Your Questions

Q: Dr. Eppley, I would like a more toned looking armpit, upper back, and upper arm. I feel that, although I am relatively lean and well proportioned throughout the rest of my body, where my arms attaches to my shoulder and chest is just too thick. I have attached some pictures so you can see what I mean. There is also a glob of fat in my upper breast next to the arm that sticks out in clothes. 

A:What you have is a very common problem, known as axillary breast fat. When combined with some circumferential fat around the upper arm and back, it makes the whole area look undesireably thick and full. Liposuction (technically liposculpture given the small volumes and discrete areas) of the axillary breast (upper lateral breast quadrant) and front and back of arms (extending into the upper back) would be a good approach to help contour this area and create a more sculpted look of the upper arm/chest area. That could be performed as an outpatient procedure done under anesthesia to get the best result in the most efficient time period. While there would be some swelling and maybe mild bruising, it would not be much of a prolonged recovery. It could be done late in the week, for example, and you could be back to work by Monday or Tuesday. (albeit with sore upper arms) Be aware that the final result from such a procedure would take a minimum of six weeks to become fully evident.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, there is an overall lack of definition to my face (flat cheeks and very prominent and long chin) which you will notice here.  It’s my belief that with some cheek contouring and possibly jaw as well, I may look as beautiful as I feel.  When I smile and when the lighting is even I have a much more appealing appearance as it seems to round out my face if you know what I mean. When I’m not smiling and when the light is harsh (as it usually is unless one is in a photography studi0 and manipulating light!) I feel like my face is a sliver- very long with nothing to break it up or draw the eye up.  I look forward to hearing what you think!

A: In looking carefully at your facial features, there are three areas that could be altered to help make the transition from a long flatter face to one with better proportion and angularity. As you have mentioned, your cheeks/infraorbital areas are flat, your chin is long and slightly retruded and your nose is slightly prominent and a little deviated. Changing all three would make the greatest change but I just want to focus on your cheeks and chin for now. Cheek implants with anterolateral augmentation and a chin osteotomy that vertically shortens the chin and brings it forward is the best way to help vertically shorten your face and ‘pull’ it outward. I have demonstrated that on the attached imaging pictures in the side and front views. I think a reductive rhinoplasty would also be very helpful to shorten and deproject the nose, which would make the midface look more full, but the pictures you have sent are not of good enough quality to do the rhinoplasty imaging justice. But these initial images will give you some good material to think about.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was just wondering do you do liposuction on teenagers? If so, will you guys take payments or do I have to pay it all at once??

A: Liposuction can be performed on many body areas regardless of patient age. Any cosmetic surgery, including liposuction, can be done under the age if 18 if one has parental consent. Teenage plastic surgery requires the blessings from one’s parents or guardians. Like all cosmetic surgery, the fees are all paid up front in advance of the surgery. While many patient do finance through outside companies, such as Care Credit, that is not going to be possible for anyone under age 18 or maybe even under age 21. This is why all teenage cosmetic plastic surgery is authorized and paid for by the parents in every case that I have ever done.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a double chin that I hate. I am only 32 years old but my neck makes me look much older and heavier than I really am. I am interested in a double chin reduction surgery that I have read about. My question is does the double chin reduction grow back after certain time due to weight, age, etc… Thanks!

A: Most double chins are due to a combination of a full neck in the submental area and a weak chin. The upper bump chin is one’s real chin (short) and the lower bump of the bubble is neck fat and skin. Therefore, double chin reduction surgery usually consists of  a combination approach of submental/neck liposuction (reduction) and a chin implant and/or osteotomy (augmentation) to eliminate the double roll. In my experience once this is done it is a long-term sustained result because the anatomy is permanently changed. The short chin bump will never return because it is been permanently brought forward. The neck roll usually stays away unless one gains a lot of weight in the future. This combined approach has a great influence on making the face and neck appear more slim and well-defined. Often when combined with buccal lipectomies (cheek fat removal) the slimming effect can influence the face above the jawline as well.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I am interested in having one ear of my previous otoplasty partially reversed. It is pulled back too far and needs to come out 4 or 5mms so the helical rim is seen again. I have a few questions about the specifics of the operation.

