Your Questions
Your Questions
Q: Dr. Eppley, I’ve been reading on your website and found a lot of interesting information. I was looking at pictures for patients, but did not see any that resemble my condition. Do you have any with flat spots that have been filled out in the back of the head? From what I have gathered while reading your site, you can only build out up to 10 cm. I’m just trying to picture how a fix for my condition would look after. My head is normal except for the back and then it has a slope. However, the slope is not uniform. It’s less of degree on one side vs the other. So from the top down there is a slope in the back, but from left to right it is almost like it is angled. Meaning if you looked at me from the back, the right side is not as sloped as the left. In fact, the right side is a little more “normal” I guess. Thanks for your help and information.
A: The most common skull augmentation procedure that I do is an occipital cranioplasty for a flat spot on the back of the head. You are correct in assuming that the buildup would be about 10 to 12mm maximum. Much greater buildup than this may pose problems with incisional scalpclosure or undue tension on the wound which usually lies directly over it. Bony asymmetries are dealt with by a differential application of the material.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Have you performed many/any superficial temporal artery procedures, either removals or ligations? I am considering this route to rid myself of the unsightly and anoying pulsation feeling. I am concerned about possible negative effects of tampering with an artery, especially one in the head. Thank you for any help or advice you may offer.
A: Improvement of a large and prominent superficial temporal artery can be successfully done. Patients may desire that the artery be diminished in size due to its appearance or from uncomfortable pulsations in it. Manipulation/ligation of the branches of the superficial temporal artery will have no negative effects on vascularization of the scalp and forehead. Thus I have seen no adverse effects from its manipulation other than some minor scars for entrance to the ligations. Generally, at least two small access incisions are needed, one in the temporal hairline and another in the forehead. The artery must be ligated from different areas since there are multiple backflow points into the artery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, my 18 year old son had his ears gauged several years ago to a size of about 2 1/2 inches. I have attached pictures as he is now. I was never for it but what can a parent do. He is now ready to have them fixed. I have Anthem insurance. How much would it cost and do you have payment options?
A: Thank you for sending your son’s picture. I have seen many gauged ears such as your son’s. Such earlobe reconstructions can be done very successfully and a normal sized earlobe, albeit with a fine line scar, canc be achieved as an office procedure done under loca; anesthesia. It would be important that the gauges are removed at least 6 weeks before earlobe reconstruction is done. That will allow the earlobe to shrink somewhat and get a better vascular supply to the remaining rim of earlobe skin for optimal healing after the procedure. These are not procedures covered by insurance since the origin of the problem is a cosmetic alteration not a medical one. The cost range is between $1500 to $2,000 for both earlobe repairs.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in making my forehead wider. I think it is too narrow for my face. My face has good features and dimensions but starting with my lower forehead it goes up into scalp like a triangle rather than having a forehead width that matches my lower facial width. I think it would look better of my forehead was wider and more prominent. Is this procedure possible and, if so, how is it done and what are the potential complications?
A: Widening a forehead as you have described means expanding its bony contours. Traditional forehead augmentation is done through a scalp incision to build out the forehead with onlay cranioplasty materials but it usually lies on the bone within the edges of the anterior temporal lines. Building out or widening a forehead behind the temporal lines is problematic as that requires lifting up part of the temporalis muscle, which will can easily be done, but almost always results in muscle atrophy seen months later. This potentially can expose the edges of the built out area (cranioplasty material) if they are not perfectly smooth and may make a once smooth transition between the two become more noticeable. Some may refer to widening the forehead as augmentation of the temporal hollows, although that would not normally be considered part of the forehead.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley,I have read that you are familiar with using platelet-rich plasma. (PRP) I have an unusual inquiry. In certain countries in Europe, they inject PRP into the nasal lining and sidewalls and turbinates to restore function and regrowth of the lining. I can send the article and I was wondering if you could do this. They say it adds volume and helps the lining function better from prior surgery.
