Your Questions

Q: Dr. Eppley, I have two large earlobes and would like for them to be smaller. They seem to be getting bigger as I get older. I am now 57 years of age and I don’t think they were this big when I was younger. Do earlobes grow as one ages? I am also wondering about the cost for this type of earlobe surgery. Could I get an estimate and would any permanent scars result from it? Also how long does it take to heal or until I can take the bandages off? Thank you very much for your time.

A: Earlobes do in fact grow with age somewhat although not in the classic sense of growth. They do not grow anymore than your sagging jowls and neck grows. Rather it is an elongation process where the tissues stretch due to gravity and ear ring wear. As the earlobe is the only part of the ear that does not contain cartilage, the skin and fat has no resistant internal structure. Earlobe reduction is an office procedure done under local anesthesia. There are different earlobe reduction techniques that vary only in where the final scars are located. The scar locations can be down the central area of the earlobe, at the junction of the earlobe and the face, and along the bottom rim of the earlobe. Which one is best depends on the shape of your earlobe and where you would prefer the scar. There really is no recovery after this procedure nor are they any bandages used afterwards.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dear Dr. Eppley, I am interested in getting a rhinoplasty and I want to know if my expectations for the result are realistic and achievable. I would like my nose to have a more delicate and feminine appearance as it is too wide. I think it doesn’t fit my face as fat as it is now. I would like it to be less wide and fat and to not project as much. My nose seems to stick straight out with very little sloping. Can this be fixed and how much can the fat tip be reduced? My nostrils also flare out considerably when I smile which I also dislike very much.

A: Rhinoplasty surgery can make very visible improvements in making a wide nose smaller but there are limitations in how much can be achieved. While the underlying cartilage framework can be resculpted and narrowed, how much that is reflected on the outside is highly influenced by the thickness of the overlying skin. Thick nasal skin not only retains swelling for a long period of time but it can only shrink so much. Taking a wide fat nose and making it a delicate one is a virtual impossibility. That dramatic a change may not be realistic. You should have computer imaging done first to determine if rhinoplasty can make enough of a change, particularly in the tip of the nose, to make surgery for you worthwhile.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: I have a lipoma of size 4″ on my back shoulder which happens to be most common place for a lipoma for many apparently. I want to be cured non-surgical way. I can travel to your location if needed. I heard about Lipostabil treating lipomas. Is it something I should consider? Please advise.

A: The standard method of a lipoma removal is complete surgical excision. While this is the proven medical method, it will result in a scar in the shoulder area. Scars in that area are very prone to becoming hypertrophic and red, although not all will. The use of a chemical injection (Lipostabil in Europe, generic name of Lipodissolve or mesotherapy in the U.S) to treat lipomas is not new. I have injected quite a few lipomas in the last five years for patients who did not want surgery. I have made the following observations about this treatment method. Lipodisolve injections have always made a visible reduction in their size. In some patients it has been a cure but some regrowth is possible if all the fat tumor cells are not adequately treated. It will take at least two and sometimes three injection sessions, spaced a month apart, to get the maximal response. There is some swelling and mild discomfort of the injection site for a week after treatment but it is in no way physically limiting.

While Lipodissolve injections can be effective, it is important to realize that neither the compounds used nor their use in lipoma treatments are FDA-approved.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I have a very flat butt and have been researching buttock augmentation with fat transfer. (aka the Brazilian Butt Lift) I have a good amount of fat to take from my stomach area so I think I am a good candidate for the procedure. I know that not all fat survives after it is injected, so how does one compensate for that problem? What are realistic expectations for how much fat will survive? How does one know how much fat to transfer in a buttock augmentation surgery? How much fat can I expect to retain with my new butt and will it be permanent?

A: While fat grafting is very popular and can be highly successful, it is far from an exact science.  There are so many unknown variables in doing it that no one can predict with any accuracy how much fat will or will not survive afterwards. Every patient and their fat is somewhat different leading to a wide variety of results. What we do know about fat grafting is that it is very safe and many people have more than enough to donate. What I have observed about fat injections into the  buttocks (aka Brazilian Butt Lift) is that it often will produce less of an effect than many patients want. This is because of the combination of unrealistic buttock size expectations for some and the variable retention of the injected fat. As a general rule, I inject as much fat as possible (between 300 to 500cc per buttock) and judge the final outcome at three month after surgery. There is never a fear that the result will be too big. The real question is whether it will be big enough.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am interested in getting breast augmentation. At 25 years of age with one child I have a height of 5’ 3” and a weight of 137 lbs. What size breast implants do you think I need? I have attached a picture of my breasts to help you decide.

