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The stomach area is the number one region that almost all women, and some men, would like to improve. Many have discovered, however, that improving that body area is not as easy as one would like. Many people work hard at it but eventually ‘hit the wall’, get frustrated and may even quit their diet and exercise routinue with no more changes are seen. But the fault may not be your own. Loose stomach skin and fatty bulges at the waistline from pregnancy or significant weight loss are not amenable to internal calorie or fat burning. This brings some to the conclusion that the only way to a more shapely torso is a surgical one.

Everyone knows that a tummy tuck is the removal of skin and fat with muscle tightening to get a flatter stomach and better waistline. While it is almost always a very satisfying procedure, and many patients say afterwards they wish they had done it sooner, it is major surgery and is not just a weekend recovery. When considering a tummy tuck, be aware of the following considerations.

There are two basic types of tummy tucks. If your excess skin and fat is mostly located below the belly button, you may do just fine with a mini tummy tuck. Because the skin and fat removal is done below the belly button, there is a shorter incision that can be placed very low and the belly button is not moved. There is also a slightly shorter recovery with emphasis on the word ‘slightly’. If  the loose skin and stretch marks are above the belly button, only a full tummy tuck will do. With that comes a longer scar, a bellybutton scar and a longer recovery.

I have seen recent treatment approaches, particularly online, that tout a ‘scar-free tummy tuck’. There is no such thing and this is just marketing spin to say they are offering stomach liposuction. That raises a question that many people would like to pursue…liposuction instead of a tummy tuck for their flabby and sagging stomachs. That has become a popular request, particularly since Smartlipo (laser liposuction) technology has become available. While it is true that Smartlipo does have some skin tightening ability, it is quantitatively different than what many people need. Smartlipo tightens skin as measured in millimeters, most people need stomach skin tightening as measured in centimeters. With this understanding, it is easy to see that liposuction is not a substitute for a tummy tuck.

Liposuction, however, is very often a part of a tummy tuck. But it isn’t necessarily used to make the tummy part looking better. It is used to shape the areas outside of where the effects of the tummy tuck occur…the outer waistline and back. (i.e. muffin tops) A tummy tuck alone is a 180 degree or frontal torso change. By adding waistline and back contouring with liposuction, the results becomes more of a 270 degree torso change.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a chin advancement by osteotomy last year but I am not happy with the result. My chin is still too short. I would like you to perform another chin osteotomy for further advancement. I still prefer the chin osteotomy because of its permanent result. I have attached some pictures for you to review. How much further do you think you can bring out my chin?

A: Thank you for sending your pictures. I can see by your side view photo that you still do not have optimal horizontal projection as you know. The key question in determining how much more horizontal advancement can be done with an osteotomy needs to be determined through a lateral cephalometric x-ray. The sliding genioplasty is based on the principle that as the lower chin bone segment moves forward, its back end or cortical segment maintains contact with the front edge or cortex of the attached upper chin segment. Some bone contact must remain between the two bone segments for it to survive and not resorb. It may be entirely possible that your chin was moved as far forward as the bone would permit. (unlikely) The real question in my mind is how much further can the chin bone be moved. That is where the value of the x-ray is so important. If it can only be moved 2 or 3mms further forward, an osteotomy approach may not be worth it. (I suspect it can be moved at least 5mms but I need to be sure) The x-ray will also show what type of bone fixation was used so there are no surprises during surgery. One would not want to run across some method of fixation that is very hard or impossible to fully remove and allow the bone to be mobilized. (e.g., lag screw fixation) 

The x-ray ultimately needed is a simple lateral cephalometric or facial film view. That can be gotten at any orthodontist and most oral surgery offices. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have had five previous rhinoplasties to get my nose built up the way I want it. At the last surgery, the doctor put in a silicone implant. While that make it look better, it is still inadequate. What I want to know is whether diced cartilage can be used to make my nose bigger as it is still too small. What are the side effects of diced cartilage in the nose?

A: If I understand your question correctly, you are asking whether a diced rib cartilage graft will make for a bigger nasal dorsal augmentation that an exiting silicone implant. The answer might be yes although a more accurate answer would come from knowing exactly what type and size implant is in your nose and what you looked like before it was placed.  In most cases, a rib cartilage graft offers more volume than an implant given the amount of rib cartilage that can be harvested. A diced rib cartilage graft can also be molded and shaped much better than an implant without the risks of warping or external deformity.  That is the value of dicing a solid rib, it because moldable like clay material when placed in a sheath of surgical or fascia. With any rib graft, there would also be no long-term risk of infection or displacement which is always a potential issue with a synthetic implant. Also understand that the silicone implant must be removed and replaced by a cartilage graft, you can not or should not add a cartilage graft over an indwelling synthetic nasal implant.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had saline breast implants of 375ccs filled to 425ccs last year. They were placed through incision in the lower breast crease and placed under the muscle. While I am happy with the size, I noticed about 6 months ago that I can feel a ridge approximately the size of a quarter to the right of my nipple on my right breast and it’s smooth in the center. What do you think this is? Is it a breast mass or lump or is it something on the implant?

