Your Questions
Your Questions
Q : I am trying to research plastic surgery on nipples but am having trouble. What I am looking for is a remedy for droopy nipples. I am 49 and breast fed my son for 3 and 1/2 years when I was about 30. As he fell asleep he tended to grit his teeth. Because of this and some some loss of size of my breasts there seems to be extra skin around the nipple area and my nipples lay down rather than remain perky (unless it is quite cold). Also, if I raise my arms, they can look like the skin around an elephants ankle. Is there a surgery for this. If so, what is it called. I would like to research it before jumping into things.
A: The extra skin around your nipples is the result of pregnancy and breast feeding. (the gritting of your baby’s teeth had nothing to do with it) Both conditions result is loose breast skin which is most noticeable around the center area of the breast mound where the nipple happens to be located. Depending upon the amount of loose breast skin, there are a variety of breast lift or breast tightening procedures to consider.
If the breast is not too saggy (the nipple still lies at or above the lower breast skin), a periareolar mastopexy may be all that is needed. Sometimes called a ‘donut mastopexy’, a ring of skin taken from around the nipple and the breast skin circumferentially tightened back up against the nipple. This results in a fine line scar around the outside of the nipple.
If the breast is very saggy (nipple lies below the lower breast skin), then breast lifting techniques are needed to remove and tighten skin that will leave scars that run down from the nipple and into the lower breast crease.
Dr. Barry Eppley
Indianapolis, Indiana
Q : I had a sliding genioplasty surgery with bone graft on my jaw angle on the 17th of august, before the surgery when i smile my chin tissue protudes downward (chin ptosis) the oral maxilofacila surgeon told me he can fix it during the sliding genioplasty surgery, its been 3 weeks now, and when i smile my chin tissue still protudes downward, i told him about it and he said my mental labial fold has not heal completely thats why it protrudes downward, i think is cos he didnt move my chin forward enough. i wan to send photo to you so you can see what i mean, i really want to get this fixed asap.
A: Generally, a sliding genioplasty will pick up loose chin tissues as it comes forward. Thus correcting a pre-existing chin ptosis. It is not so much that the bone is advanced, but the mentalis muscle and the chin skin are pulled back over a longer bone surface. This is essentially the reverse of what happens when the bony chin is set back (not a good idea) as there is too much chin soft tissue that has less bone surface to be suspended and it will then droop.
Why your chin ptosis did not at least get some correction with the advanced bony chin is not clear. The one possibility is that the mentalis muscle was not put back or resuspended as well as it could be, thus negating the effects of better bony support. This is easily corrected at this early point after surgery as little actual tissue healing has occurred. More time and having the swelling go down further will not likely show an improvement. I would recommend re-entry and better muscle suspension.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have a very strong square-shaped masculine jawline. I am not dissatisfied with my chin, but I would like to reduce the sides of my jawline, to make my face appear more oval and feminine. Does Dr Eppley do this kind of surgery? I have heard of it referred to as jaw shaving, and it seems to be popular among Asian women. I am Caucasian and I would like to reduce my jawline, not my chin. My jawline makes me look too masculine and I don’t like it.
A: One of the main reasons a jawline can look too square is at the jaw angle prominences. How much the jaw angles flare and how square the angle is has a big impact on the arched shape of the lower jaw which frames the entire lower face.
Jaw angle reduction is a procedure where the shape of the jaw angle is changed. By removing the end of the jaw angle, this area becomes more blunted or rounded. This is done through incisions inside the mouth behind the molar teeth. Using the same surgical access and instruments used to cut the lower jaw and bring it forward, jaw angle reduction is simpler and quicker to perform. There is also no risk to injury of the mandibular nerve or risk of bone healing problems as the bone is not actually split or fractured. Rather a piece of the edge of the bone is removed.
While jaw angle reduction is fairly easy to perform, one must avoid taking away too much of the jaw angle. Over resection of the jaw angle can lead to an unflattering ‘deflation’ of the angle and potential soft tissue sag. The other focus during the procedure is to make both sides evenly reduced. That seems easy but when you are working in the restricted space inside the mouth, asymmetry in resection can easily occur.
Indianapolis Indiana
The concept of non-surgical fat reduction has been around for over a century. From belt machine devices in the Sears and Roebuck catalog in the early 1900s to the infomercial weight loss supplements of today, hope is eternal when it comes to getting rid of unwanted fat. No one knows the number of fat reduction methods that have been proposed over this time but it is fair to say it must number in the thousands. So many approaches tell you that not only is there no one single method that is best, but how one loses fat varies for different people.
One concept that is important to understand is the difference between non-surgical vs surgical fat removal. Without question, the definitive way to lose spot areas of fat is liposuction. Liposuction is a proven surgical method to reduce spot areas of fat and trim down specific body areas, but it is an operation and involves expense and recovery. Non-surgical fat removal, no matter what the method, will never be as effective for spot reduction. One pursues that approach in the hope that enough fat may be lost to not need or desire the surgical solution. In short, non-surgical vs surgical fat reduction are not comparable methods. They have different outcomes.
Now enters one of the newest non-surgical fat treatments known as Zerona. Touted as a painless body slimming method that is proven to remove fat and inches without surgery with zero pain and downtime. Could such a thing be really true? Is this hype or hope?
