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Has anyone ever said to you that you look tired…have puffy eyes…or commented on the bags under your eyes or your dark circles? If you are over 35 or 40 years of age, you have undoubtably been told that at least once. Many have been told that more than just a few times. While I could espouse on the merits of pointing out the good in people rather than the bad, that would be a pertinent subject for a different column that has little to do with plastic surgery.

Without being told, most people that develop tired-looking eyes know it from looking in their own mirror. Women are particularly sensitive to how their eyes look as they engage in the daily ritual of make-up application. The vast majority of men, however, are unaware until their tired eye problem almost interferes with their vision. While there are some useful simple home ‘remedies’ that can help, such as astringents and endless numbers of creams, they do not remotely produce an improvement that is comparable to what blepharoplasty surgery can do.

Blepharoplasty, or ‘cosmetic eyelid’ surgery, is one of the most successful of all facial plastic surgery procedures. By removing loose and extra skin and fat from the eyelids, one can look refreshed again helping restore an eye appearance that one used to have. But many people are unduly hesitant about undergoing it because of misconceptions about recovery and pain after the surgery.

The thinness of the eyelid tissues and their superb blood supply make swelling and bruising an inevitable, but temporary, sequelae of the surgery. Despite how it looks, it is not painful and most patients only comment that their eyelids initially feel a little tight. There may be some slight stinging discomfort around the eyes the first night after surgery, but that passes quickly by the next day. Bruising and swelling are what persists and that will take up to two weeks after surgery until one is fully in the ‘benefits’ period. For some, this is a time for social reclusion. For others, they embrace it and do not let it be a hindrance for returning to work or getting out and about.

One of the great things about blepharoplasty surgery is that it is not a ‘one size fits all‘ procedure. There are different types of eyelid tucks based on how slight or severe the tired eye problem appears. If one has a lot of droopy or hanging skin then the traditional blepharoplasty would apply. But for those that have just a little extra skin or  lower eyelid wrinkling, then the new ‘pinch and peel’ blepharoplasty can be done where just a pinch of skin is removed and the wrinkles reduced by a chemical or laser peel at the same time. If one is just bothered by their undereye bags, that protruding fact can be removed from inside the eyelid, having no external incision at all.

While the eyes may be the window to the soul, the eyelids are the window shades. They create, fairly or unfairly, an impression of our alertness and liveliness. A crisper and refreshed eye appearance is readily possible through blepharoplasty surgery and is easier to go through than most people think. Whether one’s tired eyes are just beginning or are quite advanced, blepharoplasty surgery can be customized to just the right amount needed to put that twinkle back and still fit into one’s lifestyle.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I have looked into chin implants and, a local plastic surgeon with whom I shadowed in town, felt that a simple chin implant would only bring the skin forward in the front and not actually give me the square, fuller  jaw, and more forward chin, I was looking for to balance the face. So my question would be, is chin and jaw augmentation the same thing or are they different procedures? If they are then would “chin” augmentation be my best bet?

A: Chin and jaw augmentation are different but related. Chin augmentation refers to building out the front part of the chin or jaw, otherwise known as the anterior prominence. Jaw augmentation most commonly refers to jaw angle implants which accentuate the size and prominence of the posterior jaw prominence. While they are often done separately, it is not rare to have them both done at the same time to get a total jawline enhancement effect. A chin deficiency is frequently part of an overall ‘weaker’ jawline, so the three point augmentation approach (one chin, two jaw angles) can create a better defined and more masculine lower third of the face.

While jaw angle augmentation exclusively uses implants, chin augmentation can be done with implants or by moving the bone known as an osteotomy. Whether one is better served by a chin implant or a chin osteotomy, and the size and style of jaw angle implant needed, requires a careful facial assessment and the use of computer imaging to make those determinations for each individual patient.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Do you use the BodyTite Radiofrequency Assisted Liposuction (RFAL) for upper arms and abdomen areas? Is it safe to this while I am breastfeeding?

A: RFAL is a modest skin tightening and fat removal method. Whether that is an appropriate technique depends on how much fat vs loose skin one has in their upper arms. Based on my experience in upper arm reshaping, I would have little confidence that any method of skin tightening alone on the body in general is a good financial value. (i.e., a satisfied patient) Almost every upper arm that I have seen in my Indianapolis plastic surgery practice, even if there wasn’t a fat issue, needs at least an inch or more of skin tightening. That is well beyond what any method of nonsurgical skin tightening can do. The arm is a tough area when it comes to decision making between an arm lift and liposuction. Armlifts are never worth it unless there is a lot of skin. Even liposuction can produce only modest arm changes. For arm issues that do not justify an armlift scar, the dual approach of Smartlipo followed postoperatively by skin tightening, such as Skin Tyte or RFAL, would be a good consideration.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Hi Dr. Eppley, I am interested in filling in my lower cheeks.  They are sunken in and I have had multiple fillers from Radiesse, Juvederm etc for years. I am tired of it looking really good for 2 weeks due to swelling and then having it all disappear and look the same within the month.  Do you ever do a tissue fill on the lower cheeks?  I had one doctor do filler one time on the upper cheeks and I hated it. I looked like cat woman and I don’t like that look. I just want to fill in the bottom cheeks. I’m afraid to put in an implant because of the risk of crooked smiling. What do you suggest?

