Your Questions

Q: Dr. Eppley, I have been suffering from extremely dry lips for several years.  They are painful, inflamed, and become red throughout the day. My dermatologist prescribed several topical medications, but they did not work. I have consulted with him about a lip procedure called vermillionectomy using lasers that may provide the results I need to increase moisture to my lips. I have attached a picture of my lips for you to see my problem.

A: Thank you for sending your picture. In looking at it it appears the entire vermilion (red part of the lip may be involved….the picture is a little grainy) Then procedure of a vermilionectomy basically removes the dry part of the vermilion and moves out the wet part of the vermilion to the skin edges. This type of lip procedure is normally reserved for patients (usually older) in whom lip cancer involves the dry vermilion and it must be removed and reconstructed. It would work for the very dry lips because it is being replaced with vermilion which has salivary glands in it. It would make your lips, however, usually a little smaller and probably with a little less pout. (fullness) It could be regarded as an ‘extreme’ treatment for dry lips but, if the condition is severe enough, this may justify that surgical effort.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 66 years old. I have had breast implants for approximately 30 years and would like to have them removed.   I have Medicare / Anthem insurance, but I don’t know if they will cover this.  I would like to know how much this procedure would cost if I paid for it (without insurance). 

A: Congratulations on the longevity of your breast implants. Although at the time they were placed you probably thought they would last a lifetime, few patients ever do and one could predict a 10 to 20 year lifespan until the devices fail and have to be replaced. Thus you have done well. You did not state why you wanted your breast implants replaced. Is there a particular problem with them or is this just an aesthetic issue? Replacing them with new silicone implants will have total costs in the range of $5800. Issues to be considered are new size and style of the silicone gel breast implants and whether they should stay in their existing anatomic location (above or below the muscle) or be changed.

Your assumption is correct about insurance coverage. Breast implants are only a covered medical procedure if they are being done as part of a breast reconstruction after cancer or part of a revision of a prior breast reconstruction procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I currently have butt implants and I love the look of them, but I hate how they feel because I can feel the hard edges of the implants. I want to have them replaced using the softer silicone implants that are approved in other countries. If I purchase the soft implants online would you be able to perform the replacement surgery? Thanks. 

A: Do you know the manufacturer of the implants that you now have? I use Implantech very soft gel buttock implants that virtually feel like gummy bear candies (without any hard edges) so it is hard to imagine anything that would be any softer. But they can also be made in a very low durometer that can feel just like jello. Thus I am not sure any implant used elsewhere in the world would be any softer.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am going to have jaw angle implants in the next few weeks. I had a couple of questions for you for after the procedures.  I was wondering what my limitations will be in terms of food. I’m assuming chewing will be difficult so I wanted to prepare things to eat in advance for the first week or so after surgery. I don’t know if I will be on an all liquid diet for a while or if Iwill be able to eat soft foods (mashed potatoes, soup, jello, etc). I also have 2 big boxes of Boost just in case. Please let me know.

A: Your questions about eating are good ones as the jaw angle implants will cause some initial limitation in mouth opening due to masseter muscle trismus. That will take about 2 to 3 weeks before returning to normal. You can really eat anything you want as I don’t place any patient on restrictions, but realistically it will not be a normal diet initially. Soft foods and protein supplements like Boost are good suggestions.  You will find out quickly that cutting up solid foods into smaller bites will bypass the need for any substantial amount of chewing. Fortunately this phase is fairly short and the worst is over in 7 to 10 days after surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My problem is quite complex. I had a dimpleplasty last December and I was told it would take about 2 months for the dimple to flatten. I have waited 4 months so I had the Dr remove the retention stitch which he said would flatten my cheek. After 2 months it didn’t happen so I had a a buccal muscle closure…. It’s been 5 weeksnd no improvement. My surgeon says he’s out of ideas and there nothing more he can do..I am devastated with these two horrible indentations and would do anything to have my face back. I hope I can hear from you with great news.

