Your Questions

Q: Dr. Eppley,  I had paranasal implants placed last week. About how long will it take before my smile looks normal? And how long should I wait to attempt to smile?   Also, I can feel a hard knot like object on the left side about less then 1/2 an inch below my inner corner of my left eye next to my nose.  What is that?  Is that the paranasal implant.  I thought paranasals was supposed to be on the side of my nostrils but I can feel this bulky area below my eyes right alongside my nose way up high. The bulky area extends down to the middle of the side of my nose.  I feel it and see it on both sides but it is bulkier, harder, higher and more obvious on the left.  I attached a pic of my swelling progress. Sorry but I’m not so pretty.l My lips nose cheeks are  all numb and I keep getting strange shooting pains on the left side of my face.  Sometimes they startle me bad.

A: The general rule on any facial structural change, such as paranasal implants, is that 50% of the result will be evident by three weeks, 75% by 6 weeks and the full result by three months after surgery. Therefore, any issues related to the way it looks or feels must go through these time periods. What one sees and feels at one week after surgery will likely change or become irrelevant in another month. Swelling, fluids and tissue shrinkage take time just as it did for your rhinoplasty. When it comes to functional recovery after facial structural surgery it has a similar time course although usually much faster. Nornmal feeling and mouth movement will take 4 to 6 weeks until things are nearly normal. Paranasal implants are very much like cheek implants, they are placed around the large infraorbital nerve which supplies feeling to the side of the nose and the upper lip. (and is actually the nerve the dentist injects with local anesthetic when working on your upper teeth which is why it feels similar) By  working around this nerve it is normal that it will go numb for awhile after surgery and takes some time to get its feeling back. As the nerve recovers from being stretched it will have many strange feelings including shooting pains or shocks. This is how the nerve recovers somewhat similar to when your foot goes asleep and feeling comes back into it.

Thus, being just one week out from surgery everything that you are experiencing is perfectly normal and expected. If this were two months out from surgery it would be a different story. But this is still early in the process and the only thing you can do at this point is let healing takes its natural, albeit long for you, course. You should smile and move your mouth as you feel comfortable. What you feel up high in the side of your nose is not the implant (as that would be impossible) but swelling.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have severe Grade 3 nipple inversion since birth and had a procedure earlier this year with high hopes. It was a release and then attached to a plastic device onto which the nipple was sewn. It did not work and I am extremely disappointed. What are my options at this point?

A: Inverted nipples present in differing severities which have been classified by grades and reflect the degree the nipple is inverted and ho scarred in it is. (milk duct fibrosis) Fundamentally, grade 1 nipple inversions may only occasionally retract and are easily pulled ouot if they do. (no soft tissue deficiency) Grade 2 nipple inversions can be pulled out but retract quickly when released. (very little soft tissue deficiency but with some scar) Grade 3 nipple inversions are very hard to pull and may not even be able to done. There is considerable retraction and scarring and a true soft tissue deficiency exists underneath. While the technique of release and sustained retraction by suturing to an external plastic device is the standard treatment, it is not one I have ever liked and there is risk of nipple necrosis with such sustained retraction. I find that release of the nipple and the placement of an interpositional dermal-fat graft to be a more effective solution.  The key is that scar tissue and the natural shortage of nipple length will pull the nipple right back into hole from whence it came. This is an issue of a tissue defect, not just a release. Constant traction on the nipple by an external device allows the filling of the defect with scar tissue which is highly prone to scar retraction and recurrent nipple inversion as it  heals. A revascularized dermal-fat graft provides a better resistance to scar contracture.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I undergone a genioplasty 18 months ago where a 5mm medpor implant was inserted through the chin. It improved my profile view and made my face more masculine, but it hated how it looked from the front, making my lower face square while I originally had a V-shape that I liked. The new chin was larger and squarer than my lower dental arch, so it looked weird at different angles. I asked for a revision 6 months ago where my surgeon shaved the wings off and tried to better adapt to my natural asymmetry. Today it still looks weird to me, even though it made me get some of my original features back. The bulging is now more isolated in the front, which is another kind of weird, as a matter of speak. I am now fairly certain I want it out, even if it means losing the profile improvement.