A: In looking at your breasts, your most important decision about breast augmentation is not what size implant should be used. You have a moderate degree of breast sagging, meaning the position of your nipples is at or below your lower breast fold. Contrary to the perception of many, breast implants will not have a breast lifting effect. You are in need of some type of a lift if you are going to get breast implants. With implants alone your sagging breasts will be pushed lower, a look that I doubt you will find as an improvement. All breast lifts result in some scarring, a definite cosmetic liability. Whether larger and more uplifted breasts are worth the scars as a trade-off is what you need to think about first and foremost.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am 28 years old and I have lost about 95 pounds over the past year and a half. While I am very happy with my weight loss, I now have.a bit of loose skin around my stomach area. I work out a lot and do a lot of core work and abdominal crunches but this loose skin won’t go away. Is there some type of cream or device that will tighten this skin or do I need plastic surgery?

A:  You are to be congratulated on your weight loss efforts and results. Reduction of fat can be rewarded with diet and exercise but your loose abdominal skin will not. Skin is not metabolically responsive like fat nor can it be toned like muscle. Do not waste your money and hopes on miracles in a jar or an exercise device. Only the manufacturer will benefit from your purchase. You will need to consider some form of a tummy tuck to get rid of this loose skin and tighten your abdomen. Whether the scar and the surgery expense is worth it merits a thorough discussion with a board-certified plastic surgeon.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I had a bad car accident three years ago which left me with many scars. Most of them are on my arms and back and and don’t bother me much because I can’t see some of them and I am tan enough so that they don’t show. However, the one on my face is awful. It isn’t a flat scar, but more of a jagged edge, indented spot on my face. It looks like a large unnatural dimple when I smile along my jawline. Can this scar be removed? I am planning a wedding for next year and would love scar free photos!

A: In looking at a picture of the scar, it can be seen to be a wide and indented scar along the jawline. Scars that cross the jawline rarely do well because of going over a transition zone between two facial planes and being exposed to tension. This will cause the scar to become wide. I think scar revision can make a big improvement but it is important to realize two important realities about scar revision. First, there is no such thing as scar removal or being scar free. There is improvements that can be made to an existing scar and it is all about how inconspicuous it can be made. But you will always have some permanent scar. Secondly, scar revisions take time to mature meaning that it will be red for months afterwards before the color blends in better to the surrounding skin.With a wedding coming up sometime next year, the sooner you undergo the scar revision the better.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I have a small area of fullness on my chest that I just hate. There are bulges on both sides near my armpit that sticks out and it has always bothered me. While I am not fat and am actually fairly lean, this unusual fat bulge exists for not apparent reason. I can’t get rid of it by exercise and it does not fit the look of the rest of my chest. How can I get rid of these unsightly armpit bulges?

A:  Most of the time when one refers to ‘fat in or under the armpit’ , they are speaking of fullness at the top of the bra around the strap creating what is often called ‘axillary breasts’. Most of the time this is not true breast tissue but simply fat as it is sitting above the pectoralis muscle. This can be removed very effectively by liposuction. If the fullness is more towards the inner aspect of the armpit below the edge of the pectoralis muscle then it may be real breast tissue. This needs to be removed by direct excision with a resultant scar as opposed to liposuction.

Q: I had my nose broken seven years ago that has left me with a crookedness to it that I am pretty sure is due to the bone. I also have had trouble breathing since the injury through the left side of my nose. I would like to get my breathing problem fixed and the nose straightened again like it was before. In addition at the same time I would like to get the tip narrowed and shortened which I think would make it look better overall as well. Will insurance cover all the costs of the procedure since most of my nose problems were due to the injury?

