Your Questions
Your Questions
Q: I had a chin reduction just about two months ago. I still have not seen any results. If anything I feel that my chin seems longer then before. I spoke to the doctor about it and addressed my concerns. He said it takes up to 6 months for the final results. If by then I am not happy with it, he will then try something else. What to you suggest?
A: There is no question that any form of chin surgery takes time for the swelling to go down. In my experience in chin reduction, this is particularly true as swelling will mask a reduction longer than it will an augmentation. (the result from a chin augmentation will be seen immediately, the issue is that it initially looks too big due to the swelling) The initial soft tissue swelling from most forms of chin reduction will make it look longer or bigger initially and this is normal. Generally, however, the results start to become apparent within three to four weeks at most. By six weeks, patients should be able to say that they see a difference if not significantly so. It will take three to six months, however, for the true final result to be appreciated.
One important factor that controls the amount and duration of swelling is what type of chin reduction procedure was performed. There are two different types of chin bone reduction procedures, an osteotomy and a burring or shaving. One is done from inside the mouth (osteotomy) and the other is done from an incision underneath the chin. Knowing which one was done can help determine how long it may take to see the final results from the chin modification.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am exploring cheek implants as a solution to my flat cheekbones which i was born with.sunken cheeks (genetic). I live in Pennsylvania and wanted to find out if Dr. Eppley would initially review emailed photos before making an appointment.
A: The concept of ‘consults from afar’ in plastic surgery was once inconceivable and impractical. But the internet and the ease of photographic acquisition and transfer has changed that perception. Since almost all of plastic is external and very visible, physical and cosmetic issues can now be seen from great distances by simply sending pictures. In fact, the reach of the internet and its virtual no cost has made it possible to connect any two places in the world, at the very least by e-mail.
I regularly (daily ) do internet plastic surgery consultations. Many are from various U.S. states and provinces of Canada but some are from countries around the world ranging from the United Kingdom to China. There are two types of internet consultations. The first type is of an e-mail nature only. Inquiries are initially done by e-mail from which I request photographs for review and possible computer imaging. That may then proceed onto an actual phone call for the next level of more indepth discussion. The other type is a Skype video consultation. Its origin may be from an initial e-mail or from Skype itself. If a video Skype consultation is arranged, then photographs may be bypassed due to actually seeing the patient. However, due to the poorer resolution of many Skype video connections, photographs are recommended to be sent first.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hi. I know I might be young to ask, age 19, but I was wondering what you called a plastic surgery that takes care of love handles. But I am not talking about the hip handles. I have some pretty good handles right under my breasts that wrap to my back. I believe it is some loose skin as I have managed to loose 25 pounds this past year. I am just wondering what you would call that specific body part and maybe an average of how much it would cost to fix it. Thanking you in advance for replying. From a discouraged yound girl.
A: The important question is whether the rolls underneath your breast that extend into your back are skin, fat or a combination of both. With weight loss, most loose skin is going to develop and be seen lower due to gravity. That being said, I would have no doubt that it is a combination of loose skin and fat. Whether one is more predominant over the other would require an actual physical examination to make that distinction. But given your young age, I would recommend a liposuction procedure for fat reduction first and see how the skin adapts. The fat in the upper abdomen and the back is more fibrous in nature than lower abdominal fat and a liposuction technique, such as Smartlipo, will be more effective than traditional liposuction. There are methods of skin and fat removal by excision in the upper abdomen, which do leave lower breast fold scars, but they are usually reserved for more extreme cases of weight loss where the sagging skin is the predominant problem.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hey! I have large indentation on the right side of my frontal bone. It is becoming noticeable since I have started losing my hair. I am wondering if it is possible to correct it without any visible scars. Thanks and.hope to hear from you soon.
A: For select cranial defects, the use of the new Kryptonite bone cement may make it possible to fill out or augment deficient bony areas. Because of its flow characteristics, it can be injected through long small plastic catheters into cranial areas from a small incision placed in the most inconspicuous location as possible. Studies have shown that it is injectable through catheters as as small as a 12 or 14 French size. (roughly 4 to 5mms internal diameter) Once injected it can be molded through the skin from the outside until it steps up into a firm consistency.
When defects are present on the frontal bone, it is important to recognize the exact location if this injectable technique is to be used. Defects that exist between the anterior temporal lines are bone-based and can be augmented by onlay bone materials. If the forehead defect extends beyond the anterior temporal line, this area is covered by the upper edge of the temporalis muscle. While the temporal muscle can be lifted up and material added onto the bone, this is not possible with a limited incision injectable treatment method. Defects that extend into the temporal area require the more traditional open scalp incision for access and wider exposure.
Indianapolis Indiana
Advertising and marketing permeates our existence at every turn. It is so omnipresent that it takes outlandish claims and often near unbelieveable stories to even catch most people’s attention anymore. Nowhere is this more true than in anything connected to the pursuit of beauty and youth. From magical skin care creams that purport to make one look 10 years younger in just a fraction of that time to amazing non-prescription supplements that claim to grow body parts, it is hard to separate reality from just another pitch into your pocketbook.
The world of cosmetic surgery, even though it is done by medical doctors which should be more credible, frequently falls into these same marketing shenanigans. This has become rampant in the unregulated sphere of cyberspace where the only monitor is whomever is doing the posting. But when it comes to board-certified plastic surgeons, it is a completely different story. The American Society of Plastic Surgery provides it members with a clear set of ethical regulations and rules which clearly provides what can and cannot be marketed and claimed. Violation of these rules can result in Society expulsion. Here are a few of these highlights.
