lower eyelid. (trasnconjunctival blepharoplasty). If there is extra skin from aging, the fat and skin are removed through an incision right underneath the lashline. (external lower blepharoplasty)

Dr. Barry Eppley

Q: As I am getting older, I don’t like my neck which is getting looser and lower. I think I may need a facelift but am scared to death to go through it and it will likely cost more than I have. I have read and seen pictures about the Lifestyle Lift and that really interests me as it doesn’t look like surgery is needed and the results are great. Do you think that will work for me?

A: As we age, the very common signs of facial aging is in the development of a saggy neck and jowling. These loose facial skin issues are exactly what a facelift treats, contrary to what many patients believe that a facelift is.

Facelifts can be done in a variety of ways but fundamentally there are two types, limited and full. For smaller neck and jowl issues, a limited facelift can be a very good rejuvenative procedure. For larger neck wattles and jowls, a full facelift is often needed to get the best result.

The Lifestyle Lift, a tradename and franchise approach to delivering cosmetic facial surgery, is a variation of a limited facelift. Many patients have commented to me that they did not think it was surgery based on the ads and the TV commercials. But a Lifestyle Lift is surgery and can be combined with a wide variety of other facial procedures and injectable treatments. Usually a combination of ‘small’ procedures can collectively create a significant facial improvement.

The limited facelift approach has been around for a long time, dating even back to the early part of the 20^th century. It has re-emerged in popularity today because younger patients are seeking facial improvements. They don’t want to wait until they need a complete facelift and have such a dramatic change. Plus, they want to maintain a more youthful appearance as they are in their prime work years. About half of the facelifts I now do are of the limited variety because it fits many patient’s age, lifestyle, and budget.

When you see a good before and after picture of a significant facial change, you should know that is not possible without some form of surgery. There is no magical cream, laser, and other ‘magic’ that can create what a facelift operation can do. We all would like there to be but it does not exist. Remember a basic plastic surgery rule…’small changes require only small procedures, big changes come from big procedures.’    

Dr. Barry Eppley

Q: I’ve read your article on calf augmentation using fat transfer. Since 2008, have you performed this procedure? I have finding very mixed feedback on this. Some surgeons are saying this is high risk and will be unsuccessful because the fat will all be absorbed. Another doctor in NY I’ve been in contact with says he has had great success and with little side-effects. Appreciate your feedback.

A: Calf augmentation is most reliably done with implants. There are specific silicone rubber implants made for the calf and they are placed through a small incision on the back of the knee. (popliteal fossa) Because an implant is used, the result is stable and consistent in the amount of size increase obtained. Conversely, because it is an implant there are the associated issues of the risk of infection, malposition and asymmetry as well as a significant recovery and discomfort.

Fat injections, no matter where they are considered and what they me be used for, always have the same appeal. Using a natural tissue that has virtually none of the risks of an implant-associated procedure. Despite those benefits, fat injections have one significant downside…their volume retention is unreliable. At this time, there are no standard techniques for fat preparation and injection and the science behind its survival once transplanted remains to be discovered and utilized for more stable outcomes.

Because of the differing techniques and injection methods, fat injections for larger volume areas (breast, buttocks, calfs) have widely variable results. With these inconsistent results come quite discrepant surgical opinions about their effectiveness. There is now to reconcile one plastic surgeon’s experience vs another at this time.

Calf augmentation with fat injections is relatively ‘new’ and the worldwide experience is still evolving. The issues with the calfs are no different than the buttocks or breasts. It is a very safe procedure with minimal downtime. But one has to accept the reality that how much fat survives is the risk of the procedure. And more than one session may be needed to get the best results. (more likely than not) My experience has been with just a few cases and the early results have been acceptable. But the key is patient selection…don’t ask the fat to do what an implant can do better. (mild enlargement, not big enlargement)  

Dr. Barry Eppley

Q: I am inquiring as to whether you perform tracheal shaves? I have been bothered by the bulge in my neck caused by my Adam’s apple. As a female, it does not give my neck a very nice profile and looks too manly. I have read that the protruding cartilage can be shaved down. Is there much scarring and what is the recovery like?