A:  The area below the cheeks is known as the submalar triangle which extends from below the cheekbone down (in an upside down triangle) to below the side of the mouth. It is important to appreciate that this area is not supported by underlying bone. This is why anyone with a thin face or fat loss will show an indentation in this area and create a ‘gaunt’ look. This also means that there is no type of a bone-based facial implant providing any fullness to this area.

While synthetic injectable fillers will produce some temporary fullness, they are not a long-term solution to this area of soft tissue facial deficiency. The next logical approach is that of fat injections. While they offer at least the potential for some long-term retention, they are also plagued by potential resorption. I have mixed these fat injections with PRP (platelet-rich plasma) for facial injections and feel that this combination does offer better results. But the risk of near to complete resorption still exists. No one can predict how well fat injections will persist in any particular patient.

The remaining good alternative is that of dermal grafts. Using allogeneic dermal grafts, they can be put it in sheets and layers. They can nicely built up an area and are very soft. They are human collagen which will eventually be replaced by your own tissue. They can be put in through a limited facelift incision. Their long-term volume retention is much more assured than fat injections.

Dr. Barry Eppley

Indianapolis Indiana

Q: I had a hysterectomy which led to me having a muffin top right above the pubic area. Is there any surgical procedures that can correct this?  

A: Your so-called muffin top is medically known as suprapubic fullness or lipodystrophy. It can commonly occur after a hysterectomy or even after an abdominoplasty or tummy tuck. It actually was always there to begin with but the creation of a scar across the upper suprapubic area, it appears. It is the result of some residual lymphatic obstruction caused by the scar as well as the tightness or indentation of the scar line. Between the scars and the mons, the suprapubic area looks rounder or more full. This can particularly appear after a tummy tuck because the stomach above the scar line is very flat while the suprapubic area is now fuller or more protuberant.

Reduction of the full suprapubic area can be done quite easily. Through the use of liposuction, excess fat is removed and the suprapubic fullness eliminated. This is a very successful procedure that is often done as a follow-up to a tummy tuck should the residual suprapubic fullness be a concern. It is a simple outpatient procedure that can be done under local anesthesia or IV sedation. There is virtually no pain after and no specific physical restrictions. There will be done some postoperative swelling and bruising which often works its way down onto the mons and labia. Within weeks, the swelling and bruising are gone. With the current use of Smartlipo, much of the bruising that used to occur with suprapubic liposuction does not occur.

Dr. Barry Eppley

Indianapolis Indiana

Q:  I am 18 years old and cheek enhancement seems to have caught my interest.  I’ve been rolling the thought of having a procedure in my head for quite some time now, so here I am asking for information. People say there is nothing wrong with my face but what I want is more defined cheekbones, like the male model look. There is this heart shape the cheeks do along with the jaw angle if you understand what I mean. What effects might the procedure have on my face in a long term period of time? I mean, when I get to 50, will there be any undesirable changes on my face? Thank you for your time. I look forward to receiving an answer from you.

A: High cheek bones are a frequent aesthetic desire. In a male the triangular effect of prominent cheeks, chin and jaw angles makes for that chiseled or angular face look. That particular male facial look is certainly one that is evident in many male models in magazines and advertisements.

While strong cheek bones may be desireable, they are not achieveable in every male face. While cheek implants can make the cheek area bigger, that doesn’t necessarily mean that effect makes for a more sculpted facial look. One has to look at the other facial features and the overall facial shape to see if cheek augmentation offers an aesthetic improvement. If cheek implants are put in just any face, some of those faces will just look like they have big or puffy cheeks and may not become more angular.

One positive long-term effect that cheek implants do is help maintain cheek tissues from sliding off the bone, so to speak, with age. In fact,  they are occasionally placed in older patients for a midface rejuvenative effect to help lift sagging cheek tissues. Unfortunately, when done to an extreme, they can make the older face look odd or have an ‘apple cheek’ effect. There are numerous famous male celebrities that have this look.

Dr. Barry Eppley

Indianapolis Indiana

Q:  I am in need of revisional tip rhinoplasty. But I have been warned strongly about the risks of ear cartilage, since my septal cartilage is quite probably inadequate to serve as a graft source. It would be more than a pity to spoil the present symmetry of my nose tip in the pursuit of a small derotation/lengthening. I was wondering about the possibility of newer advancements with stem cells in plastic surgery. They have received great publicity and already articles are being written on the new potential they offer and the speeding-up of changes for reconstructive medicine. I would be extremely grateful and certainly willing to undergo the surgery at any expense if you would be in a position to predict near-future applications, and incorporate them in your practice at least for volunteers to whom this would mean so much. Lots of grateful thanks, and I hope to hear from you again with some promising news or estimations, or even information some time later.

A: Stem cells in plastic surgery to make new tissues remains a hopeful but unproven surgical technique. Its appeal is great and that makes great print and internet copy but there remains a far leap from the laboratory to that of useful clinical applications. I do not know why anyone would tell you that there is ‘danger’ with ear cartilage in revisional rhinoplasty It is a very reliable, simple, and predictable graft material to use in the nasal tip and has a very long history of successful use in revisional rhinoplasty. Even if stem cells could make cartilage (and someday they will in the near future), they could not make a graft that would be better than actual ear cartilage. .

Dr. Barry Eppley

Indianapolis Indiana

Q: Dr. Eppley I heard people with protruding brows just have some of the forehead protrusion above the eyebrow cut or shaved off some.  No metal plates and screws!  Am I correct?

