Your Questions
Your Questions
Q: I have been researching getting breast implants for some time. I know the differences between saline and silicone types of implants but am confused about these ‘gummy bear’ implants. I know it is some form of silicone but it is the best type of implant to get? Why is it different and are there any known problems with it? Is it the best type of breast implant to have?
A: The first thing to appreciate is that there are numerous type of breast implants from which to choose. They all will work and are FDA-approved with the exception of the gummy bear implant to which you refer. It has yet to be shown that there is one type of breast implant that is superior to any of the others. They all have some advantages and disadvantages and each woman has to weigh out those implant differences to determine what is the best breast implant for them. If there was one specific type of breast implant that was definitely superior that would be the only one that I would be using in my Indianapolis plastic surgery practice.
The gummy bear implant is a different type of silicone that is more firm than regular cohesive silicone gel. Hence the name gummy bear as it resembles this consistency. It is a textured anatomic implant that remains under clinical trials through the sponsoring company Allergan. It has not received FDA-approval as of yet. Because of its textured surface and its more form consistency, it must be placed through a larger lower breast fold incision than would be used for either saline or cohesive gel breast implants. Whether its added firmness is an advantage in cosmetic breast augmentation is a matter of debate. Its physical properties seem to offer advantages in breast reconstruction where the breast tissue may be thinner and more prone to contracture deformity. Gummy bear implants can and do ‘fracture’, requiring removal and replacement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I could not find info on your website regarding earlobes. Mine are large and I think it would look much more aesthetic if they were trimmed. Was wondering how it would be done. Thanks!
A: Large earlobes can be the result of one’s natural genetics or from aging and the use of heavy ear rings. In women, it is often the latter. In men, since they don’t wear heavy hanging ear rings, it is the result of one’s genetics. There is some component of aging and gravity that can make the marginally large earlobe larger and longer in later life. Either way, the surgery to reduce them is the same.
Earlobe reduction is a fairly simple surgery that often can be done under just local anesthesia. Like all earlobe surgery, it is not extensive because the earlobe is relatively small compared to the rest of the ear. There are several different methods of cutting out extra earlobe tissue and the differences are all about where the scar ends up on the earlobe. The wedge excision technique removes a triangular piece of earlobe from the central part. It is very effective at making the earlobe smaller and better shaped but does place the scar right down the middle of the earlobe. This scar usually ends up looking fairly indistinct but one must know beforehand that is where the scar will be. The other technique of earlobe reduction is to remove the lower hanging portion of the earlobe. This places the scar along the more hidden location of the rim of the earlobe. Both methods are effective and the choice between the two is partially influenced by the shape and size of one’s earlobe and preference for scar location.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have a divot in both of my shoulders from Vitamin B12 injections in which one became infected. I am a fitness competitor. Vitamin B12 is used for energy when dieting and also temporarily enhances the roundness of the shoulders (it is not discussed but used by competitors – injectable Vitamin B12 can be ordered from Canadian pharmacies). I no longer do this of course, but I am not happy with the divots left in my shoulders because of these injections. I was interested in fat grafting to replace the lost fat.
A: Loss of fat beneath the skin, known as subcutaneous atrophy, is not an uncommon sequelae of numerous types of injections. In plastic surgery, it is frequently seen in repeated steroid injections in the treatment of scars. I was not aware that Vitamin B12 has a similar effect and it is unclear if the fat destruction occurs as a result of the vitamin or the solution in which it is suspended to make it injectable.
The treatment (recontouring) of these divots is best done and is ideal for fat injections. While dermal-fat grafts can also be used, they require an incision to be placed and that requires an additional cosmetic burden that may be just as distracting as the original depression. Any of the off-the-shelf injectable fillers can also be used but there effect is only temporary and not a good long-term economic approach. Small divots like these are perfect for fat injections as their small volume makes it more likely that the fat will take and survive long-term.
Indianapolis Indiana
Q: Is there some place on the web to view close up frontal photos of scars from direct excision neck lifts? Do surgeons use traditional sutures that can leave trackmarks or are there other methods to close the site that won’t leave tracks?
A: Like a traditional facelift, the closure and the subsequent scar of the direct necklift is critically important. Since the direct necklift is fully exposed, it can be argued that the final scar is even more important than a more hidden facelift scar.
To see good close-up pictures of direct necklift scars, go to my blog…www.exploreplasticsurgery.com…and search under direct necklift. There are several blogs that address direct necklift scars and show photos of them. If you can’t find them let me know and I will send some to you to review.
The closure (suturing) of the neck wound is done with very small sutures that are removed a week later. Because the size of the suture is so small, they can not leave track marks. In my out of town patients who can not come back for suture removal as they have returned home, I use small dissolveable sutures that do not leave track marks either. Track marks are primarily the result of using large sutures that are left in a long time.
Another way to judge the outcome of a specific type of incisional scar is to look at the number of scar revisions that have been needed from the procedure. In my Indianapolis plastic surgery practice, I have yet been requested to do a scar revision from a direct necklift in a man. This can be explained by the great healing capability of bearded skin and the incidental scar therapy of daily microdermabrasion. (shaving)
Dr. Barry Eppley
Indianapolis Indiana
Q: I have a small tattoo of my upper arm that was put there years ago. While it is nothing gross or has anyone’s name on it, my boyfriend now does not like it and would like it to be gone. I have used some stuff bought over the internet for it but it hasn’t worked like they said it would. I looked into having laser treatments done for it but it was too expensive and it was going to be painful. I spent less than $200 to have it placed and with laser treatments it was going to cost over $3,000 to have it treated with no guarantee as to how much of it would be gone. Are there any other options for tattoo removal?