1) Could it be performed under local anesthetic?

2) Roughly what size would the cartilage graft be?

3) Does the graft become knitted in place by new scarring or remain somewhat movable under the skin?

4 Should I expect lumps from the cartilage/scars to be visible following healing?

5) Have you performed the operation before and if so, what success rate have you had?

Thank you for your time.

A:  In answer to your questions:

1) The procedure can be performed under local anesthesia given that it is one ear and fairly limited in scope.

2) The cartilage graft needs to fit in between the released folds and generally is no bigger than 10mm x 5mms.

3) The graft is sewn in and heals to the other cartilages so it is not moveable.

4) The graft fits between the folds of the cartilage on the back of the ear so it can not be seen or felt from the front. You may or may not be able to feel it from behind the ear.

5) I have performed this ‘reverse otoplasty’ several times successfully. There is nothing new or magical about this procedure. It is a technique borrowed from my days when I regularly performed microtia reconstructions, the most complex form of external ear surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in having the upper and lower lip advancement like the woman featured on your site who found that fillers did not make her lips large enough. I have this same problem. I am also interested in the price.

A: In thin lips, injectable fillers often produce unsatisfactory results as there is not enough vermilion (pink part of the lips) to fill. Without enough vermilion, the injectable filler material can only push outward rather than upward as well. This creates an abnormal looking often call ‘ducklips’. If one’s lips are very thin and injectable fillers have failed to produce a good look, the lip advancement procedure is an alternative. By physically moving the vermilion border up (upper lip ) or down (lower lip), the size of the lips is increased. Usually lip advgancements are done as an office procedure under local/oral sedation. The cost is $2,00 0 per lip or $3,500 for both lips. Because they permanently change the amount of exposed lip vermilion, they can have a powerful effect on the appearance of lip size. While lip advancements are the most effective procedure for making bigger lips out of thin ones, there are some minor trade-offs. There will be a resultant fine line scar at the junction of the skin and the vermilion which for most patients is barely perceptible. But it is important to know that there will be a residual scar, fine as it may be.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had saline implants placed under the muscle 12 years ago. There were fine until about three years ago when I noticed rippling on the undersides. I am a thin woman being 5’7” tall and weighing 126 lbs. Why has this rippling appeared now years after surgery? Will it get better or is it permanent? Will it get worse? What is the best way to get rid of it?I am very unhappy with the shape, size and asymmetry, along with the rippling, so am leaning towards having them redone anyway.

A: Rippling is common feature of saline breast implants and every women will develop some degree of it unless they had a fair amount of breast tissue initially. It will be felt along the bottom and sides of the implants where there is not a muscular interface underneath between the implant and the skin. While perhaps not noticeable early after surgery, it may appear months to years later as the swelling goes away and the breast tissue thins over time. This rippling issue is particularly relevant in thin women with little breast tissue. This is an important consideration to know before breast augmentation surgery so this is not a surprise when it appears later. The best correction of the rippling problem is an exchange to silicone implants where the amount of rippling is considerably reduced due to the thicker and more congealed silicone gel material. This is one of the advantages of the newer gummy bear breast implants.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have indentations/notching at the sites of my previous mandibular osteotomies. (sagittal split advancements three years ago) I want to get implants to build the bone back out as well as make my jaw angles more prominent. Given the differences between the two sides, I think I will need custom-made implants. How are custom implants made? Do you secure them to the bone somehow so they do not move afterwards? How painful is the procedure?

A: In answer to your questions:

1) Custom are hand-made off of a 3-D model obtained from a CT scan of the patient’s mandible.

2) All facial implants are secured to the bone by screws.