Zerona works by using a low frequency ‘cold’ laser that passes through the skin without injury and targets the fat cells. The laser energy targets the fat cells through a photochemical process. Not to be confused with a photothermal (heat) or photoacoustic (vibration) method, this non-heat generating process makes the fat cells ‘leaky’. The fat cells shed their liquid fat content, now known as free-fatty acids, which is then absorbed through your lymphatic system. The lymphatic system transports it to the liver where it is processed and broken down, and most importantly, not re-circulated and stored again as fat.
Zerona is more than just a machine, it is a process. Treatment sessions number six to nine and have been shown to be able to take off three to five inches in the hips, waist and thigh in two to three weeks. But to aid the lymphatic clearing process, one must significantly increase their water intake and take a twice-daily niacin supplement during the treatment process. The treatment sessions require a commitment and must be done every two to three days to really be effective. Once the fat cells get leaky, you can’t let them heal themselves by missing treatments or having them too far apart. Each treatment session takes just under an hour and is painless. You literally get up and go afterwards. Daily exercise (such as brisk walking, light running, or other cardio training) can increase the final results by aiding in lymphatic clearance and an increased metabolism.
Is Zerona fat reduction too good to be true? It is if you think it is a replacement for liposuction or a significant weight loss method. But if you are looking for a safe and no risk method to lose some fat areas, Zerona may be a good option. For some, it is an alternative approach to try before submitting to liposuction and may eliminate the need for that experience and expense altogether. For others it is a commitment and a jump start to a healthier lifestyle…and along the way you may find a few things in your wardrobe that fit again.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have these indented areas to the sides of my eyes that bother me tremendously. My temples are sunken in and I have to style my hair to keep them covered. I read in one your blogs that a temporal augmentation procedure can be done to built these areas out. I would do just about anything so I could wear my hair back and not have to spend some time making a styling effort to keep them hidden. I have attached some pictures which show the areas of the temples that bother me. Tell me what you think can be done. Do you think the temporal augmentation procedure will work for me?
A: Thank you for send these very well illustrated photos. I could not have drawn the problem or photographed it any better myself. In studying these different angles, your temporal issues are fairly unique in terms of location. They are located not primarily in the hairline (or substantially there) but anterior to the temporal hairline extending right up against the lateral orbital rim of bone of the eye. They are not large (but skull defect standards) but are deep and very apparent. I can certainly see your esthetic concerns with them.
Indianapolis, Indiana
Q: I have a forehead scar from falling as a child many years ago. It has bothered me all of my life and have always wondered if some form of scar revision could improve it. I went to one doctor and he told me it wasn’t worth it and would probably not work. That really depressed me so I have since thought that nothing could be done. Then I saw online some forehead scar revisions that you ha done and that gave me hope again. I have attached some photographs of the scar for your review. I am hoping to hear good news this time!
A: Thank you for sending your photos. I think your scar could definitely be improved. I do not know why you were ever told that improvement was not possible. Quite frankly, your scar pattern is one of the easiest in which to see improvement.
Given its vertical location near a glabellar furrow, it should be excised as a straight line (possibly a step pattern though) That is a simple office procedure done under local anesthesia. Becasue of the tightness of forehead skin, you need to think about that it may require two stages. Vertical forehead scars have a notorious propensity to widen. So the first stage may end up with it being 50 – 75% less wide as the scar matures. (hopefully not) Then a second stage could for sure get it as narrow as a pencil line. The goal, of course, with your scar revision is to get it as narrow as possible in one-stage.
Dr. Barry Eppley
Indianapolis Indiana
Q: It’s been 9 months since I underwent a sliding genioplasty (to move my chin forward and decrease vertical height). It seems like the bony portion of my chin is symmetrical but the soft tissue is not. My lip line is uneven at rest and looks more pronounced when I smile. This is very bothersome to me since my smile and lip line were even before the surgery. My doctor repositioned my mentalis muscles to help with lip incompetence and it seems like the right side is higher than the left. I think the muscles are working properly, it just seems that their origins or insertions are just not even. It has not gotten any better with time. I have an awkward dimpling on the right side of my chin also (the right side definately feels abnormal compared to the left). Wondering if the soft tissue can be corrected to give me an even lip line and smile. I’m not interested in redoing the osteotomy but really would like your opinion on the soft tissue aspect. I’m very uncomfortable with how I look right now which is really making me regret having the genioplasty done in the first place. Thank you for you time Dr. Eppley!
A: While the bone in chin osteotomies understandably gets the most attention, there is also associated soft tissues that are carried with it. Since these soft tissues, particularly the mentalis muscle, must be cut through to perform the procedure it must be put back together in the final phase of the wound closure after the osteotomy is completed. While it is not common to have mentalis muscle problems, they can happen.
The most common mentalis muscle problem relates to how it was resuspended. Inadequate suspension or suspension that has loosened during the healing phase can cause lip and chin asymmetries, dimpling in the chin, and an uneven lower lip during smiling. When these occur, they can be corrected but one must have a very clear understanding as to the location and type of muscle problem. Sometimes it may just be a matter of soft tissue release and the interposition of a fat graft. Other times it may require muscle tightening or shortening. Careful analysis of at rest and smiling photographs in front and side views will help make the correct diagnosis.
Dr. Barry Eppley
Indianapolis Indiana
Q: I have a fracture in my right cheek bone from a fall. There is a dent in bone. Is there anything that could be done to fix it. I’d like to send a picture of me to you.
