Your Questions

Q: Dr. Eppley, I met with a facial trauma seven months before and doctor have to put plates on my right zygoma bone and maxillary sinus and eye socket with 14 screws. But now I feel a lot of pain under my eye and cheek. So can removal of plates help me from getting an infection? What can be the right time to remove them? What can be complications in future? Will my bones have an adverse effect of it or they will remain healthy?

A: As a general rule, fixation hardware (plates and screws) are not removed after facial fracture repair unless there is a distinct problem. Such problems could be pain from device loosening or palpability or cold temperature transmission (usually around the eye area) Most facial plates and screws today are made of titanium which is very biocompatible and does not have any long-term issues such as corrosion or degradation. Because of the trauma of additional surgery, one therefore should have a compelling reason for removal. Should removal be necessary, they can safely be removed six months after the original repair surgery. Facial bones heal quickly and are very stable at that time.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My cheekbone injury is over 8 years old. I know doctors are leary of healed/mended cheekbones. Should have initially went to hospital but because of lack of insurance and being raised to believe a black eye is just that. I was even getting carded at 30, took only about 8months before that ended. So now I am 38 and skin is creased/hollowed only on that side. I went to a plastic surgeon but they don’t know what I am talking about. 

A: Many untreated depressed zygomatic (cheekbone) fractures will eventually show a malar or cheek flattening once all the swelling has subsided and the tissues are retracted. For many only the cheek is flatter but in more severe cases the shape of the eye may have changed and the corner of the eye tilted slightly downward. Yours sound like it has malar involvement only. A small cheek implant can usually make a significant improvement. Placed through the mouth on just one side, this can provide a simple and immediate fix to your cheek flatness/hollowness.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, my son was about a month pre-mature and spent time in the NICU. He has a very mild form of plagiocephaly behind his left ear stretching to the middle of the back of his skull. You can only really tell there is a problem if you look down from above. All of his other features(ears, eyes, jaw, etc.) are perfect and again it’s very hard to see unless you are looking for it but it’s noticeable looking down. You would have no idea he had plagiocephaly looking at his straight on. He is 3 1/2 years old and way past the time where a DocBand or Helmet could help remold his skull. From what I’ve read there are no conclusive studies that indicate that he’ll have any developmental problems in life and most agree that children with mild forms have no issues whatsoever. I went to a local pediatric neurologist and she said I could expect that it will fill out a little but his head will never be “perfect”. I guess I would really like to know your opinion if this very mild form of plagiocephaly will eventually fix itself, or at least get better as he grows over the years. Thank you.

A: At his age, the  skull asymmetry is fixed. It will not self-correct itself or likely get any better. It will stay the same as his head grows, likely not changing from what you see now. You are correct in that there are no developmental issues with non-synostotic skull deformities

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, am very unhappy with the right side of my face. My face is assymetrical; the right side looks smaller, there is less volume in the cheek, and my right eye and eyebrow are lower than the left. Also, the right side of my lower lip is smaller than the left. I feel that the left side of my face is the “good” side. I am very self-conscious of my appearance and avoid having my picture taken. I also feel that my nose is fairly wide from the front, although my profile is not that bad. Most surgeons in my area seem to focus on anti-aging procedures. I am too young (31 years old) that the right facial volume loss is due just to aging. The fact that I have always slept on my right side probably did not help. Please let me know what procedures you would suggest. I’ve attached a picture of my face straight on and also one of my right profile.

A: I would agree with you that you do have some degree of facial asymmetry. All features you have pointed out I can see and agree that it exists. The question is given the asymmetry what is reasonable to consider to do for improvement. I would also agree with youir three procedures of interest. A small right cheek implant with fat injections to the submalar (buccal space compartment) and the perioral mound area are very straightforward low risk procedures that can occur from visible improvement. While asymmetry issues exist in the eyebrow area, I would live with those for now. From a nose standpoint, a tip rhinoplasty to narrow the tip would work nicely. I would leave your profile and the upper portions of the nose alone.