3) Since you have had a prior mandibular osteotomy that is a good reference point point to discuss pain and recovery. Suffice it to say it is less than that process although there are numerous similarities such as the area of facial swelling and the temporary issue of some mouth opening restriction. But if sagittal split osteotomies are a 10 on the scale of pain/swelling etc, jaw angle implants by comparison are a 2 or a 3.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, do you ever do a forehead burring/scalp advance/brow lifts without the sinus setback? I am a woman and my brow bones are not that big so I don’t think I need the frontal sinus setback.

A: Most forehead reductions in women are actually done by burring and not osteotomies/sinus setbacks. That is more of a male procedure in most cases. In women it is common to do a brow bone reduction by burring and/or forehead reshaping with a hairline advancement (scalp advancement) or a browlift. Seeing some photos of you would be helpful in determining which are the desired procedures.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, my daughter is turning 13 next month. She had cleft lip (not palate) and had it repaired when she was 4 months old. She is very self conscious about her appearance. There is a visible scar between the upper lip and nose and a lopsided nose. I want to know about the possibilites to remove the scar and correct her nose asymmetry. Please let me know about the procedure. Thank you very much.

A: Isolated cleft lip always affects more than just the lip. The cleft defect extends to involve the nose in a very classic pattern of lower alar cartilage slumping resulting in an asymmetric tip of the nose with a widened nostril. Even in a well done cleft lip repair, the nose deformity becomes evident as the child grows manifesting itself fully by the teenage years. This always leaves two areas of potential improvement as a young adolescent, the repaired lip scar and the unrepaired nose.

 
Your daughter would undoubtably benefit by a cleft rhinoplasty and lip repair. Without seeing pictures of her I can not say whether she needs a complete septorhinoplasty or an isolated tip rhinoplasty procedure. Most commonly the fuller version of the rhinoplasty is needed with cartilage grafts. As for the lip, it is better to think of further scar reduction and not scar removal. Completely eliminating the cleft lip scar is virtually impossible. Please send me some pictures of her for a more analysis to determine her exact surgical needs.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, How much does a breast augmentation procedure cost? On one site, I read about cohesive gel. What is that? Is it better than silicone or saline implants?

A: The typical cost of breast augmentation varies based on whether one uses saline or breast implants. The cost of a pair of breast implants, which is included in the total fee for the procedure, adds anywhere from $1,000 to $ 2,200 to the composite total fee. Saline breast implants cost less than silicone breast implants because the implants cost less. In general, silicone implants are better than saline because they will last longer, do not develop rippling and the breast will not deflate immediately should the implant develop a hole or a rupture in its shell. These benefits explain why the cost of silicone implants is higher. The term ‘cohesive gel’ is a generic term that really applies to all silicone breast implants today. It means that rather than being a silicone liquid, the silicone is more congealed or is an actual gel. It does not flow like a liquid but acts more like a ‘gummy bear’ candy. This material feature explains why the silicone implant does not deflate should it rupture and why it feels more natural than a bag of water. (saline)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I feel like I have always had a weak chin amd jawline. It makes too feminine and disproportionate to the rest of my face. As a result, I have been considering getting a chin implant. My concern is that I am HIV positive but otherwise healthy. I have been on antiviral meds for the past ten years. Becuase of this medical condition I feel a little bit vain as I don’t want to risk my health and cause a problem with the surgery. What has been your experience with this surgery in HIV patients.

A: The medical evidence is fairly clear on the risks of elective surgery in HIV patients. There are no apparent increased risks or complications from surgery as long as one’s counts/levels are good. As long as you are not immunosuppressed, the outcomes from elective facial surgery are the same as non-HIV patients. I have treated numerous HIV patients with chin augmentation procedures, including implants and osteotomies, and have not seen any problems. Therefore, if this is a procedure that will make you feel better there are no increased medical risks for doing so.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I underwent otoplasty done over ten years ago with a pretty good result. But I have felt ever since that the corrections on the ears were too pronounced, particularly on the left which now has a largely hidden helix.  The technique used consisted of some skin removal on the back of the ear, weakening of the cartilage on its anterior surface and absorbable sutures used to create the fold. (from operative note from the procedure) The only scarring discernible to my touch is at the bottom of the antihelix and it is this scarring which seems to act as anchor for the over corrected folds. I have read that once scars have set several months post-op the ears become difficult/impossible to un-correct.  Nonetheless, I am emailing you my details to see whether you think my ears might have some potential for improvement and whether you think you might be able to help me with that improvement. My ears, apart from the scars, feel supple and flexible (perhaps because I’ve got in the habit of massaging them whilst pondering their post surgical shape and potential for improvement). I hope for only a subtle improvement, perhaps only noticeable to me, and would be keen to explore options or ideas which feature the least amount of invasiveness and slicing possible.

