Your Questions

Q: Dr. Eppley, I am interested in temporal implants. Anatomically speaking, can you please explain to me where exactly the temporal implant will be placed- I have a vision in my mind but it may not be accurate. Will the apex of projection be between the eyes, higher up near the brow ridge, or lower beneath the eyes. Also the size of the implant, vertically speaking, how much length does it typically occupy- I imagine 5 cms or so.

A: The temporal zone can technically be divided into five regions based on the its aesthetic problems and the procedures needed to treat them. But in your case I am only going to refer to zones 1 and 2. Zone 1 (the most common area augmented when treating temporal hollowing) is between the zygomatic arch and the mid portion between the vertical distance of the zygomatic arch and the anterior temporal line. (just above the eyebrow level) Preformed implants are placed beneath the fascial covering of the muscle (not directly under the skin) to augment this area from an incision way back in the temporal hairline. Zone 2 is the area between the top portion of zone 1 and the anterior temporal line and is rarely augmented this high unless one is looking for a completely smooth transition from the forehead and the temporal region which also implies one is looking for greater convexity/fullness in the upper temporal area. Such Zone 2 augmentations can be done with large preformed implants (although they will far somewhat short of the anterior temporal line) or custom temporal implants made to fit on top of the fascia. (subcutaneous location) The vertical height of the preformed temporal implants ranges from 4 to 4.5 cms.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a subnasal lip lift. When you perform them, how is the healing of the scar? I know the scar is placed at the base of the nose, but I have seen some horror stories where the incision is just below the nose and thus is very visible. Do you also pull the muscle or just the skin with the lip lift? I have a 21mm gap between the base of my nose and my upper lip. After my rhinoplasty (which I am having first) I am presuming this gap will stretch to approximately 23mm- in any case I am hoping to have a 15mm gap.

A: The key to a good subnasal lip lift scar is two-fold; place it exactly in the nasal-lip crease and it should follow the shape of the nasal base (wavy) and not a straight line. You never manipulate the orbicularis muscle in a subnasal lip lift, that is an assured way of causing tightness and smiling animation deformities. With a 21 to 23mm lip to nose distance and using a 1/3  distance reduction (amount of skin excised), you should be reduced to a 15mm vertical length.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in pursuing more information about eyebrow transplants. My eyebrows have thinned considerably in spots and they appear uneven. Therefore, I would like to have this corrected. I am curious as to how many sessions I may need to have in order to get my eyebrows as full as I’d like them to be. I have attached photographs of what my eyebrows currently look like and a photograph of my eyebrows as I would like them to be.

A: Eyebrow hair transplants represent the smallest surface area for hair transplantation that is done regularly. While once used just for traumatic eyebrow hair loss, it has become popular for women of all ages to thicken naturally sparse eyebrows or eyebrows which have become thinner with age or plucking. If you count the number of hairs in your existing eyebrow, you will see they are approximately 80 to 100 hairs in each eyebrow. ( I know because I counted yours) To double or triple the density of hairs in your eyebrow (which is what you are showing in your ideal picture), you would need 100 hairs or roughly 40 to 45 follicular units per eyebrow. How many hairs that can be transplanted depends on how close together they can be placed into the slits made for them. On a realistic basis it can be hard to place more than 20 to 25 follicular transplants in each eyebrow in a single session. That may be enough when they are fully grown but you would have to make that judgment six months after the initial session. Thus, one session may do but it is best to always plan on a ‘touch-up’ session depending how the hairs take or to add more for eceb greater density. As a general rule, hairs take about 6 to 8 weeks before you will see significant growth or when they start visible growing. It also takes this amount of time for the little ‘dots’ that surround each transplant to fade and blend into the surrounding skin.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in treating my tear troughs and knowing more about the Lobe procedure for treating them. I already have orbital rim/tear implants in to fix my lower eyelid depressions but they are not quite enough. A plastic surgeon that I consulted with mentioned that I might be a good candidate for the Lobe procedure but didn’t tell me what is was ot how it was done.

A: Fat transposition of the lower eyelid was originally described by Dr. Loeb in 1981 for treating tear troughs. Rather than removing fat from the lower eyelids, he was the first to describe sliding it or moving it over the lower eye socket rim to fill in the tear trough depression. As the tear trough problem has come front and center today, the concept of such fat transposition as taken on a new life and is now very popular. Different techniques have been described for doing it with subtle differences between them. It can be done either through a transconjunctival or open lower eyelid approach. It now has a place in the realm of tear trough treatments which include injectable fillers, fat injections and tear trough/orbital rim implants.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am in need of a special type of lower blepharoplasty. I had artefill injected under my eyes and have been having problems with it. Have you ever removed artefill in combinaion with a lower blepharoplasty before?