A: The complete corrective procedure to which you refer is known as a septorhinoplasty. This is a combined  reconstructive and cosmetic procedure. Insurance will usually cover the medical necessary parts of the operation that relate to breathing improvement, the septoplasty and turbinate reductions. Changing the outward appearance of the nose known as the rhinoplasty portion, however, is not covered by insurance since it results in improvement in appearance not function. Both septoplasty and rhinoplasty are commonly done together and the out of pocket expense for the rhinoplasty is often less when done together with an insurance procedure than when done as a stand alone operation.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dear Dr. Eppley, I have done a lot of reading on your website and interested in the cranioplasty procedure to fix the flat spot on the back of my head  (on the top area on the back).  I am a female and have noticed this since my teens and always thought there was no help until I came upon your website, now I am hopeful.  I am scared and nervous about this procedure and have several questions:

1)  Is this a new procedure because I don’t see where this has been performed for purely cosmetic purposes before by other doctors?

2)  Would you say the injectable approach doesn’t achieve as much as an effect as the open incision approach?

3)  Also, in the open incision approach, I know you use either PMMA or HA materials.  If the PMMA is used, does that mean you will need to use screws to attach the material?  Is it riskier than using HA since screws are used?

4)  When did you first start performing this procedure and approx how many have you done? 

5)  Have there been any complications with any of them?  If so, what were the complications and how did you fix them?

6)  I live in Houston, TX and would be traveling alone.  From what I read, this is an outpatient procedure, therefore I am concerned about being without care the first night after surgery.  Would you recommend that I get this done in the hospital as inpatient, so I am under care?  

7)  Also, how do you determine how much material to add? 

8)  Do you place expanders to stretch out the skin if I want more material added to achieve my desired result?   

9)  Will there be a noticeable difference afterwards? 

10) Do you take any sort of imaging to determine the shape you plan to mold?

11) Will you ‘sketch’ out the final shape beforehand so I know what results to expect?

12) How many visits will this procedure require?  Including pre-op and post op/follow-up visits? 

13) What is the recovery?  How many nights will I need to spend in IN? When am I ok to fly back home? When can I go back to work? 

A: In answer to our detailed questions:

1)      Although this is a relatively ‘new’ procedure from a cosmetic standpoint, it is based on the decades old principle of reconstructive cranioplasty from craniofacial plastic surgery. The only thing that is really new about it has been the development of some new cranioplasty materials to use.

2)      The injectable approach can achieve just as much as an open approach. It is about volume of material used and its costs that partially controls the result achieved.

3)      There is no increased risk of screw fixation for a PMMA cranioplasty technique.

4)      I have done cranioplasties for nearly twenty years. In the past three years, I have developed some techniques for cosmetic skull augmentation.

5)      The main complication with an injectable approach is getting a smooth contour to the material. I have had one wound healing complication from an open PMMA cranioplasty when using an old hair transplant scar for access.

6)      Having an occipital cranioplasty as an outpatient is just fine. Patients report virtually no pain afterwards.

7)      One of the key issues is how much material to use. That will be determined by the approach used and what the scalp tissues can tolerate. My experience has shown that open cranioplasties through small incision use about 30 to 40 grams with either PMMA or HA. Injectable kryptonite usually uses 25 grams for the occipital region.

8)      While the use of tissue expanders does allow for more material to be placed, it has not been necessary in my experience. This would also make the procedure an unappealing two-step process.

9)      There will be a noticeable appearance afterwards. It is a question of how much.

10)   No imaging is required. It is an artistic molding based on the extent of the defect and the patient’s after surgery shape desires.

11)  Computer imaging can be helpful in understanding what to expect.

12)  There are no after surgery visits required for an occipital cranioplasty. A good presurgical consultation can be done by phone or Skype video in addition to seeing patient pictures. Patients come in the day before surgery for a formal consultation.

13)  Most patients return home the very next day and return to work in just a few days after

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, How long does it take for the tissues to shrink back down and stick to the bone after cheek implant removal? I had anatomical malar shell implants placed three months ago and then had them removed after being in for just six weeks. I think all of the swelling is now gone but my cheeks don’t look like they did before. I have more cheek sagging and my nasolabial folds are deeper than before. I thought the stretching caused by the cheek implants was reversible and would just shrink back down. What can be done now? I want my old cheeks back!