The only point in which I disagree with you is that sleeping more on the right side of your face would not have caused the problem. This is a congenital ‘deformity’  and is a result of in utero development not from postnatal molding influences.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a grandson who is only 3 months. He was born with a mishappen ear and I do not want him to go through surgery and I read online that there is  a way to fix his ear with some sort of mold. Can you please help me and tell me where I can find this mold? Thank you for your time to read this and I hope to hear from you soon.

A: Neonatal ear molding can reshape an ear but it must be done within the first two months of life to be effective. There is a very narrow time window after birth when the cartilage remains ‘unstiffened’ and can be molded into a new shape. This is done using ear molds known as the Earwell System. It must be done by a plastic surgeon to apply the mold and change it as needed over a two to three treatment period. I am afraid at three months old your grandson has already passed the time when such non-surgical ear shaping is possible.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to get some facial cheek implants done and I have heard there is silicone and Gore tex. Do you have an idea of which one is better? And does Gore tex  implants get smaller after time passes? Thanks alot.

A: What is commercially available as preformed off-the shelf cheek implants are the materials, silicone and Medpor. Each of these materials has advantages and disadvantages and neither one is perfect. So it is not an issue that one is better than the other. Both can work very successfully and they are non-resorbable so they are permanent and do not change in size with time. Goretex is available as a block material which can be carved into a cheek implant shape during surgery but is a softer material and more deformable than either silicone or Medpor. What matters a lot more than the material is the right shape and size for your desired cheek look and a surgeon who has both the artistic skill to make that selection and then insert them properly.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in yourresults in treating facial asymmetry. I have a pronounced vertical orbital dystopia (I’m not sure if this is the result of plagiocephaly, though I highly suspect it is given the other imbalances in my face). I would like to know my options for treating this.  I have attached pictures for your review.

A: Thank you for sending your pictures. I can clearly see that you have a mild to moderate case of right orbital dystopia. (5mms of horizontal pupillary discrepancy) The entire orbital box is situated lower than that of the left side, affecting every surrounding structure from a lower eyebrow/brow bone down to an orbital rim-malar deficiency.

There are two fundamental strategies for dealing with these orbital discrepancies. The first is a complete orbital box change. Dealing with changing the fundamental problem through an orbital box osteotomy is too extreme is my opinion for the magnitude of your dystopia.  Therefore, I would recommend an alternative approach of multiple camouflage procedures. At the minimum, I would use an orbital floor-rim implant with hydroxyapatite cement which could be extended out on to the lower cheek bone. One could also use other types of implants such as Medpor or Gore-Tex which can be custom carved to fit during surgery. Ideally I would get a skull model fabricated from a 3-D CT scan to make an exact implant that reconstructs the bone levels to the opposite side. The lower eyelid would then be resuspended/tightened  which would move the lower lid level up, particulalry the outer half. One could also treat the upper orbit through either an endoscopic browlift approach with brow bone modification  through an upper eyelid approach. You can see with this camouflage approach it is a function of how far you want to go in treating all components of your orbital dystopia.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am considering getting a tummy tuck but am somewhat concerned about the scar. I know the scars can look quite good in some cases but not in everyone. Since I have a c-section scar I am wondering if this is a good ‘test’ as to what a tummy tuck scar would look like on me. I had a c-section about 3 years and the scar is still red, raised, and uneven. I remember right after my c-section I could feel my skin above and below the sutures overlapping. My question is will my tummy tuck scar be same way or will the scar be a thin line with no raised areas?

A: Your question is a good one and, in theory, how one incision on the body heals (particularly the same body area) should be an indicator of how the next one would heal. But the reality is that many factors go in to how an incision heals and they can dramatically affect how the final scar can look. C-section incisions, if closed well, should always look good because there is no tension on the wound closure. Lack of wound tension usually predicts a very narrow scar. Conversely, a tummy tuck incision is always under considerable tension which is why plastic surgeons use a meticulous multiple layer closure technique with most sutures under the skin to obtain a narrow scar. Tummy tuck scars are almost always a lot longer than that of a c-section. One of the key elements in this closure technique is to get a good leveling of the tissue layers so the skin edges are even across the scar line. Based on how you describe your c-section scar, I strongly suspect you will get a better looking tummy tuck scar.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to have temporal augmentation on both sides. I want a permanent solution which means no fat injections. I don’t want to have to do it every few years. I am ok with silicone implants. Because there are nerves in temporal area is temporal augmentation safe? I am scared of getting my nerves hurt. Can you please tell me what are the possible options for the implants.