A: What you are likely feeling is the valve of the implant. Saline breast implants are manufactured with an indwelling valve so they can be filled at the time of implantation. During surgery, the flat saline implant has a long tube attached to it at this valve. After the implant is positioned in the breast pocket, it is filled with saline through this long tube. Once filled to the desired volume, this tube is removed from the implant by detaching it from the valve by pulling on it. The valve has an attached cover which then snaps closed over the valve opening. This cover creates a very low profile bump or nipple on the implant’s surface. Usually the valve ends up on the underside of the implant by the way the implant is initially placed in the pocket. But it is possible that an implant can flip or be placed ‘valve up’. In breasts with very thin tissue, the valve may be able to be felt and it would be close to being around the nipple area. It poses no concerns other than being able to be felt.   

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I suffer from bruxism along time. I have broken teeth from the grinding and suffer from much jaw pain. In the last month I have gotten Botox injections for it. It provided some significant relief but it only lasted just over a month. Ccan you advice me if it is possible to get another botox treatment or maybe it is not my solution. Thanks for your helping.

A: Botox injections into the masseter muscles can be tremendously effective in the treatment of refractory and very painful bruxism. In my experience it lasts about as long as it does when used for cosmetic applications on the face…about 4 months. If it only worked for one month, there are several explanations. The first possibility is that simply not enough Botox (dose) was injected. The minimum effective dose is 25 units per side and 50 units per side is more ideal. Less than this dose will either have minimal effect or it will wear off very quickly. A second possibility is that the Botox used was ‘weak’, either being reconstituted days or weeks before injection, or being reconstituted with an overdilution of saline. Both can result in minimal or a very short duration of any benefit. Since you had some significant symptomatic improvement, I would repeat the Botox injections with these issues in mind. Unfortunately being the patient, the only one of these you have any control over is the actual dose.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in an onlay cranioplasty for back of my head. It is true that  hydroxyapatite would be very light and much more like my bone than PMMA materials. Is PMMA heavier than hydroxyapatite? Would I feel the heaviness in my back of my head if I choose PMMA for the surgery?  I know that PMMA would work to make my head round, What are the pros and cons of using PMMA? Are there any side effects of PMMA to my body? Thanks.

A: There is no real weight differences between PMMA and hydroxyapatite (HA), so that is not a concern. The differences between them is three fold. First, PMMA is a plastic material and it just as hard as bone if not actually harder. Secondly, it is a well tolerated and commonly used cranioplasty material. But it is not bone so, like a breast implant, it is well tolerated and accepted by the body but it never truly becomes part of the breast. It is simply walled off (encapsulated or surrounded by scar)  HA is a lot more like bone biologically since it is the inorganic mineral content of bone. Because it it more like bone, the body actually grows into it and integrates into it. It is not as strong as PMMA or bone and is more ‘brittle’ much like a ceramic. The risk of fracture is greater on hard impact although I have yet to see fracture of the material as ever having occurred or being a problem that I have heard of. Lastly, there are cost differences betwene the two in terms of volume used. PMMA has a flat rate cost that is substantially less than that of HA as it comes in 40 gram packets. HA is charged by volume in grams per 10 grams used. So the equivalent material cost for, let’s say 40 grams of material, is about 4X the cost over PMMA. That is a several thousand dollar cost difference between the use of the two materials.

As you can see, the choice between PMMA and HA offers certain advantages and disadvantages for each material.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am committed to undergoing chin augmentation with an implant but I am a little anxious. I just have a few questions. What do you see as the risks involved with a chin implant procedure, if any? Do your predictive photos mirror actual results? Thanks for taking the time to answer my nervous questions.

A:  In answer to your presurgical jitters:

1) There are always some risks with any surgery and chin implant augmentation is no exception. Fortunately those risks with chin implants are few and very low. The ones that I have observed are infection (1% to 2%) and asymmetry of the wings of the implant. (2% to 3%) Both are very correctable, albeit with a revisional surgery. There is always the risk of too little or too much chin augmentation with an improper size implant but that is not a very common problem in my experience.

2) Computer imaging is an estimate and not an exact predictor of the final outcome from any plastic surgery procedure. Its predictive ability varies based on the type of procedure being performed. Of all the facial cosmetic procedures, chin augmentation is one of the more accurate in terms of predicting the outcome as it is a profile or silhouette facial feature.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  I am interested in getting implants for my deep tear troughs. I have a few questions about them. What is the recovery time? Will there be any bruising or swelling? What are the aftercare instructions? ( i.e., how long are bandages worn, how long do I wear sunglasses?) Can I apply Latisse on my eyes? What kind of anesthesia is used and what are the side effects associated with this? Is there a possibility that this will affect my vision? Are there any negative outcomes or side effects of tear trough implants?

