A: On a volume ratio basis, the difference between a 450cc and 500cc implant is not that significant, around a 10% size difference. A sized difference in implants that is barely visible. Since you appear to have no fears about being too big, I would definitely go with the slightly larger 500cc implant. While there are no health risks with larger silicone breast implants, there is always the consideration however of loss of tissue support over time. When a breast implant becomes too big for the tissues that must envelop and support it, there is the risk of bottoming out or dropping of the implant position. Whether this is a potential issue with you can not be determined based on this discussion alone. The key determinant of that is whether the base diameter of the implant stays within your own natural breast base diameter. That is a simple measurement that can quickly be done in an examination. The use of HP or high profile implants is helpful in keeping a good implant-breast base compatibility.

Dr. Barry Eppley

Indianapolis, Indiana

A: Inverted nipple correction has a high rate of recurrent contracture/inversion after release. Your experience is not completely rare. Many methods have been described in plastic surgery for the correction of inverted nipples which speaks to the fact that it is both a difficult problem and that none of them work that well. Once the nipple has been released and brought out by suture traction during surgery, there remains a dead space or tissue deficiency underneath. I have found that filling this in with either a dermal-fat grafts or allogeneic dermis is the best way to prevent recurrent inversion. The fill must be immediately underneath the released nipple. The push from a much deeper breast implants will not work.

Dr. Barry Eppley

Indianapolis, Indiana

A: By your description, I could not imagine a more ideal candidate for Exilis fat reduction treatments. This is a spot reduction problem and undoubtably is not a large area. In addition, with your high level of physical activity you will helping the treatments work better by enhanced fat breakdown. One of the really nice things about Exilis is that there is no recovery or restrictions after any of the treatments. Each treatment is about 30 to 40 minutes so you can just get and go right afterwards. It usually takes 4 to 6 treatment sessions to get the best result and we like to space them, if possible, no more than a week apart.

Dr. Barry Eppley

Indianapolis, Indiana

A: Thank you for sending your pictures. What you have is a a very specific type of aesthetic nasal deformity in which the lower alar cartilages are very thick and strong. They overproject beyond the tip of the nose making it very broad and fleshy. With that comes broad widely-spaced nostrils. Since the tip is so broad, the area above it (known as the middle vault) looks collapsed and sunken in on profile. This then makes the upper part of the nose where the bones are also appear wide. This can be treated by an open rhinoplasty procedure that narrows the nasal tip cartilages, narrows the width of the nostrils at their base, builds up the middle vault and narrows the upper nose by osteotomies. Together this will help change your nose to one that is less broad and more refined looking. This is a 2 hour rhinoplasty procedure done as an outpatient under general anesthesia. All costs combined place the price of such surgery between $ 6,000 to $ 7,000.

Dr. Barry Eppley

Indianapolis, Indiana

A:  It is very common that many of the stretch marks and loose skin that results from pregnancies is around the belly button. This is because this is the region of the stomach that undergoes the greatest amount of skin expansion. After delivery, wrinkling and belly button deformities are common. While the type of ‘high’ tummy tuck that you are describing can certainly be done, I would advise against it. Regardless of how flat and tight the abdominal skin would be, having a horizontal scar across the center of your stomach without a bellybutton would create a secondary cosmetic deformity of its own that would not be very natural looking. You would be better served by having a mini tummy tuck with an umbilical float technique. This would create a very low horizontal scar just about the pubic hairline and keep a belly button that is positioned lower with less wrinkled skin around it. While this may not create the supertight abdominal skin that you desire, you would have substantial improvement but having a more natural look.

Dr.  Barry Eppley

Indianapolis, Indiana

A: Let me clarify some misconceptions that you have about various ‘lipo’ procedures. Lipodissolve injections are only useful for very small fat collections, no more than the size of one’s hand. I suspect your lower abdominal issue is bigger than that in size. Laser liposuction (aka Smartlipo) is simply an advanced form of liposuction and is just as invasive, it is not a minimally invasive procedure. In short, there is no non-surgical way to get rid of your abdominal fat concerns that would be as effective as liposuction. You could try Exilis radiofrequency treatments which does have some fat reduction effects.

In reality, there would be no better time than doing abdominal liposuction with your breast reduction and this is a common combination of cosmetic procedures. Otherwise you will have to have liposuction done separately where the out of pocket expenses will be higher.

Dr.  Barry Eppley

Indianapolis, Indiana

A:  It is important to recognize that there will be a scalp scar in any open cranioplasty procedure. That does not mean, however,  that it is necessarily a bad scar that is wide and highly visible. It almost never is. But in men, whose hair pattern is less than stable over their lifetime in over 50% of the male population, it is important to consider this aesthetic trade-off. It is obviously a lot more relevant issue in men who are bald or shave their head. You do not so this is one favorable factor for you. I harp on this issue so every patient gives it careful consideration. The incision/scar usually runs from about one inch above the ear across the top of the head. It is hard to get good pictures of the scalp scars to show since most patient’s hair obscures it.

