Your Questions
Your Questions
Q: Dr. Eppley, I am interested in a chin implant. Two years ago I had a sliding genioplasty chin reduction that reduced my chin about 3 mm. Now that I am fully healed, I am noticing that my chin looks too short for my face. From the profile view, my chin doesn’t look bad, but from the front, it looks too short, rounded/squared. My chin seems to be too wide and not tapered enough from a frontal view (especially when smiling). I have two screws in either side of my chin. Is it possible to put an extremely small (maybe 2mm) implant in even if I have screws in my jaw already? Also, is it possible to position it so that it only affects the vertical length of my chin and not so much the horizontal projection? Would you recommend a button implant (as opposed to an extended implant) since I don’t want my face to widened? Thank you for your time.
A: You are describing perfectly why an osteotomy is not a good idea for a chin reduction. By sliding the bone backward it creates two effects, a more square or wider chin and it can often make the submental neck tissues fuller. As you have pointed out, a chin implant can be done to improve the effects that the osteotomy has created. You are correct is assumed that it should be a central button chin implant that is positioned low on the bone and secured into position by a screw to create some vertical lengthening as well.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a question about the postop healing process for a forehead reduction/hairline advancement. It has been just about 2 months since my surgery and my scalp is still not healed. I have some large areas of scabbing over the incision sites and don’t know but it seems like they should be healed by now. I don’t know if I am doing something or taking some medication that would slow this healing process. Please just let me know if this is normal I can also send you some pictures if you would like.
A: It is certainly not common to have a forehead incision that is not completely healed after two months. The scalp is such a well vascularized tissue that it is hard for any portion of it to not heal unless there is a good reason. Most likely, these non-healing areas represent spitting sutures. If you look close at them after removing the scabs, you may see little white threads which are dissolveable sutures sticking out. Many times along the hairline the body will spit them out long before they will ever dissolve. There presence at the incision lines now serves as a chronic source of infection which appears like a pimple or small draining sinus. This is a common problem in many body areas and the hairline is no exception. If you can pick out those white sutures you will remove the source of irritation and the areas will go on to complete healing. I have seen this wound occurrence many times after pretrichial browlifts and forehead reductions.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have gained 40 lbs since I had a hysterectomy seven yrs ago. My stomach is now extremely out of portion to the rest of my body. I need to ge rid of this as I believe it’s very unhealthy. I lack disciple in terms of appetite or taking diet pills. I am interested in fat injection treatments, Will insurance cover any type of non-surgical treatment to reduce my stomach fat? What is your input on this fat treatment method?
A: In terms of getting rid of a stomach bulge, no matter how large it is, is not something that would be covered by insurance regardless of the method of treatment. When you speak of injections for reduction of fat you are undoubtably referring to Lipodissolve, a blend of phosphatidylcholine and deoxycholic acid solution. While this can help reduce very small collections of fat, it is not going to be effective for a fat collection of any size. While it was very popular several years, it has fallen out of use because it has proven to be ineffective for abdominal fat collections that many people want reduced. I still use it occasionally but only as a treatment for small postoperative liposuction ‘high spots’. Unfortunately what you are seeking is a non-surgical solution to a surgical problem…and that does not exist.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in pectoral implants and would like any information about the procedure that you can share with me.
A: There are tremendous similarities between transaxillary breast augmentation in females and pectoral implants in men. They both are placed through an incision in the armpit with a pectoral implant needing more length as the implant is bigger. Both are placed under the pectoralis muscle with a pectoral implant not being placed below the lower edge of the pectoralis major muscle. All of the pectoral implant remains covered by the muscle to give it maximum bulk and projection. (a breast implant in contrast often has at least half of the implant below the edge of the muscle) Pectoral implants come in numerous sizes and shapes from oval to a more square design. The implant selection is determined by measurements taken on the chest based on the outline of the muscle. The implants are composed of solid soft silicone elastomer material that behaves like a flexible gel. The material is inert and will never degrade or break down. Pectoral augmentation is performed as an outpatient procedure done under general anesthesia. Dissolveable sutures are used to close the armpit incision. After surgery, there will be some swelling and soreness and a chest wrap is used for comfort. One can expect that it will be about three weeks until one has full range of motion of their arms and can begin to return to working out again if desired.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, when I was a kid I had a problem with my blood platelets. The same thing happened after delivering my first baby and then with the second one nothing happened. Do you think that having breast implants will affect my platelets? If yes, by how much percent? Thanks.