A: There will be swelling and maybe some bruising for a few weeks. Recovery is all about how you look not how you feel. There is no aftercare or anything that you need to do other than to ice the eye area for the first night after surgery. There are no bandages. You may continue to apply Latisse to your upper eyelid lashes as normal if you desire. General anesthesia is used as the lower eyelids and orbital bones are impossible for anyone to stay still except if they are asleep. This surgery will have no effect on your vision. The biggest risk of tear trough implants is getting the right size and position on the bone so you do not feel them, see them and they do not move after surgery.  Implants can be used for tear troughs but so can fat injections which is another good option. Fat injections, like tear trough implants, is an operation that is done under general anesthesia as well.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a chin implant done approximately 10 years ago. I have only mildly been satisfied with the results. I believe the implant was put too far down on my chin bone to lengthen it vertically. Shortly after surgery, the implant slipped off on one side making my chin appear uneven. But it is from the profile view that I dislike my chin the most. My chin and neck are not separated by much horizontal distance. I think I may be a candidate for the vertical lengthening jaw implant that is done with the CT scan. My question is..is there a way to do a consult visit without me physically coming to Indiana? Or is an office visit required to make a determination if I am a candidate for this procedure?

A:  When considering lengthening the anterior lower face vertically, the decision is between a chin osteotomy or a custom chin implant. For the sake of this answer, I will assume that the implant choice is the better option for you. Since there are no off-the-shelf chin implants that have any significant vertical component to it, a custom implant will need to be fabricated. This is a process that requires the following steps. First, a 3-D CT scan must be obtained. This can be gotten at most CT scanning facilities in your geographic location. That scan is then sent to a model manufacturer which creates an actual mandibular (jaw) model that is an exact replica of your own lower jaw. I then take this model and hand-carve a chin implant out of a special clay material that matches your exact aesthetic needs. That custom chin implant is then sent to a manufacturer who makes and sterilizes a silicone implant from the clay mock-up. All of this can be done without you ever leaving your home. Your candidacy for any custom facial implant is determined from afar by phone, photographic and Skype video consultations. One only has to appear for the actual surgery.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in the combination of a browlift and a hairline advancement. My brows are now sagging too low and I have always had a high forehead. With a browlift alone I fear that the front part of my hairline will go back further with some of the browlift methods. I visited a plastic surgeon and he told me that both could not be done at the same time. But I have also read in your articles that it can be done simultaneously. I am confused. If they can be done at the same time, how does it work? And why would this plastic surgeon say it can’t be done?

A: Just like a browlift loosens and lifts the forehead tissues upward, the scalp can be loosened and moved forward. They key to these procedures is that when done independently, they rely on having a fixed point onto which the loosened tissues are fixed. For the browlift, it is the frontal hairline, For a frontal hairline advancement, it is the forehead tissues as the fixed point. When doing a hairline (pretrichial) browlift and frontal hairline advancement at the same time, which can easily and most conveniently be done together, the key is to create a point onto which both can be used for stabilization. There are different ways to achieve the fixation of the two flaps but I prefer to use outer cranial table drill holes with galeal suture fixation. This not only provides good fixation but keeps the tension off of the suture line so the hairline scar does not widen and excessively show. For the right patient, this combination can produce excellent results and achieve a more total forehead rejuvenation. I can understand why some plastic surgeons would not combine these two procedures as their movements seem to be working against each other. But that is a matter of preference and experience, not an issue of technical feasibility.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am interested in the corner of the mouth surgery to lift up my downturned and sad looking mouth. What are the risks, recovery time, and success rate of this procedure? Is the procedure an office visit?  What number of follow up procedures are required?

A: The corner of the mouth (COM) lift is an office procedure done under local anesthesia. Dissolveable sutures are used so no return visit is necessary for out of town patients. I would say there is really any true recovery, just some redness in the corners of the mouth for several weeks and time to let the scars fade. There are no dietary or oral hygiene restrictions afterward. It is always a successful procedure as the corners are always leveled out rather than downturned. The key is not to overdo it so the corners are turned up or give someone a ‘joker’s smile’. There will be a very fine line scar that emanates out from the corner of the mouth about 5 to 7mms, but it is very small. Sometimes there may be a need or it is of benefit to do some other minor procedures around the corners of the mouth. (e.g., fillers to marionette lines) This is why it is a good idea for me to see a picture of your mouth in a non-smiling position to determine if this is the corner of the mouth lift procedure for you.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,I am interested in liposuction of the perioral mounds. The effect I am going for is what happens when I suck in my cheeks. Would the procedure produce such an effect? However, I have read that it is difficult to do liposuction in this area and that scars and asymmetric results are common. Could you also tell me more about the risks? Thank you!

