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The discovery that fat is one of the most generous sources of stem cells in the body has generated excitement in plastic surgery as much as it has within mainstream medicine. With the theoretical potential to someday provide more effective treatments to diverse medical problems such as neurologic diseases, cardiovascular problems, and even tissue regeneration in reconstructive surgery, the research activity on this ‘wonder’ cell’ is nothing short of feverish.

Who would have thought that the very thing so many of us struggle to get rid of may someday be the key to new medical treatments? That’s like finding an outfit in the back of the closet that not only still fits but is back in style. (OK, that is beyond the common definition of a miracle.)  Since fat can be easily extracted through liposuction, and it contains a high concentration of stem cells, whole new cosmetic uses are being derived for what is known as stem cell-derived fat grafting (SCFG).  Fat is being injected all over the body by plastic surgeons, mainly because it is easy to do and perfectly safe. Injected fat has many body uses from body contouring to facial rejuvenation. For the body, buttock augmentation and breast reconstruction (lumpectomy defects) are being widely done. Fat-transplant breast augmentations are being approached more cautiously,  but even this use is gaining momentum. Another excellent use for our own ‘fat’ is for  hand rejuvenation- using the injected fat to fill hollows between the extensor tendons and to camouflage prominent veins.The face, however, is the most common target for fat and its stem cells. As we age, we lose fat in our faces,  and it produces a deflated look.  This facial deflation is one of the reasons that we begin to look older and our skin appears to slide from our faces and into our necks. This has led to younger people getting fat injections at an early age and fat injections being used as part of a facelift procedure for more advanced degrees of facial aging.

But, with every bit of hope comes a little or a lot of hype. In the most contemporary spin on fat grafting to the face, right out of Beverly Hills, comes the Stem Cell Face Lift. The theory is that stem cell-rich fat grafts combined with skin tightening makes for a better facelift result. Proponents espouse the theory that the stem cells provide a regenerative effect on the skin, also resulting in smaller pore size and less wrinkling and pigmentation.

Is this actual science or science fiction? Stem cell researchers would most certainly tell us that how such cells behave isn’t so simple. While moving them from one place to another in the body seems as though it should work…that doesn’t necessarily make it so. Conversely, a Stem Cell Facelift is a perfectly natural procedure that has no harmful effects, an almost organic procedure if you will. It uses the patient’s own tissues and may exemplify the appealing concept of ‘heal thyself’. It may even be considered a green procedure, a bit of body recycling if you will.

The use of stem cells in a cosmetic procedure may one day be the key to the proverbial fountain of youth. But for now, it more likely represents a common occurrence that has been used by overzealous cosmetic providers for years. Extrapolating a bit of science into a marketing phenomenon for patient recruitment.  It may in fact generate some ‘green’ – but it’s not magic.

Dr. Barry Eppley

Indianapolis Indiana

Q: Hi, I have two babies born via c-sections. Is it safe to have a Brazilian butt lift even though I have had these c-sections? My youngest baby is 5 months old and I am still breastfeeding. Should I  I stop breastfeeding before surgery? How long in advance should I stop my breastfeeding before having the surgery? Thank you.

A: The Brazilian Butt Lift, a bit of a misnomer but this is how the procedure has been branded, is buttock augmentation with fat injections. It has gotten this branded name because it was developed and popularized in South America where the aesthetics of the buttocks is highly regarded. It ‘lifts’ the buttocks per se by adding fat volume, not by cutting and lifting tissues in the traditional sense. Having c-sections on the abdomen does not in any way interfere with having this buttock procedure and one does not affect the other. Fat may be taken from the stomach area to be transferred to the buttocks but a c-section does not interfere with that process.

Breastfeeding, however, is a different matter. There is no reason to be having elective plastic surgery while one is still breastfeeding. There is a very remote chance of drugs from surgery passing through to the infant through the breast milk. Once none of these drugs are likely harmful to the infant, why take any chance even as remote as that possibility is. One should stop breastfeeding at least one month prior to any elective surgery. In addition, you really want your body totally focused on healing from the surgery and not having its energies split between healing and producing breast milk.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am considering having my septoplasty and rhinoplasty done at the same time. It does seem like it would be cheaper and more practical to have both done at the same time and only pay one anesthesia bill, surgery room cost, etc. If the septoplasty is medically necessary and you have to have it anyway, it should be substantially cheaper to go ahead and have the nose reshaped at that time as well. I recommend finding a Dr. that will work with you on this. There is a big variation on prices out there. I heard from a friend that needed upper eyelid surgery (blepharoplasty) for excess eyelid skin. The plastic surgeon she first went to see just assummed insurance would not pay it and did not even let me get tested to see. Then she went to an Opthalmologist, and in less than one week, had insurance approve the procedure. I am a healthy person in my thirties, who never gets sick, and don’t feel like when I do need a procedure, insurance should try to get out of paying. (Which they did not, but the first MD assumed they would not)

A: While on the surface this basic insurance coverage question seems reasonable, it reflects a deeper misunderstanding and a general societal feeling about health insurance companies. (not that I have any great compassion for them either) The issue is one of justifiable coverage and insurance fraud. Trying to get a cosmetic procedure covered under insurance, is quite frankly, fraudulent. That is not what health insurance is designed to cover and their policy guidelines make this quite clear. While some physicians will code certain diagnoses and procedures so that they appear medically necessary, so the patient doesn’t have to pay and they can bill for the procedure, this is ethically wrong and illegal. While it may be common practice, that does not make it right or justifiable. There are many plastic surgeons who will not exhibit such unethical behavior and this may make the patient feel that they are being unreasonable. In reality, they are being quite honest and forthright. And what reasonable patient would ask a plastic surgeon to risk his license or practice for something that their insurance company is not obligated to pay?