A: Thank you for sending your picture. What it shows is the sequelae of a a cheek or zygomatic infracture. When the cheek bone is struck with enough force it will fracture the ‘legs’ of bone which support it. When the cheek bone loses this support, it will always fall down and inward impacting into the maxillary sinus. This is known as a rotation fracture. When this happens the prominence of the cheek is lost, causing an indentation of the cheek. That indentation will appear just below and to the side of the eye. It is the prominence of the cheekbone which is lost.
Secondary of uncomplicated cheek fractures can take two approaches depending upon the degree of displacement and if there are other associated symptoms. Rebreaking the bone (cheek osteotomy) is only indicated when the amount of displacement is severe and there may be some nerve pain or numbness and alteration of the corner of the eye. If the indentation is the only problem, however, a cheek implant will usually suffice.
Through an intraoral (inside the mouth) incision, a cheek implant can be easily placed. It is important to have the right shape of cheek implant and that it is accurately positioned over the loss of prominence for the best correction.
Dr. Barry Eppley
Indianapolis Indiana
Q: Four years ago, I was injured and sustained a fractured zygomatic arch from a blow to the side of my face from a punch. I did not get it treated at the time because I had no medical insurance. After the swelling went down, I noticed an indentation over the side of my face which has remained ever since. Recently I visited a local plastic surgeon and he suggested to inject Artefill into the cheek area to lift up the dent. It is about the size of a dime or larger in diameter, a little less than an inch maybe. I had a CT scan which showed the zygomatic arch in the form of a U shape and it goes impressed in towards my skull. Please give me your opinion about his idea and yours.
A: The zygomatic arch is a very thin piece of bone that runs between the cheek bone (zygoma) in the front of the face back to the temple bone near the temporomandibular joint. It has a true arch shape as the large temporalis muscle runs underneath it. This arch shape provides fullness to the transition zone of the temple above to the rest of the face below.
Because of its thinness, it can be easily fractured with a direct blow. Once fractured, it changes from a convex arch to a V-shape as the fractured ends bow inward. This will create an indentation in the overly cheek skin. While easily repaired near the time of injury, it is very difficult to fix once it has healed in this position. If one has difficulty with opening one’s mouth because of the bone edges impinging on the masseter muscle, then some form of bony repair should be attempted.
If the zygomatic arch fracture is causing an external cosmetic deformity (indentation), there are multiple ways to fill out this bony deformity. Using an injectable filler is a simple and very reasonable method. While Artefill is a long-lasting filler, it is not permanent. Repeated injections may make it so however. Another method is to place a custom-shaped arch implant over the bone from an intraoral (inside the mouth) approach. This is easily done and would provide a permanent solution with a single procedure.
Dr. Barry Eppley
Indianapolis Indiana
Q: I used to use liner on my lips to make them look bigger. Now I use injectable fillers to make them bigger. But after so many years of injectable fillers, I am now looking for a different procedure that will last longer and may even be permanent.
A: Injectable fillers, of different chemical compositions, are the primary method of lip enhancement (enlargement) today. They are so popular because they are successful at creating an instant effect that most patients find very satisfying.
But because they are not permanent, injectable fillers to the lips must be repeated. Besides having to be injected with needles, there is also the long-term costs of these repeated treatments. As a result, some patients desire for a lip enlargement procedure that can done once and for all.
There are just a few limited options for permanent lip augmentation. The use of fat injections has promise but is very inconsistent in terms of permanent volume retention. Fat injections often have to be repeated to get a volume that is maintained. The use of dermal grafts (allogeneic cadaveric dermis) has been used for over a decade for lip implantation. Because it is a product out of a box, it is easy to use and insert. But it is often prone to complete resorption. Newer types of human dermis may offer a more permanent result but this has yet to be proven.
The only certain permanent method is that of lip implants. One implant product exists which is that of Advanta. These are soft spongy tubes of Gore-tex of various diameters. These are easily threaded into the lips under local anesthesia. There is no question of their permanent retention. But like all implants, they do have the risks and can usually be felt with one’s tongue or fingers. In my Indianapolis plastic surgery practice, I used them quite frequently and have found few complications with them.
Dr. Barry Eppley
Indianapolis Indiana
Q: I had a severe case of cystic acne which after treatments of accutane left me with severe crater like facial ice pick scars on both my jaws. I am an african american male and have heard due to my color I can worsen the scars with laser surgery. I am at my wits end with this. I need help.
A: Icepick acne facial scars, even in a Caucasian, would not be treated with laser surgery as it could not go that deep. Your skin color is a reason the laser should not be used but is not the main reason.
Icepick scars are treated by excision, sometimes called punch excision, for their removal. This is a technique where they are cut out by small instruments and then closed, trading off a fine line scar that is level as opposed to a deep pitted scar.
This method can be helpful for scar improvement and is usually done in the office under local anesthesia. Based on the number of pitted scars you have, this can be done in a single session or may require multiple sessions.
The concept of performing these small acne scar excisions can be unsettling as one may not be certain that sufficient improvement in scar appearance may be obtained. The best way to answer that concern is to just do a few of the worst ones and judge the results. That will tell you whether this method is helpful and can give one the confidence to do more. (or stop if one is not satisfied with the improvement)
Dr. Barry Eppley
Indianapolis Indiana
Q: I am a male who is considering having a browlift procedure. I am not sure how it is needs to be done but I do have one concern. Will a browlift make my hairline recede?
