Your Questions

Q: Dr. Eppley, do you do mole removals on the face? I have several raised moles on my face that I would like to see about removing. Is the cost for it per mole?  I have one about the size of a pencil eraser and the others are smaller. Do you have before and after pictures of facial mole removal procedures? I’m worried about the scarring and not sure if it is worth it. 

A: Every plastic surgeon does facial mole removal which is done in the office under local anesthesia in most cases. Your facial picture which makes it very clear as to your facial mole issues and their large number. I could easily identify three facial moles (right face, right nose and right upper lip) and probably six that would benefit by removal. While every faoial mole removal does leave a very fine scar in its wake, this would seem to be of less significance than what they are replacing based on your picture and the sized and location of the moles. In general a small flat scar is usually better than a raised darkly pigmented mole which often can have hair growth associated with it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had an otoplasty on my right ear, but unfortunately it was overdone and is causing a lot of problems. The surgeon removed a lot of cartilage and skin from my ear causing my ear to be set back a lot and completely attached to my head in some areas. This has affected my life greatly and now I am looking for a very experienced surgeon who can reverse this. I don’t have any stitches holding my ear to my head, so the only fix I believe is doing cartilage and skin grafts to separate my ear from my head and spring it back to match with the other one. Is this something you can do? And what is your experience with such reconstruction surgeries? I really appreciate you help.

A: Most otoplasty reversals require a method to spring the cartilage back out which can be done with a rib cartilage graft or a special metal spring that I use. If there is a true skin deficiency a skin graft will be initially needed prior to any effort at cartilage reshaping. However is some cases I have done a simultaneous fascial rotation flap after the ear is released and then skin graft on top of that at the same time as a cartilage graft. I would need to see pictures of your ear to see exactly what needs to be done. It may also be that a skin graft alone may suffice.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a very wide face and protruding cheek bones and it’s always been an insecurity of mine. I’ve also always has chubby lower cheeks.when I smile my cheeks tend to protrude a lot which makes my profile look very awkward. I really want to have a slimmer more masculine face/jawline. I’ve also been considering a lip lift to shorten the gap between my upper lip and nose, and a nose job for a slimmer less bulbous nose. What surgeries are right for me? And what combination of surgeries are safe to perform simultaneously?

A: When it comes to fullness of the lower cheeks, which are below the cheekbones and down closer to the side of the mouth, a defatting approach is needed. Given your pictures and the fullness that runs from just below the cheekbone almost down to the jawline, I would recommend the combination of a buccal lipectomy and perioral mound liposuction. These two together are the most you can do for helping change a round face to a more V-shape based on soft tissue changes only. It is also important to remember that the thickness and quantity of skin also plays a role so there are limits as to what facial defatting can do.

When it comes to a rhinoplasty and a subnasal lip lift, I do not recommend that these two procedures be done together. This has to do with ensuring good blood flow into the intervening columellar segment. They will need to be staged or done separately.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was just curious on the cost of the filler for forehead horns. My brow bone sticks out too far and I would like to have it filled like I see in the photos on the website. Do you know the cost roughly? Also, would you ever have to get this procedure done again in the future or will it be permanent once it’s done? Thanks in advance!!

A: For filling in the central depression of the forehead, I really don’t use an injectable filler technique for it in most cases. Synthetic injectable fillers are only very temporary (a few months) while the fate of fat injections is uncertain as well as its permanency. I have used injectable bone cement as a form of injectable filler but it is difficult to get it perfectly smooth and, if it does not become smooth, a secondary revision of it is going to a larger incision to access it to even it out. The most successful strategy in my experience has been the use of a wall custom implant made from a 3D CT scan. This fills in the depression nicely and is permanent. I would need to see some pictures of your forehead to provide a more specific answer as to what work best for you. But central forehead augmentation to fill in a depression between the brow bones and the upper forehead prominences is usually best done with a custom forehead implant approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 39 year old male who was born with a noticeable asymmetry in my face. This is most pronounced on my right lower which is not as full/pronounced as my left side. It has always bothered me for as long as I can remember so I finally decided to do something about it. In January of this year I consulted with a local facial plastic surgeon who seemed confident that he would be able to eliminate the asymmetry with an off-the-shelf implant and so I ended up scheduling surgery a week later. I had some initial concerns because the consultation only took about 15 minutes and no details of the surgery or what my options were was presented. The doctor sent me out for a 3D CT scan prior we did not look at the scan and measure out where the asymmetry was and what areas needed to be augmented and by how much. I reluctantly decided to proceed regardless of my intuition telling me not to and this ended up being a costly mistake. About a month after surgery when the swelling began to subside, I noticed that the implant he choose actually ended up causing more asymmetry than I originally had. The implant he chose was a Medpor  type implant that under augmented my horizontal deficiency by 50% and over augmented my vertical deficiency by 100% as well as changing the mandibular angle (something that I didn’t want to do as the angles matched before surgery).