A: When undergoing any form of facial implants, it takes time to see the final results as the tissues settle down around the implant and you adapt to your new facial look. Removing your cheek implants just six weeks after having them placed may have been premature. One of the reasons you do not want to be quick about reversing facial implant surgery is because of tissue deformation. There is no guarantee that the tissues will return to their pre-implant state. In placing cheek implants, the tissues must be stripped off of the bone over a wide area to get the implants into proper position. This not only stretches the tissues (actually a relatively minor effect) but, more importantly, the tissue attachments to the bone is forever altered. It would be natural after implant removal that the cheek tissues can sag somewhat since these tissue attachments will not jump back up into their original position. Once can see that the bigger the implant and size, the more significant that this cheek sagging problem can be. With more cheek sagging, the deeper the nasolabial folds can be. Improvement would either require implant augmentation or some form of a cheek lift or resuspension.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I’m interested in buttock implants but I want to know what implant (oval or round) will give me the most volume. Also does round implants pull up enough muscle to give you a round booty or do you have to get fat grafting added? My butt isn’t flat at all but needs volume. Will the round implant give me upper buttock volume or all over volume (upper, middle, lower buttock). I was told only the oval can give you upper, mid, lower buttock fullness but not as much volume as a round. Thank you.

A: The answer to your question starts with what you have now and where you ideally want it to be. Buttock implants differ in the amounts of volume projection and generally a rounder buttock implant will have more projection. When patients use the word ’round booty’ that almost always means to me that they want a lot of volume projection. That may not be possible for some patients no matter what technique is used and, for others, may require that they ultimately need a  implant and then fat grafting. (although this combinatio is very rare)

The effects of buttock implants is also influenced by whether they are placed subfascial or submuscular. Only subfascial placement can give the entire buttock fullness. Submuscular buttock implants mainly add mid- and upper volume enhancement. The location of the implant is often just as important as the style of implant used.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I seem to be resistant to Botox . Recently 50u was injected into my masseter muscle on both sides and very minimal improvement was seen. It has been a month now and the ever so slight response is disappearing. I have a long and fond history with Botox for my masseter muscles even before it was approved for this use in the US. My last Botox of 100u was diluted with 1cc NS, a more concentrated mix compared to the previous times which was 100u with 1 1/2 cc NS. Should I go for Xeomin now and should I start with 100u for both sides? What is your take on this?

A: In my experience, Botox has worked well for masseteric muscle hypertrophy and I have not seen any patient that has developed a proven resistance to the drug. While it is entirely possible that you may be that rare patient that has developed such a resistance, there are other factors that can also affect how well Botox work. Reconstitution and the age of Botox since it was reconstituted are common culprits that can affect its potency. I would also question why such a concentrated dose was used this last time when the diffusion of Botox is not that great. It is important when injecting the masseter because of its muscle size to cover as much of the lower half of the muscle as possible. A less concentrated mixture with more injections may prove more effective. If this is not effective then I would consider changing to Dysport or Xeomin.

By the way, the use of Botox for masseter muscle hypertrophy and spasm is not an FDA-approved use even to this day. This is an off-label use of the drug.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I am possibly going to have a chin reduction. Here is my serious concerns. I have a very thin face with hollow cheeks. My forehead is large and my chin is small. The problem is I have a projected or jutted out chin which is very pointy, especially when I smile. I have a very strong jaw line, and I just want to to get rid of the witch’s chin look but keep the exact same frontal look. I cannot afford to have my chin shortened. I want a softer look, but I am terrified that I am in for serious dissapointment. If I did this, I would want to do the submental approach and the burring teqnique because I don’t have a long chin. It seems safer, and by your articles it seems I may be correct. I want a softer, more feminine look without making my face look any thinner, and the projection gone. Is this possible?

A: Thank you for sending your inquiry and your pictures. I would take a slightly different approach to your chin. In the frontal view your chin is very square for a female and it needs tubercle reduction (side chin reduction) to soften it. From the side view, it needs some slight horizontal reduction and soft tissue tightening. I would not do any vertical length reduction. You need the length to fit the rest of your face.

