Your Questions

Q:  Dr. Eppley, I was surfing the web when I came across your blog. As I was reading I got excited in hopes that you could be help for me. I am 35 yrs of age and all my life I have avoided anyone touching my head or getting my hair wet in public places such as a pool. The reason is that one side of the back of my head is flat. I think the medical term for it is deformational plagiocepahly. The back of my head is flat, my left side to be exact. In addition, my forehead is somewhat flat as well. This condition has severely bothered me. Growing up as a child was difficult, I had plenty jokes directed at me for the shape of my head. I have used a blow-dryer most of my adult life to camouflage this area as best I can. I would hope that you can help me. What can be done for it?

A:  You are describing deformational plagiocephaly to a tee… a twisting of the skull during growth that creates a flattening on the back of one side of the head and a similar but more modest flattening on the opposite forehead. In severe occipital flattening in adults,  I have performed cosmetic skull reshaping through an onlay cranioplasty technique. Most cases of a flat back of the heads have their locations up high above the ear level. Through a small vertical incision, the bone can be built up using either hydroxyapatite or acrylic. (PMMA) There are some advantages and disadvantages to either material and they need to be reviewed carefully with the patient. But the surgery is fairly easy to go through, one’s recovery is very quick, and the results are immediate.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, My upper jaw (maxilla) seems to be slightly recessed and the natural outward projection of maxilla is not present creating an unusually flatter profile in mid-face. My chin is also recessed but interestingly don’t have any bite problem. After extraction orthodontics(to treat crowding) the problem seems to have aggravated and now the upper teeth show way behind the upper lip and now the dental arch provides minimal support to the lip. This makes the upper lip to hang without proper base support resulting in speech problems. (lisp) I also had an unsuccessful chin surgery (implant removed 1 yr back) creating awkward tensions in chin fold area and trickier lower lip movement. Combined with above, my face is in pretty bad shape and preventing me to achieve a good speech. Kindly suggest what are the options.

A: By your description, it sounds like the fundamental problem is that of maxillary horizontal retrusion. That has been magnified by the teeth extractions for orthodontics which have pulled the anterior maxillary teeth (and the lip support) further back. It would be important to have a full facial skeletal workup on you (photographs, x-rays and dental models) to determine the viability of orthognathic surgery. (maxillary and mandibular advancement combined) That would treat the fundamental underlying problem of a deficient skeletal base. Onlay implant facial augmentation is another option (midface and chin implants) but should only be considered if the orthognathic surgical approach was either not possible to do or was too extreme an approach to go through.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve found a website that can do plastic surgery to change your appearance by making your ears pointed. And can put implant horns/antlers on your forehead or the top of your head. I was wondering if you can do something like that but if not, do you know any surgeons who can do something like that? The website  I saw  is made from a surgeon/doctor.

A:  The procedures that you have requested are both unusual and dysmorphic in nature. While plastic surgery can create an enormous number of facial changes, the goals of such procedures are to reconstruct one to a more normal appearance or to enhance one’s normal physical features. Altering one’s ears to a ‘spocklike’appearance or putting forehead and skull implants in to create horn-like protrusions are a poor use of plastic surgery techniques and implant materials. While I am certain there are some ‘surgeons’ out there that perform these procedure, I would know of no board-certified plastic surgeons that would perform these disfiguring procedures that, no doubt, one day the patient will ask to reverse and restore a more normal appearance.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My cheek bones come down just past the nostril base of my nose and from what I’ve read, that is supposed to be ideal. However, to me, it appears that I am lacking some volume and “flatness” in the submalar region. My chin is also slightly weak but the idea of a chin implant concerns me since it can be easily overdone and too prominent. If possible, I’d like the chin not to look wider from the front or longer from the profile…just creating outward volume. My goal is to maintain a feminine look with naturally done contours.

A: In looking at your face and in conjunction with your stated goals, I would recommend a small submalar implant and a small central chin implant style. Your cheekbones actually are quite nice and ideally positioned and full. The submalar area could stand a little volume as you have surmised but the key is subtle or small. This is why I suggest one of the smallest submalar implants. The malar and submalar areas are very easy to overdo and too large a size is a common problem in implant selection. From a chin standpoint, females needs a more central chin implant with very limited lateral wings. Women need a more tapered chin appearance, more pointy if you will, which is more feminine as opposed to a more square chin look for men. The combination of small submalar and chin implants should provide highlights and natural contours to your already good facial bone structure rather than overpowering it or being obvious.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I am interested in a rhinoplasty which builds up the bridge of my nose.I would definitely want to use a rib cartilage tissue for it due to good long term results and safety which are my main concerns. However, I still have some questions about the operation. How will the rib operation affect my ability to function? I go to gym and exercise a lot and I wondered if there might be some long term problems with the operated rib?