A: Without knowing what your exact platelet disorder is or was, I can’t say with any certainty. You will need to better describe medically what your platelet problem was. There is a big difference between too many platelets, too few platelets, and platelets which just don’t work well as it relates to undergoing.The only thing that really matters with breast augmentation, or any surgery for that matter, is whether you have adequate clotting capability. If there is any question (and it sounds like there is) you should have a bleeding time, PT, PTT (or INR) and platelet count checked before surgery. Given that you had some type of ‘platelet problem’ as a child and after your first pregnancy, you should have a coagulation work-up before any elective plastic surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, do you do stem cell facelifts and what do you think of them? Do they really work?
A: Stem cells and their many potential uses are one of the hottest topics in all of medicine today. Much research is going into whether they have healing benefits for many diseases. It is no surprise that their appeal has reached plastic surgery as well, particularly given that fat and its extraction by liposuction is the best method to obtain them. And many people have more than an adequate store of donor fat. Fat has been shown to contain up to 500X more stem cells than bone marrow and plastic surgeons are employing many innovative ways to apply them to both reconstructive and cosmetic procedures.
Stem cells and facelifts seem like an odd combination given that facial aging hardly seems like a disease problem. But some plastic surgeons have been using them for the purposes of an enhanced healing and skin rejuvenation effect.There are two types of so-called stem cell facelifts. Those that use stem cells or stem cell -enhanced fat injections as an adjunct to a more traditional facelift procedure. Then there are those that use the stem cells or stem cell-enhanced fat as the primary method of doing the facelift, which is really known as facial volume enhancement creating some lifting effect by skin expansion. To date, either approach remains appealing in theory rather than a proven science in facial rejuvenation efforts.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I noticed that you also do reconstruction using bone cements.I had sagittal split osteotomy a couple years back which left my face unbalanced and my mandibular angles too small. I’d like to restore balance to my face without the bottom face turning too square. I’m not keen on using plastic implants. So, does hydroxyapatite make a good material for restoring facial contours for the mandible? Unlike bone grafting, it doesn’t resorb, and is comparatively easy to mold.. or so I have read.
A: Of the many materials available for facial bone augmentation, hydroxyapatite has a long history dating back over twenty-five years as a granular bone onlay material. This is a syringe method where the granules are introduced through an open intraoral approach with limited dissection. They do not resorb and are relatively easy to place. Confining them to the desired location was always an issue but it can be an effective method. Hydroxyapatite today is better known as a bone cement and has been widely used for cranial reconstructions in infants as well as adults. It needs to be mixed and applied in an open method as the setting of the material is very technique sensitive. It is not use very often as a facial augmentation material as it works best when used in an inlay bone defect that has borders. would not use bone or hydroxyapatite cement as this material composition is too difficult and unpredictable to place outside of an open cranioplasty where its setting/curing is more assured.
Hydroxyapatite granules, and a very similar material known as HTR granules, can be used for a small amount or moderate amount of mandibular angle augmentation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I recently underwent a rhinoplasty on September 19th. I found the results to be disappointing so far, it seems that my nose is twisted. Is this normal, and will the swelling go down to create a much better result? Where may I send you a before and after picture for an evaluation?
A: One of the most challenging aspects of a rhinoplasty for many patients after surgery is that the final and expected result can take a long time to see . Of any plastic surgery procedure that I have ever done, I find that a rhinoplasty takes the longest to achieve the final result. The skin of the nose can swell considerably, masking any changes that have been done to the underlying osteocartilaginous framework. And since those changes are ultimately what will make the nose look different, not seeing them for a long time can be disappointing and the wait can be frustrating.
It is important to remember that the results of a rhinoplasty are not a ‘TV moment’. Unlike the way it is frequently presented, the final results are not when the splint and take (bandages) come off. In some patients, some of the changes are immediately seen. But in many patients, particularly those with thick nasal skin or who have had relatively minor changes done, the swelling will mask any changes done and it may even look worse for some time.