My questions:

– How dangerous is it to remove medpor after 18 months ? I know you wrote it’s only relatively more difficult compared to silastic (my surgeon says the same), but it is my face I have to be really careful with what I do next. Am I facing some loss of tissue/bone/muscle ? Do I risk some sagging (perhaps having reduced the implant’s size first will help in that regard ?) ? And if I getsome sagging, does getting more weight (planned anyway) will also fill up the skin so that it’s not so much of an issue ?

– when the medpor wings were shaved, doesn’t that necessarily suppose shaving integrated tissue/bone ? If so, does that mean I have now less bone structure than before ?

– Is there any way of moving a chin forward without making wider (and still blend in with the mandible) ? Is sliding genioplasty better at maintaining the original shape (since the bone already has the patient’s natural shape) ?

Thanks a lot for the time you spend helping out online.

A: One of the most overlooked features of chin augmentation is how it can change the front view. Most chin implants, particularly those of Medpor designs, will have an appreciable widening effect. When removing a chin implant, the issue is always one of the potential for soft tissue ptosis or sag. Just like a breast implant, once the tissues are expanded, they may not go back to their original shape. That is going tgo highly depend on the degree of expansion (size of the implant) an how long it has been in place. This can be partiually or completely overcome with mentalis muscle resuspension. Removing a Medpor implant does not mean losing any bone. The concept of bone ingrowth into Medpor is overstated and does not really occur to any appreciable degree, if at all. Removing the implant and doing a sliding genioplasty is a better alternative than just removing the implant alone. By so doing you will still end up with the profile improvement, keep a narrower chin (all sliding genioplasties actually keep or make the chin more narrow not wider) and will pick up any soft tissue and avoid/treat any soft tissue sagging.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in breast augmentation. One of my breasts is bigger than the other. I would like to even them out and go up a couple of sizes. I would like to do the “gummy bear” implants. My goal would be to get the most natural look possible.

A: Generally when breast asymmetry exists, it is very rarely adequately corrected by two different sized breast implants. This is because the amount of skin, nipple position, and any degree of sagging is often quite different between the two. But for the sake of a starting point (and perhaps this will be all that is needed) I will assume that it is just a matter of two different sized breast implants for now. Otherwise the concept of a natural breast augmentation result can mean different looks to different people. While implant size is certainly one factor that goes into a ‘natural’ result, there are other factors that can also play a role in creating that outcome including  the use of round vs. shaped (tear drop) breast implants.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I really want a bigger butt but realize that I don’t have any fat in which to inject. I am too thin to get much of a anything. That leaves my only option as buttock implants but I have heard only bad things about them. Are they really that bad? What is the real truth about them?

A: Buttock implants have gotten a historic bad reputation that to some degree is undeserved. When placed by an experienced surgeon into the intramuscular location, they can produce some very good results that fat grafting can not. Intramuscular buttock implant placement will be limited to usually under 400cc for most patients although this can make for a very impressive change despite the seemingly small volume. Buttock implants can also be placed above the muscle in the subfascial location, where much larger implants can be used, but the risks of complications such as infection, fluid collections and implant shifting are higher. Buttock implants can be a very effective and safe buttock augmentation option but what is bad about them is that the recovery is going to be longer and more difficult than that of fat grafting.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have some loose skin around and above my belly button after my tummy tuck which was three years ago.  I never though it was the tightest above my belly button right after surgery but the skin seems to have gotten a little more loose since.  I’d never heard of a reverse tummy tuck before I read about it online and am now curious about how the procedure works and where the scars would be placed?