During my follow-up visit the doctor agreed that this was not a good outcome and said he would redo the surgery with a custom jaw implant. However he has now abandoned me and has left me now with this Medpor implant that needs to be removed immediately. Thus I am looking for a doctor to help me out in this situation. I would like my current implant removed and a new custom implant put in in its place. 

A: I am sorry to hear of your unfortunate outcome. In treating facial asymmetry, ‘winging it’ throws multiple variables into an already difficult problem and that usually never works out well. There is no doubt that a 3D CT scan needs to be done at the minimum for diagnostic assessment. But in 2015 designing a custom implant for facial bone asymmetry gives one the best chance for substantially improving facial symmetry. Since you already have a 3D CT scan you can proceed expeditiously to beginning the custom jaw implant design.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in breast implant replacements with or without a breast lift. I have saline implants that are 18 years old. I was a small B and the implants brought me to a small D. I’ve had two children and breast fed without complications. I feel like the implants stayed in place and my breasts didn’t. I don’t really want them this large anymore anyways but I’m unsure if I should take them out and get a lift or get them smaller with a lift. It would partly depend  on cost but also on which one will look better. I just want a normal size and breasts that are perky.

A: It is not rare that pregnancy causes the existing breast tissue over implants to sag off of them after becoming enlarged and then deflated. This indicates that some form of a breast lift is absolutely needed, the only question is whether smaller implants are still needed to maintain persistent upper pole fullness of the breasts. A breast lift, while moving the nipple back up and tightening the breast mound around it will not maintain long-term upper pole breast mound fullness. This it is very likely that a small implant may still be needed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I may be interested in skull reshaping surgery. I am contacting you because I have been searching for a professional opinion relating to some worries I have concerning the shape of my head, and I thought that you might be able to help. I have noticed that there is a clear ridge sloping outwards, and above that, the shape seems to be flatter than when compared to many other people I have seen. 

I never used to be so preoccupied, but this changed when I recently saw my head in profile. I have begun thinking that it is not ‘standard’, and I’ve been wondering whether there may be a reason for this.  

I believe that some attitudes of people towards me, in the past, have been influenced by its shape. Do you think that undertaking cosmetic surgery to correct this would be possible/advisable, based on the images provided?

I realize it’s probably nothing, but I think it’s best to be certain about something like this. 

A: I can tell you whether your skull shape should be a concern to you or not, that is a personal judgment. Beauty is in the eye of the beholder so speak…in this case an abnormality is also.

What I do see is a skull shape that has a flat occiput which has resulted in the posterior sagittal ridge area being raised up and sloping downwards toward the forehead. These skull shape issues are all interconnected and they are a well known type of skull abnormality.

Whether this skull shape should be of concern to you and whether it should be corrected is a personal and aesthetic judgement on your behalf. But it can be done through aesthetic skull reshaping surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m considering getting facial feminization surgery but I want to know the cost, recovery time and the amount of pain to be expected. I want to get the most change of my face that I can but am not sure how much I can really achieve. You are the facial feminization surgery expert so I would need your guidance as to what would be best for me.

A: Facial feminization surgery is a broad collection of hard and soft tissue procedures that are individually selected for each patient based on what has the best value to help change the shape of their face. There is no standard FFS surgery where everyone gets exactly the same procedures. I would need to see pictures of your face to make an assessment with computer imaging to see what works best for you before any cost quote can be given. Regardless of the exact procedures, FFS is always a compilation of numerous procedures that will cause a lot of swelling and takes about three weeks until one looks fairly normal and non-surgical…but really complete recovery from this type of facial reshaping surgery takes up to three months for everything to completely normalize.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley,I’ve recently e-mailed you inquiring about deltoid implants/fat grafting and I was wondering what other areas of the body that fat grafting can be applied to?