A: When it comes to lower eyelid procedures, I have seen may different materials placed in the lower eyelid tissues and along the bony orbital rims and orbital floor.  I have removed in the past lumps of fat, clumps of artefill/artecoll, goretex strands and Medpor implants while doing lower blepharoplasties. Many of the particulated injections are often in the orbicularis muscles but because they are usually in clumps. Most of the material can be dissected out and removed as part of the lower blepharoplasty procedure. Your case illustrates the potential problems with using particulated fillers in the thin tissues of the lower eyelids. The appeal of a permanent filler is great but every particulated filler with non-resorbable particles has a great propensity for clumping and fibrosis.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am writing because I have a quick question regarding cheek implants, which we had briefly discussed, vs fillers. I may have rheumatoid arthritis and I’ve heard that injectable fillers aren’t the best route with autoimmune disorders. I’m curious to know if cheekbone implants would be any better, and if you offer any that are non-silicone.  I would be grateful to read your thoughts on this topic.

A: The use of injectable fillers in patients with known autoimmune diseases is a bit of a mix bag. Historically the thought was that only collagen fillers should be avoided since they are a foreign collagen processed from a bovine source, hence the understandable apprehension when the body is injected by that material.  But more recent anectodal reports have come out that indicates even the very popular and well tolerated hyaluronic acid-based fillers may pose some concern. This has not been definitely proven and it may just represent the general ‘reactivity’ of the autoimmune patient to any stimulus, but the safest route would be to avoid any injectable fillers and lower the risk of that concern to zero.

This, of course, raises the question of whether any cheek implant, regardless of the material, might not pose the same risk…although they have not been to my knowledge in the medical literature or experience. Your concerns about silicone cheek implants is understandable although that feeling undoubtably comes from fluid-filled silicone breast implants of yesteryear and not solid preformed silicone facial implants. But alternative materials for cheek implants include PTFE-coated silicone, Medpor (porous polyethylene), pure PTFE and mersilene mesh. Whether these are all chemically and structurally different than silicone, whether one is better in the automimune patient is not known.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in the FATMA lip augmentation procedure. I was born with a strawberry mark on my top lip. I had two surgeries to remove it, one at 6 months old and the other one at six years old. This has left me with a notch deformity in my upper lip. I am now looking into the FATMA procedure to help enhance the top lip to look more even and natural.

A: The FATMA lip procedure, as you undoubtably know, is an acronym for combining fat grafting with a mucosal advancement. While the acronym makes it sounds like it new and novel, the reality is that such lip reshaping procedures have been done for decades. The most common use of these two procedures historically is in reconstruction of the cleft lip deformity of which there is often a notch deformity at the vermilion. An internal V-Y mucosal advancement/roll out is done to lengthen and level the deficient vermilion edge and then a fat graft is added underneath it for volume. In this case the fat graft is usually a solid composite dermal-fat graft. The so named FATMA aesthetic lip reshaping procedure applies these same principles to a small but normal shaped lip using two internal muscosal advacements and fat injections. Whether your lip deformity should be treated by which variation of the FATMA procedure awaits seeing some pictures of it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a Brazilian Butt Lift (fat injections to the buttocks) but I have a few questions. I want at least 900ccs of fat injection done. Are you able to meet this request or do you have a fat injection limit? I want my upper and lower abdomen, flanks and lower back for the taking of the fat to accentuate my buttock. Please let me know if this is possible. Thanks

A: When it comes to the Brazilian Butt Lift (BBL) and the amount of fat that is injected, the first important question is how much fat does a patient have to give. Liposuction is used to harvest fat from as many body sites as is needed. In thin patients with little fat, a BBL procedure may not be possible. In patients a moderate amount of fat will have to accept a modest BBL result. In patients with more fat then a large amount of donor material can be obtained and a bigger result will occur. The second issue in a BBL is to understand that concentrated fat is injected not just the liposuction aspirate only. Just because 2 liters of fat aspirate is obtained, for example, does not mean that 1liter can be injected per buttock. Rather the liposuction aspirate must be filtered and concentrated so that only pure fat is injected. As a general rule, about 1/3 of the liposuction aspirate turns into concentrated fat. Thus 2 liters of aspirate becomes roughly 700ccs of fat and that means 350cc can then be injected into each buttock.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a sliding genioplasty revision. Four weeks ago I had a sliding geniplasty but I now think it was moved too far forward. It is easier to change the chin bone now or wait until it heals. Will the chin bone become harder to correct with time? I was not aware as I thought the soft tissues should be healed as to not disrupt muscles etc (this apparently takes 12 weeks), and I still have numb areas on the right side of my chin.  Weighing up the pros and cons overall, when is the best time to perform the operation to achieve a better chin result?