A: The perioral mounds are small fat collections that lie outside of the corner of the mouth and on the lower end of the cheek area. They are not part of the buccal fat pads, as is commonly thought, but is a less defined area of subcutaneous fat between the skin and the buccinator muscle. A prominent perioral mound can be reduced by small cannula liposuction. The entrance site is just inside the corner of the mouth in the mucosa so there are not resultant scars. Generally 2 to 3 cc of fat can be aspirated from each side. I have not seen that asymmetry or skin irregularities are a problem afterwards. The only real risk of the surgery is that the effect it creates is not significant enough. While I have always seen a reduction of the perioral mounds with liposuction, it will not create the look of sucking in your cheeks. That look results because the soft tissues of the cheek are like a trampoline being suspended between the bony supports of the cheek and jawline. They can easily be pulled inward with suction but no amount of facial fat removal can create that same effect. Perioral mound liposuction is best done as part of buccal fat pad removal to create an overall better facial thinning effect.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in Botox for hand hyperhydrosis. What is your fee for both hands? How much time is involved? Is a nerve block involved due to pain issues?

A: Botox for excessive sweating of the hands, like everywhere else it is used, is done based on the number of units injected. While the effective dose differs for each individual, the minimum dose for each hand should start at 25 units. (50 units for both hands)  If one has had Botox before, they they will have a baseline for the number of units that are most effective. If they have never had it before, then this is a good starting place although maximal effectiveness may require more units. The goal with Botox, like all drugs, is to determine the least dose that is most effective. The cost of Botox is done by the unit. Each practitioner may have slightly different unit pricings so you have to inquire at each specific office for their Botox charges. No doubt the palmar surface of the hand is a very sensitive area to inject. I have managed the injections multiple ways including patients ‘taking it straight’, topical numbing creams and nerve blocks done at the wrist level for the radial, median and ulnar nerves. Bilateral wrist blocks are difficult on a patient when it comes to walking out and expecting to drive home. Treatment time for the Botox injections can vary from 15 to 45 minutes based on what type of anesthesia is done.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, do saline implants only last for 5 years? And is it true that you have to be 22 to get silicone breast implants? Im really interested in silicone implants because I’ve heard they last longer but I just recently heard that you have to be 22 to get them.

A: The longevity of breast implants is both unknown and variable. No one can predict with any accuracy how long any breast implant will last. When speaking of the longevity of breast implants one is referring to when it will fail. Failure is defined as when the bag or shell that contains the filler (saline or silicone gel) gets a hole or tear in it. When that happens with saline implants, the detection of failure is immediate as the implant develops an obvious deflation with visible loss of breast size. (i.e., flat tire) When failure occurs in silicone implants, the detection is not immediate and may not be known for a long time as deflation does not occur. This is because silicone gel material can not be absorbed and much of the material may stay in the shell because of its thicker non-liquid material properties. This is why failure in silicone gel breast implants is known as silent rupture. Detection of silicone implant failure may be only found on a mammogram or can be suspected if one breast develops some discomfort or hardening. These differences in how the two types of breast implants fail is why silicone breast implants ‘last longer’ than saline implants.

According to the FDA regulations imposed on breast implant manufacturers (based on the clinical studies for them which did not include patients 21 years or younger), the recommended guidelines for use of silicone breast implants is for patients 22 years or older. What any specific plastic surgeon will do in terms of implantation is between the doctor and the patient.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to get my ears reshaped. I think they are too big at the earlobes and they stick out a bit. My earlobes seem too big for a younger male and I have always been self-conscious about how my ears stick out. Can my ears be pinned back and the earlobes reduced in size at the same surgery? I haved attached some pictures of me from the front so you can see what I mean. It is hard to look at anything else but my ears in these pictures!

A: Thank you for sending your pictures. I can see your concerns about earlobe reduction and a little bit of ear pinning. The combination of the two would solve those concerns and make your ears blend in naturally along the side of your head. Ears should blend into the side of the face and not be a dominant facial feature. The ear can be put back a little further by adjustment of the concha through mastoid sutures from an incision on the backside on the backside of the ear. The earlobe can be reduced by half its current size. The only question there is scar location. There are three different methods of earlobe reduction with changing locations of the scar. Regardless of how earlobe reduction is done, it can be combined with ear pinning (otoplasty) at the same time and are fairly easy to undergo. There is really no significant recovery other than some slight external ear swelling.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 37 years old and I was born with a cleft lip and palate.  It has been repaired when I was a baby and child and I have had two operations, none past the age of three. I am wondering if anything further can be done to improve my appearance.  I understand that due to the deformity, repair options are limited, as well as my age being a factor, causing healing times to be greater and results limiting.  If possible I’d like to send pictures for a consult.

