Your Questions

Q:  Dr. Eppley, I am interested in breast augmentation. Iwant fuller breasts to eliminate the stretch marks and I would like to go one size bigger. I am a size B now. I have attached pictures so you can see what you have to work with.

A: Thank you for your inquiry and sending your pictures. I can see your concern about breast size and there is no question that implants would be beneficial to get you from a B cup to a C cup. However, no amount of increase in breast size will eliminate your stretch marks. With the expansion of skin from breast implants, stretch marks may become somewhat less noticeable as they are pushed out and stretched flatter. But the concept of stretch mark elimination should be erased from your mind as an expected outcome. The one concern that I have about your breasts is what degree of sagging they may have. The pictures are taken with your arms up which artifically lifts them and may camouflage the actual amount of sagging. Breast implants do not lift sagging breasts which is a common misconception. So whether you may or may not need some form of a breast lift with your implants remains uncertain. When you have the amount of stretch marks that your breasts do, this adds to that concern. If you can send me some new pictures with your arms at your sides, that would help answer that question.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I want to get rid of the little bump in my profile, and I’m wanting to smooth out my nose. It looks really bumpy in pictures and it usually looks bad in certain kinds of lighting. I would really love my nose to look anything like these celebrities: Carrie Underwood, Lauren Conrad or Blake Lively. I think their noses are great but I don’t know if they would look good with my face.

A: In looking at your pictures, your nose is bumpy because of the disproportion or asymmetries between the three regions of your nose. Your upper nose has wide nasal bones, the middle third or upper lateral cartilages of your nose is more narrow and the tip cartilages of your nose (lower alar cartilages) are separated or wide. When put together, this gives your nose an almost hourglass configuration in the frontal view as opposed to straight parallel dorsal lines. In the side view, this gives an uneven straight dorsal line with an upper hump and a downward dip in the middle third. This is why your nose appears bumpy and irregular to you.  A full rhinoplasty is needed to reshape all three areas to create an overall more harmonious blending of the three regions to create a smoother nasal appearance. I have done some imaging to show what these changes may look like. In regards to the celebrity noses you have mentioned, it is important to realize that rhinoplasty can not make your nose look like that of another person. Rhinoplasty can only make your own nose look better.  

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Is there a procedure that includes both a breast enlargement and a tummy tuck together? Breastfeeding four babies and having had multiple c-sections has left me with a body that makes me feel insecure and unhappy with my belly and breasts. I’ve never been a heavy woman, I’m 5’5″ and weigh about 140lbs. I haven’t felt comfortable in my skin since having my first child at twenty and now I’m about to turn forty.  It would be nice to be happy with myself and feel confident enough to wear a bikini again. Other than these two parts of my body, I’m completely ok with.everything else about myself. Hopefully, a physician will read this question and know exactly how I feel and and be able to help me achieve this type of procedure at an affordable rate before I get too old to enjoy it or even worry about it anymore. Thank you so much.

A: What you are referring to is a very common procedure in plastic surgery known as a Mommy Makeover. This name tells both what the procedures achieve as well as serve as a marketing approach. The Mommy Makeover is a combination of breast and abdominal reshaping, the two body parts that are usually most affected by pregnancies. Breast reshaping options include size enlargement with an implant and correction of sagging with some form of a lift. More times than not a breast lift is needed with the implant. It is uncommon that an implant alone will suffice for breast enhancement in the ‘pregnancy-induced’ breast deformity. Abdominal reshaping always involves some amount of skin removal, known as a tummy tuck. Whether it is a full or mini-tummy tuck depends on how much loose skin exists. Liposuction of the abdomen alone has little role in the post-pregnancy tummy.

The most common scenario is that both breast and abdominal procedures are performed during the same operation. But some patients, due to financial or recovery concerns, may do them in two separate stages.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am very interested in skull contouring for the back of the head using acrylic, although I do have a couple of questions. What is the maximum thickness that can be added? Where is the incision to put it in located? I have a scar running horizontal across the back of my head from a hair transplant several years back. Can the incision be placed in the existing scar line or is it a must that it be vertical? Thanks for your time.