Plastic surgeons are not allowed to claim to be the ‘best’ without indicating where that claim comes from. No claim of superiority of skills or results of those skills can be stated compared to physicians of similar training unless it can be factually verified by the public. There are no rating methods provided by any legitimate plastic surgery society. Patients may have different experiences with various surgeons, and the internet provides countless means by which to report them (unregulated and one-sided), but plastic surgeons and their results are not something that can be quantitatively evaluated like a product by Consumer Reports.
The use of before and after photographs must be of the same patient and unaltered. Photographs that have been digitally altered, are of different people, or show results that are not typical for the average patient is forbidden. Before and after surgery pictures that use different lighting, angles and poses that misrepresent results from any plastic surgery procedure is prohibited.
American Society of Plastic Surgery members cannot participate in a raffle, fund raising event, contest or promotion in which the prize is free surgery. No method of inducement to encourage patients to undergo surgery for a financial reason can be done. When you see such a contest or someone who has won a free makeover, you can be assured it is not a board-certified plastic surgeon that is involved.
Claims can not be made of guaranteed surgical results. Predictions of any outcomes of surgery, including satisfaction or any degree of improvement, is likewise prohibited.
Procedure description or outcomes that are placed next to a picture (usually a model) whom has never had the procedure is another ethical violation. This would suggest that the accompanying picture is representative of results that the plastic surgeon can produce. While models in advertisements may be used, they must clearly state next to them that the person in the picture has not received the advertised procedures.
The need for such rules in advertising and marketing in plastic surgery runs counter to what is happening in the ever expanding world of the internet and social media. On the one hand, such rules seem both fair and obvious. But in the pursuit of the cash paying patient for elective surgery, it should be no surprise that the temptation for anything goes can be a powerful one. Plastic surgery is taking the high road in ‘truth in advertising’ and is holding its member’s feet to the fire.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am a male and would be interested in receiving a surgery in order to correct my bulging forehead. Do you perform that kind on procedure on men?
A: Forehead surgery or forehead reshaping can mean different things to various patient, both male and female. The two most common procedures performed on the forehead are brow bone reduction in the male and brow bone reduction/tapering in the transgender patient. (male to female) There are also a variety of other forehead reshaping procedures from defects and asymmetry caused by craniofacial birth defects and trauma and prior neurosurgical/craniotomy operations. Bu, by far, regardless of the diagnosis the vast majority of forehead surgeries are done in men.
The typical cosmetic reason for male forehead surgery is brow bone reduction. Large brow bones, caused by overgrowth of the underlying frontal sinus, can create very prominent bulges in the forehead bone above the eye. (supraorbital rims) While most patients think it is a thickening of the bone and a simple burring down will suffice, this is not so. Rather the frontal table of the frontal sinus (visible brow bone) must be removed, reshaped, and then put back in a more flatter or recessed position. While tremendously effective, the access to perform that procedure requires a long scalp incision. This cosmetic trade-off is a serious one to consider and is usually an issue which prevents most men from having the procedure. Until a more minimally invasive approach to brow bone reduction is developed, most men with prominent brow bones will have to live with them.
Q: I have a noticeable cleft in my chin and I was wondering what procedures can be done to remove the cleft and how invasive are they?
A: Soft tissue indentations of the chin can appear as either clefts or dimples. While both involve the chin soft tissues, they are anatomically different. Chin dimples are round depressions in the middle portion of the soft tissue pad of the chin and occur because of a central muscular and fat deficiency. There is no underlying bony abnormality. Chin clefts are vertical indentations that run from the middle part of the soft tissue pad down to the lower border of the chin. While they also have a muscle and fat deficiency (cleft of the soft tissues), they almost always have some notching of the lower border of the chin bone as well. (symphysis) Embryologically, it is easy to understand how a chin cleft occurs because of the union of the mandibular arches in the midline during development. It is harder to understand the origin of the central dimple although this likely represents an area of lack of epidermal cell adhesion during the final phase of merging.
Chin cleft surgery is best thought of as a reduction rather than a complete removal. There are two fundamental ways to perform the procedure based on the depth of the cleft and the tolerance for any outward scarring. An intraoral approach can be done where the the tissues under the skin are released from the bone, the cleft of the chin bone is filled in (if deep enough) and the muscles put back together to create more of an outward pout of the muscle. This works well for modest to moderate deep chin clefts. In very deeply grooved chin clefts, this will only provide partial depth reduction. Outward skin excision is more effective in these deeply grooved clefts but the creation of a vertical scar, even if the surrounding skin edges are smooth, may not be cosmetically acceptable.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hi, I am trying to find an expert z plasty surgeon and I was wondering if you could help? Thank you.
A: Z-plasty is a common plastic surgery technique that is used to improve the functional and cosmetic appearance of scars. It has a long history of use in plastic surgery and is one of the original scar revision procedures. It can lengthen a contracted scar or change the direction of a scar’s tension line. It is conceptually done by initially drawing the he middle line of the Z-shaped incision along the line of greatest tension or contraction. Triangular-shaped flaps are then raised on opposite sides of the two ends and then switched or transposed. The transposition of these two triangular skin flaps creates the classic Z shape of the final scar lines. The angles at which the triangular flaps are cut will determine how much the scar is really lengthened. The traditional 60° angle Z-plasty will give a theoretical lengthening of the central limb of 75%. Different angles of the flaps will give variable amounts of lengthening. While the mathematics of these flap angles are interesting, the most important thing is that the z-plasty will always lengthen a scar. Single or multiple z-plasties can also be used in a variety of clever ways for longer scar problems.
