Your Questions

Q: Dr. Eppley, I am 28 year old female.When I was12 whenever I opened my mouth very wide the left side of my face clicked under my ear. Therefter it became more painful to open and I had great difficulty in eating chewy foods. By the time I was 18 my face looked obviously asymmetric. My jaw is not properly aligned. I have been to an orthodontist and was told that I would need corrective jaw surgery which I can not afford and he also said it may not necessarily make my face look straight even if my jaws were better aligned. What can I do to straighten out my face?

A: Your face is significantly asymmetric due to an underdeveloped left side. That extends from the cheek bone down to the jawline with a significant left chin deviation.Your non-major orthognathic surgery options include a combined procedure by repositioning the chin bone (opening wedge genioplasty), a left cheek implant and fat injections to the left side of the face. These three procedures will help fill out the left side of the face and straighten it by aligning the chin with the midline of the face.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hi, I currently have mandibular implants, off the shelf from Implantech.  I am unhappy with the off the shelf size and contours and have decided I need custom implants to reach the desired look. My question is can the implants be placed from and outside incision, rather than intra-orally? My current implants were placed from inside of my mouth and that was the WORSE part of the surgery. Not being able to open my mouth for 3 weeks = not eating for 3 weeks. Plus the pain on the inside was very bad. I believe by placing the custom implants from the outside incision would be much more generous when it comes to pain and downtime. Is this possible, opposed to intra-orally placing the implants? Any feedback would be greatly appreciated.

A: Jaw angle implants can certainly be placed from external skin incisions although in an aesthetic facial operation it is hard to imagine that the resultant neck scars might not be a concern. You should know that any replacement of your existing implants would likely be easier the second time around since the pocket under the muscle has already been partially created. Also, what is done on the side or below the jaw bone is the same whether one comes from inside the mouth or below in the neck (jaw opening restriction), the incisional approach is just a means to get there to do it.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I’m considering cheek implants to address the following problem. I have a wide round face with a flat midface and I want to avoid implants that make my face look wider or rounder. Should I go for malars without edges (so ones that only address the cheekbone) what part of the cheek contributes the most at creating forward projection? My main goal is to achieve a less wide face with more projection. Thank you so much!

A: When it comes to increasing midface projection without making the face wider, all implants have to remain inside of a vertical line drawn down from outside of the lateral orbital rim. This means the options of using orbital rim implants with small malar extensions relegated to the anterior cheekbone surface, paranasal, and premaxillary implants. These are the implants that can increase midfacial projection without creating width.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, Hi, I have a weird shaped head where the back of my head really sticks out so it looks long from a side view. Are there any implants that can be inserted to give it a more rounded normal shape or can the skull be reduced slightly at the back. Thanks.

A: Some reduction of an occipital skull prominence can be done which is usually about 7mms. The bone above the prominence can also be augmented to make the top part more round as it goes into the top of the skull and beyond. If done together this will create a better skull reshaping of the back of the head than either procedure done alone.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, There is no much information out there on paranasal implants. You are such treasure trove of knowledge so I will ask you this question. Someone on realself asked me whether my paranasal implants were uncomfortable, and I told her that they aren’t. This got me wondering, what exactly is the difference between a paranasal and premaxillary implant? Is the reason why my paranasal implants feel comfortable because they don’t sit on the nasal base?

A: Paranasal implants sit on the side of the nose under the nostrils along the side of the bony pyriform apertures. A premaxillary implant goes across the base of the nose under the columella and below the bony anterior nasal spine. In some cases a premaxillary implant can include the paranasal area as well or can be limited to just under the anterior nasal spine area. If properly placed at the bone level and not oversized, a premaxillary implant should be no more uncomfortable than paranasal implants. Premaxillary implants are placed by some surgeons through the nose into the soft tissues above the bone, potentially creating abnormal fullness and stiffness of the upper lip when smiling. This is not my recommended tissue location for a premaxillary implant.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, In reading about gynecomastia surgery, there seems to be an issue about the doctor removing too much tissue thus developing a “crater” look to the chest with fat pockets under the breast.  How does the doctor address this?