This chin reduction procedure is best done, as you have mentioned, from the submental approach to manage the excess soft tissues that will result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am interested in a rhinoplasty to build out my nose as it is very short. I am of Asian background and have a small flat nose which is inherited.  I have read that it can be done with either a rib graft or using a synthetic implant. I would definitely prefer using rib as that would be more natural. I have done some imaging of my nose in profile to show how I would like it to look afterwards. Can this type of result be done?

A: In looking at your profile and predictive imaging, I would make two points. First, using a rib graft for the short nose is the best long-term approach. This is particularly true when there is a significant amount of augmentation desired. Large amounts of synthetic material will put the nose skin under tension ultimately leading to thinning of the skin and tissues and risks of exposre or extrusion. A little synthetic material on the dorsum of the nose can work well. A lot  is a recipe for complications. Secondly and of equal importance, you have unrealistic results. That amount of augmentation is not possible no matter how it is done. The skin of the nose will simply not stretch enough to accommodate that much augmentation. And even if it would, you would not want it to. You should realistically expect about half of that rhinoplasty result that you are showing.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I have a big overhanging belly that I want to get rid off. I have two small children and have lost over 30 lbs since my last one but the sagging belly persists. Will exercise be enough or do you think I need a tummy tuck?

A: While I have not seen a picture of you, your description alone of your belly has already answered the question. The idea of an overhang suggests a lot of loose abdominal skin. If some weight loss has not made a difference in its size, then you know exercise is not the final answer. Undoubtably some form of a tummy tuck is what you need. You can’t exercise off loose skin no matter how hard you try. Just ask any gastric bypass patient who undergo a lot more weight loss than you have. This is a surgical problem. When it comes to exercise and weight loss, however, I would recommend that you get in the best shape as possible for a tummy tuck. Preparing for such surgery, like training for an athletic event, will have you recover faster and may also help you achieve a better result.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Is Xeomin used in masseter hypertrophy? If it is, is the amount of diluent used the same as Botox. Thanks.

A: Xeomin will work the same as Botox for masseter muscle hypertrophy. It is just as potent and has the same onset of action as a full week after the injections. Like Botox’s other competitor Dysport, the unit dosing may be somewhat different from Botox and an exact replicative dose is not well established. For a cosmetic effect in the frown lines, reports indicate that Xeomin has similar dosing to that of Botox on a 1:1 unit basis. Whether such a dosing method works the same in the masseter muscle is completely unknown. If I was a patient knowing what I know, I would not switch from Botox for massteric hypertrophy if it is working. It will take a lot more clinical experience to determine what dosing comparisons are between Xeomin and Botox. For now, there is no known advantageous reason to make that switch and there is the risk of less effectiveness.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Hello, I have been researching for a while now on getting a procedure done before my husband whose is in the service returns home from Afghanistan. I came across your page and was wondering if I could have a little more information on your Patriot Program? I am interested in getting a tummy tuck done. After having 3 children and losing a lot of weight, i am left with a loose stretch marked covered skin. I only weigh 120 lbs and am happy at the weight I’m at. But I just do not the appearance of my stomach. Any information would be greatly appreciated. Thanks so much!

A: It sounds like what you may need is some form of a tummy tuck. Whether this is a full tummy tuck or a more limited variety will depend on how much loose skin you have. In most cases if one can tolerate a longer scar, a much better abdominal result is obtained with a full tummy tuck. The Patriot Plastic Surgery Program was established to provide some reward for those and their families that are in the active military. It is not a free surgery program but substantial cost reductions are offered. To get an exact cost, please send me some pictures of your stomach for my review and my assistant will forward you that information.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Six months ago I had breast implants with an around the nipple type of lift, I had 350cc silicone implants placed in each breast. Right after the surgery, there were a noticeable difference in the shape of my left breast. It sat lower on my chest and appeared smaller than my right breast. Can this be fixed? I have attached pictures from different angles so you can see the difference.

A: In looking at your pictures, I see a fairly good result. While I do not know what you looked like before surgery, this is an overall nice result, I do see a slight difference in the breasts with the left breast having a small amount of inferior and lateral positioning, This may or may not have to do with the location of the implant.

