Your Questions

Q: I am looking into bone recontouring for my forehead. I am 22 and I have a condition called Plagiocephaly that I have become aware of within the last few years. I have been to three different doctors who have all told me that they believe the condition is “minor” and doesn’t need any treatment. Not only does one side of the back of my head protrude outward more than the other side, but my forehead also does the same thing on the same side that my head protrudes. My brow ridge seems to be fine, but the bony part of the orbital socket (the part the eyebrow itself covers) seems to protrude more than the other orbital socket. It makes my forehead look very uneven. There also seems to be a flat spot on the side of my head right around my forehead region. I would like to know if this is fixable whether it be just fixing the forehead or fixing both the forehead and the back part of my head, but I also want it to look as natural as possible. Basically, I want it to look as close to what it should’ve been without Plagiocephaly. On a side note, I was also wondering why this condition has become noticable to not only me, but others as well, recently. Up until I was around 19 or 20, I had never heard anyone say anything about this to me, but it has become very apparent now. I understand that it has been like this since I was a baby, but I am wondering why it has become so apparent recently. Is it because the forehead hadn’t fully developed yet and thus became more distorted to the point of noticeability by the time I turned into my late teens to early twenties?

A: Plagiocephaly, known as a twisted skull, is a deformational skull shape that occurs in infants,  evident either at birth or developing thereafter. Most commonly, it is the result of preferentially laying one side of the back of the head. Since the skull is very thin in infants, it can easily be inadvertently molded into an abnormal shape. That shape pattern is classic and you have described it perfectly.The side of the back of the head which is flat will cause the forehead on the same side to protrude. If significant enough, the shape of the eye (orbit) can also be affected.

What to do with this skull shape in an adult is a difficult problem. The bone is very thick and reshaping it is a major undertaking with long scalp scars. I would leave the back of the head flattening alone as the effort is not worth the result in most cases. The more visible front, the forehead, however, may be worthy of cranial reconstruction surgery (forehead reshaping) if severe enough. I would need to see photos to determine how severe it is and whether any surgery and its benefits is worth the risks. The biggest issue in forehead reshaping is whether a scalp scar is worth the trade-off.

The shape of your skull and forehead was determined long before you were fully developed. I do not think that it is more apparent now because it developed in your teens. I think it is more likely it has become apparent and now is a focus, making it seem it wasn’t there before.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Can liposuction of the ‘love handles’ be combined with the hip and inner thigh areas? I have lost several pounds through the years. I was told laser treatment to melt the bit of fat would be the way to go but not sure what would happen with the bit of excess skin?

A: It is extremely common for multiple body areas to be treated during any liposuction surgery procedure. As a general rule in my Indianapolis plastic surgery practice, I treat as many body areas that can be done in two hours or less of operative time…with no more than five or six liters of aspirate removed. This is known as ‘normovolemic’ liposuction. Studies have shown that the medical risks of liposuction increase significantly with high volume liposuction surgery. (greater than five liters) There was a time when I performed high volume liposuction but now feel that such volumes are best done in two separate procedures.

Loose or excess skin is always an issue when the underlying fat is removed by liposuction. While some minor amount of loose skin will shrink and tighten after surgical fat removal, significant amounts of excess skin will not go away and are at risk to hang more afterwards. This is of most significant concern in the abdominal area but is also an issue in the inner thighs.

Laser liposuction (aka Smartlipo) will cause more skin to tighten than traditional liposuction because of the heat it generates during the procedure. But it is not a miracle skin tightening device and one’s expectations should be tempered if more than a little loose skin exists.

Dr. Barry Eppley

Indianapolis, Indiana

Catchy and clever names are an integral part of branding in the essential game of marketing for most products. A great working product without a memorable name may never catch any attention with the public, while a mediocre product could grab a market share with just the right name. While this use of ‘naming’ is part of everyday marketing in retail sales, it is fairly uncommon in health care.

Hospitals certainly do advertise, as evidenced by the many billboards around the city but they rarely play the name game. While promoting new facilities, equipment and services, five star ratings and open houses are common marketing approaches in health care, ear grabbing phrases and slick-sounding names are not needed. When you are providing a service with proven benefit – such as a new hospital wing or MRI center, it is more about creating awareness, trustworthiness, and availability.  In plastic surgery, however, marketing often veers from the path of traditional medicine. In the world of cosmetic surgery, thanks to the reach of the internet, we are seeing the emergence and widespread use of clever names (and sometimes deliberately confusing ones) to entice patients to have procedures and surgery.

The  most well-known example is that of the ‘Lifestyle Lift’. Through their national magazine and television ads, this is a franchise approach to getting a facelift…or some version of it. Promising to turn the clock back at least ten years and look recovered in just a few days, its snazzy name seeks to assure patients that it will fit into their ‘lifestyle’. Interestingly, nowhere in their advertising does the company suggest it is actual surgery. I have seen numerous patients who have visited their facilities and were surprised to learn that it was actually an operation. These same people are certainly surprised to learn that the ‘Lifestyle Lift’ is an operation that is over twenty years old and is practiced by most plastic surgeons. This ‘mini-facelift’ operation has now cloned many spinoffs including Swiftlift and Weekend Lift to name just a few. Often touted as being innovative and original by the advertising surgeon, the names suggest that getting a fresh, younger look is really easy.