A:  No you are not correct. Brow bone reduction requires that the outer table of the frontal sinus (the bulge or protrusion) be removed (cut off), reshaped, and then put back in place in a flatter shape. Putting it back in place requires small low-profile metal plates and screws to properly hold the reshaped bone in place until it heals.

The reason that  the bulging brow bone can not simply be burred or shaved down is that this bone is actually very thin. The bulge is present, not because the bone has gotten thicker, but because the air-filled frontal sinus has expanded pushing out its front wall. For significant brow bone reduction to occur, the bone must be taken back as much as 8 to 10mms. The thickness of the frontal wall of the frontal sinus is only about 2 to 3mms thick. Burring into it would only expose a deep empty sinus cavity, not bone.

Bony protrusions or thickening above the brow bone, however, can be shaved or burred down as there is no underlying sinus cavities above the brow. Bone in most of the forehead can very safely be taken until one nears the diploic cavity or marrow space which could be 5 to 7mms of width reduction.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am interested in areola reduction surgery. I am fairly sure that I may have to lose more weight before I undergo any procedures. I was just wanting to know specifics about what I would need to do before I move forward.

A:  There is usually a strong relationship between the size of the areola (diameter) and the size of one’s breasts. Although this isn’t 100% true, the larger the breast the larger the areola. Areolar reduction is a common part of almost every breast reduction and many types of breast lifts. But it can also be done as an isolated procedure if one is otherwise happy with the size and shape of their breast and just feel that their areolas are just too big.

Areolar reduction is done by a circumferential reduction, often called the donut procedure. A ring of the enlarged areola is removed and the surrounding skin sewn down around the smaller areola. This does result in a scar at the edge of the areola. How well that scar becomes in appearance in affected by how much the areola is downsized and how tight the surrounding skin of the breast mound is. For the best result in areolar reduction, the size and shape of the breast should be stable. Therefore, if you intend to lose more weight, it would be advised that you wait until you have achieved your maximal weight loss. By then the breast size will be stable and the resultant looseness of the breast skin will be an asset towards final areolar scar appearance.

Dr. Barry Eppley

Indianapolis Indiana

Q: I have a chin implant placed crooked (right side is out and left side is in).  I had 2 revisions by the same doctor through the same incision under the chin.  The doctor argued that I have face asymmetry but he agreed that it is not apparent from the photo before the surgery.  Would you be able to help?

A: Asymmetry of the chin after chin implant surgery can happen for a variety of reasons, all related to the positioning of the implant. The implant can be centered off of the midline. Most chin implants have a central vertical line on them which should be matched up with the dental and facial midlines (central chin point, vertical line dropped down from the junction of the two lower central incisors) as well as the midline of the chin bone. Should this matching not be aligned, the implant may be shifted more to one side than the other causing an asymmetric chin. This is what I call a central chin asymmetry. The other reason for asymmetry can be with the wings of the implant. Today’s chin implants, particularly those made out of silicone, have very long and flexible implant wings that go fairly far back along the lower border of the jaw. Should one of these wings get folded onto itself or twisted, a bulge over the tail may occur and can cause lateral chin asymmetry. Similarly, it is also possible that the pockets dissected for these wings is at different levels along the edge of the jaw bone. (and maybe even off of it at the very end) This will cause of the sides of the chin to be less full than the other.

Given that you have had two revisions, you would think that if any of these problems existed they would have been identified and corrected. They may still exist, however, particularly in the tail of the implant which can be hard to recognize. It would also be helpful to know what type of chin implant you have in place. As it may have been modified in some fashion for fit and this may be a source of the problem as well.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Hi Doctor, I was born with a cyst in my cheek and had it removed when I was a teenager and it left a prominent dimple in the left side of my cheek. I would like it somehow corrected and removed, is this possible? One plastic surgeon said something about an injectable filler. Not sure what that is. Any advice would be greatly appreciated.

A: The removal of cysts on the face, even they are of any size, has the potential to leave a residual dimple or indentation. This is the result of a space where the cyst once was collapsing as it heals, resulting in an overlying surface contour indentation. While this is not apparent at the time of surgery and in the early healing phase (weeks to months), it is fluid (blood) that fills the space and makes it initially look smooth. As the blood resorbs, the underlying tissues collapse. If the cyst is small enough, the blood may be replaced with scar tissue. But in larger cyst removals, there will not be enough scar tissue created to leave the overlying skin smooth.

For this reason, I routinuely place dermal-fat grafts in the residual space left behind by the removal of large facial cysts during the initial surgery. This may make the overlying skin look a little full or a raised bump in some cases, but this will go down as the area heals.

For repair of facial dimples after excision of some mass, a dermal-fat graft still remains the best option in my opinion for this type of scar revision. While one can use an injectable filler for an immediate and non-surgical treatment, the result will only be temporary. By going through the scar, the underlying tissues are opened up and the graft placed where the dimple exists. While this does require a harvest site somewhere on the body, using one’s own tissues will produce a permanent solution in one simple operation.

Dr. Barry Eppley

Indianapolis, Indiana

Q : My issue is about my nose. It is a bit big and has a round ball at end. I have always dreamed of having a princess nose. Can rhinoplasty make this dream come true?

A: Rhinoplasty can make some significant differences in the shape of one’s nose. The three primary areas that can be reshaped are the bridge (upper 1/3), the middle vault (central 1/3) and the tip. (lower 1/3) Most patients are focused on changes in the bridge and tip as common areas of concern.