Dr.  Barry Eppley

Indianapolis, Indiana

A: Thank you for your inquiry and sending the photo attachments. What you are talking about is a cranial reduction/forehead reshaping which would be done by a burring removal technique. The important question is whether it can be reduced enough to achieve the result you are looking for. That is best answered by knowing how think the outer table of the cranial bone is. That can be evaluated by simple plain x-rays of the skull (AP and lateral views). From these films the amount of bone that can physically be removed (outer table) can be measured. There is no question some reduction be done, I (and you) would want to know the best we can beforehand if it is enough to justify undergoing surgery for it.

Dr. Barry Eppley

Indianapolis, Indiana

A: In my opinion, the sliding genioplasty is and has always been your best solution. It solves all your chin issues at the same time. I would not concern about titanium being implant and in your body for the rest of your life. Titanium is the most biocompatible metal that is known in medicine and will be completely overgrown with bone anyway. I have never had to remove titanium plates and screws from a chin nor have I ever seen it to be a problem. This is the best place for such metal materials in the face because it is has a thick bone and soft tissue cover and is not exposed to the stresses of mastication. While there is always the risk of some feeling loss from chin osteotomies, my experience is that it is very low. The key is to do the osteotomy at least 5mms below the mental foramen if not lower to avoid any risk of permanent loss of sensation to the lip and chin.

Dr. Barry Eppley

Indianapolis, Indiana

A: Low impact trauma is an unusual cause of shell failure in breast implants but it is possible. If you have noticed a breast size change after such an event, then you should return to your plastic surgeon and have it evaluated. Generally a saline implant failure is easy to detect because breast size will change. Loss of saline volume is the only reason one would have a delayed change in breast size. All breast implants from either manufacturer, either Allergan or Mentor, have lifelong replacement warranties should they need to be replaced due to shell failure. Since you are within 10 years from your original surgery, you will get a new pair of breast implants at no charge and up to $3500 towards the cost of surgery to replace them. So while the bad news is that your breast implant may have failed, you will not suffer a economic hardship to have them replaced.

Dr. Barry Eppley

Indianapolis, Indiana

A: What you appear to have is a skull indentation cosmetic deformity in the upper part of the back of your head. This may be where the original posterior fontanelle (not anterior) was. Regardless of why it is there, it is likely a simple contour defect over solid skull bone. This can be treated fairly simply with a variety of onlay cranioplasty materials. Some are placed through small scalp incisions and one of them can even be placed  through a minimal incision injectable approach. These procedures are usually performed by either plastic surgeons with craniofacial training or neurosurgeons. When skull defects are purely cosmetic in nature and have no neurologic basis, it would be treated by a plastic surgeon.

Dr. Barry Eppley

Indianapolis, Indiana

A: It is extremely common for the outer appearance of the nose to be changed at the same time that the internal breathing function (septoplasty and turbinates) is being improved. While plastic surgeons may suggest these changes in the patient who just appears for breathing problems, such recommendations are often welcomed very enthusiastically. The convenience of having both nose issues addressed simultaneously is obviously appealing…provided that one does have some real concerns about their nose appearance and they are very clear on what is going to be done. It appears you now have some early ‘buyer’s remorse’. This could be premature regret since it has only been a few months from surgery and swelling is most certainly present. It may also be that you did not have a clear understanding of what the objectives of the rhinoplasty were. This could have been avoided by computer imaging analysis before surgery. While you may have a rhinoplasty revision to try and reverse some of these changes,it is too early to consider that now. You should give your nose up to a full year after surgery for all swelling to go away and you to adapt to the new look. It could very be how you feel now may change at this time next year.

Dr. Barry Eppley

Indianapolis, Indiana

A:  This is the type of surgery that has to be paid for up front, like all of cosmetic surgery. Many patients opt for financing their surgery through such companies as Care Credit to name the most well known. The typical cost of forehead reduction through hairline advancement is in the range of $5500 to $ 6500.

Dr.  Barry Eppley

Indianapolis, Indiana

A: You have very astutely pointed out one of the most overlooked deficiences in breast lifts for some women. The fullness that it creates in the upper pole of the breast will likely only be temporary and often an implant is needed as well. When using implants in a breast lift, there are two general size considerations. A smaller implant can be used in which the goal is persistent upper pole fullness but not a significant change in breast size. A larger implant is used for both upper pole fullness and an overall breast size change. That is a decision that requires patient input. Whether the to go with a  saline  or silicone implant is matter of personal choice, the most significant factor is a cost difference (saline less costly) and the risk of eventual implant deflation (saline) versus silent implant rupture. (silicone)

A:  Your abdominal situation with your weight loss after bariatric surgery is a common one. The weight loss has been great but the abdominal overhang (pannus) is now a ‘new’ problem. Your description of symptoms is classic and I would have no doubt that a tummy tuck would be of great benefit. Your biggest challenge is getting a tummy tuck is an economic one. By being on disability I would assume that your health insurance is through Medicare or Medicaid. This would require you finding a plastic surgeon who participates in those programs which I do not. Even with private health insurance, there are fewer and fewer plastic surgeons today who will perform this surgery through insurance anymore. In addition, there is also the issue of whether you would qualify for an abdominal panniculectomy/tummy tuck which is an insurance determination not a plastic surgery one.

Dr.  Barry Eppley

Indianapolis, Indiana