This is not to be confused with the benefits of performing a cosmetic procedure with a medically necessary one, such as a rhinoplasty and a septoplasty. Many believe that the benefit is that the insurance company will pay for the operating room and anesthesia costs of the rhinoplasty as just part of the septoplasty. Again that is fraudulent behavior that the hospital or surgery center will no longer allow. The patient is obligated to pay for all additional costs related to the rhinoplasty once the septoplasty is completed, including operating room and anesthesia costs. The combined benefit is that the additional time to complete the cosmetic portion is less than if the cosmetic procedure was performed alone, thus reducing one’s out-of-pocket expenses. In addition, many plastic surgeons may discount their professional fee for the cosmetic procedure as a courtesy for doing both at once. That is the ethical and legal approach to getting a financial benefit for the patient from combining such procedures.

Dr. Barry Eppley

Indianapolis, Indiana

This upcoming Thanksgiving will be the unofficial kickoff to holiday indulgence and overeating. Each holiday season, through the New Year, many of us excuse the mountains of calories consumed as just part of the festivities. Admittedly it is difficult to resist so many of our favorite foods when they are strewn around and we have a lot of time off from work. And eating is an activity that definitely helps fill that void of time.

Most people gain weight during the holidays and this accounts for many hopeful New Year’s resolutions to eliminate those extra pounds. But most weight loss resolutions don’t last…and many never really get even started.

One body contouring and weight loss approach that has been having a lot success is Zerona. Not to be confused with liposuction, Zerona is a non-surgical treatment. A painless procedure that is done in the office, Zerona exerts its effects through a ‘cold’ laser that passes through the skin and goes after the fat cells.  It makes them leaky which releases the fat which is then absorbed and eliminated naturally.

Zerona is not just a machine, it is a process. Multiple treatment sessions are needed and studies have been shown that it can take off three to five inches in the hips, waist and thigh in three weeks. To help the fat loss, one must increase their water intake and take a twice-daily niacin supplement during the treatment periiod. The program require a commitment and must be done every two to three days to really be effective. Each treatment session takes about an hour and is painless. You literally get up and go afterwards. Daily exercise can increase the final results by aiding in lymphatic clearance and an increased metabolism.

How well does Zerona fat reduction work? There has been a lot of claims of inches lost in the media and internet. Our experience from our first twenty patients treated showed that the average inches lost (from three body area measurements) was 7 inches Over 70% of the patients were extremely satisfied patient and would readily do it again.

Right after the holidays could be a perfect time to get that jumpstart on weight loss and body toning. Many of you will probably implement some sort of a program. Zerona could be that perfect fit into such a program. A total treatment takes just three weeks and provides a safe and no risk method to lose some fat and slim some body areas.. At the least it is a commitment and a jump start to a healthier lifestyle for 2011.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Hi Ii am 22 years old and would like to undergo a rhinoplasty procedure with you since I have read some very good things about you. I am aware about the rhinoplasty surgery and I don’t need further information on that procedure. But I was wondering if you can fix another facial problem. The distance between the mouth and the nose is very good. But when I close my mouth its like fat or muscles pile up and that makes the area between my mouth and the nose look big, even though it is not. In addition,  the corners of the mouth droop down and give me a sad face appearance. Is there any surgical techniques to fix these problems?  

A: The upper lip fullness to which you refer seems like a natural phenomenon . If you open your mouth, the upper lip thins as the nose moves upward and the upper lip stretches downward over the teeth. When you close your mouth, the ‘accordion’ shortens and the upper lip gets fuller again. This seems to be a normal tissue reaction and there is certainly nothing that can be done to surgically change the thickness of the upper lip at rest.

The downturning of the corners of the mouth, however, is a different issue. That can be changed through a simple procedure known as a corner of the mouth lift. A small triangle of skin is removed just above the downturned corner to bring it back to a more horizontal lip level.

Dr. Barry Eppley

Indianapolis Indiana

Q:  Hello, I recently had a consultation with a plastic surgeon in Indianapolis for rhinoplasty and breast augmentation. The doctor told me that I could have both procedures for a low price as long as I did not finance it. I felt the Doctor was not personable. I have looked at your before & after photos and wanted to know if you would discount the procedures if I paid without financing.

A: Financing of elective cosmetic surgery procedures today is extremely common. While once accounting for about 5% of cosmetic surgeries in the United States in 2000, that number is approximating near 40% in 2010 based on my practice experience. While financing has been a boon to plastic surgeons in general, there is a surcharge from the financing company to do it and some of that comes out of the plastic surgeon’s fee. A similar issue applies to credit cards which extracts about a 3% surcharge.

For these reasons, there is always a financial benefit in most plastic surgeon’s offices if a patient can handle paying for their cosmetic surgery without financing. That would be true for just about any other business as well so this not unique to plastic surgery.

When combined cosmetic procedures are done, it is also common practice to provide some discount over what those procedures would be if they were done separately. For this reason, it is always best to combine as many procedures as you desire in a single surgery. This is not only more efficient from a  recovery standpoint but financially as well.   

Dr. Barry Eppley

Indianapolis Indiana

Q:  I have 5 lipomas in my stomach area and would love to have their size reduced, if not completely gone. I’ve been looking into having them treated by deoxycholate injections. What has been your success in getting rid of them (all of them are less than 4 cm in diameter) and how many injections sessions does it usually take? 

A:  The traditional method for lipoma removal is excision. These are encapsulated benign fat tumors that actually pop out of small incisions made directly over them fairly easily with a little pressure. But in an effort to avoid surgery, the use of fat-dissolving injections has been done for them as well. Known chemically as deoxycholate or phosphatidylcholine deoxycholate (often called Lipodissolve), this solution has been well described for the cosmetic reduction of small body fat collections. Working through an inflammatory process, this solution is known to break down the cell walls of fat allowing their fatty acid content to be released. It is less well described and known for fatty tumors (lipomas) treatment but it works through a similar inflammatory process. The fat in a lipoma is more densely packed and , in theory, is a little more resistant.

