Your Questions

Q: I have a deviated septum. I am pretty sure my insurance covers surgery to fix a deviated septum. I was wondering whether would there be anyway of sliding in a rhinoplasty while fixing the deviated septum to cover majority of the costs. How would that work, thanks so much.

A: The premise of your question is…can I get insurance to pay for part or all of a cosmetic procedure? While the answer to that seems obvious, it is actually an understandable and common question that has historic precedence. In the past, many cosmetic procedures were done at the same time as medical or insurance-covered procedures…and the patient was never charged for the associated expenses of operating room charges and the anesthesiologist’s time. They were just ‘rolled into’ and considered part of what was billed to insurance. The hospital or surgery center never really knew or just looked the other way.

But such surgical behavior is now long gone and is viewed for exactly what it is…insurance fraud. Getting the insurance company to pay for part of a cosmetic procedure, just because a medical procedure is being done, is not what any patient’s health insurance is intended to cover. Nor are they obligated to do so. And the insurance companies understandably take a very dim view of such actions. As a result of such past behaviors, health insurance companies have gotten very vigilant of such behavior as well as hospitals and surgery centers. There are substantial fines and even criminal sanctions  if such actions are discovered on the providing facility. Therefore, any operating facility is fully aware of whether a cosmetic procedure is going to be done and expects to be paid in advance for the time involved in performing the cosmetic part of the operation.

Similarly, expecting or asking your treating plastic surgeon to make an operation appears as if it were medically necessary, when it isn’t, is just a different form of fraud. Septoplasty, or internal nasal surgery, provides functional breathing benefits and is medically necessary. A rhinoplasty, unless done as a result of a birth defect (e.g., cleft lip and palate), accident, or as a result of tumor removal, is a cosmetic change that is not eligible for medical coverage.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am interested in getting just a mini-armlift. I can’t seem to find any plastic surgeons that say they have actually done one. I don;t think my arms are bad enough for a full armlift and I don’t want that scar anyway. I just need a little tightening in the upepr part of my arm.

A: Armlifts, known in plastic surgery as brachioplasty or upper arm reductions, are traditionally thought of as a long excision of skin and fat between the armpit (axilla) and the elbow. While this is tremendously effective for ‘bat wings’ after a lot of weight loss, those women with more minor degrees of upper arm sagging on not good candidates because the scar would be worse than the sagging arm problem. This leaves the alternative arm strategy to either liposuction alone or liposuction combined with some limited upper arm skin removal, known as the limited brachioplasty or mini-armlift.

In the mini-armlift, the removal of skin for tightening is restricted to the upper 1/3 of the arm or just that of the armpit area only. (crescent-shaped excision) It can be removed  staying inside the axillary skin folds or be extended somewhat further out onto the upper third of the arm. That scar can be placed on the inside of the upper arm or from the backside. The scars end up in different locations and there may be advantages either way for each patient. I have done the skin removal from both upper arm locations successfully and each patient must carefully consider their preference for scar location. While the skin removal adds an obvious tightening effect, the aggressive use of liposuction is really the mainstay of the procedure and is responsible for much of the result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Hi, I am a 16 year-old that is doing at school an assignment called the Research Project. It is where we have to choose a topic and learn about it and, in the end, we have to do a 10 minute oral presentation on it. I was wondering if you could help me with some questions. The question that I am focusing on is ‘How does craniofaical reconstruction change someone’s life?’. And also how would I write a survey for this type of question or topic. I hope that you can help me. I need all of this done in about three weeks so if you could email me that would be good.

A: Craniofacial surgery is a specialized area of plastic surgery that involves the reconstruction of deformities of the skull and face, whether they be from birth defects, traumatic injuries or from various benign or malignant tumors. Much of this work is about the rebuilding or moving of misplaced or missing bones of the face and skull. While not exclusively done in infants and children, much of craniofacial surgery is done early in life when possible to work with the growing face and to help children develop more normal social interactions. While there may be many functional problems that come with craniofacial deformities, creating a more normal looking skull and face helps provide a significant psychological benefit as well. While we may not always like it, how we look and are seen by others plays a tremendous role in one’s self-image and acceptance by society.

If one was constructing a survey on the topic, one would want to ask how the craniofacial reconstructive procedure made them feel after surgery and what specific impact it had on their lives.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I’ve had a consultation and qouted prices for surgeries. However I wanted to know if Dr. Eppley particiapates in the Doctors Say Yes finance program. I am willing to do this however only if I’m able to use a good reputable plastic surgeon like Dr. Eppley. Please let me know if he is apart of this type of finance. Thank you for your time.

A: The use of financing for cosmetic surgery, whether it is done through separate financing companies or using one’s own credit cards, is common practice. I would estimate that up to 30% to 40% of cosmetic surgeries across the United States are now financed in some fashion. That is a far cry from what it was a mere decade ago where estimated numbers were around 5%. This obviously reflects the national trend toward financed luxury purchases in general as well as the greater demand for cosmetic surgery. Over the years, my practice has used a variety of financing programs which now number into the dozens. We have had both good and bad experiences with them in terms of ease of use, financing terms, and the ability to get patients actually financed. Currently we use Care Credit as our primary referral for cosmetic surgery financing. They have worked out to be the best in terms of approvals, finance terms, and ease of use for both our office and the patients to work with. I am not saying they are absolutely the best as we have not worked with every single financing agency out there. Just that in our financing experience, they have worked out the best for both the patient and ourselves.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Hello Dr Eppley. I have several issues about my face that I would like changed. I am a 21 year old female with prominent eyes along with an oblong face shape. My eyes are not bulging out but they are just prominent. I have no cheek bones. It must just come with having a longer face shape I guess and I lack fat below lower eyelids. I was considering a mini face lift to make my eyes less prominent and my face look less tired. But as I have researched it’s too early to get it done at my age. What options do I have? What would you recommend in order to make my eyes look less prominent and get some volume on my face to get rid of the tired look and make my face look fuller (rounder).