This is why it is important to try and ignore what you are seeing right now. Swelling always creates distortions, many of whom may go away as the swelling subsides. Six weeks after a rhinoplasty understandably seems like an eternity to you but, in the rhinoplasty world, this is just a small fraction of time. What you are see at six months after rhinoplasty surgery is more relevant as this gets into a time period when revisional surgery can start to be considered if significant deformities/asymmetries persist.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like to change the shape of my chin. It seems too wide. Several years ago I went to a doctor for a rhinoplasty and came out with a rhinoplasty and a chin implant. I went in with no desire for a chin implant but in the consultation he suggested I had a recessed/ weak jaw and that a chin implant would correct it. So as a young naive first timer to plastic surgery I said ok and every doctor I’ve seen since can not understand why that first doctor recommended that.
I’ve had x-rays done of it and showed them to other doctors, one has said it is minor and not causing much protrusion at all. This he thought it best to leave in as removing it could cause a gap or “witches droop” as he called it .
Another doctor said it can easily be removed, and should be, so as usual Im confused. But I am erring on the side of caution and not touching it due to potential resulting problems. (i.e. its been there 15 years so I assume all the nerves/ muscles would have grown around it, thus to a non- medical mind as myself the removal of it seems complex) And by the way, that nose job was a failure too. Its the nose job where I pay $10,000 and come out looking exactly the same except with a round bulky nose.
A: Your chin implant information is very relevant, as while the chin implant may not have provided much horizontal projection, it often adds width. So it could be making a contribution to your chin width issue. This would depend on what type of chin implant it is, but most used today are of the extended or winged type which always adds width. That is usually fine for men but I almost never use them in women because of that issue. Women look better with a more angular or tapered chin.
A chin implant removal is actually very straightforward and not complex at all. The key is to make sure the mentalis muscle is adequately resuspended if done intraorally or a submental tuck-up is done if removed from below.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am thinking that I need something to make my face look better. I realize that I am young to be thinking about surgery, but I’ve never liked the way I looked. I thought maybe cheek implants might help, but I was wondering if you had any other suggestions of how I could make myself look better.
A: In looking at your pictures, I can see that you have some mild cheek flattening or hypoplasia. Higher cheekbones may be an accent to your facial appearance. Should you be so motivated, I would suggest you initially pursue injectable fillers for cheek augmentation. This would be a good temporary test to determine if the placement of permanent cheek implants would be aesthetically beneficial.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 35 years old and I am 5’ 7 “and weigh 246 pounds. I am been married for eight years I have three girls. I feel that I’m now really fat because around five years ago I was a size 16. Now I am a size 24 and I exercise and diet and have tried mesotherapy with very little results. I have skin that hanghs over the sides which really bothers me. Can you help me?
A: Based on your height and weight now, you are close to be over 100lbs from your ideal body weight. I suspect that you were never near your ideal body weight by the numbers so that it is not a realistic goal. While weight is just a number, getting you somewhere between 170 and 190lbs ir probably an achieveable weight target. That being said, you are not a candidate for liposuction or any form of excisional body contouring, such as an abdominal panniculectomy, until you reach the 200lb mark. You are simply too big now to get the best benefits out of any form of plastic surgery. You need to consult with a weight loss clinic or specialist as the first step in your potential body metamorphosis begins with a non-surgical weight loss appproach not plastic surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a genioplasty with iliac bone grafting five years ago. The result was disastrous. I got a long and prominent chin and it was so completely different than I planned. After that, I had several revisions to get an imprrovement. For example the jaw bone had been suspended back and I also I had a chin reduction. This resulted in an unpleasant scar under my chin. Now the chin soft tissue is scarred and hanging down. If my mouth is closed I feel a strain on the chin muscle. During relaxation my lower lip hangs down showing my bottom teeth. The mentalis muscle shows a strong contraction.
I couldn´t find any surgeon who had enough knowledge in this specific area of genioplasty revision and chin ptosis. In various discussion forums about this topic I came across your name. I hope that your skills and experience in this special field could be helpful in my case. Is there any possibility to solve my problem and what could this be? What is the probability of improving my situation? Your help would be very much appreciated. I have attached some pictures for you to see my chin problems.