Also, I had a rhinoplasty two years ago but have never been happy with my tip. It is still bulbous, maybe even bigger than it was before. Should the revision be done open or closed?

A: A revision of a sliding genioplasty can really be done at any time whether the bone is completely healed or not. The time to do revisional surgery on your chin is based on two considerations, when you are certain that the result you have is aesthetically unacceptable and the state of the bony union of the osteotomy. On the one hand, you would ideally like to change the chin before the bone has completely healed. (6 to 8 weeks) On the other hand, you never want to do a revision before the final result is seen so the patient has time to both adjust to the new look and is certain that a change is needed. You can see how both of these concepts must mesh to pick the ideal time for a revision. The state of the soft tissues (muscles) has really nothing to do with it.

In regards to the nose, the best chance for an improved outcome is an open approach where the needed and desired tip changes can be done under direct vision.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a rhinoplasty that changes the upper part of my nose. The lower half of my nose is fine but I have a large nasal hump and would like to get it reduced. In playing with some online imaging programs, I have noticed that removing the nasal hump actually looks worse in my opinion of the nasal radix is not also reduced. If the radix is not reduced it makes my nose and forehead appear as one with a sloped straight line, making more forehead looking like ‘volvo windshield’ in a profile view. If I am not given more of an obvious nasofrontal angle, my forehead will look weak Getting a good nasofrontal angle is the most important point of a rhinoplasty to me. How can this be effectively be done?

A: One of the more obscure aspects of rhinoplasty surgery is radix reduction.  Radix augmentation is more common in many hump reductions. But in very large hump reduction in which the nasal bones are high and extend into the glabellar region of the forehead, radix reduction may be needed. In looking at your pictures your assessment is correct, a break between the forehead and your nose is needed to avoid a complete connected slope effect of the forehead down through the nose. Significant radix reduction as part of a rhinoplasty can be done by one of two methods; a guarded rotary burr or a percutaneous osteotomy method. Having done both, I find the osteotome method to work well when a really deep notching of the frontonasal angle needs to be done. This is done by using a 2mm osteotomy placed through the skin at the bridge of the nose creating one bone cut into the frontnasal angle, The other osteotome cut is done from inside the nose to complete the 90 degree angle creation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a chin reshaping/chin reduction procedure. My chin is fairly square and big and I feel very insecure about it. It’s not big to the point where it’s the first thing people notice, but I hate it so much and I think it makes my otherwise feminine face look disproportionate. What can be done to reshape a chin? It seems to be one plastic surgery procedure where very little is written about it and very few plastic surgeons actually do it. How is it done and what is the recovery like?

A: There are numerous option in chin reshaping/reduction surgery. Your chin is wide and square for your face and even maybe a bit vertically long. It does not appear to be to protrusive or horizontally long which is a key feature that affects how chin reshaping is done. .Your chin can be reshaped to be slightly shorter and more narrow through an intraoral genioplasty approach. From inside the mouth, the bone is cut, like a sliding genioplasty, and narrowed and then put back together, thus leaving no external incisional scars. This will create a more tapered chin that is more triangular shaped rather than square as it is now. Any bony chin surgery is associated with a fair amount of swelling that will take about three weeks to enter the benefits phase and a full six weeks to see the final result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a chin implant questions/issue.  In my opinion, I have a recessed chin and jaw. Eight years ago, I had a large silicone chin implant inserted, and liposuction below my chin. At my consultation, the plastic surgeon asked if I breathed through my mouth, which I realized I do. Ever since then, I have been on a quest to resolve this issue. I have been to an ENT doctor who said my nasal passages checked out fine. But since I feel that my chin implant did not provide me with enough projection (I am 41 years old but one year ago I had a platysmaplasty for loose skin beneath my chin), and my lips still do not close with out mentalis strain, and as I age I feel that my lack of a supportive jaw is not helping, I would really like to take action. Also, I recently discovered that chin implants have been known to cause bone erosion, which frightens me. I had braces as a teenager, and still have a bit of an overbite, but I do not know where that leaves me as far as options to both improve my appearance and breathing functions. I sincerely appreciate your time and thoughtfulness, as this is quite daunting to me.