A:  The use of preformed synthetic implants is the only assured method of permanent temporal augmentation. There are several different designs from two manufacturers today. These implants are most commonly placed below the temporalis fascia on top of the muscle. The frontal branch of the facial nerve which runs through the temporal area lies above the deep temporal fascia, thus subfascial temporal implant placement poses no danger to this nerve which is responsible for movement of the forehead and eyebrow. There are some cases in severe temporal hollowing with a tight fascial lining in which the implants are better placed above the fascia to get the desired augmentation effect.  This is usually necessary when there is a large step-off between the zygomatic arch and the temples. When above the fascia, it is important to place it right up against the deep fascia and avoid dissection in the more superficial fascial layers where the nerve runs. When done properly, temporal implants placed above the fascia are safe.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a question related to my paranasal implants. from Korea. Five months ago I had this augmentation but now I am disappointed with the result. I start to have awkward smile and a much longer upper lip. But because I have a sunken nose base, I do need the augmentation. In short, I am planning to remove the paranasal implant and change to a new one. I am wondering if I want to have an improved result whether I need to do these procedures separately (6months or so after removing current implant then add a new one) or can I do these two procedures together in one single surgery. It would be much easier for me to have only one surgery. But I am really worried that if I do so (removing and changing the implants at one time), that the swelling during the surgery might affect the doctor’s aesthetic decision for the new implant. Besides I am also worried that if I have only one surgery, whether it is possible the new implant would be much more likely to change its position on my face in future. Do you have any suggestion for my problem?

A:  To provide a very specific answer, it would be helpful to know what type of paranasal implants these were, what was their shape and how were they placed. (through the mouth and and on the bone around the pyriform apertures or placed through the nose in the soft tissue of the nasal base) One of the advantages of having existing implants in place is now you know the result they create. That provides valuable information as to how to change them for an improved result. The existing problems with your current paranasal implants could be their size, shape, and/or anatomic location. The change should be predictable before surgery, not during the procedure. Therefore, there should be no problem removing and replacing them during the same procedure. I see no advantage to a staged procedure. In fact, I would find that actually counterproductive. Knowing what didn’t work well is a good guide to improving it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have some additional questions about thigh liposuction. I need a fair amount of fat removed frm my thighs and during our consult you estimated that it would be about 1.5 L per thigh.  I know you are the expert but I’m wondering if I should get more removed (have you seen these thighs lately? Ha!). I believe your concern was that I have somewhat of  “cellulitic” thighs – nothing too severe but my legs aren’t perfect either (I’m 5’5, 165 lbs). How big of a factor is this when taking the amount of lipo into consideration?  Would it be risky to remove a little more per thigh?  Part of me would like more removed.  However, the other part of me worries about skin elasticity and “lumpiness” or other skin irregularities produced from the procedure.

A: The key concept for your thigh reduction to consider is that the more aggressive you are with liposuction in someone who has pre-existing thigh cellulite, the more likely you are to worsen the appearance of the cellulite and create unevenness. Contrary to a common public misconception, liposuction is not a treat for thigh cellulite but a potential exacerbation of that problem. It is a delicate balance between improvement in thigh size and not worsening the overlying skin’s contour. The ‘price’ to be paid for aggressive liposuction (maximal fat removal) is increased skin irregularities. Removing anywhere near 1 liter of fat from the saddlebag area is a lot and is certainly aggressive. But almost assuredly, increased skin irregularities will be the trade-off.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, my 14 year-old son had his foreheasd bone fractured in an accident this past April 2012 . The bone was removed by the doctor then and he now now needs reconstruction of that part. The place is between both eyes with a size of size of 7cm length and 5.5 cms width. The doctor here is saying they will take out a piece of bone from the front table of head bone and put that on. Is it safe? I need your view.