The use of z-plasty scar revision and contracture releases is very common and every plastic surgeon is trained and knows how to use them. Therefore, ‘expert z-plasty’ surgeons would be any board-certified plastic surgeon in your local or regional community.
Dr. Barry Eppley
Indianapolis Indiana
Q: Dear Dr. Eppley, I am about to undergo a third surgery for my short mandible. My first surgery consisted of bone grafts to the jaw angles with a sliding genioplasty for my chin. I then had a second surgery in which silastic jaw angle implants were placed as the bone grafts had resorbed. For my upcoming third surgery, a medpor chin implant is going to be used which will extend back to the jaw angle. My doctor is concerned, however, about placing the medpor implants over the indwelling silastic implants (to improve the angle still) because of issues with bonding medpor to silastic. I assume it will take some method to secure the two implants together. He is concerned with slippage of the two implants placed on top of each other. Do you have any suggestions as to how to fix these two implants together? Your comments will be very appreciated. Thanks.
A: Commenting on another surgeon’s operative plan or method of surgery is not really appropriate from my perspective. I am certain that your surgeon would not really appreciate it and, if he needed help in the planning, he would have his own reference sources to ask. In addition, the details of exactly what has been previously done and the specifics of this next proposed surgery are lacking in your brief description of the issues. I wish you the best in this upcoming surgery and hope that your desired final aesthetic goals from your jaw reconstruction will be successfully met.
Dr. Barry Eppley
Indianapolis Indiana
Q: Hello, I had a hair transplantation done about 6 years ago which left me with a terrible strip Scar on the back of my head. Because of the failure of the hair transplant, I now shave my head smooth and this scar is particularly noticeable. Getting the hair transplant was the worst decision I ever made in my life. I am trying to get to a scar revision to reduce the size and appearance of the scar.Is it possible to get good results? I have attached pictures of my scar. What is the best procedure available?
A: Thank you for sending pictures of your hair harvest scar. Admittedly it is not a good looking scar from this procedure as it is very long and wide and the suture or staple marks are quite evident. It is also unusual in that is obliquely oriented which was undoubtably done to get the most follicles for the transplant but poor orientation for good scar formation.
Most certainly, this scar should be able to be substantially improved with scar revision. The length and orientation of it can not be changed but it can be made much thinner. In that regard, scar revision can offer improvement. The scar must be cut out completely but the key to a narrower result is what is done underneath. The galea deep to the follicles must be released and undermined so the scalp can come together without much if any tension. Tension is the enemy of any scar narrowing effort. The deep layers are put together to take tension off of the skin. The sutures to close the skin are merely put in help it heal quickly but will not ward off tension on the closure line. The skin must also be handed gently to avoid injuring any hair follicles. Loss of hair in the scalp equates to a wide and noticeable scar.
Dr. Barry Eppley
Indianapolis Indiana
Q: I have a very noticeable buffalo hump and I have tried the traditional liposuction and it didn’t work. I just recently tried smart lipo and the Doctor said the area was too fibrous and he could not get the laser probe in. He said that there was too much scar tissue. My neck is still swollen since this procedure was just attempted several weeks ago. Are there any other solutions to get this buffalo hump off of me?
A: When neither liposuction option will work, there is always the traditional method of excision for the buffalo hump neck deformity. This is actually more effective than liposuction in terms of the amount of reduction because the buffalo hump is a different form of fat that is not as easily removed due to its natural more fibrous composition. But there is the trade-off of a midline scar from the nape of the neck down into the upper back to do the procedure. The length of the scar would be no longer than the vertical height (length) of the buffalo hump. There will also be a need for a drain after surgery as the tendency to form fluid collections (seromas) after open excision is quite high.
While this approach may leave a scar, this may now be a good alternative given that two attempts at ‘non-scar’ liposuction has not worked. It is a matter of trading off one deformity for the other. You have to decide whether the scar is a better ‘problem’ than the buffalo hump.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am in need of a septoplasty and turbinate reduction for nasal obstruction and snoring. I am considering rhinoplasty at the same time as I have a larger nose which I want to make smaller. Do you perform turbinate reduction with radiofrequency ablation? Do you have an idea how much my insurance may cover due to breathing problems and what part I would have to pay for the rhinoplasty?
A: Contemporary turbinate reduction can be done by a variety of methods, all intended to shrink the size of the turbinates rather than by just cutting them out. Several methods exist including radiofrequency ablation. That is not a technique that I use. I use diathermy or cautery ablation and have done so for years. Whether one method over the other provides a better result is unknown as both approaches cause shrinking of the inferior turbinate by devascularization and some degree of mucosal necrosis.
Insurance almost always covers any form of internal functional nasal airway surgery and their willingness to do so has actually improved over the years unlike many elective medical procedures. Such allowed coverage is determined beforehand through the typical insurance pre-determination process.
Doing rhinoplasty at the same time as nasal airway surgery is obviously common and efficient from a nasal perspective. While insurance does not cover rhinoplasty, there is no question that it does help to lessen the cost of rhinoplasty as opposed to it being done as a stand alone procedure due to time efficiencies and many surgeon’s willingness to accept some reduced cosmetic fee for doing it.