The fear of what transpires during a ‘Tummy Tuck’ keeps many women from actually having one. While there are different versions of tummy tucks, they all involve some degree of invasion of your mid-section, and some period of recovery. The ‘Smooth Tuck’ procedure puts a different twist on it. Promising less than a week of recovery and six-pack abs, who would not want to have one?  After all it is smooooth. The reality is the closest most tummy tuck patients can get to a six-pack is at their local convenience store. Flat, fairly taught tummies can be realistically achieved,  and that is more than enough for most patients. But getting back to work in less than a week looks better in an advertisement than it will feel in real life.

My current favorite is the Vampire Lift. Yes, that is an actual name that I hate to admit even exists in the industry. Using modern platelet and stem cell biology, the concept of extracting and purifying your blood for its healing components is used in many surgical specialities. While it can be a useful adjunct to certain surgeries, the fact that it is natural does not give it ‘pixie dust’ properties. The Vampire Lift  takes that concept and uses it as a substitute for injectable fillers to plump up your face. Promising to grow your own tissues to make lips bigger,  and injecting blood to make facial parentheses less noticeable certainly seems better than any synthetic product off-of-shelf. While this is an organic way to dispose of your money, it is a far fantasy from actual medical science.

What’s in a name? In cosmetic surgery, clever names often disguise an established procedure and might be just another way to catch the attention of a prospective patient.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr Eppley, How long does it take for a bull horn lip lift scar to fade? I read that a lot of people experience bumps and track marks from the sutures. Also, looking at some pics, it looks like a crack or line between the nostrils that the make-up is not hiding very well. Can you advise? (I’m interested in the procedure) Thanks.

A: Like all facial scars, it takes 3 to 6 months for it to either fade completely or be headed that way significantly. I would equate the lip lift scar to that of facelift incisions in terms of how they mature over time. The thickness and pigmentation of one’s skin and one’s age will also influence the time to scar fading. Thicker skin will take longer than thinner skin, older skin fades quicker than younger skin.

I have not seen the bumps or track marks that you refer to in lip lift scars. The bumps are typical reactions to buried sutures as they dissolve and may appear many weeks after the surgery. I use very small internal buried sutures, such as 5-0 and 6-0 monocryl,  and probably explains why I haven’t seen them. Track marks along any suture line is the result of using skin sutures that are too large or left in too long. I use either a buried subcuticular running 6-0 monocryl or interrupted 7-0 prolenes, neither of which will result in any visible track marks. For out of town patients, I use a running 6-0 plain for the skin suture which also will not leave any track marks.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am interested in a full body lift. How much does that cost?

A: The term ‘full body lift’ is a rather vague term from a plastic surgery standpoint. Even though it is a widely used term for a plastic surgery procedure, I have learned that what it means to a patient can be very different from what it means to a plastic surgeon.

A body lift is  a specific procedure that is almost exclusively used in the extreme weight loss patient, usually after bariatric surgery. It is essentially a 360 degree or a circumferential tummy tuck. It is best perceived as a combined tummy tuck (front) and buttock lift (back) done together through a single incision that rums around the waistline. It is done to deal with the extreme skin excess that develops after a lot of weight loss with an abdominal overhang, sagging thigh skin, and a deflated and droopy buttocks. By removing a large amount of circumferential skin, the lower half of the body is lifted, like pulling up your pants so to speak.

From a patient’s perspective, however, a body lift can often imply that things are lifted from the arms done to the thighs in a single procedure. Much like the confusion from a facelift, where people almost always believe it lifts the face from the forehead down to the neck when it does not (only lifts the neck and jowls), a body lift is a waistline procedure. While it has a dramatic and often life-changing effect, it does not lift the ‘entire body’.

When patients ask about price for the body lift procedure, it is important to know exactly what they are really talking about and what a body lift means to them. To get a meaningful price for such a procedure, one really needs to come into the office and be seen and evaluated. It is a little like calling the auto shop and just asking how much it is to overhaul your car…one has to know exactly what it needs before an accurate quote can be given.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am interested in having lip reduction surgery some time in the near future. However, there is not much detailed information or before and after pictures regarding the procedure. Is it possible to enhance or alter the look of the cupid’s bow while simultaneously reducing the size of the upper and lower lips?

A: Lip reduction is far less common than its cousin lip augmentation. I would estimate that for every 1,000 lip augmentations done by any method, one lip reduction is done. Much like breast augmentation, lip enhancement is more glamorous than going the opposite direction. As a result, much less is written about it and very few pictoral results are available to be viewed. This does not mean that it is not done very successfully, just that the requests for it are very few.

Lip reductions are exclusively done from incisions further inside the lip. While it could be done by an incision at the junction of the lip skin (vermilion) and the facial skin, this would leave a visible scar. In addition, rolling the lip tissues outward  towards the incision, even while removing lip tissue, works against the objective of trying to show less lip. By removing excess lip tissue by an incision at the junction of the wet-dry line (vermilion-mucosal junction) just inside the visible lip rolls the lip inward helping to reduce its show.

By the way lip reductions are done, the cupid’s bow on the upper lip is not changed. While it could be changed through direct excision and flattening of the bow, this would again leave a small but visible scar at the central portion of the upper lip.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: I have loose wrinkled skin on the inside of my arm where my elbow bends. Is there a procedure that would improve this area? It is not due to weight loss. It is due to aging. I am 50 years old and this just appeared recently.

A: Loose skin often appears across joints like the knees and elbows as a result of aging. The near constant flexion and extension of these major extremity joints over time can result in some eventual sag from the wear and tear on the skin. While not seen in flexion, this skin becomes more evident in extension of these joints.