A: While laser tattoo removal can be effective, it is fairly costly because the laser machine has to be paid for and that is understandably factored into the cost of the treatment. A new non-laser method of tattoo removal does exist known as Tatt2Away. With this method a special fluid is placed into the tattoo using the same technique that got in there known as micropigmentation. This fluid causes the tattoo pigments to leach out of the skin. While it takes several treatments for optimal clearing (three or four), it offers results that are as least as good as that of the laser without the cost and potential risk of skin scarring. Unlike lasers which can not effectively treat all pigment colors, hues and blends, Tatt2Away is color blind and removes pigments regardless of their color base. It is also less painful than laser tattoo treatments because no heat is generated during the treatment. At roughly half the cost of a laser treatment, Tatt2Away now offers an effective alternative for tattoo removal.
Indianapolis, Indiana
Q: I would like to know few things about butt implants Dr. Eppley did my breast implants few years ago and now i would love for him to do my butt. I want to go big. What sizes and shapes can I pick from?
A: Buttock augmentation is similar to breast augmentation in some ways but different in others. Buttocks implants, unlike breast implants, are made from a very soft and flexible solid silicone rubber material. They are not fluid-filled. Like breast implants, they can be placed above (subfascial) or under (actually into) the gluteal muscle. Those two different locations carry greater significance in buttock implants than in breast implants,, particularly in terms of recovery. Intramuscular implant placement is preferred but that also limits the size of the implant that can be used and makes the recovery much more prolonged and uncomfortable. One’s anatomy also can also drive this choice because if there is little subcutaneous fat present over the buttocks, the intramuscular location will produce a smaller but more aesthetic looking result. (concealing the implant edges better)
Buttock implants come in either round or oval shapes and have volumes ranging from about 150cc to 400ccs. Unlike breast implants, in which the size range that can be used is much more variable, the size and shape of buttock implants must be more closely matched to the surface anatomy and measurements of one’s buttocks. In the buttocks you don’t have the luxury of just putting in whatever size implant you want. The risks of postoperative problems and complications is higher when you do so.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hey doc, I’m a girl who is of Chinese and Siamese descent. My question is, is it possible to reduce the size of my face in general through plastic surgery? The thing is I don’t have a specifically prominent area of my face as it is generally very wide and big. There is little to no fat and just very wide bones and I would like them to be smaller. My cheekbones are the most prominent while my jaw is simply wide but not very defined This gives me a very flat looking profile from the side but a very ‘big’ face from the front. So what is your take on this?
A: The best way for me to answer your question is to let me see some photos of you. The description is helpful but is not the same as actually seeing you. That being said, changing a facial ‘look’ is about picking a few facial areas that can help create a different facial gestalt or general appearance. Changing a ‘flat face’ requires providing more anterior projection and maybe doing some spot areas of reduction. In the Asian face, cheek and jaw angle reduction possibly combined with augmentative rhinoplasty helps change facial projection. While you can not really make a face smaller by actual measurements, you can make it appear more proportioned and this not look ‘so big’.
Dr. Barry Eppley
Indianapolis, Indiana
Q: My ears stick out and I am looking into getting them fixed. Can you tell details of the procedure to do it?
A: The correction of protruding ears, known as otoplasty, is a relatively simple procedure that makes for a dramatic change in the shape of one’s ears. Using an incision on the back of the ears, the shape of the ear cartilage is changed primarily by using suture techniques. The primary reshaped areas of the ear are the antihelical fold, which often is missing or poorly developed, and the concha which is often too big or too strong. Both the size of the concha and the absence of an antihelical fold make the ear stick out too far from the side of the head. Once the cartilages are reshaped, the incision is closed with small dissolveable sutures. A wrap-around ear dressing is used in adults for just one day. It can be removed the next day and one can shower and wash their hair normally.
While the change is immediate and clearly visible once the dressing is removed, the ears after otoplasty will definitely be swollen and sore. The swelling will go away in about a week. The tenderness will remain for several weeks longer however. Complications from otoplasty are not common. The most significant ones would be over- or undercorrection, asymmetry between the ears, and delayed extrusion of one of the permanent sutures. (which can occur years to decades later) Of all of the otoplasties that I have done, revisional surgery has been limited to less than a handful.
Dr. Barry Eppley
indianapolis, Indiana
Q: I have a high forehead along with a long face and I think it would look better if my hairline was brought forward and my forehead shortened. Is this something you could do in a male? I am 27 years old.
A: Shortening the vertical length of one’s forehead can be done by bringing the hairline forward. Much like a ‘reverse browlift’, the hairline is lifted up and brought forward rather than the eyebrows lifted. As a simple variation of the hairline or pretrichial browlift, forehead skin is removed to allow the hairline to come forward into a new and lower position, usually 1 to 2 cms of forehead reduction can be obtained. For women with long foreheads (greater than 7 cms. of length between the frontal hairline and the eyebrows), this is a very effective procedure that may allow them to change their frontal hairstyle afterwards.