A: The reverse tummy tuck is a distant cousin to the traditional tummy tuck, not only in location but to how it is performed to some degree. For those women who have loose skin around and above the belly button but not below it or have had a prior tummy tuck with loose residual skin above the belly button (the usual candidate for the procedure), a reverse or superiorly-based tummy tuck is the only skin removal option. A crescent of skin and fat is removed along the lower breast folds and across the sternum. This lifts the tummy above the belly button, just like pulling up with your hands along your rib cage. This places most of the scar along the inframammary breast fold with the exception of a small area that crosses the sternum. Unlike a traditional tummy tuck, no muscle usually needs to be tightened. In some reverset tummy tuck patients, I have only removed skin and fold under the breasts, keeping the scar from crossing the sternum. In the properly selected patient this can be a very good option if one can accept a scar along the lower breast folds. While always called a reverse tummy tuck, it should really be called a tummy tuck lift or superior tummy tuck.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was wondering if I can send pictures for your opinion of a chin pad re-suspension/jaw line augmentation. I have taken some pictures from different angles. I love the fact that you are also a Doctor in dental medicine, and you have a vast understanding of the chin and mandible bones, and have plenty of experience re-suspending the chin muscles to correct the appearance of “witch’s chin”, producing natural looking results as well.  I am 46 years old and a little more heavy by 10-15 pounds so the contrast between my round face and triangle chin is now more evident. My chin and pre-jowl area are looking worse as I age. I’m looking forward for your opinion.

A: I have looked at your chin/jawline issues and there are two different directions to go. The first is to simply resuspend the chin pad back up with submental liposuction. (illustrated in Facial prediction 2) The other approach is to build the chin and jawline out with submental liposuction. (illustrated in Facial Prediction 1) I think you have always had a smaller chin being a small women so your chin pad is more likely to become ptotic with age. It would seem more anatomic to pull the chin pad back up but the stability of keeping it there is suspect when the bone support is not strong. Conversely, the concept of some chin-prejowl augmentation is a more assured result but it does create a bit of a different (new) look for you. So you have to be certain this facial change (slightly stronger chin and jawline) is one you see as better. I personally favor the buildup as it automatically takes care of the chin sagging issue. Either approach incorporates submental liposuction which is a given as an improvement need.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a fairly muscular 20 year old guy and am a junior in college. I starting lifting weights about three years ago and, while my chest has gotten bigger, so has my nipples. I have to admit that I have been taking muscle building supplements until about six months ago. My nipples are puffy and stick out so when I am wearing shirts it looks horrible. I really need a fix for this so that I can go to the beach again and feel comfortable taking my shirt off. Even with muscles having puffy nipples does not make my chest attractive. I am at about 12% body fat now.

A: There is no question that there are certain stimulants that can cause breast tissue development and this is not the first time that I have seen it in bodybuilding young men. It is good that you have stopped taking the supplements even though that will not cause the breast tissue to regress. This will require surgical excision done through a lower areolar incision. Most likely they are lumps of firm breast tissue behind the nipple-areolar complex that is causing it to be pushed out and puffy. After surgery you will need to refrain from weight lifting for about 2 to 3 weeks to prevent the development of a seroma (fluid build-up) in the space where the gynecomastia was removed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I visited a craniofacial surgeon for advice because my right zygoma is lower, depressed and flat while the left one is just perfect (high, round, nice projection, and I want to leave it like that without surgical approach) He than diagnosed me with hemifacial microsomia. I asked him about the option of a custom implant on the right zygoma to make it just as high, round and projected as the left one.  He than said it is a bad idea to use implants for several reasons that sound convincing but proposed to use Beta-tricalcium phosphate granules trough a surgical approach to achieve the symmetry. He said it will act like an implant and also be permanent. He is a very well known surgeon and I do trust him, but I can’t find alot about this approach and that kind of worries me a bit. Are those granules really able to bring the zygoma (not the arch) forward?