A: There will be no long-term sequelae/dysfunction from taking a portion of a lower rib for rhinoplasty. Not only is the rib harvest not bone but cartilage but it is a small portion of it and not the whole rib. Th function of ribs is to provide structural support to the chest wall but it would take many whole ribs being removed to destabilize that function. This is just a portion of one of the lower ribs ( 8, 9 or 10) which actually have no real function for chest wall support and pulmonary function as they lie below the level of the bottom portion of the lung.  What is associated with some rib removal is pain and discomfort. To manage this immediately after surgery I inject a 24 hour local anesthetic into the surrounding rib tissues from the harvest so one does not wake up in severe pain. While this does wear off, it gives one time to acclimate to the soreness. One can usually return comfortably in 3 to 4 weeks to exercise and more strenuous activities.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Hi Doctor Eppley, can the type of cheekbone and jaw angle advancement be done without implants but with the patients own bone? Such as with a cheekbone osteotomy? Also, do you have any before and after pics of this kind of procedure. I would like the male model look, but I have relatively flat and narrow cheekbones and a weak chin. I am currently undergoing orthodontic treatment and will eventually have a rotational advancement of my jaw, but this will not necessarily improve my cheekbones –do you perform cheekbone advancement widening? And could you send me some before/after pics of such results? Thank you very much for any help! I would certainly be willing to travel to consult with you.

A: Most facial bone augmentations can only be done using synthetic implants on top of the bone. The one exception to that is the chin where the option exists of either a chin osteotomy or chin implant. This is because there is enough bone to cut and move and the direction needed is a favorable one from a bone movement and blood supply concern. Such is not the case with the cheek. While the cheekbone can be cut and moved, it will only produce a widening effect and not a forward or anterolateral effect which is what most patients need and want when they undergo cheek augmentation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I have poor elasticity and a pannus that is causing problems sitting and walking. However I’m not that obese at 175. My skin is just weird after years of battling anorexia and bulimia. I’m in recovery now and off weight causing meds (depakote and seroquel). I don’t like liposuction outcomes and want to avoid that. I am hoping you can tell me that this is just from atrophy and break down of muscle from my disorders, and healthy work with weights and aerobic exercise and good meal plan can get rid of my thin skinned pannus covering mainly groin and hips (not over pubis). It’s causing pinching pain when I walk or sit and sweat related problems like chaffing. It’s  getting worse even though I’m losing weight to hopefully go back to my previous set-point of about 133. I should add that I’m an apple with a lot of adipose fat in relation to my hips. Also, I am wondering if my insurance might cover a panniculectomy, and if that is an option for me. Thanks for you time.

A: No abdominal pannus can ever be removed short of excisional surgery. Skin excess will not disappear with exercise, diet or even any form laser or ‘skin-tightening’ liposuction. Only a panniculectomy or amputational abdominoplasty will work. This is a surgical problem. When it comes to potential insurance coverage, your description of your pannus sounds like it would not qualify. One of the clear insurance coverage criteria for an abdominal panniculectomy is that the pannus hangs over the groin crease onto the thighs.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, There are several parts of my face that I wanted to improve, but I feel like the nose is the most significant feature that I want to change. I attached some pictures which show the amount that I want my nose to be built up. I would like to know if this is realistic. What is the best way to accomplish this, implants or your own tissues. I have heard implants can get infected and that rib cartilage is known for warping. I am uncertain as to which choice to make. What do you recommend?

A: What you are demonstrating is nasal dorsal augmentation from the frontonasal junction down to the supratip area below and behind the lower alar cartilages. The greatest amount of dorsal augmentation is in the radix because it is also the lowest. I think the kind of result you have imaged is realistic.