In men, however, a long forehead is usually due to a receding hairline. The frontal hairline position in most men is not stable and naturally lengthens with age as hair loss ensues. While a young male does not yet have this problem, and it may not occur in every male, it is impossible to predict which male hairline may or may not recede. If a hairline lowering is done in a man, the scar line will eventually be seen as the hairline recedes later in life. I do not think this is a wise risk to take in just about any male patient.
Dr. Barry Eppley
Indianapolis, Indiana
For those who don’t know, the “wattle” is that fleshy fold of skin hanging down from the neck or throat. While not seen as an endearing piece of anatomy as one gets older, it is quite common in birds be it the pelican, common rooster or a Thanksgiving turkey. While it may be cute in a bird and makes it identifiable as a species, I have found no human yet that finds it flattering. Common amongst men and women alike as they get older, this sagging piece of skin and fat is often what bothers them the most about their aging face.
The wonderful world of digital cameras and cell phones have helped some people discover their neck wattles by seeing themselves in side view in a picture. Men make the discovery when wearing certain shirts and often feel it ‘flopping’ around when they move their heads. (swinging a golf club seems to bring on this sensation)
The good news is that neck wattles can be successfully eliminated and usually much easier than one thinks. The trick is matching the proper solution for the size of the neck wattle. Some wattles are small, others are quite large. Different wattles need different approaches.
The two things that we know about neck contouring is what doesn’t work. There has yet to be a cream that has a real ‘neck rejuvenation’ effect. The winner in that transaction is always the manufacturer and seller of the magical potion. If there was a cream that could really change your neck, we would all know about it and it would cost hundred to thousands of dollars per jar. (wrinkles are one thing, wattles are quite different) The other hopeful but unsuccessful effort is that of neck exercises. If the loose neck was primarily due to muscle looseness, this approach might have some benefit. But for the skin and fat that has become loose and is sliding off the face into your neck, the ‘neck gym’ remains more theoretical than useful. Neck exercising will have about the same benefit as it would for lifting the sagging breast or those eyebrows that just keep getting lower.
While many people would consider having a necklift, they wouldn’t dare undergo a facelift.This comes from a misunderstanding of the two procedures, not realizing that they are largely one and the same. I have found only a handful of patients who have ever actually known what a facelift really was. A facelift is really a necklift. But facelifting comes in two varieties which differ based on how much improvement in the neck is needed. A limited facelift (popularly known as a Lifestyle Lift or jowl lift) is great for jowling but not so much for the neck wattle. For small neck wattles, a Liftstyle Lift combined with liposuction in the neck may just do the trick. For a neck that hangs more, a full facelift is what is needed. It has a powerful change effect on making that neck more shapely and tucked up again.The difference between the two is the location and extent of the incisions around the ears. To really change the neck in more significant wattles and sagging, the facelift must have an incision that goes up behind the ear and back into the scalp. It is the pull from behind the ear that draws up and tightens the loose skin in the middle of the neck.
The other neck wattle surgery that few people have ever heard of is the direct necklift. It is the real wattle reducer and is the simplest of procedures to go through with but a few days of recovery. By cutting out the wattle directly, it is gone forever and creates a neck shape that hasn’t been seen for decades. The price for this most effective and simplest of wattle solutions is a fine line scar down the center of the neck. For the beard skin of men, this scar heals beautifully and may be the procedure of choice in the older male. For women, the location of this scar must be thought about carefully to determine if this is a good trade-off.
Dr. Barry Eppley
Indianapolis, Indiana
Q: After two rhinoplasties (a good minor tip refinement in 2001 and a rather aggressive septo-rhinoplasty in 2009 which contrary to my request shortened and upturned my nose a little), my aim is very mild tip lengthening, about 1.5 to 2mms and downward rotation. There are no problems of symmetry or breathing now, but my doctor used columellar strut, dorsal onlay, tip onlay and peck grafts and believes that my septal cartilage is probably inadequate so an ear graft must be used. Is this a safe solution for a very small improvement, or could the removal/repositioning of some used graft contribute to slight de-rotation? Can a combined solution, or even the use of hyaluronic acid, provide the best and least risky solution? I would really appreciate even a very mild lengthening/de-rotation, and much is being reported about the impressive progress in stem cells engineered cartilage. I really hope that you might be able to help me without extreme procedures and considerable risk.
A: To lengthen and de-rotate your nasal tip slightly, an onlay graft is a good solution. For the small amount of change that you want in your nasal tip, building out the area with a graft would be the most predictable. The use of ear cartilage grafts from the concha in rhinoplasty is very common, safe, and produces predictable results. It is a simple cartilage to harvest as it is taken from the back of the ear, leaving no visible scar. The natural curve of the cartilage is quite good for use in the nasal tip, which has numerous curves to it. The use of injectable fillers will produce your desired result quite simply but will go away in six months or less so it would need to repeated with some frequency and expense. Cartilage grown from stem cells currently remains a laboratory technique that may one day be useful in humans.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I always had a very thin upper lip with down turned corners. I have had dental implants (7) and a permanent bridge for my upper teeth recently. I noticed that my top teeth no longer show when my mouth is at rest and that my bottom teeth which hardly showed before are now quite visible when my mouth is relaxed and when I am talking. My dentist said this was due to aging (I am going on 51) I read an article by you on Lip Augmentation and was curious if I should be looking into a face lift or a lip procedure? I had my lips enchanced once (not sure what product was used, I am allergic to collagen) and the results were overly swollen and then within two weeks all was gone. What do you recommend?