A:What are you are referring to is reconstruction of the forehead with a split calvarial bone graft. That is certainly one accepted cranioplasty method to do the reconstruction and is the only natural or autologous method. It is a well known craniofacial surgical technique and is very safe if done in experienced hands. Given that it is a full thickness frontal bone defect, the size is not too big (7 x 5 cms) and he is only 14 years of age, this is probably the best approach. His skull should be thick enough that the outer table can be removed elsewhere on the skull in a single piece and moved to cover the forehead defect. There are numerous alternative methods that are technically easier such as titanium mesh and hydroxyapatite combinations as well as custom HTR cranial implants, which are also acceptable methods, but the cranial bone graft for his size defect should work well. This is particularly important of the frontal sinuses have been exposed in the defect, which I suspect that they have.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, regarding the skull augmentation will the bone cement be set beneath the periosteum. Could that involve any risk of “osteolysis”? Could the bone cement be put on the periosteum instead? Thanks!

A: Your question is an interesting one and is only relevant based on the type of cranioplasty material that may be used. When using any of the hydroxyapatite (HA) formulations, you definitely want to be under the periosteum for two good reasons. First, the material does bond directly to bone with no risk of osteolysis and you want to take advantage of this biologic benefit. Secondly, if HA materials do not bond to the bone they will ultimately be unstable and may likely shift position afterwards and develop fractures or fragmentation of the materials at their feather edges. When it comes to poly methylmethacrylate (PMMA) cranioplasty material, this can be placed on top of the periosteum and will set up and will likely not shift or fragment afterwards particularly if microscrew anchorage is used. PMMA materials, unlike HA, do have a known and low risk of settling into the bone a little bit and are what you refer to as ‘osteolysis’. But this is not a particularly progressive process and is self-limiting. Conversely, I have greater concerns for its effects on the overlying scalp and tissue thinning. Therefore I think it more important to provide as much barrier between the material and the overlying scalp tissues as possible and would recommend staying beneath the periosteum for this important long-term reason.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I really need your advice, I have a problems with my eyes. There are very round, there are always dry and the corner of my eyes there is no fullness. (no arch shape) . My questions is are infraorbital rim implants right for me? Should a midface lift be done with the infraorbital implants? Please send info to my email please get back to me if you can.

A: To best answer your questions, I would need to see some pictures of your orbital/facial area. Round eyes with too much scleral show can be improved by tightening  procedures at the corners (canthopexy) which may alone offer an improvement. In some cases of round eyes, there is laxity and/or a lower eyelid malposition contributed to by a lack of underlying skeletal support. That is where infraorbital rim implants can be helpful. By providing skeletal augmentation and a push upward to the lower eyelids, lower eyelid tightening procedures can be more effective and the lower eyelid position better maintained in its new position. This is also the role of a midface lift, to provide soft tissue support to the lower eyelid. By definition, infraorbital-malar implants produce a midface lift by the displacement of the soft tissues.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have been researching doctors for breast augmentation this fall. I  am interested in breast augmentation and was wondering what your philosophy is about going big enough but not too big for your body. I am an A cup and would like to be a D cup. Another doctor told me a DD would put my body at significant risk for re-operation. My biggest fear is a doctor not letting me go as big and I would like or not setting the limits for too big and my body being injured. Thank you for your time!

A: Selecting breast implant size is, by far, the most discussed patient issue in the breast augmentation procedure for understandable reasons. The whole purpose of the operation is to get a larger breast size. I do not choose what size implant any patient should have, I merely help the patient select a volume that matches their desires. There is no absolute science to selecting breast implant size but through experience and the use of shaped sizers, I found that the desired result is obtained in just about every patient. I personally have never had a patient who has undergone a reoperation to get a larger breast implant size because they didn’t get what they wanted the first time. Conversely, I have had a few patients that opted for bigger implants but it was because they chose a smaller size initially.

