Your Questions

Q: I have several old scars on my legs that really bother me. I had laser done on my scars over a year ago in a plastic surgeon’s office but I  don’t see any improvement. How can I get rid of my scars?

A: When discussing possible scar treatments, one concept that needs to be eliminated from any patient’s vocabulary is the phrase, ‘getting rid of scars.’ A scar represents permanent damage to the skin layer that once had normal tissue (with good color and suppleness) replaced by abnormal tissue. (depigmented, less pliable) Therefore, the realistic goal is scar reduction not scar elimination. This is why the term ‘scar revision’ is fairly accurate, the scar may be improved but it is not completely eliminated.

While scars on the face represent the best opportunity for maximal scar reduction, scars below the neck are not so forgiving. This is because trunk and extremity skin is thicker (thicker dermis creates more scar) and the healing wounds are exposed to more shear and frictional stresses which work to stretch out the scar. Therefore, non-face scars never (and I emphasize never) can look as good as facial scar work no matter how it is done or by whom.

Leg scars represent the least successful area for scar revision on the body in my Indianapolis plastic surgery experience. They are particularly refractory to any significant improvement for the reasons stated above, particularly below the knee. The thickness and tightness of the skin in this area makes scar revision work difficult.

Lasers are often touted and perceived as having some magical properties for scar improvement. While lasers do have a role in scar treatments, it is not a dominant one. They are best used as a finishing treatment for some minor skin resurfacing or retexturing. They are not like an eraser tool on Photoshop.

Dr. Barry Eppley   

Indianapolis Indiana

Q : My jaw is asymmetrical. It is tilted and is also bigger on one side. I have read some of the articles you have written on facial asymmetry and wanted to ask you about how best to correct my problem?

A: Jaw or mandibular asymmetry is often a major cause of facial asymmetry. Often the entire side of one’s face is different if one looks for it carefully. Sometimes it is the lower face (jaw) that is the most significant part, other times the cheek, orbital, and forehead bones are equally involved and part of the problem. It is critically important to assess both sides of the face from top to bottom with photographs and measurements from different angles to get an accurate assessment.

In most cases of minor to moderate facial asymmetry, camouflage techniques are used. This means the use of facial implants to lengthen and broaden the smaller and flatter facial prominences. These are good options for jaw angles and cheeks. Chin asymmetry is often better done with osteotomies where the bone can be differentially lengthened between the vertically shorter and normal sides. Soft tissue deficiencies can be simultaneously improved by fat injections.

If significant facial asymmetry exists and one’s occlusion (bite) is very tilted, another consideration is orthognathic surgery. In younger patients this may be a better option if one is prepared to go through several years of preparatory orthodontics and then jaw surgery to directly treat the primary bone, differential bone growth.  

Dr. Barry Eppley

Q : I would like information on the horizontal chin reduction procedure.  My chin juts forward to a point (witches chin) and I think it being reduced would really help my appearance.  Most interested in knowing how the procedure is done, down time needed for recovery, surgery location (outpatient in center or hospital, or in physician’s office),  and rates of success.

A: A big chin (macrogenia) can be either too far forward (horizontal excess), too long (vertical excess) or a combination of both. Determining the 3-D dimensions of what makes the chin too big is important as it can change the method by which the chin is reduced.

Horizontal chin excess is best reduced through a submental (under the chin) incision rather than from inside the mouth. This is because it is important to properly manage the soft tissue excess which will result once some of the bone support is removed. If the soft tissues are not removed and tightened, one will end up with what is known as a witch’s chin deformity. (exactly the appearance of what you wanted to improve in the first place!)

The chin is horizontally reduced by burring down its prominence and tapering the bone into the sides of the chin. The mentalis muscle is brought down over the underside of the reshaped chin and any excess removed as it is re-attached to the its fellow muscle. Likewise, redundant skin and fat are removed so that the chin soft tissues are nice and tight.

Chin reduction surgery is done as an outpatient surgery under general anesthesia. It takes about an hour to perform. The chin is taped and will be sore but there are no restrictions after surgery. It takes about 3 weeks for the chin swelling to largely go away and it begins to feel normal again. The success rate is 100% in terms of having less horizontal projection. The usual amount of actual horizontal chin reduction  that is achieved is from 5 to 8mms.

Dr. Barry Eppley

Q : I have broken my cheekbone 2 times and never had surgery. Now my face is assymetrical and I have frequent headaches and can’t breath thru one side of my nose. People close to me say that my face looks caved in. It also affects my vision and I sometimes have localized pain in my cheek. Do you think my insurance will pay for reconstructive surgery? How would this be fixed?

A: Cheekbone, or zyomatic or malar, fractures are common facial bone injuries. They are second in frequency to the most common facial fracture, that of the nose. When a cheek bone fractures, a classic set of problems results from the bone rotating downward into the maxillary sinus. The cheek prominence will become flatter (caved in), one may develop sinus congestion, and numbness or pain may occur from the infraorbital nerve being bruised or pinched. (the fracture line usually goes through the nerve foramen) It does not usually cause any vision problems.

If not repaired early, the secondary cosmetic deformity is that of an asymmetrical face with a flatter cheekbone prominence. There are two ways for its correction after the bone has healed. Building out the depressed cheekbone with a cheek implant is often very successful and is certainly the easiest. The other approach is to re-cut the cheekbone and move it back into its proper place. This is obviously more complicated with a longer recovery but can also be successfully done. Which approach is best is largely determined by the magnitude of the cheekbone depression and whether it extends into the surrounding orbital (eye) area.

Typically, reconstructive surgery from a facial bone fracture should be covered by one’s medical insurance. However, this must be determined by a written pre-determination process before proceeding to surgery.  