I’m sorry for the long question but I’m so excited to come across your site since I see that you are experienced in almost all areas of cosmetic surgeries.

A: By your description, it appears that you have a longer but flatter face. Flatter in the face refers to a recessed development of the midface, particularly the zygomatic-orbital skeletal areas. (midface, cheek and lower eye socket bones) This lack of anterior projection makes a face appear longer, particularly if the vertical height of the face is long to start with. This also accounts for the lack of fullness in the lower eyelids (sunken in appearance) and the apparent big size of the eyes.

While your eyes may be big in size and your face long, the lack of cheek and lower orbital rim bones can really accentuate that appearance. Improvement of midface deficiency at this level is done by the use of cheek and orbital implants, specifically a combined infraorbital rim-malar implant. This provides fullness across this deficient bony area and provides some horizontal projection. (fullness) This helps balance the face better, make it look a little shorter and can help make the eyes look a little less prominent. These implants are placed through a lower eyelid incision.

Any form of a facelift is exactly what you don’t want to do. This is not a skin problem but a bone-based issue.

Dr. Barry Eppley

Indianapolis Indiana

The drug, Botox, has become a household name in less than decade. It is used in every form of grammar from a noun to a verb to an adjective (check out Urban Dictionary) to convey the treatment of facial wrinkles to looking like one has a frozen face. Who would have conceived that the use of an injectable drug for the treatment of something as seemingly trivial as a few wrinkles would strike such a cultural phenomenon?  With nearly two billion in sales annually and climbing, the thirst for a less-scowling countenance and a smoother forehead is only as limited as the population that is aging.

But Botox and the concept of ‘selective muscular weakening’ have a much longer history than its current use as a wrinkle treatment and a future that exceeds that as well. It was originally conceived as a treatment for unstoppable eye twitching (blepharospasm) and for painful and contracting muscle spasms for those with neuromuscular diseases. It’s even used in the same context for veterinary medical indications- such as the treatment of stringhalt in horses.  These uses predated any cosmetic application, and its use for muscular-based problems is still undergoing medical development with great promise.

Last week, Botox was officially approved by the FDA for use in certain types of chronic migraines. For people who struggle with migraines, this could be viewed as a near-miracle cure, offering almost instant relief that is both prolonged and presents no significant side effects. For migraine sufferers that have tried and failed to get relief with every other available treatment, and who have a very specific trigger located at the base of the neck, temple, or along the brow bones above the eye, Botox injections could be immensely helpful. With the theory that it is the muscles pinching down around nerves which come out of the bone in these areas of the skull that causes the migraine pain, weakening or paralyzing these muscles relieves pressure on the nerves. Botox can be injected directly into the muscles around these nerves to produce this muscle weakening. With the pressure on the nerve relieved, the trigger for the migraine is either eliminated or significantly reduced.

Plastic surgeons have long known of the potential beneficial effects of Botox for migraine sufferers. The number one location for Botox injections is for wrinkles between the eyebrows known as the glabellar furrows,  popularized in Botox Cosmetic advertisements as the ‘11’s. This facial wrinkle area is what the FDA used to approve Botox for cosmetic use in 2002. This brow area, ironically, is exactly where the supraorbital and supratrochlear nerves emerge from the brow bones. They are well known triggers for migraines that come out of the eye area. Every plastic surgeon has seen from time to time patients that comment on how their headaches have been reduced after their ‘11s’ have been ‘Botoxed’. Such observations have led plastic surgeons to try with good success the use of Botox injections at the back of the neck (occipital area) where the muscles attach to the bottom edge of the skull. This is where the greater occipital nerves come out through the muscle and can be another trigger point due to  muscle compression on the nerves. Occipital-based migraines are actually more common than those of the brow or eye area.

While plastic surgery has played a contributing role in discovering this new injectable treatment option for chronic migraines, it is also leading the way to a potentially longer-lasting treatment that for some migraine sufferers may be a ‘cure’. If Botox provides a dramatic migraine reduction through these trigger point injections, then surgically removing the muscle from these nerves should produce a more permanent effect. Known as surgical decompression, it can be done through very small incisions in the scalp. Cleaning the muscle off of the nerves is really a form of ‘surgical Botox.’ Thus, the use of Botox for migraines is both a treatment (lasts about four months) and a test to prove if surgical decompression would be helpful. My experience with this type of migraine surgery over the past year has been extremely encouraging. All patients that I have decompressed have had immediate and significant reduction in their migraines. I’ll be more even more enthused if these results persist for one year or longer.         

Dr. Barry Eppley

Indianapolis, Indiana

Q: Can a chin implant be done after a sliding genioplasty? 

A: The premise of this question is that the result of the bony chin advancement did not produce the desired amount of horizontal chin projection. That could be because the bony chin was not moved forward enough or that the amount of chin advancement needed exceeded how much the bone could be safely moved forward.

