Your Questions

Q: Dr. Eppley, I was inquiring on if you have any experience with congenital symmastia? It’s something that I’m quite certain I have and something that has always bothered me. I do not think I need breast implants and my breasts are a good size. But I do not like this web of skin that crosses between my two breasts. In bras it looks even worse. How can this be corrected?

A: Symmastia presents in one two ways, either from a congenital basis (like yours) or iatrogenically created by breast augmentation surgery. In congenital symmastia, there is usually a web of tissue between the two breasts. In this web there is fat and therein lies the way to treat it…liposuction. By removing the fat in the web and with postoperative compression, the tissue between the breasts can be made to stick down to the sternum thus eliminating the web. This can be done as s stand alone procedure or combined with breast augmentation. (although by your pictures this is not something that you need)

The success of symmastia correction by liposuction depends on how well the skin will adhere down to the sternum. After liposuction compression is applied but this is a difficult area in which to keep good compression on the skin for any sustained amount of time.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in pursuing more information about eyebrow transplants. My eyebrows have thinned considerably in spots and they appear uneven. Therefore, I would like to have this corrected. I am curious as to how many sessions I may need to have in order to get my eyebrows as full as I’d like them to be. I have attached photographs of what my eyebrows currently look like and a photograph of my eyebrows as I would like them to be.

A: Eyebrow hair transplants represent the smallest surface area for hair transplantation that is done regularly. While once used just for traumatic eyebrow hair loss, it has become popular for women of all ages to thicken naturally sparse eyebrows or eyebrows which have become thinner with age or plucking. If you count the number of hairs in your existing eyebrow, you will see they are approximately 80 to 100 hairs in each eyebrow. ( I know because I counted yours) To double or triple the density of hairs in your eyebrow (which is what you are showing in your ideal picture), you would need 100 hairs or roughly 40 to 45 follicular units per eyebrow. How many hairs that can be transplanted depends on how close together they can be placed into the slits made for them. On a realistic basis it can be hard to place more than 20 to 25 follicular transplants in each eyebrow in a single session. That may be enough when they are fully grown but you would have to make that judgment six months after the initial session. Thus, one session may do but it is best to always plan on a ‘touch-up’ session depending how the hairs take or to add more for eceb greater density. As a general rule, hairs take about 6 to 8 weeks before you will see significant growth or when they start visible growing. It also takes this amount of time for the little ‘dots’ that surround each transplant to fade and blend into the surrounding skin.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My question is in regards to the safety and security of chin implants. While I firmly believe such a procedure would improve my appearance my hesitation lies in the uncertainty of the implant being a permanent solution. To be specific my job is such that at times is of a physical nature and am worried that the implant could become dislodged. How is it kept in place? And are there certain implants designs that are better then others? Would hard impact to the chin or jaw cause it to become dislodged? Perhaps you know people in the Military who have had this done? My second line of questions are about the health risks of a foreign element placed in the body. Are there long term effects from having a implant inserted and is this something that once done should remain for life? Thanks for your time.

A: Chin implants, almost of any implant placed on the body, are the safest (less likely to have complications) in my long plastic surgery experience. There are a permanent chin augmentation solution as the material will never degrade. The implants are secured in place by small titanium screws so that they will never move or become dislodged. I have yet to have a case where a chin implant became dislodged or displaced because of trauma of any nature, including patients in the military. There are no health risks from performed silicone since it is a molecularly stable material that does not degrade or release any free silicone molecules.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My temples bulge out too much and I know it is the muscle because it gets worse when I clench my teeth together. Is it true that the less your muscle expands and contracts when chewing, the thinner it is? If I use my mouth less will the muscle shrink? Is surgery the only method to reduce the size of the temporalis muscles? How much would the surgery cost please, and would the muscles be taken off by excision? What risks are involved?

A:  Like all muscles, size is somewhat dependent on use. But one would have never open their mouth again to have the temporalis muscle shrink in size.

The non-surgical approach to temporalis msucle reduction is Botox injections. It would require a series of Botox injections done 4 months apart up to a year to get teh muscle to shrink. Presumably this would be permanent but that is not assured.

The temporalis muscle is released from behind the ear and at the top of the skull,  4 to 5 cms removed and then retacked done through a vertical incision in the hairline above the ear. The only real risk to the procedure is in how much correction (reduction in convex profile) can be achieved. It does not affect mouth opening or movement. Its total cost for both sides is in the range of $6500.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, My daughter had craniosynostosis. After which she was left with plagiocephaly(right side). Was wondering what are the best options for her, she has 5mm deformity after wearing the helmet for 1 year. Now she is 9 years old. Need to know if the surgery can be done anytime or there is a certain period that is beneficial for the kids.