I’m 24 years old and have a very thin and bony structure, thin wrists, narrow shoulders, and thin neck which has led to years of insecurity, yet at the same time I have a decent amount of fat on my stomach and chest.Due to severe tendonitis and several joint problems – accompanied with a muscular dystrophic disease in earlier life, I’m entirely unable to engage in hypertrophy training so the option to increase muscle mass through weight lifting isn’t possible, though I have tried for many years to work around it.

I was wondering if somewhat of a comprehensive fat grafting/contouring upper body transformation (increasing forearm, upper arm, deltoid, and neck thickness) is possible. Could it be done and look natural? or is there an alternative surgery that could be more suitable? I just want to feel/look like a normal person.

Thank you.

A: I think the key issue in you, who is very thin most everywhere, is that fat grafting is very unlikely to be successful. This is because most likely you do not have enough fat to harvest to be used and in very thin people the injected fat rarely stays or stays so little that it does not make much difference. The only option for arms, shoulders, chest and calfs are body implants which can look natural as long as they are not overdone. (too big) There is no procedure that can make your neck thicker.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I’m a 32 yo man going for a sliding genioplasty. .I have lip incomptence therefore the surgeon is planning to remove a 5mm wedge of bone and I asked him to move the chin 10mm forward. However I’m a bit afraid of removing that amount of bone. I’ve read that with an angled genioplasty is also possible for height reduction but he seems reluctant because of the notch left on the jaw. I don’t know if these two procedures give the same result. The second picture is approximately what I expect and since I’ve had time I ‘simulated’ it on the x ray. Even though I rely on him, I’m looking for the best result that’s why I’m asking for another thought on it. Thanks for reading.

A:Please send me pictures of your face from the side view. That will be helpful to see how much vertical chin height reduction is needed if any in your sliding genioplasty procedure. If you really need vertical height reduction it is better to do it by a vertical wedge resection than a severely angled bone cut. That is the more assured method of achieving adequate vertical chin height reduction. Ideally seeing pictures of your lateral cephalometric x-ray would also be most helpful.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, a year ago I made a big mistake, I had a buccal fat removal operation (buccal lipectomy) and now I’m really sad about the results. My cheeks are too sunken and this makes me look older. I was reading an article you had written where you said that there two solutions for the buccal lipectomy defect. To add volume where my buccal fat was is it better a dermal-fat graft or fat injections? Will this leave scars on my face? 

A: To restore lost volume from an over aggressive buccal lipectomy you can either do fat injections into the buccal space or place an actual dermal-fat graft into the original buccal space. One harvests the fat by liposuction (injection) while the other by an excision. (dermal-fat graft) A dermal-fat graft creates more assured volume but does leave a scar somewhere in your body to harvest it. For this reason many patients may initially opt for the fat injections.  Either approach will leave no scars on the face as they are done from inside the mouth….just like your buccal lipectomy was done. In short, restoration of a buccal space defect must replace like with like…or fat lost with fat grafting.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in skull augmentation. I haven’t managed to find any possibility here for my skull flat shape and also smaller size, which is always a problem due to hiding its flatness in a puffy hair and that takes a lot of time and doesn’t allow me to wear the desired hair style. I’m 34 years old and I am struggling with such issue for a lifetime, and now I’m seriously looking for a permanent fix. My forehead is also flat and what I’ve lately done was to get injected fillers in my forehead, its corners and all over it, for creating a nicer curvature which is not a permanent but only temporary one, then within 1 year or a year and a half, I need to re-do this process which is not the most desirable fix, also only temporary.  I’ve been reading about a latest discovery, Kryptonite, and also learning about you Dr Eppley from online and also searching your website, and I’ve noticed you’re extremely experienced and a specialist in such matters.  I’d like to kindly ask about your opinion, if some injections with suitable bone adhesive (Kryptonite or otherwise) would solve my problem permanently, without any side effects or other later surprises?  I’m aware the injections would be the quickest fix, especially when 1.5 cm to 2 cm height in my skull’s curvature would be perfect and also a bit at the top back, plus a bit on the laterals for creating more volume around, therefore in a nutshell needing some attached patches in the right spots of my skull. I’m also reading online that such injections would have some side effects and in the longer term may bring some problems, not sure if that’s correct or not?  If possible, I’d appreciate it receiving your kind reply regarding such procedures, or if it’s better going for a whole skull patch addition through a more complex operation?  Obviously, I’d prefer the simplest but most efficient procedure, but if such quick injectable permanent safe fixes don’t exist, please kindly elaborate about the best fit in my case, in order for my forehead to be considered as well and curved accordingly with no weird marks after a possible operation or implants. 