A: I have read many ‘unconventional’ uses for PRP, but must admit that I am unfamiliar with its potential use in the nasal linings. As an autologous material, its use there would certainly be safe with no untoward effects. I could not attest, obviously, to its effectiveness for this use and would be happy to review any article that reports on it. Doing the procedure would be no different than any other PRP procedure using a 60cc blood draw from the patient. Centrifugation of the extract is then done to create an approximate 3cc concentrate of platelets.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’ve lost more than 200 lbs. The extra skin is making it harder every lb I lose for me to get around. How will I know when I need to have surgery to take off the skin?
A: I would say that after losing 200lbs, almost no matter what weight you started out at, that you have a substantial abdominal pannus that would benefit by being removed. If this weight loss was achieved by bariatric surgery, then you should get the advice of your bariatric surgeon as to when would be a good time for some body contouring surgery. Usually bariatric surgery patients have to be at least one year from their bypass surgery and they have stable and normal laboratory studies. If this weight loss was achieved by dieting alone, then you may be ready at any time with this amount of weight loss. You may be getting to the point where not much further weight loss can be achieved because of having to drag around this large amount of loose skin. It would be important before this surgery that you have laboratory studies that show a good blood count, normal electrolytes and adequate protein levels that would support good healing.
I would recommend that you get an evaluation by a board-certified plastic surgeon at this point and be evaluated for your readiness for abdominal plastic surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, even though I am fairly young (35 years old), I have some bags over my cheeks. These are not lower eyelid bags but cheek bags/puffiness. I tried injectable fillers in the tear trough but that just made me look puffy and did not solve my problem. I have heard about using some external devices to help shrink them and tighten the skin. In talking to several doctors and reading, I am looking at the Exilis device for the treatments. But one doctor is saying the Exilis is the first generation radiofrequency device (RF) and they now use this Ultherapy instead. There is also an Apollo device whichi is powered by TriPollar technology which is the 3rd generation of RF, allegedly the most advanced RF technology currently in the market. Many clinical studies published on the TriPollar technology demonstrated that it is very effective for wrinkle reduction, skin tightening and body contouring I don’t understand why or what to do. I have set up some consultations with some docs but I am worried. Can you tell me what I should do?
A: The world of non-surgical fat reduction and skin tightening devices is very confusing. It is filled with much inaccurate and sometimes deceiving information. Between manufacturer promotions of the devices that they make and doctor’s pushing the devices that they own, it is impossible for any patient to weave their way through this maze of voluminoos and often contradictory information.
What I can tell you with great certainty is that there is no single device out there that has been proven to be superior to any other…no matter what you are told or have read. Many devices may have comparative results but none can claim to be more effective at fat reduction or skin tightening than another one. We know this because no comparative studies have ever been done between the devices that exist nor it is likley any will be done.
I mentioned Exilis only because I am familiar with it and use it in my practice so I know its effects. This is what I would try if you were coming to my practice. This does not mean it is the best device available or that there may be others that worko just as well and perhaps even better. Exilis is not a first generation RF device nor is it similar to ultherapy which uses a different enegy to creates its tissue effects.
I think the conclusion is that some effort using any of the available energy-based devices is what you should try. I would not get hung up on which one. Availability and reasonable costs are the parameters to use on what device to try. The point is that if it does not have any effect, it is not likely any other device will be any better.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a significant flat spot on the back of my head. Starts at the area of my crowns and then goes out. It is kind of big in size (12 oz can circumference). It is really a flat spot/slope down. Is there a procedure for fixing this or can material be injected to build up the low area? What options are available to help make an area like this look normal? Thanks in advance for your help.
A: There is only one basic option for your concern, a procedure known as an occipital cranioplasty. That is a sophisticated medical term meaning to build up the deficient or flat bone area. This is done with a variety of potential cranioplasty materials including PMMA, hydroxyapatite and even custom silicone implants. These materials need to be placed through an 8 to 10cm posterior scalp incision. This is a fairly straightforward procedure that is done as an outpatient surgery. Since the buildup is on the outside of the skull, there are no major medical risks in having it done.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like a straighter more refined nose and a stronger jawline. This may require a chin augmentation but I am not sure what I really need. I just want to look more refreshed and have a more attractive face. I have attached some pictures for you to see and give me your recommendations.