A: When building up the back of the head (occiput), the limiting factors on the thickness of the augmentation is the scalp and the incisional approach. How much the scalp will stretch is important as its expansion is what creates the space for the material. Usually the augmentation can be anywhere from 10 to 20mms at the greatest point of the arc of convexity. (midline occiput) Where the incision is located and how long it is always influences the shape and volume of the augmentation. While a traditional bicoronal incision provides unparalleled access for any location of skull augmentation, that scar is aesthetically unacceptable. For this reason, I use a vertical incision for an occipital cranioplasty. It provides good exposure over the most important part of the occiput where the buildup needs to be the greatest. Whether your  existing horizontal scar can be used depends on where it is located. Most hair transplant harvest sites are usually fairly low but I would need to see a picture of the scar location to tell if it can be used for incisional access. I would certainly be motivated to try and use it if possible for the obvious aesthetic benefit.
Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, This is a micropigmentation inquiry. I have a rather pronounced scar of 3 to 4mm width above the left eye, in the middle of my forehead, from a car accident many years ago. Will micropigmentation be effective in hiding the scar? Will the sun still reveal it if the skin around it tans? Thanks.

A: As a general rule, tattooing a scar is almost never a good technique for scar camouflage. It is very difficult, if not close to impossible, to match the surrounding skin color with any implantable pigments. It would always appear different in color to that of the skin and risks actually making the scar more noticeable. Tattoo pigments are also not very stable and are probe to fading and needing re-treatment. Lastly, as you have pointed out, the skin around the scar will tan and the tattooed scar will not creating a noticeable color mismatch. For these reasons, you need to think more about excisional scar revision as it will narrow the scar and bring naturally-colored skin that will tan closer together.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have migraines which are predominantly left sided. A few weeks ago I received injections to both the left corrugator and temporalis muscles. There has been a reduction in migraine attack intensity but no reduction in attack frequency. But there is a definite change in pain pattern as the forehead and cheek are considerably less involved but the temporal headache persists. Would you consider this to be indication of the injected sides being trigger points or just a part of a pain pattern, triggered elsewhere? What would be your next step in the diagnostic process in my case? Local anesthetics into the pain site or a botox injection to the occipital area?
Do you find the local anesthetic nerve block to be a good predictor of a successful vascular decompression?

A: The identification of potential loci for migraines can be difficult. While Botox injections can identify trigger points, they are technique-dependent. The corrugators is fairly easy to inject because it is a small area of muscle that is discretely located. The temporalis, however, is a very broad muscle and there is no well-defined injection point. Not knowing where your tenporalis muscle was injected or with what dose, it is impossible to say whether that area has been properly tested. It must be injected around the zygomaticotemporal nerve lateral to the orbit or in the temporal hairline near the area of the course of the auriculotemporal nerve. Until that area is adequately injected, I would not proceed to the occipital site unless it is a very specific pain site that can be definitely palpated. While local anesthetics can be a limited substitute for Botox, it is not helpful at all to determine any potential role of vascular compression.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I think that I need my chin lengthened downward. I have a very deep overbite. I have attached a variety of photos as I wanted to show you my face shape when my teeth are closed together (I have a deep overbite) and when they are not. Most of my teeth are bridges and crowns and I have recently been advised to have all of them removed and implants put in place and that would help my overbite and give me a lovely smile. I don’t know if this would help as it is unclear to me if my overbite is dental or skeletal. I am under the assumption that my problem is skeletal as I thought my overbite would be addressed when all my teeth were replaced around 6 years ago but this wasn’t the case. Unfortunately it  isn’t really a financially viable option for me to now have all my teeth removed and replaced. I also sought advice a couple of years ago and although I was only 45 at the time, I was advised to have a facelift and nose job to improve my jowling and small chin. I did so but I don’t feel the real problem has been solved. I would appreciate your professional advice on how an improvement can be made.

A: Thank you for sending your pictures. I can see that you have a 100% overbite, which means your lower jaw is over rotated on closure thus shortening the entire lower face. This is a skeletal problem that is manifest by the presence of the occlusal discrepancy. But because of the arc of rotation, the vertical shortening is greatest anteriorly at the chin. As a general rule, the amount of vertical shortening in a 100% overbite can be calculated at the vertical height of the incisor teeth. (crown length) That would be somewhere between 10 and 15mms in most patients. So you are absolutely correct in desiring a vertical chin lengthening osteotomy. That would provide the greatest benefit in terms of improving lower facial height and overall facial balance. I have done some computer imaging which shows the predicted outcomes from that procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I am trying to decide on whether forehead augmentation is right for me. If this procedure turns out right I would be beyond grateful but the size of the scalp scar does make me think about whether I should reconsider having this procedure done. But what concerns me most is the risk of asymmetry. I don’t want to have an asymmetrical hair line or forehead in general. I don’t know, however, if that’s a possible negative outcome when getting forehead augmentation. I also don’t want this procedure to change my eye shape. I simply want to add fullness to the area in between my brow bone and hair line. I usually wear hats or head bands at times to give my face an over all nicer flow. In this message I am attaching a frontal pic and an oblique view., I hate taking profile pictures so much but of course its necessary so I can be better evaluated.