I have treated a series of lipoma patients with these Lipodissolve injections in my Indianapolis plastic surgery practice and do find it to be effective. It does take more than one injection session to get maximal reduction in most patients. How many injections sessions that would be depends on the size of the lipoma. As a general rule, expect about a 50% reduction with each injection session. 

Dr. Barry Eppley

Indianapolis Indiana

Q:  Hi I was wondering what you think of Bioplasty or have you ever heard of  it. Doctors in Brazil does the whole face with pmma called Newplastique,  injecting it into the jaw, cheeks, chin, eyes, brow anywhere.  I saw a doctor in Mexico who uses this new plastic pmma and he quoted me $2400 for jaw jawline cheeks chin and said second touch up treatment would be half the price. What do you think?

A: What you are referring to are ‘permanent’ injectable fillers for facial fillers and volume enhancement. They are permanent based on that they contain a percent of non-resorbable particles (usually about 30% or less in volume) mixed in with fluids which allow them to be injectable. (flow through a relatively small needle) The percent of particles in any given size syringe is always less than the amount of fluid otherwise they would clog up the needle and not be injectable. There are a variety of these type injectable fillers that exist in the world using different plastic particles and different fluids. The concept, however, is the same and the potential complications are similarly the same.

Quite frankly, I am not a proponent of these type of injectable fillers for widespread facial use. I would be concerned about the potential for long-term problems from the particles such as granulomas and lumpiness. They would be difficult to remove and may have to be cut out should these types of problems arise. Advocates of their use feel that these problems can be minimized by good injection technique, which I am sure is true, but how do you know who does it well and who does it poorly? Around the world, where the medico-legal implications are not as severe, these fillers are more widely used. In the United States, however, their use and many of these type of fillers are not widely done and are not even FDA-approved for use. Nonetheless, It is not an injectable procedure that I feel comfortable doing to patients. That doesn’t make it wrong, just that I have a different practice philosophy.

I feel more comfortable doing enhanced fat injections for facial volume and reshaping. While their permanency is variable, they also are not associated with any long-term complications since it is the patients own tissues. While it is more effort and expense, and may have to be repeated sometimes as well, safety is more important than a lower cost.

Dr. Barry Eppley

Indianapolis Indiana

Q:  Hello,  I have several questions regarding cosmetic surgery. First off I want to say I am a single mom of four wonderful children but they have destroyed my once nice looking tummy. But I HATE how I look. I have suffered an eating disorder since my first child being born, to the point I was approx. 90 lbs and I am 5′ 5″. I still do not eat right as I am petrified that I am going to gain weight and make my stomach even bigger. I am also a full time student so I know I cannot afford surgery. There is simply no way. Is there ANYTHING I can do? I hate the way I look, I hate to take showers, I hate to be seen by my fiance naked!!! I literally HATE my body. I currently weigh 135 lbs. So I have done very well maintaining weight. I am at a loss as to how can I rid myself of this awful belly? Please help!!

A: Unfortunately, the short answer is that only surgery can offer any help. After multiple pregnancies, your abdominal wall has been irreversibly changed. The abdominal muscles are no doubt separated along the midline and are lax which accounts for the protruding appearance of your belly despite being at a good body weight. In addition, the overlying skin has been stretched beyond its elastic limit as evidenced by stretch marks. All you can do with your weight is keep the fat layer thin but that will not change your skin and muscle of the abdominal wall. Perhaps one day you will be able to have the tummy tuck surgery that can provide the solution that you are looking for.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I feel like I am ready for a facelift and want to get the best result that I can. In doing my research on the internet, I have come across several recent articles on a procedure called the Stem Cell Facelift. In reading them, they make it seem like it is the best way to go with the best results. But I don’t understand what stem cells have to do with a facelift. Do they help lift the droopy skin or do they make what is already there better. I would like to go to a doctor that does them but I am also worried about whether this is so new that maybe it doesn’t really work that well or it is just some sort of a scam. What is your opinion?

A: The concept of the Stem Cell Facelift is based on two simultaneous techniques, a traditional facelift to lift and tighten loose neck and jowl skin and fat/stem cell injections to add facial volume. The injections are not responsible for any type of skin lifting. They add volume to areas of fat absorption that have happened with age and are purported to help make the skin look better. (which remains far from proven) They may be done together but the fat and the stem cells they contain can not make for any tightening effect on the skin

Is this facelift concept hype or hope. At this point, a little of both in my opinion. The concept is very appealing and the technique uses all natural products from each patient, thus there are no risks involved in doing it. Conversely, whether this facelift approach is better than the traditional proven methods has yet to be adequately studied over the long-term. It may well prove to be an improved method with better results but at this point the promotion of it is ahead of the actual science.

Dr. Barry Eppley
Indianapolis, Indiana

Q:  There seems to be a multitude of people out there with chin/lip problems arising from intraoral surgery who don’t know where to turn or what to rely on to remedy their situation. Mostly their problems are attributed to mentalis detachment/loosening and scar tissue, particularly in the labiomental fold region. Chin/lip deformity poses a significant quality of life issues and must be taken seriously. A case study of scar revision in this instance, with before and after photos and details of the surgery, would be of great assistance. Mentalis resuspension seems straight forward enough if its loosened or detached from its origins. The question in my mind with regards to scar tissue excision, is how much mentalis muscle in the labiomental fold or chin pad region, can be safely excised before the mentalis can no longer function properly?

A:  Ptosis, or sagging, of the soft tissues of the chin can occur after any form of chin surgery done through an intraoral (inside the mouth) approach. When it occurs, one surgical method to put the soft tissues back onto the chin bone is mentalis resuspension. This is fairly way to do and the most important technique for the procedure is how the muscle is secured back to the bone.