The tip of the nose is its most projecting point and, like a peninsula of land, its shape is out there for all to see. The most common tip complaints are its width, shape, and its projection. (too high or too low). A wide tip, often called a fat tip or a round ball, is caused by large amounts of lower alar cartlilages. The width of these cartilages and how the two come together to make the dome (tip) is the most indivualistic part of anyone’s nose. The tip of the nose is like fingerprints, it is uniquely shaped for everyone.

Tip reshaping is part of almost every rhinoplasty. The lower alar cartilages can be reduced in size and reshaped by sutures. The changes in one’s nasal tip can be really significant and is usually the most impressive part of most rhinoplasty results. The only limiting factor to tip reshaping is the thickness of the overlying skin. Thick-skinned noses will not show the underlying sculpting of the cartilages as well as thin skin and will hold swelling in the tip much longer.

I don’t know if a princess nose is possible for you but I am certain that the size of the can be made smaller and less round.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I have a severe asymmetry in my face. I was born with a condition called plagiocephaly which has twisted by face and skull around in a weird fashion. My eyes are at two different levels and this really makes my face go to one side. I had a browlift performed locally but it did not make ay difference in how I look. I have attached some pictures. What do you think can be done?

A:  Thank you for the facial pictures. On evaluating them it is important to realize that the apparent orbital asymmetry is not the basis of the problem. It is that the entire facial skeleton below the orbits is severely rotated to the left. This makes the orbits seem much further asymmetric than they really are. There are some differences in the forehead and orbital shapes but the real problem is what lies below.

Such facial asymmetry is best improved by doing total facial skeletal repositioning that can open up right facial vertical length and shorten the longer right side. In essence, to derotate the face back to the right. This would be done by preparatory orthodontics followed by orthognathic surgery to change the entire position of the maxilla and mandible. (LeFort I osteotomy and mandibular sagittal split osteotomies) I don’t know if that has ever been discussed with you or whether is a viable option for your consideration.

If orthognathic surgery is not in the future, then there are a variety of what I call camouflage procedures to attempt to achieve one similar goal…lengthen the left side of the face. Camouflage procedures can not be done that will really shorten the right facial skeleton. These would include a chin osteotomy with a shift of the chin midline to the right with lengthening of the left side of the chin and shortening of the right side of the chin. This would be combined with a left cheek and jaw angle implants to provide further left facial fullness. A rhinoplasty coule be done to narrow the tip and move the nasal midline back to the right. The left nasal alar base would be rotated down and around to be level with the other side. Lastly, a right brow release would be done with the intent of lowering the brow on the right side. This combination of fairly standard facial procedures combined into a single operation would help the facial asymmetry considerably. This still leaves the smile line tilted up to the left but this is virtually unchangeable.

I have attached a frontal view of the proposed changes that would occur. These are done conservatively and may likely be more significant in real life. The photo has been leveled at the eye level to demonstrate that the real problem is the rotated facial skeleton below the eyes. You undoubtably have a head tilt to the left side as well but that can not be changed.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am currently pregnant and I can tell that my stomach is going to be a problem after I deliver. I have gained 60 lbs with my pregnancy and stretch marks have appeared that weren’t there before. Do you think liposuction or a tummy tuck would work best to get my stomach back to being flat again after I deliver?

A:  There is no doubt that pregnancy, for most women, has an adverse effect on the look and shape of the abdomen afterwards. Large weight gains and the appearance of stretchmarks are synonymous and signify that the elasticity of the abdominal skin has been altered. The ability for the skin to snap back into place afterwards is not likely.

The two choices of liposuction and some form of a tummy tuck are the only truly effective abdominal contouring options. In many cases, they are done together as a combined lipoabdominoplasty procedure. What they are effective for, however, is different, Liposuction removes fat only and relies on the overlying elasticity of the skin to get a smoother abdominal contour. A tummy tuck removes skin and fat (the fat that lies directly underneath the skin cutout) and uses excision and abdominal flap advancement as the skin tightening method. It is easy to see that how much loose skin one has is the determining factor in the choice between the two options. With a large weight gain and the stretch marks, it is most likely that you should be thinking tummy tuck rather than liposuction alone.

The timing of any abdominal contouring procedure after pregnancy does vary but, as a general rule, it should be about six months. This will allow adequate time for any remaining ‘baby weight’ to be gone and have a full appreciation of what the final ‘damage’ really is. In addition, this allows you time to focus on the baby and enjoy the experience of the very early months of their life.   

Dr. Barry Eppley

Indianapolis Indiana

Q: I am 55.  I love wearing pierced earrings.  I notice that they are sagging a little bit.  I wonder if putting filler in the ear lobes is the best action to take, or would it just allow me to wear heavy earrings and destroy the cartilage that much faster?

A: The earlobe, unlike the rest of the ear, is only composed of skin and fat. It does not contain any cartilage which would give some stiffer support. This is why earlobes get stretched out, sag with aging, and even develop splits or tears in them from earring wear. If they had cartilage in them, none of these problems would develop.

Your question is based on the concept of adding a ‘stiffener’ to the earlobe to make it more resistant to sag or to be able to wear heavier earrings.While injectable fillers are quick and easy to do, and they can immediately make the ear lobe bigger, they will not make it more resistant to the pull effect of earrings. Injectable fillers are soft and much more like ‘jello’. The one exception to that would be the injectable filler, Radiesse, which has tiny ceramic particles in it and is more like toothpaste than jello. If you were to consider an injectable filler into the earlobe, Radiesse would be the one of choice.