When it comes to size selection, here is definitely a growing trend and philosophy amongst many plastic surgeons to place implants whose size stays within the existing breast base diameter and does not exceed the ability of the breast  tissues to support it long-term. When you look at the relatively high rate of breast implant revisions (nationally around 30% in the first three years after augmentation…my practice revision rate is less than 10%) it is understandable why a more conservative size approach has become popular. While the need for revisions comes from a lot of different reasons (infection, hematoma, implant failure, etc), very large implants potentially contribute to these causes. ( e.g., due to bottoming out, asymmetry, symmastia, breast tissue thinning ,etc)

What defines a large breast implant size or too large of a breast implant for the patient is going to be different based on each patient’s breast anatomy and chest/body size. For most patients, I would not think that going from an A to a D cup would constitute in my mind an implant that is too large or, more relevantly, places the patient at a substantially increased risk of subsequent breast tissue support problems. But that would have to be determined by an actual physical examination of the patient.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 44 year-old male interested in a direct neck lift but I think a modified version. My saggy neck skin is caused after neck liposuction when skin did not fully re-attach firmly and/or shrink, so the underlying muscle is fine. I just need the excess sagging skin removed and the neck tightened up. I do NOT want a behind the ear neck lift and like the direct neck lift. Also I like the fact it can be done under local anesthesia.

A: The direct neck lift has the advantage of treating loose neck skin by direct excision and is very effective as a result. But it does so at the price of a scar. This is usually not a big concern in the older male (> 65 years old) who has a classic turkey neck problem but may be more of a potential aesthetic issue in the younger male with less loose neck skin. For this reason I might consider an alternative to a vertical neck skin excision to that of a horizontal excision right under the chin. This is more formally known as a submentoplasty. It removes much less skin than the direct neck lift but has a much better scar camouflage. At your young age, I question the wisdom of vertical neck skin removal and the subsequent scar when the problem is loose neck skin after liposuction. This tells me that the skin redundancy issue is mild and much less than a drooping neck wattle.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a pretty big scar which runs down the middle of my forehead. It is from an accident I was in last October. It was cut down to the skull and they did plastic surgery but my doctor said its all healed now. I want it to blend in more and not look so scary. What type of scar revision would help me the most?

A: As your scar is now nine months old, it is likely close to maturity. This is confirmed by your doctor saying that it is ‘all healed now’. In looking at your pictures, your scar could be improved through further manipulations. It is not tremendously wide but it is visually obvious because it is a vertical scar in the forehead where the relaxed skin tension lines (RSTL) run horizontal, completely perpendicular to your scar’s orientation. I think you would benefit by a two-staged scar revision approach. A first-stage running w-plasty scar revision done under local anesthesia in the office. This would help change the straight line vertical scar appearance to a more of a broken line closure. That would achieve two things. First it will help redistribute the tension better by the interdigitation of the wound edges so it will likely end up as a more narrow scar. Secondly, an irregular line is a better camouflage when the scar runs adversely to the RSTL of the forehead. If needed, a second-stage fractional laser resurfacing of the scar several months later for optimal blending into the surrounding skin.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am just enquiring about getting my head wider. I have a fairly thin head and want it wider. Is that possible?

A: When it comes to widening faces, most of the narrowing that I see is in the temporal regions from the lateral orbital wall  back into the temporal muscle above and behind the ear. Augmentation of the narrowed temporal region can be done one of two ways. The first method would be to use off-the-shelf silicone temporal implants. They are designed to fill out temporal hollows and are placed under the temporalis fascia just above the muscle. While they are primarily intended to be used to fill out the temporal hollows between the side of the eye and the temporal hairline, an additional implant can also be placed above the ear level also. This does not give the ideal augmentation because of the shape of the implant, but it is the most economical approach because it uses ready-made implants. The second approach is to use custom-fabricated implants made out of either Gore-Tex (carved out blocks during surgery) or silicone (pre-made off of a skull model) materials. They would provide the most ideal augmentation because the implants cover the optimal surface area of the temporal regions.

The other narrowed area is more of the head and is in the upper temporal region back to the occiput. This is a more challenging because the temporalis fascia gets very thin the higher it goes up the skull/forehead. This makes it difficult to have a subfascial implant which helps camouflage the contours of the implant.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting some volume back in my face. I lost a fair amount of weight over the past two years and my face has become quite gaunt. After doing a lot of reading, I know that there are the options of either some type of injectable filler or using your own fat. There doesn’t seem to be any consensus as to which is best. What is your opinion?

A: The development of synthetic fillers has created a whole new field of aesthetic medicine, mainly for facial rejuvenation. They are understandably hugely popular because of their instantaneous effects. While some last longer than others, in the end they are all temporary fillers. This issue only becomes truly relevant with major facial volumization is desired. The issue is simply one of cost. Given the volume of synthetic filler needed and the time that they last is the cost worth it? That, of course, is an individual question but the cost:benefit ratio does come into play for most patients.

