Your Questions

Q: Dr. Eppley, I already had several consultations with other surgeons, but nobody seems to understand my “problem”. I would like to have cheekbone augmentation, but I already have high and prominent cheekbones.But in my opinion there is a difference between the body of the zygomatic bone (where the cheekbone goes around the corner and what is usually called “the cheekbone”) and the arch of the zygomatic bone (the very lateral part of the cheekbone that extends to the ear and looks like a rather thin bow). My surgeons always acted like I was crazy after I explained that difference to them and that I only would like to have an augmentation of the arch of he zygomatic bone. They told me they have never heard of this kind of augmentation and there are even no implants out there that could address this problem. Then I found out, that there is a very popular kind of surgery around South Koreans.Many South Koreans have very wide zygomatic archs that stick out of the sides of their face although they often have a rather flat body of the zygomatic bone. For some reason (I think because they prefere a more western look) many Koreans don´t like this wide zygomatic arch and get zygomatic arch reduction surgery. It is a reduction osteotomy of this bone, that is done through an incision just in front of the ear. (like a face lift incision). I thought if it is possible to reduce the zygomatic arch, it should be also possible to augment this area. After I told this another surgeon, he said that this is called a preauricular incision that is only done in superficial layers, for example to do a face lift, but it is not possible to have a safe access to the bone via this incision, because the facialis nerve lies there. But I don´t belief him, because I have seen many pics on the Internet of this kind of incision that goes right down to the bone. It is used for correction of a fractured zygomatic arch or for operations on the temporomandibular joint. Does this sound crazy to you, Dr. Eppley?
Is there a way to augment only the arch of my zygomatic bone? Is it possible to carve impants for this area? I know that midface implants are usually placed through the mouth, but it seems logical to me that it would be easier to put a “zygomatic arch implant” through a praearuicular incision. Is it possible to have save access to the bone through this incision?

A:  I think you have a very good grasp on what you are trying to achieve. Can you just augment the zygomatic arch with an implant…absolutely yes. While wide zygomatic arches are reduced by osteotomies, expanding or augmenting the arch requires an implant not an osteotomy. Since they are no specifically designed zygomatic arch implants, they would have to be fabricated by either modifying an existing stock implant (such as by using the wings or flanges from an anatomic chin implant) or hand-making custom ones. Which implant technique would  be better depends on how much augmentation you are desired the exact location on the arch. When it comes to placement, zygomatic arch implants could be put in either through the mouth (anterior access) or from a preauricular incision. (posterior approach) Which method of access would depend on the shape and thickness of the implant, although I would likely prefer the posterior approach because the implant could be secured to the bone much easier this way.

In conclusion, your request for zygomatic arch augmentation is very uncommon but most certainly not crazy. One should not confuse unfamiliarity with impossible.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, my son had gynecomastia surgery last year and has developed severe scarring from this surgery. We have tried creams, silicone sheets, several rounds of shots and laser treatments as well.  Nothing has helped for his scarring.  It is so sad that a 17 year old young man is unable to remove his shirt in front of anyone, due to the embarrassment from these scars.  He often has sharp pains from the scarring that requires him to rub out the pain. As you can tell from the attached pictures, the scarring on his right side is much worse than the left.  This is due to the fact that he formed a hematoma under his right nipple after surgery and required a second surgery on the right side to remove the hematoma. I would appreciate your opinion to see if a scar revision and possibly radiation to prevent new keloids from forming is a possibility.

A: Thank you for sending your son’s pictures. I can clearly see that he had an initial periareolar approach to his gynecomastia reduction surgery. Due to the maturity of his scars, it appears that surgery was done at least a year ago. While I have no idea as to the magnitude of his original gynecomastia problem, I see the following current problems; wide hypertrophic periareolar scarring, a residual mega-areola deformity and some persistent gynecomastia fullness. His periareolar scarring does not represent keloids but rather is hypertrophic scarring, a not uncommon reaction to periareolar mastopexies in general. This is normal scarring that develops from tension and/or suture reactions from this type of procedure. It is not pathologic scarring nor would ever merit being treated by radiation after revision. While I can appreciate all of the scar treatment strategies done after his surgery to try and improve his scarring, re-excision was only ever going to be a strategy that has a chance to work. No scar treatment other than excision will ever make wide scarring more narrow. The main benefit to all these other scar treatments was that they have allowed time to pass for the scar tissue to settle down as well as being proactive along the way.