A: Your chin surgery history and outcome has certainly been that of a nightmare. What you currently have is chin ptosis with severe contracture. What need is an intraoral approach to release the scarred chin tissues, mentalis muscle resuspension with suture anchors and a V-Y vestibular closure. Your submental scar should also be released and revised. The divot (indentation) in your chin would be treated by the placement of a small dermal-fat graft at the same time. All of these procedures would be done simultaneously address all of your current chin problems. My experience in doing these chin ptosis repair procedures is that improvement is always obtained, it is just a matter of the degree of improvement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m 14 going on 15 and I hate the shape of my nose. What i want is some kind of injectable filler to go in the top of my nose (the part in between my eyes) because that is where you can really see the hump and I want to lift that bit of skin/fat to even out my nose. Would I be able to do that at the age of 14?
A: The first thing to point out is that at age 14 I can not have any type of communication with you without written consent from your parents. I am not even able to answer your questions until I receive such consent. Providing medical information to potential patients on the internet is somewhat similar to seeing you in the office. I wouldn’t be able to that without at least one parent in attendance. (sent to patient)
Injectable fillers can be used to build up the upper bridge of the nose (radix) to help camouflage a hump or bump on the nose. This is probably one of its best uses when it comes to non-surgical or injectable nose reshaping. Whether this is a good idea at age 14 is a matter of debate and that is best determined by a discussion between the teenager and the parents. It can certainly be a good test to determine if a more formal rhinoplasty will one day be a satisfactory procedure to undergo.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in changing my round face to a more shapely one. I have attached a photo of myself for you to show my very round face which I want more V-shaped. My perfect outcome would be something like Kelly Rippa, which is probably impossible, but at least I can dream!My main questions are do you actually break the jaw and how long until I could return to work? I have seen some of your other work and have been very impressed so I know you can help me.
A: It is always good to see what changes other females have been able to achieve in terms of facial reshaping, but each patient is unique. In looking at your picture that you sent, it demonstrates two particular facial features of interest in terms of trying to achieve your facial reshaping and jawline enhancement goals. First, your lower jaw/chin is stronger rather than weaker. It is always ‘easier’ to create a V-shaped face in weaker jaws than stronger ones. Augmentation of the jawline is always more successful than reduction in facial narrowing/reshaping. This means that you would require chin reshaping either through an osteotomy or a submental approach where it is shaving down to more of a triangular shape. Which approach is better for you would depend on seeing some additional photographs from different angles, particularly a side view. Secondly, it is clear that you are older than in your teens or 20s and you have some facial skin laxity or looseness. This is relevant on how the skin will facial skin will respond when there is less support. That is an important consideration to take into accountwhe considering what procedures would be best. You may require some form of jawline tuck-up with chin/jaw reshaping but until I see additional photos I can not be clear on this need.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a teenage daughter with nonstop migraine headaches for over a year and I suspect occipital neuralgia. I’d like to know more about what you do for migraines. Thank you.
A: There are some specific non-surgical and surgical treatments for migraines that have identifiable trigger points. Most so-called migraines do not have trigger point, however, Trigger points can be identified by both history and physical examination. Almost all of the patients that I treat for migraines as a plastic surgeon have been through full medical work-ups usually by a neurologist and have failed all conventional medical therapies.
Trigger points are specific areas where sensory cranial nerve branches pass through muscles on their way to supply specific skins areas. The muscles squeeze or pinch the nerves which serves as the trigger point for the migraine. The three most common trigger point areas are the occipital, temporal, and frontal regions. Sometimes only one trigger point exists but it can include two or even three. By far, the occipital trigger point is the most common in my migraine patient experience.
The initial treatment of a suspected ‘trigger point’ migraine is Botox injections. This is both a treatment as well as a diagnostic test. If sufficient relief is obtained, then one can continue with Botox injections or proceed with nerve decompression surgery where the constricting muscle is removed around the nerve.
This is a general migraine treatment overview. The use of Botox and decompressive surgery are rare in adolescents for migraines but, in the properly qualified patient, would be acceptable.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 48 yr old female. Over the past few years, the corners of my mouth have started drooping, to the extent that I am often asked if something is wrong (it appears that I am frowning all the time). I don’t want major surgery, and in researching options for my issue, the corner of the mouth lift seems to be a possibility. One additional note; the droopiness is more pronounced on the right side. I have attached some photos for your assessment.