A: The best way to avoid that problem to be aware of it and not create it. When deciding how much breast tissue to remove in an open gynecomastia operation, it is a matter of pure judgment. There is no scientific way to really know how it will look until it heals based on how much tissue is removed. Because an open procedure has the potential to remove more of the breast tissue in a central position (under the nipple) than around the perimeter, it is important to not over resect (remove too much) from this area.Since solving the gynecomastia crater deformity is more challenging than having to take more should a revision be needed, it is always better to use caution rather than indiscriminate aggression in gynecomastia reduction.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, for my chin and jaw angle implant surgery I have couple of questions. I had originally mentioned the idea of some liposuction below the Jaw line/ chin and wanted to see if you thought that was still an option( especially if it could be done through the chin implant incision.) Finally, any ideas of a realistic downtime from work? Would 3 weeks be enough to be off work and able to go back without looking extremely swollen? Also can the surgery be done under IV/ twilight sedation?  Thanks again for your time. Thanks again 

A: In answer to your questions:

1) Submental liposuction can certainly be done at the same time with access through the same incision as that of the chin implant.

2) The vast majority of the swelling from this type of surgery is from the jaw angles and you are correct to assume that 2 to 3 weeks is enough time for you to look normal, even though the final details of the result will take months to fully emerge.

3) This is not a procedure that is done under sedation anesthesia. Lifting the large masseter muscles off of the mandible is less than a pleasant experience to place the jaw angle implants. This is a procedure that requires general anesthesia to be done correctly.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley,  Thank you for your follow up on my questions about reshaping the top of my skull.. I realize that you are a surgeon in high demand and you taking the time to follow up is very impressive and kind. The cost is fair given the amount of work that needs to be done. The 10″ incision is my only concern. How large would the incision need to be if we simply build up the uneven side and leave the bump untouched.  What would the cost be if we went this alternative route?

A: Understandably a long incision in your scalp is a concern, even to me given your young age and for the correction of only an aesthetic skull shape concern. But the same length of the incision is needed whether one merely reduces the high midline sagittal ridge or does a concomitant build along the side of it. The reason it needs to be of that length is that the hardest part of the skull reshaping procedure is getting the implanted material to have feather edges and blend into the surrounding skull smoothly and without a visible or palpable edge to it.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, First, do you have a web site I can look at?  And second, knowing you do not have a crystal ball, how long can the average person anticipate a traditional breast lift to last? Thank you.

A: All breast lift results ‘last’ but it is important to realize that they will change or settle over time during the first six months after surgery. This is known as tissue relaxation as seen by changes in the lower pole of the breast. Since the skin has to support the uplifted breast tissue, some stretching or relaxation of the bottom part of the breast will occur in most patients. This is why it is important that the way the operation is done has the breast initially looking a little ‘upside down’. (the top part of the breast looks too full, the bottom part of the breast looks cut off or too short) This factors in the settling that will occur in the first few months after surgery as the mound drops and more round or tear drop breast shape results. In essence, one has to heal into the proper breast shape. But once a breast lift is healed and settled (3 to 6 months after surgery), there should be no major changes thereafter. The nipple position always stays in the new uplifted position, it is just that the breast mound settles around it.

I make these statements assuming that one does not get pregnant after a breast lift, gain or lose a lot of weight, or is having implants placed at the same time as a breast lift. Any of these can modify the aforementioned commentary on the stability of breast lift results.

You may go to my website, www.eppleyplasticsurgery.com/breast-lift/ for more information and patient results on breast lifts.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley,  Attached are the pictures of my scar on my cheek. What bothers me the most is the indentation. I would like to get surgical scar revision as I’ve tried lasers etc and nothing has worked. Do you think I’d be a candidate for scar revision?  My scar is 6 years old or so. It looks red in some photos as I had a tca peel done a few months ago, which didn’t help with the indentation. I was interested in finding out what you would think would help? I read up about geometric line closure correction do you think this would be more favorable than a single line surgical scar? Let me know your thoughts, Thanks so much.