There are plastic surgery procedures to remove this excess skin. Known as elbow and knee lifts, they are almost exclusively done in extreme weight loss patients. With a lot of weight loss, the sagging skin extends from the body outward towards the hands and feet. Rolls of skin can frequently be seen past the elbows and knees. In bariatric plastic surgery patients, removal of this excess skin is commonly considered and done. While this results in scars, it is  usually considered a more favorable trade-off.

In the comparatively mild amount of loose skin that can develop from aging around knees and elbows, replacing it with scars is a more dubious trade-off. Many cosmetic procedures involve scars as a substitute for the original problem. As a result one has to be crystal clear that this trade-off is clearly better. In the weight loss patient, there is usually no doubt. In the non-weight loss patient, the amount of loose skin and how bothersome it is must be carefully considered.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am 58 yrs old and in good health. I have never smoked, drank alcohol or done any drugs. While I am an upbeat person, I have had a difficult past and been exposed to a lot of physical and mental abuse. I just want to have a natural smile. My mouth has always had a natural turn down which makes me appear angry and unhappy. (which I should be because of my past but am not) I can pull my cheeks up at my ears and have a great turned up smile and the jowls disappear.  I read about the thread procedure and thought this might be possible for me.  Anxious to hear from you.

A: In reading your e-mail, by your own description, you have the classic signs of face and jowl laxity. By pulling the skin up by your ears or cheeks, you are creating the classic results of what a facelift can achieve.

Your inquiry regarding a Threadlift suggests that you believe that this may produce a result similar to a facelift or maybe approximately so. Unfortunately, this is not true. While the Threadlift concept has a lot of appeal in the mid-2000s, it is a procedure which has largely disappeared from clinical use. The original ‘threads’ are no longer even manufactured. When an initially popular and marketed plastic surgery procedure ‘disappears’ within five years from when it comes out, that is because it has basically failed to work. Such is the fate of the Threadlift.

Even of the Threadlift procedure was still available, it was never intended for severe facial skin laxity. In other words, it does not sound like it would have worked in you anyway. Some form of a facelift is what you need. Even a limited facelift, or jowl lift, would be better than any form of a Threadlift.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I had a baby about 16 months ago and still have a little pooch I cannot get to go away. I am interested in finding out about whether lipodissolve, smart lipo, and liposuction and seeing which one may be best for me.

A: Pregnancy does one thing that works against the effectiveness of any fat reduction method alone…it changes the abdominal skin. By stretching out the skin and losing some of its elasticity for most women, the abdominal pooch problem is often a combination of extra skin and fat.

It may be possible that liposuction (Smartlipo or traditional) alone will provide a satisfactory result for that abdominal pooch. But in most cases it has to be combined with some form of skin removal, maybe just a mini-tummy tuck will suffice.

One observation about Smartlipo that has become apparent to me over the past year is its apparent confusion as being different than traditional liposuction. Smartlipo is still liposuction and is invasive. It is simply a different and improved method of initially melting and loosing the fat before it is suctioned out. For whatever reason, patients often mistakenly think that Smartlipo is not surgery and is not liposuction.

The use of fat-dissolving injections for body fat removal has largely been relegated to a non-role in body contouring today. Despite its popularity from several years ago, it has failed to live up to the results we had hoped. While it can have some effectiveness, the fat areas must be quite small. Even in small areas, the use of Smartlipo under local anesthesia produces better results in a single stage procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q : I have heard that regular use of Botox and injectable fillers over years can reduce the need to do them so often. Is that true or just wishful thinking?

A: Recent research presented at plastic surgery meetings have indicated that such a ‘rumor’ may have some truth to it. A study out of Oregon looked at women between the ages of 30 and 50 who received Botox every four months for two years. After that time, the frequency of their injections could be adjusted down to every six months and still have sustained satisfying results.

The same observation has been seen with injectable fillers. If the treatments are done long enough, they seem to be needed less often. One possible explanation may be the filler’s ability to stimulate new collagen.

Is less Botox and fillers really needed if they are done long enough? One of the problems is assessing long-term effectiveness is that it is very subjective and not able to be quantified objectively. Can facial muscles be re-trained by long-term Botox?  Can injectable fillers create new collagen? Or are these apparent effects more of a function of the patient being able to tolerate a few wrinkles longer or less full lips or deeper nasolabial folds between injection sessions? The economics of regular injection treatments can certainly make patients space out their injection treatment intervals and still be satisfied.

It is tempting to want to believe that Botox and filler’s effects have some long-term benefits after they wear off…but it is far from a proven fact.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I suffer from a condition called Geniospasm, which affects the mentalis muscle.
I have read that it might be possible to treat this condition with Botox injections.
Have you had any experiences with this condition? What are your thoughts?

A: Geniospasm is a rare movement or tremor disorder of the mentalis muscle of the chin. Because the muscle has its origins from the bottom of the chin bone and inserts into the soft tissue of the chin and lower lip, involuntary up and down movements of the chin and lip will result. They are uncontrollable and episodic which makes it a socially embarrassing problem.  Interestingly, it has been shown to have a genetic basis being linked to chromosome 9q13-q21 and is reported to have a strong autosomal dominant inheritance pattern. The movements are usually continuous albeit at a low level. (i.e. a tremor) But stress and other triggersd may make it go into more obvious spasm.

While I have never seen in my Indianapolis plastic surgery practice a patient with geniospasm, I am certain that Botox would be an excellent treatment. Since Botox is a muscle paralyzing/weakening agent, it would work quite well.