A: The simple answer to your question is that no method injectable skull enlargement works well and has lots of complications. Kryptonite is no longer available and has been removed from clinical availability. The only effective method of significant skull augmentation (and a 1.5 to 2 cm enlargement would be considered significant) is a two-stage surgical procedure. The first stage is the placement of scalp tissue expander (to gain the room for the bone expansion) and the second stage is the placement of a custom skull implant made from a 3D CT scan. Like all surgical procedures, they are not risk free but this approach has had few complications in my experience.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was interested in removing the dimple or cleft in my chin. I have attached pictures of it so you can see if chin cleft removal will work for me. It is not a big chin cleft but it bothers me nonetheless.

A: Thank you for sending your pictures. What you have is a lower vertical chin cleft which is a direct manifestation of a notch in the chin bone. If you feel the chin bone under the cleft you will probably feel a notch or a groove in the middle of the chin bone. In this type of cleft it is important to fill in the bone ‘defect’ as well as add a little fat right into the soft tissue portion of the chin cleft since it also is making a contribution. This is done from inside the mouth with the placement of a very small mesh implant into the bony groove. The fat can be harvested from inside the bely button and injected into the soft tissue cleft or a small graft can be harvested from inside the mouth from the buccal fat pad and placed directly into the defect.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m 18 years old at height 5’4 and weigh 125lbs. I have breasts the size of 32DDD. I know I want to have a breast reduction sometime in life, and my question is if it’s worth having one before I have children?

A: When one undergoes breast reduction depends on how symptomatic one is from their large breasts. If they are heavy and painful and are interfering with your lifestyle then you do the procedure before children since you can get the benefits sooner rather than later. If they are large and not that uncomfortable then you wait and see what effect having children as on their sizes and the symptoms that are causing.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to inquire about depressor septi release surgery for correcting a transverse crease above my upper lip just below my nose. I do not know of this is the right approach but ti seems like it might work.

A: The release/removal of the depressor septi nasii muscle is usually done to stop the top of the nose from pulling down while smiling. It may or may not have an effect on a transverse crease in the upper lip. The best way to find out if it does is to initially do Botox injections first and prove that the elimination of its action will make an improvement. If Botox is successful then you should consider depressor septi muscle release surgery

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I have a question about the genioplasty and v-line surgery. ( jaw reshaping) What’s a good prediction of what the recovery will be like two  weeks forward in terms of speech, looks and smile? 

For the genioplasty, I definitely want to reduce the width. I think rather than projecting it forward to slightly bring in some height, I’d rather just lengthen it vertically right where it is. I prefer this because I don’t want dramatic length added so I wouldn’t think I want to do both, and I assume extending my chin bone downward will help change my chin profile from “slumping up” at the chine edge, to a more aesthetic look. 

In other words, I assume bringing the chin forward wouldn’t help change my chin’s profile and hence, moving the bone downward would benefit me best. I think if anything perhaps my chin could be brought forward a millimeter, but again the real thing I’m looking for is to reduce the width and add a little height for the sake of creating a more v-line jaw line.

A: I think your insights into creating more of a V-line jaw shape are correct. (v-linje surgery) Chin width reduction and vertical lengthening will go a long way towards changing the shape of the front half of the jawline.

