Your Questions

Q: Dr. Eppley, I am interested in a rhinoplasty and want to know if it is better to have it done open vs. a closed approach. My nose has a big and wide tip and hump that I want changed. Does one approach offer a better result for my nose?

A: The question of whether a primary rhinoplasty procedure should be done with an open or a closed approach is an historic debate. When it comes to revisional rhinoplasty, there is no debate that an open approach is almost always better depending upon the nasal problem being addressed. But in an unoperated nose like yours (thick skin, bulbous tip, dorsal hump) the operative approach is largely based on surgeon experience and preference. But most rhinoplasty surgeons today would opt for an open approach because it provides a more complete assessment of the structure changes and the prevention of complications that can occur from these structural changes. (middle vault collapse, asymmetries, supratip defomities) Open approaches do tend to have more prolonged tip swelling but that is a small price to pay for a more exacting result long-term. Many patients are concerned about the  scar from an open rhinoplasty but an incision is this small strip of skin between the nostrils heals remarkably well and rarely can be ever seen afterward even on close inspection.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in an HTR cranial implant replacement. (or maybe one made of PEKK)  I suffering a stroke in April which required a decompressive craniotomy. The removed cranial bone flap was finally reinserted 6 weeks later but then it got infected which required a heavy course of antibiotics and subsequent removal of it. I am now seeking to replace it with an alternative.

I have been in contact with Biomet, and as far as my understanding goes, they are able to make an exact replica of my skull from an MRI image and also that the bone cells actually adhere to this material.  Please confirm.

If you could share with me your experience regarding these materials, including but not limited to length of time you have been performing this surgery, risk, success rate, recovery time, cost, risk of flying with a bone flap, how long I would be under your care, how soon I could anticipate the surgery and anything else that I may have missed, I would very much appreciate it.

A: My experience with cranial implants and HTR cranial implants specifically is considerable. Understand that PEKK is a different material and manufacturing process and offers no advantages in cranial implants in my opinion, most importantly it is not a porous material that creates interconnect porosity. I have worked with Biomet since 1991 on HTR-PMI and have done many cases since, both cranial and otherwise. The HTR material and its composition does offer excellent tissue ingrowth and direct bone bonding to it. (I did the original research in 1995 that substantiates those tissue effects to it) As a synthetic replacement for cranial bone, it offers the best material properties in my opinion. Of the many I have placed i have yet to have an infection or the need to remove one from any complications.

While I don’t know the exact location of his cranial bone flap loss, the replacement surgery is fairly straightforward. A 3D CT scan is obtained from which an exact patient model is made. From the model, an exacting HTR cranial implant is made. Surgery involves reopening the scalp incision and inserting it into position, which usually has a good fit and rarely requires any intraoperative modification. The implant is then secured into place by small plates and screws and the incision closed. Depending upon the size of the defect and the patient’s physical health, it could be either an outpatient or overnite stay at the longest. The patient could return home within 48 hours and there would be no problem flying with a new cranial implant in place. Neither implant or the small titanium plates and screws are detectable in airport scanners. (do not set them off)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in some form of facelift or facial rejuvenation but just not sure what. Not sure what procedures I would need to get rid of wrinkles, sun damage, and acne scars. I have attached some pictures of my face so you can see how bad I look.

A: In looking at your face, one of the fundamental problems is the large amount of loose skin which is contributing to the appearance of so many wrinkles. Rather than the loose skin just hanging off the facial bones, some people like you have it just pile up on the face. This also makes the acne scars look worse.

With this underlying skin problem, there are two fundamental approaches to take for your facial rejuvenation. The ideal approach would be a two-stage treatment consisting of a  first stage lower facelift and browlift to get rid of much of the loose skin and to tighten the face. Then a second stage could be done of a full face laser resurfacing or deep chemical peel to smooth out more of the smaller wrinkles and lessen the acne scars as well. Such skin resurfacing can not be done at the same time as the facelift due to healing concerns of the skin.

The second approach, not as ideal, is to just do the facelift or the laser resurfacing. Both are beneficial and would provide some significant benefit by themselves without the other. But the result would not be the same as if both were done. If one had to choose just one, skin tightening provided by the facelift would be the best choice as the one treatment.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in cheek augmentation but am not sure which option to pursue.  Can you help me decide between fillers and cheek implants?

A: Cheek augmentation can be done with a variety of methods because the cheek is a rather indistinct structure that does not have sharp contours. Thus cheek augmentation usually only requires a mass effect which rarely has to have very distinct contours. Fillers and implants make up the two categories of treatment options that can have similar effects but different methodologies and short and long-term effects.

Synthetic injectable fillers are the easiest approach as they can be done in the office and can be placed anywhere on the cheek. Their effects are instantaneous and there is little swelling and no recovery. Their downside is that they will not be permanent and must be repeated to have a sustained result, regardless of the filler type used. For many this can be  a good test or trial if one is uncertain about whether cheek augmentation is for them.