For the sake of discussion, let us assume that it is an implant location issue. One of the most common reasons for revisional surgery after breast augmentation surgery is implant asymmetry or malposition. This presents in many ways from an implant being too high, too low, too far to the side, to being too far to the middle. Invariably, there is always the good breast and then the bad one. (or as I call it the good sister and the bad sister)

Implants that are too low or too far to the side can be corrected using an internal suture technique decreasing the size of the pocket and moving the implant to a more symmetric position to that of the other side. Expect improvement but not perfection. It is unlikely that your breasts were perfectly symmetric from the beginning and this surgery has likely unmasked that pre-existing issue.

I would also think very carefully about revisional surgery for a minor amount of breast asymmetry. All surgery involves risks which are always greater when a synthetic implant is involved. Those risks are not necessarily less than that of the original breast augmentation/lift surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I had liposuction surgery of my stomach and waistline four months ago and I think it was botched. My surgeon removed too much on one side of my waistline and left the other side straight. I can still feel that there is fat remaining at the love handle area of the straight side. It is very odd looking in appearance to me. How can there be such a difference between the two sides? There are also dents in different areas across my stomach. Can all of this be fixed and made to look better? I am very upset about the way it looks as I used to have a very smooth and even waistline before even if it was too fat.

A: While I can understand how you feel, calling your result botched is most likely an inaccurate assessment. Liposuction is an art form and not an exact science. Irregularities and asymmetries are not rare from liposuction even in the best of hands. It is a blind procedure done by feel and how it looks from the outside in the face of fluid distention and the patient laying horizontal….distortions that assure some degree of imperfections in most results. There is also the influencing issues of your skin and how well it adapts to the fat removal…a variable not controlled by the surgeon. Your issues can most likely can be improved by some refining liposuction of the bigger love handle and fat grafting into the stomach indentations. Expect improvement but not perfection from any revisional liposuction procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a breast augmentation about three months ago. My problem is that my implants are literally touching each other. There is no gap between them. While I wanted better cleavage, this is too much. In addition, when I move my arms more than just a little bit, both implants jump to the sides which is freaky. I now know that my implants are too big and I want to go smaller. I currently have in 450cc and want to go down to 350ccs. Will I need a lift if I go down to that size? Will switching to smaller implants stop them from touching each other? I’m attaching a picture, how would you correct my problem?

A: What you have are several implant issues. First, the implant pockets nearly join over the sternum, This is known as symmastia. Downsizing your implants will not correct that problem. Correction requires the pockets to be sewn down in that area and may even require an allogeneic graft placed along the sternum to prevent recurrence. Secondly, your implants are definitely too big as they are wider than the base of your natural breasts. This is why you have both symmastia and that the implants go too far to the sides. Downsizing your breast implants by 100ccs and changing to a high profile implant will make them look more natural. Based on your pictures, you will not need a lift if you go smaller in implant size.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had gynecomastia surgery one month ago. I have noticed that my nipples are depressed inward. Is this just a temporary look and will it go away and the nipples even out with more time? The tissue directly under my nipple is still hard and stiff. I know I may be panicking but I don’t want it to stay like this.

A: At only one month after surgery, it is too early to say that what you are seeing is the final result. However, a retracted nipple appearance this early after gynecomastia surgery is not a good sign. This indicates that either too much tissue has been removed directly underneath the nipple or the surrounding tissues beyond the nipple have not been adequately feathered to make for a smooth transition into the nipple area. I would much rather see a slightly puffy nipple at this point as all of the swelling from surgery has not yet gone away. Once it does the nipple will likely retract some more. The other reason is that too much residual nipple tissue is an easier problem to treat than when too much is removed. I would wait a full three months and even as long as six months to make your final assessment. This length of time is needed to not only allow the chest tissues to fully heal and relax but because revisional surgery would not be done before this time anyway. If the nipple retraction persists, this is going to fat grafting for correction.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in creating a more symmetrical look to my face via fillers and eventually implants. As a result of my jaw being asymmetrical, the right side of my lower face appears fuller and more defined than the left. I have attached some pictures for you to see.