Dr. Barry Eppley

Reality TV is often far from ‘reality’ but sometimes there is a kernel of significance in a portion of a show. In a recent episode of the ‘Real Housewives of New York City’, one of the women accompanies her friend to a plastic surgery consultation. During the show, she recommends and helps her friend to ask the plastic surgeon some important qualifying questions about liposuction in which she has interest. During the consultation, the women asked the plastic surgeon if he was board-certified and when, did he have  operating privileges at a hospital for the procedure in question, and if he was a member of American Society of Plastic Surgery.

While these questions would no doubt bring acclaim for our national organization, these queries today can be answered long before you ever enter a plastic surgeon’s office. If you have to get these basic qualifying answers from a personal visit, you mustn’t have a computer in your house or have never ‘Googled’ or ‘Binged.’

Historically, patient’s were advised to ask a basic list of questions to their plastic surgeon to be certain they were qualified to perform the surgery. These included board certification and in what specialty, society membership and hospital privileges. While these are still good questions, they are so simple to find and don’t have the significance that they once did. If the plastic surgeon doesn’t have a contemporary website that easily provides this information, I would quickly move on to one that does. An informative website for a plastic surgeon, or any business for that matter, is an essential as any individual having a cell phone. If one isn’t investing in an internet forum for patient education, I doubt if they are investing much in advanced medical education either.

With today’s ease of information gathering, photo acquisition, and methods of presentation, contemporary plastic surgery qualifiers are much different and more defining. I believe these are the more relevant questions to search for in finding a qualified plastic surgeon.  They include photographic demonstration, recent patient experiences, and educational information.

Photographic publication surrounds us at every corner today. Whether it is on Facebook or other social media, even the most basic cell phone can take a pretty good picture. Plastic surgeons are the most advanced and proficient of all medical specialities in photography on average. Therefore, one should come to expect a good demonstration of a plastic surgeon’s most valued asset, before and after patient photographs. While it is true that any business is going to put out its best results, at the least you need to see a handful of actual patient before and after photographs. The more, the better.

A past customer’s experience is a good barometer of service and results for any business. But a patient who had surgery a long time ago is not as useful as one who has had a surgical experience in the past weeks to months. Fresh experiences are what you need and preferably from more than just one patient. Having a  recent patient also suggests that the procedure is performed more than just a few times a year.

Brochures and flyers are standard educational pieces in any plastic surgery practice. But there are so many boiler-plate pieces that are available to purchase for any plastic surgery procedure that they are not only unimaginative but provide generic (and often useless) information as well. What you want to see is customized practice information that provides detailed and meaningful procedure information that reflect’s what that plastic surgeon specifically does. You want to know what this plastic surgeon does, not what the ‘average’ plastic surgery approach is.

Dr. Barry Eppley

Q: I am inquiring about the correction of a pixie ear deformity from a previous face lift done two years ago. I have read about so I know what it is. How did this happen and how can it be corrected. My ears really look funny and that is not a good look for someone 55 years old!

A:  The pixie ear is a well known earlobe deformity that can occur after a facelift. It has been described for decades and, while once more common, modern facelifting techniques have largely eliminated this problem.

While folklore pixies are usually cute and even beautiful, they often have distorted facial features. One of those is the elongated earlobe, hence the name pixie ear deformity. If a facelift is pulled up too much (undue tension), there will be some secondary pullback of the tissues later due to gravity and wound relaxation. Since a facelift incision goes around the ear, the earlobe at the lower end of the facelift incision can show how much the tissues have pulled back down. Because the earlobe is the only portion of the ear that is not supported by cartilage, it can easily be pulled downward months later as tissues settle. Since this is a well recognized potential problem, plastic surgeons strive to keep the tensions point on the scalp areas above and behind the ear and not on the earlobe. It is also helpful to not try and pull a facelift so tight.

Correction of the pixie ear is relatively simple. The earlobe can be detached and restored to its normal shape. This will leave a small residual scar below the earlobe but it can be done in the office under local anesthesia. If it has been years and some jowl or neck relaxation has occurred, one can undergo a simple tuck-up facelift and restore the earlobe shape. By relifting some small amount of loose facial skin, there would be no visible scar below the earlobe as it is tucked back up underneath.

Dr. Barry Eppley

Indianapolis Indiana

Q: Hello, I am in the beginning stages of finding a surgeon for breast implant replacement to suit my needs the best. My previous surgeon has since retired and my breast implants are almost 10yrs old. They are saline and I am now a D cup but was a C cup when they were new. I don’t think the increase is due to weight gain.  I think its because they have dropped a bit. What do you recommend in regards to implant replacement.

A: The ‘need’ to replace breast implants occurs either to a desire for some type of further enhancement (size change) or an existing problem with one of both of the implants. When it comes to saline implants, the absolute need to replace them is when one fails or deflates. There is no need to change just because they are getting older. My Indianapolis plastic surgery practice motto has been on this very subject…’if they look and feel fine, then there is never a need to replace a saline breast implant.’

That being said, most saline breast implants will eventually undergo a deflation usually in the 10 to 20 year range after their initial placement.

One of the unrecognized (by patients) phenomenon of breast implants is that they can change position over time. Whether it be weight loss, pregnancy, or a larger size implant, the soft tissue containing them can and often does change. When the soft tissue around the implant changes (stretches or relaxes), the position and shape of the breast may soften and settle. In larger implants, their size and weight may cause the lower breast fold (inframmary crease) to drop. This sounds like what has happened in your case.

While silicone gel breast implants were not available 10 years ago, you should seriously consider converting to them at this point if you are looking for further breast improvements. They will not have rippling and may feel softer and more natural. You would also eliminate the lifelong risk of a spontaneous implant deflation. When replacing the implants, you may also consider repositioning of the lower breast fold back up higher to correct any implant bottoming out that has occurred.