It will take a good three weeks to have about 75% recovery and a full 6 weeks to show 90% of the result from V-line surgery. This surgery does not affect speech or the ability to eat but is mainly an appearance issue due to swelling and temporal chin distortion. There is no doubt your chin will be very swollen the first 7 to 10 days after surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I wanted to have a chin implant and midface augmentation (orbital rim, paranasal and cheek implants). Recently, I discovered a question on Realself where you said that one big, custom midface implant would be the best choice. This looks like it would augment exactly what I want to be augmented! Wouldn’t this save me money and be the perfect option for a flat/droopy midface because the implant would be adapted to my bone structure? What I’m searching for is a chiseled, “bone” look, because I see many cheek augmentations that are too low or feminine on men! The chin implant is a standard design though, isn’t it?

A: There is no question that a single total midface augmentation by a custom made implant from a 3D CT scan would have the best and most comprehensive effect. (custom midface implant) Since there are no true preformed midface implants (cheeks and paranasal do exist but nothing for the maxilla or orbital rim), only a custom midface implant would work. This type of implant combines all the skeletal areas on the midface into a single implant, thus creating almost a LeFort III advancement effect. (minus the occlusion changes)

Chin implants, however, do come in a wide variety of styles and sizes so something ‘off the shelf’ may well work.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have extremely narrow clavicles which have caused years of insecurity. I’m very interested in the deltoid implant surgery that you offer. I think I read that the maximum amount that you can add to each shoulder in width is 1.5cm. Is this figure correct and does it apply to both the method of silicone implant as well as the fat grafting technique?

A: Deltoid augmentation (aka deltoid muscle augmentation) can be done by either fat injections or actual deltoid implants. If you have adequate fat, fat injections would be preferred since they are the most natural and are scarless to perform. While not all the fat will survive, fat injections would always be the first choice. If one does not have enough fat than only an implant can be used. This is placed through an incision in the skin crease at the back of the axilla (armpit) and the implant is placed in a subfascial location over the central segment of the deltoid muscle.

Both deltoid augmentation approaches take about the same amount of time in surgery and both have about the same recovery. Neither deltoid augmentation technique will create a full 1.5 cm per side, close but not always.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, what is the nest method for scar treatment after surgery? I know there are lots of topically applied products most which appear to be made of silicone gel or oil. I also see there are scar tapes. Are scar tapes better than the topical ones? How are they applied and where can get them?

A: There are also multiple scar tapes most of which have silicone in them. But my preferred scar tape is the Micropore tape. It is from 3M, flesh colored and is microporous so moisture can escape from them. The regimen I use for my patients for just about any type of surgical scar is as follows. The tape should be applied to your scars immediately after surgery and left on until they fall off on their own (usually about 7 days).  The tape can then be reapplied.  It is important to ‘shingle’ the tape, using short 2″ pieces that overlap slightly.  The tape must be worn continuously for several months until all signs of inflammation are gone (no residual redness, swelling etc).  When the scar is white, you can discontinue the tape.  There are more expensive tapes and wound support technologies available and under development, but the tape technique is very economical and probably equally effective to other scar treatment methods.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had braces when I was about 18 years old and that was my second time for them. My first time was a few years before my second time. The reason I went back again was because I had a problem closing my mouth. It’s either because I didn’t really wear my retainer or because of my protruding jaw. So I went to the doctor and what I had in mind was just that I wanted to close my lips without looking like they are protruding. The doctor took off 4 of my teeth, 2 upper and 2 lower on each side. And as a result, now I realized that it’s been narrowed down too much. Both front part and side part being forced inwards and so I find that when I smile, my cheekbone is more obvious, I have lines besides my nose, and my teeth doesn’t look as good since it’s way inside, not showing like before. Also, the part above my upper lips under my nose look like it’s went further inside and I think it’s because the orthodontist pushed it backwards quite a lot. 

I’m not sure if the solution years ago about my protruding lips was to rearrange my teeth without extracting those 4 teeth or there is actually the need to take them off. (I went to the first dentist and he insisted that he wouldn’t take off my teeth, since I didn’t want my lips to look like that I went to other dentist and he said it was fine to take them off). 

So the bottom line is, is there any solution to this ? Is it possible to move my upper jaw a bit forward so that I don’t look like an old lady whose teeth’s all gone since they are way hidden inside?