The natural injectable filler of fat offers the potential of longevity but its complete survival is not assured. This is why cheek fat injections are often overdone to some degree building into the result some amount of postoperative fat resorption. Because this requires the harvest of fat, it is usually done in the operating room and usually as part of other face or body procedures.

Cheek implants offer a reliable method of permanent volume augmentation that can be placed in a variety of cheek locations due to the different implant styles and sizes available. This is the most invasive approach and is done from an incision inside the mouth under the upper lip. If the implants are properly selected and placed, potential complications such as cheek asymmetry or an unaesthetic shape can be avoided.

When all put together, one should do synthetic fillers if one is uncertain about the benefits of cheek augmentation, use fat if doing other surgery and want a natural cheek augmentation effect or use implants if one is certain about their desire for cheek augmentation and/or want a permanent and/or dramatic effect.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a rhinoplasty revision.I had my nose done twenty years ago. I have a boxy tip and I would like to shorten my nose . My nostrils are big and long. I want them short and round. I want a cute small shorter nose. I’m wondering if there is hope for me. Thank you.

A: When it comes to a rhinoplasty revision, there is always hope. The key to achieving a shorter or smaller nose, in just about any patient, is the thickness of the overlying skin. When the cartilaginous portion of the nose is reduced, particularly the tip, the overlying tip skin must shrink down to reveal the reduced length of the tip cartilages and the greater narrowness of the dome cartilages that has been created. In a thin-skinned patient, such as yourself, this is most likely to occur. In thicker-skinned noses the thickness of the skin often does not reveal the new cartilage shape very well as it may actually become thicker as it contracts, failing to show the details of what was done underneath it.

When the nasal tip length shortens, the shape of the nostrils will change somewhat. Instead of oblong vertically oriented nostrils, they will be shorter in length and somewhat rounder in shape.

Whether any of these rhinoplasty revision changes will create your ideal shorter nose is a matter of personal opinion, but it is fair to say that it will be closer to your nose shape goals that before. You do have the best nasal skin to make that possible.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a new procedure that I have read about known as a knee lift. I have ugly rolls of skin just above my kneecaps that I just hate. They make me look like I have old lady knees. I know there is a scar but I think that would be a lot better than what I have now. How is a knee lift done and what is the cost? 

A: Like all body areas, the knees do show the signs of aging. The constant flexion and extension of the knee eventually causes loose skin to appear in folds or rolls above the kneecap. These suprapatellar skin folds can also be exaggerated by the downward descent of the thigh skin which pushes down against the fixed skin on the kneecap.

A surgical knee lift involves the direct excision of these folds of knee skin and leaves behind a curved suprapatellar scar. The creation of this scar in a visible area is the primary reason why it is infrequently performed. This is done through a crescent-shaped excisional pattern. The key to creating the best knee lift scar possible is precise placement of the excision location and to not remove too much skin. Since the width and appearance of scars is highly influenced by the tension they are under. too much skin removal across a joint that repeatedly flexes will lead to a wide and very visible scar.

The knee lift is done under local or IV sedation anesthesia. Long-term suture support is needed to resist the stretching of knee flexion and to help keep the scar as narrow as possible. The knee incisions are taped and ace wraps applied. Patients only need to avoid bending their knees greater than 90 degrees for a month after surgery. Other than that ther are no specific physical restrictions.

For the woman who considers a scar trade-off better than unsightly knee skin rolls, the knee lift can be a very satisfying procedure. Whether done under local or IV sedation anesthesia, the total cost is in the $4000 range.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have some questions about brow bone reduction. I read your case study “Reduction of Prominent Brow Bones in Men” and was wondering what the cost would be to have a surgery done like this? I have a prominent brow bone and would like to have this feature removed from my face. How long is the surgery? What are the long-term effects of the surgery? Are there any medical conditions that could occur as a result of the surgery? 

A: Brow Bone Reduction surgery is typically a 2 to 2.5-hour procedure. The surgery is performed through a scalp incision way back from the frontal edge of the hairline. The outer portion of the prominent brow bone is removed and reshaped to create a flatter appearance. The procedure is highly successful with no known medical conditions or problems associated with the surgery. The only potential issues are aesthetic in nature, with the risk of asymmetry of the bones and some persistent forehead numbness (though both are uncommon). The cost of a brow bone reduction procedure falls in the range of $8,000 to $9,000. I would be happy to review any pictures you could send me to see how this procedure may be of benefit to you.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in some lip augmentation procedures. My lips are getting thin with lines above them and the sides of lips are turning downward. So I would also want to have lip enhancement like implants which are permanent. And a treatment to reduce the lines above my lips.  Can I have these procedures on the same day? I have attached some pictures of my lips close-up.