A: The use of hydroxyapatite granules (or beta-TCP) in craniomaxillofacial surgery is an older approach for bony augmentation. It has a long history that dates back to the 1980s when hydroxyapatite blocks and granules became commercially available. I used it fairly frequently back then myself as there were no other non-bone material available. While it is a more ‘natural’ material, injecting/placing granules is an imprecise and relatively uncontrolled method of augmentation. For small amounts of augmentation that do not require a precise shape, it may still have a role in some select circumstances. But a ball of granules placed on the bone is easily compressible and displaced and defies being able to be accurately shaped. I have no doubt HA granules will provide you some augmentative benefit but it will not be effective in getting the most accurate and symmetric result to your normal side. It is simply a matter of the limitations of the material’s properties. The use of HA granules today is usually limited to older craniofacial surgeon’s who still have the historic belief that any synthetic material is ‘bad’. As for achieving perfect bone symmetry in the face to an opposite normal side, it is impossible to rival a custom computer-generated implant approach that creates the perfectly-shaped implant down to fractions of a millimeter. Such an implant on the zygoma/zygomatic arch is really conceptually the same as any other synthetic implant used in cosmetic cheek augmentation. I fail to see what makes that approach ‘bad’.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a mentalist strain and my chin is receding, I was told i needed a chin implant. Problem is that i’m not a fan of plastic surgery and I want to be natural. Is it still considered plastic surgery if I need it? Are there other options?

A: A small chin combined with a mentalis muscle strain is ideally treated with a sliding genioplasty. This brings the chin bone forward with the muscle and is a more effective and ‘natural’ (non-implant) solution to your problem.  It is more effective because, rather than just stretching out the strained muscle which is already short, moving the chin bone forward actually lengthens the muscle by the bony movement. (thus eliminating the muscle strain) You may consider that approach a reconstructive solution to your chin concerns rather than a pure cosmetic one if that makes you feel more comfortable.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Will getting the hair transplants have any adverse effect on brow ridge implants?  My surgeon has informed me that he’ll be using sheets of intermediate hardness silicone to build up the brow ridges while carving them to smoothen them out by hand. He will also only use sutures to secure them rather than using screws. Is this something that you do too, and should I insist on him using screws? For reference, the incision will be made via the upper eyelids.

A: My method doing brow bone implants (rather than cement) is quite different. Symmetry of the implants shapes and ideal location on the bone is a challenging issue when more limited access approaches are being done. I prefer to use either preformed brow bone inplants (made out of silicone and using designs from other patients) or have custom ones made off of the patient’s 3-D CT scan. Then I place them through en endoscopic approach and secure them into place with a percuatneous 1.5mm screw technique.

There are no adverse effects of hair transplants on the underlying brow ridge implants.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a few questions regarding occipital cranioplasty. the back of my head is kind of flat and it’s been bothering me since high school. As I get older I notice that it gradually get flatter, to a point where I don’t tie up my hair anymore because I am so self conscious about it. Now that I am 36 years old and am financially capable of fixing this problem, I am contemplating on getting the surgery done.

Below are my questions:

1. If I decide to have the occipital cranioplasty done, will I have to shave all my hair off for the surgery? 

2. Since I will have extra material at the back of my head will it affect the growth of my hair or the health of my scalp?

3. What are the possible side effects of the surgery?

4. Do you have patients who already had the surgery done for solely aesthetic purposes? And are the cases with these patients successful?

5. Where is the best place to have the surgery done? ( country/state/doctor)

Your advise will be much appreciated.

A: Thank you for your inquiry. In answer to your questions

1) No hair is ever shaved to perform an occipital cranioplasty.

2) Any placement of material on the skull bone does not affect the growth of the hair or the health of the overlying scalp tissues.

3) While infection is always a concern when any material is placed in the body, that is not a problem I have yet seen in cranioplasty. The most common side effects for any form of cranioplasty are aesthetic is the material smooth, even and symmetric? Was the buildup enough?

4) Most skull augmentations that I perform today are done exclusively for aesthetic purposes. The most common type of aesthetic cranioplasty that I perform is to treat a flat back of the head.

5) I can not speak for who else in the world performs aesthetic cranioplasties, I only know that I do.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, can someone who is overweight have a tummy tuck with liposuction? I’m 36 years old and am 5’4” and 195lbs. I have very bad back pain due to my large stomach. I have not been very successful with any efforts at weight loss and my doctor feels it is due to the medications that I am on. Would a tummy tuck with liposuction help me? I think it would be very beneficial for my back not to mention my self-esteem.