A: Thank you for your inquiry and sending your pictures. I have taken a look at them and can give you the following thoughts.
Your chin deficiency is as much a vertical one as it is a horizontal one. This can not be treated by a traditional chin implant as they can only provide increased horizontal projection. Vertical increase is very important in your chin augmentation. Either a custom chin implant needs to be fabricated or a chin osteotomy needs to be done. Either approach can be successful and I have done many both ways. There are advantages and disadvantages to either approach and they can be discussed in detail further by phone or by Skype.
Your nose shows a lack of tip projection and definition. The nasal tip is rounded and more ball-like. I do not see the lack of straightness in your nose that you have indicated in your inquiry. This can be improved by an open rhinoplasty with the use of a columellar strut graft alar rim grafts and tip reshaping.
I have attached some before and after computer imaging to show the potential changes of the nose and chin based on these approaches.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had orthognathic surgery three years ago when my upper jaw was moved forward. While the surgery was successful and my underbite was fixed, I have a persistent problem with my lower lip. My lower lip hangs down and I have too much tooth show. I notice now that when I pull my lower jaw back, the lower lip comes up and corrects the problem. I am now thinking that instead of having my upper jaw brought forward, I should have had my lower jaw moved back. What do you think?
A: It is hard for me to pass any comment on your previous orthognathic surgery, not having seen any preoperative x-rays or work-up. It can be difficult to determine in a Class III malocclusion (cross-bite) whether the upper jaw should come forward or the lower jaw to go back. Either manuever will correct the malocclusion but they can have different aesthetic outcomes, even if that can be somewhat subtle.
Everyone when they move their jaw backward creates more lower lip and allows it to move upward on the front teeth. So I don’t necessarily think that you doing so proves that a sagittal split setback of the mandible was a better procedure than the LeFort advancement.
At this point, this discussion is somewhat irrelevant. You can’t undo your jaw relationship without repeating your orthodontics and undergoing further orthognathic surgery…a process that would take years and likely result in some permanent loss of sensation of the lower lip from the mandibular setback.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, First of all I would like to appreciate your approach to educate general people like me about plastic, reconstructive and cosmetic procedures. I have a question regarding my scar revision. I have done scar revision yesterday. The revision was done to revise a pox scar on the lower middle forehead about 1 cm up of the starting of nose bridge. The scar was 5mm in wide and 6mm in length. Right now I am very much concerned about the post scar it will leave. I am hoping for a linear scar rather than the circular one. I would really appreciate your feedback regarding this.
A: Not having any knowledge of how your scar revision was performed, this is a question you should ask the doctor who performed it. By your description, I would assume that a simple horizontally-oriented elliptical excision of the forehead pox mark would be done with a resultant linear scar trade-off. This circular scar result is a bit confusing to me unless some form of subcision was done in an effort to raise up a depressed scar rather than excising it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Can silicone implants be replaced and the procedure partially paid for by your insurance company if they are entirely encapsulated?
A: No physician can tell you for sure whether your health insurance company will cover any plastic surgery procedure. There is a process known as predetermination which makes that decision about any elective non-urgent procedure. This requires a written letter by the plastic surgeon to the insurance company with the medical issues, diagnosis and proposed surgery outlined. The insurance company will then review it and make its determination to you, a process that will take at least several weeks.
That being said, a general rule is that insurance will not pay for any implant-related plastic surgery procedures in which the implant was not initially placed for a medically necessary reason. This refers to breast reconstruction procedures with an implant done to restore a breast partially or fully removed after cancer. It is unlikely that capsular contracture in breast implants placed for cosmetic reasons, unless there is evidence of an implant rupture, would be covered.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley,I am female, 35, interested in brow bone shaving. My brow bone is a bit too thick, and I feel it looks a bit masculine. Is there any risks to shaving the bone in the glabella area? Would this make the bone there too thin and easier to fracture in the event of an injury? I don’t need too much shaved, but wondering if even a bit of shaving is risky. Thank you.