A: A tracheal shave, known medically as a chondrolaryngoplasty reduces the size of the thyroid cartilage through a small horizontal incision in the neck. While often thought of as only a transgender procedure (facial feminization), I have performed more of these procedures on men and women who are merely just uncomfortable with the prominence of their Adam’s Apple.

The procedure is actually fairly simple and does truly consist of shaving down the protruding cartilage with a scalpel. Through a small horizontal incision in a favorable or prominent skin crease near the thyroid cartilage, the vertical strap muscles are separated to get direct access to the protruding cartilage. It is shaved down as much as possible to get a throat line that appears smoother and less angular. One must be careful to not take too much cartilage away which can de-stabilize the attachments of the underlying vocal folds, risking potential hoarseness after surgery. While the goal is as smooth a neckline as possible, sometimes it can merely be reduced significantly but not made completely flat. The small neck incision will go on to heal very nicely with little scarring.

Recovery is quite quick with minimal discomfort. I do not place patients on any type of restrictions after surgery. There are no sutures to remove. There is some mild swelling and bruising which goes completely away in two weeks. There may be some temporary discomfort on swallowing. Usually, there is little to no change in the pitch of a patient’s voice. There are some topical scar treatments that can be done beginning three weeks after surgery to optimize the fading of the fine line scar.

Dr. Barry Eppley

Q: I am writing you because I need information on gynecomastia reduction. I have been battling with fat around my chest ever since I was young. I am now 28 and not the least bit out of shape. Actually I am a certified personal trainer and have participated in body building contests. Even when dieting down to as little as 4% body fat I still have this fat on my chest. It is very humiliating and I have never been comfortable with my body because of this reason. I am completely happy with my body except for this part. Being a trainer and a single man my appearance is important. Can you help me?

A: Male breast enlargement, known medically as gynecomastia, comes in all forms. How it appears in different men is as variable as breasts are in women. While many people may think that gynecomastia presents as an actual breast, that is only partially true. About half the men I see today in my Indianapolis plastic surgery practice have what I call ‘minimal gynecomastia’. Their stories are all very similar. They are younger (under age 40) men who are in extremely good shape (many are trainers and body builders) who just can’t get off that little bit of fat on their chest. While a lot of other people may not think it significant, they are extremely bothered by it due to their understandable sensitivity to their body shape. I suspect in some patients their extraordinary focus on conditioning and body shaping may be a compensatory response to their self-image issues with it.

Such smaller amounts of gynecomastia are easily treated and resolved with simple liposuction techniques. This leaves essentially no significant scarring, can be done in one hour of surgery, and there is minimal recovery. Because of its effectiveness and skin tightening potential, I prefer to use laser or Smartlipo as the liposuction method. Men can return to full chest exercises in two weeks.

Dr. Barry Eppley

Q: I had a car accident in February 2009 that resulted in the need for big operation on my stomach. This has left me with a long big scar. I want to know what percent of it can be removed? I want to remove this scar for me because  don’t want to get naked in front of my husband or any person because of the scar. It is so bad that I cry a lot about it as I picture how good my stomach looked before the accident. I am 23 years old, been married two years and have no kids.

A: Scar revision is about scar reduction, not scar elimination. While I wish as a plastic surgeon I could wipe them away for patients, that is not currently possible. Therefore, the judgment about the merits of scar revision are about the degree of improvement. Is the result worthy of the efforts is the consistent question about scar revision.

The answer as to whether scar revision is meritorious for any patient lies in the physical characteristics of the particular scar. There are several features of scars that can be consistently improved by surgical methods. Scars that have surface texture problems such as being wide, raised (hypertrophic), or depressed (indented) are good candidates. These type scars can be cut out and reclosed in a variety of ways whose objective is to make them flatter and narrower. Scar features that are difficult or impossible to improve include lack of pigment (normal skin color) and visible flat narrow scars.