A: I obviously can not tell you on a personal level whether forehead augmentation is right for you. All I can speak to are the potential risks and benefits. What I can tell is that through the open scalp approach, the forehead shape can be perfectly built up and be smooth. That is the advantage of seeing completely what one is doing. A nice buildup can be done between the brow ridge and the frontal hairline. It is quite clear were the buildup would be based on your profile view. This would in no way affect your eye shape nor would the forehead or hairline be asymmetrical.

I would say there is a very good chance that your need to wear hats may be eliminated…at least if this is the reason you are wearing them.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I read your explanation of the temporal migraine with a vascular component rather than a muscular one caught my attention. Are there any research into the effectiveness of this kind of surgery or do you have a personal experience with it´s alleviation of migraines? Do you have a personal experience of local anesthetic as a diagnostic test? I am currently undergoing Botox injections into triggers points to determine how best to help my migraines.

A: I wrote that migraine surgery blog based on my clinical experience in doing it. While temporal migraines can usually be relieved by avulsion of the zygomaticotemporal nerve just outside the lateral orbit, it is not always completely effective. That is why I often will ligate/decompress the anterior branch of the superficial temporal artery as it courses along with the auriculotemporal nerve in the scalp portion of the temporal region. Through a single vertical temporal incision both procedures can be done simultaneously. Since there is no harm is eliminating this vascular element, it is often a part of my temporal migraine surgical approach. The use of local anesthetics would not be effective in determing if there is a vascular component to your temporal migraines. Like Botox, local anesthetics only provide insight into a muscular compression source of a migraine.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I am interested in permanent lip augmentation with Advanta. I have read about the split technique. What can you tell me about this procedure in terms of effectiveness and potential complications.

A: Advanta, in my experience, has been a good permanent method for lip augmentation. While it is an implant in the soft and moveable tissues of the lip, the material is a double porosity tubed construct that has the feel of a marshmellow. While most patient can feel the implant, I have not had a patient who has ever wanted it removed yet due to palpability. if removal should be desired or necessary, it is easy to slide out as it has a surrounding capsule without any real tissue ingrowth. Because of the capsular tunnel left behind, that could be filled with fat injections which would probably take well in an established capsular space. (backup plan or salvage procedure)

The key to placing Advanta for lip augmentation is two-fold. First the lip must be immediately stretched out after the implant is placed so that there is no bunching of it prior to the ends being trimmed and the small corner of the mouth incisions closed. Secondly, I find it a good idea to do a partial central implant split so that the potential risk of banding or tightness across the lip is reduced. But the entire implant should not be sectioned in the middle as that will cause it to widely separate in the middle and each piece migrate towards the corner of the mouth, losing any augmentative benefit in the central third of the lip.

Advanta lip augmentation is a fairly simple and effective procedure, particularly for those patients who are tired of repeat injectable filler treatments or do not want to run the risk of volume unpredictability with fat injections.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I am planning on removing silicone malar implants without replacement that I had done 8 years ago. I am hoping that my skin will contract down once the imlant is removed. However, I realize that sagging is a possibility due to the stretching of my soft tissues from the cheek implants. I do not want any kind of implant again and a subperiosteal resuspension surgery is something that I would want to avoid at my age. Therefore, I was wondering if surgical adhesives, like a fibrin glue sealant would be useful in preventing or at least minimizing sagging and would help the tissues to better redrape the face. Would there be any potential complications from using surgical adhesives?

A: Your concern and questions about cheek implant removal are good ones. Like all implants in the body that push off of the underlying bone, their effects are seen by the stretching of the overlying tissues. Whether this soft tissue stretch is significant, and would result in malar tissue sagging after their removal, depends on how large an implant was originally used and how much elastic deformation of the skin was created. For some patients with smaller cheek implants, no significant malar sagging will occur. For other patients with larger implants and more significant cheek hypoplasia to begin with, the sagging may very well be noticeable.

Regardless of the size of the implant, the question is whether any surgical manuever (from the intraoral approach) during cheek implant removal surgery can prevent sagging and maintain a better soft tissue position on the underlying cheek bones. I think there are two options. As you have mentioned, tissue adhesives can be used. Whether they can really glue the outer capsular lining to the inner capsular lining on the bone is debatable (the surrounding cheek implant capsule is not removed so these two layers are present) But there are no risks to doing so. I would use an autologous tissue adhesive made from the patients’s own blood, like that obtained from the GPS III system. (Biomet) Another option is to place several sutures between the capsular layers to prevent the outer capsular lining, of which the cheek soft tissue are attached, from sliding off of the inner capsular lining and bone below. This is, in reality, a subperiosteal suspension done from below. That is a more likely effective manuever that would be more secure than tissue adhesives.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I had a facelift several years ago that I am very happy with the results in the neck and jowls. However, it has resulted in my earlobes being pulled down which I believe is called a  pixie ear deformity. I have spoken to the surgeon who did the facelift, and he has attempted to fix the ears by putting a suture behind the ear and pulling them up.  At least that is what it felt and looked like.  The ears came right back down.  I understand that another way to correct them may leave a scar on my lateral face where they were attached and at this point I’m not to excited about that.  Other than performing a facelift revision, is there another way to fix the ears that is not to extreme?