A: The issue with brow bone shaving is not one of real medical risk. The only issues with brow bone reduction are two-fold. First, you need a scalp incision and turn down flap to do it. So there will be a resultant fine line scar in the scalp. Secondly, and more relevant to your question, shaving the brow bone has the risk of burring right into the frontal sinus cavity. Most of the brow prominence is not composed by bone at all, but by air from the sinus cavity undermeath. How significantly one can burr down the brow bone depends on how thick the outer cortical table of the frontal sinus is. Often times it is no thicker than 2 to 3mms. The glabellar area, the part of the brow bone between the eyebrows, often will have no frontal sinus cavity underneath so it may be able to be reduced much more.
For these reasons, it is necessary to determine a patient’s eligibility for brow bone reduction knowing in advance the location of the frontal sinuses and measuring the thickness of the bone. This can be done with simple plain x-rays taken from the front and side views. For some patients, brow bone reduction by burring is adequate (minority of patients), but other patients need to have done an osteoplastic bone flap technique due to their thin outer bone covering of the sinus.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, my question is about face fillers. I had some permanent filler injections done on my cheeks 4 years ago. I am now developing hypersensitivity, not at the site of the filler, but over the sinus and neck muscles and headaches. Plus my eyebrows are thinning .The surgeon told me the filler used is BIOALCAMID .What is your opinion on can the filler be removed?
A: Bio-AlCamid is a gel polymer filler that is composed of a 3% to 4% concentration of alky-amide polymer and 96% water. It is used around the world but is not approved in the U.S. It maintains it volume through the attraction of water to the non-resorbable polymer which is then surrounded by a scar capsule. The manufacturer says that it can be removed relatively easily and this may be true if it is well encapsulated and can be palpated. Once the capsule is entered, the material will likely be expressible. The other key question is what to do after the material is removed as there may likely be a deflation effect seen on the outside of the face. While one could use any of the available temporary hyaluronic injectable fillers, I would strongly think about fat injection replacement. Otherwise, I see no direct correlation between it and your hypersensitivity symptoms.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have read and would like to have rhinoplasty done with you if its possible. However I don’t have a visa to come to Indiana. I don’t know if it’s possible but I am just inquiring, is it possible for me to travel to indiana without a visa if I have a doctor’s letter from you? And that letter can be posted to me in my home country? Thanks.
A: I could not answer your question about traveling to the U.S. without a visa. That is a question for your country’s immigration department and U.S. foreign visitor policy. We do not provide medical letters of necessity for cosmetic surgery procedures, such as rhinoplasty, to any international inquires or consultations. One has to work through the proper visitor/immigration procedures for their country and abide by the regulations for U.S. foreign visitors.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am looking to improve the appearance of my lips, acne scars, and face contouring. I have very large lips and the upper lip is very full and bigger than the lower one, it gives me a duck lip appearance. The upper lip rests above the lower lip instead if the other way around. What would be the best thing to do about that? I have also attempted to loose weight to slim the face yet there is much fat around the lip area and the cheek bone area which does not go well with the full cheeks. I am attempting to achieve a slim-defined male model type of face as well as diminish the appearance of my acne marks. Somehow my facial features don’t mix well with one another. I believe my face is feminine in a way, is there a way to give it a more masculine look?
A: While many people want to achieve an upper lip size that matches the lower one, you have an opposite concern. The upper lip can be reduced by an internal vermilion reduction to reduce its size and roll back the pout of the upper lip. That leaves any scar on the inside of the upper lip.
From a face standpoint, I don’t see large buccal fat pads to remove but I could see some benefit by perioral liposuction to reduce the perioral mounds out to the side of the lips. While you did not provide a side profile view, chin augmentation with more width and horizontal projection may be more masculinizing for you. But I would need to see some additional photos to be sure that is of benefit.
Acne scars can be improved by fractional laser resurfacing but it is important first to have the acne eruptions under control. With laser resurfacing the ointments needed afterwards as it heals can cause a lot of pore obstruction and an onset of new eruptions.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting breast augmentation and the new gummy bear breasts implants have me intrigued. They seem like they would be so much better than a bag of water or a bag of liquid silcone gel. Can you give me some more information about them? What happens to the material if they rupture? Do they feel soft and natural? How long do they last?