While I have not treated a patient with this specific mentalis disorder, I have done numerous mentalis muscle injections for dimpling and unaesthetic contractions of the muscle causing chin soft tissue deformities. I have found Botox (or Dysport) to be very effective for this muscle problem. While the injections are not permanent, you should expect about four months of relief before additional injections would be needed. Most patients will need about 20 units as a startign dose whichi will have to be individually tailored based on response. (more or less units) After injection, results will be seen in about seven to ten days.

Another treatment option could be selective resection of portions of the muscle done from inside the mouth. This may help break the muscle spasm in the resected areas.

Dr. Barry Eppley

Indianapolis, Indiana

Q: The procedure that interests me is the one that will reduce the size of my buttocks.  I am in good shape and target workouts to the area, but my  buttocks hangs down over the gluteal crease and no matter how much I strengthen those muscles, I am not getting the results I want. I would like to somehow reduce the area.  I have already had liposuction on pther areas but my my doctor did not want to treat my buttocks as she feared there was a risk that the buttocks would droop more after liposuction.  I will continue to workout my glutes to raise them by strengthening the muscles, but I think that I will still want to reduce it by removing excess tissue because it is still too large in proportion to the rest of my body.  What are my options for this surgery?

A: Your description describes perfectly a lower buttocks lift. Used for correction of buttocks ptosis, it removes the part of the buttock (skin and fat) that overhangs the gluteal crease. Your plastic surgeon was wise to avoid liposuction of the lower buttocks as that would accentuate the problem, creating what is known as the ‘banana peel’ buttock deformity. This is a very effective procedure but you are correct in assuming that it leaves a residual scar.

The biggest issues with a lower buttocks lift is the scar location and what one was must refrain from after surgery for up to a  month. The scar will be at your existing lower buttocks crease, maybe ending up just a smidge higher. To prevent wound healing problems, such as incisional separation, one needs to avoid 75 to 90 degree bends particularly during exercise. I have never seen problematic scars or patients unhappy with the scar results. But I certainly have seen wound separation issues.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I was looking at having breast augmentation done. One of my breasts is larger than the other. But I was woundering if you could use instead of saline implants fat from somewhere else on my body, like my stomach area?? That would solve two problems at once!

A: The appeal of using fat instead of a synthetic material certainly is of interest to some patients. If fat worked just as well as implants, and was no more costly to perform, then it truly would be a better option. However, as of today, fat remains a breast technique in evolution and development. The harvesting and injection of the fat are standard plastic surgery methods. However, fat after injection is not yet completely predictable and is prone to resorption, uneveness and lumps. It is also highly likely that multiple sessions of fat injections would be needed to get close to what most women would want. With multiple treatments, the cost would exceed what breast implant surgery would cost.

Scarring and lumps in the breast are also a concern for long-term breast cancer surveillance. It is not yet known if fat grafts into a non-reconstructed breast who has not had a mastectomy interferes with the detection of breast cancer.

Until the science of fat transplantation is better understood, fat injections into the breast should only be considered for those patients who are willing to accept the risks that come with being an early adopter of a surgical technique. For now, the use of a breast implant is more predictable and economical.

Dr. Barry Eppley

Indianapolis, Indiana

Q:Hi Dr Eppley i just read your”The Advantages of a Chin Osteotomy Vs a Chin Implant ” paper. I have a medium to small chin deficiency and am a  male  that is 41 years old. Is bone resorption something to worry about in the long time results with silicone chin implant? Thanks a lot!

A: The phenomenon of chin implant bone resorption, or the implant ‘settling into the bone’, is well known but is rarely of any clinical significance. This is a natural phenomenon when large chin implants are used. The pressure put on the underlying bone from the stretched overlying soft tissue is transmitted through the implant. Since the implant is composed of a non-resorbable synthetic material, it can not change from the overlying pressure. To accomodate the pressure, the underlying bone may resorb a little bit. This will allow the implant to settle into the bone which can be seen quite clearly in a profile x-ray.

This implant settling causes no problems other than perhaps the loss of a millimeter or two of chin projection. Since this resorptive process is so gradual, one would never know it. In most chin implants, however, this does not occur as smaller implants do not push on the chin soft tissue as much.

This potential bone change should have no bearing whatsoever on whether one chooses a chin implant or a chin osteotomy. The degree of chin shortness and the age of the patient are the most important factors in the choice one can make for chin augmentation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am very interested in breast augmentation.  I have been pregnant four times and between weight gain and loss my breasts are in need of some repair.  Do you think I will need a breast lift also?

A: The anatomic determination of whether any breast needs lifting is based on where the nipple is sitting relative to where the lower breast crease or fold is. If the nipple is at or above the lower fold, one will not need a lift in combination with breast implants. If the nipple sits below the fold, whether it be a little or down so far the nipple points to the floor, then a combination implant and lift will be needed to get a well shaped breast that has the nipple centrally positioned on the mound and pointing forward.

When a women has had more than two pregnancies, it is almost a certainty that a breast lift will be needed. I do not recall ever seeing in my Indianapolis plastic surgery practice a patient with three or four pregnancies who has not needed one. When you combine the number of pregnancies with up and down body weight, there has undoubtably been a lot of stress and strain on the breast skin. This translates into breast skin that is loose, deflated and has a low nipple position. This will happen to most breasts whether one has breastfed or not.