He clearly would benefit from periareolar scar revision combined with further areolar reduction and maybe some additional gynecomastia tissue reduction. The burning question is will this scarring problem recur and what can be done to prevent it. While I have my own techniques for how I do this surgery, it is always helpful to know what was done in the past. As the old motto goes ‘past history predicts future behavior’. From that perspective, I would need to see his previous operative note to understand what closure techniques were done so what didn’t work well would not be repeated.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I hate my fat knees and my ankles just don’t exist. I know that liposuction can be performed just about anywhere on the body. How effective is it in these areas and will I be back to working out and be physically unrestricted in two weeks after the procedure? (I’ll be leaving for a European vacation)

A: Liposuction of the inner knees can get rid the bulge that interrupts a desired straight line from the thigh down to the calf. Small cannula liposuction can also help one reduce one’s ‘cankles’ by creating a noticeable difference between the calves and the ankles. While these are some of smaller areas on the body to treat by liposuction, they can be tremendously effective. Despite their small size, however, I would not call recovery quick particularly if the criteria you are using is a high level of physical activity in a foreign country. The knee and ankle are unique because they are the only areas of the body in which liposuction is done across a moveable joint. This means that the knees and ankles will be stiff for a while (4 to 6 weeks) and the swelling in the lower extremities will take a long time to go away. (months) This does not mean that one can not perform all normal activities of daily living but placing a lot of physical stress on the knees and ankles (like occurs in traveling) is not something that is going to be fun just two weeks after surgery. I would highly advise that you defer knee and ankle liposuction until after your European vacation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had an otoplasty about 15 years ago that I was never completely happy with. While it did pull my ears that stuck out back, I always felt that it was pulled too far back in the middle making the shape of my ears look funny. I lived with it all the years thinking that I would just get used to it but I never have. In doing some research I got the impression from reading several doctor’s comments that nothing could be done, that it was unfixeable. I know that you a very creative and innovative plastic surgeon, so have you ever tried to reverse an otoplasty with any success.

A: When an otoplasty is overdone, the outer rim of the ear (helix) drops out of view behind the antihelical prominence. This is most manifest in the middle of the ear as you have described as this is the center of the arch so to speak. While sutures used to create the bend in the cartilage, what really holds the ear back long-term is the growth of scar tissue between the two sides of the cartilages. Some amount of otoplasty reversal is possible in my experience. But simply releasing the scar tissue between the two sides of the cartilage will not make it magically spring out again. This might be effective in the first several months after surgery but not after so many years. The scar tissue must be released//removed but that is not enough. The cartilages must be scored and then a small cartilage graft placed between the sides of the released ear cartilage like a spring. This will help hold in out as it heals and prevent total recurrence of ear shape. One can usually get 3 to 5mms of outward helical rotation/show. The cartilage graft can conveniently be harvested from the concha which is right next to the release site.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, is it true that it is hard to have a bloc rib cartilage inserted into the nose since I've got so many diced rib cartilage pieces in the nose? Will the surgery be somewhat messy and exhibit unpredictable outcome? A surgeon I consulted said he may need to remove all those diced pieces and that he doesn’t believe I will have enough rib cartilage to be harvested and carved into a bloc graft. I was somewhat speechless, because I thought rib cartilage is abundant. Then he pointed out that since I'm already 26 years old most of the rib cartilage has ossified. I'm really confused. Please help, thanks very much Dr Eppley.

A: With a prior diced cartilage graft nasal augmentation, it does make it more difficult to replace it with a new solid cartilage graft. But just because it is a little more difficult does not make it impossible. Many times diced cartilage grafts can be removed without a lot of difficulty because they have fused into a near solid mass that is held together by scar/fibrous tissue. I do not see the inswelling diced cartilage being a big obstacle to a second effort at a rhinoplasty for more dorsal augmentation. It is not true that at age 26 most of your ribs are ossified. I can assure you that your ribs # 6,7,8, and 9 are still very cartilaginous and abundant.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Can a combination premaxillary implant and paranasal implant be done?

A: A premaxillary implant is different that a paranasal implant as your question implies. A premaxillary implant goes under the base of the nose in front of the anterior nasal spine. It opens up the nasolabial angle and provides some augmentation of the upper lip. Paranasal implants are different in that they go along the side of the nose to add volume to the flatter or more deficient midface or maxilla. This is above the alveolar level and to the side of the nose. Both implants are used for similar overall facial profile indications…for the patient with a flatter or retrusive midface. These implants actually exist most commonly in silicone are are done as a combined premaxillary and paranasal implant known as the peri-pyriform implant. It can be used to wrap around the entire nasal based or can be cut to be used as separate premaxillary and paranasal implants.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, my question is actually regarding lip reduction. Two years ago I had silicone injected into my top and bottom lips. One year ago I had a lip reduction procedure performed. Since last march I have been receiving steroid and 5-FU injections into my lips to help calm the swelling. Now my doctor is telling me I need another lip reduction. My problem is that the first surgery was botched. After reading your website about where lip reduction incisions should be placed (inside vermilion cutaneous border) I realized that my surgery placed my incisions about 1/4 inch away from this location. My incisions were made in the mucosa region roughly halfway between the nose and the vermilion ridge on the top lip and just above the labiomental groove on my bottom lip.  Now the entire cutaneous region surrounding the pink part of my lips protrudes and is swollen from these ill placed incisions. My surgeon believes the the swelling is due to residual silicone left in my lips from the first surgery. I know there is silicone left in there because I can feel it. However, I don’t believe that is what is causing the distortion. My question to you is what do I do now? 