Dr. Barry Eppley

Q:  I was just wondering if I am a good candidate for a tracheostomy scar revision. I had a tracheostomy back in 2005 and never knew that a revision surgery was possible until recently. I am really self-conscious of this hole in my neck. Plus it constantly reminds of why it is there in the first place. (a car accident)

A: Tracheostomies that remain in for any extended period of time (weeks to months) will often leave a depressed scar once they are removed and heal. This is the result of a phenomenon known as pressure atrophy of the subcutaneous fat. The pressure of the tube and the subsequent scar that it creates results in fat loss and tethered or scarring down of the skin edges. Tracheostomies wounds are now closed after tube removal and are allowed to heal in on their own.

Some initial tracheostomy scars may look depressed or indented but may ‘fill out’ as healing progresses to an acceptable level. This is why I don’t do tracheosotomy scar revision in the first six months after tube removal unless the wound has real trouble healing. Conversely, it is never too late to revise the depressed neck scar.

Many tracheostomy scars can be improved by simple scar revision. Others may require some fat volume restoration with scar revision. I prefer a small dermal-fat graft to replace the lost tissues between the scar overlying the trachea and the underside of the skin. Even a small graft, 2.5 cm x 1 cm, can be really helpful. There is no substitute for your own natural fat for small areas of tissue filling. The graft can be easily harvested from old scars almost anywhere on the body.

Dr. Barry Eppley

Q: I have some acne scarring on my face that I`d really like to get rid of. I have a rolling icepick scar and I want to know if a deep chemical peel would help. It isn`t very deep. One maybe two layers deep. Help! What should I do?

A: To understand whether any form of skin treatment or resurfacing will reduce a specific scar, it is important to appreciate the depth of the scar compared to the thickness of skin. Then one can look at the treatment method and see if it can go to the level of the depth of the scar.

Let us, for the sake of this discussion, assume that facial skin thickness is 1mm or 1000 microns. (some areas of the face are thicker and some areas are thinner, but let’s use this simplistic number as it is easier to understand) The top epithelium usually occupies about 5% or so, around 50 to 75 microns. This is the part of the skin that peels and sloughs off and is easily regenerated. The rest of the skin, 95%, is a thicker collagen called dermis. It is into the dermis that all visible scars really go. Most visible scars are at least several 100 microns (100 to 500 microns) Pitted or icepick acne scars will usually go much deeper than even that level.

Microdermabrasion, for example, removes only 2 to 4 microns of skin. This is why it is not an effective scar treatment, it simple can’t go deep enough. Microlaser peels, or superficial laser peels, remove skin from 10 to 50 microns. They have a minor effect but it will take a lot of treatments to have any visible scar reduction. Deeper CO2 laser peels do go down 200 to 400 microns which is why they can be more effective for scar reduction. But a laser peel can not go too deep (greater than 400 microns or so) or it will be a source of its own scarring.

Chemical peels, even deep ones, do not reach these laser depths. This is why a chemical peel, of any sort, is not an effective scar treatment.

 Dr. Barry Eppley

Q: Hello there… I was curious on whether you dabble in computer imaging for let’s say a jaw enhancement procedure. Thanks.

A:  When considering structural facial alterations, as opposed to age-related changes, it is extremely important for the patient to have a reasonable idea as to what their face may look like. For this reason in my Indianapolis plastic surgery practice, I never do such facial surgery without computer imaging before surgery.

Several points about computer imaging, however, are important for patients to understand. First, facial computer imaging is a prediction but not a guarantee of results. It is the plastic surgeon’s best estimate of what he or she thinks may happen. But plastic surgery is not like Photoshop. How the body heals and responds to surgical manipulation of its tissues is not precisely predictable. Think of computer imaging as a communication tool primarily. It helps ensure that what the patient finds acceptable is surgically possible.

Secondly, the most predictable facial features to image are those that can be done in profile. With a contrast between flesh-colored skin and a solid color background, it is much easier to change the feature in a more precise manner. Therefore,  procedures that change the brow (brow bone reduction), nose (rhinoplasty), chin (chin augmentation/reduction), and neck (liposuction, facelift, tracheal reduction) can be imaged with reasonable realistic accuracy. Certain frontal (face forward) structures can also be done, such as the ears and lips, but most of the face is this view do not have good color contrast between adjacent parts.

Last, if you can not get computer imaging for these types of facial plastic surgery procedures…go find another plastic surgeon.

Dr. Barry Eppley

Q: I have read about using my own fat as an injectable filler. This seems like a perfectly natural, and if I must say, an obvious thing to do to build up certain body areas. Is it not widely done however and several plastic surgeons that I have talked to either don’t do it or seem uncomfortable or unfamiliar with it. Is this because it doesn’t work well or is there something unsafe about it?

A:  The concept of injectable fat grafting is in a state of development or evolution. Liposuction makes for an easy way to harvest an injectable natural material but its survival or retention after injection has been the issue. Using the fat suctioned from the body, technologies exist and are being developed to process the fat and extract and concentrate either the fat and/or the stem cells which naturally occur there. The concentrated fat with or without stem cell concentrate is then injected into the desired areas of the body or face.

Currently, more marketing than science exists about injectable fat grafting. Unfortunately, some surgeons actually tout that they have developed such a procedure and have ‘proprietary or special’ methods of their own to prepare an injectable fat concentrate. Multiple uses are being done from to facial or hand fillers. I have even read from some surgeon’s websites that their procedure ‘not only removes fat you don’t want, but it replaces it and changes multiple areas of your body, making for a more full-body change.’