The major question is what material to use for nasal dorsal augmentation. There are two main choices; synthetic implants and rib cartilage of which I have used both. (although many more rib cartilage grafts than implants) While there are advocates for each, I would heavily lean towards the use of rib cartilage given your young age and skin type and quality. While it requires a greater investment of time and recovery up front, the use of your own tissues will not give you any infection, extrusion or tissue thinning problems for the remainder of your long life. In using rib cartilage, it can be done as a whole piece or as a fabricated diced roll construct. Which one is better is based on the quality of the rib tissue harvested and surgeon’s preference. Because most rib cartilages have some curve to them, it requires good surgical technique in how to harvest and shape them to avoid the potential for warping concerns.  I always use the cartilages from either the 8^th or 9^th rib. Sometimes a very straight piece can be obtained and shaped and then I use it as a solid graft. If the rib is very curved and a very straight piece can not be fashioned out of it, then it is cut into very small pieces (1mm) and packed into a surgical wrap to create a very moldable long implant like a piece of sausage. Once in place it is easy to shape and the splint after surgery holds it into place. It becomes very solid in a short period of time as the small pieces of cartilage allow very rapid fibrovascular ingrowth. As a young man, you should have very good rib tissue and I suspect the solid rib graft for your rhinoplasty will work just fine. That has been my experience in younger male patients.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, my jaw grew asymmetrically from birth. I had a surgery when I was 18 years old where they shaved off part of the chin, and added implants around much of my jaw. However, when it was done I thought my face looked too full. I had a second surgery to remove some of the implants. The result was better, but I am still not satisfied. I don’t need to look perfect, but I don’t enjoy having one side of my face be fuller than the other. Would it be possible to do surgery and simply shave off a little of the implant? I don’t want it out, because it needed to be in there, it is just too large.

A: Onlay augmentation of the jaw with implants is a common method to improve jaw asymmetry. This is a good treatment option when an osteotomy and occlusal adjustment is not needed or desired. There are numerous types of implants used in the jaw including silicone, Medpor (porous polyethylene) and Gore-Tex. (polytetrafluoroethylene) Each has their own advantages and disadvantages but they all share one similarity…they are relatively easy to carve and shape with a scalpel. Even though you did not say and may not even know what type of material that was implanted, it should be able to be pared down to a smaller size without the need to remove it first. Jaw implants are usually fairly easy to modify once in place.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I am a Mexican-American and want to get my nose fixed. My nose is flat in the middle while the tip is wide and droopy. Do you think a non-surgical nose job can lift my nose? I am afraid of surgery since I have never had any and because it would take time to heal.

A: The concept of a non-surgical rhinoplasty is understandably appealing but it is a far overblown treatment method in terms of what it can really achieve. It is the use of injectable fillers to augment or plump out certain areas of the nose. For the right problem, such as an indentation or depression in the nose, it can be very effective. It can also raise up part or all of the dorsal line of the nose or even push out a retracted columella. But it can not create an overall global change in the nose such as what you appear to need by your description. An injectable filler will help fix the ‘flat area in the middle of your nose’ because that is an augmentation issue. But the technique can not make a ‘tip less wide and droopy’ as that is a reduction issue. In trying to lift your nose with a filler you would merely make it more wide and fat with little lifting effect. A non-surgical injectable approach has its best use in correction of some postoperative irregularities after a rhinoplasty and is the most common usage in my plastic surgery practice.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve just recently had upper and lower jaw surgery to correct an underbite. I also had a sliding genioplasty (4 mm vertical reduction).   All of this was just done 5 weeks ago, so I realize I need to give it more time before know what the final results will be; it seems I still have some swelling. My questions/issues: 1) I’m wondering if the chin should have been reduced more. 2) I’m wondering if a have a bit of ptosis. I don’t notice it so much normally, but when I smile big, my chin gets flatter and seems to project out more. There seems to be a little loose/excess skin. The bottom half of my chin (maybe my chin pad?) seems a bit puffy and fatty, but maybe some of this is swelling.  I’m not sure if a lipo of the chin area would fix this, or if the mentalis needs to be resuspended, etc.  Or maybe it’s just in my head and it’s normal. Or maybe it’s swelling. I should note though that in 2002, I had a chin reduction that was done with a burr, and I’ve since learned that that can cause soft tissue issues. 3) The right side of my chin is a little longer than the left side, so it kind of makes my chin look a little slanted and the right side looks a little pointy.  I’d prefer for the bottom of the chin to just be straight across (square-ish jaw line maybe?)

A: The first thing I would say, of which you already know, is that it is way too early to judge the final results of your recent bimaxillary jaw surgery even in the chin area. Quite frankly, you still have an ‘orthognathic’ facial appearance which means there is still swelling and the tissues havge not settled over the new skeletal base. I would not critique the results until a minimum of 3 months and preferably 6 months after the date of your orthognathic surgery. When the tissues feel soft, move normally, and most of the feeling has returned, then you can focus on the aesthetic outcome.