A: While this is water over the dam now so to speak, your situation illustrates the problem with permanent injectable materials particularly in the lips. Once in there there is virtually no way to get it out in any completely satisfactory manner. Lip reduction will remove part of it through direct excision but a fair quantity will still remain in lip areas not amenable to the excision. While your lip reduction incisions may have been placed a little too far inward on the musosal surface, I would not consider this botched surgery. That is just not the most effective position to place them for maximal lip reduction. As to what to do now? I would give yourself a good year from the lip reduction and see how things are then. This will give the maximum amount of time for swelling to go down and the scars to soften. Whether another attempt at lip reduction is worthy will be more apparent then.

Q: Dr. Eppley, I have had three c-sections, gained and lost over 100 lbs at least three times. ( after each pregnancy) I want to know if I need a tummy tuck or some type of pannus removal.

A: The difference between a tummy tuck and an abdominal panniculectomy is really one of magnitude. They are in many ways the same procedure with some different variations to them. A panniculectomy is nothing more than a ‘big’ tummy tuck. It involves a larger amount of abdominal skin and fat removal as a pannus means an apron or overhang of abdominal tissues across the waistline often onto the pubic areas or upper thighs. This means the horizontal incision and resultant scar may be longer and even extend into the back area from that of its smaller cousin, the more traditional tummy tuck. Given your description of recurrent weight loss of that magnitude and pregnancies, I would have no doubt that you have a pannus and your surgery would be a panniculectomy, often called an extended tummy tuck. The recovery from a tummy tuck or an abdominal panniculectomy would be the same. Longer incisions do not really mean a longer or more significant recovery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting a tummy tuck but have been told that I can’t due to my gall bladder scar. I have attached pictures and have highlighted my scars with a marker so that you can see them better. I am told that my appendix removal scar (30 yrs old) and c- section scar (9 years old) are no issue since they are below the belly button and would be removed. My gall bladder removal scar is 11 years old. I was told by one doctor that the skin below the scar would not survive if a tummy tuck was done. What technique for my tummy tuck would you recommend?

A: A long traditional gall bladder removal scar does place at risk for survival the triangle of skin that will ultimately result between the lower edge of the old gallbladder scar and the new horizontal tummy tuck scar. If done with care and looking out for several factors in the execution of the tummy tuck it can be done safely and without problems. The key factors are not to place the tummy tuck closure under too much tension (not too large of a horizontal excision), a limited central tunnel dissection of the upper abdominal skin flap and avoidance of any lateral abdominal wall liposuction. This will preserve the maximal amount of blood supply to the skin both above and particularly below the old gallbladder scar. This will allow the tummy tuck to heal uneventfully.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, Let me say right off the bat that I've had rhinoplasty 3 times. The first one, done in 1999, was kind of silly because the change was so minute that I felt I wasted my time and money. My complaint was that I wanted my bridge to be higher. The doctor took a bone off my hip, and placed it on top my nose. Basically it looked the same. Yet, I dealt with it and moved on but the feeling that the surgery was a failure never went away. I did a second rhinoplasty in 2005. The doctor placed Gortex on top my nose towards the bridge, which made my nose look a little dented in at the middle part of the nose. For a few years, I tried to convince myself of a positive change, but to no avail. Lastly, the third surgery was done in 2009 to address the dent. The surgery was successful in removing the slight dent but it didn't remove how I felt about my profile. All the doctors made conservative changes to my nose which I am fine with since my intention was not to change the racial characteristics of my nose. Again, I did it with the hope that it would improve my facial profile.

None of these surgeries addressed my main concern which is to make my profile at the midface less pushed in looking when I am expressive with my face. When I do this my profile looks ape-like, so I try not to make expressive facial profile which is really hard to do. It is not easy to walk around stoned face. I also had Invisilign work done last year. This was not done to correct crooked or misaligned teeth, as I have relatively straight teeth. It was to hopefully undo the imperfection I see in my profile while at the same time maintaining my facial identity. My teeth still flares out. The results were not a major difference from what I started with. So basically my teeth is the same way. The orthodontic treatment was done by filing in between the teeth to create space for the teeth to move back. I did this because I absolutely didn't want to loose four teeth to create space. I didn't see any noticeable change.

All the above doctors I visited were never aware of my underlining concern which is that I am not please with my profile because it make me look ape-like, due to how the mid part of my face is position with respect to the lower part, especially when I make facial expressions. This is not an easy issue for me to talk about so I kept it to myself instead of disclosing my feelings to the doctors. The orthodontist I visited last year told me that I have a large lower jaw and a smaller upper jaw which is the reason he was having trouble getting my teeth in the position he wanted, which was more vertical. Hence, the teeth moved backed, but not much. The change was so imperceptible (honestly I don't think It made any difference what so ever to my face) that no one ever commented to me of any change.

That is pretty much my situation in a nutshell. I am not happy with my profile, and as you would expect it is hurting my ability to live a happy, social life because of the way I feel about myself. I've attached pictures for you to look at. Pictures are of me after all procedures.