A:  You are correct in your assumption that ears that have undergone otoplasty surgery are difficult to undo, meaning to bring the ear back out. This is due to the long-established fold in the cartilage and the scar surrounding it. While it is difficult that does not mean that it is impossible. Since your goal is a ‘subtle one, perhaps a few millimeters, to bring the helix out from behind the antihelical margin, there is one approach that can be effective. Releasing the scar between the folds, scoring the cartilage and the placement of a small cross-beam cartilage graft (harvested from the concha right below the release) between the folds can bring the helix back out a little bit. This sounds complicated but it is not and can be done through just a portion of your old post-auricular incision.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley,  I have suffered a jaw angle deformity since I had jaw surgery two years ago. There is a big notch along the border of my lower jaw in front of the jaw angles. I think jaw angle implants would make a massive difference. It is something that’s high on my list to do providing I can find someone who will do a good job and providing there isn’t any major risks with my prior surgery. I was thinking fillers as a temporary fix until I can find someone who can perform the surgery as I would much rather have a permanent fix. 

How would you build up the bone? What’s involved in that? 

How does notching come about?  Was that a complication from surgery? Was it something I was born with?

A: Without question, jaw angle implants are the solution to your problem. The only question is what size and shape should they be. Most likely, off-the-shelf inferolateral border jaw angle implants will be satisfactory. Ideally, custom jaw angle implants are the best but that adds some expense to the procedure.

Injectable fillers are fine if you are not planniing to have the surgery anytime in the next six months or so. But if you are then I would not do them so they do not interfere/obscure the surgery.

Notching of the inferior border after sagittal split mandibular osteotomies can occur from a variety of reasons including a non-union, bad osteotomy split, too much rotation of the posterior mandibular segment, inadequate bone fixation, and the shape of one’s natural mandibular ramus anatomy.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a lip lift procedure and I have attached some pictures. I have several questions and concerns about the procedure. Is my columella retracted? Do I have an acute nasalabial angle? I am concerned about visible scarring. I read you use dissolvable sutures for out of town patients. I want to look great for my daughter’s wedding, which is Oct 7 this fall. Can you schedule me soon enough?
I’m in excellent health.

A: In Answers to your questions:

1) Your columella is veryretracted with an acute nasolabial angle.

2) Although most subnasal lip lift scars do very well, scarring is always a risk particularly in patients with pigmented skin. Your retracted nasal base does help with the potential scarring visibility.

3) With less than six weeks before the wedding, I would not advise it to be done that close to an important date. That is about the time a scar, anywhere on the body, will likely be looking its worse long before it has adequately matured. I wouldn’t do this procedure any sooner than three months before an important social event.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I am 21 years old and want to have a better-shaped upper lip. Which  is better for reshaping the cupids bow, a v-y advancement or a lip lift? I have a short distance between nose and my upper lip.

A: There is no question that the best way to reshape or accentuate the cupid’s bow of the upper lip is an external skin excisional procedure. Whether it is a lip lift done from under the nose or a lip advancement done directly at the cupid’s bow area, the closer the tissue excision/movement is done to the cupid’s bow the more likely a significant change can be seen in it. However, both of these procecures will SHORTEN the upper lip which is a problem when one already has a short upper lip. The v-y mucosal advancement procedure is about improving the volume of the vermilion of the upper lip but it will not change the shape of the cupid’s bow area in any appreciable way. I am afraid that in someone with a short upper lip, there are no truly effective procedures for improving the shape of the cupid’s bow area.