For the sake of discussion, if all of these chin asymmetry/shape issues persist, they can be further improved by a chin revision. Whether this is done by a submental or intraoral approach remains to be seen based on exactly what the issues are. The key is what the overlying soft tissues do and how they settle out.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, what I would like to know is would liposuction and laser treatment to tighten abdomen area help with my problem area?  I seem to have small area over belly button that has always been there even when I lose and get almost too skinny for frame.  My skin on lower abdomen seems to be fine its tight when I stand but when I sit it gets kind of mushy with the rest of stomach.  I just have a hard time fathoming the fact that I would need a tummy tuck it’s not huge like some peoples I have seen.  I have had two pregnancies but no C-sections. Thank you so much!

A: In looking at our pictures, I can appreciate the slight quandry you have being uncertain whether liposuction alone or a mini-tummy tuck is needed. As a general rule, when you see a roll of skin above the bellybutton that is a sign of skin excess that can really only be flattened by a mini-tummy tuck. Since a mini-tummy tuck loosens and repositions the belly button from underneath, the roll of skin above is stretched out and moved lower which is how it gets ‘removed’. However, when your lower abdomen is in good shape (no excess skin) and the roll of tissue above the bellybutton is as much fat as skin, then liposuction alone is a viable treatment. In your case, I would have laser liposuction alone accepting that the postoperative flatness will be much improved even if it is not ‘washboard’ tight.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  My question is what is your opinion on fat transfers? I¹ve heard that there is some disagreement about it. Would that be an option instead of using Radiesse every six months which I have been getting for my depressed scars on the top of my nose and forehead?

A: The ‘disagreement’ on fat injections revolves completely around how they survive after injection. In the face and in small amounts, fat injections have the best chance for optimal survival but it can never be guaranteed. I do think that fat injection grafting is a very viable option for your facial scars and there is no real downside or risk of complications by doing so. The issue with fat injections for small facial scars, however, is about the hassle of doing it. Synthetic injectable fillers, despite their short-lived effects, have their appeal because they are quick and easy to do being an off-the -shelf product and treatment. Fat injections require a harvest site, preparation and then injection under very clean conditions like in the OR. I think if you were having some other surgery then fat injections would really be worth a try. But as a stand alone procedure, it is not very cost effective and the risk of complete resorption may not justify that effort for such a small amount of fat.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, our son is in need of some revision of scars about his face and lips. he is only 4 years old. I have some questions about the procedure if you wouldn’t mind answering them for me.

1. Would it be necessary for you to remove any stitching afterwards? And if so, how long would it be before they would be removed.?
2. One concern I have is that he is so young that he might damage or pick at any stitches if he had the operation now.
3. Is the operation done under a local?  He may also be a little too young to sit still for a long time. If the operation is under local how long would the procedure take?
4. Do you perform the procedure?

A: In answer to your questions of facial scar revision in children:

1. I never use stitches that have to be removed in children under the age of around 8 years old. Children are understandably fearful and uncooperative when you approach their face with instruments, as you might imagine. Therefore, I use very tiny dissolveable sutures that go away on their own. For lip scar revision, there are no restrictions afterward in regards to eating and oral hygiene practices.
2. I have never children picking or manipulating their stitches to be a problem. I have done many hundreds of cleft lip and nose repairs in children, for example, and have never seen that to be an issue.  The only issue with children, particularly boys, is their tendency to get inadvertent trauma such as falls and collisions while playing.
3. I would never perform facial surgery on a child under the age of about 10 unless they were asleep. Just like stitches that they won’t let you take out, they most assuredly are not going to allow the process to get them in.
4. There is only me to perform the procedure. I have no assistants or trainees. And even if I did, they would still not be performing the surgery. That is what people pay for me to do.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I am ready to change the look of my face and am willing to spend whatever money it takes to do it. First I want to make my nose smaller as it is too big for my face I think. Second, I want to reduce my jaw size and I want to shift it little back and narrow it from the front view. If these are possible, please get back to me. I have attached some pictures of me for you to see my problems.

A: Based on your pictures, your nose is wide and broad from the front and has a low dorsal profile from the side. Your nose could be made to look smaller by a rhinoplasty which includes dorsal augmentation, nasal bone osteotomies, tip narrowing and nostril reduction. How much smaller it would appear would ultimately be controlled, particularly in the tip area, by the thickness of your nasal skin. From a jaw standpoint, I am a little perplexed that you want your jaw smaller when it already has a horizontal chin deficiency when view from the side. But in applying your request, it could be made slightly smaller by chin reduction by burring through a submental approach and jaw angle reduction by oblique osteotomies. I have attached some predictive imaging with those nose and jaw changes in mind.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I would like to achieve a radical but natural look. My main problem is that I was born with a bad bone structure. I want a bigger chin, jaw implants to make my face more square, high cheekbones (but natural i´d like to know if fat grafting would be an option), and I see some irregulaties in the form of my forehead and i like to look uniform. Is it possible to correct it with a natural and safe filler? I also think that some liposuction under my chin will help me to create a better facial profile. I have attached some pictures of myself for imaging these changes. Thank you so much.