A: While the simplest and most effective way to correct the pixie ear deformity is a V-Y advancement, that will leave a fine line vertical scar in its wake as you have pointed out. It actually is very small, and one’s concern may be slightly overblown about it, but it is a scar nonetheless. The second best way is to advance the preauricular skin flap up slightly so the face skin can craddle under the earlobe after its release. This is also effective and uses the existing scars inside the ear up into the hairline. You might call this a revision of a facelift, albeit a minor one, but moving the pulled down skin up is the only way to truly correct the earlobe tethering. Just trying to ‘tuck’ the earlobe from behind will never work as it needs skin redistribution in an upward direction.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I had otoplasty done four years ago that was over done. I have just tried to live with it but it just makes my face look odd and unbalanced. I read an article that you were interested in correcting this issue. I have seen numerous plastic surgeons who have suggested a variety of surgical treatments. I want to know if there is any new non-surgical break throughs in this area? I wanted to ask you if you know of any devices, information or any experimentation in trying to stretch the ear cartilage, in cases where cartilage is still present, to increase ear projection? I mean can cartilage be stretched so if there was a stretching device you wore on your head, like a head brace with levers that have custom ear clamps molded to your ear, and you worn them at night set to pull your ears in the right angle, could this work?

A: The simple answer to your question is no. Cartilage, unlike skin, is not a tissue that is subject to elastic deformation or stretching. It does not have the right cellular composition for that phenomenon to work. Only a surgical approach has any chance to be successful.  During an otoplasty, the curving and setback of the cartilage actually creates ‘less’ cartilage from a practical standpoint. Therefore, in attempting to bring the ears back out, the only plausible solution is a cartilage release and interpositional cartilage grafting. A release alone will only immediately relapse. Skin grafting of the postauricular sulcus or postauricular surface is also unlikely to work unless the problem is a direct fusion of the back of the ear to the mastoid skin or there is a prominent scar band between the two. While it is understandable why any patient would seek a non-surgical solution, the pursuit of that type of otoplasty revision is a mirage when it comes to changing the position of the ear cartilage.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I am a 21 year old female that has very small breasts and would like to consider breast augmentation but would like to know my options. I also have inverted nipples and wasn’t sure if your specific practice in Indiana was able to help with that also. I would love to receive some information.

A: With breast augmentation there are numerous options to consider with the procedure, all which revolve around the implant. Implant choices include what type (saline vs silicone), what size (they range from 150cc to 800cc in volume), and what projection. (low, medium, high) Despite a tremendous amount of information that is easily accessible on the internet, I find that most women I see for breast augmentation consults are either confused or misinformed on many of these important decision points. Much of this information and how it applies to any particular patient can only be finally sorted out in an actual consultation with a plastic surgeon.

It is not uncommon to see a patient for breast implants who has an inverted nipple. In some cases, some or all of the nipple inversion may come out with the ‘push’ of the breast implant from behind. In most cases, however, it will not and it will require surgical correction. This can conveniently be done at the time of the breast augmentation procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, my earlobe tore as a teen and it went on to heal on its own. While it did heal, it has left me with thick earlobes. The split closed up but it left me with an abnormally long lobe that makes me very self conscience. I would love to get it corrected.

A: All earlobe tears will heal on their own and one would normally be left with a crease or groove along the healed tear line. Otherwise the earlobe will not be significantly distorted.  Occasionally, when an earlobe tear heals on its own it will develop thick scar tissue which may also make the earlobe look longer. Both issues can be solved through a procedure that is very similar to an earlobe reduction operation. The scar tissue and the surrounding elongated central earlobe tissues are removed and the earlobe is closed back together. This makes the earlobe vertically shorter and much softer. This earlobe reconstruction is an office procedure done under local anesthesia. The sutures are removed in one week. The earlobe can be re-pierced 8 weeks after the procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley,  I have a depressed skull fracture as a result of a head butt injury.  What are my options for reconstruction?