A: The question is not whether you can have a tummy tuck at your weight but whether you should. It would take a physical examination to feel your abdominal area and see how much of the tissue can be removed. In some overweight stomachs the skin is very tight and the yield on a tummy tuck is not as much as one would think. For these patients, weight loss is key so that they create the necessary loose tissue to make the surgical effort most beneficial.  In other patients, particularly those with an abdominal overhang (pannus), the results of a tummy tuck are more significant and even back pain may be improved as the strain from the weight of the overhang is removed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I read about you on some forums and was recommended to contact you regarding this issue. Anyway, based on your website, you seem to be one of the few surgeons who perform brow ridge implant and eyebrow hair transplants. Basically, I’ll be getting my brow ridge implants done next week, but I also have an appointment set up for my eyebrow hair transplants a month later. However, the surgeon doing the brow ridge implants has asked me to wait 6 months between procedures, whereas the hair transplant surgeon has advised me that it shouldn’t be too big of an issue to space them 3-4 weeks apart. Based on your experience, do you think it will be fine for me to get the brow ridge implants done, recover for 3-4 weeks and let majority of the swelling subside, then get the eyebrow transplants? Or, should I wait 6 months? I understand that it’ll take 6 months for swelling to subside fully, but will the small amount of residual swelling at 3-4 weeks post-op present a major risk to the eyebrow hair grafts? I sincerely thank you for taking the time to answer this as you are doing me a huge favor.

A: I see no biologic reason as to why eyebrow hair transplants can not be done a month or so after brow ridge augmentation. The blood supply to the eyebrow tissue is unaffected by the underlying implants, regardless of whether the overlying tissues have fully resolved their swelling and achieved final tissue adaption. In addition, the access incision for the brow bone implants is far away from the eyebrows and has no deleterious effect on their blood supply, even if a revision may be needed and done on them later.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have silicone breast implants which have hardened from lack of sex and age of implants. What can be done to get them replaced and have nice soft breasts again?

A: Many old silicone breast implants originally placed in the 1980s are very firm today due to capsular contracture. There are many reasons why these old implants have this aesthetic pathologic condition, from gel bleed to implant ruptures, but there is no scientific evidence to correlate a lack of sex as one of them. While massage of breast implants was preached as a necessary technique to prevent capsular contracture back then, this is not needed today. The best approach for your implant problem is to have them removed, perform total removal of all surrounding breast scar/capsule (which often shows signs of calcification) and have new breast implants placed under the pectoralis muscle. While the cause of breast implant capsular contracture is still not fully understood even today, what is known is that an under the muscle implant position (submuscular) is much better than on top of the muscle (subfascial) for prevention of it developing.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, For an injectable sternoplasty approach for a minor pectus proble on one side, is it possible to apply the hydroxyapatite granules in layers in order to avoid over correction? Can a mold of my good side be done, using it to fix the deformed side. I am asking all these questions because I wouldn’t want to proceed with the operation knowing it will not result in a positive outcome.

A: Obviously no patient or doctor wants to do a procedure that does not have a good chance of a positive outcome. But the reality is that there is no precise method to figure out how much hydroxyapatite to apply in an inejctable sternoplasty approach. A mold of the size of the defect would be done before surgery to estimate the volume of the material needed. And, at surgery, it is always better to place less material rather than too much as more can always be added later and too much would be problematic to remove. I have found that using these guidelines is very helpful in getting the best outcomes, but the limited approach of a small site injection delivery method always introduces variables that do not exist when operations are done in a more open incisional approach. (which is not an advised option due to the scar in your case)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had an upper blepharoplasty done 6 months ago where too much skin was removed. My eyebrows were pulled down and my eye shape changed! They become widely open and I can’t completely close my eyes when I’m asleep. I have got dry eyes every morning. Can skin graft be performed so that my brows can go back to the normal position? After the skin graft, will my eye shapes change back to original shape? Does skin graft on eyelid look natural? Or very noticeable? How long does it take to heal?

A: The only effective treatment for too much skin removal in a blepharoplasty is skin grafting. Certainly a skin graft will restore 3 to 5mms of extra skin which often is the margin between an aggressive and an overly aggressive upper blepharoplasty. In theory replacing lost upper eyelid skin should restore your brow position. A skin graft will have a slightly patch look as their is no other place on the body where a skin graft can be harvested that has the exacft thickness and perfect color match. But this is more of an issue when the eye is closed than when it is open. Skin grafts heal quickly in the eyelids but it will take a few months for them to settle in and achieve their final aesthetic result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to have PRP treatment on my face. My best friend who is a dermatologist in another country told me that the treatment is wonderful.