A: Browlifting in men poses unique concerns because of the varied and often absent frontal hairlines. Even in a male with a reasonably good hairline, it is impossible to predict what the hairline may do in the future. For this reason, the typical open browlift operations (either at the edge of the frontal hairline or behind the hairline) should be avoided. The endoscopic browlift remains the only ‘safe’ option even in a male with good hair density and frontal edge pattern.
The question of whether hairline recession make occur after a browlift is probably not directed towards actual hair loss from the procedure. This question likely relates to whether the hairline will move backwards as the brow is lifted. This is an excellent question and is a particularly relevant one in the endoscopic browlift.
This non-excisional (skin or scalp) type of browlift employs tissue shifting, or an epicranial shift, to create the effect of brow elevation. In other words, the entire forehead and scalp skin is shifted backwards, moving the excess tissue up and back where it sticks back down in a new position. As a result, the frontal hairline will move back to some degree. This creates some small amount of forehead lengthening, an increased distance between the brows and the frontal hairline. This is not hairline recession per se, just hairline repositioning.
Male patients in particular considering an endoscopic browlift should be aware of this hairline change. If the hairline is already fairly far back, this operation may not be a good choice or should be considered carefully.
Dr. Barry Eppley
Indianapolis Indiana
Q: I have a wide circular scar in the middle of my lower forehead from removal of basal cell cancer in the fall of 2009. It measures 5 mm wide by 10mm long and is depressed. (atrophic) The dermotologist used the ‘scraping method’ the remove the skin cancer. As the scar is in a very prominent place, I am strongly considering scar revision to make the scar is long and narrow. What are your thoughts?
A: Whether scar revision will be helpful is determined by two primary features of the scar in question. First, what does the scar look like? Scars that have width and height issues (raised, depressed and/or wide) are prime candidates for a positive outcome from scar revision. Narrowing and leveling a scar is one of the main changes that scar revision does well. Second, what is the age of the scar? Most scars must be mature enough to allow for good tissue handling and manipulation. In general, scars should be at least 6 months old if not longer. But the most important feature, not just time, is how pliable or flexible the surrounding skin is. Soft flexible skin is important to make most scar revisions successful.
Because the scar is located on the forehead, it is also likely that simple straightforward excision and closure, while better than what currently exists, is not ideal. Most likely, some form of geometric scar line rearrangement is needed to optimize its ultimate visibility. Scar revision using non-linear closure is best for any forehead scar that is not parallel to one’s natural wrinkle lines.
Dr. Barry Eppley
Indianapolis Indiana
Q:I had a breast reduction about 5 years ago. I was left with scars on both sides left and right by the clevage area. The length of each is about 2 inches and they use to be raised scars. However I did go see a doctor and he injected it with some solution which did work and flatten the scar, but you can still see it. It is unsightly and I can’t wear low cut tops because its visible. What are my options? Will a scar revision make it worse? The scar skin feels and looks like nuckle skin its thin and soft. Please advise, Thank you.
A: The breast reduction operation works well but at the price of significant length of scarring. While the scars are extensive, most of them are in more natural locations being around the areola and along the length of the lower breast fold or crease. The only part of the scar that is ‘unnaturally placed’ is the vertical one which runs between the nipple and the lower breast fold. Most breast reduction scars turn out well but there is an occasional patient that is not happy with some of the scar and some scars which become wider or even raised.
While steroid injections will help soften and lower a raised scar, they will not make it more narrow. Narrower scars are less visible than wide ones. Scar revision usually works better because it gets rid of the wide scar in exchange for a more narrow one. Your breast scar problem is the medial tail of the lower breast fold scar. While it can not magically be erased, scar revision can most likely cause an improvement in its appearance. These small scars could be done in the office under local anesthesia.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I would like to schedule a consult with Dr. Eppley. I have migraines and have found that Botox was a big help to me making it at least 50-60% better. I also have neck pain badly. I think his decompression Surgery may be beneficial. I would like to speak to him about this.
A: The debilitating nature of many migraines begs for more effective solutions. In the past, the only approaches to the treatment of migraines has been pharmaceutical, obtaining some symptomatic relief. The most recent pharmaceutical treatment has been the use of Botox injections. For a very specific subset of migraine sufferers, Botox has been shown to be effective if the focus or trigger has been associated with the exit of sensory nerves from the skull base. This is usually the supraorbital/supratrochlear nerves in the brow area and the greater occipital nerve at the back of the head.
Botox works by relieving the spasms of the enveloping muscles as the nerve exits close to or at some distance from the bone. If Botox produces a profound response, this strongly indicates that surgical decompression (removal of muscle around the nerve) could be equally effective and offer better long-term results. In some cases, even a cure might be achieved. Plastic surgeons have long recognized this surgical approach coincidentally with endoscopic browlift procedures where muscle removal around the nerve is done to help decrease wrinkling after surgery and some cosmetic patients comment that their headaches are better.
If the origin of the migraine and Botox injection relief is from the back of the head (occipital area) then decompression of the greater occipital nerve and release of the fascial attachments frm the back of the skull may work quite well. This is done through two small incisions in the hairline where the neck muscle meets the bottom of the skull bone in the back of the head. It is a fairly simple procedure that is done as an outpatient. Migraine relief should be seen quite early after surgery. There is only very mild discomfort after the operation which passes ina week or so.