A: In reviewing your pictures I see that the deficient bone structure is really isolated to the short lower jaw/chin and a forehead that slopes backward. I would agree that a chin augmentation using a square chin implant, and jaw angle implants that both widen and lower the angle would compensate nicely for the lower facial bone deficiency. The jawline improvement would be enhanced by submental and neck liposuction. From a cheek standpoint you can certainly use fat injections. Another fat alternative is to remove part of the buccal fat pads and use this as a ‘cheek implant’, serving the dual purpose of malar augmentation and some submalar contouring. Fat injections could also be used as a forehead filler as well for any irregularities. The attached imaging illustrates some of these potential facial reshaping changes.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My  3 year-old son fell and cut his lip in two places about 1 year ago. We did not get it stitched up and it healed on its own. I now find that he has 2 scars, obviously more noticeable when he smiles and the skin is taught. To describe the scar if you imagine placing a ruler into his mouth towards the edge of the mouth that would be the location and direction. They are on the bottom lip and go across the interface between lip and face and travel approx half way across the lip It is every parents worst nightmare to be responsible for their child’s suffering. I have spent a lot of time searching but found no helpful guidance until your site. Could you advise me as to what degree the scar will fade and become invisible, if we decided to pursue surgery of some form would this eradicate the visible scar and when would be the best time to operate i.e. soon or as a teenager for example?

A: Many lip lacerations fortunately occur along the vermilion lines or grooves which are the natural weak tissue planes in the lip mucosa. This is the equivalent to having a laceration along a natural skin crease anywhere else in the body. (e.g., horizontal lines in the forehead) This usually results in the best scar but also a perfect location to perform a linear scar revision if needed.

In looking at our child’s pictures, I can see that he has two such lip scars, the one closest to the corner of the mouth being wider and more noticeable. The one in the front of it is not as wide and hence less obvious. At one year after the injury, these scars are mature and will nto fade from what they appear today. Only excisional scar revisional can provide an opportunity for improvement in their appearance. The time to do such s scar revision is whenever you as parents or he decides that it is an appearance issue. The outcome from such a lip scar revision is not based on age. It can work well at any age.   

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a young girl who is scheduled to have a hysterectomy as part of my conversion to a male. I have seen some postoperative photos of this surgery after one year of healing, and there is a visible scar in most cases. Is it possible to remove this completely, and have you performed a surgery like this? Also, do you do a surgery which will accentuate the adam’s apple for a more male appearance? Thank you for giving me advice in advance.

A:  All hysterectomies result on a low horizontal scar. That scar is permanent and there is no such thing as secondary scar removal or complete eradication. Some hysterectomy scars look quite good on their own and others benefit by a subsequent scar revision. Either way, there will be a scar. It is just a question of how diminuitive in appearance it will be. But there is no procedure than can produce a complete scar removal.

In regards to tracheal or adam’s apple augmentation, I have actually performed such a procedure. It is done with a specially-shaped implant that sits on top and in from of the tracheal cartilage. It has a v-shaped upper edge to it to resemble the typical appearance of the shape of the adam’s apple. It appears to work best in necks that are thin without a lot of subcutaneous fat so the new outline of the tracheal can be appreciated as opposed to just a larger neck bump.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have uneven eye sockets, my right eye is higher than the left, just at the top, making it so my eyebrow is up higher on that side. I was wondering if there is any way to fix this? And what would have to be done if so? I would just like for my brow on that side to be moved down and out just a tiny bit.

A:  Brow bone asymmetry may be caused by differences in the position of the entire orbital box, but more commonly it is just differences in the brow bones themselves. The shape of the brow prominences or the underlying shape or pneumatization of the frontal sinuses may just be different. In a female, it is the actual brow bone shape or arch. This can be treated by brow bone reshaping by burring which can be done through an upper eyelid incision, provided that only the outer 2/3s of the brow bone needs to be changed. If the entire brow bone needs to be altered, then the best approach is through a scalp or coronal flap with turn down with complete brow bone access and preservation of the supraorbital and supratrochlear nerves. If the outer tail of the brow bone needs to be built up, this is best done by adding a small amount of hydroxyapatite cement. The combination of select burring and augmentation can change the shape or arch of the brow to a lower level with a more symmetric tail.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My right leg and buttock is smaller then my left due to scleroderma. Is there anything that can be done to improve their appearance and make them look more symmetric?