A: The chin implant issue that you describe is a common one that I hear about. Between your appearance and breathing issues, your description suggests that your lower face/jawline appearance can be improved. With a naturally short lower jaw, a large chin implant that is still inadequate in projection and a residual mentalis strain, this indicates to me that you need a sliding genioplasty for a chin implant replacement. Besides the limitation of chin implant projection (10mms or less), increasing the chin point by an implant will not improve mentalis muscular function nor any lower lip incompetence should it exist. Your existing chin implant may have also developed some settling into the bone. (often erroneously referred to as ‘bone erosion’ which is not harmful) By removing your chin implant and performing a sliding genioplasty you will improve your chin projection, eliminate the mentalis strain, and also improve your neck profile. I would need to see some pictures of your face to verify these statements but your description is not a rare problem that I see with indwelling large chin implants.

As for your breathing issues, nothing you do to the chin will have any impact on your nasal airway exchange.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in facial reshaping/liposuction for my son. For several years my 16 year old son has expressed concerns with excess fat in the cheek/chin/neck area. He has a genetic double chin that upon weight loss did not help and did not go away. In tears, my son asked if he could do what I did (lower face lift/liposuction) While I do not feel it would be necessary for him to go as extreme, I told him I would research his options. In my own experience, I know it’s not something that diet and exercise alone can help with. As a parent though I am conflicted regarding the risks/ psychology etc. of a surgery for cosmetic purposes at his age. Thank you in advance for your help and information!

A: When it comes to facial reshaping via fat removal, there are several specific areas in the face where fat extraction can be very helpful. This includes the neck (liposuction), buccal fat pad (buccal lipectomy) and the perioral mounds. (liposuction) All three areas would be of benefit to your son based on his pictures. That may not necessarily completely deround is face or give him a thin face but would make a substantative improvement.

When it comes to plastic surgery in teens, the major consideration is their level of expectations. Being less mature and often being guided by information that they find on the internet, their sense of realistic expectations and the necessary recovery process until they truly see the final results is often not accurate. But from a physical standpoint, there is no greater risk of these facial procedures in a teen ager than in an older adult.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in scar revision of my wide midline abdominal scar from a prior surgery. One surgeon I saw recommended a geometric broken line closure (GBLC) type of scar revision. You have recommended a more simpler vertical excision and straight line closure. My question is why would you choose that particular procedure over the GBLC if the broken line procedure yields better results?

A: There is no guarantee that a broken line closure will produce a better result on a midline abdominal scar and there is no medical evidence to support that it will. And if the scar should widen to any degree, you will have more scar length than what you started with. Whomever advised you that a GBLC for your midline abdominal scar (that has never had a revision before) was the right choice for scar revision is simply wrong. That is simply not done on many body scars. It is most commonly done on facial scars which are a completely different in how they heal than any scar below the neck. You should initially do the simplest and least risky scar revision technique first and then proceed to more complex forms should that not produce a substantial improvement.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to get a tummy tuck and belly button reconstruction. I’m not sure what type I need. I workout approximately 5 days a week. I have a lot of scar tissue near my c-section scar that is bothersome. Would a procedure also help with the scars? What type do you recommend?

A: You are correct in your assessment that you would benefit by a tummy tuck. When it comes to tummy tucks there are really only two fundamental types; a mini- or limited and a full tummy tuck. The difference between the two is in the the location and amount of abdominal tissues removed. With uncommon exception, most women are better off with a full tummy tuck because it produces a better result, remakes the belly button and provides the best exposure for complete rectus muscle plication. As part of the tummy tuck, all scar tissue from the previous c-section(s) would be removed regardless of whether one gets a mini- or full version.

Be aware that many tummy tucks also incorporate liposuction as part of it to get a better overall result.. That could be liposuction of the flanks beyond the zone of the tissue excision or above the zone of tissue excision in the upper abdominal area.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in abdominal scar revision. I’m a 22 year old female who had a major surgery resulting from a self inflicted wound that occurred in a more troubled time as a youth. I still have the ugly scar and started research on my z-plasty scar revision for two years now. I’d love to do a consult with you. I’m turning 23 this year and would love to be in my first two piece. I have attached a photo of “my struggle”. Hope to hear from you soon.

A: When it comes to your abdominal scar revision, I see no reason why you would ever have a z-plasty type revision. Your scar revision would be a straight linear scar revision in which the scar is simple vertically excisioned and then closed in a linear fashion. This is the only type of scar revision you should ever have. While it will not make the scar go completely away, it will make it much more narrow.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have been diagnosed with a mild midface deficiency.  I would like to have this corrected to end up with the most aesthetic appearance possible. I have been reading about facial implants and the work you have done with them. I would like to achieve a reduction of the depressions on either side of the nose, reduction of the heavy creases going down to the corners of my mouth and better projections of my face to make it look less wide and flat. In addition I am also interested in lip implants. I already have some lip implants placed. They were the type that look like spaghetti and the size was 4mm top and bottom. I would like to add to these to make my lips bigger. Specifically I would like to show more of the pink lipstick area rather than just make them stick out more. I would also like to bring the implants out to the edges of my mouth to make the lips and mouth appear wider.