A: Thank you for sharing your surgical history, concerns and pictures. Your fundamental underlying problem is maxillary alveolar prognathism, which is common with your ethnicity. I am not surprised that orthodontics alone, of any form, did not improve that problem., It never had a chance to, its movements are too small for your problem. Ultimately you would have to have upper teeth extracted and the entire cant of the maxillary incisors brought back in to make a visible difference. Your rhinoplasty using a bone graft was a poor choice because that type of nasal augmentation will end up just resorbing, even if you get enough dorsal augmentation. A cartilage rib graft would have been much better. You had had three inadequate dorsal augmentation approaches because the materials and their volumes used were insufficient. You need a combined dorsal onlay with a columellar strut approach to get a much higher dorsal profile.

There are other midfacial procedures that can be used to help change your profile at rest or in expression but their effectiveness is uncertain. These include augmentations of the paranasal and cheek bones. And perhaps a good nasal augmentation with paranasal implant enhancement may be beneficial. I have attached a computer imaging prediction of that potential outcome.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I had a facelift which left my pixie earlobes. I had three procedures to fix my pixy ear but it stretches back toward my jaw due to not enough skin or too tight skin. Is there any other technique for my case which you think would work better? The last two ear procedures where done three and one month ago by two different doctors. One doctor cut the skin around the earlobe and the other doctor chose only to cut behind the lobe in order not to push the cheek skin. In both cases I was not satisfied. I have attached two pictures, one before the scar and one the way I am now.. I used to have a small high based ear with square jawline that now I can't see due to bad ear position.

A: The pixie ear deformity is marked by a lack of a definitive separation of the earlobe from the face and an earlobe that is ether elongated or abnormal in shape. In essence the earlobe is pulled down. Usually small local procedures of releasing and tucking the ckin around  the earlobe, while tempting and worth a try, do not usually produce a very satisfying improvement. This is because they do not recruit/move skin to make a separation between the earlobe and the face that stays and the problem quickly becomes a recurrent one. The options are either an earlobe release and reshaping with a resultant vertical scar below the earlobe in its wake or a secondary mini-facelift to move more skin underneath the earlobe for a definitive separation. These approaches will likely be more successful than your previous procedures.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I would like to have an upper lip reduction, along with a reshaping of my upper lip. Are you able to perform this surgery? If so, do you use laser surgery for the  procedure?

A: I am a bit confused by the combination of an upper lip reduction and reshaping of the upper lip. What do you mean by reshaping and what are you trying to achieve? An upper lip reduction is performed on the inside of the lip at the wet-dry mucosal junction. A horizontal strip of dry vermilion is removed and the remaining dry vermilion is rolled inward, thus reducing the visible vermilion or size of the lip. While this reduces the size of the lip, I am not so sure that I would call it a reshaping. Lasers are never used for skin or mucosal surgery. While they have theoretical appeal because they seem like a better way to do surgery, they actually have worse outcomes, delayed healing and usually bad scars. Lasers essentially burn the tissues that they cut through which causes all the aforementioned problems. They are also associated with wound complications such as edge separation in the healing period because of the tissue burn at the wound edges. They actually cause a more longer healing period and are not used for any plastic surgery operation.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I want to create dimension to my face by making bony features more prominent. I would like to correct my flat midface, drooped nasal tip, recessed chin, flat cheeks and forehead, and create a more prominent bridge to my nose.  What procedures would you use and how would you make these changes?

A: To make those facial changes, I would perform forehead augmentation with PMMA, a rhinoplasty using either a synthetic implant or rib cartilage grafts, and cheek and chin implants. I have done a side imaging photo to illustrate what I believe you are after with this compilation of procedures, to pull your face out and provide projection to a face that is naturally flatter and more wide. The only thing that I couldn't properly illustrate in the imaging is the bridge of the projection that would be achieved. Your natural bridge is hidden behind the eye so its profile can not be pulled based on this one photo. Always remember that computer imaging is just a visual way to start the discussion about what changes one wants and how much they want those changes to be. All of these facial changes can be done in varying degrees. Finding the correct amounts when multiple facial areas is being done is the key to a successful result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want to get the size of my chin reduced but am afraid of pain. Is there any painless way to reduce the size of my chin?

A: What you are asking is not possible. The surgery to do reduce the chin may be painless during the procedure because you are asleep. But after surgery there would be some pain and swelling. Most chin reductions involve bone removal, which by definition, will cause some after surgery discomfort. For the most part, anything painless in plastic surgery also correlates with things that don't work.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 27 year-old male. I have my nipples removed 8 months ago because it was too sensitive. I know the male nipple can be highly sensitive sexually and most of the men enjoy it but in my case I am unhappy with this sensation from childhood because it is intolerable and disgusting. And you know more than 30% male do not like that. I am among those men. So if someone tell that it is one kind of mental disorder, I do not believe it since I have taken mental and skin treatments since 2007 but there was no progress and I do not want to spend anymore money for medication. However, after the reduction of nipple there is little sensation on the center of the areola until now. When this place is pressed, it make me feel of the same sensation that I felt before. Finally, I have decided to remove the areola totally and want to make this place permanently numb. So what I want to achieve is the following:

1. Permanent numbness on areola by removing them.

2. Removing breast gland. (Actually, I have removed breast gland before but just need to check whether any gland tissue left. If it is then need to remove it.)