Dr. Barry Eppley
Indianapolis Indiana
Q : Hi, I found you in reading an article you wrote. This situation applies to me as I very recently had a subnasal lip lift done and I am still in recovery. I can see that my upper lip is crooked and way over corrected so much that my upper lip may be unfunctional. The worse part is however I had no idea I would not be able to smile, and appear deformed should I try to smile!!! I was told to expect some tightness but this is beyond tightness. What are my options? Can I get my smile back?
A: In the subnasal lip lift procedure, a wavy amount of skin (thicker in the middle) is taken directly beneath the nose with advancement of the lower edge of the incision to the area directly beneath the nose. The final closure is tucked in along the base of the nose from one side of the nostril to the other. This procedure shortens the distance between the top of the upper lip vermilion and the base of the nose allowing for more upper tooth show when the lips are slightly parted. It also everts more of the upper lip vermilion, therefore creating an increased amount of a central pout of the upper lip. It is always slightly overcorrected as there will be some relaxation (mild re-lengthening) of the upper lip afterwards.
While this is a fairly simple procedure, I have seen and read of some problems associated with it. One complication appears to be from manipulating the underlying orbicularis oris muscle besides the skin while doing the upper lip lift. In theory, sewing the orbicularis oris muscle to the periosteum underneath the nose may make for a more stable long-term result. However,such a maneuver creates an unnatural stiffness and deformity of the upper lip when can be evident during smiling. This is not a good trade-off for the theoretical benefits of this manuever. It is far better to run the inconsequential risk of doing a secondary tuck-up the procedure if there has been some relapse. Correction of this stiff lip problem can be done with re-opening the incision and releasing the abnormal attachments, with the possible insertion of a dermal or dermal-fat graft to prevent recurrence. The sooner this is done the better.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I want to have a breast lift, liposuction on my stomach,thighs,buttocks,under the arms,between my chin and lower neck line, an eyebrow lift, and some under the eye work. (dark and somewhat deep and little wrinkles) I am a mother that is curious of amount of the cost. I’m not even sure that I can afford this but I truly have self esteem issues. My weight topped out at 202 lbs but I i am now down to 178 lbs. I have always been one to want to look and feel good about myself and I do not feel that way at 35 yrs old. I am too young to feel this bad about myself!
A: How we feel about ourselves is one of the most important characteristics of a person. While inner beauty and well-being is all that really counts, there is no doubt that how we look on the outside affects how we feel on the inside. Your plastic surgery wish list is comprehensive and, affordability aside, all of that could and probably should not be done in a single surgery. Therefore, it is important to prioritize this face and body plastic surgery wish list. The best way to approach that, and is what I discuss with all my patients who want an extreme body makeover, is to ask yourself this question. If I could only do one plastic surgery operation and could never return to the operating room, what procedures would you do on this list? I say pick just three and even put those in order of importance to you. Whether you would ever get to phase 2 or not is unknown, but if you don’t, then you will have accomplished the most important changes anyway.
Looking at your list, I can divide it into body and face work. While I am not you, most likely the body work is of greatest importance to you because you have listed/described it that way. It appears that a breast lift (with or without implants) and some abdominal and waistline contouring are your prime targets for change. It may also be possible to do so thigh and arm liposuction at the same time if your budget allows for it.
Dr. Barry Eppley
Indianapolis, Indiana
Q:I was wanting to know if Dr. Eppley has any experience in the repair of stretched (gauged) earlobes and how much a consultation would cost?
A: Repair or reconstruction of earlobe deformities are common in-office plastic surgery procedures. Short of congenital microtia or earlobe loss from injury, the gauged earlobe deformity is of greater complexity that simple earlobe split repairs. Gauging the ear is a form of earlobe expansion. When the gauge size is not too big (not bigger than the original size of one’s natural earlobe) the expanded earlobe has a generous amount of tissue. This enables it to be put back together in a normal size because there is adequate soft tissue. When the gauge becomes much bigger, the earlobe tissues become stretched and actually thinner. (tissue atrophy) When putting this type of gauged earlobe back together, the final appearance of the earlobe will be smaller than it originally was.
I have done lots of ear and earlobe reconstructions over the years of many different causes. The gauged earlobe is but a newer type of deformity but its reconstruction still uses the same basic plastic surgery principles. In many cases it can still be done in the office under local anesthesia.
If you send me pictures of your ear, we can consult for free by e-mail. This is an easily visualized problem that allows photographs to suffice in lieu of an actual office visit. That way, you can schedule a repair and get it done by only having to make one visit. (although a second visit will be needed for suture removal)
Dr. Barry Eppley
Indianapolis, Indiana
Q:I had a genioplasty to move the chin forward and now i want to do another surgery that doesn’t involve implants to make the chin wider. Is that possible and will the chin resorb after awhile because of splitting the chin and expanding it in the horizontal direction?
A: As you have discovered, moving the chin forward by an osteotomy will usually make it appear more narrow or tapered. This is because of simple geometry. If you move the front part of an arc forward (think of the lower jaw as u-shaped or an arc), it will make the overall shape of the total arc longer but more narrow in front. For this reason in male patients, I evaluate the front shape of the chin very carefully so if an osteotomy is performed for advancement, and the patient wants the chin to end up wider, I factor that into the osteotomy design and plan a central osteotomy with expansion.