A: I am assuming by your description that you have a cheek dimpleplasty to try and reduce/eliminate your cheek dimples as opposed to a dimpleplasty to create them. Both surgical efforts appears by your description to be done close the soft tissue defect/herniation below the dimple and nothing else was added. If this is an accurate interpretation on my part, my suggestion at this point is to add volume either through fat injections or a dermal-fat graft. Given the scar that is there now and the refractory nature of your cheek indentations, I would have more confidence in dermal-fat grafts at this point.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was curious if it is possible to receive these exact results from forehead reduction if I decided to go with the sinus removal and reshape instead of the tool to burr them down. Also I have what I feel to be extra bone above and on the sides of my eyes that are pretty prominent, thus making my eyes look a little sunk in. Can that be reduced as well? Lastly how far down do you think my hairline have to be reduced and does it look as though I need a tissue expander to achieve the results I’m aiming for or just a stage one?

A: Maximal brow bone reduction is always achieved with brow bone removal and reshaping. It is a far more effective procedure than just burring alone. By doing so I would be also be able to burr down the bone outside of the frontal sinuses (above the brow bone and on the side of the eyes) This bone is thick enough that burring alone would suffice. This would help open up the eyes.

In looking at where you are now and where you would like our hairline to be, that appears to be about a 3cm movement lower. That would require a first stage tissue expander for about three weeks prior to the second stage at which time the hairline can be advanced and the brow bones and eyes reshaped at the asme time.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am looking for someone who can give me realistic advice on how to reduce the size of my chin (mentalis) I heard botox is an option but probably wont have much affect. Are there any other options I could explore? I think there is fat in that area so would laser liposuction be an option? Any help would be great.

A: Thank you for your inquiry. I am not sure what you mean by realistic advice but here are the facts on chin reduction. A large chin is due to too much bone, too much soft tissue or both. Its reduction therefore must involve surgical reduction of either bone, the soft tissue cover or both. If the bone problem is one of too much vertical length, then an intraoral vertical reduction bony genioplasty is needed. If the bone problem is too much horizontal with or without vertical bone excess, then a submental bine burring reductyion needs to be done. All excessive soft tissues problems need a submental excision and tuck unless it is just a mild amount of laxity then an intraoral soft tissue suspension must be done.

I don’t know where the concept of Botox comes from since that is a temporary muscle paralyzer not a soft tissue reduction method anywhere it is applied on the face. No form of liposuction should ever be done on the chin as all it will do is dimple the chin and make it look irregular. The amount of fat in anyone’s chin no matter how big it is is very small and the chin needs it to keep an outer smooth skin contour.

The only way to reduce a large chin is surgery, removing either bone, soft tissue or both.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, can you tell based on your extensive experience as a plastic surgeon what is the deal with the Lifestyle Lift? I see their commercials all the time and it just sounds too good to be true. They say nothing about that it is surgery but no cream or laser can produce those kind of results. Is it legitimate or a scam?

A: The Lifestyle Lift is both a tradename and a company that sells a form of a facelift surgery. It is a company that spends a lot of money every year to generate business for its franchisees so to speak. Its most popular TV ad is the one that features Debbie Boone who is the daughter of Pat Boone, a teen idol of many years ago and is still alive. (I just saw him on an infomercial for a whirlpool tub for seniors just this morning)

Like anything that is highly marketed, it is going to attract its share of detractors. While I haven’t done an official poll, I feel confident to say the whole Lifestyle Lift concept is probably not thought of highly by many board-certified plastic surgeons…at the very least for competitive reasons. And there is no question the company has had its share of legal entanglements brought on by a history of aggressive marketing practices.

But all the political and emotional issues aside, the company promotes its facial rejuvenation techniques through licensed physicians who enroll to be a provider in a certain geographic territory. It is surgery and it is a form of a limited facelift. Many of the patients seen in ads clearly have had other procedures done than just the Lifestyle Lift as many facelift patients are prone to need and do.

What turns off most board-certified plastic surgeons is that the Lifestyle Lift is marketed as a new and innovative procedure (I believe ‘break through medical procedure’ is what the ads say) which it is not by any plastic surgery standards. The most novel feature of it is the name as such facelift techniques date back decades in time. Doing the procedure awake and having it done in ‘just over an hour’ is obviously very appealing to patients but that does not necessarily convey that it is a superior surgical result or one that any sustained longevity. Since no scientific study has ever been published on the Lifestyle Lift  in terms of its technique or patient outcomes in any professional plastic surgery journal or presented at any plastic surgery meeting, it is easy to understand why many board-certified plastic surgeons are taken back by its claims in its ads.