Either way, an implant can easily be added onto the front of the chin bone. This is best done through a submental incision under the chin as would be done traditionally. Placing the implant on the front edge of the chin bone does not disrupt the healed chin bone and disrupt the blood supply to the bone. While it can also be placed through the same intraoral incision as the of the sliding genioplasty, this causes a lot of extra tissue disruption going through an area that is already scarred from previous surgery.

Gauging the amount of chin advancement needed is one of the most predictable forms of facial computer imaging. Since the chin soft tissue moves on a 1:1 basis with how the bone position changes, side view predictions can quite easily show how much movement is needed. In doing a sliding genioplasty, if one notes beforehand on the computer prediction imaging that it remains still horizontally deficient, an implant can be placed on the front of the chin at the same time as the chin bone is moved forward. I have done this successfully several times and it works to get  3 to 5 mms of chin projection if needed.

Dr. Barry Eppley

Indianapolis Indiana

Q:  Hi there. I read your blog about rippling in implants. I had breast implants 10 years ago and over the last few years I have noted rippling. I am not sure if I had saline implants or silicone but I want to know if it is possible to inject more saline or silicone into the implant to rectify this problem.

A: The physical characteristic of rippling in saline breast implants is quite normal. Not every women will feel the rippling unless they had scant breast tissue prior to their augmentation. It will always be felt on the side of the breast where the tissue is the thinnest. While most plastic surgeons overfill saline breast implants to lessen rippling, it inevitably occurs over time as the containment bag relaxes a little. (just like a stretched rubber band) The manufacturers generally recommend that a saline implant can be filled up to about 20% over its base volume size. (e.g., a 500cc implant can be safely inflated to 600cc)

More saline can be added to the implant at a later date through a simple procedure. This can help decrease the amount of rippling. But one has to be careful to not place too much volume as the implant can get a very hard feel which is quite unnatural.

Silicone implants generally have little to no rippling as they do not contain a liquid filler but a gel material. This reacts with the containment bag differently as is not prone to the same amount of rippling as that of saline implants.  

Dr. Barry Eppley

Indianapolis Indiana

Q:  I just had my second baby six months ago and I want to get my body fixed. I am almost back to my pre-baby weight, maybe just 4 or 6 pounds more than I was.  It seems like I have a lot of grease accumulations especially in the tummy and  thighs that I would like removed.  But I would need to know more or less how much it would cost so I discuss it with my husband.

A:  Recovering one’s body shape after pregnancies usually focuses on the abdomen and waistline areas. For some women, this is just a matter of resistant fat accumulations that can be relatively easily improved by liposuction alone. For most women, however, it is more than just a fat issue. It is skin that has been stretched out and is lax. Liposuction alone will not tighten this skin but merely deflate it. Some form of a tummy tuck, combined with liposuction, is often what is needed.

Whether it is liposuction, a tummy tuck, or some combination thereof is impossible to know without actually seeing you. Women are so different in how their bodies respond to pregnancy that any one of these options may be right for you. But to give you a price range based on pure liposuction alone up to a fully tummy tuck with liposuction is in the range of $4,500 to $8,000, all costs included. This may be a wide range but costs of such surgery are dependent on the extent and time required to do the procedure.

Dr. Barry Eppley

Indianapolis Indiana

Q: I have some bothersome fat areas on my stomach and thighs that I have wanted to get rid of for a long time. I now have the money to do it and have done a lot of research on the internet about liposuction. I never knew there were so many different ways to do liposuction. I keep reading about Smartlipo and it seems that it is the best tool for doing liposuction currently. What are your thoughts?

A: Using devices to remove unwanted fat is a surgical necessity. So, to some degree, we as plastic surgeons have to rely on devices to perform the surgery. Unlike ten years ago, there are numerous devices today that can make the fat easier to suction out. While many will espouse the benefits of one device over another, I would submit that the hands and brain that is using them is far more important than the technology of the device. No matter what the device can do to get rid of fat, it will be no better than the one who is driving it.

That being said, I can only comment on what my experience with Smartlipo has been over the past two years. In my hands, I can say without question that it does result in less pain and bruising after the liposuction procedure. I think that the swelling seen is about the same as traditional liposuction. I have no scientific data to support that it is more effective but my feeling is that it is. The heat generated in the fat tissues during the procedure accounts for some continued fat cell death and lipid release that otherwise would not be seen with traditional liposuction. While there does appear to be a mild skin tightening effect, most patients overinterpret that result thinking that it can remove inches of unwanted skin. Realistically ti causes some tightening of skin but that is best perceived as firmer skin tautness, not the elimination of an inch or two of excess skin.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I hope you can help answer some questions about chin/jaw implants please? I have a weak jaw line in that my bottom jaw is slightly further back than that of my front, if you follow. I was wondering if I would be a candidate for a chin/jaw implant and if you believe this would assist in aligning my jaw whilst avoiding a lower jaw construction which I would rather not go through?

A: Small horizontal chin deficiencies are usually the result of lack of bone growth in the chin area only. (symphysis) More significant chin deficiencies, however, are a problem with the growth of the entire lower jaw (condyle, ramus and body), meaning that the whole jaw is short not just the chin. This can be clearly evident by how one’s teeth comes together. In a jaw deficiency, the lower teeth are offset behind the upper teeth by a 1/2 to full tooth. (known as a Class II malocclusion) Chin augmentation, whether done by an implant or cutting just the chin bone, improves the projection of the chin and the facial profile but does not align the entire lower jaw.