Certainly a second chin osteotomy can be done and the downfractured chin segment split and expanded. It will be held apart by the necessary plates and screws needed to fix the overall osteotomy into position. This should not cause the bone segment later to undergo any resorption. A simpler method to get chin width expansion is to place a chin implant in front of or on top of the bone. There are chin implant styles that provide lateral fullness without any significant horizontal advancement and they would be a good choice here also.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I read in Dr. Eppley’s blog about using Kryptonite Bone Cement for pectus excavatum. I had the Nuss procedure done 5 years ago and breast implants done 4 years ago. I got very good results with the procedure and implants with the lower part of my ribs; however, the upper area (below the collarbone) is still indented. I would like to inquire about this procedure and whether or not I would be a viable candidate.
A: Kryptonite bone cement is a new type of bone filler/replacement that works well as an onlay, meaning to build out a bone surface to create a better contour. Currently it is approved in the United States for cranioplasty, the filling in or building out of skull bone contours. While it has never been formally tested for use on the sternum, there is no reason to think that it would not work just as well there as on the skull. What makes Kryptonite a possibility in the sternum is that it can be injected after it is mixed before it sets up into a hard mass. This is a very unique characteristic of a bone cement and no prior ones have ever had this physical property. As valuable as that material property is in the skull, it becomes a critical material characteristic in the sternum as incisions of any size are easily seen there.
For an upper sternal problem, a small incision inside the sternal notch can be used to develop the subperiosteal/supraperiosteal pocket. It is into this pocket that the material is injected and molded. The critical step in injectable sternoplasty, like injectable cranioplasty, is to make a good recipient pocket that matches the external outline of the contour defect.
Indianapolis, Indiana
Q : I AM A 39 Y/O FEMALE. WEIGHT 155LBS, 5FT 9′ WITH A B CUP WANTING A LIFT AND C CUP AND SILICONE IMPLANTS. AFTER LOOKING OVER MANY PLASTIC SURGEONS IN INDIANA I HAVE CHOSEN DR EPPLY AS MY FAVORITE IN RELATION TO THE WORK IVE SEEN. A FEW QUESTIONS: HOW MANY YEARS HAS HE BEEN PERFORMING BREASTS LIFTS, & IMPLANTS. DO YOU HAVE AN APPROX OF HOW MANY HE HAS PERFORMED? AND WHAT WOULD BE THE APPROX. COST? ALSO, WITH ME BEING A SMOKER WOULD THIS AFFECT MY BEING ABLE TO GET THE SURGERY PERFORMED? THANK YOU i HOPE TO HEAR FROM YOU SOON
A: Thank you for your inquiry regarding breast enhancement. I have done such cosmetic breast surgery for the past 20 years and have done over 1,000 breast augmentation/lifts patients. The cost of breast augmentation with silicone implants (Mentor memory Gel) is right aorund $ 5,900 all costs included. Adding some form of a breast lift to it does increase the cost but that can not be predicted without seeing you since there are 4 different types of breast lifts which add varying amounts of time to the procedure.
Smoking does not have any significant effect on complications from a routinue breast augmentation. There is a slightly higher risk of wound problems when any form of skin lift is done such as a breast lift. How risky that would be would be based on what type of breast lift is needed…the more extensive, the more risk of wound healing problems. The best way to handle the smoking issue is to refrain 2 weeks before and 2 weeks after surgery if possible.
Dr. Barry Eppley
Indianapolis, Indiana
Q : I had a chin implant 9 years ago, when I smile its seems to be without form, like flat. And after X-rays I noticed that the implant is placed higher up where it should be (close to my teeth). A doctor told me it would be very laborious, because it would be two operations, one to remove the chin implant which would remain a hole, wait 3-6 months to heal the skin and the second to put the new implant from under the chin. Is there another solution? Thanks!
A: It is very common to have a chin implant that ends up being positioned too high on the chin bone when it is placed from inside the mouth and is not secured with a screw. When the implant is too high on the bone, it loses some of the projection or forward position of the chin that it would otherwise have.
Replacing a misplaced chin implant is fairly easy and can be routinuely done in a single operation. I have never heard of having to do it in two operations nor does that make any biologic sense to me. Going through a small submental (under the chin) incision, a new lower pocket can be made, the old implant removed, and a new chin implant placed and secured. In some cases, I have left the old chin implant where it was and just placed a new one beneath it. If someone has a deep labiomental crease, keeping a ‘spacer’ (old implant) high can help push that area out and prevent it from becoming deeper.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am a 43 year-old male who is bothered by my long upper lip. When I smile I show no teeth and this makes me look older in my opinion. In addition, I have almost no red part of my line, it is just like a thin pencil line. I have done some reading and it seems a lip lift work. My measured vertical distance between the base of my nose and the top of the red part of my lip is 23mms. I have not read anywhere or seen that a man has had this type of lip shortening. Can it be done in a male? I have attached a front photo of myself for you to see what my lip looks like.
A:Thank you for sending your facial photo. While it is not a completely closed mouth view, it does show how long your upper lip is. You are correct in assuming that the only option for shortening your upper lip is a subnasal lip lift. As a general rule, I remove about 1/3 of the natural philtral distance. Since you are at 23mms, you could remove about 6 to 7 mms without any difficulty… maybe more. Whether this will be enough to unmask your teeth in smiling is to be seen but, at the least, the upper lip will be centrally shorter. The subnasal lip lift does not shorten or reduce the sides of the lip since the width of the tissue removal is limited to between the nostril bases. The lip near the corners of the mouth will not improve from a subnasal lip lift.