A:  While I don’t know the location or exact extent of your depressed contour skull deformity, it is highly likely that an onlay cranioplasty procedure can completely restore the shape of the skull. Material can always be added to build the bone back to a normal contour and there are multiple options to do so including polymethylmethacrylate (PMMA) and a variety of hydroxyapatite formulations. This is actually a fairly simple procedure that is very effective. The only significant question is as to what incisional approach can be used to adequately perform the cranioplasty. Without knowing where the exact location and size of the skull issue i, I could not answer that question. I would be able to answer that question better if you could send me a picture of the depressed skull area.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting a tummy tuck but have a few questions about it. In reviewing the photos of other women whom have had the procedure, I noticed that the scars are up fairly high, is that necessary to achieve proper results? You see, in having two cesarean births, both incisions were very neat along the hairline, I really like the way it had healed. Do you cut through the muscle in this procedure? Oh, and the other thing, in viewing some post-op footage, there were these drainage apparatus, is that something always done? Sorry for all of the questions, I hope you don’t mind. 

A: A full tummy tuck always pulls the incision up higher than a mini- or more limited tummy tuck. Only a min-tummy tuck can keep the incision as low as most women have their c-sections scars at. C-section scars should almost always heal beautifully because they are closed under no tension. (loose stretched out skin) Tummy tuck scars rarely look quite that good because they are close under considerable tension. (tight taut skin) Tension is the enemy of a narrow scar line.

No muscle is ever cut though in a tummy tuck of any form.

The use of a drainage tube is a necessary evil after tummy tuck surgery that stays in for about a week.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a dermoid cyst in my forehead bone that needs to be removed. Because of its size, it will leave a significant bone defect after its removal so it will need to be reconstructed. One  plastic surgeon told me that he has to take out too many bad products from people’s head’s so he now only uses a titanium mesh covering for these repairs. My question is which is a better method for reconstruction, metal mesh or a bone filler? Also, two different incisions  have been discussed.  Since the lesion is not too far from the hairline, is it possible to do a smaller incision, one that goes from the  sideburns to the midline  of the forehead and just very slightly into the hair line? I know that a bicoronal incision can be used but it is a more difficult recovery and some  scalp numbness will result. Which incision would be better to perform the surgery with the least risk of problems?

A: It appears that you have an epideroid cyst in the diploic space of the frontal bone. I assume the reason for its removal is that it is slowly growing.

I have no picture of you to see where exactly the lesion is located in reference to your frontal hairline so it is impossible for me to comment on what incisional approach could be used. Certainly some variation of the bicoronal incision can be used. The only question is whether some other form of more limited incisionall approach could be used. Without knowing where on the forehead it is (seeing a picture with a mark on your forehead), I can comment no further.

In terms of reconstruction, I would disagree strongly with the idea that there are a lot of bad products for skull reconstruction. I have used all available materials and have never had a problem with any of them in hundreds of cases. They all work well when used with proper technique. For covering a ‘crater’ in the forehead after the cyst removal, I absolutely would go with an hydroxypatite cement. It can fill in the defect and make the forehead perfectly smooth. While covering the defect with low profile plates and screws is also acceptable, there is always the chance that you will be availble to feel the outline of the metal hardware and even some risk that it may leave a negative image on the forehead skin should it thin out after the surgery. 

Dr. Barry Eppley

Indianapolis, Indiana

When the subject of breast implants or breast enlargement surgery comes up, many people immediately think about size. Large breasts that create eye-catching cleavage are what comes to many minds, a concept that has not been helped over the past two decades from celebrities ranging from Pamela Anderson to Heidi Montag of more recent note.

The reality of breast implant surgery, however, is far from this image. There are certainly a minority of women who do want this look. But the  vast majority of women who choose to have breast implants are much more interested in finding the right size for their body and not to have overpowering breasts that become the focal point of their appearance.

Most breast augmentation patients are average women who simply want to look good in clothes and sport attire. I have seen many women who have told me that they are embarrassed to wear a bathing and won’t go to the pool or beach with their family. While breast underdevelopment is the most common motivation for getting implants, there are numerous other reasons. These include such breast conditions as postpregnancy sagging, asymmetrical breasts, body proportioning, breast asymmetry and reconstruction after mastectomies.

Pregnancy and nursing can have an adverse effect on a woman’s breast shape and size causing sagging and, almost always, a change in the amount of breast tissue. Many women are unaware that it is completely normal to lose breast tissue after pregnancy, a phenomenon known as involution. For some women who have had multiple pregnancies, they lose all of the breast tissue they originally had. When combined with stretched out skin, the change in a woman’s breasts can be deflating for their self-image as well. These are women who simply want to return to their pre-baby size and shape.