A: Thank you for sending your pictures. I have taken a careful look at them and the fundamental issue is that the two sides of your face are different. The asymmetry is that the entire right side of the face is lower than that of the left. This can be seen from the eyebrow down to the bottom of the lower jaw. the right eyebrow is lower, the right orbital box and eye is lower as well as the lower eyelid, the cheek is lower and more recessed and the inferior border of the mandible is more inferiorly positioned. In short, you have a classic case of facial asymmetry where the two halfs have developed differently. For the sake of any correction, you have to take the position that the left side of the face is the good side or the objective for the right side to try and achieve. No form of injectable filler can make any significant difference in such facial asymmetry. A variety of surgical procedures can be considered from top to bottom including right endoscopic browlift, right orbital floor-infraorbital rim implant, right lower eyelid tightening by canthopexy, right cheek implant and right inferior border mandibular shave reduction.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want to get rid of my frown lines between my eyebrows. I know that Botox is most commonly used to treat them but I am looking for something more permanent. I have read that a browlift operation can be used to get rid of those scowling muscles. What I am now confused about is whether a coronal or an endoscopic browlift technique would be better.

A: The first thing to understand is that the idea of permanently getting rid of frown lines by surgery does not exist. Browlift methods can help reduce their action but can rarely permanently eliminate their effects. Their action can be reduced by partial muscle avulsion through either an open (coronal) or closed (endoscopic) browlift. There are indications for either type of browlift depending upon the anatomy of the eyebrow and forehead, the location and density of the hairline and the vertical length of the forehead skin. These features are what decides which browlift approach is best, not the action or depth of the frown lines. There are some that would say that an open browlift approach is more effective at getting more frown muscles out due to the open exposure. But those very skilled in endoscopic browlift techniques may be able to offer similar results. For now, however, Botox injections remain as the most effective method of obliterating frown lines even though its effects are not permanent. This effectiveness over that of surgery is one reason why Botox and its competitive analogues are so successful commercially.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in kryptonite bone cement treatment as a craniomaxillofacial treatment for a small skull deformity. I have an area just below my hairline where there is a bonelike material that protrudes a few mm from the rest of my forehead and is unsightly but doesn’t hurt at all. It happened after an accident a few years ago. Can kryptonite be injected into the surrounding area to make the surrounding area more natural in appearance? If so how much? And what are the likely complications?

A: While I don’t know exactly what your skull area of concern looks like, the use of injectable Kryptonite can work very well for small skull contour problems. Done through a small incision close to the skull defect, it can be injected into and around the area of bone irregularity as an onlay contouring material. The biggest challenge with its use is to get an absolutely smooth contour and not to overcorrect the problem or build out too much of a contour. Other than that this is a very simple technique with very little to no real recovery, particularly in such small skull areas The cost of the procedure depends on the size of the defect and the amount of material needed. I would need to see a picture of the problem to determine the suitablity of an injectable skull contouring approach and an accurate estimate of the cost.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am going to get breast implants and have had several consultations. One confusing point for me is whether the implants should be above or below the muscle. Of the two consults I have had one says above the muscle and the other is adamant that they go below the muscle. What do you think?

A: There are is no absolutely best position for breast implants in any particular patient. There are advantages and disadvantages to both approaches. The vast majority of patients today have implants placed beneath the muscle for better pocket stability, a more natural look (upper pole shape), better tissue coverage, a lower rate of rippling and less interference with mammograms. The one downside to under the muscle is that there will be animation deformities, meaning the implants will be pushed to the side unnaturally with pectoralis mucle contraction when the arms are extended.  The one benefit to an implant being above the muscle is when there is some breast tissue sagging, it can fill out the sagging tissues better. The other under the muscle benefit is for someone who was looking for less recovery time and pain and could not avoid adjusting their fitness regimen or someone who has to have the procedure done under local anesthesia for medical and fear of anesthesia reasons.

In the end, one has to weigh these advantages and disadvantages from the perspective of their own breast anatomy and shape. As a general rule, always remember that any implant in the body always does better in the long run (i.e., less complications) when placed under a thicker soft tissue cover particularly when under well-vascularized muscle.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in creating a more symmetrical look to my face via fillers and eventually implants. As a result of my jaw being asymmetrical, the right side of my lower face appears fuller and more defined than the left. Additionally, my upper jaw is recessed. I have consulted with oral surgeons but none believe my problems are severe enough to warrant jaw surgery as my jaw is fully functional. What do you recommend?