Generally speaking, the only scar tissue that ever needs to be removed during any chin revisional surgery is the scar capsule around an existing chin implant. (if the implant is being removed) This needs to be removed because it will not allow the overlying muscle to heal back onto the bone.

Dr. Barry Eppley

Indianapolis Indiana

Q: I’ve done Botox injections on my frown line and crow’s feet. Thinking about having Botox to treat TMJ pain and maybe some on my face. Please let me know if he accepts insurance for the Botox treatments.

A: The use of Botox to treat “TMJ’ problems  is done by numerous practitioners with variable degrees of success. Botox is a very specific treatment for muscle spasms and tightness or overactive muscles. The term TMJ, however, is a broad term that actually is a collection of different pain sites that is not really a unified diagnosis. For this reason, so called TMJ patients are being injected who may not be ideal candidates for a muscle treatment.

The best orofacial pain patients, in my experience, to get relief from Botox injections are the bruxism or clenching patient. This is a very specific masseter muscle problem that can be localized in most cases to the part of the masseter that is near the bony jaw angle. This is also a perfectly safe area to treat without causing any complications. The tight and painful muscle can be easily felt and the most painful part of the muscle specifically injected. These are also patients that have either been through or are currently undergoing some form of traditional mouth splint therapy. Often this treatment has failed or its effectiveness has decreased…as this is why they are seeking Botox injections.

Because the use of Botox for bruxism or as any part of TMJ problems is not FDA-approved, it is not eligible for insurance coverage.

Dr. Barry Eppley

Indianapolis Indiana

Q: Do you offer chemical peels? What is available to forehead and brow wrinkles?

A:  Assuming that these two questions are linked, so to speak, points out a basic misunderstanding of what certain procedures can do. Chemical peels, of which there are many types which penetrate from superficial to deep, are good for improving skin texture problems which does include very fine wrinkles. But they will not work on any skin problem which lies deeper, such as scars or deep wrinkles, folds, or furrows. Almost all commonly used chemical peels treat more superficial skin problems. It is best to think of chemical peels as an outer skin treatment.

Forehead and brow wrinkles are not superficial skin concerns. While they may appear on the surface as a skin change, the primary problem is deep. It is the excessive muscle action that eventually causes the outer skin layers to become etched or permanently wrinkled. Since the problem lies deep, no superficial treatment can provide any visible improvement. This is why the initial treatment for forehead and brow wrinkles is Botox injections. As a muscle-weakening agent, it can lessen or stop their movement creating an immediate improvement in the depth of the wrinkles seen. In more severe cases, a browlift may be a better answer. This procedure treats the muscles at fault through their selective removal. With less muscle action, which is  combined with skin tightening through a lift, there can be a dramatic reduction in the forehead and brow wrinkling problem.

Dr. Barry Eppley

Indianapolis Indiana

Q:  Hello, I went to see a plastic surgeon about repairing my one stretched ear ring hole. I pretty much made it clear why I was in the office. The office workers did not pay attention to my needs and instead pointed out all my other flaws and pushed selling other procedures on me. I wish I could afford to correct all flaws, however at this time, I just want my little ear repaired. After they had me under the bright light and made me feel awful about myself, they finally told me the cost of the ear repair… $800. Just because the way they treated me, I would rather stitch it myself then give that office the money. Can you please tell me how much the procedure would be? Thank you.

A:  Earlobe deformities from the use of ear rings creates two basic correctable problems, an enlarged or elongated hole and a complete split or tear. Both can be easily and quickly treated in the office under local anesthesia in less than 30 minutes. There is no pain afterwards or significant swelling or bruising. Tiny dissolveable sutures are used so there is no suture removal afterwards either. One can shower and get it wet the very next day. Once it is healed, re-piercing can be done six weeks later.

From an office standpoint, every plastic surgery practice has differences in philosophy. Some promote and sell harder than others which often, understandably, turns some patients off. That doesn’t make them a bad practice, just one who may not be a good fit for you. From a pricing perspective, fees will vary around the country for any elective cosmetic surgery procedure based on geographic location and the size of the practice. There are no standard fees for cosmetic surgery nationally. It is a simple matter of what value the practice puts on their time and expense to do the procedure and what a patient is willing to pay. Here in Indianapolis, the prices for earlobe repairs is more typically in the range of $300 to $450 per earlobe.

 Dr. Barry Eppley

Indianapolis Indiana

Q: Hi Dr. Eppley, I have a question regarding my face since it has gotten thinner after a facelift.  I had a facelift last summer after losing 45 pounds. My plastic surgeon said he took four inches of skin out of my neck. However I did lose my round face because my cheeks are more sculpted now due to loss of volume.  While I like the change it is a weird look for me because I have always had a round face since I was just a kid.  I never had sculpted cheeks even at a normal weight.  I used to get carded well in my 30’s because of my baby face.  So there is some merit to having volume. It is weird for me to see my cheekbones as opposed to my puffy cheeks.  I almost feel like I look older without my round face.  So my question to you is it possible to add some volume in my lower cheeks BELOW the cheek bone to get my “baby face” back.   What would you suggest?  I can send pix if you want me to. Thanks for your advice.

A:  There is no doubt that between having a facelift and undergoing considerable weight loss, one can end up with less facial volume. This is usually most manifest around the cheek areas when it occurs, specifically in the area below the cheeks known as the submalar area. I prefer to call this area the submalar triangle as it is a soft tissue area that has the configuration of an inverted triangle and has no underlying bony support. That is why it suffers the greatest indentation or hollowing on the face with fat loss…it has no underlying bony support so it sinks in.