A: It is important to understand that age is not a factor in making healing times longer or in limiting the results from revisional facial cleft surgery. There is just as much that can be done for a 37 year-old as there is for a 7 year-old. The limiting factors, like in all cleft patients, is the magnitude of the original deformity and the quality and scarring of the lip, nasal, alveolar and palatal tissues. Since you have had but two surgeries that would suggest to me that there is room for improvement without even seeing your pictures yet. The influence of growth on the face makes for a lot of distorting changes around the orofacial cleft site. Even in the best of primary repairs as an infant, revisional surgery is almost always beneficial and desired in the teen years. It is very likely that there is room for visible improvement in the appearance of your external nose and lip through septorhinoplasty and a cleft lip revision.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley I am 34 years old and in the past several years I have noticed quite a lot of sagging in my mid and lower face along with  volume loss. Cheeks have gravitated downward, neck sagging and my eyes have hollows under and around them. I see much of the same in my mother.  I have researched many plastic surgeons this past year and have heard only great things about you online! I am most concerned with sagging in my lower face, neck and around cheeks. I also would maybe like to add some volume to lips especially from a profile view. And one more thing, my ear lobes tore several years ago from scabbing due to hypersensitivity to earrings so I would like to have ear lobes repaired as well.

A:  I have taken a careful look at the pictures you have sent me. As you know you are fairly young for any major procedures and you really don’t need anything too drastic. But I can see your concerns about having an overall tired appearance. There are several things I might consider for some structural improvement. These would be the following: small cheek implants to lift the midface and fill out some hollowing, small chin implant for more chin projection and to improve the jawline, and liposuction of the jowl and neck for a little contouring and skin tightening. I think if you can just ‘slenderize’ your face a bit and give it some more structure or angularity, it will look more youthful and rested. You most certainly don’t need anything done around your eye area.

As you know, you already have excellent lips with good vermilion show so increasing their size is a matter of adding some more volume. This could be done with fat injections as you can take advantage of a surgical opportunity since this is not a traditional office procedure. Obviously the earlobe repair can be done at the same time with any of the aforementioned procedures.

Dr. Barry Eppley

Indianapolis, Indiana

One’s face is revealing of many things, sometimes good and sometimes not so good. Time, genetics, sun, illnesses, smoking, and stress or good fortune all leave their marks on one’s face. Right or wrong, people make instant judgments about one another’s age, health, mood, personality and character based on their facial features. But many things can be gleaned from a face than just a smile or a frown.

Certain medical conditions may be able to be diagnosed just from one’s face. Hypothyroidism can result in hair loss which can be seen in thinning or absent hairs of the eyebrows. A round or clsssic moon-shaped face develops when steroids are taken over a long time or high doses are given for shorter time periods. Small strokes can be detected from changes in facial expressions or laugh lines. Sleepy eyes may be a sign of a neuromuscular disorder known as myasthenia gravis which makes the eyelids droop. The ears can be a tipoff to gout as they can develop bumps under the skin which are crystalline depositions. Pale lips and eyelids can be a sign of anemia. A whitish ring at the colored portion of the eye (iris) may be a sign of high cholesterol.

One’s stated age versus their appearance can alsobe a sign of good or ill health. A youthful look is usually a sign of good health as illnesses tend to make people look older. Even if one look older than their stated age and has no medical illnesses it may also reflect various psychological disorders.

Some research studies show that certain facial anomalies, such as ears with attached lobes, hair whorls, and widely spaced eyes, are related to mental disorders, such as schizophrenia, and to physical characters, such as clumsiness. There is some evidence that structural asymmetries of the face predict hyperactivity and schizophrenia and susceptibility to infectious diseases.

The face is also a well known reflection  of one’s age and occurs in a classic triad. First, wrinkles, age spots and tiny spider veins appear which are worsened by long-term sun exposure and smoking. Secondly, a loss of volume appears which is the shrinking of the fat layers in the face, most commonly in the cheeks. This will create a gaunt or deflated look and cause bags under the eyes to stick out more than before. Lastly, certain parts of the face simply drop, the jowls, neck and cheeks sag downward due to stretched out skin and loose ligaments.

But one’s skin color has a huge impact on facial aging. The more pigment you have in your skin, the thicker it is. Thicker skin has more elastic fibers which are more resistant to aging changes. The increased pigment also blocks the sun better. In addition, darker skin has more oil glands so it remains more supple over a lifetime and less prone to wrinkling. These are the advantages that Blacks, Asians, Hispanics and people of Mediterrranean descent have over most Caucasians.

The face is truly a trove of information about our health, age and demeanor. Between good medical care and plastic surgery, one can make their face appear healthy and more youthful.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to know how much of a cup size is lost after having a breast lift. I am currently a 42 DDD and my breasts really hang down after a 75 lb weight loss. I want them lifted but I definitely don’t want to be any smaller than a D or DD cup. I wonder if having implants would make up for any loss of size after a lift. I really don’t want to get implants but I don’t want to be any smaller either. What are your recommendations?