Fat injections do not suffer from volume concerns and are more cost effective when considering the volume that is capable of being injected. Fat also has the added benefit of providing some stem cells as well although what their role is and how much they contribute to fat graft survival and overall tissue rejuvenation is still a matter of some debate. While fat grafts have the potential for long-term survival, their retention is not completely assured. Fat grafting procedures are a surgical procedure, however, and need to be performed under either local anesthesia or IV sedation depending upon the volume needed.

In the end, both synthetic fillers and fat grafts have their advantages and disadvantages. When it comes to substantial facial filling as in the gaunt face, fat grafting has more advantages as long one is willing to commit to more than an office procedure with some downtime.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I took a look at the computer imaging that you did for me for my jawline. I like what you did to the chin but don’t like the jaw angle result. I saw a case of a guy onlione who had custom made jaw angle implants done and he did not had that square look. Is that possible to be done to me like that as well?

A: Let me explain the purpose of facial computer imaging. Initially it is to create a dialogue or communication as to what the patient wants. No knowing what anyone really wants when they say a stronger jawline, I have to have a starting point for discussion. I made those angles square to see if this is the tyhe of jaw angle look you prefer. They do not reflect any particular implant selection as of yet. Therefore, looking at other jawline examples is helpful only for the standpoint of giving me guidance as to what look someone prefers…it means nothing about the implant style. So custom jaw angle implants are not what you need. Custom facial implants are usually used when the final look is more extreme or when stock off-the-shelf implants can achieve the desired look if they are intraoperatively modified. When going for less than a square or flared jaw angle look, stock jaw angle implants will work just fine…and they are far less expensive.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I weighed around 95 pounds before I had ovarian cancer.  After my cancer treatments, I gained 130 pounds.  I ended up have gastric bypass surgery and now have lose skin that needs to be taken off. Had a tummy tuck in 2001 so, don’t have too much loose skin in the tummy area. I am interested in my butt, arms and legs…can you help me with this?

A: Thank you for your inquiry. I am going to assume that you need a traditional arm lift (brachioplasty) and an extended inner thigh lift, which would be standard for many extreme weight loss patients after gastric bypass surgery. While every patient is different, I will assume these issues as a starting point. Your butt concern is harder to figure as I am uncertain whether an upper buttock lift or a lower buttock tuck tuck needs to be done. I will assume for now that an upper buttock lift (lower back lift) need to be done as this would be most common in the bariatric surgery patient. It is also a way to finish off a circumferential lower body lift as a second stage procedure to your initial tummy tuck done previously.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in the lipodissolve or liposmart for underneath my chin and abdomen area. I have excess skin and fat due to having a child. I am still a thin female, but have insecurity in these areas and feel these procedures would benefit me the most in regards to my weight and issues I am having. Please email me with more info and pricing estimates if possible.

A: The best way to get an accurate price quote is to come in for a consultation so I can see what you really need. or send me some pictures. The under the chin area (submental) fat is going to need to be treated by liposuction (Smartlpo) not lipodissolve for a variety of good reasons, mainly a much better result in a single treatment session.  The abdominal issue is less clear given that I have no idea what it looks like. When you use the words ‘excess skin and fat’, that may imply that liposuction may not be a good treatment approach because of the skin excess. No form of liposuction is going to shrink much loose skin, not even Smartlipo. If you have any stretch marks at all on this loose abdominal skin, there is no chance of shrinkage due to complete loss of elastic fibers/elasticity in the skin. Depending upon how much loose skin there is, this may put you more in need of some form of a tummy tuck.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I have concerns about my nose and I focus on it all the time. I think (know) my nose is too pointy at the tip and people confuse me as if I am Native American. I could see why. What can be done to make my nose less pointy?