A: When it comes to facial implants, there are a lot of facial changes that they can make…and there some changes that they can not. For a mild midface deficiency, consideration can be given to paranasal implants to bring out the base of the nose and anterior submalar implants to provide some upper midface projection. The lower nasolabial folds as they approach the corners of the mouth will not be affected by any bone-based implant. This area is best treated by fat injections.

In regards to the lips, you either have more recent Permalip silicone implants or older style Advanta lip implants. Either way it is not a good idea to double stack lip implants as there will be a great tendencey to have them roll or twist on one another. You may exchange them for the largest 5mm implants but, for the sake of a 1mm increase, that is not likely to make much of a difference. Furthermore, some of the lip changes you desire can not be achieved by lip implants. No implant will increase the vertical height of the vermilion (pink lipstick area) nor will they make the corners of the lip appear fuller or wider, they are too thin in this area. To make these kind of lip changes, you will need to consider a vermilion or lip advancement procedure which directly changes the location of the vermilion…which is what is needed to make the type of lip changes you desire.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in skull reshaping reduction of the size of the back of my head. For a long time, I have had a distressing issue with the prominence of the back of my head in what I believe to be the occipital bone region. The problem is primarily located slightly right of centre of the back of my head. In other words, from side view, my head sticks out more on the right side than it does on the left and the bone can visibly be felt as thicker and more protruding. It also doesn’t help that my crown area feels very flat and almost leads into a boat shape back of the head. After much research, I do not necessarily believe that I have a form of craniosynostosis, though I am not ruling out the possibility of perhaps a mild manifestation of it.

As a young 25 year-old man, are there options out there for me to possibly reduce the ‘sticking out’ of the back of my head, so that I can have a more ‘normal’, flatter back of the head? I have attached two photos, taken from either side of my head, so that you can notice how one side sticks out more than the other (though my occipital bone in general sticks out much more than normal). I also appreciate that it may be hard to tell by the photos because of my hair coverage, which I keep as an attempt to mask the bumps. I understand that things of this nature are usually dealt with more in children but I came across your site when researching possibilities for occipital reduction.

A: Skull reshaping of the prominent back of the head is very common in my practice. It is never a question of whether occipital bone reduction can be done, it is always a question of whether the reduction achieved will be significant enough to justify the effort. As a general rule, 5 to 7mms of occipital bone can be reduced. That may not sound like much but usually produces a noticeable size reduction. Just based on your description of the problem, it sounds like this amount of reduction would be adequate to make a difference in your back of the head shape.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had fat grafting to my face and I love it. I am three weeks out and I have noticed already that some of the fullness has started to go down. I would prefer it to stay this way and I don’t want it to go down. How much of the fat will stay and how will I know when the result is finally stable? I don’t think my doctor overfilled at all. And the first two weeks I looked amazing, but things have changed over the past week and it is not nearly as full now as it once was. 🙁

A: Fat  grafting is a wonderful technique for a variety of facial enhancement issues but it plagued by unpredictability of fat graft survival. A good guideline for the amount of volume retention after fat grafting is to wait at least until 6 weeks after the procedure. Generally the success of most fat grafting results is seen by then by ultimately a final judgment should not be done until 3 months after the procedure.  That is also the time when fat grafting can be repeated if necessary. At just three weeks after the procedure you will very likely lose more fat, it is just a question of how much more over what period of time.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a subnasal lip lift. I have a long upper lip and I think it would make my face more balanced and attractive. I have not read anywhere on how one determines the amount of skin that can be removed between the lip and the cupid’s bow. I want the maximum to be removed but I still want it to look natural and not be overdone. I want to increase the size of my upper to the maximum as it is basically non-existent now. Also, will the subnasal lip lift increase the size of the whole upper lip and not just the cupid’s bow directly underneath the nose? Thank you.