A: When patients use the terms “PRP Facial’ or “PRP Treatment of the Face’ that can imply multiple types of facial treatments using PRP. (platelet-rich plasma)  They fundamentally breakdown into either topical or injectable approaches. PRP injections can be done either alone or mixed with fat or filler to create a volumizing effect and are often dubbed as PRP facelifts or  even the marketed Vampire Facelift. When applied as a topical treatment, it is done in conjunction with either fractional laser resurfacing or the dermaroller, both methods which create channels into the skin by which the PRP can be absorbed and exert its effects. You would have to clarify for me whether you are interested in either a topical or an injectable facial treatment.

While the science of whether PRP really provides an immediate or a sustained long-term effect in facial rejuvenation is unknown, having it injected with other agents (fat, injectable fillers) seems the most plausible for having its high levels of growth factor exert a tissue stimulating effect.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Have you ever heard of ANS reduction in conjunction with Maxillary advancement (i.e. jaw surgery). My surgeon is proposing this but has been vague about the aesthetic and functional effects. From what I have read, it makes the nasolabial angle more obtuse. Would this mean removing the ANS results in longer upper lip and turned up nose? He is also advancing the upper jaw 3.5mm and rotating it ccw 3mm. Finally, would removing ANS during surgery preclude me from a future nose job should I need one? Thank you!

A: I not only have heard of ANS reduction with LeFort osteotomies but have done that many times in conjunction with them. The reason ANS reduction may be done in large maxillary advancements is that it may cause the tip of the nose to rotate upward or, at the least, widely open up the nasolabial angle. Removing it would prevent that concern. Whether removing the ANS is necessary in just a 4mm maxillary advancement, however, is different as it may not really be needed if the total bony movement is simple forward. But if there is any upward rotation of the upper jaw it would be needed. I would trust your surgeon in that decision. But whether it is removed or not, it does not preclude or maake difficult any future rhinoplasty efforts.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to have my lower jaw length reduced and a more tapered shape (lean 40 year old male). Is this possible without ending-up with an excess of soft tissue? I believe a big difference could be made with minor over-all length reduction, but especially a tapering of the front at the chin where my jaw is currently just a broad, rounded mass. I would also like to have otoplasty.

A: It would be helpful to see some pictures of your face for a more definitive assessment. But your concern about potential soft tissue excess is always relevant when losing some bony support. Whether that would actually be a real problem depends on three factors; 1) how much bony, 2) the technique used for the bone reduction and 3) whether soft tissue resuspension is employed. (for the chin) But in looking at your pictures,  I believe you are right on the money in regards to what you need. This could be achieved by an intraoral vertical reduction genioplasty (7mms) and lateral chin tubercle ostectomies done concurrently to reduce the vertical height of the chin and make it less square. An otoplasty could be done at the same time. I have attached a predicted image of what I envision the result to be from these procedures. Lastly, I see no concerns about loose skin after this procedure as muscle and soft tissue tightening would be done at the same time as closure of the intraoral incision.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I have a forehead issue that has been bothering me since I was like 14 years old. I know I need more than just one thing done to my forehead but my finances won’t allow me to do everything so I just try to do one step at a time. What do you suggest? I hate taking pics of myself but here are some for your review.

A: Thank you for sending your pictures. I am assuming that you are referring to/bothered by the deep horizontal crease that goes across your forehead. I doubt that forehead crease is caused by an underlying bone issue but rather is an indentation into the soft tissues over the bone. The one and only thing you can do is to have the crease released and injected with your fat. How well the fat  injections would survive and how much improvement would be obtained is uncertain but this is the safest and most natural approach to a facial skin indentation problem. You will never be able to eliminate it but fat injection will be able to reduced the depth of it. Given that a line is never going to be able to be completely eliminated, another possible approach is to excise (cut out) the groove and close it so that it is at least smoother and not indented.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was looking through your cases and saw some where the ANS was reduced. Does this cause the nose to “droop”, either immediately or long-term, due to losing bony support? If it doesn’t, can you explain why not?