A: Your lip augmentation will require a composite of procedures to get the best overall result. You actually do have some reasonable vermilion height although the upper lip is thinner than the lower. Your upper lip is also very long. Putting these lip issues together the best approach for your upper lip is a subnasal lip lift (to shorten the length of the upper lip), lip implant (for permanent volume), extended corner of mouth lifts (to lift up the corners and to make the tail ends of the upper lip thicker) and laser resurfacing of the upper lip. (to reduce the depth and number of vertical lip lines) These combined lip procedures can be combined with a lower facelift which is commonly done.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a large breast augmentation. I am  5′ 3”, 112lb, cup size 32 A. Would a 500cc breast implant be too big for me do you think? I know what look I want and I know there is some increased risk with bigger implants. I tried on sizers in the office with the Volumetric Sizing System and 500 did not look too big to me. But the number does sound big.

A: The concept of a large breast augmentation is somewhat of a subjective one. Everyone’s interpretation of what that means may be somewhat different. While the number of 500cc breast implants is a big number and on a small frame will certainly look big, the most important question is what you think about its size. If you have tried on sizers and feel that it it not too big, then it is not too big for the look that you want. The other thing that you have to look at is the base width of the implant and see how that compares to your natural breast base width. With a high profile breast implant you want to make sure that it does not exceed  your natural breast base with so the implants are not too far to the side. When the implants get too far to the side because of their base width, they will generally be considered too big.  If so, you should then consider dropping down to 450ccs or less.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have bilateral implants for my top lateral teeth. I was born without my permanent ones. I had this surgery and the oral surgeon told me my bone was not thick enough for the implants. They did the implant surgery and then did graft work. I had a total of 3 den grafts which my body rejected all three. They said the next step was to use my own bone, by removing it from somewhere or growing new bone from my DNA in a lab and then grafting it. Also, my implants are slightly exposed when I smile big and I am very self conscious about this. I would like this fixed. I am also wondering if I can have this grafting  done with bone from my protruding chin. Is there a way they can reduce and graft in one surgery.

A: Your prior maxillary bone graft failures sound like it was allogeneic or cadaveric bone, which is commonly used and can be successful, is never as good as your own bone. Forget about growing your bone cells in the laboratory, use good stock bone grafts harvested from the nest donor source available…you!!

Small bone grafts can be harvested from numerous face and skull areas. Each graft probably needs to be less than 1 x 1 cm so using your chin is a real likely possibility for  for a donor source. Depending upon how your protruding chin is reduced would determine how the grafts would be harvested and shaped. Chin reductions (bone graft harvests) can be done from an interpositional intraoral osteotomy or from a submental vertical chin reduction approach. When you are using your own bone, it is imperative that it is harvested and placed during the same procedure.

The more practical limitation of using your chin as the donor source for maxillary grafting is whether your surgeon feels comfortable harvesting and reshaping the chin at the same time.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in liposuction of one thigh. I had an injury that created a large hematoma on my upper thigh and I would like it removed. (It is stable). The hematoma occurred when I fell off of one of my horses and he jumped on my leg a few times (also happened to the other leg, but not as extensively).  It tore my quad and created the “dent” that you can see as shadowing in the picture. The hematoma is behind that.  It has settled into the size that it is now.  My grandfather (retired surgeon), stated that he was most familiar with cases where they would evacuate the hematoma after it was non-expanding.  He may have outdated information, as he is 84!  If you have any other ideas for treatment, I would be very interested.  I also attached a picture a few days after the injury occurred.

A: Liposuction may or may not be what you are looking for. Large expanding hematomas may need to be surgically drained if they create a large pocket, but that is not what you had. You had generalized bruising through the thigh musculature which must be allowed to resolve on its own…which yours now has. Liposuction is never a treatment for a hematoma regardless of the type.

The dent that is now in your leg is the result of the initial hematoma due to subcutaneous fat atrophy. Between the initial trauma to the tissues and the breakdown products of blood, some fat loss has occurred and this is why you have the dent. (tissue loss) This is extremely common occurrence from large hematomas.

Fat management is the key to improvement in your thigh contour but there are two different approaches depending upon what you want to achieve. If you want the surrounding contour to be even at the level of the dent, then the surrounding thigh areas need to have liposuction down to it. If you want the dent to be built out back to the level of the rest of the thigh (as it was before) then fat injection grafting is needed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in temporal reduction. (head width narrowing) Since I am a young child I haven had a serious problem with the shape of my head. It is almost totally flat at the back and bulges out quite a lot not just above my ears but at the whole temporal area, because of the permanently wrong sleeping position as a baby. Now I am 21 years old and my head width is 177-178 mm , while the average male human breadth is about 150-155mm (depends on ethnicity and height). I am 183 mm tall and in my whole family there is no such a case like me so that it is definitively no genetic reason for that excessive width. Furthermore there is an asymmetry as the right temporal region sticks out for about 3-4 mm more than the left side, so that when I haven’t long hair it can be seen. Now my two questions:

1) Is it possible to reduce the temporal region in order to make it more acceptable ?