A: What you had done was extraction of four premolars to allow all remaining front teeth to be moved back, thus reducing the prominence of the lips. You are correct in that is a source of premaxillary/midface retrusion. While doing a maxillary advancement would reverse these effects it is important to realize that if you move the upper jaw forward you must move the lower jaw forward as well.  (bimaxillary surgery or double jaw surgery) This will maintain the occlusion you now have. Otherwise you will create a substantial bite discrepancy.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have recently lost 100 pounds. I still want to loose another 50 pounds but would like to get some information about doing an extreme tummy tuck since my skin and fat hang by my mid thighs. I would also like to get information about a breast lift.

A: Thank you for your inquiry. Congratulations on your success at such a significant amount of weight loss. I would agree that you should maximize your weight loss before any body contouring surgery is done to get the best benefit from the procedure. It his likely that the next 50 lbs will be harder to lose than the last 100lbs but the effort will still be worth it.

Anytime a female loses more than 75lbs there are always going to be the sequelae of loose redundant skin on the abdomen and waistline and the development of breast sagging. While weight loss causes the reduction of fat, no skin is lost and how much skin redundancy remains depends on its natural elasticity and its ability to contract which is often very poor. (men do much better in this regard with large amounts of weight loss) In the extreme weight loss patient, a standard type of tummy tuck is always inadequate so you are correct in that an ‘extreme tummy tuck’ is needed. At the least this is an extended tummy tuck but may be a flour-de-lis type of even a circumferential body lift to create the greatest degree of redundant tissue removal. I would need to see smoke pictures to provide you with a more accurate answer as to the type of tummy tuck you need. For the breasts, the vast majority of time one needs a full or anchor style breast lift. Whether implants would be needed to restore volume is the only issue to be determined.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Can I get a hair line lowering procedure, forehead contouring, and shaving of the brow browsing, lip lift, lip augmentation, corner lip lift and maybe jaw implants all during the same surgery? My goal is to feminize my forehead, the distance between my lips and nose is extremely far a lip lift would feminize my lips, and I’d like a heart shaped face and girls with heart shaped faces always have a nice feminine jawline.

A: What you are referring to is known as facial feminization surgery and in the classic use of that plastic surgery term refers to a type of transgender surgery. By your inquiry it does not appear that you are a transgender patient. But the concept is really the same and there is nothing unique or different in terms of the number of facial reshaping procedures that can be done on a male to female or a female patient. It is very common to perform up to a dozen or more different facial operations during facial feminization surgery. These are perfectly safe and are well tolerated to be done all at the same time. It does create the need for significant recovery, however, as the more facial procedures you do the more swelling that occurs as you might imagine.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I have a vermilion lip advancement a few years ago and am not too happy with the results. My scars are healed but it is too large which makes the distance between my nose and upper lip too close. My bottom lip is also too large that makes opening and stretching my lips difficult. Overall, my lips look unnatural and is too big for my face. My question is: is it possible to cut the vermilion again to bring it down making the size of the lips smaller and improve the shape? I don’t think a lip reduction will work because my vermilion will still sit to high. What would you recommend? Thank you.

A: Once skin is removed from the upper lip, whether it is from below the nasal base in a subnasal lip lift or above the upper lip in a lip advancement, there is no way to put the skin back. These are permanent lip enhancement procedures that change the skin-vermilion relationship by excision. The vermilion can not be moved back down, short of a skin graft which would look like a patch and be aesthetically worse than before.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 32 years old with a full 34C cup breast size.. I went for a plastic surger consult last week and I figured I would need a breast lift because my breasts were very saggy. I also wanted a breast lift with implants as I want perky very round (ok to look fake) looking breasts. I wouldn’t mind being bigger even a DD cup. My plastic surgeron said he won’t do a lift and breast implants at the same time. I was shocked that he would not do them at the same time as this ultimately means more money, recovery and longer to finally get the breasts that I want. Why won’t he do them together? And do you think just a lift will give me the perky round look I want?

A: It is important to understand the combination of breast lift and breast implants is a ‘ying and yang’ type or procedure where want (how much) is done in one will usually adversely affect the other. If I needs a big breast lift (lifts and tightens the breast skin) it will be impossible to put in very big implants at the same time. Conversely if one wants big breast implants the amount of lift obtained will be small and you will likely end up with some residual sagging.