There are several ways to build out the submalar triangle. The simplest is to replace what is lost through fat injections. Fat is both natural and easy to harvest through liposuction and its injection is not ‘invasive surgery’. Its downside is that its survival is not always predictable. The other is to use a specific submalar implant which sits on the underside of the cheek bone. This will build out the upper part of the submalar triangle but not the lower area near the corner of the mouth. The total submalar area can also be built out by the insertion of onlay dermal grafts. Using part of your old facelift incision, allogeneic dermal grafts (human dermis out of a box) can be cut and laid underneath the skin to add a soft natural volumetric fill. The dermal grafts will integrate and become part of your natural tissues.

As you can see there are a variety of submalar augmentation options. Which one is right for you depends on which approach offers the simplest, most natural, and predictable outcome.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am very interested in learning more about the Kryptonite Bone Cement for injectable cranioplasty. I am a 36 year old female with a very unusual shaped head in which I have always hid behind various hairstyles for shame of the overall appearance of my head. I strongly believe that the shape of my skull may be the result of some form of untreated craniosynostosis or other undiagnosed craniofacial disorder. Or maybe it might just be plain old bad genes.

My skull is very narrow and somewhat small. The shape of my forehead slopes back at such an undesirable angle and is very flat and narrow in width. The resulting slope of my forehead extends up into the top of my skull of which I can only describe as a point. There is somewhat of a flatness in the center of my skull and the back of my skull is very flat and extremely narrow in width as well. I am also very hollow in the frontal view at my temple area around my eyes with very wide cheekbones and a deficient jaw and chin.  I have always wondered if there were any such cosmetic procedure that could help in this kind of skull case.

My questions are: 1) What are  the biggest benefits of using the older PMMA and HA methods over the new Kryptonite Cement method? How long has Kryptonite Bone Cement been used? 2) Can it be used for adding volume to reshape an entire skull like mine, making it more rounded and add mass in largely deficient areas?  3) Can it be done with scalp hair in place or does the hair need to be shaved for a better view of the entire head? 4) Is there any chance that the material will become detached from the skull and slide out of position? 5) Will the scalp expand and conform to the newly added volume comfortably? 6) Can it be used in place of such procedures as chin and jaw implants?

A:  Thank for your insightful questions in regards to your craniofacial concerns. My answers would be as follows. 1) All three cranioplasty materials will work in an open scalp approach. Only Kryptonite can be injected. There are substantial cost differences between the material cost of HA and Kryptonite being over 10X the price of PMMA. For very large scalp areas, the issue of cost makes PMMA the only practical choice for most patients. 2) All the materials can be used over large skull areas. In larger areas, the cost of PMMA makes it the material of choice. 3) For large skull areas, the hair would have to be shaved to see what one is doing. For an isolated forehead cranioplasty, the hair is not shaved. 4) No, all cranioplasty materials stick quite well to the underlying bone. 5) The scalp can expand to a large degree but the skull must not be expanded (built out) greater than what can be closed over it. 6) No as yet. Kryptonite has not been yet tested for use in this way. For now, standard facial implants are more predictable and far less expensive.

Dr. Barry Eppley

Indianapolis Indiana

Q:I am looking at having a revision surgery on my chin for what I believe is a partial non-attachment of the soft tissue to the hydroxyapatite implant. Some of my chin hang independently from the rest and looks aged. My surgery was two years ago. I am contacting you because I see you have specific knowledge of the intricacies of chin surgery. Could you give me some information about what I should do now and whether you have dealt with this problem before?

A:  Thank you for your inquiry. Before I can answer your questions specifically, let me get some details as to your chin surgery from two years ago. You refer to having a hydroxyapatite implant placed. Since there are no off-the-shelf hydroxypatite implants of which I am aware, I assume that this was an intraoperatively carved one that was done from a block of material. Furthermore, I am assuming that it was placed intraorally (through the mouth) as opposed to under the chin through the skin.

Your description of your concern’s sounds like what is known as a ‘witch’s chin deformity’, otherwise known as soft tissue chin ptosis. There is where the chin soft tissues sag off of the end of the bone/implant. Because any type of chin implant augmentation must detach the muscles, there is that risk after surgery although it almost exclusively occurs from an intraoral approach.

Please send me some photos of your chin and provide answers to my questions, then I will be able to confirm this diagnosis. I have seen this numerous times and the appropriate correction (implant notwithstanding) in most cases is a mentalis muscle resuspension procedure.

Dr. Barry Eppley

Indianapolis Indiana

The internet continues to redefine our existence on a daily basis. From how we shop for everything from clothes to cars, to how we shop for information, it now influences and controls our culture. Even our English language is being affected.

This is best reflected in the Urban Dictionary. This is a web-based dictionary of slang words and phrases. The definitions on the website are meant to be those of slang or subculture words, phrasing phenomena not found in standard dictionaries. Most words have multiple definitions, often quite different than you think. It contains over five million definitions and is expanding rapidly with an average of over 2,000 new submissions per day. While it has tremendous web traffic, most of its users are younger than 25. For this reason you may not have heard about it…but eventually you probably will.

When it comes to  ‘urban’ terminology, plastic surgery has many such terms. Used everyday with patients or in the operating room, these thinly veiled innuendos instantly describe the cosmetic problem. Let me share with you a few of the most common ones- some which you will know,  and others which you may find enlightening.

Elevens–  Not a number but a type of facial wrinkle. Popularized by the manufacturer of Botox in their advertisements, these vertical lines appear between the eyebrows when a person is scowling or frowning. Because they most commonly appear as paired lines, they are appropriately described as this number. The elevens are exactly what Botox injections were initially FDA-approved to treat.

Crow’s Feet – Long recognized as the wrinkles that radiate out from the corners of the eyes as we smile, a crow would probably be delighted to have its feet so described. Since wrinkles on our face always form perpendicular to the direction that the underlying muscles move, these naturally occur from eye squinting. Botox works well to reducing these also.