There are many women who have breast asymmetry where one breast is larger or different in shape than the other. In some cases the breast size difference can be as much as a cup size, sometimes even more. For women so afflicted, finding a bra to fit comfortably and properly is not as easy as going to Victoria Secret’s and pulling a good fit off the rack. Often they are forced to add padding to create a more even look in their clothing.

One of the most recognized and easily understandable reasons for implants is in breast reconstruction. The physical and emotional devastation of going through any form of a lumpectomy or mastectomy procedure can be softened knowing that an immediate or even a delayed reconstruction can be done. While numerous forms of breast reconstruction exist, including flaps that form the breast mound out of your tissues, implants remain the backbone of how most breasts are recreated.

Dr. Barry Eppley

Indianapolis, Indiana

Rhinoplasty surgery can make many changes to the nose, from taking down a bump on the bridge to narrowing the tip. But in the end, the result that will be seen depends how the skin of the nose redrapes and adapts to the new changes that have occurred in the supporting framework underneath it. Given that removing skin from the nose or tightening it through incisions and creating external scars would be unacceptable, the wildcard in any rhinoplasty outcome is ultimately the patient’s nasal skin.

Thus, unlike any other piece of nasal anatomy, the skin is really a fixed and not a variable component of rhinoplasty. It is the one piece of nasal anatomy in which its surface area can not be reduced. It is a common principle in rhinoplasty teaching that the skin will shrink down and adapt to show the changes that have occurred in the bone and cartilage framework. But this is not always so and is not necessarily even always predictable.

How well the skin of the nose can shrink down is influenced by many variables. The two most important are the thickness of the skin and where on the nose it is located. Skin in the upper half of the nose seems to be better at adapting than the lower half of the skin. But that may be just a reflection of the complexity of the anatomy underneath it. The upper nose is like a saddle while the lower nose has a much more complex shape and is more similar to wrapping paper around one side of a ball. Thin skin is believed to shrink better than thick skin and probably reflects that it has less overall mass. In theory, thick skin should shrink more than thin skin due to a higher number of elastic fibers. But its thickness provides 50% more mass given any  surface area so significant skin contraction does not occur.

When one has thick skin on the nose and is undergoing a rhinoplasty, it is important to temper one’s expectations and to have extreme patience in awaiting the final result. This is particularly relevant to many ethnic rhinoplasties including Africa-American, Hispanic, and Middle Eastern. Since one of the main objectives of these rhinoplasties is to have a more slim and refined nose, thick skin will have an influence on how achieveable that goal is. It is also important when performing these rhinoplasties to not attempt to slim the nose by  removing too much underlying structure. That will cause the skin to ‘ball up’ particularly in the tip area since the now ‘excessive’ skin has nowhere to go but to contract onto itself.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting a browlift and an upper blepharoplasty fro my hooded eyes and low brows. I am now 54 years old. Three years ago I had a facelift done and, although I am happy with the neck and jowl results, the scars around my ears have significantly widened. This has made me afraid of doing any type of browlift as I don’t want a wide scar in my scalp. I wear my hair with bangs and I also have a high forehead. What are your thoughts on the transpalpebral approach to browlift surgery?

A: While a transpalpebral browlift avoids any hairline scars, the ‘price’ to be paid for that decision is that it does a relatively poor job of lifting the brow. At best, it can only make a minor elevation of the tail of the eyebrow. It illustrates a basic principle that you can’t really lift much when all you are doing is pushing up from below. It can not elevate at all the inner half of the eyebrow because the supraorbital and supratrochlear neurovascular bundles are in the way. With your already high forehead, I would strongly consider a hairline or trichophytic browlift technique. That would achieve the dual effect of lifting the brows and shortening the vertical length of the forehead at the same time. Provided you have a good frontal hairline density, the resultant fine scar at the edge of the hairline is one that is usually not associated with any significant scar widening. I would not equate what can happen along the ears from a facelift to that of the effects of a browlift on the hairline. Excellent scars can be obtained, however, from each with good surgical technique.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a rhinoplasty several years ago that changed the angle of my nose from convex to acute. I would like to have this corrected with a premaxillary implant. Do you prefer silicone, mersilene mesh or hydroxyapatite?