A: In looking at your pictures, the pointiness  of your nose is the direct result of the alar cartilages which make up the tip. Your alar cartilages show rim retraction (an acute alar angle backwards) and a narrow dome area. Together this makes your nose tip come to a point. Since the overlying skin just follows the underlying cartilages, this gives you a sharp and pointy nose appearance. This could be improved through a tip rhinoplasty with cartilage grafting. In some cases of a pointy nose, the tip is both narrow and very long. This requires tip cartilage shortening. But your tip is not too long, it is just too narrow. Cartilage grafts would be harvested from your septum and used to augment the alar rims combined with a tip shield and dome spreading grafts. The objective is to change the shape of the dome and lower alar cartilages to make the tip more round and drop the rim of the nostrils down. This should help make a substantial change in the way the tip of your nose looks.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to reshape my chin. My chin doesn’t stick out, it just looks boxed look especially when I started losing weight. Also my ears don’t stick out, I feel they look big as in length for my small head. What do you recommend? I have a front and side picture for you to see.

A: Thank you for sending your excellent pictures. Your square chin can be contoured fairly simply through an intraoral approach where the square corners are removed (chin ostectomy) and the chin made more rounder as a result. The vertical height of your ears is a more challenging issue. It can be seen that what makes your ears long is that the upper half of the ear is big compared to the lower half.  While they can be reduced substantially in height, this necessitates a scar which would run across the outer helix in the upper ear area. I am not so sure this is a good aesthetic trade-off. There is an alternative approach for ear height reduction that is done from behind the ear, which leaves no scar on the outside, but it would only reduce the height of the ear a minor amount. So you can see neither approach is ideal, substantial reduction with a scar or minimal reduction with no scar.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, about 4 years ago upon a surgeons recommendation, I got infraorbital implants. Shortly afterward, I noticed a “bulge” underneath my eyes. I am not sure if the implants need to be removed or if this is a case of my cheeks dropping and my own bones would have produced the same appearance. I believe the implants were placed close to the lower lid. (I have attached  a picture of where they are placed ) I am not sure exactly what they are made out of.  When I went to the web-site, it just said a porous material. I believe that they were placed from inside the mouth.

A: Based on that information, you have Medpor implants placed through the mouth. This means they are actually a combined infraorbital rim/malar type implant. The bulge to which you refer, given that it appeared shortly after surgery, is undoubtably that of the implant and not your natural bone. As the tissues eventually contract and shrink around the implants, their outline and placement become fully evident.

The good question now is what to do with them. The only way to get rid of the bulge is to remove the implants. The interesting question is what will happen to the soft tissues that have been expanded because of them. It may be that is largely a non-issue or it may be that it will cause some soft tissue sagging over the cheek afterwards. It is hard for me to tell the likelihood of either just based on one single photo. However, knowing their location, size (bulge) and that they are a Medpor material (which means they will be harder to remove), that all suggests that there may be some additional cheek sagging afterwards. An alternative approach to removal is to feather the edges of the implant so that a bulge no longer is seen, but keeping the implant volume in place.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Is it possible to place the wing of a chin implant separately from the front part of the implant by cutting it loose? On one side of the jawline my implant wing crosses the bone and sticks out. My jawline is asymmetric and is higher on one side. On the higher side the wing sticks out. My doctor told me the implant wing can’t be placed upward and inserted on line with the jawline because the shape of the implant doesnt allow it. The wings on the implant don’t have the right angle to match my higher jawline. Placing it on line with the jawline would stress the implant and eventually lead to malposition. Is it possible to cut the wing loose from the implant and place it separately from the rest of the implant on line with the jawline?

A: The simple answer to your question is yes. You are referring to a chin implant revision due to a wing malposition. Although the malposition in your case is a direct result of your own anatomy which is not symmetric. During your revision, the wing can be separated from front or main bofy of the implant. But that alone will not make the wing move into the desired position. The implant pocket must be modified as well to accommodate the desired position of the implant wing.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a facelift about six weeks ago. This was a very traumatic experience for me. While my jowls and neck got better, my nasal folds and turned down corners of the mouth did not. They initially looked good while I was still swollen but that has now all gone away. This is very disappointing since this was one of the main reasons I had the operation. I feel like a wasted my money as my jowls and neck were not that bad.