3. Removing whole areola. (It is not just the upper surface but also inner part. I mean after removing areola it will looks like a hole on skin.Probably, numbness surgery and whole areola removing may be at the same time.)

#2 and #3 is not mandatory but #1 is mandatory for me. #2&#3 is optional.

*** It is notable that My problem is not gynecomastia. This surgery will be just for numbness on areola place to live rest of life with happiness. I think it can be done by local anesthesia.

A: The most likely reason you only lost partial nipple sensation is that only the tops of the nipples were removed. The nipple and its ducts extend deeper which is where it receives its nerve supply and sensation. While initially after surgery the nipples were completely numb, some feeling has returned because these deeper tissues remain. While the entire areola can be removed, it should not be necessary to do that to eliminate all sensation permanently. A lower areolar incision can be made and all tissues removed right up to the underside of the dermis of the areola. When this is done, the remaining areola is just a cosmetic feature on the outer side of the chest skin. As you have mentioned, removal of the areola will result in a purse-string type scar on the chest wall which may be indented. I am not sure that is a good trade-off but only you can make that decision. I would agree that either approach could be done under local anesthesia.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, One week ago I had a syringe of Juvederm injected injected under my eyes. So far, the results are not fantastic but at least It did not create bags, as I often read in “horror stories”. Maybe I look less tired. I know I won’t go for a touch up, I had a bruise which freaked me out and “perfection is the enemy of good”. But I m wondering… Does this HA create any long term side effect such as lumpiness or swelling  months after the injection? Also based on your experience, how long does it really  last?  Because my injector said it could last for 3 to 5 years because there is no hyaluronidase in this part of the face (!!). And if people get treated again, it is because they have aged, the filler won't disappear. What do you think? Does HA under the eyes ever get broken down by the body? Thank you very much.

A: The information you have received about the longevity of Juvederm or any HA (hyaluronic-acid based) injectable filler is erroneous. No form of HA is permanent and they all eventually go away by the absorption of water which breaks down the filler. How long they last depends on the concentration of the HA in the filler and how it is cross-linked. It is true that they do seem to last longer in the lower eyelid/periorbital region, perhaps up to 12 to 18 months but definitely not three to five years. One of the real advantages of an HA filler is that it is a natural material as the body is composed of lots of HA material in its tissues. Thus there are no known untoward effects of repeated HA filler injections such as accelerated aging or tissued damage. Age also does not seem to play a role in how quickly or slowly any particular HA material persists.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I'd like to know based on your experience, how big of a chin implant would you consider as big enough to cause substantial amount of bone erosion From what I understand, chin implant of any size is bound to have some bone erosion to an extent whether or not it's substantially significant or just insignicant at all. Correct me if I'm wrong. When we talk about bone erosion, are we saying a 3-4mm bone erosion years after the surgery depending on the size of the implant? A surgeon suggested 1cm silastic chin implant and she said it's not considered big at all. I thought 1 cm is quite big isnt it so?

A: The issue of bone setting, not erosion, likely occurs with every chin implant to some degree. It is safe although speculative to say that the larger the implant the more settling into the bone that occurs. It is possible that implants of 1cm or more may have up to several millimeters of bone settling. While this is a frequently talked about phenomenon, I think it is clinically irrelevant. It has little impact on the aesthetics of the implant look and no other negative medical issues. It is only relevant if the implant is placed too high on the chin over thinner alveolar bone where implant settling into the bone may have adverse effects on the anterior incisor teeth. But a chin implant has no business being that high up on the bone anyway. It is also less of an issue today in anatomic or more extended implants where the pressure imposed by the implant on the bone is spread over a much larger area. In short, I would not concern yourself with this issue as I have never seen it to pose a problem when the chin implant is in good position over the lower basal bone.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 48 years old and am tired of my ugly looking inner thighs. Not only do they touch and rub all the time, which is irritating and embarrassing, but the skin is loose and not very tight.I want to know if liposuction on my inner thighs will tighten them or make them even more saggy. I want some fat removed but I don’t want to make them look worse.

A:  The inner thighs, although not a big area, represent a challenge for satisfying liposuction results. The quality of skin in the inner thighs is typically not good in that it has poor elasticity. This translates into a very limited ability to contract which is a critical factor needed to get good liposuction outcomes. As a result, liposuction of the inner thighs does not tighten the skin and in some cases may even make it look worse.While liposuction can help slim down the inner thighs, it is an area that is notorious for irregularities and unevenness. This is because the skin in this area does not shrink or tighten well after it is deflated by fat removal. It is also an area that is very difficult to get smooth results because it is a curved structure rather than a flat surface. While everyone's skin elasticity is different, your description of your inner thighs does not sound very favorable for good skin contraction after liposuction. This does not mean that you should not have it but that a conservative approach should be done with expected modest changes. You may want to consider liposuction combined with an inner thigh lift. That is a great way to hedge against the risks of loose and irregular skin by treating the skin problem at the same time.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I suffer from migraine at my right temple and rarely at the left. Because medicines never helped me, I had a surgery in last August,. The surgeon cauterized many arteries of mine. My quality of life improved but I still have pain at the same places, though less severe in general. Months before the surgery, I had tried Botox (injected by a neurologist) and it did not help at all. Will the auricular-temporal decompression surgery help me? I appreciate your attention to my concerns.