One potential option is to do a peak triangular excision at the current peak of your cupid’s bow to give it more of a sharper outline. This will not change the vertical distance from the nose to the upper lip in any appreciable manner.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have had prior jaw surgery which hasn’t gone so well. I was just wondering if you can have jaw angle implants put over a metal plate that was left in my face? I have bone scans which I can send to you to have a look at.

A: I suspect what you are referring to is a jaw angle/inferior border deformity after an orthognathic surgery procedure. I have placed jaw angle implants over metal plates in the mandibular ramus area numerous times. It is not rare to have mandibular ramus notching and bone resorption around healed sagittal split osteotomy sites. This problem may be severe if one developed a non-union or infection after the procedure. These deformities may be able to be improved by implant augmentation. Even though fixation hardware (plates and screws) exist on the outside of the bone and considerable scar tissue will be present, and pocket dissection is not easy, jaw angle  implants can be successfully placed. I shall look forward to reviewing your bone scans and photographs.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am writing you because I had an scar revision and the post surgical treatment was wrong. Now I am desperate and want to know if there is any solution to my problem. I have attached pictures of my before and after surgery condition.

A: In looking at your before and after pictures, I fail to see what you have described as wrong treatment. Your initial scar pictures shows an extremely wide scar, up to 2 cms, that extends from the corner of your mouth down to your jaw angle/neck area. Your postoperative photo shows a much more narrow scar that is in the healing process. In my practice, I would have told you from the beginning that a good result from your type of scar revision would take at least 2 stages (surgeries) and 12 to 18 months to get the final result. You have a horrendously wide scar that runs completely perpendicular to the relaxed skin tension lines of your face. These combined eatures makes your scar revision extremely difficult. The first stage (surgery) would be to just get the scar much more narrow and I would expect some rebound widening afterwards. That appears to be where you are now. You need to let this first stage scar revision heal and then proceed to the second stage (surgery) where further narrowing will be possible and the introduction of some broken line/geometric scar revision techniques used for improved scar camouflage.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had Gortex implants removed from my upper lip in hopes to be able to smile fully again. It did not relieve the tension on my upper lip so no success. The only thing I can think of that may work is the mouth widening procedure. If we could widen my mouth just a little I think it would release some of the tension from my upper lip. The area above my lip has spread out and widened from the gortex and now scar tissue . It has caused some damage so i’m hoping this procedure will help so there’s no further damage to the area. I have small features so we don’t have to take off too much from the corners. How much does this cost and do you think it will work? I have realistic expectations so if we can only relieve the tension a little it’s ok, anything is better than nothing. Thanks!

A: The mouth widening or lateral commissuroplasty procedure may be effective for your problem IF you feel that the tightness is at the corners of your mouth. This would be most evident when you open your mouth and you feel tension or band where the upper and lower lips meet. This procedure is done in the office under local anesthesia.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I am wanting chin reshaping surgery to get rid of my prominent square chin which is not a good look for a woman. If possible, please give me some indications on the following questions.

 1) How long before I could go to work?  I don’t mind being a little black and blue.  More concerned about pain and my ability to focus on things. 

2) How soon could I fly after the intraoral surgery?

3) How soon could I drink liquids?  Eat solids? 

4)  Would I need to bring a companion?

5) I assume you detach and reattach the muscles immediately under the chin. 

Also, I wanted to let you know that rather than a smooth curved chin, I would like the square to just be made narrower and the asymmtery in length of chin to be corrected in favor of the shorter side, but no shorter of a chin than that.  I think a slight square (albeit narrower) is more interesting than a perfect oval. 

A: In answer to your questions:

1) For just the intraoral chin  contouring, this is a fairly simple and uncomplicated procedure. There will be sone chin swelling but almost never any bruising. The chin will be more numb that it will be painful for awhile. I certainly think you can be back to work in less than a week. There are no restrictions of amy kind after surgery.