A: Downturning of the corners of the mouth is a common aging issue. The lip line is the union of the upper and lower lip at rest when one is not smiling or has any oral animation or movement. It is like a level and one should be able to draw a straight line between the two end points to create a straight lip line. The corner positions of the lips or the commissures have a great influence on the appearance of the lip line. You don’t want them upturned (Joker look) or downturned (frowning or sad) as it gives one a static expression that is not favorable. Corner of the mouth lifts change the location of the commissures through a very small amount of skin resection and lip vermilion repositioning. It is a relatively simple procedure that can have a dramatic effect. It can be done under local anesthesia as an office procedure. It does the one thing that many people think a facelift does but does not. A facelift can not change the corner of the mouth because its pull is too distant. Changing the corner of the mouth must be done by direct excision.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I feel like the base of my nose is sunken in and needs to be built up. I know that implants are made for the paranasal area but I just don’t want a piece of synthetic material in me. How else can this be done, injectable fillers, bone grafts etc?
A: Paranasal augmentation is the buildup of the portion of the midface around the base of the nose. It should be differentiated from submalar and premaxillary regions of the midface of which they can often be confused. When considering paranasal augmentation, the most common technique is a preformed synthetic paranasal implant. But an implant is not the only paranasal option. Other choices include injectable materials and an autogenous graft. While there are numerous off-the-shelf synthetic injectable fillers, they all have only a temporary effect. For a permanent injectable material, I would use either hydroxyapatite or HTR granules which can be ‘injected’. This is not done in the typical percutaneous approach through a fine needle. Rather it is done through a small intraoral incision and placed on top of the bone underneath the base of the nostrils. The granules or beads are packed into a syringe but are only injected through the open end of its barrel so it requires an incision and some limited subperiosteal pocket dissection to be injected. These materials are non-resorbable and gets good tissue ingrowth. From an onlay graft option, small rib grafts taken from a very small incision at the bottom of the rib cage will also work well and will not resorb unlike onlay bone grafts.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have earlobes that go straight down. They don’t have the curve up, just a straight down line to the side of my face making my ears look big when they are actually very normal. Can you fix this without scarring?
A: What you have is a natural earlobe that attaches to your face without a break or upward curve. This lack of a well-defined earlobe attachment is known as a pixie earlobe. Pixie earlobes are usually thought of as an aesthetic complication of a facelift but they are also a natural earlobe shape for many people. Because of the downward and otherwise low attachment of the earlobe to the face, it does make the ear look longer. While there is a relatively simple solution to changing how the earlobe attaches to the face, it can not be done without some scarring. The earlobe can be released and reattached higher through a procedure known as a V-Y advancement. This will move the earlobe up almost a full centimeter and give it an upward curve to its attachment. This will result in a very fine line scar in the wake of where the earlobe attachment used to be. While it is a scar, it is a very fine line. This simple earlobe reconstruction can be done in the office under local anesthesia.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in cheek implants as I think they would make my face look better. My cheeks just seem to be so flat and weak. I would like higher and stronger cheekbones as I think they would match the rest of my strong facial features. I have attached some face pictures from different angles for your opinion.
A: In looking at your pictures, I think your goal with cheek augmentation is to create better facial balance by making your cheeks bigger to go better with your longer face and prominent chin. Your chin and lower jaw is your most prominent facial feature and, by comparison, your cheeks are far less prominent. Ideally, the best way to get better facial balance is a combination of cheek implants and vertical chin reduction. I have done and attached some predictive imaging which shows the result of cheek implants with and without vertical chin reduction. The ‘ying and yang’ approach to facial reshaping is often best as most facial imbalances are usually combination problems and not just one single feature alone. Through computer imaging, you can determine if larger cheek implants alone or medium cheek implants with vertical chin reduction produces a more appealing facial change for you.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 24 year-old Hispanic female who is interested in breast augmentation. My breasts have shown very little growth and I don’t think there is any chance that they will grow any further at this point. But besides that they are small, they also look peculiar. My nipples and areolas are so big for someone who has very little breasts. Whatever breasts I have just seem to be like a ball that is right underneath the nipple and makes them stick out and point downward. I have attached some pictures of my breasts so you can tell what type of implants I would need to make my breasts look not only bigger but better.