A: Thank you for sending your pictures. Given your scar’s appearance, I would think the only possible improvement for it would be geometric scar revision. Scar indentations can never be improved by very superficial skin treatments like chemical peels or even laser resurfacing. The entire scar must be excised and normal tissue brought together over the indented area. By the perimeter shape of the scar, it would be brought together in a geometric pattern, merely its irregular shape from the beginning. While one could make an argument to do a wider elliptical excision of it and close it in a linear or straight line fashion given is parallel orientation to the nasolabial fold, I would initially prefer a geometric approach which would also produce less total scar size.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I have had TMJ problems for years and have had just about everything under the sun to treat the condition with no success. I read Botox might be a solution to the symptoms. What type of success have you had in this area and should I come in for consult?

A: When it comes to the term ‘TMJ’,  that is a highly variable and diverse term. I would need to know specifically what are your exact symptoms. Botox may be able to help with certain masticatory problems that are primarily muscular in origin. But true intracapsular joint issues require other treatments than muscle modulation.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I have had nasal congestion bilaterally for years since I was young. So I think it make my flabby upper eyelids and lower eyelid bags is related to that nasal congestion. If I remove the the lower eye bags without treating the nasal congestion, can the eye bag regrow again after surgery? 

A: It is a common misconception that puffiness of the lower eyelid is related or caused by nasal and sinus congestion. Actually, there is no correlation between nasal congestion and excess tissue on the upper eyelid or bags in the lower eyelid. They may be close in anatomic proximity but one’s genetics, aging and environmental factors is what makes for such changes in the upper and lower eyelids Thus the results of eyelid surgery, like a lower blepharoplasty with bag (fat) removal will not be affected by persistent nasal congestion after surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in jaw implants for my weak chin. I would like to know what the implants are made from and how durable they are. I do martial arts and blows to the face are quite common, so I wonder how well the implants will endure against physical trauma? Also do you believe there might be a possibility that corrective orthognathic surgery might help me, both cosmetically and in terms of snoring/breathing issues? Thank you. 

A: The chin and jaw angle implants are made from silicone of a firmness slightly less than bone. I screw the implants into the bone that they will never move from their implanted position. It will require a force great enough to break the bone to ever dislodge them. And they might actually be a buffer against traumatic forces, ultimately protecting the bone to some degree. Whether you would benefit by orthognathic surgery instead of jawline implants is not a question I can answer based on the information you have provided the best way to answer that important question would be to get and orthodontic evaluation and see if the process of pre- and postsurgical orthodontics and orthognathic surgery would be a more appealing alternative that at least partially address the underlying bone problem of your weak jawline. You owe it to yourself for the sake of educational completeness to get such an evaluation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Wow. Information about dents on a persons head is next to impossible to find on the internet. I have about dent on the very top of my head that is about 2 inches in diameter, so it is a fairly large dent. After an accident, some skin was literally ripped from the top of my skull. Eventually, the skin did grow back, but I have no hair there now as the hair follicles went with the skin when it was ripped from my skull. The main problem is though I have a dent in my head there too. At first I thought that all the tissue ( the matter under the skin ) didn’t grow back even though the skin did. Recently, a CT scan showed that part of my skull was thin, so now I don’t know if I have the dent because I need tissue or if it’s because of my skull. Is there any way to determine what the actual cause of this dent is, and if it’s the skull, would anything procedure done to the skull raise the tissue so that it is flush with the rest of my head?

A: While I don’t know the details of your original injury, it strikes me as unlikely that you would have pushed in your skull or removed the outer layer of cranial bone with an avulsion type injury. My suspicion is that this is more of soft tissue defect than bone. the scalp is incredibly thick in many patients particularly of your ethnicity. If you lost enough scalp to remove the hair what is healed is now a partial thickness of scalp which can certainly create an ‘indentation’. The definitive answer, however, would be the CT scan which should clearly show what the bone looks like underneath of the scalp…if the scan was done using coronal images and not just axial slices. I would need to see the the scan and pictures of your scalp defect to definitively determine the anatomic basis of your head indentation.