A prospective patient should view the Lifestyle Lift like having any other consultation from a plastic surgeon. Take in the information, do your research and make your own educated decision about whether it is right for you.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 42 year-old male whose hair is thinning. I am on Propecia and Rogaine and it seems to have slowed it down but is not causing any regrowth. I have read about PRP blood treatments for hair loss and wondered what your thoughts were on how effective it might be. I know you have a lot of experience with PRP so your insight would be very valuable.

A: PRP, an acronym for platelet-rich plasma, is a concentrate of platelets derived from a patient’s own blood. Because platelets are packed with growth factors, small peptides that help modulate wound healing when injured, they have been used and shown to be effective in many medical applications. Their success in wound healing and many reconstructive surgery applications and their lack of any known adverse effects  has naturally led for PRP to be extended into numerous cosmetic applications. It has been used as an adjunct in facelifts, injectable filler and fat grafting. It is presumed that the platelet concentrate has a tissue stimulating effect for regenerating lost or aging tissues such as fat and skin elasticity. The medical evidence for such effects is weak at best but the idea is so logical that its current use can best be described as a ‘what can it hurt’ approach. PRP use in hair loss treatments or in combination with Neograft follicular unit hair transplantation is another PRP application that has not been scientifically evaluated but numerous practitioners report favorable results with its use. The question of exactly how effective PRP is on stimulating the follicles of hair whether they are in their natural location or after transplantation is not yet known. I am optimistic about the effects of PRP on hair regeneration but no one yet knows how many injection sessions or how often or how many treatments need to be done for maximal benefit. Its use with other hair loss/regeneration treatments therefore is up the patient and their hair restoration physician.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My temples bulge out too much and I know it is the muscle because it gets worse when I clench my teeth together. Is it true that the less your muscle expands and contracts when chewing, the thinner it is? If I use my mouth less will the muscle shrink? Is surgery the only method to reduce the size of the temporalis muscles? How much would the surgery cost please, and would the muscles be taken off by excision? What risks are involved?

A:  Like all muscles, size is somewhat dependent on use. But one would have never open their mouth again to have the temporalis muscle shrink in size.

The non-surgical approach to temporalis msucle reduction is Botox injections. It would require a series of Botox injections done 4 months apart up to a year to get teh muscle to shrink. Presumably this would be permanent but that is not assured.

The temporalis muscle is released from behind the ear and at the top of the skull,  4 to 5 cms removed and then retacked done through a vertical incision in the hairline above the ear. The only real risk to the procedure is in how much correction (reduction in convex profile) can be achieved. It does not affect mouth opening or movement. Its total cost for both sides is in the range of $6500.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I find that my jaw slants downwards and my chin appears too long for my face. My chin is also weak as it does not protrude as far as my lower lip. If possible, I have attached photos and some crude imaging to get your opinion on what you would recommend for me. Thank you.

A: Thank you for sending your pictures. What you are describing and have is the classic steep mandibular plane angle problem. With a short chin many times the jaw angles are high, all which reflect some degree of underdevelopment of the mandible.  I can see from your attempts at imaging that you need a sliding genioplasty to move the chin forward but to vertically shorten it (an implant will keep it just as long if not longer) and vertical lengthening jaw angle implants that adds zero width. You are correct by that imaging in that the best way to change a steep mandibular plane angle is to lower the jaw angle and shorten the chin as it comes forward.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have had cheek impants and a chin implant to attain a more asethetic facial balance as I had very little cheekbone prominence. But I also have benign parotid hypertrophy for about six years now which I now think attributes greatly to my facial imbalance.  I would like to entrust someone to use their best judgment as to what i might need to make it more harmonious.  Do you a parotidectomies will help?  I also model so its really important that my face is in balance and looks good.  I want a more sculpted face. I also was interested in a lateral canthoxpexy to elongate my eye shape…a more almond shaped eye? I’m attaching photos…thanks!