A: One of the main effects of scleroderma is the shrinking of all soft tissues in the skin dermatome that it involves. Why it causes significant subcutaneous fat atrophy and even skin thinning is not known but its effects are quite clear, particularly when its involvement is severe. The most effective treatment is to restore soft tissue volume through fat augmentation, most commonly through an injection technique. A fat injection approach allows large areas to be treated and substantial volumes to be added rather easily. Despite the uncertainty of how much fat will survive, it is very effective at the time of surgery. Repeat fat injections may be required for additional volumes or for touch-ups. The only limitation to using fat injections is whether one has enough fat to harvest. While not all scleroderma patients are thin, many are and this may preclude this treatment approach for them.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Thank you so very much for the information you have provided on blepharoplasty.  I found you through a Google search hoping to find some information on whether insurance will cover surgery in severe cases.  My hooding is genetic; insurance paid for my grandmothers surgery by the age of 50.  Now at almost 50, I look 20 years older all because of my hooding.  My huband doesn’t understand my desire to have surgery because he sees me as beautiful the way I am.  After reading your information and seeing the images, I can see that perhaps someday there is hope for me as well.  Thank your for your encouragement.

A: Hooding or extra skin that hangs on the upper eyelids is easily and often dramatically improved by the blepharoplasty procedure. Of all the anti-aging surgeries of the face, an upper blepharoplasty is one of the ‘simplest’ in terms of the results, short recovery and very low risk of any significant complications.

When it comes to medical coverage, things have changed dramatically since your grandmother’s time. Insurance rarely covers an upper blepharoplasty anymore and, even when they say they will, they often reverse their position when the procedure is done and the physician submits their charges. For this reason, many plastic surgeons no longer process a cosmetic or even a functional blepharoplasty as a medical procedure to an insurance company. It is done on a cosmetic fee basis only.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m currently seeking to get rid of a facial scar from trauma (long, hypotrophic, discolored, widened vertical cut on the cheek about 3cm long running perpendicular to the RSTL and a “v” shaped hypertrophic, discolored scar on the jaw line below) that’s over a year old now. Treatment thus far has been with silicone tape on and off. I’m not sure if w-plasty, z-plasty or laser resurfacing would be the best option? I’m not sure if you specialize in these types of cases. Any suggestions/advice/thoughts would be greatly appreciated. I was searching online and came across your website. Thank you.

A: There are two important features of your right vertically-oriented facial scars; they are both wide and they are actually parallel (not perpendicular) to the RSTL in that area of your face. Because the scars are wide, they are not improveable by any form of laser or skin resurfacing. Wide and depressed scars by definition need to excised and reclosed to be made more narrow. The only question is whether they should be closed in a straight vertical line or in an irregular pattern like a running w-plasty. The irregular scar revision pattern is aesthetically preferable for better camouflage.

As a final note, the concept of getting rid of a facial scar is not possible. The scar can be made less conspicuous but it can never be completely removed. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a breast lift with implants 6 weeks ago. I have 3 spots on my right breast where the stitches were sticking out a little bit. A week ago I pulled these stitches out pretty easily and they seemed ok. A couple days ago, they had gotten some puss in them and kind of looked like an open sore. So I put neosporin on them and covered with a band aid. Well, now one of the spots around my areola is split open. It seems to have gotten worse as far as the skin opening up. But mostly just some clear, slightly bloody fluid in it. The other  2 spots aren’t as bad. Just wondering if I should leave everything alone, keep using neosporin and covering with a bandaid, or do I need to actually put a butterfly bandaid on it? I have a stitch slightly sticking out on my left breast but I’m not going to touch it. Is this normal and what can I do to make them heal up and go away.

A: These are very typical spitting sutures that almost always occur anywhere from 3 weeks to several months after this type of surgery with long incisional lines in thin breast skin. They are the result of dissolveable sutures being used in the dermis of the skin. Rather than the body resorbing them , which takes up to a year after surgery, it rejects or spits them out because they are so close to the surface of the skin. They appear as red, fluid-filled, or pussy spots along the incision lines. They confuse and concern patients because they appear long after one thinks they are completely healed. (this does not really occur until at least 3 months after surgery) The best thing, and the only curative technique, is to get the knot of the suture out. In the office, I will either squeeze them like a pimple until the knot pops out or pick out the knot or suture end with a fine pickups. They are easily resolved problems that will have no negative influence on the final scar. These are temporary nuisance problems that are the final hurdle to complete healing.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I came upon your case study thru google –Case Study: Secondary Liposuction After Tummy Tuck Surgery.  I am 3 months post op for diastasis repair (to above button) and c-section scar revision . I did not have a full tummy tuck and no liposuction. The skin was pulled down at area of incision. I had a drain at upper abdomen below ribs for 5 days. There is persistent skin elevation there, like a bulge, delimiting the curvilinear path of the drain.  Dr says it’s fibrosis and to massage area.  I’ve done this daily and no change. I am now wondering if this is fat as you state in your case study.  I am, and was, very thin, especially upper abdomen. The area is soft to touch and no fluid (ultrasound was done).  It’s just so odd that it follows the path of the drain yet what you state in article makes a lot of sense. Any advice will be greatly appreciated as this is very disturbing for me to look at . Thanks!