If it is just soft tissue you can have the defect excised and the hair-bearing scalp defect loosened and used to repair the defect. If there is a loss of bone component to it this can be simply filled in with hydroxyapatite cement (cranioplasty) and the hair-bearing scalp tissue closed over it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Do you do a suture suspension breast lift?  If so, can you please tell me how it is done, and what are  the associated risks. Thank you.

A: The concept of a suture suspension breast lift can take many forms. In theory, many of the traditional forms of breast lifts use sutures for support whether they are skin-only or whether the breast pillars are sewn together to create an uplifted mound. Even more recently the use of GalaFLEX mesh (a resorbable mesh) can be implanted along the lower breast pole. All of these approaches are still an open method with scars and the objective is to try and prevent long-term bottoming out of the breast mound.

That being said, when you ask about suture suspension breast lift you are likely referring to a true suture suspension that is being used to support the lower breast pole by lifting it toward the collarbone (clavicle)…without removing lower pole breast skin. This is done by making a incision next to the clavicle and attaching a small metal screw into the underside of the collarbone. To this scres is attached a very large permanent polymer suture. The suture is passed by a curved needle under the skin the whole way around the breast and back up to the collarbone. By tightening the suture and typing it down to the collarbone screw, the breast mound is ‘lifted’ and suspended upward. Having done this procedure what I can say about it is that it is a technique in evolution (not perfected) and only applies to a certain type of sagging breast. It is a breast where the nipple is in a reasonably good position and it largely needs a tightening of the lower pole only to get a good shape. This can be done in breasts that also need more volume by a simultaneous implant placement. For those breasts in which the nipple sits at or below the lower breast fold, a more traditional excisional breast lift approach needs to be done.

The risks of a suture suspension breast lift include a small scar over the midportion of the collarbone, palpability of the large knot under the collarbone scar, unknown longevity of this breast lift method, potential palpability of the suture under the skin along the perimeter of the breast, and risk of further breast sagging long-term.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was treated by a “#1 Migraine Specialist” in my state. I had been seeing this Dr. for 1 yr. and 4 months before he suggested Botox and I finally did the treatment because my insurance paid for it! YAY! I finally did the treatment in November 2012 and it was so painful! There was no spot left untouched. It helped the headache I had then so I was sure it was going to prevent the future ones! And low and behold just days later I get a Migraine and been having them as usual! I never had migraines until I had my stroke on May 10, 2010. When I get them they stay until i have to go to the emergency room for relief. Ten dr.’s later and I still have no relief. I have taken over 50 different types of meds and STILL NO RELIEF! I am so disappointed! I cannot live like this anymore! What can I do???

A: I am so sorry to hear about your terrible migraine history and current condition. Just based on your description I comment on your Botox experience. First, it should not have been that painful. When skillfully done wirth a small 30 gauge needle, it is at best of minimal discomfort. Secondly, when Botox is used for migraines it is not done ‘all over the head’. It needs to be placed specifically into known trigger point areas of which there are three very specific locations. This does not sound like what was done. Whether you have the type of migraine headaches that may be improved by Botox is unknown…as of yet. I would suggest that you have the Botox injections repeated at the identified trigger points based on your headache pattern. This will the tell you if you may be a good candidate for surgical decompression which is what, as a plastic surgeon, I can offer for your potential migraine headache relief.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have had two kidney transplants and now my stomach looks like a smiley face im very embarrassed lost 85 lbs in 6 months working off my body fat and eating healthier. No matter what I do it never can get smaller. I’ve recently gone through a divorce and with all my weight loss, i would really like to be happy with my body overall and not feel embarrassed to be naked in the bedroom. I’m writing because I would like to know what my options are for me.