A: Your breasts definitely show underdevelopment for the size of your chest but the real aesthetic challenge is their very wide spacing and a mild case of tuberous breast deformity. The small amount of breast tissue you have is herniating through the base of the areola, thus the very prominent nipples and protruding wide areolas with a very small breast base. This is the very definition of a tuberous breast deformity. Fortunately, the tuberous deformity is fairly mild and I believe could be adequately treated by breast augmentation alone. Given your ethnicity and to avoid a prominent breast scar, I would do a saline breast augmentation through a transaxillary (armpit) approach. I would wait and see how the nipple-areolar complex appears after being pushed out by the implant. There is the possibility that a revision of it may be needed after breast augmentation if it becomes more rather than less protrusive.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had my ears pinned back six weeks ago. Before surgery one ear did stick out further than the other and, even after surgery, it still does. Although both ears are much better looking they are still not as good as I had hoped. I would be happy if the left ear was brought back further to match the other one. When they get better with more time and, if not, when should I have the left ear revised?
A: The surgical techniques used in otoplasty rely on the use of sutures to reshape the cartilages. The final results are a mixture of skillful placement, tightening and their ability to hold as the tissues heal. Between swelling and tissue relaxation it will take up to six months after surgery to see the final result. Besides a good shape, it is also important to have symmetry between the two ears. Even though both ears are rarely seen at the same time, it is still important to have them look as close as possible. Perfect symmetry between the two ears in otoplasty does not always occur and about 10% of patients in my experience may desire some minor touchups to improve their shape and symmetry. In the case of one ear that still sticks out further than the other, this may require a revision to place another suture or two or to remove a little conchal cartilage to get the ear back into a better position. It is a better problem in otoplasty to have an undercorrection than an overcorrection. Undercorrected ears are infinitely easier to improve by an otoplasty revision. I would embark on that revision six months after your original procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 35 year African-American woman who is seeking to have a rhinoplasty to make some desired changes in the shape of my nose. Building up the bridge and lifting my tip and making it a little more narrow seems to be a standard rhinoplasty changes to my type of nose. I also want my wide nostrils narrowed but there seems to be different ways to do it. Some plastic surgeons place incisions on the inside of the nose and other place them on the outside. While I don’t want more scar than I need, I do want to see a very visible difference in the width and size of my nostrils? What do you recommend for nostril narrowing?
A: To do nostril narrowing, some nostril skin has to be removed. Whether nostril narrowing is done by incisions on the inside your nose or out is a matter of the extent of the incisions and their locations. Internal nostril narrowing incisions cut through and place scars on the skin of the nostril sill. It does create an external scar but it is very small and vertical in nature. By removing a vertical wedge of sill skin it pulls in the base of the nostril by the exact amount of sill skin removed. (usually around 5mms or so). An external nostril narrowing approach uses a similar vertical sill excision but extends it out to involve a horizontal resection of the side of the nostril as well. It is more effective at changing the width and shape of the nostril but does so with a longer scar that lies in the groove at the alar-cheek-upper lip junction. While poor scarring is possible, if done well the scar is well hidden and not visible.
Either nostril narrowing technique can be a very useful adjunct to the final rhinoplasty result. Which technique is better for you depends on the size and shape of your nostrils and how much of a change is needed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 33 year-old blonde female with fair skin. I think my skin is in fairly good shape as I have avoided the sun much of my life. However, even though I am young I have bags and dark circles under my eyes that are far worse early in the morning as compared to the evening. This makes me look tired and I am tired of always looking tired even though I think I get enough sleep. Do I need an eyelid job or will fillers be the right thing to do? I have attached some pictures to help you see my eye problem.
A: It is hard to imagine at your young age that any traditional form of lower blepharoplasty would be needed. These more ‘complete’ eye jobs usually involve skin removal and that is something you do not need. What your pictures show is some lower eyelid hollowing which creates dark shadows or circles. The use of injectable fillers is the treatment you need. This simple office treatment creates an immediate result that will quickly provide a visible improvement by adding volume into the hollows. This is a bit of a tricky area to inject to avoid bruising, irregularities and over correction. Injectable fillers in the tear troughs and lower eyelid hollows can last much longer than in other facial areas, often 12 to 18 months in duration. .
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had liposuction done in my abdomen, lower back, inner and outer thighs and knees six weeks ago. I was told that just over two liters was removed. The day after surgery I definitely felt smaller. But now, six weeks later, I feel that What Can You Do To Get Your Ex Girlfriend Back I am back right where I started. I see no changes and I don’t look any different in the mirror nor do my clothes feel any looser. I know that swelling takes a long time to go away and I may still be swollen but when am I going to see changes in my body? Could this be fat coming back so soon?