 The good news is that injecting your fat poses no harmful effects other than it may not work well. The less than good news is that some are claiming benefits that have yet to scientifically substantiated or proven. Injectable fat grafts holds great promise and, for small volume areas like the face and hands, does seem to be significantly retained. Good success has also been seen in the buttocks although multiple grafting sessions may be needed to get the best size result. Other areas, such as the breast, are purely investigational for now and are far from a replacement for implant augmentation.

Dr. Barry Eppley

Celebrities who undergo plastic surgery without question have a compelling influence on the general population, particularly those under the age of 40. One has to look no further than the checkout aisle in the grocery store to see how celebrity visibility is thrust upon us. From these consumer magazines to numerous television shows, anyone with a Hollywood connection is tracked and speculated upon about their cosmetic surgery, even if they have never had it. The media’s desire to push these cosmetic surgery tales of the stars fuels the public’s obsession with discovering the secrets to what keeps the beautiful and famous looking so.

While the star’s experiences may fascinate, they do little to actually educate. It is easy to confuse entertainment with reality because it is simply more interesting. Take the recent case of 23 year-old Heidi Mondag who had numerous cosmetic procedures done to satisfy her narcissistic and career agendas. While she may have had a lot of procedures, they were all quite small in scope. Most of her procedures were really ‘nip and tucks’ and not major overalls. After all, how many physical problems could a young person really have particularly given her appearance beforehand?  But this is not how the media interpreted her surgery. Rather it was made to sound like it was a great undertaking and required supernormal surgical skills to complete.

These ‘tweakments’ are largely what is fueling the increasing visibility of plastic surgery. Botox, injectable fillers, lasers and minor skin lifts of the face have created a whole new set of treatment options that did not exist just a decade ago. While a 23 year-old partaking of this cosmetic menu does border on the overly self-indulgent, those in their late 30s and 40s have a more significant purpose. Fending back the early signs of aging is proving to be a more effective strategy than awaiting the day when major plastic surgery is needed. While my mother may have waited until retirement to wage the battle against the effects of time, today’s middle agers understandably what to look better and more rested now.

What is unique about these minimal procedures is that most of them are fueled and promoted by the cosmetic device and pharmaceutical industry. Plastic surgeons have taken a back seat to the promotions and marketing that billion-dollar-in-sales companies can do. The once retail approach to cosmetic and beauty products has expanded to include drugs and surgery. Targeting consumers through popular magazine and internet strategies, rebate coupons for Botox and eyelash stimulants are widely available as well as even franchise surgery for facelifts. Breast implant sizer kits are mailed to prospective patient’s homes with incentives for other procedures packed inside. Plastic surgeons collectively spend an insignificant fraction on marketing compared to that of the corporate world. This wave of industry’s promotion for profit and media attention for sales is why most people today know something about cosmetic enhancement and why it is now mainstream.

But like all entrepreneurial endeavors, making a profit and driving sales does produce some good byproducts that have wide benefit. Like the old commercial slogan from decades ago, there is ‘better living through modern chemistry’.

Dr. Barry Eppley

Q: Just wondering how common abdominal etching is amongst females.  Most research online seems to be pointing to men only. 

A: Abdominal etching is a plastic surgery procedure for the artificial creation of a ‘six-pack’ appearance. This is done through liposuction techniques by removing linear strips of subcutaneous fat to highlight where the muscular inscriptions would be. This creates indentations in the overlying skin which looks like muscular definition. It should only be considered in a fit individual whose has a limited fat thickness over the abdominal area. It not only works better in this type of patient but will also look more natural. I currently use a Smartlipo technique which has a 3mm wide probe and metal cover which creates nice thin tunnels with very small entrance incisions. The heat from the laser helps the skin contract down as well.  

You are correct in that it is much more commonly requested and done in men. That undoubtably reflects our current cultural fashion standards where men are defined by their muscle mass and definition while women are better appreciated for their curves. (history also shows that this is true through the ages) In my Indianapolis plastic surgery practice for every 10 abdominal etchings I have done, nine are done in men.  But I have done a few in women. 

The surgical technique is the same in women and is actually a little easier to do with more consistent definition in my observation. This is likely due to the thinner subcutanous fat layer that exists in most athletic women.

Dr. Barry Eppley

Q: Hello, I wonder if you can help my son (19 year of age) who suffers from low self esteem due to the appearance of his head size since he started school. He has seen  four psychologists and therapists to help him deal with his concerns. The problem is his head size which is too big. I know that nothing can be done to reduce the overall size of his skull but he also has very prominent brow bones which draws attention to his face making him more self conscious. Can anything be done about this?

A: Skull shape and size is one of the features of our appearance that we take for granted…unless it is too big or small and out proportion to the rest of the face. When the skull is bigger, a form of cosmetic macrocephaly, the sheer thickness and surface area of the bone make any reduction not practical to surgically consider.

It is not surprising that another part of the skull (brow bones) is big given the overall size of the skull. Changing something on the face that is likewise bigger and out of proportion as an alternative is a  form of  ‘camouflage’ and can be psychologically empowering. When faced with a physical problem that is unchangeable, being able to positively modify something else can be a good diversion that can provide some self-image enhancement.

Prominent brow bones are the result of overgrowth or pneumatization of the frontal sinus. Reducing them involves takes off the front table of bone, which is quite thin, and putting it back in a reshaped and flatter form. That can soften the forehead and orbital appearance which is where most eye contact in conversation is directed.

Dr. Barry Eppley

Q: I have multiple lipomas along nerves in my arm and am interested in finding out how to get injections to decrease their size. These lipomas give me pain because they are up against my ulnar nerve. I have about 80 lipomas all over my body. I am female, fit, 35, and frustrated with surgeries to remove them.