A: In a subnasal lip lift, you do not want to remove more than 1/4 to 1/3 of vertical distance as measured along the philtral columns. Whether that is 6 or 8mms is a judgment between aggressiveness but also wanting to avoid an unnatural and potentially irreversible overdone result. Applying the principle that it is easier to remove more later but you can’t reverse it, I would take no more than 6 to 6.5mms of skin. Also a subnasal lip lift will not change the amount of exposed vermilion out to the mouth corners, it will only change the upper in teh middle third or within or under the nose area.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in learning about suprapubic liposuction. I’ve been searching for answers for my 8 year old son for 8 years. He has a buried penis. He has had two surgeries already when he was 2, which rearranged the skin on his penis to have it appear normal looking, however nothing was done with the suprapubic fat pad. It took me two years to finally get someone to acknowledge that there was actually a problem with my son’s penis. He was a stalky baby weighing nearly 9lbs, and I was told he would lose the mound when he grew and was a toddler. He didn’t, he’s still a stalky child, very active but never loses the mound. His penis is totally hidden, but can be exposed if he pushes the fat pad down around it. He is active in hockey and baseball and is getting to the age where it needs to be addressed before he starts getting ridiculed by his peers. I would really y appreciate any information you could give me regarding this procedure.

A: Suprapubic liposuction can very helpful in children and adults with a buried penis problem. The suprapubic mound is a common companion of the buried penis problem. It is not fat that is responsive to weight loss nor will it go away as one gets older. Suprapubic mound liposuction can be very effective at reducing the mound and helping get some more penile exposure. There is a limit as to how much penile exposure will occur but the fat mound can be significantly reduced. Suprapubic mound liposuction is a simple outpatient procedure that uses small cannulas to extract the fat through two small groin incisions. (4mms) The recovery is very short although it takes several months for all the swelling and firmness to dissipate from the base of the penis.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in ear reconstruction. I lost my right ear several years ago in a car accident. I have attached a couple of pictures so you can see the extent of the ear loss. How can my ear be fixed?

A: A complete ear avulsion represents the most complex type of ear reconstruction. The obvious injury seen in the pictures you sent is a traumatic avulsion of the complete external ear. In dealing with such ear injuries, there are two methods of reconstruction which are dramatically different. The first method is known as the autologous or natural tissue reconstruction method using the patient’s own tissues. The framework of an ear can be fabricated from one’s own cartilage since the ear (minus the earlobe) is cartilage covered by skin. To create the necessary skin, an initial tissue expander must be placed to stretch out (expand) the skin around the ear hole. (external auditory meatus) Once enough skin is created, the tissue expander can be replaced with an ear framework fabricated and carved out of rib cartilage. Somke minor touchups are needed later to make the earlobe and a crease or sulcus on the back of the ear. The other approach is to make a prosthetic ear which is held into placed by end osseous (dental) implants. Three implants are initially placed around the ear hole and allowed to heal. They are eventually uncovered and then used as magnetic retention posts onto which a prosthetic ear can be attached.

There are advantages and disadvantages with either approach. (autologous = multiple reconstructive surgeries, prosthetic = need to continuously remake new ear prostheses)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I recently read your blog about malar and submalar implants. I just have one question since there doesn’t seem to be much information on these implants, but where exactly are the malar and submalar regions?

If I’m looking at implants to provide a swoop from the nose to the cheeks (sorry, not sure how to describe it, but think of Bradley Cooper’s midface), which implant would actually provide that kind of volumetric augmentation?

A: The difference between malar and submalar implants is subtle but very different. As shown in the attached drawings on a person’s face, the malar region is the cheek bone itself while the submalar region is actually below that off of the bone.

There is no preformed or standard shaped implant that provides fullness (a swope) from the nose to the cheek because directly in its path is the large infraorbital nerve. An implant can be fashioned with notching of the nerve to avoid compression (maxillomalar implant) of the nerve using either a 3D model of the patient or pre making it off of a basic skull shape.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I understand that malar and sub-malar facial implants can be used to add volume, 3-dimension and contour to the face. Initially the imaging you provided showed the malar implants only, I think? I am interested to know if the sub-malar implants can be added as well, and more laterally, to camoflauge the slighly hollow buccal area of my face.

Can you please also explain to me the use of paranasal implants? I understand these are largely popular in Asia.

In your opinion, would they assist in the roundening and softening of my face as a whole?

You mentioned the chin augmentation I did may have produced an extreme result, compared to what is actually achievable? Do you think I would notice a measurable reduction in both the width and length of my chin with the sliding genioplasty?

A: What I previously showed was the use of malar implants in your face. The combination of malar and submalar implants is known as malar shells. That would extend the fullness into the underlying buccal space right below the prominence of the cheek bone.