A: There is always going to be some considerable swelling after liposuction but the usual course of swelling resolution is as follows. Within the first day or two after surgery when the garments are taken off to shower, it is a very encouraging sign when patients say it is already better. If not does not look smaller already, that is not a bad sign for the long-term result but I would prefer to hear it is already looking better. Swelling will then set in and much of the initial improvement can be seen to ‘disappear’. By three weeks after liposuction, one should be in the visible benefits phase where the improvement is clearly evident. By six weeks after surgery, much of the improvement in the body contours is even better even though further improvement can continue up to three months after surgery.
How much improvement any liposuction patient will see after surgery is largely volume dependent. How much fat has been removed will determine how visible the changes will ultimately be. While I don’t know what you looked like to start with and how much fat you had, removing two liters of fat aspirate from all those body areas seems like a small amount. While the final verdict awaits six more weeks, I would question if you had enough removed to really make a noticeable change. Whay we do know is that it is definitely not fat coming back at this point.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am 44 years old and have had silicone implants for just over 10 years. I have noticed recently that under my left breast near the sternum it has gotten sore. I also have had chest, back and arm pain on and off over the past year. My doctor sent me for a mammogram and I also got an ultrasound at the same time. Both were negative for any problems. Do you think my breast implants are a cause of my problems.? Can a breast implant release harmful chemicals or toxins? I want tio keep my breast implants but if they are dangerous then I want them out.
A: It is impossible to say with an certainty that there is a relationship of the symptoms you are having and your breast implants. What we do know for sure is that breast implants do not release toxins, poisons, or any other harmful chemicals. While you have had a good breast screening work-up, mammograms and ultrasound are not 100% accurate when it comes to detecting an implant rupture. If anything, that is where my suspicion would lie as it relates to your left breast pain. If it persists or increases in severity, I would consider getting an MRI which is the most accurate test we have to detect breast implant rupture.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I don’t like having a large forehead. I would like it reduced by at least an inch. I understand by having the eyes done that will also can help. I also hate how one eye brow is lower than the other one. I am sending pictures from the front and side views so you can what I mean.
A: Thank you for sending your pictures. I can see the three issues of concern, your very long forehead, eyebrow asymmetry and extra skin on the upper eyelids. Most frontal hairlines (forehead reductions) can be advanced close to an inch, depending upon how mobile one’s scalp is after it is freed up. The advancement is always greatest in the middle and tapers out towards the temporal hairline. To improve your eyebrow asymmetry, more skin would be taken out on the left side than the right as it tapers outward. The upper and lower blepharoplasties would be done in the conventional fashion with skin and fat removal. The combination of all three would make for quite a periorbital and forehead rejuvenation effect.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Is it possible to have a baby after a tummy tuck and hip liposuction? I already have two children, and don’t think I want another one, but you never know. I am a single mom and in case I decide to remarry I might want another child. Can pregnancy occur normally after a tummy tuck and how long should I wait until it’s safe? Thanks for your time!
A: It is absolutely no problem to carry a normal pregnancy after a tummy tuck, whether the muscle is sewn back together or not. I have seen more than a dozen women over the years who have gotten pregnant after a tummy tuck and it has never been a problem. It may not be aesthetically desireable and is not a good way to protect your investment but it is perfectly safe.
Obviously getting pregnant is not the concern, but whether the abdominal muscles will stretch out as the fetus grows. Even if the rectus muscles have undergone midline plication, they will stretch out to accommodate the growing fetus. The amount of abdominal protrusion may be slightly less but there will be no risk of ‘compression’ of the fetus. This is because pregnancy is a slow form of tissue expansion that takes place over nine months. Such a slow rate of expansion can stretch out just about anything. Pregnancy might be a problem after a tummy tuck if the gestation period was just a month or two, but a nine month period of expansion allows it easily to happen. I don’t think there is any specific safe period for getting pregnancy after a tummy tuck. I recently had a patient who learned she was pregnant just six weeks after her tummy tuck!