Aligning the lower jaw, by bringing the entire jaw forward that contains the teeth, provides chin enhancement but also improves one’s bite (occlusion) as well. This is most commonly done by a sagittal split osteotomy of the lower jaw which is performed in the ramus of the mandible. It is clear to see that jaw alignment and chin augmentation are the not the same thing. Jaw alignment by bone advancement will simultaneously give chin augmentation but chin augmentation alone will not create a lower jaw alignment.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I have had breast augmention and a full tummy tuck with liposuction about 8 years ago. I have been happy with my breasts but never really happy with the rest of my surgery. My tummy has a huge uneven scar that goes from hipbone to hip bone. My belly bottom was moved, which I expected, but there is a scar fron my belly button to the horizontal scar with no way of hiding it in a swim suit . Also, my tummy and love handles are uneven as far as being flat. They are lump and uneven. Can you help me?

A: Tummy tucks are a much bigger operation than most breast augmentations. Because they involve cutting out tissues and extensive reshaping, they also result in more imperfections such as prominent scars and uneven areas across the stomach and waistline. Revisions of tummy tucks are probably more common than that of breast augmentations. Tummy tuck scars can end up wide and uneven because of the tension on them at the time of closure. Revisions of tummy tuck scars always makes them look better as they do not involve as much tension on the wound closure. Scars can get both more narrow and even. In some cases, they can even be made to go a little lower than before. Liposuction can reduce uneven areas of fat across the stomach and into the flanks and back. Many tummy tucks benefit from secondary liposuction in the upper abdomen (which can be safely done during the first procedure because of blood supply concerns) and the pubic area. (which often becomes more noticeable with the tighter waistline.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am considering having augmentation for my short chin. I am confused as to whether to use an implant or move the bone. Doctors seem to recommend both ways and it is not clear as to which way may be best for me. Can you help me decide?

A: Your two main choices for chin augmentation are either an implant or a sliding osteotomy. Both will work and each has its own disadvantages and advantages. An implant is simpler, has a quicker recovery and can make the chin wider as it comes forward. (if you want to change your v-shaped chin in frontal view to a more round or even a more square shape) There are even square chin implants to help create that look. The only disadvantage is that it is an implant…although I don’t really see any lifelong problem with having an implant in the chin. That is a very safe place for a facial implant and it is not likely to ever cause any problems requiring its removal. The osteotomy involves moving the chin bone instead of an implant. It is a ‘bigger’ operation, requires a plate and screws and thus there is more expense. It’s main advantage over an implant is that it is better at increasing the vertical length of the chin should that be needed. An implant can not do that very well at all. Also in big horizontal advancements (8 to 10mms or more) in a young person, moving your own chin bone forward is probably better than having a big implant on the end of the chin. An implant can deepen the labiomental sulcus whereas an osteotomy can keep it from getting deeper than where it started. This means that it may look more natural in the long run for big chin advancements.

In the end, you have to look at the anatomy of your chin deficiency and determine whether an implant or osteotomy can correct it the best and the most natural. Other important consideration are your age and the economics of the surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I have approximately 30 lipomas on my arms that range from a large pea to an almond to a large marble.  On my rib cages and abdomen are about a dozen the size of walnuts, and on my legs there are too many to count and of the same various sizes. I am a 45 y.o. female that has always taken pride in eating healthy and being overweight no more than 5 to 10 pounds. I was physically very active, an avid runner, and love to mountain hike. In the past two years the lipomas have erupted in such great quantities all over my body that my life has changed and taken away much of the life that I enjoy. I know that these lipomas can be cut out but that would leave so many scars that it would be horrible and maybe just as bad as the original problem. Are there any new methods for lipoma removal that would not leave so much scarring?

A: With so many lipomas, you obviously have the condition of familial lipomastosis. While you have many now, this suggests that there are more to come in the future. Besides excision (cutting them out), there are not any other conclusively proven methods of lipoma removal. However, I have found some success with both Lipodissolve injections and spot Laser Liposuction (Smartlipo) treatments. Lipodissolve injections cause an inflammatory reactions within the lipoma that causes it to shrink. Most of the time, it takes more than one injection session to get ti to go completely away. Laser liposuction treatment uses the tip of the laser probe to melt the lipoma. Through a small stab incision, the probe is inserted into the lipoma and it is turned on until the lipoma begins to melt.

With so many lipomas, I suspect that the combination of excision, Lipodissolve injections, and laser probe treatments may be needed based on their size and location. Given the multiple locations, all of this could be done in a single outpatient procedure done under general anesthesia. That would be the most comfortable way to treat all of them in a single setting.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Sir, I have a couple two to four inch long hypertrophic scar on my inner forearm and it looks HORRIBLE. I have been using silicone sheets and scarguard with little help. I heard that steroid injections canhelp unbulk the scar and was wondering what your recommendations were?

A: Based on your pictures, you have a common scar condition known as hypertrophic scars. While often confused with keloids, they are not. They are still a normal scar process in which the scar tissue raises above the level of the surrounding skin bit still stays within the original boundaries of the scar. They also reach a certain point of hypertrophy and then get no higher. In the early phases of scar healing, a hypertrophic scar has the potential to be improved by numerous topical therapies including silicone sheeting and topical products. When collagen is being laid down, ti can be suppressed and even flattened by these type of scar approaches. This is also the period when steroid injections may also be useful. Once the scar is mature, however, these non-surgical therapies are unlikely to work. A mature scar is when collagen formation is no longer active and this is why the cross-linking of the collagen molecules is unlikely to be reversed.