2) You could return home the next day.

3) You can eat and drink immediately after surgery.

4) Most out of town patients come by themselves. We just have to have one of our nurses take you back to your hotel from the recovery room. We can not just push you out into the parking lot on your own right after surgery.

5) No muscles are ever deattached from under the chin. The mentalis muscle is elevated to access the chin bone are to be reduced and then reattached at the end of the bony contouring. This muscles sits in front of the chin not beneath it.

In regards to chin contouring, I would agree that in your case and face that a more narrow but slightly still square chin is better than a perfectly oval shaped chin.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have asymmetry of my jawline that I want to improve. While I think  both jaw angles need to be be bigger for a better jawline look, they are not the same size now. What is the best way to making them both bigger and more symmetric? I don’t want to get jaw angle implants and then afterwards have bigger jaw angles that may look even more asymmetric. 

A: There are two approaches to both increasing and improving the symmetry of your jawline. Either use two different-sized jaw angle implants or have custom jaw angle implants made. Stock off-the-shelf implants are less expensive but it is a guessing game in terms of the symmetrical improvement. If you can live with less than perfect symmetry then this is the way to go. Even in the patient who has weak but symmettric jaw angles before surgery, it is difficult to end up with perfect symmetry afterwards even using two symmetric  and identically-sized implants. If you want the most ideal symmetry possible, then custom jaw angle implants are needed but they are more expensive. The most common complications from jaw angle implants, ironically, is asymmetry so you can see that having initial asymmetry makes jaw angle implant surgery even more challenging than it normally is.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a facelift with lipo done two years ago. While the result has overall been very good, I am unhappy with the appearance of my neck under the chin area. I’ve included a few photos so you can get a better idea of my situation. When I don’t lift my chin or move my head things look good, but moving my head or chin around creates a really unattractive situation that distracts from the very nicely done lower facelift. I am thinking these are muscle bands that need to be swen together to fix it. What do you think?

A: In looking at your pictures, I don’t think that the vertical bands you are seeing in your neck are platysmal muscle edges. Notice that there are numerous ones not just two isolated long parasagittal bands. I think what you have is a ‘skeletonization’ effect.  This means the there is very little neck fat between the skin and the muscle which can lead to adhesions and scar contractures in the neck which are vertical in orientation and almost always occur primarily in the submental area. They are most evident when the chin is raised and the neck stretched upward. This is prone to occur in thin women when the neck is aggressively liposuctioned as part of the submental management of their facelift. There always needs to be some fat left on the skin otherwise adhesions will result. The question then becomes as to how to manage that issue as further muscle plication may not be the ultimate answer. In my experience, re-elevation of the involved skin (adhesion release) and possible muscle plication if needed is the best approach. In an ideal world, some fat would be put back or a dermal graft placed as an interface between the skin and the muscle but I would go with the simpler skin flap elevation/adhesion release initially.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, your discussion of laser use to somewhat camouflage the appearance of self-injury scars was the first I have been able to find on this subject. You seem to truly understand that removal may not be possible, but if they are changed to look like another type of scarring then the social stigma is reduced. I was hoping that you might be willing to provide more information. My daughter self-injured for years and has the scars you described. She has received treatment and is now pursuing a degree in the health field. Camouflaging clothes are not always an option.

A:  Having seen many self-inflicted scars on the wrists, forearms and upper extremities, it is obvious in seeing almost all of them that removal is simply not possible. Many patients have a large number of these scars that usually are very fine and white. No amount of laser resurfacing will get rid of them because the white scar goes all the way through the skin. Laser resurfacing only continues to expose the scar as it gets deeper. Cutting them out is not an option because of both the large number and the amount of scar improvement by narrowing is negligible.