A: While I think there is no question the lateral face reduction by superficial parotiodectomies would be aesthetically beneficial, you have to balance that with the risks of visible scars, facial nerve injury and salivary gland leaks. This would be particularly relevant for anyone but particularly someone who models. That is a question up for further discussion. Lateral canthopexy can be effective for moving the corner of the eye out more to the side, thus elongating the eye shape. This is a much easier decision to consider.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley I was just wondering the cost of gummy bear breast implants. I would like a D cup and was also wondering if that makes a price difference. Really I just need to know how much all together it would cost me? Also do you offer financing? Thank you

A: The total costs for gummy bear (highly cohesive silicone gel) breast implants is right around $5800. It does not matter what size breast implants you would get (150cc to 800cc) the costs are the same regardless of the size chosen. All financing is done through Care Credit, the largest cosmetic surgery financing company in the U.S. Gummy bear breast implants use a high cohesive gel which is more like a firm jello or like the gummy bear candies as the name suggests. Even if the outer shell of the breast implant gets disrupted, the gel is not going to extrude and the external breast will show no signs of deflation or loss of volume. (because there is no loss of volume)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 46 year old female who is interested in getting breast implants. I am currently weight training and looking to compete in bodybuilding contests next year. I am not a heavy body builder, my physique is more feminine but I do have to acquire a certain amount of muscle. I want to know how augmentation can improve my physique naturally. My questions about breast augmentation are should the implants be over or under the muscle? Can I still train after augmentation? How long do I have to wait to return to training after augmentation? Can I still run after augmentation? I have attached one of my training videos so you can see what kind of body that I have?

A: Congratulations on taking up a focused and goal directed workout program. It appears your goal is more towards figure competition rather than heavy muscular body building. Your body frame appear fairly small and petite so you would need proportionate breast implant size. (although that is a matter of one’s interpretation)

Since most breast implants are placed under the pectoralis muscle for less long-term risks (capsular contracture), this is very relevant given your exercise regimen. While disrupting the pectoralis muscle is always a concern in the avid exercise person, I have done breast augmentation in several true female body builders over the years and it has not turned out to pose any long-term disruptions in their regimens. There should be no problem returning to running and body building within two to three weeks after surgery. It may take you a month to get back to speed in regards to chest strength and arm range of motion.

There is always the option of placing the implants above the muscle (subglandular). But the only benefit that provides is quicker recovery.

The other consideration of above or below the muscle would be what shape of augmented breast one desires. (round vs tear drop) The location of the implant can influence that look although shaped breast implants today make that issue less relevant than it once was.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 21 years old and I bit unhappy about my profile…I was thinking about doing something on my chin,nose and ears what would you recommend me. I have sent you some recent pictures of me.

A: In answer to your questions, You would benefit by any three of the procedures that you described.

1) Your ears do stick out the left more than the right. A setback otoplasty would be very effective.

2) Your nose is very ‘juvenile’ in shape with a low dorsum and a soft amorphous round tip. An augmentative rhinoplasty to build up the bridge, give the tip more projection but also narrow it would give your nose a more defined structure.

3) Your chin is short both horizontally and vertically. A sliding genioplasty or a combined horizontal/vertical lengthening chin implant would make your profile more balanced and proportionate for a male.

I have attached some imaging which reflects these proposed changes.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have rather convex temples that I’d like to be thinned please. My widest points appear to be at the upper squamous temporal parts, between the hairline and the ear (beyond hairline but visible still), and on the latitude 1mm above the brow.

1) If you know roughly which point in the temporal area I’m talking about, is convexity in that area governed by temporalis muscle thickness or convexity of the squamous temporal bone itself. 

2) If it is due to the muscle, then from your experience, is the muscle in that area thick at all? Is 4mm a realistic amount that can be taken off at that very point on either side of my head?

3) If it’s a possible procedure, is it an internationally recognized cosmetic surgery procedure?

A: To answer your questions in regards to temporal reduction surgery:

1) The temporal area to which you refer is exclusively controlled by muscle thickness. The temporal bone is naturally concave in that area and has a little significance on the external shape of the temporal area.

2) The temporalis muscle is an exquisitely thick muscle, easily approximating 10 to 12 mms thickness in that area.