A: While the benign fatty tumor, known as a lipoma, are common soft tissues masses seen, multiple or many lipomas that recur in a patient is uncommon. When large numbers occur, they are as familial lipomatosis. Throughout one’s life new ones continue to grow and develop. Modern medicine does not have an explanation for why they develop or what causes them.

While I have had positive experiences with Lipodissolve in the treatment of more superficial lipomas, I would have concerns about injecting near a motor nerve. There is the distinct possibility that permanent damage may occur to the nerve, causing forearm and hand dysfunction. That is a risk that would not be a good trade-off.

Lipodissolve remains a non-FDA approved treatment method for any type of fat removal or shrinkage. It is not even a pharmaceutical-grade chemical as it is made through compounding pharmacies. While widely used as a cosmetic treatment for ‘dissolving’ fat, its use as a lipoma injection treatment has never been scientifically evaluated in any clinical trial method although anectodal reports exist that attest to its effectiveness. 

If these ‘lipomas’ in fact do involve or are connected to the nerves, they may well be neuromas or neurofibromas which would not be responsive to fat-dissolving injections anyway.

Dr. Barry Eppley

Q: I am interested in getting a portion of my skull reshaped. The top part is narrow and slopes off to the sides. As a man with shorter hair, it would look better if the top was rounder and didn’t slope so much. Can some material be added to build up these areas? There are also two smaller areas on the sides which need reduced. I have attached some photographs which show the areas that I am concerned about.

A: Thank for sending your detailed photographs. That is extremely helpful and you have clearly defined what your skull contouring needs are. There is no question that all of those contours issues can be done. Whether it is some side reduction by burring in the two spots you have indicated or adding a material (PMMA acrylic vs  HA hydroxyapatite) to give it a more rounded shape and decrease the slope, that is very straightforward from my standpoint. This is fairly simple craniofacial plastic surgery as it is outer table cranial contouring.

The most relevant question is one of surgical access. While all of those can be done, it is most ideal to do that through an open scalp incision. While you have a wonderful head of hair, this would leave a fine line scar. Given that you wear your hair very closely cropped, I would be concerned that the trade-off of this scar versus the skull contour concerns may not be a good one. I would need your further input on that issue.

Otherwise, there are some more limited injection methods to place materials under the scalp onto the skull bone. This is best done with PMMA which hardens after being injected and can be molded while it hardens. Such limited approaches do not provide enough access for the side bone reductions though. The other injection option would be to place fat grafts instead of a synthetic material. This can be done with a few simple punctures using your own abdomen as the harvest site. The disadvantage of fat grafts is their unpredictability of survival however and how smooth and even the contours would be.

Dr. Barry Eppley

Q: I am interested in some form of gynecomastia surgery. At one time I was much heavier and have lost a lot of weight through the help of bariatric surgery several years ago. Since the weight loss, much of my chest has not only gone flat but it sags with nipples that are very stretched out. My chest needs to be reshaped. Help!

A: Chest changes after weight loss are common in men. Men suffer a deflation of the chest soft tissues after bariatric surgery which is magnified by the usual presence of weight-related gynecomastia. This results in a skin sag with enlarged nipples that is particularly unflattering in a man.

Correction of this type of male chest wall change is not really gynecomastia surgery per se. There is usually not much fat or breast tissue to contend with. Rather it is more like a breast lift in a female. Skin needs to be removed and tightened and the nipple needs to be lifted and usually made smaller. If the skin sag is very minor, a circumareolar skin lift with nipple reduction can be made. This has the advantage of keeping the scar relegated to around the nipple area. More significant chest skin sag, however, needs a skin excision pattern that goes beyond the nipple. This is always problematic in men where scars are not well hidden in the more flat topography of the male chest.

Chest wall reshaping is usually the second most requested change (abdominoplasty is number one) in men who have had gastric bypass.

 Dr. Barry Eppley

Q: I am inquiring about breast surgery for my son who is 14. He has developed small breasts and is quite conscious of it. He will not go swimming or even take his shirt off during gym class. (so I am told by his brother) My family doctor said it is gynecomastia and that it goes away in most teenage boys. He said we should wait until he is 18 years old before considering surgery. Given that it bothers him so much, and has made him very shy and reclusive, I was wondering what your thoughts were.  Can surgery be done sooner rather than waiting? I am just desperate to help him and make him feel better.

A:  While gynecomastia, male breast enlargement, does go away in some teenage boys, many times it does not. The historic teaching is to wait until the teenage male is near full development. In analyzing that approach further, its intent is to not subject a teenager to unnecessary surgery. In the spirit of such waiting, however, the  teenage boy may (likely) develop self-image issues and psychosocial issues.

Given the exposure to potential social pressures and ridicule, I not think that such waiting is worth the trade-off. Gynecomastia surgery can be repeated (although I have never seen that necessary) but the emotional damage can be very difficult to get past. Therefore, in my Indianapolis plastic surgery practice I am an advocate of surgically treating gynecomastia early (age 14 is an acceptable age) provided that it is significant enough and one is certain that there is not a hormonal reason for it. While a hormonal cause (endocrine tumor) is a very rare cause of gynecomastia, they do occur. If the gynecomastia involves both sides of the chest and is not subtle, I would recommend getting him seen by an endocrinologist first.

Many cases of teenage gynecomastia that I seen today are less significant than they used to be. This is undoubtably a reflection of the changing cultural standards from decades ago.

Dr. Barry Eppley

Q: I have always wanted plastic surgery but can’t afford it. I have not aged well and I think it would make me feel better about myself. Do you know where I can get it for free? I would be willing to be a guinea pig to let someone learn on me. I would be willing to let them use an extra skin removed from me for help in reconstruction of burn victims.