A: Once the skull has undergone much of its growth spurt and it is clear that ongoing growth is not improving the asymmetry, it is reasonable to consider an onlay skull augmentation. The decision to do so is based on an aesthetic judgment since there are no neurologic benefits to doing it. So the question is not whether it can be done but whether it should it be done. At 9 years of age, that is a decision for the parents to consider or to allow the child to decide for herself when she is old enough to do so.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I had a rhinoplasty in 2010 and I feel that it looks short for my face, nostrils not the same shape or size, alar base too round and wide, nostrils are flared. Nose is upturned and too short for my face. I feel my upper lip has too much space from lip to nose. Would like a softer more feminine appearance.

A: Thank you for sharing your story and photos. I obviously do not know what your nose looked like to start with and exactly what was done to your nose. It would be extremely helpful to see photos and the original operative record from your 2010 rhinoplasty. What types of grafts were harvested (if any), where they may have been placed, and what is left of the original cartilaginous structures will all play a part in what needs to be done. Secondary rhinoplasty surgery is usually much more difficult because of scar, distorted structures and sometimes depletion of easily available cartilage graft harvests.

But that important issue aside, your nose is short with wide nostrils. The tip lacks projection, the columella is short and upturned and the dorsum is low. Such a nasal shape is very characteristic of many ethnic rhinoplasties. (as said by a Caucasian plastic surgeon) In changing your nose to your desired goals, it is a matter of the degree of change. It is an issue of either tip derotation and nostril narrowing or that combined with dorsal augmentation. That aesthetic difference is important as that would determine the type and amount of cartilage grafting that will be needed. But either way cartilage grafts would be needed and most likely that means costal or rib graft harvesting to get the amount of straight pieces of graft needed, particularly if dorsal augmentation is going to be done.

As for the lip lift, I don’t see the benefit in your case. Your upper lip skin is already at a good length with substantial upper lip vermilion show. I think you perceive your upper lips as short, as least partly because of your short and up turned nose. While I doubt its benefits to you, I would at least wait until the nose is done and see what you think about your lip then. An open rhinoplasty and lip lift has to be performed separately anyway due to blood supply concerns of the intervening columellar skin.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I took a look at the computer imaging that you did for me for my jawline. I like what you did to the chin but don’t like the jaw angle result. I saw a case of a guy onlione who had custom made jaw angle implants done and he did not had that square look. Is that possible to be done to me like that as well?

A: Let me explain the purpose of facial computer imaging. Initially it is to create a dialogue or communication as to what the patient wants. No knowing what anyone really wants when they say a stronger jawline, I have to have a starting point for discussion. I made those angles square to see if this is the tyhe of jaw angle look you prefer. They do not reflect any particular implant selection as of yet. Therefore, looking at other jawline examples is helpful only for the standpoint of giving me guidance as to what look someone prefers…it means nothing about the implant style. So custom jaw angle implants are not what you need. Custom facial implants are usually used when the final look is more extreme or when stock off-the-shelf implants can achieve the desired look if they are intraoperatively modified. When going for less than a square or flared jaw angle look, stock jaw angle implants will work just fine…and they are far less expensive.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, my question is about face fillers. I had some permanent filler injections done on my cheeks 4 years ago. I am now developing hypersensitivity, not at the site of the filler, but over the sinus and neck muscles and headaches. Plus my eyebrows are thinning .The surgeon told me the filler used is BIOALCAMID .What is your opinion on can the filler be removed?

A:  Bio-AlCamid is a gel polymer filler that is composed of a 3% to  4% concentration of alky-amide polymer and 96% water. It is used around the world but is not approved in the U.S.  It maintains it volume through the attraction of water to the non-resorbable polymer which is then surrounded by a scar capsule. The manufacturer says that it can be removed relatively easily and this may be true if it is well encapsulated and can be palpated. Once the capsule is entered, the material will likely be expressible. The other key question is what to do after the material is removed as there may likely be a deflation effect seen on the outside of the face. While one could use any of the available temporary hyaluronic injectable fillers, I would strongly think about fat injection replacement. Otherwise, I see no direct correlation between it and your hypersensitivity symptoms.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am considering a chin osteotomy as opposed to a chin implant for my weak chin. What I am most concerned about, however, is the complications that may be involved (numbness around the area and using titanium plates/screws inside my bod). As I have decided not to correct my overbite, would you still recommend that a sliding genioplasty would be a good option for me? Thank you very much.