Paranasal implants are designed to add fullness to the base of the nose or push it out further. They are common in Asians because they naturally have a flatter mid face throughout. I can not tell if they would be of benefit to you without looking at picture of your face from different angles, like the side view and the three-quarter or oblique. Midface augmentation in general requires a more 3D type assessment not just a flat 2D picture from the front view.

As for our chin reduction/narrowing, what you had demonstrated was a bit too sharp and extreme which is not surgically possible. But an osseous genioplasty (not a sliding one) can reduce the height of the chin as well as make it more narrow through vertical and midline bone removal.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have always had a long upper lift, and a downturned mouth, causing people to think I’m sad or annoyed, when I’m simply feeling neutral. As I have aged (over 40 now), the downturn has become more pronounced, and in the last year, I’ve started to have problems with the seal in the corner of my mouth being imperfect–leading to drooling at night, and occasional infections in the corner of my mouth. I am interested in a corner of the mouth lift–but am not concerned about the asymmetry in my vermillion, or the longer top lip–just the corners. I have a fabulous smile, and would hate to have anything change it!

I am also a very “moley” person–with new moles popping up every year…and have at least one, almost pencil eraser sized one that I would like removed–and possibly a cluster of four, on the other side of my face, as well. I’m looking for your opinion as to the advisability of the mole removals (potential scarring), as well as a corner of the mouth lift. I am also working on losing weight–have lost 50 pounds so far, and have about 70 to go…I had originally wanted to wait until I lost all the weight until I did anything about this…but the mouth infections are making me push this forward a bit–do you think that additional weight loss would be a concern, in having this done sooner, rather than later?

I’m attaching two images–including all the moles–with the second one approximating the neutral/barely upturned mouth corners I’m hoping for–and with the moles removed.
Thank you for any help you can provide!

A: By your pictures and the imaged changes you have shown, that type of result from a corner of mouth lift is very realistic. I have usually found that the corner of mouth lift can improve or eliminate the yeast infections from the salivary wetness. Your weight, loss or not, has no bearing on the corner of the mouth lift procedure. (in other words there is no benefit to doing it after weight loss)

All of the facial moles you have can be removed with minimal scarring. Given their raised non-melanotic appearance, I would not routinuely send them for pathologic evaluation as nothing about them makes them suspicious for any form of skin cancer.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in scalp scar revision. I had hair transplantation done twenty years ago. However I now shave my head but the recipient area at the front is knobbly and raised where the last line of plugs were placed which is my main concern. There is also a scar running along the top middle of my head an initial scalp reduction which is my second concern and lastly scars on the back of head (donor site) which is much more of a minor concern. So my first priority is to flatten and smooth the recipient area at the front then depending on costs try to break up the linear scar that runs up the middle of my scalp. The donor scars at the back aren’t too much of an issue to me at moment. Do I have to have the old plugs removed (don’t really want to go thru another round of surgery again if it’s at all avoidable) or could I fix this up with dermabrasion/laser/kenalog injection s etc. I would appreciate some advice.

A: When it comes to scar revision of previous hair transplantation recipient sites, there are really fairly limited options. The knobbly appearance is certainly not going to be improved by excising the plugs, that will likely make it worse. There is a substantial surface contour difference between the implanted sites and the native scalp that is not likely to be ever improved by any type of skin resurfacing. Like the face with deep acne scars, laser resurfacing would be a disappointing experience. Dermabrasion may be more effective but at the risk of inducing pigmentation changes. The only procedure that I would remotely consider would be fractional laser resurfacing, as it would be safe, but I doubt particularly effective. The linear scalp reduction may be capable of being improved in appearance by replacing it with a running w-plasty type of scar revision.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a woman who is interested in umbilicoplasty. I have attached one photo which is similar to how my bellybutton looks. I am not certain if it is a hernia  as I have had this my entire life. I am wondering how if an umbilicoplasty procedure could  successfully change my outie bellybutton into an innie bellybutton, even if it is not a hernia.

A: The umbilicoplasty procedure involves a variety of small procedure to reshape the belly button or umbilicus. It can be done t change an outie to an innie as you desire or to remake an umbilicus lost from prior surgeries. An outie belly button may or may not represent an actual hernia. If you stick your finger and push the outie in…and feel an inner ring or hole and the outie pushes into an innie…then it is a hernia. If you push on it and the outie simply gets flattened but does not push in, then it is not a hernia, it is just a ‘button of skin’ so to speak. It is not possible to answer that question by just looking at your picture but I suspect, given your young age and perhaps not having children (??) that your outie is not a true hernia. Eitehr way, an umbilicoplasty can convert an outie into an innie whether it is a hernia or not, just some slightly different techniques are used to do it. An umbilicoplasty can be done under just local and, at the most, some IV sedation as a simple outpatient procedure. There is no real recovery from it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I am interested in breast augmentation surgery and am having trouble deciding between saline vs silicone implants. I know there are numerous differences between them but one specific question I have is about capsular contracture. Does silicone implants lead to a higher rate of capsular contracture problems than saline implants?