The best long-term approach to prevent earlobe sag or stretching is to place small curved cartilage grafts beneath the underside of the piercing hole. This is done through a small incision on the back of the ear. The graft is harvested from above from the backside of the concha. One conchal harvest is enough for both sides. This then makes the earlobe more like the rest of the ear as the ear cartilage graft directly resists earring wear better.  

Dr. Barry Eppley

Indianapolis Indiana

Q: I am a 40 year old male with medium acne scars over my cheeks While I have acne scars other places, these are the most bothersome to me. Will cheek implants help lessen the acne scars and be a good anti-aging step?

A: Acne scars come in a variety of shapes which determines what procedures may be helpful for them. Surgery by excision is the preferred approach, for example, of the classic ‘ice-pick’ acne scar because of its depth. No superficial treatment of a deep acne scar, such as laser resurfacing, will work.

Many of the most troubling acne scars over the cheek area tend to be the ‘saucer-shaped’ variety. These are larger, less deep, acne scars that do resemble a saucer or a moon crater. They still are too deep to respond well to laser resurfacing (taking down the edges will not usually work) and their larger surface area causes a noticeable contour deformity. These are the type of acne scars that can respond well to injectable fillers as the problem is loss of skin dermis (thickness) and some subcutaneous fat. They represent a true volume deficient problem.

While injectable fillers can work for cheek acne scars, it is not unreasonable to consider the push of an underlying cheek implant. By pushing out from the bone, the expanded underlying tissues can help ‘fill out’ some of the saucer-shaped skin depression. I have done this a few times and do find it helpful. The existing size of the cheek area should be considered as the trade-off of a flatter acne scar for an overbuilt cheek may not be worth that trade-off.

Dr. Barry Eppley

Indianapolis Indiana

Q: I was interested in the buttock augmentation with fat injections. I was wondering what parts of the body the fat is taken from, whether I would be a good candidate for the procedure, and the time it will take to heal.

A: The use of injectable fat grafting for buttock augmentation, also known as the Brazilian Butt Lift, has become popular as an alternative to the use of buttock implants. The success of the procedure is based on three factors; having enough fat on the body from which to harvest from, having enough buttock subcutaneous tissue to inject into and how well does the inject fat survive.

Patient selection is the key element in the first two factors and can be determined before surgery is ever performed. The best donor site to get then most fat is usually the abdomen, flanks, and thighs. In general, a harvest volume of at least 1,500 ccs is needed to end up with a processed and concentrated volume of around 800ccs. This allows 350cc to 400cc to be injected into each buttock. Less volumes than this will usually not make the procedure worthwhile. The patient also gets the benefit of contouring from the harvest site as well. Whether one has enough fat to harvest is very easy to determine. Whether one has enough buttock subcutaneous tissue into which to inject is a bit more subjective. Buttock far augmentations work better in those that already have ‘some butt’ present. Completely flat and non-existant buttocks will have a much better result with an implant.

 Recovery from buttock augmentation with fat injection is related to the donor site and not the buttocks. Overall recovery is just a few short weeks whicih is far less than when buttock implants are used.

Dr. Barry Eppley

Indianapolis Indiana

Q: Do paranasal implants any effect on the length of the upper lip? Do they lengthen the upper lip, what is common with premaxillary implants, or do the paranasal implants rather lift the upper lip a little bit? In one of your You Tube videos about Advanta PTFE facial implants you soaked these implants in an antibiotic solution before they are implanted. Would you similarly dip the Medpor implants in a antibiotic solution also? I noticed that you use both implant materials – silicone and Medpor – and you obviously know the advantages and disadvantages of both very well. I personally would prefer the Medpor implants because they permit tissue ingrowth. But I often hear that Medpor implants are virtually unremovable once they are incorporated. Have you ever removed an incorporated Medpor implant? Is it true that it is extremely difficult to separate the periosteum from the surface of an incorporated Medpor implant?

A: Paranasal implants will not lengthen or push the lip down like a premaxillary implant. Neither will they lift the upper lip either. They merely provide fullness to the nasal base.

I soak all implanted materials in an antibiotic solution. This is particularly valuable in porous implants where bacteria can become trapped into the pores of the implant and not easily washed or rubbed off. The porous nature of the Medpor material also allows an antibiotic solution to be impregnated into the implant with vacuum infiltration or prolonged soaking.

Tissue incorporation into a facial implant is a two-edged sword. It has a benefit of providing anchoring of the implant to the bone site through tissue fixationalthough that advantage can be gained by screw fixation at the time of placement. Removal is definitely more difficult but by no means impossible, particularly for a small anteriorly located implant under the nose. It is more tedious and more tissue disruption must be done to get them out but it is not that difficult.

Dr. Barry Eppley

Indianapolis Indiana

Q : I have a bad scalp scar from a prior brain surgery that I would like revised. I have read about a product from a company called Acell that says it can make scars heal and look better if put into it at the time of the surgery. I have talked to someone at the company and it sounds very promising. Have you ever heard of it and would you use for my scar revision?

A: The search for ‘pixie dust’ in plastic surgery is both alluring and ongoing. We would love to be able to add something to our surgical wounds and incisions that would make them heal better and scar less. While this is of great interest in plastic surgery, I suspect every other surgical specialty would feel the same.