Dog Ears-  Having nothing to do with a dog’s ear or anyone’s ear for that matter, this is the bunching of skin at the tail end of a scar. They commonly appear when skin areas are ellipitically removed, like the shape of a football, and the closure results in a straight-line scar. From procedures such as tummy tucks and breast reductions, dog ears may develop at the ends of the scars. They are a frequent source of minor scar revision.

Turkeyneck – Who doesn’t recognized this one, particularly if you are middle-aged or older. It needs no description and it often drives the desire for a necklift procedure.

Saddlebags – An older, urban plastic surgery term that many women recognize. That fat collection at the side of the thighs that resists every form of diet and exercise, but which liposuction can treat so well. If only they were as simple to get rid off as pulling their historic corollary off a horse.

Parentheses – Not an English quotation mark but those classic lines that develop from the sides of the nose down past the sides of the mouth. They are one of the major places for the use of the very popular injectable fillers (such as Juvederm) to make them look less deep and obvious.

Muffin Tops – While a tasty and crunchy part of a muffin, eating enough of those will put them on your waistline. These are the classic fat rolls that stick out from the side and back of your pants…and which are nearly impossible to get rid of.  Liposuction machines love this part of the muffin, too.

Puff Daddy – Men won’t recognize this problem, but most women will. It is the fullness or puffiness of the pubic area just below the waistline. It can become evident after a tummy tuck when the waistline becomes narrower than what lies below. It can be an embarrassing bulge in pants that no slimwear can flatten.

If you recognize more than five of these terms, you can consider yourself to be both hip and plastic surgery savvy.  

 Dr. Barry Eppley

Indianapolis, Indiana

Q: I have a very square jaw with a lot of fullness towards the front which has always bothered me and made me self conscious.  I try to keep myself thin because any weight gain will make it even fuller.  I am currently 43 and it seems to be feeling fuller, where I always felt when I got older the baby fat would decrease.  My mother and father both had full faces with fairly square jaw lines as well.  I am hoping the buccal fat procedure and would help my profile and thin my face from the front and side…like when I bring in my cheeks by sucking them in…it seems to show the angles more rather than looking chubby.

A:  A square facial architecture is strongly influenced by the shape of the lower jaw and the cheek bones. To make a square face less full, the only area that can be changed is an inward movement of the submalar triangle facial zone. That is the area beneath the cheek bone done past the corner of the mouth in an inverted triangle shape. This is an area that is not supported by bone or muscle which is why you can suck it inward. Fat removal of this area is the only way to create some tapering in of this zone. The buccal fat pad occupies the upper region of the submalar triangle but not the area down by the mouth, known as the lower submalar triangle area. So a buccal lipectomy will help but needs another method of fat removal of the lower area also known as the perioral mounds. Microliposuction should be done from inside of the mouth to help this area in conjunction with the buccal lipectomies. The combination of both has the best chance to help achieve the look you are after.

Dr. Barry Eppley

Indianapolis Indiana

Q: I have a cyst like lump right in between the eyebrow. In stead of cutting the cyst off with the knife vertical to the skin, is it possible to make a cut right underneath the frown lines and slice the lump off from the cut? Is it possible to transfer some fat to that area if the area is dented after the lump is sliced off?

A: Those are two very good insights into how to remove your forehead (glabellar) cyst while leaving the most aesthetic outcome. Using a close wrinkle or frown line would be preferable to making an incision directly over the cyst. That would make for a far better scar. Even if the scar turned out less than ideal, it is more favorable area in which to perform scar revision. It may also be possible to remove it by an endoscopic technique, although I would have to see pictures of it to be sure that is a possibility.

Also, placing a fat graft at the time of a facial cyst removal is almost a standard technique that I do since indentations may follow later due to a mass removal effect. An indentation may now appear initially, due to fluid fill of the cyst removal space, but will appear once that fluid is absorbed weeks to months after surgery. If the cyst is more than just the size of a pea, I would recommend that at the same time rather than waiting for it to appear later. It is just as simple to do it at the time of cyst excision.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am 5’7″ and weigh 128 lbs. Even though I am relatively thin, I have always had a double chin for some reason. But I feel like it has gotten worse since I have given birth to two children and have gained over 40 lbs with each pregnancy.  I am interested in knowing what could be done and how much improvement I could expect. Getting rid of this double chin would help me feel more confident. Thank you so much for your time.

A: The cause of a  ‘double chin’ is a combination of three anatomic factors; neck fat, neck skin, and chin projection/prominence. Every double chin is made up of differing ratios of all three components. It is always about how much neck fat is there, how much extra neck skin there is, and how short one’s chin may be. While you didn’t state your age, that number also has an influence because it suggests how much neck skin you may have and, most importantly, how elastic it is.

Some double chins can be corrected by as simple a procedure as neck liposuction in someone who is young and with decent chin projection. On the flip side, an ‘older’ severe double chin may require everything including neck liposuction, chin augmentation, and some form of a necklift to help tighten the extra loose skin. Each patient must be assessed individually and a custom treatment plan devised as double chin correction is not a one size fits all procedure.

One surprising aspect to the ideal correction of double chin problems is that of the chin. Many people have short chins that are magnified by this problem. Lengthening the jawline with a chin implant while bringing the angle of the neck back (or making it more defined) is the classic ‘ying and yang’ approach which together makes a better result than either change alone.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am interested in getting some facial implant work done and was wondering if I can have wisdom teeth extraction done at the same time? I want to get orbital rim implants with a possible midface lift. Is there any reason why these two can not be done together? Will one potentially cause problems with the other or is it better to have them done separately, like a decreased risk of infection?