At this point, scar excision and re-closure is the most assured method for improvement. The scars will get much narrower this way from the beginning. When the scar is removed in this controlled fashion, hypertrophy is less likely to occur. After scar revision, it is still appropriate and helpful to do topical scar therapies from the very beginning of new scar healing.

Dr. Barry Eppley

Q:  I had Medpor implants placed in the paranasal area several years ago in 2007. It appears that I will be undergoing a LeFort I osteotomy in future. I was wondering whether these implants need to be removed for this procedure and how difficult is it to do so?

A:  Paranasal implants are placed around the curve of the pyriform aperture to add fullness under the nostril base of the nose. They help push out the base of the nostrils and are most commonly used to augment a midface deficiency. They are made out of different materials of which Medpor is one of them. This porous material does allow for tissue ingrowth which makes it more difficult to remove than that of silicone, for example. But they can still be removed without a lot of tissue destruction to do so.

A LeFort I osteotomy makes a bone cut directly across the pyriform aperture area. Advancing the upper jaw at this level creates midface fullness, particularly in the paranasal and anterior nasal spine area. (base of the nose) It would be absolutely necessary to remove paranasal implants when performing this procedure. The fullness created by moving the upper jaw at this level makes the need for paranasal implants after bone repositioning as irrelevant.

Dr. Barry Eppley

Indianapolis Indiana

Q:  I am the parent of a son who is suffering terribly. He is developing breasts like a woman. This started when he was fifteen years old and he will now turn twenty next month. The doctor said that it is Gynecomastia and that he will require surgery to correct it. Although he is not in any danger medically, this is a source of embarrassment for him as it shows no sign of going away and he is not happy with it. We would like to know what it will cost for the surgery.

A:  Gynecomastia is extremely emotionally disturbing for many young teenagers and men that are afflicted with it. This has become particularly so in our current youth culture in which the very flat chest is exemplified in many ads aimed right at teenagers. (e.g., Abercrombie Fitch) Given the obesity and overweight issues that now exist in the young American population, gynecomastia problems and young males seeking treatment exist now like never before.

The cost of gynecomastia reduction surgery is in direct correlation to its size and the type of surgery needed to correct it. Smaller gynecomastias may be removed with liposuction only or simple areolar excisions. Larger gynecomastias require both excision of skin and breast tissue as well as liposuction. Without seeing pictures of the gynecomastia problem, it is impossible to give an accurate fee for the surgery. Generally, the will be somewhere between $5,000 to $8,000, which includes the associated costs of operating room and anesthesia expenses.  

Dr. Barry Eppley

Indianapolis Indiana

Q:     Hello Dr. Eppley, I wanted to that you for such a fast reply. I have looked through your facial scar revision work you have done and believe you can do something for me. I got a scar along my left lip to the side of my nose over one year ago. I have a few scars since I was a kid but I have gotten used to them. This new scar is by far the ugliest and biggest scar I have gotten. I don’t see anything but the scar when I look in the mirror and it bothers me alot. I understand that half of it is mental but I still would like to keep my face as close to perfect as possible. I already went and saw a doctor who charged me $150 for consultation and really couldn’t help me. I have used Bio Oil, and Mederma regularly and not sure if it’s a good thing to do. My scar is the same color as the rest of my skin but the only problem is its indented. All you see is a deep line which makes my appearance stand out. I went to a place where I paid lots of money and got some kind of liquid that they shot under the skin. It is a filler that only lasts 8 to 12 months. Like I said the scar being indented is the only problem. Whenever I stretch my mouth you can’t see the scar at all, and that’s all I need is to stretch my skin somehow so it stays that way. The filler they have shot in to my scar came in size .8, I have used .2 the first time and .2 the next time. I don’t know if any of this information helps but using that filler didn’t help much. Please tell me if using too much of Bio Oil or Mederma is bad for it. What are you suggestions?

A: Thank you for sending your history and the pictures. You have a mature scar that is obvious, not only by its location, but by its indentation along its entire vertical length. The indentation of the scar, fortunately, is in a favorable orientation being vertical on the side of the lip. That is advantageous for a favorable scar revision outcome.

As you have correctly pointed out, improvement in the scar is only going to come from improving its indentation. There are two options for long-term/permanent improvement. The first is to surgically treat it by doing a formal scar revision, excising the depression from the scar and re-closing it so that it is even. That will require a ‘stepping back’, so to speak, as the scar will be read for a while before the color fades. The other approach is to place a thin dermal graft underneath to push the indentation upward. That avoids cutting out the entire scar and the required time for scar fading. Either option is better, in my opinion, than injectable fillers and any method of skin resurfacing. You may stop the topical treatments as they will have no effect on a mature scar and are not capable of raising up the indentation.

Dr. Barry Eppley

Indianapolis Indiana

Has anyone ever said to you that you look tired…have puffy eyes…or commented on the bags under your eyes or your dark circles? If you are over 35 or 40 years of age, you have undoubtably been told that at least once. Many have been told that more than just a few times. While I could espouse on the merits of pointing out the good in people rather than the bad, that would be a pertinent subject for a different column that has little to do with plastic surgery.

Without being told, most people that develop tired-looking eyes know it from looking in their own mirror. Women are particularly sensitive to how their eyes look as they engage in the daily ritual of make-up application. The vast majority of men, however, are unaware until their tired eye problem almost interferes with their vision. While there are some useful simple home ‘remedies’ that can help, such as astringents and endless numbers of creams, they do not remotely produce an improvement that is comparable to what blepharoplasty surgery can do.