A: Your question is not as simple as mere anterior nasal spine (ANS) reduction. That specific procedure is always done as part of an overall rhinoplasty so the effects on the nasal tip are also influenced by what else is being done. Otherwise, the tip is primarily supported by the septum (tentpole effect) and the suspension of the lower alar cartilages. The influence of the removal of a small spicule of bone (maxillary spine), in and out of itself, is not that signficant if at all on the nasal tip if done in isolation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 52 year-old male and am concerned after some weight loss that my lower abdomen is still fatty, and my pubis area is sagging. This is not exactly the look I want, what can I do? I have attached some pictures for your assessment from the front and the side.

A: Thank you for sending your pictures. What I see is mainly a pubic sag issue, not so much go an abdomen overhang. While there is some fat in the pubic area, an equal contributor to the problem is loose skin. Your options for improvement are either liposuction alone or liposuction combined with a pubic lift. A pubic lift, in essence, is really an inverted or reverse mini-abdominoplasty.  It lifts the skin from above along the waistline.

There is also some abdominal fat, but no real excess skin that I can see. Thus liposuction of the abdominal area could be performed at the same time.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a cosmetic issue with one side of my chest. My right pectoral bone/cartilage formation is good but my left inner pec seems to be either missing the inner bone or it may be indented like a minor pectus excavatum. What are my options for fixing this cosmetuc chest issue. I have attached a picture so you can see the area I am referring to.

A: Thank you for sending your picture. I do think it is a very minor manifestation of a pectus excavatum. I think given its very minor cosmetic issue and its location, I would only an  injectable sternoplasty technique. One option is fat injections which can be precisely placed and are not a foreign material. While its volumetric survival can not be assured and there certainly is a question of whether you have any fat to donate at all, but that would be my first choice. (although lack of a donor site may make it not an option) The other reasonable option would be injecting hydroxyapatite (HA) granules onto the sternum. These granules can be mixed with PRP (platelet-rich plasma) to form an injectable gel that can be molded once placed into the defect area.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was wondering if you could answer a quick question for me: Is there a way to perform a sliding genioplasty without having to cut the mentalis muscles? Is it possible to use an extraoral incision under the chin (if the patient didn’t care about small scars) to reduce damage to the underlying muscles of the lips? I am tired of hiding my face but I don’t think I’m brave enough to risk damaging the nerves or musculature of my lower face. How risky is this procedure?

A: Whether you go from inside the mouth or from below the chin, the mentalis muscle has to be cut. Even in a chin implant the muscle has to be cut. In skilled hands, a sliding genioplasty is a very safe and effective procedure with no long-term muscle or lip issues. The key is not whether the muscle is cut but if the surgeon knows how to put it back together.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Is there a wait time needed for healing after the original scar has developed? I had an accident this past February where I injured my forehead. The ER doctor said that it was hard to pull the wound together because I had skin lost and the wound might need to be reopened and restitched. Well I had the stitches removed and it left a scar that is about 2.5cm long and at its widest less than .5 cm wide. Please let me know if there needs to be a certain amount of time before scheduling an appointment. I look forward to your response.

A: My approach to scar revision may differ from the historic approach of waiting one year or more before having a revisional procedure. Waiting on scar maturation is advised when the problem that is making the scar visible will improve with time. If the scar is narrow, has a relatively even surface contour and is red in color, then time will help the scar’s color to fade. (although even that problem is treated earlier today with BBL therapy) But if the scar is wide, indented or raised (color aside), time will not improve those scar characteristics. This scar revision may be undertaken as early as 3 months after the injury when much the inflammation from primary healing has subsided.