The company to which you refer is known as ACell, Inc. which has developed an implantable material that exergts its effect through the concept of regenerative technology. The product name is MatriStem which is a bioscaffold derived from porcine tissue. (from their bladders) When implanted into a surgical site or wound, it is resorbed and replaced with normal tissue where scar tissue would normally be expected. It purportedly does this by bypassing the typical inflammatory process of wound healing and inducing the body to heal the wound with tissue that is native to the site rather than just dense scar, It comes in sheets and a powder form (micronized particles). It is this powder form that some may call pixie dust. The product is relatively new and has been used for a diverse range of wounds including partial and full-thickness skin wounds, pressure ulcers, venous stasis ulcers, diabetic ulcers, skin donor sites and grafts, after laser skin resurfacing, burns and traumatic abrasions and lacerations.

The material is certainly easy to place into a wound and could be easily applied at the time of closure of your scalp scar revision. It is also not overly expensive as medical products go. Whether your scar will turn out better as a result of using MatriStem particles is unknown but there is no downside to doing so and it does sound promising.

Dr. Barry Eppley

Indianapolis, Indiana

Q : I am a male. I would like to know if Dr. Eppley can do orbital brow bone shaving and whether this can be done without coronal incision. My goal is to achieve a more feminine smooth forehead.

A: Brow bone reshaping can involve different areas of the brow depending upon what one’s aesthetic goal is. If one is interested in a total brow bone reduction, as one would want for a very prominent supraorbital ridge (brow bone), then a coronal incision is needed. This is because at the inner half of the eyebrow are the supraorbital and supratrochlear nerves which supply feeling to the forehead. They can only be pushed out of the way from above without injuring them. In addition, the inner half of the brows are not solid bone but just a thin bone covering over the air-filled frontal sinus. Total brow bone reduction can not be done by shaving but by taking the outer bone off, reshaping it, and putting it back in place.

The outer half of the brow, however, can be surgically altered by both shaving  and without needing a large coronal incision from above. This is because the outer half of the brow is solid bone and away from the frontal sinus. It can be done through an upper eyelid incision. The tail of the brow can be reduced and tapered to create more of a lateral sweep which is associated with more of a feminine look.  

Dr. Barry Eppley

Indianapolis, Indiana

Q : I am interested in cheek implants but am not looking for a drastic change, just enhancement. I want to look better but have people not be able to tell what is different. I have a few questions. What is the recovery time from work and  physical activity (running and cross training/weight lifting)? Are the implants inserted from the mouth and fixed to the jaw? Do cheek implants inhibit ability to smile? Approximately what  % of patients are happy with the cheek implant procedure?

A: Cheek implants are done as a simple 1 hour outpatient procedure. They are inserted through the mouth and secured to the bone with a screw. There are no restrictions of any kind after surgery. While you will have some cheek swelling (but no bruising), there is nothing you can do from an activity standpoint that will hurt the implant or their position on the bone. One can eat and drink right after surgery. Pain is very minimal although usually there will be some temporary numbness of the cheek skin and a little bit of the upper lip. Cheek implants will not change your ability to smile or how your smile will look. Initially, your smile will feel a little stiff but that is due to the swelling. The vast majority of patients who receive cheek implants are happy but I also feel that it is the one facial implant that undergoes higher revision rates than all others due to inexperience in placing them, size and position selection, and style of implant used. It is a simple procedure to do but there is definitely an artistic flair to doing them well.

 Dr. Barry Eppley

Indianapolis, Indiana

Q : I’m interested in having paranasal implants and I noticed that you have experience in using these implants. Could you please tell me how exactly these implants effect the nose and the upper lip? Does this implant usually widen the alar base of the nose? Does it lift the tip of the nose, which is common in LeFort I osteotomies? Is the upper lip lifted by these implants or is the upper lip seemingly becoming smaller, because of the new relation between the new volume around the nose and the volume of the upper lip? How does it usually effect the nasolabial angle and how does the upper lip change in the profile view? Are there slightly different ways to place the paranasal implants, for example to place the implants closer together towards the spina nasalis anterior or a little bit more apart from each other? I talked to another plastic surgeon and he said they had the same effects on the nose as the LeFort 1 advancement, but I´m not sure if this is correct, because the position of the spina nasalis anterior is usually changed by performing a LeFort I osteotomy. However, by placing the paranasal implants the position of the spina nasalis anterior stays the same. Also the upper teeth stay in the same position and I wonder what effect this might have on the upper lip.

A: Paranasal implants are placed at the base of the ala along the perimeter of the pyriform aperture. They help fill out the paranasal area but will not create the same effect as  LeFort I osteotomy. To do so they have to be combined with a premaxillary  implant which sits in front of the anterior nasal spine. They have no significant effect on the size, shape, or position of the upper lip or the nasolabial angle.

For central midface deficiency they can help ‘pull the face forward’ when used in conjunction with cheek implants. They add fullness to the nasal base but will not change nasal tip projection. Over the years, the greatest use of them in my Indianapolis plastic surgery practice is in unilateral cleft lip and palate to help build out the upper alveolar and nasal base deficiency.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Are you familiar with the wire release for nasolabial folds and does it work? Will it leave a scar?

A: The nasolabial fold, also known as the facial parentheses, is an interesting facial fold that is not really a wrinkle. It develops as the cheek tissues fall with aging over the more fixed and immobile upper lip. This creates a deepening fold as the cheek tissue piles up on top of the lip. While injectable fillers are the most common method of softening the nasolabial fold, they are temporary and don’t address the actual problem. There are surgeries that treat the real problem, cheek sagging, through a midface or cheek lift but that is usually too extreme for most patients and is best done if the lower eyelid has significant signs of aging as well.