A: Thank you for your inquiry and good question. While arguments can be made for any of the materials you have mentioned, and I have used them all, I prefer mersilene mesh in the premaxillary/pyriform aperture area. While I don’t use this material for most other facial areas, it has several advantages under the base of the nose including easy shaping and fabrication, no need for implant fixation, rapid tissue ingrowth with firm fixation and minimal palpability to the touch. Silicone implants tend to be a little firm and placing them under the thin mucosa of the maxillary vestibule makes them prone to future problems of tissue thinning, exposure as well as palpability. Hydroxyapatite granules is another reasonable alternative as a good long-term facial implant material. Its only problem is that one does not have ideal control over the placement of the material and the granules do settle out so the amount of premaxillary augmentation may not be enough or may be uneven or irregular.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am very interested in a knee lift.  I have had liposculpture around the front of my knee and thigh with the hope it would remove the wrinkly look I have around my knees.  I am 48 yrs old therefore the loss of skin elasticity has effected the look of my knees.  I am desperate for some advice of where I can go to improve  this part of my body. I have considered a thigh lift but have been advised that it is not possible to lift my problem area because there is a long distance between my knees and upper thighs.

A: The loose skin and wrinkles above and around the knee area is a difficult problem. As you have discovered, deflating thin older skin by liposuction will usually just create more loose skin. Like anywhere else on the body where there is loose skin, it is possible to do some form of a lift. Essentially a knee lift is the direct removal of skin above the knee cap area. This is actually a fairly simple procedure in concept but is flawed by the creation of a scar. While lifts are done in many areas of the body and they all create scars, the knee lift is unusual in its location. It is placed in an area that is directly exposed to high degree of motion and a high angle of potential flexion…which puts stretching forces on the scar in a perpendicular direction. This will likely result in noticeable scar widening. Whether such a scar is a better aesthetic result than the wrinkly skin around the knee is a critical question. While I would have to see how ‘bad’ your knees look now, I would be suspicious that this may not be a good aesthetic trade-off.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, How long does it take to heal from a tummy tuck? What is the success rate to keep the contour? How much does the procedure cost?

A:  Recovery from a tummy tuck depends on how you want to view the concept of recovery. To be 100% full recovered (feeling like before the surgery and doing all normal and strenuous activities), it will take a full 6 weeks. If you are talking about returning to work in a sitdown job, it will be closer to 10 days. Returning to a more strenuous job will be closer to three weeks. Up and about after surgery around the house will be a few days.

The success of tummy tucks in terms of long-term contour preservation is actually pretty good. The excess or loose skin is never going to return provided one does not get pregnant again, which is the primary skin-stretching mechanism for most women. (extreme weight loss is the other) One can thicken up the fat layer around the trunk and waistline based on one’s weight and diet. I have seen that in a few patients over the years. It all depends on the stability of one’s weight and the type of body build one has.

There are different forms of tummy tucks that may or may not include liposuction. For the sake of simplicity, I would look at the concept of a full tummy tuck with flank liposuction which is the most commonly performed one. As an out patient procedure this more complete tummy tuck is in the range of $6500 to $7500, all costs included. This is an approximation and may change based on an actual examination of the patient.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 25 year old man and I want to fix the sunken look I have in my midface area. Below my cheeks it is very hollow. In addition, there are indented lines which I call railroad track lines in my midface? I have read about filler injections but I know they are only temporary and may leave a plump, round shape which I don’t want. I would like to have a more narrow/angular look. Do you think cheek implants will work?

A: Hollowing below the cheeks, known as submalar hollowing, is the result of the cheek soft tissue not being supported by bone. Without a large buccal fat pad or thick subcutaneous fat being there, this area will become a concavity and not a convexity. Injectable fillers can certainly be used as a temporary augmentation method but I would agree that it lacks the ability to create sharp definition. Cheek implants are the only other options and they do provide a permanent change. But there are numerous types of cheek implants and it would be very important to get the right implant shape to achieve the desired result. Submalar cheek implants would theoretically be the best choice but they do add some cheek width and lateral fullness.. It may be better to use a combined malar and submalar implant, known as a malar shell, and modify the submalar edge to create medial augmentation of the submalar hollow but not lateral fullness.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was wondering if forehead reduction was possible. I have a high forehead and it makes my head look rather large. I also feel like my forehead comes outward too much like bossing. Can anything be done to fix these problems?

A: Forehead reduction is done by loosening and advancing the frontal hairline forward and removing the forehead skin that it overlaps. Since this is an open procedure, the bulging upper forehead (frontal) bone can be shaved down four to five millimeters for some mild bossing reduction. The key to doing this procedure is that the one must have a stable and fairly dense frontal hairline as this is where a fine line scar will result. This means that it is a procedure that can be done for many women but only in a very limited number of men. I actually have never performed a forehead reduction in a male for this very reason.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: Hi Dr. Eppley, I was wondering whether trauma to the brow bone early in life could have caused it to grow differently than it should have. I was on a trampoline as a child  and fell onto the left side of my face and had large swelling there for about a week before it went away.  Now that I am older I have noticed that the side of my brow seems to be lower, giving my left eye a perpetual sad look that I do not like. While I could be mistaken, and it could be scar tissue causing this asymmetry, I am wondering if this is due more to bone. If so, is there a cosmetic procedure to fix this and if the childhood trauma could have been the cause. Thank you.