The answer of the cost of rhinoplasty with internal nasal surgery would be based on what type of rhinoplasty is needed (partial vs. full) and what facility the procedure may be performed in. (different facilities have varying fees for operating room use and anesthesia charges) As a result of these variabilities, definitive cost estimates would require knowing what type of rhinoplasty you need and where it would be performed.
Dr. Barry Eppley
Indianapolis Indiana
Q: I have a deviated septum. I am pretty sure my insurance covers surgery to fix a deviated septum. I was wondering whether would there be anyway of sliding in a rhinoplasty while fixing the deviated septum to cover majority of the costs. How would that work, thanks so much.
A: The premise of your question is…can I get insurance to pay for part or all of a cosmetic procedure? While the answer to that seems obvious, it is actually an understandable and common question that has historic precedence. In the past, many cosmetic procedures were done at the same time as medical or insurance-covered procedures…and the patient was never charged for the associated expenses of operating room charges and the anesthesiologist’s time. They were just ‘rolled into’ and considered part of what was billed to insurance. The hospital or surgery center never really knew or just looked the other way.
But such surgical behavior is now long gone and is viewed for exactly what it is…insurance fraud. Getting the insurance company to pay for part of a cosmetic procedure, just because a medical procedure is being done, is not what any patient’s health insurance is intended to cover. Nor are they obligated to do so. And the insurance companies understandably take a very dim view of such actions. As a result of such past behaviors, health insurance companies have gotten very vigilant of such behavior as well as hospitals and surgery centers. There are substantial fines and even criminal sanctions if such actions are discovered on the providing facility. Therefore, any operating facility is fully aware of whether a cosmetic procedure is going to be done and expects to be paid in advance for the time involved in performing the cosmetic part of the operation.
Similarly, expecting or asking your treating plastic surgeon to make an operation appears as if it were medically necessary, when it isn’t, is just a different form of fraud. Septoplasty, or internal nasal surgery, provides functional breathing benefits and is medically necessary. A rhinoplasty, unless done as a result of a birth defect (e.g., cleft lip and palate), accident, or as a result of tumor removal, is a cosmetic change that is not eligible for medical coverage.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am interested in getting just a mini-armlift. I can’t seem to find any plastic surgeons that say they have actually done one. I don;t think my arms are bad enough for a full armlift and I don’t want that scar anyway. I just need a little tightening in the upepr part of my arm.
A: Armlifts, known in plastic surgery as brachioplasty or upper arm reductions, are traditionally thought of as a long excision of skin and fat between the armpit (axilla) and the elbow. While this is tremendously effective for ‘bat wings’ after a lot of weight loss, those women with more minor degrees of upper arm sagging on not good candidates because the scar would be worse than the sagging arm problem. This leaves the alternative arm strategy to either liposuction alone or liposuction combined with some limited upper arm skin removal, known as the limited brachioplasty or mini-armlift.
In the mini-armlift, the removal of skin for tightening is restricted to the upper 1/3 of the arm or just that of the armpit area only. (crescent-shaped excision) It can be removed staying inside the axillary skin folds or be extended somewhat further out onto the upper third of the arm. That scar can be placed on the inside of the upper arm or from the backside. The scars end up in different locations and there may be advantages either way for each patient. I have done the skin removal from both upper arm locations successfully and each patient must carefully consider their preference for scar location. While the skin removal adds an obvious tightening effect, the aggressive use of liposuction is really the mainstay of the procedure and is responsible for much of the result.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hi, I am a 16 year-old that is doing at school an assignment called the Research Project. It is where we have to choose a topic and learn about it and, in the end, we have to do a 10 minute oral presentation on it. I was wondering if you could help me with some questions. The question that I am focusing on is ‘How does craniofaical reconstruction change someone’s life?’. And also how would I write a survey for this type of question or topic. I hope that you can help me. I need all of this done in about three weeks so if you could email me that would be good.
A: Craniofacial surgery is a specialized area of plastic surgery that involves the reconstruction of deformities of the skull and face, whether they be from birth defects, traumatic injuries or from various benign or malignant tumors. Much of this work is about the rebuilding or moving of misplaced or missing bones of the face and skull. While not exclusively done in infants and children, much of craniofacial surgery is done early in life when possible to work with the growing face and to help children develop more normal social interactions. While there may be many functional problems that come with craniofacial deformities, creating a more normal looking skull and face helps provide a significant psychological benefit as well. While we may not always like it, how we look and are seen by others plays a tremendous role in one’s self-image and acceptance by society.
If one was constructing a survey on the topic, one would want to ask how the craniofacial reconstructive procedure made them feel after surgery and what specific impact it had on their lives.
Indianapolis, Indiana
Q: I’ve had a consultation and qouted prices for surgeries. However I wanted to know if Dr. Eppley particiapates in the Doctors Say Yes finance program. I am willing to do this however only if I’m able to use a good reputable plastic surgeon like Dr. Eppley. Please let me know if he is apart of this type of finance. Thank you for your time.