A: The use of the term ‘gummy bear’ breast implant is an urban term, not a medical one or one used by any manufacturer of them. That is a term given to them many years ago by a plastic surgeon because of how the material feels and behaves. This is a more cohesive high-strength silicone gel that does act somewhat similar to the also named candy, although I think they do feel a little softer than the candy. If you cut the implant in half and squeeze on it, it does behave like the candy. The material stays together, does not run, and only puffs out when the implant sides are completely squeezed together. I have attached a video to this answer so you can see better how they behave once cut. This would represent the most extreme form of an implant ‘rupture’ so there are no concerns about the material migrating elsewhere in the body. Since the material does not leave the shell or containment bag if it should develop a hole or tear, the outward appearance of the breast will not change. (deflate or become deformed) The lifespan of the new gummy bear implants is not known although it would be fair to say that they are going to last longer than saline implants or any older generation silicone gel breast implant. This is without a doubt the best breast implant that I have ever seen and is the most common one I use for my breast augmentation patients.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have been thinking about getting a breast procedure since I was 13. I have 34DD and I’m 5’1 ½. I’m very self conscious about them but my boyfriend thinks they are fine but I do not. They are too big and saggy (gross) I just hate them! If I got a breast reduction how much smaller would my breast’s be and would you recommend having implants put in?
A: Breast reduction surgery not only reduces the size of one’s breast but also incorporates a lift of the breasts as well. There would be no reason to place implants during a breast reduction, that would partially defeat the purpose of the procedure. The amount of breast reduction that can be achieved in the procedure is different for each patient. There is great variability in how much breast tissue would be removed and takes into account how much or little breast tissue one wants to remove. One could easily go from a saggy DD breasts to an uplifted and more perky full C cup. It is important to remember that the trade-off for that amount of breast shape improvement are permanent scars. You are trading off one breast problem for another, just be sure the scar issue is less of a concern than the way your breasts look now.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I want to do something about my breast shape but am confused as to what to do. I have a little sag to them after two pregnancies and would love for them to be a little fuller and up higher. So I think that is why I need a breast lift but I really don’t want any scars on my breasts if I don’t have to. On the other hand, I am not opposed to breast implants if it will lift up the breasts and avoid any obvious scars on them. I have attached some pictures of my breasts for you to see. What is your recommendation?
A: Your breast dilemma is a common one in that you are what I call a ‘tweener’. You have some sagging so breast implants will add volume but the breast position will likely stay low. A larger than desired breast implant may be needed to get the lifting effect you are after. A breast lift alone will changhe the position of the nipple and the breast mound but often the breasts may look smaller afterwards despite the better shape. A lift with an implant will allow you to have a smaller implant and slightly higher positioned breasts but that comes with the trade-off of scars.
Either way you have to accept some disadvantages with either approach and different plastic surgeons will have different preferences for either approach. You must think it through and decide which of the trade-offs is the better choice for you.
In ‘tweener’ patients like you, I wil often choose the middle of the road choice…breast implants with a superior or crescent nipple lift. This provides a slight upward nipple repositoning with minimal scars (no scars on the breast mound) while relying on the implant to add volume and provide a bit of an upward push.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, about three months ago my plastic surgeon cut out a chunk of skin out from the center of my forehead that had pock-like scarring and sutured it together. He told me that once the line heals, it would barely be noticeable and flow in into the creases of my forehead. He did a v-shaped straight line which looks anything at this point but a natural horizontal forehead crease. Is it normal right now for the closure line to appear indented and red and would you recommend Fraxel lasers and silicon strips at this point in time. Is all that i’m seeing pretty normal or did this doctor jack up my face?