A: The thin upper lip can be due to aging, a naturally smaller amount of vermilion tissue (pink part of the lip) or a combination of both. When you combine a naturally thin upper lip with aging and the need for dental implants (maxillary bone atrophy), you have the perfect setup for a very thin upper lip problem. When the vermilion is this thin, no injectable filler will provide a good outcome. While I think it is good that you tried the simple approach of a filler, one could have predicted that the results would not be good. But you have now at least proven that a surgical treatment is needed.
The way to get a fuller upper lip is to create more vermilion. This can be done very successfully through a lip advancement procedure. By removing a strip of skin above the lip and moving the existing vermilion upward, the upper lip will instantly and permanently become fuller. When this is combined with a corner of the mouth lift (through the removal of small triangles of skin above the downturned corners), you will have an instant change in the entire look of your upper lip and mouth area.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hello, I underwent a heart surgery in 1987 and I have a scar that gives me a problem. I always wear something to hide the scar because I think all the time that people see it. My question is how much of a scar is possible to reduce in percent?
A: While I have not seen your chest scar, you most likely had an open heart procedure through a classic midline sternotomy approach. This leaves a scar right down the center of the sternum from just below the sternal notch to just above the xiphoid process. For some patients this long vertical scar can get wide and raised, now as a hypertrophic scar. While often confused with a keloid, a hypertrophic scar is fortunately different. It is the result of the typical tension forces on a scar that runs perpendicular to the relaxed skin lines of the chest rather than a true pathologic abnormality of healing like a keloid. In women with large breasts, this scar may be pulled on even more than in a man due to the weight of the breasts. This can be a particualr problem in the cleavage area.
Scar revision of hypertrophic sternotomy scars is not rare in my plastic surgery experience. Scar revision of them consists of complete excision (cutting them out completely) and re-closure. Usually a significant improvement in their appearance can be obtained, trading off a wide raised scar for one that is flat and much more narrow. By percent, that improvement would be between 50% to 75%.
Dr. Barry Eppley
Indianapolis, Indiana
As the recession has continued now for over two years, most businesses have noticed. The number of cosmetic procedures performed has been no different. After continuous and unprecedented growth for over a decade, the number of elective plastic surgery procedures has taken a downturn these past couple of years. With this downturn has come the ‘shrunken pond’ effect that inevitably occurs when the same number of fish occupy a smaller body of water… competition for food increases dramatically. In the world of sales this translates to an increase in discounting for some to keep a steady flow of customers.
While discounting is a great idea for retail products like cars, jewelry and clothes, it has definite drawbacks in plastic surgery. Price reductions and the ever famous :Buy One, Get One Free” advertisements have appeared like never before. While the use of clever marketing is ethical and business-savvy, bargain-basement operations could exact their own price. The recent rash of major problems and deaths from plastic surgery procedures in the news is an example. Most of these tragic events are related to choices of doctor training, location where the procedures were formed, and the use of unethical or illegal substances and procedures.
One method of cost-cutting in plastic surgery that I have noticed to be prevalent is the use of local or sedation anesthesia as opposed to a general anesthetic which requires an anesthesiologist. While usually touted as being safer and offering a quicker recovery, it is understandable while some people would be attracted to it. But that doesn’t mean it is the most comfortable or allows the surgeon to perform the best job. A recent story covered one physician nationally touting breast augmentation without general anesthesia. In the story the doctor claimed that he would sit the half-awake sedated patient up during the operation so they could agree to the size of their breasts before he stitched them back up. Had a board-certified plastic surgeon developed this method I might have listened but these arguments from a gynecologist are less persuasive.
Much of this discount approach to surgery is being led by doctors who have studied an unrelated area of medicine and have entered cosmetic surgery through a low-fee approach. Not having to bill and process insurance makes the allure of patients who pay up front very appealing. Doctors not trained as plastic surgeons usually have to perform their procedures in their office. While they can legally do so, they also have to because they don’t have the privileges for these procedures in hospitals and surgery centers. Unfortunately, some privately-owned surgery centers are so crimped for cash that they may allow the stringest requirements of training that hospital requires to be bypassed to get any doctor in there to do procedures.
Breast augmentation and liposuction are the most common cosmetic surgeries where discounting and dubious training seem to parallel each other. This is particularly prevalent in bikini-clad sections of the country like Miami, Southern California and Las Vegas. We see less of it here in more clothed Indiana but it still is not rare. But body contouring is not alone in this trend, the facelift franchise known as the Lifestyle Lift offers a ‘mini-facelift’ at a discount rate under local anesthesia. While volume surgery may be predicated on rapid turnover…your face may be more interested in a long-lasting result that is suited to your aging needs…even if it costs more.
While bad plastic surgery is not always cheap plastic surgery, it can be a warning sign. Plastic surgeons with great skills and experience usually don’t have to resort to discounting to sustain their business. If you want to save money, do it when buying a vacation, clothes, or a gym membership. Think twice before being price swayed when considering plastic surgery. Skill, experience and a track record of satisfied patients is more important than a low price.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am 20 yrs old. I would like some advice on jaw angle implants. I want a more defined angular jawline. I feel that my jaw is disproportionate and makes both my nose and forehead appear large. Also I would like to see about a rhinoplasty because I have a hump midway up my nose. Thank you for your time.