2) How much would it cost as it is not just a small bulge but an area with about 40 to 50 square cm on each side? I have attached pictures of my head with line drawings so you can see what I am talking about.

A: Temporal reduction can be an effective head narrowing procedure in the properly selected patient. A bulging side of the head is made up of a combination of temporalis muscle and temporal bone. While many perceive that the problem is too much bone, the reality is that more than 50% of any temporal convexity is muscle. The smaller the amount of temporal convexity, the more that the attachment and thickness of the muscle is the problem. Your pictures show a mild to moderate temporal convexity (in my experience) which indicates to me that a muscle reduction/shortening would be an effective solution.

When it comes to temporal muscle reduction, there are two approaches…injectable Botox and surgical reduction. Botox injections can work for permanent reduction in the thickness of the muscle and has the advantage that it can work on any area of the muscle. Its disdvantage is that the result from its use take time, require multiple treatment sessions and may not work for everyone. Surgical reduction produces an instantaneous result by permanently and immediately removing a portion of the muscle. Its disadvantage is that it does require small vertical incision and can not reach all areas of the muscle.

When you look at your side diagram with your drawing, surgical reduction can reach the back half of that drawing but the thickness of the muscle at the edge of temporal hairline and in the non-hair bearing skin to the side of the eye is beyond what surgical muscle reduction can reach.

Based on your temporal areas of concern, you could either try a series of Botox injections or combine surgical reduction with Botox injections for the most forward part of the temporalis muscle.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in custom facial implant (jawline) revision. One month ago, I had a custom wrap around jawline implant placed which is way too big and disproportionate to the rest of my face. I think that it should be removed or at least reduced in size as soon as possible. Is this possible at just one month after surgery?

A: Let me first provide you with some comments about a custom jawline implant that come from a more objective perspective. I have done many standard and custom implants for young men and there is almost always a fairly standard pattern of postoperative behavior and anxiety in the early postoperative period….many think the implants are too big/asymmetric/not right and want it immediately downsized/revised or even removed. Sometimes this is true but most of the time it is because the patient has does not have an objective perspective and is finding it difficult to go through adjusting to their new look…even if it was exactly what they said that wanted. This is a phenomenon that I call Facial Structural Accommodation. I would urge you to be more patient with your result, not because a great amount of swelling resolution is going to make it smaller, but because you need time to let the result soak in. Oe month is simply not long enough to really know. Doing something now may be very capricious and a decision you may come to regret later. While I obviously don’t know what you looked like before or after this surgery, most men that I have seen in similar situations rarely have an after surgery result that would be objectively viewed as way too big.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am wanting to change the look of my face I am 20 years old and am very desperate about my appearance. I want to change my facial features like someone else, like maybe a 60% look like that person. I am willing to change my ears and eyes. Is it possible?

A: As a general rule, It is not usually possible for anyone to look like someone else regardless of how much plastic surgery they have. (although there are clearly documented instances where this is not exactly always true as a few people have spent have spent a lot of money on so called celebrity makeovers)  Having said that there are instances where substantial improvements/changes to a face can be made (perhaps a ‘60% look’) based on how close one looks like what their ideal face is. In some cases there may be just a few facial features that is the real difference between two faces and changing these may make that ‘60% look’ possible. I would have to see pictures of your face and your ideal face to see whether such changes may be possible. You have  mentioned the eyes and ears so I am assuming you see these areas as the biggest changes needed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am getting breast implants in the near future. I am currently a 32A and am looking at 400cc silicone breast implants. (high profile) My hope is that they will make a full C or a small D cup. I am 24 years old and am 5’ 3” and 115 lbs. I tried the 400cc sizers in the office and they looked a little big to me. But I was told that they may look a little smaller since they are going under the muscle and that it was always a good idea to go a little bigger than you think anyway. I’m not sure if I should go with 400 cc or go smaller to be safe. On the one hand I don’t want to be too big but I’d hate to wish I would’ve gone bigger afterwards.

A: There is no question that the biggest issue in getting breast implants, for the patient, is what size in volume to get. The reality is that there is no magical and assured method that can guarantee any patient that they will get end up with the exact breast size that they want. No matter how it is done there is some ‘guessing’ involved and there is always the unknown variable of how any patient interprets what a C or D cup looks like in their mind. With that being said, there are certain presurgical measurements that can be done to help hedge the bet so to speak.

The Volume Sizing System is very good at providing a good estimate of the final size and this should be a good guide. If you think it is just a little big then drop down 25cc to 50cc. From this volume, the patient’s breast base width can help guide the projection that the implant should have, keeping it within the dimensions of one’s natural breast base width. High projection silicone implants should only be used if one wants a very round or full look, If not then consider either a lower projection or even a shaped (teardrop) implant.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I may need a revisional rhinoplasty? I did not have breathing problems before I had a rhinoplasty? When I went back for a six month follow up I was told I had a deviated septum and needed more surgery. I was told I did not have one before surgery but that it has grown back that way now. Could the rhinoplasty have caused the deviated septum? Or was the deviated septum there before and it was just missed during the initial rhinoplasty?