A: One of the risks of breast augmentation surgery is capsular contracture. Capsular contracture is the result of excessive scar tissue forming around the implant. Then like a shrink wrap, it tightens around the implant causing it to feel more firm and can also distort the shape and position of the implant.

Historically silicone gel implants were associated with a higher rate of capsular contracture problems. This occurred because the implant allowed for some of the gel material to get through and out into the breast tissue (gel bleed) leading to the soft tissue reaction known as capsular contracture. In addition there was a moderately high rate of silicone implant rupture which exposed a lot of the gel material to the breast tissues. By comparison, today’s newer silicone gel implants do not have any significant gel bleed and a much lower rate of implant rupture. (less than 1% in the first five years for one manufacturer)  Thus, silicone gel breast implants of 2014 are much improved designs over those used in 1989 with a much lower rate of capsular contracture.

The other issue that has led to a dramatic drop in capsular contracture problems over the past two decades has been the change in implant position. Today the vast majority of breast implants are placed in a partial submuscular (dual plane) position. Decades ago it was far more common for implants to be placed above the muscle (subglandular) position. Submuscular breast implants have a known lower risk of capsular contracture rate.

While the risk of capsular contracture always exist with any type of breast implant, it is a very low risk today with the use of either silicone gel or saline implants placed in either a total submuscular or dual plane pocket position.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had liposuction recently on numerous areas of my body including my stomach, love handles, and thighs. My doctor told me he removed two and a half liters but couldn’t tell me exactly how much it weighed. He showed me a picture of a bag that contained the fat removed, which looked like a lot, but he said he didn’t weigh it. can you tell how much you think it weighed? 

A: A question that I often receive from my Indianapolis liposuction patients is “how much does fat weight after removal?” While plastic surgeons remove and record the volume of fat in liters, this often has little meaning to most patients.

In calculating liposuction weights, one has to start with knowing that 1 US gallon equals close to 3.8 liters. While a gallon of water weighs about 8.4 lbs, fat however will weigh less because it is less dense.  A gallon of fat is known to weigh about 7.4lbs. The density of fat is 0.9 grams/ml or 1000ml (1 liter) or a weight of 0.9 kg. Taking these calculations, one liter of fat equals roughly 2 lbs. Therefore 2.5 liters of liposuctioned fat will weigh close to 5 lbs.

While one liter of pure fat weighs about 2 lbs, it is actually less straightforward than that when it comes to fat removed by liposuction. What is removed in liposuction is called the aspirate and not just pure fat. Liposuction aspirate is a mixture of solid pieces of fat, free fatty acids (broken fat cell contents or oil) blood and tumescent solution. (what was injected into the area before liposuction) Thus, liposuction aspirate is not 100% fat but just a fraction of it. (a big fraction just not 100%) As a result, one liter of liposuction is really less than 2 lbs of fat removed and may be realistically closer to 1.5 lbs of actual fat. However when you factor in the number of fat cells that have remained behind inside the patient that have been damaged or destroyed and will be lost as the tissues heals, it is still fair to round up the total fat ‘removed’ to 2 lbs/liter.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want to know if my breast implant got ruptured. I got in a car accident last week. My car was from the side and the air bag was deployed, striking my right breast with considerable force. Although both cars were badly damaged, no one was injured. The only injury I got was a big right breast bruise and pain. I still have pain and numbness on the right side of breast as well as the bruising. Is there any chance that my breast implant ruptured? I had silicone gel breast implants placed five years ago. I am worried about tearing my implant bag. There is no sign of any difference in size between the breasts and the pain is slowly becoming less. Do you think my breast implant is ruptured?

A: The majority of silicone breast implants fail (breast implant rupture) by the development of a small tear or hole that develops from fatigue fracture of the shell in one area. But acute high impact trauma, like from the deployment of an airbag, is one example of the type of force impact that could cause breast implant failure. With considerable bruising of the breast and pain you understandably have legitimate concerns about the integrity of the underlying breast implant. For a variety of reasons, including legal documentation, you should have the breast implant evaluated. Either an ultrasound or an MRI would provide a good assessment of the integrity of your breast implant. You should see a board-certified plastic surgeon for an evaluation and to have the appropriate test ordered.

Dr. Barry Eppley

Indianapolis, Indiana