When one needs a lot of breast lifting and also wants larger breast implants, it is best that the procedures are staged. That way you can get the maximal breast lift and then secondarily (3 months later) you can put in implants of the size needed to obtained the amount of fullness that you want. Trying to both at the asme time dramatically increases the your risks of complications and has a very high incidence of the need for revisional surgery. If you are going to get two surgeries anyway it is far better to have the second surgery on your terms…not managing complications from the first procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, You said that there is no deltoid implants but I found on internet that there is. I know about people get implants to their arms and belly to have muscles and six packs. so what kind of implants is it and can it be used for implants for the deltoid? o beside fat transfer/fat implants to the deltoid, is there any implants for the deltoid? Thank you.

A: What I said was that there are no preformed off-the-shelf deltoid implants that are made specifically for the deltoid/shoulder area. This is the same for other arm implants as well such as the biceps and triceps. The only body implants besides breasts that are commerically made are for pectoral, buttock and calf implants. It is unlikely that other body implants will be commercially made in the near future given their low demand. That does not mean that deltoid, bicep or tricep implants are not done as they are and I have done them as well. What is used for all arm and shoulder implants are the different sizes for calf implants.  They are soft long and oblong and usually the small or medium size works well for the deltoid area. There soft silicone elastomer helps simulate muscle tissue which they are designed to augment.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a rhinoplasty done and ever since something about it has been bothering me since I have done it. I’m not sure what the doctor called it since it’s been 4 years ago. I was concerned that the side of my nose was big. It was the bone beside the bridge of the nose. I originally thought I wanted it to  be smaller. I just realized after that what I was after wasn’t to get rid of that but I wanted my bridge to be smaller. I feel like now there is a hollow line of a downward from under eye to about 3-4 cm. And the width is about from the bridge to the side around 1-2 cm. I only remember him saying that he has made the bone in that area less thick. I think as a result, it leaves some kind of hollow, especially when taking picture that area seems to be looking deep and I don’t think it was like that before I did it. I think it’s not supposed to look like this. I think the doctor wasn’t skillful enough and removed too much bone and now I look kind of old. When I smile it’s the most obvious. 

Is it possible at all to fill it up with something permanent fixed to my bone beside the bridge(basically to make the bone on that area thicker) that wouldn’t move when I smile? I don’t want a fat graft which doesn’t last and would move or get pushed up when I smile. Or any other material ? I’m aware that there would be a curve at the bridge down to the sides. But I’m really not sure where exactly the doctor got rid of my bones. But it wasn’t by squeezing the bone, he literally kind of use some tools to get rid of the bone.

A: I can not tell from your description whether this high paranasal deficiency is the result of nasal bone infracturing done at the time of a rhinoplasty or whether this area was directly burred from an incision inside the mouth. Regardless of its origin, the paranasal/medial maxillary process region can be built up using a variety of different material from an inside the mouth approach. (paranasal augmentation) Having built up this area before, it is a highly sensitive areas to augmentation and it only takes a few millimeters to make a very visible difference. Whatever material is used the upper edges need to have fine tapered edges ti avoid any visible external transition areas.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have an umbilical hernia and have been told that a general surgeon would be needed for this procedure. In addition to needing a mesh piece placed in the hernia, I would like the resulting belly button to be aesthetically pleasing. I also have a c-section scar with some loose abdominal skin. Can you address all my concerns during a single procedure without an additional general surgeon in the OR at the same time?