This only leaves the alternative of scar camouflage by trade-off. Can the scars become another scar that is more ‘explainable and socially acceptable’ to the patient. In that regard, I have used two approaches. One is deep laser resurfacing to essentially convert it into a burn scar or replacing the most severely scarred areas with a skin graft. This requires the right patient with a large number of visible scars to justify the appearance of a burn injury or as skin-grafted patch. But in the properly motivated patient, it can be a successful scar treatment strategy.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My question is about the after surgery effects from getting jaw angle implants. I am also going to get an osteoplastic genioplasty at the same time for a complete jawline makeover. What level of pain do most patients experience and how long does the recovery and healing process typically take?

A: To answer the recovery question, it all depends on one’s definition of recovery. But if defined in terms of return to work and being in public without significant residual swelling, that is going to be in the range of 2 to 3 weeks. It could be shorter or longer based on what one does and what activities one wants to engage in. This does not mean that all swelling is gone in three weeks, just a large part of it.  It takes up to three months after surgery for final swelling resolution and tissue adaptation to the implants to occur. This is as true for a chin osteotomy as it is for jaw angle implants.

From a discomfort standpoint, jaw angle implants are the most uncomfortable of all facial implants because the major chewing muscle (masseter) must be lifted up to put them in. It also affects one’s ability to chew well for a few weeks, again because of the masseter muscles being traumatized. A chin osteotomy causes more swelling than an implant and similarly takes up to three months after surgery to really see the final result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Can I have a full facial surgery at the same time starting from the skull then eyes,nose and ears? I am interested in having my forehead and brow area built up but then I also want a nose job to get rid of my hump and fat tip as well as cheek and chin inplants with facial liposuction, all at the same time. Is this possible?

A: Yes you can. It is not rare to do more complete craniomaxillofacial skeletal remodeling from the skull down to the jawline. In addition to skull and forehead procedures, often facial implants are used in conjunction with open rhinoplasties. These more complete aesthetic craniofacial procedures can take 6 to 8 hours to perform, requiring a patient to be in good health,, relatively young, and ready to sustain a significant recovery from a facial swelling standpoint. These composite procedures are often done for major facial reshaping, facial feminization surgeries, and extensive male masculinization makeovers.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have several questions regarding the mouth widening procedure. How is the procedure done and much can the procedure help? How natural are the results?  

A: In answer to your questions about mouth widening, also known as a lateral commissuroplasty:

1) The corners of the mouth can be moved outward  anywhere from 5 to 10mms per side. As a general rule, the corners of one’s mouth should not be any wider than that of a vertical line dropped down from the pupil of the eye. This is not a hard and fast rule but an historic aesthetic anthropometric one. It can be surprising how much difference a few millimeters can make. The procedure is done by a skin excisional method known as a Y-V advancement where triangles of skin are removed from a line drawn out from the corner of the mouth to the desired distance. The corners of the mouth are then brought out to that point and closed.

2) The corners of the mouth, as long as they are not extended too far, can look natural. There are fine line scars at the junction of the red of the lip and the skin at the corners of the mouth as a trade-off. Generally these scars are fairly discrete and not a distraction to the result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had cranioplasty surgery one and a half years ago. A bone cement called acrylic was put on the area between my eyebrows(glabella) to elevate the depression on that area due to an accident. but now I noticed that there is a slight swelling on that area. This is the second time this swelling appeared. The first time was one year and three months ago and I had a cold at that time. But now I don’t have a cold but the swelling appeared again. This has never been hit by a strong force. Is this normal? Or is this a sign that the acrylic is starting to deplete and thus irritating the skin tissue covering it? But that surgery was just one and a half years ago.. too short for depletion to occur. What could be the reasons for this swelling? Thank you very much! 

A: My initial reaction is no this is not normal. Since there is a synthetic material in that area that has had a few bouts of swelling, one would have to initially conclude that this does not bode well long-term for that area of reconstruction. Something is causing the area to swell up. Fortunately it does go down but I suspect this will not be the last time that it occurs.