A breast implant will add volume to the mound but will not significantly lift a downturned or low nipple position. That is exactly what a breast lift does…get the nipple back up to where it once was or close to it. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: I have had an overaggressive weir excision to my nostrils, causing my nose to look unbalanced. I also have difficulties breathing as my nostrils are always flaring. I have read your website and other studies with regards to fixing the problem with concha cartilage. In your opinions, is that a feasible option aesthetically or will it result in unnaturalness? I am wondering if I should just live with it and flare my nostrils all the time or get it fixed. It is impacting me very much emotionally as well. But I don’t want to end up like Michael Jackson with no nose.

A: The removal of skin from the inside of the nostril where it comes down and joins to the upper lip is known as weir wedges. Removing skin in this area is a rhinoplasty technique that is designed to narrow the nostrils for those whose nostrils are flared, too wide, and are not in balance with the rest of the shape of the nose.

Overresection of the nasal base, or narrowing the nostrils too far, not only can give a pinched look but can cause difficulty in breathing through the nose. Collapsing the wing of the nostril (lower alar cartilage and nostril rim) can cause narrowing of the important internal nasal valve, an important area inside the nose which plays a major role in breathing. 

Correcting nostril stenosis requires replacing what has been removed in the area where it has been removed. This can be done with a composite cartilage and skin graft from the ear. While this will work, one has to be aware that the graft may be slightly visible as the skin color between it and the nasal skin will not be perfectly matched.

Whether one should consider correction of nostril stenosis from a prior rhinoplasty or injury depends on how severe the nasal breathing problem is and how unbalanced the nose looks. If both are significant, then I think it is reasonable to undergo it. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: I have two scars, one on each side of my head from previous surgery (about 1.25 inches by 0.25). I was wondering if it was possible to make them less noticeable?

A: While all lacerations and surgical incisions leave scars, scalp scars are unique in what makes them visible. That is the fact that they occur in skin that contains hair. Any loss of hair along an incision or scar in the scalp will result in a wide and visible scar. The same scar somewhere else on the body may not be as noticeable as there is only the color change in the skin that draws attention to it. Scalp hair follicles are frequently injured during incision and lacerations and sometimes even from the suturing and stapling that is done to close them. It is actually fairly uncommon to not have scalp hairs injured dueding handling.

Scalp scar revision is done by cutting out the non-hair bearing scar and bringing the edges of the scalp that contain hair together. The scar will end up better and less noticeable if the distance between the skin that contains hair ends up less wide. My Indianapolis plastic surgery experience is that most scalp scars can be made better but there are certain surgical manuevers that must be done to increase the chances of improvement.

Handling of the unscarred scalp is critical to not injure new hair follicles that will make up the edges of the scar closure. Scalp scars do not tolerate tension very well at all and the tissues must be elevated sufficently to allow for as tension-free closure as possible. In some cases,a straight line closure must be changed to an irregular one, such as a w-plasty pattern, to distribute the tension better and get ‘fingers of hair’ to interdigitate with each other.

Dr. Barry Eppley

Indianapolis, Indiana

Q : I have a medpor chin implant as part of some cosmetic surgery 4 years ago.  The implant is eroding the bone and my oral surgeon says it must come out.  He doesn’t want to replace it.  I am in no pain and I like the way I look.  Do I have to have this surgery to remove it?

A: Medpor chin implants have a uniquely porous material of which they are composed. One of the purported benefits to its material is that it will cause less bone erosion underneath when it is placed in the chin area. The phenomenon of the implant settling into the chin bone is known as pressure resorption. This unique chin implant phenomenon has been recognized for decades. It is a natural phenomenon and is very similar to what is seen in breast implants. When breast implants are replaced many years later, the underlying rib cage will often have a concave surface or bowl where the implant sat. Such bone resorption is what happens when the soft tissue is stretched by an implant, it pushes back just a little bit over a long time. Since the synthetic implant is a solid non-resorbable material, the underlying bone relieves itself of the pressure by some resorption. ..and the implant settles or erodes to some degree into the bone.

While you may have some chin implant settling into the bone as evidenced on an x-ray, it is not a problem in my opinion. You have no symptoms and you are satisfied with your existing chin projection. Surgery to replace your chin implant seems to be an overreaction to a non-problem.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Can a chin implant be an alternative route to mandibular advancement? I went to the orthodontist today for my overbite and excessively gummy smile and was told that my options are to get the Lefort maxillary surgery (or place 2 screws on my upper jaw and have wires pull my teeth-in  sections via braces- upwards to reduce the gummy areas) and mandibular advancement.  Read about LeFort and mandibular advancement and don’t think I want to go through all the pain and side affects so I looked into chin implant and I am entertaining the idea of a chin implant and the 2 screw method to pull my teeth upwards….. any suggestions?

A: Both chin augmentation and mandiibular advancement will have similar effects on the chin…bringing it further forward. How much each approach will bring it forward is more adjustable with a chin implant as different sizes can be chosen. In mandbular advancement, the chin will only be brought forward as far as the jaw comes forward and the teeth still fit together properly.

Chin augmentation is certainly a far easier and more efficient choice if the primary motivation for the surgery is the aesthetics of the chin. But it will not obviously change one’s bite so there may be some functional chewing and temporomandibular joint tradeoffs if the lower jaw is significantly short.