A: A small jaw shape or jawline can make even well proportioned other facial features seem ‘big’. Since the features of a face are all interacted to make an overall appearance, it is not surprising that an imbalance in one part of one’s facial anatomy makes other parts seem out of balance. It may well be that the nose is too big or overprojecting as well and this will conversely magnify a shorter jaw.
Understanding how one facial feature impacts another is best played out for each patient through computer imaging. By just changing one feature, such as the chin or nose, one can appreciate whether the primary focus of facial restructuring should be.
Like the nose and chin, the jaw angles lend themselves well to computer imaging. Changes can be easily visualized in both front, oblique and side views to see if jaw angle implants would be facially beneficial. When imaging jaw angles, it is important to look at both an increase in jaw angle width as well as jaw angle vertical lengthening. It is this vertical angle lengthening that is often underappreciated or forgotten when considering this facial prominence change.
Dr. Barry Eppley
Indianapolis Indiana
Q: I had rhinoplastic surgery two months ago to remove the hump present on my nose. Day before yesterday again I found a big hump on my nose. Please suggest to me what I should do now.
A: Removing a bump on the nose, known as dorsal hump reduction, is one of the most common changes done as part of many rhinoplasties. The size of the hump varies in different patients and the type of rhinoplasty technique used to take it down and make the dorsal line smooth varies accordingly. In small humps, a simple rasping or filing down may be all that is needed. In humps of more significance, greater than 1 or 2 mms, an actual osteotomy technique is needed. While in rhinoplasty days gone by, many humps were converted to a ‘ski slope’ appearance which created an over reduced look. Today, a higher dorsal line is more aesthetically pleasing and a lot of better for maintaining good nasal airflow exchange.
Because of swelling, it may not be possible to fully appreciate if a small hump has been adequately reduced for weeks to months after rhinoplasty surgery. However at two months after surgery, it would be fair to say that the hump reduction achieved should be visible. I don’t think the ‘hump reappeared’ or reformed, it is just that all the swelling may now be gone and the shape of the dorsum is fully apparent again.
While revisional surgery is not generally performed for at least 6 months after surgery, it is reasonable to ask your plastic surgeon about your concerns at this point. He or she can give you better insight as to where you are now in your postoperative recovery compared to your preoperative nasal shape.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am 54 years of age and have dealt with large breasts since I was in high school. I exercise daily, diet and nothing makes them go away. Even though my wife says it doesn’t bother her, it bothers me a lot. I have still not psychologically gotten over being told in high school gym class that I had bigger boobs than the girls! Is 54 too late to have something done? I hate taking off my shirt at the gym or anywhere else, including the doctor’s office. I actually had them liposuctioned and they were flat for a few days but now that are big as ever. Please advise.
A: Age has nothing to do with whether gynecomastia can be surgically treated. It is only about how much the problem bothers you, there is no age limit for gynecomastia surgery. Gynecomastia, however, comes in many different sizes and the surgical techniques used to treat it are different. By your description and the fact that you had an unsuccessful liposuction experience indicates that your chest problem is just as much about too much skin as it is about too much breast tissue. In other words, when the chest starts to or has the appearance of an actual breast mound, the reduction technique must be more like a female breast reduction to be successful. This means that skin has to be removed which will result in visible scars on the chest wall. To be able to get you a lot flatter, you will have to accept the trade-off of scarring. That, rather than age, is the real rate-limiting consideration at your or any male age.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am going to have breast reduction surgery and I was wanting to know if I have more children in the future will my breasts go back to the before size, or just bigger than the after size? My insurance will cover it now, not then, that is why I was curious.. Thanks for the help.
A: From a breast shape and size standpoint, the answer would be that one should wait until after having completed all the pregnancies that one desires then have a breast reduction. But life is rarely ideal and breast reduction followed by pregnancies are not rare. Teenagers and young women commonly have breast reduction followed by pregnancies. The back, neck and shoulder pain from large breasts make the appeal of such surgery very attractive to get relief now rather than years later. Also, if you have insurance now and may not later there is the obvious financial attraction to doing something while you have coverage.
That being said, breast reduction and secondary pregnancy are not mutually exclusive…provided one acknowledges that the breasts shape and size that is obtained from the surgery will be negatively affected by future pregnancies. Most likely they will get smaller, they will sag more (the bottom will fall out more) and they will become flatter in shape. Pregnancy stretches out the skin and shrinks away breast tissue causing a deflation effect. In rare cases, the reverse may actually happen where the breasts become bigger again.
There is nothing wrong with doing breast reduction before pregnancy as long as one realizes that the breasts will not stay the same size and shape afterwards.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I had rhinoplasty surgery one week ago today. Ever since the surgery my nose has been very congested and I can only really breathe through my mouth. It runs all the time and I constantly have to wipe it. My concern is whether this is normal? What can I do to make my breathing better?
A: Such nasal congestion after a full septorhinoplasty is very common and almost the norm for the first week after surgery. Even though most plastic surgeons today don’t use nasal packing, often some form or resorbable or dissolveable packing may be used. This takes a week or two to go away. This combined with the swelling of the nasal linings, clots and reactive production of nasal secretions can make for a difficult first week. Yours sounds like a very typical one for many more complete rhinoplasties.
While time will improve the nasal congestion substantially, it make take up to 10 to 14 days until it is really better. Complete resolution of the congestion and drainage will be seen by three to four weeks after surgery.