A: Just because you have had kidney transplants does not preclude you a tummy tuck surgery. It is important to know, however, as to what type of immunosuppression drugs you are on (if any), where exactly is the kidney located in the abdomen and have you had any healing problems in the past. You would also need to get clearance from your nephrologist/transplant doctor for surgery. Having done tummy tucks in the past on kidney transplant patients, the one difference is that you rarely do any rectus muscle plication or abdominal wall liposuction. It is a primarily an excess skin removal procedure (skin-only tummy tuck)  in which the excisional pattern must be carefully designed give the ‘smiley face’ scar you already have and the risk of skin necrosis.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a chin implant done intra orally which gave me a strange double chin when I smiled. I had it removed 2 weeks later after the doctor told me removing it would make my chin go back to normal. My chin did not go back, it’s still deformed.

A: Intraoral chin implant placement is associated with a higher incidence of mentalis muscle deformity, particularly when the implant is removed if the muscle is not adequately resuspended/repositioned. In theory, a quick removal of an implant should not have allowed time for the overlying soft tissues to become stretched (past their elastic deformation state) and this is undoubtably what your surgeon meant by ‘it would go back to normal’. But that does not factor in the malposition of the muscle which it sounds like you have. Depending upon how long ago the chin implant removal was and what your chin looks like now, it may be improveable with a muscle resuspension procedure. Please send me some pictures at your convenience so I can see exactly the chin problem you now have.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have been bothered by my ears since I was in grade school. I am noiw 21 years old. While they don’t stick out as bad as some ears I have seen, I just don’t like and I wish they were further back than they are now. What type of otoplasty procedure do I need? I have attached some pictures for you to see what I mean.

A: Thank you for sending your pictures. It appears you have a moderate case of protruding ears caused by some conchal hypertrophy as opposed to the more typical lack of an antihelical fold. Your antihelical fold is fairly well defined by the concha (the bowl around the ear canal) is a little too prominent which is why your ears protrude a little. Your ear position along the side of your head can be brought back by an otoplasty procedure in which the concha is weakened and then sutured closer to the mastoid fascia. This is done as a simple outpatient procedure that takes one hour to complete. There are few restrictions after surgery and a head dressing is only worn for the first night after surgery in adults.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, How is fat accurately determined and measured before suctioning it out by liposuction. I haven’t read anything about how body fat is measured to accurately determine how much might be safely suctioned out from each target area. How do doctors concretely know how much of fat to remove so the patient gets the best result and is even on both sides?

A: The reason you can’t find anything on this aspect of liposuction is because it does not exist. There is no way to know beforehand  how much fat to remove from any area. That is and will likely always remain the ‘artistic’ side of liposuction. It is based on the surgeon’s experience and artistry to do the fat removal. The amount of liposuction aspirate is measured as it is removed and that does help in establishing some symmetry by taking equal amounts from any body area that is bilaterally treated…but this assumes that there is good symmetry beforehand which often is not the case. Thus liposuction remains an inexact surgical procedure and also explains the highly variable results seen in liposuction patients in general.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I had occipital neuralgia decompression surgery 5 weeks ago, My doctor also talked about decompressing the auriculotemporal nerve. I was nervous to have them done at the same time, so we were conservative and are waiting to see if it will be necessary after the 3 month mark from surgery. I have never suffered from migraines. I had a whiplash in my neck that had caused my neuralgia. I had mild temple pain on the right side, but my doctor said that could come from the greater occipital as well, so I wanted to wait see if that went away like the nerve pain has. What are your thoughts? I have been reading your website and wanted to get your input. I also wanted to know what the recovery time was for the auriculotemporal nerve. Is it the same as the occipital nerve decompression surgery. Also what are the percentages of success after auriculotemporal decompression.

A: Given that the origin of your head pain was from a whiplash injury and not a ‘traditional’ migraine trigger, I don’t think anyone can answer your question as to the success of auriculotemporal nerve decompression in your case. For refractory temporal pain it is also important to identify where the potential nerve source involved is the auriculotemporal or the zygomaticotemporal nerves. They are in different locations on the temple with one being in the hairline and the other between the hairline and the brow. If the pain location is between the hairline and the brow (the zygomaticotemporal nerve), this should first be tested by Botox injections which can predict the success of surgical nerve decompression/avulsion. There is no test for the auroiculotemporal nerve and whether its decompression will be successful.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley,  I am interested in nose reshaping, but I also have been told that I would need nasal surgery.  Do you do both at the same time?