3) Temporal reduction is not a common aesthetic procedure and is probably performed by very few doctors in the world.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve been seeing a lot of stuff online regarding abdominal and pectoral etching that brings out the corresponding muscles.  Is this something you can do along with the liposuction/gynecomastia procedure I am undergoing?  Thanks.

A: Pectoral and abdominal liposculpture (to be differentiated from volumetric liposuction reduction) are fine cannula liposuction techniques that can be done as a stand alone procedure or combined with overall chest and abdominal liposuction. They are designed to try and highlight the natural underlying musculature which everyone has. In the abdomen it is known as etching where linear liposuction is done along the linea alba vertically and horizontally along the tendinous inscription lines to hopefully create more of a six- or eight-pack look. In the chest, the lateral pectoral triangle is aggressively reduced along the lateral pectoral muscle border up into the axilla as well as fat injections done into the lower pectoral muscle border hopefully creating a more defined pectoral outline. The success of these manuevers is highly dependent on the patient’s natural fat anatomy and work best in individuals that are already somewhat thinner.

What done as a stand alone procedure in already thin patients who do not require much volume reduction, they produce the best results. When done as part of an overall gynecomastia and abdominal reduction in someone who is not heavy or grossly overweight (you) usually modest definition is achieved. In  heavier patients or patients with thicker abdominal fat and fuller gynecomastia problems, these are not good techniques as the results will simply not be very visible.

In short, these liposculpture techniques can be applied at the time of your gynecomastia and abdomninal liposuction procedure. They add a little more time to the procedure as they involve etching manuevers after the gross fat removal is done. They key about them is that patients need to have realistic expectations as how visible the muscular outlines will be and that it usually takes up to 3 months to see the fine details of the result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have consulted with various surgeons regarding my Medpor orbital rim implants as I would like to have them removed. However, these surgeons seem divided in thought – with some claiming that it’s impossible to remove as it causes too much damage, while others said that it would be possible but difficult. This has left me slightly confused as to what the actuality of Medpor removal is. Based on your experiences, do you think removing these Medpor implants with minimal soft tissue damage would be possible if the surgeon were meticulous about it?

A: In short, the removal of Medpor implants can be safely done. I have removed numerous Medpor implants over the years from the chin, jaw angles, cheeks and orbital rims. While it is true that there are much more adherent than silicone (which isn’t at all), there are far from impossible to remove. I have yet to see a Medpor implant that has any bone ingrowth for which they are touted to have. One very interesting feature about Medpor implant removal is that they are less hard after they have been implanted in the body and have had tissue ingrowth than when they are initially put in. This is undoubtably due to water absorption into the interstices of the implant.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a buried penis problem and was wondering if liposuction of the pubic mound would help. I have always been obese, my last 12 yrs I have been morbidly obese. I remember my penis has always been small I have had sex many times but is very uncomfortable. Normally I have to choose an small lady, but I can remember seeing it better when I was not as obese as I am now. I can feel the erections coming from way inside under the fat and if I push the fat back the penis will pop out .. I can only push so much that I am able to grab it with a full fist not including the head. But if I was to push more I can see that I have an average penis and of course if I don’t push that fat back it goes all the way in and can’t be seen.

A:  The buried penis problem is usually multifactorial in what causes it. Certainly a large suprapubic fat pad is one easily identifiable cause and in the obese male can be the major factor. The shape of the suprapubic mound must be looked at carefully to see whether loose skin hanging down may also be a cause in addition to the fat content of the mound. These helps makes the determination as to whether liposuction alone or liposuction combined with a pubic lift may be needed. The other factor in the buried penis is that the penis itself may be part of the problem as well. It may be naturally small or may be tethered down by fibrosis. It may need to be released as well.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have reads that some doctors offer pain-free breast augmentations. How does that work and why isn’t that done for every braest augmentation surgery. Who would not want it?

A: The idea of a pain-free breast augmentation is more of a marketing concept that a reality. It is simply an impossibility to lift up the chest muscle (pectoralis muscle) and put an implant underneath it that is without pain anymore than it is to tear a muscle without any discomfort. What this so-called ‘pain-free’ procedures are is that they incorporate a new long-lasting local anesthetic. This new type of local numbing medicine, known as Exparel or Depofoam Bupivicaine, has been specifically studied in breast augmentations (as well as other plastic surgery procedures) and has shown showed good results with no complications. This local anesthetic when injected into the muscle during the breast augmentation does reduce pain after the procedure that has a lasting effect upt o three days afster surgery. While pain may be reduced, no study has ever shown that any method of breast augmentation can result in a ‘pain-free breast augmentation’. It may reduce the pain one may feel after surgery but will not eliminate it completely.