The use of hot showers or a dehumidifier in your bedroom at night and the liberal spraying of your nose with Afrin (decongestant) and saline nasal sprays will reduce the swelling in the nose and help loosen obstructive clots. During your first postoperative visit to your plastic surgeon, those clots that are easily visible and not too painful to remove can be cleared.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am interested in getting a mini-facelift done. I would like to know some information about it and the cost.
A: The mini facelift to which you refer is also known by many marketed and highly promoted names. Its primary effect is to dramatically improve saggy jowls, smooth out the jawline and have some secondary effects in the neck. It is different from a full facelift because it is not effective for the really saggy neck. It is often combined with other facial rejuvenation procedures such as neck liposuction, chin augmentation and eyelid tucks. It takes just over an hour to perform and is usually done under IV sedation or general anesthesia. In my Indianapolis plastic surgery practice, it is not usually performed under local anesthesia. While the use of local anesthesia is an understandable attraction point for many patients, it makes the operation longer and takes an already limited operation and makes it more’limited’. The limited facelift is an outpatient procedure that uses no drains or sutures that have to be removed. One can shower and style their hair normally the next day after the overnight dressing is removed. While there is someswelling and bruising, this is more limited than what occurs in a full facelift. One can expect a complete social (how do I look?) recovery in 7 to 10 days.
The average cost for a limited facelift, all costs included, is in the range of $5,500 – $6,500
Dr. Barry Eppley
Indianapolis Indiana
Q:I would like my cranium to be more symmetrical. I didnt notice how misshapen it was until I started going bald. The shape is extremely incongruous with my handsome face. I would love to have a consult via skype. thank you for your time.
A: The true shape of one’s skull (cranium) often remains hidden under the cover of hair. For women this rarely becomes a subsequent issue as their hair pattern and density is more stable. This accounts for why I have had very few adult women requesting any skull reshaping procedures. For men, however, close-cropped hair or an eventual bald pate makes the shape of the skull very obvious. This is particularly true when it comes to the back of the head or the occipital region.
While loss of hair makes the skull shape more obvious, it also limits what can be done from a surgical reshaping standpoint. The use of scalp incisions and the subsequent scar must be considered as an aesthetic trade-off for a abetter shaped skull. For many men, this trade-off may not be a good one.
Skype is a wonderful to communicate for potential plastic surgery patients. It allows patients to ask questions and get answers from an expert from the convenience of their own home. I always ask patients to send me some pictures of their concerns beforehand so I can have a good idea during our online discussion. If one has a webcam that is even better as a video consult is the most interactive and informative.
Indianapolis, Indiana
Q:Dr. Eppley, Can you tell me how to get rid of my pesky double chin? It bothers me tremendously. I am only 43 years old and my neck looks twenty years older! I am too young to look like this. I am at a good weight and haven’t been able to shake these two chins off no matter what I do. What do you recommend?
A: The ‘double chin’ appearance comes from two upside down hump areas. The first is the chin, which everyone has, but in the double chin patient it is often short or set back. This can make it appear that it is part of the neck when it should be a more distinct forward prominence of the jaw. The second hump or sag is the soft tissue of the neck. This may be just a lot of fat but is usually mixed in with some loose skin as well. This is particularly so in older patients who may have overall neck skin laxity. Given your relatively young age, I would envision that the anatomic composition of your double chin is a bony chin shortness and a collection of fat with some mild amount of loose skin in the neck.
Therefore, correction of your jaw and neck contour could be done by a combined chin augmentation and neck liposuction. It may also be beneficial to do a little neck muscle (platysma) tightening at the same time to get the best neck angle. I doubt if you need any removal of skin at your age and we would rely on the natural skin tightening that occurs after liposuction in good quality skin.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dear Dr.Eppley, I am 27 years ol male and when I was born I had a skull deformity in which the bones of the skull were bonded together. For that reason I had a surgery at the age of 3 year s old in order to be fixed. But the surgery left me with a disfigurement on my forehead, which is a deformity which affected how people were looking at me since I was little. I was hoping after I have read an article of yours on the web that you can help me. I look forward if you can give me your opinion and the possibility to treat my forehead problem.
A: The congenital skull deformity to which you refer is generally known as craniosynostosis. The skull bones are connected by fibrous connections known as sutures. If one or more of these is fused, the skull can not grow (expand) properly and a variety of craniofacial deformities results, depending upon which cranial sutures were affected.
I suspect that your form of crasniosyntosis was either trigonocephaly (metopic suture) or plagiocephaly (coronal sutures). While early surgical intervention (frontal and orbital bone reshaping) is very helpful, it often leaves some residual forehead contour issues. I would have to see pictures of you to determine exactly what the forehead shape issue.
In men, forehead reshaping is complicated by the need to use a scalp incision for access to do the surgery. In patient’s that have had a prior craniofacial surgery in infancy or as a young child, an incision (scar) would already exist making this surgery obstacle irrelevant.
Indianapolis Indiana
This advertising phrase has been used countless times in the world of cosmetic surgery. I usually just gloss over it and write it off as exuberant advertising. After all, very few things in life of any value can really be obtained in just five minutes…even a good cup of coffee takes almost that long to get. But seeing this phrase as the main topic on the cover of a major magazine of good reputation made writing about it irresistible.