Mandibular advancement is a commitment both in orthodontic preparatory time and in surgical recovery. Therefore the amount of jaw shortness and how well one is able to chew and bite comes into play as to whether this effort is worth the risks.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I was wondering if a scar on my forehead can be improved by plastic surgery. Two years ago, I fell and had a deep cut into between my eyebrows. Even though it was stitched up in an emergency room, it has still left a very noticeable scar. Because of where it is located next to my eyebrow, it always looks like I am frowning even though I am not. I am only 29 and don’t want to look like I am scowling or have wrinkles at this age. Would scar revision be helpful?

A: Scars are particularly noticeable when they are in unnatural locations. Whle most people will eventually develop some vertical lines between their eyebrows due to excessive muscle activity (expression), that is not a ‘natural line’ for a younger person. Having seen such scars in this are before, they are noticeable because they are indented along the scar line. This creates a vertical groove which can certainly look like a deep glabellar furrow or wrinkle.

Unlike expression-induced glabellar furrows, Botox is not an answer because it is caused by injury and scar. The problem is in the skin and not the muscle. Most scars in this area can be significantly improved by surgical scar revision. By cutting out the old scar and closing the line in an irregular (running w-plasty) pattern, the scar will usually become much less noticeable. Not only in the scar line no longer completely straight but it will not indent and be smoother. This simple procedure can be done in the office under local anesthesia.

While scar revision is not  a magic eraser, it can reduce its appearance to be much less noticeable.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am a 58 year old female who is looking for a highly qualified plastic surgeon to perform a breast reduction surgery.  I need to be able to work with someone who can help me get my insurance plan to cover the cost as I feel this is medically necessary.  I honestly don’t have a clue how the insurance works in a case such as mine . My health issues include fibromyalgia, arthritis, diabetes type 2, GERD, chronic depression, and anxiety disorder.  I had a back surgery in 2008 for a lower back condition that required a L5S1 partial laminectomy, spinal fusion, surgical hardware, and a bone graft.  I have arthritis in the rest of my spine as well.  I have many issues with headaches, neck pain, shoulder and back pain.  I also have problems with rashes under my breasts and bruising caused by wearing underwire bras for support.  My bust size is a 44DD and, although I am not a small person, the size has become a hinderance to me as far as activities, heat intolerance, and the pain I live with daily.  Please let me know if you think there is a chance we might be able to have a reduction covered under my insurance.  I simply cannot afford to pay for any kind of health care or surgery on my own.  Thank you for your time.

A: Breast reduction is often covered by one’s insurance if you qualify by their standard and well-known criteria. These include the following three items that your insurance will evaluate. First, you can not be obese or significantly overweight. One should not be more than 20% over their ideal body weight. If you are, you will be told by your insurance company that you have to lose weight to qualify. Secondly, you must have symptoms of back, shoulder and neck pain that has NOT responded to three months of conservative management such as physical therapy and/or chiropractic therapy. Such treatments must have documentation, not just saying that you have had them. Lastly, the amount of breast tissue that is going to be removed must be of a certain amount based on a calculated number known as your BSA. (body surface area) If the amount of breast tissue that can be removed does not meet the amount based on your BSA, you will be denied.

All of this information is put together in a letter, written by your plastic surgeon, and then sent in to the insurance company. This is known as a pre-determination. One then waits to get back written approval or denial before ever proceeding to breast reduction surgery.

Dr. Barry Eppley

Indianapolis, Indiana

The first of the month of July marks the first visible sign of the recently passed Health Care Reform Act. You might not notice it unless you are paying to get a tan. The 10% tax on tanning salons has gone into effect and it will cost you that much more to get one now. Tanning salons were easy targets for Washington legislators. With analogies to tobacco and alcohol, its association with increased skin cancer risks made it easy pickings with no significant protest. The initial cosmetic target was a Botox tax but that ran aground due to being a gender-biased tax. The elephant sitting in the room with the tanning salon tax is that it is a racially-biased tax…but I digress.

The debate over the Health Care Reform Act is all but a faint rumble now but it was really a largely economic and taxing exercise over an issue that has long been decided. With Medicare and Medicaid now making up well over half of whom most doctors and hospitals service, and with the percent growing, we have insidiously grown into a nationalized health service that existed before this recent discussion. Throw in the large Veteran’s Administration and military service health facilities and the government is by far the biggest payor for our nation’s health. The recent legislation was merely the tipping point that made the path to greater government control over heath care just go faster and even more evident.

While many clamored that the health system in the U.S. was broken, the reality is that it functions pretty well but is overwhelmed with demand that exceeds the economics to pay for it. The idea of insurance coverage and a societal safety net established in the 1960s never could have envisioned the population demand and the magnitude of health care advancements that have occurred in the past forty years. The very feature that makes our health care system the best  in the world…a system driven by entrepeneurship…is exactly what is making it suffocatingly affordable to many individuals and businesses now.

The one certainty that will result from this legislation is that you will be paying more…and eventually getting less. No matter how it was painted and sold in Washington, this is an absolute certainty. As a result, we have been seeing for the past few years the development of the field of  concierge medicine. As a fee for service concept, you pay a flat fee per year for an individual or family and get access to medical care 24-7. Various tests that may be needed are still billed to your insurance company. This allows you to use your health insurance as a catastrophic plan (and even a one day stay in the hospital can be an economic catastrophe) and pay lower premiums. This may only lower your out-of-pocket a little but it changes the level of service and cuts down on the amount of paperwork needed for doctor visits, etc.