Without even seeing a picture of the scar on this patient, one can be fairly certain that it is a wide vertical scar running down the middle of her stomach area. Such scars often get quite wide and indented as they have healed. Scar reduction can most certainly be done with the goal of making a much narrower and flatter scar. While that will not make it invisible, it will provide at least a 50% or greater degree of improvement.   

Dr. Barry Eppley

Q: I am a male and am interested in the direct neck lift and want to know more about it. I don’t want a complete lift and think this may be my answer. How much of a scar remains visible and will it last a long time. Also, do you tighten the muscles and remove some of the fat?

A: The direct necklift is an alternative to a facelift for a select number of men and women that are interested in getting rid of their neck wattle. A facelift works out excess neck and jowl tissues by chasing them back towards the ears and placing the scars there. A direct necklift cuts out the neck wattle directly, placing the scar right down the middle of the neck. It is a highly effective procedure that produces neck results that are just as good, if not better, than what a facelift can do particularly in men.

In the direct necklift, not only is skin removed but fat and muscle tissues are changed as well. With the skin cutout, the underlying fat is removed as well right down to the muscle. The split platysma muscle is widely exposed with the overlying tissue removed. Because of the excellent visibility, it can be sewn together from under the chin right down to the thyroid cartilage with superb tightening achieved.

The direct necklift is not for everyone but for just a select few patients. In my Indianapolis plastic surgery practice, I reserve it primarily for older men (55 years and older) who either do not want to undergo a facelift or have a very poor hair pattern and density around their ears. The occasional woman is done but they are almost universally 65 years and older and are choosing the direct necklift vs a facelift because of its lower cost.

The obvious issue with a direct necklift is the scar. Generally these scars are quite thin and the only widening that occurs in them is in the middle of the neck where the tension is the highest. For this reason, I usually place a z-plasty scar orientation in this area to avoid hypertrophic scarring there. I have performed no scar revisions on them to date which speaks to patient acceptance of their final aesthetic appearance.

Dr. Barry Eppley

Q : I have a weak chin that has bothered me my whole life. I am so self-conscious that I turn away so people can not see me in profile. I also think my entire jawline is weak, it overall looks too small for the rest of my face. Can my jawline be improved with different types of implants?

A: Historically, most people think of jaw enhancement as that of the chin only. Chin implants have been around for over fifty years and have evolved today to include a wide variety of different chin styles and sizes. For horizontal jaw shortness, a chin implant can provide a simple, quick and permanent method of significant profile improvement.

Today, jaw enhancement has progressed to consider changes along the entire jawline from back to front. Besides chin implants, the use of implants to accentuate the jaw angle have become popular. Designed to increase the width of the jaw (and some designs will lower the jaw angle as well), they increase bigonial width and create a stronger and more masculine.

Chin implants are most commonly done as a stand alone facial augmentation procedure. Jaw angle implants can also be done by themselves if an adequately projecting chin already exists. For cases of an overall weak lower jaw, the combination of chin and jaw angle implants together can make for a more dramatic change in jawline appearance. This combination (the ‘jawline trifecta’) is increasingly popular for those men who have a congenitally shorter jaw or for those want to make a stronger jawline out of an otherwise normal sized one.  

Dr. Barry Eppley

Q: I have a rib graft on the bridge of my nose which I would love to have removed. The surgery to place it was 12 years ago. At the time, the doctor thought my nose would be better off with the bridge higher. I liked my bridge before the rib graft. Is it possible to remove this graft? Is there any hope for me because I also dislike how it feels, not to mention how it looks which is not good?

A: Rib grafts to the nose are usually done for dorsal augmentation (building up the bridge, the distance between the top of the nose and the tip) secondary to prior trauma or rhinoplasty surgery or for altering certain ethnic noses. Whether dorsal augmentation is aesthetically beneficial, like all rhinoplasty changes, can be determined prior to surgery with computer imaging. The harvest of a rib graft and changing the dorsal line of the nose is not an insignificant adventure and everyone needs to be sure that it is a worthwhile procedure.