A: The use of financing for cosmetic surgery, whether it is done through separate financing companies or using one’s own credit cards, is common practice. I would estimate that up to 30% to 40% of cosmetic surgeries across the United States are now financed in some fashion. That is a far cry from what it was a mere decade ago where estimated numbers were around 5%. This obviously reflects the national trend toward financed luxury purchases in general as well as the greater demand for cosmetic surgery. Over the years, my practice has used a variety of financing programs which now number into the dozens. We have had both good and bad experiences with them in terms of ease of use, financing terms, and the ability to get patients actually financed. Currently we use Care Credit as our primary referral for cosmetic surgery financing. They have worked out to be the best in terms of approvals, finance terms, and ease of use for both our office and the patients to work with. I am not saying they are absolutely the best as we have not worked with every single financing agency out there. Just that in our financing experience, they have worked out the best for both the patient and ourselves.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hello Dr Eppley. I have several issues about my face that I would like changed. I am a 21 year old female with prominent eyes along with an oblong face shape. My eyes are not bulging out but they are just prominent. I have no cheek bones. It must just come with having a longer face shape I guess and I lack fat below lower eyelids. I was considering a mini face lift to make my eyes less prominent and my face look less tired. But as I have researched it’s too early to get it done at my age. What options do I have? What would you recommend in order to make my eyes look less prominent and get some volume on my face to get rid of the tired look and make my face look fuller (rounder).
I’m sorry for the long question but I’m so excited to come across your site since I see that you are experienced in almost all areas of cosmetic surgeries.
A: By your description, it appears that you have a longer but flatter face. Flatter in the face refers to a recessed development of the midface, particularly the zygomatic-orbital skeletal areas. (midface, cheek and lower eye socket bones) This lack of anterior projection makes a face appear longer, particularly if the vertical height of the face is long to start with. This also accounts for the lack of fullness in the lower eyelids (sunken in appearance) and the apparent big size of the eyes.
While your eyes may be big in size and your face long, the lack of cheek and lower orbital rim bones can really accentuate that appearance. Improvement of midface deficiency at this level is done by the use of cheek and orbital implants, specifically a combined infraorbital rim-malar implant. This provides fullness across this deficient bony area and provides some horizontal projection. (fullness) This helps balance the face better, make it look a little shorter and can help make the eyes look a little less prominent. These implants are placed through a lower eyelid incision.
Any form of a facelift is exactly what you don’t want to do. This is not a skin problem but a bone-based issue.
Dr. Barry Eppley
Indianapolis Indiana
The drug, Botox, has become a household name in less than decade. It is used in every form of grammar from a noun to a verb to an adjective (check out Urban Dictionary) to convey the treatment of facial wrinkles to looking like one has a frozen face. Who would have conceived that the use of an injectable drug for the treatment of something as seemingly trivial as a few wrinkles would strike such a cultural phenomenon? With nearly two billion in sales annually and climbing, the thirst for a less-scowling countenance and a smoother forehead is only as limited as the population that is aging.
But Botox and the concept of ‘selective muscular weakening’ have a much longer history than its current use as a wrinkle treatment and a future that exceeds that as well. It was originally conceived as a treatment for unstoppable eye twitching (blepharospasm) and for painful and contracting muscle spasms for those with neuromuscular diseases. It’s even used in the same context for veterinary medical indications- such as the treatment of stringhalt in horses. These uses predated any cosmetic application, and its use for muscular-based problems is still undergoing medical development with great promise.
Last week, Botox was officially approved by the FDA for use in certain types of chronic migraines. For people who struggle with migraines, this could be viewed as a near-miracle cure, offering almost instant relief that is both prolonged and presents no significant side effects. For migraine sufferers that have tried and failed to get relief with every other available treatment, and who have a very specific trigger located at the base of the neck, temple, or along the brow bones above the eye, Botox injections could be immensely helpful. With the theory that it is the muscles pinching down around nerves which come out of the bone in these areas of the skull that causes the migraine pain, weakening or paralyzing these muscles relieves pressure on the nerves. Botox can be injected directly into the muscles around these nerves to produce this muscle weakening. With the pressure on the nerve relieved, the trigger for the migraine is either eliminated or significantly reduced.
Plastic surgeons have long known of the potential beneficial effects of Botox for migraine sufferers. The number one location for Botox injections is for wrinkles between the eyebrows known as the glabellar furrows, popularized in Botox Cosmetic advertisements as the ‘11’s. This facial wrinkle area is what the FDA used to approve Botox for cosmetic use in 2002. This brow area, ironically, is exactly where the supraorbital and supratrochlear nerves emerge from the brow bones. They are well known triggers for migraines that come out of the eye area. Every plastic surgeon has seen from time to time patients that comment on how their headaches have been reduced after their ‘11s’ have been ‘Botoxed’. Such observations have led plastic surgeons to try with good success the use of Botox injections at the back of the neck (occipital area) where the muscles attach to the bottom edge of the skull. This is where the greater occipital nerves come out through the muscle and can be another trigger point due to muscle compression on the nerves. Occipital-based migraines are actually more common than those of the brow or eye area.
While plastic surgery has played a contributing role in discovering this new injectable treatment option for chronic migraines, it is also leading the way to a potentially longer-lasting treatment that for some migraine sufferers may be a ‘cure’. If Botox provides a dramatic migraine reduction through these trigger point injections, then surgically removing the muscle from these nerves should produce a more permanent effect. Known as surgical decompression, it can be done through very small incisions in the scalp. Cleaning the muscle off of the nerves is really a form of ‘surgical Botox.’ Thus, the use of Botox for migraines is both a treatment (lasts about four months) and a test to prove if surgical decompression would be helpful. My experience with this type of migraine surgery over the past year has been extremely encouraging. All patients that I have decompressed have had immediate and significant reduction in their migraines. I’ll be more even more enthused if these results persist for one year or longer.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Can a chin implant be done after a sliding genioplasty?