A: In a breast lift procedure, only skin is removed to create the lift and breast reshaping effect. So a loss of cup size should not really occur since no breast tissue is removed. But there is often a perception that the breast can seem smaller because the conical reshaping of the breast results in less overall surface area. What most women expect from a breast lift is to have not only an uplifted breast but one with more upper pole fullness as well. While this most certainly occurs early after a breast lift, the settling of the breast after surgery will cause some loss of upper pole fullness. That is the role that a breast implant plays in many breast lift surgeries, to get and maintain upper pole fullness. Given the size of your existing breasts and the amount of lifting that will be required, it is understandable why you would be on the fence about the need for implants in your lift. When in doubt, do the breast lift without the implants first. Let the six month results determine whether implants would really be beneficial.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like my nose to be in better balance to my face. I feel that my nose is too long for my face. Also I think that the tip and the nostrils needs to be narrowed. Can a rhinoplasty reasonably achieve these goals for my nose. I have attached some pictures for you to image so I can see what can possibly be done.

A: Thank you for sending your pictures. I have done some predictive computer imaging based on a rhinoplasty that shortens tip projection, does some slight upward tip rotation, tip narrowing, spreader grafts to the middle vault and narrowing of the width of the nostrils. In looking at your profile there is a mismatch between the projection of your nose and a horizontal maxillo-mandibular deficiency. Both your jaws are recessed which is also reflected in your thin upper and lower lips. This horizontal jaw projection deficiency makes the nose look longer than it really is. It is a bit long but not as long as it may seem which is confirmed by actual measurements of the nose. Only so much de-projection (shortening) of the nose can be achieved so combining a rhinoplasty with some increased jaw projection would be aesthetically helpful. I have added a chin augmentation to the rhinoplasty prediction with that concept in mind.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a small bump on my nose from when i was kicked in the nose when i was younger. I want a more curved shape nose like I used to have. Also I think my nose looks too big towards the end. Here are some pictures for you to see. What type of rhinoplasty do I need?

A: Your nose shows a great disproportion between the tip and the bridge. The tip of your nose is incredibly wide and thick. The lower alar cartilages can be seen to be very large and your nasal skin is quite thick. This is in contrast to the bridge or upper area of your nose which is much smaller in size and lower in height, albeit wide at the base. While there may be a small bump on the bridge of your nose, the key in your rhinoplasty approach is to not take down the bump. Rather in an effort to create better balance on your nose, the upper bridge needs to be built up while the tip needs to be narrowed. This will make for a more pleasing nasal appearance by creating better proportions between the upper and lower nose. This is of particular importance in your nose given your thick nasal skin which will limit how much reduction can be done in the tip of your nose. By building up the bridge this will help improve the appearance of the lower nose narrowing. I have attached some images which shows how these rhinoplasty changes would look.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, In early June I had Botox injections for migraines through my neurologist. I’ve suffered with migraines for over 20 years and tried just about everything protocol.  The neurologist did a lot of injections in the forehead and temples and then a bunch in the back of my head/hair and at the base of my skull and a few along my shoulders. I was migraine free for a week for the first time in I don’t know how long.  After a week, my neck became progressively weaker until it was like a bowling ball on my shoulders and I could no longer hold it up for simple things like looking down, brushing teeth, vacuuming, simple picking up the house, etc. It’s been almost two months now and while it’s not as bad as it was a month ago, my neck is not recovered to its former strength, and gets tired very easily. My neurologist has stated that we can do a lower strength and a different pattern in the future.  I am leery of ever doing this again based on my reaction and unsure.  Have you ever heard of this reaction? 

A:  I think you are merely experiencing the effects of Botox in the neck muscles which has resulted in some temporary muscle weakness. This is not a reaction but an expected response based on the muscles that were injected. In the treatment of migraines with Botox, the key is to inject the potential trigger points that are where the sensory nerves come through the muscle. In the back of the head, this is a very specific location that relates to the path of the greater occipital nerve. This is at the base of the occipital skull and can be precisely palpated. While this does involve injecting into the upper end of the splenius capitus muscles, this will not cause any neck muscle weakness. It sounds like neck muscle was injected below this point which is not helpful in determining the location of a trigger point and can cause some neck muscle weakness, particularly if a high number of units was injected. The good thing is that in another month or so your neck muscle problem will be self-solving as the Botox wears off. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was born with a face that to me looks a little crooked.  It seems my jaw line is shorter on one side and it looks like my face is bent in one direction. Would you be able to look at the pictures I am enclosing and please tell me what you think.  My face is definitely not even and my chin is crooked. I think it is too big, but is it also receded?  I am so self conscious that I hide behind my hair and makeup.  Thank you so very much for your time and please, any advice and recommendations would be greatly appreciated!