Blepharoplasty, or ‘cosmetic eyelid’ surgery, is one of the most successful of all facial plastic surgery procedures. By removing loose and extra skin and fat from the eyelids, one can look refreshed again helping restore an eye appearance that one used to have. But many people are unduly hesitant about undergoing it because of misconceptions about recovery and pain after the surgery.

The thinness of the eyelid tissues and their superb blood supply make swelling and bruising an inevitable, but temporary, sequelae of the surgery. Despite how it looks, it is not painful and most patients only comment that their eyelids initially feel a little tight. There may be some slight stinging discomfort around the eyes the first night after surgery, but that passes quickly by the next day. Bruising and swelling are what persists and that will take up to two weeks after surgery until one is fully in the ‘benefits’ period. For some, this is a time for social reclusion. For others, they embrace it and do not let it be a hindrance for returning to work or getting out and about.

One of the great things about blepharoplasty surgery is that it is not a ‘one size fits all‘ procedure. There are different types of eyelid tucks based on how slight or severe the tired eye problem appears. If one has a lot of droopy or hanging skin then the traditional blepharoplasty would apply. But for those that have just a little extra skin or  lower eyelid wrinkling, then the new ‘pinch and peel’ blepharoplasty can be done where just a pinch of skin is removed and the wrinkles reduced by a chemical or laser peel at the same time. If one is just bothered by their undereye bags, that protruding fact can be removed from inside the eyelid, having no external incision at all.

While the eyes may be the window to the soul, the eyelids are the window shades. They create, fairly or unfairly, an impression of our alertness and liveliness. A crisper and refreshed eye appearance is readily possible through blepharoplasty surgery and is easier to go through than most people think. Whether one’s tired eyes are just beginning or are quite advanced, blepharoplasty surgery can be customized to just the right amount needed to put that twinkle back and still fit into one’s lifestyle.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I have looked into chin implants and, a local plastic surgeon with whom I shadowed in town, felt that a simple chin implant would only bring the skin forward in the front and not actually give me the square, fuller  jaw, and more forward chin, I was looking for to balance the face. So my question would be, is chin and jaw augmentation the same thing or are they different procedures? If they are then would “chin” augmentation be my best bet?

A: Chin and jaw augmentation are different but related. Chin augmentation refers to building out the front part of the chin or jaw, otherwise known as the anterior prominence. Jaw augmentation most commonly refers to jaw angle implants which accentuate the size and prominence of the posterior jaw prominence. While they are often done separately, it is not rare to have them both done at the same time to get a total jawline enhancement effect. A chin deficiency is frequently part of an overall ‘weaker’ jawline, so the three point augmentation approach (one chin, two jaw angles) can create a better defined and more masculine lower third of the face.

While jaw angle augmentation exclusively uses implants, chin augmentation can be done with implants or by moving the bone known as an osteotomy. Whether one is better served by a chin implant or a chin osteotomy, and the size and style of jaw angle implant needed, requires a careful facial assessment and the use of computer imaging to make those determinations for each individual patient.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Do you use the BodyTite Radiofrequency Assisted Liposuction (RFAL) for upper arms and abdomen areas? Is it safe to this while I am breastfeeding?

A: RFAL is a modest skin tightening and fat removal method. Whether that is an appropriate technique depends on how much fat vs loose skin one has in their upper arms. Based on my experience in upper arm reshaping, I would have little confidence that any method of skin tightening alone on the body in general is a good financial value. (i.e., a satisfied patient) Almost every upper arm that I have seen in my Indianapolis plastic surgery practice, even if there wasn’t a fat issue, needs at least an inch or more of skin tightening. That is well beyond what any method of nonsurgical skin tightening can do. The arm is a tough area when it comes to decision making between an arm lift and liposuction. Armlifts are never worth it unless there is a lot of skin. Even liposuction can produce only modest arm changes. For arm issues that do not justify an armlift scar, the dual approach of Smartlipo followed postoperatively by skin tightening, such as Skin Tyte or RFAL, would be a good consideration.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Hi Dr. Eppley, I am interested in filling in my lower cheeks.  They are sunken in and I have had multiple fillers from Radiesse, Juvederm etc for years. I am tired of it looking really good for 2 weeks due to swelling and then having it all disappear and look the same within the month.  Do you ever do a tissue fill on the lower cheeks?  I had one doctor do filler one time on the upper cheeks and I hated it. I looked like cat woman and I don’t like that look. I just want to fill in the bottom cheeks. I’m afraid to put in an implant because of the risk of crooked smiling. What do you suggest?

A:  The area below the cheeks is known as the submalar triangle which extends from below the cheekbone down (in an upside down triangle) to below the side of the mouth. It is important to appreciate that this area is not supported by underlying bone. This is why anyone with a thin face or fat loss will show an indentation in this area and create a ‘gaunt’ look. This also means that there is no type of a bone-based facial implant providing any fullness to this area.

While synthetic injectable fillers will produce some temporary fullness, they are not a long-term solution to this area of soft tissue facial deficiency. The next logical approach is that of fat injections. While they offer at least the potential for some long-term retention, they are also plagued by potential resorption. I have mixed these fat injections with PRP (platelet-rich plasma) for facial injections and feel that this combination does offer better results. But the risk of near to complete resorption still exists. No one can predict how well fat injections will persist in any particular patient.

The remaining good alternative is that of dermal grafts. Using allogeneic dermal grafts, they can be put it in sheets and layers. They can nicely built up an area and are very soft. They are human collagen which will eventually be replaced by your own tissue. They can be put in through a limited facelift incision. Their long-term volume retention is much more assured than fat injections.