While concierge medicine may not be the right choice for everyone, it is taken out of the playbook that plastic surgeons have used for decades. Elective cosmetic surgery, such as breast augmentation, facelifts and tummy tucks, is the original form of the concierge medicine fee-for-service concept. The idea of paying a fixed price for a certain medical service is re-emerging and will become increasingly popular. As more doctors withdraw from Medicare and Medicaid, due to the abysmal reimbursements and the labryinth of befuddlling paperwork and coding schemes, cash providers and practices will again become more commonplace.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Hi, I’m an Asian female in my late 20s. Over recent years, my jaws have become really prominent, making me look somewhat masculine and heavy. Looking for a way to reduce the angle of my jaw, I found the masseter reduction with botox injection on the web. Since I don’t want to change my bone structure, I came to consider botox as a solution. My only concern is how much the cost would be. I know it is hard to get an estimate before I visit you, I’d have even a ball-park idea about the money I should pay, including consultation fee. Could you please let me know  the range of cost? Thank you so much!

A: The protocol for Botox injections for masseter muscle reduction along the jaw angles is a one year program.  It has been shown by multiple studies that it takes at least three injection sessions to get the most muscle reduction. Since the effect of Botox is approximately four months, injection sessions are done every four months for one year. Results are usually seen as early as a few mmonths after the first injection session. The amount of Botox should be a minimum of 25 units per side or 50 units per injection session. More may be needed in men depending upon the size of the masseter muscle. While the cost per unit of Botox varies greatly across the country, in my Indianapolis plastic surgery practice the cost of such a treatment session would be around $ 700.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I was very impressed by your comments on lip lift. I feel confident that you understand more about this procedure and the possible things that can go wrong than other plastic surgery websites I have seen. Since I have had two prior rhinoplasty surgeries, will this procedure affect my nose? Some surgeons have said that I would need another operation on my nose if I were to have a lip lift. I really don’t want to touch my nose again. I’m happy with it and just want to leave it alone. If a lip lift will alter the shape of my nose, then it’s probably not the best option for me.  In terms of why I need the lip lift. I’m only 30 but have always had a VERY long lip lift. My lips themselves are very full and attractive, but even when smiling, you can’t see ANYTHING of my upper teeth and I feel that it’s quite a big thing and stops me looking as attractive as I otherwise could be.

A: I do not know of, nor have I ever seen, any problems with a lip lift affecting the shape of the tip of the nose. A lip lift is a simple removal of skin at the base of the nose. It does not, and should not, remove any muscle from the subnasal area. In theory, I can see how it is possible with too much skin removal to pull down on the columella causing distortion of the nasal base. But the skin resection should never be greater than 1/4 to 1/3 of the vertical skin height along the philtral columns. Since there is no recovery (replacement) of too much skin removal, it is always best to not be too aggressive in the lip lift procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Hi Dr Eppley, I was wondering if fillers can be used on a sagging elbow area instead of the surgical procedure?

A: Sagging of skin around the elbow area can be the result of age, body type, and weight loss. Most commonly I have seen it to be an issue in the extreme weight loss patient (greater than 75 to 100 lb weight loss) and it is one of the areas dealt with using bariatric plastic surgery techniques. While the usual approach to loose skin is to cut it out, the creation of a scar around a joint area can be problematic. The skin around joints, such as the elbows and knees, is not meant to be fixed. Rather it needs to have some flexibility and movement so the joint can go through its range of motion. Scarring around the joint may cause joint motion restriction in the long run and wound healing problems in the short run. (motion across a suture line) Known as elbow or knee lifts, the excision of loose skin must be carefully done to avoid these problems.

I suspect in this question that it is not a weight loss issue. Rather it likely  is aging and the development of some loose skin around the elbow in an otherwise non-overweight person. (can particularly happen in an aging thin person) Therefore, excision and the scar that it creates is not an acceptable solution. This changes the approach to maybe an opposite solution…filling or reinflating the tissues. While injectable fillers can be placed anywhere, their temporary effects and the large volumes needed for a body area make them impractical. The only soft tissue filling option to be considered would be fat grafts. Harvested by liposuction, fat can be purified and then reinjected into soft tissue spaces. This is the only option I would consider when it comes to injecting any body area.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I have a deep vertical line in between my eyebrows that is still noticeable despite having Botox injections. I was wondering if endoscopic browlift could correct this. Im only 27 years old. Please help.

A: The development of vertical wrinkles between your eyebrows, known as the glabellar area, is common and is the result of excessive muscle activity. There are a set of six paired muscles that affect the glabella area and create what has been described as a number system of galbellar wrinkles or furrows. As the popular ad goes, are you a 1, 11 or 111? These numbers describe whether one has one, two or three vertical glabellar wrinkles.

The first approach for glabellar wrinkles is Botox which will be highly effective for most people. For many the wrinkling is completely or nearly completely gone by this temporary muscle paralyzing treatment. For those with more deeply etched glabellar furrows, Botox will soften it to some degree but may not reduce it enough for the person’s satisfaction. This is the result of the skin being ‘etched’ or having a permanent v-shaped change in the skin. Muscle paralysis will not change permanent deformation of the skin.

An endoscopic browlift will not create a better effect than that of Botox because it works on the muscle only. It may help decrease the long-term need for Botox and, rarely, the need for Botox at all.

A companion treatment for the deep glabellar furrow is some type of soft tissue fill.  Usually this is an injectable filler but its effect will only be temporary. More permanent options include the threading of an allograft collagen dermis material or actual synthetic implant. (e.g., Advanta)

Dr. Barry Eppley

Indianapolis, Indiana

Q: I have multiple lipomas over my arms and legs. Is there anything new to having them removed?