A: With temporal migraines, the question is whether zygomaticotemporal and/or supraorbital nerve decompression would be helpful. A good diagnostic test would be Botox injections. Just because you have had Botox and had no benefit does not mean that the injections were placed in the proper locations. I have seen many Botox injections done by neurologists and other doctors that were not properly placed. They must be placed in the exact location of the course of the nerve to work. If effective, then these nerve decompressions could be very helpful.

I would not expect auriculotemporal nerve decompression/avulsion to be helpful based on the information provided. It rarely when done alone can produce significant migraine symptom improvement. If one is going to surgery, it would be best to do multiple nerve decompressions including the zygomaticotemporal, supraorbital and auriculotemporal nerves at the same time. This would be most likely to produce migraine intensity and frequency improvement.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, my son was born with a bilateral cleft lip and palate. He just turned 9 years old. He is about to get his bone graft surgery in December. What is too early to have nose reconstruction? The surgeons said he would rather not touch his nose until he is age 15 or 16.

A: The nose deformity in bilateral cleft lip and palate is uniquely different from even that of a unilateral cleft. The lack of columellar skin and weak and short tip cartilages poses a significant reconstructive challenge that is present at any age that a patient undergoes any form of a rhinoplasty.

It is best to think of the nose reconstruction in bilateral clefts as done in stages. There are many variations as to how it is approached and will vary by surgeon. Fundamentally, it is divided into stages based on age and development. Under 12 years of age, the focus is on columellar lengthening, nostril narrowing and/or tip cartilage manipulation. After the age of 12, a full septorhinoplasty is done where the entire nose is reconstructed from the nasal bones down to the tip cartilages including the septal and turbinate deformity. At what age this full septorhinoplasty is done is open to debate but most plastic surgeons think more around the age of 14 or 15 years old when the face is essentially fully developed. There may be some modifications to this age based on the extent of the nasal deformity and the timing of orthognathic surgery (LeFort osteotomy) if needed.

In short, major manipulations of the septum and nasal bones should not be done under the face is more fully developed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I got breast implants one year ago an am not happy with the size. They are too big. They are only 175cc but they are just too big for me. In exchanging the implants to something smaller, I am not sure what size implant to change to In reading around online, there is much discussion about the base width diameter of the implant like its the holy grail, even though, interestingly, opinions diverge. Some say stay the same implant diameter and no larger, a bit larger, can be smaller by up to one cm, thin women should have smaller, and on and on…. so no hard-and-fast-rule it seems. But 8.2 cm (diameter of smallest available 100cc implants) to my 10.5/11cm change does seem a lot, if base width diameter is typically a consideration that you guys seem to have strong opinions on. I recognize that results are harder to pin down than one might wish, but why do you think that’s better than 130’s with a 10cm diameter, or 125 mod-plus with a 8.9cm diameter, in my case? Related to that, do you think that a lower diameter will diminish the lateral projection that I do not like? Do you think that a similar or slightly smaller diameter than my current 175’s, even if the ccs are lower, will leave me with the same lateral projection “issue”?

A: When the fear from the initial implant is that is was too big, you want to make sure you don’t repeat the same problem. Given that the initial implants were only 175cc and the lowest selection is 100cc, you want to make sure you never say I didn’t go low enough. Thus choosing 100cc implants eliminates that possible outcome.

Implant base width diameter has merit but its biggest contribution in my opinion is in the initial breast augmentation when it is important to not exceed the natural width of the breast so the implants do not get too far to the sides. Once a pocket is established and the implant replacements are going down in size, that issue does not become that important anymore. For you, however, with a fear of too much projection you need to get the flattest and broadest implant base. possible…spread whatever volume there is over a wide base. But the decrease in based width diameter of a 100cc implant may also help the problem of too much lateral projection as well.