Dr. Barry Eppley

Indianapolis Indiana

Q: I had a hysterectomy which led to me having a muffin top right above the pubic area. Is there any surgical procedures that can correct this?  

A: Your so-called muffin top is medically known as suprapubic fullness or lipodystrophy. It can commonly occur after a hysterectomy or even after an abdominoplasty or tummy tuck. It actually was always there to begin with but the creation of a scar across the upper suprapubic area, it appears. It is the result of some residual lymphatic obstruction caused by the scar as well as the tightness or indentation of the scar line. Between the scars and the mons, the suprapubic area looks rounder or more full. This can particularly appear after a tummy tuck because the stomach above the scar line is very flat while the suprapubic area is now fuller or more protuberant.

Reduction of the full suprapubic area can be done quite easily. Through the use of liposuction, excess fat is removed and the suprapubic fullness eliminated. This is a very successful procedure that is often done as a follow-up to a tummy tuck should the residual suprapubic fullness be a concern. It is a simple outpatient procedure that can be done under local anesthesia or IV sedation. There is virtually no pain after and no specific physical restrictions. There will be done some postoperative swelling and bruising which often works its way down onto the mons and labia. Within weeks, the swelling and bruising are gone. With the current use of Smartlipo, much of the bruising that used to occur with suprapubic liposuction does not occur.

Dr. Barry Eppley

Indianapolis Indiana

Q:  I am 18 years old and cheek enhancement seems to have caught my interest.  I’ve been rolling the thought of having a procedure in my head for quite some time now, so here I am asking for information. People say there is nothing wrong with my face but what I want is more defined cheekbones, like the male model look. There is this heart shape the cheeks do along with the jaw angle if you understand what I mean. What effects might the procedure have on my face in a long term period of time? I mean, when I get to 50, will there be any undesirable changes on my face? Thank you for your time. I look forward to receiving an answer from you.

A: High cheek bones are a frequent aesthetic desire. In a male the triangular effect of prominent cheeks, chin and jaw angles makes for that chiseled or angular face look. That particular male facial look is certainly one that is evident in many male models in magazines and advertisements.

While strong cheek bones may be desireable, they are not achieveable in every male face. While cheek implants can make the cheek area bigger, that doesn’t necessarily mean that effect makes for a more sculpted facial look. One has to look at the other facial features and the overall facial shape to see if cheek augmentation offers an aesthetic improvement. If cheek implants are put in just any face, some of those faces will just look like they have big or puffy cheeks and may not become more angular.

One positive long-term effect that cheek implants do is help maintain cheek tissues from sliding off the bone, so to speak, with age. In fact,  they are occasionally placed in older patients for a midface rejuvenative effect to help lift sagging cheek tissues. Unfortunately, when done to an extreme, they can make the older face look odd or have an ‘apple cheek’ effect. There are numerous famous male celebrities that have this look.

Dr. Barry Eppley

Indianapolis Indiana

Q:  I am in need of revisional tip rhinoplasty. But I have been warned strongly about the risks of ear cartilage, since my septal cartilage is quite probably inadequate to serve as a graft source. It would be more than a pity to spoil the present symmetry of my nose tip in the pursuit of a small derotation/lengthening. I was wondering about the possibility of newer advancements with stem cells in plastic surgery. They have received great publicity and already articles are being written on the new potential they offer and the speeding-up of changes for reconstructive medicine. I would be extremely grateful and certainly willing to undergo the surgery at any expense if you would be in a position to predict near-future applications, and incorporate them in your practice at least for volunteers to whom this would mean so much. Lots of grateful thanks, and I hope to hear from you again with some promising news or estimations, or even information some time later.

A: Stem cells in plastic surgery to make new tissues remains a hopeful but unproven surgical technique. Its appeal is great and that makes great print and internet copy but there remains a far leap from the laboratory to that of useful clinical applications. I do not know why anyone would tell you that there is ‘danger’ with ear cartilage in revisional rhinoplasty It is a very reliable, simple, and predictable graft material to use in the nasal tip and has a very long history of successful use in revisional rhinoplasty. Even if stem cells could make cartilage (and someday they will in the near future), they could not make a graft that would be better than actual ear cartilage. .

Dr. Barry Eppley

Indianapolis Indiana

Q: Dr. Eppley I heard people with protruding brows just have some of the forehead protrusion above the eyebrow cut or shaved off some.  No metal plates and screws!  Am I correct?

A:  No you are not correct. Brow bone reduction requires that the outer table of the frontal sinus (the bulge or protrusion) be removed (cut off), reshaped, and then put back in place in a flatter shape. Putting it back in place requires small low-profile metal plates and screws to properly hold the reshaped bone in place until it heals.

The reason that  the bulging brow bone can not simply be burred or shaved down is that this bone is actually very thin. The bulge is present, not because the bone has gotten thicker, but because the air-filled frontal sinus has expanded pushing out its front wall. For significant brow bone reduction to occur, the bone must be taken back as much as 8 to 10mms. The thickness of the frontal wall of the frontal sinus is only about 2 to 3mms thick. Burring into it would only expose a deep empty sinus cavity, not bone.

Bony protrusions or thickening above the brow bone, however, can be shaved or burred down as there is no underlying sinus cavities above the brow. Bone in most of the forehead can very safely be taken until one nears the diploic cavity or marrow space which could be 5 to 7mms of width reduction.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am interested in areola reduction surgery. I am fairly sure that I may have to lose more weight before I undergo any procedures. I was just wanting to know specifics about what I would need to do before I move forward.