Dr. Barry Eppley
Indianapolis, Indiana
Q:I have had a c section with my son and I have no feeling toward the bottom of my belly. I have lost 52 pounds but still over weight. I am so frustrated but I think the only thing that will work is plastic surgery. Based on my readings, it looks like liposuction and a tummy tuck will do the trick. What has been your experience with the amount of improvement that thees two procedures can do?
A: Your question is a bit of a loaded one but the answer is in most cases very well. In fact so well for some people that it can be considered a ‘waistline’ miracle. This may seem a bit of an overstatement but for many tummy tuck patients it is not. The sheer removal of a full-thickness piece of skin and fat (either above or below the belly button) does something that no diet and exercise program ever could for someone who has lost a lot of weight. (50 lbs count as a lot!) When this skin and fat removal is combined with liposuction around the waistline and into the back, significant mid-trunk reshaping is done.
Already having a C-section scar (with numbness) and the extra skin created by your weight loss makes the consideration of a tummy tuck a fairly easy one as there are no viable alternatives. It is hard to predict how many inches may be lost around your waistline but it is fair to say at least 2 to 3 inches and maybe more. As impressive as the frontal change may be, I am always excited to help create the narrowing of the waistline by aggressive flank and back liposuction.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have read about fat injections to the breast but am concerned that it won’t give me enough of a cup increase. In my reading it says that the average increase in volume is around 100cc. Is that only a 1/2 cup increase. I have also read that an external suction device can be used with fat injections to get a better result, is this a hoax?
A: A 100 to 200 ml improvement in breast size for most women (depends on what they have to start with and how wide their breast base diameter is) will only be a 1/2 cup to 3/4 cup at best. You have to remember that much of fat breast augmentation work currently comes from Japan where small breasts (B cup) is the desired size by their cultural standards. That is why fat injections may be more ‘successful’ in this population. In the American population, such small breast size increases would not be considered enough. I have never placed a breast implant that was 200ml or smaller. Occasionally a 250ml to 275ml breast implant may be used but this is very uncommon. Most American breast augmentations are in the 300 to 375cc range.
The concept of external suction on the breasts to increase breast size is not a hoax. It is an actual device known as the Brava system. It has been shown to increase breast in the range of a 1/2 cup or more. The theoretical science is that pulling on the breast tissue stimulates fat or stem cell replication or growth. It is currently being studied in combination with fat injections to the breast. Combining the two makes biologic sense and I would suspect that their combined use is better than either one alone.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I would like to know more about laser liposuction. I had two C-Section deliveries and abundance of skin because of it.
A: While laser liposuction does have the ability to tighten some skin, it is not a replacement for a tummy tuck. Your description of having had two pregnancies with C-sections and now an ‘abundance of skin’ suggests that your skin excess problem is not slight. In addition, the skin that is there has lost its elasticity (which is why there is an abundance) and does not have the ability to respond to the tightening caused by the heating effect of the laser. Such loose abdominal skin is always more effectively removed by an excisional procedure, aka a tummy tuck.
Laser liposuction, often called Smartlipo, is an improved method of fat removal than traditional liposuction. By using a laser probe to create an elevated temperature in a zone of fat, the fat cells break apart and loose their lipid content. This not only makes it easier to suction out, but fat cell damage continues beyond the surgical period much like the progression of a burn injury on the skin. Even some fat cells which were not directly injured by the laser probe at the time for surgery may go on to die later from the laser injury. This produces more fat loss in the days ahead. Whether that amount of fat loss is significant or not depends on how high and uniform the temperatures were at the time of the laser liposuction procedure.
The skin tightening effect of laser liposuction is similarly caused by the heat created. The temperatures must be high enough and close enough to the underside of the skin for this effect to be created however. Whether that occurs is dependent on the skill and the expertise of the physician driving the laser probe.
Dr. Barry Eppley
Indianapolis Indiana
Q: I have read that there is a cosmetic procedure that cures migraine headaches. I have had migraines for years and sometimes they are so bad I can’t leave the house. If there is an operation to cure this migraine problem, I would sign up for it in a minute! Can you tell what they are talking about?
A: The use of Botox for the treatment of glabellar furrows (wrinkles between the eyes) has been done for decades. One of the very interesting findings from that cosmetic treatment was that plastic surgeons discovered that some patients with frontal migraines got a temporary cure, as long as the Botox lasted. The now proven theory is that in those patients with a focus of their migraines that starts above their eyes in the brow area are caused by the muscles squeezing the sensory nerves that exit from the bone there. This is why Botox relieves those migraines…it stops those muscles from working.
If you take that one step further, a browlift (of any type) can create the same effect as Botox except that its results will last much longer and maybe even permanently. That is because during a browlift some of the muscles are removed to prevent that type of wrinkling action. Recent studies and publications in the journal Plastic and Reconstructive Surgery has shown that certain types of migraines can be cured by performing a modified forehead/brow lift. Therefore, the type of forehead lift used to cure migraines could also lead to one looking younger as well. This type of cosmetic operation has been shown to be safe, effective and can lead to a tremendous improvement in the quality of some migraine patient’s lives.
Dr. Barry Eppley
Indianapolis Indiana
Q: Hello Doctor, I am 18 years of age, an Asian Chinese and I have big cheekbones. It was almost twice the size of the other people and that makes my face looking round and unpleasant big. I’ve read articles about cheek implants but I was wondering if there is a surgery that reduce the cheeks size, the best case scenario, to make it look flatter? Thanks in advance for helping me.