Exparel is a longer-acting form of an already long-acting local numbing medicine. (Bupivicaine or Marcaine) It is formulated in a liposome carrier that allows for slower absorption and lasting effects up to 3 days after surgery. This is a critical period for most cosmetic procedures as this is when the most severe discomfort occurs. This also reduces the need for oral narcotics and reduces the likelihood of nausea and vomiting and constipation, all common side effects of pain medication in women.

The one problem with Exparel injections is the cost. It adds at least $200  for the injections in a single patient, a significant expense when a patient is already paying $4,000 to $6,000 for their breast augmentation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m a Caucasian male in my mid-twenties.  I had an unfortunate accident in my late teens in which I fractured my left parietal bone.  At the time, I wasn’t particularly concerned about it – I don’t  think I realized the severity of it.  Now, a few years down the line, I’m balding and I have a dent in my head.  Coupled with my hair-loss, it’s something that I’m very insecure about.  

One of the first things that I did after I decided that I want to do something about it was to see a neurosurgeon.  He sent me for CT scans, which showed that the parietal bone is indented and that the bone around it, towards the top of my skull, is raised.  The dent is very obvious, as is the fact that the back of my skull, on the left side, seems to protrude further outwards than the right.  I  feel that it gives my skull a lopsided appearance.  The neurosurgeon said that he could fix it, but that the scars that it would involve would not be a worthwhile trade-off; it may look just as bad, if not worse, than the dent.  I also saw a plastic/reconstructive surgeon – one of the leading craniofacial surgery specialists in my country – about the dent.  He gave me the option of injections using either fat or cosmetic fillers; neither of which would be permanent.  He also advised me against surgery, due to the scars that it would leave.  I don’t want to go the fat/filler injection route, since it is only temporary, and it will not do anything to fix the lumpy bone that surrounds the dent.

My questions, therefore, are as follows;

1.)  Is there anything that can be done that would fix both issues (dent and lump) without significant scarring?  I am hoping that one can remove some of the bone (it should be around 2 – 5 mm’s, by my estimates) to smooth out the lump and restore the normal contour of my skull.  I can imagine that this would not be trivial since it involves that back of my head where the bone “rounds” down towards both the back and the left side of my skull.

2.)  If surgery is an option, can bone by removed from the lumpy area and placed in the dent, or would a bone cement of some sort be used, regardless of whether or not bone is removed from the lumpy area?

3.)  How bad will the scarring be, in the event of surgery?  I found a blog (tracysigler . com/brain-surgery-experience / this-is-the-end) while I was doing my research.  Does that image offer a good benchmark of what a healed scar would look like?

The attached images shows my issues. 

Perhaps this question may also be of benefit to others visitors to your website.

Thank you kindly for your time.

A:  Thank you for your inquiry and sending your pictures. While an open approach could obviously be done to create the optimal contour skull contour through a combined reduction of high areas and filling of the defect with bone cement, one has to be careful of the scar trade-off. I have done many open cranioplasty procedures through more limited incisions (5 cms.) in that very area and the scar can be acceptable. (ironically many of these have been done on men that actually shave their head. So I would not rule out that incisional approach. I think why other surgeons have not been enthusiastic is that they were envisioning a larger more traditional coronal incision which would obviously create an aesthetic trade-off that would not put you in a better position.

The other concept to consider is an injectable cranioplasty approach just for filling in the defect. Through a small 1 cm incision, the tissues can be lifted up over the defect (pocket creation) and a bone cement introduced through a tube into the defect space and molded from the outside until set. That would certainly fill in the defect in the most minimally invasive manner in regards to the scar.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I am a 34 yrs old with a hidden penis problem I am uncircumcised too.. so I am getting a this surgery if suitable for me… please reply to me … I know below all that fat there a small but decent penis.