A: If I understand what you had done…a muscle repair to a level above the umbilicus and some form of a mini-abdominoplasty. (c-section scar revision) The key in determining why this bulge exists has to do with the muscle repair and how the abdominal skin was elevated to do it. I suspect that the muscle repair was done through a ‘tunnel approach’ above the belly button given that a  mini-abdminoplasty incision was used. This means a tunnel of abdominal skin and fat was raised above the belly button to perform the muscle repair rather than a wide undermining of the upper abdominal skin flap. When the muscle was sewn together, this creates a midline bunching or bulge because the side tissues remained attached to the muscle. As the muscle is brought in by suturing, so is the side tissues pushing them together in middle. The fact that a drain was temporarily there is coincidental not causatory. (I have never seen a drain cause a raised skin tract) In essence, this is an ‘excess‘ of abdominal skin and fat that has created the bulge. The best treatment would be for some small cannula liposuction to reduce the underlying fat thickness and the overlying bulge.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a chin osteotomy several years ago but still feel my chin is short. Do you think another chin osteotomy can be done. I do not want an implant for more chin if I can avoid it. I have attached an x-ray so you can see what my chin looks like now.

A: Your x-ray shows that you had a sliding genioplasty fixed together with cerclage wires. What this means and shows is that the back cortex of the chin segment has been brought forward enough to be attached to the front cortex of the mandible. This means that the chin segment has been brought forward as far as it can go. This is an older genioplasty technique that dates back to a time when only wires were available for facial bone fixation. Since the wires can only attach to the cortices of the bone, the chin is brought forward whatever distance the back end of the chin and the front edge of the upper bone will allow as they match together. In today’s genioplasty bone fixation techniques, plates are used that move and hold the chin together at any desired distance horizontally as well as vertically.

In theory, you should not be able to get any more advancement out of the chin segment once a ‘maximal’ bony genioplasty has been performed. But there is one thing that is a bit unusual in the way your chin osteotomy was performed. The x-ray shows that it was cut at a very low horizontal level. This has left a lot of bone height between the lower end of your incisor teeth and the top edge of the bony cut. This suggests that a new osteotomy could be done above the old one, bringing more of the chin forward. This would create a ‘stairstep’ chin osteotomy approach which I have done at the same time but never as a staged procedure which is actually safer. So I do think a repeat chin osteotomy is possible to gain more chin projection. In stairstep chin osteotomies, I do recommend the use of hydroxyapatite granules or demineralized bone to fill in the steps at the end of the procedure for maximal bony healing.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am looking into working for the Medicis company and was wondering what you could tell me about their two aesthetic products, Restylane and Dysport.

A: All I can say about the company’s products is that Restylane is one of the most popular and well known names in injectable fillers The injectable filler market, however, is a crowded one with nearly a dozen other competitors. The name recognition in the market is not only because it is product that works well with very few complications but also because they were the first to enter the modern-day injectable filler era as a hyaluron-based material.  Dysport lags far behind Botox as an injectable facial expression reducer and probably has less than 10% of the U.S. market. They just don’t don’t have the advertising and name recognition that Botox does and as a late entry into the field never established any clinical advantages over Botox. For all intent and purposes, it works the same and has very similar patient costs. As a result, it has had a tough time finding widespread traction in the market place. One day, at best, it may become Pepsi compared to Coke…but it is far from even that now.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have had deformity to my face due to scleroderma. I am now in remission, but the damage is done. Tightening around the mouth and jowls make me appear to be so much older than I am. I see you have replied to several people who have the same disease. Have you helped people with scleroderma and what type of procedures do feel would help me? Thank you.