Dr. Barry Eppley

Indianapolis, Indiana

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Q: Dr. Eppley, I got breast implants one year ago an am not happy with the size. They are too big. They are only 175cc but they are just too big for me. In exchanging the implants to something smaller, I am not sure what size implant to change to In reading around online, there is much discussion about the base width diameter of the implant like its the holy grail, even though, interestingly, opinions diverge. Some say stay the same implant diameter and no larger, a bit larger, can be smaller by up to one cm, thin women should have smaller, and on and on…. so no hard-and-fast-rule it seems. But 8.2 cm (diameter of smallest available 100cc implants) to my 10.5/11cm change does seem a lot, if base width diameter is typically a consideration that you guys seem to have strong opinions on. I recognize that results are harder to pin down than one might wish, but why do you think that’s better than 130’s with a 10cm diameter, or 125 mod-plus with a 8.9cm diameter, in my case? Related to that, do you think that a lower diameter will diminish the lateral projection that I do not like? Do you think that a similar or slightly smaller diameter than my current 175’s, even if the ccs are lower, will leave me with the same lateral projection “issue”?
A: When the fear from the initial implant is that is was too big, you want to make sure you don’t repeat the same problem. Given that the initial implants were only 175cc and the lowest selection is 100cc, you want to make sure you never say I didn’t go low enough. Thus choosing 100cc implants eliminates that possible outcome.
Implant base width diameter has merit but its biggest contribution in my opinion is in the initial breast augmentation when it is important to not exceed the natural width of the breast so the implants do not get too far to the sides. Once a pocket is established and the implant replacements are going down in size, that issue does not become that important anymore. For you, however, with a fear of too much projection you need to get the flattest and broadest implant base. possible…spread whatever volume there is over a wide base. But the decrease in based width diameter of a 100cc implant may also help the problem of too much lateral projection as well.
Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I took my son to the Children’s Hospital to assess his deformational plagiocephaly and they told me that they would not address my son's skull deformity since it was not negatively impacting his facial features. They described the procedure as extremely painful and invasive. Where can I find more information describing the pros and cons of this procedure. I would also like to know more about the procedure itself in terms of surgery and recovery. Any information would be greatly appreciated. My son has a pretty severe flattening on the right posterior of his head. My pediatrician convinced me that helmeting was the wrong decision and his condition would improve over time. At this point, I regret listening to the pediatrician and am looking for solutions for my son.

A: What they were saying at the Children's Hospital is that major cranial remodeling surgery is not justified for a cosmetic skull deformity. That is certainly true, particularly if your son is older than 18 to 24 months old. An alternative treatment option is to build out the flattened occipital area with onlay hydroxyapatite cements. That may be able to be done in some cases with an injection technique or a small incision. This is a far simpler approach to major cranial bone reshaping and the risk:benefit ratio is much more favorable. Whether the magnitude of the occipital skull deformity justifies an onlay craniopasty procedure depends on many factors, most of which is the emotional concern of the parent about the shape of their child's skull.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am writing to you because you are an expert with osseous genioplasty and maybe you can help me. I had a sliding genioplasty 7 months ago. But after the surgery one little piece of bone was missing at the site of the osteotomy. Also I had asymmetry. So the result was ok except for the noticeable notching effect and asymmetry. So yesterday I had HA injection to make it look better and the results are great. But now I am wondering can this HA interact with the titanium plates I have? Maybe it can be dangerous?  Also, can this HA interact with the bony remodeling which might not be completely complete? What do you think? Thank you very much for your help.

A: Notching along the inferior border of the mandible at the back end of a genioplasty is very common, particularly when a significant horizontal advancement is done. The injection of HA into the notch areas is a perfect treatment for this secondary genioplasty deformity. It has no negative interaction with the indwelling titanium plates and screws. Filling in the bone defects will not change any residual bone remodeling and may, in fact, help the process.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, After breast feeding, my breasts are less than perfect. My confidence has drastically decreased. I'm in incredible shape but my breasts are just mush. What kind of breast procedure do I need, augmentation or a lift?

A: For many women, the decision between needing an implant or a lift is very straightforward. Breast sagging after childbirth may be improved by implants if there is not too much loose skin and the nipples do not hang below the lower breast fold. If there is significant breast sagging then a combined implant and lift will be needed. It would be very rare to get a breast lift alone unless you already have substantial breast tissue volume. Having breasts described as ‘mush’ indicates a significant loss of breast tissue so some amount of volume through the use of implants is needed. With enough added volume, the loose skin may be adequately filled out and the nipple will sit in a good position. But if there is too much loose skin and the nipple sits even a little bit too low beforehand, the implants will not lift the nipple upward enough and some form of a breast lift will be needed.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I have breast implants placed in 2008 but I want to replace them and go smaller. Right now I have Mentor smooth round gel breast implants that are 500 each. I am a full D cup size. I prefer to be a C. I am 5'4” and weigh 127 lbs. I really don't know how the cc's translate to actual size. I imagine 350 to 375 each would be better though. I explained at the time of my surgery that I thought they were too big but the doctor encouraged me to wait. I've waited and still feel they are too big and do not want to return to the same surgeon.

A: When considering changing breast implant size, it is important to look at volumetric or percentage changes. As a general rule to drop a full cup size, one should drop volume by at least 30% or more. Thus having 500cc implants, your perception of changing volume down to 350cc is spot on. This represents a change of 150cc or 30% in volume. This will make a perceptible change in breast size. It will not decrease the width of the breasts much but will decrease projection. The good news about replacing existing breast implants is that it is a lot easier than the first time. With an existing pocket and the muscle already elevated, the postoperative pain and recovery is minimal…a far cry from the first surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a bulging blood vessel on the right side of my forehead. I have been told that it is an artery from a dermatologist and a vascular surgeon because it has a pulse in it. I want to get it tied off because it really sticks out and sometimes feels uncomfortable. How is this procedure done and roughly what percentage would you say were completely happy with the results versus some improvement versus not happy at all with the outcome? I would like to get an idea of what scarring can be expected. Any potential side effects specific to this procedure other than scarring?  Read somewhere about a pretty important nerve that hangs around this artery, obviously you would avoid this, but what are the chances of any problems?