While I don’t know the exact details of your procedure, my concern is that an acrylic material was used over an area of an old frontal sinus fracture. One of two things could be happening. First, there could be an area of residual communication between the underlying frontal sinus and the acrylic material. That could lead to intermittent low-grade infection and swelling. Secondly, a polymerized plastic like acrylic does leach out a low level of its base monomer which in a few patients may cause intermittent inflammatory reactions and tissue thinning. This would be most manifest in areas where the soft tissue cover is thinner, such as the glabellar area.

Most certainly this is not due to any degradation of the material as that does not occur. It is either frontal sinus communication or an inflammatory reaction to the material. Since it has happened only twice since surgery and always resolves, it would be something I would not immediately charge in and replace. But if it happens a third time in the near future it may give me pause to consider replacing your cranioplasty with a more biocompatible material and to check and make sure there is no communication into the frontal sinus.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a lower facelift/necklift that left me with a prominent (at least in profile) Adam’s Apple and showing some platysmal muscles under the chin probably because of lipo done in that area years ago. I’m wondering whether a tracheal shave would be helpful and possibly a resuturing of the platysmal muscles directly under the chin to smooth that area out? Thank you.

A: I suspect that the reason you have the submental hollowing is that either fat was liposuctioned from that area and the platysmal muscles not sewn together (unlikely) or the subplastysmal fat was directly excised and the platysmal muscles that were sewn together separated sometime after surgery. (very likely and most common reason) The thyroid cartilage has become unmasked due to the muscle tightening above it (it is carried down to it but never can be done over it or below it).  This pulls the muscles and overlyng neck skin up and back, creating a much better cervicomental angle but not exposing the prominence if the thyroid cartilage. I have seen this complaint from necklift patients numerous times and it is usually thin women that are most predisposed to this potential aesthetic trade-off problem.

I would agree that the best approach is a direct tracheal shave and a limited submentoplasty using a z-plasty approach to overlapping the platysmal muscles. (to lessen the risk of a recurrent submental problem) This is a far easier procedure to go through than your original facelift with a very limited recovery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 44 year-old male who has a heavy brow. I think a brow lift/ would be beneficial but I am a little worried about the hairline gong back, making my forehead even longer. Would a hair transplant to lower the hairline after work or is that a little to risky?  I think a brow lift would look good but worried that my hair line would become too high.

A: In men, browlifts are a difficult decision due to the instability or lack of a permanent stable frontal hairline. I think given the risks involved, I would be reluctant to do any open superior scalp approach to a browlift. It is a classic example of the risks being greater than the benefits. The safest approach to browlifting in men is the transpalpebral or eyelid approach, coning from below and pushing up with an endotine device. It does not produce as signfiicant a lift as that from above but it is always safer because there is no disturbance in the hairline. Another option is the endoscopic browlift which has much less scar than any open approach but it will lengthen the forehead as it works on the principle of an endocranial scalp/forehead shift superiorly to lift the brows.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a neck scar that is hypertrophic. My dermatologist just finished 3 steriods injections spaced 2 weeks apart per session. He told me that if I want to do a scar revison I must let the doc know about the steriod injection as steriods will cause delay in tissue healing.What do you think? I also have some other questions about the scar revision.

1) What kind of excision pattern will you use to resect my scar?

2) Are the stitches used in the layers are dissolvable or permanent?

3) Also, what are the chances of hypertrophic scar recurring after removal? Mine is definitely not a keloid, but several doctors tell me that scar revision is not ideal as removal of hypertrophic scar will lead to hypertrophic scarring again. Is this true? 

Please kindly advise.

A: In answer to your questions:

The doctor who performs the scar revision should know about the steroids but they will not have a major effect on wound healing, particularly if there is some delay in moving forward with the scar revision.

1) Based on your scar shape, I would do a simple elliptical excisional pattern scar revision.

2) Sutures under the skin are always dissolveable. It is up to the doctor’s discretion and how easy it is for the patient to come back for follow-up as to whether sutures that are used on the outside will need to be removed or not.

3) There is always a chance of recurrent hypertrophic scarring. But the use of pre-revisional steriods before re-excision is a proven approach to lessen that risk.

Dr. Barry Eppley

Indianapolis, Indiana