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a scar question.What about when a dog ear scar is right in the middle of your cheek. I hate it and I have had it for almost 7years. I am scared to undergo a scar revision as the excision will make the scar longer. Are there any alternatives?
A: Dog ears are excess tissue at the ends of scars or healed incisions. They are usually composed of skin and fat. To get rid of many dogears, it does require a scar revision by excision which will result in a lengthening of the scar. But some dogears can be flattened by defatting alone without skin removal. Through the end of the scar, fat can be excised without extending the scar. This technique relies on the overlying skin to flatten as the fat underneath it is removed. The fat can be removed through either direct excision or sometimes microcannula liposuction. Short of this approach, there are no other alternatives to the dog ear scar problem.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, lastyear ago I had a septoplasty to correct a severely deviated septum that resulted from a broken nose when I was a teenager. My surgeon removed a sizeable bone spur that was obstructing my breathing and that improved it a lot. Unfortunately, it did little to correct the aesthetic appearance of my nose. The septum is still very deviated midway up the nose so it has maintained its crooked appearance. Furthermore, my right nasal bone is caved in slightly.When I consulted a plastic surgeon a recently about the possibility of a revision of the prior procedure, he said it would not be worth it considering a lot of cartilage was removed. This would make it hard to re-anchor/attach the septum and would also increase the risk of perforation. What can I do to fix this asymmetry? Is a rhinoplasty still possible?
A: A septoplasty, in and of itself, will rarely make a significant change in the correction of a deviated or asymmetric nose. This is because deviation of the nose is a multi-factorial problem that is caused by aberrant anatomy than involves more nasal structures than just the septum. While it is true that a secondary septoplasty will be difficult due to scar tissue, there is no way to really know beforehand if it will be a good source of cartilage for the rest of the rhinoplasty. I have found more times than not that there is still some cartilage to be harvested. When combined with ear cartilage, there will be enough graft to so a more complete septorhinoplasty procedure. I would still approach your nasal concerns as a correction of the entire anatomy of the nose rather than camouflage techniques such as injectable fillers.
Dr. Barry Eppley
Indianapolis, Indiana
The removal of unwanted fat through liposuction does not always result in the shape of the desired body contour. This has lead to a liposuction concept known as liposculpture. What is liposculpture and how is it different? Is it a better at achieving natural body contours and a more attractive body shape? Who is it best used on?
Liposculpture moves beyond the removal of just localized areas of too much body fat to a more artistic approach to fat removal. Instead of using large bore cannulas which indiscriminately remove fat rapidly, smaller size cannulas are used. These tools are more selective about how much and where fat is removed. Smaller cannulas may also be combined with powered equipment such as oscillating, ultrasonic and laser-assisted liposuction devices.
But the most important element in liposculpture is that of the surgeon. There has to be an appreciation of what makes up natural and pleasing body contours. The tools used are only as good as the hands that are directing them in shaping new contours. There also has to be an understanding of what the structure of fat looks like underneath. In some areas there may only be a thin fat layer which can reveal an improved body contour through superficial cannula extraction. Such aggressive right-under-the skin fat removal must be applied carefully to avoid scarring and undesireable skin retractions. Areas such as the inner knee, neck, back rolls, axillary breast and flanks are good examples of where superficial liposculpture must be used to get good contouring results as there are not deeper fat layers.
While liposculpture sounds appealing, it is not a method that is needed for most liposuction patients. The most common liposuction patient has larger amounts of fat on the abdomen, waistline, thighs and arms. In these areas there are two distinct fat layers, superficial and deep. Extraction from the deeper layers is needed and should be the first layer that the cannula enters. Treating the superficial layers as well, while improving the amount of contour reduction, will increase the risks exponentially of surface contour irregularities. The abdomen, arms and inner thighs are particularly at risk for this problem with superficial liposculpture. The quality of the skin, its thickness and elasticity must be assessed to determine if it is wise to attempt removal of fat right under the skin.
While good marketing and pictures of models (who have never had the surgery) are appealing as sales tools for liposculpture surgery, it is important to remember that traditional liposuction methods with solely deep fat removal will satisfy most patients. Liposculture techniques should be applied judiciously and applied to areas that are best served by them. It is a liposuction technique that takes into account the anatomy of the fat and the contouring goals and not a method that replaces traditional liposuction for most body areas.
Dr. Barry Eppley
Indianapolis