A: I do not know what you looked like before and was not involved in how the decision for that approach was decided. I can make no educated comment on the decision for that particular approach to your problem. This is not an approach that I have ever used for pock scarring issues in the forehead. Most certainly if I would have done that large forehead excision I would not have made it v-shaped. There is nothing natural about that scar orientation in the forehead. What I can say is that for three months out in thick pigmented skin, the scar is what I would antiipate…very red and noticeable. It is going to take considerable time for any amount of fading that may occur. Given the way it was done, your scar appearance does not surprise me at this point. I do envision the eventual need for some additional work, whether it is scar revision or fractional laser resurfacing remains to be seen with more time.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am 30 years old and have had one child. Last year, I had liposuction to get rid of some ugly fat deposits on my stomach and thighs. It turned out very well and I am overall very pleased with the contour reduction of the treated areas. But I have noticed a little loose skin on my stmach and there are a few small uneven areas. My skin doesn’t look quite as tight as it did before the procedure. Is this normal? Is there anything that can be done to help tighten and smooth out the skin any further?
A: It is very common after liposuction to have less than perfectly smooth skin. That is often the trade-off for the volume reduction. Simply put, when you have less fat you need a little less skin. That accounts for what you perceive as skin that is just not as tight as before. This particularly occurs in the abdominal region in women who have lost a little skin elasticity after pregnancy. There certainly is no harm in trying any of the numerous skin tightening devices that are available, such as Exilis. The only question will be how effective it may be.
In addition, liposuction is about fat removal but it is a blind procedure. There is no way for the treating doctor to see what they are removing and how even that removal is underneath the skin. This is the art form of liposuction and it takes a lot of experience and attention to detail to get the smoothest result possible. Eventually the healing will reveal how close to even that fat removal was.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in complete removal of the fatty tissue located in my chest area. I don’t know why I have developed actual breasts but it is very embarrassing. I am a 32 year-old male and I have to wear loose fitting shirts to hide my jiggling breast mounds. I am not really much overweight, no more so than some of the pro golfers that I have seen. I wanted to know the average recovery time. Also how long does the procedure usually last as well.
A: Thank you for your inquiry. Gynecomastia deformities the size of yours, where there exists a real breast mound, is a difficult challenge to get the flattest result with the least amount of scarring. It may likely require a two-stage approach. The first stage would be a circumareolar approach with nipple lift/reduction with open excision of underlying gland tissue and surrounding contouring liposuction. Depending upon how it looks and heals, this may be all that is needed. But I like to prepare patients for the high probability of the need for a revision based on how the circumareolar scar heals and contour of the chest looks. This would be known as the second stage if needed. (areolar scar revision, touch-up liposuction) It is difficult, although not impossible, to get a good symmetrical chest result with good-looking scars in one procedure.
This type of gynecomastia reduction procedure is done under general anesthesia as an outpatient. Drains would be needed for up to 5 days after surgery. Recovery time would depend on what type of work/activities you do. For a more physical job, it would be two to three weeks before one should actively stress the chest area. This restriction is done primarily to affect fluid build-up after the removal of the drains. The results of gynecomastia are fairly long-lasting and in many cases would be considered permanent…provided one does not gain a lot of weight.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I found your website while looking for other penises like my husbands. He is an overweight man of 37 and his penis is slightly hidden. referring to this article– http://exploreplasticsurgery.com/category/buried-penis/ I found you can do surgery to help his “show size”. He basically looks like the pictures within this article. He would not let me take pictures of his body. I hope you can still give me a price idea. Thanks!
A: Thank you for your inquiry. Without seeing some pictures of the problem, I can not even tell if it is improveable. As a plastic surgeon, what I can do for buried penises is to decrease the size of the surrounding suprapubic mound through liposuction or lift away overhanging skin that is contributing to penile concealment. Often times both have to be done to get the best result. But many concealed or hidden penises also have penile contraction due to tissue fibrosis which requires the use of an experienced Urologist to diagnose and treat. In this cases, a combination Urologic-Plastic Surgery approach is needed.
But as a general guideline, I will have my assistant contact you to give you a cost for the combined procedure of a suprapubic lift with mound liposuction, which was what was discussed in that article.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 38 year-old female that has chubby cheeks. They make me look ten years older than I am and I just hate them. I have been to several plastic surgeons and they have uniformly said there is nothing to do about them. I have tried injectable fillers around them but that just makes me look puffy and is not an improvement. What do you recommend? I have attached pictures so you can see what they look like in different lighting.