Please send me a picture of your forehead scar for my assessment.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a large chin implant placed three months ago.  It looks OK but it has pulled my lower lip in to my mouth and I have no projection of my lower lip.  The implant was not screwed in and is rising up and the bottom of the implant is not parallel with the bottom of the chin. When I have my mouth closed and lift my lower lip up higher into my upper lip it feels like muscle is wrapping around the implant and causing a very tight feeling.  Will I aways be able to feel the implant?  If so that is ok. but I would like for someone to at least be honest with me.  If you do not know, that is ok.  Just say so.  I have only been able to talk to people that have had it as long as me or people who have removed the implant because they still felt it.  Would sliding genioplasy solve that?

A: When I hear chin implant experiences like yours, it usually indicates that an intraoral placement route was done and either the implant was initially placed low enough but has slide upward (silicone) or was never quite placed low enough. (Medpor) Everything you are describing indicates that the implant is riding up too high in the chin. In conjunction with an intraoral route of placement (if that was done), the mentalis muscle may be partially disinserted or scarred down creating an inversion of the lower lip. With good implant placement and size selection, all edges of the implant should blend fairly smoothly into the surrounding bone. Until I have some more information about your chin implant surgery (route of insertion, size and type of implant) I can not yet answer the question as to whether improvement will come from implant repositioning/muscle repair or removal and replacement with a sliding genioplasty.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I  had an appt with you to talk about  a limited facelift and upper lip laser resurfacing and a bilateral lower blepharoplastics. I am having these items done to look younger for myself esteem and for my son’s wedding in November. I hope that telling you that  bit helps you remember me. I know you are a very busy man. I have a few questions about the upper lip laser resurfacing. Will this be like scar tissue that stays red or white color for life or will my natural face color come back? Also how long will this take to heal? Scale of 1 -10 pain wise ? I am a huge baby when it comes to pain. We mentioned my crows feet and my forehead with like three vertical lines.  I wanted gone do they need be resurfaced too if you do these other procedures how much extra would it be?

A: I remember you just like it was yesterday. When it comes to laser resurfacing, the skin is NOT turned to scar or does it remain red forever. There is definitely a ‘pink’ phase of the skin once it heals after the first week but that generally is gone by 4 to 6 weeks later. This would be particularly true in the white Caucasian (Fitzpatrick Type 1) skin that you have.

Most facial procedures, surprisingly, don’t have a lot of pain. Think back to your original lower blepharoplasty procedure years ago and, it may have looked bad, but it was not particularly painful.

As for your crow’s feet and vertical forehead lines, those are best treated by Botox injections. The most economical way to have that done is to have my nurse Lora do it. She is trained by me and provides those injectable treatments at 1/3 less cost than if I did them.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I just want breast augmentation with implants and don’t want a lift. But based on my pictures do you think I need an uplift. My sternal notch to nipple distance measures 24 cms on each side. I had one plastic suregry consultation and was told I need a lift with breast implant. I would prefer them filled out and was hoping the use of an implant would lift them up. I have lost weight and breastfed so I have lost the fullness they once had.

A: Your pictures show an undeniable need for a combined breast lift and augmentation surgery. Implants only provide some degree of a lift if the nipples are initially at or above the lower breast crease. (inframammary fold) If not, the nipples will only be driven lower as the breast volume get bigger. Having a breast lift is really about accepting the scars as a trade-off for the improvement in breast shape. This is easier for some than others but is the defining decision about whether to do anything at all. There is another option, often called the ‘minimal’ or  ‘crescent breast lift. It is not really a breast lift at all but does lift the nipple a bit by removing a small crescent of skin at the upper nipple skin edge. For those women that have a minor amount of sagging, nipple lifts with implant placement must just be enough to get them an acceptable result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a woman that has a very square chin with a cleft in the middle. What can I do to make my chin more feminine looking?

A: A bony chin reshaping procedure is needed to both narrow the chin and eliminate the vertical cleft. This is done by filling in the cleft of the bone in the middle of the chin, repairing the overlying split muscle and shaving down the lateral tubercles (sides) of the chin. This would give your chin a more narrow shape without losing projection and get rid of the vertical cleft as well. This is a procedure that is done from the inside of the mouth, although it could be done from a external submental approach as well. Feminizing the chin is a common procedure in facial feminization surgery but is also occasionally requested by a woman who simply has too strong of a chin as well.

Dr. Barry Eppley

Indianapolis, Indiana