A: What you are specifically asking is to have a tummy tuck done with an umbilical hernia repair at the same time. This is not a rare situation for a plastic surgeon to encounter and manage. During an open tummy tuck procedure most umbilical hernias are repaired by using your own natural tissue through midline muscle plication. It would be very uncommon for a plastic surgeon to have to resort to the placement of a synthetic mesh for hernia repair during a tummy tuck. The only concern is the fate of the belly button during an open tummy tuck operation. Many umbilical hernias have disrupted the attachment of the belly button to the abdominal wall. During a full tummy tuck the outer connection of the belly button is removed from the surrounding skin. If the umbilical hernia has also separated the base of the belly button, it may not have adequate blood supply to survive afterwards and be lost. So the objective of obtaining a better looking belly button may be a difficult challenge when a full tummy tuck is done with a concomitant umbilical hernia repair. This does not mean that the two should not be done together, as they should, but one has to appreciate the potential implications for the belly button and its postoperative fate.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I contacted you last year about liposuction. I’m finally ready to get the right procedure cause I’m not sure what would be best. I’m 5ft 7inchs tall and weight 283 pounds. I would like to lose as much as possible. Can you tell how much I might be able to lose just so I have an idea. I would like to get down to 195 pounds but I don’t know if that is possible or if that is dangerous. Can you please help me pick the safe and best procedure. thank you for your time.

A: I am afraid that you have the wrong idea about liposuction surgery and what it can accomplish. It is not a weight loss method nor would it be appropriate at your current weight of 283 lbs. Liposuction is a body contouring surgery to remove select areas of fat that are diet and exercise resistant.The only way you are going to lose 75 to 100 lbs through surgery is by a bariatric surgery approach with either a lap band or a gastric bypass. Liposuction at 283 lbs is not only dangerous but would be ineffective at making any substantive body shape or weight loss changes.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have mild muscular dystrophy that has left my right leg and ankle much smaller than my left. I have two calf implants in now but my ankle and the inside of my leg are still much smaller. Is there any way you think you could help?

A: Calf implants do a good job of increasing the size of the upper half of the lower leg between the knee and ankle. But its augmentation effect stops where the gastrocnemius and soleus muscle meets which is about halfway between the knee and ankle. One way to augment the lower half of the leg and continue the effects created by the calf implants are fat injections. As long as one has enough fat to harvest, fat injection augmentation can be done in the lower half of the leg. (leg fat grafting) Its biggest problem is in how well the fat will survive which can be difficult in the tight tissues of the lower half of the lower leg. Multiple fat injection sessions may be required.

Another option would be a custom made implant for the lower leg. But this has a much higher risk of complications than calf implants do because of its subcutaneous location as opposed to that of a subfascial one.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in your assessment of my jawline issues. and what you would recommend for surgical improvement. I have a weak jaw but a fairly good bite. Had orthodontics as a teenager and they never recommended any surgery. The other issue which may be helpful is that I have obstructive sleep apnea (OSA) and wear a mouth piece at night to push my chin forward. I am tall and thin so I do not fit the ‘typical’ body type for many OSA patients. I have attached pictures for your review. I have been to several plastic surgery consults but each one suggests a chin implant. While that might be somewhat helpful it just seems that it is an inadequate solution for my problem.

A: Thank you for sending your pictures. My assessment is that you have an overall short lower third of our face as evidenced by a horizontal and vertical deficiency of your entire jawline. (mandible) Besides the visually apparent facial third discrepancy, the fact that you have OSA and require the use of nighttime CPAP speaks to the potential contribution of a short jaw as a contributing factor.

The optional treatment for this type of jaw deficiency is a custom jawline implant that can augment smoothly the entire jawline in a wraparound fashion from jaw angle to jaw angle including the chin with tridimensional changes including increased vertical, horizontal and some width changes. (see attached predictive imaging) Having significant OSA, however, throws a variable into such a plan however as it would provide no functional improvement in your airway….and that seems like a shame given its potential lifelong occurrence.

A variation on the custom jawline implant would be to combine a sliding genioplasty to bring the chin down and forward (carrying the anterior attachment of the tongue muscles with it and potentially offering some OSA symptom improvement) combined with a pre made custom implant that would augment the rest of the jaw. This would be the only way to have a completely smooth transition from the posterior edges of the sliding genioplasty osteotomy line to the body and angle of the jaw behind it from an augmentative standpoint. Like the total custom wraparound jawline implant it would need to be made from a 3D CT scan from which the osteotomy and implant design would be done.

The ‘simplest’ option would be to just have a sliding genioplasty with standard off-the-shelf vertical lengthening jaw angle implants.  While offering aesthetic and functional jawline improvement, it would not create a perfectly smooth jawline from front to back.

Dr. Barry Eppley

Indianapolis, Indiana