A: The standard treatment for lipomas remains excisional, making a small incision over the lipoma and pushing it out. While effective, this does result in a very small skin scar. While this approach is fine for several or even up to ten or so lipomas, it is tedious and results in many fine scars.

An alternative non-surgical approach is Lipodissolve injections. A needle is used to inject each lipoma with about a .5ml solution of phosphatidylcholine and deoxycholic acid. This is a fat dissolving solution that will shrink the size of the lipoma and in some cases get rid of it completely. Usually, however, it takes more than one injection to be assured of its complete eradication. If you are seeking a truly non-surgical approach, these injections are a treatment to be considered as long as one understands that more than one injection may be needed for maximal results.

Another ‘minimally-invasive’ approach is spot laser treatment. Using a Smartlipo (laser liposuction) fiberoptic probe, a nick is made in the skin and the probe is inserted next to or into the lipoma, it is turned on and used to heat up the lipoma until it is melted or destroyed. Like excision, this does require a local anesthetic.

Dr. Barry Eppley

Indianapolis, Indiana

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Q: I am interested in getting an inner thigh and knee lift procedure but am concerned about the scarring. I have looked on the internet but pictures of these type of scars seem hard to find. Do you have any suggestions about how I should make the decision for this kind of surgery?

A: Body contouring of almost any kind always results in scars. Short of scars on the face or breasts, most scars that result from body contouring procedures will not look as good as they do on these two areas. Regardless of even seeing good scar outcomes from these procedures, that does not mean that yours will turn out as well.

Therefore, the decision to go forth with any type of ‘leg lift’ should be based on the acceptance that the scarring will not be as good as you would like it. Scars are the lower extremities are never great. They are faced with too much tension and movement after surgery that always stretches them out to some degree. You have to decide which is more acceptable, the loose skin or the scars. If you can not accept the concept of scars or have any hesitancy about them, then you should not do the procedure.

My approach to scarring in body contouring surgery is…it is always about trading off one problem for another. The operation is good one for you if the trade-off into scars is better in your mind that the excess skin problem that you had before.

Quite frankly, mentally going through this thought process is better than looking at pictures of scars from the procedure. The people that are truly happy with the results from this type of body contouring procedure don’t care what the scars look like because they hate what they have now. That is the attitude to have the scarring, no matter how it looks it is better than this loose hanging skin that I have now.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I had jaw angle reduction surgery three months ago and I am unhappy with it. I wanted to make the thickness of my jaw angles more narrow and thought that Botox injections to the muscle would work. Instead the doctor told me that I needed bone removed instead. During surgery, the doctor cut off my entire jaw angle and I just don’t understand why? It’s make my face look too short now and I am less attractive than before. I am very sad about having this surgery.
I am only 32 years old and don’t want to live the rest of my life looking like this. I have attached some pictures and x-rays (before and after surgery) for your review. 

A: I have reviewed your case and the x-rays. What you had was a classic jaw angle reduction surgery. This is well shown on the x-rays and in your before and after photographs. Overall, I think the surgery was done adequately. One of the jaw angles has been cut off more than the other, accounting for the asymmetry in how the jaw angles look now.

For those seeking to get a narrower and less square face, this can be a good operation. One of the negative aspects to the procedure is that it makes the jaw angles blunted in addition to making it more narrow. In fact, it makes the jaw angles more narrow by virture of changing a square corner into a rounded one. That may not always be a good aesthetic trade-off. (and is what bothers you now)

In the desire to make a square face more narrow in a female, you have to distinguish between keeping the jaw angle square but making the bigonial width more narrow…or narrowing the width of the jaw angles but keeping the squareness to it. That is a very important distinction to make because achieving those looks requires two completely different approaches. The former needs to be done with Botox injections or doing a sagittal bone reduction in a flaring jaw angle (if present). The latter is done by the classic jaw angle reduction osteotomy. They both will make the lower face more narrow but the shape of the jaw angle will look different. Jaw angle reduction surgery makes the face look shorter in the back, muscle reduction or sagittal bone reduction does not create that effect.

The question now is. where do you go from here? Do you want some of the squareness to the angle back? If you do, then one may consider a thin jaw angle implant. (3 -4 mms) This will get the definition of the jaw angle and not add much width to it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: How come with breast augmentation the work seems flawless with no scarring at all. But with a breast lift, there appear to be scarring and are not always even. Your augmentation is beautiful, the best i’ve seen so far. I dont think I need an implant because I am already a DD.

A: Breast augmentation is virtually scarless because the small incisions that are used to pass the implants through are placed in very unnoticeable areas. Whether it be in the lower breast crease, around the nipple, or in the armpit, they are undetectable except on the very closest of inspections.  Breast implants do all the work of making the breast, including its new shape, and this makes it almost scarless.

Conversely, breast lifts must create their reshaping effect by removing skin. Because all aspects of the breast skin are in view in a well shaped breast mound, the scars are much more visible. In a typical breast lift, the scars will run around the nipple and vertically down to the lower breast crease. In more extensive breast lifts, the scar may also run along in the lower breast crease.

Unlike breast implants, which are symmetric in shape to start with and can be equal in volume, breast lifts are much more artistic in execution. They require a lot of judgment in how and where to cut the skin and, as a result, can not be expected to be as perfect in shape and symmetry as many breast augmentation results. 

Dr. Barry Eppley

Indianapolis, Indiana