A: Thank you for your inquiry. Many buried penis problems are a combination of a suprapubic mound and a retracted penile length. Thus, suprapubic liposuction may not be completely effective for all buried penis patients as the penis may need to be released/lengthened as well. Do you develop a visible penis with an erection? Was the penis visible when you were younger before there was a significant suprapubic mound? To best answer your question I would need to see some pictures of the mound area, particularly from the side view to see what type of buried penis problem that it is you have.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have read a lot about the Vampre Facelift and wanted to know what you think about it. While the name sounds a little creepy, using your own blood to help make you look younger seems like it might work.

A:Platelets are ubiquitous cellular fragments in the blood stream that is most known for helping blood clot. But platelets also make a major contribution to wound healing as they contain a multitude of growth factors which are well known to help repair and regenerate connective tissues. Application of these growth factors in high concentrations through platelet-rich plasma (PRP) has been used as an adjunct to wound healing for almost 20 years.

Platelet-rich plasma (PRP) is blood plasma that has a high concentration of platelets due to processing techniques. A small amount of blood can be drawn from the patient and the platelets removed from it by centrifugation. This creates a platelet concentrate gel that can be added to a variety of plastic surgery procedures such as facelifts and fat grafts to theoretically improve their results through the delivery of its growth factors.

While PRP can be used alone, a variety of aesthetic facial procedures have been developed that combine it with different types of injectable fillers. Marketed brand names such as Selphyl and the Vampire Facelift create either a platelet-rich fibrin matrix or are used in conjunction with other well known fillers such as Juvederm and Restylane. The benefits of PRP in these facial rejuvenation techniques, while theoretically appealing, has not been fully substantiated in widespread clinical use and ongoing patient studies continue to evaluate this autologous therapy in aesthetic surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have read a lot recently about stem cells and their potential rejuvenative properties. It seems logical that if our body is full of them that they can be used to treat a lot of problems including the negative effects of aging. I see some plastic surgeons offer a stem cell facelift. Does this really work and, if not, how come some doctors do it?

A: The use of adult stem cells for their potential cosmetic and anti-aging effects is very controversial at present. While our fat is a large reservoir of stem cells (300X to 500X more than bone marrow), that does not necessarily mean that they work as we would like or hope. The popularity of stem cells is largely because of the ability to harvest fat through liposuction as a source for stem cells,. It is fairly easy to ‘recycle’ the liposuctioned fat and put it back into the patient as an injection with the assumption that tissues of the face can be rejuvenated, Numerous anectodal claims are made about such injections as creating youthfulness, adding permanent volume and improving the appearance of the skin. This has led to a number of touted procedures carrying such names as the stem cell facelifts. Despite their appeal, there is no medical evidence by published clinical studies that proves that it actually works.

Most of the time, such stem cell injections are really nothing more than fat injections that unavoidably contain some stem cells. It is the fat that creates any volumetric or lifting effect and not the stem cells that it may contain. While such ‘stem cell’ injections are unlikely to be harmful, they have not been proven to have anti-aging effects. But the hope that they might, and the lack of any adverse effects, provides plenty of motivation for marketing hype.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want to have the flat spot on the back of my head built up. I understand that various materials can be used to do it but don’t know which one would be better. What are my options?

A: Bone cements in cranioplasty can be either polymethylmethacrylate (PMMA) or various calcium-containing materials. All of these materials are joint powders and liquids that are mixed in surgery to create a self-curing putty that offers enough set times to create the desired shape on the bone. The most ‘natural’ bone cement is that of the synthetic calcium compositions, of which the most common ones used are calcium phosphate-based also known as hydroxyapatites. (HA) They are natural to the bone because the inorganic mineral content of human bone is hydroxyapatite. Another calcium-containing bone cement is that of calcium carbonate, known commercially as Kryptonite. It offers superior biomechanical properties (less prone to fracture) than the calcium phosphate-based masterials but is no longer commercially available. Whether PMMA or HA is better for any cranioplasty is based on a variety of factors (cost, inlay vs onlay, size of incision) and not necessarily because one is more natural or more synthetic. There are different material properties for each type of bone cement and these must be considered also.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am inquiring about getting liposuction.  I am in the Military and am curious about the Patriot Plastic Surgery Program.  Quick bit about me, I was injured a little bit ago, and was pretty much unable to work out for a little over a year; where I gained weight and loss quite a bit of muscle mass as well.  I would like to get my abdomen and love handles sized down as much as possible (or that is possible).