A:  I have taken a look at your pictures and your concerns. I think there is no question that you have facial asymmetry that is almost completely due to the shape of the lower jaw. The differences in the jaw length has resulted in frontal chin asymmetry with the midportion of the chin being deviated to your right side. This can be corrected (straightened) through a chin osteotomy, sliding it over to the left until its midportion is in alignment with that of your nose and upper and lower lips. This may also require some vertical chin adjustment with a reduction of the left side or an opening lengthening on the right side, depending upon which aesthetically looks better. Your side view shows a mild amount of recession which, given that an osteotomy would be done, I would take the opportunity to give more horizontal projection to the chin as well. I have attached some predictive imaging of the potential outcome with this sliding chin osteotomy procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a long pointy head that is completely abnormal. It has looked this way since I was born. I have managed to get along in life and be a very productive person at 30 years of age. But I always wear a hat and never let anyone see me without it. My other brothers have completely normal head shapes. I would do anything to have a more normal head shape and live a more normal life. I know you have a lot of experience in reshaping of skulls, so I am very interested in your recommendations. I have attached pictures of me with a closely cropped haircut. Please help me.

A:  Thank you for sending all of your pictures and describing your situation. I have great empathy for your head concerns. It appears you have a rather classic case of undiagnosed and untreated sagittal craniosynotosis. The AP cranial dimension is long, the transverse cranial dimension is narrow and there is frontal bossing which is wider than the occiput. This condition is rare to see in adults these days since almost all of them are treated as infants with the advent of widespread craniofacial surgery since the 1980s.  

First, let me start off by saying what can’t be done. The traditional approach to sagittal craniosynostosis is complete cranial bone remodeling. But that can only be done in infants where the bone is very thin and pliable and one can work with the molding influence of the growing brain. As an adult, such a procedure can not be done as the bone is too thick and not pliable, the extent of surgery and the bleeding would have a high risk of significant complications, and there is not growth of the brain to fill the underlying dead space that is created.

While the bone can not be removed and reshaped, a camouflage skull reshaping approach can be done. This would consist of some burring reduction of the sagittal ridge and the frontal bossing and augmentation of the parasagittal skull and temporal regions. The combination of these reduction and augmentation procedures, while not making any shortening in the cranial AP dimension can give an improved appearance to the skull shape. I have attached some imaging which I think is achieveable. 

To embark on this cranioplasty approach, good treatment planning is needed. This would consist of getting a 3-D craniofacial CT scan and then have an exact skull model made from it. It is off of this patient-specific skull model that the exact dimensional changes can be planned and the volume and shape of the needed implants fabricated.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dear Dr. Eppley, I would like to replace my existing saline implants which are now 10 years old with new ones. The original size was 800cc shells filled to 960cc which I was told was the maximum fill at that time. My annual mammogram is coming up and I worry about my decade old implants failing under the pressure (yes I know it is a remote possibility, but I still am concerned). In doing a replacement, I want much larger implants. It would have to be done with either custom made implants or largely overfilling the largest saline breast implants that are made. In doing a replacement I would want a lot more volume than 960cc with as much as a 200% fill to give me more upper pole fullness and more projection. In effect a “mastopexyless” breast lift (had one masto, don’t want to do it again). There are several surgeons in US who are doing very large fills of 800cc saline shells at a patient request. Fills of 1400cc to as high as 2000cc are documented in various internet implant breast forums.

A:  While available at one time, custom breast implanrs are no longer made by any US manufacturer. Neither breast implant manufacturer will custom make any implant size at this time. The largest off-the-shelf saline implant are still 800cc of which the manufacturer recommended maximum fill is 960cc. (which you obviously know) The 800cc imlants only come in moderate plus projection. (Mentor) What any plastic surgeon is willing to fill to beyond the recommended fill is between the surgeon and the patient. Beyond the manufacturer’s recommended maximum fill, the patient risks losing the lifetime implant replacement warranty from the manufacturer. Nobody knows for sure how much overinflation affects the potential for deflation or rupture, although it may be fair to say that it has a negative influence. As the implant becomes highly overinflated it also becomes quite hard and unnatural feeling. These are all issues that a patient needs to consider when requesting and/or receiving high volume overfills.

I have heard rumors that the manufacturers have requested from the FDA approval to manudfacture and sell larger breast implant sizes than that which is currently available. (I can not verify that this is true) So larger implants with a base size over 1000ccs may be available in the future.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dear Dr. Eppley, I have a question for you concerning the removal of some subtle scar tissue. The scar is above my lip and was caused from a small burn from a do it yourself type laser hair remover. The initial wound was not very deep and I didn’t think it would even cause a scar, but it has in fact left my skin a bit irregular in a very noticeable place on my face. I was curious if the irregular area could simply be excised, since the effected tissue is not very deep, and then the new wound could be healed with ACell to restore normalcy to the skin in the area. Would that be possible?

A: Burns create unique scars that can be very difficult to treat. Rather than a more discrete amount of scar in a linear pattern, most burn scars have a larger surface area geometry. This often makes it very difficult to simply excise them because they are too wide. With burn scar excision, the surrounding tissues will often become distorted with the closure. There are exceptions to the burn scar problem which can do well with excision but they are in the minority.