I have not found most rib grafts that hard to remove or manipulate in my experience, provided that they are completely composed of cartilage and are limited in location to the nasal bones and middle vault. Cartilage grafts to the dorsum, while wonderfully biocompatible, heal with a surrounding capsule and never truly integrate into the underlying structures like a bone graft would to bone. As a result, they can be usually be removed without as much difficulty as one would think.

The exceptions that make removal more difficult is if the rib graft was more bone than cartilage (which it usually isn’t) or if it was an L- strut configuration extending around the tip and down along the columella. It is not that the removal is that much more difficult, it is that it is more destructive to do. (more of the nose has to be taken apart to do it)

The description of a rib graft to the bridge of the nose done for aesthetic purposes suggests two things. The graft is small and probably all cartilage and that its location is just to the dorsal line of the nose. Both of these qualifiers would indicate that’s its removal is both possible and minimally destructive. Its removal, however, should be done through an open rhinoplasty approach even though it may have been placed initially through a closed or endonasal incision.

Dr. Barry Eppley

Q : Is umbilicoplasty recommended only after you’re done having children? I heard the procedure could be ruined during pregnancy.

A: As a general rule, changing the shape or form of the umbilicus (belly button) is a simple procedure that is usually permanent. However, pregnancy is well known to affect the umbilicus due to its expanding effects. The usual way it can change the umbilicus is to convert an ‘innie’ to an ‘outie’. This is the result  of an actual hernia coming through where the umbilicus attaches to the abdominal muscle wall. One must remember that the umbilicus is really nothing more  than a scar that goes all the way through to the underside of the muscle wall to the peritoneum. This can be appreciated during a mini-abdominoplasty where the umbilicus is often released and repositioned lower. Once it is cut off at the level of the abdominal wall, a small hernia is immediately apparent.

Because of the potential negative effects of pregnancy on the umbilicus, one should usually wait until after pregnancy for a female umbilicoplasty procedure. If you are converting an outie to an inner,  it is possible with the increased abdominal pressure from pregnancy to have it change back to an outie after surgery. The one exception to this id if one is not planning to get pregnant for years. Adequate healing and scarring will then have occurred and it will be able to better resist stretching forces. But if one thinks it is possible to get pregnant within the first year after repair, then one is better to wait.

There are some umbilical changes that may be not be so adversely affected by pregnancy. Removal of skin tags, small scars, nevi, and a ‘pseudoinnie’ (looks like a partial outie but is just a lump of scar tissue) can be done with a low risk of post-pregnancy change.  

Dr. Barry Eppley

Q: Hello sir, I did my first rhinoplasty for a  minor problem.  Initially I had a thin and pointed nose but overall it was not too bad looking. I went to this inexperienced surgeon because me or my parents didn’t know anything about surgery at that time. He made my nose shorter with a  round tip and I got very bad dark circles under my eyes for a year. My nose is still short, fat and twisted.  After three years, I have gotten the courage to consider another rhinoplasty surgery to make it look better. What do you recommend to be done?

A: Most likely what has happened is a fundamental problem that is reminiscent of rhinoplasty  from days of old…removal of too much cartilage structure. This results in collapse of the nasal tip due to loss of support as well as wound contracture. Almost certainly, this rhinoplasty was done through an endonasal approach where  removal is what can largely be achieved. Only the real masters of rhinoplasty can do significant restructuring that has predictable outcomes through the limited access of the endonasal approach.

For a revisional rhinoplasty such as this, the open approach needs to be done. The tip cartilages and nasal septum can be separated, cartilage grafts placed and reshaping done through suture techniques. It may also only require an onlay cartilage graft but that must be precisely placed. Only the open approach offers this degree of visibility. The cartilage grafts will likely come from the ear (conchal) due to the size and shape needed.

At three years from the initial surgery, the nasal tissues are more than soft enough to allow for good manipulation and healing.

Recovery from the short nose problem in revisional rhinoplasty is usually quite good, but access and cartilage grafting are the keys.

Dr. Barry Eppley

Q: I am interested in getting breast implants. I am 34 years old, have had three children and my breasts are just not what they used to be. They are smaller and now droop. They are disgusting to look at and are nothing like they used to be when they were nice C cups and round. I want to get implants so my breasts can look like they did before. Is this possible?