A:  There is usually a strong relationship between the size of the areola (diameter) and the size of one’s breasts. Although this isn’t 100% true, the larger the breast the larger the areola. Areolar reduction is a common part of almost every breast reduction and many types of breast lifts. But it can also be done as an isolated procedure if one is otherwise happy with the size and shape of their breast and just feel that their areolas are just too big.

Areolar reduction is done by a circumferential reduction, often called the donut procedure. A ring of the enlarged areola is removed and the surrounding skin sewn down around the smaller areola. This does result in a scar at the edge of the areola. How well that scar becomes in appearance in affected by how much the areola is downsized and how tight the surrounding skin of the breast mound is. For the best result in areolar reduction, the size and shape of the breast should be stable. Therefore, if you intend to lose more weight, it would be advised that you wait until you have achieved your maximal weight loss. By then the breast size will be stable and the resultant looseness of the breast skin will be an asset towards final areolar scar appearance.

Dr. Barry Eppley

Indianapolis Indiana

Q: I have a chin implant placed crooked (right side is out and left side is in).  I had 2 revisions by the same doctor through the same incision under the chin.  The doctor argued that I have face asymmetry but he agreed that it is not apparent from the photo before the surgery.  Would you be able to help?

A: Asymmetry of the chin after chin implant surgery can happen for a variety of reasons, all related to the positioning of the implant. The implant can be centered off of the midline. Most chin implants have a central vertical line on them which should be matched up with the dental and facial midlines (central chin point, vertical line dropped down from the junction of the two lower central incisors) as well as the midline of the chin bone. Should this matching not be aligned, the implant may be shifted more to one side than the other causing an asymmetric chin. This is what I call a central chin asymmetry. The other reason for asymmetry can be with the wings of the implant. Today’s chin implants, particularly those made out of silicone, have very long and flexible implant wings that go fairly far back along the lower border of the jaw. Should one of these wings get folded onto itself or twisted, a bulge over the tail may occur and can cause lateral chin asymmetry. Similarly, it is also possible that the pockets dissected for these wings is at different levels along the edge of the jaw bone. (and maybe even off of it at the very end) This will cause of the sides of the chin to be less full than the other.

Given that you have had two revisions, you would think that if any of these problems existed they would have been identified and corrected. They may still exist, however, particularly in the tail of the implant which can be hard to recognize. It would also be helpful to know what type of chin implant you have in place. As it may have been modified in some fashion for fit and this may be a source of the problem as well.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Hi Doctor, I was born with a cyst in my cheek and had it removed when I was a teenager and it left a prominent dimple in the left side of my cheek. I would like it somehow corrected and removed, is this possible? One plastic surgeon said something about an injectable filler. Not sure what that is. Any advice would be greatly appreciated.

A: The removal of cysts on the face, even they are of any size, has the potential to leave a residual dimple or indentation. This is the result of a space where the cyst once was collapsing as it heals, resulting in an overlying surface contour indentation. While this is not apparent at the time of surgery and in the early healing phase (weeks to months), it is fluid (blood) that fills the space and makes it initially look smooth. As the blood resorbs, the underlying tissues collapse. If the cyst is small enough, the blood may be replaced with scar tissue. But in larger cyst removals, there will not be enough scar tissue created to leave the overlying skin smooth.

For this reason, I routinuely place dermal-fat grafts in the residual space left behind by the removal of large facial cysts during the initial surgery. This may make the overlying skin look a little full or a raised bump in some cases, but this will go down as the area heals.

For repair of facial dimples after excision of some mass, a dermal-fat graft still remains the best option in my opinion for this type of scar revision. While one can use an injectable filler for an immediate and non-surgical treatment, the result will only be temporary. By going through the scar, the underlying tissues are opened up and the graft placed where the dimple exists. While this does require a harvest site somewhere on the body, using one’s own tissues will produce a permanent solution in one simple operation.

Dr. Barry Eppley

Indianapolis, Indiana

Q : My issue is about my nose. It is a bit big and has a round ball at end. I have always dreamed of having a princess nose. Can rhinoplasty make this dream come true?

A: Rhinoplasty can make some significant differences in the shape of one’s nose. The three primary areas that can be reshaped are the bridge (upper 1/3), the middle vault (central 1/3) and the tip. (lower 1/3) Most patients are focused on changes in the bridge and tip as common areas of concern.

The tip of the nose is its most projecting point and, like a peninsula of land, its shape is out there for all to see. The most common tip complaints are its width, shape, and its projection. (too high or too low). A wide tip, often called a fat tip or a round ball, is caused by large amounts of lower alar cartlilages. The width of these cartilages and how the two come together to make the dome (tip) is the most indivualistic part of anyone’s nose. The tip of the nose is like fingerprints, it is uniquely shaped for everyone.

Tip reshaping is part of almost every rhinoplasty. The lower alar cartilages can be reduced in size and reshaped by sutures. The changes in one’s nasal tip can be really significant and is usually the most impressive part of most rhinoplasty results. The only limiting factor to tip reshaping is the thickness of the overlying skin. Thick-skinned noses will not show the underlying sculpting of the cartilages as well as thin skin and will hold swelling in the tip much longer.

I don’t know if a princess nose is possible for you but I am certain that the size of the can be made smaller and less round.

Dr. Barry Eppley

Indianapolis, Indiana