A: I believe you are referring to needing improvements in your breathing inside the nose as well as external nose reshaping. It is most common to do both functional and cosmetic nasal surgery at the same time, a procedure better known as a Septorhinoplasty. It is always better done together as external nose reshaping often needs cartilage grafts which are most easily obtained with the septal straightening to improve the breathing. Thus the septorhinoplasty ends up after healing with better breathing as well as a more balance and pleasing external nasal shape.

You may feel free to send me some picture of your nose and I would be happy to do some computer imaging of them to see the possibilities of what can be done. A front and side view pictures are best for imaging purposes.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley,  Thank you for your information on temporal implants.  I live in Los Angeles, and I have been getting fillers injected into my depressed temples for a couple year with limited and very short lived results. My hollow temples are genetic and non trauma related.  I understand from your site that you perform a silicone temple implant procedure.  I am however in Los Angeles, and wonder if you could recommend a surgeon here or in the Beverly Hills area who may also perform this procedure.  Thank you for your help.

A: By your description of the temporal hollowing and lack of any sustaned results from the use of injectable fillers, you appear to be a good candidate for a permanent solution using subfascial placement of silicone temporal implants. Unfortunately due to the relative newness of the commercial availability of the the temporal implants, I am not in a position to know whom in Los Angeles or even California has yet performed this procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a 2 year-old daughter that had a lip laceration repaired in the emergency room earlier this week. They put in 3 sutures and I was told to follow up with a plastic surgeon later in the week to make arrangements for the sutures to be removed in five to seven days. Can you take tell me when to bring my baby in to your office to have the sutures removed?

A: First of all, any doctor or physician’s assistant that would put sutures in the face of a 2 year-old that need to be taken out later is not very thoughtful of the patient or the parents. You always use resorbable sutures in the skin in any child under the age of 8 because it is going to require a general anesthetic to remove them. While they may have wrapped the baby in a papoose board in the ER to put them in, you can be certain that is not going to happen in a plastic surgeon’s office. Nor are most plastic surgeons going to try it with the baby screaming at the top of their lungs which is exactly what is going to happen.

My suggestion is to send me a picture of the lip so I can see what it looks like. And be aware of the very distinct possibility of having to sedate the baby to do it in an operating room setting.

I am well aware that you will likely be stunned  to find out that an anesthetic will be needed to remove the sutures. But anyone in the ER can say anything when they don’t actually have to remove them later. Trying to get sutures out of the lip when the baby is thrashing around is not a good experience for all involved and will likely do damage to the lip repair that was just done.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I am a 38 year old female. I had lap-banding in June 2012 and have since lost a lot of weight. I have gone from 339lbs to 268lbs. Currently, I am contacting you because I need help. I have always had large breasts. I have a 48E bra size at this time and despite my weight loss, have not decreased in bra size. My concern now, is that I have not been able to exercise properly because of the pain that my large breasts cause. In fact, in November of this last year I had an anterior cervical discectomy and fusion on an emergent basis due to a severely herniated c6-c7 disc- presumably caused by my large breasts. I have recently sought several consultations for a breast reduction due to this, but the consensus is that I need to have a lower BMI. I have very few comorbidities, so my surgical risk is minimal. Would it be reasonable to request a consultation from your office? I have Blue Cross Blue Shield and if deemed “medically necessary” breast reduction is a covered entity.

A: Thank you for your inquiry. While your weight may still be high by ‘ideal’ standards, the symptoms you experience with your breasts are not likely to be improve regardless of further weight loss. From that perspective, breast reduction at this point is not unreasonable. Sometimes the breast reduction just needs to be done regardless of the patient’s weight. This is more of getting the procedure approved through insurance at your weight than it is about the technical capability to do the procedure or in its ability to heal.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, Let me first give you some background information. About 6 years ago I had several procedures including a rhinoplasty. The dr. that did the rhinoplasty removed something under the base of my nose possibly part of the nasal spine. The result was a change in the angle under my nose. Also my top lip seems to come down lower than it did before. While I know I am not at the point of looking abnormal I would like to look more like myself before the rhinoplasty. When I push up under my nose it looks more like the way it did presurgery. I think this can be achieved with a peri-pyriform implant. I am not sure if silicone or meseline mesh would be the best material. I am attaching photos. the first in each set is with no expression the second ones are of me pushing up under my nose to show the look I want. I look forward to hearing your opinion.