A: One of the most common reasons for revisional rhinoplasty surgery is nasal airway obstruction. A recent published study of revisional rhinoplasty reported that up to 70% of patients had some degree of airway obstruction and was a main motivating factor for the surgery. There are many potential causes of breathing problems after rhinoplasty of which a deviated septum is but one. Usually, however, a deviated septum is diagnosed before or during the initial rhinoplasty and only ‘recurs’ because it was inadequately corrected. If there were no breathing problems before surgery, it would be unlikely that a deviated septum has developed now. With cartilage graft harvest, presuming that was done, septal deviation is less likely to occur.

One of the most common causes from the initial rhinoplasty is if osteotomies or breaking of the nasal bones was done, particularly if a low-to-low or even a low-to-high osteotomy pattern was done. A low initial starting point for the osteotomy can partially close down the airway. Another common reason is collapse or pinching of the middle vault which narrows the internal nasal valve, a critical point for airway passage in the nose. Both of these sources of nasal airway obstruction come from the common aesthetic manuever of taking down a hump or bump in the nose particularly if it is large. This can cause collapse of nasal structures which have to be recognized during the initial procedure to enable preventitive manuevers to be done.

The short answer to your question is that there may be other causes of airway obstruction besides a deviated septum that must be taken into consideration.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had gynecomastia reduction surgery 2 months ago and I am not happy with the results. It was initially very flat right after surgery but I have subsequently developed hard lumps under the nipples that now make them stick out a bit. This makes me mad since I paid good money to have a flat chest. What can I do about it now?

A: What you are describing is very common after gynecomastia reduction surgery in young men. Many open gynecomastia patients will develop a scar lump under the nipple after their procedure even though it looked initially quite fat. Whether this scar lump will go away or not takes time to see and two months after surgery is too early to tell. About 10% of open gynecomastia reduction in young men will develop these persistent scar lumps that may require a revision to remove and make completely flat if it persists. This is not reflective of a poor surgical technique or even a poor surgical result but is the unknown and uncontrolled variable of how one forms scar tissue in the space where a small or large lump of tissue had been removed. What I would recommend now is to have either Kenalog (steroid), 5-FU or combination kenalog/5-FU injections to try and soften the scar and make it go flat. Now is the time to do this, not 6 months after surgery where it would be much less effective when the scar tissue is mature. Whether this will be completely effective can not be predicted but at least this provides a chance for success. If not, you are going to require a revisional gynecomastia reduction procedure to remove the scar that has developed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have an unusual tummy tuck question. Can a tummy tuck be performed at the same time as when one is delivering a child? I have never heard of this before but it just seems to make sense to me. I have had two children by c-section and am thinking about having a third  and with the excess skin already present this just seems like a perfect time to do it. Is this a crazy time to do a tummy tuck? Or should I just wait and do it after? How much weight should I lose before doing it after delivery?

A: Having performed three tummy tucks at the time of delivery I can speak to the fact that it can be done. While a ​tummy tuck can be done at the time of delivery, it is not going to be the traditional or full tummy tuck procedure. Because of the enlarged uterus, muscle repair is not done in the traditional fashion (hard to close over a big uterus) and the tummy tuck is limited to the amount of skin that can be easily removed without too much tension. The scar will end up being much longer than that of the c-section scar you have now. While producing a significant improvement, it is never as good as a tummy tuck that is done six months or later after delivery. When done well after pregnancy, it is a good idea to lose as much weight as possible to get the best benefit from the tummy tuck procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in an umbilicoplasty procedure. I hate the look of my bellybutton as it sticks out and want a prettier bellybutton that turns in like most people. How is the procedure done and was is the approximate cost of turning an ‘outie’ into an ‘innie’. Thank you.

A: The bellybutton or umbilicus is the residual attachment of the umbilical cord. It forms a visible depression in a very constant and central location on the abdomen. Underneath it lies the midline union of the paired vertical rectus muscles which will also have a depression or concavity in it, making it a structural point of potential weakness and the potential for a hernia. Most commonly the navel appears as a depression or innie which occurs in about 90% of people. In the minority (10%) an outie belly button is present which can either just be from extra skin left over from the umbilical cord or exists because the skin at the base of the belly button is pushed outward from a protruding hernia.

Differentiating the type of outie bellybutton is important as that determines how it is done and the cost of the surgical techniques to do it. An outie that is just a stump of skin (no hernia) can be done in the office under local anesthesia. The stump of skin is removed and the edges sewn down to create the innie look at a cost of $1500. If the outie has a palpable hernia, it will need to be repaired in the outpatient operating room under IV sedation. The umbilical hernia needs to be repaired at the same time with a total cost of between $2500 to $3000.