A: Interest in cosmetic surgery continues to increase. While there are some people who say they wouldn’t subject themselves to something as vain or as drastic as plastic surgery, most people do not feel that way. In a recent online surgery of over 2,000 people done on behalf of theWeb community RealSelf.com, they  reported that more than two-thirds (69 percent to be exact) said they would choose to undergo cosmetic surgery if they had the money. Perhaps to no surprise, a lot more people would have cosmetic surgery if money wasn’t the limiting step. I suspect in this group that some of those state opposition to plastic surgery would change their mind.

The bottom line is that there is no place where cosmetic surgery is done for free. There are costs involved, beyond the plastic surgeon’s time, that are incurred in surgery. In addition, there are medicolegal risks and exposure that one would not risk for no reimbursement. There was a time, years ago, when plastic surgery training programs did do cosmetic surgery for free for the educational experience of the residents and fellows. But that time has long passed and will not likely be seen again.

By the way, a patient can not use someone else’s skin for reconstruction. It would be rejected and cause infection. Skin can only be used from yourself.

Dr. Barry Eppley

Q: I am interested in corner-of-the-mouth lift surgery? I tried injections to turn up the corners of the mouth but that didn’t work. Then I went to a plastic surgeon who told me a facelift would make the corner of my mouth look better…and it didn’t! Since injectable fillers and a facelift didn’t work, I read about this procedure on the corner of the mouth. That seems like it would work. Can you tell me about the scars? Thanks!

A: For the downturned corner of the mouth (frowning or upside down U-shaped smile line), neither injectable fillers or a facelift will be successful. Either one may help a little but not generally for mouth corners that are more than just a little down.

The corner of the mouth lift is a simple but very effective procedure for leveling out the smile line. While it is a very small procedure, it can easily be overdone if the plastic surgeon is not careful and go the other way, up too high. (i.e., joker’s smile) By removing a small triangle or heart-shaped piece of skin just above the corners of the mouth, the tail of the smile line is brought. This does result in a small scar, about 7mms or so, off of the corner of the mouth that points up in the direction of the ear. But it is a very small scar that fades quite quickly.

A corner of the mouth lift can be done at the same time as a facelift or can be done as a stand alone procedure. When done by itself, it can be done under local anesthesia in the office. There is no recovery or any significant swelling or bruising. Tiny sutures are removed in a week or for out-of-town patients only small dissolveable sutures are used.

The corner of the mouth lift is a ‘cute’ little procedure that really can make quite a difference in one’s smile.

Dr. Barry Eppley

Q: I am interested in getting a tummy tuck. I have had two children and do not want any more. I can not get rid of this lower stomach pouch no matter what I do. A tummy tuck would do the trick but I am concerned about the scar. I am Hispanic and I am afraid I might scar badly. My c-section scar looks great so I seem to scar well. Will my tummy tuck scar look the same? I know it will be longer but will it look so fine and narrow?

A: While there are many factors that influence how a scar will ultimately look, one of the most important is that of tension. How tight is the wound on closure. A wound closed under tension will usually develop a scar that is somewhat wider  than one that is not.

The concept of wound tension is what differentiates the c-section vs an abdominoplasty scar. C-sections are closed under absolutely no tension. They literally fall together loosely because of the expanded abdominal skin. This is why they usually look so good no matter how or by whom they were closed. A tummy tuck, however, is quite a different story. It is closed under considerable tension and requires the closure skills and training of a plastic surgeon to get a scar that may approximate that of a c-section. A good c-section scar is not necessarily a good predictor of what a tummy tuck may look like.

While scar outcomes are not always predictable, darker pigmented skin may widen and hyperpigment more than skin with less pigment. This is the risk of an abdominoplasty scar in one of Hispanic origin. Always remember that a tummy tuck is a trade-off, getting rid of that loose skin and fat with a better waistline for a scar. A scar is still an imperfection but, hopefully, one that is more tolerable.

Dr. Barry Eppley

Q: I  have read numerous blogs that talk about the value of facial exercises. With so many debates on this subject, I wonder if there is any benefit to doing facial exercises to tone up the face. Plastic surgery seems so drastic.

A: Much has been written over the past fifty years about using exercise to lift up a sagging aging face…or to prevent it from happening. This concept is not new. I have an original copy of a book entitled ‘Lifting Up Your Face’ from 1951. The more recent books that I have seen today in the book stores are beautifully done, and even have their own DVDs in the cover, but they are just modern re-inventions of this original concept.

It is certainly reasonable to do anything to avoid actual surgery, if it has some benefit. The problem that I have with facial exercising is three-fold. First, most of the signs of facial aging that are bothersome to people (appearance of jowls, loose skin in the neck, dropping brows, etc) are not muscular in origin. They did not occur because the muscles were loose and sagging. Anatomically, they are the result of the skin and the subcutaneous fat becoming loose and sliding off of the deeper tissues. That is not something that muscle tightening, even if it were possible with facial exercises, can really treat or prevent. Secondly, all facial wrinkles that develop are the result of muscle movement. That is why Botox is so popular, because it decreases this wrinkle-causing muscle movement. Moving those muscles a lot more through facial exercising will likely increase, not decrease the age signs of wrinkling. Lastly, I have yet to see adequate before and after photographs of believeable results from any facial exercising program. The photographs shown are never standardized. There are always some subtle changes in angle and lighting that can make a big difference in how the result looks. We know this very well in plastic surgery. It is very easy, intentional or not, to have an after result that appears to show a facial change that does not really exist.

For the sake of discussion, however, let’s us assume that there is some minor benefit to facial execising. In most patient cases, it is likely that the result would not be adequate…a lot of effort for a minor improvement. With todays’ minimally invasive and limited downtime facial procedures, they quickly surpass what exercising could do and require less effort. Plastic surgery does not have to be so drastic, one can get a few ‘tweakments’ that can make a real visible difference.