A: Thank you for sending your pictures. What you are demonstrating is not what any type of nasal base/pyriform aperture augmentation will achieve. In fact, it will achieve the opposite effect…pushing out on the nasolabial angle…but it will not push it back up as you have demonstrated nor will it cause the tip to elevate/rotate.

The changes you are demonstrating can only be done by a revisional rhinoplasty in which lower caudal septal resection and suturing the lower ends of the medial footplates of the lower alar cartilages back to the resected caudal septal area is done. That is what needs to be done to drive teh base of the nasolabial angle in a more superior position.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My son is 16 years old was born with a cleft lip It is now closed , but the scar is clear and the lip is not filled propwely. A fat transfer was done last December but the results are not satisfactory. Please advise if anything further could be done.

A: Without seeing pictures, it is would be impossible to make an accurate comment about any further potential improvements…although I have yet to see a cleft lip repair that could not stand some further efforts. I would not think that fat injections had any chance to offer improvement as the issue is one of proper alignment of the muscle, skin and vermilion not just a volume issue even though it may visually seem so.

Please send me some pictures of your son’s lip at your convenience.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I am interested in having the surgery of gluteal crease correction. I do not need a buttock lift per se but a correction of buttock crease. I am 5 ‘9″ tall & very thin & had a thigh lift years ago which was not done very well & gave me a lower uneven shaped buttock crease which makes my buty look loger than it should and the crease needs to be higher. I want to make the crease more even and have it round and higher. I have sent you pictures to study. I just recently had the crease corrected three weeks ago but this surgeon made the same mistake and just followed the original surgeon’s incision marks which were completely wrong and so it has not been corrected and still pretty much looks the same and the right cheek is also lower than left. I should have much better results for what I paid. I am so very disappointed. The top portion of my butt looks normal and  round, but now I have loose skin and square/pointy shape at side view hanging down lower than the butt. The incisions/scars needed to be redone in the right position and be made more even, rounder and higher and the bit of loose skin on back of thighs needs to be excised and lifted. Have you ever seen anything like this done before? Do you have experience correcting this issue and think you could correct it and make it look much better and completely normal? This disfigurement has made me very self conscious & sad.

A: Thank you for sending your pictures and describing your concerns. I think you are spot on and  I am completely bewildered as to what was actually done doing your recent procedure. I am going to assume that the size of the fresh incisions/scars that I see are the extent of the skin resection/crease creation? I will assume for now they are. If so, they are far too limited to adequately address the creation of a more complete lower buttock crease, create a distinct break between the lower buttocks and the upper thighs, and get rid of the bulge or overhang that you have. Perhaps you were unreceptive to a more complete or longer incision ??? At any rate, the lack of a distinct buttock/thigh demarcation, improved lower buttock crease/shape symmetry and elimination of the transitional bulge can be done by a longer and more wide excision of skin and fat with a tuck down to the gluteal fascia. This can be trememdously effective for your type of problem provided you can accept a longer but well placed scar. One of the keys to a lower buttock lift/crease creation is to not have the side part of the scar extend into the visible lateral thigh area.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I’m 4 months out from having upper and lower jaw surgery. A 2.5mm upper advancement with a 4mm transverse expansion and 3mm posterior impaction to correct an anterior open bite, along with a 3.5mm lower advancement through a BSSO. In addition to this, I had a 7mm chin augmentation through sliding genioplasty. While everything else went perfectly well, unfortunately the genioplasty ended up asymmetrical.