A: When you are referring to big cheekbones, you are undoubtably referring to them being too wide. Big in cheekbones invariably refers to how far they stand out from the side of one’s face. Wide and prominent cheekbones are most common in Asians as their genetic face tends to be less projected forward (horizontally) and more projected to the side. (wide)
Cheekbone reduction surgery can be done and understanding how it is done requires a knowledge of the bony anatomy of the face. The front part of the cheekbone is a fairly solid bone that is partially made up of bone from the side of the eye socket. This is the location, for example, where cheek implants are placed to make the cheek more full. But the part of the cheek that makes it wide is known as the zygomatic arch which acts as a span of thin bone that arcs out from the cheekbone in front to the temple bone in back. How much this piece of bone arcs determines how wide the cheek bones appears. Cutting the attachments of the cheekbone from the side of the eye socket and the back part where it attached to the temporal bone allows it to fall in. It falls inward (less wide) because not only are the bone attachments cut but there are muscles attached to it that help to pull it in also.
While cheekbone reduction surgery sounds drastic, it is done from inside the mouth with small bone-cutting instruments.
Dr. Barry Eppley
Indianapolis, Indiana
This is one of those headlines that attract a lot of attention as the concepts of Free and Plastic Surgery go as much together as Peyton Manning and quarterback sacks. One of the not infrequent requests that I get as a plastic surgeon, however, is about this very concept. On my practice website and numerous blog sites, requests come in every week for some form of plastic surgery ‘donation’. Many of the requests go into great detail about why they want a certain procedure and they are often quite moving. While the idea of performing surgery for free seems fairly simple, it actually is not.
This can best be explained by my response to a recent request for a free breast augmentation with a heart-felt plea for an improved perception of herself.
‘I have great empathy for the concerns you have about your breasts, and wish that providing you with a free procedure were an easy choice. Given the number of women who come into my office with similar concerns about their bodies, I can understand how connected self-esteem and a positive self-image are. Providing surgery for free may seem like a simple and straightforward thing to do, but there are many factors involved that make the concept of ‘donated’ surgery not exactly free. While any plastic surgeon can give away his time to perform the operation, a surgeon’s fee represents just a fraction of the total costs of surgery. The cost of the breast implants, use of the operating room, and the fee for the anesthesiologist expertise are other cost factors that must be accounted for and paid. The surgery center or hospital, implant company and anesthesiologist are under no obligation, and usually are unwilling, to provide services and materials at their expense for an elective procedure. Often times, these costs make up more than that of the plastic surgeon’s normal fee.’
One of the hidden costs of any donated surgery in this country is the potential medical-legal responsibility. Unfortunately, donating surgery does not waive any responsibility on the plastic surgeon for the outcome. Should any untoward events happen, such as a rare but possible complication, the surgeon is still liable and responsible. The possibility also exists for the need for revisional surgery after the initial procedure should the result not be ‘perfect’ and the question then arises is the surgeon again expected to waive his or her fees? While many patients say they will sign anything to get the procedure for free, the legal reality is that there are no forms or waivers that a patient can sign that will legally hold harmless the physician for the services that he or she has provided.
One may wonder then how do they do these free makeover surgery contests, either done locally or even on TV? The answer is whoever is doing it most likely is not a board-certified plastic surgeon. The American Society of Plastic Surgery strictly forbids providing any free surgery as a result of a contest, promotion, or any other method of inducement which encourages a patient to undergo surgery based on an economic incentive. Doing so is an ethical violation of its membership and could be grounds for dismissal from the Society. Those non-plastic surgeons who do offer such free surgery are not bound by these ethical guidelines and merely see the risk as a marketing expense.
While a plastic surgeon may choose to donate his or her skill and experience for free, the rest of the costs of surgery remain, and are usually out of the surgeon’s control. The legal and ethical issues, that are completing unaware to most patients, makes donating an invasive operative procedure not quite the same as giving away a more traditional retail product.
Dr. Barry Eppley
Indianapolis, Indiana
Q : I am a 55 year-old male and am bothered by low hanging brows. It makes me look angry all the time and I am actually a good-natured and upbeat person. It seems my eyebrows are falling off of the brow bone and they look so heavy. My mother had a facelift and browlift several years ago and I am wondering if this would work for me.
A: While a man can aesthetically tolerate a lower brow position than a woman, there is a point when the brow descent is too excessive. When the eyebrow is below the brow bone, the look that is created is a perpetual scowl or frowning. At the least, it makes the size of the eye look small and the forehead look very long.
Browlifting in men poses unique challenges that are not present in most women. The lack of a well-defined and permanent hairline with good hair density makes the options for a browlift more limited and less effective. Browlift scars are not easily hidden and the risk of visible scarring is beyond just a theoretical possibility. None of the hairline or scalp approaches that are most commonly used for lifting the brows are worthy of that scar trade-off. In some cases, an endoscopic approach can be used but it stills creates small scars that can be visible through most men’s hair patterns.
There is a mid-forehead incision approach to a browlift but it requires a man to have a deep and prominent horizontal wrinkle in which to use. The scar with this approach takes a long time to settle and the redness to fade. While effective, this central forehead scar should be reserved for a few select patients.
This leaves the eyelid or transpalpebral approach as the only browlift option without the risk of adverse scarring. The eyebrow is lifted and sewn back up to the bone through an upper eyelid or traditional upper blepharoplasty incision. It is not as effective as a ‘superior-based’ browlift but the risk of adverse scarring is eliminated.
Dr. Barry Eppley
Indianapolis, Indiana