A: Most certainly trauma to the brow bones can be a source of brow asymmetry. The trauma could have caused an actual deformation of the bone by infracturing the thin bone over the frontal sinus in an adult or causing a compression fracture in children that changes how the shape of the bone grows and expands. Such asymmetry is the result of the edge of the brow bone being lower than the unaffected side. This can usually be corrected by a brow bone reshaping procedure by shaving ‘up’ the lowered edge of the brow bone. This can be done through an upper eyelid incision. It usually takes about two to three weeks until all the swelling and bruising is gone.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 72 years old and in excellent health… exercise, good diet, etc.  When I was around age 45 I had a blepharoplasty operation as I had developed large bags under my eyes. The surgery was to remove fatty tissue from my eyelids.  It did me a world of good, as I was quite self-conscious of my appearance.  Those bags have gradually come back and I am, again, very self-conscious of them.  I look relatively young except for this excess fatty tissue.  I can hardly imagine how I would look now had I not had the first operation! My question is how could this fat come back since I haven’t really gained any significant weight. Can they be removed again and do you think that it would be covered by Medicare? Thank you for your help.

A:  Bags that develop from the lower eyelids is a common problem that occurs largely in aging eyes and occasionally in younger people due to genetics. The bags are due to fat which is sticking out from underneath the eyeball. One can think of it as a hernia. Our eyeballs are surrounded for their protection by fat. This fat is held in place underneath the eyeball by a special tissue that runs from below the lashline (tarsus) of the lower eyelid down to the rim of the lower eye socket. As we age this tissue becomes weak and the fat is no longer held back and begins to stick out. (bags) For some people, they have a congenital weakness of this tissue and they may have bags as early as their teen years. Once this protruding fat is removed, it is still possible later in life for it to ‘return’. This is really just more fat that is coming out from around the eyeball as the supporting tissues become weaker. Like the first surgery, further fat can be removed by additional lower blepharoplasty surgery.

Lower eyelid surgery is never covered by insurance because it does not interfere with one’s vision. Only the upper eyelid can create that medical problem.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I need advice as to whether I should have a mini- or full tummy tuck. I have attached some pictures of my stomach so you can see. I have been to two plastic surgeons and have gotten two different opinions. In listening to them, both make sense for what they want to do so I am confused.

A: When considering the type of tummy tuck one may need, it is important to look at the components of the excess tissue problem. The most important consideration in choosing between a mini- vs a full tummy tuck is how much skin is present. While you don’t have a large amount above your belly button, there is enough there that a mini-tummy tuck will not fully get rid of it.  The other tissue consideration is the amount of muscle laxity or protrusion. You appear to have a protuberance of your abdomen starts way above your belly button.  Like the skin excess, this muscle protrusion indicates that you will get a much better result from a full tummy tuck. One issue to consider in doing a fully tummy tuck is the vertical level of the horizontal scar. If the belly button cut out in the skin needs to stretch down to meet the lower incision, the horizontal scar will likely end up a little high. Therefpre, I would recommend that you end up with a small vertical scar in the lower part of your abdomen.  That way the scar can stay low and the belly button hole can be closed vertically. I think this would be better given how jeans and underwear are cut and designed today for women.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting breast implants but am having a hard time figuring out the right size. There does not seem to be any specific method about how to select the size. know I should not focus on the cup size but more on what I want it to look like. I do want want them to be large though.  I am 5′ 6″, weigh 135 lbs and am athletically built. I want them to be large, but not so large that they will cause me problems down the road. One plastic surgeon I consulted with recommended 500cc implants. But in trying them on inside my bra, they seemed too small. What would you recommend?

A: While there is no exact science to selecting breast implant size for any patient, there are some guidelines to follow. Remember, however, the goal is in how the breast loko after surgery not necessarily what cup size they fit into or what volume of implant it is. It is all about the look. There are two criteria that I use.  The first is how wide is your natural breasts, known as the base breast width. Select an implant whose base width does not exceed that of your own breasts. That will keep them from getting too fat to the side or into the swing of the arm. Secondly, what breast look is the patient after. This requires the patient to s look at and select some after breast augmentation photos of sizes (look) they like. When putting the two together, a good breast implant size can usually be chosen that satisfies most patients. If the breast look appears bigger than what one’s breast width can accomodate, then select a bigegr implant that has a high profile. This will allow for more volume while keeping the implant diameter within the boundaries of the side of your breast.