A: I see no reason why these two facial bone procedures can not be done at the same time. It is quite common to do multiple hard and soft tissue procedures of the face together. The face is tremendously well vascularized and very resistant to infection. (I didn’t say impossible just very resistant) While such a combination (facial implants and 3rd molar extraction) is unusual, it is by no means contraindicated. The hardest part is not the operation, but finding someone who is well qualified to do both at the same time.

Orbital rim augmentation and a midface lift is done from the outside through a lower blepharoplasty incision. Wisdom tooth or 3rd molar extraction is done intraorally from inside the mouth.  The two areas are not anatomically contiguous and would not connect, thus ensuring no risk of oral bacterial contamination coming in contact with any implanted material. Because of this risk, the orbital/midface procedure is done first so cross-contamination from instruments does not cause any inadvertent oral bacterial inoculation on the implant.

Dr. Barry Eppley

Indianapolis Indiana

Q:  I am considering getting involved in martial art training and was wondering if having a chin implant would pose a problem with that activity. I have a porex chin implant and I’m afraid it will shift if struck. Have you ever seen a porex implant shift from blunt trauma? Is there a difference in potential shifting between porex and silicone implants. Please let me know so I will know whether or not to proceed with martial arts training.

A: I would not personally refrain from martial arts training, or any other contact-related sports activity, if I had an indwelling chin implant. The risk is always there that a good blow to the chin could cause a problem such as shifting of the implant but that risk to me seems very low. There is an equal, if not greater risk, of breaking one’s nose or having a tooth knocked out. Such are the orofacial risks of any contact sport.

The potential advantage of a porex (medpor) chin implant over a silicone one in terms of shifting in the face of trauma is theoretical. Because the porex implant has greater tissue adherence and even some amount of tissue ingrowth, one would assume that it is more resistant to movement after surgery over a purely non-ingrown encapsulated silicone implant. But blunt trauma to the jaw with enough force can easily fracture the bone so the potential for implant movement, regardless of its composition, is always a low occurrence possibility.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am interested in the Fat Injection Breast Augmentation surgery but have a few questions. What are the preop requirements and do you have to have multiple operations?

A: Breast augmentation with fat injections is in the early stage of technique development. While the appeal is enormous for some patients, it is a concept which has not been shown to be consistent in results just yet and the long-term outcome on breast health and cancer surveillance is unknown. Breast augmentation with implants remains a proven technique. Whether fat injections will one day be a comparative procedure remains to be seen.

What is known about fat injections for breast augmentation is that one has to select the patient for it very carefully. Several criteria are important. First, one has to have enough fat to transfer into the breast. If one is very thin or skinny, they will not be a candidate due to lack of adequate donor tissue. Secondly, one’s desired breast size increase must be modest. At best, only a 1/2 cup or maybe more can be gained in size. Desiring a bigger change than that is beyond what fat injections can yet achieve. Lastly, one must be prepared to accept the likely possibility that more than one fat transfer may be needed. Injecting too much fat in a single session will not work. It is better to incrementally increase the fat breast volume to ensure the best survival and decrease the risk of fat necrosis. Therefore, patients must be willing to accept, and have enough donor tissue, to do a second fat injection session in most cases.

Dr. Barry Eppley

Indianapolis Indiana

Q:  Hi, I need your help. Three months ago I had a gynecomastia operation done and now I have a problem. The problem is that my nipples are folded in now and going inside. My skin is also very dry around nipples and my nipples have become cracked. This looks like a serious problem. How can I fix my nipples?

A:  Gynecomastia reduction procedures can be done two fundamental ways; liposuction or open excision (removal) of excess breast tissue. Sometimes the two techniques are done together to get the best result. With the open excision technique, breast tissue is removed through an incision on the underside of the nipple. (technically the areola) Removal of this breast tissue is largely an art form. How much to remove and how to shape what is left behind is more of matter of experience than an exact science.

One of the known complications of open gynecomastia removal is over-resection, removing too much breast tissue. This make look alright in the very beginning (or not) but as the swelling subsides and scarring sets in, the nipple gets pulled into the over-resected space where breast tissue once was. This is called nipple inversion or a retracted nipple. It most commonly appears underneath the nipple since this is closest to the incision but it can appear outside the diameter of the areola if the over-resection goes beyond just that area.

Correction of the inverted nipple after gynecomastia reduction requires replacement of the missing tissue to support the projection of the nipple. This is best done by a fat graft or a dermal-fat graft using the patient’s own tissues. This requires a donor site and a scar elsewhere on the body to do it.

Dr. Barry Eppley

Indianapolis Indiana

Q: I was wondering if I could get a Botox procedure done in my masseter muscles to help with my teeth clenching. I have tried mouth guards and it doesn’t solve the problem because I’m also clenching my teeth a lot when I am awake. Please send me any information you can regarding this issue.

A:  I have used Botox for masseter muscle injections for clenching and bruxism for the past five years. I have yet to see a patient who has not had some near immediate and significant improvement of their clenching afterwards. The duration of the pain relief will last as long as the Botox is effective, generally around four months or so. This makes perfect sense as the clenching is muscular in origin. While it can also involve the temporalis muscle, the large masseter muscles are certainly a major source of the  clenching problem. While the simultaneous use of oral splints still has a role, particularly to prevent excessive tooth wear, the direct injection of a true ‘anti-spasm’ agent into the muscle is undoubtably more effective and immediate. (results within a week or less)

I have found that the starting dose of Botox is 25 units per side. Both sides are only done if the patient feels that the pain is on both sides. Many patients will have only a one-sided or unilateral source of masseter pain and clenching. The injections are placed in the lower half of the masseter. If a line is drawn from the earlobe to the corner of the mouth, the injections are placed in the part of the masseter muscle that lies below that imaginary line. This is a simple office procedure that is both quick and fairly painless. Compared to cosmetic Botox injections in the forehead, masseter muscle injections are surprisingly more comfortable.  