A: The concept of looking like you did before is an understandable one but may not always be possible. The reason is that the breast skin and breast tissue you now have is different than what it used to be.

Women considering breast augmentation almost always fall into two main types; those who have always had little breast tissue whether they have ever been pregnant or not (type 1)…and those  women who have lost their natural breasts and have developed droopy smaller breasts due to childbearing and nursing. (type 2) The results of placing a breast implant will be different for each type of patient. Type 1 patients will do fine with a breast implant alone and will often get the more ideal breast shape result. Type 2 patients may need a breast lift in addition to an implant to get a better shape with a good nipple position. It is this consideration of a lift and breast mound scarring that will often catch the Type 2 patient by surprise.

It is important to appreciate what a breast implant can and can not do. Implants do a superb job of making the breast mound bigger. But they have very little ‘lifting’ ability. The only lift effect that can occur is from inflation of the breast mound and this will move the nipple up a little. The operative word here is…a little. Significant movement upward of the nipple for most breast ptosis patients is a matter of at least several centimeters, not millimiters.

Dr. Barry Eppley

Q : I am 52 years of age and my upper lip seems to be getting longer. When I was younger my upper lip didn’t seem to be as long. When I smile I barely show any upper teeth at all anymore. Is there some form of lip surgery  that can help me?

A: A long upper lip can develop in some patients due to the natural process of aging. The upper lip can literally lengthen due to shrinkage of the vermilion (pink portion of the lip) which gets smaller and actually rolls inward. These age changes of the lip can be accentuated by tooth loss. Loss of lip volume combined with other falling facial features makes the skin portion (between the base of the nose and the vermilion) of the upper lip a bigger percentage of upper lip length.

There are two specific procedures for shortening the upper lip. Both involve removing skin in a horizontal fashion at either the top or bottom skin portion of the lip. The subnasal lip lift, also known as the bullhorn lip lift, removes skin from right under the nose and truly is a lifting procedure. Removing skin just above the pink lip line is known as a vermilion or lip advancement. This advances the pink part upward directly. Both result in fine line scars although the subnasal lip lift places the scar in a more hidden location in the crease under the nose.

While both of these procedures are effective at creating a slightly shorter upper lip, both will increase the amount of vermilion show. The subnasal lip lift is limited to increasing only the central pout of the upper lip with lip shortening. The vermilion advancement moves the entire pink portion upward from one corner of the mouth to the other.

Which procedure is best for any patient depends on the anatomy of their upper lip, specifically the shape and thickness of the vermilion.

Dr. Barry Eppley

Q: My boyfriend is concerned about the size of his areolas. Do you offer areola reduction surgery? He is very interested because he feels his nipples stick out too far and his areolas are too wide. They stick out when he is in t-shirts and some clothes.

A: The nipple and areola, known in plastic surgery as the nipple-areolar complex, is a two-tiered structure. Surrounding a central protruding and darker pigmented nipple, the areola is flat and much larger in diameter. The size of this complex can be quite variable with significant amounts of nipple protrusion and very wide areolas. But the extent of these variations is largely in women since this is a functioning gland that changes as a result of pregnancy. Men rarely show such variations in size as it serves no functional purpose.

Todays’ fashion and styles, however, have placed a little more focus on the nipple-areolar complex. Men do not like when their nipple protrudes through clothing and, rarely, a few men feel that their areola is too wide. Most wider areolar concerns are in patients with gynecomastia where the breast is also larger. But wide areolas can occur when gynecomastia is not present. In women, the typical areolar diameter measurement is around 38 to 45 mms. In men, those numbers are usually half those amounts.

Both nipple and areolar reductions are simple procedures. The nipple protrusion can be flattened by a simple wedge excision without any visible scarring. The areolar diameter can be narrowed by a circumareolar excision. This does leave a fine line scar at the junction of the areolar and skin. Both can be done under local anesthesia in an office setting.

Dr. Barry Eppley