A: Ligation or tieing off of a prominent vessel in the forehead can be done to reduce its prominence. This happens because the flow through the vessel is cut off. The surgical approach for arterial ligation to a prominent forehead vessel is done through a small incision inside the temporal hairline (to get the anterior superficial temporal take-off from the main trunk of the superficial temporal artery) and a very small incision on the forehead where the most distal end of the branch can be seen. In rare cases, a third nick incision is needed in the forehead if there is an additional feeding branch) These are very small incisions and scarring is not usually a concern. The nerve to which you refer is the auriculotemporal nerve which is a sensory nerve that only supplies feeling to the temporal region. It is not an important nerve in that it is not a motor nerve responsible for facial movement. That nerve is identified and preserved as the dissection is done in the temporal region while searching for the anterior superficial temporal artery branch. The primary risks of the procedure is how well it works, reduction vs elimination of the visible artery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, my son is 2 yrs old with mild to moderate plagiocephaly. One side of his head is noticeably flat on the back. I’ve read on here about the procedures available to fix this, in particular the cement injections. My question is if we decide to do this now at his age will the material expand with his head growth or will the procedure have to be done every so often throughout his life until his head reaches its final size? Thank you

A: The application of a calcium phosphate cement to the outside of the bone, known as an onlay cranioplasty, builds out the contour of the bone. It does not influence the growth of the skull in anyway. It allows it to grow as it normally would, albeit in its misshapen form. Knowing that non-synostotic occipital plagiocephalies do not display progression of the deformity, it is safe to assume that an altered/improved occipital shape achieved at a young age would be relatively stable as they grow.  I would not envision that a periodic addition of material would be needed until the child reaches skeletal maturity. The skull grows by resorbing bone on its inside and adding it to the outside. When done at age two, I would imagine that much of the added material would be incorporated into the bone as the child grows.

 
Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I had a tummy tuck three weeks. I had my drained pulled after 8 days and I developed a fluid collection right after. My doctor removed the fluid by needle twice and the third time today there was no longer any fluid. Since I had no fluid today and I don't have to come see my doctor until another six weeks can I go ahead and start exercising?

A: Given that you have an abdominal seroma after your tummy tuck, I would wait another week before you should start exercising again. Even though your recent tap was negative (empty), that does not mean you may still not build up a little fluid. The most assured way to make that happen is get very active. Strenuous activity increases lymphatic flow to the tummy tuck area which could cause more fluid to build up again. Give your body another week to heal and not show any evidence of further fluid buildup before ‘stressing’ the competency of the sealed lymphatics at the surgery site.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I suffer from a congenital malformation of the face and skull. The shape of my face and my head is too skinny and started with me this problem since I was 15 years old. I am now age 29 years old and I want a solution to my problem. But before that I want to know the answers to the following questions:

1. Is it possible to find a surgical solution to my problem? 

2. In the case of the possibility of surgery, you could be a final solution? 

3. Can surgery be done through the addition of natural bones? 

4. How serious is the surgery and what is the success rate? 

5. How long will I need to heal, and to engage in normal life? 

6. What will be the cost of surgery?

A: I would be happy to answer all of your questions but I will first need to see some pictures of your head for any assessment. It would be impossible to give an opinion without first seeing what the exact problem is. But what I can tell you without even seeing your skull problem is any correction can not be done by using bone grafts or natural bone. They will simple melt away and be absorbed. Skull surgery requires an incision across the top of the head so this is a trade-off you must be willing to accept. Most patients have full recovery after skull reshaping in just a few weeks.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 40 year-old male and my eyebrows are bothering me. I have read that they can be lifted by opening the the upper eyelid and putting in some device to lift them.  I know that  this procedure does not lift much however. Do you think that it can resolve my problem or do you have another  suggestion for me. Please find me some solution to lift my brows. Perhaps a mid-forehead lift will lift my brows and then you can even take the excess skin that I have in my forehead out. I have two very deep long  wrinkles in my forehead that you can use. I know that there will be scars even inside  the wrinkles but we can not have something without scars so I am willing to correct a problem that is bothering me and accept scars that I can treat later with laser. Or you can do the direct brow lift by making a scar right above each brow. Please I want to lift those brows so there has got to be some way to do it for me. 

A: As for browlifting in young men, there is never a completely satisfactory solution. The endotine device to which you refer lifts the male brow slightly but does not nothing for the rest of the forehead or wrinkles. Whether the amount of lifting that can be achieved, which is just the middle to outer brow area, is enough show be considered carefully before surgery. No scar across the forehead would ever be acceptable in any male but an older one who already has deep horizontal forehead wrinkles. A mid-forehead or direct browlift is a major concern in younger men where the trade-offs for doing something are worse than the original problem. Male browlifting is a challenging issue, particularly in the younger patient. The endotine device approach through the upper eyelid is the only browlift option I would consider at your age.

Dr. Barry Eppley

Indianapolis, Indiana