Dr. Barry Eppley

Q: I had breast implants done about 8 to 9 years ago and am looking to have them redone. Thr original size was 600cc implants. I am between D and DD cup size I think…but it depends on the bra.  I want them increased but not sure if that is something you do? I know I would like to be DDD cup. I am a body builder as a hobby. I think it would balance my shape better.

A: Breast implant size is a personal choice and no one can really say what size someone should or should not be. Breast implants of 600cc size can be big or not so big depending upon whose chest they are on. For a small person this could be fairly large, for a bigger and broader-chested woman this may only be average looking in size. Most women are interested in having breasts that are in proportion to the size of their body but a few women want more than that.

Within reason, just about any breast implant size can be put in any patient. Whether that final size is in or out of proportion, or what someone really desires, is up to the patient to judge. In my Indianapolis plastic surgery practice, I try and accomodate a woman’s breast implant size desires. That being said, women should know that there are potential long-term consequences for having large breast implants. (i.e., extreme breast augmentation) Over time, the weight and size of the implant may cause tissues to stretch out and a ‘bottoming out’ of the implant may occur as the implant falls on the chest wall. This is known as loss of tissue support. This is why as a general rule it is wise to keep the base width size of the implant within the natural breast base width. Also remember, it is easy to go up in size without significant scar consequences. Should one day the desire arises to go smaller, there will be significant breast scars to remove and tighten the loose skin that the implant has created.

Dr. Barry Eppley

Q : I have one ear that sticks out more than the other. My right ear is just fine and looks good. But the top of my left ear sticks out further than the right and it bothers me. This seems like it would be a simple thing to fix. How is it done? Does it require surgery to fix it?

A: The position of the ear and its angular relationship to the side of the head is the result of the shape of the ear cartilage. The ear cartilage has many folds and grooves. If one of these folds is not quite bent or shaped symmetrically, the ear will stick out further from the side of the head.

Otoplasty, or ear cartilage reshaping, is done but rebending the ear with sutures from an incision on the backside of the ear. With this technique, much of the ear can be brought back and made less prominent. When only one part of the ear is protruding out, a single suture can usually solve the problem. ‘Mini-otoplasties’ can be done under local anesthesia in the office in a short period of time. There are no dressings to wear afterwards. One does have to be careful not to pull on the ear or traumatize it in the first months after surgery to prevent dislodging the retaining suture as the ear heals.  

Dr. Barry Eppley

Q: I am really curious about brow bone shaping. I am wondering if it is possible to lower the brow bone. My concern is that the distance between my eyes and brow bone is very large and therefore my mid face looks very long. I want to shorten this and I think one of the most effective ways would be to lower the brow bone. Is this possible? How is it done, etc?

A: The brow bone is traditionally reshaped because it is too prominent. The so-called Neanderthal look occurs due to excessive growth of the frontal sinus which causes the outer table of the brow bone to stick out. This can be reduced by setting back this outer table of brow bone.

The brow bone can also be built up by various materials should it be underdeveloped or deformed from a traumatic injury.

Lowering the brow bone is a very unusual request as the need to do it is very rare. But the lower edge of the brow bone, however, can be brought lower. This is not done by moving the bone though. The lower edge of the brow bone can be built up with an implant material that is secured to the bone with very tiny screws. The implant is custom-carved during surgery to make an exact as fit as possible. This would be done through an upper eyelid (blepharoplasty) incision. Whether this would actually make the eyebrows look lower or create the effect that one wants is uncertain.

Besides considering a build-up of the lower brow bone, there are other considerations such as dermal-fat grafting to the upper eyelid sulcus which may create the same desired effect. I would have to see photos to make a more educated opinion on what is possible.

Dr. Barry Eppley

Q : Hi Dr Eppley, I am inquiring about how to reduce a long forehead. My forehead is so long it is ridiculous. I have good hair but my hairline is so far back I can’t wear my hair pulled back. My forehead also has a bulge in it near the hairline which makes it look like it is even back further. I have heard that a plastic surgery procedure exists that can pull my hairline forward. Is this possible?

A: The typical distance for most people between their eyebrows and their hairline (forehead length) is up to 7 cms. When that distance is greater than that, most people would consider it to be a long forehead. In actuality, however, if one thinks that they have too much forehead skin then they do.

One’s forehead can be shortened through a skin excision procedure. The skin is removed in front of the hairline and the scalp hair brought forward in its place. In essence, this is a reverse browlift. The amount of scalp advancement can be up to 2 cms to 2.5 cms without any problem. More can sometimes be obtained by a very posterior scalp elevation at the subgaleal level the whole back to the occiput. Even more than that can be obtained by a two-stage procedure using a tissue expander although this is reserved only for the most severe cases.

The trade-off for a forehead reduction is a fine line scar along the hairline. As long as one has reasonable hair density and hair quality this is not a concern. With the forehead bone exposed, any bony contouring or reduction can be done at the same time.

Dr. Barry Eppley

Q : I would like perky and fuller breasts. I have had three children and my breasts have just lost everything. They are so saggy and droopy they are disgusting. I am so embarrassed about them I won’t even let my husband see them. My right breast is also different than the left. It is bigger and more saggy and the nipple is much bigger. I know I want implants but I think I may some sort of lift too. Can you tell me how bad the scars will be?