A: The use of injectable fillers does have a role in facial reshaping/contouring but it is more limited than most patients appreciate. Because of the volumes of fillers needed to create visible facial contour changes and their temporary effects, the use of fillers must be done judiciously. For lower jaw asymmetry, and particularly for midfacial flattening, injectable fillers have very little role to play in a long term improvement strategy. Lower jaw asymmetry is often the result of a smaller jawline or mandible on one side. That is best addressed with the consideration of a jaw angle implant. Midfacial flattening, particularly done at the upper jaw level (maxilla, LeFort 1 region), needs horizontal volume augmentation. This is best done with either paranasal, premaxillary or both types of lower level midfacial implants. These would be far more effective than any type of synthetic filler injections.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I recently had a breast augmentation with a lift six weeks ago. My lift was the vertical type and my implants were silicone gel above the muscle. While I know it is still sort of early and the breasts are still settling into place, I am concerned that I am experiencing that they already sit lower than I would like and they have some rippling on the sides. This rippling is most apparent when I bend over and goes away when I push the implants upward.  I am concerned that I will need another lift in the near future if they sit this low already. Should the implants have been positioned higher in the first place?

A:  The combination implant-lift breast reshaping procedure (augmentation mastopexy) is a tough one to get just right. It is an artistic balance during surgery of implant size and positioning and how much lift and tissue tightening needs to be done. On top of these difficulties is the unknown variable of how the whole breast settles and what support the breast tissue and skin provides. While six weeks is not the final result, more settling may or may not occur. It would be best to wait a full six months before considering any revision. The rippling you have is a result of the implant being above the muscle and the lack of a substantial breast tissue thickness between the implant and the skin. This might be improved by a higher implant position or a change to an under the muscle position…but there is no guarantee that even with these changes that it will be completely gone.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I have read more and more about people having a tummy tuck and the doctor did not use a drain aftewards. I am interested in getting a tummy tuck but the whole drain scares me. I just can’t get over the idea of having a tube sticking out of me. Is this a safe type of tummy tuck?  Are there additional risks to this procedure? Is there an additional cost to have a tummy tuck without a drain?

A:  Fluid buildups, known as a seroma, after a tummy tuck is common. The use of a drain is to prevent that build-up from occurring. A drain will stay until there is enough healing inside that the body stops producing so much fluid. Most drains stay in for a week to ten days after surgery. While drains are very effective at decreasing fluid-related problems, they obviously are an inconvenience to say the least. This has led to the concept of a ‘drain-free tummy tuck’ or a ‘no-drain tummy tuck’. This is slightly more than just not using a drain but an actual modification of how a tummy tuck is done.  Less skin undermining is done and the underside of the skin is sutured back down to the abdominal wall to decrease the open space where fluid can build-up. This does take more time to do and involves the use of more expensive suture. Whether a plastic surgeon charges more for this tummy tuck technique varies by the practice. I have done many tummy tucks with drains and some without. Some drainless tummy tucks do go on to build up fluid which has to be drained in the office later however…so the technique is not infallible.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I am a 48 year old female and have begun to notice some fat under my chin, some jowling and some neck wrinkles. I have had gotten two plastic surgery consultations with differing opinions. One said I needed liposuction of my neck with a submentoplasty and fat injections to the jowls. The other said I needed neck liposuction with a jowl tuck-up. These choices seem so different that I am confused. Both plastic surgeons are board-certified and respected in the community.I don’t know which one is right. Any advice would be appreciated.

A:  In reality, both are right and these are just two different options for the same facial aging problem. It is clear that you are what I call a ‘tweener’. Your aging issues are not quite enough for a more extensive facelift (neck-jowl lift) but are more than what liposuction alone can ideally improve. In other words, you have a mild amount of excess skin along the jawline and in the upper neck. As these two options are different in technique, they will also produce different results. I think the right answer for you is defined by how much you want to go through for what result. While neither operation is a big procedure, the liposuction/fat injection approach is less invasive but will not tighten the jowl line as much as a limited facelift with liposuction. (jowl lift) It would help to define what bothers you the most, jowling or neck fat. If it is neck fat go with liposuction. If it is jowling, go with the lift.

Dr. Barry Eppley

Indianapolis, Indiana