The concept of the ‘5 Minute Facelift’, beyond the slathering on of alleged beauty crèmes that ‘really work’, relates to the contemporary use of injectable fillers. Not to be confused with Botox (which paralyzes small areas of facial muscles) which is also injected, fillers add volume to the face underneath the skin. Most commonly used for the lips and the facial parentheses (a.k.a. lip-cheek grooves), it has become more widely used for many other areas of the face. Since one’s face is known to lose fat as we age, plumping up the face with fillers can have some rejuvenative effect. Inflating the face pushes out the skin and accounts for the claims of ‘making wrinkles disappear instantly’.
The allure of the 5 Minute Facelift, however, must be looked at more closely to see if it is real. The five minute part for any injectable treatment is not exactly accurate. Since placing the material requires multiple needle sticks, most people would prefer to take a little longer…if they could be numbed up for it. Getting good local anesthesia before having your face injected is appealing to just about everyone. As I always say…nobody ever says they are too numb. (or conversely, can I have just a little more pain?) While the actual injections may only take five or ten minutes to do, the preparation for it is much longer.
Time is not important, however, if the procedure does what it promises. I’ll bet most people would be willing to spend several hours if it would take away five or ten years in such a short period of time. Does plumping up the skin really achieve a facelift? Not by what most people would consider a facelift to be. While inflating a hot air balloon will lift it, such a phenomenon does not really occur in the aging face. While some areas of the facial skin can be made smoother and little volume added to the cheeks and lips, those falling eyebrows, heavy eyelids, or jowls and sagging neck will not be improved. A few wrinkles may be better but calling that a facelift is more than just a bit grandiose.
But for the sake of argument, let’s assume that the 5 Minute Facelift was really possible. Would it be a good idea? If you were going to an event or wanted any improved look for a few months, then it is clearly better than any surgical alternative. When viewed from the perspective of value, however, it is not a good investment. The volume of injectable fillers needed and their cost could easily be several thousand dollars. For a treatment that lasts six months or less (there are no permanent injectable fillers) that money would be better saved and eventually invested in a surgical facelift which is proven to last many years.
The 5 Minute Facelift, also called the Liquid Facelift, sounds too good to be true because it is. It undoubtably appears on magazine covers because it makes you instantly grab it off the rack and turn to the article. Injectable fillers have been a revolutionary facial treatment for adding small areas of temporary plumping. But to say they can lift a sagging face is like that hot air balloon…over plumped and soon to be lost in the horizon of hope.
Dr. Barry Eppley
Indianapolis, Indiana
Q:How difficult would it be to remove a dorsal onlay graft composed of a continuous piece of septal cartilage? The underlying structure of the nose was not changed.
A: Cartilage grafting in rhinoplasty is commonly done for a variety of structural enhancement reasons. Building up the bridge of the nose, widening the middle vault, and supporting and expanding the tip of the nose are common reasons for the use of cartilage grafts in rhinoplasty. Raising up a low dorsum, also known as the bridge of the nose or dorsal augmentation, can be done with cartilage grafts or synthetic materials. When possible, the use of your own natural cartilage is always best as it poses no long-term problems in terms of infection or tissue reaction. The most common problems with cartilage dorsal augmentation is shifting or asymmetry of the graft, underprojection (not enough height) or overprojection. (too much height which is rare)
Cartilage grafts to the nose heal with a surrounding capsule or scar. Inside this envelope sits the cartilage graft. Much like the original mucoperichondrial lining from which it was harvested (septum), this lining can be raised up and the cartilage graft exposed and removed. The cartilage grafts do not heal and become one with the surrounding cartilage like a bone graft would do in other areas of the face. There remains a clear demarcation between graft and the surrounding tissues. It should not be a problem to remove it in one-piece although it is best done through an open rhinoplasty approach.
Because it is a septal graft, it is unlikely that enough volume has been placed to make the graft too big or too high. I would be curious to know what about the graft makes you want to remove it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: What is the name of the computer program application which allows a plastic surgeon to show anticipated changes prior to surgery?
A: Computer imaging, or predictive surgical outcomes, is a very useful tool in elective cosmetic plastic surgery. Its value is not in that the predictions are a guarantee of what the final results will be, but as a communication tool between plastic surgeon and patient. Through the exchange of predictive images, it is far more likely that the plastic surgeon will have a good idea as to exactly what the patient does, and does not, want to achieve by the proposed surgery. Some unhappy outcomes from plastic surgery are the direct result of a misunderstanding of what the procedure(s) could do. This type of complication can be avoided by good communication before surgery and computer imaging can help that important process.
While it can be used all over the body, computer imaging is most effective and predictive for the face. It is particularly good in profile changes, such as rhinoplasty, chin and neck changes and forehead contouring. Because it is morphing anatomy that is contrasted with a different color background, the changes can be very accurate in many cases. They are also quite easy to see and appreciate. Frontal face imaging is also very useful but it is less accurate as one is pushing around and changing colors of pixels that are more similar. It is very easy to overpredict outcomes (looks better than what can really be achieved) in frontal views and the experienced and artistic hand of the plastic surgeon is really needed here to avoid an exaggerated prediction.
There are numerous software programs out there for computer imaging of the plastic surgery patient. The most common and widely available one is that of Photoshop Elements.