A: This is a common misconception and occurs either as a result of inadequate education during the consultation or a failure to understand what a facelift does best on your part. Because the tissue pull of a facelift occurs from around the ears, it has the least effect on anything far away. The mouth area is the furtherest point from the ears on the face, thus deep nasolabial folds or a downturned corner of the mouth will ultimately remain unchanged. It is just biomechanically impossible to substantially change the center of the face from back in the hairline. This is an issue that has frustrated facelift surgeons for years and many techniques have been tried, few with much success. This is why adjunctive techniques are often done with facelift that address the mouth area directly, like fat injections and a corner of the mouth lift. These can be at the time of a facelift or afterwards as may be desired in your case.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have deep nasolabial folds and a mouth whose corners turn down. I have read about a way to improve them by using your own tissue through grafting. I had a facelift already which got rid of my jowls and helped my neck but didn’t do a thing for the area around my mouth. I don’t want to treat them with injectable fillers because that will only be temporary. Are you familiar with this tissue grafting technique?

A: What you are talking about is an old plastic surgery technique, dermal-fat grafts, that has been applied to a cosmetic problem. A dermal-fat graft is a piece or strip of skin that has a thin layer of fat on its underside. The overlying epithelium or skin layer is removed, leaving just the dermal skin layer with the attached fat. Provided that the graft size is not too big, it survives quite well as the blood vessels of the recipient site attach quickly to the vessel ends in the dermis. This allows a quick return of blood flow to the fat thus enabling it to survive.

For use in the face for nasolabial folds,  it must be taken from the lower buttock crease or any other large scar site and must be at least 6 to 7 cms in length for each nasolabial fold. From inside the nose, a tunnel is made under the nasolabial fold curving down to the corner of the mouth. The dermal-fat graft (dermis side up) is then placed through tunnel and fixed to the corner of the mouth through a small incision from inside the corner. It is then lifted and tightened from inside the nose and the excess graft trimmed and closed. The graft simultaneously augments the nasolabial fold and lifts the corner of the mouth. I have done this procedure numerous times and it does have its merits. But the issue is that it requires a harvest site and the buttock crease is almost always the best choice because of the thicker dermis. The discarded skin from a pretrichial browlift can be used as well. There are also other simpler ways to achieve both of these facial objectives. Fat graft injections combined with a corner of the mouth lift is another approach. But for the right patient who does not mind a buttock scar, the dermal-fat graft approach can be used.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hello, I’m a 19 year old male. I recently cut my hair short and to my surprise, I have a very Neanderthal-esque brow ridge. It doesn’t stick out as far as some people from pictures I’ve seen, just a couple of millimeters probably. I was wondering if there was any alternatives to plastic surgery for this? Can small amounts of pressure be applied to the area over an amount of time to reduce the appearance, or anything similar? Obviously at such a young age I don’t want to resort to plastic surgery, but I dislike the appearance that my brow ridge gives my face. Thanks in advance.

A: The pneumatization or expansion of the frontal sinus cavity creates the prominence of the brow bones. This is not bone growth but bone stretching due to underlying air expansion. This is why the brow bones, the bigger they are, are very thin often only being a few millimeters in thickness. The development of a brow bone prominence or bossing is genetic and can not be modified once established by any external pressure or molding. If it is too aesthetically excessive, it requires surgery for brow bone reduction.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 32 year old and about six months ago an ENT specialist diagnosed me with having a deviated septum. I have not had good sleep in about 15 years, because I have extremely restricted breathing. I do have insurance to cover the surgery but would prefer a plastic surgeon to perform the procedure, so that I may also correct a very large bump on my nose that I have extreme insecurities about. Do you know if your services would be covered by the insurance company? Also, is this a procedure that can be done if I am in my first trimester of pregnancy?

A: Your inquiry has two fundamental misconceptions. First, no elective surgery or procedure is ever performed on any patient who is pregnant. Pregnancy is an absolute exclusion for surgery and anesthesia because unknown and potentially deleterious effects on the developing fetus. Secondly, insurance does not pay for any external change to the nose such as removing a large nasal hump. That is cosmetic surgery and must be paid for as an out of pocket fee. Insurance will usually cover septoplasty and other functional nasal airway surgery but not for any rhinoplasty procedure. The two most certainly, and commonly, are done together but you will have to pay additional surgeon, OR and anesthesia fees for the cosmetic portion.

Dr. Barry Eppley

Indianapolis, Indiana