A: I have seen many variations of the effects of scleroderma on the face from a small area to an entire hemifacial region. In the facial areas of scleroderma involvement, the subcutaneous fat is lost, the overlying skin is thinner, and in severe cases even the underlying bone can be notched or atrophic. In the treatment of scleroderma, the fundamental principle is to add volume which almost always is fat. Because it is injectable and can be placed anywhere, liposuction-aspirated fat is a mainstay of treatment today. While it’s success (survival) is not always assured, and scleroderma defects are more challenging than normal tissues due to less vascularity, the versatility of fat injections makes it a preferred method in most cases. There are indications for other augmentation methods, such as dermal-fat grafts, allogeneic grafts, and onlay bone implants, but there use is more limited.

For involvement around the mouth and jowl area, the use of fat injections would be the best treatment choice. It may require more than one injection session to get the ideal result but adding volume will relieve that tight feeling and make it look rejuvenated as well.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in two facial procedures and I believe you are the right doctor to do them. I already have a chin implant in place but it is not ideal. I would like to have a sliding genioplasty to correct my underbite and have a slightly more balanced chin. Also I want buccal fat removal. I have a heavy lower face with full cheeks that I would like to look slightly more sculpted.

A: Based on the procedures you desire and your objectives, I would make the following comments and clarifications.

A sliding genioplasty is an alternative, and is sometimes better than a chin implant for more severe cases of chin deficiency. It will not, however, correct any occlusal problems as it is a chin procedure and not a total jaw advancement. The correction of one’s underbite requires a sagittal split ramus osteotomy jaw procedure (done in the back part of the lower jaw) which moves the tooth-bearing portion of the jaw bone. This requires pre- and post-surgical orthodontics. It fixes the bite as well as produces an amount of chin augmentation in millimeters that matches how far the lower teeth have moved to fit better to the upper teeth. Do not confuse a sliding genioplasty and a sagittal split mandibular osteotomy.

A buccal lipectomy removes fat and its associated fullness right under the cheek bone (submalar region) It does not create any slimming effect below this area. Most patients envision the entire cheek area done to and past the corner of the mouth when they refer to making their face less full. For this reason, many buccal lipectomies (done from a small incision inside the mouth) are combined with small cannula liposuction of the perioral mounds. (mound or fullness to the sides if the mouth or lower cheek region) This combination creates a better overall slimming effect.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had my earlobes reconstructed after several years of having them expanded by gauges. I was not completely happy with how they looked so the doctor has done a few revisions on them of which I am still not completely happy. Could you take a look at these pictures and tell me what you think. The left earlobe is a little red due to some recent laser resurfacing and I am ok with that side. It is the right side that does not look good to me. Is there any type of scar revision that would be further beneficial?

A: Thank you for sending your pictures. The left earlobe is in good shape and has a reasonably good connection to the face given there there is a deficiency of earlobe tissue. It does not appear to me that it would be improved by any form of further scar revision. (although I can’t really see the scar given its recent laser resurfacing but the connection to the face looks natural) The right earlobe shows some scar widening but it has less of a good connection to the face with some obvious tethering and pull down. This is undoubtably a reflection that it may have had even less earlobe tissue to start with than that on the left side. Can this be improved by scar revision? The fundamentral problem is that there is not enough earlobe tissue. So to get the tissue closed during  the prior procedure some facial tissue was ‘recruited’.  This is why the connection is more unnatural as facial skin has been pulled into the earlobe area and this is a completely different type of skin than that of the earlobe. Simply cutting out the scar and reclosing it will not improve the underlying problem. However, a z-plasty through the scar or even a v-y advancement type scar revision at the lower edge of the earlobe should be able to improve the look of the earlobe-face connection.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was born with cleft lip and palate and am now 28 years of age. I would like to have more symmetry of my profile, which could be improved by either a bigger upper lip or smaller lower lip. I just feel as though I could look better than I do now now.

A: Thank you for sending your pictures. I do believe you are correct in that there is room for further facial improvement and symmetry. You have all of the typical lip and nose manifestations that I have seen in just about every adult patient affected by a cleft. By your pictures, you had a unilateral cleft lip and palate on the right side. The one thing that you don’t want to do is to make the lower lip smaller. That is the normal lip and it is better to focus on making the upper lip (the abnormal one) larger and more aligned to match better to the lower lip. In paired facial structures, it is rarely a good idea in the pursuit of symmetry to try and make the normal half look like the abnormal half. While I don’t have a good frontal view of your face, I suspect that the upper lip needs to be taken apart along the scar lines and reassembled with emphasis on achieving a better vermilion roll and pout. (cleft lip revision) There may even be some benefit to adding some upper lip volume through a dermal-fat graft or allogeneic dermis at the same time. It would also be possible to do a complete septorhinoplasty during the same procedure to treat the nasal component of the cleft as well.

Dr. Barry Eppley

Indianapolis, Indiana