Other methods of nasolabial fold treatment have focused on releasing the attachment of the fold. One of these methods has become known as the wire release. Through several small stab incision and a triangulation technique, an actual wire under the skin is used to widely release the dermal attachments of the fold. While the same technique could be done with scissors, it would require a larger, more visible, incision. This is the advantage of the wire technique. The wire does effectively release the nasolabial fold and produce some initial impressive early results. (after the bruising clears) But the long-term results with this method show a fair amount of relapse as the tissues adhere back down. For this reason, I like to place a dermal graft underneath the released tissues to provide a better long-term result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Hello, I read about the Patriot Plastic Surgery Program on your website and have a few questions. I was wondering if that included the National Guard as well. I am in the Army National Guard and I am being deployed next summer. I was looking to have a tummy tuck done before my deployment so I would have time to get back in shape. I have lost around 50 lbs from the birth of my daughter and have the excess skin that needs to be removed. I would appreciate any information you may have about the Patriot Plastic Surgery Program. Thank you so much for your time.

A: The Patriot Plastic Surgery program is for all members of the Armed Services and their immediate families. It provides some financial relief for those desiring many popular cosmetic surgery procedures. The costs of surgery are both fixed and variable. The fixed costs of any surgery are the fees associated with the use of the operating room, anesthesia charges, and the costs of any implants used. The only variable fee in cosmetic surgery is what the plastic surgeon chooses to charge for his/her professional time. Dr. Eppley makes an adjustment in his surgical fees to provide some well deserved financial relief for those who qualify for the program.

Many members of the Armed Services have taken advantage of the program since its inception in 2009. Given the young age of most program participants, the most popular procedures include tummy tuck and liposuction, breast reshaping, and rhinoplasty and otoplasty. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: I have two differently sized nostrils. My left nostril is smaller than my right. It looks like just removing some skin will fix the problem. How easy is this to do? I have attached a picture of my nose from below for you so you can see the problem.

A: There are numerous causes of one nostril being different than the other one. Since the nostril is geometrically a triangle, changes in the any of three legs (columella, alar rim, nostril sill) can cause a change in nostril size and shape. The most common cause of nostril asymmetry is an alteration of the vertical leg. That is the piece of skin between the nostrils known as the columella. It is supported from behind by the end of the septal cartilage, known as the caudal septum. This is frequently deviated or deflected to the side into the nostril space. When this occurs, the oval-shape of the nostril will become deformed making it look smaller. This is exactly what your picture shows…a classic deviated caudal end of the septum.

Whether more of the septum is off of the midline as it goes deep into your nose is unknown. You would probably know that because such a deviation is likely to cause breathing problems of which you would be aware. Regardless, correction of this problem is through a septoplasty procedure. The septum is moved back to the midline behind the columella. This anatomic correction returns the nostril size and shape back to better symmetry with the opposite nostril.

Septoplasty is commonly performed as part of many cosmetic rhinoplasty surgeries.

Dr. Barry Eppley

Indianapolis, Indiana

The desire for fat reduction is a near universal one that crosses all age, gender and ethnic lines. From the countless number of diet and exercise approaches to the opposite choice of liposuction surgery, loss of body fat can be successfully done with varying degrees of individual effort. But between these two ends of the fat loss spectrum lies the developing field of non-invasive body contouring. The concept of losing fat without surgery through an external device is both appealing and promising.

External ‘machine-driven’ methods for fat reduction are not new. Whether it was the belt-driven shaking machines from the first half of the last century to sitting in a sauna box and sweating it off, letting something else do the work and hopefully losing weight will always catch the public’s attention. Taking a pill, of course, is the simplest and requires the least amount of effort. But you probably didn’t get overweight or develop those few fat areas by taking pills, so it seems unrealistic that you can lose this fat by pills alone. While science and technology has come a long way, does today’s non-invasive body contouring devices really work…or are they just a modern-day version of the old ‘shaking machine’?

The newest technology for non-surgical body contouring is Zerona. This is an external cold laser that helps make fat cells leaky and loss some of their lipid contents. While people think of a laser as being a focused beam of light that hits a target and causes it to vaporize or melt, cold laser technology is different. It can pass through the skin without injuring it and penetrate up to 5 cms (2 inches) in depth. This can reach localized fat and exert its photochemical effect. The concept of photochemical-induced leakiness of fat cells is a bit hard to grasp but its physics are a little similar to the way cell phones actually work. I have a hard time wrapping my mind around cell phone technology to understand how all these messages and images are flying around and get to their intended recipients….even when I am on an elevator or a plane. But despite my ignorance I have plenty of evidence every day that it does work. So I won’t hold it against photochemical-induced fat loss simply because I don’t completely understand the science behind it.

The effects of Zerona on fat is very short-lived so multiple treatments are needed, spaced but a few days apart. Over a course of several weeks and multiple treatments, many patients have been shown to lose several inches around the waist, hips and thighs. But along with the treatments it is advised to drink water and take a niacin supplement to support the lymphatic clearance of the released fat. Herein lies the important difference from today’s technology and yesterday’s devices of hope…the use of some modest lifestyle changes and good patient selection.