How do you know if your outie has a hernia? Push inward and see if you can feel a ring or hole underneath. Also an outie that is just a stump of skin can not be displaced inward. (the stump gets pushed in but the stump keeps its shape) The outie that can easily be pushed inward through the inner ring or hole has a hernia.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am considering jaw angle implants. I have been considering your reply to me about the possible unaesthetic fullness of my lower face due to the horizontal impact of the implant. I was wondering if this is a set figure or if some of the width could be “shaved” off prior to insertion? I am anxious not to have a “chipmunk” roundness I am truly very aware that I am by no means a beauty, far far from it, but my reasons for the jaw angle option was that I could get rid of the prominence of the jaw in my profile. I think you can see that there is quite a difference in my profile looking left and right. There is also a slight asymmetric difference in my jaw angles as the right appears to be higher.  If this is to proceed then I am wondering about the length of time that I should set aside for a visit to you , consultation and surgery and recovery. I should mention that my current weight is 83kg and I understand that my proper weight should be closer to 77kg. Would dropping this weight have any affect on the procedure? I ask this as I am currently working very hard to reduce my weight with diet and lots of exersize. 

Many many thanks.

A: JAW ANGLE IMPLANTS COME IN A WIDE VARIETY OF VERTICAL AND WIDTH NUMBERS AND ANY OF THEM CAN BE ADJUSTED DURING SURGERY. THE BEST WAY FOR YOU TO AVOID AN UNAESTHETIC ROUNDNESS IS TO SHAVE THE JAW ANGLE IMPLANT sO THAT IT ACTUALLY COMES TO A VERY SHARP FLARE. WITH YOUR THICKER TISSUES THIS WILL THEN NOT MAKE IT LOOK ROUND BUT RATHER PROVIDE A HINT OF ‘ANGULARITY’. THE POTENTIAL UNAESTHETIC FULLNESS IS CONTROLLED PRIMARILY BY HOW THICK THE SOFT TISSUES ARE AND THE HEIGHT OF THE JAW ANGLE. MOST PATIENTS COME IN THE DAY BEFORE SURGERY, HAVE SURGERY THE NEXT DAY AND RETURN HOME IN 48 HOURS BASED ON THEIR COMFORT TO TRAVEL. I DON’T THINK THAT RELATIVELY SMALL AMOUNT OF WEIGHT MAKES ANY DIFFERENCE FOR THIS FACIAL SURGERY. I BELIEVE YOU HAVE EXPLAINED IT VERY WELL. THE KEY IS TO CUSTOM CARVE AN IMPLANT FOR YOU THAT REALLY ACCENTUATES THE ANGULARITY OF THE JAW ANGLES. MOST JAW ANGLE IMPLANTS HAVE ROUND ANGLES WHICH IN YOUR CASE MUST BE MODIFIED.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in having superficial temporal artery ligation done. I’m a 30 year old male who over the past year I’ve lost weight and workout very frequently, which I believe has caused the superficial temporal artery on one side of my forehead to become very prominent. I’ve been checked out by a vascular surgeon and there is nothing medically wrong that is causing this. I’ve subsequently consulted with two plastic surgeons who’ve both said they don’t recommend having this removed. It’s really become bothersome to me. In searching, I found that you have provided information about performing this procedure. Do you consider this procedure safe or what are the possible risks? I guess I’m wondering why other plastic surgeons seem so reluctant to do this. Is there a possibility I could travel to your location to have this procedure done? I greatly appreciate any help you can provide. I’d really to do something about this issue and am hoping you can help.

A: Superficial temporal artery (STA) ligation is a fairly simple procedure that is often done under local anesthesia. There are no significant risks in doing it other than the small scars needed to access the artery to tie it off. Generally there needs to be at least two points of ligation to prevent backflow and return of the visible pulsations. One of these small incisions is always in the hairline and the other one or two is determined by the course of the artery beyond the temporal hairline. STA ligation is done under local or IV sedation anesthesia. There is no real recovery from the procedure as no swelling or bruising usually occurs. As this is an uncommon aesthetic facial procedure and patient request, most plastic surgeons have most likely not performed it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I am interested in scalp scar revision. I see you have extensive experience on scars from hair transplantation. Nearly twenty years ago, I had the old hair plugs and have about 1,000 elevated plugs on top of my scalp that look like mosquito bites. I tried to shave my head and get micro pigmentation to conceal them so I could wear my hair short. Unfortunately the bumps are noticeable in the bright light. I would like to have them flattened as much as possible but have received mixed reviews from Doctors. Some recommend laser resurfacing, others say kenalog injections, others say dermabrasion. What would you recommend if there is anything? My goal is to keep my hair buzzed so I would need to improve the 1,000 circular scars in the back of the scalp as well as a strip scar on the sides and back. Any recommendations?