I suspect when you are talking about excision combined with Acell you are referring to a topical approach. Rather than a full-thickness excision, you probably mean just remove the surface burned tissue and cover it with Acell. Your premise is that it would heal completely normal in appearance. Unfortunately, this is not what would happen and the result would not be an improvement and likely will look even worse. I believe you are assigning healing properties to Acell that are beyond what it can really do.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve read the section with patient questions about lipomas and I have a similar case. I had surgery 3 years ago that removed the biggest lipomas from my body but I still have multiple smaller ones all over my arms, upper legs and back. Maybe 20 on my arms, 20 to 30 on my legs and 3 to 4 on my back ( half of them are the size of a walnut). I’ve read that a combination of injections and laser treatment would be the best approach in my case . I completely understand that it would be just an estimate (and multiple treatments might be required) but I would like to know at least what would be the general range. I would appreciate your help in this matter.

A:  While lipomas can be treated effectively by lipodissolve injection therapy and Smartlipo laser probe ablation, this approach is best used for a limited number of lipomas. This is because each lipoma so injected is associated with a significant inflammatory response (and pain) and will definitely require multiple treatments. When the lipomas number more than a handful, one is better off having an outpatient procedure where they are completely excised as this is simply more efficient and cost-effective….not to mention has less discomfort and an easier recovery compared to a  multi-stage non-excisional approach. I would only consider an injection approach in a limited number of them to bother determine their response and a patient’s tolerance for it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to get my upper arms reshaped. I am most interested in Smartlipo and having it done under local anesthesia.

A: The first question is whether any form of liposuction is appropriate  for the upper arms. I ask this because I have seen many patients, particularly those interested in Smartlipo, who believe that the procedure can do more than what is possible. Most of these patients have more than fat with some amount of skin excess. While Smartlipo has some minimal skin tightening capability, what most patients need is far in excess of minimal. Smartlipo tightens skin in terms of millimeters, what most patients need is in the centimeters range. Millimeters signifies that just a small pinch of skin can be tightened. Many patients that want upper arm reshaping need inches of skin tightened/removed. What shape your upper arms have I obviously don’t know. So this would be my first concern. You may feel free to send me some pictures of your arms and I can tell whether Smartlipo liposuction is the appropriate procedure for your upper arm reshaping.

Secondly, while upper arm liposuction can be done under local anesthesia, I do not recommend it. This is because of two important reasons, results and cost. Arm liposuction done under local anesthesia will not get the same results as that done when the patient is asleep. It is a simple matter of you can only remove what the patient deems is comfortable. Because any procedure done under local anesthesia takes longer to do, the cost of doing it rises accordingly. Patients often mistakenly assume that a procedure done under local anesthesia will create the same result and cost the same as that done under an anesthetic…this is a wrong assumption.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dear Dr. Eppley, I am not sure if I need a lift or lipo on the love handles. That decision I would leave up to the expert. But I would love to have breasts that look like actual breasts and not deflated socks. I have never had breasts. Growing up there was just a small protrusion of breast itself but was mostly at the nipple.(hard to explain) My stomach has stretched out due to 4 pregnancies, 3 in quick sucession. I run sprints, lift weights, and eat very healthy, I have attached pictures for you to see what I am left with.

A: Thank you for sending your pictures. In reviewing them you can see many of the typical changes that have occured with multiple pregnancies and having very small breasts to start with. The little breast tissue you have has stretched out and the nipple now hangs down over your existing high lower breast fold. You will need both breast implants  and a small vertical breast lift to get a much improved breast size and shape. The vertical breast lift is a key component of the procedure as an implant alone will provide volume but will not get the nipple up and centered on the newly enlarged breast mound. This results in fine line scars around the nipples and then down vertically towards the lower breast fold. Whether one wants saline or silicone gel implants is a matter for further discussion of their benefits and liabilities. From abdominal stand point, I would recommend a mini-abdominoplasty with flank liposuction. While there are stretch mark across a lot of your trunk areas, there does not appear to be enough of loose abdominal skin to justify a full abdominoplasty procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dear Dr. Eppley, do you perform scarless breast reduction? If so how is it done and how small and what shape will my breasts be afterwards?

A: There is no such thing as true scarless breast reduction. The only ‘scarless’ method of breast reduction is liposuction. This can remove some volume of breast tissue but it can not improve any shape features of the breast. It can not lift or tighten skin, reduce the size of the areola, elevate the position of the nipple-areolar complex, nor give the breast a rounder or even a more conical shape. For most breast reduction patients, these changes are just as important as the amount of breast tissue removed. Liposuction of the breast, in fact, can even make the shape and the sagging of the breast worse. As you reduce the breast volume, but do not change the skin that contains it, the breast will sag worse. At the least, the amount of breast sagging will certainly not improve.

There is a very limited role for liposuction or scarless breast reduction for a few select patients. But they have to have large breasts which sit adequately high on the chest wall, have a good nipple position and fairly tight breast skin. Most women with large breasts that want a reduction do not have these breast shape features. This is why the traditional method of breast reduction with scars is needed.

Dr. Barry Eppley

Indianapolis, Indiana