Non-invasive body contouring is not a substitute for what liposuction can achieve or for the large amounts of weight loss that occur from bariatric surgery. Rather it is intended to benefit those who have some stubborn areas of fat that are just not responsive to what you can do at home with your best efforts. And for those who do not feel they have enough of a fat problem to justify surgery or want to do anything to try and avoid that solution. By using these criteria, most patients that use Zerona have more modest fat collections. This size of the problem and the modest lifestyle changes that are part of the program account for the generalized success and satisfaction that occurs from this non-invasive body contouring device.

Dr. Barry Eppley

http://eppleyplasticsurgery.com/

Indianapolis, Indiana

Q: I have two forehead bumps that are very distressing to me. They have been there since I was very young. They stick out like horns and I am very self-conscious of them. Can they be taken down and made smooth with the rest of my forehead? What is involved in this type of surgery and what are the risks?

A: Thank you for sending your pictures. I can clearly see the two upper forehead bumps. While they are not true osteomas, they are protrusions of the frontal bone. They can easily and simply be reduced through burring reduction. You can take down the outer table of the frontal bone in these areas up to 5mms to 7mms which should make them smooth and even with the rest of your forehead contour. This can be done through an incision either back in your hairline or just along your hairline. This would result in a very fine line scar. The hairline incision, commonly used in pretrichial or hairline browlifts, offers an advantage in that one could advance the frontal hairline forward if one desired. In your pictures, it appears that your forehead is fairly long between the hairline and the eyebrows. That distance could be easily reduced at the same time by bringing the hairline forward. I have found that to be very helpful with burring down upper forehead prominences as the combination of bone reduction and a shorter forehead length makes for a very smooth and more pleasing forehead shape.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  I have had some body changes which have left me looking like a man. My head is also bigger. I have lost the contours of my face and my hips are strapped like boy’s. My hair is shorter too. Is there a way you can help?

A: Questions like this, while well intentioned, are a waste of time for both the patient and the plastic surgeon. The description of concerns are very vague and non-specific. Plastic surgery is about doing very specific procedures for identifiable specific and focused concerns. When a collection of procedures are done, it may very well be possible to change the look of one’s face or body. But plastic surgery is not magic and having plastic surgery does not ensure anyone that they will look different or feel better about themselves.

The most satisfied patients in plastic surgery are those that come in with observable anatomic problems and a reasonable amount of concern about them. As a plastic surgeon, I have no hope of making someone satisfied with a result when the exact problem is not clear beforehand. As the old motto goes, ‘you can not hit a target you do not have’.

When I sit done with patients in a consultation, I want at the end to have a list of specific concerns and have them listed in their order of priority. If we start at the top of the list and only do just one or two procedures gthat are directed to improve them, the patient is likely to end up feeling that their results were worth the effort.   

Dr. Barry Eppley

Indianapolis, Indiana

Q: My son has torticollis which has contributed to his skull and facial plagiocephaly. We did not know about the cranial helmet when he was young and his condition was left untreated. He is now a teenager and very self conscious about his head being flat on one side and his face being skewed. He asked if there were any surgeries or anything we can do to correct it. I found your website and was amazed that you have experience with his exact condition. What can be done for him at this point?

A: Deformational plagiocephaly causes a very predictable pattern of skull and facial changes when untreated as an infant. As the craniofacial bones rotate around an axis, the pattern of asymmetries become flatness on one side of the back of the head and a protruding forehead, brow bone, cheek and jawline on the same side on the front. This can create very visible facial and front (forehead) and back (occipital) skull changes. I have seen a wide range of facial plagiocephaly problems in the degree of expression of the amount of asymmetrical differences.

Since the fundamental problem can not be reversed, changes must be done in an effort to camouflage or improve the different asymmetries. These can include an occipital cranioplasty to build up the flat area on the back of the head and numerous facial structural changes. The face can be altered by forehead and brow bone reshaping, cheek augmentation and jaw angle , and a chin osteotomy, all done with the objective of improving facial symmetry. The combination of skull and facial procedures that are helpful will be different for each patient. It requires an individualized assessment and computer imaging to determine the best plastic surgery plan for each patient.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Hi. i am an 18 year old male who is looking at getting something done to flatten my forehead and reduce my brow ridge, as I am unhappy with how it looks. i just wanted to know if I am a bit young to be getting something like this done? Also I play a fair bit of soccer so would like to know if it would affect how I header the ball permanently if I was to get surgery like this? Also would the scarring be noticable if it were not on the hairline?

A: From your description, it appears that one side of your forehead is more protrusive than the other, giving you forehead and brow asymmetry. The surgical technique for brow reduction is more effective than forehead reduction. The middle and tail of the brow bone (which is usually the most noticeable) can be burred down fairly significantly. The forehead bone that extends above it, however, can not be so significantly reduced. The outer table of the forehead bone (cranium) is only about 5mms or so thick before the diploic space is entered. From a practical standpoint, you don’t want to be reducing the bone into the diploic space so only about 4mms or so of bone can be reduced. While this would make some difference, the brow reduction and shaping would be more significant. The other important issue is that to do the forehead reduction, a large coronal scalp incision would be needed. This creates it own aesthetic issues and the trade-off of the scar for the amount of forehead reduction may not be a good one.

Doing the brow bone reduction, however, can be done through an upper eyelid incision. Given this hidden scar and for the amount of brow improvement, this would be a much better trade-off.

Dr. Barry Eppley

Indianapolis, Indiana