Dr. Barry Eppley
Indianapolis, Indiana
Q : My son is 5 years old and he has three scars on his face that we would like to have improved. The first scar is a laceration scar that is located above his eyebrow that happened about 2 years ago. The other two scars are minor scars that just never went away. We are just looking to see what options we have for scar revision and if he is even old enough to receive surgical treatment for his scars.
A: Age of the patient is rarely a reason that scar revision can not be done. The most important issue regarding age is how old is the scar? Scars that are immature, usually less than 6 months old, are often too ‘young’ for treatment as their appearance is still evolving. Scars that are raised, red or have initially appearing uneven skin edges will usually have improvement in these features as healing progresses.
Time is a scar’s best friend unless the scar has physical characteristics that time does not improve. One of the time-resistant features of a scar is width. As scars heal they will not get more narrow. Often the opposite will occur, they will get wider due to the effects of skin tension on them. For this reason, I may do scar revision early in very wide scars as waiting further only loses time in getting to a point of a better appearing scar.
On a different scar note, one of the most frequent misconceptions about what makes scars look better is that of laser resurfacing. It is commonly believed that the laser is the primary tool used in scar revision. This is completely false. It rarely can make a significant difference in how a scar looks. It’s role is often as an adjunctive tool after surgical scar revision is done.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I want to know if my protruding nipples can be reduced on size and made to lay flat. I am a 23 year-old guy that has gotten big nipples just in the past several years. I never noticed them before but now that really bug me. I am very conscious of them and have to be careful as to what type of shirt that I wear or they will be sticking out and obvious. I want them to be flat and smooth with the rest of my chest. I have read that women can have their nipples reduced but can’t find that it is done in men.
A: Nipple reduction can be done just as easily and simply in men as it is done in women. In fact, it is actually easier in men because there is no effort needed to preserve nipple sensation or any height of the nipple. Also, men rarely have the degree of protrusion of the nipple that many women have making it, by comparison, an easier problem to cure.
In men, nipple reduction is done by a wedge-excision approach. This will completely eliminate the nipple and will make a seamless color transition into the areola as it is that tissue which is actually closed over where the nipple was. This will always make the nipple completely flat and eliminate any chance that it will ever protrude again. While nipple sensation will be lost that is rarely a concern for most men. It is a simple procedure done in the offiec under local anesthesia. There is no recovery or restrictions any activities afterward. Tiny dissolveable sutures are used and one can shower the very next day.
Indianapolis, Indiana
Q : I have a deformity of the skull known as plagiocephaly. I stumbled across your site a few days ago and a sudden feeling of relief came over me. For the first time in my life I feel as if there is hope for me. I would like to know what can be done to correct the condition that I have. I know that nothing is perfect in this life, I am a living example of that but I would sure love to give your treatment a try. I have lived my life in the shadows, hiding away from the world. I think that Dr. Eppley will help me live for once.
A: Plagiocephaly, meaning crooked or twisted skull, affects more than just the shape of the cranium. Since the face is attached to the cranial base, it also is affected by how the skull develops. Untreated plagiocephaly can affect the front or back of the skull. When untreated as an infant, if severe, it can lead to a variety of predictable face, ear and skull deformities.
The first question is whether your plagiocephaly is frontal or occipital in origin. Facial photographs will make that fairly clear. Either way, the key in providing some cosmetic improvement to the craniofacial deformities is to understand what can and cannot be done. While much can be done to improve facial asymmetries, less can be done with adult skull deformities. Forehead recontouring can be done but changes in the back or side of the skull are more difficult and much less can be done.
What I ask every patient is to make a list of what bothers you from most significant to least significant. Then we go over the list, look at what can be done, and come up with a practical and value-oriented plan for improvement. Such improvements as forehead and brow reshaping, rhinoplasty, cheek, chin and jaw angle augmentations, and otoplasty are common procedures that can be very helpful in attaining improved facial symmetry. Augmentation procedures on the back and sides of the skull can also be done but very little can be gained by any form of reduction cranioplasty.
Dr. Barry Eppley
Indianapolis, Indiana
Q : I am trying to research plastic surgery on nipples but am having trouble. What I am looking for is a remedy for droopy nipples. I am 49 and breast fed my son for 3 and 1/2 years when I was about 30. As he fell asleep he tended to grit his teeth. Because of this and some some loss of size of my breasts there seems to be extra skin around the nipple area and my nipples lay down rather than remain perky (unless it is quite cold). Also, if I raise my arms, they can look like the skin around an elephants ankle. Is there a surgery for this. If so, what is it called. I would like to research it before jumping into things.
A: The extra skin around your nipples is the result of pregnancy and breast feeding. (the gritting of your baby’s teeth had nothing to do with it) Both conditions result is loose breast skin which is most noticeable around the center area of the breast mound where the nipple happens to be located. Depending upon the amount of loose breast skin, there are a variety of breast lift or breast tightening procedures to consider.
If the breast is not too saggy (the nipple still lies at or above the lower breast skin), a periareolar mastopexy may be all that is needed. Sometimes called a ‘donut mastopexy’, a ring of skin taken from around the nipple and the breast skin circumferentially tightened back up against the nipple. This results in a fine line scar around the outside of the nipple.
If the breast is very saggy (nipple lies below the lower breast skin), then breast lifting techniques are needed to remove and tighten skin that will leave scars that run down from the nipple and into the lower breast crease.
Dr. Barry Eppley
Indianapolis, Indiana