A: The premise of this question is that the result of the bony chin advancement did not produce the desired amount of horizontal chin projection. That could be because the bony chin was not moved forward enough or that the amount of chin advancement needed exceeded how much the bone could be safely moved forward.
Either way, an implant can easily be added onto the front of the chin bone. This is best done through a submental incision under the chin as would be done traditionally. Placing the implant on the front edge of the chin bone does not disrupt the healed chin bone and disrupt the blood supply to the bone. While it can also be placed through the same intraoral incision as the of the sliding genioplasty, this causes a lot of extra tissue disruption going through an area that is already scarred from previous surgery.
Gauging the amount of chin advancement needed is one of the most predictable forms of facial computer imaging. Since the chin soft tissue moves on a 1:1 basis with how the bone position changes, side view predictions can quite easily show how much movement is needed. In doing a sliding genioplasty, if one notes beforehand on the computer prediction imaging that it remains still horizontally deficient, an implant can be placed on the front of the chin at the same time as the chin bone is moved forward. I have done this successfully several times and it works to get 3 to 5 mms of chin projection if needed.
Dr. Barry Eppley
Indianapolis Indiana
Q: Hi there. I read your blog about rippling in implants. I had breast implants 10 years ago and over the last few years I have noted rippling. I am not sure if I had saline implants or silicone but I want to know if it is possible to inject more saline or silicone into the implant to rectify this problem.
A: The physical characteristic of rippling in saline breast implants is quite normal. Not every women will feel the rippling unless they had scant breast tissue prior to their augmentation. It will always be felt on the side of the breast where the tissue is the thinnest. While most plastic surgeons overfill saline breast implants to lessen rippling, it inevitably occurs over time as the containment bag relaxes a little. (just like a stretched rubber band) The manufacturers generally recommend that a saline implant can be filled up to about 20% over its base volume size. (e.g., a 500cc implant can be safely inflated to 600cc)
More saline can be added to the implant at a later date through a simple procedure. This can help decrease the amount of rippling. But one has to be careful to not place too much volume as the implant can get a very hard feel which is quite unnatural.
Silicone implants generally have little to no rippling as they do not contain a liquid filler but a gel material. This reacts with the containment bag differently as is not prone to the same amount of rippling as that of saline implants.
Dr. Barry Eppley
Indianapolis Indiana
Q: I just had my second baby six months ago and I want to get my body fixed. I am almost back to my pre-baby weight, maybe just 4 or 6 pounds more than I was. It seems like I have a lot of grease accumulations especially in the tummy and thighs that I would like removed. But I would need to know more or less how much it would cost so I discuss it with my husband.
A: Recovering one’s body shape after pregnancies usually focuses on the abdomen and waistline areas. For some women, this is just a matter of resistant fat accumulations that can be relatively easily improved by liposuction alone. For most women, however, it is more than just a fat issue. It is skin that has been stretched out and is lax. Liposuction alone will not tighten this skin but merely deflate it. Some form of a tummy tuck, combined with liposuction, is often what is needed.
Whether it is liposuction, a tummy tuck, or some combination thereof is impossible to know without actually seeing you. Women are so different in how their bodies respond to pregnancy that any one of these options may be right for you. But to give you a price range based on pure liposuction alone up to a fully tummy tuck with liposuction is in the range of $4,500 to $8,000, all costs included. This may be a wide range but costs of such surgery are dependent on the extent and time required to do the procedure.
Dr. Barry Eppley
Indianapolis Indiana
Q: I have some bothersome fat areas on my stomach and thighs that I have wanted to get rid of for a long time. I now have the money to do it and have done a lot of research on the internet about liposuction. I never knew there were so many different ways to do liposuction. I keep reading about Smartlipo and it seems that it is the best tool for doing liposuction currently. What are your thoughts?
A: Using devices to remove unwanted fat is a surgical necessity. So, to some degree, we as plastic surgeons have to rely on devices to perform the surgery. Unlike ten years ago, there are numerous devices today that can make the fat easier to suction out. While many will espouse the benefits of one device over another, I would submit that the hands and brain that is using them is far more important than the technology of the device. No matter what the device can do to get rid of fat, it will be no better than the one who is driving it.
That being said, I can only comment on what my experience with Smartlipo has been over the past two years. In my hands, I can say without question that it does result in less pain and bruising after the liposuction procedure. I think that the swelling seen is about the same as traditional liposuction. I have no scientific data to support that it is more effective but my feeling is that it is. The heat generated in the fat tissues during the procedure accounts for some continued fat cell death and lipid release that otherwise would not be seen with traditional liposuction. While there does appear to be a mild skin tightening effect, most patients overinterpret that result thinking that it can remove inches of unwanted skin. Realistically ti causes some tightening of skin but that is best perceived as firmer skin tautness, not the elimination of an inch or two of excess skin.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I hope you can help answer some questions about chin/jaw implants please? I have a weak jaw line in that my bottom jaw is slightly further back than that of my front, if you follow. I was wondering if I would be a candidate for a chin/jaw implant and if you believe this would assist in aligning my jaw whilst avoiding a lower jaw construction which I would rather not go through?