A: When it comes to reducing the raised hair plug areas, it is best to think of it as reduction of a hypertrophic scar…as this is essentially what it is. This requires an aggressive form of skin resurfacing.. This is not an indication for steroid injections. Dermabrasion would be the best approach as it can create the greatest amount of selective reduction of each plug site. Laser resurfacing could also be used but it would have less of an effect and may take longer to heal due to the thermal injury.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in breast augmentation revision. I had breast augmentation three years ago. Right after I had major issues with my right breast implant.  It was smaller and now moves around a lot, almost like its not even in place now. In addition, it is painful. My previous surgeon went through my armpit to place them and whatever he tied his suture to it is no longer attached. And he doesn’t see an issue after multiple visits.  I just want to cry. I have decided to move forward and have heard multiple positive reviews from patients that came to see Dr. Eppley.  Very excited to see the light at the end of the tunnel!!!

A: It is hard to tell based on your description as to the exact nature of the problem with your right breast implant. Besides being smaller and moving around more, the source of the pain is not clear. Usually pain with breast implants is associated with either a tight pocket, capsular contracture or a ruptured silicone implant. I am going to assume that since your implants were placed through the armpit that they are saline implants.

Regardless at least a right breast implant revision is going to be needed. That will have to be done through a new inframammary fold incision. You talked about ‘ a suture that was tied that is no longer attached’ but such an entity during transaxillary breast augmentation surgery does not exist so that is an irrevelant issue. The question is whether this is a pocket adjustment with more volume added to the existing implant or whether a new implant is needed. This will require a physical examination to determine exactly what needs to be done.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a custom jawline implant. Roughly what is the cost of a Custom Jawline Implant and the procedure if I want a very large implant enclosing the entire chin and jawline and angles, adding quite a lot around the angles, increasing chin projection up to 25mms?

A: A custom jawline implant is fabricated from a patient’s 3D scan. From this a completely customized implant is made from one jaw angle to the other. While any dimensions can be made on the model using design software (up to 25mms at the chin), there has to be enough soft tissue along the jawline so that the implant will actually fit into place. Realistically, having placed many custom wrap around jawline implants, a chin enlargement of 25mm horizontal advancement is likely more than the neck soft issues (which is where the skin must come from) can accommodate.  This is too much soft tissue stretch when you factor in that the implant wraps the whole way around the jaw. A more reasonable approach is around 15mms or so of horizontal chin advancement. You must also factor in the lower lip position and the depth of the labiomental sulcus which will be severely left behind when the chin comes that far forward. The total cost of such an implant, all costs including fabrication and surgical placement, is in the range of $12,000 to $ 13,000.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in skull reshaping. The occipital bone on my skull is flat and I am interested in correcting this, preferably with an implant. Surprisingly, you and a Korean clinic are the only 2 places I have found so far for this procedure. I have already ready about the risks and complications for elective surgery, I have read some of your blogs and had a few other questions. How many skull implants have you preformed and what complications have you seen? Do you recommend the putty over implants or no? I would worry that the putty would cause more complications and would be harder to remove if something went wrong. How much do you charge of this surgery? How long does the surgery take and what is the procedure? Could a rhinoplasty be combined with tis surgery and at what additional cost? If I opt for a rhinoplasty, would it be better to do the skull reshaping first and base the amount rhinoplasty on the new skull shape or vice versa? Thank you for your time and consideration.

A: Skull reshaping surgery is commonly done for a flat back of the head. When it comes to occipital augmentation for a flat back of the head, there are different types of augmentation approaches as you have mentioned. Bone cement or bone putty (PMMA or HA) and a preformed silicone implant can be used. There are advantages and disadvantages to either approach. Bone cements offer materials that do bond to the bone and can be impregnated with antibiotics as they are mixed intraoperatively which are their advantages. I have yet to see an infection with a bone cement cranioplasty. Their disadvantages are that they must be molded and shaped as they are applied as a putty so they can have some irregularities and palpable edge demarcations which is the number one reason a revision on them may occasionally be done. A preformed silicone cranial implant is perfectly shaped and its flexible characteristics makes it very adaptable to the bone without edge demarcations. Its softer material also allows it to be placed through a smaller incision. But the material does not bond to the bone and ideally should be secured in place by a small titanium screw. Its infection risk is somewhat higher and it is the only cranial implant that I have ever seen develop an infection and had to be removed. (one case)

Regardless of the material, both are easy to remove and the actual material cost is not significantly different. Most occipital cranioplasties take between one to two hours to perform and total cost will be in the $8,000 to $9,000 range.

Rhinoplasty can certainly be done at the same time as any skull reshaping surgery and actually commonly done, regardless of the type of rhinoplasty needed. If one separated the two procedures,   the order that are done on does not make a difference.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am looking to see if you can do a lip widening surgery technique. I have tried fillers and implants and nothing seems to work as my lips are just toooo small for my face. I look so disproportionate and really I am tired of it. I’m still single, and would really like the confidence to know that I have a beautiful smile.