I’ve attached both frontal and profile pictures for you here, as well as frontal and profile pictures from before the surgery. In addition, my latest panoramic x-ray is included as well. I’ve also included a picture of my sulcus as it was before surgery, and as it currently looks now, as well as a “relaxed lip” picture as I believe I show more lower incisors at rest than I used to. Forgive the photo quality…interestingly, I look much worse in photos than in 3-dimensions. I’ve never been terribly photogenic. In addition, I have a bit of residual swelling in my upper center face.

In any case, obviously, I’d like to have the asymmetry corrected (I think its very obvious). So, I have these questions:

1) How difficult is it to correct? My OMS seemed to be very reluctant to do a correction and implied it could be very difficult which is why I’m looking to you for correction based on several recommendations I’ve received about your work. Do you think I be better off with fillers or pre-jowl implants to mask the asymmetry rather than redoing the osteotomy? There are also those pesky “dents” on either side of my chin (pre-jowl)…

2) Is there a risk of more lower lip drop–greater than the first surgery? I did notice my lower lip dropped a little bit…perhaps 1-3mm though I can’t be completely sure as I never really looked at it before and don’t have any previous pictures of my lips in repose. It’s obviously not a devastating lip drop/incompetence issue as I’ve heard about. Do you see anything with the sulcus that looks abnormal in any way? Would an additional surgery in this area be more risky in this respect? If there is a problem…can it be corrected?

I’m planning on coming up there in the next 4-6 weeks for an in-person consult, but wanted to get an initial opinion from you as to what you believe needs to be done. 

A: Thank for detailing your surgery and sending your pictures. Now that you are four months out from surgery, you can see largely see the effects of the surgery as all of the swelling has subsided and the tissues hav contracted back done to the bones. What I see is the chin asymmetry and the very typical notching at the back end of the osteotomy sites which can occur from a sliding genioplasty based on how it is cut. (angle) Your lower lip position is hard for me to judge since how you are now is all I know. But I will assyme that there is a slight lower lip sag/ptosis.

In terms of improvement, two out of three issues are straightforward. First, the jawline indents will need to be filled in which can be done with either a shaped mersilene mesh overlay implant or a wrap-around prejowl silicone implant. (1mm thick in the middle so it adds no further horizontal augmentation) Second, since an intraoral approach would be redone the mentallis muscle would just be repositioned and resuspended not only as a prevention of any further sag but may actually improve where your lower lip is now. Lastly, the bony chin asymmetry can be delt with two ways, eitehr reposition the genioplasty or shave down the large or more prominent side. Since you may be getting an overlay implant anyway I would think burring the bone is far simpler. The only reason to reposition the genioplasty is if there are other dimensions to it you want to change. I suspect what has happened is that with the typical central plate fixation used, one side got rotated a bit (no lateral stabilization) and the asymmetry resulted. The genioplasty can be recut and repositioned without a problem (never confuse can with want to) but you just should have a godo reason to do so and to make sure that something simpler may not work just as effectively.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am interested in making my face look thinner. Even though I am not fat (below the neck), my face makes me look like I  am. I have read about the buccal lipectomy procedure and that seems like it would work for me. I am most interested in getting the lower part of my face thinner. Thank you for your help!

A: To treat the soft tissue facial triangle area (lines drawn between the cheek, chin and jaw angles), the procedures of buccal lipectomies and perioral mound liposuction may be useful for ‘facial derounding’.  It is important to realize that these procedures are most effective for the areas below the cheek down to about the mouth level and not for fullness at the jaw angle or in the lower part of the face. Facial defatting procedures work best in areas that are not directly supported by bone where the fullness is more the result of the thickness of the fat and not the bone. A buccal lipectomy removes a very distinct large ball of fat that sits right below the cheek bone. It is done from a small incision inside the mouth. It is important to not totally remove it so one does not get a gaunt look later in life. But for someone with a really round ‘fat’ face this potential issue may be irrelevant. The perioral liposuction procedure removes fat from below the buccal fat pad that sits right under the skin opposite the mouth. It is done from a small incision inside the mouth. Done together these two distinctly different facial fat removal procedures can help create a facial thinning effect.

Dr. Barry Eppley

Indianapolis, Indiana