A: The Patriot Plastic Surgery program offers some reduction in fees for any cosmetic surgery for those who are in or have been in military service. While I have no idea as to what your body looks like, you are obviously a young man who is probably in reasonable physical condition. (not obese) Because you are a male your abdominal and flank skin is likely in good condition (no stretch marks) and can shrink down nicely after the fat is extracted. Reducing your abdomen and flanks should, therefore, provide an effective and visible improvement with liposuction.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, What’s the recovery time for a rhinoplasty? How soon could I return to work and look somewhat “normal”

A: The recovery time for a rhinoplasty is usually no more than 10 to 14 days at worst. This is not the total time that it takes for the nose to achieve its final shape, as that takes months, but until it really looks ‘non-surgical’. I have seen some patients who actually look pretty good when the tapes and splint is removed at one week but it would be safe to use the time period of 10 days for returning to work, etc. Normal is defined when one can walk around in public and not look like they have had surgery. Often the key determinant is when the bruising under the eyes will go away provided that one has had nasal bone osteotomies as part of their rhinoplasty. For those rhinoplasties in which the nasal bones do not need to be manipulated, the recovery in appearance is sooner.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, In February 2012 I had a Mitrofanoff diversion done using small intestine. (appendicovesicostomy) Cathing thru the stoma has been a problem since day one. The hole keeps shrinking. Have to “punch thru” for each cath. Usually bleeds, plus painful. One stoma revision done last summer which lasted a few weeks. The urologist has suggested plastic surgery but I am skeptical and tired or surgeries. The total problem was radiation damage from prostate cancer treatment.

A: I think in the face of radiation, it is virtually impossible to keep a stoma open by any type of ‘simple’ scar revision around the stoma. As taking the same tissue that have been exposed to radiation and asking it to heal without shrinking by scar contracture will not work. These are not normal tissues. Any hope of sustained stoma enlargement must occur by altering the involved tissues to have improved vascularity.  This could be done by injectable fat grafting around the stoma which adds healthy fat and stem cells and then secondarily performing an interpositional skin graft to the stoma opening. But this approach would be hard to get enthusiastic about when one has had repeated surgeries that did not work.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have read some articles online and some doctors said skin graft on eyelid looks horrible. Is that true? Have you done skin graft for your patients similar to my case? Will my eyes look uneven after the graft? And how to measure how much skin is needed for the graft? Will my eye shape change back to its original shape after the grafting? When the grafting is done, do I have to patch my eyes for few days? Is that mean I can’t open my eyes for few days? Do u think makeup can cover the unmatched color? I await your advice.

A: Skin grafts on the eyelids will create somewhat of a patch look as it is impossible to match the exact color of skin on the eyelids from anywhere else on the body. I would not necessarily call them horrible-looking. Generally one does skin grafting to the eyelids for a very compelling reason and not for a minor aesthetic concern. Skin grafts are covered by a small sewn-on bolster after surgery for five days which does not prevent the eyes from opening or closing nor does it occlude them. The graft does take time to blend better into the surrounding skin and makeup can be worn in the interim.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve read online that you do infraorbital rim implants. I’m really sorry to trouble you, but I have a concern regarding my upcoming procedure with these implants. Basically, my doctor has informed me that he will be using an intraoral approach for the Medpor Extended Orbital Rim implants, but every resource I’ve seen has said that the implants are placed through an eyelid incision. Do you think an intraoral approach is possible, and will the results be affected by using it? Should I at all be concerned that he isn’t going to use the eyelid incision?

A: The placement of infraorbital rim implants can be done either through an eyelid or an intraoral approach. Both are acceptable approaches and which one is done is based on surgeon preference. It is a little easier to assure good implant position on the bone from above (eyelid incision) as one does not have to work around the large infraorbital nerve. But an infraorbital implant can be effectively placed from inside the mouth, it is just a little more technically challenging to do so and the risk of some protracted lip numbness from infraorbital nerve traction will occur.

Dr. Barry Eppley

Indianapolis, Indiana