A: The need for a lift with the use of breast implants can be determined by one simple anatomic measurement…where does the nipple sit relative to the lower breast fold. (inframammary crease) If the nipple is above this level, an implant alone will give the breast a good shape with the nipple reasonably centered on the new larger mound. If the nipple sits at or below the fold, then an implant will make the breast bigger but the nipple will be on the ‘southside’ of the mound. (i.e., pointing downward)

There are essentially four types of breast lifts based on how much the nipple needs to move upward. They are with their resultant scars; type 1 superior nipple lift (scar on top part of nipple), type 2 circumareolar lift (scar 360 degrees around the nipple), type 3 vertical breast lift (scar around the nipple and vertically down to the fold) and type 4 full breast lift. (around the nipple and vertically down into the fold and then horizontally along the fold, an anchor scar pattern)

In general, breast lift scars usually turn out pretty well. The scars around the nipple and along the inframammary fold do the best. If a vertical breast scar is needed between the nipple and the fold, this is the one that has the most potential to widen due to the constant pulling by the weight of the breast against the scar. Most breast lift scars revisions involve that scar if needed.

Dr. Barry Eppley

Q : I would love to sign up for some free plastic surgery. I have never been happy with the way I look. My ex-boyfriends always told me I’m not good enough for them and they could do better. I always wanted plastic surgery but with no money and no time to work extra hours. I’m a single parent of three and try to give them the best. My time and money is for them, they are my life. I’m unable to save for surgery. Please contact me and let me know what I need to do.

A: The possibility of free plastic surgery is certainly appealing. Like a winning lottery ticket, the opportunity to be able to ‘afford’ something you could not previously is intriguing to say the least. But unfortunately, real life is not like a television show. Extreme makeovers for free really only do exist on the television screen. It simply is not provided by any plastic surgeon in any community.

There are a variety of reasons plastic surgeon do not provide cosmetic surgery for free. First and foremost, cosmetic surgery does not usually improve any medical function. Yes it is true it will make one feel a whole lot better about themselves but that is different than reconstructive surgery where the origin of the problem is from a birth defect, cancer, or a traumatic injury. Patients in need of reconstructive surgery are more in need than that of any cosmetic concern. Plastic surgeons have a long history of being very benevolent with their services for reconstructive surgery. Secondly, there are more costs involved than just the plastic surgeon’s time or expertise. The use of the operating room and an anesthesiologist (if needed) must be accounted for.  Those providing these costs do not feel or have any obligation to give away their materials and labor. Lastly, free cosmetic surgery does not waive the plastic surgeon from medicolegal liability and exposure. Why should a plastic surgeon assume those financial and professional risks without compensation?

Board-certified plastic surgeons also cannot provide cosmetic surgery as a prize from a contest or giveaway. This is an ethical violation as a member of the American Society of Plastic Surgeons. While many cosmetic surgeons from different specialities freely do promote such contest prizes, board-certified plastic surgeons can not do so.

Dr. Barry Eppley

As people age, two of the most noteworthy and bothersome facial changes is what occurs along the jaw line and neck. These two changes are usually progressive, first comes the jowls then goes the neck.  Like wax melting off of a candle, cheek skin and fat begins to slide off of the face creating those fleshy droopy folds at the jaw line known as the jowls. Recent research also indicates that it is more than just gravity that causes jowls, it is the shrinking of facial fat as well.

The appearance of jowls will eventually occur in everyone with enough time. Jowling creates an undesireable change in facial shape, making it wider and more rectangular in the lower face which is characteristic of  an older person. It also causes a distinct disruption of a smooth jaw line from the chin on back, which is characteristic of a more youthful appearance.

Jowl correction is generally part of a facelift procedure. This is done during a facelift by either trimming the jowl fat, suturing the jowl fat back up to a higher level,  or some combination of both of these manuevers. Facelifting is a relatively common procedure as evidenced by the 95,000 performed in the U.S. in 2009 according to the American Society of Plastic Surgery.

When only jowls are present and the neck has minimal loose skin, a different variation of a facelift can be done. Scaling back the ‘size’ of the facelift procedure can very effectively eliminate those troublesome jowls. Known by a wide variety of different names, the limited or downsized facelift tucks up the hanging loose jowls with very minimal recovery. Unlike a traditional facelift where incisions are made in front of and on the back of the ears, the jowl facelift only uses a fine incision in the front. The lack of any significant recovery is noted by the different names that are used to describe it, such as Lifestyle Lift, Swiftlift and EZ Lift. Expect one week for the significant recovery period of some mild swelling and bruising.

One of the great advantages of a jowl lift or ‘short scar facelift’ is that it also addresses a common facelift fear, that of looking unnatural. Few patients that I have ever met want to look like they have had  a facelift.  These procedures have no risk of that ever happening as they deliver a more subtle and less dramatic result. One will never look have that windwept or overdone look as, by definition, the procedure is more limited.

Q: Hi Dr. Eppley. I am a 56 yr old female and I am interested in liposuction for my arms. I am currently losing weight and have lost just about 25 pounds. My current weight is 186 and my question is… do I need to wait till I have lost all the weight I want to lose or could I have liposuction on my arms now? I am exercising on a regular basis, but I am seeing very little if any progress on my arms. I am having to cover my arms as much as possible and I so want to wear sleeveless tops. I have researched this subject and have read where liposuction of the arms produces  “only modest improvement”. Would I even benefit from such a procedure?

A: Like all liposuction, but particularly in the arms, patient selection is key for a satisfactory result. The real question is what is making your arms big? Is it fat alone, extra skin or a combination of both? Conversely, a good question is how much improvement is needed to make a visible difference? How much change is necessary to be able for you to comfortably wear sleeveless tops again? That is the bottom line question and objective.

While I can not obviously see your arms, I have never seen any patient at a weight of 186 lbs where fat removal alone with liposuction will produce a significant arm contour change, particularly in someone losing weight. Significant arm changes at this size require both skin and fat removal, otherwise known as an armlift or brachioplasty. That procedure can make a dramatic arm change at the price of a scar running down the backside of the arms. More likely your decision is whether an arm scar is a good trade-off for a noticeable arm improvement.

Dr. Barry Eppley