Dr. Barry Eppley

Indianapolis Indiana

Q: Dr. Eppley, I have a question about the cranioplasty operation. I had some frontal bone augmentation done two weeks ago with acrylic material. I had it done to get rid of some irregular areas that were quite prominent on my forehead. I had a craniosynostosis repair when I was one year old. I know that swelling is to be expected but I thought most of it would be gone by now. It appears asymmetric between the two sides of my forehead and doesn’t look quite even. Am I being too optimistic about the swelling?

A: It is normal that patients are generally quite overoptimistic as to how long it takes to see the final result of the cranioplasty procedure. While two weeks may seem like an eternity when you are the patient, six to eight weeks is the realistic time period to see about 90% of the final result…and 3 months after surgery before one can make a final critical analysis. That’s how long it takes for the scalp tissue swelling to go completely away and all areas to settle. The thicker the tissues are, the more swelling and the longer it takes for it to go away…and the scalp tissues are quite thick. 

Another interesting note is the concept of bilateral (two-sided) surgery. Even though the same thing is done to both sides, the swelling that occurs is never, or rarely, the same. So any asymmetry at this point I would still judge to be swelling differences and not yet proven to be some differences in the degree of forehead symmetry from the augmentation.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am unhappy with the mid- and lower cheek area of my face. My cheeks are sunken in below the cheek bone causing a hollow/gaunt appearance. I have smile lines that are becoming heavier and more visible all the time. I had fat injections in the area of the smile lines about 3 months ago. I would estimate that about half remains at this point. I saw your videos on Youtube and would like your opinion on whether a submalar implant would fully correct, partially correct, or have minimal effect in this area of my face. I would like to understand your recommendations on improving this area. My objective is to create a permanent and fuller looking face in the cheek area and pull out the smile lines without creating a chubby or fat face.

A:  The key to answering your question is to understand the anatomy of the submalar triangle area. This is an inverted triangle facial zone that lies below the cheek bone in which the apex of the inverted triangle goes down below the corner of the mouth. Almost all of this area is not supported by bone, but by soft tissue only. As a result, a submalar implant will only help create fullness in the upper region of the submalar triangle. The smile lines lies in the lower end of this triangle and will not be changed by a submalar implant. Soft tissue augmentation must be done in the smile line area. Fat injections is one method but is fraught with unreliable take as you have experienced. But its simplicity remains its appeal and another effort at it may produce even better results. The other option, which I currently prefer due to its better effect and longevity, is interpositional dermal grafting. By placing layers of allogeneic dermal grafts in this area, the skin and the underlying tissues are released and separated by the grafts. They add an eventual well-vascularized tissue layer that can be from 2 to 5mms thick which is not unduly bulky. They must be placed through a limited facelift (preauricular) incision. Their longevity is much more assured than injectable fat grafts in this facial area.

Dr. Barry Eppley

Indianapolis Indiana

Q: I live in  New Jersey and loved reading your advice articles on injectable fillers. I am a 42 year-old female with dark circles under my eyes with hollowing, upper lip wrinkles, and horizontal forehead ceases. I would love to know if you could recommend a skilled Dr in my area who could do my eyes? Thank you for your time.

A: Injectable fillers can be used to create a variety of instantaneous facial effects by adding volume under the skin. While once limited only to lessening the depth of the nasolabial folds or increasing the size of one’s lips, their uses are being expanded. One of these newer areas is around the eyes, specifically for hollowing of the lower eyelids or treatment of the tear trough depression. This lack of volume can be one of the contributing factors to the appearance of dark circles under the eyes. Suborbital injection filling is one of the more technique sensitive (trickier) areas to inject well however. There is definitely much greater risk of bruising due to the many blood vessels in this area. Missing all of them can not always be predicted. Proper placement of the filler in the deeper tissue level down to the bone is important to not only get the best fill but to avoid lumps of the material if injected just under the skin. For those physician injectors that regularly perform blepharoplasty (eyelid) surgery, they will more likely feel comfortable placing the injectable filler into the proper tissue level. They will also be in better position to judge whether an injectable filler is the best treatment option and how it might compare to other methods of treatment such as fat grafting.

Dr. Barry Eppley

Q: I am interested in what a limited facelift or lifestyle lift might do for me or if I can get away with fillers or something like that. What is the comparative recovery time? Costs? How long do they last?

A: One of the common misconceptions in management of the aging face is that injectable fillers and some form of a facelift treat the same problems. They do not and, as a result, are not comparable treatments. They are often companions (done together or in separate stages) but are never substitutes for each other. Injectable treatment are for the central part of the face and do things that surgery generally can not either achieve or do very well. These include Botox for forehead and eye wrinkles and fillers for nasolabial fold depth reduction and lip wrinkle reduction and lip size increase. Any form of a facelift deals only with the sagging skin and excess fat in the neck and jowls, lower third of the face sagging.

There are procedures touted as ‘liquid facelifts’ but these are a bit (or maybe a lot) misleading and are associated, in my opinion, with a relatively poor value. By using injectable fillers, the sides of the face and cheeks can be puffed up which does create a mild temporary lifting effect due to the expansion of the tissues. The operative word is temporary (six months or less) and, when one compares the cost of numerous syringes of injectable fillers, one could already be more than halfway to one of the variations of a facelift. This injectable approach will also do nothing for the neck area which is the primary target of facelift surgery.

For the patient with lesser amounts of facial aging, the combination of a limited facelift (aka Lifestyle Lift) and injectable fillers can create a very dynamic effect by being able to treat the entire face more effectively. There is a very definite role and benefit to injectable fillers but their results are not comparable to facelift surgery.

Dr. Barry Eppley

Indianapolis, Indiana