A: In my opinion, the sliding genioplasty is and has always been your best solution. It solves all your chin issues at the same time. I would not concern about titanium being implant and in your body for the rest of your life. Titanium is the most biocompatible metal that is known in medicine and will be completely overgrown with bone anyway. I have never had to remove titanium plates and screws from a chin nor have I ever seen it to be a problem. This is the best place for such metal materials in the face because it is has a thick bone and soft tissue cover and is not exposed to the stresses of mastication. While there is always the risk of some feeling loss from chin osteotomies, my experience is that it is very low. The key is to do the osteotomy at least 5mms below the mental foramen if not lower to avoid any risk of permanent loss of sensation to the lip and chin.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Ever since my chin osteotomy was done over a year ago, the muscle in my chin does not seem to be working right. It feels tighter on the right side and dimples in when I smile or make a pout or blowfish face. It feels tight all the time and twitches often. Can muscle work be done on the chin without having to do anything with the chin bone? I do not want to go through another chin osteotomy. I have attached some photographs, at rest and in animation, for your review.

A:  Thank you for sending those very illustrative photographs. I couldn’t have asked or instructed you to take those animated views any better. The one observation that seems to be consistent is that there is mentalis muscle asymmetry, both at rest and in animation. With your history and photographs this suggests to me that the right mentalis muscle has been tightened, lifted more or otherwise sewn donw tighter to the bone. This would explain why the right side has better lip competence (elevation at rest) but moves and feels abnormal. 

Given that you are over one year months from surgery, I would expect to see no improvements or changes. You certainly could have some muscle done on that side. That would require no bone work or secondary chin osteotomy. Your chin bone position and overall facial appearance look very good to me, very balanced. That is a very simple procedure that could be done under local anesthesia or IV sedation. It is nothing like what you have experienced with the original chin osteotomy. I would go intraoral on that side and release part of the mentalis muscle in the area where the greatest dimpling is/loss of labiomental fold. I would then place a small dermal graft so the muscle in that area stays released.

I couldn’t guarantee that that would be a complete cure but there is no downside (can’t make it worse) and it is fairly simple to do with no real recovery. 

Dr. Barry Eppley

Indianapolis Indiana

The recent hullabaloo over the controversial Health Care Reform Act brought to the surface many pertinent issues of our entrepreneurial medical industry. While no piece of legislation will solve most of the really important problems, lost in the fray were economic and legal issues that impact more than just who pays for what and why.

A recent news story from Georgia brings to the surface one of these issues. CBS has reported that a woman almost bled to death during a surgical procedure performed by an ophthalmologist. According to their accounts, the woman awoke during the procedure and heard the doctor calling 911 for help as she was bleeding extensively.

Just this much of the story should raise two pertinent questions. The first being how do you bleed to death from eye surgery?  Even the anatomically uninformed would assume there are no major blood vessels around the eye. Contrary to what one would think, he wasn’t performing eye surgery at all. He was performing breast augmentation! And the second question is how was it that she awoke to find herself in this dilemma? She was having it done in the doctor’s office. Luckily, a plastic surgeon was on staff at a nearby ER and helped save her life.

Such a story, while not common, is by no means rare. Today, every medical specialty is suffering from plummeting insurance reimbursements and skyrocketing malpractice premiums.   (The Health Care Reform Act has addressed neither of these issues).  This sets the stage for economically struggling doctors, and borderline unethical ones as well, to turn to more profitable fee-for-service cosmetic procedures to enhance their income. The public would assume, incorrectly, that there are laws in place to keep doctors practicing outside of their scope of training…but there are not. In most states, Indiana included, there is no law against physicians performing whatever procedure they choose, whether they have qualified training or not. All you need is a valid medical license. Because hospitals protect their own liability and will not allow doctors to perform procedures outside of their training, this can be easily bypassed by performing these procedures in their own office where the only governing body is the providing physician. There is no law against me, a board-certified plastic surgeon, performing Lasik vision correction or cataract removal in my office, even though I have no formal training to do it.

But this disturbing story does not stop there. Months after this event has occurred, the state medical licensing board refuses to suspend his medical license or has yet to even have a formal investigation. This lack of regulatory intervention is not rare. Licensing boards are shockingly slow and often very reluctant to pull any license even when the issue that is being reviewed is one of blatant disregard for the rules and does place patients at risk. The take home message is do not count or give too much credit for any governmental agency looking out for you. The legal roadblocks and delay tactics will often let a rogue doctor continue in practice for years.

The obvious message of the story from Georgia is that the burden is completely up to the patient to determine whether their physician is qualified to perform the cosmetic or plastic surgery procedures they seek. Slick-looking websites and discounted or low-fee incentives can make it easy to overlook the big picture…your safety.

Do your research and bear in mind that most, if not all, physicians in good standing will welcome your questions.  An informed patient is a great patient.

Dr. Barry Eppley

Indianapolis, Indiana