A: Thank you for sending your pictures. I can clearly see your concerns of the ‘fatty or chubby cheeks’. The first question is always what is the diagnosis. Why do your cheeks look chubby? Is it because they are chubby or is what is around has become indented or atrophic? I am going to assume that they did not look like this originally ten or fifteen years ago. Many people with aging will develop malar festoons. These occur because the cheek pad falls off of the bone (ptosis) and in much later years can even become chronically swollen. While your cheek problem initially may appear as festoons, on close examination of the pictures they are not. Your cheek tissues are up high on the bone as would be commensurate with your still young age. It is easy to see that you have little aging around the eyelid area. In short, I do not feel that your chubby cheeks are from soft tissue laxity or ptosis. You clearly have tear troughs and a descending infraorbital groove which goes below the cheek area. This is what I think makes your cheeks look chubby, it is what is around them either from the early signs of aging or genetic predisposition that makes them look fat.
In theory, the correct treatment would not be cheek reduction but augmentation of the tear troughs and infraorbital groove. Having had this done through injectable fillers with an unsatisfactory result, this appears to not be a good option for you. It may be that the injectable fillers were not placed correctly or overdone, but I will assume for now they were and the look from that approach was not an improvement.
This raises the next question of what can be done with the cheek pad tissue. Simple ‘removal’ is not a realistic treatment as you can not liposuction the cheek pads or perform direct excision. Even if that was technically possible, it would leave the cheek skin deflated, possibly wrinkled, and thus create an alternative problem that would not be viewed as an improvement. Treatment possibilities include some higher malar suspension through a transcutaneous lower eyelid incision, possibly combined with a small cheek implant that would augment the lower cheek groove. Even though you don’t have true malar ptosis, lifting and repositioning this cheek tissue slightly higher would help to efface the lower malar groove. One way you can get a feel if this approach might be effective is to push up on the skin by the corner of the eye and see what happens to the appearance of the chubby cheeks.
Another option to consider before surgery is non-invasive skin tightening and fat shrinking devices. There are numerous device options out there. My current favorite is that of Exilis. It is a radiofrequency device that has the ability to perform some small amounts of fat reduction and skin tightening. It always takes a series of treatments, usually four, to get the final result. But I would be very interested in seeing you have this done before any surgical efforts are made. Whether it would solve your cheek issues is unknown, but it would be more reassuring that you tried every less invasive option before you came to the conclusion that surgery was warranted.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Can stem cells be used for buttock augmentation practically? I mean can we use stem cells to culture enough volume to be used in buttock augmentation ? I am trying to avoid fat harvest .
A: Fat injections have a certain percentage of stem cells in them so they are used routinuely in the procedure. But stem cells can not be used alone. The sheer quantity of stem cells that would be needed in volume is beyond what can be practically done if used alone. But it would be possible, and maybe even ideal, if cutured stem cells were added in increased numbers to what naturally occurs in fat to get improved volume take and preservation.
On a practical basis, however, stem cells can not be used for buttock augmentation for numerous reasons. It would take 200cc to 300cc of stem cell volume per buttock to be able to do it. This can be done by numerous companies but at around $1500 to $2000 per 3cc to 5cc aliquot, it would be prohibitively expensive. In addition, the FDA has recently clamped down on stem cells being harvested, grown and then returned even to the same patient. So it is now not even allowed by federal regulations.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am wondering if getting Botox injected into the masseter muscles will cause a slack in the skin on the cheek/loose skin/jowls. I’d like to try the Botox in that location but am hesitant because I already have some pre-nasolabial folds developing. I am 27 years old. Thank you for your time!