A: Small horizontal chin deficiencies are usually the result of lack of bone growth in the chin area only. (symphysis) More significant chin deficiencies, however, are a problem with the growth of the entire lower jaw (condyle, ramus and body), meaning that the whole jaw is short not just the chin. This can be clearly evident by how one’s teeth comes together. In a jaw deficiency, the lower teeth are offset behind the upper teeth by a 1/2 to full tooth. (known as a Class II malocclusion) Chin augmentation, whether done by an implant or cutting just the chin bone, improves the projection of the chin and the facial profile but does not align the entire lower jaw.
Aligning the lower jaw, by bringing the entire jaw forward that contains the teeth, provides chin enhancement but also improves one’s bite (occlusion) as well. This is most commonly done by a sagittal split osteotomy of the lower jaw which is performed in the ramus of the mandible. It is clear to see that jaw alignment and chin augmentation are the not the same thing. Jaw alignment by bone advancement will simultaneously give chin augmentation but chin augmentation alone will not create a lower jaw alignment.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have had breast augmention and a full tummy tuck with liposuction about 8 years ago. I have been happy with my breasts but never really happy with the rest of my surgery. My tummy has a huge uneven scar that goes from hipbone to hip bone. My belly bottom was moved, which I expected, but there is a scar fron my belly button to the horizontal scar with no way of hiding it in a swim suit . Also, my tummy and love handles are uneven as far as being flat. They are lump and uneven. Can you help me?
A: Tummy tucks are a much bigger operation than most breast augmentations. Because they involve cutting out tissues and extensive reshaping, they also result in more imperfections such as prominent scars and uneven areas across the stomach and waistline. Revisions of tummy tucks are probably more common than that of breast augmentations. Tummy tuck scars can end up wide and uneven because of the tension on them at the time of closure. Revisions of tummy tuck scars always makes them look better as they do not involve as much tension on the wound closure. Scars can get both more narrow and even. In some cases, they can even be made to go a little lower than before. Liposuction can reduce uneven areas of fat across the stomach and into the flanks and back. Many tummy tucks benefit from secondary liposuction in the upper abdomen (which can be safely done during the first procedure because of blood supply concerns) and the pubic area. (which often becomes more noticeable with the tighter waistline.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am considering having augmentation for my short chin. I am confused as to whether to use an implant or move the bone. Doctors seem to recommend both ways and it is not clear as to which way may be best for me. Can you help me decide?
A: Your two main choices for chin augmentation are either an implant or a sliding osteotomy. Both will work and each has its own disadvantages and advantages. An implant is simpler, has a quicker recovery and can make the chin wider as it comes forward. (if you want to change your v-shaped chin in frontal view to a more round or even a more square shape) There are even square chin implants to help create that look. The only disadvantage is that it is an implant…although I don’t really see any lifelong problem with having an implant in the chin. That is a very safe place for a facial implant and it is not likely to ever cause any problems requiring its removal. The osteotomy involves moving the chin bone instead of an implant. It is a ‘bigger’ operation, requires a plate and screws and thus there is more expense. It’s main advantage over an implant is that it is better at increasing the vertical length of the chin should that be needed. An implant can not do that very well at all. Also in big horizontal advancements (8 to 10mms or more) in a young person, moving your own chin bone forward is probably better than having a big implant on the end of the chin. An implant can deepen the labiomental sulcus whereas an osteotomy can keep it from getting deeper than where it started. This means that it may look more natural in the long run for big chin advancements.
In the end, you have to look at the anatomy of your chin deficiency and determine whether an implant or osteotomy can correct it the best and the most natural. Other important consideration are your age and the economics of the surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have approximately 30 lipomas on my arms that range from a large pea to an almond to a large marble. On my rib cages and abdomen are about a dozen the size of walnuts, and on my legs there are too many to count and of the same various sizes. I am a 45 y.o. female that has always taken pride in eating healthy and being overweight no more than 5 to 10 pounds. I was physically very active, an avid runner, and love to mountain hike. In the past two years the lipomas have erupted in such great quantities all over my body that my life has changed and taken away much of the life that I enjoy. I know that these lipomas can be cut out but that would leave so many scars that it would be horrible and maybe just as bad as the original problem. Are there any new methods for lipoma removal that would not leave so much scarring?
A: With so many lipomas, you obviously have the condition of familial lipomastosis. While you have many now, this suggests that there are more to come in the future. Besides excision (cutting them out), there are not any other conclusively proven methods of lipoma removal. However, I have found some success with both Lipodissolve injections and spot Laser Liposuction (Smartlipo) treatments. Lipodissolve injections cause an inflammatory reactions within the lipoma that causes it to shrink. Most of the time, it takes more than one injection session to get ti to go completely away. Laser liposuction treatment uses the tip of the laser probe to melt the lipoma. Through a small stab incision, the probe is inserted into the lipoma and it is turned on until the lipoma begins to melt.
With so many lipomas, I suspect that the combination of excision, Lipodissolve injections, and laser probe treatments may be needed based on their size and location. Given the multiple locations, all of this could be done in a single outpatient procedure done under general anesthesia. That would be the most comfortable way to treat all of them in a single setting.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Sir, I have a couple two to four inch long hypertrophic scar on my inner forearm and it looks HORRIBLE. I have been using silicone sheets and scarguard with little help. I heard that steroid injections canhelp unbulk the scar and was wondering what your recommendations were?