A: Lip widening surgery, know as a lateral commissuroplasty, is done by opening up the corners of the mouth in a Y-V mucosal advancement procedure. The Y is in the incision pattern with the vertical aspect of the Y being the horizontal incision that determines how much the corners should be opened up. The V part of the Y are the incisions that then follow the natural  border of the vermilion-cutaneous junction of the upper and lower lips. Small triangles of skin are then removed and the vermilion and mucosal are brought out from inside the mouth to make the new corner of mouth opening. This does result in very fine line scars that end up along the vermilion-cutaneous junction of the upper and lower lips at the mouth corners. This lip widening surgery is done under local anesthesia as an office procedure in most cases. Usually the width of the mout can be opened 5 to 7mms per side without causing any lip distortions. There will be a period of time when the mouth corners will feel a little tight and stretching exercises can be done beginning three weeks after surgery when the incisions are well healed to hasten the softening process.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in skull reshaping. I am a 25 year old male that has  suffered from an odd shaped head. Its wide on the sides and irregular shaped on top. For years I’ve had a great insecurity every time I looked in the mirror. I have tried many different hairstyles to hide my head shape but none work for very long. I just feel like its the only part of me thats incomplete and if i have it fixed i will be so much happier and confident. I am determined to have it fixed even if i have to do it myself. I have attached a few pictures of my head.

A: What your pictures show is that the shape of your head is due to a minor variant of sagittal craniosynostosis. This is why the shape of your head has a sagittal ridge or crest from front to back and is a little elongated. Accompanying this is a parasagittal deficiency, which with the sagittal crest, gives your head a peaked or more triangular shape. The typical skull reshaping strategy is to burr as much of the sagittal crest as possible and buildup the sides to create a less peaked and more rounded skull shape.

While this is surgically possible, and a major improvement can be obtained, this has to be done through an ear to ear scalp incision. This must always be considered careful in any man who shaves his head.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a form of scalp scar revision I had hair plugs done many years ago which has left me with a lot of ‘bumps’ on my head since I now shave my head. Can these be reduced in any way so that my scalp is more smooth and not so bumpy and irregular?

A:  Your scalp issue does represent an unusual form of hair transplant scar revision. Most commonly this issue relates to the donor site scar on the back of the head. But old style large follicular unit plugs can certainly be an issue if one is now shaving their head or wants to. Trying to get good improvement in your scalp situation is not an easy one even though the techniques to do it are not hard per se. Ideally what you should do is a ‘test patch’ of a scalp area with dermabrasion to see how improvement you can get before launching forward on your whole scalp. If a small area done under local anesthesia shows good improvement then you could do your whole scalp under anesthesia. On the one hand this is not the most efficient way to do it but there would be little sense in doing your whole scalp if the amount of improvement would not be worth it. This issue applies to both the donor and recipient areas. It is just hard to predict what the level of improvement would be had with dermabrasion for your hair transplant scar revision so you want gauge the depth of your efforts by testing first.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had cheek and jaw angle implants four months ago. I see that you are ubiquitous on the Internet for cheek and jaw angle implants. My question: my right jaw has been very swollen to the point where I had an MRI that shows unusual swelling. As a result I’m scheduled to have that jaw area opened up and cleaned out with hopes of immediate replacement of implant. I was hopeful that during this same procedure I would have the cheek implants replaced with smaller ones and located a bit higher in my cheek area with more emphasis on the enhancement of the upper cheekbone. My surgeon said its not a good idea to work on the cheeks because of the inflammation in the right jaw. Is this true? If I’m going to be under sedation I would prefer to have the cheek implants adjusted. It would save me a third flight and money for sedation in the future. Your thoughts?

A: In regards to the simultaneous management of your cheek and jaw angle implants, I see no problem with doing them together. The ‘cleaner’ cheek implants should be downsized first and then the presumably infected right jaw angle implant should be opened and managed. I do not necessarily believe that one infected implant will affect unaffected ones of the sequencing in surgery is done in the right order.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I am interested in scalp scar revision. I see you have extensive experience on scars from hair transplantation. Nearly twenty years ago, I had the old hair plugs and have about 1,000 elevated plugs on top of my scalp that look like mosquito bites. I tried to shave my head and get micro pigmentation to conceal them so I could wear my hair short. Unfortunately the bumps are noticeable in the bright light. I would like to have them flattened as much as possible but have received mixed reviews from Doctors. Some recommend laser resurfacing, others say kenalog injections, others say dermabrasion. What would you recommend if there is anything? My goal is to keep my hair buzzed so I would need to improve the 1,000 circular scars in the back of the scalp as well as a strip scar on the sides and back. Any recommendations?

A: When it comes to reducing the raised hair plugs, it is best to think of it as a scar revision of a hypertrophic scar…as this is essentially what it is. This requires an aggressive form of skin resurfacing.. This is not an indication for steroid injections. Dermabrasion would be the best approach as it can create the greatest amount of selective reduction of each plug site. Laser resurfacing could also be used but it would have less of an effect and may take longer to heal due to the thermal injury.

Dr. Barry Eppley

Indianapolis, Indiana