A: The simple answer is no. The masseter muscles have no impact on the tone or position of the overlying soft tissues. They are rigidly fixed to the mandible, pterygoid plates of the maxilla and the zygoma and never get lax with Botox injections. They may get smaller with some muscle atrophy but will never lose their fixation points or become like a loose rubber band. Any looseness or descent of the overlying soft tissues with time and gravity is due to laxity developing in the osseo-muscular and osteocutaneous ligaments, not the masster muscle proper. Therefore, getting Botox injections into the masseter should not pose any concern in that regard.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Approximately 15 years ago, I fell over and knocked my front two teeth out. Today, I suffer from cross-bite and a deviated chin during occlusion. It is quite apparent to me that my jaw has been shunted ever so slightly to one side posteriorly, and slightly superiorly also, this is the side to which my chin deviates. I believe that I could have had a unilateral condylar fracture which has subsequently healed in a dislocated position. Could you advise me as to what diagnostic modality could be used to evaluate a historical condylar fracture, or what factors may suggest a condylar fracture that has thus gone undetected. What methods can be used to correct this issue? Many thanks.
A: The best way to diagnose condylar position is a 3-D CT scan of the face. That will clearly show you the position of the condyles and the entire shape of the lower jaw. At this point you want to only correct the asymmetry through a chin osteotomy and midline realignment. The condylar position, regardless of where it is, is beyond changing at this point as lpng as one has a functional and good interdigitating occlusion.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have had 3 C-sections, bowel obstruction surgery, hernia surgery and hysterectomy. I was wondering if getting a tummy tuck would be possible for me and would this be a feasible avenue to take? Also, would I be a viable candidate for the insurance to cover this procedure? Thanks for your assistance.
A: Thank you for your inquiry. It would be impossible for me to say whether you are a good candidate for a tummy tuck based on your complex abdominal surgical history alone. I have seen many patients with similar histories and they all were perfectly good candidates for tummy tuck surgery. So based on your information alone, I would assume until proven otherwise by actually seeing you that you would be a reasonable candidate. One of the very good benefits of a tummy tuck in patients with complex abdominal surgeries is that many of the abdominal scars as well as the loose skin and fat can be removed and traded off into one single horizontal scar placed low on the abdomen. Often, one gets a simultaneous pubic lift as well. Insurance does not cover nor do we attempt to process it for elective cosmetic tummy tucks. While you have a complex abdominal history and likely numerous contour deformities from them, these are still cosmetic and not functional issues.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a dorsal hump on my nose. I had a consult with another doctor who mentioned using fillers or if electing surgery breaking my nose. I do have breathing problems in my nasal area which we discussed also. But, I am concerned about dramatically breaking my nose. I am African American. I do not want a slender Jackson Family nose. I want to look like myself, just better 🙂
A: While the African-American nose typically has a low and wide nasal bridge, it can still have a dorsal hump. Or in the low nasal bridge a pseudo dorsal hump, a dorsal hump that appears to be there because of a low nasofrontal junction or radix area. There are two approaches to your dorsal hump removal , augmentation or reduction, which has already been discussed with you. Augmentation may be a better approach for you since you already have a breathing problem and you fear too slender of a nose. The only role that fillers would play in my hands for your nose is to determine whether augmentation above the hump produces the desired effect. This is a good simple and reversible test using the non-surgical rhinoplasty concept. If filling above the hump produces a good look, then you can proceed with a rhinoplasty doing dorsal augmentation using either a cartilage graft or an implant. Each has their own advantages and disadvantages which needs to be discussed in detail.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have had frontal headaches for about 10 years. I don’ t like getting toxins, but a low dose Botox injection cut my usual debilitating headache from a 9/10 to about a 5 for seven weeks and then about a month later last week, I am back to a 9/10 again. Can you do a surgical procedure to get me more permanent relief? If so, do you think insurance will cover it?
A: You may have had more significant migraine relief if the dose of Botox was higher than just ‘low dose’. The wearing off of the Botox effects after three months or so is a fairly standard period of time for the duration of its effects. If Botox is effective in the supraorbital area for migraine reduction, then surgical decompression of the supraorbital and supratrochlear nerves should provide similar (and hopefully greater) and more sustained relief than the injections. The general quoted numbers is 70% of patients will get a noticeable and sustained reduction in the frequency and severity of their headaches with surgical nerve decompression. The remaining 30% is a mixture between ‘cures’ and those with limited to no benefit.
Insurance is very unequivocal about not covering migraine decompression surgery. They have a hardline stance that it is still ‘experimental’ at this time.
Dr. Barry Eppley
Indianapolis, Indiana