A: Based on your pictures, you have a common scar condition known as hypertrophic scars. While often confused with keloids, they are not. They are still a normal scar process in which the scar tissue raises above the level of the surrounding skin bit still stays within the original boundaries of the scar. They also reach a certain point of hypertrophy and then get no higher. In the early phases of scar healing, a hypertrophic scar has the potential to be improved by numerous topical therapies including silicone sheeting and topical products. When collagen is being laid down, ti can be suppressed and even flattened by these type of scar approaches. This is also the period when steroid injections may also be useful. Once the scar is mature, however, these non-surgical therapies are unlikely to work. A mature scar is when collagen formation is no longer active and this is why the cross-linking of the collagen molecules is unlikely to be reversed.
At this point, scar excision and re-closure is the most assured method for improvement. The scars will get much narrower this way from the beginning. When the scar is removed in this controlled fashion, hypertrophy is less likely to occur. After scar revision, it is still appropriate and helpful to do topical scar therapies from the very beginning of new scar healing.
Dr. Barry Eppley
Q: I had Medpor implants placed in the paranasal area several years ago in 2007. It appears that I will be undergoing a LeFort I osteotomy in future. I was wondering whether these implants need to be removed for this procedure and how difficult is it to do so?
A: Paranasal implants are placed around the curve of the pyriform aperture to add fullness under the nostril base of the nose. They help push out the base of the nostrils and are most commonly used to augment a midface deficiency. They are made out of different materials of which Medpor is one of them. This porous material does allow for tissue ingrowth which makes it more difficult to remove than that of silicone, for example. But they can still be removed without a lot of tissue destruction to do so.
A LeFort I osteotomy makes a bone cut directly across the pyriform aperture area. Advancing the upper jaw at this level creates midface fullness, particularly in the paranasal and anterior nasal spine area. (base of the nose) It would be absolutely necessary to remove paranasal implants when performing this procedure. The fullness created by moving the upper jaw at this level makes the need for paranasal implants after bone repositioning as irrelevant.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am the parent of a son who is suffering terribly. He is developing breasts like a woman. This started when he was fifteen years old and he will now turn twenty next month. The doctor said that it is Gynecomastia and that he will require surgery to correct it. Although he is not in any danger medically, this is a source of embarrassment for him as it shows no sign of going away and he is not happy with it. We would like to know what it will cost for the surgery.
A: Gynecomastia is extremely emotionally disturbing for many young teenagers and men that are afflicted with it. This has become particularly so in our current youth culture in which the very flat chest is exemplified in many ads aimed right at teenagers. (e.g., Abercrombie Fitch) Given the obesity and overweight issues that now exist in the young American population, gynecomastia problems and young males seeking treatment exist now like never before.
The cost of gynecomastia reduction surgery is in direct correlation to its size and the type of surgery needed to correct it. Smaller gynecomastias may be removed with liposuction only or simple areolar excisions. Larger gynecomastias require both excision of skin and breast tissue as well as liposuction. Without seeing pictures of the gynecomastia problem, it is impossible to give an accurate fee for the surgery. Generally, the will be somewhere between $5,000 to $8,000, which includes the associated costs of operating room and anesthesia expenses.
Dr. Barry Eppley
Indianapolis Indiana
Q: Hello Dr. Eppley, I wanted to that you for such a fast reply. I have looked through your facial scar revision work you have done and believe you can do something for me. I got a scar along my left lip to the side of my nose over one year ago. I have a few scars since I was a kid but I have gotten used to them. This new scar is by far the ugliest and biggest scar I have gotten. I don’t see anything but the scar when I look in the mirror and it bothers me alot. I understand that half of it is mental but I still would like to keep my face as close to perfect as possible. I already went and saw a doctor who charged me $150 for consultation and really couldn’t help me. I have used Bio Oil, and Mederma regularly and not sure if it’s a good thing to do. My scar is the same color as the rest of my skin but the only problem is its indented. All you see is a deep line which makes my appearance stand out. I went to a place where I paid lots of money and got some kind of liquid that they shot under the skin. It is a filler that only lasts 8 to 12 months. Like I said the scar being indented is the only problem. Whenever I stretch my mouth you can’t see the scar at all, and that’s all I need is to stretch my skin somehow so it stays that way. The filler they have shot in to my scar came in size .8, I have used .2 the first time and .2 the next time. I don’t know if any of this information helps but using that filler didn’t help much. Please tell me if using too much of Bio Oil or Mederma is bad for it. What are you suggestions?
A: Thank you for sending your history and the pictures. You have a mature scar that is obvious, not only by its location, but by its indentation along its entire vertical length. The indentation of the scar, fortunately, is in a favorable orientation being vertical on the side of the lip. That is advantageous for a favorable scar revision outcome.
As you have correctly pointed out, improvement in the scar is only going to come from improving its indentation. There are two options for long-term/permanent improvement. The first is to surgically treat it by doing a formal scar revision, excising the depression from the scar and re-closing it so that it is even. That will require a ‘stepping back’, so to speak, as the scar will be read for a while before the color fades. The other approach is to place a thin dermal graft underneath to push the indentation upward. That avoids cutting out the entire scar and the required time for scar fading. Either option is better, in my opinion, than injectable fillers and any method of skin resurfacing. You may stop the topical treatments as they will have no effect on a mature scar and are not capable of raising up the indentation.
Dr. Barry Eppley
Indianapolis Indiana
